Report
Grenfell Tower Inquiry: Phase 2 Report
¶GRENFELL TOWER INQUIRY:
PHASE 2 REPORT
¶REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017
¶The Panel: Chairman: The Rt Hon Sir Martin Moore-Bick Ali Akbor OBE Thouria Istephan September 2024
Volume 1: Part 1 – Introduction Part 2 – The path to disaster
¶HC 19–I
¶GRENFELL TOWER INQUIRY:
PHASE 2 REPORT
¶REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017
¶The Panel: Chairman: The Rt Hon Sir Martin Moore-Bick Ali Akbor OBE Thouria Istephan September 2024
¶Presented to Parliament pursuant to section 26 of the Inquiries Act 2005 Ordered by the House of Commons to be printed 4 September 2024
¶Volume 1 Part 1 – Introduction Part 2 – The path to disaster HC 19–I
¶This report contains content which some may find distressing.
¶© Crown copyright 2024 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. This publication is available at www.gov.uk/official-documents. Any enquiries regarding this publication should be sent to us at contact@grenfelltowerinquiry.org.uk. ISBN 978-1-5286-5080-9 (Volume 1 of 7) 7 volumes not available separately E03165832 09/2024 Printed on paper containing 40% recycled fibre content minimum. Printed in the UK by HH Associates Ltd. on behalf of the Controller of His Majesty's Stationery Office.
vContents
¶Volume 1 Part 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Chapter 1: Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Chapter 2: Executive summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Part 2: The path to disaster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Chapter 3: Introduction to Part 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Chapter 4: The development of the regulatory regime . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Chapter 5: Fire testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Chapter 6: Regulations and guidance relating to external walls. . . . . . . . . . . . . . . . . . . . . . 69 Chapter 7: The government and the Building Research Establishment. . . . . . . . . . . . . . . . 81 Chapter 8: The Investigation of Real Fires project. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Chapter 9: The government's response to the Lakanal House fire . . . . . . . . . . . . . . . . . . 131 Chapter 10: The Department for Communities and Local Government 2013–2017. . . . . . 145 Chapter 11: Combustible cladding: warnings to government. . . . . . . . . . . . . . . . . . . . . . . . 173 Chapter 12: Regulation of fire risk assessors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Chapter 13: The Fire Safety Order . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Chapter 14: The Local Government Association Guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
¶Volume 2 Part 3: The testing and marketing of products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Chapter 15: Introduction to Part 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Chapter 16: Arconic - evidential matters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Chapter 17: Arconic's testing of ACM panels 1997 to 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Chapter 18: Obtaining a BBA certificate for Reynobond 55 PE . . . . . . . . . . . . . . . . . . . . . . . 19 Chapter 19: The BBA certificate for Reynobond 55 PE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Chapter 20: Subsequent testing and marketing of Reynobond 55 PE . . . . . . . . . . . . . . . . . . 35 Chapter 21: The review of the Reynobond certificate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Chapter 22: Kingspan K15 insulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Chapter 23: Certification of Kingspan K15 by LABC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Chapter 24: Celotex RS5000 insulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Chapter 25: Certification of Celotex RS5000 by LABC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Chapter 26: The National House Building Council. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Chapter 27: Siderise cavity barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 Chapter 28: United Kingdom Accreditation Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Chapter 29: Failures in the system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
vi¶Volume 3 Part 4: Tenant Management Organisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Chapter 30: Introduction to Part 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Chapter 31: Structure and governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Chapter 32: RBKC's oversight of the TMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Chapter 33: The TMO's relationship with its residents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Part 5: The management of fire safety at Grenfell Tower . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Chapter 34: Introduction to Part 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Chapter 35: The Fire Safety Order . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Chapter 36: Fire safety management at the TMO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Chapter 37: Development of fire safety strategies and policies. . . . . . . . . . . . . . . . . . . . . . . 55 Chapter 38: Fire risk assessments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Chapter 39: Response to fire risk assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Chapter 40: The replacement of entrance doors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Chapter 41: Inspection and maintenance of entrance doors. . . . . . . . . . . . . . . . . . . . . . . . 111 Chapter 42: Fire safety information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Chapter 43: The smoke ventilation system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Chapter 44: Lifts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Chapter 45: Emergency planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Chapter 46: Vulnerable residents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
¶Volume 4 Part 6: The refurbishment of Grenfell Tower . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Chapter 47: Introduction to Part 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Chapter 48: The legislative background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Chapter 49: Industry guidance on the construction of external walls . . . . . . . . . . . . . . . . . 21 Chapter 50: Organisations involved in the refurbishment . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Chapter 51: The origins of the Grenfell Tower Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Chapter 52: The appointment of Studio E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Chapter 53: Planning the refurbishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Chapter 54: Fire safety strategies; the contribution of Exova . . . . . . . . . . . . . . . . . . . . . . . . 67 Chapter 55: The choice of ACM PE rainscreen panels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Chapter 56: The choice of insulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Chapter 57: Cavity barriers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Chapter 58: Window infill panels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Chapter 59: Window reveals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Chapter 60: The new smoke ventilation system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 Chapter 61: The Health and Safety File . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 Chapter 62: Building Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 Chapter 63: The contribution of Studio E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 Chapter 64: The contribution of Rydon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 Chapter 65: The contribution of Harley . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293 Chapter 66: The contribution of the Tenant Management Organisation. . . . . . . . . . . . . . . 315 Chapter 67: Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
vii¶Volume 5 Part 7: Replacement of the gas riser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Chapter 68: Replacement of the gas riser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Part 8: The London Fire Brigade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Chapter 69: Introduction to Part 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Chapter 70: Organisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Chapter 71: Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Chapter 72: Incident command training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Chapter 73: Modern materials and methods of construction . . . . . . . . . . . . . . . . . . . . . . . . 47 Chapter 74: The response to the Lakanal House fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Chapter 75: Existing sources of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Chapter 76: Operational planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Chapter 77: High-rise firefighting: policy and guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Chapter 78: The control room. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Chapter 79: Fire survival guidance: training and management . . . . . . . . . . . . . . . . . . . . . . 133 Chapter 80: Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Chapter 81: The supply of water. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 Chapter 82: Aspects of firefighting at Grenfell Tower. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Chapter 83: Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
¶Volume 6 Part 9: The deceased . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Chapter 84 : Introduction to Part 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Chapter 85: The expert evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Chapter 86: Floor 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Chapter 87: Floor 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Chapter 88: Floor 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Chapter 89: Floor 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Chapter 90: Floor 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Chapter 91: Floor 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Chapter 92: Floor 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Chapter 93: Floor 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Chapter 94: Floor 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Chapter 95: Floor 21 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Chapter 96: Floor 22 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Chapter 97: Floor 23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
viii¶Volume 7 Part 10: Response and recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Chapter 98: Introduction to Part 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Chapter 99: The legislative framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Chapter 100: Personal experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Chapter 101: Local government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Chapter 102: The London-wide response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Chapter 103: The government's response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Chapter 104: The response of RBKC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Chapter 105: The response of the Tenant Management Organisation . . . . . . . . . . . . . . . . . 143 Chapter 106: Voluntary, community and faith sectors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Chapter 107: Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Part 11: Matters outstanding from Phase 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Chapter 108: Introduction to Part 11. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Chapter 109: Testing the materials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Chapter 110: The escape of fire from Flat 16. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Part 12: The fire testing regime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 Chapter 111: Assessing the fire performance of external walls. . . . . . . . . . . . . . . . . . . . . . . 201 Part 13: International responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Chapter 112: The response of other countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219 Part 14: Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Chapter 113: Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 Appendix A: Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 Appendix B: Guide to references. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 Appendix C: The Inquiry Team. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
1Part 1: Introduction
3Chapter 1: Introduction
¶1.1 In his introduction to his Phase 1 Report published on 30 October 2019 the chairman described the circumstances which led to the setting up of the public inquiry into the fire at Grenfell Tower on 14 June 2017. He also described the way in which the Inquiry had been organised and how it had gone about carrying out its task. Anyone who is not already familiar with those matters should refer to paragraphs 1.1 – 1.25 of that report. This second phase of the Inquiry builds on the findings made by the chairman in Phase 1 and is a direct continuation of that work. In those circumstances we do not think that it is necessary to repeat what is said in the introduction to the Phase 1 Report, but there have been some developments since it was published to which we should draw attention before turning to the substance of our report.
¶1.2 In Phase 1 the chairman set out to examine in detail the course of events on the night of 14 June 2017 with a view to identifying with as much confidence as possible what had taken place during the period between the outbreak of fire in the kitchen of Flat 16 at 00.54 and the escape of the last survivor at 08.07 that morning. The purpose of doing so was twofold: to enable those who had been directly involved in the fire, both residents and fire fighters, to give their accounts of the events of that night at the earliest opportunity and to find out as far as possible exactly what had happened during the early hours of 14 June 2017 before seeking to establish exactly what had gone wrong and why.
¶1.3 In Phase 2 we have set out to answer the question that has been at the forefront of many people's minds: how was it possible in 21st century London for a reinforced concrete building, itself structurally impervious to fire, to be turned into a death trap that would enable fire to sweep through it in an uncontrollable way in a matter of a few hours despite what were thought to be effective regulations designed to prevent just such an event? There is no simple answer to that question, but in this report we identify the many failings of a wide range of institutions, entities and individuals over many years that together brought about that situation.
¶1.4 Following the publication of the Phase 1 report, the Prime Minister appointed Ms Thouria Istephan and Ms Benita Mehra as additional members of the Inquiry panel. In October 2019 Ms Redfearn resigned as an assessor and in February 2021 Mr John Mothersole, a former chief executive of Sheffield City Council, was appointed an assessor in her place, joining Mr Joe Montgomery and Professor David Nethercot, both of whom have continued to assist us generously with their time and advice. Needless to say, however, we remain entirely responsible for the conclusions in this report.
¶1.5 In January 2020 Ms Mehra resigned from the Panel. Mr Ali Akbor OBE was appointed in her place in October 2020.
¶1.6 In June 2022 Mr Mark Fisher resigned as Secretary to the Inquiry on his appointment as Chief Executive of the NHS Greater Manchester Integrated Care Board and was replaced by Ms Nicole Kett later that month. Her death in August 2022 after a short illness caused profound shock and sadness. In October 2022 Mr Matt Lewsey was appointed as Secretary in her place.
4¶1.7 The procedure adopted in this Phase of the Inquiry has been the same as that in Phase 1. In particular, we have continued to ensure that our investigations have been as detailed and thorough as the extensive material that we have been able to gather has allowed. The chairman decided at an early stage that this phase could conveniently be divided into a number of separate modules, each reflecting an aspect of the background to the fire. That enabled the evidence to be adduced in an orderly way and minimised the need to call witnesses more than once. In most cases it also allowed expert evidence to be heard immediately after the factual evidence to which it related.
¶1.8 The Inquiry sat to hear evidence and opening and closing statements for Phase 2 for a total of 312 days. The hearings for Phase 2 began on 27 January 2020 but were interrupted almost immediately for a period of about five weeks at the instigation of certain core participants while an undertaking was obtained from the Attorney General to protect witnesses from the risk of having their evidence used against them in criminal proceedings.1 The Attorney-General's Undertaking is at https://www.gov.uk/government/news/attorney-general-provides- undertaking-for-grenfell-tower-inquiry. Hearings began again in earnest on 2 March 2020 but had to be suspended on 16 March 2020 as a result of the restrictions imposed in response to the Covid 19 pandemic. Hearings resumed on 6 July 2020 and continued until 9 December 2020. During that period access to the hearing room was limited to those whose presence was essential, but the proceedings continued to be streamed and could be viewed by anyone interested in doing so.
¶1.9 Between 9 December 2020 and 8 February 2021 the proceedings were interrupted again by restrictions imposed in response to the pandemic, but between 8 February 2021 and 25 March 2021 our increasing familiarity with remote conferencing facilities and the outstanding assistance of our technical support teams at RTS Communications and Opus 2 International made it possible for us to continue hearings while observing the requirements of lockdown. On 19 April 2021 we were able to resume hearings at 13 Bishop's Bridge Road, albeit still with restricted access. Unrestricted public access to the hearing room resumed in September 2021 and continued until November 2022.
¶1.10 As before, all witness statements and documents put in evidence during the course of the hearings have been published on the Inquiry's website and the proceedings have been streamed live on the internet. In addition, arrangements were made for the proceedings to be video-recorded and transcribed and for access to both the video-recording and the transcript to be available through the Inquiry's website.
¶1.11 In his introduction to the Phase 1 report the chairman explained the effect of rule 13 of the Inquiry Rules and the approach that he had decided to take to sending warning letters to those who might be subject to criticism.2 Phase 1 Report Volume I paragraph 1.24. In this phase we decided that we should take the same approach, but that inevitably presented us with a considerable challenge, given the number of people who were likely to face criticism of one kind or another. Between June 2023 and April 2024 the Inquiry's solicitors wrote to 247 individuals and organisations informing them of the criticisms that we were minded to make of them and providing them with the relevant chapters of the draft report identifying the evidence on which those potential criticisms were based.
¶1.12 Between July 2023 and May 2024 the Inquiry received responses from the vast majority of those to whom warning letters had been sent, but the process as a whole took much longer than had been expected because in some cases the amount of material that a recipient had to consider was substantial. All the responses were carefully considered and in some cases we modified our provisional conclusions in the light of them. As in Phase 1, however, for the reasons explained by the chairman in the Phase 1 Report we did not take into account fresh evidence or new arguments that could have been, but had not been, put forward during the hearings.3 Phase 1 Report Volume I paragraph 1.25.
5¶1.13 In pursuing our investigations we have had the benefit of receiving the expert advice and assistance of a number of leading practitioners in a wide range of disciplines, all of whom provided us with written reports and subsequently gave evidence to the Inquiry at public hearings. We are most grateful to all of them for the enormous amount of time they devoted to our work and the enthusiasm which they brought to it. In most cases their opinions were not seriously challenged, but to the extent that they were, we have set out the points made in opposition to their evidence in the body of our report and have given reasons for our conclusions. Except in those cases, however, we consider that the weight of their expertise and the absence of any real challenge to their evidence justifies us in accepting their opinions unless we have some good reason not to do so. Where we have relied on their evidence we have identified in footnotes the relevant passages in their reports or oral evidence without referring to them in the body of the text.
¶1.14 Section 2(1) of the Inquiries Act 2005 expressly prohibits us from ruling on questions of legal liability, civil or criminal. That is a matter for the courts. However, section 2(2) expressly provides that we are not to be inhibited in the discharge of our functions by any likelihood of liability being inferred from any facts we find or recommendations we make.
¶1.15 When dealing with an area of activity, such as the refurbishment of Grenfell Tower, which involved a large number of organisations bound together by a web of contracts and subject to legislation in the form of the Building Regulations, it is impossible to describe the relationships between them and their individual responsibilities without referring to those contracts and the relevant regulations. We have taken the view, therefore, that to refer to them merely for what they state does not amount to determining liability and we have not expressed a view about any disputes that may exist between the parties to the refurbishment or others about their respective obligations. The contracts and the regulations say what they say and establish certain relationships; we have simply treated them as part of the context in which our findings are to be read.
¶1.16 It is not possible to identify any single cause of the tragedy; many different acts and omissions combined to bring about the Grenfell Tower fire, although some were more significant than others. With some exceptions we have not attempted to apportion blame. We have in general asked ourselves whether a particular act or omission contributed in some way to the fire and, if so, to what extent.
¶1.17 In response to the evidence that emerged during the Inquiry, all of which was published contemporaneously in one form or another, the government has already taken steps to overhaul the regulation of various aspects of the construction industry. In particular, it has prohibited the use of metal composite materials with unmodified polyethylene cores on external walls of buildings of any height, it has prohibited the use of materials that are not classed A2 (s1, d0) or better in the external walls of buildings over 18 metres in height, it has introduced new requirements for obtaining building control approval in relation to the construction and refurbishment of higher-risk buildings and has reformed the arrangements for the exercise of building control functions generally. The creation of an Office for Product Safety and Standards and the appointment of a National Regulator for Construction Products has also been put in hand and measures have been taken to improve the competence of those engaged in the design and construction of buildings generally. To that extent, it has already taken steps to cure many of the more glaring defects in the system we have identified and the scope for making recommendations is correspondingly reduced. Nonetheless, we think there are some important areas in which improvements need to be made and others in which the action taken by the government does not go far enough. In those cases we have made recommendations for change that in our view would make a significant difference to ensuring that fires of the kind that destroyed Grenfell Tower and took the lives of many of its occupants never occur again.
6¶1.18 From the earliest days of the Inquiry there have been those who have asserted that discrimination on the grounds of race or social background played a significant part in the tragedy that befell Grenfell Tower on 14 June 2017. Originally that was reflected in calls for the Inquiry to examine social housing policy generally as well as the way in which flats in Grenfell Tower had been allocated. Those calls reflected a widely held belief that people of minority ethnic and socially disadvantaged backgrounds were routinely the subject of active discrimination that took the form of making available to them low quality or unsafe housing. A large proportion of the residents of Grenfell Tower at the time of the fire were from ethnic minorities and many were socially disadvantaged. The implication was that they had been allocated flats in what was known to be an unsafe building as a result of racial and social discrimination.
¶1.19 It may well be that the Grenfell Tower fire has raised questions about social housing policy, whether in RBKC or more generally, that deserve examination, though whether a public inquiry conducted under the Inquiries Act 2005 is the most suitable method of doing so may be open to debate. To have acceded to the calls for us to undertake that task, however, would have extended the scope of the Inquiry (and the time taken to produce a report) very significantly, since, even if limited to the allocation of social housing by RBKC, it would have required an examination of the council's housing records over a period of some years. Any examination of social housing policy more widely would have extended that task enormously. As a result, the Prime Minister decided not to include those matters in the Inquiry's Terms of Reference.
¶1.20 Nonetheless, at various stages during the Inquiry we have been urged to investigate what is alleged to have been a culture of racial and social discrimination in the institutions involved in one way or another in the refurbishment, particularly RBKC and the TMO. The desire to investigate and expose discrimination of that kind flowed from the undeniable fact that a significantly disproportionate number of those who died in the fire and of those who survived the fire but whose homes were destroyed were from ethnic minorities or socially disadvantaged.
¶1.21 For the reasons we have explained, the existence of racial or social discrimination in the allocation of social housing falls outside our terms of reference, but any factors that affected the decisions that led to the creation of an unsafe building are within our scope and we have done our best to investigate them thoroughly. Our response to those who wanted us to investigate racial and social discrimination has always been that we would look out for it and that if we came across any evidence that racial or social prejudice might have affected any of the decisions that led, directly or indirectly, to the disaster, we would examine it thoroughly and publish our findings, as befits an inquiry seeking to uncover the truth.
7¶1.22 We should say at once that we have seen some evidence of racial discrimination in the way in which some of those who survived the fire were treated in the days immediately following it at a time when they were at their most vulnerable and we have described what happened in Part 10 of this report. We have also seen evidence that the TMO failed over the course of years to treat residents of the tower and the Lancaster West Estate more generally with the courtesy and respect due to them. That is described in Parts 4 and 5. However, we have seen no evidence that any of the decisions that resulted in the creation of a dangerous building or the calamitous spread of fire were affected by racial or social prejudice and none of those representing the bereaved, survivors or residents has drawn any such evidence to our attention, although they have had access to all the material before us.
¶1.23 How Grenfell Tower came to be home to a disproportionately large number of socially disadvantaged people, many from ethnic minority backgrounds, is a question that lies outside our terms of reference. It must be remembered, however, that almost without exception they had been living there, in some cases for many years, before the refurbishment was ever contemplated. Many residents told us how much they liked living there. The tower was a concrete structure and before the refurbishment was largely impervious to fire. At the time most residents were allocated their flats it was perfectly safe and we have seen nothing to suggest that following the refurbishment anyone in the RBKC housing department thought it had ceased to be so. There was no question, therefore, of allocating homes to those of non-white ethnicity in a building known to be dangerous.
¶1.24 In the course of the Inquiry we have examined a very large number of documents relating to the refurbishment and many hours of testimony from those involved in designing, planning, executing and approving the work. In this report we have described in some detail the course of events that led to the disaster. We have identified many errors, due in the most part to incompetence, carelessness and a failure to take responsibility for important aspects of the work that affected fire safety. In a few cases, principally involving the manufacturers of building products, we have identified dishonesty. However, we have seen no evidence that any decisions directly affecting the design or execution of the refurbishment were affected by racial or social prejudice. Although the TMO was anxious to keep the cost of the refurbishment down, and although some of the decisions taken to achieve that end were ultimately responsible for the tragedy, we saw no evidence that any of those responsible for them was aware of their potential consequences.
¶1.25 Given the repeated urging by some of those representing the bereaved, survivors and residents to consider whether the race or social background of those who lived in the tower played a part in bringing about the disaster and the implicit assertion that it did, we think it right to make it clear that our investigations have not brought to light any evidence to support that conclusion.
¶1.26 We are only too well aware that our investigations into the fire and the production of our report have taken longer than many would have wished. However, as our work has gone on it has become increasingly apparent that the disaster was the result of shortcomings in the construction industry that were far more extensive than had previously been envisaged. As the scale of the problems became ever clearer it seemed to us that those most directly affected by the fire deserved to be given a detailed and thorough description of the circumstances that led to the fire so that they could understand how it had come about and where responsibility for it lay. We hope that they and others who read our report will be satisfied that our investigations have been as detailed and thorough as they would have wished.
8¶1.27 An inquiry of this magnitude involves an enormous amount of work and could not be conducted without a large and well-organised team of lawyers, administrators and technical professionals. We are fortunate to have had the support throughout the duration of the Inquiry of some of the most skilled, loyal and dedicated people one could hope to find, many of whom have been working for the Inquiry since it was set up in June 2017. Some have played a very public role, while others have remained entirely in the background, but they have all played an essential part in enabling us to discharge our terms of reference. A list of those who have worked with us on our investigations can be found in Appendix C. We cannot speak too highly of their professionalism and dedication.
9Chapter 2: Executive summary
¶2.1 This chapter contains an overview of the contents of our report. Our terms of reference were broad and we have followed many lines of inquiry, sometimes with unexpected results. The report is therefore inevitably lengthy and detailed. It is not possible to summarise the whole of its contents in a few pages and we have not tried to do so. The purpose of this chapter is to describe in broad terms the contents of the report and the main conclusions we have reached about the events that culminated in the tragedy at Grenfell Tower. We hope that it will assist readers in understanding the scope of the report and directing their attention to the parts of greatest interest to them. However, there is no substitute for reading the report itself.
¶2.2 For ease of reference we have referred to the contents of the report under headings that correspond to those of its various Parts.
Part 2 The path to disaster (Chapters 3 – 14)
¶2.3 In this Part of the report we describe the course of events leading up to the fire, beginning with the regulatory regime and its development in relation to the external walls of high-rise buildings. We describe the part played by the government in the form of the then Department for Communities and Local Government in the development of the statutory guidance and the investigation into the fire at Lakanal House, Southwark in 2009. We also describe the parts played by other influential bodies in creating the circumstances in which refurbishment of Grenfell Tower took place.
¶2.4 We conclude that the fire at Grenfell Tower was the culmination of decades of failure by central government and other bodies in positions of responsibility in the construction industry to look carefully into the danger of incorporating combustible materials into the external walls of high-rise residential buildings and to act on the information available to them.
The government
¶2.5 In the years between the fire at Knowsley Heights in 1991 and the fire at Grenfell Tower in 2017 there were many opportunities for the government to identify the risks posed by the use of combustible cladding panels and insulation, particularly to high-rise buildings, and to take action in relation to them. Indeed, by 2016 the department was well aware of those risks, but failed to act on what it knew. In particular, it failed to heed the warning of the Environment and Transport Select Committee in December 1999 that it should not take a serious fire in which people were killed before steps were taken to minimise the risks posed by some external cladding systems. It also failed to implement or keep under review the committee's recommendation that the large-scale test that had recently been developed should be substituted in Approved Document B for previous requirements relating to the fire safety of external cladding systems (thereby abandoning Class 0).
10¶2.6 The department also failed to pay due regard to the striking results of a large-scale test in 2001 involving aluminium composite panels with unmodified polyethylene cores, which burned violently, or to take any steps either to ascertain the extent to which panels of that kind were in use or to warn the construction industry about the risks they posed. It failed even to publish the results of the test.
¶2.7 On many subsequent occasions the department was made aware that national Class 0 was an inappropriate standard by which to determine the suitability of external wall panels but allowed it to remain as part of the statutory guidance until after the Grenfell Tower fire. It could and should have been removed years earlier.
¶2.8 The review of Approved Document B carried out by the department between 2005 and 2006 provided an opportunity to clarify the guidance on compliance with functional requirement B4(1), but the language used was vague and ill-considered words were added at a late stage in the process without proper consultation.
¶2.9 Between 2012 and 2017 the department received numerous warnings about the risks involved in using polymeric insulation and aluminium composite panels with unmodified polyethylene cores. It also became aware of several major cladding fires abroad involving products of those kinds. By 2013 at the latest, it knew that Approved Document B was unclear and not properly understood by a significant proportion of those working in the construction industry and by February 2016 it had become aware that some in the industry were worried that combustible insulation and aluminium composite material (ACM) panels with unmodified polyethylene cores were routinely being used on high-rise buildings in breach of functional requirement B4. However, despite what it knew, and the warnings it received from some quarters, the department failed to amend or clarify the guidance in Approved Document B on the construction of external walls.
¶2.10 The department itself was poorly run, in as much as the official with day-to-day responsibility for the Building Regulations and Approved Document B was allowed too much freedom of action without adequate oversight. He failed to bring to the attention of more senior officials the serious risks of which he had become aware, and they in turn failed to supervise him properly or to satisfy themselves that his response to matters affecting the safety of people's lives was appropriate. It was a serious failure to allow such an important area of activity to remain in the hands of one relatively junior official.
¶2.11 The Building Research Establishment (originally known as the Fire Research Station) had been established in 1921 as a government body to carry out research into and testing of construction methods and products. After it was privatised in 1997 the department limited the scope of the advice it was asked to provide on fire safety matters. As a result, the department deprived itself of the full benefit of BRE's advice and experience. On occasions it deliberately curtailed investigations before any proper conclusion had been reached.
¶2.12 The department displayed a complacent and at times defensive attitude to matters affecting fire safety. Following the fire at Lakanal House the coroner recommended that Approved Document B be reviewed, but her recommendations were not treated with any sense of urgency and officials did not explain clearly to the Secretary of State what steps were required to comply with them. Similarly, legitimate concerns about the fire risks of cladding raised by the All-Party Parliamentary Group on Fire Safety were repeatedly met with a defensive and dismissive attitude by officials and some ministers.
11¶2.13 In the years that followed the Lakanal House fire the government's deregulatory agenda, enthusiastically supported by some junior ministers and the Secretary of State, dominated the department's thinking to such an extent that even matters affecting the safety of life were ignored, delayed or disregarded.
¶2.14 During that period the government determinedly resisted calls from across the fire sector to regulate fire risk assessors and to amend the Fire Safety Order to make it clear that it applied to the exterior walls of buildings containing more than one set of domestic premises. Although it commissioned a review of the advice in the Local Government Association Guide Fire safety in purpose-built blocks of flats relating to the evacuation of vulnerable people, it failed to consult those who represented their interests.
The Building Research Establishment
¶2.15 BRE held a trusted position within the construction industry and was recognised both nationally and internationally as a leader in fire safety. However, from 1991 much of the work it carried out in relation to testing the fire safety of external walls was marred by unprofessional conduct, inadequate practices, a lack of effective oversight, poor reporting and a lack of scientific rigour.
¶2.16 Although BRE recognised from as early as 1991, following the fire at Knowsley Heights, that small-scale testing of the kind that provided the basis for national Class 0 did not enable a proper assessment to be made of the way in which an external wall system would react to fire, it did not draw that to the government's attention, formally or informally. Similarly, following its large-scale test of a system incorporating aluminium composite panels with unmodified polyethylene cores in 2001, BRE failed to draw the department's attention in clear terms to the way in which the material had behaved and the dangers it presented.
¶2.17 BRE's reports into the major fires at Knowsley Heights (1991), Garnock Court (1999) and The Edge (2005) were far from comprehensive and in each case failed to identify or assess important contributory factors. The reports of fires it provided to the department were characterised by superficiality and a lack of analysis, with the result that they gave the department the false impression that the regulations and guidance were working effectively.
¶2.18 There were weaknesses in the way BRE carried out tests in accordance with BS 8414 and in its record-keeping, which exposed it to the risk of manipulation by unscrupulous product manufacturers, as happened in the case of the second test carried out for Celotex, the manufacturer of the insulation specified for use on Grenfell Tower. Senior BRE staff gave advice to customers such as Kingspan and Celotex on the best way to satisfy the criteria for a system to be considered safe, thereby compromising its integrity and independence. In some cases we saw evidence of a desire to accommodate existing customers and to retain its status within the industry at the expense of maintaining the rigour of its processes and considerations of public safety. The unprofessional behaviour of some of BRE's staff was in part the result of a failure to provide them with adequate training in their responsibilities.
12Part 3: The testing and marketing of products (Chapters 15 – 29)
¶2.19 One very significant reason why Grenfell Tower came to be clad in combustible materials was systematic dishonesty on the part of those who made and sold the rainscreen cladding panels and insulation products. They engaged in deliberate and sustained strategies to manipulate the testing processes, misrepresent test data and mislead the market. In the case of the principal insulation product used on Grenfell Tower, Celotex RS5000, the Building Research Establishment (BRE) was complicit in that strategy.
¶2.20 Those strategies succeeded partly because the certification bodies that provided assurance to the market of the quality and characteristics of the products, the British Board of Agrément (BBA) and Local Authority Building Control (LABC), failed to ensure that the statements in their product certificates were accurate and based on test evidence. UKAS, the body charged with oversight of the certification bodies, failed to apply proper standards of monitoring and supervision.
Arconic Architectural Products
¶2.21 Arconic Architectural Products manufactured and sold the Reynobond 55 PE rainscreen panels used in the external wall of Grenfell Tower. They were an ACM product made of two thin sheets of aluminium with a polyethylene core to provide stiffening. The material was manufactured and sold in flat sheets designed to be cut to size and attached to a metal sub-frame, either as flat panels by rivets or as three-dimensional structures, known as cassettes, by slots, making use of the force of gravity. Polyethylene burns fiercely and when used in cassette form Reynobond 55 PE was extremely dangerous.4 See in particular Part 11 chapter 109. From 2005 until after the Grenfell Tower fire Arconic deliberately concealed from the market the true extent of the danger of using Reynobond 55 PE in cassette form, particularly on high-rise buildings.5 See Part 3 Chapters 16 to 21.
¶2.22 The product in its riveted form had been classed under the European classification system B-s2, d0, but from early 2005 Arconic had been in possession of test data showing that in its cassette form the product reacted to fire in a very dangerous way and could not be classified in accordance with European standards. Nonetheless, Arconic persisted in telling the market that the panels had been classed B-s2, d0 without drawing any distinction between the cassette and riveted forms.
¶2.23 By late 2007 Arconic had become aware that there was serious concern in the construction industry about the safety of ACM panels and had itself recognised the danger they posed. By the summer of 2011 it was well aware that Reynobond 55 PE in cassette form performed much worse in a fire and was considerably more dangerous than in riveted form. Nonetheless, it was determined to exploit what it saw as weak regulatory regimes in certain countries (including the UK) to sell Reynobond 55 PE in cassette form, including for use on residential buildings.
¶2.24 Despite the knowledge gained from cladding fires in Dubai in 2012 and 2013, Arconic did not consider withdrawing Reynobond 55 PE in favour of the fire-resistant version then available. Instead, it allowed customers in the UK to continue buying the unmodified product, giving them to understand that it would tell them if it was unsuitable for the use to which they intended to put it, although without any intention of doing so.
13¶2.25 Following further testing in 2013, Arconic decided that Reynobond 55 PE would be certified as Class E only, whether used in riveted or cassette form. However, it did not pass that information to its customers in the UK or to the BBA. That was not an oversight. It reflected a deliberate strategy to continue selling Reynobond 55 PE in the UK based on a statement about its fire performance that it knew to be false.
¶2.26 In December 2014 the French testing house Centre Scientifique et Technique du Bâtiment (CSTB) classified the panels in riveted form as Class C and the panels in cassette form as Class E. However, Arconic failed to inform the BBA of those revised classifications.
¶2.27 Although Reynobond 55 PE required some degree of fabrication and could not be used in the form in which it left the factory, Arconic persuaded the BBA to issue a certificate that drew no distinction between the different forms of fixing. It concealed important information from the BBA, in particular the test data relating to the product in cassette form, that showed that it performed much worse than in riveted form. It caused the BBA to make statements in the certificate that Arconic knew to be false and misleading.
Celotex
¶2.28 Celotex manufactured RS5000, a combustible polyisocyanurate foam insulation. In an attempt to break into the market for insulation suitable for use on high-rise buildings, created and then dominated by Kingspan K15, Celotex embarked on a dishonest scheme to mislead its customers and the wider market.6 See Part 3 Chapters 24 and 25.
¶2.29 With the complicity of BRE, in May 2014 Celotex tested in accordance with BS 8414 a system incorporating RS5000 that contained two sets of fire-resistant magnesium oxide boards placed in critical positions to ensure that it passed. It then obtained from BRE a test report that omitted any reference to the magnesium oxide boards, thereby rendering it materially incomplete and misleading.
¶2.30 Celotex then marketed RS5000 as "the first PIR board to successfully test to BS 8414", and as "acceptable for use in buildings above 18 metres in height". However, the test on which Celotex relied in support of that claim had been manipulated as we have described above, a fact that Celotex did not disclose in its marketing literature. Moreover, BS 8414 is a system test and does not involve the testing or classification of individual products. Celotex deliberately tucked that information away in the small print of its marketing literature.
¶2.31 RS5000 had previously been marketed as FR5000. From 2011 it had been sold as having Class 0 fire performance "throughout", a claim which was false and misleading. Celotex presented RS5000 to Harley as suitable and safe for use on Grenfell Tower, although it knew that was not the case.
Kingspan
¶2.32 From 2005 until after this Inquiry had begun, Kingspan knowingly created a false market in insulation for use on buildings over 18 metres in height by claiming that K15 had been part of a system successfully tested under BS 8414 and could therefore be used in the external wall of any building over 18 metres in height regardless of its design or other components. That was a false claim, as it well knew, because BS 8414 is a method for testing complete wall systems and its results apply only to the particular system tested. As Kingspan knew, K15 could not honestly be sold as suitable for use in the external walls of buildings over 18 metres in height generally, but that is what it had succeeded in doing for many years.7 See Part 3 Chapters 22 and 23.
14¶2.33 In marketing K15 Kingspan relied on the results of a single BS 8414-1 test performed in 2005 on a system whose components were not representative of a typical external wall and it continued to rely on that test without disclosing that it had changed the composition of the product in 2006. Tests performed in 2007 and 2008 on systems incorporating the then current form of K15 were disastrous, but Kingspan did not withdraw the product from the market, despite its own concerns about its fire performance.
¶2.34 Kingspan concealed from the BBA the fact that the product it was selling, to which the certificate issued in 2008 referred, differed from the product that had been incorporated into the system tested in 2005. Moreover, the BBA certificate contained three important statements about the fire performance of K15 that were untrue. It used a form of words suggested by Kingspan and drawn from its own marketing literature.
¶2.35 In 2009 Kingspan succeeded in obtaining from the LABC a certificate that contained false statements about K15 and supported its use generally on buildings over 18 metres in height. Kingspan relied on that certificate for many years to sell the product. It made a calculated decision to use the LABC certificate to mask, or distract from, the absence of supporting test evidence.
¶2.36 When the BBA certificate was re-issued in 2013, Kingspan persuaded the BBA to include a statement that K15 complied with paragraph 12.7 of Approved Document B, which wrongly implied that it was a product of limited combustibility.
¶2.37 When it did return to carrying out tests on systems incorporating K15, Kingspan did not use the product currently on the market but used modified or trial versions. It dishonestly relied on the results of those tests to support the sale of K15 for use on buildings over 18 metres in height and continued to do so until October 2020.
¶2.38 Kingspan's claim that K15 met the requirements for Class 0 was based on a test of the foil facer alone and was disingenuous.
¶2.39 Kingspan cynically exploited the industry's lack of detailed knowledge about BS 8414 and BR 135 and relied on the fact that an unsuspecting market was very likely to rely on its own claims about the product, not least because the BBA certificate directed the buyer to consult Kingspan in relation to its use on buildings over 18 metres in height.
Siderise
¶2.40 Siderise manufactured the Lamatherm cavity barriers used in the refurbishment. Although there is no evidence of any dishonesty on its part, some aspects of its marketing materials gave cause for concern. It also supplied cavity barriers for use in voids larger than those for which they had been tested.
The British Board of Agrément
¶2.41 The British Board of Agrément (BBA) is a commercial organisation that certifies the compliance of products with the requirements of legislation. It issued certificates of compliance in respect of one of the insulation products used on Grenfell Tower, Kingspan K15, and the Reynobond 55 PE panels used as the rainscreen. Its certificates were accepted in the industry largely without question but its procedures were neither wholly independent nor rigorous and were not always rigorously applied.
15¶2.42 The dishonest strategies of Arconic and Kingspan succeeded in a large measure due to the incompetence of the BBA, its failure to adhere robustly to the system of checks it had put in place, and an ingrained willingness to accommodate customers instead of insisting on high standards and adherence to a contract that was intended to maintain them. As a result of systemic shortcomings and inadequate levels of competence and technical expertise among its staff, its scrutiny of the fire performance of K15 and Reynobond 55 PE was seriously deficient and the certificates it produced for those products were misleading.
¶2.43 The underlying problem was that the BBA failed to manage the conflict between the need to act as a commercial organisation in order to attract and retain customers and the need to exercise a high degree of rigour and independence in its investigations in order to satisfy those who might consider relying on its certificates. It accepted for inclusion in certificates forms of wording proposed by manufacturers that were wrong and misleading. Its lack of robust processes and reluctance to enforce the terms of its contracts enabled it to become the victim of dishonest behaviour on the part of unscrupulous manufacturers.
¶2.44 So far as Reynobond 55 PE was concerned, the certificate issued by the BBA in 2008 contained false statements, including that the product "may be regarded as having a Class 0 surface". The BBA accepted the results of tests carried out on a different product. It failed to take advice from BRE when drafting the certificate. It completed and approved periodic reviews and re-issued the certificate without having received any new information, despite having asked Arconic repeatedly to provide it. It failed to suspend or withdraw the certificate in response to Arconic's failure to co-operate.
¶2.45 Until December 2013 the BBA effectively allowed the contents of the certificates relating to Kingspan K15 to be dictated by Kingspan itself, including the requirement to seek advice from Kingspan in relation to the use of the product on buildings over 18 metres in height. The BBA did not assess any aspect of the product's manufacture, testing or fire performance before it issued the certificate. It did not obtain any test data relating to K15 before it issued a certificate containing a statement that the product had been classified as national Class 0, since none existed. It ought to have known that the statement in the revised certificate issued in July 2013 implying that K15 was a material of limited combustibility was false because K15 was a phenolic foam product.
Local Authority Building Control
¶2.47 The LABC must take its share of the blame for the acceptance by the market of Celotex RS5000 and Kingspan K15 for use on buildings over 18 metres in height. There was a complete failure on the part of the LABC over a number of years to take basic steps to ensure that the certificates it issued in respect of them were technically accurate.
¶2.48 The LABC was vulnerable to manipulation because its processes were not implemented rigorously enough. The task of producing an initial assessment should not have been given to building control officers, who did not have the degree of knowledge and experience necessary to make an informed assessment of the product in question, and those who carried out the second stage review were not always competent to do so and in some cases did not take the necessary degree of care.
16¶2.49 Over a period of some years the LABC's certificates relating to Kingspan K15 and Celotex RS5000 contained misleading statements about their fire performance and about the suitability of both products for use in the external walls of buildings over 18 metres in height. Despite warnings from various quarters, the LABC failed to scrutinise properly the claims made for the products by the manufacturers and instead adopted uncritically the language they suggested. In short, it was willing to accommodate the customer at the expense of those who relied on the certificates. As a result, the LABC was also the victim of dishonest behaviour on the part of unscrupulous manufacturers.
The National House Building Council
¶2.50 The National House Building Council (NHBC) employed a large number of Approved Inspectors through whom it provided building control services to a large part of the housing construction industry. It also wielded considerable influence on the industry through its membership of the Building Control Alliance, a body established in 2008 to promote the role of building control bodies, and its publication of guidance notes. However, it failed to ensure that its building control function remained essentially regulatory and free of commercial pressures. It was unwilling to upset its own customers and the wider construction industry by revealing the scale of the use of combustible insulation in the external walls of high-rise buildings, contrary to the statutory guidance. We have concluded that the conflict between the regulatory function of building control and the pressures of commercial interests prevents a system of that kind from effectively serving the public interest.
The Building Research Establishment
¶2.51 BRE played an important part in enabling Celotex and Kingspan to market their products for use in the external walls of buildings over 18 metres in height. BRE's systems were not robust enough to ensure complete independence and the necessary degree of technical rigour at all times. As a result, it sacrificed rigorous application of principle to its commercial interests. From 2004 it had engaged in discussions with Kingspan about the steps it might take to ensure that a system incorporating K15 met the performance requirements, and during the test of a system incorporating K15 in March 2014 it gave advice on its performance, including how the results of the test might be interpreted. It accepted the inclusion of magnesium oxide boards in the system incorporating RS5000 tested for Celotex in May 2014.
United Kingdom Accreditation Service
¶2.52 UKAS did not always follow its own policies and its assessment processes were lacking in rigour and comprehensiveness. Even when failings were identified they were not properly explored and opportunities to improve were not always taken. The process relied too much on the candour and co-operation of the organisations being assessed and too much was left to trust. UKAS should have taken a more searching, even sceptical, attitude to the organisations it accredited. Its powers to take action were surprisingly limited, with no powers of enforcement. The most it could do in response to unsatisfactory conduct was to suspend or withdraw accreditation.
17Part 4: The Tenant Management Organisation (Chapters 30 – 33)
¶2.53 The relationship between the TMO and its residents had been a troubled one for many years before the refurbishment of Grenfell Tower. Two independent reports in 2009 had drawn attention to numerous serious flaws in that relationship. The second of those reports identified governance, customer service, staff attitudes and a poor repairs service as constant themes of the investigation. It also found that the residents' lack of trust in the TMO lay at the heart of the problems. The reports made some 34 recommendations for change.
¶2.54 Despite those penetrating reports and the recommendations they contained, eight years later the TMO had shown little sign of any change and appeared to have learnt nothing about how to treat, or relate to, its residents.
¶2.55 We have concluded from all the evidence that from 2011 to 2017 relations between the TMO and many of the residents of Grenfell Tower were increasingly characterised by distrust, dislike, personal antagonism and anger. Some, perhaps many, occupants of the tower regarded the TMO as an uncaring and bullying overlord that belittled and marginalised them, regarded them as a nuisance, or worse, and failed to take their concerns seriously. For its part, the TMO regarded some of the residents as militant troublemakers led on by a handful of vocal activists, principally Edward Daffarn, whose style they found offensive. The result was a toxic atmosphere fuelled by mistrust on both sides.
¶2.56 In the end, however, responsibility for the maintenance of the relationship between the TMO and the Grenfell community fell not on the members of that community, who had a right to be treated with respect, but on the TMO as a public body exercising control over the building which contained their homes. The TMO lost sight of the fact that the residents were people who depended on it for a safe and decent home and the privacy and dignity that a home should provide. That dependence created an unequal relationship and a corresponding need for the TMO to ensure that, whatever the difficulties, the residents were treated with understanding and respect. We have concluded that the TMO failed to recognise that need and therefore failed to take the steps necessary to ensure that it was met.
¶2.57 However irritating and inconvenient it may at times have found the complaints and demands of some of the residents of Grenfell Tower, for the TMO to have allowed the relationship to deteriorate to such an extent reflects a serious failure on its part to observe its basic responsibilities.
18Part 5: The management of fire safety at Grenfell Tower (Chapters 34 – 46)
¶2.58 RBKC and the TMO were jointly responsible for the management of fire safety at Grenfell Tower. The years between 2009 and 2017 were marked by a persistent indifference to fire safety, particularly the safety of vulnerable people. We have examined in detail a wide variety of matters that have led us to that conclusion, the most prominent of which we set out here.
¶2.59 RBKC was responsible for overseeing the TMO's activities, not monitoring its operations on a day-to-day basis, but its oversight of the TMO's performance was weak and fire safety was not subject to any key performance indicator. The absence of any independent or rigorous scrutiny by RBKC of the TMO's performance of its health and safety obligations, and in particular its management of fire safety, was a particular weakness. RBKC took little or no account of an independent and highly critical review of fire safety carried out for the TMO in 2009. It did not even know about a further independent and highly critical report produced in 2013 because the TMO had failed to disclose it to RBKC.8 See Part 5 Chapter 37.
¶2.60 The TMO's performance of its own functions and the effectiveness of RBKC's oversight depended on full and candid reporting by the TMO's senior management to its board. Although there was a satisfactory system for senior management to report to the board and to RBKC, it did not operate effectively because of an entrenched reluctance on the part of the TMO's chief executive, Robert Black, to inform the board and RBKC's scrutiny committees of matters that affected fire safety. That failure was all the more serious because there were chronic and systemic failings in the TMO's management of fire safety of which the board should have been made aware. Robert Black consistently failed to tell either the board or RBKC of the LFB's concerns about the TMO's compliance with the Fire Safety Order or the steps taken to enforce it.
¶2.61 First, although in 2009 an independent fire safety consultant had recommended that a fire safety strategy be prepared, nothing was done until November 2013 and a strategy had still not been finally approved by the time of the Grenfell Tower fire.
¶2.62 Secondly, the TMO's only fire assessor for its entire estate, Carl Stokes, was allowed to drift into that role without any formal selection or procurement process. He had misrepresented his experience and qualifications (some of which he had invented) and was ill-qualified to carry out fire risk assessments on buildings of the size and complexity of Grenfell Tower, let alone to hold the entire TMO portfolio. As a result there was a danger that fire risk assessments would not meet the required standard.
¶2.63 Thirdly, although Mr Stokes' methods for carrying out fire risk assessments generally reflected the Health and Safety Executive's five steps for managing risks, the LGA Guide and PAS 79, they suffered from serious shortcomings. He often failed to check whether the TMO had taken action in response to risks he had identified in previous assessments. Despite the concerns expressed by the LFB about his competence, the TMO continued to rely uncritically on him, a situation which made the danger more acute in the absence of any arrangements for assessing the quality of his work.
19¶2.64 Fourthly, there was no adequate system for ensuring that defects identified in fire risk assessments were remedied effectively and in good time. The TMO developed a huge backlog of remedial work that it never managed to clear, a situation that was aggravated by the failure of its senior management to treat defects with the seriousness they deserved. Indeed, on one occasion senior management intervened to reduce the importance attached to the implementation of remedial measures. The demands of managing fire safety were viewed by the TMO as an inconvenience rather than an essential aspect of its duty to manage its property carefully.
¶2.65 Certain important features of the fire prevention measures at Grenfell Tower were not of an appropriate standard. For example, the new front doors installed by the TMO in 2011 and 2012 did not meet the fire resistance standards suggested by Approved Document B because the TMO had failed to specify the correct fire safety standard when ordering them.
¶2.66 Inspection and maintenance regimes affecting fire prevention systems did not reflect best practice and were inconsistently followed. Many self-closing devices on the front doors of flats in Grenfell Tower failed to work effectively and some were missing entirely. The TMO did not institute an effective inspection and maintenance programme for self-closing devices on entrance doors despite an Enforcement Notice issued by the LFB in late 2015 relating to ineffective door closers in another high-rise residential building it managed, Adair Tower, and a Deficiency Notice issued in 2016 in relation to Grenfell Tower itself on the same grounds.
¶2.67 Although the TMO had no obligation to produce a general evacuation plan, its Emergency Plan for Grenfell Tower was out of date and incomplete and did not reflect the changes brought about by the refurbishment. The TMO was well aware of that fact following a fire at Adair Tower in October 2015, but failed to address it. The absence of fire action notices in the tower was a prominent subject of complaints by residents and led to the issue of a Deficiency Notice in November 2016.
¶2.68 The Grenfell Tower fire revealed the importance of ensuring that the responsible person under the Fire Safety Order collects sufficient information about any vulnerable occupants to enable PEEPs to be prepared, when appropriate, and, in the event of a fire, appropriate measures to be taken to assist their escape. The TMO did take some steps to gather information of that kind, both before and during the refurbishment, but its data systems were not properly co-ordinated. Such information as was collected was not always used to revise its records, with the result that the spreadsheet available on the night of the fire was incomplete. The TMO's failure to collect such information amounted to a basic neglect of its obligations in relation to fire safety.
20Part 6: The refurbishment of Grenfell Tower (Chapters 47– 67)
¶2.69 In this Part we trace the origins of the refurbishment project and its relationship to the Kensington Aldridge Academy and Leisure Centre (KALC) projects. We describe the persons and organisations principally involved in the project and the legislative background against which the refurbishment was carried out. We also identify two significant problems relating to Approved Document B that in our view call for urgent attention. The first is the assumption that compliance with functional requirements B3 and B4 will provide a high degree of compartmentation, thus rendering evacuation of the building unnecessary. The second is the tension between functional requirements of the Building Regulations and the prescriptive language of the guidance and the propensity of many in the industry to treat the guidance as definitive.
¶2.70 We explain how the KALC project influenced the appointment of Studio E as architect and describe the way in which the TMO manipulated the procurement process to avoid having to put the contract for architectural services out to public tender. Artelia was appointed by the TMO as a consultant, having acted as employer's agent and quantity surveyor for the KALC project.
¶2.71 The initial plans for the refurbishment ran into difficulties because the estimated cost of the project produced by the principal contractor on the KALC project exceeded the budget by a significant margin. However, in about May 2013 the TMO's former emphasis on maintaining the momentum of the project changed to one of saving cost. That led in turn to a recommendation, reluctantly supported by Artelia, that a principal contractor should be appointed through a formal procurement process. Such a process was then implemented.
¶2.72 Although Rydon's tender was judged to be the most competitive, it still exceeded the TMO's budget. As a result, although the TMO had received advice from its lawyers that it would be improper to do so, it entered into discussions with Rydon before the procurement process had been completed leading to an agreement that, if Rydon were awarded the contract, it would reduce its price to an acceptable level.
¶2.73 Although Studio E had wanted to use zinc rainscreen panels, cost became an increasingly important consideration for the TMO and eventually an aluminium composite material (ACM), Reynobond 55 PE, was chosen, largely on the grounds of cost. Rydon was able to offer a substantial saving through the use of ACM panels as a result of its relationship with its intended cladding sub-contractor, Harley.
¶2.74 The choice of combustible materials for the cladding of Grenfell Tower resulted from a series of errors caused by the incompetence of the organisations and individuals involved in the refurbishment. Studio E, Rydon and Harley all took a casual approach to contractual relations. They did not properly understand the nature and scope of the obligations they had undertaken, or, if they did, paid scant attention to them. They failed to identify their own responsibilities for important aspects of the design and in each case assumed that someone else was responsible for matters affecting fire safety. Everyone involved in the choice of the materials to be used in the external wall thought that responsibility for their suitability and safety lay with someone else.
21¶2.75 None of those involved in the design of the external wall or the choice of materials acted in accordance with the standards of a reasonably competent person in their position. They were not familiar with or did not understand the relevant provisions of the Building Regulations, Approved Document B or industry guidance. Studio E demonstrated a cavalier attitude to the regulations affecting fire safety and Rydon and Harley relied on their previous experience rather than on any technical analysis or expertise. The risks of using combustible materials in the external walls of high-rise buildings were well known and they should have been aware of them.
¶2.76 RBKC building control did not properly scrutinise the design or choice of materials and failed to satisfy itself that on completion of the work the building would comply with the requirements of the Building Regulations.
¶2.77 Exova was instructed by Studio E on behalf of the TMO to prepare a fire safety strategy for the building in its refurbished form. A draft was prepared but never completed. In particular, it did not include an analysis of the external wall or its compliance with functional requirement B4(1) of the Building Regulations.
¶2.78 Although our criticisms are directed principally towards Studio E, Exova, Rydon, Harley and RBKC building control, the TMO must also bear a share of the blame for the disaster because it failed to ensure that the position of Exova was clarified after Rydon had been appointed and that the fire safety strategy was completed.
¶2.79 As architect Studio E was responsible for the design of the external wall and for the choice of the materials used in its construction.9 See generally Part 6 Chapter 63. Although the TMO as the client wanted to reduce the cost by using ACM rainscreen panels, it was the responsibility of Studio E to determine whether the use of such material would enable the building to comply with functional requirement B4(1) of the Building Regulations and advise the TMO accordingly. Its failure to recognise that ACM was dangerous and to warn the TMO against its use represented a failure to act in accordance with the standard of a reasonably competent architect. It also failed to recognise that Celotex insulation was combustible and not suitable for use on a building over 18 metres in height in accordance with the statutory guidance. Studio E therefore bears a very significant degree of responsibility for the disaster.
¶2.80 We have identified many other respects in which Studio E failed to meet the standards of a reasonably competent architect, of which the following are the most significant. It failed to ensure that Exova completed the fire safety strategy for the refurbished building or advise Rydon and the TMO that it should be required to do so. It failed to understand that it was responsible for design work carried out by sub-contractors and so did not check Harley's designs to ensure that on completion the building would comply with the Building Regulations. It did not devise a proper cavity barrier strategy or check Harley's designs for the cavity barriers and it failed to produce detailed drawings of the window reveals or to notice that the materials specified for the window infill panels were unsuitable.
¶2.81 Exova also bears considerable responsibility for the fact that Grenfell Tower was in a dangerous condition on completion of the refurbishment.10 See generally Part 6 Chapter 54. Our most serious criticism is that it failed to produce a final version of the fire safety strategy for the refurbished building and that it failed either to draw that fact to the attention of the design team or to warn it about the potential consequences. None of those responsible for drafting the fire safety strategy visited Grenfell Tower; the only site visit by a member of Exova's staff took place at a preliminary stage. Exova's attitude was wholly inconsistent with the careful approach to matters affecting the safety of life to be expected of a reasonably competent fire engineer.
22¶2.82 We consider that the principal contractor, Rydon, also bears considerable responsibility for the fire.11 See generally Part 6 Chapter 64. It gave inadequate thought to fire safety, to which it displayed a casual attitude throughout the project and its systems for managing the design work did not ensure that its sub-contractors and consultants properly understood their different responsibilities. Rydon itself did not understand where responsibility for individual decisions lay and as a result it failed to co-ordinate the design work properly.
¶2.83 Rydon had an inexperienced team on the refurbishment that did not have sufficient knowledge of the Building Regulations or Approved Document B. It relied entirely on its cladding sub-contractor, Harley, to draw its attention to any errors in the design, but it did not specifically ask Harley to assess Studio E's work. It failed to take proper steps to investigate Harley's competence and ensure that it was competent to undertake the work and capable of providing the services required of it. It was complacent about the need for fire engineering advice and took the decision not to retain Exova without consulting the TMO, Studio E or Artelia. Its understanding of the work already carried out by Exova was superficial; as a result, it failed to realise that the fire safety strategy had not been completed.
¶2.84 Harley itself failed in many respects to meet the standards to be expected of a reasonably competent cladding contractor and it too bears a significant degree of responsibility for the fire.12 See generally Part 6 Chapter 65. It did not concern itself sufficiently with fire safety at any stage of the refurbishment and appears to have thought that there was no need for it to do so, because others involved in the project, and ultimately building control, would ensure that the design was safe. It failed to ask the kind of questions about the materials being considered that a reasonably competent cladding contractor would have asked. It was induced to buy Reynobond 55 PE panels partly by its existing relationship with Arconic and the cladding fabricator, CEP Architectural Facades, with which it was able to negotiate a favourable price. Its staff were unaware of the requirements of the Building Regulations relating to fire safety, the guidance in Approved Document B or industry guidance and did not understand the underlying testing regime.
¶2.85 Although Celotex RS5000 (as opposed to Celotex FR5000) had not been specified, Harley accepted it for use on the tower without enquiring in any detail whether it could be safely used and did not ask any of the other members of the design team that question before doing so. Its design for the cavity barriers was incomplete and did not comply with the guidance in Approved Document B.
¶2.86 RBKC's building control department failed to perform its statutory function of ensuring that the design of the refurbishment complied with the Building Regulations.13 See generally Part 6 Chapter 62. It therefore bears considerable responsibility for the dangerous condition of the building immediately on completion of the work. The surveyor responsible for the refurbishment was overworked, inadequately trained and had a very limited understanding of the risks associated with the use of ACM panels. He failed to obtain full information about the construction of the external wall at the stage of the full plans application and did not ask whether Exova had provided a completed fire safety strategy. He knew that ACM was to be used as the rainscreen but paid little or no attention to the BBA certificate for Reynobond 55 PE. He failed to recognise that Celotex RS5000 insulation was not a material of limited combustibility and, if he looked at any information about it, he simply accepted the assertion that it was suitable for use on tall buildings. He failed to consider whether the external wall system proposed for Grenfell Tower was the same as that tested by Celotex and said to support the use of RS5000.
23¶2.87 The TMO must also take a share of the blame for the disaster.14 See generally Part 6 Chapter 66. As the client it failed to take sufficient care in its choice of architect and paid insufficient attention to matters affecting fire safety, including the work of the fire engineer.
24Part 7: Replacement of the gas riser (Chapter 68)
¶2.88 This short chapter describes the work carried out in 2016 and 2017 to replace one of the six gas risers in Grenfell Tower that was suffering from corrosion. There were defects in the design and execution of the work, to which we draw attention. The work had not been completed by the time of the fire, but neither the defects we have identified nor the failure to have completed the work contributed to the fire.
¶2.89 On the night of the fire it was not possible to find the two pipeline isolation valves designed to enable the supply of gas to the tower to be shut off quickly, almost certainly because they had been covered over in the course of landscaping work. However, that did not affect the course of events surrounding the fire because burning debris falling on the east side of the tower would have prevented access to them.
25Part 8: The London Fire Brigade (Chapters 69 – 83)
¶2.90 The Lakanal House fire in July 2009 should have alerted the LFB to the shortcomings in its ability to fight fires in high-rise buildings that revealed themselves once more at Grenfell Tower on the night of 14 June 2017. Those shortcomings could have been made good if the LFB had been more effectively managed and led. In particular, it should have responded more effectively to its experience at Lakanal House and made better use of the knowledge it had gained of the dangers posed by modern materials and methods of construction. Importantly, it failed to ensure that in the years immediately preceding the Grenfell Tower fire regular training of a suitable kind was provided to its control room operators on handling many fire survival guidance calls concurrently and on their duties more generally. Senior managers at the LFB failed to take steps to ensure that its arrangements for handling fire survival calls reflected national guidance.
¶2.91 Those failures were attributable to a chronic lack of effective management and leadership, combined with an undue emphasis on process. Senior officers were complacent about the operational efficiency of the brigade and lacked the management skills to recognise the problems or the will to correct them. Those managerial weaknesses were partly the result of an historic failure to integrate the operational departments and the departments responsible for support functions, in particular the control room. There was a tendency to treat problems of which managers became aware as undeserving of change or too difficult to resolve, even when they concerned operational or public safety.
¶2.92 Those failures were compounded by an entrenched but unfounded assumption that the Building Regulations were sufficient to ensure that external wall fires of the kind that were known to have occurred in other countries would not occur in this country. After the Lakanal House fire senior officers recognised that compliance with the regulations could not be guaranteed, but no one appears to have thought that firefighters needed to be trained to recognise and deal with the consequences.
¶2.93 The main failings on the part of the LFB that led to the shortcomings identified in the Phase 1 report included a failure to identify training needs combined with a system for commissioning new training packages that was cumbersome and slow. Incident command training was poorly devised and was not effectively delivered; inadequate provision was made for refresher training and regular assessment.
¶2.94 The LFB failed to ensure that the knowledge of the dangers presented by the increasing use of combustible materials, in particular the risk of external fire spread and the resulting loss of compartmentation, held by some specialist officers was shared with the wider organisation and reflected in training, operational policies and procedures. Firefighters were not given proper training or guidance on how to carry out inspections of complex buildings and there were no effective arrangements for sharing information about risks posed by particular buildings. Internal recommendations for improving the inspection of high-rise residential buildings were not implemented.
¶2.95 The policy on high-rise firefighting did not reflect national guidance and senior management failed to recognise that producing contingency plans for a full evacuation and training firefighters to implement them was an essential aspect of fighting fires in high-rise buildings.
26¶2.96 One significant shortcoming was a failure to recognise the possibility that in the event of a fire in a high-rise residential building a large number of calls seeking help, both from within and outside the building, might be generated. The LFB failed to take any steps to enable it to respond effectively to that kind of demand. As a result, when faced with a large number of calls about people needing to be rescued from Grenfell Tower, both those in the control room and those responsible for handling that information at the fireground were forced to resort to various improvised methods of varying reliability to handle the large amount of information they received.
¶2.97 The senior officers responsible for the control room understood the need to give priority to training staff in handling fire survival guidance calls, but in the years between 2010 and 2017 no structured or regular refresher training in handling fire survival guidance calls was designed or delivered to control room staff. Such training as was provided did not reflect national guidance in some respects; nor did it respond to the experience of those control room officers who had been on duty at the time of the Lakanal House fire. The failures in the effective functioning of the control room were due in a large measure to weak management over the preceding years combined with sporadic and ineffectual oversight by senior officers.
¶2.98 The communication equipment in use at the time of the Grenfell Tower fire proved to function inadequately in a high-rise building constructed largely of reinforced concrete. That was a well known problem but nothing had been done to alleviate it and firefighters were not trained to recognise and respond to it. The LFB's approach was to do its best with what it had available. As a result, it failed to make sufficient efforts to modernise its equipment, thereby significantly impairing its operational efficiency. The LFB's policies did not contemplate a widespread loss of communications or provide guidance on how it could effectively be restored.
27Part 9: The deceased (Chapters 84 – 97)
¶2.99 The detailed description of the events of 14 June 2017 contained in the Phase 1 report places us in a good position to make comprehensive findings about the circumstances in which the deceased met their deaths. Although it is for the coroner to decide whether she should adopt our findings as sufficient to enable her to discharge her responsibilities, we hope that she will be able to do so and thus spare the bereaved the distress of a further investigation.
¶2.100 We begin this Part with a general introduction followed by a description of the painstaking methods adopted to recover and identify the remains of the individual deceased. In that context we refer to the work of the teams of forensic archaeologists, forensic anthropologists and forensic pathologists, as well as other experts and police disaster victim identification officers and licensed search officers. We also describe in general terms the evidence given by Professor David Purser CBE BSc PhD DipRCPath, an expert on toxicology.
¶2.101 We devote a separate chapter of this Part to each floor on which people died. After a general description of the circumstances affecting that floor, our findings deal in turn with each of those who died on, or fell from, that floor. In the case of those who died on the stairs we have described the circumstances relating to the floor on which their flat was located. In each case we give a brief description of the deceased before describing the immediate circumstances in which he or she died.
¶2.102 Although the evidence was sometimes rather confused, we have been able to make findings about emergency calls made by those who were trapped, the transmission of information from the LFB control room to the incident ground and thence to the bridgehead and the deployment of firefighters in response. To the extent possible we have made what we consider to be reliable findings about the time of death in each case, although in many cases there is inevitably a large measure of uncertainty. In the light of the expert evidence we are able to make findings about the cause of death, including findings that all those whose bodies were destroyed by the fire were dead or unconscious when the fire reached them.
28Part 10: Response and recovery (Chapters 98 – 107)
¶2.103 In the first week after the fire at Grenfell Tower the response of the government and RBKC was muddled, slow, indecisive and piecemeal. RBKC's systems and leadership were wholly inadequate to the task of handling an incident of such magnitude and gravity, involving, as it did, mass homelessness and mass fatalities. The resilience machinery in London and within central government was not flexible enough and took too long to move into action.
¶2.104 Certain aspects of the response demonstrated a marked lack of respect for human decency and dignity and left many of those immediately affected feeling abandoned by authority and utterly helpless. RBKC should have done more to cater for those from diverse backgrounds, in particular those many residents of the Muslim faith who were observing Ramadan at the time. They were left feeling that the council had no regard for their cultural and religious needs. For many, their only source of support was local voluntary organisations, which moved in to help and provide for basic needs where those in authority had failed. Many who had particular religious, cultural or social needs suffered a significant degree of discrimination in ways that could and would have been prevented if the guidance had been properly followed.
¶2.105 The response to the disaster was inadequate principally because RBKC did not have an effective plan to deal with the displacement of a large number of people from their homes and such plan as it did have did not make effective use of the TMO. It had made no contingency arrangements for obtaining a large amount of emergency accommodation at short notice and had no arrangements for identifying those who had been forced to leave their homes or for communicating with them. Arrangements for obtaining and disseminating reliable information were also lacking.
¶2.106 One reason for the lack of effective plans was that RBKC had failed to train its staff adequately. They did not have a sufficient understanding of the importance of resilience or sufficient commitment to it. Exercises had not been held regularly and staff had not been required to attend the training sessions run by the London Resilience Group. Deficiencies that were well known to senior management had not been corrected.
¶2.107 Over a number of years, RBKC had allowed the capacity of its staff to respond to major emergencies to decline. There had been clear warnings to senior management that it did not have enough trained staff to enable it to carry out its responsibilities as a Category 1 responder and that contingency plans had not been practised enough. As a consequence, RBKC lacked the people it needed to respond to the fire effectively, both for the purposes of staffing the borough emergency communication centre and to deal with those who needed help. It was therefore ill-equipped to deal with a serious emergency. None of that was due to any lack of financial resources.
¶2.108 RBKC's chief executive, Nicholas Holgate, was not capable of taking effective control of the situation and mobilising support of the right kind without delay. He had no clear plan and did not receive all the information he needed. He was not well suited to dealing with the crisis that was unfolding in front of him and lacked a strong group of officers to whom he could delegate responsibility for some aspects of the response. He was reluctant to take advice from those with greater experience and was unduly concerned for RBKC's reputation.
29¶2.109 RBKC had failed to integrate the TMO into its emergency planning. It should have realised that the TMO's knowledge of its buildings and their occupants could play an important part in the response to any disaster affecting any part of its housing stock.
¶2.110 The arrangements designed to promote the resilience of London as a whole did not provide for an experienced leader to take over the direction of the response to a disaster that had occurred within the confines of a single borough except by agreement with the chief executive of that borough. In the event, Nicholas Holgate was persuaded under pressure from a senior government official to hand over control to John Barradell, but not until two days after the fire.
¶2.111 The training of resilience personnel in London was piecemeal and not co-ordinated; it was also voluntary and not subject to any external assessment or validation. That contributed to a situation in which the capacity of individual local authorities to respond to emergencies varied between boroughs.
¶2.112 The government began monitoring the response to the fire at an early stage, but its ability to take effective steps to provide practical assistance was undermined by a shortage of reliable information and by the restricted nature of its powers to intervene. The Civil Contingencies Act 2004 did not give it the power to take control of the response without invoking the powers under sections 5 or 7. Those powers are far-reaching but cumbersome in operation and not well suited to taking control of the response when a local authority is failing.
¶2.113 The TMO attracted criticism from many quarters, but in relation to its response to the fire much of it was unfair. Although its staff should have received more training in how to respond to an emergency, they threw themselves into the response and helped to provide support, insofar as they were equipped to do so. Some of those within government who criticised the TMO did not properly understand its position or the scope of its powers, and it was unfairly tainted by association with RBKC. Many of the difficulties encountered in returning residents to flats in the Walkways were not of its making. The TMO teams that went to some of the rest centres on 14 June 2017 to give what help they could are to be commended for their willingness to become directly involved and for the efforts they made at what was a very difficult time.
¶2.114 Those who emerge from the events with the greatest credit, and whose contribution only emphasised the inadequacies of the official response, are the members of the local community. With the support of local voluntary organisations, they provided support in the hours immediately following the fire when the authorities were conspicuous by their absence. Indeed, one of RBKC's failings was to make too little use of the local voluntary organisations and to fail to have adequate standing arrangements to enable them to be called on in the event of a major emergency.
30Part 11: Matters outstanding from Phase 1 (Chapters 108 – 110)
¶2.115 Two matters remained outstanding from Phase 1. The first concerned the respective contributions to the fire made by the ACM rainscreen panels and the polyisocyanurate and phenolic insulation boards. The second concerned the mechanism by which the fire had escaped from the kitchen of Flat 16 into the external wall of the building.
¶2.116 In a series of experiments designed by Professor Bisby and Professor Torero and carried out at Edinburgh University by Professor Bisby and his colleagues the ACM panels were shown to have been by far the largest potential contributor to energy release in the external wall system at Grenfell Tower. Celotex RS5000 (a polyisocyanurate foam) and Kingspan K15 (a phenolic foam) both had a much lower heat release rate per unit area.
¶2.117 The experiments showed that the presence of a cavity is not by itself sufficient to cause a fire in the rainscreen panels to develop to full involvement. Insulation also needs to be present, either to retain energy in the system or to burn and contribute additional energy. Even non-combustible insulation in the form of mineral wool resulted in the growth of the fire to full involvement of the ACM panel. The method of fixing the panels has a significant effect on the way in which they perform in a fire. Panels in cassette form behave far worse than panels in riveted form.
¶2.118 The experimental work confirms that the principal factor which led to the rapid growth of the fire was the presence of unmodified polyethylene in the cores of the ACM panels rather than the insulation, although the presence of the insulation and its ability to retain heat was a decisive factor in promoting the growth of the fire.
¶2.119 The second matter outstanding concerned the mechanism by which the fire had escaped from the kitchen of Flat 16 into the external wall of the building. A reconstruction carried out by BRE in May 2019 had led it to conclude that the mechanism was different from that identified by Professor Bisby and Professor Torero. The chairman therefore indicated that the findings expressed in the Phase 1 report would remain provisional until they had had a better opportunity to study the report of the reconstruction. Having done so, Professor Bisby and Professor Torero both concluded that the reconstruction had not been truly representative of the fire that occurred on 14 June 2017 and adhered to their original opinions. We therefore confirm the findings made in the Phase 1 report.
31Part 12: The fire testing regime (Chapter 111)
¶2.120 In the years leading up to the Grenfell Tower fire test methods available for determining the reaction to fire of materials, products and even external wall systems did not provide designers with the information needed to assess the risk of fire spreading across the external wall of a building. Moreover, the statutory guidance on complying with functional requirement B4(1) of the Building Regulations was fundamentally defective.
¶2.121 The use of Class 0 as a standard of fire performance for products to be used on the external wall of tall buildings was wholly inappropriate. Neither of the main British Standard tests relevant to that classification reflected the development of a fire on the outside of a building or provided the information needed to assess how an external wall incorporating the product would perform in a fire. The European classifications based on the single burning item test were of similarly limited assistance in assessing the fire performance of external wall systems.
¶2.122 The performance criteria for large-scale system tests in BR 135 were inadequate, in particular because they could not be clearly linked to the functional requirements in the Building Regulations or the guidance in Approved Document B. They were also directed too much to the spread of flame through cavities and contained no criteria for mechanical performance. The BS 8414 test itself provided limited information relevant to assessing the rate at which fire was likely to spread over an external wall. Critically, an external wall system that met the criteria in BR 135 could still allow fire to spread through it and beyond the compartment of origin at a rate that was incompatible with a stay put strategy. Accordingly, although failure to meet the performance criteria in BR 135 would demonstrate that a system was unlikely to comply with functional requirement B4(1) of the Building Regulations, the converse was not necessarily true. A system might meet the performance criteria of BR 135 and yet fail to comply with the functional requirement.
¶2.123 There was a widespread but erroneous assumption that, if an external wall system tested in accordance with BS 8414 met the performance criteria in BR 135, the building would comply with functional requirement B4(1) without any need to analyse the information obtained from the test or the conditions likely to be encountered in use. Approved Document B helped to perpetuate that assumption, not least by failing to make it clear that the results of the test always had to be analysed in conjunction with all other available information in order to understand the way in which the wall was likely to behave when exposed to the flames and heat of a fully developed compartment fire. The method adopted in BR 135 for assessing compliance was too simplistic. It provided a simple pass or fail result, when the results of the test required a degree of interpretation beyond the competence of most in the industry.
32Part 13: The response of other countries (Chapter 112)
¶2.124 We have referred in the course of our report to fires that have occurred in other tall buildings around the world, principally as a result of the use of ACM rainscreen products. With the help of Professor Torero, who has extensive knowledge of the regulatory regimes in many other jurisdictions, we have examined the response of other countries to the danger posed by combustible cladding in order to see what we can learn from their experience.
¶2.125 In this chapter we describe the approaches to the problem that have been adopted in countries from the United States through Europe and the Middle East to Australia. Some countries have adopted a prescriptive approach to regulating construction, which is fundamentally different from a regime based on functional requirements of the kind that applies in this country and is therefore less useful as a model. Others, however, in particular Australia, have adopted functional requirements similar to our own and provide an example from which we can learn.
Part 14: Recommendations (Chapter 113)
¶2.126 We are invited by our Terms of Reference to make recommendations that we have reason to think will help prevent another disaster of the kind that overwhelmed Grenfell Tower and improve the ability of the authorities to respond to emergencies when they occur, as inevitably they will.
¶2.127 We do not think it would be appropriate or helpful to attempt to summarise those recommendations here because to do so would inevitably fail to do them justice. We should make it clear, however, that they are all firmly grounded in the evidence we have received and the findings we have made.
33Part 2: The path to disaster
35Chapter 3: Introduction to Part 2
¶3.1 One of the primary purposes of our Inquiry has been to find out how a relatively modern building like Grenfell Tower could have fallen prey to a fire of such magnitude and ferocity as to destroy it almost completely, taking the lives of so many of its occupants. Although a disaster of that kind may appear to some to have come out of the blue, there is inevitably an important history of events that provide not only the context in which it occurred but also part of the explanation for it. In this Part of our report we describe the background to the fire and identify the main events that set the scene for what later occurred.
¶3.2 In a modern society one of the functions of the government is to introduce and enforce effective measures to ensure that the built environment is reasonably safe for those who live and work in it. For many years building work in England and Wales has been subject to regulation and in his Phase 1 report the chairman provided a summary of the primary and secondary legislation affecting the construction and the later refurbishment of Grenfell Tower and the statutory guidance relating to it. If it is to be effective, however, legislation and guidance of that kind must be kept under review and revised from time to time to ensure that it responds to developments in materials and methods of construction. In this Part of our report we examine the part played by the government and certain other organisations in responding to developments in the construction industry and the growing body of knowledge about the behaviour of certain materials, particularly when exposed to fire. We also examine the broader approach of the government to intervening in aspects of commercial activity in order to protect its citizens from the harmful effects of fire.
¶3.3 This Part of our report complements Part 3, in which we examine the way in which some of the products used in the refurbishment of Grenfell Tower were tested and marketed. The conclusion we have drawn from the facts described in Parts 2 and 3 is that in this case there were serious failures in the system designed to keep people safe. We describe those failures in Chapter 29.
37Chapter 4: The development of the regulatory regime
Introduction
¶4.1 In Chapter 5 of the Phase 1 report the chairman briefly described the regulatory context in which the original construction of Grenfell Tower in the early 1970s and the refurbishment carried out between 2012 and 2016 each took place.15 Phase 1 Report Volume I paragraphs 5.1 - 5.7. In this chapter we set out in more detail the key changes which occurred in the regulatory regime in the 20th century and which help to explain the nature of that regime at the time Grenfell Tower was refurbished. In Chapter 5 we have described the reaction to fire tests which supported the regulatory framework relating to the fire safety of external walls in the years leading up to the Grenfell Tower fire and in Chapter 6 we have set out how the requirements relating to the construction of external walls changed over time. Given the central role played by the external wall in the fire at Grenfell Tower, our summary of the legislative context concentrates on the regulations relating to the construction of the external walls of tall buildings, although we have also touched on other important aspects, where relevant.
¶4.2 In producing our summary we have had the benefit of reports from two of the experts instructed to assist the Inquiry. In his report entitled Legislation, Guidance and Enforcing Authorities Relevant to the Fire Safety Measures at Grenfell Tower, dated March 2018, Colin Todd described the development of the two main branches of legislation dealing with fire safety in England and Wales, one directed to ensuring proper standards of construction, the other directed to ensuring fire safety in occupied buildings. In this chapter we concentrate on the first of those areas. The second is addressed in Chapter 13, in which we consider the Regulatory Reform (Fire Safety) Order 2005 (the Fire Safety Order) made under the Regulatory Reform Act 2001. In his report entitled Regulatory Testing and the Path to Grenfell, dated 10 November 2021, Professor Luke Bisby described the background to the fire testing regime which underpinned the Building Regulations 2010 in force at the time of the refurbishment.
¶4.3 In their reports Mr Todd and Professor Bisby have described the history of the legislation and the development of the tests by which it is supported. The relevant material is all available in its original form, whether that be primary or secondary legislation, approved documents or other publicly available standards, but in producing this summary we have been particularly assisted by the passages in their reports referred to in the footnotes.
Terminology
¶4.4 Before we begin discussing the development of the regulatory and testing regimes, it may be helpful to clarify two expressions, the meaning of which has sometimes not been clearly understood but which ought now to be firmly established. "Fire resistance" (which is always expressed as a period of time) describes the ability of an element of construction, such as a door, floor or wall, to withstand exposure to heat in a standard test without the occurrence of specific failure criteria set out in the test specification. The failure criteria relate to the ability of the element to resist the passage of flame or provide thermal insulation or, in the case of a loadbearing element, to maintain its ability to support a test load. "Reaction to fire" describes the behaviour of a material or product when exposed to heat in a standard test, such as the fire propagation test (BS 476-6), the surface spread of flame test (BS 476- 7) or the European single burning item test (BS EN 13823).
38Local Acts and Byelaws: prescriptive building regulation
¶4.5 For many years building work in England and Wales was regulated at a local level under a patchwork of local acts and byelaws.16 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/50} paragraph 228. Local byelaws were often based on model byelaws produced by central government, adapted as appropriate to accommodate local customs. Consequently, local authorities and municipal fire services created and enforced their own fire safety provisions and construction professionals had to adapt their work to meet local demands.17 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/50} paragraph 228.
¶4.6 In London, building legislation took the form of a series of London Building Acts.18 Todd {CTAR00000001/26} paragraphs 4.1.1 - 4.1.2. The London Building Acts 1930–1939 and associated byelaws were in force at the time Grenfell Tower was built.19 Phase 1 Report Volume I paragraph 5.1. The London Building Acts themselves gave local authorities powers to require fire safety measures to be put in place, without specifying any measures in detail,20 Todd {CTAR00000001/29} paragraph 4.2.1. but the byelaws made under them contained detailed requirements for the fire performance of roofs, externals walls and other elements of construction.21 Todd {CTAR00000001/28} paragraph 4.1.14. The design of buildings tended to follow local guidance, such as that published by the Greater London Council, or codes of practice, such as the British Standards Institution (BSI) Code of Practice CP3 1971, which was probably the guidance which most influenced the designer of Grenfell Tower.22 Phase 1 Report Volume I paragraph 5.1; Todd {CTAR00000001/29} paragraphs 4.2.1 - 4.2.3. In London guidance was issued by the Greater London Council, including guidance under section 20 of the London Building Act 1939, known as "section 20 guidance". Section 20 enabled the Council to require additional fire precautions in buildings with a storey or part of a storey more than 100 feet above ground.23 Todd {CTAR00000001/26} paragraph 4.1.6.
Creation of the first testing standard for building construction
¶4.7 In the early 20th century the Royal Institution of British Architects (RIBA) pressed for a standardised method of testing the reaction of construction products to fire. Practitioners were frustrated by the use of ill-defined terminology, with no universal agreement on what was meant by expressions such as "fire-resisting" or "incombustible", despite those terms appearing in legislation, including the London Building Acts.24 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/52} paragraphs 237 - 239. In 1929 RIBA urged the British Engineering Standards Association (which soon after became the British Standards Institution (BSI)) to produce standard definitions of reactions to fire and methods of assessing them. The outcome was the publication in 1932 of the first version of BS 476, entitled British standard definitions for fire-resistance, incombustibility and non-inflammability of building materials and structures (including methods of test).25 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/53} paragraphs 240 - 241. That original version of BS 476 contained four distinct testing methods, including a test for "incombustibility". The test involved heating a small sample of material to 750°C at the rate of 500°C per hour. If the specimen did not flame or exhibit what was described as "glowing combustion", it was regarded as non-combustible. The assessment of its performance was therefore purely visual.26 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/54} paragraph 248. The Fire Offices' Committee was established in 1868 by the major fire insurance companies.
39¶4.8 Although it was published in 1932, it was several years before BS 476 began to make its mark on regulations and guidance. Moreover, a new research facility was required to carry out the larger "fire resistance" tests then included in BS 476. It was constructed at Borehamwood, Watford, by the Fire Offices Committee.27 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/57} paragraph 252. A revised version of the London County Council Constructional Byelaws in 1938 made explicit reference to the recently published BS 476,28 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/57} paragraph 253. which was an important step for the construction industry. Previously a manufacturer would have had to lobby for its product to be included in an approved list of "fire-resisting" materials and then wait for the next revision of the legislation. However, the introduction of BS 476 enabled a product that had been tested and met the defined criteria to be used without further inquiry.29 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/57} paragraph 254.
State-sponsored fire research organisation
¶4.9 In 1944 the government decided to create an organisation to conduct research into aspects of the behaviour of fire and the response of materials to it, and so in January 1947 the Joint Fire Research Organisation was created, which brought together in a single organisation various disparate branches of fire safety research.30 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/60} paragraph 270.
The move towards functional requirements
¶4.10 From as early as the 1920s there had been a demand from the architectural profession for greater flexibility in the application of building legislation.31 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/51} paragraphs 236 - 238. In response, in 1936 the Building Research Board32 In 1917, the then Department of Scientific and Industrial Research proposed the creation of an organisation to investigate various building materials and methods of construction suitable for use in new housing following the First World War. In June 1920, the Building Research Board met for the first time – see https://bregroup.com/about-us/our-history. set out its vision for the replacement of the existing byelaws with legislation which described the result to be achieved without prescribing the means by which it was to be achieved.33 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/61} paragraph 275; Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/65} paragraph 304.
¶4.11 In the early 1950s the Department of Housing and Local Government in England (and the equivalent body in Scotland) created a new form of building regulation. It involved a new set of model byelaws for use by local authorities as precedents when drafting their own byelaws.34 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/61} paragraph 276. The model byelaws described in general terms certain requirements to be met by all buildings, together with certain "performance standards" that were deemed to achieve those requirements. In addition, a series of "deemed to satisfy" clauses were included under which materials meeting certain requirements were "deemed to satisfy" the requirements of the byelaws and were assumed to provide an acceptable standard of performance. The intention was that basic standards of safety would be maintained but that the legislation would be flexible enough to take account of developments in building materials, products and techniques.35 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/61-62} paragraph 277. Although the model byelaws did not apply in London, they marked an important shift in the way that fire safety in buildings was regulated.
40¶4.12 One effect of that change was that testing standards and codes of practice became relevant to compliance with legislative requirements. Once functional standards had been adopted, it became necessary to have a means of assessing whether the relevant standard had been reached and testing standards and codes therefore became increasingly important.36 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/62} paragraph 281. Furthermore, whereas previously a committee had decided which products could or could not be used in specific applications, the model byelaws allowed manufacturers and designers to demonstrate by reference to individual tests that products were suitable for use.37 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/65} paragraph 303.
¶4.13 In the late 1950s the Guest Committee38 This committee was established by the Secretary of State for Scotland in 1954 and was chaired by Mr C. W. G. Guest QC. It was tasked with examining the regulation of building in Scotland – see Hansard at https://hansard.parliament. uk/Commons/1954-01-27/debates/3119ce49-a62d-4264-8f21-12b3623be4d1/BuildingControl(InquiryCommittee). recommended that the patchwork of local building laws be replaced with a new national Building Act.39 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/65-66} paragraph 306. At the time there was a range of views about the extent to which functional standards ought to be underpinned by codes of practice or "deemed to satisfy" clauses that would demonstrate how compliance with the functional requirements could be achieved.40 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/66} paragraphs 307 – 314. Some, including RIBA and the British Research Station,41 In 1921 a central government-funded laboratory – the Building Research Station – was formed to carry out research work for the Building Research Board. envisaged a flexible approach, under which the link between functional requirements and technical standards was severed so that only the functional requirements were mandatory. There was a concern that performance standards could be overtaken by new ideas and technology and become as restrictive as the former byelaws. However, RIBA did recognise that complete flexibility could lead to inconsistency in the application of the legislation.42 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/66} paragraphs 308-309.
¶4.14 During the Second World War a method was developed for testing the effectiveness of "incombustible" products at resisting incendiary bombs. It was recognised that some materials which failed the incombustibility test could still afford a degree of protection against such bombs. That led to a series of full-scale tests in corridors lined with different types of wallboard, which in time evolved to become the BS 476-7 test for surface spread of flame.43 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/58} paragraphs 259-261. In 1953 BS 476 was revised to incorporate the test, which had been added as an appendix in 1945.44 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/62} paragraph 282. We describe the test in detail in Chapter 5.
The Building Regulations 1965
¶4.15 The Building Regulations 196545 {INQ00015096}. contained a mixture of functional requirements, performance standards and "deemed to satisfy" provisions. The provisions relating to fire performance were mostly statements of performance standards, with few statements of function.46 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/68} paragraph 318. Codes and standards became an important means by which innovation and flexibility were embedded in the new functionality-based system of building regulation, although many of the testing standards did not change at that time.47 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/68} paragraphs 321 - 323. Unlike the London Building Acts of the 1930s, the 1965 Regulations contained no requirements for means of escape in case of fire until they were amended in 1974, following a recommendation from the Holroyd committee (discussed below) that they should do so.48 Todd {CTAR00000001/39} paragraph 5.1.1. As noted further below, the Building Regulations did not apply to Inner London until January 1986.49 Todd {CTAR00000001/39} paragraph 5.1.2.
41¶4.16 The 1960s also saw the Building Regulations Advisory Committee (BRAC) expressing dissatisfaction with the binary nature of the existing BS 476 (1953) test for the combustibility of materials, since it was felt that relaxing the requirement for external walls and cladding to be non-combustible could sometimes be appropriate.50 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/69} paragraph 325. Innovations in building materials and techniques meant that a broader range of construction materials were becoming available, including plastics. The kinds of buildings that were being proposed were also changing and high-rise flats were becoming increasingly popular among architects and housing developers.51 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/61} paragraph 274. As we discuss further in Part 6, in the 1960s national Class 0 was introduced into the Building Regulations, which permitted non-combustible external wall products to be covered with a combustible surface and combustible products to be covered with non-combustible linings.52 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/70} paragraphs 328-333.
The Agrément Board (later the British Board of Agrément (BBA))
¶4.17 In 1964 BRAC suggested that a third-party organisation might provide approval for new building materials, products and methods.53 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/72} paragraph 339. It was recognised that a significant number of new materials and products were entering the building industry and it was difficult for building professionals to assess their performance in use.54 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/72} paragraph 339. Consequently, it was suggested that an independent third party might be created to approve materials and products, and in 1966 the Agrément Board was established for that purpose. The existing Building Research Station and Fire Research Station became the laboratories of the Agrément Board.55 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/72-73} paragraph 343. The Agrément Board issued its first certificate in January 1967.56 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/73} paragraph 347. In 1982, it was renamed the British Board of Agrément.57 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/92} paragraph 449.
Dissatisfaction
¶4.18 The new system of building regulation soon encountered a number of problems. In particular, the checks that had to be performed by local authorities were taking longer than under the old byelaws. As a result, in 1967 the Ministry of Housing and Local Government's own Building Legislation Committee recommended the establishment of a body to administer the regulations centrally. In particular, it advised that compliance with the regulations should be checked by an organisation large enough to have competent staff with the required range of skills, supported by a network of local enforcing officers.58 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/73} paragraph 348. RIBA also complained that the 1965 Building Regulations were complex and the language obscure; there were demands for regulations written in plain English with the use of diagrams to convey information more quickly.59 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/73} paragraph 349. There were also criticisms of the first BBA certificates and concerns were expressed by ministers that it was taking too long for the BBA to issue certificates.60 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/73-74} paragraph 349.
42¶4.19 During the 1970s revision of the Building Regulations brought more dissatisfaction, due to the number of documents to which reference had to be made to understand them. By 1971 there had been seven amendments to the regulations and they were reissued in full in 1972 and 1976.61 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/74} paragraph 350. By the late 1970s there were numerous proposals for reform and a degree of dissatisfaction with the BBA.62 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/74} paragraphs 351 – 352.
The Holroyd report
¶4.20 In May 1970 Sir Ronald Holroyd, chairman of the Parliamentary Fire Service Departmental Committee, delivered a report which had been commissioned by the Home Secretary.63 See Hansard https://hansard.parliament.uk/commons/1970-07-14/debates/f5a42851-fe75-4485-ad22- f3afb15db306/FireService (Departmental Committee). The primary focus of the report was the organisation of the UK's fire services, but he also addressed fire safety legislation and fire research.64 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/74} paragraphs 353 – 354. The Holroyd report65 Holroyd, Report of the Departmental Committee on the Fire Service {CTAR00000002}. recommended that fire safety regulation be divided into two main branches, one applying to new buildings and alterations to existing buildings and another applying to occupied buildings after construction or alteration. The committee recommended that enforcement of the second branch should be the responsibility of fire authorities, who should use the services of their fire brigades for that purpose.66 Todd {CTAR00000001/23} paragraphs 3.3-3.4. The concept of two branches of legislation, which for some time thereafter was known as the "Holroyd Divide", has largely been adopted in England and Wales from the time of its proposal.67 Todd {CTAR00000001/20} paragraph 3.6.
¶4.21 As a result of the Holroyd report, changes were made to the government's research capability. Accordingly, in 1972 the Building Research Station, the Fire Research Station and the Forest Products Research Laboratory were combined to create the Building Research Establishment (BRE).68 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/74-75} paragraph 355. In 1976 the Joint Fire Research Organisation was dissolved.69 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/74-75} paragraph 355.
¶4.22 The 1970s also saw the introduction of new fire tests and the relaxation of requirements relating to the construction of external walls.70 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/75-80} sections 10.2 and 10.3. In particular, research by the Joint Fire Research Organisation had shown that materials and products that achieved the same classification in the surface spread of flame test sometimes behaved very differently in 1/5th scale compartment tests.71 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/75} paragraph 356. A new test method was therefore developed which eventually became BS 476-6. It was introduced as a British Standard in 1968. We have described it in detail in Chapter 5.72 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/75} paragraph 359.
43Move to functionality-based building regulations
¶4.23 In December 1979, the Secretary of State at the Department of the Environment, Michael Heseltine, gave a speech to the National House Building Council (NHBC) in which he set out his vision for the reform of the system for regulating building work. He identified four criteria for his new system: (1) maximum self-regulation, (2) minimum government interference, (3) self-financing, (4) simplicity in operation. In February 1981 a White Paper on the future of building control in England and Wales was published.73 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/81} paragraph 385. At the time there was general agreement that the Building Regulations needed to be revised.74 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/81} paragraph 386.
¶4.24 The White Paper proposed that the functional requirements should be supported by a wide range of approved guidance, including British Standards Institution (BSI) standards and codes and Agrément certificates.75 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/81} paragraph 387. Part of the motivation for changing the system was the Secretary of State's conviction that local authority building control was attracting too much liability for defective buildings. He suggested that architects might themselves be allowed to certify that their plans met the functional requirements and that certification could be carried out by private bodies. He also suggested that the NHBC might become a private building control authority.76 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/82} paragraph 390.
The Building Act 1984, the Building Regulations 1985 and the Approved Documents
¶4.25 After much debate about the nature of the legislation required,77 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/82} paragraph 393. the Building Act 198478 {HOM00035068}. and the Building Regulations 198579 {INQ00015097}. were enacted. The new legislation resulted in a radical change to the system of building regulation in England and Wales.80 Todd {CTAR00000001/40} paragraph 5.1.8; Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/90} paragraphs 441 – 442. The new regulations extended to only 25 pages (in contrast to the 306 pages of the Building Regulations 1976).81 Todd {CTAR00000001/39-40} paragraphs 5.1.5 and 5.1.9. All technical requirements were eliminated from the regulations, which were now cast purely in functional form.82 Todd {CTAR00000001/40} paragraph 5.1.9.
¶4.26 The Building Regulations 1985 contained only four functional requirements in relation to fire safety, namely, means of escape, internal fire spread (surfaces), internal fire spread (structures) and external fire spread.83 Schedule 1 {INQ00015097/11-13}; Todd {CTAR00000001/40-41} paragraph 5.1.12. Requirement B4(1) relating to external fire spread provided that "The external walls of the building shall offer adequate resistance to the spread of fire over the walls … having regard to the height, use and position of the building".84 {INQ00015097/13}.
¶4.27 The Building Act 1984 gave legal status85 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/84} paragraphs 402 – 405. to Approved Documents, which were produced by the relevant government department responsible for the Building Regulations and contained guidance on the means by which, in the opinion of the Secretary of State, the functional requirements could be achieved.86 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/83} paragraph 400. In 1985 the first version of Approved Document B on fire safety was published.87 Todd {CTAR00000001/52} paragraph 5.2.4. In fact, the content of the new Approved Documents was remarkably similar to that of the previous regulations and in their first editions it was intended that the requirements should change more in form than content.88 Todd {CTAR00000001/42} paragraph 5.1.19; Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/83} paragraph 396. The performance standards defined in the new Approved Documents also remained largely unchanged from the pre-existing regulations.89 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/90} paragraph 441. There was a belief that, by moving them out of legislation and into statutory guidance, the Approved Documents could be revised more frequently to take account of innovation.90 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/83} paragraph 396. However, some mandatory measures remained, such as the requirement to follow the parts of CP3 Chapter IV dealing with means of escape.91 Todd {CTAR00000001/11} paragraph 2.26; Todd {CTAR00000001/42} paragraph 5.1.20; Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/83} paragraph 397.
44¶4.28 Unfortunately, many in the construction industry treated the Approved Documents as if they were prescriptive and many were confused about the difference between the regulations and the Approved Documents. It is still not uncommon for professionals in the construction industry to refer to the Approved Documents as if they were regulations. Indeed, we saw many examples of that during this Inquiry.92 Todd {CTAR00000001/42} paragraph 5.1.16.
¶4.29 The Building Act 1984 also allowed private persons and commercial bodies to carry out building control functions, subject to the Building (Approved Inspector etc.) Regulations 1985. Unlike local authorities they were not required to be non-profitmaking.93 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/83} paragraph 394.
¶4.30 Apart from the shift away from linking functional requirements to mandatory standards of performance, the Building Act 1984 and the Building Regulations 1985 did not introduce any fundamental changes to the testing standards which underpinned the approved documents, the majority of which were retained.94 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/90} paragraph 442. Since the standards of performance and tests previously applicable were no longer seen as constraints, the need to review and revise the tests regularly became less urgent. If a new product failed to meet the standard set out in the relevant approved document, the manufacturer or designer could simply look for other ways of demonstrating that its use would not prevent compliance with the functional requirements. Devising ways to comply with the Regulations without following the guidance in the Approved Documents was therefore not an exercise in finding loopholes; it was in accordance with the spirit of the new regulatory system.95 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/90} paragraphs 443 - 444.
¶4.31 Where the new, more flexible, regime might lead was not lost on some at the time. We were struck by the prescient opinion of H. L. Malhotra, a veteran of the Fire Research Station, who in 1986 wrote:
45"Historically over the last three centuries we have moved from strict constructional specifications to functional or semi-functional requirements with performance-oriented objectives as and when feasible. Rigid controls are being replaced progressively by a more flexible system which permits alternative solutions to be considered. The burden of responsibility is being shifted from the central or the local authorities to the individual or corporate designer/contractor for the adequacy of his system … It will be perhaps another 2 or 3 decades before the consequence of this approach can be seen."96 Malhotra, Fire Safety in Buildings {HOM00035070/15} paragraph 1.20.
The Building Regulations applied to London
¶4.32 In January 1986 the Building (Inner London) Regulations 1985 came into force. Thereafter the Building Regulations 1985 (with certain limited exceptions) applied to Inner London.97 Todd {CTAR00000001/38} paragraph 4.3.2. Building control remained the responsibility of the Greater London Council until its abolition by the Local Government Act 1985 on 1 April 1986, when the responsibility was transferred to the London Boroughs and the Corporation of the City of London.98 Todd {CTAR00000001/38} paragraph 4.3.2.
¶4.33 The Building (Inner London) Regulations 1985 also introduced in London the Building (Approved Inspectors etc.) Regulations 1985, under which approval of plans under the Building Regulations could be granted by an approved inspector, rather than the building control department of a local authority. However, approval of work under section 20 of the 1939 Act (relating to fire safety in tall buildings) continued to rest solely with the local authority until repeal of section 20 by the Building (Repeal of Provisions of Local Acts) Regulations 2012 in January 2013.99 Todd {CTAR00000001/38} paragraph 4.3.3.
The Building Regulations 1991
¶4.34 The Building Regulations 1991 came into force in June 1992. They revoked and replaced, with amendments, the Building Regulations 1985.100 Todd {CTAR00000001/43} paragraph 5.1.26. The main changes brought about by the 1991 Regulations were that functional requirement B1 relating to means of escape was no longer mandatory and a new functional requirement B5 relating to access and facilities for the fire service was introduced.101 Todd {CTAR00000001/43} paragraph 5.1.27.
¶4.35 Although functional requirements B1 to B4 remained largely unchanged, some small changes were made to their wording and in some places the word "adequate" was either added or removed.102 Todd {CTAR00000001/43-44} paragraph 5.1.28. In the case of functional requirement B4, the word "adequately" was removed, so that it read "The external walls of the building shall resist the spread of fire …".
¶4.36 The 1991 Regulations were amended on a number of occasions before being revoked by the Building Regulations 2000.103 Todd {CTAR00000001/45} paragraph 5.1.29. During that time the only changes affecting fire safety were those made by the Building Regulations (Amendment) (No. 2) Regulations 1999, which introduced into functional requirement B1 a requirement for the early warning of fire (a change which brought the provision of fire detection and fire alarm systems within the scope of the Building Regulations for the first time),104 Todd {CTAR00000001/45} paragraph 5.1.30. and reintroduced into functional requirements B2, B3 and B4 the word "adequate". Functional requirement B4 therefore restored the qualifier, eliminated in 1992, that external walls "shall adequately resist the spread of fire over the walls…".105 Todd {CTAR00000001/45-46} paragraph 5.1.35(iii). Functional requirement B5 was also amended so that facilities to assist the fire service and the provision for access to fire appliances should be "reasonable".106 Todd {CTAR00000001/46} paragraph 5.1.36. "Adequately" and "reasonable" are both words whose effect depends on the context in which they are used. It was therefore left to the person carrying out the work and the building control officer or approved inspector to decide as best they could whether the particular work did or did not meet the functional requirement.
46The Building Regulations 2000
¶4.37 The Building Regulations 2000 came into force on 1 January 2000, revoking the Building Regulations 1991.107 Todd {CTAR00000001/46} paragraph 5.1.38. The functional requirements were identical to those set out in the 1991 Regulations (as amended). They were subject to various amendments between 2001 and 2010,108 Todd {CTAR00000001/47} paragraph 5.1.40. an important one being the amendment of functional requirement B3(3) on internal fire spread to require a suitable automatic fire suppression system to be installed where reasonably necessary to inhibit the spread of fire within a building, either as an alternative to, or in addition to, the sub-division of the building with fire-resisting construction.109 2006 Amendment (No. 2) Regulations; Todd {CTAR00000001/48} paragraph 5.1.43. As a result, it became necessary to install sprinklers in newly built blocks of flats over 30 metres in height.110 Todd {CTAR00000001/48} paragraph 5.1.44. A further amendment introduced in 2006 required a person carrying out work on a building to give fire safety information to the responsible person under the Fire Safety Order on completion of the work or occupation of the building or extension to assist that person to operate the building or extension with reasonable safety.111 Todd {CTAR00000001/48} paragraph 5.1.45. This requirement became Regulation 38 in the Building Regulations 2010.
The Building Regulations 2010
¶4.38 The Building Regulations 2010112 {INQ00015098}. came into force on 1 October 2010 and revoked the Building Regulations 2000 (as amended).113 Todd {CTAR00000001/49} paragraph 5.1.51. The Building Regulations 2010 were amended on a number of occasions between 2011 and 2015, however, none of those amendments are relevant to this report – see Todd {CTAR00000001/51} paragraph 5.1.65. Apart from largely editorial amendments to functional requirement B3 on internal fire spread, the functional requirements were unchanged.
¶4.39 We consider the Building Act 1984 and the Building Regulations 2010 in greater detail in Chapter 48, in which we discuss the legislative regime as it applied to the refurbishment of Grenfell Tower between 2012 and 2016.
47Chapter 5: Fire testing
Introduction
¶5.1 In this chapter we describe the reaction to fire tests which supported the regulatory framework governing the fire safety of external walls of buildings in England & Wales in the years leading up to the Grenfell Tower fire. They include the national and European reaction to fire tests114 Reaction to fire must be distinguished from resistance to fire. They are different concepts and subject to different tests. and classification regimes, as well as the national large-scale testing and classification regime.
¶5.2 There are eight reaction to fire tests referred to in Approved Document B; four national test standards (BS 476 Parts 4, 6, 7 and 11) and four European test standards (BS EN 13823, BS EN ISO 1716 and 11925-2 and BS EN 1182). National test method BS 8414 and the criteria contained in a document published by BRE entitled Fire performance of external thermal insulation for walls of multi storey buildings, generally known as BR 135, relate to the large-scale testing of external wall cladding systems. A number of experts instructed by the Inquiry, including Dr Lane, Professor Bisby and Professor Torero, gave evidence about the background to those tests, their purpose, the methods by which they are conducted, and the information that can be derived from them. Here we summarise the key points arising from their evidence and the documents on which it was based.
National reaction to fire tests
¶5.3 Before considering each of the key national reaction to fire tests, it is useful to understand the basic stages of a fire in a compartment or room, since it is that "reference scenario" (i.e. the test conditions and related assumptions) which underpins many of the national and European tests. In broad terms, the development of a fire in a room can be divided into three key stages: ignition and growth, fully developed and decay.115 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 1, page 6.
¶5.4 The phenomenon commonly known as "flashover" occurs at the transition between the second and third stages and is characterised by an exponential growth in the size of the fire caused by the rapid ignition of all fuel sources within the compartment.116 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/136} at 12.4.18. It is an important indicator of the onset of a fully developed fire.117 Lane {Day68/9:12-13}. Reaction to fire tests are used to characterise the capacity of products and materials used in construction to contribute to the initiation and growth stages of a fire, leading up to flashover,118 BSI 476-10:2009 "Fire tests on building materials and structures" {BSI00001757/16} at 5.1. and therefore each of the tests in the BS 476 series is relevant when considering these stages of a fire in a room.119 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 1, page 9. More specifically, the small and intermediate scale tests that are referred to in the guidance in Approved Document B on constructing external walls are associated with the early stage of fire growth before flashover has occurred.120 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 1, page 9.
48BS 476-4: non-combustibility
¶5.5 BS 476-4121 {CTAR00000014}. is a test to determine non-combustibility. In paragraphs 91 to 101 of his report entitled Regulatory Testing and the Path to Grenfell122 Bisby, Phase 2 Report - Regulatory Testing and the Path to Grenfell {LBYP20000001/20}. Professor Bisby summarised the evolution of testing for combustibility and non-combustibility, both in the UK and internationally, including the publication in 1970 of BS 476-4.123 With further amendments made in 1978 and 1983 and further information added to the foreword in 2014 - Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 1, page 21. The test involves a small cuboid sample124 Measuring 40mm x 40mm x 50mm - Lane, Expert witness presentation - 10 November 2020: https://www. grenfelltowerinquiry.org.uk/hearings/expert-witness-presentation-dr-barbara-lane-10-november-2020, Part 1, page 24 of the material being placed in an electric furnace which has been heated to 750°C for a minimum of 10 minutes before the test.125 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/ expert-witness-presentation-dr-barbara-lane-10-november-2020, Part 1, pages 21-29 and see Lane {Day68/15:9}-{Day68/17:25} including video played of the test procedure. Three specimens are tested separately and a record is made of the measurements made by two thermocouples placed at the centre of each specimen. Heat is provided in the furnace by metal coils and no direct flame impingement occurs. The sample is inserted into the furnace and a record is made of the temperature at the thermocouples for 20 minutes. The occurrence of any flaming in the furnace is noted. Air is allowed to flow through the furnace to enable the combustion of any fuel vapours released by the specimen to the extent that they are capable of forming a combustible mixture and are ignited.126 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/120} at 12.3.11.
¶5.6 A material is deemed to be non-combustible if, during a test conducted in accordance with BS 476-4, none of the three specimens either (1) causes the temperature reading at either of the thermocouples to rise by 50°C or more above the initial furnace temperature or (2) is observed to flame continuously for 10 seconds or more inside the furnace. Otherwise, the material is deemed to be combustible.127 {CTAR00000014/10}. As explained by Professors Torero and Bisby, it is important for the user of this test data to understand that a designation of "non-combustible" does not mean that the material is completely inert,128 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/120} at 12.3.19. since the criteria are somewhat arbitrary, including the criterion of no continuous flaming for 10 seconds.129 Bisby Phase 2 Report - Regulatory Testing and the Path to Grenfell {LBYP20000001/23-24} at 109-110 and 116.
BS 476-11: method for assessing heat emission
¶5.7 BS 476-11130 {CTAR00000015}. is the method used for assessing the heat emitted by materials. It is the national test for assessing whether a material is of "limited combustibility", as defined in Approved Document B. The standard makes it clear at the outset that it is not intended to assess the effect of materials on fire growth.131 {CTAR00000015/4} and see discussion by Torero at, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/123}. It was first published in 1982 and has not been amended since.132 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 1, page 30. Some information was added to the foreword in 2014. The test apparatus is similar to that used in the BS 476-4 test.133 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 1, pages 31-36 and Lane {Day68/18:1}-{Day68/21:18} including video played of the test procedure. A small134 Specimens are 45mm in diameter and 50mm in height. cylindrical specimen, whose mass has been measured before the test, is inserted into a furnace which has been heated to 750°C. A thermocouple is inserted at the centre of the specimen and thermocouples are also provided for measuring the temperature of the furnace and the wall of the furnace. The temperatures measured by the thermocouples during the test are recorded and in addition visual observations are made. The procedure is repeated five times. The duration of each test is longer than under BS 476-4 and can be up to 120 minutes. Following each test, both the rise in the temperature of the furnace and the rise in the temperature of the specimen are calculated in relation to each of the five specimens and an average value is obtained. The average duration of sustained flaming is also recorded. Additional measurements are also made, including of the loss of mass of the sample. Other than the reporting of measurements and temperature differences, there is no classification or designation in the test standard itself. Such classifications and designations are to be found in other documents, including Approved Document B.135 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/124} at 12.3.40. It is a requirement of BS 476-11 that any report make it expressly clear that the results relate only to the behaviour of the specimens under the particular conditions of the test and that the results are not intended to be the sole criterion for assessing the potential fire hazard of the material in use.136 {CTAR00000015/9} at 8(g).
49BS 476-6: method of test for the fire propagation of products
¶5.8 BS 476-6, which was first published in 1968,137 Three further versions were published with the most recent in 2009 {CTAR00000016} and in 2014 a change was made to its foreword – see Lane, Expert witness presentation - 10 November 2020: https://www. grenfelltowerinquiry.org.uk/hearings/expert-witness-presentation-dr-barbara-lane-10-november-2020, Part 1, page 37. is the test method for assessing the fire propagation properties of products. Professor Bisby explained that it was developed in order to distinguish better between the fire hazards presented by different products when used within a compartment.138 Bisby, Regulatory Testing and the Path to Grenfell {LBYP20000001/32-35} at 156-162. The standard makes clear that the result of the test is expressed as a fire propagation index which provides a comparative measure of the contribution to the growth of fire made by an essentially flat material, composite or assembly.139 {CTAR00000016/5} at 1 Scope. The test is primarily intended for the assessment of the performance in a fire of internal wall and ceiling linings.140 {CTAR00000016/5} at 1 Scope. This test, together with BS 476-7, is used to determine national Class 0 as defined in Approved Document B.
¶5.9 The test apparatus comprises a combustion chamber with a specimen holder fixed onto the front face. The combustion chamber contains a gas burner and two electrical heating elements and is surmounted by a removable steel chimney. The specimen holder is recessed and takes a specimen measuring 225mm x 225mm. Because the opening to the combustion chamber measures only 190mm x 190mm, the edges of the sample are not directly exposed to heat from the gas burner or electric heaters.141 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/ expert-witness-presentation-dr-barbara-lane-10-november-2020, Part 1, pages 39-50 and see Lane {Day68/21:19}-{Day68/33:8} including video played of the test procedure. Only the front face of the specimen is heated and the fire propagation index subsequently calculated reflects that surface heating.142 See also Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/127} at 12.3.54 and {JTOR00000006/129} at 12.3.64. The test runs for 20 minutes. During the test, the output from the thermocouples measuring the temperature of the flue gases in the chimney is recorded and specific temperature measurements are taken at prescribed intervals. For a composite material the outer surface is heated first and any rise in temperature recorded in the chimney reflects the combustion of that surface together with any combustion of the material behind it.143 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 1, page 54. Visual observations are also made during the test, including of deformation or spalling of the specimen, which can result in the test being regarded as invalid in certain circumstances. Data obtained from the test is compared with data obtained when a calcium silicate board is tested. At least three, and no more than five, specimens must be tested. If more than three specimens are tested, three can be selected to provide the test result.144 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/127} at 12.3.53. This is a depiction of the test apparatus, taken from Dr Lane's presentation:
50¶Figure 5.1: Depiction of apparatus for BS 476-6 test.
¶5.10 The results of the test are expressed as a Fire Propagation Index, which is based on the difference in the rise in temperature of the effluent gases between the tested samples and the calcium silicate board. In respect of each sample, an average is calculated of the differences in temperature recorded during each period of time in which the rate of heating of the furnace varies. An average of the results is then calculated to obtain a single value for each sample (known as sub-indices i1, i2, i3), which are added together to give an overall Fire Propagation Index, referred to as I.145 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/127} at 12.3.56; Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert-witness- presentation-dr-barbara-lane-10-november-2020, Part 1, page 52. That overall value, together with the subindices, are the critical results of the test and are referred to in Approved Document B. The key information which the test provides is an indication of how much heat the product is capable of releasing.146 Torero {Day292/28:7-16}.
51¶5.11 The contents of the test report are laid down in the standard, which provides that it shall include details of the form in which the specimens were tested (i.e. material, composite or assembly), together with the thickness of the specimen and, where appropriate, its orientation and backing material.147 {CTAR00000016/11} at 11(f). The test report must also contain a statement that the test results relate only to the behaviour of the test specimens of the product under the particular conditions of the test and are not intended to be the sole criterion for assessing the potential fire hazard of the product in use.148 {CTAR00000016/11} at 11(i). Annex B to the standard makes it clear that the influence of underlying layers on the assembly should be understood and that care should be taken to ensure that the results obtained on any assembly are relevant to its use in practice.149 {CTAR00000016/18} left column; Lane, Expert witness presentation - 10 November 2020: https://www. grenfelltowerinquiry.org.uk/hearings/expert-witness-presentation-dr-barbara-lane-10-november-2020, Part 1, page 43. The standard also provides that where the product is to be used in conjunction with a particular substrate, it should be tested in conjunction with that substrate.150 {CTAR00000016/18} top right column; Lane, Expert witness presentation - 10 November 2020: https://www. grenfelltowerinquiry.org.uk/hearings/expert-witness-presentation-dr-barbara-lane-10-november-2020, Part 1, page 44.
¶5.12 When ACM PE panels are tested using this method, the aluminium can shield the polyethylene, protecting it from exposure to a direct flame and allowing it to melt and flow away, rather than ignite within the panel during the test. If it does not ignite, the temperatures measured in the chimney are lower.151 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 1, pages 58-59; Lane {Day 68/32:2-10}. It follows that if a product containing a core that is completely enclosed does not suffer a failure of the external material, the results of the test will not reveal the presence of any combustible material within.152 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/129} at 12.3.64.
BS 476-7: surface spread of flame test
¶5.13 BS 476-7153 {CTAR00000017}. was first published in 1971 and was revised in 1987 and 1997.154 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/ expert-witness-presentation-dr-barbara-lane-10-november-2020, Part 1, page 61. There was also a change to the foreword in 2014. It is a test method designed to determine the ease with which flame will spread across the surface of a product. It is the second main test used to support a national Class 0 classification. The test was developed as one of a new breed of small-scale fire tests which were intended to assess the fire hazard presented by a product when used in practical applications.155 Bisby, Regulatory Testing and the Path to Grenfell {LBYP20000001/29-31} at 144-151. It measures the horizontal spread of flame across the surface of a product and provides data which is suitable for comparing the performance in use of flat materials, composites or assemblies used primarily as the exposed surfaces of internal walls or ceilings.156 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 1, page 63.
52¶5.14 The scale of apparatus used is very different from that used for the national fire tests described above; generally, this is a much larger test.157 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 1, pages 64-72; Lane {Day68/33:9}-{Day68/40:24} including video of test procedure. The apparatus consists of a radiation panel measuring 850mm by 850mm, with a specimen holder protruding at a right angle to the radiating surface. The specimen holder comprises a water-cooled steel frame with water-cooled face-plates which overlap the specimen at the edges, thereby ensuring that the edges are not exposed during the test. The specimen is marked with reference lines at set distances before it is mounted into the test rig. Four vertical lines are marked at the distances corresponding to the classification limits for Classes 1–4. A minimum of six and a maximum of nine specimens are tested, which should be representative of the exposed surface of the product. If the product is normally used in conjunction with a substrate, it should be tested with that substrate.
¶5.15 During the test the radiant burner swings into place at a right angle to the specimen and a pilot flame is ignited in the lower corner of the specimen nearest the radiant panel. The pilot flame is extinguished one minute after the start of the test. The test involves recording the extent of flame spread along the face of the specimen after one and a half minutes and ten minutes, the latter being the duration of the test. Any flaming which occurs from material that has fallen or melted below the test rig is disregarded, although observations of such phenomena should be made. The test is terminated if the flame front reaches the 825mm line towards the end of the sample away from the radiant burner.158 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 1, pages 71-72. During the test the radiant panel provides an external heat flux of 32.5 kW/m² at the face of its vertical edge closest to the panel, which drops to 5k W/m² at the distant end of the sample.159 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/130} at 12.3.70. This is a picture of the test during operation taken from Dr Lane's presentation:
¶Figure 5.2: Image of BS 476-7 test in operation
53¶5.16 Depending on how far the flame has spread after one and a half and ten minutes, the product will receive a classification ranging from Class 1 to Class 4, Class 1 being the best and Class 4 the worst.
National testing classification regime
¶5.17 Unlike Europe, the UK has no overarching system for classifying the reaction to fire of products and materials. Instead, the national classes rely on definitions contained in Approved Document B. We set out below a diagram from Dr Lane's presentation which sets out the relevant definitions in Approved Document B. We have concentrated on the three definitions central to our work: non-combustible, limited combustibility and national Class 0.
¶Figure 5.3: National framework - reaction to fire definitions
Non-combustible
¶5.18 Table A6 of Approved Document B sets out the "Use and definitions of non-combustible materials".160 {CLG00000224/131}. The national class definitions of non-combustible materials are based principally on testing in accordance with BS 476-4 and BS 476-11. Any products classified as non-combustible in accordance with BS 476-4 are non-combustible pursuant to the definition.161 {CLG00000224/131} sub-paragraph (d) in Table A6 national class. BS 476-11 itself does not provide any limits on temperature rise or duration of flaming, but Table A6 states that a material will be classified as non-combustible when tested to BS 476-11 if it does not flame or cause any rise in temperature on either the specimen or furnace thermocouples.162 {CLG00000224/131} sub-paragraph (a) in Table A6 national class. In addition Table A6 makes it clear that any totally inorganic materials such as concrete are also to be regarded as non-combustible.163 {CLG00000224/131} sub-paragraph (b) in Table A6 national class – see (b) in Table A7 national class.
Limited combustibility
¶5.19 Table A7 of Appendix A sets out the "Use and definitions of materials of limited combustibility".164 {CLG00000224/132}. The table is divided into different rows by reference to particular parts of the guidance in Approved Document B which refer to a requirement for materials of limited combustibility. Any material classed as non-combustible meets that definition165 {CLG00000224/132} sub-paragraph (a) in Table A7 national class. and in some cases testing to BS 476-11 is relevant. For insulation materials in external wall constructions referred to in paragraph 12.7 of Approved Document B, Table A7 provides that any material with a density less than 300kg/m³ will satisfy the definition of limited combustibility if, when tested to BS 476-11, it does not flame for more than ten seconds and the rise in temperature on the specimen thermocouple is not more than 35°C and on the furnace thermocouple is not more than 25°C.166 A more onerous requirement is set for materials of a density of 300/kg/m³ or more.
54National Class 0
¶5.20 In the 2013 version of Approved Document B,167 {CLG00000224} 2006 edition with 2007, 2010 and 2013 amendments. in a section headed "Internal linings", paragraph 13 of Appendix A provided the following definition of national Class 0:168 {CLG00000224/122}.
"The highest National product performance classification for lining materials is Class 0. This is achieved if a material or the surface of a composite product is either: a. composed throughout of materials of limited combustibility; or b. a Class 1 material which has a fire propagation index (I) of not more than 12 and sub-index (i1) of not more than 6. Note: Class 0 is not a classification identified in any British Standard test."169 {CLG00000224/122} at 13.
¶5.21 Two different ways of meeting the requirements for Class 0 are apparent from that definition. First, they are met if a material or the surface of a composite product is composed throughout of materials of limited combustibility. That takes the reader back to Table A7 of Approved Document B, which contains the definitions of limited combustibility. Item 6 in Table A7 refers to "Class 0 materials meeting the provisions in Appendix A, paragraph 13(a)". The definitions of materials of limited combustibility for that category are based on testing to BS 476-11 (or BS 476-4 if the material is non-combustible).170 {CLG00000224/132}.
¶5.22 There is some ambiguity in the reference in Approved Document B to the "surface" of a composite product being composed "throughout" of materials of limited combustibility. This appears to contemplate that, provided the surface of a composite material is of limited combustibility, national Class 0 can be achieved regardless of the nature of the material behind that surface, or whether the surface is capable of encapsulating what lies behind. In addition, the reference to "surface" is uncertain. No definition of "surface" is provided in Approved Document B and it is not clear whether it is intended to refer to a paint surface or other coating only, or whether it includes a more substantial surface of the external wall, such as an outer skin or sheet which is itself bonded to another material.
¶5.23 In our view, therefore, there are difficulties with the interpretation of paragraph 13. On one reading of it, the author appears to have contemplated that the "surface" of a composite product might be composed "throughout" of materials of limited combustibility, but in this context the word "throughout" more naturally refers to the interior of a material or product than to its surface; and if the intention had been simply to refer to the whole of the surface area, that could have been achieved much more simply and clearly by referring to the "entire" surface of a composite product. We therefore think it unlikely that that is what paragraph 13 was intended to mean. It is more likely, in our view, that the wording is the product of a clumsy attempt to condense into one compendious expression the following distinct ideas: (i) an homogeneous material of limited combustibility, (ii) a composite product composed throughout of different materials, all of limited combustibility and (iii) a composite product whose surface is composed of one or more materials of limited combustibility. It can, and in our view should, be read as referring to those three distinct situations.
55¶5.24 The second way of meeting the requirements for Class 0 refers to test results from BS 476- 6 on fire propagation and BS 476-7 on surface spread of flame. The reference to a "Class 1" material comes from the BS 476-7 test171 Class 1 means that the flame must not spread more than 165mm from the heated end after 1.5 minutes of the test and it should also not exceed this limit for the full duration of the test (10 minutes). and the reference to the "index (I) of not more than 12 and sub-index (i1) of not more than 6" refers to results from the BS 476-6 test. It is only by combining the results from both tests that a Class 0 classification can be obtained.
¶5.25 The history of how national Class 0 has evolved over time is set out in Chapter 6. As we explain in that chapter, the language used in the Approved Documents from 1985 onwards introduced ambiguities and a lack of clarity in relation to the definition of Class 0 which had not existed in the Building Regulations of the 1960s and 70s.
European reaction to fire tests
¶5.26 Some of the European reaction to fire tests are similar to the national tests and others are very different. Unlike the national classification system, the European classification system has been designed specifically for the purpose and contains carefully chosen classification standards. Each European reaction to fire test has its own number and is issued by the European Committee for Standardisation, an association which brings together the national standardisation bodies of 34 countries.172 Lane {Day68/61:1-5}.
BS EN ISO 1182: non-combustibility
¶5.27 BS EN ISO 1182 is a test method for determining the non-combustibility of materials. At the time of the Grenfell Tower refurbishment the fifth edition (2010) was current.173 {BSI00001742}. The test apparatus is very similar to that used in BS 476-11,174 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 2, pages 133-137; Lane {Day68/62:25}-{Day68/64:22} including video of the test procedure. including an electric furnace capable of maintaining a steady temperature of 750°C. Five cylindrical specimens are prepared175 Each with a diameter of 45mm and a height of 50mm. and are tested individually, although data from all five is used to produce the final test result. The mass of each specimen is measured before and after the test. The specimen is inserted into the furnace, after which various temperature measurements are taken. The occurrence of any sustained flaming and its duration are also noted. The following information is recorded: (i) the percentage loss of mass of the specimen, (ii) the temperature difference between the maximum gas phase temperature and the temperature in the final minute before the test concludes and (iii) the total duration of any sustained flaming.176 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/142} at 12.4.41 and see {BSI00001742/25-26} at 8.1-8.3. Despite the title of the test standard, it contains no criteria for determining whether a material can be classified as non-combustible. The purpose of the test is simply to provide data that can be used for the purposes of the reaction to fire classification system set out in EN 13501-1.177 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/142} at 12.4.42. The standard makes it clear that a statement should be included in the report of the test explaining that the results relate to the behaviour of the product under the particular conditions of the test and are not intended to be the sole criterion for identifying the potential fire hazard of the product in use.178 {BSI00001742/26} at 9(p).
56BS EN ISO 1716: gross heat of combustion
¶5.28 BS EN ISO 1716 is a test method for measuring the gross heat of combustion (calorific value) of a product or material. The 4th edition (2010) version of this standard was current at the time of the Grenfell Tower refurbishment.179 {BSI00001737/19} at 10(q). It is used to determine the gross heat of combustion of materials or products at constant volume in a piece of apparatus called a bomb calorimeter.180 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 2, pages 139-146; Lane {Day68/64:23}-{Day68/67:10} including video of the test procedure. Essentially, a sample of material of a known mass is ground to a powder and burned in an atmosphere of oxygen. A flaming wire is used to ignite the material and the rise in temperature of the surrounding vessel of water is measured. Three specimens are tested, the result being an average of the values obtained expressed in joules or megajoules. The rise in the temperature of the water can be used to establish the amount of energy in the form of heat produced by the combustion of the test sample.181 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/143} at 12.4.48. Metal powders are not suitable for testing in this way because they present a risk of explosion.182 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 2, page 143. Again, the test report must make it clear that the results relate only to the particular conditions of the test and should not be the sole criterion for assessing the fire hazard in use.183 {BSI00001737}.
BS EN 13823: single burning item test
¶5.29 BS EN 13823 is commonly referred to as the "single burning item test".184 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 2, page 147; Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/148} at 12.4.65. The full title of the standard is "Reaction to fire tests for building products - Building products excluding floorings exposed to the thermal attack by a single burning item" - see {BSI00000119}. The 2002 version of this standard was relevant to some of the tests on ACM commissioned by Arconic.185 {BSI00000119}. The 2014 version was current at the time of the Grenfell Tower refurbishment,186 {BSI00000119}. although there are no material differences for present purposes. The single burning item test is known as a "scenario" test187 Professor Torero categorises any tests which represent a scenario which is deemed to be realistic as a scenario test - Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/86} at 10.2.16. because it is intended to establish the performance of materials under conditions representative of a fire within a compartment. It is intended to act as a scaled-down version of the full-scale room corner test – ISO 9705 – and was developed in such a way that the results would be indicative of those that would be obtained in a full-scale test.188 Torero, Phase 2 Report, Adequacy of the Current Testing Regime{JTOR00000006/148} at 12.4.66; Bisby, Phase 2 Report - Regulatory Testing and the Path to Grenfell {LBYP20000001/35} at 166.
57¶5.30 The method involves testing a specimen forming a corner.189 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 2, pages 147-162; {Day68/67:11-74:6} The specimen holder is a metal frame with a calcium silicate backing board. The intention of the test is to represent the end-use application of the product, so the specimen is fixed to the backing board in a manner consistent with the fixing conditions adopted in the end-use application.190 {BSI00000119/15} at 5.2.2(b) and see Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/150} at 12.4.69. The specimen holder contains two wings, one long one (1m in length) and one short one (495mm in length), each 1.5m in height. Apart from the BS 8414 test, it is the largest specimen used in any of the reaction to fire tests, either in Europe or this country.
¶5.31 The test sponsor may choose to mount the specimen in an "end-use application" mounting, reflecting how the product will be used in a building, or a standard mounting as defined in BS EN 13823.191 {BSI00000119/15-16} at 5.2. For instance, in the case of a rainscreen panel, the sponsor may choose the type of fixing to be used and can also attach insulation behind the panel to reflect end-use conditions, provided the dimensions of the specimen satisfy certain requirements, including a maximum thickness of 200mm.192 {BSI00000119/15} at 5.1.1. If the sponsor chooses an end-use application mounting, the test results are valid only for that application.193 {BSI00000119/16} at 5.2.1.
¶5.32 The test rig contains two burners, a primary burner and an auxiliary burner. The primary burner is located in the corner between the two wings and although it is offset by 40mm, flames given off by the burner can make direct contact with the outside face of the test specimen. It is a gas and sand burner which is calibrated to give a heat output of 30kW and intended to represent a waste paper bin on fire in the corner of a room. The auxiliary burner is located at a distance from the test apparatus; its only purpose is to run for a short period before the primary burner is ignited to provide a baseline average burner heat and smoke output at the start of the test. The contribution of both burners is subtracted at the end of the test to calculate the contribution of the specimen. The specimen is mounted on a trolley which is moved under the test rig. Above the rig is a hood which contains an exhaust system. During the test several measurements are taken in the duct through which the smoke is extracted, including the temperature and density of the smoke. This is a depiction of the test apparatus taken from Dr Lane's presentation:194 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 2, page 153.
58¶Figure 5.4: Depiction of test apparatus for BS EN 13823
¶5.33 The test runs for about 20 minutes during which the rate of heat production from the specimen is determined by means of measurements taken within the extractor hood. This information is expressed in a range of forms that include the average heat release rate, the total heat released, including in the first ten minutes, and the fire growth rate index "FIGRA".195 The FIGRA is intended to represent, in a standardised manner, how fast a fire spreads over the sample. It does not relate to any physical phenomenon beyond the fact that if the fire reaches a large heat release rate in a short period of time it delivers a large FIGRA - see Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/153} at 12.4.88. The propensity for lateral flame spread is measured by a single visual observation of whether sustained flames reach the end of the long wing (1m) at any time during the test. The rate of progression of the flame is otherwise not recorded. The propensity to produce flaming droplets is recorded within the first ten minutes if droplets reach floor level outside the burner zone. Information about smoke production is also produced by means of measurements which include the average smoke production rate, the total smoke production and the smoke growth rate index "SMOGRA" which measures the rate of increase of smoke production.196 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/150} at 12.4.72-12.4.75, 12.4.89.
¶5.34 Data is collected from three separate tests.197 {BSI00000119/18} at 5.4. The results of the test are expressed primarily in a series of graphs which display both burning and smoke production behaviour.198 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 2, page 156. Numerical values are calculated and recorded for some parameters, including the FIGRA and the total heat release rate ("HRR"). These figures are recorded in the test reports and then averaged over the three tests and expressed as a single figure. The average is relevant for classification to EN 13501, as discussed further below. If a specimen does not perform as expected in a single burning item test, it is possible to test up to two more specimens. If that occurs, the highest and lowest results are discarded and the mean value is calculated on the remaining three values to arrive at an overall average figure.199 {BSI00001738/17-18} at 7.1-7.5.
59¶5.35 The standard also identifies a range of information which must be included in the test report, including a statement that the test results are not the sole criterion for assessing the potential fire hazard of the product in use.200 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 2, page 157. The rate at which the fire is able to grow due to ignition of the product being tested is considered indicative of the product's propensity to bring a fire from its initial stages to the point of flashover.201 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/151} at 12.4.77.
BS EN ISO 11925-2: single-flame source test
¶5.36 BS EN ISO 11925-2 is known as the "single-flame source" test.202 {BSI00000125} the full title of the standard is "Ignitability of building products subjected to direct impingement of flame. Part 2 – Single-flame source test." The 2010 version was current at the time of the Grenfell Tower refurbishment. The test is designed to simulate a small flame being applied directly to the surface or to the edge of a material. The test standard makes it clear that the configuration of the test specimen should reflect the end-use application and if the product is installed with unprotected edges, tests should be performed on both covered and unprotected edges.203 {BSI00000125/10-11} at 5.4.4 and 5.5.
¶5.37 The apparatus for the test comprises a Bunsen burner housed within an outer compartment called the combustion chamber.204 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 2, pages 163-177; Lane {Day68/74:7}-{Day68/79:18} including video of test procedure. The test sample is 250mm long by 90mm wide205 With a maximum permitted thickness of 60mm. and is suspended from the back wall of the combustion chamber with an aluminium tray placed below containing sheets of paper which can catch any flaming droplets. During the test the Bunsen burner applies a flame directly to the surface or edge of the material at an angle of 45°.206 When a surface exposure is used the flame is applied 40mm up from the bottom of the specimen on the front face of the specimen. When an edge exposure is used the flame is applied on the bottom edge of the specimen. The flame is applied for either 15 or 30 seconds207 If applied for 15 seconds, the total test duration is 20 seconds and if applied for 30 seconds, the total test duration is 60 seconds. That allows for a period of time after the flame has been removed to observe what happens when the flame is removed. depending on the classification the test sponsor wishes to obtain. Ignition and any vertical flame spread is observed and recorded, together with the amount of flaming droplets or particles and whether they ignite the paper below. The presence of any flaming on the specimen once the pilot flame is removed is also recorded.
¶5.38 The following picture of a sample about to undergo an ISO 11925-2 test is taken from Professor Torero's report on the adequacy of the current testing regime:208 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/147}.
60¶Figure 5.5: Picture of sample about to undergo ISO 11925-2 test
¶5.39 This is another "scenario" test, the purpose of which is to simulate the initiation of a compartment fire and to establish if a small, localised heat source can ignite a product or material within the compartment and sustain a flame away from the initiating flame.209 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/146} at 12.4.54.
European reaction to fire test classification system
¶5.40 BS EN 13501-1 is the European standard which contains the European reaction to fire classification system. The 2009 edition was current at the time of the Grenfell Tower refurbishment.210 {BSI00001738} BS EN 13501-1:2007+A1 2009 "Fire classification of construction products and building elements. Classification using test data from reaction to fire tests." See also the 2002 version at {BSI00000620}. It contained a reaction to fire classification for all construction products, including products incorporated into building elements. The system was designed to create a single system of classification that would capture a broad range of physical processes.211 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/136} at 12.4.16.
¶5.41 Table 1 describes the European reaction to fire performance classes. There are seven classes, from A1, which is the highest classification, to F, which means that no performance can be determined.212 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 3, pages 178-190. For each category the standard provides that the classification can be obtained only by undertaking the tests or the extended application process required for that particular product. This is a copy of Table 1:213 {BSI00001738/40}.
61¶Figure 5.6: Table 1 from BS EN 13501-1
¶5.42 As is apparent from the table, in order to achieve European classification A1 data obtained from the following two reaction to fire tests is required: (1) EN ISO 1716, the gross heat of combustion using the bomb calorimeter method and (2) EN ISO 1182, the non-combustibility furnace test method. In order to be classified A1, the material must achieve certain results in both.
62¶5.43 There are two combinations of tests that can be used to determine European classification A2. In either combination the single burning item test (BS EN 13823) is required. In addition, the material should be tested either using the bomb calorimeter method (EN ISO 1716) or the non-combustibility furnace test method (EN ISO 1182). For Class A2, the requirements are less stringent than for A1: for example, if using the bomb calorimeter method a gross heat of combustion less than 3MJ/kg is permitted, whereas for Class A1 a gross heat of combustion of less than 2MJ/kg is required.
¶5.44 For European classes B to D, test combinations are required. Those classifications rely on the single burning item test and the single-flame source test only, with the requirements for each of the tests becoming less onerous as one moves down the classes. For example, a Class B material must achieve a FIGRA of less than 120W/s in the single burning item test, whereas a Class C material must achieve a FIGRA of less than 250W/s and a Class D material less than 750W/s. For classification E, only the single-flame source test is required.214 There has to be flame spread less than 150mm within 20 seconds and no ignition of the paper below. Class F is appropriate when a product fails to obtain Class E and is applied when a product has no performance criteria.
¶5.45 The following summary of the European classes and the properties required to obtain them is taken from Dr Lane's presentation:215 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 3, page 190.
¶Figure 5.7: Summary of the European classes
¶5.46 Each of the classes is also divided by reference to the volume of smoke and flaming droplets produced by the sample, which is designated by the notations s1, s2 and s3 for smoke production and d0, d1 and d2 for flaming droplets. Classification of smoke production is obtained from data taken during the single burning item test only, whereas classification relating to the production of flaming droplets is obtained by reference to observations taken during both the single burning item test and the single-flame source test.216 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 3, pages 192-193.
63¶5.47 EN 13501-1 provides that the field of application of any classification which has been achieved must be identical to the field of application resulting from the test(s) or from any extended application process.217 {BSI00001738/38} at 15 "Field of application of the classification". It also makes it clear that a different classification may apply if different end-use applications are envisaged for the particular product.218 Ibid. It also states that while the classification may be valid for products within the same family where the reaction to fire classification can be proven to be unchanged, it may be that the field of application is extended in an extended application report, separate rules for which are given in CEN/TS 15117.
The European classes cited in Approved Document B
¶5.48 The 2013 version of Approved Document B referred to the European classifications at various places in relation to the construction of external walls. In Table A6 dealing with the use and definition of non-combustible materials,219 {CLG00000224/131}. any material which is classified as A1 under the European classification system is regarded as non-combustible. In addition, certain materials are regarded as Class A1 without the need for testing and are also regarded as non-combustible.220 As defined in European Commission Decision 2003/424/EC 6 June 2003 e.g. cement, masonry cement.
¶5.49 In Table A7, which addresses the use and definitions of materials of limited combustibility,221 {CLG00000224/132}. any insulation material used in an external wall construction of the kind referred to in paragraph 12.7 of Approved Document B must either be non-combustible, as specified in table A6, or be classified A2-s3, d2 or better in accordance with BS EN 135011. The reference to "s3, d2" in Table A7 means that no limits are set for the production of smoke or flaming droplets or particles.
¶5.50 In Diagram 40 of Approved Document B the external surfaces of walls of buildings over 18m in height were required to be either national Class 0 or European Class B-s3, d2 or better. That meant that, if one were seeking to adopt the European classification, the external surface had to have achieved certain results in the single burning item and single-flame source test, but that there were no minimum requirements for the production of smoke or flaming droplets or particles.
Large-scale testing to BS 8414 and classification to BR 135
¶5.51 Methods for large-scale fire testing of cladding systems are contained in BS 8414 Parts 1 and 2. The classification method and performance criteria are set out in BR 135.222 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 3, page 222. At the time of the Grenfell Tower fire BRE was the UK's only testing laboratory with accreditation to undertake BS 8414 testing. There is no European equivalent of the BS 8414 test.
¶5.52 BS 8414 is a two-part British Standard. Part 1223 BS 8414-1:2002 "Fire performance of external cladding systems – Part 1: Test method for non-loadbearing external cladding systems applied to the face of the building." {BSI00000163}. A second edition was published in 2015 - BS 8414-1:2015 {BSI00000253}. contains the method for testing external cladding systems applied to masonry walls; Part 2224 BS 8414-2:2005 "Fire Performance of external cladding systems – Part 2 Test methods for non-loadbearing external cladding systems fixed to and supported by a structural steel frame." {BSI00000097}. A second edition was published in 2015 - BS 8414-2:2015 {BSI00000167}. contains the method for testing external cladding systems fixed to and supported by structural steel frames. The exposure to fire of the system being tested is intended to be representative of an external fire source or a fully developed (post-flashover) fire in a room venting through an opening such as a window and exposing the cladding to the effects of external flames.225 See {BSI00000163/5} and {BSI00000097/5} under "1 Scope".
64¶5.53 The system to be tested is formed of two walls, each at least 8m high. One, the main wall, contains the combustion chamber and has a wing wall set at right angles to it at one side. The composition and structure of the walls are determined by the person commissioning the test. The main wall contains an open-faced combustion chamber at ground level measuring 2m by 2m226 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/ expert-witness-presentation-dr-barbara-lane-10-november-2020, Part 3, pages 242-246 and see Lane {Day68/106:25}-{Day68/114:11}, including video of the test procedure. in which the fuel source is located. The fuel source is a timber crib comprising layers of softwood sticks arranged alternately; when ignited, it is designed to produce a total heat output of 4,500 megajoules with a peak heat release rate of 3 megawatts. This fire source is designed to produce flames which are typical of a fully developed building fire impinging on the façade.227 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/100} at 12.2.15 and see BR 135 1st Edition {BRE00001077/5} bottom left column. The main wall of the test specimen must be a minimum of 2.6m wide and 6m in height (when measured from the top of the combustion chamber); the wing wall must be a minimum of 1.5m wide and 8m high. No guidance is given on how the system is to be constructed around the opening to the combustion chamber.228 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/100} at 12.2.9. The second editions of BS 8414-1 and 8414-2 provided that "the test specimen shall include all relevant components assembled and installed in accordance with the manufacturer's instructions".229 {BSI00000167/13} under section 6 "Test specimen". The "external cladding system" is defined in 3.3 under Note 1 as including "for example, sheeting rails, fixings, cavities, insulation and membranes, coatings, flashings or joints" see {BSI00000167/7}.
¶5.54 Two types of data are recorded during the test: temperatures and visual observations. To measure temperatures a number of thermocouples230 Thermocouples on the main wall are positioned on the centreline of the wall and then at 500mm and 1000mm either side of this centre line. Thermocouples on the return wall are positioned at 150mm, 600mm and 1050mm from the junction with the main wall. are located on the exterior of the cladding system at 2.5m (level 1) and 5m (level 2) above the test opening. These thermocouples do not make direct contact with the cladding system and are positioned at a distance of 50mm from the surface. Internal thermocouples are also placed within the cladding system in any combustible layers greater than 10mm in thickness. These internal thermocouples are positioned at level 2 only. A photograph and diagram from Dr Lane's presentation showing the location of the different thermocouples appears below.
65¶Figure 5.8: Diagram and picture showing the location of thermocouples in BS 8414 test
¶5.55 The visual observations to be taken during the test include any change in flaming conditions or the mechanical behaviour of the cladding system, especially detachment of any part of the system (whether flaming or otherwise) or any other penetrations through fire stops incorporated within it.231 See Second Edition of BS 8414-2:2015 at 8.4 Test Observations {BSI00000167/14}. A continuous audio-visual record of the full height of the test face is taken throughout the test and for steel-framed systems an audio-visual record is also required of the internal face of the cladding system, so that any burn-through can be assessed.232 {BSI00000167/12} at 5.9 and Lane, Expert witness presentation - 10 November 2020: https://www. grenfelltowerinquiry.org.uk/hearings/expert-witness-presentation-dr-barbara-lane-10-november-2020, Part 3, page 246.
¶5.56 Temperature and visual recordings are taken from five minutes before ignition until 60 minutes after ignition.233 Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert- witness-presentation-dr-barbara-lane-10-november-2020, Part 3, page 247. The crib is allowed to burn for 30 minutes, at which point it is extinguished and the test allowed to run for a further 30 minutes during which any observed flaming is allowed to continue. The test is stopped early if at any point flames extend above the test rig or if there is a risk to the safety of the personnel within the test facility.234 The provision for early termination was contained in BS 8414-2:2005 but not BS 8414-1:2002. It was introduced to the Part 1 test in 2015 - see {BSI00000253/14} at 8.6 Early test termination criteria. The reference to early termination was also introduced into the 3rd Edition of BR 135 in 2013 - see {BRE00005555/27} at A2. A test report should be provided for each test undertaken, even if the test is terminated early; the standard sets out a list of information which should be included in the test report.235 See example for Part 2 {BSI00000167/15} at section 10. The following photographs of a BS 8414 test in operation are taken from Dr Lane's presentation:
66¶Figure 5.9: photographs of a BS 8414 test in operation
¶5.57 The second236 {BRE00005554} Colwell, Martin 2003. and third237 {BRE00005555} Colwell, Baker 2013. editions of BR 135 both contained two annexes each providing performance criteria relevant to the BS 8414 tests. The third edition, which is most relevant to the Grenfell Tower fire, contains three main performance criteria: external fire spread, internal fire spread and mechanical performance. In relation to external and internal fire spread the document contains failure criteria only. Failure due to external fire spread is deemed to have occurred if the rise in temperature over the initial ambient temperature of any of the thermocouples at level 2 exceeds 600°C for a period of at least 30 seconds within 15 minutes of the start time, which is defined as the time at which any thermocouple at level 1 equals or exceeds 200°C for a period of 30 seconds.238 {BRE00005555} at Annex A, A2.1 and Annex B, B2.2. Failure due to internal fire spread is deemed to have occurred if the rise in temperature above the initial ambient temperature of any of the internal thermocouples at level 2 exceeds 600°C for a period of at least 30 seconds within 15 minutes of the start time.239 {BRE00005555} at Annex A, A2.3 and {BRE00005555/33} at Annex B, B2.3.,240 In addition, Annex B for steel-framed systems tested to BS 8414-2 provides that where system burn-through occurs so that flame reaches the internal surface, failure is deemed to have occurred if continuous flaming, defined as a flame with a duration in excess of 60 seconds, is observed on the internal face of the test specimen at or above a height of 0.5m above the combustion chamber within 15 minutes of the start time - see {BRE00005555/33} at Annex B, B2.3. No failure criteria are set in respect of mechanical performance, but continuing combustion of the system following extinction of the crib is to be included in the test and classification reports, together with details of any collapse, spalling, delamination of the system, the production of flaming debris or pool fires.241 {BRE00005555/29} at A2.4 and {BRE00005555}/33} at B2.4. Although there are no criteria for mechanical failure, the nature of the mechanical performance should be considered as part of the overall risk assessment when specifying the system.242 {BRE00005555/29} at A2.4 and {BRE00005555/33} at B2.4.
67¶5.58 The third edition of BR 135 made it clear that, in order for a system to be classified in accordance with BR 135, it must have been tested for the full duration provided for in BS 8414 without any early termination of the period of exposure to the full fire load.243 {BRE00005555/27} at A2 and {BRE00005555/32} at B2. Parts 1 and 2 of BS 8414 stipulate that records must continue to be made for an additional 30 minutes up to a maximum duration of 60 minutes, unless no part of the system is still burning 30 minutes after ignition, in which case the test should be terminated.244 Part 1 (2002) {BSI00000163/10} at paragraph 7.4; Part 2 (2005) {BSI00000097/11} at paragraph 8.5. The third edition of BR 135 also provides in terms (unlike the second edition) that the classification applies only to the system as tested and described in the classification report.245 {BRE00005555/28} at A2, left column and {BRE00005555/32} at B2 right column. Both a BS 8414 test report and a BR 135 classification report are therefore necessary to demonstrate that the system has been fully tested and classified to the necessary standard.
69Chapter 6: Regulations and guidance relating to external walls
Introduction
¶6.1 Legislative involvement in the construction of external walls has its origin in the Great Fire of London, 1666. For many years prescriptive rules contained in local Acts of Parliament and byelaws determined the kinds of materials and methods of construction that could be used, but during the latter half of the last century there was a move towards reliance on functional requirements of a kind that were capable of being applied in accordance with the nature, location and use of the particular building. The regulations were supported by statutory guidance contained in a series of approved documents.
¶6.2 Our survey of the development of the regulatory framework relating to the construction of external walls reveals the extent to which restrictions on the use of non-combustible materials were relaxed by degrees to permit the use of combustible materials in certain circumstances. The relaxation of the requirements was accompanied by an increasing lack of clarity in the language of the regulations and associated guidance. Over time, certain definitions (including the definition of national Class 0) were altered in a way that rendered them unclear. Both developments are important in explaining the environment in which the building profession was operating when the refurbishment of Grenfell Tower was undertaken between 2012 and 2016.
¶6.3 In the chapters that follow we have sought to put the most important of those changes into context and to explain the reasons why they were made, insofar as the evidence permits us to do so. We have begun our survey with the fire at Knowsley Heights in Liverpool in 1991 because it seems to us that the events that followed laid the ground for the tragedy which occurred at Grenfell Tower in June 2017.
The London Building (Constructional) By-laws
¶6.4 At the time Grenfell Tower was built London had its own system of building legislation, principally the London Building Acts 1930–39 and associated byelaws. The London Building (Constructional) Amending By-laws (No. 1) 1964 provided that all elements of construction were to be non-combustible, but a specific byelaw permitted external cladding to be made of such materials, of such thicknesses and fixed and supported in such a manner as the District Surveyor might approve.
¶6.5 In March 1973 all existing byelaws were revoked by the London Building (Constructional) By-laws 1972. The 1972 byelaws required the construction to be non-combustible, but any external cladding could either satisfy the requirements of the District Surveyor or comprise 1mm of combustible material applied to a non-combustible backing, such that the composite material would achieve a Class 1 surface spread of flame if tested in accordance with BS 476-7.246 Todd {CTAR00000001/28} paragraph 4.1.16.
70¶6.6 It is clear, therefore, that by 1973 the London byelaws not only drew a distinction between the construction of the external wall and external cladding but also permitted a thin layer of combustible material to be used as the surface of any external cladding provided that the composite product met certain requirements in relation to the surface spread of flame.
The 1965 Building Regulations
¶6.7 A similar approach was taken in the Building Regulations 1965 (which did not apply to Inner London). The 1965 Regulations provided that any external wall of a building exceeding 50 feet in height should not include any combustible material except any external cladding not required by paragraph (3) to be non-combustible.247 Regulation E7(2)(b)(i) {INQ00015096/42}; Lane, Expert witness presentation - 10 November 2020: https://www. grenfelltowerinquiry.org.uk/hearings/expert-witness-presentation-dr-barbara-lane-10-november-2020, Part 2, page 103
¶6.8 By paragraph (3), any cladding on an external wall situated more than three feet from a relevant boundary, if the building was more than 50 feet248 50 feet is 15.24 metres. in height, was required to have a surface complying with the requirements for Class 0, save that cladding below 50 feet could consist of timber of 3/8in finished thickness. That was the first time that Class 0 had been introduced into the regulatory regime in England and Wales. By regulation E14, in order for the surface to be of Class 0 the material had to be non-combustible throughout or
"comprise a base or background which is non-combustible with the addition of a surface not exceeding 1/32 inch thick so that the spread of flame rating of the combined product is not lower than Class 1 in clause 7 of … [BS 476:7]; or comprise a base or background which is combustible but with any exposed face finished with a layer not less than 1/8 inch [3.175mm] thick of non-combustible material and with the other face not exposed to air."249 Regulation E14 {INQ00015096/50-51}; Lane, Expert witness presentation - 10 November 2020: https://www. grenfelltowerinquiry.org.uk/hearings/expert-witness-presentation-dr-barbara-lane-10-november-2020, Part 2, page 104; Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/69-71} paragraphs 325-335.
¶6.9 It is apparent, therefore, that the 1965 Regulations drew a distinction between the external wall and "cladding". They also permitted the use of external cladding with a very thin surface layer of combustible material, provided the panel as a whole achieved a Class 1 surface spread of flame rating when tested in accordance with what is now BS 476-7. The regulations also permitted cladding which consisted of a combustible "base or background", provided that any exposed face was finished with a 1/8in thick layer of non‑combustible material.
¶6.10 The 1965 Building Regulations also expressly provided that any reference to the "surface of a wall" should be construed as a reference to that surface excluding any door, door frame, window or window frame.250 Regulation 14(4)(e) {INQ00015096/51}. Taken together with the Class 0 definition, there was no room for doubt about what constituted the "surface" for the purposes of the external cladding requirements, and specific thicknesses and descriptions were prescribed for external cladding so that there was no ambiguity about what type of cladding was permitted and what was not. As we will see, that clarity was lost in later guidance provided in Approved Document B.
71The Building Regulations 1972
¶6.11 The Building Regulations 1972 retained the requirement for the external wall of a building over 15 metres251 Metric units of height replaced imperial. in height to be non-combustible and any external cladding to be classified Class 0.252 Regulation E7(2)(a)(i) of the Building Regulations 1972; Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert-witness-presentation-dr-barbara-lane-10-november-2020, Part 2, page 107. However the definition of Class 0 was changed to refer to materials which were non-combustible "throughout" or which had a surface material which, when tested in accordance with BS 476-6, achieved a fire propagation index (I) not exceeding 12 and a sub-index (i) not exceeding 6.253 Regulation E15(1)(e) of the Building Regulations 1972.
¶6.12 The 1972 Regulations also made it clear that if the surface material were bonded to a substrate, the surface material in conjunction with the substrate had to achieve that level of performance.254 Regulation E15(1)(e)(ii) of the Building Regulations 1972. The definition of "surface" remained the same as in the 1965 Regulations.255 In Regulation E15(b). The provision in the 1965 Regulations that a combustible substrate with a non-combustible surface could be rated Class 0 was not retained in the 1972 Regulations.
¶6.13 As Professor Bisby has explained, those who developed the BS 476-6 method to test fire propagation appear to have been satisfied, based on the (limited) experimental data they had at the time, that a fire propagation index (I) of less than 12 indicated a lower hazard, whilst a fire propagation index above 20 indicated the highest possible hazard.256 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/78} paragraph 375. That was based on comparing the performance of products in the BS 476-6 test with how they performed in small-scale compartment fire tests.257 Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/77} paragraphs 373-374.
The Building Regulations 1976
¶6.14 In the Building Regulations 1976 the position remained the same,258 Regulation E7(3)(a) and (4) of the Building Regulations 1976; Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert-witness-presentation-dr-barbara-lane-10-november-2020, Part 2, page 120. save that the definition of Class 0 was changed again. Class 0 was defined either as non-combustible throughout, or by reference to a surface material which was tested both to BS 476-7 on surface spread of flame and BS 476-6 on fire propagation.259 Regulation E15 (1)(e)(ii) of the Building Regulations 1976; Lane, Expert witness presentation - 10 November 2020: https://www.grenfelltowerinquiry.org.uk/hearings/expert-witness-presentation-dr-barbara-lane-10- november-2020, Part 2, page 120; Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/79} paragraphs 380-383. Again, the regulations made clear that if the surface material was bonded to a substrate, the surface material in conjunction with the substrate had to achieve that level of performance.260 Regulation E15(1)(e)(ii).
¶6.15 This reliance on tests according to both BS 476-7 and BS 476-6 to establish Class 0 remained essentially unchanged until the Grenfell Tower fire in 2017.
72Building Regulations 1985 and Approved Document B 1985
¶6.16 Following the introduction of the Building Act 1984 and the Building Regulations 1985, all technical requirements were eliminated from the regulations themselves. Instead the regulations were cast in the form of functional requirements supported by approved documents which gave practical guidance on the means by which the functional requirements could be achieved.261 See Chapter 4.
¶6.17 Section 7(1) of the Building Act 1984 provides that, in any civil or criminal proceedings, if it is alleged that a person contravened a provision of the Building Regulations, proof of compliance with an Approved Document may be relied on as tending to negative liability and a failure to comply with an Approved Document may be relied on as tending to establish liability. Its effect has been greater than may have originally been envisaged, because it has led many involved in the construction industry, including designers, contractors and building control officers, to treat the guidance in the Approved Documents as prescriptive, thereby making it unnecessary to worry about the functional requirement itself. As we shall see when we come to the history of Approved Document B, some designers and contractors set out not to satisfy the functional requirements themselves but simply to follow the Approved Documents. Some of those who acted in that way may have been motivated by a cynical desire to obtain the benefit of section 7(1), regardless of whether the functional requirement was in fact satisfied, but we suspect that many more, including many building control officers, simply felt more comfortable working within a prescriptive regime and regarded the Approved Documents as providing it.
¶6.18 Whatever the reason may have been, contractors, designers and consultants generally soon began to regard compliance with the Approved Documents as tantamount to compliance with the Building Regulations themselves.262 Todd {CTAR00000001/52} paragraph 5.2.5(ii). Section 7 thus encouraged the industry generally to place more importance on complying with the Approved Documents, and thereby obtain the benefit of section 7(1), than on compliance with the Building Regulations themselves. The Approved Documents thus became a de facto prescriptive code.
¶6.19 Functional requirement B4(1) of the Building Regulations 1985 relating to the spread of fire over external walls provided that "The external walls of the building shall offer adequate resistance to the spread of fire over the walls…"263 {INQ00015097/13}.
¶6.20 In Approved Document B 1985 dealing with fire safety, the longstanding requirement in the Building Regulations that external walls should be non-combustible was changed to provide that all external walls should be constructed of materials of limited combustibility if the building was more than 15 metres in height264 {CLG10002325/15} paragraph 2.7; Lane, Expert witness presentation - 10 November 2020: https://www. grenfelltowerinquiry.org.uk/hearings/expert-witness-presentation-dr-barbara-lane-10-november-2020, Part 2, page 109; Todd {CTAR00000001/52} paragraph 5.2.5(ii). and the BS 476-11 test was introduced as a method of testing to that standard.265 Under "Materials of limited combustibility" Appendix A, paragraph A13 {CLG10002325/50} and Table A7 at {CLG10002325/51}; Bisby, Regulatory Testing and the Path to Grenfell Report {LBYP20000001/86} paragraph 413.
¶6.21 In addition, in the case of buildings over 15 metres in height, any cladding at a height of 15 metres or more above the ground could be combustible if it was not being relied on to contribute to the fire resistance of the wall and satisfied Class 0.266 {CLG10002325/15} paragraphs 2.9, 2.13 and Table 2.2. However the definition of Class 0, which was now also set out in the Approved Document, was changed again. The description of Class 0 to be found in Appendix A of the Approved Document B under the heading "Walls and Ceiling Linings (etc)", was as follows:
73"Class 0 which restricts both the spread of flame across a surface and also the rate at which heat is released from it, imposes a more strict control than Class 1. Class 0 is not a classification identified in a British standard test, and is considered a higher class than Class 1. A Class 0 material or the surface of a composite product is either: (a) composed throughout of materials of limited combustibility, or (b) a Class 1 material which has a fire propagation index (I) of no more than 12, and (i) of not more than 6."267 {CLG10002325/49} Appendix A at paragraphs A7 and A8.
¶6.22 The definition of Class 0 therefore changed in two important ways when Approved Document B was first introduced. First, a requirement that materials or surfaces of materials should be of limited combustibility was introduced in place of the requirement that they be composed of non-combustible materials; secondly, the requirement to consider the substrate and the surface of a composite product together was removed. As a result, the definition of Class 0 no longer made it clear that any test of a composite product had to be carried out on the surface in conjunction with its substrate. To many that might have appeared self-evident, but in the absence of any clear statement to that effect the reader might be led to think that a composite product with a combustible core could be rated Class 0 provided that its surface was a material of limited combustibility, regardless of whether or how the composite product had been tested.
¶6.23 However, the reference in the alternative requirements to testing in accordance with both BS 476-6 and BS 476-7 remained unchanged.
¶6.24 A summary of the guidance given in Approved Document B 1985 on the construction of external walls is set out in the following chart taken from Dr Lane's presentation.
¶Figure 6.1: Chart showing guidance on construction of external walls in ADB 1985
74The Building Regulations 1991
¶6.25 The Building Regulations 1991 contained some minor amendments to the wording of the functional requirements, including functional requirement B4(1), which was amended to remove the word "adequate" so that it read "The external walls of the building shall resist the spread of fire…".268 Todd {CTAR00000001/43-44} paragraph 5.1.28.
Approved Document B 1992
¶6.26 In the 1992 version of Approved Document B a separate performance standard for insulation was introduced for the first time. It provided that in a building with a storey at more than 20 metres above ground level, any insulation material used in the external wall construction should be of limited combustibility.269 {BLA00005482/74} paragraph 12.7, second paragraph.
¶6.27 A general warning about the risk of fire spreading in the external envelope was also included. It provided as follows:
"The external envelope of a building should not provide a medium for fire spread if it is likely to be a risk to health or safety. The use of combustible materials for cladding framework, or of combustible thermal insulation as an overcladding or in ventilated cavities, may present such a risk in tall buildings, even though the provisions for external surfaces in Diagram 36 may have been satisfied."270 {BLA00005482/74} paragraph 12.7, first paragraph.
¶6.28 Diagram 36271 {BLA00005482/75}. set out guidance on the construction of external walls. (It became Diagram 40 in later editions of Approved Document B.) Diagram 36 indicated that the surface of external walls of buildings over 20 metres in height (an increase from the previous 15 metres) should be Class 0. Reading the document as a whole, therefore, the reader was warned that the use of combustible materials for cladding might present a risk even though the external surface of the cladding was rated Class 0.
¶6.29 The definition of Class 0 was unchanged and again appeared under the heading "Internal linings".272 At paragraph A12 of Appendix A {BLA00005482/96}. The definition was introduced with the words "The highest product performance classification for lining materials is Class 0." Anyone reading that definition should therefore have appreciated that the primary purpose of the classification was as a performance standard for lining materials and might have questioned why that classification was being used in relation to the external surface of a building. Anthony Burd, at the time an official in DCLG, could not explain why it had been decided that a standard devised for internal lining materials had been considered appropriate for assessing the suitability of the surface of an external wall. He agreed that it was not the most suitable standard and as a result we are unable to understand how it could have been considered appropriate.273 Burd {Day238/158:24}-{Day238/161:15}.
75¶6.30 A summary of the guidance given in Approved Document B 1992 on the construction of external walls is set out in the following chart taken from Dr Lane's presentation.
¶Figure 6.2: Chart showing guidance on construction of external walls in ADB 1992
The Building Regulations (Amendment) No. 2 Regulations 1999
¶6.31 The Building Regulations (Amendment) No. 2 Regulations 1999 amended functional requirements B2, B3 and B4 by the re-introduction of the word "adequate". Functional requirement B4(1) therefore provided that external walls were adequately to resist the spread of fire over the walls.274 Todd {CTAR00000001/45-46} paragraph 5.1.35 (iii).
Building Regulations 2000 and Approved Document B 2000
¶6.32 In the Building Regulations 2000 functional requirement B4 was unchanged, but a number of changes were made to the guidance in Approved Document B 2000.
¶6.33 First, it introduced an alternative to meeting the external wall surface classification (shown now in Diagram 40) by reference to Fire Note 9: Assessing the fire performance of external cladding systems: a test method published by BRE in 1999.275 {INQ00014107/89} paragraph 13.5. Fire Note 9 contained a large‑scale test method which had been developed by BRE in the late 1990s as an alternative method of assessing the fire performance of an external wall.
¶6.34 Secondly, the guidance changed in a way that, if it were followed, the requirement of limited combustibility applied only to insulation used in ventilated cavities and not insulation generally.276 {INQ00014107/89} paragraph 13.7 second paragraph. (The restriction did not apply to insulation used in a masonry cavity wall construction). The guidance also provided that advice on the use of insulation in external walls could be found in the BRE report Fire Performance of external thermal insulation for walls of multi-storey buildings BR 135 1988 (first edition).
¶6.35 Thirdly, the definition of a high-rise building was changed from 20 metres to 18 metres, for the purposes of the performance of both external surfaces and insulation.277 {INQ00014107/89-90} paragraph 13.7 second paragraph and Diagram 40(e).
76¶6.36 Importantly, the introductory text to paragraph 13.7 of Approved Document B continued to warn, in reasonably clear terms, that the use of combustible materials in the external wall might present a risk in tall buildings, even though the guidance in Diagram 40 had been satisfied.278 {INQ00014107/89} paragraph 13.7 first paragraph. The reader should have understood, therefore, that the fact that the surface of a cladding material was rated Class 0 might not exclude the risk posed by the use of combustible materials. In other words, following the guidance in Approved Document B might not amount to compliance with the functional requirement.
¶6.37 A summary of the guidance given in Approved Document B 2000 on the construction of external walls is set out in the following chart taken from Dr Lane's presentation.
¶Figure 6.3: Chart showing guidance on construction of external walls in ADB 2000
Approved Document B 2000 with 2002 amendments
¶6.38 In Approved Document B 2000 with 2002 amendments,279 {CLG10000740}. introduced after and as a result of the RADAR (Research on Approved Document B and Revision) project and the harmonisation exercise conducted by the government with the assistance of BRE in 2000 and 2001,280 See Chapter 7 for the detailed analysis. the guidance on the construction of external walls was unchanged, save that the European classification system of fire performance was added as an alternative to the national system. Thus, the guidance contained in Diagram 40 was that any surface over 18 metres from the ground should be national Class 0 or European Class B-s3, d2 or better.281 {CLG10000740/91}. (The references to s3, d2 mean that no limits were set for the production of smoke or flaming droplets.)
Approved Document B 2006
¶6.39 In Approved Document B 2006282 {CLG10000007}. a number of important structural and textual changes were introduced to the guidance on the construction of external walls. Paragraph 12.5 read as follows283 {CLG10000007/95}.:
77"The external envelope of a building should not provide a medium for fire spread if it is likely to be a risk to health or safety. The use of combustible materials in the cladding system and extensive cavities may present such a risk in tall buildings. External walls should either meet the guidance given in paragraphs 12.6 to 12.9 or meet the performance criteria given in the BRE Report Fire performance of external thermal insulation for walls of multi storey buildings (BR 135) for cladding systems using full scale test data from BS 8414-1:2002 or BS 8414-2:2005."
¶6.40 The general warning contained in the first paragraph was similar to that which had appeared in the 1992 and 2000 versions of Approved Document B, but there was now no mention of the fact that the use of combustible materials might present a risk, even though the provisions for external surfaces in Diagram 40 had been satisfied. That important warning had disappeared.
¶6.41 The second paragraph introduced an alternative way in which functional requirement B4(1) might be satisfied. Either the external wall could be constructed in accordance with the guidance set out in paragraphs 12.6-12.9 (sometimes called "the linear route"), or it could be the subject of a large-scale test in accordance with BS 8414, its performance being judged by reference to the criteria set out in BR 135 (2003, 2nd edition). In practice, that meant that combustible materials could be used in an external wall system only if the system intended to be constructed had been tested and met the performance criteria set out in BR 135.
¶6.42 The performance requirement for insulation was also changed so that it read:
"In a building with a storey 18m or more above ground level any insulation product, filler material (not including gaskets, sealants and similar) etc. used in the external wall construction should be of limited combustibility (see Appendix A). This restriction does not apply to masonry cavity wall construction which complies with Diagram 34 in Section 9."284 {CLG10000007/96} paragraph 12.7.
¶6.43 In Chapter 7 below we have explained how the words "filler material…etc." found their way into this part of the guidance. We have also explained our interpretation of that wording, including our conclusion that it did not apply to the polyethylene core of the composite aluminium panels used at Grenfell Tower.
78¶6.44 A summary of the guidance in Approved Document B 2006 on the construction of external walls is set out in the following chart taken from Dr Lane's presentation.
¶Figure 6.4: Chart showing guidance on construction of external walls in ADB 2006
Approved Document B 2007, 2010 and 2013
¶6.45 The guidance on the construction of external walls performance in the 2006 version of Approved Document B remained unchanged in the 2007,285 {CLG10000005}. 2010,286 {CLG00000161}. and 2013287 {CLG00000224}. versions.
¶6.46 A summary of the guidance given in Approved Document B 2013 on the construction of external walls is set out in the following chart taken from Dr Lane's presentation.
¶Figure 6.5: Chart showing guidance on construction of external walls in ADB 2013
79Summary of the external wall requirement/guidance changes over time
¶6.47 Dr Lane helpfully included the following table in her presentation which shows the changes in the external wall requirements as defined in the Building Regulations and subsequently in ADB through time.
¶Figure 6.6: Chart showing changes in the external wall requirements as defined in the Building Regulations and subsequently in ADB through time.
81Chapter 7: The government and the Building Research Establishment
Introduction
¶7.1 In this chapter, we describe the role played by the government in investigating cladding fires and regulating the use of combustible materials in the external walls of high-rise buildings. The name of the department responsible for those matters has undergone several changes during the period with which we are concerned, from the Department of the Environment, Transport and the Regions (from 1997), to the Department for Transport, Local Government and the Regions (from 2001), to the Office of the Deputy Prime Minister (from May 2002), the Department for Communities and Local Government (from May 2006), the Ministry of Housing, Communities and Local Government (from January 2018), the Department for Levelling-up, Housing and Communities (from September 2021 to July 2024) and the Ministry of Housing, Communities and Local Government (since July 2024). In this chapter we refer to it simply as "the department". We also examine the part played in those matters by the Building Research Establishment (BRE). The period covered by this chapter runs from the fire at Knowsley Heights in 1991, widely regarded as the first cladding fire of relevance to what later happened at Grenfell Tower, to the amendment of Approved Document B published in April 2007, the relevant provisions of which remained current at the time of the Grenfell Tower fire, despite later amendments.
¶7.2 Our findings are based on the documents and the evidence of four principal witnesses, Dr Deborah Smith and Dr Sarah Colwell, both employees of BRE, and Anthony Burd and Brian Martin, both officials in the department. Mr Martin was employed by BRE for nine years, during which he was seconded part-time to the department.
Knowsley Heights: 1991
¶7.3 On 5 April 1991 a fire was started in an external refuse area at the base of Knowsley Heights, an eleven-storey block of flats in Huyton, Merseyside. By the time the firefighters arrived, the entire external wall on one side of the building was alight and flames were issuing from windows on all floors and from the roof.288 {BRE00035385/3} paragraph 3.1; {BRE00035385/5} Figure 3.1.1 "External view of the damaged block". Fortunately, there were no fatalities; the fire had spread vertically up an unoccupied area of the building that did not interfere with the escape route289 {BRE00035385/4} third paragraph. and all the residents were safely evacuated.290 {BRE00035385/3} paragraph 3.1.
¶7.4 In 1988 Knowsley Heights had been clad in what was later described by BRE as "Class 0 GRP rainscreen cladding". GRP (Glass Reinforced Plastic) is a combustible polymer material.291 For further details of the GRP panels used at Knowsley Heights, see Bisby, Phase 2 Report {LBYP20000001/94-95} paragraph 465. Behind those panels, a layer of mineral wool insulation had been fixed to the building with a gap between the insulation and the cladding to allow the movement of air.292 {BRE00035385/3} paragraph 3.1. The refurbishment at Knowsley Heights was carried out as part of a pilot scheme run and funded by the government's Housing Management Estates Action programme to improve the appearance of high-rise blocks, to reduce energy consumption and to prevent the damp from which many such buildings suffered at the time.293 {BRE00035385/3} paragraph 3.1.
82¶7.5 The fire was investigated by BRE, then a government-owned laboratory,294 BRE (previously FRS) was Government-owned until it was privatised in March 1997. Field {BRE00043710/6} page 6, paragraph 28; Smith {MET00081237/7} page 7, paragraph 18; Shipp {BRE00047594/6} page 6, paragraph 38; Bisby, Phase 2 Report {LBYP20000001/113} paragraph 592. which produced a report for the department in November 1992 under the Investigation of Real Fires contract.295 {BRE00035385}; the report's authors were Penny Morgan, Derek Jones and Sharon Clinch {BRE00035385/2}. In a section headed "Implications for Building Regulations" BRE drew attention to the absence of cavity barriers in the cladding system and concluded that there was no reason to suggest that cladding in general posed a risk to life unless there were cavities large enough to allow the vertical spread of fire.296 {BRE00035385/5} first paragraph. It also suggested that where the use of a Class 0 cladding material was recommended the material should be Class 0 on both sides exposed to air.297 {BRE00035385/4} fourth paragraph. It also advised that there were implications for the protection of window reveals in circumstances where refurbishment had involved the use of certain types of combustible materials in close proximity.298 {BRE00035385/5} first paragraph.
¶7.6 Notably absent from the report was any reference to the combustibility of the GRP panels themselves or the contribution they had or might have made to the spread of fire. When noting that cavity barriers had not been fitted as part of the system, the report said that the guidance in force at the time allowed them to be omitted if the cladding system was not combustible.299 {BRE00035385/3} penultimate paragraph. Morgan {BRE00043866/18} page 18, paragraph 96; Shipp {BRE00047594/48} page 48, paragraph 237. In the same vein, it noted that the fire had called into question the departmental guidance on cavity barriers because it had spread vertically up the entire height of the building.300 {BRE00035385/4} fourth paragraph.
¶7.7 It is not clear what that guidance was.301 Asked what "DOE/BRE guidance" she had been referring to in the report, one of the authors, Penny Morgan, could not recall; Morgan {BRE00043866/18} page 18, paragraph 97. At the time Knowsley Heights was refurbished, Approved Document B recommended that the external walls of buildings over 15 metres in height should be constructed of materials of limited combustibility.302 {CLG10002325/15} paragraph 2.7; Bisby, Phase 2 Report {LBYP20000001/87} paragraph 424. Cladding used on walls over 15 metres in height could be combustible if it was not relied on to contribute to the fire resistance of the wall and if it was certified Class 0.303 {CLG10002325/15} paragraphs 2.9 and 2.13, Table 2.2. Although Approved Document B did not specifically address cavity barriers in ventilated rainscreen cladding systems, it did recommend that they be fitted in any cavity abutted by a wall, ceiling, roof or floor.304 {CLG10002325/65}; Bisby, Phase 2 Report {LBYP20000001/96} paragraphs 473 - 475. It seems likely, therefore,305 Bisby, Phase 2 Report {LBYP20000001/96} paragraph 480. This view is also supported by the evidence of Martin Shipp and Dr Raymond Connolly, Shipp {BRE00047594/48} page 48, paragraph 238; Connolly {BRE00047667/4} page 4, paragraph 8(b). that BRE was referring there to the first edition of BR 135, which had been produced in the same year as Knowsley Heights had been refurbished (1988) and stated that in ventilated cladding systems constructed of non-combustible materials fire barriers were not essential.306 {BRE00001077/9} paragraph 1, second bullet point. That remained the advice at the time of the fire and could fairly be described as "departmental",307 {BRE00035385/4} fourth paragraph. given that at the time BRE was a governmental organisation. We have not been able to find any other guidance to which that passage could have been referring.
83¶7.8 However, the cladding at Knowsley Heights was not non-combustible and it is therefore difficult to see why BRE said that cavity barriers could be omitted if the cladding was non-combustible. Anyone reading that passage might well understand that the omission of cavity barriers from the system installed at Knowsley Heights was justifiable precisely because it was a non-combustible system, which of course was not the case.
¶7.9 Given the passage of time, very few of those who had been involved in the investigation into the fire or in drafting the report were able to assist us by providing background information, details of the investigation or the thinking behind the report. The only two who could were Penny Morgan, one of BRE's investigators,308 Morgan {BRE00043866/1-16} pages 1, 2 and 16, paragraphs 6, 12 and 83-85. and her line manager, Martin Shipp, who in November 1992 was the Head of BRE's Fire and Security section with responsibility for fire investigations.309 Shipp {BRE00047594/3} page 3, paragraph 14. He was aware of what was going on in relation to the fire at Knowsley Heights, since both Penny Morgan and Derek Jones, both of whom visited the scene of the fire on 10 April 1991,310 Morgan {BRE00043866/31} page 31, paragraphs 174 and 178. reported to him,311 Shipp {BRE00047594/43-45} pages 43-45, paragraphs 205 and 218. but he did not personally take part in the investigation into the fire.312 Shipp {BRE00047594/45} page 45, paragraph 220. However, it is very likely that he reviewed the report both for technical and editorial purposes.313 Shipp {BRE00047594/47} page 47, paragraph 229.
¶7.10 Mr Shipp said that, as he read the report, the authors had been aware that the cladding was combustible, since they had recorded that it had been destroyed.314 {BRE00035385/4} second paragraph. They must therefore have understood that the panels had burnt and therefore were combustible.315 Shipp {BRE00047594/49} page 49, paragraph 245. However, although that is a reasonable analysis of the report, we do not think that it necessarily reflects Penny Morgan's understanding. The tenor of the report suggests that she did not realise that the system was combustible, which would explain the reference to the omission of cavity barriers and the calling into question of the current guidance that cavity barriers were not required in non-combustible systems. If the authors of the report had understood that the fire had been caused by a failure to comply with a requirement for cavity barriers in what was recognised to be a combustible cladding system, there would be no reason for the guidance to be called into question. Instead, we should have expected BRE to have identified and questioned the use of combustible GRP panels.
¶7.11 Penny Morgan told us that she had considered the vertical fire spread to be significant and unusual because a fire that had started at ground level had spread over what was purportedly non-combustible cladding.316 Morgan {BRE00043866/22-23} pages 22-23, paragraphs 125 and 127. It appears that she thought that the GRP rainscreen panels used at Knowsley Heights were non-combustible because they had been certified Class 0.317 Morgan {BRE00043866/21} page 21, paragraph 115; Morgan {BRE00043866/19} page 19, paragraph 105; Morgan {BRE00043866/20} page 29, paragraph 113; Morgan {BRE00043866/24} page 24, paragraph 140. That is supported by a note dated 5 April 1991 from Alison Curtis of the Housing Management Estates Action Division, who had spoken with Penny Morgan by telephone on the day of the fire,318 Morgan {BRE00043866/29} page 29, paragraph 162. in which she said that the cladding system had no vertical fire stopping "in line with BRE recent advice in cases where all materials used in the over cladding and insulation are non-combustible".319 {INQ00014995} paragraph 4.
84¶7.12 Although Penny Morgan's recollection of events so long ago was understandably limited,320 Morgan {BRE00043866/15} page 15, paragraph 80. it seems likely to us that she and the other authors of the report had equated Class 0 with non-combustibility and that others, both in BRE and the department, repeated that error. That might explain why the report produced by BRE in November 1992 contained no analysis of the contribution of the cladding panels themselves to the fire. It might also explain why the report was silent on the combustibility of the panels, their contribution to the vertical spread of fire, their compliance with current guidance or the adequacy of Class 0 as a classification for external walls of buildings over (at the time) 15 metres in height.
¶7.13 On the day of the fire, Penny Morgan was alerted to its outbreak by a telephone call from Alison Curtis, followed by a note which said that the fire was of particular interest to the department because the building had been overclad using techniques that were relatively new to public sector housing and were currently being used on other blocks.321 {INQ00014752} paragraph 1. Ms Curtis also referred in the note to concerns about the innovative and high profile nature of the improvements to the block.322 {INQ00014752} paragraph 4. A second, handwritten, note dated 11 April 1991 from "Lyn" to "Mr Sage" contains the following comment,
"We have received, via HMEA,323 Housing Management Estates Action Division. a request from M. St Press Office [the department's press office]324 Morgan {BRE00043866/32} page 32, paragraph 187. Bisby, Phase 2 Report {LBYP20000001/105} paragraph 543. to play down the issue of the fire. Our briefing for [the Secretary of State] is purely factual and as far as I am aware Knowsley will not be making an issue of the fire."325 {INQ00014755}.
¶7.14 In the light of the fact that other high-rise residential buildings had been, and were still being, overclad using the same or similar materials under the department's programme,326 {INQ00014752} paragraph 1; {INQ00014995} paragraphs 1-12. we find it difficult to understand why the press office thought it necessary to play down the fire at Knowsley Heights.
¶7.15 The failure by the BRE's investigators to understand the distinction between combustibility and Class 0 was a basic error. In our view, the fire represented a significant opportunity for the department, and perhaps industry more widely, to recognise and respond to the fact that the use of combustible cladding panels on high-rise buildings, even where the surface of those panels was certified as Class 0, might lead to the uncontrolled spread of fire to the full height of the building if fire were to take hold in the external wall. If that and the tendency of many in the industry to treat Approved Document B as containing a definitive statement of what was required had been more clearly recognised, it might, and indeed should, have prompted consideration whether Class 0 was a suitable standard to include in Approved Document B for cladding panels used on high-rise buildings.
85¶7.16 The fire at Knowsley Heights was frequently referred to in BRE reports and presentations327 {BRE00043751/5} "The most significant of the historic fires is that of the 1991 fire in Knowsley Heights."; {CLG00019445/3} second paragraph, "One of the most significant of the historical fires is the 1991 fire in Knowsley Heights.". and by witnesses328 Crowder {Day230/158:21-25} "…one of, you know, the major fires in terms of understanding external fire spread"; Colwell {MET00080530/8} page 8 "...those fires were our anchor points. They were the reference points that we were using in terms of moving guidance and understanding"; Martin {Day250/76:17-23}; Smith {Day234/129:5-12}. as an event of major significance in the understanding of the spread of fire across the external walls of high-rise buildings. However, when asked why it was of such significance, Dr Crowder (who in 2014 was appointed to lead the fire investigation business group at BRE)329 Crowder {BRE00043716/50} page 50, paragraphs 164-165. reiterated that the key factor was the absence of cavity barriers.330 Crowder {Day230/158:25}-{Day230/160:15}; {Day230/182:2-10}. He went so far as to say that, if the cladding system at Knowsley Heights had included cavity barriers, the fire would probably not have spread to anything like the same extent.331 Crowder {Day230/182:8-10}; Martin {Day250/77:20-22} "I'm pretty sure the focus was on undivided cavities". That suggests to us that, even with the benefit of hindsight, some in BRE had not recognised that the combustibility of the cladding panels themselves had been an important factor in the development of the fire.
¶7.17 Dr Sarah Colwell, who became involved in BRE's large-scale testing programme in 1996,332 Colwell {BRE00047571/2} page 2, paragraph 9. In 1991, Dr Colwell was a Higher Scientific Officer in the BRE's Explosion Protection section: Colwell {BRE00047571/2} page 2, paragraph 6. By 2016, Dr Colwell was the Director of the Fire Suppression Team, Colwell {BRE00047571/3} page 3, paragraph 14. told us that one of the lessons from the fire was that the testing of individual components of a cladding system could not tell one much about its overall performance in fire,333 Colwell {Day231/127:1-14}. and it appears that following the fire at Knowsley Heights both the department and BRE accepted334 Smith {Day234/130:15-22}. that a large-scale fire test method was needed to provide a better means of assessing and controlling the potential fire hazards associated with external cladding systems.335 Smith {BRE00005624/8} page 8, paragraph 24. The department therefore funded further research by BRE into large-scale testing,336 Smith {BRE00005624/8} page 8 paragraph 25. Dr Sarah Colwell agreed that it was the fire at Knowsley Heights that led to funding for further research on large-scale testing, Colwell {Day231/128:24} -{Day231/129:2}. a subject to which we return below.
¶7.18 However, even if the department had recognised that small-scale testing (such as the methods used to determine Class 0) was not adequate to assess the danger of the spread of fire over the walls of high-rise buildings, it does not appear that at that stage it gave any consideration to restricting the use of combustible cladding on high-rise buildings. Other than including in paragraph 12.7 a general warning of the risks involved in the use of combustible materials,337 {BLA00005482/74} paragraph 12.7, "The use of combustible materials for cladding framework, or of combustible thermal insulation as an overcladding or in ventilated cavities, may present such a risk in tall buildings, even though the provisions for external surfaces in Diagram 36 may have been satisfied". no action was taken in that regard in the revised version of Approved Document B, published in 1992.338 {BLA00005482}. Instead, the only practical action taken was to strengthen the guidance on the use of cavity barriers339 {BLA00005482/2} Section B3, paragraph w; {BLA00005482/64}; Crowder {Day230/159:9-14} and {RCO00000001/7} second paragraph. and to provide that the panels forming the external walls of buildings over 20 metres in height should have Class 0 surfaces on both sides.340 {BLA00005482/74} paragraphs 12.5- 12.6; {BLA00005482/75} Diagram 36; Martin {Day250/73:17-22}. Those amendments directly reflected the contents of BRE's report on the fire at Knowsley Heights.
861994: Dr Raymond Connolly's ten large-scale tests
¶7.19 In 1993, the department commissioned BRE to examine the hazards associated with external cladding systems and to assess the influence of a range of fire barriers on both the fire hazard and on the movement of air within the cavity in relation to the control of damp.341 {RCO00000001/3} penultimate paragraph; {RCO00000001/7} points (i)-(iii). The research was carried out by Dr Raymond Connolly, a Senior Scientific Officer in BRE's Structural Fire Protection section,342 Connolly {BRE00047667/1} page 1, paragraph 2(b). and was published on behalf of the department in 1994.343 {RCO00000001}. He designed and carried out full-scale tests on ten different external cladding systems344 {RCO00000001/12} section 3. chosen as representative of systems in use at the time.345 Connolly {BRE00047667/9} page 9, paragraph 21(d). The four-storey (nine metre high)346 {RCO00000001/46} section 4.2.3 final paragraph. test rig had been designed specifically for the purpose of the tests.347 {RCO00000001/8} section 2.1.
¶7.20 In his statement Dr Connolly said that the purpose of the research had been to develop a means of examining all the relevant variables in a holistic manner by full-scale testing, rather than by relying on tests of individual components.348 Connolly {BRE00047667/9} page 9, paragraph 21(g)(ii). In the opening paragraph of his report, however, he had said that the purpose of the work had been to assess the effectiveness of fire barriers349 {RCO00000001/3} first paragraph. and in that context to develop the most appropriate heat source for large-scale testing.350 Connolly {BRE00047667/9} page 9, paragraph 21(a). That suggests that at that stage the department was still more interested in learning how to limit the spread of flame by the use of cavity barriers than in assessing the combustibility of different products. That is significant because successive versions of the large-scale test method that became BS 8414 were all derived directly from Dr Connolly's original work.351 The theoretical basis of Fire Note 3 "is as set out in Dr Connolly's 1994 report", Colwell {BRE00047571/11} paragraph 63; {Day231/132:15-22}; {Day231/152:14-17}. Fire Note 9 simply incorporated the method in Fire Note 3 and contained no changes to the method or the assessment criteria, Colwell {BRE00047571/19} paragraph 127; {BRE00047571/21} paragraph 138; {Day231/200:8}-{Day231/201:16}. The BS 8414 test series represented the adoption by the British Standards Institution of the test method set out in Fire Note 9, Colwell {BRE00047571/26} paragraph 168; {Day232/135:6-15}. The test method did not change between Fire Note 9 and BS 8414, though the classification element of Fire Note 9 was removed and published separately in the second edition of BR 135, Colwell {BRE00047571/29} page 29, paragraph 184 and {Day232/139:21}-{Day232/140:1}.
¶7.21 The second of the ten tests was carried out on a system comprising 6mm polyester glass reinforced sheeting with a Class 0 certification, mineral wool insulation and no cavity barriers. The object was to examine the need for fire barrier protection. Dr Connolly expected the fire hazard to be limited by the fire properties of the cladding sheet material (i.e. its Class 0 rating).352 {RCO00000001/16}. After the test, however, he reported unlimited spread of the fire over the full height of the test facility353 {RCO00000001/18} final paragraph. and that flames had reached the level of the roof 15 minutes after ignition of the crib.354 {RCO00000001/17} Plate 6. He also reported more generally that the polyester- bound sheet Class 0 cladding, which had been used in eight of the ten tests,355 {RCO00000001/12} section 3. had suffered from extensive surface spread of flame in nearly all configurations,356 {RCO00000001/46} section 4.2.3 second paragraph. often spreading to the top of the test facility,357 {RCO00000001/46} section 4.2.3 final paragraph. and that fire barriers had not been not completely effective in any test.358 {RCO00000001/46} section 4.2.3 second paragraph.
87¶7.22 Dr Connolly considered it clear that BS 476 Parts 6 and 7 (i.e. the tests relevant to a Class 0 classification) did not accurately reflect the fire hazards that might be associated with cladding systems.359 {RCO00000001/46} section 4.2.3 fourth paragraph. Furthermore, in his overall conclusions he recorded that the way in which cladding materials reacted to fire in small-scale tests did not reflect the fire hazard associated with a full-scale system360 {RCO00000001/48} paragraph 8. and were an inadequate measure of the hazard if used in isolation.361 Connolly {BRE00047667/13} page 13, paragraph 24(c)(i).
¶7.23 Dr Connolly told us that that was neither new or surprising; it simply confirmed what had already been suspected and what he understood already to have been publicly recognised by the department,362 Connolly {BRE00047667/12} page 12, paragraph 23(g). albeit in what he described as an "open-ended"363 Connolly {BRE00047667/12} page 12, paragraph 23(g). general warning in Approved Document B that Class 0 might not provide adequate assurance of safety. It is surprising, therefore, that the department took no action, either then or for many years after, to amend the guidance in Approved Document B to take account of what was known to be the unsuitable nature of Class 0 as a standard for assessing the spread of flame over an external wall. That is particularly so when the cladding systems used by Dr Connolly in his tests had been chosen precisely because they were then in current use on high-rise buildings.
¶7.24 There is no evidence that anyone in the department gave any consideration to introducing a recommendation that only non-combustible materials be used in the construction of external walls of high-rise buildings. Dr Connolly did not think that was necessary364 Connolly {BRE00047667/16} page 16, paragraph 25(f)(i). and neither he, nor it seems anyone else, thought that there was a need to take action as a matter of urgency.365 Connolly {BRE00047667/13-14} pages 13-14, paragraph 24(c)(ii). He considered that the results of the tests that BRE had carried out confirmed the need for a full-scale test to enable evaluation of a complete system366 Connolly {BRE00047667/12} page 12, paragraph 23(f). and that BRE should develop such a test. He envisaged that Approved Document B would then be amended to require external wall systems used on high-rise buildings to pass that test.367 Connolly {BRE00047667/12-13} pages 12-13, paragraphs 23(g)(i) and 24(c)(ii).
1996–1998: Fire Note 3
¶7.25 In the years that followed, staff at BRE (including Dr Connolly368 Connolly {BRE00047667/17} page 17, paragraphs 26(c) and 27(b). and Dr Colwell369 Colwell {Day231/155:6-10}.) worked on the development of a large-scale test method for the fire performance of external cladding systems. That method was initially known as Fire Note 3, which was submitted to the department in 1996370 Colwell {BRE00047571/18} page 18, paragraph 120; Colwell {Day231/179:25} - {Day231/181:4}. and published in 1998.371 {BRE00005868}. It built on the work Dr Connolly had done in 1994372 Colwell {Day231/150:3-5}; {Day231/152:14-17}. and adopted the theoretical basis of his experimental research.373 Colwell {BRE00047571/11} page 11, paragraphs 63 and 67. Following various additional tests on various types of rainscreen cladding and insulated renders (no records of which have been provided to us)374 Colwell {Day231/150:3-5}; Colwell {BRE00047571/11} page 11, paragraphs 61, 62 and 67; Colwell {Day231/161:24} -{Day231/162:22}. and discussions with the department and other interested bodies,375 Colwell {Day231/173:6-11}. three performance criteria were eventually selected against which the performance of a system was to be evaluated: mechanical performance, external fire spread and internal fire spread.376 {BRE00005868/9} paragraph 10.1; Colwell {BRE00047571/12} page 12, paragraph 68.
88¶7.26 No pass or fail criteria were set for mechanical performance.377 {BRE00005868/10} paragraph 10.5; Colwell {BRE00047571/12} page 12, paragraph 68. Fire Note 3 simply stated that observation should be made of any collapse or partial collapse judged to be hazardous.378 {BRE00005868/10} paragraph 10.5. Dr Connolly, who said that he had no specific recollection of the evolution of, or the reasoning underlying, the test method,379 Connolly {BRE00047667/17-18} pages 17-18, paragraphs 27(b) and 27(e). thought that that might have been the result of a comparison with glazing systems, which were not required to exhibit any mechanical resistance when exposed to fire.380 Connolly {BRE00047667/19} page 19, paragraph 27(k). By contrast, Dr Colwell told us that it had proved too difficult to set criteria for mechanical performance because that depended very much on the particular system.381 Colwell {Day231/168:9-15}; {Day231/177:15}-{Day231/178:1}. It was therefore left to the end-user to assess the significance of whatever signs of collapse had been observed.382 Colwell {Day231/178:1-9}.
¶7.27 In relation to both the external and internal spread of fire, Fire Note 3 provided that failure would occur if the temperature of the relevant thermocouples at certain levels on the test rig exceeded 600 degrees for a period of at least 30 seconds within 15 minutes of the start of the test.383 {BRE00005868/9} paragraphs 10.3 and 10.4. Although Dr Colwell was asked to explain the basis on which each of those criteria had been chosen,384 Colwell {Day231/168:25}-{Day231/169:18}; {Day231/170:21}-{Day231/171:12}; {Day231/173:12}-{Day231/174:7}. she was unable to give us any precise information.385 Colwell {Day231/174:11}-{Day231/175:24}. Ultimately, she agreed that she and the other authors of Fire Note 3 had worked collaboratively and had sought to reach a consensus on its contents. The criteria they had adopted were generally accepted as suitable by those involved in testing of that kind,386 Colwell {Day231/176:19-23}. by which we understood her to mean that the department considered them to reflect an acceptable degree of risk. Dr Connolly had a rather vague recollection that he and his manager, Tony Morris,387 Tony Morris was Dr Raymond Connolly's immediate line manager: Connolly {BRE00047667/2} page 2, paragraph 3(c). He supervised the work on and was one of the authors of Fire Note 3: Smith {Day234/159:3}-{Day231/160:1}. had calculated that flames spreading vertically at the rate of 2.5 metres in 15 minutes from a level of 2.5 metres immediately above the source of the fire388 2.5 metres was chosen as representative of the minimum height between storeys, Connolly {BRE00047667/18-19} pages 18-19, paragraph 27(j). did not represent undue fire spread, but he could not remember how or on what basis that calculation had been made.389 Connolly {BRE00047667/18-19} pages 18-19, paragraph 27(j). We have been left with the impression that the criteria emerged from discussions among those involved in the process without being supported by any specific data or calculations.
891999: the Garnock Court fire
¶7.28 On 11 June 1999, a fire broke out in a flat on the fifth floor390 {BRE00035375/4}. of Garnock Court, a fourteen- storey391 {BRE00035375/3} second paragraph. block of flats in Irvine, North Ayrshire, Scotland. By the time firefighters arrived the fire had spread externally up the face of the building to the eighth floor. It continued to spread rapidly thereafter, eventually enveloping a vertical section of the external face from the fifth floor to the roof.392 {BRE00035375/4} third paragraph; {BRE00035375/11} Figure 3.1.3.13 and Bisby, Phase 2 Report {LBYP20000001/126} Figure 15. Three residents were rescued from the seventh floor of the block, several were evacuated safely and one, who had been in the flat where the fire had started, died.393 {BRE00035377/5} section 1 first paragraph; {BRE00035377/8} section 3.2.3.
¶7.29 Garnock Court had been built in 1968394 {BRE00035375/3} second paragraph. and was one of a group of five blocks that had been refurbished in 1991 in an attempt to solve problems of damp.395 {BRE00035375/3} fourth paragraph. As part of that work, glass reinforced polymer (GRP) spandrel panels had been used to clad certain parts of the external walls396 Bisby, Phase 2 Report {LBYP20000001/123} paragraphs 634-635. together with new windows, each of which had been enclosed in a GRP "pod".397 {BRE00035375/3} penultimate paragraph.
¶7.30 BRE, which had become a commercial organisation in 1997, was asked by North Ayrshire Council to investigate the fire.398 {BRE00035375/3} first paragraph; {BRE00035377/5} section 1 first paragraph. It produced two confidential reports dated 8 September 1999399 Report 79902 {BRE00035377/2-13}. and 5 May 2000.400 Report 81310 {BRE00035377/22-56}. The investigation was undertaken in phases and was carried out by Penny Morgan, Brian Martin (both of whom reported at the time to Martin Shipp)401 Shipp {BRE00047594/8-70} pages 8 and 70, paragraphs 47 and 380. and Tony Morris.402 {BRE00035377/2}; {BRE00035377/5} section 2 first paragraph; {BRE00035377/22}. The reports were approved by Nigel Smithies, then BRE's Fire Safety business group manager.403 Shipp {BRE00047594/7} page 7, paragraph 45. This group had responsibility for fire investigations and for the Investigation of Real Fires contract with the department, Shipp {BRE00047594/23} page 23, paragraph 116.
¶7.31 After some years working in construction, first as a carpenter, then as a site manager and finally for nine years as a building control officer,404 Martin {Day250/6:12}-{Day250/7:16}. Brian Martin joined BRE in 1999405 Martin {Day250/15:2-5}. as an expert on the Building Regulations specialising in fire.406 Field {BRE00043710/8} page 8, paragraph 39; Martin {Day250/18:8-14}. It is unclear to us how he was chosen for that position or what experience he had in fire safety matters. He had no fire engineering qualifications and could tell us only that his experience in fire safety came from his nine years working as a building control officer.407 Martin {Day250/18:12-19}. Very shortly after he joined BRE Mr Martin was seconded part-time to the department's Building Regulations Division as the lead consultant providing technical support on fire safety, principally working and advising on Part B of Schedule 1 to the Building Regulations and Approved Document B.408 Martin {CLG00019469/2} page 2, paragraph 6; Martin {Day250/25:11-23}. He remained in that dual role, dividing his time about equally between BRE and the department,409 Martin {Day250/22:20-24}. for nine years until September 2008, when he joined the department full-time as the Principal Construction Professional in the Building Regulations Division.410 Martin {Day250/29:23}-{Day250/30:3}. He worked in that role until November 2017.411 Martin {Day250/39:2-5}. During that period Mr Martin played a central role in reviewing, drafting, implementing and shaping government guidance and policy on the Building Regulations as they related to fire safety. During the period in which BRE was working on the fire at Garnock Court, Brian Martin therefore had one foot in the department and one in BRE. It is not clear whether any of those involved recognised the risk that Mr Martin's involvement might result in the department's interests influencing the advice it obtained from BRE, or if so, how that risk should be managed.
90¶7.32 Separately from its reports into the fire at Garnock Court for North Ayrshire Council, BRE produced a report for the department under the Investigation of Real Fires contract.412 We explain that project in more detail in Chapter 8. The report, dated August 2000,413 {BRE00035375}. was written by Penny Morgan414 {BRE00035375/2}. and submitted to Anthony Burd, then Principal Fire Safety Professional at the department.415 Burd {CLG00019461/1-2} pages 1-2, paragraph 4. As we explain below, the contents of that third report replicated the first report to North Ayrshire in September 1999 almost verbatim, save in two key respects.
¶7.33 In contrast to the report into the fire six years earlier at Knowsley Heights, the report produced by BRE into the fire at Garnock Court416 8 September 1999 {BRE00035377}. recorded in clear terms the contribution of the GRP cladding, which it identified as the main material involved in the fire.417 {BRE00035377/10} section 4, first paragraph. It said that the GRP panels had been ignited by the fire plume spilling from the living room of the fifth floor flat in which the fire had started418 {BRE00035377/4} paragraphs 1 and 2. and that the GRP had then generated a self- propagating fire.419 {BRE00035377/10} section 4, first paragraph. It recorded rapid external fire spread to the full height of the building, with full involvement of the GRP cladding within 15 minutes, and noted that the even burning of the GRP cladding and the production of flames and dense black smoke indicated the involvement of the GRP alone.420 {BRE00035377/7} first paragraph. Investigators were able to make these observations from video footage of the fire captured on security cameras, {BRE00035377/5} Section 2, second paragraph; {BRE00035379/12} paragraphs 3-5. In a section dealing with the remedial measures planned for the five blocks in Irvine, BRE suggested that non-combustible materials should be chosen wherever possible.421 {BRE00035377/10} section 4, paragraph 6.
¶7.34 BRE noted that, in order to comply with the provisions of Approved Document B at the time, the cladding panels should have been certified Class 0422 {BRE00035377/10} section 5, paragraph 4. and expressed doubt about whether in their aged state at the time of the fire the panels met that requirement.423 {BRE00035377/10} section 4, second paragraph and section 5, paragraph 5. For that reason, BRE recommended a series of tests on undamaged samples of the panels to assess (amongst other things) their surface spread of flame and fire propagation characteristics.424 {BRE00035377/10} section 5, paragraph 6.
91¶7.35 To that end, on 16 February 2000 BRE carried out tests in accordance with BS 476 Part 6 on three specimens425 {BRE00035377/38} paragraph 4.1. from the panels.426 {BRE00035377/37}. They reacted so badly427 The sample (tested as three specimens) achieved a fire propagation index of 20.8 {BRE00035377/42} paragraph 8. that they put the integrity of the test equipment itself at risk. Following that test, BRE decided to abandon any further testing of the GRP panels in accordance with BS 476 Parts 6 or 7. It was clear from that test alone that the GRP panel would not obtain a Class 0 classification.428 {BRE00035377/26} "Results of Test 2". Shipp {BRE00047594/74-75} pages 74-75, paragraph 416. As a result, BRE concluded not only that it was highly unlikely that the panels used at Garnock Court had been Class 0 at the time of the fire but also that it was highly unlikely that the panels would ever have obtained a Class 0 classification.429 {BRE00035377/29} paragraphs 1 and 2. In other words, the fire at Garnock Court was primarily caused by a failure to follow the statutory guidance then in force.430 As BRE noted in an internal outline document for the report for North Ayrshire, "Can we say that we think they were sold a pup?": {BRE00035380/18}; Martin {Day250/135:7-20}.
¶7.36 Despite its obvious importance, neither that finding nor any mention of the test on the GRP panels in accordance with BS 476 Part 6 was included in the report BRE sent to the department in August 2000.431 {BRE00035375}. In fact, that later report contained no reference at all to Class 0. Having examined the two reports carefully, we think that in at least one case432 {BRE00035377/6} section 3.1.1 as compared with {BRE00035375/4} first paragraph, where the words "either... or Class 0" from the former has clearly been removed in the latter. (and probably in all the others) the reference to Class 0 must have been deliberately removed from the text of the later report, which otherwise reproduces the earlier one.433 Bisby, Phase 2 Report {LBYP20000001/134-136} paragraphs 704-710. We have been unable to determine why or by whom the changes were made, not least because none of the witnesses was able to shed any light on the matter.
¶7.37 Penny Morgan, one of the authors of the reports provided to North Ayrshire Council and the sole author of the report provided to the department, could not remember how the references to Class 0 had been omitted from the report she had sent to the department in August 2000, although she said that if there had been a conscious decision to remove them, she would have remembered it.434 Morgan {BRE00043866/51} page 51, paragraphs 302 and 303. Brian Martin, the other author of the report provided to North Ayrshire Council in September 1999, had no recollection of reading either the report given to the department or the second report given to North Ayrshire Council.435 Martin {Day 250/112:12-21}; {Day250/115:6-13}. He told us that he knew nothing about the removal of any reference to Class 0 from the report to the department, had not been aware of it at the time or since436 Martin {Day250/118:23}-{Day250/119:17}; {Day250/137:16-24}. and could offer no explanation for the discrepancy between the reports.437 Martin {Day250/118:13-22}; {Day250/157:11-16}. Their line manager, Martin Shipp, could not recall whether he had read or reviewed the reports to North Ayrshire Council at the time438 Shipp {BRE00047594/70} page 70, paragraph 383. and did not know whether a decision to remove references to Class 0 had been made.439 Shipp {BRE00047594/78} page 78, paragraph 432.
¶7.38 Martin Shipp's evidence that the report given to the department contained no more than a factual description of the findings of the investigation440 Shipp {BRE00047594/78} page 78, paragraph 430. does not provide an answer to the mystery. The fact that the panels did not meet the requirements of Class 0 was the key finding, as Mr Martin agreed.441 Martin {Day250/135:7-20}. Even if Mr Shipp's suggestion that that report (although dated August 2000) could have been written before the reports for North Ayrshire Council442 Shipp {BRE00047594/78} page 78, paragraph 431. were correct, it would not explain why BRE did not amend the text to include the important finding that the GRP panels did not meet the requirements of Class 0 before sending it to the department in August 2000. Mr Martin accepted that that the absence of any reference to Class 0 in the report sent to the department was strange,443 Martin {Day 250/137:20}; Martin {Day250/157:15} "It does seem odd". but denied that the references had been removed on the instructions of either the department or BRE.444 Martin {Day250/118:18-22}.
92¶7.39 Equally surprising, if true, is the fact that, as Brian Martin told us, he did not discuss BRE's findings about the cladding panels with Mr Burd, to whom he reported at the time445 Martin {Day250/24:14-16}. and with whom he worked closely throughout the period.446 Martin {Day250/127:18-23}; {Day250/128:14-22}; {Day250/136:21}-{Day250/137:8}. Anthony Burd told us that he had not previously seen BRE's second report to North Ayrshire Council dated 5 May 2000, which contained the results of its tests.447 {BRE00035377/22}; Burd {Day238/136:20-25}. Mr Burd was concerned by the absence of any reference to Class 0 in the report to the department.448 Burd {Day238/142:2-7}. He said that it was imperative that the department should receive the fullest information about fires investigated for it by BRE.449 Burd {Day238/143:8-11}. Following the fire neither the department nor (so far as we are aware) any other authority carried out any investigation into the use of cladding panels that did not comply with existing guidance,450 Martin {Day250/137:25}-{Day250/140:17}. but without some kind of investigation the department could not have known whether the problem was limited to the refurbishment of the blocks in Irvine or was more widespread.451 Martin {Day250/140:6-17}. Viewing the evidence in the round, we think it much more likely than not that the omission of any reference to Class 0 in the report to the department was deliberate, but we are unable to identify the person responsible for it or the reason why the information was suppressed.
¶7.40 There was a second important omission from the report to the department, namely, the suggestion that non-combustible materials should be used wherever possible, which had been included in the second report to North Ayrshire.452 Compare {BRE00035377/10} Section 4, third paragraph "The remedial measures planned for the high-rise blocks in Irvine should address the problems identified i.e. damp penetration and the avoidance of an external route for fire spread. We suggest that non-combustible materials are chosen wherever possible" with {BRE00035375/7} fifth paragraph "The remedial measures planned for the high-rise blocks in Irvine should address the problems identified i.e. damp penetration and the avoidance of an external route for fire spread". Again, none of the witnesses could explain that.453 Martin {Day250/136:21}-{Day250/137:8}. We accept that the suggestion was probably directed to the remedial work at the five blocks in Irvine,454 Martin {Day250/125:12-19}. but we are nonetheless surprised that BRE did not advise the department that only non-combustible materials should be used in the construction of the external walls of high-rise buildings and that the department itself did not consider the implications of using combustible materials in the context of the Building Regulations and guidance.455 Martin {Day250/143:15-21}; {Day250/125:12-19}.
¶7.41 We find those omissions surprising when considered against the background of the fire at Knowsley Heights, which was not a case of a failure to comply with the recommendation in the Approved Document for the use of Class 0 materials, and the apparently clear understanding that the panels used at Garnock Court had been highly combustible.456 Martin {Day250/101:2-5}; {Day250/131:15-19}; Burd {Day239/135:23-25}; Morgan {BRE00043866/44} page 44, paragraphs 264 and 266. They were particularly surprising, given that Mr Martin himself told us that one of the most important lessons drawn from the fire at Garnock Court had been not to use combustible cladding.457 Martin {Day250/102:10-14}. In contrast to his colleagues Martin Shipp,458 Shipp {BRE00047594/66} page 66, paragraphs 354 and 356. Dr Smith, Dr Colwell459 Colwell {Day231/130:13-17}; {Day231/131:15}-{Day231/132:2}. and Dr Connolly,460 Martin {Day250/93:10-17}. Brian Martin did not share the view (which on their evidence had become widely accepted following the fire at Knowsley Heights) that Class 0 was an inadequate standard for assessing or controlling the danger of fire spreading across the external walls of high-rise buildings. He had regarded Class 0 as a reasonable form of control461 Martin {Day250/124:6-14}; {Day250/126:15}-{Day250/127:5}. and told us that he had never seen the report produced by Dr Connolly in 1994.462 Martin {Day250/93:5-11}.
93¶7.42 The section of BRE's report to the department entitled "Implications for the Building Regulations" stated only that the matter had been thoroughly explored by a Select Committee.463 {BRE00035375/7} final paragraph. In fact, by August 2000, a Parliamentary Select Committee had recommended that the full-scale test and performance criteria developed by BRE that were subsequently adopted by the British Standards Institution as BS 8414 should be substituted in Approved Document B for the previous requirements relating to the fire safety of external cladding systems.464 {CLG00019478/9-10} paragraph 20. However, as BRE was well aware by August 2000, that recommendation had not been implemented by the department.465 {CLG10000347/2-3} paragraphs 8-11.
Fire Note 9
¶7.43 In 1999, BRE published Fire Note 9,466 {CTAR00000019}. a revised version of the test method that had been set out in Fire Note 3.467 {BRE00005868}. Fire Note 9 was written by Dr Colwell and David Smit, who at the time was a laboratory technician and therefore junior to her.468 Colwell {Day231/198:13-16}. As Dr Colwell explained,469 Colwell {BRE00047571/19-21} pages 19-21, paragraphs 127 and 134-135; Colwell {Day231/200:8}-{Day231/202:7}. Fire Note 9 contained no technical or substantive changes to the test method or assessment criteria set out in Fire Note 3. Similarly, the drafting of Fire Note 9 did not involve any reconsideration of the theoretical basis for the test method. The only revisions to Fire Note 3 were the inclusion of a definitions section,470 {CTAR00000019/4} section 3. a sample graph (for showing the determination of test start time and temperature)471 {CTAR00000019/10}. and a maximum thickness for test samples to ensure that samples would fit on to the test facility.472 {CTAR00000019/4} clause 1.2.
1999: recommendations of the Parliamentary Select Committee
¶7.44 Following the fire at Garnock Court, the Environment, Transport and Regional Affairs Select Committee,473 {CLG00019478/2} for a list of members of the Committee. acting through its Environment sub-committee, established an inquiry to examine the potential risk of the spread of fire through external cladding systems.474 {CLG10000349/1}. The Select Committee heard evidence on 20 July 1999 from a variety of witnesses,475 {CLG10000349/4}. including witnesses from BRE476 {CLG10000349/19-22}. and the department.477 {CLG10000349/32-37}. It also received memoranda from the department478 {CLG10000349/29-32}. and several other organisations.479 The memoranda are listed at {CLG10000349/3} and included either as appendices to the minutes of evidence {CLG10000349/39-51} or within the evidence {CLG10000349/5-11}; {CLG10000349/17-18}; {CLG10000349/23}; {CLG10000349/29-32}.
94¶7.45 The Select Committee reported on 14 December 1999.480 {CLG00019478}. It concluded that the evidence it had heard did not suggest that the majority of external cladding systems currently in use in the UK posed a serious threat to life or property in the event of fire481 {CLG00019478/9} paragraph 18. and it made a number of recommendations. Notwithstanding that conclusion, however, it added that it did not believe that it should take a serious fire in which many people were killed before all reasonable steps were taken towards minimising the risks and it went on to note that the evidence it had heard strongly suggested that the small-scale tests then in use to determine the fire safety of external cladding systems were not fully effective in assessing the performance of such systems in a fire.482 {CLG00019478/9} paragraph 19. (Those small-scale tests included the BS 476-6 and BS 476-7 tests which supported the Class 0 classification.) The Select Committee noted that the department had said that Fire Note 9 would be referred to in Approved Document B but pointed out that that would represent only one of the ways of ensuring that the system complied with the Building Regulations and would not amount to a requirement that cladding systems pass the test.483 {CLG00019478/9} paragraph 17. The Select Committee therefore expressed the view that all external cladding systems should be required either to be entirely non-combustible or be proved through full-scale testing not to pose an unacceptable level of risk through the spread of fire484 {CLG00019478/9-10} paragraph 20. and recommended that compliance with Fire Note 9 be substituted in Approved Document B for the existing requirements relating to the fire safety of external cladding systems.485 {CLG00019478/9-10} paragraph 20 and {CLG00019478/7-8} paragraphs 9-10 and 12. The Select Committee's recommendation was therefore clear: that only non-combustible materials should be used, unless the entire construction had been tested as a complete system and met the performance criteria in Fire Note 9.
2000: The department's response
¶7.46 However, the Select Committee's recommendation was not implemented. Instead, in the revised edition of Approved Document B that was published in January 2000 and came into force on 1 July 2000486 {INQ00014107}. the guidance in the 1992 edition that the external surfaces of walls of high-rise buildings should be Class 0487 {BLA00005482/74-75} paragraphs 12.5, 12.6 and Diagram 36. remained unchanged,488 {INQ00014107/89-90} paragraphs 13.5, 13.6 and Diagram 40. although Fire Note 9 was referred to as an alternative to meeting the provisions of Diagram 40, which contained the Class 0 guidance.489 {INQ00014107/89} Note to paragraph 13.5.
95¶7.47 In his response to the Select Committee on 6 April 2000,490 {CLG10000347}. the Rt Hon Nick Raynsford MP, Parliamentary Under Secretary of State and Minister for Construction at the time,491 Raynsford {CLG00035627/3-4} pages 3-4, paragraphs 6-7. who had given evidence before the committee, explained that decision on behalf of the department.492 {CLG10000347/3} paragraph 9. He said that during its review of the 1992 edition of the Approved Document, which had been completed by December 1999,493 {CLG10000347/2} paragraph 5. there had been no suggestion that the existing guidance was insufficient or that, if followed, it would tend to create an unsafe situation.494 {CLG10000347/2} paragraph 6. Mr Raynsford also said that when Fire Note 9 had been adopted as a British Standard and Approved Document B had been amended to reflect the new status of the test method, the department would consider whether the reference to that method of demonstrating compliance should be strengthened.495 {CLG10000347/3} paragraph 11.
¶7.48 In the event, there is no evidence that the department ever considered strengthening the reference to full-scale testing in 2002 when the European supplement to the Approved Document was published and references to European test methods were incorporated into Diagram 40.496 {CLG10000740/90-91} paragraphs 13.5, 13.6 and Diagram 40; Martin {Day250/166:2-15}. In fact, for the purposes of that review it was agreed by the members of the working party that consideration of any amendments to Approved Document B for the 2002 revision would be limited to facilitating the process of harmonisation and would not involve reconsideration of any of the general technical guidance.497 {CLG10000508/2} paragraph 7; Martin {Day250/166:13-15}. Nor have we seen evidence that any serious consideration was given to adopting the Select Committee's recommendation in the reviews, consultations or discussions leading to the publication of the 2006,498 {CLG10000007/95-97} paragraphs 12.5, 12.6 and Diagram 40. 2007,499 {CLG10000005/98-100} paragraphs 12.5, 12.6 and Diagram 40. 2010500 {CLG00000161}. or 2013501 {CLG00000224/95-97} paragraphs 12.5, 12.6 and Diagram 40. editions of Approved Document B. In all those editions the guidance continued to refer to a Class 0 surface as an appropriate standard for external cladding on high-rise buildings. Meeting the criteria in BR 135 following full-scale testing in accordance with BS 8414 was included as an alternative.502 Burd {Day238/177:18-25}; Martin {Day250/167:6-16}.
¶7.49 Largely due to the passage of time, few witnesses were able to give us any insight into the reasoning behind the department's response to the Select Committee's recommendations. Paul Everall, then Deputy Director of the Building Regulations Division503 Everall {CLG00019482/1} page 1, paragraphs 3-5. could not recall what had led to the formulation of the department's response.504 Everall {CLG00019482/10-13} pages 10-13, paragraphs 44 and 57. Anthony Burd thought505 Burd {Day238/174:12-20}. that the advice to ministers not to adopt the Select Committee's recommendation had been given by Tony Edwards506 Principal Fire Safety Professional in the Department's Building Regulations Division at the time, Burd {Day238/136:15-18}. and did not know why or how it had been formulated.507 Burd {Day238/175:2-5}.
¶7.50 Mr Raynsford told us that he had no recollection of the Select Committee's report but that he was confident that he had read it and had taken advice on it from officials at the time.508 Raynsford {CLG00035627/21} page 21, paragraph 52. He recalled that the department had had concerns about the application of small-scale fire tests in the context of large-scale cladding systems,509 Raynsford {CLG00035627/18} page 18, paragraph 40. but did not recall any concerns about reliance on Class 0 as a classification for materials that could be used on the external walls of high-rise buildings.510 Raynsford {CLG00035627/18} page 18, paragraph 41. He did not recall having given any consideration to the creation of guidance recommending that all components of an external wall system should be of limited combustibility and did not recall the proposal having been brought to his attention by any official.511 Raynsford {CLG00035627/20} page 20, paragraph 48. He told us that his role in the department's response had been to consider the advice of officials and give directions at a high level.512 Raynsford {CLG00035627/22} page 22, paragraph 54.
96¶7.51 There was only one ministerial submission which touched on the subject. It was dated 9 March 2000 and was drafted by Caroline Cousin, the Building Regulations Division's Head of Technical Policy. The submission was sent to Deputy Director Paul Everall, who approved it, and then sent to the minister513 {CLG00019457/1}. It stated that none of the Select Committee's recommendations was substantial in nature514 {CLG00019457/1} paragraph 4. and explained that the draft response the minister was being asked to approve had assumed that he would wish to accept the spirit of the recommendations.515 {CLG00019457/2} paragraph 9. It referred to the recommendation that the BRE large scale test for the fire performance of external cladding systems should be substituted in Approved Document B as a requirement for the safety of cladding systems but it did not tell the minister that the Select Committee believed that all external cladding systems should be entirely non-combustible unless proved through full-scale testing not to pose an unacceptable level of risk. It therefore failed to provide the minister with enough information to question the rationale behind the department's response or to decide to adopt a different course. None of the witnesses was able to assist us with any aspect of the drafting of the submission. Although Mr Burd suggested that more comprehensive advice and options might have been given to the minister in separate discussions,516 Burd {Day238/182:21}-{Day238/184:10}. we saw no evidence of that.
¶7.52 Brian Martin said that in the period after the publication of the 2000 edition of Approved Document B he had not asked his colleague Anthony Burd why the Select Committee's view had not been followed.517 Martin {Day250/170:5-10}. It seems that within the department the matter was considered closed.518 Martin {Day250/165:20-22}.
2000–2001: review of BR 135
¶7.53 In response to the Select Committee's inquiry and the pending adoption of Fire Note 9 as a British Standard test, in January 2000 the department entered into a contract with BRE519 Contract CC1924. to carry out research leading to the proposed revision of BR 135,520 {CLG10000347/2} paragraphs 6-7; {BRE00041836/3} final paragraph; Colwell {BRE00047571/29-30} pages 29-30, paragraphs 185-187; Colwell {Day232/12:15-25}; Smith {Day234/195:23}-{Day234/196:8}; Martin {Day250/206:13-18}. the first edition of which had been published in 1988.521 {BRE00001077}.
97¶7.54 Among other things, the department's objectives were to review the guidance in Approved Document B on the external walls of multi-storey buildings, to revise the Building Regulations and guidance based on a series of experimental studies on new and existing cladding systems522 {BRE00041836/3} section 2. and to use the large-scale test to determine the most appropriate method for specifying the fire performance requirements of cladding systems.523 {BRE00041836/4} section 2, second bullet point; {BRE00041836/6} task 6. The work fell into five main parts: a literature review, a survey of building owners, analysis of the survey results, an experimental testing programme and the drafting of a revised edition of BR 135,524 Colwell {Day232/13:1-14}. each of which we consider below.
¶7.55 Dr Colwell was the project leader.525 {BRE00041836/1}; {BRE00041836/9} "Project Team"; {BRE00041836/11} sixth paragraph. Brian Martin was responsible for the survey and the drafting of BR 135.526 {BRE00041836/9} "Project Team"; Colwell {Day232/14:17}-{Day232/15:13}; Martin {Day250/207:18}-{Day250/208:8}. Both Dr Colwell and Mr Martin were involved in the project from beginning to end527 Colwell {Day232/13:18-20}; {Day232/15:14-16}; Martin {Day250/208:10-14}. and all the work on the project, including in relation to technical detail, was supervised and monitored by Dr Smith.528 {BRE00041836/11} second and sixth paragraphs; {BRE00041836/12} "Project Responsibilities"; Martin {Day250/211:19}-{Day250/212:1}; Colwell {Day232/17:19-21}. Dr Colwell and Dr Smith met frequently during the course of the project.529 Colwell {Day232/17:19}-{Day232/18:6}. Dr Smith was responsible for supervising the work and exercising quality control530 {BRE00041836/12} "Project Responsibilities". and Dr Colwell consulted her whenever necessary.531 Smith {Day234/198:5-14}. All project reports were submitted to Anthony Burd at the department.532 Burd {Day239/99:11-14}.
The literature review: 2000
¶7.56 The first piece of work produced under the project was a report entitled Fire Spread in External Cladding – a Literature Review dated 30 March 2000.533 {BRE00001353/4-29}. It was written by Dr Colwell, Brian Martin and J Foster534 Mr Foster was a junior member of the Reaction to Fire team: Colwell {Day232/29:25}-{Day232/30:4}; Smith {Day234/205:6-8}. and was approved by Dr Smith.535 {BRE00001353/4}. The executive summary stated that the report identified and summarised the types of external cladding systems then in use, the existing requirements and guidance contained in the 2000 edition of Approved Document B and the research previously undertaken on the spread of fire across the external walls of high-rise buildings.536 {BRE00001353/6} Executive Summary. Dr Colwell told us that the purpose of the review was to provide a point of reference based on previously published information that would provide a platform for future work.537 Colwell {BRE00047571/24} page 24, paragraph 155; Colwell {Day232/32:22}-{Day232/33:3}.
¶7.57 Among other matters, the review resulted in a number of findings, two of which are important for present purposes. First, that a large-scale test method was necessary to assess the performance in fire of a complete external cladding system. Secondly, that the revised (2000) edition of Approved Document B had gone some way to addressing "the issues of fire performance of external cladding systems" and that the review of BR 135 would help to "clarify any remaining issues".538 {BRE00001353/27} paragraphs 2-3.
98¶7.58 The word "issue" used in that way is notoriously imprecise but usually connotes something unsuitable or unsatisfactory. It is not clear from the paper itself what "the issues of fire performance of external cladding systems" were and neither Dr Colwell nor Mr Martin could tell us. Although there were references to Approved Document B, none of them suggested that it was defective in any way. Nor was either of them able to explain the basis of the finding that the 2000 edition of Approved Document B had gone some way towards addressing them. The most that either of them could tell us was that they had been referring to the addition of the new reference to the large-scale test method539 Colwell {BRE00047571/25} page 25, paragraph 159. and the guidance that both surfaces of cladding panels used in the construction of the external walls of high-rise buildings should be classified Class 0.540 Martin {Day251/19:8-21}. Neither of them explained what "issues" they had thought would be clarified by BRE's work on BR 135.541 Colwell {Day232/46:13}-{Day232:50:2}; Martin {Day251/19:8}-{Day251/21:12}. Mr Burd was equally unclear about those matters, saying only that he could not recall precisely what the issues were but that there was a need to look at full-scale testing and the guidance provided by BR 135.542 Burd {Day239/4:14}-{Day239/6:1}.
¶7.59 The literature review was, in our view, a poor piece of work, as the uncertainty surrounding its conclusions demonstrates. It was superficial at best, even as a reference point, and contained at least one significant inaccuracy. The report appeared to misrepresent what Class 0 actually signified and conflated it with non-combustibility, thereby repeating the error in the report of BRE's investigation into the fire at Knowsley Heights. It was an error that was repeated many times in the years to come, particularly in BRE's summaries of the relevant provisions of Approved Document B.543 {BRE00041986/15}; {BRE00005881/18}; {CLG00019202/2} paragraph 7; {CLG00019445/3}. Most significantly, in a section summarising the guidance given in the 2000 edition of Approved Document B, the report stated that "Diagram 40…restricts the combustibility of external walls of high buildings".544 {BRE00001353/14} first paragraph. That was not correct. Diagram 40545 {INQ00014107/90}. did not restrict the combustibility of materials used in the external walls of buildings over 18 metres in height; it described an appropriate classification for the surfaces of external wall products that was primarily concerned with the spread of flame.
¶7.60 Dr Colwell said that Mr Martin had written the paragraphs summarising the provisions of the guidance,546 Colwell {Day232/36:15-18}. that Approved Document B was outside her area of expertise547 Colwell {Day232/36:11-14}; {Day232/37:11-13}. and that she had not noticed the error at the time.548 Colwell {Day232/37:14-18}. Dr Smith, who had approved the report and was responsible for the technical accuracy of the project as a whole,549 Smith {Day234/198:8-11}; {Day235/85:11-14}. told us that her review had been essentially editorial and typographical.550 Smith {Day234/206:15}-{Day234/207:6}. She accepted that there appeared to be a degree of confusion in the mind of the author about the effect of Diagram 40551 Smith {Day235/5:6-17}. and said that she would not have described it in that way.552 Smith {Day235/3:23-24}. All in all, the review does not reflect the work of an institution wedded to rigorous thinking, careful analysis or precise expression.
99¶7.61 Although he said that he could not remember having done so, Mr Martin probably did write the sections of the literature review dealing with the 2000 edition of Approved Document B.553 Martin {Day251/5:8-12}. He accepted that the statement that Diagram 40 restricted combustibility was not accurate but did not go so far as to agree554 Martin {Day251/8:19}-{Day251/9:6}. with Mr Burd that the use of the word "combustibility" had been a basic mistake.555 Burd {Day238/193:20-23}. He attempted to justify his use of it by saying that he had used it in a lay sense.
¶7.62 Just as we are critical of the way in which BRE expressed itself in the literature review, we are equally critical of the loose way in which Mr Martin used expressions such as "combustibility" and "Class 0" when giving his evidence. We have already referred to his use of the word "combustibility". He also said that he considered Class 0 to form part of a sliding scale on which there were degrees of combustibility.556 Martin {Day251/7:2-10}; {Day251/10:6-7}. We found this aspect of his evidence unsatisfactory because we should have expected someone in his position to use language more carefully when dealing with matters on which he was credited with some expertise. That would not have been "pedantic", as he put it, merely careful and precise. However, his casual use of language had led us to question whether his grasp of the concepts with which he was dealing was as sure as it should have been. In our view Mr Burd was correct to describe the use of the word "combustibility" as a basic mistake. Despite those misgivings, we think that Mr Martin was in fact well aware of the distinctions between Class 0, limited combustibility and non-combustibility and of their importance in the context of Approved Document B and that his unsatisfactory evidence reflected an attempt to justify his poor choice of language.
¶7.63 The BRE's literature review contained three tables setting out the typical costs of using different cladding systems based on information obtained from the February 1998 edition of the Architects Journal.557 {BRE00001353/12-13} Tables 1-3. In the third table, relating to "In-fill panels", figures were given for a composite panel made of 0.5mm aluminium skins with a 3mm polyethylene core,558 {BRE00001353/13} row 4. i.e. ACM panels with polyethylene cores.559 Colwell {Day232/42:21-23}; Burd {Day238/194:23}-{Day238/195:6}; Smith {Day234/13:19-20}; Martin {Day251/12:14-16}. Dr Colwell, Dr Smith, Mr Martin and Mr Burd each told us that, at the time of the report, they had not been aware that material of that kind was being used in the external walls of high-rise buildings in England and Wales.560 Martin {Day251/12:18-22}; Colwell {Day232/42:24}-{Day232/43:2}; Smith {Day234/14:23}-{Day234/15:4}; Burd {Day238/195:12-19}.
¶7.64 Mr Martin told us that he had not noticed at the time the reference to aluminium composite panels with polyethylene cores.561 Martin {Day251/17:9-11}. Anthony Burd said that he had not noticed it either.562 Burd {Day238/195:2-9}. Dr Colwell said that she had no experience of the product and that although she would have been aware that it was combustible (as were Mr Martin and Dr Smith),563 Martin {Day251/14:9-14}; Smith {Day235/17:20-24}. she was not particularly struck by its inclusion and could remember no discussions about it either within BRE or with the department.564 Colwell {Day232/43:7}-{Day232/45:6}. Nor could Dr Smith or Mr Martin.565 Smith {Day235/19:21-24}; Martin {Day251/16:15-17}. None of them paid sufficient attention to the fact that the product, or something very similar to it, had been included in the experimental phase of the project because it was of interest to the industry566 {BRE00041882}. and none of them appears to have realised that it would have been difficult to obtain costs for aluminium composite panels from the Architects Journal if they had not been in use in the United Kingdom at the time.567 Colwell {Day232/43:16-19}.
100The survey
¶7.65 One of the Select Committee's recommendations had been that the department should instruct local authorities to undertake a review of existing buildings in order to ascertain how many of them had external cladding systems and how many of those might not comply with the Building Regulations. The Select Committee had recommended that in the light of the responses fire safety assessors should be called on to advise on the work required to ensure that none of them posed any undue risk.568 {CLG00019478/10} paragraph 22. As a result,569 {BRE00041887/5} first and second paragraphs; Colwell {Day232/51:3-20}. one of the tasks set by the department as part of the project was to carry out a survey of high-rise buildings in Great Britain in order to determine the composition and design of existing cladding systems and the changing nature of the materials currently in use.570 {BRE00041836/3} section 2, fourth bullet point.
¶7.66 To that end Dr Colwell designed a questionnaire571 Colwell {Day232/52:7-12}. directed to local authorities and companies in the construction industry seeking information about the number of buildings over 18 metres in height with which they had been involved, their age, the proportion that had external cladding, whether it had been installed as part of a refurbishment and the nature of the cladding systems and the materials used.572 {BRE00041885}. The questionnaire also asked respondents whether they had experienced the spread of fire due to external cladding systems and if so, to provide details.573 {BRE00041885/5} question 11.
¶7.67 In the event, only 45 questionnaires were sent out.574 {BRE00041886} "Circulation List"; {BRE00041887/5} "Distribution and Selection". Responses were received from 17 recipients, four of which contained no relevant information575 {BRE00041886} "Introduction". and only eight of which came from local authorities.576 {BRE00041887/7} Figure 1. The decision to send out only 45 questionnaires and to proceed with only 13 completed returns was taken by Mr Burd,577 Colwell {Day232/53:25}-{Day232/54:5}; {Day232/57:24}-{Day232/58:23}. who told us that it had been taken on the advice of BRE and the Industry Advisory Group,578 Burd {Day239/9:2-8}; {Day239/9:18}-{Day239/10:24}. a group of 27 representatives drawn from building owners and the construction industry579 {BRE00001392/5}; {BRE00001392/9} Table 1. to provide advice and support during the project.580 Colwell {Day232/22:2}-{Day232/23:4}; Smith {Day235/201:2-13}; Burd {Day238/190:13-20}; Smith {MET00081237/12-13} pages 12-13, paragraph 44. One of its functions was to make sure that the products and systems tested during the experimental phase of the project were representative of materials and designs in use at the time.581 Colwell {Day232/23:7}-{Day232/24:10}.
¶7.68 It is clear that the data from which BRE worked had not been derived from the comprehensive review of the country's building stock that the Select Committee had originally envisaged.582 Colwell {Day232/61:1-9}; Burd {Day239/13:3-6}. Nonetheless, Dr Colwell thought it contained enough information to provide a reliable view of the types of external cladding systems currently being used in the public housing sector583 {BRE00041887/3} first bullet point. and the department apparently considered it to be representative.584 Burd {Day239/14:10-22}.
101¶7.69 Mr Martin collated the responses to the survey,585 Colwell {Day232/54:16-24}. which were also provided to the department in tabulated form.586 Colwell {Day232/56:25}-{Day232/57:2}. It is clear that no immediate action was taken as a result. The report to Mr Burd informed the department that the use of cavity barriers appeared to be very sporadic,587 {BRE00041887/10} "Fire Breaks". a finding that piqued his interest and eventually led to a further piece of research on the use of cavity barriers some years later for the guidance in the 2006 edition of Approved Document B.588 Burd {Day239/15:21}-{Day239/16:11}.
¶7.70 One of the companies that responded to the survey, WS Atkins, said in response to the question about the spread of fire caused by external cladding systems "Spread of flames generally rapid due to loss of integrity of composite aluminium panels using combustible cores".589 {BRE00041886} row 54, column C. Neither Dr Colwell nor Dr Smith could remember receiving that response or knew whether the company had been asked for further information.590 Colwell {Day232/55:22}-{Day232/56:6}; Smith {Day235/52:7-16}. Nor is there any evidence that anyone approached WS Atkins on behalf of the department to seek further information. That is surprising, because it ought to have alerted BRE and the department to a potentially widespread problem relating to ACM panels.
Experimental testing programme
¶7.71 The information produced by the survey was used as the basis for the programme of tests that subsequently took place, including the choice of the types of system to be tested.591 {BRE00041887/10-14}; Colwell {Day232/69:22-24}. In 2001 and 2002, BRE carried out a series of full-scale tests on cladding systems and small- and intermediate-scale tests on various products. They included 14 full-scale tests (using the test method in Fire Note 9),592 {BRE00041882/23} Table 8; {BRE00041913}. national reaction to fire tests in accordance with BS 476 Parts 6 and 7 on 11 products593 {BRE00041882/12} Table 2. and several tests relating to the relevant European classifications (BS EN ISO 11925 Part 2,594 {BRE00041882/13} Table 3. BS EN 13823595 {BRE00041882/15} Table 4. and ISO 9705596 {BRE00041882/17} Table 5.). The testing was done as part of the project that was itself carried out under a framework contract with the department bearing the number cc1924. As a result, the testing series became known as "cc1924".597 {BRE00001353/1}.
¶7.72 The 11 products and systems selected for testing were chosen in collaboration between BRE, the Industry Advisory Group and the department, with the department having the final say.598 Colwell {Day232/22:8-15}; {Day232/24:2-4}; {Day232/69:25}-{Day232/70:10}; {Day232/75:22}-{Day232/76:24}; Smith {Day235/92:22-25}; {Day235/94:9-22}. Although Mr Burd approved the testing programme, it was devised by BRE and the Industry Advisory Group with little contribution from the department.599 Burd {Day239/23:8-11}; {Day239/25:17-24}. Materials and products were chosen for testing largely on the advice of the Industry Advisory Group about what was most relevant and pertinent to the industry.600 Colwell {Day232/23:1-15}. The aim was to test materials that were widely used so that the tests would be of maximum value both to the department and the industry.601 Colwell {Day232/70:5-10}.
102¶7.73 BRE's report on the cc1924 tests, written by Dr Colwell and approved by Dr Smith, was dated 19 September 2002 but the results of those tests were not published until after this Inquiry had begun its investigations.602 Burd {Day239/104:22}-{Day239/105:9}. They revealed two matters of great significance, neither of which appears to have been met with any appropriate response from either BRE or the department, let alone any action on the part of either of them.
Products sold as Class 0 did not achieve Class 0
¶7.74 All 11 of the products selected by BRE for testing in accordance with BS 476, Parts 6 and 7 had been chosen on the basis that they were marketed as being classified Class 0.603 Colwell {Day232/112:15-24}. However, only four actually achieved that classification when tested.604 {BRE00041882/11} first paragraph; {BRE00041882/19} first paragraph; {BRE00041882/12} Table 2, final column. BRE's report simply recorded that the results were not as expected605 {BRE00041882/11} first paragraph. and said that there did not appear to be any one reason for that lack of performance.606 {BRE00041882/19} first paragraph. Brian Martin said that he could not remember having seen any of the small-scale test data,607 Martin {Day251/65:22-24}. and doubted that he had seen it until he was preparing to give evidence before us.608 Martin {Day251/66:22-23}. He said that he had no recollection of any reaction to or discussions about those findings at the time609 Martin {Day251/65:22}-{Day251/67:16}. but that they might have been discussed in his absence.610 Martin {Day251/67:23-25}.
¶7.75 There are two possible explanations for those results: either the manufacturers were misrepresenting the characteristics of their products (deliberately or otherwise) or there were problems reproducing the results of the tests used to achieve the original classification. Either way, the results were a matter of serious concern to BRE.611 Colwell {Day232/113:25}-{Day232/114:2}. Dr Smith did not think that the explanation lay in the reproducibility of the tests612 Smith {Day235/133:11-16}. and she and Dr Colwell agreed that, since it was not possible to know whether the same situation applied more widely across the market, the matter needed to be considered further.613 Colwell {Day232/115:1}-{Day232/116:1}; Smith {Day235/136:24}-{Day235/137:3}.
¶7.76 Nonetheless, neither BRE nor the department contacted the manufacturers of the seven products that had failed to achieve Class 0 in the tests to tell them of the results614 Colwell {Day232/116:2-5}. and neither of them took steps to report the manufacturers to National Trading Standards or any other authority.615 Colwell {Day232/116:6-9}; Smith {Day235/134:9-20}. Despite its concerns, BRE did nothing other than present the results to the department. Dr Colwell and Dr Smith considered that it was for the department to review the position and take any appropriate action.616 Colwell {Day232/116:11-19}; Smith {Day235/134:18}. As far as Dr Colwell could recall, there had been no reaction from the department when the test results were presented to it.617 Colwell {Day232/114:19-21}; Smith {Day235/136:12-19} who could not recall the reaction of Anthony Burd. Mr Burd's recollection was very limited. He thought that misrepresentation by the manufacturers must have been a consideration618 Burd {Day239/73:21-25}. and that he might have had discussions with Dr Smith about it,619 Burd {Day239/73:3-20}. but he could not remember his or the department's reaction, beyond saying that it would have been one of surprise620 Burd {Day239/75:9-13}. and would have given rise to concern.621 Burd {Day239/74:5-7}. However, he could not recall any contact having been made with the manufacturers, National Trading Standards or any other authority and confirmed that ministers had not been informed of the results.622 Burd {Day239/88:15}-{Day239/89:12}.
103¶7.77 Accordingly, less than three years after the Select Committee had made recommendations directly connected to the fatal fire at Garnock Court623 {CLG00019478}. the discovery that the majority of a selection of typical cladding products marketed as Class 0 did not in fact meet that standard was simply ignored by the department. It did not alert the industry to the potential danger and took no steps to review the statutory guidance. We do not understand its failure to act in relation to a matter of such importance.
Aluminium composite panels with polyethylene cores
¶7.78 One of the four products that did achieve Class 0 in BRE's tests was a panel described in its report as an "aluminium sheet",624 {BRE00041882/12} Table 2 "Rainscreen Systems", row 3; Colwell {Day232/98:16-18}; Smith {Day235/107:11-14}. which was also tested under the three European test methods625 {BRE00041882/13} Table 3 "Rainscreen Panels", row 5; {BRE00041882/15} Table 4 "Rainscreen System", row 5; {BRE00041882/17} Table 5 "Rainscreen System", row 5. and was incorporated into one of the 14 systems subjected to a full-scale test.626 {BRE00041882/23} Table 8 "Rainscreen System" row 5. Despite the generic description of the product in almost all the BRE reports,627 {BRE00041912}; {BRE00041895/9}; {BRE00042045/5}. Dr Colwell told us that it was the practice of BRE not to refer to specific products or manufacturers in its reports in deference to the wishes of the department: Colwell {Day232/28:23}-{Day232/29:8}; Colwell {Day232/84:5-11}. Burd {Day239/44:15-22} and {Day239/45:24}-{Day239/46:7}. it is clear from other documents that it was in fact a composite aluminium panel with a polyethylene core.628 {BRE00041882/10} Table 1 "Rainscreen", row 5; {BRE00041909} "Rainscreen", final row.
¶7.79 Aluminium composite panels with polyethylene cores were selected for testing because they represented a product that was available on the market and was of interest to the construction industry.629 Colwell {Day232/95:14}-{Day232/96:11}; Smith {Day235/104:2-23}. When subjected to a full-scale test, a system incorporating panels of that kind reached the failure criteria in Fire Note 9 at a very early stage,630 {BRE00041912} row 15, column R; {BRE00041882/23} Table 8, row 5. exceeding the external temperature limits within three minutes of the start631 {BRE00041882/23} Table 8, row 5, column "Ext". and the internal limits after 4.34 minutes.632 {BRE00041882/23} Table 8 "Rainscreen System", row 5, column "Insulation". Staff intervened to terminate the test, manually extinguishing the crib fire at 5.45 minutes633 {BRE00041911/3}. and ending the test at 5.75 minutes.634 Colwell {Day232/97:9-20}; {BRE00041882/23} Table 8, row 5, column "Test Time (min)". Detailed observations recorded during the test included the fact that at 3.05 minutes molten aluminium was dropping from the front face of the system, that at 4.20 minutes flames had reached the top of the test rig and that 5.00 minutes from the start flames had reached 20 metres in height, approximately twice the height of the test facility.635 {BRE00041911/3}. On any view, that was a catastrophic escalation.636 For further analysis of the test data Bisby, Phase 2 Report {LBYP20000001/148-151} paragraphs 807-816.
104¶7.80 Dr Colwell was present at the test and was shocked both by the rapid rate at which the fire grew and the extent of its growth.637 Colwell {Day232/96:23-24}; {Day232/97:5-8}; {Day232/99:25}-{Day232/100:4}. By contrast, Dr Smith did not recall the test as being particularly notable638 Smith {Day235/101:19}-{Day235/102:2}. and did not remember anyone at BRE being particularly surprised at the way in which the system failed.639 Smith {Day235/106:10-17}; {Day235/109:17}-{Day235/110:7}. She simply noted that the test had failed at an early stage.640 Smith {Day235/107:3-10}.
¶7.81 Neither Dr Smith nor Mr Martin recalled having seen the test data or detailed observations from that test at the time.641 Smith {Day235/107:24}-{Day235/108/8}; Martin {Day251/51:5-10}; {Day251/52:6-7}. Mr Martin did recall that Dr Colwell had come into his office at BRE to tell him about the test and to show him a sample of the aluminium cladding panel,642 Martin {Day251/47:14}-{Day251/48:15}. but did not remember her being shocked or alarmed.643 Martin {Day251/48:20-22}; {Day251/49:16-20}. As far as he could recall, they had not discussed the performance of the system in any detail.644 Martin {Day251/49:21}-{Day251/51:10}.
¶7.82 In the light of the test it was clear to Dr Colwell645 Colwell {Day232/100:11-25}. and Dr Smith646 Smith {Day235/111:7-13}. that ACM panels with unmodified polyethylene cores were not suitable for use in cladding systems on high‑rise buildings. Nonetheless, in its report dated 16 September 2002647 {BRE00041895}. BRE said only that the aluminium sheet product had satisfied Class 0 but had proved to be one of the worst performing products in the intermediate scale and Single Burning Item tests. It concluded by saying that, as the current guidance in Approved Document B asked for Class 0 performance in Diagram 40, those matters might require further consideration.648 {BRE00041895/13} paragraph 5. That was as far as the report went.
¶7.83 BRE expected the department to decide what it wanted to do in response.649 Smith {Day235/152:3-16}. Apparently, no report it produced for the department spoke in overt terms about an immediate risk to life, because its function was simply to present the evidence, including the technical facts and the data.650 Smith {Day235/152:24-25}. It was for the department to decide what to make of it.651 Colwell {Day232/127:24}-{Day232/128:25}. It is clear that BRE did not share with the department, at least in any formal way, its opinion that aluminium composite panels with unmodified polyethylene cores should never be used on tall buildings.652 Smith {Day235/113:8-18}.
¶7.84 We are not convinced that it was as clear to the department as apparently it was to Dr Smith and Dr Colwell what the results of the tests incorporating the ACM PE panels meant in practical terms for the degree or immediacy of the danger their use presented or why there was a need to make changes to the guidance. Whatever may have been the accepted way of reporting the results of experimental work carried out for the department, the disastrous performance of the panels in the full scale-test should have prompted BRE to draw the department's attention to the dangers inherent in the use of ACM PE rainscreen panels.
105¶7.85 Dr Smith eventually agreed that the results of the tests had led her to have serious misgivings about the existence of statutory guidance that treated Class 0 as an appropriate standard for external panels on high-rise buildings.653 Smith {Day235/141:8-19}. Dr Colwell went so far as to agree that the results indicated that there was a serious problem with the relevant provisions of Approved Document B.654 Colwell {Day232/111:14-24}. In those circumstances, given the performance of the product both in full-scale tests and in small-scale tests using the European methods,655 {BRE00041882/14} fifth paragraph "The aluminium system generated high rates of fire growth and in both cases was extinguished early due to excessive temperatures and fire growth. This is reflected in the indicative classification of D-s2, d0." Smith {Day235/141:20-23}; Colwell {Day232/118:12-20}. BRE's comments on the performance of the ACM panels fell far short of what was required.656 {BRE00041895/13} paragraph 5.
¶7.86 One object of the research project was to find a test method that ensured that products that performed badly in response to fire would not be able to pass it. Dr Smith appears to have thought that the broader reaction of those at BRE to the tests had been communicated to the department in the course of discussions about the criteria to be included in BR 135.657 Smith {Day235/111:14-24}. However, that fails to take account of the fact that full-scale testing was not the only way of demonstrating compliance with functional requirement B4(1) recommended by Approved Document B658 Smith {Day235/29:6-13}; Colwell {Day232/111:14-21}. and apart from anything else, the guidance continued to recognise the use of ACM panels with a Class 0 surface.
¶7.87 BRE itself was not asked for its opinion on the retention of Class 0 as an appropriate standard for panels to be used on the external walls of high-rise buildings and did not give any consideration to that question.659 Smith {Day235/114:23}-{Day235/115:6}; {Day235/143:4-13}. In its view, that was a matter for the government.660 Smith {Day235/143:23}-{Day235/144:3}.
¶7.88 Mr Burd was aware that the full-scale test on the system incorporating ACM panels had produced a very fierce, fast fire.661 Burd {Day239/51:25}. That made him think that it was imperative to ensure that the work being carried out on BR 135 would produce a test that would exclude the use of products of that kind.662 Burd {Day239/51:13-21}; {Day239/54:13-22}; {Day239/55:23}-{Day239/56:1}; {Day239/59:2-7}; {Day239/64:6-11}. He appears to have thought that it was the responsibility of BRE to explain the significance of the results to him,663 Burd {Day239/53:19-21}. but could not recall that BRE had communicated to him any sense of shock at the test results.664 Burd {Day239/52:7-10}.
¶7.89 The department discussed the report with the Industry Advisory Group but Mr Burd could not recall whether any consideration had been given to intervening in the use of ACM on high-rise buildings.665 Burd {Day239/58:18}-{Day239/59:7}. Nor could he recall whether the department had taken any steps to alert others to the danger posed by the product666 Burd {Day239/57:19}-{Day239/58:17}. or to find out how many high-rise buildings might already have been clad in ACM products.667 Burd {Day239/60:6-17}; {Day239/61:10-21}. There is no evidence of any discussions within the department about withdrawing Diagram 40 (and thus Class 0) as a relevant standard for the fire performance of the external surfaces of high-rise buildings.668 Burd {Day239/75:14-17}; {Day239/76:17}-{Day239/77:4}.
106¶7.90 One might reasonably question whether Mr Burd or anyone else in the department, including Mr Martin, studied the BRE report in any detail or really gave any thought to the implications of the results of the full-scale test using the ACM product. If they had done so, they would surely have realised that although it had a Class 0 surface, it was highly combustible and entirely unsuitable for use on the external walls of buildings, particularly high-rise buildings. Mr Burd's view at the time was that the use of ACM panels on buildings over 18 metres in height did not comply with functional requirement B4(1) of the Building Regulations.669 Burd {Day239/55:5-22}; {Day239/61:15-18}; {Day239/64:14-23}; {Day239/65:8-12}; {Day239/94:12-19}; {Day239/100:22}-{Day239/101:13}; {Day239/167:17}-{Day239/168:8}. In his view, the general warning in paragraph 13.7 of Approved Document B against the use of combustible materials670 {INQ00014107/89} paragraph 13.7 and the existence of functional requirement B4(1) were sufficient to prevent the use of such products on high-rise buildings.671 Burd {Day239/59:5-7}; {Day239/70:8-11}. That view is difficult to reconcile, however, with the selection of ACM panels for testing on the grounds that they were a form of material then being widely used.
¶7.91 Brian Martin also thought that, although Diagram 40 allowed the use of ACM panels with a Class 0 surface to be used on buildings over 18 metres in height,672 Martin {Day251/71:16-21}. their use would contravene functional requirement B4(1) of the Building Regulations,673 Martin {Day251/71:25}-{Day251:72:1}. but he could not explain why Approved Document B contained guidance that appeared to allow the use of a product that would result in a breach of the Building Regulations.674 Martin {Day251/72:22-25}; {Day250/87:4-21}. On any view, that created a deeply unsatisfactory position for at least two reasons: first, because following the guidance is evidence of compliance with the requirements of the Building Regulations and, secondly, because although the contents of Approved Document B are no more than guidance, their detailed nature encourages people in the construction industry to treat them as prescriptive and not to pay sufficient attention to the functional requirements themselves. If the department thought that the use of some cladding panels with Class 0 surfaces did not comply with the Building Regulations, it should have given urgent thought to withdrawing Class 0 as a standard or at least to including in Approved Document B an explicit warning about the use of composite products, substantial parts of which were combustible. As it is, there is no evidence that any discussions of that kind took place.
¶7.92 We have been unable to establish how or why such important information was ignored. There are three possibilities: the first is that those in the department who were responsible for the research project, principally Mr Burd and Mr Martin, did not read it carefully or appreciate its implications; the second is that they did read it but did not understand the full seriousness of its implications for the use of ACM and put it aside without taking appropriate action; the third is that they understood the seriousness of the implications for the use of ACM panels and decided to suppress it.
¶7.93 There is no evidence to support the conclusion that the department deliberately decided to refrain from acting in response to what it knew constituted a serious danger to people working and living in high-rise buildings. The fact that the results of the research were not published at the time suggests that their significance was not fully appreciated and is consistent with the failure of Dr Smith and Mr Martin to refer to the cc1924 tests when they took part in a meeting in June 2017 to advise the government whether the cladding used on Grenfell Tower had been fit for its purpose.675 Smith {Day238/109:7-13}; {Day238/109:18}-{Day238/110:4}; {Day238/111:1-9}; Martin {Day257/208:7-14}; {Day257/215:12}-{Day257/216:9}; {CLG00005247/5}. BRE's failure to draw the attention of the department to the performance of the ACM panels in the full-scale test in suitably forceful terms bears some responsibility for that.
107¶7.94 No one was able to explain why the results of the tests had never been made public,676 Burd {Day239/104:22}-{Day239/106:4}; Martin {Day251/85:16}-{Day251/86:20}; Smith {Day235/155:21} -{Day235/156:25}; {Day235/159:12-24}; Colwell {Day232/129:24}-{Day232/130:10}. even in the wake of the fire at Grenfell Tower, when they would have been highly relevant to the department's investigations into the fire performance of similar products. We think that the explanation lies in the fact that having once been shelved they had subsequently been entirely forgotten.
Harmonisation and RADAR 2
¶7.95 In February 2000 the European Commission directed that the European reaction to fire classification system, EN 13501, which we have described in a separate chapter of this report,677 Chapter 5. be adopted across all European member states and that national testing standards should be harmonised.678 2000/147/EC implementing Council Directive 89/106/EEC. There was no harmonisation of building regulations, however. Although it remained open to member states to determine how and in what circumstances particular test methods and classifications would be required or recommended, each member state was obliged to incorporate the new European classification standards into its own regulations and associated guidance, if necessary alongside existing national standards.679 {CLG00007308/2} paragraph 3.2; Burd {Day238/166:10-19}; {Day239/109:18}-{Day239/110:1}; Martin {Day250/65:17-23}; Smith {Day235/160:12-18}; Bisby, Phase 2 Report {LBYP20000001/115} paragraph 600. In the UK the approach taken by the department was to recognise both the European and national testing methods and standards.680 Burd {Day239/157:21-23}; {CLG00007308/3} paragraph 3.7.
The RADAR research
¶7.96 In preparation for the introduction of the European classification system the department commissioned research from Warringtonfire Research Centre Ltd681 Now Warringtonfire Testing and Certification Ltd. to help it decide how the European test methods and classifications should be incorporated into UK regulations and guidance and to understand the effect of their adoption.682 {CLG00001464/4} paragraph 17; Smith {Day235/160:19-25}; Burd {Day239/109:23}-{Day239/110:14}; Martin {Day250/175:15-25}. Warringtonfire produced a series of reports under the title "RADAR" (Research on Approved Document B and Revision).683 {CLG00001068/1} paragraph 4; Burd {Day239/109:15-17}; RADAR 1 addressed fire resistance and RADAR 3 dealt with tests for roofing materials. A two-part RADAR 2 report delivered in May 2000 specifically addressed the reaction to fire test methods under BS 476 Parts 6 and 7 and related national classifications.
¶7.97 The RADAR 2 report entitled "Correlation of UK Reaction to fire classes for building products with Euroclasses and Guidance on Revision of Approved Document B"684 {CLG00000950/2}; {CLG00000951/1}. was intended to determine whether satisfactory correlations could be established between the different methods of testing and classification.685 {CLG00000951/3} paragraph 1. The focus of the work, therefore, was on comparing the classifications of various products under the Euroclass and national systems.686 {CLG00000950/4} section 3. For that purpose, 64 different products687 {CLG00000950/5} paragraph 4.1. The seven industry sectors referred to were: Wood, Mineral Wool, Paints, Cellular Plastics, Wallcoverings, Board and Sheet and Plastics {CLG00000950/5-6} paragraphs 6.2-6.8. were chosen for testing.688 {CLG00000951/3} section 1. The RADAR research was commissioned under the Partners in Innovation Scheme, meaning that it was funded half by the department and half by industry, including manufacturers.689 Martin {Day250/175:25}-{Day250/176:1}; Smith {Day235/162:14-20}; Burd {Day239/111:23}-{Day239/112:3}. Mr Burd told us that the products selected for testing were chosen following discussions with those industry partners.690 Burd {Day239/113:2-12}.
108¶7.98 Following the testing, the results for 60691 {CLG00000951/5} section 3, first paragraph. of the 64 products were plotted onto a matrix. The second RADAR 2 report stated that where a high density (in other words a large number) of products occurred at any given transposition point on the matrix, that could be interpreted as giving confidence that a "representative correlation" existed and that a "reliable transposition" could be made.692 {CLG00000951/3} section 2, first paragraph.
¶7.99 The report contained a table that suggested possible options for the transposition of classes for performance in reaction to fire. It suggested a transposition between national Class 0 and Euroclass B (or better).693 {CLG00000951/6} Table 6. Of the products tested, 35 satisfied the requirements of Class 0 under the national system. When those 35 products were tested under the Euroclass systems, 21 achieved Class B, 10 achieved Class A1 or A2 and, at the other end of the scale, one achieved Class C, two achieved Class D and one achieved only Class E.694 {CLG00000951/4} Table 2. The Class 0 products which achieved Euroclass C, D or E were not identified in the report.
¶7.100 The possible options for transposition were discussed by members of the Part B Working Party of the Building Regulations Advisory Committee (known as "BRAC")695 The Building Regulations Advisory Committee was a statutory advisory public body sponsored by the department ordinarily made up of twelve members. The Secretary of State was required to consult the Committee on any changes to the Building Regulations. When changes were being considered, a technical working party (such as the Part B Working Party) was normally set up, Ledsome {CLG00019465/30} page 30, paragraph 116; {CLG00007308/1} for a list of members of the Part B Working Party. at a series of meetings between 2000 and 2002,696 See for example meetings on 28 February 2001 {CLG00001051}; 10 May 2001 {CLG00007308}; 15 April 2002 {CLG00000720}; 2 May 2002 {CLG00001462}. as well as with the Industry Advisory Group that had been set up to steer the project.697 {CLG00000950/3-4} section 2. Mr Burd attended a number of those meetings, as did Dr Smith,698 {CLG00007308/1} and {CLG00001462/1}. who told us that she had been called in to advise because of her expertise in fire testing and European harmonisation.699 {CLG00007308/1} paragraph 1.3; Smith {Day235/174:19-21}; {Day235/194:10}-{Day235/195:1}. Her role was to act as a co-ordinator of BRAC's discussions.700 {CLG00000950/3} section 2, second row, third column; Smith {Day235/164:2-4}.
109Transposition
¶7.101 The department concluded that the most appropriate transposition point for Class 0 was Euroclass B and so the proposal made by Warringtonfire was accepted.701 Martin {Day250/181:9-13}; Burd {Day239/156:11-15}. In the amended (2002) edition of Approved Document B, Diagram 40 therefore referred both to Class 0 and to Euroclass B-s3, d2 (or better) as the recommended standard for the external surfaces of walls over 18 metres in height.702 {CLG10000740/91} Diagram 40.
¶7.102 The second RADAR 2 report had suggested that a decision to treat Class 0 as equivalent to Euroclass A2 would severely restrict the choice of materials available to designers and clients. Euroclass A2 is a more stringent standard than Euroclass B and there may have been a view that very few Class 0 products were capable of achieving Euroclass A2. Accordingly, placing the transposition point at Euroclass A2 rather than at Euroclass B might not only have restricted market choice but would potentially have met resistance from, and caused losses to, the UK construction industry.703 Smith {Day235/192:7}-{Day235/193:3}. However, if the transposition point for Class 0 had been Euroclass A2, at the end of any transition period buildings would be clad in materials that performed better in a fire.704 Smith {Day235/193:4-9}. The decision to use Class B as the transposition point to Class 0 was a compromise between the need to maintain fire safety standards and the need to avoid distortion of the market.705 Smith {Day235/193:15-22}.
¶7.103 The effect on manufacturers of the harmonisation scheme rested largely in the hands of the department, since it determined the transposition points, any notional equivalence between classification under the two systems, and any period of co-existence.706 Burd {Day239/134:7-15}. However, Mr Burd said that the likelihood of resistance from the construction industry to a correlation between Class 0 and Euroclass A2 had not been a factor in his consideration of the possible transposition points707 Burd {Day239/128:15-21}. and that he had not considered whether that transposition point might restrict choice at the end of any period of co-existence.708 Burd {Day239/128:5-8}. He did concede, however, that it might have been too demanding. Indeed, one of the stated objectives of the RADAR research was to ensure that the introduction of the new European test methods did not significantly change the existing regulatory position.709 {CLG00000950/3} section 1, third paragraph. The department appears to have made no attempt to find out whether the four products that had achieved Class 0 but only Euroclass C, D or E were in widespread use,710 Burd {Day239/118:5-10}. and if so, in what circumstances.
The retention of Class 0
¶7.104 When considering what amendments to make to Approved Document B in the light of the RADAR report, the department gave no thought to the removal of Class 0 as the appropriate standard for the fire performance of materials used for the external surfaces of walls of buildings over 18 metres in height, despite the catastrophic performance of a system incorporating Class 0 aluminium composite panels with polyethylene cores in a full-scale test under contract cc 1924.711 Burd {Day239/209:12}-{Day239/210:1}; Smith {Day236/37:17}-{Day236/39:7}. One reason for that was the fact that Class 0 represented the established method of determining the suitability of products for use in the external walls of high-rise buildings712 Burd {Day239/207:10-21}. and the purpose of the exercise then being conducted was seen as being to harmonise national and European classification and testing standards, not to review the technical requirements of Approved Document B generally.713 Burd {Day239/121:19-20}; {Day239/123:4-5}.
110The transitional period
¶7.105 It was originally intended that the national classes (including Class 0) would be retained in use alongside the Euroclass system for a limited transitional period, after which they would no longer be relied on as the relevant classification standards.714 {CLG00000720/4} paragraphs 6.11 and 10 "The UK currently utilises our own British Standards – mainly the BS 476 suite of documents, however these will eventually be withdrawn"; {CLG00001464/3-4} paragraphs 15-16; {CLG00001462/3} paragraph 6.7 "The transpositions proposed for AD B are for Class B to be substituted for Class 0 in time". In the event, the transitional period continued until December 2018, after the fire at Grenfell Tower.715 Martin {Day250/167:12-16}.
¶7.106 A Regulatory Impact Assessment prepared by the department in May 2002 suggested that the transitional period would begin in 2002 and would last for three years,716 {CLG00001464/4} paragraph 16. but no date for the end of the period of co-existence was fixed at the time.717 Burd {Day239/164:3-14}; {Day239/175:21}-{Day239/176:19}.
¶7.107 It was difficult to discern what other factors led to the retention of Class 0 for so many years. As far as we can see, it did not form part of any of the discussions or consultations leading to the amendments of Approved Document B in 2010718 Burd {Day240/12:8-22}. or 2013.719 Burd {Day240/13:20}-{Day240/14:3}; {Day240/16:5-14}.
¶7.108 Reliance on the national classes in Approved Document B could have been discontinued at any time,720 Burd {Day239/188:12-16}; {Day239/191:4-25}. provided the proper processes for amendment had been followed.721 Burd {Day240/13:2-9}; {Day240/14:9-25}. Similarly, Diagram 40 could have been amended at any time to recommend the use of materials of limited combustibility for the external surfaces of buildings over 18 metres in height.722 Burd {Day240/18:15-25}.
Equivalence and the note in Diagram 40
¶7.109 As everyone agrees, there was no technical correlation or equivalence between Class 0 and Euroclass B because the two classification regimes were completely different, testing for different properties according to different criteria and in different circumstances.723 Smith {Day235/184:17-19}; {Day235/185:1-13}; {Day235/188:24}-{Day235/189:1}; {Day235/197:8-23}; {Day236/17:14-15}; Burd {Day239/144:19}-{Day239/145:8}; {Day240/6:17-19}; Martin {Day250/190:11-16}; {CLG00007308/7} paragraph 5.8; {CLG00001051/1-2} paragraph 6. Nonetheless, a footnote to Diagram 40 was added in the 2002 version of Approved Document B stating:
"National classifications do not automatically equate with the equivalent European classifications, therefore products cannot typically assume a European class unless they have been tested accordingly".724 {CLG10000740/91} Diagram 40.
¶7.110 The note was intended to warn readers that Class 0 could not be achieved by testing under the European system and obtaining a Class B (or vice versa). Only tests under the national system (i.e. BS 476-6 and 476-7) could provide a Class 0 classification and only tests under the European system could provide a Class B classification.725 Burd {Day239/202:13-17}; Smith {Day236/30:14-18}; {Day236/33:22}-{Day236/34:1}; Martin {Day250/188:9-18}. Although we agree that that is one possible reading of the footnote, we think that it could equally be understood to mean that there could be an equivalence of some kind between the two classifications, albeit not an automatic one. Indeed, the note uses the word "equivalent" in that very context.
111¶7.111 In our view the footnote was certainly confusing. The use of the word "automatically" suggested that there could be an equivalence in some cases, though not all, and the expression "equivalent European classifications" suggests that there is an equivalence between national classes and European classes. Although some readers might have understood that testing under each system was necessary in order for a product to obtain the related classification, they might have understood that Class 0 and Euroclass B were technically equivalent, which was not the case. They were equivalent only for the limited purposes of complying with the guidance in Diagram 40, but they were not technically equivalent and did not confirm the same characteristics.
¶7.112 Although Brian Martin, Anthony Burd and Dr Smith all told us that they had not been aware of any manufacturers claiming that Class 0 was equivalent to Euroclass B,726 Martin {Day250/204:9-18}; {Day250/205:7-10}; Burd {Day240/8:6-17}; Smith {Day236/35:19-21}; {Day236/60:12-21}. they all saw an email to the department from the fire safety authorities in Singapore sent in December 2009727 {CLG10004229}. asking specifically whether the two were equivalent. However, that inquiry did not lead any of them to think that the note in Diagram 40 might not be clear or that consideration ought to be given to amending it.728 Martin {Day250/196:14-22}; {Day250/197:14-22}; {Day250/200:18-21}; {Day250/203:16-24}; Burd {Day240/7:6}-{Day240/8:4}; Smith {Day236/59:12-19}. Mr Martin's view, which seems to have been shared by others involved, was that people understood that the two systems operated in parallel and were not interchangeable.729 Martin {Day250/204:15-18}. The department appears to have assumed that the inquiry from Singapore was an isolated instance, but that may have been wishful thinking. There was evidence before us that some manufacturers and others in the construction industry thought that Class 0 and Euroclass B were technically equivalent and that others did not know whether they were equivalent or not, whether technically or for the purposes of Diagram 40.730 {KIN00000060/3} left column, fourth paragraph, "Class 0 correlates with Euroclass B in the new regime"; Rochefort {Day80/60:13}-{Day80/61:1} "...if I remember correctly, you can read across from a C-s1 d0 and that was deemed to be equivalent to a BS 476 Class 0"; French {Day87/84:21}-{Day87/85:9}; {Day87/86:15-25}; Gregorian {Day105/19:24}-{Day105/20:14}.
The development of the BS 8414 test series and the second edition of BR 135
BS 8414 Part 1: 2002
¶7.113 While the work on harmonisation of testing standards had been going on and the work towards the revision of BR 135 under contract cc 1924 was continuing, Fire Note 9 had been submitted to the British Standards Institution for adoption as a British Standard. Following editorial amendments and approval,731 Colwell {BRE00047571/27} page 27, paragraph 172. BS 8414 Part 1 was published in December 2002.732 {CEL00001205}.
112¶7.114 BS 8414-1 set out the test method for full-scale testing of external wall systems. The performance criteria against which the test data were to be assessed were moved from Fire Note 9 into the second edition of BR 135, which Dr Colwell and Brian Martin drafted as part of their work under contract cc1924.733 Colwell {BRE00047571/30} page 30, paragraph 190; Colwell {Day232/150:1-4}. The second edition was published in 2003.734 {BRE00005554/22} Annex A. Separating the test method from the performance criteria reflected the approach then being taken in relation to European standards, in which test methods and classification criteria were contained in separate documents.735 Colwell {BRE00047571/29} page 29, paragraph 184; Colwell {Day232/140:2}-{Day232/141:16}.
BR 135, second edition: 2003
¶7.115 Dr Colwell and Mr Martin, together with the department, decided that the first edition of BR 135736 {BRE00001077}. provided a suitable basis for the second.737 Colwell {BRE00047571/30} page 30, paragraph 192; Colwell {Day232/150:16-23}. They reviewed the text of the first edition and revised the contents to take account of developments in the testing of external cladding systems and advances in knowledge about the mechanism of fire spread, including those that had arisen from the work undertaken for the department under contract cc1924.738 Colwell {BRE00047571/31-32} pages 31-32, paragraph 196. The classification performance criteria, which had themselves been derived from Fire Note 3, were taken from Fire Note 9.739 Colwell {Day232/152:5-11}; Smith {MET00081237/12} page 12, paragraph 41; Colwell {BRE00047571/32} page 32, paragraph 200; Colwell {Day232/165:21}-{Day232/166:4}.
¶7.116 The second edition of BR 135 placed heavy emphasis on the potential difference that cavity barriers could make to the performance of external cladding systems.740 Colwell {Day232/165:13-17}; {BRE00005554/14} "Fire Barriers". However, it took no account of the fact that all five of the ventilated rainscreen systems subjected to a full-scale test under contract cc1924, including the system with cavity barriers fitted, had failed to meet the criteria in Fire Note 9.741 Colwell {Day232/162:18}-{Day232/163:10}. It also took no account of the fact that Dr Connolly had concluded in 1994 that a number of the fire barriers used in his testing had proved to be ineffective.742 {RCO00000001/48-49} paragraphs 9-11. It is not clear why the second edition of BR 135 placed so much emphasis on cavity barriers.743 Colwell {Day232/163:3}-{Day232/164:16}. There seems to have been a widely held view that properly designed cavity barriers could potentially improve performance,744 Smith {Day236/102:2-13}. but that does not appear to have been supported by any empirical evidence and in our view BRE should not have allowed its conclusions to be influenced by unsubstantiated opinion in that way.
¶7.117 The first (1988) edition of BR 135 had contained an explicit warning that BS 476 Parts 6 and 7 could provide information only about external surfaces.745 {BRE00001077/4} under the heading "Regulatory aspects". That warning was removed from the second edition, but it is not clear why. Neither Dr Colwell nor her co-author, Mr Martin, was able to provide a satisfactory explanation.746 Martin {Day251/113:9-15}. He expressly rejected the suggestion that the passage in the first edition had been deliberately omitted to avoid upsetting the industry.747 Martin {Day251/111:9-16}; {Day251/111:24}-{Day251/112:2}; {Day251/112:19}-{Day251/113:2}.
113¶7.118 We find it difficult to accept that the omission was an oversight. On the contrary, the removal of a passage pointing out the limitations of Class 0 was wholly consistent with the attitude that the department had taken to Class 0 since the Knowsley Heights fire in 1991, namely, that it must be retained, despite the evidence that it was unreliable and much misunderstood and despite a Parliamentary Select Committee expressly recommending its abrogation. We think it likely that commercial considerations played a part in the decision to delete the warning from BR 135.
BS 8414 Part 2: 2005
¶7.119 In October 2005, BS 8414 Part 2, setting out the large-scale test method for cladding systems on steel-framed structures, was published.748 {BSI00000097} BS8414-1 applied only to masonry structures. By that time, Dr Colwell had become chair of the British Standards Institution's joint committee working on the test standard.749 Colwell {BRE00047571/52} page 52, paragraph 330. She produced the initial draft750 Colwell {Day232/186:4-9}. and was responsible for obtaining a consensus on the draft text before it went out to consultation.751 Colwell {BRE00047571/52} page 52, paragraph 330. The test method in BS 8414-2 was based on the same principles as BS 8414-1. The need for a test method for steel-framed structures had become apparent during BRE's work on large-scale cladding tests under contract cc1924752 Colwell {Day232/70:13}-{Day232/71:25}; Colwell {BRE00047571/53} page 53, paragraph 333. and during the development of BS 8414-1,753 Colwell {BRE00047571/58} page 58, paragraph 367. as a result of which it was realised that there was insufficient knowledge about the fire performance of external cladding systems where no masonry wall was present.754 {BRE00041887/13} Option 2; {BRE00041895/9-10} tasks 6 and 7. Following its publication, BRE produced a document containing the performance criteria and classification method for BS 8414-2.755 Smith {MET00081237/22-23} pages 22-23, paragraph 89. They were attached to BR 135 as Annex B.756 {BRE00005552}.
BR 135, third edition: 2013
¶7.120 In 2013, a revised version of BR 135 was published, written by Dr Tony Baker757 Dr Tony Baker joined the BRE in 2004. He was the Certification Scheme Manager for the Passive Fire Protection Group and from 2013 onwards the fire resistance Test Laboratory Manager: Baker {BRE00005774/1-2} pages 1-2, paragraphs 4-7. and Dr Sarah Colwell.758 {CEL00000584}. The performance and classification criteria remained unchanged.759 Smith {MET00081237/23} page 23, paragraph 91; Colwell {BRE00047571/59} page 59, paragraph 378; Colwell {Day233/46:10-14}. The guidance in the third edition contained new wording making it clear that a classification in accordance with BR 135 applied only to the system tested and not to any other.760 {CEL00000584/9} left-hand column, final paragraph; {CEL00000584/27} left-hand column under bullet points; {CEL00000584/33} right-hand column under bullet points. Dr Baker told us that he had thought that the second edition of BR 135 had not been quite as clear as it could have been in that respect. New clauses had been added in order to clarify the position761 Baker {Day100/122:3-13}. because he was concerned that the message was not getting through to the industry.762 Baker {Day100/122:15-24}. For the same reason, BRE decided to insert the same wording into all classification reports.763 Baker {Day100/122:12-13}.
114Approved Document B 2006
The background to the amendment
¶7.121 In March 2004, the department commissioned BRE to undertake a review of Part B of Schedule 1 to the Building Regulations and Approved Document B.764 {BRE00001953}; {CLG00001508}. It did so because it felt that the technical aspects of the requirements of Part B and the guidance in Approved Document B were due for revision.765 {BRE00001953/4} section 1, third paragraph. The work was led and managed by Brian Martin in his capacity as an employee of BRE766 {BRE00001953/10} section 3; Martin {CLG00019469/2} page 2, paragraph 6. (although he continued to be seconded part-time to the department). It was split into a number of tasks, one of which was a survey of interested parties intended to identify matters they might think it important to include in the review.767 {BRE00001953/5} section 2 Task 1. In the light of the responses to those enquiries Mr Martin and Mr Burd prepared a draft revision of Approved Document B for public consultation.768 Martin {Day251/195:21-24}; {Day251/181:16-24}.
¶7.122 The topics considered as part of a "Forwards Look" exercise and on which recipients were consulted769 {CLG00002410/10-11} and {CLG00002410/22-23} in relation to B4 External Fire Spread, the topics consulted on were space separation and roof coverings. did not include the retention of Class 0, any amendments to Diagram 40 or the guidance relating to the construction of the external walls of buildings over 18 metres in height.770 Martin {Day251/145:19}-{Day251/146:4}. For whatever reason, none of those involved in the survey raised the question whether Class 0 should be retained as one of the standards by which the suitability of materials used in the external walls of buildings over 18 metres in height was to be judged.771 Martin {Day251/145:19}-{Day251/146:4}. Mr Martin did not suggest that topic for discussion because the object of the exercise was to find out what other interested parties thought the department should be considering.772 Martin {Day251/142:20}-{Day251/143:4}; Burd {Day240/25:11-24}. At that time he himself had not given any thought to the suitability of Class 0 for that purpose773 Martin {Day251/171:6-11}. and thought that it would have been odd to identify that particular subject, given the wide range of matters covered by Approved Document B.774 Martin {Day250/171:12-22}.
The 2002 edition
¶7.123 The 2002 edition of Approved Document B provided in paragraph 13.7 as follows:775 {CLG10000740/90}.
115"External wall construction The external envelope of a building should not provide a medium for fire spread if it is likely to be a risk to health or safety. The use of combustible materials for cladding framework, or of combustible thermal insulation as an overcladding or in ventilated cavities, may present such a risk in tall buildings, even though the provisions for external surfaces in Diagram 40 may have been satisfied. In a building with a storey 18m or more above ground level, insulation material used in ventilated cavities in the external wall construction should be of limited combustibility (see Appendix A). This restriction does not apply to masonry cavity wall construction which complies with Diagram 32 in Section 10."
¶7.124 Three things should be noted. First, the paragraph contained a warning that the fact that the surface of an external wall might satisfy Diagram 40 by having either a Class 0 or Euroclass B classification did not eliminate the risk of the spread fire across it. In other words, it drew attention to the fact that satisfaction of the requirements of Diagram 40 would not necessarily result in compliance with functional requirement B4(1). The person carrying out the work, therefore, always had to make a judgement about whether the wall as a whole (including the proposed cladding system) met the functional requirement, even if the surface of the outer material was classified Class 0.776 Burd {Day239/81:14}-{Day239/84:14}. That was how the department understood that provision and it does not appear to have crossed the mind of anyone within the department that it might be understood in any other way.777 Burd {Day 239/64:14}-{Day239/67:17}.
¶7.125 Secondly, notwithstanding the reference to external surfaces and Diagram 40 in the first part of paragraph 13.7, external surfaces were dealt with in paragraphs 13.5 and 13.6. Moreover, Diagram 40 had nothing to do with insulation.
¶7.126 Thirdly, the guidance suggested that only insulation used in a ventilated cavity in an external wall of a building over 18 metres in height need be of limited combustibility.
The 2006 edition
¶7.127 In the 2006 version of Approved Document B the former paragraphs 13.5, 13.6 and 13.7 were reorganised and re-worded as paragraphs 12.6 – 12.9. The first part of paragraph 12.5, which now bore the heading "External wall construction", read:
"The external envelope of a building should not provide a medium for fire spread if it is likely to be a risk to health or safety. The use of combustible materials in the cladding system . . . may present such a risk in tall buildings."
¶External surfaces were then covered by paragraphs 12.6, and insulation by paragraph 12.7.
¶7.128 On the face of it, the reorganisation did to some extent make the section easier to use, but in the attempt to achieve greater simplicity the warning that had existed in the first part of paragraph 13.7 of the 2002 edition was removed, so that there was now no overt statement that the use of a material or product that was Class 0 did not itself mean that the external wall would comply with functional requirement B4(1). Neither Mr Burd nor Mr Martin could offer any satisfactory explanation for the change.778 Martin {Day252/28:7}-{Day252/31:5}; Burd {Day240/79:25}-{Day240/82:21}.
¶7.129 Paragraph 12.7, which was the successor to paragraph 13.7 of the 2002 edition, now read as follows:
"Insulation Materials/Products In a building with a storey 18m or more above ground level any insulation product, filler material (not including gaskets, sealants and similar) etc. used in the external wall construction should be of limited combustibility (see Appendix A). This restriction does not apply to masonry cavity wall construction which complies with Diagram 34 in Section 9."
¶7.130 There were two other amendments of linked significance: first, the title of the paragraph was new, and secondly, the paragraph itself now contained the phrase "filler material (not including gaskets, sealants and similar) etc…". The significance of those changes lies in the fact that the department's contention, at least after the fire at Grenfell Tower, was that the words required the core of an external wall cladding panel to be of limited combustibility. Acceptable materials therefore, it argued, did not include ACM panels with unmodified polyethylene cores. However, we do not think that an ordinary reader would understand those words in that way and it is clear that in the years that followed many in the construction industry did not do so.
116The origin and evolution of the amendments
¶7.131 In the light of subsequent events we think it is useful to consider the origin of those amendments and the way in which they were introduced.
¶7.132 On 6 January 2005 a fire broke out at The Edge, a partly-occupied 19-storey block of flats in Salford, Greater Manchester.779 {BRE00035368/1} under heading "Type of building". Within ten minutes it had spread from the point of origin on a second floor balcony to the top of the building.780 {BRE00035368/1} final paragraph. BRE investigated the fire for the department under the Investigation of Real Fires contract781 Martin {Day251/148:5-8}. and Mr Martin discussed it with BRE colleagues, including Dr Colwell.782 Martin {Day251/146:25}-{Day251/147:11}; {Day251/149:5-9}. BRE found that the fire had spread externally over the building's aluminium composite cladding panels,783 {BRE00035368}. which had delaminated, exposing the combustible polystyrene cores, which had then become involved in the fire.784 {BRE00035368/1} final paragraph; {CLG00019455/76} paragraph 4.1.148. In its report it also pointed out that what had then been paragraph 13.7 of Approved Document B785 {CLG10000740/90} paragraph 13.7. had limited the combustibility of insulation alone and that, although polystyrene might ordinarily be used as an insulation material, in that case it had been used to stiffen the decorative panels rather than for its insulating properties.786 {BRE00035368/2}; Martin {Day251/154:6-13}. It referred to the polystyrene core of the panels as "a low cost filler".787 {BRE00035368/2}.
¶7.133 It is clear that neither BRE nor the department thought at the time that those responsible for the choice of the panels used at The Edge had failed to follow the existing guidance in Approved Document B; on the contrary, they thought that there was something wrong with the guidance that needed to be corrected. It does not seem to have occurred to anyone in the department that many in the industry were treating the guidance as prescriptive and that the warning in section 13.7 was insufficiently clear.788 Burd {Day240/57:21}-{Day240/58:17}.
¶7.134 At the time of the fire at The Edge Approved Document B did not warn against the use of aluminium composite panels with combustible cores on the walls of high-rise buildings; on the contrary, Diagram 40 tended to support the use of such panels if they had Class 0 surfaces.789 Martin {Day251/161:1-17}. BRE's second report into the fire dated 31 March 2005 warned that even if the construction had complied with current guidance, that would not have restricted the speed at which the fire had spread through it. It also reported that the fire and rescue services had grave concerns that a fire of that nature could quickly get out of control and put the lives of occupants at risk.790 {CLG00019455/76-79} paragraph 4.1.148 (Investigation of Real Fires Report April 2004 to March 2005, dated 31 March 2005). To that extent the guidance in Approved Document B was ineffective.
117¶7.135 On 18 January 2005, Brian Martin sent Anthony Burd some suggested amendments to section B4 of the working draft of Approved Document B then being prepared for consultation.791 {CLG00018832}. The reference to ventilated cavities in what was proposed as paragraph 11.8 was removed and the words "or any other material" were added, so that it read:
"In a building with a storey 18m or more above ground level, insulation or any other material used in ventilated cavities in the external wall construction should be of limited combustibility."792 {CLG00018833}.
¶7.136 If that form of words had been adopted, the guidance would have been that all materials used in the external wall construction of a building over 18 metres in height should be of limited combustibility.793 Martin {Day251/197:9-15}; Burd {Day240/45:19-23}. However, they thought that a blanket provision of that kind would go too far, because it would prevent the use of many materials that might otherwise have been considered acceptable in various circumstances.794 {CLG00018832}.
¶7.137 Accordingly, paragraph 11.7 of the draft sent out for consultation in July 2005795 {CLG00000022}. was amended to provide that:
"In a building with a storey 18m or more above ground level, insulation used in the external wall construction should be of limited combustibility."796 {CLG00000022/147}.
¶7.138 The intention at that stage was to ensure that what eventually became paragraph 12.7 covered materials which, although normally used as insulation, were being used for purposes other than their thermal performance.797 Burd {Day240/53:13-21}. Apparently, the department was not willing to delay the consultation to allow time to improve the wording but was willing to reconsider it after the consultation had been completed.798 Martin {Day251/209:15}-{Day251/210:8}.
The response of NHBC to the consultation
¶7.139 The origin of the word "filler" lies either in the first BRE report into the fire at The Edge or in NHBC's response to the consultation,799 Burd {CLG00019461/8-13} pages 8-13, paragraphs 23-31; Martin {Day252/16:25}-{Day252/17:11}. in which it sought clarification whether sandwich panels that used polystyrene as what it described as a "filler" could be used on buildings over 18 metres in height. "Filler" was not a word that had any settled technical or customary meaning. Mr Martin did not have a clear understanding of what it meant800 Martin {Day251/155:4-19}. and Mr Burd described it as "something that fills a void".801 Burd {Day240/101:20-21}, {Day240/102:24}. Both said that they had intended it to include the core of a sandwich panel, regardless of whether it was a material that could in other circumstances be used for the purposes of insulation,802 Martin {Day252/19:14-17}; Burd {Day240/72:22}-{Day240/73:9}; {Day240/100:8}-{Day240/101:6}. and thus to control the combustibility of the material below the surface.803 Martin {Day251/171:18}-{Day251/172:21}. Mr Martin may have thought that if the combustibility of the core was controlled, the classification of the surface would become less of a problem,804 Martin {Day251/191:7-16}. but that seems unlikely, because at the time no one in the department thought there was any problem with the use of Class 0.
118¶7.140 We accept that the use of the broad expression "filler material" was also intended to capture the use of materials in ways or circumstances that Mr Martin and Mr Burd had not yet come across,805 Martin {Day252/16:2-11}; {Day252/23:15}-{Day252:24:1}; {Day252/51:8-13}. such as the use of sheet materials to provide additional stiffness to a steel frame.806 Martin {Day252/21:24}-{Day252/22:16}. Mr Martin807 Martin {Day252/13:13-25}; {Day252/20:12-23}; {Day252/47:3-8}. and Mr Burd808 Burd {Day240/73:10-13}. both said that they had wanted people to think about it and work out for themselves what did or did not fall within its scope.809 Martin {Day252/24:2-7}. That approach was wholly inappropriate, however, since the purpose of Approved Document B was to provide clear guidance on how to comply with the regulations.
¶7.141 A new heading to paragraph 12.7, "Insulation Materials/Products", was introduced when the revised edition of Approved Document B was published. Mr Martin said that its purpose had been to prompt people to think more broadly about other combustible material they might be thinking of using, but he was unable to explain how it might achieve that.810 Martin {Day252/35:2-20}. It is much more likely that it was included simply to reflect the scope of the paragraph, which on a natural reading is directed to insulation materials and products.
¶7.142 Later confusion over the meaning of paragraph 12.7 may have reflected two competing aims we have mentioned: preventing the use of combustible materials in the cores of composite panels and in other, as yet unforeseen, ways811 Martin {Day252/16:4-11}. and allowing some combustible materials to be used in the construction of the external walls of high-rise buildings.
The course of the amendment
¶7.143 The reference to "filler material" was added at a very late stage in the revision process. The expression made its appearance for the first time, together with the new heading, in a single-page document drafted by Mr Martin on 22 November 2006.812 {CLG10002070}. The final revision came even later with the insertion of the words "(not including gaskets, sealants, and similar) etc.", which are not found in any drafts and appear to have been added to the version approved for publication by Anthony Burd on 18 December 2006 as the final proofs went to press.813 {CLG10002200/96}. Neither Mr Martin814 Martin {Day252/42:5-24}. nor Mr Burd815 Burd {Day240/95:11-23}. was able to recall any discussion about the addition of the reference to gaskets and sealants or the reason for it.
¶7.144 It was highly unusual to make changes to Approved Document B without going through a number of established procedures,816 Burd {Day240/14:9-25}; Martin {CLG00019469/6} page 6, paragraph 18. which included public consultation and scrutiny by the Building Regulations Advisory Committee, an independent body whose function was to ensure that any changes were appropriate.817 Harral {CLG00019487/38} page 38, paragraph 149. In this case, however, none of the established procedures was followed in relation to the additional wording and we have been left with the clear impression that the changes were rushed through by the back door without proper consideration.
119¶7.145 No statements appear to have been made by the department about the meaning of paragraph 12.7 after the revised edition of Approved Document B had been published. The reference to filler material was not listed as one of the main changes818 {CLG10000007/2}. and there was no reference to it in a circular issued by the department to building control organisations in December 2006819 {CLG10000038}. alerting them to the main changes. Mr Martin accepted that the circular should have contained a reference to it and could not explain why it had not done so.820 Martin {Day252/65:11-25}.
¶7.146 The term "filler material" was later addressed in a series of821 Burd {Day240/124:1-2}. presentations given by the department to professional organisations and building control bodies following the publication of the revised version of Approved Document B,822 Burd {CLG00019461/13} page 13, paragraph 32; Burd {Day240/117:10}-{Day240/119:11}. but the slides used in those presentations simply set out the text of paragraph 12.7 and gave no indication that the expression applied to the core of a composite panel or to any material other than insulation.823 {CLG00019451/55}; Burd {Day240/120:6-22}. No effort was made to draw attention to the change; on the contrary, as Mr Martin accepted, it was made quietly and without publicity in order to avoid a fuss.824 Martin {Day252/39:21}-{Day252/40:3}; {Day252/36:13-19}.
¶7.147 Although from time to time during the four years or so leading up to the Grenfell Tower fire Mr Martin was asked about the meaning of the phrase "filler material", it was not until he attended the meeting organised by the Centre for Windows and Cladding Technology in March 2016 that he said that it was intended to cover the core of a composite panel. Even when he did offer that explanation, it was restricted to a relatively small group of industry participants.825 See Chapter 11. Why he was so reticent is not entirely clear. There appears to have been some concern on his part that being more specific about the products that fell within the guidance might lead to legal challenges by manufacturers.826 Martin {Day252/39:11-20}. The fact that the changes had been slipped in without consultation was also one of his concerns827 Martin {Day252/39:21}-{Day252/40:3}. and he may also have thought that it was not for him to say what the statutory guidance issued in the name of the Secretary of State was intended to mean. However, he could have drawn the attention of more senior officials to the confusion in the industry about the meaning of paragraph 12.7, albeit at the risk of having to explain how the amendment had found its way into Approved Document B in the first place. At all events, no document or statement emanating from the department until after the fire at Grenfell Tower explained that the expression "filler material" was intended to include the cores of cladding panels.
121Chapter 8: The Investigation of Real Fires project
Introduction
¶8.1 Between 1988 and 2017 the government engaged BRE to monitor the effectiveness of the Building Regulations and the guidance contained in Approved Document B by examining the circumstances and causes of real fires. The work was known as the "Investigation of Real Fires" project.828 {BRE00001054/6}; Shipp {BRE00047594/24} page 24, paragraph 118. It was carried out under a series of contracts between BRE and DCLG (the department),829 Martin {CLG00019469/27} page 27, paragraph 86; {BRE00001054/6}. each of which ran for about two or three years and was based on an invitation to tender, and a proposal submitted by BRE for the work.830 Crowder {Day229/126:11-14}; {HOM00046292}; {CLG10003892}.
Background
¶8.2 BRE, originally known as the Fire Research Station, had been involved in the investigation of fires since the early 1970s. In 1970 the Fire Survey Group was formed, which consisted of a number of scientists who attended the scene of selected fires.831 Shipp {BRE00047594/21} page 21, paragraph 108. In 1988 Martin Shipp took over as head of the Fire and Security Section of the Fire Research Station, which by then was the department with responsibility for carrying out investigations into fires.832 Shipp {BRE00047594/3} page 3, paragraph 14; Shipp {BRE00047594/21} page 21, paragraph 108; Shipp {BRE00047594/24} page 24, paragraph 118. In that capacity he attended the scenes of fires, drafted reports for the department and engaged with departmental officials.833 Shipp {BRE00047594/24} page 24, paragraph 118. Thereafter, he was involved in the investigation of a number of significant incidents, such as the fire at the Yarl's Wood Detention Centre in 2002 and the fire at the Rose Park Care Home in 2004.834 Shipp {BRE00047594/5} page 5, paragraphs 27 and 28; {CLG10003892/1} paragraph 1.
¶8.3 The purpose of the Investigation of Real Fires project was to ensure that the government was informed in good time of new matters affecting fire safety, particularly those that emerged from significant incidents, and thereby to inform government policy.835 Shipp {BRE00047594/26} page 26, paragraph 127; {CLG10003892/3}. More particularly, the principal objective was to identify whether there were aspects of the guidance in Approved Document B or the functional requirements in Part B of Schedule 1 to the Building Regulations that were not working as intended and required amendment.836 Crowder {Day229/94:23}-{Day229/95:11}; Crowder {BRE00047668/12} page 12, paragraph 51; Shipp {BRE00047594/26} page 26, paragraph 127; Martin {CLG00019469/27} page 27, paragraph 86. The project had been established following the coming into force of the Building Act 1984 in recognition of the fact that it was necessary to monitor the introduction of the functional requirements to ensure that they were operating as envisaged.837 Crowder {Day229/95:13-24}. Dr David Crowder was involved in the project at BRE from 2006 onwards and took over responsibility for running it from April 2015.838 Crowder {BRE00047668/6} page 6, paragraph 27; Crowder {Day229/96:1-7}.
122¶8.4 The project was not concerned with matters that had no potential bearing on the statutory guidance or the Building Regulations, such as fires started deliberately and accidental fires resulting from a simple failure to follow the regulations or guidance.839 Crowder {BRE00047668/12} page 12, paragraph 51; Crowder {Day229/101:6-23}. By 2006 the following objectives for the project had been identified:840 {HOM00046642/13} section 2. a. To provide timely reports to the department on the effectiveness of the guidance in
¶Approved Document B in achieving fire safety in buildings in England and Wales. b. To improve understanding of how unusual fires develop and grow, particularly in domestic and other residential properties. c. To monitor the effect of European standards on building materials and systems. d. To monitor the approach adopted by fire safety engineering and other means of meeting the requirements of the Building Regulations. e. To identify the need for research relating to specific problems identified in fire investigations. f. To identify the efficacy of the Building Regulations in providing protection for fire fighters. g. To maintain close contacts with investigators, including the fire and rescue services, to
encourage the exchange of information on unusual fires that would be of benefit to the department.
¶h. To disseminate findings from fire investigations to the fire and rescue services, designers and owners of buildings and others, as appropriate.
¶8.5 From 2007 onwards Dr Debbie Smith was BRE's contract manager for the project and remained responsible for it at the time of the Grenfell Tower fire.841 Shipp {BRE00047594/23} page 23, paragraph 117; Smith {MET00081237/45} page 45, paragraph 179; Smith {Day236/159:22-25}; Day236/160:24}-{Day236/161:5}. However, she did not have day to day involvement in it, although she was involved in any formal correspondence with the department.842 Crowder {Day229/98:18}-{Day229/99:20}; Smith {MET00081237/45} page 45, paragraph 179; Lennon {BRE00043688/9} page 9, paragraph 48. Most of the reports produced pursuant to the project after 2007 were approved by Dr Corinne Williams, deputy contracts manager for the programme, acting on her behalf. Each report underwent technical checks or peer review before being sent to Dr Williams or Dr Smith for approval.843 Holland {BRE00043829/10} page 10, paragraph 33; Crowder {Day229/99:22}-{Day229/100:18}.
¶8.6 The department regarded the project as a means of providing robust evidence to ensure that the Building Regulations and Approved Documents were effective and continued to be fit for their purpose.844 Martin {CLG00019469/27-28} pages 27-28, paragraph 86. It was seen as a means of enabling the department to take an active approach to ensuring that policies and guidance were proportionate to the risk and gain a greater understanding of industry practice.845 Martin {CLG00019469/28} page 28, paragraph 87(c) and (d). The information obtained from the project, together with the statistics it was receiving, led to a general understanding within the department that Approved Document B provided adequate guidance on the use of combustible materials.846 Burd {CLG00019461/25} page 25, paragraph 64.
123The operation of the project
¶8.7 In practice, the project involved monitoring news reports of fires, from which BRE selected incidents to include in its reports. Important sources of information were media reports or local fire and rescue service reports,847 Shipp {BRE00047594/25} page 25, paragraph 123; Crowder {Day229/122:10}-{Day229/123:24}. both of which were monitored on line.848 Crowder {Day229/121:7-23}. A list of high – and low-priority considerations were agreed with the department at the beginning of each contract and was used by BRE to determine whether a more detailed examination of any particular incident was required.849 Shipp {BRE00047594/25} page 25, paragraph 124. At the top of the high-priority list were fatal fires, but the list also included fires of relevance to the Building Regulations or Approved Document B and fires of particular scientific interest, including fires involving cladding.850 Crowder {BRE00047668/41-43} pages 41-43, paragraph 171; Crowder {Day229/129:12}-{Day229/131:16}. Included in the low-priority list were fires overseas, a subject to which we return below.851 Crowder {BRE00047668/41-43} pages 41-43, paragraph 171. The list of priorities did not fundamentally change during the life of the project852 Crowder {Day229/131:17-22}. and largely determined the way in which BRE responded to or investigated any particular incident.853 Crowder {Day229/124:18}-{Day229/126:3}; Williams {BRE00043695/10} page 10, paragraph 43; Shipp {BRE00047594/25} page 25, paragraphs 124-125.
¶8.8 If a site inspection was considered necessary, BRE contacted the relevant fire and rescue service in order to gain access to the scene, assuming that the department was content for it to do so.854 Shipp {BRE00047594/25} page 25, paragraph 125. Sometimes BRE was unable to obtain access to the scene of a fire, for example, if the premises were a crime scene.855 Shipp {BRE00047594/25} page 25, paragraph 126.
¶8.9 BRE produced a range of different reports for the department based on its investigations, including quarterly progress reports, year-end reports, research reports at the end of each two or three-year contract cycle and reports on fires of special interest if site investigations had been carried out.856 Holland {BRE00043829/17-18} pages 17-18, paragraph 51 (category 1 fires being identified at Holland {BRE00043829/11} page 11, paragraph 37); Crowder {Day229/102:3}-{Day229/103:2}. BRE also wrote articles for various publications based on its work.857 Holland {BRE00043829/17-18} pages 17-18, paragraph 51. Some experimental fire testing was carried out under the project.858 Martin {CLG00019469/27-28} pages 27-28, paragraph 86.
¶8.10 BRE typically produced a few hundred reports on fires each year, although the number varied in accordance with the quality of the information available and the type of fires that had occurred. For example, in the year from July 2010 to July 2011 204 reports were produced, whereas 511 were produced in the year from July 2011 to July 2012. The budget for the project allowed for 28 days a year to be spent on preparing reports, which included monitoring news reports and sifting out fires that were not worth reporting. In practice three quarters of the time was spent on monitoring and one quarter on writing reports. That amounted to about 15 minutes a fire.859 Crowder {BRE00047668/43} page 43, paragraph 173. The contract for the years 2012 to 2015 allowed for a maximum of eight site visits a year.860 Holland {BRE00043829/14-15} pages 14-15, paragraph 42; {BRE00000951/21} under heading "Category 1 incidents". The total budget for the project remained at around £100,000 per year between 2006 and 2017.861 Crowder {BRE00047668/44-45} pages 44-45, paragraph 179; Crowder {Day229/145:16}-{Day229/146:3}.
124¶8.11 At the start of each contract a letter was sent to all fire and rescue services asking for their co-operation with the project and describing the list of high and low priorities that had been agreed with the department so that they could understand which fires BRE was interested in.862 Crowder {Day229/126:25}-{Day229/127:13}; {BRE00011186}.
A change in the scope of the project: October 2012
¶8.12 The department changed the terms of the contract for the period November 2012 to March 2015, which was put out to tender on 3 September 2012.863 {BRE00027677/1} paragraph 1(ii). Those changes were reflected in BRE's proposal dated 1 October 2012.864 {BRE00000951/4}. That proposal, which was prepared by Martin Shipp and approved by Dr Smith,865 {BRE00000951/2}. was submitted to Brian Martin at the department.866 {BRE00000951/1}. The overarching objectives of the project included the provision of unbiased, robust and independent evidence and information that would enable the department to ensure that the guidance in Approved Document B remained fit for purpose and to support the review of policy more generally.867 {BRE00000951/4}. They also included identifying areas for research and for potential changes to Part B of Schedule 1 of the Building Regulations or Approved Document B arising from specific problems identified in investigations.868 {BRE00000951/4}.
¶8.13 The proposal also contained a section describing the way in which reports would be produced. It included the following provision, which reflected a requirement that had been introduced for the first time in the department's request for a proposal:869 {BRE00000951/51}; Crowder {BRE00047668/12-13} pages 12-13, paragraph 53.
"All reports will: … • Not contain any policy recommendations. All reports produced by BRE for this project will not contain any proposed text for a revision to an Approved Document or supporting guidance. With the agreement of, or at the request of, DCLG, such material will only be provided in a separate Policy Implications Report (as and when necessary…) as this will typically need to be published separately."870 {BRE00000951/51} under heading "All reports will:".
¶8.14 The contract for the project was awarded to BRE on 8 November 2012.871 {BRE00027677}. At a meeting held at the start of the contract between Martin Shipp, Ciara Holland and Dr Crowder for BRE and Brian Martin and Steve Kelly for the department, the department made it clear that BRE should not volunteer policy recommendations but provide them only if asked to do so.872 Crowder {Day229/110:10-19}. Dr Crowder regarded that as a fundamental change in the way in which the contract operated873 Crowder {Day229/113:14-15}. and thought it was a result of the government's deregulatory policies.874 Crowder {Day229/114:1-3}; {Day229/118:4-10}. That shift in approach was entirely consistent with the evidence we heard from senior civil servants in the Department who explained to us the pressures they were under at the time due to the government's overarching desire to deregulate.875 As discussed in more detail in Chapter 10. As far as we know, the department did not ask BRE to produce any reports on policy implications.876 Crowder {Day229/119:3-13}; Smith {Day236/170:12-25}.
125Findings in reports
¶8.15 Each of the final research reports produced by BRE for the department between 2001 and 2015 pursuant to the project, contained the following conclusion:
"The findings from this period have reaffirmed the overall effectiveness of the building regulations and ADB in providing for the safety of life in the event of fire and most of the significant issues that have been identified during this study fall outside the scope of these regulations."877 {BRE00000936/15} section 3.
¶8.16 Although Martin Shipp said that the paragraph correctly reflected the position, there were periods during which it self-evidently did not.878 Martin {Day251/174:1-8}; {Day251/174:20}-{Day251/175:1}. One striking example is the report dated 31 March 2005,879 {CLG00019455/1}. which included a summary of the fire at The Edge, Salford, on 6 January 2005.880 {CLG00019455/76-79} paragraph 4.1.148. It contained the same standard paragraph.881 {CLG00019455/3}. However, the fire at The Edge had not only raised obvious questions within the department at the time, but had shown that the guidance in Approved Document B was not effective in restricting the use of external wall panels with combustible cores on high-rise buildings,882 Martin {Day251/175:2-9}; {Day251/176:1-5}. which had led in turn to a significant amendment. In those circumstances the inclusion of that paragraph is inexplicable.883 Martin {Day251/175:10-16}; {Day251/175:21-25}.
Sudbury House and Taplow House fires: 2010–2012
¶8.17 Two fires that featured in the reports prepared by BRE were those that occurred at Sudbury House in Wandsworth in August 2010 and Taplow House in Swiss Cottage in January 2012.
¶8.18 A report on the fire at Sudbury House was included in the report for the period July 2010 to July 2011 dated 27 July 2011.884 {BRE00000945}. It contained the following account:
"Block of flats, London, 1st August 2010 Sudbury House, Wandsworth High Street, London. A fire occurred on the fifth floor of a 24-storey block of flats at around 11.00. A man, presumed by BRE Fire and Security fire investigators to have been in the flat of origin, was suffering from smoke inhalation and was rescued from the fifth floor and another person was rescued from the third floor. The cause of the fire was under investigation."885 {BRE00000945/33} paragraph 5.1.3.
¶BRE did not carry out an investigation at the site of the fire;886 Crowder {Day229/160:15-17}. the summary was prepared solely on the basis of news reports.887 Crowder {Day229/160:18-20}. However photographs taken later showed that a fire in the compartment of origin had caused the building's cladding to catch fire. The fire had spread vertically through the cladding and up a column and had clearly gone beyond the compartment of origin.888 Crowder {Day229/161:18-20}. The rainscreen at Sudbury House was replaced after the Grenfell Tower fire because it also consisted of Aluminium Composite Material (ACM) panels with a polyethylene core.889 Crowder {Day229/161:23}-{Day229/162:3}.
126¶8.19 The fire at Taplow House was included in the report for the period July 2011 to July 2012 dated 26 July 2012.890 {BRE00000947/53} paragraph 5.1.64. It contained the following account:
"Block of flats, London, 16th January 2012 Swiss Cottage, London. The fire started at about 22:00 on the 17th floor of a 22-storey block of flats. 130 people were evacuated to a nearby community centre. The 17th floor was partially gutted, but fire fighters confined the fire to that floor and brought the fire under control in over three hours. The fire was caused by a candle setting fire to papers, prompting a warning by a London Fire Brigade spokesman on storing large amounts of papers, magazines and books in dwellings."
¶Again, BRE did not visit the scene of the fire to carry out an investigation; the summary was based on media reports.891 Crowder {Day229/163:8-15}. However, the fire spread both upwards and downwards over one column of the tower.892 Crowder {Day229/164:4-6}. After the Grenfell Tower fire the cladding system at Taplow House was found to consist of Reynobond 55 ACM PE rainscreen panels with mineral wool insulation.893 Crowder {Day229/163:16-19}.
¶8.20 Although the fire at Sudbury House had required the rescue of two people, which suggested that it was a high-priority for investigation,894 The second category under the high-priority list was "Non-fatal fires with injury or rescue": Crowder {BRE00047668/41-43} pages 41-43, paragraph 171. there was nothing in BRE's summaries of either of those fires that suggested that they ought to be the subject of further investigation.895 Crowder {Day229/168:18-23}; {Day229/169:13-22}. It seems that BRE did not regard fires in high-rise buildings as in themselves requiring further investigation, because they were not expected to spread beyond the compartment of origin.896 Crowder {Day229/170:2-22}. The fire at Sudbury House was not regarded as a cladding fire comparable to Knowsley Heights, Garnock Court or Lakanal House, since it had been largely contained in the dwelling of origin.897 Crowder {Day229/170:22}-{Day229/171:1}.
¶8.21 The approach to these two fires exposes a fundamental flaw in the way the Investigation of Real Fires project was conducted. BRE's research was based on very limited information (mainly media reports), with the result that it had no reliable way of telling whether a particular fire required more detailed investigation. It may be that the quality of the information available to BRE was declining over time, either because of reduced funding by the department or because it was increasingly dependent on the media rather than information from fire and rescue services.898 Crowder {Day229/171:3-20}. In our view, however, it was unsatisfactory for the department and BRE to be pursuing a project of this kind on the basis of such superficial information. BRE ought to have told the department that its findings and advice were becoming increasingly unreliable and that unless the budget could be improved to maintain standards it could no longer provide information of the quality the department expected to receive. For its part, the department should have considered whether the project was any longer meeting its objectives, and if not, why not.
127¶8.22 In fact, there was additional information available in the public domain about the fire at Sudbury House that would have made it clear to BRE that the incident involved a cladding fire that deserved further investigation.899 Bisby, Phase 2 Report {LBYP20000001/213} paragraph 1210. In a YouTube video posted online on 1 August 2010 (the same day as the fire) flames could be seen spreading up the column (and to a lesser extent down it) and it was clear that the fire had been extinguished only when firefighters had been able to bring water directly to bear on it.900 See stills from the video {INQ00015117/3-4}. The title of the video was "Fire on the 5th floor, Sudbury House, Wandsworth High Street" and includes a link to a BBC article about the fire.
¶8.23 BRE ought to have found that video.901 Crowder {Day229/178:15-25}. The incident looked like a cladding fire of the kind that the department would wish to have been aware of902 Crowder {Day229/179:4-9}. and more should have been done by BRE by way of investigation.903 Crowder {Day229/179:11-21}. In our view BRE did not pursue the project with the vigour that was required, but the project itself was flawed in a number of respects,904 Crowder {Day229/180:25}-{Day229/181:2}. not least because the funding provided for the work did not increase between 2006 and 2017 to match the increased cost of carrying out the work.905 Crowder {Day229/180:3-24}.
Identification of patterns and trends
¶8.24 Another weakness affecting the project was the existence of a belief on the part of the department and BRE that the findings from any particular investigation could not be of general significance906 Shipp {BRE00047594/27-28} pages 27-28, paragraph 134. and that it would therefore be necessary to identify patterns or trends before drawing the department's attention to developments that might call for action. Each annual report began with a table907 {HOM00046642/16-29}; {BRE00000945/19-30}; {BRE00000947/25-43}. that identified aspects of interest from which BRE attempted to identify trends that required specific identification in the report.908 Crowder {Day229/147:8-13}. Individual incidents, however serious, did not influence the conclusions in the end of year reports because no pattern had been identified.909 Crowder {Day229/147:25}-{Day229/149:9}. BRE was interested in whether a problem had become endemic;910 Crowder {Day229/149:25}-{Day229/150:20}. a single incident would need to be combined with information from other events to identify trends that satisfied the objectives of the project.911 Crowder {BRE00047668/44} page 44, paragraph 177.
¶8.25 That was a very naïve approach, both on the part of BRE and the department. Although the identification of patterns or common occurrences was no doubt an important part of BRE's work, it failed to accord sufficient recognition to the fact that a single rare but significant incident might well have important implications for the effectiveness of the regulatory regime. It might take only one serious fire to demonstrate that the guidance was inadequate. The fire at Grenfell Tower was but one example in a long line that included Knowsley Heights, Garnock Court and Lakanal House. The fundamental shortcoming of the Investigation of Real Fires project was that it concentrated on patterns based on the frequency rather than the severity of incidents. In that way the project undermined rather than enhanced the ability of the government to make a proper assessment of fire risk in the built environment. BRE ought to have made that clear to the department.
128Concerns about downward fire spread and flaming droplets
¶8.26 The narrowness of the approach taken to the identification of patterns or trends was particularly apparent in the way in which project reports addressed the subject of downward fire spread. Dr Crowder was concerned about the absence of any express provision in Approved Document B relating to downward fire spread.912 Crowder {BRE00043716/25} page 25, paragraph 82. Between December 2007 and August 2016 there had been a number of incidents in which there had been downward spread of fire as a result of the building fabric, all of which had been individually reported to the department.913 Crowder {BRE00043716/23-24} pages 23-24, paragraph 79 (a) to (g). Materials that formed burning droplets were often fitted against other flammable materials, such as combustible insulation. Burning droplets would typically promote the rapid spread of fire by igniting other combustible materials more quickly than would otherwise have been the case.914 Crowder {BRE00043716/25} page 25, paragraph 83.
¶8.27 Despite Dr Crowder's concerns, none of BRE's reports identified the creation of burning droplets or the downward spread of fire as matters that deserved to be brought to the department's attention as potential reasons for reviewing the statutory guidance. That appears to have been because the incidents had occurred sporadically over a 10-year period915 Crowder {Day229/214:13-23}. and a trend had not been identified in any one report.916 Crowder {Day229/217:7-11}. Dr Crowder thought that such incidents could have been attributable to other causes.917 Crowder {BRE00043716/25} page 25, paragraph 82. There was, therefore, little or no effort to identify trends that might extend across separate reporting periods. BRE made it clear to the government that it needed to look at innovative construction products and techniques from a fire safety perspective918 Crowder {Day229/214:23}-{Day229:216:2}; {Day229:217:12-18}. but the government gave the impression that it was unwilling to make changes.919 Crowder {Day229/208:23}-{Day229/209:9}.
¶8.28 We accept that the government's enthusiasm for deregulation after 2010 made it reluctant to receive advice that the regulatory regime was inadequate, but it is regrettable that BRE did not give clear advice about what could be learnt from individual incidents or about trends that were evident over a number of years, such as with the danger posed by burning droplets and their contribution to the downward spread of fire. At no stage did BRE offer to report to the department on the policy implications of the downward spread of fire and the adequacy of Approved Document B to address it.920 Crowder {Day229/209:1-9}. Instead, BRE appears to have decided not to give advice to the government that it knew would be unwelcome.
International fires
¶8.29 Another area of importance that received limited attention from BRE was international fires, including international cladding fires. Overseas fires were identified by the department as a low priority for the project.921 Crowder {BRE00047668/41-43} pages 41-43, paragraph 171. However, it would have been useful for BRE to obtain better information about international fires, such as the various fires involving ACM panels that occurred around the world and were prominently reported in the five or so years before the fire at Grenfell Tower.922 Crowder {BRE00047668/47} page 47, paragraph 184. Dr Crowder had been able to attend the scene of only one overseas fire as part of his work on the project, a fire in Dublin in 2008 that was relevant to the spread of fire in car parks.923 Crowder {BRE00047668/47} page 47, paragraph 184. Although some international fires were mentioned in BRE's reports, very little detail was given about their causes. For example, two cladding fires in Dubai that occurred in 2016 were referred to in the end of year report for the period April 2016 to March 2017.924 {BRE00000959/111-113} paragraphs 6.14.6 and 6.14.17 – the two fires were the Sulafa Tower fire in Dubai on 20 July 2016 and the Palm Jumeriah fire in Dubai on 12 December 2016. Although a brief description of each fire was provided, no information was given about what materials were thought to have been involved, even though reports available in the UK indicated that they had included ACM panels.925 https://www.dailymail.co.uk/news/article-3699272/Fire-breaks-luxury-75-storey-tower-Dubai.html (20 July 2016). Nor was there any discussion in the report about the spread of fire downward, which was a feature of both fires. Mr Martin said that he had asked BRE to use its contacts to obtain more information about some of the international cladding fires that were being reported, but that the Investigation of Real Fires project was limited by the resources allocated to it.926 Martin {Day252/118:2-6}.
129¶8.30 At no stage during the time that Dr Crowder was involved in the project was any proposal, whether formal or informal, put to the department by BRE recommending that closer attention should be given to international cladding fires.927 Crowder {Day229/141:22-25}. The prevailing view was that the incidents had occurred as a result of inadequate regulation and that there was no cause for concern in the UK,928 Crowder {Day229/141:4-21}. which had higher regulatory standards. It was also thought within the department that ACM panels were not being installed in the UK.929 Crowder {Day229/135:2-14}; Smith {MET00081237/21} page 21, paragraph 83; Martin {Day255/108:7-12}. That was obviously wrong. The department could have discovered by July 2014 that ACM cladding panels with a polyethylene core were in widespread use and that many people in the industry thought that if a panel had a Class 0 surface it could be used at any height. After early 2016 Mr Martin could have been in no doubt about that.
¶8.31 Although we recognise the significance of hindsight, we find it surprising that more was not done to monitor international fires, particularly international cladding fires. A spate of such fires occurred in the UAE in 2012 and 2013 and a further spate in 2015 and 2016. It is a matter of concern that they do not appear to have prompted any serious consideration within BRE or the department of whether closer attention should be paid to them or to the lessons they might offer. Had they done so, there might have been a more thorough investigation of what had caused such a catastrophic spread of fire across the walls of the building in each case. That might in turn have shaken the department out of its complacent belief that it could not happen here. Both the department and BRE were warned on a number of occasions about the problems that could be caused by the use of combustible materials in the external walls of tall buildings with specific reference to cladding fires that had occurred abroad. Those warnings appear to have generated at best some informal conversations between BRE and the department, but more could and should have been done.
130Conclusions
¶8.32 In a number of important respects the Investigation of Real Fires project was flawed. Most of the reporting amounted to little more than reciting information about fires obtained from news reports, followed by formulaic conclusions that assured the department that the regulations and guidance were effective, without their efficacy having been subjected to any proper scrutiny. There was no analysis of the lessons to be learnt from significant single incidents, from the identification of patterns across different reporting periods, or from significant fires overseas. The work was being carried out at such a high level of generality that it would have been difficult for BRE to identify any patterns indicating that changes to the statutory guidance were necessary to ensure that it remained relevant to the risks posed by the built environment. From 2012 the BRE was hobbled in its reporting by a prohibition on making policy recommendations involving changes to the regulations or guidance. It knew that the government had no appetite for further regulation and therefore decided not to offer unwelcome advice. In our assessment the operation of the project epitomised what had gone wrong in BRE's relationship with the government; what was needed was proper independent advice, which the department did not want to receive. The project thus helped to foster an attitude of complacency within both BRE and the government about the adequacy of Approved Document B. We are critical of both BRE and the department for allowing that state of affairs to persist for so many years.
131Chapter 9: The government's response to the Lakanal House fire
Investigations immediately following the fire
¶9.1 Following the Lakanal House fire,930 Phase 1 Report chapter 8.1. BRE was asked by DCLG to investigate the incident under a standing contract known as the "Investigation of Real Fires" project.931 Crowder {BRE00043716/2} paragraph 5(a). It was to form part of BRE's continuing project monitoring fires of special interest. Mr Martin Shipp and Dr David Crowder carried out the investigation. Initially, Mr Shipp led the investigation932 Martin {Day256/30:19-25}. and supervised Dr Crowder's work,933 Shipp {BRE00047594/9} page 9, paragraph 54. but later Dr Crowder took over as point of contact for the investigation.934 Martin {Day256/30:25}-{Day256/31:1}. The police and LFB carried out their own investigations. They had statutory powers to control the scene of the fire and pursue relevant prosecutions and therefore BRE could examine the site only with their permission.935 Martin {Day256/32:12}-{Day256/33:1}.
¶9.2 The purpose of BRE's investigation for DCLG was to establish whether the fire could be traced to a defect in the Building Regulations or the guidance in Approved Document B (and if so, whether there any changes to either of them should be recommended) or whether there had been a failure on the part of those carrying out the refurbishment to follow the guidance and comply with the regulations.936 Crowder {BRE00043716/2} page 2, paragraph 5(a); Martin {Day256/26:5}-{Day256/27:15}.
¶9.3 The version of Approved Document B that applied to the refurbishment was the edition published in 2000 with amendments made in 2002.937 Crowder {Day229/227:2-7}. See Chapter 6 for a summary of the requirements relating to the construction of external walls. Unlike the 2006 version, which provided that all insulation material used in the external wall of a building over 18 metres in height should be of limited combustibility, the 2002 version of Approved Document B required only that insulation used in ventilated cavities in external walls should be of limited combustibility. Accordingly, the guidance did not advise that the insulation in composite panels of the kind used at Lakanal House should be of limited combustibility. It did, however, advise that if the building were over 18 metres in height the external surfaces of the walls should be classified Class 0.938 {CLG10000740/91}.
¶9.4 BRE first attended the scene at Lakanal House on 6 July 2009, three days after the fire.939 Crowder {BRE00047668/24} page 24, paragraph 89. Dr Crowder said that he attended the site on about another six days that month.940 Crowder {BRE00043716/27} page 27, paragraph 88 (b); Crowder {Day229/229:17-24}. During that time BRE's investigation included examining and removing one heavily damaged composite window panel and exploring the internal construction of the building. At a later stage, further composite panels were removed from the site for testing.941 Crowder {Day229/230:11}-{Day229/231:15}. In the first week, contact between DCLG and BRE was mainly between Mr Shipp and Brian Martin, but thereafter Dr Crowder began to communicate directly with Mr Martin about the investigation.942 Crowder {Day229/230:1-10}. BRE reported regularly to Mr Martin about the progress of the investigation.943 Crowder {BRE00043716/27} page 27, paragraph 88(b); Crowder {Day229/232:4-20}. Mr Martin also attended the site himself on one occasion to gain a better understanding of the building and what had happened.944 Martin {Day256/34:11-20}; Crowder {BRE00043716/22} page 22, paragraph 76; Crowder {Day229/233:9-18}.
132¶9.5 A Fire of Special Interest (FOSI) report was prepared by BRE, a draft of which was sent to Brian Martin on 16 July 2009. The final report was sent on 10 August 2009.945 Crowder {BRE00047668/24} page 24, paragraph 91. A draft of the 16 July 2009 report is at {BRE00036261/3}, another at {BRE00036265/5} and an earlier draft from 7 July 2009 at {CLG00001693/2}. In that report BRE identified the fact that the external wall had included "polymeric panels" in various locations,946 {BRE00032286/196}. i.e. that the panels had been made of a type of plastic that was combustible. At that stage, however, their exact composition had not been determined.947 Crowder {Day230/6:19}-{Day230/7:4}. BRE also said that falling burning debris, probably from both the façade itself and the contents of Flat 79 on floors 11 and 12, had ignited fires lower down the building on floors 5 and 7. At that early stage it had not been possible to determine from the physical evidence precisely what was the source of the debris which had ignited the contents of each flat.948 {BRE00032286/202}; Crowder {Day230/10:17}-{Day230/11:4}. Under the heading "Potential Implications for the Building Regulations" the report drew attention to the external spread of fire as a matter of potential importance.949 {BRE00032286/203}. No explanation was offered, however, for the spread of fire and the report contained no information about the construction of the external wall. No conclusions were reached about whether it followed the guidance in Approved Document B or complied with the Building Regulations. At the time the report was prepared BRE had not tested any samples of the window panels.950 Crowder {Day230/4:25}-{Day230/5:3}. As Dr Crowder explained, BRE was unable to provide a more detailed report in the time available based on its initial investigation. Unfortunately, the investigation remained incomplete.951 Crowder {Day230/8:20-25}; Crowder {BRE00047668/36} page 36, paragraph 153; Crowder {Day230/10:11-14}.
¶9.6 On 14 July 2009, just 11 days after the fire, Brian Martin told someone who had offered to help DCLG with its investigation into the fire that, based on the information he had received so far, he did not think there would be any need for changes to Approved Document B.952 {CLG10003915} exchange between Brian Martin and Glenn Horton of Locke Carey, a firm of fire safety consultants. Mr Martin told us that his preliminary view, based on the reports he had received from BRE, was that the problem lay mainly with the original construction of Lakanal House. Although he recalled a discussion with BRE about external fire spread, he could not remember when it had occurred or what had been said.953 Martin {Day256/38:8}-{Day256/41:14}.
¶9.7 Although BRE's investigation was then still at a very early stage, on 28 July 2009 Mr Martin sent an email to Mr Shipp stating that he was satisfied that there would be no need for BRE to visit Lakanal House again and that any further visits would have to be funded by someone else.954 {BRE00043742}. Mr Martin told us that he had discussed the matter with his colleagues in the Fire Resilience directorate and that they were happy for BRE to drop the investigation.955 {BRE00043742}. After it received Mr Martin's email BRE produced its final report into the incident on 10 August 2009.
133¶9.8 Dr Crowder said that he had been disappointed956 Crowder {Day230/17:1-5}. by DCLG's decision to curtail BRE's investigation because he had thought it important957 Crowder {Day230/16:12-19}. and had wanted it to be completed.958 Crowder {Day230/9:2-7}. He had wanted to understand better what had happened and why,959 Crowder {Day230/10:21-22}. including the time at which the fire had spread vertically and the cause of the downward fire spread, which he said had not been common at the time.960 Crowder {Day230/11:5-16}; {Day230/4:15-23}. When the investigation was shut down Dr Crowder had not begun to review Approved Document B961 Crowder {Day230/12:13-23}. and he did not know how Mr Martin had come to the conclusion that there was no need for any changes to it.962 Crowder {Day230/22:5-15}.
¶9.9 According to Mr Martin, the decision to discontinue BRE's investigation was taken by officials in DCLG after discussion with Sir Ken Knight,963 Martin {Day256/64:12-21}. Sir Ken Knight was the Department's Chief Fire and Rescue Adviser at the time. then the Chief Fire and Rescue Adviser. The decision proceeded on the basis that since the police and the LFB were pursuing their investigations, it was better to leave it to them, given the nature of the incident and its seriousness.964 Martin {Day256/58:8-21}; {Day256/59:3-24}. That was consistent with Dr Crowder's understanding of the position.965 Crowder {Day230/19:10-20}. Mr Martin also said he was concerned about whether the department's resources might be exhausted in the investigation of one incident if too much time was spent on the Lakanal House fire.966 Martin {Day256/60:16-23}.
¶9.10 Although we accept that those were some of the reasons for the decision to terminate BRE's investigation, we consider that the decision was premature and find it hard to understand, given that its fundamental objective had not been achieved. Although the police and the LFB might have been expected to find out whether the Building Regulations and Approved Documents had been complied with, DCLG could have had no confidence, based on what had been investigated thus far, that they would or could reach a conclusion about whether the regulations and guidance were themselves satisfactory. Indeed, we note that, when BRE's investigations were terminated, there had been no substantial dialogue between its investigators and the police.967 Crowder {Day230/16:20-25}. We also consider that conserving resources should not have been a priority in circumstances where six people had died and completion of BRE's investigation might prevent more deaths in the future.
¶9.11 Although Mr Martin told us that he thought that discussions about the downward fire spread at Lakanal House had taken place with BRE at an early stage, he also said that Sir Ken Knight had taken the view that it was not unusual for falling debris to result in secondary fires.968 Martin {Day256/45:1-12}. The latter view seems to us to be consistent with DCLG's lack of interest in learning lessons from the incident, which is evident in Mr Martin's correspondence shortly after the fire969 {CLG10003915} on 14 July 2014 Mr Martin told a third party that "Based on the snippets of info I've had so far I don't think there's any need for changes to ADB." and in his evidence to us.970 Martin {Day256/47:10-22}; Martin {Day256/56:22}-{Day256/57:1}. He was clearly of the view that the 2006 edition of Approved Document B had dealt with the combustibility of the façade more effectively than the 2002 version971 Martin {Day256/49:7-18}. and it is apparent that there was little appetite on his part or that of the department for revisiting the guidance, despite the fact that it did not specifically refer to the danger of fire spreading downward or the creation of burning droplets.972 Martin {Day256/51:15-19}.
134¶9.12 We accept that Dr Crowder and Mr Shipp973 Crowder {Day230/17:20-24}. were disappointed that their investigation was not able to reach a conclusion. However, it is a matter of some concern that there is no formal record of BRE's expressing that dismay to the government, let alone formally advising the government that it was important for more investigative work to be done. In circumstances where BRE thought that its investigation needed to be completed to understand the incident fully, it is surprising that it did not say so clearly in a letter to the department. Although in its report of 10 August 2009 BRE drew attention to some matters that called for further investigation,974 Including communications between the LFB and the occupants at Lakanal - see {BRE00032286/203}. that did not include the spread of fire across external walls.975 See {BRE00032286/203} and contrast the wording at penultimate and antepenultimate paragraphs. While Dr Crowder explained that omission as a poor choice of language,976 Crowder {Day230/14:11-22}. that does not do justice to complete silence on the subject. The episode suggests a lack of independence on the part of BRE and a failure to provide robust advice to the government on reasonable steps necessary to ensure safety from fire.
Sir Ken Knight's report to the Secretary of State
¶9.13 On 30 July 2009 Sir Ken Knight submitted a report to the Secretary of State on the questions arising from the Lakanal House fire in which he said that the problem of fire spreading over external walls was not significant and that initial enquiries did not suggest that it had occurred in a new way.977 {HOM00045791/21} paragraph 39. Sir Ken told us that at the time the Lakanal House fire was not seen as a fire in an external wall because the cladding system itself had not caused it.978 Knight {Day245/165:8-18}. However he also accepted that the downwards spread of fire had been unusual979 Knight {Day245/170:20-23}. and "very much a one-off".980 Knight {Day245/187:7-16}. He also accepted in hindsight that it would have been helpful if, as the government's Chief Fire and Rescue Adviser, he had asked for an investigation to determine the extent to which the external window panels at Lakanal House had promoted the downward spread of fire.981 Knight {Day245/172:18}-{Day245/173:14}. We agree.
Further testing by the LFB of the external wall panels
¶9.14 Following the termination of its investigation for DCLG, BRE was engaged by the police and the LFB to assist them with their investigations into the fire.982 Crowder {BRE00043716/28} page 28, paragraph 88(d); Crowder {Day230/28:7-10}. That included carrying out reaction to fire tests on some of the external wall panels taken from the building after the fire. In particular, in November 2009, surface spread of flame tests were carried out on three types of the external wall panels with insulating cores in accordance with BS 476-7. Three different colours of insulating foam had been found on site and tests were carried out on all three.983 Crowder {Day230/24:19}-{Day230/25:15}.
135¶9.15 The panels performed poorly in those tests, most of which were directly observed by Dr Crowder.984 Crowder {Day230/80:21}-{Day230/81:1}. They all achieved only Class 3, meaning that the flames spread a considerable distance across them.985 BRE's Investigation of Real Fires Report dated 17 November 2009 {BRE00032286/243}. They were therefore incapable of achieving national Class 0, which requires Class 1 to be achieved in a test under BS 476-7. In addition, incandescent spalling was observed during all test runs and specimens were flaming strongly at the end of the tests. During some of the tests flaming debris was observed on the floor.986 {BRE00032286/242} section 4.2. Those observations were worrying because they showed that the combination of materials in the panels was dangerous.987 Crowder {Day230/82:11-14}. The material behaved so badly that BRE feared its equipment might be damaged if it carried out fire propagation tests in accordance with BS 476-6.988 Crowder {BRE00043716/8} paragraph 18. It is to be noted that no further reaction to fire tests (including testing to BS 476-6) were ever carried out on the panels from Lakanal House.
¶9.16 Dr Crowder reported the results of the tests to Mr Martin in November 2009. Although contact between BRE and DCLG on the subject of the Lakanal House fire had diminished by this time, he recalled a telephone call on about 18 November 2009 with Brian Martin during which it was likely that they had discussed the results of the BS 476-7 tests.989 Crowder {Day230/26:23-25}. He said that he had told Mr Martin that during the tests the panels had produced burning embers which had fallen out of the test rig.990 Crowder {Day230/30:20}-{Day230/31:1}. Dr Crowder regarded the downward spread of fire as unusual.991 Crowder {Day230/34:24}-{Day230/35:1}. That information was provided informally and was never committed to writing, despite the fact that it was important and BRE had a contract with DCLG to inform it of any failure in the regulations or in compliance with them.992 Crowder {Day230/32:12}-{Day230/33:6}.
¶9.17 Although Dr Crowder did not recall the details of his telephone call with Mr Martin, he did recall having been told, either by Mr Martin or Mr Shipp, that the problem with the external wall panels at Lakanal House had been one of a failure to follow the guidance in Approved Document B or to comply with the Building Regulations. It was not that the panels had been compliant with the Building Regulations but had nevertheless produced burning debris.993 Crowder {BRE00043716/22} page 22, paragraph 78. As far as he could recall, he had been told by Mr Martin or Mr Shipp that if the panels had been Class 0, they would not have produced burning debris during a BS 476-7 test, but his recollection of that was not very clear.994 Crowder {Day230/31:2-8}. Mr Martin could not remember having told Dr Crowder that the problem with the panels was one of non-compliance,995 Martin {Day256/71:1-17}. although he agreed that it was something he was likely to have discussed with him. On the whole, we think it likely that Dr Crowder's recollection is reliable and it is consistent with an unwillingness within DCLG to accept that there was anything fundamentally wrong with the 2002 version of Approved Document B. It is troubling that the department should have reached a conclusion of any kind without having taken expert advice based on a full understanding of what had occurred.
136¶9.18 BRE was not asked to provide a report on the policy implications of the downward spread of fire at Lakanal House.996 Crowder {Day230/51:3-6}. It drew the department's attention informally to the problem of fire spreading downwards and debris falling from burning panels,997 Under the Investigation of Real Fires contract there was an obligation on the BRE to maintain informal, direct and regular contact with DCLG policy officers - see {BRE00000951/44} second paragraph. but the department does not appear to have given any serious consideration to the implications that might have had for the regulatory regime. In the years before the investigation into the Lakanal House fire, fire safety staff at BRE were not allowed to hold direct conversations with the department's officials outside formal meetings attended by senior managers.998 Crowder {Day230/43:5-19}. However, there do not appear to have been any formal meetings to discuss the downward spread of fire or the danger posed by falling debris following the Lakanal House fire.
¶9.19 Brian Martin gave Dr Crowder the impression that since the external wall and other aspects of the construction of Lakanal House had not complied with the relevant regulations and guidance, he doubted that there was any problem with the guidance itself.999 Crowder {Day230/87:19}-{Day230/88:7}; {Day230/89:11-15}. Further, Dr Crowder's impression was that Mr Martin had decided that there were other explanations for the downwards fire spread at Lakanal House which did not point to any fundamental problem with the regulatory regime.1000 Crowder {Day230/41:2}-{Day230/42:13}. We understood Dr Crowder to mean that because burning debris might have fallen from the flats that had caught fire, it could not be proved that falling debris from the exterior wall panels had caused the downward spread of fire. A number of times during their evidence both Dr Crowder and Mr Martin gave that as an explanation for the failure to investigate the downward spread of fire.1001 Martin at {Day256/49:7}-{Day256/50:6}; Crowder {BRE00043716/22} paragraph 78; Crowder {Day230/39:14}-{Day230/41:11}. See also {CLG10005528/1} email dated 4 March 2013 from Brian Martin to Anthony Burd and others. However, that overlooks the worrying behaviour displayed by the composite panels in the BS 476-7 tests. Once that evidence had become available, there was no reasonable excuse for the department's failure to obtain further advice on whether the Building Regulations and the guidance in the Approved Documents were sufficiently robust. Its failure to do so was a serious abdication of responsibility.
BRE's Investigation of Real Fires report: November 2009
¶9.20 BRE covered the Lakanal House fire in the Investigation of Real Fires Report which it produced on 17 November 2009 but it made no recommendations for changes to the Approved Documents or for further investigative work.1002 {CLG00019142/9} item 23; {CLG00019142/16}. In addition, the report contained the familiar phrase that the findings from the project reaffirmed the overall effectiveness of the Building Regulations and Approved Document B in providing for the safety of life in the event of fire.1003 {CLG00019142/3}. Despite being one of the authors of the report,1004 Crowder {Day230/37:23}-{Day230/38:8}. Dr Crowder could not explain why it did not refer to the downward spread of fire spread at Lakanal House or to the fact that Approved Document B gave no guidance on how that might be prevented.1005 Crowder {Day230/38:17}-{Day230/39:12}. He did say, however, that Martin Shipp had decided what went into the the report.1006 Crowder {Day230/37:15}-{Day230/39:2}.
137Failure to learn wider lessons from the Lakanal House fire
¶9.21 On 14 December 2009, five months after the Lakanal House fire, Commissioner Dobson wrote to Sir Ken Knight to express the LFB's concern about the panels forming part of the external walls of Lakanal House and the fact that similar panels on other buildings could present a risk of fire spreading across or through the walls. In his letter the Commissioner explained that BRE's tests had demonstrated that the composite panels used at Lakanal House did not comply with the requirements of the Building Regulations in relation to the spread of fire over external walls or the guidance in Approved Document B on how those requirements might be met.1007 {LFB00104291}. The tests to which he referred were the BS 476-7 surface spread of flame tests to which we have referred above. The Commissioner went on to say that it was the LFB's understanding that the type of panel tested had been supplied by more than one company. He suggested that either Sir Ken Knight or the department should write to housing providers across the country advising them to check that external wall panels in high-rise housing stock met the correct specification and to include such checks in fire risk assessments for the relevant properties. The LFB was concerned that a fire similar to that which had occurred at Lakanal House could occur at any number of buildings if similar panels had been used.1008 Dobson {Day210/122:20}-{Day210/123:11}.
¶9.22 Sir Ken responded on 22 December 2009 saying that the Metropolitan Police had recognised that the results of the tests carried out by BRE had tended to show that such panels did not comply with the requirements of the Building Regulations or the guidance in Approved Document B. However, he thought there was insufficient information at that time to warrant alerting housing authorities or property owners generally to the matters raised, in particular because it had not yet been determined whether the ability of the exterior panels at Lakanal House to resist the surface spread of flame had been specified by the housing authority and, if so, whether panels of the kind specified had been fitted.1009 {HOM00046018}.
¶9.23 In a letter dated 22 December 2009 addressed to the chief executives of local housing authorities in England, Terrie Alafat, the Director of Housing Delivery and Homelessness at DCLG, said that the department had been made aware of concerns about window and cladding systems used on high-rise blocks and reminded them of what had become section 12 of Approved Document B. If they had any doubt about the application of, or compliance with, the regulations she advised them to seek the assistance of the local Building Control body.1010 {LFB00041215}.
¶9.24 In our view, that letter was an inadequate response to the problem exposed by the Lakanal House fire because it did not encourage local housing authorities to take active steps to ensure that their high-rise residential buildings complied with the Building Regulations. Sir Ken said that he would have expected them to carry out checks on receipt of that letter if they were not immediately aware of the materials used in the external walls of their high‑rise buildings,1011 Knight {Day246/4:5-19}. but we regard that as unrealistic. When asked why the department had not adopted the approach advocated by Commissioner Dobson, Sir Ken initially said that it was not possible to refer specifically to defects at Lakanal House while a police investigation was continuing,1012 Knight {Day245/199:2-4}. but the contemporaneous correspondence between Sir Ken and the department shows that the Crown Prosecution Service was willing to consider requests for disclosure in the interests of public safety.1013 {CLG00019120/2}. In any event, it would have been possible for the department to ask housing authorities to carry out checks on the external walls of their high-rise buildings without referring specifically to Lakanal House. We think it should have done so and that the decision to send out a very broad message was a misjudgement.1014 {CLG10004194/3}.
138¶9.25 There is no evidence that any further attempt was made by the department to understand the implications of the tests carried out by BRE in order to discover whether the risk posed by similar panels was likely to be repeated elsewhere.1015 {CLG00019120/2}; Knight {Day245/207:18}-{Day245/208:3}. Whether it should take a more active approach was therefore not considered at any stage, despite concerns raised by the LFB at a meeting on 21 April 2010, at which Mr Martin was present, about the quality of construction and checking of newly built and newly refurbished residential properties.1016 {LFB00025654/13}. Following a significant number of fires during the previous two years that had exhibited an unusual spread of smoke or fire, the LFB had become worried that the regulations covering the construction and approval of building work were not being enforced with sufficient vigour to ensure that new residential buildings in London were fit for their purpose.
¶9.26 Mr Martin candidly accepted that the department had concentrated on the need for amendments to Approved Document B and had not concerned itself with whether there might be existing high-rise buildings with combustible insulation materials in their external walls.1017 Martin {Day256/78:11}-{Day256/79:9}. Mr Martin's explanation was that the department had been concentrating on improving building standards for the future and did not consider examining the effect of previous standards to be part of its function.1018 Martin {Day256/79:10-25}. In our view that was not a responsible approach to take to a fire in which six people had died.
¶9.27 A detailed investigation into the fire performance of composite panels with foam cores of the kind used at Lakanal House was never carried out,1019 Crowder {Day230/62:8-12}; {Day230/74:12}-{Day230/78:3}. primarily because BRE's investigation was terminated prematurely.1020 Crowder {Day230/79:19}-{Day230/80:13}. Such an investigation might have been of benefit to the building industry,1021 Crowder {Day230/78:4-11}. although Dr Crowder did not think that high-pressure laminate panels with foam cores were widely used.1022 Crowder {Day230/78:15}-{Day230/79:18}. That view may have been based on the absence of other fires involving similar panels,1023 Crowder {Day230/82:15}-{Day230/83:16}. but that was scarcely a sound basis for drawing a conclusion of that kind. At all events, BRE did not advise DCLG that it might be important to investigate the prevalence of that particular kind of panel.1024 Crowder {Day230/79:19}-{Day230/80:13}.
The inquests into the deaths at Lakanal House
¶9.28 The hearings at the inquests into the deaths at Lakanal House took place between 14 January and 28 March 2013. Both Dr Crowder and Brian Martin gave evidence. Before they did so, the coroner heard evidence from Mr David Walker, a chartered building surveyor who had been appointed as expert to the inquests. Mr Walker's initial view (which was wrong) was that the composite panels in the window sets on the external wall of the building had to satisfy certain requirements in relation to fire resistance (i.e. resistance to the passage of heat and flame), as well as having surfaces classified Class 0 for reaction to fire. When seeking to apply the guidance in Approved Document B, Mr Walker initially told the coroner that the panels beneath the bedroom windows should have had 30 minutes' fire resistance,1025 {INQ00015064/102} lines 4-6. but he changed his opinion during cross-examination to say that the requirement was 120 minutes.1026 {INQ00015065/103} lines 13-16. Finally, after reflection overnight, he said that the panels were not actually required to be fire resistant at all.1027 {INQ00015066/29} line 11. It seems that, when giving evidence to the inquests, Mr Walker struggled to interpret the provisions of the Building Regulations and Approved Document B. The coroner commented during Mr Walker's evidence that she found it extraordinary that a document intended to be used by contractors, subcontractors and others wanting to do building work was, in her words, "impenetrable".1028 {INQ00015065/120} lines 14-17.
139¶9.29 Although both Dr Crowder and Mr Martin quite properly sought to correct the misunderstandings which had arisen as a result of Mr Walker's evidence, aspects of their evidence relating to the external wall of Lakanal House were not as clear as they should have been, as we explain below. Mr Martin was defensive about the clarity of Approved Document B and dismissive of suggestions that it could be improved. Those are important matters because they are consistent with the longstanding pattern on the part of both the department and BRE of failing to grapple with problems relating to the guidance in Approved Document B on the construction of external walls. As a result, the coroner and the jury were not as well informed about the limitations of Approved Document B, and Class 0 in particular, as they should have been.
Class 0 and combustibility
¶9.30 There were a number of passages in Dr Crowder's evidence at the inquests in which he confused Class 0 with limited combustibility. In particular, when explaining the meaning of Class 0, he indicated that the surface of the material "should be of limited combustibility".1029 {INQ00015064/8} lines 4-5; Crowder {Day230/116:16}-{Day230/17:23}. That was fundamentally erroneous (and, to be fair, Dr Crowder admitted to us that it had been a mistake), because a material that was not of limited combustibility might still be able to satisfy Class 0 if it achieved the required results when tested in accordance with BS 476-6 and 476-7.1030 Crowder {Day230/116:16}-{Day230/117:23}. In circumstances where the coroner was also told that a material of limited combustibility was capable of burning, but not liable to burn unless under an imposed heat source,1031 {INQ00015064/7} lines 14-15; Crowder {Day230/110:3-13}. anyone listening to the evidence might well have obtained the impression that products with Class 0 surfaces normally perform adequately in fire so as to satisfy Regulation B4(1) of the Building Regulations. The fact that some products may perform very badly was never explained. Much of the confusion appears to have been due to a failure to distinguish clearly between the reaction of a product to fire and the ability of its surface to resist the spread of fire.
¶9.31 In addition, when Dr Crowder was asked what difference it would have made if the surfaces of the composite panels at Lakanal House had achieved Class 0, he said that he would not have expected them to ignite and burn on their own.1032 {INQ00015064/11} lines 11-12; Crowder {Day230/118:2-15}. At a later stage he also said that if the panels had been Class 0 they should not have burned.1033 {INQ00015064/20} line 25; Crowder {Day230/121:7}-{Day230/122:7}. Both of those statements failed to reflect the fact that both the department and BRE (including Dr Smith and Dr Colwell, though not Dr Crowder1034 Crowder {Day230/183:2-14}.) knew by that time that products with Class 0 surfaces could perform very poorly in fire, as the cc1924 tests had shown.
140¶9.32 A similar confusion between Class 0 and limited combustibility was made in Dr Crowder's written report to the Metropolitan Police on the Lakanal House fire, in which he said that the recommendation to use Class 0 materials meant that walls in common and circulation spaces should be of very limited combustibility.1035 {BRE00005881/18}; Crowder {Day230/122:24-25}. He admitted that that had been a poor choice of words.1036 Crowder {Day230/122:17}-{Day230/123:8}. We think it was more than that. It was the perpetuation of a confusion that had bedevilled official thinking about Class 0 at least since the Knowsley Heights fire.
¶9.33 Misleading statements of a similar kind were also made by Mr Martin in the course of his evidence to the inquests. In his witness statement he said that the 2002 version of Approved Document B had introduced the principle of limiting the combustibility of external walls of tall buildings to reduce the danger of fire spreading up the face of the building, which was related to the need to use Class 0 products for walls above 18 metres in height.1037 Martin {CLG00019202/2} page 2, paragraph 7. That implied that Class 0 limited the combustibility of materials used in external walls, although materials which have a Class 0 surface can be highly combustible, as demonstrated by the composite polyethylene cored panels used in the cc1924 test. Mr Martin told us that Class 0 was one of a range of classifications of combustibility,1038 Martin {Day256/125:19}-{Day256/127:1}. but that is technically incorrect. The main tests which are relevant to Class 0, including BS 476-6 and 476-7, are tests which measure fire propagation and surface spread of flame respectively. They are not tests which measure the combustibility of a material; those are BS 476-4 and BS 476-11.
¶9.34 In his evidence at the inquests Mr Martin said that if the panels caught fire they probably were not Class 01039 {INQ00015070/51} lines 15-16. and that a Class 0 material would burn but not very much.1040 {INQ00015070/72} line 25. He also said that the non-combustible classification was only slightly more stringent than Class 0.1041 {INQ00015070/57} lines 21-22. When he gave evidence to us, Mr Martin accepted that some of those answers were imprecise, although he again referred to what he described as a "sliding scale of combustibility"1042 Martin {Day256/145:2-19}. and explained that he might not have understood some of the limitations of Class 0 at the time.1043 Martin {Day256/141:8}-{Day256/142:24}. We do not accept that explanation, which is directly contradicted by what Mr Martin and those at BRE undoubtedly knew as a result of the cc1924 tests in 2001.1044 As to which see Chapter 7. Indeed, Mr Martin accepted that he probably should have made the connection between Class 0 products and the fires in the UAE the year before, in which composite materials had burned ferociously.1045 Martin {Day256/146:11-16}.
¶9.35 Although neither Dr Crowder nor Mr Martin was asked in terms to comment on the suitability of Class 0 as the sole criterion adopted in Approved Document B for panels to be used in the external wall of Lakanal House and high-rise buildings generally, we find it surprising that neither of them thought it appropriate to draw the coroner's attention to what they knew to be its limitations.
141¶9.36 Nor did either of them draw attention to the way in which the fire had spread downwards, which in their experience had been an unusual feature of the incident.1046 Crowder {Day230/4:15-21}. It is unfortunate, therefore, that the unusual way in which the fire had spread and the absence from Approved Document B of any guidance on how to prevent it was not considered during those proceedings.
Approved Document B
¶9.37 Although Mr Martin had been asked to include in his witness statement for the inquests a description of the extent to which requirements for the fire resistance of external walls and the use of Class 0 panels had been revised in the 2006 edition of Approved Document B,1047 Martin {CLG00019202/4} page 4, paragraph 17 (question (d)). he did not include in his response any reference to the fact that the 2006 edition stated that all insulation materials in external walls should be of limited combustibility.1048 Martin {Day256/131:18}-{Day256/132:20}. Nor did he mention the addition of the word "filler" to what had become paragraph 12.7 or explain what that word had been intended to capture. Mr Martin accepted that in hindsight it would have been useful to identify the key textual changes to Approved Document B as well as changes in its structure and format.1049 Martin {Day256/131:21}-{Day256/134:24}.
¶9.38 It was suggested to Mr Martin during questioning at the inquests that it might be desirable for Approved Document B to be revised so that it was clearer to those who had to use it. Mr Martin disagreed and said that enquiries he had received suggested that most professionals in the industry seemed capable of applying it without too much difficulty,1050 {INQ00015070/43} lines 22-24. and that, having not received any indication to the contrary, he did not think that any revision to Approved Document B was necessary.1051 {INQ00015070/43-44} lines 25-1. As we see below, however, in fact Mr Martin did know that Approved Document B was not a model of clarity.
¶9.39 Although Mr Martin thought that Approved Document B was straightforward, the coroner, who was not unfamiliar with the construction industry, clearly found it difficult to understand. Despite what he told her, by March 2013 Mr Martin had become well aware that there was widespread confusion in the industry about the meaning of parts of Section 12 of Approved Document B dealing with the construction of external walls. In late 2010 he had been told that a former senior head of building control for several local authorities who was advising the LFB had misunderstood functional requirement B4 and the guidance in Approved Document B in a way that left him "horrified".1052 {LFB00052135/4}; {HOM00046917}; Martin {Day256/87:13}-{Day256/88:18}. In January 2013, just a few weeks before he gave evidence at the inquests, Mr Martin also told a colleague who had asked for his advice on the use of panels that were not made of materials of limited combustibility, that Approved Document B needed to be read two or three times to work out what it meant.1053 {CLG00019193/1}.
The jury's verdicts
¶9.40 Verdicts were returned by the jury in the Lakanal House inquests on 28 March 2013. They included two important findings: first, that the composite panels beneath the bedroom windows were not Class 0, contrary to the requirements of Approved Document B; secondly, that even if they had been Class 0, that would not have prevented the fire from spreading from Flat 65 to Flat 79, although the spread of fire within Flat 79 would have been slower.1054 {INQ00015079/40} lines 14-18. Those findings should have been a warning to the department that building professionals were not aware of, or were misinterpreting or ignoring, Approved Document B. They should also have served as a warning that the effectiveness of the Building Regulations and Approved Document B to protect life were in question. The department ought to have undertaken further investigations to find out whether the use of unsafe panels in the external wall of Lakanal House was an isolated incident or had been due to systemic ignorance or misunderstanding of the Regulations and Approved Document B. However, the department failed to undertake any such investigation.
142The coroner's rule 43 letter
¶9.41 On 28 March 2013, the coroner wrote a letter to the Secretary of State for Housing, Communities, and Local Government, The Right Honourable Eric Pickles MP, now Lord Pickles, under rule 43 of the Coroners Rules.1055 {CLG00001870}. The letter addressed four separate matters: (1) fire safety, firefighting and search and rescue, (2) fire risk assessments pursuant to the Fire Safety Order, (3) retro-fitting sprinklers in high-rise residential buildings and (4) the Building Regulations and Approved Document B.
¶9.42 In relation to the last matter she said:
"During these inquests we examined Approved Document B (2000 edition incorporating 2000 and 2002 amendments) ("AD B"). I am aware that AD B has subsequently been amended, and believe that a further amendment is due to be published soon. The introduction to AD B states that it is " ... intended to provide guidance for some of the more common building situations". However, AD B is a most difficult document to use. Further, it is necessary to refer to additional documents in order to find an answer to relatively straightforward questions concerning the fire protection properties of materials to be incorporated into the fabric of a building. It is recommended that your Department review AD B to ensure that it • provides clear guidance in relation to Regulation B4 of the Building Regulations, with particular regard to the spread of fire over the external envelope of the building and the circumstances in which attention should be paid to whether proposed work might reduce existing fire protection • is expressed in words and adopts a format which are intelligible to the wide range of people and bodies engaged in construction, maintenance and refurbishment of buildings, and not just to professionals who may already have a depth of knowledge of building regulations and building control matters • provides guidance which is of assistance to those involved in maintenance or refurbishment of older housing stock, and not only those engaged in design and construction of new buildings."
¶9.43 On receipt of that letter, and in the light of the observations of the coroner at the inquests and the jury's verdicts, the department could have been in no doubt that the guidance in Approved Document B, particularly on the construction of external walls, had been found to be lacking in clarity. Even though specific problems had been identified at the inquests, any official paying proper attention should have appreciated that the coroner's concerns were not limited to matters of structure and language but extended to the substance of the guidance on the construction of external walls, which was regarded as inadequate. That should have prompted an immediate review of that part of the guidance, particularly since the department already knew that there were existing concerns about the suitability of Class 0 as an indicator of the suitability of materials for use in external walls and that some building control officers were having difficulty in interpreting the guidance.
143Conclusions
¶9.44 In our view the department's response to the Lakanal House fire was inadequate. The BRE's investigation was prematurely and unreasonably curtailed and at every stage, even including the inquests, officials displayed a complacent and short-sighted attitude towards learning wider lessons from the fire. That included lessons about the adequacy of the regulatory regime itself. Although we recognise that the Lakanal House fire had particular features that were not directly relevant to what occurred later at Grenfell Tower, there were lessons that could and should have been learnt from it which might have improved the robustness and clarity of the regulatory regime before the Grenfell refurbishment took place.
¶9.45 In particular, we consider that more should have been done to investigate the propensity of composite panels to contribute to the downward spread of fire, the adequacy and clarity of the statutory guidance on the construction of external walls, including the suitability of Class 0 as a criterion and whether the use of materials liable to create flaming droplets when exposed to fire ought to be regulated. The Lakanal House fire also provided an opportunity to consider whether more general problems existed in the construction industry, including a failure within it to understand or apply the regulations and guidance and a resulting stock of tall buildings with external walls containing combustible materials.
145Chapter 10: The Department for Communities and Local Government 2013–2017
Introduction
¶10.1 In his letter of 20 May 2013 responding to the coroner at the Lakanal House inquests the Secretary of State made a number of commitments which purported, for the most part, to address the coroner's concerns and recommendations.1056 {CLG00002788}. However, in the years that followed, the work that the department had undertaken to carry out in response to those recommendations was delayed and merged with other projects. As a result, by the time the Grenfell Tower refurbishment had been completed in mid-2016 very little progress had been made in reviewing Approved Document B, which had not been clarified in any significant respect.
The officials
¶10.2 In the period between 1 January 2013 and 31 December 2017 responsibility for the Building Regulations and the statutory guidance relating to them lay with the Department for Communities and Local Government (the department). Robert (Bob) Ledsome was the Deputy Director in charge of the Building Regulations and Standards Division, assisted by Anthony Burd1057 Head of Technical Policy. until December 2013 and then by Richard Harral. Responsibility for the Building Regulations was entrusted mainly to Brian Martin, the principal construction professional. He reported to Anthony Burd and later Richard Harral and had a background in building control. He had taken primary responsibility for the Building Regulations and the Approved Documents since joining the department in September 2008.1058 Martin {Day250/29:23}-{Day250/30:5}; Martin {Day250/39:2-5}. Within the department Mr Martin was the person with the most detailed knowledge of those parts of the Building Regulations that related to fire safety and others (including those senior to him) would turn to him for advice on that subject.1059 Martin {Day250/38:15-25}. Between 2010 and March 2015 the late Sir Bob (subsequently Lord) Kerslake was the permanent secretary; from March 2015 the post was held by Dame Melanie Dawes.
The ministers
¶10.3 Between 2013 and May 2015 the Rt Hon Eric Pickles MP (now the Rt Hon The Lord Pickles) was Secretary of State for Communities and Local Government. He was succeeded by the Rt Hon Greg Clark MP, who held office until July 2016, and subsequently by the Rt Hon Sajid Javid MP. Junior ministers with responsibility for the Building Regulations included the Rt Hon Don Foster MP, Stephen Williams MP, James Wharton MP (now the Rt Hon The Lord Wharton of Yarm) and Gavin Barwell MP (now the Rt Hon The Lord Barwell).
146Deregulation
¶10.4 One of the principal policies of the government that came to power in May 2010 was deregulation. The idea was not new and indeed the Regulatory Reform (Fire Safety) Order 2005 is an example of an earlier initiative of a similar kind. The policy was based on the proposition that national productivity and economic growth were being held back by unnecessary regulation which needed to be swept away. The policy was best expressed in a letter dated 6 April 2011 from the Prime Minister, the Rt Hon David Cameron MP, to all government ministers, in which he described the government's ambitious deregulation agenda which included a new "one in, one out" rule relating to new regulations and a drive to reduce the overall burden of regulation. Ministers were told they were personally accountable for the number of existing and new regulations for which their departments were responsible.1060 {HOM00018307}. Although Lord Pickles characterised that letter as "veneer",1061 Pickles {Day262/6:14-15}. it was intended to send a serious message to ministers and we have no doubt that the Prime Minister intended it to be taken seriously.
¶10.5 The "one in, one out" rule was an administrative policy introduced within government in January 2011 under which no new regulation would be introduced without a compensating reduction in regulation being made.1062 "One-In, One-Out (OIOO) Methodology" {INQ00015131}; and "One-in, Two-out" in the "Better Regulation Framework Manual, Practical Guidance for UK Officials" dated March 2015 {INQ00015132}; Ledsome {CLG00019465/8} page 8, paragraph 29(a). For the purposes of the rule, a regulation was defined as
"a rule or guidance with which failure to comply would result in the regulated entity or person coming into conflict with the law or being ineligible for continued funding, grants and other applied for schemes."1063 {INQ00015131/4} paragraph 13.
¶The policy was extended to "one in, two out" in January 20131064 As set out in the "Better Regulation Framework Manual, Practical Guidance for UK Officials" dated March 2015 {INQ00015132}. and to "one in, three out" in March 2016.1065 Ledsome {CLG00019465/8} page 8, paragraph 29(a).
¶10.6 The "Red Tape Challenge" was also launched in 2011 and ran until 2014. It was designed to obtain the views of business, other civil organisations and the public on whether existing regulations should be improved, kept or revoked. The main area of work resulting from that exercise so far as the department was concerned was the Housing Standards Review, which explicitly excluded standards relating to safety (including Approved Document B).1066 Ledsome {Day241/81:12-22}; {Day241/83:25}-{Day241/84:11}; Harral {Day243/55:14-21}. A Red Tape Challenge for construction was launched in 2012.1067 Ledsome {CLG00019465/9} page 9, paragraph 29(c); Harral {CLG00019487/10} page 10, paragraph 30. The Regulatory Reform (Fire Safety) Order 2005 was excluded from the Red Tape Challenge by ministers in 2012.1068 {CLG00018638}; {CLG00018639}; {CLG00019597}.
The department's response to the coroner's rule 43 letter
¶10.7 In her rule 43 letter the coroner recommended that DCLG review Approved Document B to ensure i. That it provided clear guidance on compliance with functional requirement B4, in
147particular in relation to the spread of fire over the external envelope of the building and the circumstances in which work might reduce existing fire protection.
¶ii. That it was expressed in a way that was intelligible to the wide range of people engaged in the construction and maintenance of buildings. iii. That it provided guidance of assistance to those involved in the maintenance or refurbishment of older housing stock. The response from the Secretary of State might therefore have been expected to deal directly with those three recommendations. Regrettably, however, that was not to be.
Submission to the junior minister
¶10.8 On 11 April 2013 a submission signed by Brian Martin1069 {CLG00000461}. was put up to the then junior Housing Minister, Don Foster, containing advice on how to respond to the coroner's letter in so far as it concerned the Building Regulations. It had been drafted primarily by Mr Martin with contributions from other officials, including Mr Burd and Mr Ledsome.1070 Martin {Day256/177:9-11}. Although her letter was annexed to it, the coroner's three recommendations were not summarised in the body of the submission itself. Mr Martin may have expected the minister to read the coroner's letter,1071 Martin {Day257/124:19-22}. but in view of what transpired we are not sure that he did.
¶10.9 The submission recommended that the minister respond to the coroner's letter by i. Acknowledging that Approved Document B could be difficult for inexperienced people to apply. ii. Commissioning a review of the guidance given to members of Competent
¶Persons Schemes.1072 Competent Persons Schemes are government-authorised schemes which monitor compliance with the building regulations of certain elements of construction, such as windows and doors. FENSA is the Fenestration Self- Assessment scheme. Certification of an installer of windows or doors under the FENSA scheme is intended to demonstrate that it is competent to carry out work which complies with the building regulations. iii. Setting out the government's intention to issue a revised version of Approved
Document B in 2016 or 2017 following a full review of the fire safety aspects of the Building Regulations that would take into account current research which was due to be delivered in 2014.
¶10.10 If the minister had read the part of the coroner's letter that concerned the Building Regulations and Approved Document B he would have realised that the recommended response did not properly respond to her recommendations in some important respects. In particular, a review of the Competent Persons Scheme, which occupied a significant part of the submission1073 {CLG00000461/2-3} paragraphs 7-9 and 12. and was said to have given rise to most of the problems relating to the Building Regulations,1074 {CLG00000461/3} paragraph 12. was not something she had called for, having concluded that there was no evidence that reliance on it had contributed in any way to the deaths at Lakanal House.1075 Lakanal House Coroner's Inquest {INQ00015074/77} lines 16-21. The submission also sought to place the blame for the criticisms the coroner had made of Approved Document B on the legal process and the evidence of the expert, Mr David Walker, which was described, with some justification, as "confused and conflicting". The submission suggested that, given the confusion in court, it was unsurprising that the coroner had criticised the clarity of the guidance given in Approved Document B.1076 {CLG00000461/2} paragraphs 9 and 10.
148¶10.11 The submission was disingenuous in that it did not make it clear that the coroner had been concerned about the clarity of Approved Document B even after Mr Martin had explained it in the course of his evidence. We have been left with the clear impression that in drafting the submission Mr Martin set out to give the minister to understand that the coroner's concerns were in fact groundless and that no criticism could be levelled at himself or the department for the structure or language of Approved Document B. In our view that was the result of a defensiveness born of a prolonged involvement in a technical field and an understandable, albeit misplaced, pride of authorship. He appears to have thought that, since the text was clear to him, it was clear enough for everyone.1077 Lakanal House Coroner's Inquest {INQ00015070/80} lines 5-11 and line 25.
¶10.12 In the submission Mr Martin advised the minister that re-writing Approved Document B would be a significant project and recommended that it be undertaken as part of a fuller review leading to the publication of a revised document in 2016 or 2017. However, the coroner had not recommended a full review of Approved Document B, only that part which contained guidance on the construction of external walls. As Mr Martin accepted in his evidence to us, the coroner's first recommendation was a narrow and focused one,1078 Martin {Day257/133:1-8}. and yet the option of carrying it out as a discrete piece of work was not canvassed.
¶10.13 Mr Martin told us that one reason why he did not recommend reviewing only those aspects of Approved Document B that related to functional requirement B4 of the Building Regulations was that he and others in the department had thought that the 2006 version had adequately addressed some of the coroner's concern about its clarity1079 Martin {Day257/134:1-16}; Martin {Day256/189:16-22}; Martin {CLG00019469/13} page 13, paragraph 38. and that as a result the work had not been urgent.1080 Martin {Day257/154:20}-{Day257/155:1}; Martin {Day256/189:16-22}. However, if officials thought that the coroner's concern was misplaced in the light of the 2006 revision to Approved Document B (of which she had been aware), they ought to have made that clear to the minister and given him an appropriate explanation. The failure to do so went on to shape the understanding of ministers (and later that of officials) both of the coroner's concerns and of the work that might be needed to address them.
¶10.14 Mr Ledsome1081 Ledsome {Day241/110:24}-{Day241/111:7}; {Day241/116:2}-{Day241/117:10}. and Mr Burd1082 Burd {CLG00019461/18} page 18, paragraph 45; Burd {Day240/186:4}-{Day240/187:9}. agreed with the approach taken in the submission. We accept that, when dealing with matters requiring technical expertise, such as the Building Regulations and fire safety, it may be appropriate for senior officials to rely on the detailed knowledge and expertise of more junior officials. Mr Ledsome described himself as a "policy professional" and did not profess to have detailed knowledge of technical matters.1083 Ledsome {Day241/6:10-24}. As the senior official involved in the discussions Mr Ledsome should have ensured that the submission summarised the coroner's recommendations accurately and offered suggestions for a response supported by appropriate explanations.
149¶10.15 The minister, Mr Foster, was invited to approve the recommendations with a view to their being included in a submission for the Secretary of State.1084 {CLG00000461/3} paragraph 13; {CLG00000485}. He approved the submission on 15 April 2013.1085 Martin {CLG00019469/9-10} pages 9-10, paragraph 26.
Submission to the Secretary of State
¶10.16 A submission was subsequently sent to the Secretary of State on 13 May 2013.1086 {CLG00002889}. It included a brief description of the background to the Lakanal House inquests and the coroner's rule 43 letter and the Secretary of State was informed that junior ministers, including Mr Foster, had already agreed recommendations for the response. The submissions to junior ministers were annexed to the submission.1087 {CLG00002889/1} paragraph 5. In the part dealing with the Building Regulations the evidence given by the expert witness and the nature of the legal process were said to have led to confusion and that it was therefore unsurprising that the coroner had criticised the clarity of the guidance in Approved Document B. In the final paragraph the Secretary of State was advised that a full review of Approved Document B would require significant resources and have a disruptive effect on the construction industry. Officials suggested that confirmation be sought from FENSA and other Competent Persons Scheme providers for replacement windows that their members were fully aware of the scope of the schemes and the requirements applicable to their work. That, it was said, could be completed by the end of the summer without the need for the department to divert significant resources away from other work. A new edition of Approved Document B was expected to be ready by 2016 or 2017.1088 {CLG00002889/4} paragraph 17.
¶10.17 The submission was formally sent to the Secretary of State by Louise Upton, but Brian Martin accepted that he had been the author of the section on the Building Regulations, and although he could not be sure who had suggested the particular wording,1089 See draft of the submission {CLG00000559/4}; Martin {Day257/137:15}-{Day257/138:12}. it drew heavily on the submission previously made to Don Foster. Mr Martin was unable to explain why different language had been used from that found in the submission to Mr Foster and in particular he could not explain the reference to the disruptive effect a revision of Approved Document B would have on the construction industry.1090 Martin {Day257/139:5-13}. He accepted that it might have been included to ensure that the submission received a warm reception in a department committed to deregulation and reducing costs.1091 Martin {Day257/139:14}-{Day257/141:2}. Both he and Mr Ledsome1092 Ledsome {Day241/150:3-18}; {Day241/151:4-12}. told us that any change to guidance, even if it involved no more than a need for industry to familiarise itself with new language, would be considered as imposing a cost because of the disruptive effects of such a change.1093 Martin {Day257/139:14}-{Day257/141:2}. Construction was an area of the economy in which the government was trying to reduce the burden of regulation and stimulate growth.
¶10.18 Mr Martin accepted that the department did not consider a review of the guidance in Approved Document B on the construction of external walls to be essential in the interests of safety,1094 Martin {Day257/153:15}. but it is clear that its view had been influenced by his initial misrepresentation of the position and his decision not properly to inform ministers of the coroner's concerns or the basis of them. He also accepted that the department had missed the opportunity to look beyond the coroner's recommendations to investigate the use of inappropriate materials on high-rise residential buildings generally and the fire risks associated with them.1095 Martin {Day256/184:6-21}.
150¶10.19 Lord Pickles gave evidence about what he had understood when he considered the submission, including discussions he had had with officials at the time. He said that his assessment of the need to clarify Approved Document B had been influenced by the suggestion that the coroner had been confused by the expert evidence.1096 Pickles {Day261/136:8-15}. He said that he had been told that the windows at Lakanal House had not been installed in accordance with the Building Regulations.1097 Pickles {Day261/142:5-6}. He had not been told that the officials in his department thought that the 2006 version of Approved Document B had cured the problems that had come to light at Lakanal House.1098 Pickles {Day261/145:14-15}.
¶10.20 Lord Pickles said that he had tried quite hard to bring forward the date of the review of Approved Document B but that the Permanent Secretary (Sir Bob Kerslake) had told him that it was not appropriate to do so and that the matter was complex.1099 Pickles {Day261/137:4-10}; {Day261/177:3}-{Day261/178:1}; Pickles {CLG00019471/17} page 17, paragraph 56. He also said that he had asked if part of the work on the Approved Document could be undertaken separately but had been told that the different parts of the document were interlinked and that it would cause difficulties if that were tried.1100 Pickles {Day261/179:1-8}. We understand that a Secretary of State has various conversations of an informal kind with the Permanent Secretary of his department which are not minuted. If he had voiced any significant objection to any aspect of the recommendations made to him, however, we think that that would have been recorded and would probably have led to a further submission. Since there was no record of any such objection, we conclude that he did not pursue one. Nor did any of the civil servants from whom we heard suggest that the Secretary of State had offered such resistance.1101 See, for example Martin {CLG00019469/10-11} pages 10-11, paragraph 28; Ledsome {CLG00019465/44-46} pages 44-46, paragraphs 173-177. Other aspects of Lord Pickles' evidence1102 Pickles {Day261/178:2-8}. suggested that he accepted the estimate he had been given of how long the work would take.
¶10.21 Before us Lord Pickles expressed dismay at the suggestion that officials had included in the submission an assertion that a full review of the Approved Document would have had a disruptive effect on the construction industry in order to make it more appealing to him.1103 Pickles {Day261/192:2}. However, there was a wealth of material that showed both that he was personally an ardent supporter of the government's deregulation policy and that the pressure within the department to reduce red tape was so strong that civil servants felt the need to put it at the forefront of every decision.1104 Martin {Day255/19:20-23}; {Day255/19:23}-{Day255/20:6}; {Day 255/19:25}; Harral {Day243/42:25}; Ledsome {Day241/80:11-12}; Pickles {Day262/8:14-17}.
¶10.22 Annexed to the submission was a draft letter of reply;1105 {CLG00002889}; {CLG00000589}. it was sent to the coroner on 20 May 2013.1106 {CLG00002788}. In relation to the Building Regulations, the Secretary of State said that he was aware that some of those involved in the inquests had encountered difficulties in interpreting Approved Document B and that the department was committed to a programme of simplification, but that the design of fire protection in buildings was a complex subject and should remain, to some extent, in the realm of professionals. He said that research had been commissioned to contribute to a review of the part of the Building Regulations relating to fire safety and was expected to lead to the publication of a new edition of Approved Document B in 2016 or 2017. He aimed to ensure that the guidance was capable of being more easily understood and the need to cross-refer reduced.
151¶10.23 As Mr Martin and Mr Ledsome accepted, the letter did not respond directly to the three recommendations made by the coroner in relation to Approved Document B nor even make it clear whether they had been accepted or rejected.1107 Martin {Day257/135:11-20}; Martin {Day256/181:21-25}; {Day256/197:6-17}; Ledsome {Day241/109:4}-{Day241/110:19}. Indeed, there does not seem to have been a clear view within the department about whether it should review Approved Document B to ensure that it provided the clear guidance that the coroner had wished to see. Lord Pickles thought that he had accepted the first recommendation1108 Pickles {Day261/138:13-16}. and in a sense he had, because he told the coroner that the department would review the relevant part of the Building Regulations and expected to publish a new edition of Approved Document B in 2016 or 2017. Mr Martin's initial response was that the first recommendation had been accepted, but then he was at a loss to explain how a ministerial submission he had sent to Don Foster's successor, Stephen Williams in June 2014,1109 {CLG00011293} paragraph 3. had stated in terms that the recommendation had been rejected.1110 Martin {Day256/197:10}-{Day256/198:17}. He put it down to a "bad choice of words",1111 Martin {Day256/198:11}. but that was not plausible because the words he used were clear. Mr Ledsome's understanding was that the first recommendation "was not absolutely accepted or absolutely rejected" because, although the department had agreed to review Approved Document B, it would be a fuller review to be completed by 2016/17. In the event, the decision to conduct a complete rather than a partial review of Approved Document B combined with departmental inertia to cause significant delay to the work.
¶10.24 When Mr Ledsome approved the ministerial submissions and the draft letter to the coroner, he thought that the best way to deal with her recommendations was to include them in a fuller review of Approved Document B, rather than carry out a specific review of the guidance relating to functional requirement B4.1112 Ledsome {Day241/113:6-12}. However, he accepted that a full review was not what the coroner had asked the department to undertake.1113 Ledsome {Day241/153:9-12}. He also accepted that the department should perhaps have been bolder and considered reviewing the guidance on the construction of external walls more quickly.1114 Ledsome {Day241/126:11-20}. He agreed that the Secretary of State should have been presented with two options: reviewing the guidance on the construction of external walls within a shorter time, or a wholesale review of Approved Document B by 2017.1115 Ledsome {Day241/145:6}. It is not clear whether anyone gave any thought to what would be involved in complying with the second part of the coroner's first recommendation.
152¶10.25 The department made a number of important admissions in its submissions to the Inquiry about the adequacy of its response to the coroner's recommendations.1116 DLUHC Phase 2 opening submissions for Module 6 (Government, FRA, Testing and Certification) {CLG00036387/36} page 36, paragraph 112(a) to (e). The submissions were repeated in its closing statement for the module: DLUHC Phase 2 closing submissions for Module 6 (Government, Testing, FRA) {CLG00036422/23} page 23, paragraph 81. In particular, it accepted that the advice given to ministers failed to make it clear that the work was not considered essential for safety or to explain how or why that view had been reached.1117 DLUHC Phase 2 opening submissions for Module 6 (Government, FRA, Testing and Certification) {CLG00036387/32} page 32, paragraph 97. The department accepted that the response to the coroner should have set out clearly in relation to each recommendation whether it had been accepted in whole or in part, together with any relevant reasons. It admitted that it had not done that. It also acknowledged that the Secretary of State's letter in response had not been well structured and had been unclear and difficult to follow when read against the text of the coroner's recommendations.1118 DLUHC Phase 2 opening submissions for Module 6 (Government, FRA, Testing and Certification) {CLG00036387/32} page 32, paragraph 95. It accepted that the department should not have worked on the basis that her first recommendation related to the 2000 rather than the 2006 version of Approved Document B; nor should it have concluded that the exercise to clarify and simplify the 2006 version of Approved Document B was not essential to safety, and therefore not urgent, without making its position clear in the response to the coroner.
¶10.26 Those admissions are justified as far as they go, but we do not think they go far enough. The department's response to the Lakanal House fire in the four years leading up to the inquests was complacent and short-sighted. Regrettably, its approach to the coroner's recommendations was little better. No one treated them with any sense of urgency, despite the fact that they had arisen out of an incident in which six people had died and the coroner had seen fit to make a number of recommendations with a view to preventing future deaths. Officials produced submissions to ministers which failed to describe accurately the points on which decisions were required or the courses of action open to them and significantly understated the importance of the criticisms of the existing guidance made by the coroner. Even worse, some officials within the department appeared to treat the coroner with disdain.1119 {HOM00047478}. In particular, Mr Martin displayed an arrogance and a lack of respect that was quite contrary to his assertion that recommendations from coroners were always treated seriously and accorded a high priority.1120 Martin {CLG00019469/8} page 8, paragraph 23. It was an attitude that should have had no place in any government department.
The appointment of Stephen Williams as Parliamentary Under Secretary of State for Communities and Local Government and Richard Harral as Head of Technical Policy: 2013–2014
¶10.27 Stephen Williams replaced Don Foster as the Minister with responsibility for, amongst other matters, the Building Regulations on 7 October 2013.1121 Pickles {CLG00019471/4} page 4, paragraph 13(c). He was in post until May 2015. On joining the department he was provided with a series of briefings and although they included a briefing on the Building Regulations in general, he did not recall having been told about the progress the department had made in responding to the coroner's recommendations.1122 Williams {Day259/58:5-23}. He did not believe that he had ever read, or indeed that he had ever been shown, the coroner's Rule 43 letter.1123 Williams {CLG00034291/3} page 3, paragraph 6; Williams {Day259/52:5-16}. He had no detailed conversation with any officials about the Lakanal House fire.1124 Williams {Day259/50:11-12}. The impression he gained was that a contractor installing new windows had failed to comply with the Building Regulations and that the coroner had recommended that some action be taken in connection with the Competent Person's Scheme for window installers.1125 Williams {Day259/51:2-5}.
153¶10.28 In January 2014 Richard Harral took over from Anthony Burd as Head of Technical Policy at DCLG. He was given to understand that the coroner's first recommendation relating to the clarity of the guidance on the construction of external walls had been covered by the amendments made to Approved Document B in 2006.1126 Harral {Day243/78:2-10}. He also thought that the coroner's third recommendation, to provide guidance or assistance to those maintaining or refurbishing older housing stock, was never going to be addressed because it had been covered in 2011 by the LGA Guide on purpose-built blocks of flats.1127 Harral {Day243/108:15}-{Day243/109:12}. As a result, he appeared to think, based on what he had been told by Mr Martin,1128 {CLG00018930/1}. that the commitments made to the coroner following the Lakanal House inquests involved two things: the clarification and simplification of Approved Document B, and improving the Competent Person's Scheme.1129 Harral {Day243/91:18}-{Day243/92:14}. Mr Harral could not recall whether he had gone back to the coroner's letter to check what recommendations she had made and what commitments had been given in response.1130 Harral {Day243/92:16-19}. If he did not, plainly he should have done so.
¶10.29 Richard Harral never clearly understood what changes needed to be made to Approved Document B in order to implement the coroner's recommendations.1131 Harral {Day 243/83:5}-{Day 243/85:22}. He should have known what was required from the earliest days of his involvement. Part of the problem was that at no stage did Mr Martin or any other official prepare a proper briefing document identifying the criticisms expressed by the coroner in the course of the inquests so that they were clearly and consistently understood within the department.1132 Harral {Day243/88:3-9}. However, Mr Harral was also at fault in failing to find out exactly what the task of responding to her recommendations involved and in failing to ask Mr Martin to provide him with a detailed briefing.
¶10.30 The failure to make more rapid progress between 2014 and 2015 in responding to the coroner's recommendations was due in a large measure to a substantial piece of work that the department was doing on the Housing Standards Review. It was a large project that had absorbed much of the division's resources and delayed the work on Approved Document B.1133 Harral {Day243/89:7-16}. The Housing Standards Review was due to be completed in October 2014 but it was delayed until March 2015 and in turn delayed planning the review of Approved Document B.1134 Harral {Day243/129:17}-{Day243/130:3}; {Day243/134:3-7}; {Day243/144:11-14}.
¶10.31 By 30 March 2015 research relating to Part B of Schedule 1 to the Building Regulations was expected to be completed by the end of the first quarter of 2017 and work on the review of Part B was due to continue throughout 2018.1135 {CLG10006856}. The indication given to the coroner by the Secretary of State that a new edition of Approved Document B would be published by the end of 2017 was therefore not going to be met. Officials did not tell the minister at that stage that his previous indication had been over-optimistic, as they expected to put further advice before him before mid-July 2015 explaining how matters had developed.1136 Ledsome {Day241/217:11-14}. The general election due to take place in May 2015 was also liable to have an effect on the department's resources and new ministers might wish to determine priorities.1137 Ledsome {Day241/205:4-13}.
154Lord Wharton becomes a junior minister: May 2015
¶10.32 The Conservative government came to power on 7 May 2015 and shortly thereafter Lord Wharton was appointed as a junior minister within DCLG1138 His ministerial role was Parliamentary Under Secretary of State for Local Growth and Northern Powerhouse. with responsibility for the Building Regulations.1139 {CLG00019462}. There was no handover of any kind between ministers or any discussion between them about the work that was going on in the department.1140 Wharton {Day258/18:1-17}. On about 26 May 20151141 Wharton {CLG00034289/1-2} pages 1-2, paragraphs 3-4. Lord Wharton received a briefing from Bob Ledsome on behalf of the Building Regulations team.1142 Wharton {CLG00030834/4} page 4, paragraph 13; Wharton {Day258/58:2-17}. It was a high-level briefing which included a one-page note and a pack of slides.1143 Wharton {CLG00034289/2} page 2, paragraph 5. Although one slide contained a picture of the Lakanal House fire,1144 {CLG10007022/8}. it does not appear that the briefing included any discussion of the fire or the coroner's recommendations.1145 Wharton {Day258/62:13-20}; Ledsome {Day241/211:21}-{Day241/212:24}. That is surprising, as he agreed.1146 Wharton {Day258/62:21}-{Day258/63:1}. Mr Ledsome accepted that the minister may well have been told that the system of regulating building work was working well, that the number of fires had fallen substantially over the years and that that was attributable in part to the efficacy of the Building Regulations.1147 Ledsome {Day241/212:8-15}; Wharton {CLG00034289/12} page 12, paragraph 29.
¶10.33 On 28 May 2015 officials sent the minister a note on Building Regulations identifying matters that were expected to arise in the future in relation to building regulation policy.1148 {CLG00019275}; Ledsome {CLG00019465/21} page 21, paragraph 75. Attached to the submission was a table which included a reference to the publication of a discussion document on technical changes to the Building Regulations, particularly changes needed to follow up previous government commitments to the coroner following the Lakanal House fire. However, the minister was given no further information about the fire or any pending review of Approved Document B; nor at that time was he given a copy of the coroner's recommendations.1149 Ledsome {Day241/214:20}-{Day241/215:24}. Despite Richard Harral's expectation that research into Part B of the Building Regulations would extend into 2017, the date of publication of the discussion document was said to be the end of June 2015. That was clearly over-optimistic, but Mr Ledsome said that he had hoped at the time that more detailed advice could be given to the minister before the summer recess, at which time more information would be provided.1150 Ledsome {Day241/216:2}-{Day241/217:18}.
155Merger of the review of Approved Document B with the review of Building Regulations policy and Building Control: summer 2015
¶10.34 In the summer of 2015 Bob Ledsome and Richard Harral proposed that the review of Approved Document B should be merged into a wider review of Building Regulations policy.1151 Harral {Day243/148:21}-{Day243/149:13}. They thought that making changes to Approved Document B alone might impose significant costs on the construction industry and that any changes would be more likely to be favourably received if they formed part of a package of proposals which covered Building Regulations more broadly. They hoped that by doing so they would be able to reduce regulation in one area to balance any increase in regulation in another and thereby enhance the prospect of obtaining ministerial approval.1152 Harral {Day243/149:9}-{Day243/150:15}; Ledsome {Day241/78:9-21}; Ledsome {CLG00019465/22} page 22, paragraph 80. According to Mr Harral, officials felt that they had no option but to proceed in that way because the prevailing policy on deregulation was designed to make it difficult to introduce new regulations, even where measures affecting the safety of life were involved.1153 Harral {Day243/152:1-20}. They also felt that it was more coherent to carry out the work on Part B as part of a broader programme, rather than to make piecemeal changes.1154 Ledsome {CLG00019465/21-22} pages 21-22, paragraph 77; Ledsome {Day241/152:6}-{Day241/153/6}.
¶10.35 On 15 September 2015 Richard Harral sent a submission to Lord Wharton and the then Secretary of State, the Rt Hon Greg Clark MP, in which he proposed to include the review of Approved Document B in a wider review and revision of the Building Regulations and statutory guidance expected to last over a period of four years.1155 {CLG00019302}; {CLG00019304}; Ledsome {CLG00019465/22} page 22, paragraph 79. The submission emphasised the government's commitment to deregulation and recommended that a broad based review of all aspects of building control should take place in order to deliver substantial savings to industry by way of reducing regulation and technical requirements.1156 {CLG00019302/2} paragraphs 5-7. Mr Harral recommended a two-stage programme of work in relation to the Building Regulations and Approved Documents, the detail of which was contained in Annex B to the submission.1157 {CLG00019302/2-3} paragraph 10.
¶10.36 Annex B proposed a two-stage process: a simplification of the Approved Documents, that was expected to take until October 2017, and a review of the technical requirements of the Building Regulations and Approved Documents, that was expected to take until October 2019.1158 {CLG00019304/7}. Mr Harral could not recall why the submission had not made it clear to ministers that that represented a significant departure from what the coroner had been led to expect by the previous Secretary of State.1159 Harral {Day243/162:18-23}. He said that he thought the reason why the submission did not make it clear that some of the matters to be reviewed affected the safety of life was because he thought that was implicit.1160 Harral {Day243/165:3-5}; {Day243/165:24}-{Day243/166:3}. We nonetheless consider it a significant failure on the part of officials not to have drawn ministers' attention to those matters in clear terms.
¶10.37 On 19 October 2015 three of the most senior officials responsible for the Building Regulations and Standards Division, Peter Schofield (the Director General), Sally Randall (the Director) and Bob Ledsome (the Deputy Director) attended a meeting with Lord Wharton to discuss the submission.1161 {CLG00019305}. Lord Wharton told us that he had been content to accept their advice that it was appropriate to proceed with a larger and more comprehensive piece of work.1162 Wharton {Day258/90:2-18}; {Day258/95:14-20}. He thought he might have questioned the time it would require, but was told that it was a complex matter which could not be carried out in a short time.1163 Wharton {CLG00030834/5-6} pages 5-6, paragraphs 15 and 17; Wharton {CLG00034289/7} page 7, paragraph 15; Wharton {Day258/114:15-18}.
156¶10.38 Lord Wharton told us that he could not conceive that the deregulation policy had prevented or delayed the simplification or clarification of those aspects of the Building Regulations that had a bearing on fire safety.1164 Wharton {CLG00030834/6} page 6, paragraph 18. However, the submission itself laid some emphasis on the opportunity that the review of the Building Regulations and Approved Documents provided for deregulation.1165 See in particular {CLG00019302/2} paragraph 5.
¶10.39 Dame Melanie Dawes, who had become the Permanent Secretary in March 2015, was not aware at the time of the decision to include the work on Approved Document B in a wider review, but defended it on the basis that it made for a larger, more coherent, and more visible piece of work that was easier to track.1166 Dawes {Day249/48:3-25}. However, despite those apparent merits, it appears that no one gave much thought to the countervailing disadvantages. Ministers were not presented with the option of carrying out some work more quickly; nor were they told that failing to respond promptly to the coroner's recommendations might adversely affect the safety of life.
The effect of deregulation on ministers and officials
¶10.40 We heard detailed and consistent evidence from civil servants about the effect of the deregulatory policies on the department in the period 2010 to 2017. They had all clearly understood that the "one in, one out" policy and its successors applied to changes to the Building Regulations and the Approved Documents1167 Ledsome {Day241/85:4-9}; Harral {Day243/47:6}-{Day243/48:3}. and they all spoke about the effect that those policies had had on their approach to their work and on the culture within the department at the time.1168 See for example {CLG10007289/2}. In his response to colleagues about a request in July 2015 that teams identify the cost per unit of individual regulations, Brian Martin commented "Ok ta. So let's spend a couple of years working out what the unit cost of the building regulations is. It's better than actually doing something I suppose…".
¶10.41 Anthony Burd told us that the "one in, one out" policy meant that he and his team spent an inordinate amount of time looking at how they could deregulate.1169 Burd {Day240/191:10-14}. He understood that the policy applied to the Approved Documents as well as to the Building Regulations.1170 Burd {Day240/191:15}-{Day240/192:7-10}. He felt that, as time went on, it had become increasingly difficult to oversee the Building Regulations because of the reduction in the number of staff and the changes involved in deregulation.1171 Burd {Day240/195:8}-{Day240/196:4-5}.
157¶10.42 Bob Ledsome also understood that neither the Building Regulations1172 Ledsome {CLG00019465/8} page 8, paragraph 29(a); Ledsome {Day241/73:14}. nor the Approved Documents1173 Ledsome {Day241/74:6}. were exempt from the "one in, one out"' policy, and no one considered seeking an exemption for them.1174 Ledsome {Day241/76:11}. It was only after the loss of life at Grenfell Tower that regulations affecting fire safety were exempted from the policy.1175 Ledsome {Day241/79:14-20}. Before that, he thought that the policy would have made any case for an exemption difficult.1176 Ledsome {Day241/80:11-12}. He also told us that energy efficiency had been an important consideration1177 Ledsome {CLG00019465/9} page 9, paragraph 30. and that the department's approach had been to look for areas where the regulations and guidance could be simplified in order to produce savings to offset the costs of introducing requirements for increased energy efficiency in Part L of the Building Regulations in 2013.1178 Ledsome {Day241/97:5-12}.
¶10.43 Richard Harral told us that under successive governments the approach to deregulation had become more rigorous, with increased scrutiny of regulatory proposals through various policies at different times.1179 Harral {CLG00019487/8-9} pages 8-9, paragraph 26. He said that as a result officials had been working in a policy environment in which regulatory intervention was regarded as a last resort1180 Harral {Day243/107:22-24}. and there had been a general view within government that regulation was bad.1181 Harral {Day243/42:25}. Mr Harral accepted that he had not considered seeking an exemption from the "one in, one out" policy for the parts of the Building Regulations or Approved Documents that had a bearing on the safety of life.1182 Harral {Day243/53:7-12}. He understood that the "one in, two out" policy applied to them, despite the fact that most of what they contained affected safety.1183 Harral {Day243/44:22}; {Day243/53:13-24}. He also said that he had assumed that even a simplification or clarification of an Approved Document would be caught by the policy because there would be a cost to industry in familiarising itself with any new version and that would be captured by the relevant impact assessment.1184 Harral {Day243/50:23}-{Day243/51:7}.
¶10.44 Brian Martin's evidence was to similar effect. He told us that there had been a great deal of pressure on the Building Regulations and Standards Division to reduce regulation.1185 Martin {Day255/19:20-23}. He said that after the 2015 election, there had been an even greater drive for deregulation and that any document issued by the department, even an answer to a frequently asked question, needed to have political approval.1186 Martin {Day255/19:23}-{Day255/20:6}. He said he had felt that committing more resources to fire protection or any other aspect of regulation was contrary to government policy and that strong evidence was required to justify any increase in regulatory requirements.1187 Martin {Day255/37:9-14}.
¶10.45 The evidence of these officials on the effect within DCLG of the government's deregulatory policies was strikingly different from the evidence we heard from most of the former ministers.
158¶10.46 Stephen Williams said that he had had an open and candid relationship with his officials and did not recall their saying that they felt under pressure to reduce regulation.1188 Williams {Day259/39:1-4}. He thought that, if officials had felt that they were being put under pressure to weaken health and safety standards, they would have found a way of resisting it.1189 Williams {Day259/42:20-23}.
¶10.47 Lord Wharton said that he had not felt that deregulation had imposed a particular pressure on his decision-making or his role as minister at the time.1190 Wharton {Day258/27:5-8}. He felt that clarifying Approved Document B would involve a reduction in regulation rather than new or additional regulation.1191 Wharton {Day258/30:6-7}. He was not aware that any officials in the Building Regulations and Standards Division had felt that their hands were tied by the "one in, two out" policy.1192 Wharton {Day258/41:7}.
¶10.48 Lord Pickles told us that he had not thought that officials within the Building Regulations and Standards Division believed that deregulation applied to the Building Regulations, and that he would have regarded that as being "ludicrous" and "wholly disproportionate".1193 Pickles {Day261/85:10-12}. He said that it was "utterly inexplicable" that officials in the division should have thought that Part B was subject to the deregulation policy and that he was "genuinely amazed" that that was the case.1194 Pickles {Day262/100:2}. Moreover, he rejected the suggestion that he might be out of touch with what was happening in the Building Regulations and Standards Division.1195 Pickles {Day262/101:4} Lord Pickles also told us that he was dismayed to find that officials in the division felt under pressure because of the policy on deregulation.1196 Pickles {Day262/96:18}. He blamed the officials, in particular Mr Martin, for making what he called "political assumptions"1197 Pickles {Day262/96:19-20}. and the senior officials for not easing the pressure or bringing it to the attention of ministers, who could then raise the problem with the Permanent Secretary.1198 Pickles {Day262/97:17-23}.
¶10.49 The differences of recollection between officials and successive ministers about the effect of the government's deregulatory policies on the work of the department in the years after the Lakanal House inquests is striking, but the contemporaneous documents support the evidence of the officials from whom we heard that those policies were a dominant influence in the department at the time. We saw a significant number of documents that showed that DCLG saw itself as a deregulating department, and indeed it described itself in that way in a Star Chamber internal briefing pack in May 2012.1199 {HOM00002080}; Ledsome {Day241/88:8}-{Day241/89:4}; {HOM00018307}; {LABC0009720}. Deregulatory policies and considerations were also highlighted in numerous ministerial submissions, including some put up in May 2012,1200 {CLG10005222/1} paragraph 8; {CLG10005223/2}. September 20151201 {CLG00019302/2} paragraph 5. and November 2015.1202 {CLG10007804}. Dame Melanie's evidence was that the deregulatory imperative had "cast quite a shadow" and by 2015 had become, as she put it, "almost quite an extreme set of policy demands".1203 Dawes {Day249/49:12-16}. From the documents we have seen and the evidence we have heard, we accept what she said.
159¶10.50 A number of documents also illustrated the extent to which Lord Pickles was not only aware of, but supported, that approach, including the application of the policies to the Building Regulations.1204 {CLG10004826}; {CLG00018639}; {CLG00018602}; {HOM00002080/3}; {CLG00030973}; {CLG10004742}; {CLG00014665/4}; {CLG00013957}; {CLG00014724}; {HOM00018307/3}; {CLG10007280/2} paragraph 1. While he was Secretary of State deregulatory considerations appear to have permeated every aspect of the department's development, assessment and implementation of policy. Far from its being inexplicable that officials were under the impression that the Building Regulations and Approved Document B were subject to the various demands of the policy, the documents demonstrated in clear terms that their understanding was correct. Those documents included letters sent to ministerial colleagues by Lord Pickles, in which he specifically sought clearance from deregulation committees and others for changes to various parts of the Building Regulations and Approved Documents.1205 {CLG00014698}; {CLG00014462}; {CLG10005767}; {CLG10006068}; {CLG10006758}. They also included a letter he wrote to the Welsh Government in May 20131206 {CLG00019243/7-8}. admonishing it for introducing legislation1207 {CLG00020138}. requiring the installation of sprinklers in all newly built and newly converted homes1208 {CLG00019216}; {CLG00020138}. on the basis that it was increasing the cumulative burden of regulation on the housing market in Wales. He also expressed fear that the burden of red tape would harm the Welsh housing market. It was not uncommon for those in the Building Regulations and Standards Division to receive emails thanking them for their support and for their efforts in meeting the Secretary of State's ambitions on deregulation.1209 {CLG10007394/2}. In this email from Justin Vetta of the Deregulation Team, templates capturing "ins and outs" were to be submitted by all policy teams, including the Building Regulations and Standards Division.
¶10.51 Although Lord Pickles sought to distance himself from those documents and play down their significance,1210 Pickles {Day262/36:19}-{Day262/40:20}; {Day262/76:14}-{Day262/80:22}. there was nothing to suggest that they were inaccurate or incomplete or gave a misleading impression. Lord Pickles' assertion that the exemption of the Regulatory Reform (Fire Safety) Order 2005 from the policy showed that the Building Regulations as a whole were exempt from the policy1211 Pickles {Day262/63:5}-{Day262/66:5}. The submission dated 3 May 2012 {CLG10005222} and {CLG10005223} was clear that the Building Regulations were not receiving special treatment under the policy on deregulation. served only to reveal the limits of his understanding of the distinction between fire safety regulations on the one hand and the Building Regulations and Approved Documents as they related to fire safety on the other.
¶10.52 None of the documents or any of the witnesses, other than Lord Pickles, supported the conclusion that Part B of Schedule 1 to the Building Regulations or Approved Document B was exempt from the policy on deregulation. We have been unable to accept his evidence on that question, which was flatly contradicted by that of his officials and by the contemporaneous documents. Moreover, in its written closing statement the department accepted that the policy on deregulation being promoted across government since 2010 created an environment in which officials working on Building Regulations felt unable to propose regulatory interventions or refer their concerns to more senior managers.1212 DLUHC Phase 2 closing submissions for Module 6 (Government, Testing, FRA) {CLG00036422/3-4} page 3, paragraphs 6(h) and 10; DLUHC Phase 2 closing submissions for Module 6 (Government, Testing, FRA) {CLG00036422/35-38} pages 35-38, paragraphs 124-136. It is a matter of serious concern that officials in the Building Regulations and Standards Division were so affected by the deregulation policy that they were inhibited from giving candid and clear advice to ministers on the implications of not taking certain regulatory steps. It is impossible to know with certainty whether an exemption from the policy would have been granted, if it had it been sought, but it is clear that the limits of the deregulation policy and the process for seeking an exemption from it were not fully understood across government. Given the fact that many regulations affect public safety, that was a serious flaw.
160¶10.53 However well-intentioned the government's aim of reducing the burdens on industry may have been, it was not in the public interest to allow the policy on deregulation to impede the ability of officials to promote changes to regulations or statutory guidance that would improve public safety. If ministers were not fully aware of the extent to which officials felt constrained by the policy when giving advice, there was a serious failure of communication within the department. It is disappointing that when officials became aware of matters which posed serious risks to life, effective steps were not taken to draw those risks to the attention of ministers. The failure to foster a culture in which concerns could be raised and frank advice given represents a serious failure of leadership on the part of ministers and senior officials.
Ministerial submission: November 2015
¶10.54 On 10 November 2015, Alex Murphy, an official in what had become the Building Regulations and Energy Performance Division, sent a submission to Lord Wharton and the Secretary of State, Greg Clark, on the simplification of the Building Regulations, Approved Documents and the Building Control system.1213 {CLG10007804}. The submission recommended the publication of a discussion paper setting out an ambitious programme of deregulation, including consolidating and simplifying the Building Regulations and Approved Documents, and proposals to improve the building control system. The submission had been approved by Bob Ledsome. The proposed programme was to start with the publication of a discussion document in early 2016 and culminate in new Building Regulations and Approved Documents coming into force in 2018.1214 {CLG10007804/3}.
¶10.55 On 7 December 2015 Lord Wharton's private office sent an email to the Secretary of State's private office stating that he agreed with the proposed programme and the next steps.1215 {CLG10007855}.
Further delays in 2016
¶10.56 On 1 April 2016, a submission written by Richard Harral and approved by Bob Ledsome was sent to Lord Wharton setting out the proposed next steps in the programme of simplifying the Building Regulations.1216 {CLG00019344}. They recommended that officials should work with the Building Regulations Advisory Committee (BRAC) to develop a discussion paper for publication that would set out the government's ambitions to simplify the statutory guidance and reform the building control system (including the possible expansion of the role of approved inspectors).1217 {CLG00019344/1} paragraph 3. The date for publication of the discussion paper had now slipped to May 2016. Mr Harral explained that that had been caused by the need to give priority to other urgent matters.1218 Harral {Day243/176:5-19}. The dates for completing the revision of the Approved Documents and Building Regulations had also moved back to mid-2018 and 2019 respectively.1219 {CLG10008122}.
161¶10.57 The submission did not refer to the Lakanal House fire, the inquests or the Secretary of State's response to the coroner's rule 43 letter. Lord Wharton accepted that that was important information which should have been included, preferably in bold at the beginning of the submission,1220 Wharton {Day258/117:17-23}. since the minister could not reasonably have been expected to remember the contents of previous submissions.1221 Wharton {CLG00034289/5-6} pages 5-6, paragraph 13. He was unable to say whether he was, in fact, aware of what the Secretary of State had said to the coroner1222 Wharton {CLG00030834/17} page 17, paragraph 40(b). and Richard Harral was unable to recall whether the slippage had been communicated to the minister,1223 Harral {Day243/170:18}-{Day243/171:2}. but Lord Wharton was doubtful whether anything would have been done differently if the change in timing had been drawn to his attention. He might have asked for an explanation, but in his experience everything happened slowly in the civil service and he thought it unlikely that he could have done anything to speed up the review.1224 Wharton {CLG00034289/6} page 6, paragraph 14.
¶10.58 Mr Harral candidly accepted that the department should have been tracking the progress of the work far better and that he should have ensured that ministers were aware that the original expectation would not be met.1225 Harral {Day243/180:6-19}. One reason for having failed to do so was the absence of any procedure within the department for recording a coroner's recommendations and the progress made in responding to them.1226 Harral {Day243/102:6-8}. It appears that at about that time officials had been instructed to limit the length of submissions to ministers to two pages,1227 Harral {Day243/181:5-16}. but even so, the key points about the response to the coroner could have been conveyed in a sentence. It is also notable that the submission did not indicate that any sense of urgency attached to the project, despite Mr Harral's email to Mr Ledsome in January 2016 to that effect.1228 {CLG10007954}. Although officials were privately expressing frustration at the delay, they were not conveying that to ministers.
¶10.59 On 19 April 2016 Lord Wharton approved the submission.1229 Wharton {CLG00030834/17} page 17, paragraph 40(c). He said that he remembered having raised the delay with officials at around that time but had been persuaded that the work needed to be done comprehensively.1230 Wharton {Day258/133:2-24}.
Lord Barwell becomes a junior minister: July 2016
¶10.60 On 17 July 2016, Gavin Barwell MP, now Lord Barwell, took over ministerial responsibility for the Building Regulations and remained in post until a few days before the Grenfell Tower fire. He had introductory briefings with each of the teams in his policy areas, including an initial briefing on 21 July 2016 from Bob Ledsome on the work of the Building Regulations and Energy Performance Division.1231 Barwell {CLG00030960/3} page 3, paragraph 10; Ledsome {CLG00019465/26} page 26, paragraph 96. The introductory slides1232 {CLG00019362}. used by Mr Ledsome as part of the briefing did not refer to the coroner's recommendations or the Secretary of State's response and Mr Ledsome did not discuss any matters relating to fire safety with the minister at that time.1233 Ledsome {CLG00019465/26} page 26, paragraph 96. The new minister gained the impression that fire safety policy was working and that the number of fatalities from fires was decreasing.1234 Barwell {CLG00030960/4} page 4, paragraph 13.
162¶10.61 In mid-July 2016 Richard Harral proposed that a submission should be put up to ministers attaching the proposed discussion document on the simplification of the Building Regulations and seeking their agreement to start research into the "simplification, deregulation and maintenance of the Building Regulations".1235 {CLG00019359/1}. However, he was told on 14 July 2016 by Simon Gallagher, the planning director, that the department should not be rushing to put things to new ministers1236 {CLG00019359/1}. and in the event it was not until the autumn of 2016 that further submissions were put up to ministers on those subjects. By that time the delay was causing considerable frustration within the division, particularly for Richard Harral, who described himself as "pretty despondent".1237 Harral {Day243/198:11-13}.
¶10.62 On 15 September 2016, Andrew Newton, an official in the division, put up a submission to Gavin Barwell seeking the minister's agreement to procuring research contracts to support the simplification and deregulation [sic] of the Building Regulations.1238 {CLG00019370}. It indicated a completion date for the project of 31 May 2019.1239 {CLG00019370/8-9}. Again, no mention was made in the submission of the correspondence with the coroner.
¶10.63 Lord Barwell became aware of the coroner's rule 43 letter during an oral briefing in the autumn of 2016, probably given to him by Steve Quartermain, the director, on 18 October 20161240 Barwell {CLG00030960/4} page 4, paragraph 11; Barwell {Day260/58:1-13}. to enable him to answer questions in the House of Commons on 24 October 2016.1241 Barwell {Day260/58:1-20}; Barwell {CLG00030960/4-5} pages 4-5, paragraphs 11 and 12. As part of that briefing Lord Barwell was given a note which said that in 2013 the coroner had recommended that the guidance in Approved Document B should be simplified.1242 {CLG10008654/3}. The briefing note went on to state that Lord Pickles had said that the government would review Part B "during this parliament" and that that would include simplification where possible.1243 {CLG10008654/3}. As a comprehensive summary of the coroner's recommendations and the department's response it was clearly inadequate, but it had been produced for a limited purpose. Lord Barwell said that one or other of two briefings he had received from Mr Quartermain had led him to understand that three out of four of the coroner's recommendations had been implemented by Lord Pickles when Secretary of State and that only the one relating to Part B of the Building Regulations remained outstanding.1244 Barwell {CLG00030960/4} page 4, paragraph 12. He understood that the three recommendations that had been implemented had been the most urgent1245 Barwell {CLG00034283/5} page 5, paragraph 11. and said it had been implicit in what he had been told that the remaining work was not urgent.1246 Barwell {Day260/116:22}-{Day260/117:11}.
¶10.64 Lord Barwell told us that if the briefing document had said that the review of Approved Document B had been promised to the coroner by March 2017, he would have realised the urgency of it. However, he had understood the reference to "this parliament" to mean the current parliament and that the deadline was therefore 2020.1247 Barwell {Day260/105:15}-{Day260/106:14}. He said that he had accepted the advice he was given by officials that the outstanding matter would be dealt with as part of a broader review of Building Regulations as soon as the Housing White Paper had been published.1248 Barwell {CLG00030960/4} page 4, paragraph 13. Apparently, he did not see the coroner's letter or the Secretary of State's response.1249 Barwell {Day260/111:2}.
163¶10.65 However, on 15 November 2016 Lord Barwell did receive a letter from the Minister of State for Policing and the Fire Service, Brandon Lewis MP, which referred to the government's longstanding commitment to review Approved Document B and reported that the Fire Sector Federation was concerned about a number of developments, including the increased use of combustible materials.1250 {CLG00019380}. Since that letter referred to a commitment on the part of Lord Pickles to the coroner, it should at the very least have prompted Lord Barwell to ask to see the coroner's rule 43 letter and the Secretary of State's response and that in turn should have prompted him to ask for an explanation for the delays which had occurred. Apparently, it did not.
Further delay in the publication of the discussion document
¶10.66 Obtaining ministerial approval for the discussion document was an important milestone because it effectively established the scope of the review of Approved Document B.1251 Harral {Day243/143:6-9}. Brian Martin's plan had been to publish the discussion document immediately after the new government had come into power, but he was not allowed to do that and the timetable drifted.1252 Martin {Day255/104:15-18}. Richard Harral thought that the discussion document had been ready for publication in early October 2016, but he was told by Lord Barwell's private office that the minister would not be looking at anything other than the highest priority submissions until the Housing and Planning White paper had been published. That White Paper had been originally scheduled for publication in late October or early November 2016 but in the event it was delayed and was not published until the middle of February 2017.1253 Harral {Day244/19:20}-{Day244/20:15}.
¶10.67 On 23 March 2017, Richard Harral sent a final draft of the discussion document, and a submission seeking approval of the proposed scope of work,1254 {CLG00019391}. to Lord Barwell and the Secretary of State, Sajid Javid MP.1255 {CLG00019392}. The submission had been cleared by Bob Ledsome. Under the heading "Key risks and Issues" it said that in 2013 the coroner had criticised the guidance in Approved Document B and that in response Lord Pickles had committed the government to reviewing it. The submission sought approval for officials to publish the discussion document which would enable them to engage with industry representatives, including by convening working groups under the aegis of BRAC.1256 {CLG00019392/5} paragraph 15. Thereafter proposals would be provided to ministers with recommendations on what work to take forward.
¶10.68 Lord Barwell told us that the discussion document had not been published before the Grenfell Tower fire because the day after he approved the submission in the spring of 2017 a general election had been called.1257 Barwell {Day260/112:1-3}. He explained that the department did not have sufficient capacity to deal with the Housing White Paper and the publication of the discussion document at the same time. He had not been told that the discussion document had originally been due to be published before the end of 2015, or that there had been several delays before he had taken office.1258 Barwell {Day260/157:8-16}. It is clear that by that time the department had lost sight of the urgency of the commitment made to the coroner and that everyone, including himself and the Secretary of State, had failed to appreciate how critical the work was.1259 Barwell {Day260/130:14-19}.
164¶10.69 On 18 April 2017, Lord Barwell told his private office that the submission had been approved,1260 {CLG00030961}; Barwell {Day260/214:16-17}. but there is no record of that having been communicated to Bob Ledsome and his team. Both he and Richard Harral told us that they had not received approval of the proposal from Lord Barwell's office.1261 Ledsome {Day242/88:10-17}; Harral {Day244/22:3}-{Day244/23:4}. Lord Barwell could not explain why the submission had not reached him in February 2017 as soon as the White Paper had been completed1262 Barwell {Day 260/220:10-20}. and candidly accepted that the delay in publication of the discussion document had been wholly unsatisfactory.1263 Barwell {Day 260/220:22}.
¶10.70 The policy of deregulation underwent a change in emphasis when the Rt Hon Theresa May MP became Prime Minister,1264 Barwell {Day260/81:14-24}. but it was not abandoned and officials were not told that it had been relaxed.1265 Barwell {Day260/145:21-24}; {Day260/84:2-10}. Although the Housing White Paper indicated a willingness in principle to impose new regulations where there was a case for making changes,1266 Barwell {Day260/87:22}-{Day260/89:1}. by that time four years had passed since the coroner's recommendations and little had been done in response.
Other work on fire safety
The seven workstreams
¶10.71 At the time of the Grenfell Tower fire in June 2017, not only had the discussion document on reform of the Building Regulations and building control system (including a review of Approved Document B) not been published, but the department had carried out very little other work in relation to fire safety, despite officials' being aware that the guidance in the Approved Documents was somewhat incoherent1267 Harral {Day243/99:15-23}. and that there had been a lack of investment in them over a very extended period.1268 Harral {Day244/37:16}-{Day244/38:1}.
¶10.72 A series of research papers (referred to as "the seven workstreams") had been commissioned by Brian Martin for the department in 2012 to support a review of Approved Document B.1269 Harral {CLG00019487/19-20} pages 19-20, paragraph 65; Martin {CLG00019469/15} page 15, paragraph 45. They related to 1. Periods of fire resistance. 2. Maximum fire compartment sizes. 3. Construction details, roof voids, cavity barriers and fire and smoke dampers. 4. Fire protection of basements and basement car parks. 5. Sprinkler provisions.
165¶6. Space separation. 7. Means of escape for disabled people.1270 Harral {Day243/121:19}. None of them specifically related to the spread of fire over external walls or the dangers posed by the use of combustible materials.
¶10.73 The research was delivered to the department in February 2015, but although ministers' approval for publication was sought in December 2015,1271 Martin {CLG00019469/15} page 15, paragraph 45. the research was not published until February 2019.1272 Harral {Day243/126:20-22}.
¶10.74 It was important that the work was carried out and published before the technical review of the Building Regulations and Approved Document B was launched so that the department could engage properly with industry.1273 Harral {CLG00019487/20-21} pages 20-21, paragraph 70. Until officials had clearance to share it, the review could not begin.1274 Harral {Day243/120:6-12}. A number of those reports, including the report on means of escape for disabled people, had implications for the safety of life and the team was therefore anxious to put them in the public realm where they could start to have an effect.1275 Harral {Day244/186:23}-{Day244/187:14}. The report on means of escape for the disabled included a survey which was highly critical of the adequacy of means of escape guidance for disabled people: {CLG00006270/17}; Martin {Day257/156:8-12}. However, none of them was directed to the problem of fire spreading over external walls or the dangers posed by the use of combustible materials.1276 Ledsome {Day241/192:3-4}.
¶10.75 Despite frustration on the part of officials at the delays in obtaining ministers' approval for the publication of the reports, none of the ministerial submissions put up by the officials emphasised the urgency. On the contrary, in each case the timing was marked "routine". None of the later submissions explained that approval had been outstanding for a long time.1277 {CLG10008140}; {CLG00019392}. Nor did they make it clear that without the publication of the research the review of Approved Document B promised to the coroner could not be undertaken. Again, there were serious failures in communication between officials and ministers. Lord Barwell told us that it was "absurd" that it had taken four years for the research to be published after it had been provided to the department.1278 Barwell {Day260/137:22-23}. We can only agree.
¶10.76 In addition, some ministers appeared to be under a misapprehension about the nature of the reports. Lord Pickles did not know that none of them related to the spread of fire over external walls. He merely assumed that, because the coroner had recommended it, the research would cover it, since he had accepted the coroner's recommendations.1279 Pickles {Day261/171:3-8}. Stephen Williams was under the impression that the seven workstreams had been commissioned in response to the coroner's recommendations.1280 Williams {Day259/84:7}. He too was unaware that none of the workstreams dealt with the spread of fire over external walls or the refurbishment of older housing stock.1281 Williams {Day259/138:21}.
166Research on the spread of fire over external walls
¶10.77 In 2014, Brian Martin instructed BRE to carry out research on the spread of fire across the external walls of multi-storey buildings.1282 Crowder {Day230/129:1-10}; Martin {CLG00019469/30} page 30, paragraphs 88-89; Martin {CLG00019469/50} page 50, paragraph 141. That was in addition to the work being done on the seven workstreams. The experimental research, managed principally by Dr Crowder and approved by Dr Smith, was completed in January 2015.1283 {BRE00043751}. Note that the report is dated January 2014 in error; Crowder {Day230/129:20}-{Day230/130:8}. It made its way into the public domain in a shorter form in April 2016 in the form of an article1284 {CLG00019444}. on the BRE website1285 Martin {CLG00019469/30} page 30, paragraph 89. and in an industry journal.1286 Building Engineer magazine {CLG00031088}; Martin {CLG00019469/50} page 50, paragraph 142. The article was less detailed than the research report itself but the findings remained.1287 Crowder {Day230/133:3-9}. Published alongside the article was a second article covering background research into external fire spread with accompanying case studies.1288 {CLG00019445}.
¶10.78 The experimental research purported to assess the performance of three different types of external spandrel panels (with glazing) in fire ("fire-resisting" panels, "Class 3" panels and "Class B-s2 d0" panels) using a test method similar to BS 8414 on a specially modified test rig.1289 {BRE00043751/3} paragraph 4. In fact, both the fire-resisting panels and the Class B-s2 d0 panels used in the tests had achieved those classifications as part of systems1290 {BRE00043751/10} paragraph 2.2; Crowder {Day230/200:7-20}; {Day230/202:21}-{Day230/203:14}. that were not used in BRE's experiments, making the classifications meaningless. The panel referred to as national Class 3 was simply assumed to be Class 3.1291 {BRE00043751/10} paragraph 2.2; Crowder {Day230/205:7}-{Day230/206:1}. In all three experiments, the glazing failed, the fire-resisting and Class B panels behaved in a similar manner and remained intact for the duration of the test and the Class 3 panels burned through.1292 {BRE00043751/35-36} paragraph 5.
¶10.79 Even on the basis that it was a simple scoping study,1293 {BRE00043751/3}; {BRE00043751/6} paragraph 1.2. as both Dr Crowder and Mr Martin told us,1294 Crowder {BRE00043716/33-24} page 33, paragraph 105; Crowder {Day230/215:21}-{Day230/216:15}; Martin {Day257/162:16}-{Day257/163:7}; {Day257/164:6-23}. Dr Crowder accepted that the research had been flawed.1295 Crowder {BRE00047668/47} page 47, paragraph 186; Crowder {Day230/147:19}-{Day230/148:14}. He told us, however, that it had been carried out under difficult circumstances1296 Crowder {BRE00043716/74} page 74, paragraph 278; Crowder {Day230/220:9-22}. and would have been improved if greater resources and more time had been available.1297 Crowder {Day230/148:7}-{Day230/149:18}. That was an understatement. In truth, both the research and the articles based on it were fundamentally flawed in almost every respect. The experiments had no properly defined purpose, did not test the materials they purported to test, were not carried out within proper parameters or in accordance with an approved method and were not subjected to any meaningful analysis. The background article was superficial at best and both the research and the articles were riddled with errors.1298 See for example {BRE00043751/35} paragraph 5, where the Class B panels were described as Class 0 panels; Crowder {Day230/209:11}-{Day230/210:13}; {CLG00019445/5} Case Study 3, where an acrylic render system was described as non-combustible; Crowder {Day230/174:18}-{Day230/175:9}; {Day230:181/5}-{Day230/182:1}; {CLG00019445/6}; Crowder {Day230/190:14-25}, where Dr Crowder accepted that none of the "potential risks" referred to are identified anywhere within the work. In summarising the relevant provisions of the Building Regulations and Approved Document B, the background article repeated the technically incorrect language used by Dr Crowder and Mr Martin at the Lakanal House inquests which confused the concepts of Class 0 classification and combustibility.1299 {CLG00019445/3}; Crowder {Day230/160:22}-{Day230/162:21}. Most significantly, it purported to reach the conclusion that there was adequate guidance available in the public domain to ensure that buildings were designed and constructed so that the spread of fire across the external surface and within the external façade was inhibited, as required by the Building Regulations.1300 {CLG00019444/9}. That conclusion could not, on any view, sensibly be drawn from any of the work that had been undertaken. We do not agree with Dr Crowder's view that that conclusion (which, although he was listed as one of the article's authors,1301 {CLG00019445/1}. he told us he had not written)1302 Crowder {Day230/160:15-16}; {Day230/189:7-9}. was simply "too broad".1303 Crowder {Day230/214:3-19}. In fact, the work as a whole had no scientific or other value. The conclusion bore no relation to the work the BRE had actually carried out; it was unfounded and misleading. There was no basis on which Mr Martin could reasonably have regarded that research as supporting the view that the Building Regulations and statutory guidance were sufficient to minimise the danger of the spread of fire over external walls,1304 Martin {CLG00019469/50} page 50, paragraph 142. even if, as he later explained, he had been really concerned only with matters of fire resistance.1305 Martin {Day257/167:16}-{Day257/168:19}.
167Usability study
¶10.80 The only other research carried out for the department during the period 2013 to 2017 was a usability study commissioned by Mr Martin in 2015 from RIBA Enterprises,1306 {CLG10006615/1}; Martin {Day255/24:20}-{Day255/25:8}. the publishers of the Approved Documents.1307 Harral {Day243/92:25}-{Day243/93:1}. The objective of the project was to carry out a review of a number of the Approved Documents, including Approved Document B. However, it was not technical research or a review of the substantive content of the Approved Document.1308 Martin {Day255/25:9-12}; Ledsome {Day241/130:8-10}; {Day241/195:8}-{Day241/196/10}. The study, which was carried out in various stages and included interviews with users of the document, was specifically limited to the way in which the content could best be delivered to users considering matters such as style, internal consistency, plain English and the development of a digital version.1309 {CLG10006383}; {CLG10006616/2}; {CLG10007016/1}; {CLG10007686/1}; {CLG00002962/1} an email from the afternoon of 14 June 2017 in which Brian Martin noted his concern about the use of the word "research" to describe the user survey in a draft press statement about the Grenfell Tower fire, commenting that this "may be overplaying it".
Engagement with the All-Party Parliamentary Group on Fire Safety
¶10.81 In the years before the Grenfell Tower fire the All-Party Parliamentary Group on Fire Safety had regular correspondence with the various ministers responsible for fire safety. In particular, following the Lakanal House inquests and between March 2014 and April 2017, the Group wrote to the department at least 14 times, raising concerns over the need to review Approved Document B and important matters affecting the safety of life.1310 {CLG00019243}; {CLG00019248}; {CLG00011290}; {CLG00030867}; {CLG00019411}; {HOM00043035}; {CLG00019298}; {CLG10007860}; {CLG10008064}; {CLG00019334}; {CLG00019398}; {HOM00002220}; {CLG10009024}.
168¶10.82 Throughout the correspondence some of the concerns raised by the Group displayed a prescience about what was later to occur at Grenfell Tower. They included the danger posed by the use of Class 0 as the sole criterion of suitability for external wall coverings,1311 {CLG00019243}. research that showed that Approved Document B was out of date,1312 {CLG00019248}. aspects of the guidance in Approved Document B that required immediate attention,1313 {CLG00011290}. significant consequences for the safety of life if Approved Document B were not reviewed more quickly,1314 {CLG00019298}. the increased use of combustible material,1315 {CLG10007860}. the risk to life caused by the use of combustible materials,1316 {CLG10008064}. the dangers created by the use of modern materials and methods of construction,1317 {CLG00019398}. and the need to review Approved Document B in a timely manner.1318 {CLG10009024}.
¶10.83 The Group sent at least five letters to Stephen Williams between March 2014 and March 2015. He told us that he thought that the problem at Lakanal House had been that the windows had not been installed in compliance with the regulations and therefore the plastic had melted and run down the building.1319 Williams {Day259/161:13-25}. It is possible that his misunderstanding of what had occurred influenced his approach to the matters being raised by the Group. Mr Williams could not be sure that he had read all the letters from the Group to which replies went out in his name because it was not his practice to do so in every case.1320 Williams {Day259/100:23}-{Day259/101:4}. Brian Martin told us that in each case he had provided the minister with a copy of the Group's letter and a draft reply and we have no reason to think otherwise.1321 Martin {CLG00019469/60} page 60, paragraph 173.
¶10.84 Mr Williams told us that he thought that the All-Party Parliamentary Group had raised some reasonable points about the time for the review of Approved Document B and that he therefore wanted to meet them.1322 Williams {Day259/114:11-22}. Brian Martin prepared a briefing note1323 Martin {CLG00019469/62-63} pages 62-63, paragraph 174(f). for the meeting, which took place on 17 June 2014.1324 All Party Parliamentary (Fire Safety & Rescue) Group Meeting Minutes dated 17 June 2014 {RKI00000012/3}. The correspondence reveals that before the meeting officials had been dismissive of the Group's concerns.1325 {HOM00048451}.
¶10.85 On 5 August 2014, the Group sent a detailed letter to Stephen Williams identifying three ways in which they thought Approved Document B needed to be amended. The letter contained a long history of Class 0 and what they thought was wrong with it.1326 {CLG00011290}. However, Mr Williams' letter of reply was curt and dismissive. In essence it simply said that he had neither seen nor heard anything to suggest that consideration of specific potential changes to Approved Document B was urgent.1327 {CLG00019439}. That was despite the fact that he had never been given any advice on changes to Approved Document B which went beyond simplification of the wording.1328 Williams {CLG00034291/10} page 10, paragraph 19. The response had been drafted by Brian Martin. His explanation was that none of the changes suggested by the Group had been consistent with government policy.1329 Martin {CLG00019469/64} page 64, paragraph 174(h). Mr Williams told us that he regretted having sent that letter.1330 Williams {Day259/178:14}-{Day259/179:7}. He said that he had tried to soften its effect by adding a handwritten note to Sir David Amess that read "Happy to have a chat in the lobby, as always".1331 Williams {Day259/178:22}-{Day259/179:3}.
169¶10.86 Lord Wharton received at least four letters from the Group between September 2015 and February 2016. The first, from the late Sir David Amess MP, referred to the previous correspondence with Stephen Williams and pointed out that three matters of particular concern to the Group had been raised which it thought deserved immediate attention.1332 {CLG00019298}. Lord Wharton replied on 23 October 2015 and agreed to meet the Group.1333 {CLG00019454}. Brian Martin briefed him before the meeting1334 {CLG10007718}. and provided him with a note of the meeting when it was over.1335 {CLG10008066}. Lord Wharton confirmed that at the meeting he had understood clearly that the Group considered that the guidance in Approved Document B was out of date and required revision, that the regulations themselves were incoherent and in places outmoded, and that a unified and all-encompassing system of regulation was required.1336 Wharton {CLG00034289/10} page 10, paragraph 23. Lord Wharton recalled raising the flammability of materials with officials but was told that the matter would be considered as part of the review of Approved Document B.1337 Wharton {CLG00034289/10} page 10, paragraph 24.
¶10.87 Lord Wharton responded to the Group in writing on 6 January 2016 saying that he hoped to set out the government's intentions regarding the Building Regulations in the next year.1338 {CLG10007862}. He agreed that his letter could have been more fulsome.1339 Wharton {Day258/181:11-15}. Following another letter from the Group on 1 February 2016,1340 {CLG10008064}. he wrote again on 14 February 2016,1341 {CLG10008061}. saying merely that he was sorry that the Group was unhappy and hoped that the department could continue to work closely with it. That was not a satisfactory response. Lord Wharton accepted that it had been curt, but said that it reflected his frustration, since he had instructed his officials to involve the Group in the review process and felt that its concerns were premature.1342 Wharton {Day258/188:15-25}.
¶10.88 However, the defensive and dismissive attitude of the department's officials towards the All-Party Parliamentary Group was evident from their internal communications.1343 See Brian Martin's comments on Ronnie King of the APPG in emails dated 8 December 2010 {CLG10004547} "Bob Neill signed a slightly toned down version of my letter to Ronnie. Still quite funny though…."; Email dated 10 November 2014 {CLG00002824} "Ronnie will not listen to reason so I just ignore him". In an email to Richard Harral on 16 March 2016 Brian Martin referred to the Group's correspondence as "increasingly tetchy"1344 {CLG10008060}. but failed to acknowledge that it might have some justification in wanting to see progress with the review of Approved Document B. The internal communications at that time reveal that the department's officials, particularly Brian Martin, were becoming tired of dealing with the constant stream of letters from the Group and as a result had become increasingly defensive and personal in their reactions. Unfortunately, that was not picked up by any of the more senior officials in the department.
170¶10.89 For his part, Lord Barwell received at least four letters from the Group between October 2016 and April 2017.1345 Barwell {CLG00030960/11-12} pages 11-12, paragraphs 27-32. Gavin Barwell thought that the first letter did not arrive and therefore it was re-sent on 17 October 2016. Although he was aware that it had previously written to Lord Wharton, he was unaware that the correspondence had a much longer history.1346 Barwell {CLG00030960/11} page 11, paragraph 27. He ought to have been told about it by his officals. He also ought to have asked to see the earlier correspondence, or asked that someone review it to enable him to obtain a better appreciation of the strength of the Group's concerns.1347 Barwell {Day260/182:4-10}. He initially rejected a meeting with it1348 {CLG10008717}. on the advice of Brian Martin, on the basis that the discussion document was still outstanding at that time (as it was).1349 Martin {CLG00019469/67-68} pages 67-68, paragraph 174(t). Lord Barwell assumed that the Group's concerns were being taken into account in formulating the discussion document and accepted the advice of his officials that it was better to have a meeting once that document had been drafted.1350 Barwell {Day260/188:9}; {Day260/189:2-7}.
¶10.90 Lord Barwell wrote to the Group again on 5 April 2017.1351 {CLG00020106}. He went as far as to provide his telephone number so that it could arrange a meeting with him without further delay. In the event, no meeting occurred because a general election was called before it could take place.1352 Barwell {CLG00030960/12} page 12, paragraph 32.
¶10.91 In the days immediately after the Grenfell Tower fire, Simon Ridley, the department's Director General for Decentralisation and Growth, was instructed by Helen MacNamara to review the correspondence between the department and the All-Party Parliamentary Group. At her request, he provided her with his immediate impressions.1353 Ridley {CLG00034719/2-3} pages 2 and 3, paragraphs 5 and 10. Simon Ridley confirms in the latter paragraph of his statement that the work was carried out before 19 June 2017. He concluded that the Group had warned ministers about cladding and combustibility and about more general problems with modern construction materials, none of which had been acknowledged or addressed in the department's responses.1354 {CLG00030840/7}. He was scathing in his criticism of the department, describing the correspondence as "appalling – delayed, partial and … chaotic".1355 {CLG00030840/7}. Having reviewed the correspondence, we agree with his assessment, even though it was made in haste and with a degree of hindsight after the fire.
¶10.92 The way in which the department dealt with the All-Party Parliamentary Group was unacceptable. Correspondence was lost, important matters were ignored, ministers either refused, or at any rate failed, to engage with the material or understand the serious issues being raised. They relied entirely on officials, who appeared to have been given almost free rein to decide on timing and policy, were dismissive both of the coroner and the MPs on the Group and displayed a marked lack of appetite to embark on a review of Approved Document B within a reasonable time. Mr Martin's attitude is epitomised by his email to Anthony Maude1356 Maude {CLG00034279/1-2} pages 1-2, paragraphs 5-6, an official in the Fire and Resilience Directorate. in November 2014, commenting on the repeated requests for amendments to Approved Document B by Ronnie King, the Secretary to the All-Party Parliamentary Group, as follows: "Yes, he's very annoying. Basically, we will not be changing the AD [Approved Document] as and when Ronnie asks – we'll do it when we're ready".1357 {CLG00002824}. The department never did do it and was never ready. Its failure was profound.
171The management of the department
¶10.93 Between 2006 and 2015 the number of staff within the Building Regulations Division had been significantly reduced. In 2006 there had been 14 construction professionals and three Grade 6 civil servants in a division whose responsibilities were narrower than they later became. By 2015 that had fallen to five technical specialists and one Grade 6 official.1358 Harral {Day243/144:17}-(Day243/145:4}. Richard Harral explained that the numbers of personnel had increased again since the Grenfell fire: Harral {Day243/145:4-7}. As a result the department's capacity was significantly below that which some officials thought was really required.1359 Harral {Day243/145:8-15}; Ledsome {Day245/122:11}-{Day245/123:9}; Burd {Day240/195:8}-{Day240/196:4-5}. A ban on instructing consultants meant that it was no longer possible to engage experts to carry out key work, including the management of research programmes.1360 Harral {Day243/145:16}-{Day243/146:5}. Mr Harral did not feel able to raise the constraints on resources with senior management because the department's policy was to concentrate on manifesto commitments and legal requirements. He did not think that he would be able to obtain more staff until ministers had committed themselves to a plan of work for a review of the Building Regulations.1361 Harral {Day243/147:9}-{Day243/148:1}. A shortage of staff also made it difficult for the department to engage with industry in a way that enabled it to develop the Building Regulations and the Approved Documents.1362 Harral {Day243/124/18}-{Day243/125:3}; Ledsome {Day245/114:14-25}. The department had neither the ability nor the capacity to issue practical guidance to industry because its systems for reviewing guidance had become obsolete.1363 Harral {Day243/60:11}-{Day243/61:4}; {Day243/137:19-22}.
¶10.94 The Division's ability to recruit and retain qualified technical staff was significantly hampered both by insufficient salary levels and by the lengthy process involved in taking on new staff.1364 Ledsome {Day245/114:18-25}; {Day245/122:17}-{Day245/123:9}; Harral {Day243/17:4}-{Day245/18:16}; {Day243/191:24}-{Day243/192:8}. One result of the increase in work and reduction in staff numbers was that the Building Regulations and Energy Performance Division felt itself to be something of a Cinderella. By 2015 and following further cuts to staff,1365 Harral {Day243/17:4-16}; {Day243/143:15}-{Day243/147:7}. the team was seriously overworked,1366 Harral {Day243/172:10-22}. and struggled to meet the demands of its very broad workload.1367 Harral {Day243/102:21}-{Day243/103:4}; {Day243/20:24}-{Day243/21:13}; {Day243/64:21}-{Day243/65:6}; {Day243/91:4-11}; {Day243/101:25}-{Day243/103:4}; {Day243/144:17}-{Day243/147:7}; {Day244/55:16-23}. It was under-valued and no longer able to be forward-looking.1368 Harral {Day243/11:23}-{Day243/12:1}; {Day244/144:5-9}. The team's sense that it was always at the back of the queue1369 Harral {Day243/11:11}; {Day243/12:25}. for submissions to be put up to ministers1370 Harral {Day243/11:12-14}. was acknowledged by Mr Ledsome, who recognised that it had been his responsibility to press for a fair allocation of the resources available to the department. Mr Ledsome accepted that in that respect he had failed to discharge his responsibilities as well as he would have wished.1371 Ledsome {Day245/116:21}-{Day245/117/14}.
¶10.95 Following the Lakanal House inquests, the engagement of the members of the Building Regulations and Energy Performance team with officials at director level was sporadic and with more senior officials virtually non-existent.1372 Harral {Day243/12:18-22}. Before the Grenfell Tower fire, Dame Melanie Dawes, Permanent Secretary from March 2015 to 2020, had not met any members of the team and had very little knowledge of its work.1373 Dawes {Day249/30:7}-{Day249/31:19}. She had not heard of Lakanal House or the coroner's recommendations.1374 Dawes {Day249/69:13-17}. Dame Melanie confirmed that both she and Helen MacNamara, Director General from September 2016 to 2018, should have been made aware of the coroner's recommendations.1375 Dawes {Day249/73:1-4}. She put the omission down to the fact that somehow their importance had not been appreciated by the team and to the fact that the department did not have a system for monitoring recommendations. She said that as a result, the team had lost sight of how important they were.1376 Dawes {Day249/73:7-14}.
172¶10.96 All that strongly suggests a failure of leadership within the department at the highest levels stretching back over some years. Dame Melanie said that she had been struck by the fact that her predecessors appeared to have had no inkling of the problems that had started to appear when she was in post.1377 Dawes {CLG00030839/6-7} pages 6-7, paragraph 18. The fact that some of the most senior officials were not aware how demoralised and demotivated the Building Regulations team were is indicative of serious structural defects. Although Mr Ledsome must bear considerable responsibility for failing to communicate effectively with those above him, the most senior officials in the department ought to have been aware of the failure of the more junior officials to take effective action in response to the coroner's recommendations within the time indicated by the Secretary of State in May 2013. They ought also to have realised that the deference paid to Brian Martin by those around him in relation to technical aspects of the Approved Documents, his sense of ownership of Approved Document B and the absence of any proper peer review of his work all stood in the way of critical thinking and were obstacles to progress. Senior officials should have taken a closer interest in the working of a small, but important, part of the department that was responsible for significant matters affecting the safety of life.
173Chapter 11: Combustible cladding: warnings to government
¶11.1 Between 2012 and 2017 the government received warnings from many sources about the use of combustible materials in the construction of the external walls of high-rise buildings. They included specific warnings about the risks posed by polymeric insulation products and aluminium composite cladding products with unmodified polyethylene cores. However, the government failed to provide guidance on how to avoid the dangers posed by the use of combustible materials or to take any other action in response to the warnings it had received. As a result an increasing number of high-rise buildings were constructed using dangerous materials.
2012–2013: international cladding fires
¶11.2 Throughout the period from 2012 to 2017 Brian Martin was the department's principal construction professional1378 Martin {CLG00019469/1} page 1, paragraph 2. and primary custodian of Approved Document B.1379 Martin {Day252/206:3-7}. On 17 and 18 May 2012, he received emails from Dr David Crowder of the BRE attaching links to news reports, including video footage, of a fatal cladding fire that had occurred on 14 May 2012 at Mermoz Tower, an 18-storey block of flats in Roubaix, France.1380 {CLG00019178}; {CLG00019179}; Martin {CLG00019469/36-37} pages 36-37, paragraph 109. In his response to that email, sent to Sir Ken Knight, Louise Upton and Anthony Burd, Mr Martin described the video as "pretty alarming" and expressed the view that a construction of that kind would probably not be in accordance with the Building Regulations.1381 {CLG00019179}. Mr Martin said "probably", because he did not have enough information at the time to determine whether the building's façade would have complied with functional requirement B4(1) of the Building Regulations.1382 Martin {CLG00019469/36-37} pages 36-37, paragraph 109. He said that he had had a limited amount of time to look into the fire and that he did not think he had discovered until after the fire at Grenfell Tower that Mermoz Tower had been clad in aluminium composite panels with polyethylene cores.1383 Martin {Day252/107:16-25}. Anthony Burd did not consider carrying out a review to find out whether any buildings in this country had been constructed using similar materials.1384 Burd {Day240/151:1-6}. He said that he had not had the time or the information necessary to do so.1385 Burd {Day240/153:2-7}; {Day240/152:6-17}.
¶11.3 On 5 December 2012, following another cladding fire on 18 November 2012 at Tamweel Tower, a residential high-rise building in Dubai, Mr Martin and Mr Burd received an email from Sam Greenwood at BRE,1386 Sam Greenwood was a consultant at BRE, reporting to Martin Shipp, and had investigated the fire at the Edge in January 2005 alongside Dr Colwell: Shipp {BRE00047594/82} page 82, paragraph 461; Colwell {BRE00047571/44} page 44, paragraph 270. in which he compared the fire at Tamweel Tower to the fire at The Edge in Salford in January 2005.1387 {CLG00019192}. For the details of that fire see Chapter 8. Mr Martin may already have been aware at that time of the Tamweel Tower fire and of the fact that it had involved aluminium composite cladding with a polyethylene core.1388 Martin {Day252/111:12-16}. When responding to Mr Greenwood's email he remarked on what he described as the "awesome" power of the fire in the videos he had seen of the event.1389 {CLG00019192}; Martin {CLG00019469/37} paragraph 110; Martin {Day252/110:1}-{Day252/111:3}. However, it was his view that such a fire could not occur in this country1390 Martin {CLG00019469/37} page 37, paragraph 110; Martin {Day252/110:20}-{Day252/112:1}. because he understood that people were following the guidance in paragraphs 12.5 and 12.7 of the 2006 version of Approved Document B.1391 Martin {Day252/111:4-10}. The purpose of paragraphs 12.5 and 12.7 had been to encourage people to think beyond insulation1392 Martin {Day252/112:5-7}. and he had thought that the guidance they contained was both adequate and sufficiently well understood to prevent a fire of that kind occurring here.1393 Martin {Day252/112:17}-{Day252/113:13}.
174November 2013 to January 2014: questions from BRE
¶11.4 Brian Martin did not become aware that the application of section 12 of Approved Document B was causing difficulties in practice until late 2013.1394 Martin {Day252/158:12-14}. The construction of external walls had not been a prominent feature of his work before that.1395 Martin {Day252/159:9-11}. The first time he was asked about the meaning of paragraph 12.7 was on 25 November 2013,1396 Martin {Day252/184:3-6}; Martin {Day253/23:6-10}. when he received an email from Tony Baker of BRE,1397 {CLG10005895}. who told him that BRE was receiving an increasing number of inquiries about the interpretation of Diagram 40 and paragraphs 12.6 and 12.7 of Approved Document B. Mr Baker hoped to reach a general understanding with the department so that BRE could give consistent advice to those who contacted it. Mr Baker referred to a debate that had arisen within the construction industry about how paragraph 12.7 and Diagram 40 were intended to apply to boards used as the outer layer of an external wall. He suggested that a definition of the words "finish" (paragraph 12.6) and "filler" (paragraph 12.7) would help to clarify the matter.1398 {CLG10005895/2-3}.
¶11.5 In response Mr Martin said that he thought it was reasonable1399 Martin {Day252/188:21-23}. to interpret those paragraphs as meaning that a homogenous1400 Defined in EN 13501 as "a product consisting of a single material, having uniform density and composition throughout the product": {BSI00001738/10} paragraph 3.1.3. board that was Euroclass B would be fine,1401 {CLG10005895/2}. in that all of it could be classed as a "surface" and therefore need not be of limited combustibility, but that a composite board was subject to the guidance on limited combustibility in paragraph 12.7.1402 Martin {Day252/188:15-20}; {CLG10005895/2}.
¶11.6 Mr Martin told us that the question Mr Baker had raised was not one that he and Mr Burd had considered in 2006 when drafting the amendment to paragraph 12.7 of Approved Document B,1403 Martin {Day252/190:1-15}. but that in his view, Mr Baker's assessment of the relevant provisions1404 {CLG10005895/1}. was accurate,1405 Martin {CLG00019469/39-40} pages 39-40, paragraph 116; Martin {Day253/5:4-19}. in that paragraph 12.6 directed readers to consider the surface of a wall while paragraph 12.7 directed readers to consider materials below the surface.1406 Martin {Day252/198:7-17}; Martin {Day253/6:14-15}; {Day253/7:10-15}. The obvious difficulty with that explanation, however, is that paragraph 12.7 did no such thing.1407 Martin {Day253/7:16-25}. Instead, it directed readers in clear terms, both by the heading and the text, to consider insulation materials. Perhaps unsurprisingly, Mr Baker was not satisfied with Mr Martin's responses1408 Baker {BRE00043700/8-9} pages 8-9, paragraph 45. and asked for a meeting in order to resolve the matter.1409 {CLG10005895/1}; Martin {Day253/15:14-19}.
175¶11.7 A meeting subsequently took place between Mr Baker, Dr Colwell and Mr Martin on 30 January 2014.1410 {CLG10005953}; Baker {BRE00043700/14} page 14, paragraphs 72-75; Colwell {Day233/160:9-13}. Neither Mr Baker1411 Baker {BRE00043700/15} page 15, paragraphs 78-82. nor Mr Martin could remember much, if anything, about it1412 Martin {CLG00019469/39-40} pages 39-40, paragraph 116; Martin {Day253/24:21-23}. but Dr Colwell recalled that Mr Martin had accepted that paragraph 12.7 could have been written more clearly.1413 Colwell {Day233/164:25}-{Day233/165:4}.
¶11.8 Despite having been made aware that there was uncertainty in the construction industry about the meaning and effect of paragraphs 12.6 and 12.7 of Approved Document B, Mr Martin took no steps to provide clarification. Mr Martin does not appear to have been troubled by the fact that the provisions were not well understood1414 Martin {Day252/191:6-12}. and did not ask BRE who had been raising questions.1415 Martin {Day252/182:24}-{Day252/183:2}. Nor did he ask how many there were or how often they were received. In short, he made no attempt to understand how those paragraphs of the guidance were being understood by those who had to use it.
¶11.9 Mr Martin saw no need to tell his managers that there was a problem that required attention in one form or another,1416 Martin {Day253/29:8-14}; {Day253/30:20-23}. apparently because he did not consider it to be urgent1417 Martin {Day253/20:20}-{Day253/21:3}. or particularly significant. He did not, therefore, raise it with Richard Harral, who by January 2014 had replaced Anthony Burd as Head of Technical Policy,1418 Harral {CLG00019487/1} page 1, paragraph 3. or with his Deputy Director, Mr Ledsome.1419 Martin {Day252/185:22-24}; Martin {Day253/29:8-14}; Harral {Day244/72:15-19}; Ledsome {Day242/190:19-23}. Both told us that they would have expected him to draw to their attention matters of the kind that were being raised by BRE.1420 Harral {Day244/74:23}; {Day244/74:14-15}; Ledsome {Day242/194:8-12}. Instead, Mr Martin proceeded on the basis that the questions that BRE was receiving showed that the guidance was making people think broadly.1421 Martin {Day252/193:18}-{Day252/194:10}. In any event, he did not consider himself to be the ultimate arbiter of the meaning of any particular part of the guidance,1422 Martin {Day252/200:7}-{Day252/201:3}. the function of which, in his view, was to help people to make their own judgments about what was required to comply with the functional requirements of the Building Regulations.1423 Martin {Day252/194:11-18}. He also thought that industry was producing its own guidance on how to comply with functional requirement B4.1424 Martin {CLG00019469/54} page 54, paragraph 155; Martin {Day252/166:10-22}.
¶11.10 Although Dr Colwell thought that Mr Martin had taken BRE's concerns seriously,1425 Colwell {Day233/162:2-6}. neither she nor Mr Baker thought that the question they had raised had received a definitive answer.1426 Baker {BRE00043700/15} page 15, paragraph 83; Colwell {Day233/165:10-14}. He told them that the matter would be picked up in the next review of Approved Document B,1427 Colwell {Day233/160:19-25}; {Day233/164:17-19}; Baker {BRE00043700/15} page 15, paragraph 83. which he envisaged would start a year later, when the department's work on the Housing Standards Review had been completed.1428 Martin {Day253/25:25}-{Day253/26:4}. In the event, however, that did not happen.
176An FAQ?
¶11.11 From time to time the department published on its website answers to "Frequently Asked Questions", which themselves became known as "FAQs".1429 Harral {Day243/60:24}-{Day243/61:7}; {Day244/46:25}-{Day244/47:4}; Ledsome {Day241/181:15-21}. For an example of an FAQ in relation to Approved Document B {CLG10000003}. It seems likely that the possibility of clarifying the meaning and scope of paragraph 12.7 by publishing an FAQ had been raised at the meeting.1430 Baker {BRE00043700/15} page 15, paragraphs 82-83. Under certain circumstances that could be done without the need for any formal process of review.1431 Harral {Day244/41:14-20}; Ledsome {Day242/158:2-16}.
More international cladding fires
¶11.12 Following the fires in the United Arab Emirates in 2012 and 2013, Dr Colwell had travelled to Dubai several times to work with the authorities there on revising their fire safety codes1432 Colwell {Day233/208:18}-{Day233/210:10}. and was aware that those fires had involved aluminium composite cladding panels with polyethylene cores.1433 Colwell {Day233/54:23}-{Day233/55:3}; {Day233/208:14-16}. She said that she had discussed some of them with Mr Martin during the meeting in January 2014. He did not recall that but we think it likely the subject was raised on that occasion.1434 Martin {Day252/118:7-11}.
¶11.13 Mr Martin could remember being aware in 2014 of some, but not all, of the fires involving aluminium composite material with a polyethylene core that had occurred abroad between 2012 and 2014.1435 Martin {Day252/114:6}-{Day252/115:4}. For example, he did recall the fire at the Lacrosse building in Melbourne in November 2014, but said that he had only limited information about it at the time.1436 Martin {Day252/114:9-14}; {Day252/115:10-14}. None of those fires appears to have led to anything more than brief conversations with his former colleagues at BRE,1437 Martin {Day252/117:21}-{Day252/118:6}. though he appears to have had no discussions about them at all with Mr Harral, to whom by January 2014 he reported within the department.1438 Harral {Day244/79:12}-{Day244/80:25}. His knowledge of the use of aluminium composite panels with polyethylene cores in other countries and the fires associated with them did not cause Mr Martin to ask himself whether similar materials might be in use in this country.1439 Martin {Day252/118:22-24}. It did not occur to him that uncertainty about the meaning of paragraph 12.7 of Approved Document B might have led some designers, contractors and building control officers to accept the use of materials that were dangerous and did not consider that to be a major problem.1440 Martin {Day252/193:11-18}.
¶11.14 Equally, Mr Martin had made no connection at the time between the use of aluminium composite panels with polyethylene cores and the large-scale test carried out on a system incorporating similar material under contract cc1924 in 2001,1441 Martin {Day252/118:25}-{Day252/119:24}. See Chapter 7. even though Mr Baker had referred to those tests in the email he had sent to him asking about the meaning of paragraph 12.7 on 3 December 2013.1442 {CLG10005895/1}. Mr Martin said that he had thought that at the time of the 2001 tests aluminium composite panels with polyethylene cores were new products, not generally in use in the UK construction industry, and that if they had been in widespread use at the time of the test they would not have continued to be used following it.1443 Martin {Day252/120:14-18}. However, it is difficult to understand how he could have thought that, given that the results of those tests were not published until many years later.
177February 2014: Wintech's intervention
¶11.15 On 7 February 2014, Chris Macey, a director1444 Macey {WIN00000005/1} page 1, paragraph 1. of Wintech Ltd, a façade and engineering consultancy,1445 Taylor {WIN00000002/1} page 1, paragraph 1. contacted the department by email to express concern about the use of combustible insulation in high-rise buildings. He also drew attention to what he saw as a conflict between the guidance in Approved Document B on the use of insulation materials in the external walls of high-rise buildings and the requirement in Part L of Schedule 1 to the Building Regulations1446 Part L and Approved Document L, Conservation of Fuel and Power, set standards for energy efficiency in new and existing buildings. to make reasonable provision for the conservation of fuel and power by limiting heat loss through the fabric of buildings.1447 {CLG10006010/2-3}. In an email to Paul Decort, an official in the Building Regulations Division leading on sustainability,1448 Martin {Day253/31:24}-{Day253/32:4}. that was sent on to Brian Martin on 10 February 2014 Mr Macey warned that a number of major developers, contractors and manufacturers were ignoring the requirements of Part B1449 {CLG10006010/3}. and asked for a meeting with officials to discuss the matter.1450 {CLG10006010/3}. Within twenty minutes of receiving the email, however, Mr Martin had decided that there was no need to pursue the matter.1451 {CLG10006010/2}.
¶11.16 Mr Martin said that the department had neither the resources nor the authority to carry out an investigation of the kind suggested by Mr Macey.1452 Martin {Day253/42:12-15}; {Day253/44:9-11}. At any rate, he did not give any consideration to a potential conflict between the provisions of Parts B and L of Schedule 1 to the Building Regulations1453 Martin {Day253/41:13-16}. and did not ask Mr Macey for further information about the practices he had referred to.1454 Martin {Day253/42:16-24}. Indeed, it appears that he did not respond in any way to Mr Macey's message.1455 Macey {WIN00000005/35} page 35, paragraph 111.
April 2014: discussions with BRE
¶11.17 On 24 April 2014 Mr Martin received an invitation by email1456 {CLG00031072}. from Brenda Apted1457 Brenda Apted was the Centre for Window and Cladding Technology's office manager: Metcalfe {Day228/47:17-18}. of the Centre for Window and Cladding Technology (CWCT)1458 The Centre for Window and Cladding Technology is a not-for-profit research and technical organisation formed in the 1980s. The organisation produces guidance and training materials on various aspects of facades with the aim of improving standards in the façade industry: Metcalfe {Day228/4:4-24}; Metcalfe {CWCT0000115/2} page 2, paragraphs 6-8. to attend a meeting to discuss various aspects of fire and facades. In her message, she explained that the CWCT had recently received a number of inquiries, including about the use of combustible insulation in rainscreen facades and the fire performance of aluminium composite rainscreen materials. One of the topics for discussion at the meeting was to be the adequacy of the existing regulations. Mr Martin suggested that Dr Colwell might be interested and said he would assist where he could. He copied her into his reply.1459 {CLG00031072/1}.
178¶11.18 On 24 April 20141460 {BRE00047459/2}. Brenda Apted sent an email to Dr Colwell inviting her to the meeting. Dr Colwell sent it on to Dr Debbie Smith and others in BRE, including Mr Baker and Stephen Howard.1461 In April 2014 Stephen Howard was business group manager for the BRE's Passive Fire Group: Howard {BRE00005771/2} page 2, paragraph 6. Dr Smith was clearly alarmed at the CWCT's involvement, which she saw as threatening BRE's pre-eminence in the field of fire safety.1462 {BRE00047459/1}. Indeed, she referred in the same internal email chain to the CWCT as a potential threat.1463 {BRE00047459/1}. Dr Smith said she could not remember why she had reacted in that way,1464 Smith {Day237/50:3-4}; {Day237/50:22}-{Day237/51:3}; {Day237/56:15}; {Day237/58:8-21}. but it is clear that her primary concern at the time was a desire to protect BRE's commercial position. It is equally clear both from that internal BRE email correspondence1465 {BRE00047459/2} "This is something we need to be aware of and should consider being involved with because of the increasing number issues (sic), similar to those identified below, which we are being asked by industry"; {BRE00047459/1} "The problem is now the issues we are seeing in the industry…". and from Dr Colwell's evidence,1466 Colwell {Day233/172:19}-{Day233/173:13}. that BRE was continuing to receive questions from industry about the meaning and scope of paragraph 12.7 of Approved Document B.
2 July 2014: the CWCT meeting
¶11.19 The meeting of the CWCT's Fire Group took place on 2 July 2014. Dr Colwell attended, as did Brian Martin, David Metcalfe and Alan Keiller of the CWCT, Chris Mort of Siderise, Ivor Meredith of Kingspan and others from across the industry and various interested associations.1467 For a full list of those who attended, see {CLG00019336/1}. Mr Martin was present for only part of the meeting,1468 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/4} third paragraph. but he did receive the minutes1469 Martin {CLG00019469/41} page 41, paragraph 119. and read them.1470 Martin {Day253/51:7-14}. They recorded discussions about two important matters: the use of aluminium composite material on high-rise buildings and the relationship between limited combustibility and Class 0.
¶11.20 At the meeting discussions proceeded on the common understanding that aluminium composite material normally consisted of two skins of aluminium separated by a polyethylene core and generally obtained a national Class 0 or Euroclass B classification. That was referred to as "the normal material". It was recognised that there had been several cladding fires in various countries where such material had been responsible for external fire spread.1471 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/3} under the heading "Use of ACM on high rise buildings". Someone appears to have said that paragraph 12.7 of Approved Document B was intended to prohibit the use of such material in buildings over 18 metres in height because it was not of limited combustibility, but that the wording did not make that clear, particularly because the heading referred to insulation materials and products. It was accepted that the expression "filler materials" could refer to the core but it was thought that that was not clear either.1472 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/4} second paragraph.
179¶11.21 Mr Martin was not present for that part of the meeting.1473 Martin {CLG00019469/41-42} pages 41-42, paragraph 119(c); Martin {Day253/63:6-8}; Metcalfe {Day228/81:12-18}. When he read the minutes, it did not occur to him that the reference to "the normal material"1474 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/3} penultimate paragraph. might indicate that it was being used widely in this country,1475 Martin {Day253/54:6-16}; Metcalfe {Day228/82:2-18}. or, for that matter, in any other part of the world.1476 Martin {Day253/54:17-22}. All he understood from that part of the minutes was that different types of aluminium composite panels were available in this country.1477 Martin {Day253/55:9-10}. Despite the heading of that paragraph ("Use of ACM on high rise buildings"),1478 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/3}. Mr Martin said that he had not realised that aluminium cladding panels with combustible cores might be in use on high-rise buildings in this country.1479 Martin {Day253/55:24}-{Day253/56:1}.
¶11.22 Mr Martin noted that at least one person present had, in his view, correctly understood that the word "filler" had been intended to prohibit the use of aluminium composite panels with polyethylene cores on high-rise buildings,1480 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/4} second paragraph. but that was to ignore both the fact that wording of paragraph 12.7 was not thought to be clear1481 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/4} second paragraph. and also the fact that the minutes referred to another possible interpretation of the clause, namely, that the word "filler" applied to all materials other than those specifically excluded, i.e. gaskets and sealants, and therefore included breather membranes.1482 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/4} first paragraph under the heading "Breather membranes"; Martin {Day253/78:12}-{Day253/79:16}.
¶11.23 Mr Martin did not know who had put forward what he regarded as the correct interpretation of the expression "filler material" and did not take any steps to find out.1483 Martin {Day253/100:9-21}. It did not occur to him that others at the meeting might have disagreed with that interpretation or that it might have been new to them1484 Martin {Day253/102:21}-{Day253/103:11}. and was not concerned by the fact that the matter was being debated by a group of professionals seven years after the publication of the text.1485 Martin {Day253/102:13-20}. He said that until he read the minutes of the meeting in July 2014 it had not crossed his mind that the use of the word "insulation" in the heading of paragraph 12.71486 {CLG10000005/99}. might lead readers to think that the paragraph was directed specifically to insulation.1487 Martin {Day253/104:1-12}. We find that hard to believe.
¶11.24 A number of building professionals who had attended the meeting said that they had been surprised by the suggestion that the word "filler" in paragraph 12.7 had been intended to apply to the core of a composite cladding panel,1488 Taylor {WIN00000002/56} page 56, paragraphs 126-127. We note that Stuart Taylor, Technical Director at Wintech, having read paragraph 12.7 and been unsure of its intended meaning, had checked the matter with Dr Colwell shortly after the publication of the 2007 edition of Approved Document B and that it was her advice that formed the basis of his understanding of the meaning and scope of the paragraph. which did not accord with their own understandings of the provision.1489 Metcalfe {CWCT0000115/10-12} pages 10-12, paragraphs 36, 40 and 41; Metcalfe {Day228/90:1-5}; {Day228/91:3-12}; Hepworth {LMD00000001/1} page 1, paragraph 2(b); Rowan {AFP00000002/4-16} pages 4-16 and page 16, paragraphs 2(b)-(d) and paragraph 7(d). David Metcalfe could not recall anyone else at the meeting agreeing1490 Metcalfe {Day228/91:13-15}. with what Mr Martin considered to be the correct interpretation of paragraph 12.7,1491 Metcalfe {CWCT0000115/11} page 11, paragraph 40. which he and others said had been put forward by Dr Colwell.1492 Metcalfe {CWCT0000115/10} page 10, paragraph 36; Hepworth {LMD00000001/5} page 5, paragraph 7(a); Taylor {WIN00000002/73} page 73, paragraph 175. See also Colwell {Day233/199:16}-{Day233/200:5}; Martin {Day253/101:21}-{Day253/102:7}. Mr Metcalfe also said that he could not recall having spoken to any construction professional who thought that paragraph 12.7 applied to anything other than insulation.1493 Metcalfe {CWCT0000115/11} page 11, paragraph 40. Mr Martin made no attempt following the meeting to find out whether aluminium composite panels with combustible cores had been or were currently being installed on high-rise buildings in this country.1494 Martin {Day253/54:23}-{Day253/55:2}; {Day253/67:19-24}. It seems that he did not pay a great deal of attention to the minutes at the time.1495 Martin {Day253/59:19-20}.
180¶11.25 During the discussion someone suggested that the meaning and scope of paragraph 12.7 of Approved Document B could be clarified by the publication of an FAQ on the department's website and Dr Colwell agreed to raise the matter with Mr Martin.1496 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/4} third paragraph. In the event, she failed to do so in circumstances we describe below. Nonetheless, when no draft arrived, Mr Martin did not take the matter up with her.1497 Martin {Day253/121:21}-{Day253/122:3}. In effect, he forgot about it1498 Martin {Day253/121:24}-{Day253/122:3}; {Day253/126:7-16}. and as a result the department did not consider publishing any clarification of paragraph 12.7 before the fire at Grenfell Tower.1499 Martin {Day253/120:22}-{Day253/121:2}.
Brian Martin's reaction
¶11.26 Brian Martin told us that he had not deliberately ignored the significance or seriousness of the possible use of ACM panels on the external walls of high-rise buildings or the uncertainty within some sections of the construction industry about the meaning of paragraph 12.7,1500 Martin {Day253/58:22-23}; {Day253/59:3-6}; {Day253/59:10-20}; {Day253/62:11-12}; {Day253/65:7-12}; {Day253/64:3-8}; {Day253/65:8-12}; {Day253/66:20-25}; {Day253/68:7-9}; {Day253/104:21}-{Day253/105:4}; {Day253/132:9-21}. but that he had underestimated their importance.1501 Martin {Day253/112:9-17}. He also failed to make a connection between the matters under discussion and the test that had been carried out some years earlier using aluminium composite panels under contract cc1924. He did not discuss what had been said at the CWCT meeting or the contents of the minutes with Mr Harral or Mr Ledsome1502 Martin {Day253/62:8-12}; {Day253/116:16-19}; Harral {Day244/77:8-13}; {Day244/84:21-23}; Ledsome {Day241/208:1-7}; {Day242/195:10-12}; {Day242/198:11-15}; {Day242/200:14}-{Day242/201:1}. because he saw no need to do so.1503 Martin {Day253/116:24}. Neither of them was made aware, therefore, that members of the CWCT's fire group were all of the view that the meaning of paragraph 12.7 of Approved Document B was unclear.1504 Ledsome {Day242/200:14-18}; Harral {Day244/81:23}-{Day244/82:13}; Martin {Day253/131:20}-{Day253/132:7}. In our view Mr Martin should have taken the matter more seriously and should at least have informed his immediate superiors that there was a problem that required attention.
¶11.27 We find it difficult to understand why Mr Martin did not appreciate the significance of the discussions or the potential consequences of the use of ACM panels for the safety of those living in high-rise buildings. If he saw the discussion as an opportunity to improve compliance,1505 Martin {Day253/68:7-9}. it is surprising that he took no steps to clarify the guidance. His failure to alert more senior officials in the department to the discussions fell short of the response that could be expected of the person with day-to-day responsibility for the Building Regulations and Approved Document B.
181Dr Colwell and the FAQ
¶11.28 Although at the CWCT meeting on 2 July 2014 Dr Colwell had said that she would speak to Brian Martin about the publication of an FAQ to clarify the meaning of paragraph 12.7, in the event she failed to do so.1506 Colwell {Day233/204:3-8}. After the meeting she tried to draft something suitable1507 Colwell {Day233/205:13-15}; {Day233/218:13-19}; {Day233/219:17}-{Day233/220:7}. but in discussions with her colleagues, including Dr Smith,1508 Colwell {Day233/205:21}-{Day233/206:4}. she formed the view that, if there was going to be a review of Approved Document B in the near future, it would be better to deal with the matter as part of that review.1509 Colwell {Day233/204:9-18}. By August or September 20141510 Colwell {Day233/206:23}-{Day233/207:7}. Dr Colwell and Dr Smith had reached a decision not to produce a draft FAQ for consideration by Mr Martin,1511 Colwell {Day234/27:21}-{Day234/28:5}. but Dr Colwell did not tell him of that. She and her colleagues knew that he had received the minutes of the meeting and knew that he was aware that the work needed to be done, so they decided not to pursue it.1512 Colwell {Day233/221:25}-{Day233/222:12}. None of the others who had attended the meeting on 2 July 2014 were told about the decision not to draft an FAQ .1513 Colwell {Day233/206:18-21}; {Day234/13:9-19}. The CWCT had thought that a draft would be produced quickly1514 Metcalfe {Day228/115:17-18}; {Day228/116:6-7}; {Day228/116:19-23}; {Day228/117:24}-{Day228/118:2}; {Day228/137:1-5}; {CWCT0000040/2}. and was waiting for Dr Colwell to provide it, while growing increasingly frustrated as the months passed.1515 Metcalfe {Day228/120:12}-{Day228/121:2}; {Day228/121:9-13}; {Day228/141:11-12}; {Day228/142:11}-{Day228/143:3}; {Day228/148:6-18}. It seems that she did not regard it as a matter of much importance, either.
¶11.29 That is perhaps surprising, because Dr Colwell had been well aware of the startling results of the test carried out on aluminium composite panels under contract cc1924.1516 Colwell {Day232/97:21-23}. The product had been offered to BRE for testing under that programme because the extent of its use made testing of interest to the construction industry.1517 Colwell {Day232/95:14}-{Day232/96:11}. In addition, she had been engaged in recent work on cladding fires with authorities in the United Arab Emirates following fires involving the same kind of material.1518 Colwell {Day233/208:18}-{Day233/210:10}. She could therefore not have been unaware of the risk to life its use on high-rise buildings presented in the event of fire. Having said that she would produce a draft FAQ, it is therefore hard to see why she did nothing at all, even if she and others at BRE had not realised at the time that aluminium composite panels were already being used on high-rise buildings in this country.1519 Colwell {Day233/213:5-10}. Dr Colwell had a longstanding professional relationship with Brian Martin and could have pursued the matter with him at any time. She could at least have told him that BRE would not be providing a draft.
¶11.30 In fact, Dr Colwell misled the CWCT about the preparation of a draft FAQ. She did not respond1520 Colwell {Day234/7:9-13}. to an email from Stuart Taylor of Wintech on 7 July 2014 which referred to "great confusion" about the meaning of paragraph 12.7 and to her agreement to draft an FAQ to clarify it.1521 {BRE00016101/2}. Dr Colwell, together with Stephen Howard and possibly Mr Baker,1522 Colwell {Day234/10:6-10}; Taylor {WIN00000002/84} page 84, paragraph 203; Colwell {Day234/10:24}-{Day234/11:1}. met Mr Taylor and Alan Keiller of the CWCT on 8 September 2014 to discuss the matter.1523 Keiller {CWCT0000119/7} page 7, paragraph 25; Colwell {Day234/10:3-5}; Taylor {WIN00000002/84} page 84, paragraph 203. Inexplicably, although by the date of that meeting BRE was having second thoughts about producing a draft,1524 Colwell {Day234/12:16}-{Day234/13:2}. she did not tell anyone else that. Mr Keiller's recollection was that it had been agreed that the matter would be dealt with by way of an FAQ.1525 Keiller {CWCT0000119/7} page 7, paragraph 26. Mr Taylor recalled the same outcome, specifically that BRE had confirmed that it would prepare some draft wording.1526 Taylor {WIN00000002/84} page 84, paragraph 204(10).
182¶11.31 However, after the meeting Dr Colwell simply did nothing. As late as 13 March 2015, five months after she and Dr Smith had decided that BRE would not produce a draft FAQ, she sent a brief response to an email from David Metcalfe asking about progress,1527 {CWCT0000040/2}. in which she referred to a note that she said would be finished soon and circulated so that others could comment on it.1528 {CWCT0000040/1}. Dr Colwell told us that that was a reference to some draft wording for a revised version of Approved Document B, not for an FAQ,1529 Colwell {Day234/18:16-20}; {Day234/19:8-10}. but we are not convinced that that was how it was intended to be understood. After that exchange, Dr Colwell failed to reply to five further emails from Mr Metcalfe.1530 {CWCT0000116}; Metcalfe {CWCT0000115/14} page 14, paragraph 48; Metcalfe {Day228/146:16-19}; Colwell {Day234/22:9}-{Day234/23:2}. She had no real explanation for that1531 Colwell {Day234/19:12-15}; {Day234/22:6-8}. and accepted that she should have responded to them.1532 Colwell {Day234/23:9-14}.
A missed opportunity to clarify Approved Document B
¶11.32 In our view, in the absence of any draft from Dr Colwell Mr Martin could and should have taken action himself. If, as he told us, the words "filler material" had been added to paragraph 12.7 to restrict the use of cladding panels with combustible cores on buildings over 18 metres in height,1533 See Chapter 7. that was a good reason for him to take careful note and at the very least to have reported to Mr Harral the fact that there was disagreement about its meaning. The CWCT meeting on 2 July 2014 should have prompted him to find out how paragraph 12.7 was understood. He told us that he wished he had done that but that he had not thought of it at the time.1534 Martin {Day253/84:13-21}.
¶11.33 The discussion at the CWCT meeting had produced some important information,1535 Harral {Day244/82:19-23}. both because it showed that the meaning of paragraph 12.7 was unclear to many and because the material being discussed had been linked to a series of major fires.1536 Harral {Day244/84:8-12}. Mr Martin should have reported the problem to Mr Harral,1537 Harral {Day244/82:14-18}; {Day244/84:18-20}. which would have prompted a serious discussion about whether to refer it to more senior officials or the minister.1538 Harral {Day244/84:24}-{Day244/85:6}. Mr Martin, Mr Harral and Mr Ledsome all thought that an FAQ could have been published without any particular difficulty,1539 Martin {Day253/125:9}-{Day253/126:6}; Harral {Day244/43:3-18}; {Day244/86:4}-{Day244/87:3}; Ledsome {Day242/204:14-25}. although it would have to be approved by the department's lawyers and political advisers. Mr Ledsome also said that in an appropriate case a definition could be added to the glossary attached to Approved Document B.1540 Ledsome {Day242/191:11-25}. It was the task of Mr Martin, as the official with primary responsibility for that area of policy, to assess the nature and urgency of the problem and decide whether an FAQ was justified.1541 Harral {Day244/42:19}-{Day244/43:7}; {Day244/45:2-8}; Ledsome {Day242/159:3-11}; {Day242/160:8-14}. If he thought it was, he should have raised it with Mr Harral or Mr Ledsome.1542 Ledsome {Day245/30:2-4}; Ledsome {Day242/196:3-5}; Harral {Day244/87:12-15}. There was no formal process for doing that, even if he considered the matter to be urgent.1543 Harral {Day244/44:25}-{Day244/45:8}; {Day244/54:11}-{Day244/55:14}; {Day244/111:7-23}; Ledsome {Day242/195:22}-{Day242/196:5}. In the event, however, the question of producing an FAQ did not arise because Dr Colwell failed to provide a draft for Mr Martin's consideration and Mr Martin did not act on his own initiative.
183¶11.34 Neither Mr Harral nor Mr Ledsome was aware of questions or concerns raised with Mr Martin unless he chose to tell them,1544 Martin {Day253/132:22}-{Day253/133:3}. which, since he was responsible for matters affecting the safety of life, was unsatisfactory and potentially dangerous. In our view a more senior official, probably Mr Ledsome, should have obtained regular reports from Mr Martin about current developments in the construction industry and the way in which the Building Regulations and guidance were operating. The absence of a reporting system created an obvious risk that a single busy official might either overlook the importance of something or simply fail to act on it. Although we think that in July 2014 Mr Martin should have drawn the minutes of the meeting on 2 July 2014 to the attention of Mr Harral and Mr Ledsome, the department's awareness or otherwise of a serious risk to public safety should not have depended on whether one official recognised it and acted appropriately upon it.
The confusion between Class 0 and limited combustibility
¶11.35 The second important subject of discussion at the CWCT meeting on 2 July 2014 was the relationship between limited combustibility and Class 0. Paragraph 12.7 of Approved Document B said that only insulation materials of limited combustibility should be used in the external walls of buildings over 18 metres in height, but some of those present said that other materials, principally foil-faced phenolic foam, were often used in rainscreen constructions. It seems to have been accepted that in some cases, probably through ignorance, some people were confusing Class 0 with limited combustibility. In other cases, building control officers were permitting the use of Class 0 materials, making it difficult for cladding consultants to insist on the use of insulation of limited combustibility.1545 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/3} under the heading "Combustibility of insulation". Mr Martin was present during that discussion1546 Martin {Day253/134:4-6}; Martin {CLG00019469/42} page 42, paragraph 120. and had sent an email to NHBC on that very subject earlier that day.1547 {NHB00000712/3}.
184¶11.36 That appears to have been the first time that Mr Martin had become aware of any confusion between limited combustibility and national Class 01548 Martin {Day253/135:15}-{Day253/136:1}. or that anyone could consider that polymer foam was a material of limited combustibility,1549 Martin {Day253/136:25}-{Day253/137:9}. which he regarded as implausible.1550 Martin {Day253/136:22-24}. He was surprised1551 Martin {Day253/136:2-3}. and concerned1552 Martin {Day253/136:22}. by both, but he did not ask any of those who attended the meeting for further information.1553 Martin {Day253/138:16-22}. Mr Martin had recently attended a meeting at Arup Fire on 25 June 2014 to discuss fire and facades, including the use of combustible materials.1554 {CLG00031777}. The discussion had touched on the definitions of non-combustibility and limited combustibility1555 Smith {Day237/74:7-10}. and there may also have been some discussion about the use of combustible insulation in the external walls of buildings over 18 metres in height.1556 Smith {Day237/76:21-25}.
2 July 2014: Brian Martin's friendly warning
¶11.37 The matters discussed at that meeting may have been the catalyst for the email Brian Martin sent to Neil Smith of NHBC on 2 July 2014.1557 Martin {Day253/147:2-10}; {Day253/147:24}-{Day253/148:4}. He described the purpose of the email as a "friendly warning" and told Mr Smith that he had heard from relatively reliable sources that buildings over 18 metres in height, including blocks of flats, had been clad in PIR (polyisocyanurate) insulation on the basis of an erroneous view that such insulation was a material of limited combustibility. He asked Mr Smith to check the matter with his inspectors.1558 {NHB00000712/3}. Mr Martin told us that in sending that message he had been fishing for information;1559 Martin {Day253/150:16-19}. he had not known at the time whether combustible insulation was being widely used in a way that did not comply with Approved Document B.1560 Martin {Day253/156:20}-{Day253/157:1}. NHBC's carefully considered response, which was sent by Steve Evans on 11 July 2014,1561 As to which, see Chapter 26. confirmed that that was the case and that NHBC had been in discussion with industry, in particular Kingspan, about the use of Kooltherm K15 on high-rise buildings for some time.1562 {CLG00000686}. That came as a surprise to Mr Martin.1563 Martin {Day253/157:7-8}.
NHBC's response
¶11.38 When he responded, Mr Evans informed Brian Martin of a number of important matters. First, he told him that Kingspan was asserting that K15, a combustible phenolic foam insulation material,1564 See Chapter 26. was suitable for use on buildings over 18 metres in height. Secondly, he said that since 27 October 2008, K15 had held a BBA certificate stating that it was acceptable for use in accordance with paragraph 12.7 of Approved Document B, subject only to advice being sought from Kingspan for use on buildings over 18 metres in height.1565 That was not correct. The original BBA certificate, issued on 27 October 2008 {BBA00000038}, contained no reference to the use of K15 in accordance with paragraph 12.7 of Approved Document B. That wording was first introduced in Amended Issue 1, dated 6 April 2010 {BBA00000037}. It was on the basis of that BBA certificate, he said, that NHBC inspectors had been accepting K15 for use on high-rise buildings, including blocks of flats. Mr Evans also mentioned in his email that there existed an LABC Registered Details Certificate for K15 approving the material for use in the external walls of buildings over 18 metres in height.1566 {CLG00000686/1}.
185¶11.39 Mr Evans also said that a revised BBA certificate for K15 dated 17 December 2013 did not refer to paragraph 12.7 of Approved Document B. Instead, it stated that K15 had been tested for use in the external walls of buildings over 18 metres in height only in one particular construction on masonry walls.1567 {CLG00000686/1}. Mr Evans attached both the previous1568 {CLG00000688}. and the (then) current BBA certificates to his email.1569 {CLG00000687}. He said that NHBC had approached Kingspan which was in the process of carrying out further tests, the results of which were expected at the beginning of August 2014.1570 {CLG00000686/1}. Mr Evans also said that if those tests did not prove that K15 was suitable for use on buildings over 18 metres in height on anything other than the one masonry system tested to BS 8414, NHBC planned to tell the industry and others who were interested that it was no longer suitable for use on high-rise buildings.
¶11.40 Thirdly, Mr Evans assured Mr Martin that there was no reason to suspect that buildings that had been built with Kingspan K15 were at risk at that time.1571 {CLG00000686/2}. That statement was clearly wrong, as Mr Martin, Mr Harral and Mr Ledsome should have realised immediately. It betrayed a fundamental misunderstanding of the purpose and nature of the regulations and guidance. It was quite wrong to suggest that a widespread failure to comply with the guidance on fire safety created no risk simply because future tests might show that none existed. On the contrary, without test evidence to show that K15 could be used safely in the external walls of high-rise buildings, there was every reason to suspect the existence of a real and immediate risk and every reason to take action.
The department's reaction
¶11.41 Concerned that there might be a significant problem,1572 Martin {Day253/167:24}-{Day253/168:1}; Martin {CLG00019469/43} page 43, paragraph 124. Mr Martin sent the email from Mr Evans on to Richard Harral and Bob Ledsome on the same day with the comment that "If it is a problem, some blocks may need to have their cladding replaced. (possibly a lot of them)".1573 {CLG00000686/1}. Having discussed the matter, they decided that the best course was to wait and see what NHBC found out.1574 Martin {Day253/187:12-15}; {Day253/188:10-12}; {Day253/190:22}-{Day253/191:6}; {Day253/192:23}; {Day253/193:5-6}; {Day254/14:13-18}; {Day254/16:12-25}; {Day253/213:11-12}; Martin {CLG00019469/43} page 43, paragraph 124; Ledsome {CLG00019465/57} page 57, paragraph 220; Ledsome {Day242/211:22}-{Day242/212:7}; Harral {Day244/93:4-11}. They did not decide how long they should wait;1575 Martin {Day253/191:7-10}; {Day253/193:7-11}. it seems that all three of them took some comfort from the assertion by NHBC that there was probably no real risk1576 Martin {Day253/179:11-17}; {Day253/189:20-21}. and that Kingspan's testing would resolve the problem.1577 Martin {Day253/173:19-21}; {Day253/180:1-3}. Mr Martin thought it possible that the question might be academic rather than represent a genuine safety problem.1578 Martin {Day253/190:4-10}.
186Contact with the BBA
¶11.42 The only action the department itself took in relation to the matter was to contact John Albon at the BBA. In an email to Mr Albon, sent on the day he received the message from Mr Evans, Mr Martin asked him to find out how the previous BBA certificate had stated that K15 satisfied paragraph 12.7 of Approved Document B, which he described as a "serious safety matter".1579 {BBA00000178/3}. When Mr Albon responded on 16 July 2014, he told Mr Martin that the reference to paragraph 12.7 had been an unfortunate and rare oversight that had not been repeated in any other certificates.1580 {BBA00000178/2}. In response Mr Martin asked Mr Albon to summarise the systems the BBA had put in place to ensure that the error would not be repeated and to confirm whether or not the BBA had notified Kingspan of it.1581 {BBA00000178/2}.
¶11.43 Mr Albon's response on 23 July 2014 evaded the latter question, saying only that he expected that Kingspan would have been made aware of the matter. Mr Martin did not press for an answer, as he should have.1582 Martin {Day253/208:18}-{Day253/209:3}. Mr Albon went on to say that it was extremely unlikely that anyone had inferred from the wording of the 2010 revision of the certificate that K15 was a material of limited combustibility.1583 {BBA00000178/1}. As Mr Martin agreed, that was nonsense.1584 Martin {Day253/211:4-21}. It could not reasonably have meant anything else.1585 See Chapter 22. Nonetheless, the department did not pursue the matter with the BBA.1586 Martin {Day253/209:24}. Both Mr Martin and Mr Ledsome were satisfied with its assurances that the error had been an isolated occurrence.1587 Martin {CLG00019469/44} page 44, paragraph 126; Ledsome {CLG00019465/57-58} pages 57-58, paragraphs 221- 222; Ledsome {Day242/219:4-25}. It did not occur to Mr Martin to ask how such a fundamental error in a BBA certificate had come about.1588 Martin {Day253/206:22}-{Day253/207:20}. In our view he should have pursued the matter.
¶11.44 Mr Martin read the BBA certificates for K15 that Mr Evans had attached to his email on 11 July 2014,1589 Martin {Day253/166:2-8}. as did Mr Harral and Mr Ledsome.1590 Harral {Day244/89:10-15}; Ledsome {Day242/206:25}-{Day242/207:9}; Ledsome {Day245/3:21}-{Day245/4:6}. Mr Martin was concerned by the reference to paragraph 12.7 in the earlier certificate dated 6 April 2010.1591 Martin {Day253/167:22-24}. He accepted that he had realised immediately that the assertion that a combustible foam could be used in accordance with paragraph 12.7 was a fundamental error.1592 Martin {Day253/167:9-21}; {Day253/168:11-21}. However, he did not appear to be particularly alarmed, as we think he plainly should have been, by the fact that NHBC had not spotted that error and had considered itself to be bound by the contents of the certificate1593 Marshall {Day225/101:25}-{Day225/102:14}; Evans {NHB00003020/17} page 17, paragraph 52; Martin {Day253/196:13-20}. over the course of several years.
The department's omissions: K15
¶11.45 However many BS 8414 tests Kingspan planned to carry out in the future, they could never have established that K15 was generally suitable for use in the external walls of buildings over 18 metres in height, as Mr Martin accepted.1594 Martin {Day253/177:11-15}. Moreover, they could not establish that it was suitable for use on buildings already completed unless a replica of each system were subjected to large-scale testing. The department did not know how many of those buildings there were, because it did not ask and it did not occur to it to do so.1595 Martin {Day253/184:16-21}; {Day253/187:25}-{Day253/188:6}; Ledsome {Day245/10:24}-{Day245/11:4}; Martin {Day254/16:5-14}. Mr Martin presumed that there were a significant number of buildings affected, possibly about one hundred.1596 Martin {Day253/187:16-24}; {Day253/189:7-13}.
187¶11.46 Mr Ledsome's confidence that the NHBC had got a grip on the issue1597 Ledsome {Day245/7:20-25}. was wholly unjustified and we cannot accept that Mr Harral was right in thinking that the department had done all it could.1598 Harral {Day244/100:5-9}. Despite the fact that all three of them appeared to acknowledge that the matter was, at least potentially, a serious safety issue,1599 Harral {Day244/92:14-16}; {Day244/137:13-16}; Ledsome {Day242/211:4-6}; {BBA00000178/3}; Martin {Day253/167:24}-{Day253/168:1}; {Day253/198:24}-{Day253/199:11}. none of them referred it to anyone more senior.1600 Harral {Day244/92:17-19}; Ledsome {Day242/211:7-8}. They did not ask for advice or speak to anyone else about it.1601 Harral {Day244/100:14-22}; {Day244/138:22}-{Day244/139:2}. They took no steps to alert the industry to what they had learnt.1602 Ledsome {Day242/216:23}; Martin {Day253/153:1-18}. Mr Ledsome, who also managed a separate policy team that had oversight of the building control system,1603 Ledsome {Day245/20:19}-{Day245/21:3}. did not notify it that building control officers had been accepting a combustible insulation material as generally suitable for use on buildings over 18 metres in height for some considerable time.1604 Ledsome {Day245/21:25}-{Day245/22:5}.
¶11.47 Their omissions did not end there. They neither sought to obtain a copy of the LABC certificate to which Mr Evans had referred in his email nor contacted the LABC to find out how it had been possible to issue a certificate approving the use of a combustible insulation material in the external walls of buildings over 18 metres in height.1605 Martin {Day253/191:11}-{Day253/192:15}; {Day253/160:23}-{Day253/161:9}; Ledsome {Day245/14:6-14}; Harral {Day244/105:17-22}. That was despite the fact that in late 2009 Mr Martin had received two letters from Larry Cody of Rockwool alerting the department to that claim and to the fact that the certificate stated that K15 could be considered a material of limited combustibility.1606 {LABC0000924}; {LABC0000853}. Mr Martin could not recall having received those letters1607 Martin {Day253/159:5-8}; {Day253/160:6}; {Day253/163:3}. but said that, if he had read them, he would have considered the matter to be one for the LABC, Rockwool and Kingspan to deal with. In his view it was not the function of the department to police the system.1608 Martin {Day253/160:6}-{Day253/161:7}.
¶11.48 None of the officials warned any building control organisation, other than NHBC, against approving the use of K15 on high-rise buildings, even when it became clear from Mr Evans' response that other bodies had also been accepting it.1609 Harral {Day244/104:16-22}; Ledsome {Day242/209:24}-{Day242/211:3}; Martin {Day253/151:22}-{Day253/152:25}; {Day253/170:15-25}. Mr Martin thought that, as the largest building control organisation, NHBC was well-resourced1610 Martin {Day253/152:8-13}. and had taken the lead by talking to others, including the Building Control Alliance (BCA)1611 The BCA is a voluntary membership organisation, later incorporated as a limited company, established in 2008 to promote the role of building control organisations and to publish guidance: Evans {NHB00003020/59-60} pages 59‑60, paragraph 164. about it.1612 Martin {Day253/170:21}-{Day253/171:14}. However, he accepted that he should have contacted the LABC himself.1613 Martin {Day253/152:14-19}. Mr Harral had been under the impression that the problem was limited to NHBC,1614 Harral {Day244/91:23}-{Day244/92:8}. but that was plainly not the case. None of the three officials did anything to establish the location of the buildings affected or how many there were.1615 Ledsome {Day245/15:21}-{Day245/16:16}; {Day245/19:3-7}; Harral {Day244/105:23}-{Day244/106:1}; Martin {Day253/184:16}-{Day253/185:10}; {Day253/188:1-6}; {Day253/188:16-21}. They did not alert the Advertising Standards Agency or Trading Standards.1616 Harral {Day244/97:17-23}; Ledsome {Day245/9:9}-{Day245/10:3}. They did not contact Kingspan1617 Harral {Day244/97:9-11}; Ledsome {Day245/7:17-18}; Martin {Day253/192:16-21}. or examine its marketing literature.1618 Martin {Day253/210:24}-{Day253/211:3}; Harral {Day244/97:12-16}; Ledsome {Day245/8:3-6}. The department had assumed that Kingspan would act responsibly, but, as Mr Ledsome accepted, that had been rather naïve. Faced with evidence that a commercial organisation was relying on false statements to market its products, we think that the department should have taken steps to draw its activities to the appropriate authorities.
188¶11.49 None of the officials involved thought it necessary to alert the United Kingdom Accreditation Service (UKAS)1619 UKAS was established in 1995 to accredit conformity assessment bodies against national and international standards of technical competence to undertake certain activities, including certification: Turner {UKAS0011242/4‑5} pages 4-5, paragraph 7 (a)-(b). to the errors in the certificates issued by the BBA or to remind Mr Albon that the BBA ought to report the matter to UKAS itself. Mr Martin accepted that he should have reported the matter to UKAS,1620 Martin {Day253/202:5-20}; {Day253/207:17-23}. but he did not think at the time that it might uncover wider problems in the BBA's processes1621 Martin {Day253/202:16-20}. or that the failure by UKAS to identify the error was itself a matter of concern.1622 Martin {Day253/203:3-6}. It did not occur to him that there might be a similar problem in relation to insulation products other than K15.1623 Martin {Day254/14:10-25}.
¶11.50 Mr Martin did not take any steps to pursue the matter following his email exchange with Mr Evans. On 15 August 20141624 {CLG00019253}. Mr Evans reported that Kingspan had been encouraged by the preliminary results of two large-scale tests involving K15 but gave no results. He said that Kingspan had asked Arup to prepare a desktop report using the results from the three tests it had by then carried out under BS 8414 to describe the conditions that any cladding system should meet to allow K15 to be used in the construction of external walls of buildings over 18 metres in height.1625 {CLG00019253/1}. In the event, however, no such report was forthcoming1626 Martin {Day254/11:25}-{Day254/12:2}. and it is difficult to see on what basis Mr Martin could have thought that that might be a satisfactory method of assessing the suitability of K15 for use on high-rise buildings.1627 Martin {CLG00019469/45} page 45, paragraph 128; Martin {Day254/7:15}-{Day254/8:7}; {Day254/10:4}-{Day254/11:9}. As far as he was aware, in August 2014 there was no satisfactory test data to support the use of K15 on high-rise buildings.1628 Martin {Day254/13:25}-{Day254/14:25}. Nonetheless, he said that, having discussed the matter further with Mr Ledsome,1629 Martin {Day254/17:1-18}. they had concluded that the best course was simply to wait and see how the matter developed.1630 Martin {Day254/17:24}-{Day254/18:1}.
189¶11.51 In the event, Brian Martin did nothing further until 4 December 2014, when he sent an email to Mr Evans asking whether NHBC had any further information.1631 {CLG00019264/1-2}. On 5 December 2014, Mr Evans said that he should be able to respond after a BCA meeting the following Monday,1632 {CLG00019264/1}. but in the event he failed to do so1633 Martin {Day254/26:23}-{Day254/27:1}. and Mr Martin let the matter lie. There was no further contact between NHBC and the department until 2 April 2015,1634 Martin {Day254/28:3-17}. when Mr Evans sent an email to Mr Martin simply telling him that Kingspan was committed to further testing. It does not appear to have occurred to Mr Martin to ask for existing test results or the desktop report that was to be produced by Arup.1635 Martin {Day254/70:7-12}. It was clear to Mr Martin at that stage that the problem relating to the use of combustible insulation on high-rise buildings had not been resolved.1636 {NHB00001057}.
¶11.52 No reasonable excuse was offered for that remarkable list of omissions. Mr Martin appears simply to have allowed himself to be guided by NHBC, which had in turn been taken in by Kingspan's repeated assurances that further testing would demonstrate that all was well.1637 Martin {Day253/179:10-23}; {Day253/180:1-3}; {Day253/182:20}-{Day253/183:5}. Although he had been told by Mr Evans that NHBC's inspectors had been accepting K15 for use on buildings over 18 metres in height for many years, it did not occur to Mr Martin that NHBC might have its own reasons for seeking to demonstrate that K15 was suitable for use on high-rise buildings.1638 Martin {Day254/25:22}-{Day254/26:17}. Although they had been sent to Mr Harral,1639 {CLG10006884}; Harral {Day244/113:24}-{Day244/114:23}. neither he nor Mr Martin had had time to read the notes1640 Martin {Day254/21:21-23}; {Day254/23:4-5}; {Day254/24:7-8}. of a BCA meeting on 8 December 2014 which appeared to suggest that both NHBC and the LABC in the persons of Steve Evans and Barry Turner were doing exactly that.1641 {CLG10006889/4} section 12.0. Mr Martin regarded the people he knew at NHBC as responsible professionals; he trusted them and did not question their motives.1642 Martin {Day254/26:12-22}.
¶11.53 We accept that the department was ill-equipped to investigate the use of combustible insulation on high-rise buildings1643 Harral {Day244/98:1-2}; Martin {Day253/42:12-15}. and was busy with other work.1644 Harral {Day244/76:23}-{Day244/77:4}; {Day244/98:1-6}; {Day244/103:3-7}; Martin {Day253/171:15-21}; Martin {Day254/12:10-13}; {Day254/28:16-22}; {Day254/29:8-10}. It was not responsible for enforcing the Building Regulations, had limited power to intervene in operations and had a negligible role1645 Harral {Day244/36:2-6}. in the direct regulation of the industry. That was the responsibility of the building control bodies and the department left it to industry bodies to resolve any problems that might arise.1646 Ledsome {CLG00019465/57} page 57, paragraph 221; Ledsome {Day245/22:10}-{Day245/23:20}; {Day245/24:25}-{Day245/26:5}; Harral {CLG00019487/17} page 17, paragraph 56; Harral {Day244/35:22}-{Day244/36:21}; {Day244/93:4-11}; {Day244/98:6}-{Day244/99:13}; {Day244/99:24}-{Day244/100:13}; {Day244/101:3-19}; {Day244/103:7-14}; {Day244/109:2-8}; Martin {CLG00019469/38} page 38, paragraph 113; Martin {Day253/151:14‑19}; {Day253/161:22}-{Day245:162:14}; {Day253/171:9-14}; {Day254/15:12}-{Day254/16:4}. However, that does not justify its failure to act on what it knew and indeed, as all three officials accepted during their evidence, more could and should have been done.1647 Harral {Day244/107:2-11}; {Day244/99:14}-{Day244/100:13}; {Day244/103:22}-{Day244/104:8}; Ledsome {Day245/9:22}-{Day245/10:3}; {Day245/10:24}-{Day245/11:5}; {Day245/13:10-16}; {Day245/14:15-24}; {Day245/17:8}-{Day245/18:22}; {Day245/23:21}-{Day245/24:19}; {Day245/25:20-25}; Martin {Day254/29:8-10}; {Day254/71:3-10}. The department's failure to act was a serious error.
190August 2014: BCA Technical Guidance Note 18
¶11.54 On 15 August 2014 Brian Martin received from Steve Evans1648 {CLG00019253}. a copy of Technical Guidance Note 18 (Issue 0),1649 {CEL00003725}. drafted principally1650 Lewis {NHB00003433/9} page 9, paragraph 29(d). by John Lewis of NHBC.1651 John Lewis joined NHBC as a building control surveyor in 1997 and from 2013 until he left in October 2021, he was NHBC's specialist fire engineer: Lewis {NHB00003433/3-4} pages 3-4, paragraphs 8-9. The guidance note, entitled Use of combustible cladding materials on residential buildings (which Mr Martin had not previously seen),1652 Martin {CLG00019469/44} page 44, paragraph 127. set out three recommended options for securing compliance with paragraph 12.7 of Approved Document B.1653 {CEL00003725/2}. Option 1, which has come to be known as the "linear route", referred directly to paragraph 12.7 of Approved Document B and required the use of materials of limited combustibility for all elements of the external wall, including the external facing material.1654 {CEL00003725/2}. Option 2 was the classification of a system in accordance with the criteria in BR 135 following a test in accordance with BS 8414. Option 3 was a desktop assessment.
Option 1 and the "linear route"
¶11.55 The interpretation of paragraph 12.7 in Option 1 of the note was not consistent with the meaning Mr Martin and Mr Burd had intended that paragraph to bear when they originally drafted it. They had intended it to cover the core of a composite panel but not the external surface of the cladding material.1655 Martin {Day254/37:23}-{Day254/38:6}. In that respect, therefore, the BCA guidance was more restrictive than they had intended.1656 Martin {Day254/32:4-8}; {Day254/33:19-25}; {Day254/35:22-24}; {Day254/36:7-11}. Paragraph 12.7 of Approved Document B did not recommend that all components of the external wall of a high-rise building should be materials of limited combustibility.
¶11.56 Mr Martin thought that the BCA guidance note was an effective way of resolving the uncertainty over the meaning of paragraph 12.7 to which he had been alerted by the discussions at the CWCT meeting in July 2014.1657 Martin {Day254/42:7}-{Day254/43:15}. He may even have relied on it for that purpose, at least until he could cover it in the next review of the statutory guidance.1658 Martin {Day254/43:9-15}; {Day254/44:4-13}; {Day254/55:8-14}. That was not an appropriate position to adopt, however, not least because the department had not publicly endorsed the BCA guidance.
¶11.57 Although the BCA guidance did not have the same status as statutory guidance,1659 Martin {Day254/48:9-11}. Mr Martin appears to have thought that it was the most effective way to get the message across.1660 Martin {Day254/45:3-5}. He did not think that information published on the department's website was widely read or easily accessible.1661 Martin {Day254/49:8-14}; {Day254/88:17}-{Day254/89:9}. There was some evidence that the BCA's guidance note might not have had as wide an audience as Mr Martin assumed,1662 Everett {CEV00000001/30} page 30, paragraph 128; Taylor {WIN00000002/61} page 61, paragraph 144. but in any event, he did not think about publishing an FAQ on the matter.1663 Martin {Day254/49:8}; {Day254/49:24}-{Day254/50:1}; {Day254/50:25}-{Day254/51:4}. It does not seem to have occurred to him that the BCA's Option 1 might have contributed to further uncertainty about the meaning of paragraph 12.7.
19121 February 2015: The fire at The Torch
¶11.58 On 21 February 2015, the department's Chief Fire and Rescue Adviser, Peter Holland, sent an email to Mr Martin and others in the department about a fire that had occurred in the early hours of that day at The Torch, a high-rise block of flats in Dubai. In it he asked Mr Martin to confirm that such fires should not occur in the UK. Mr Martin did so, commenting that there were provisions in the Building Regulations designed to prevent that kind of problem but noting that there were no guarantees,1664 {CLG00031073}. by which he meant that no regulatory system was perfect.1665 Martin {Day254/54:19}-{Day254/55:14}. In his response he did not mention the warnings he had received about the way in which the words "filler material" in paragraph 12.7 of Approved Document B was being understood by some in the industry;1666 Martin {Day254/60:2-17}; {Day254/60:21}-{Day254/61:5}; {Day254/62:6-15}; Ledsome {Day245/52:7-10}; {Day245/52:19}-{Day245/53:14}. nor did he mention them to Richard Harral or Bob Ledsome, to whom he copied his response. He accepted that he should have done both.1667 Martin {Day254/65:13-15}. Mr Martin accepted that he had not been candid with the others to whom the email had been sent about the controversy over the meaning of paragraph 12.7 that he had been aware of since the summer of 2014,1668 Martin {Day254/66:4-12}. and agreed that he had known at that stage that there was a risk that the statutory guidance was not being understood correctly.1669 Martin {Day254/61:8}-{Day254/62:2}.
June 2015: NHBC's question
¶11.59 Notwithstanding NHBC's involvement in the drafting of BCA Technical Guidance Note 18, on 15 June 2015 Steve Evans wrote to Brian Martin in effect asking him the same questions that Tony Baker of BRE had asked him in November 2013,1670 Martin {Day254/132:10-14}. namely, what was meant by the word "filler" in paragraph 12.7 of Approved Document B and to what components of an external wall was it intended to apply.1671 {NHB00002792/3}. Like Mr Baker before him, Mr Evans received no proper answer to those questions.1672 {NHB00002792/2}. Mr Martin's response was vague; he said that he could not offer a formal view and instead offered an anecdote about the fire at The Edge in January 2005,1673 {NHB00002792/2-3}; Martin {Day254/141:1-4}. as he had done in response to Mr Baker. Given that he thought the BCA guidance note covered the very point that NHBC was now raising again, Mr Martin ought to have been seriously concerned. He told us that he had been under the impression that NHBC was involved in a disagreement with a developer1674 Martin {Day254/113:13-25}; {Day254/115:16-20}; {Day254/117:15-21}. and that he had therefore told Mr Evans that specific projects were a matter for the relevant building control authority.1675 Martin {Day254/130:19-25}; Ledsome {Day245/42:10-15}. That is not apparent from the face of the document, however, in which Mr Evans specifically asked for the department's view on the meaning and scope of the word "filler".1676 {NHB00002792/3}.
¶11.60 Mr Martin said that he had to be careful about providing a formal interpretation of the statutory guidance or telling building control what would or would not comply with the Building Regulations. We were not persuaded, however, that he was as constrained as he suggested. Although Mr Ledsome agreed that there was a limit to what officials could say about specific situations,1677 Ledsome {Day245/41:22}-{Day245/42:2}; {Day245/42:23}-{Day245/43:2}. he said that there was nothing to stop Mr Martin providing proper answers to questions of a general nature, including the questions that Mr Evans had asked in his email.1678 Ledsome {Day245/46:5-18}. Asked why he had not done that, Mr Martin said that at the time he had not thought to do so1679 Martin {Day254/133:23}-{Day254/134:8}. and that his response was probably more unhelpful than he had intended.1680 Martin {Day254/143:23}-{Day254/144:7}; {Day254/185:2-11}.
192¶11.61 The fact is that, as Mr Martin well knew, he was being asked to respond to a longstanding problem that had created confusion across the industry and needed to be resolved in the next review of Approved Document B.1681 Martin {Day254/119:20}-{Day254/120:6}; Martin {Day253/25:17-23}; Martin {Day254/135:16-25}; {Day254/44:4-13}; {Day254/55:19}-{Day254/56:15}; Martin {Day255/84:19-{Day255/85:2}. His failure to tell more senior officials about it at any stage is extremely difficult to understand, particularly since the opportunity to do so arose again and again.
¶11.62 Neither Richard Harral nor Bob Ledsome was aware of Mr Martin's correspondence with NHBC in July 2015 and did not learn of it until much later.1682 Ledsome {Day245/40:4-7}; Harral {Day244/118:25}-{Day244/119:2}. Once again, he failed to tell them that there was a difference of view within the industry about the interpretation of paragraph 12.7.1683 Ledsome {Day245/53:14}; Harral {Day244/119:3-7}. Moreover, despite the fact that paragraph 12.7 was the only provision in Approved Document B that might have prevented the widespread use in England of aluminium composite panels with unmodified polyethylene cores, Mr Martin did not see a connection between the debate about the meaning of paragraph 12.7 and the assurance he had given Peter Holland in February 2015 following the fire at The Torch.1684 Martin {Day254/118:14}-{Day254/119:19}. He should have done so. One obvious reason why there could be no guarantee that a similar fire could not occur in the UK was because the specific provision in the guidance designed to prevent it was being widely misinterpreted, as Mr Martin had known since November 2013.
January 2016: the fire at the Address Downtown
¶11.63 On 31 December 2015 there was another serious fire in Dubai at a 63-storey building called the Address Downtown. On 4 January 2016, Mr Ledsome asked Mr Martin whether as a result there was anything the department needed to worry about in the Building Regulations or Approved Document B. In his response Mr Martin referred to paragraph 12.7 and said that the polyethylene core of an aluminium composite panel would be considered a filler material and so should not be used in the external walls of buildings over 18 metres in height.1685 {HOM00043106}.
¶11.64 Mr Martin told us that, as far as he was aware at the time, everyone understood that the core of an aluminium composite panel was a filler material,1686 Martin {Day254/167:2-11}; {Day254/170:13-18}. but it is impossible to see how he can have thought that in January 2016, given the debate that had been taking place over the previous eighteen months. It was demonstrably untrue, even on his own evidence. Given his exchange with BRE in November 2013,1687 {CLG10005895}. the debate at the CWCT meeting in July 20141688 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/4} second paragraph. and Mr Evans' clear statement six months earlier that the meaning of "filler" was unclear,1689 {NHB00002792/3} final paragraph. Mr Martin must have known that the words "filler material" had not been understood by everyone in the same way. Although he refused to accept the fact, Mr Martin ought to have realised that there was a serious risk that material of that kind was being used on high-rise buildings in this country.1690 Martin {Day254/165:8-19}.
193¶11.65 At about the time of the fire at the Address Downtown Dr Crowder had discussed the fires in the UAE with Brian Martin who had expressed the view that, in contrast to this country, there were no regulations in Dubai that would prevent the use of aluminium composite cladding panels with polyethylene cores.1691 Crowder {Day229/139:1-16}. That may have been his understanding, but despite knowing that there was confusion over the meaning of paragraph 12.7 of Approved Document B, he had taken no steps in the period between the CWCT meeting in July 2014 and the fire at the Address Downtown in December 2015 to find out whether aluminium composite panels with polyethylene cores were in fact being used in this country.1692 Martin {Day254/165:20-24}; Harral {Day244/150:2-5}.
¶11.66 In January 2016 Mr Harral and Mr Ledsome were both unaware that a difference of view existed about the meaning of paragraph 12.7 and again, Mr Martin did not tell them.1693 Martin {Day254/173:17}-{Day254/174:10}; Harral {Day244/148:19-24}; Ledsome {Day245/53:5-14}; {Day245/57:8-14}. He could not explain why he had not told them and accepted that he should have done so.1694 Martin {Day254/171:6-10}; {Day254/174:4-13}. Mr Ledsome did not think there was a risk that aluminium composite panels with polyethylene cores might be in use on high-rise buildings in the UK.1695 Ledsome {Day245/58:6}-{Day245/59:2}. He took what Mr Martin told him on trust1696 Ledsome {Day245/56:25}-{Day245/57:7}; {Day245/58:3-5}; {Day245/59:14-17}; {Day245/74:13-20}. accepted that paragraph 12.7 of Approved Document B applied to the cores of such panels.1697 Ledsome {Day245/59:18-23}. If there had been any doubt about that, he would have expected Mr Martin to say so.1698 Ledsome {Day245/60:5-22}. Mr Ledsome did not check the text of the Approved Document for himself.1699 Ledsome {Day245/56:15-24}; {Day245/74:13-20}.
¶11.67 Neither Mr Ledsome nor Mr Harral was told at any time before the Grenfell Tower fire about the results of the test carried out in 2001 on a system incorporating aluminium composite panels under contract cc1924.1700 Harral {Day244/67:4-17}; Ledsome {Day242/185:8-20}. Mr Harral knew little about the product1701 Harral {Day244/66:19-23}; {Day244/69:4-10}. and thought that the guidance in Approved Document B would preclude its use on high-rise buildings.1702 Harral {Day244/68:4-23}; {Day244/125:12-17}; {Day244/139:13-21}. Despite that, he accepted that checks should have been made and that more should have been done, telling us that he wished the division had had the confidence, remit or resources to do that.1703 Harral {Day244/144:4}-{Day244/145:21}.
16 February 2016: correspondence with Booth Muirie Ltd
¶11.68 On 16 February 2016, Brian Martin received an email1704 {CLG00031093/5}. from Nick Jenkins, then an Executive Director1705 Jenkins {BLM00000884/3} page 3, paragraph 1.7. of Booth Muirie Ltd, a company providing architectural cladding services, including the design, fabrication and supply of aluminium composite panels.1706 Murden {BLM00000004/1-2} pages 1-2, paragraph 7. In his email Mr Jenkins asked Mr Martin whether he could answer some questions about the meaning of paragraph 12.7 of Approved Document B that he had initially directed to Dr Sarah Colwell at BRE. The key point that Mr Jenkins had made in his email to Dr Colwell was that it was unclear whether paragraph 12.7 was directed to both insulation and the core of an aluminium composite panel and whether the latter should be a material of limited combustibility. He had expressed the view that if it was, only aluminium composite panels classified Euroclass A2 or better could be used on buildings over 18 metres in height in compliance with the guidance.
194¶11.69 In his original email Mr Jenkins went on to say that in his experience Euroclass A2 panels were rarely specified. The vast majority of panels requested were classified Euroclass B or, in many cases, contained an unmodified polyethylene core and were often installed in combination with combustible insulation materials. In a later message pressing Dr Colwell for a response he said that he had discussed the matter with Steve Evans of NHBC and David Metcalfe of the CWCT and referred to the recent fires in the Middle East where fire had been seen to spread over the facades of buildings clad in aluminium composite material.1707 {CLG00031093/8-11}. In his email to Mr Martin he said that there was much confusion and misunderstanding in the industry and that the topic was being widely discussed.1708 {CLG00031093/5}.
¶11.70 Mr Martin read the emails, including the original message that Mr Jenkins had sent to Dr Colwell.1709 Martin {Day254/194:18-21}. Although he told us that it had been clear to him that Mr Jenkins was correct in his interpretation of paragraph 12.7, he accepted both that that was not clear from the wording and that there was a debate about the matter.1710 Martin {Day254/192:19}-{Day254/193:6}; {Day254/194:13-17}. When he responded on 16 February 2016, he told Mr Jenkins that the word "filler" had been added to the text deliberately to cover things that formed part of a cladding system and were not insulation but could provide a means for the spread of fire. He said that it was for the designer and building control body to decide whether the requirements of the Building Regulations had been met and added that his view that the core of an aluminium composite panel could reasonably be considered to be a "filler".1711 {CLG00031093/4}. In our view that was an inadequate response to a question that deserved careful attention.
¶11.71 Mr Jenkins tried again later the same day to get a clear response from Mr Martin, telling him that the aluminium composite panels commonly used in the UK would not comply with Approved Document B for use on high-rise buildings and that none of the existing buildings in the UK over 18 metres in height that were clad in aluminium composite panels currently met functional requirement B4. He said that there were many such buildings and that their number was growing. He described the situation as one of grave concern and asked for a meeting to review the guidance.1712 {CLG00031093/4}. Mr Martin responded the following day, expressing the view that the text of paragraph 12.7 was "not really all that ambiguous". He invited Mr Jenkins to attend a second meeting of the CWCT's Fire Group in March 2016 and suggested that he contribute his views to the Part B user survey then being conducted by the department.1713 {CLG00031093/2-3}. His superficial, hurried and unhelpful response to a serious question that required careful thought was clearly inadequate. A response by Mr Jenkins to the Part B user survey would have achieved nothing since, as Mr Martin accepted, it was not intended to deal with technical aspects of Approved Document B.1714 Martin {Day255/25:9-12}.
195¶11.72 Mr Martin did not tell Mr Harral, Mr Ledsome or anyone else in the department about his correspondence with Mr Jenkins or what he had said about the widespread use of combustible aluminium composite panels in the UK.1715 Martin {Day255/20:15-22}; Harral {Day244/154:9-21}; {Day244/157:10-15}; {Day244/160:10-19}; {Day244/160:24}-{Day244/161:2}; Ledsome {Day245/65:8-24}; {Day245/67:5-11}; {Day245/72:24}-{Day245/73:9}. They both said that he should have referred the matter to them1716 Harral {Day244/160:20-23}; Ledsome {Day245/69:6-16}. and regarded it as a matter of the utmost seriousness that warranted being raised at ministerial level.1717 Harral {Day244/158:11-20}. However, their failure to take any action in response to the email sent by Steve Evans on 11 July 20141718 {CLG00000686}. leads us to doubt whether decisive action would have been taken.
¶11.73 Mr Martin told us that in February 2016 he had not previously come across Nick Jenkins or Booth Muirie. He had not known whether what Mr Jenkins was telling him was true and had not recognised the significance of what Mr Jenkins was telling him, given that it was one of many conversations he had about matters of non-compliance.1719 Martin {Day255/5:12-23}; {Day255/22:18-21}; {Day255/10:17-25}. However, those were not good reasons for taking no action, since he could easily have contacted Mr Jenkins and asked for more information.
¶11.74 Mr Martin agreed that his reluctance to say what paragraph 12.7 meant made it all the more important to publicise the department's position formally, but said that it had been almost impossible to get anything done in government at the time1720 Martin {Day254/199:8-10}. because of the deregulatory policies of the day.1721 Martin {Day255/19:17}-{Day255/20:6}; {Day255/20:22}-{Day255/21:2}. A culture of deregulation certainly pervaded the department between late 2013 and February 2016, but it provides no excuse for Mr Martin's failure to take appropriate action in response to the confusion over the meaning of paragraph 12.7.
¶11.75 Mr Martin told us several times that he had underestimated the scale and seriousness of the hazard to which Mr Jenkins had alerted him.1722 Martin {Day254/197:4-5}; {Day255/5:16-19}; {Day255/6:19}-{Day255/7:22}; {Day255/8:12-17}; {Day255/14:1-3}. He said that the division dealt with allegations of non-compliance every day1723 Martin {Day255/13:15-24}. and that he had not recognised that the danger identified by this particular warning was greater than the other dangers that had been drawn to its attention. However, the information Mr Jenkins had provided was obviously of great potential importance and should not have been ignored.1724 Martin {Day255/41:20-23}.
Evidence and statistics
¶11.76 The fact that few, if any, of the fires in Dubai had resulted in fatalities may have played a part in Mr Martin's failure to recognise the danger of the use of aluminium composite materials on high-rise buildings.1725 Martin {Day255/7:9-15}; {Day255/31:23}-{Day255/32:2}. He thought it would be difficult to justify changes of a kind that made the guidance more restrictive when the statistics showed a steady reduction in the number of deaths through fire.1726 Martin {Day255/38:1-6}. However, relying only on statistics of that kind took no account of the magnitude of the risk that had not yet resulted in fatalities and was fundamentally and dangerously flawed.
19624 February 2016: more industry concerns about ACM PE
¶11.77 On 24 February 2016, Mr Martin received an email1727 Soane {CUK00000002/2} page 2. from Alastair Soane, a structural engineer and director of the group of organisations known as Structural Safety,1728 Structural-Safety is an organisation that combines the work of SCOSS (UK Standing Committee on Structural Safety) and CROSS (Collaborative Reporting for Safer Structures UK) involving committees of expert volunteers: Soane {CUK00000002/1} page 1, paragraph 1; Soane {CUK00000002/4-5} pages 4-5, paragraphs 6-13. about the fire at the Address Downtown on 31 December 2015. He asked whether similar panels were used in the UK and whether there was a risk of a similar fire occurring in this country.1729 Soane {CUK00000002/2} page 2. The honest response would have been that the risk did exist,1730 Martin {Day255/44:23}-{Day255/45:3}. but Mr Martin gave the same response as he had given to Nick Jenkins a few weeks earlier, namely, that the core of an aluminium composite panel could reasonably be considered a "filler" within the meaning of paragraph 12.7 of Approved Document B.1731 Soane {CUK00000002/3} page 3. He ignored Mr Soane's offer to issue an alert.1732 Soane {CUK00000002/2} page 2; Martin {Day255/50:16}-{Day255/51:1}.
¶11.78 That answer plainly misled Mr Soane, who understood it to mean that it was unlikely that such panels were being used in the UK and was therefore reassured by it.1733 Soane {CUK00000002/3} page 3; Soane {CUK00000002/17} page 17, paragraph 45. Mr Martin said that he had thought at the time that his response was appropriate1734 Martin {Day255/47:3-4}; {Day255/47:23-25}. and that the BCA's technical guidance note had effectively answered the problem.
17 March 2016: the second meeting of the CWCT Fire Group
¶11.79 On 17 March 2016, Brian Martin attended the second meeting of the CWCT's Fire Group.1735 Martin {CLG00019469/49} page 49, paragraph 138. Dr Colwell also attended, as did Nick Jenkins, David Metcalfe and Alan Keiller of the CWCT, David White of the NHBC, Stuart Taylor of Wintech, Adrian Pargeter from Kingspan, Clive Everett from St Gobain and others from across the industry.1736 CWCT Technical Group Minutes of Fire Meeting dated 17 March 2016 {CLG00019440/1}. The minutes of the meeting recorded the view of those present that paragraph 12.7 of Approved Document B was poorly written and open to different interpretations. The heading was also thought to be misleading.1737 CWCT Technical Group Minutes of Fire Meeting dated 17 March 2016 {CLG00019440/2} final two paragraphs. Those present noted that BCA Guidance Note 18 had extended the requirement for insulation and filler material to be of limited combustibility to all materials used in the construction of the external wall.
¶11.80 At the meeting Mr Martin undertook on behalf of the department to revise paragraph 12.7.1738 Martin {CLG00019469/49} page 49, paragraph 138. He had agreed with others at the meeting that the paragraph was open to different interpretations1739 Martin {Day255/54:2-15}. and accepted that to that extent it had failed in its purpose.1740 Martin {Day255/55:18-24}. He could not say when he had come to that conclusion. He told us that the recognition that people did not all understand it in the same way had grown progressively in his mind from about 2014 until the second CWCT meeting.1741 Martin {Day255/54:16-25}; {Day255/59:2-7}; {Day255/60:3-6}; {Day255/84:19}-{Day255/85:13}.
¶11.81 The minutes went on to record that the term "filler material" in paragraph 12.7 had been intended to be of wide application, as it was not possible to list all the materials that should be covered by it. Most significantly, they also recorded the conclusion of those present that the paragraph was intended to cover all the materials in the external wall.1742 CWCT Technical Group Minutes of Fire Meeting dated 17 March 2016 {CLG00019440/3}. Mr Martin was the only person present who could say what paragraph 12.7 had been intended to achieve,1743 Martin {Day255/61:8-14}. but if he agreed (as it appears he did) that the intention had been to cover all the materials in the external wall, that represented a significant departure from his original intention. We think it possible, therefore, that the discussion on this point was more consistent with Mr Metcalfe's recollection, namely, that those present agreed that paragraph 12.7 should apply to all materials in the external wall, not that it did so.1744 Metcalfe {CWCT0000115/18} page 18, paragraph 65; Metcalfe {Day228/191:21-24}; {Day228/202:16}-{Day228/203:6}. That would also be consistent with Mr Martin's later approval of the language of Option 1 in BCA Technical Guidance Note 18.
197¶11.82 Mr Martin acknowledged that the interpretation of paragraph 12.7 that by March 2016 he had come to prefer was not one he had ever professed.1745 Martin {Day255/65:3-7}. He had come to think that the BCA's interpretation was a safer one that provided a good starting point for designers.1746 Martin {Day255/65:12-19}. He had not given any consideration at the time to the effect it would have on paragraph 12.6 and the relevant part of Diagram 40,1747 Martin {Day255/67:15}-{Day255/68:1}. but he agreed that it created an anomaly1748 Martin {Day255/68:25}-{Day255/69:7}. in that paragraph 12.6 had no part to play if that was the correct interpretation of paragraph 12.7. Mr Martin did not see that as a problem, however.1749 Martin {Day255/69:8-23}; Martin {Day254/123:24}-{Day254/124:17}; {Day254/124:25}-{Day254/125:6}; {Day254/126:1-13}; {Day254/128:7-15}. He said that readers of Approved Document B should have recognised that paragraph 12.7 was imprecise1750 Martin {Day255/81:20}-{Day255/82:8}. and should have referred back to the functional requirement.1751 Martin {Day255/72:2-15}; {Day255/75:8-12}; {Day255/80:2}-{Day255/81:6}.
¶11.83 It seems clear to us that Mr Martin had not given the question enough thought. The purpose of the guidance was to advise readers on how to go about complying with the various functional requirements in commonly encountered situations. If the guidance was so imprecise and contradictory that it had to be disregarded, it simply created confusion. That was a significant and serious problem.
¶11.84 The CWCT meeting on 17 March 2016 was the first occasion on which Mr Martin had stated publicly what paragraph 12.7 of Approved Document B had been intended to mean.1752 Martin {Day255/82:13-21}. (Whether it actually bore that meaning, despite the inconsistency it would create with paragraph 12.6, is another matter which we have addressed separately in Chapter 7.) He appears to have thought at the time that the conclusion he had reached would be disseminated by those who attended the meeting and by the guidance that the CWCT planned to publish,1753 Martin {Day255/86:15}-{Day255/87:12}. but he did not report the outcome of the meeting to Mr Harral or Mr Ledsome, nor did he tell them that he intended to propose an amendment to paragraph 12.7 when Approved Document B was revised.1754 Martin {Day255/87:13}-{Day255/88:5}; {Day255/89:12-20}; {Day255/101:20}-{Day255/102:5}; Harral {Day244/166:9-21}; Ledsome {CLG00019465/54} page 54, paragraph 207; Ledsome {Day245/79:12}-{Day245/80:1}; {Day245/83:9}-{Day245/84:16}; {Day245/88:17-23}; {Day245/96:11-17}. In short, he was complacent and did not appreciate the severity of the risk.1755 Martin {Day255/91:24-25}; {Day255/93:4-9}.
198¶11.85 For the same reason, he did not view the problem as urgent.1756 Martin {Day255/94:7}-{Day255/95:4}; {Day255/98:22}-{Day255/99:14}. All he could say was that, in his mind, industry guidance was doing the job, but in March 2016 he should have given further thought to the publication of an FAQ.1757 Martin {Day255/99:10-14}; {Day255/99:20-22}. He did not make it clear to any senior official that the revision to paragraph 12.7 that he thought was needed could wait until the next review of the document,1758 Martin {Day255/100:16-21}. but he knew that the scope of the next revision was still being discussed and that there was no timetable in place for it.1759 Martin {Day255/90:1-8}; {Day255/90:20}-{Day255/91:21}; Ledsome {Day245/96:18}-{Day245/97:1}.
28 March 2016: the fire at the Ajman One complex, Dubai
¶11.86 Less than two weeks after the CWCT meeting on 17 March 2016, Mr Martin corresponded with Dr Crowder and Martin Shipp at BRE about yet another high-rise cladding fire that had occurred in the Ajman One complex, Dubai, on 28 March 2016.1760 {CLG10008111}. Although he noted that aluminium composite material again seemed to have been involved,1761 {CLG10008111/1}. he failed to make the connection between that fire and what Mr Jenkins had told him about the widespread use of similar material in the UK.
7 July 2016: the NHBC's new guidance
¶11.87 On 7 July 2016 Mr Martin spoke at a seminar1762 Martin {CLG00019469/51} page 51, paragraph 144. at which the NHBC was launching its new guidance, Acceptability of common wall constructions containing combustible materials in high-rise buildings.1763 {NHB00000065}. Mr Martin told us that he had read the guidance when he met Steve Evans and Diane Marshall on 30 June 20161764 Martin {Day255/143:1-6}. and was satisfied that it was a reasonable approach to satisfying the functional requirements of the Building Regulations.1765 Martin {CLG00019469/52} page 52, paragraph 146; Martin {Day255/163:19-23}. For the reasons we have given we disagree.
¶11.88 Mr Martin's speech at the seminar was about the regulatory requirements for facades. Nonetheless, for reasons which are not clear to us, he did not use the opportunity to tell those present what he understood to be the effect of paragraph 12.7 following the discussion at the CWCT meeting four months earlier.1766 Martin {Day255/128:15}-{Day255/130:3}. He said that he had not been thinking in that way at the time1767 Martin {Day255/130:17-22}. and that his mind was on a broad range of issues rather than one particular matter.1768 Martin {Day255/130:24-25}; {Day255/131:21}-{Day255/132:23}.
¶11.89 Although no-one at NHBC had told him so, Mr Martin assumed that the guidance note was based on a number of large-scale tests in accordance with BS 8414.1769 Martin {Day255/146:18-20}; {Day255/147:13-15}; {Day255/148:3-25}; {Day255/149:23}-{Day255/150:25}; {Day255/151:22}-{Day255/152:4}; {Day255/152:16-18}; {Day255/155:23-25}; {Day255/156:17-23}; {Day255/158:6-13}. He was therefore1770 Martin {Day255/146:18-21}; {Day255/152:5-18}; {Day255/158:1-9}. not concerned by that part of the guidance which said that the use of aluminium composite material with a polyethylene core that was not classified Euroclass B fell outside of the scope of the guidance1771 {NHB00000065/4} left-hand column under the heading "Restrictions on use". (thereby indicating that if it was classified Euroclass B it fell within it). He agreed that Euroclass B did not indicate a material of limited combustibility1772 Martin {Day255/148:2-3}; {Day255/150:12-15}. but said that he had assumed that tests in accordance with BS 8414 had been carried out on systems incorporating panels classified Euroclass B.1773 Martin {Day255/149:1-13}.
199¶11.90 Mr Martin accepted that, under NHBC's 2016 guidance, a building control officer could approve a cladding system on a building over 18 metres in height containing a combustible insulation, such as Kingspan K15 or Celotex RS5000, and aluminium composite panels with polyethylene cores classified as Euroclass B.1774 {NHB00000065/4}; Martin {Day255/154:2-12}; {Day255/155:14-20}; {Day255/161:15-21}. He appears to have thought that NHBC had assessed the guidance thoroughly,1775 Martin {Day255/155:23-25}. including through testing,1776 Martin {Day255/148:3-18}; {Day255/151:22}-{Day255/152:4}. but some basic enquiries of Diane Marshall1777 Diane Marshall was NHBC's Head of Technical Services between 2012 and 2017: Marshall {NHB00003434/2} paragraph 11(d). or Steve Evans would have revealed that not to have been the case. Although Mr Martin appears to have taken the view that that was not his responsibility,1778 Martin {Day255/156:9}. the fact is that NHBC's guidance was inconsistent with what by then he was telling people that paragraph 12.7 was intended to mean. Given Mr Martin's awareness of the risks inherent in using aluminium composite panels with polyethylene cores in the external walls of high-rise buildings, he should not have lent his (and thereby the department's) support to guidance that sanctioned the use of them, even if they were classified Euroclass B. The position was made worse by NHBC's advice that such material could safely be used in combination with Celotex RS5000 or Kingspan K15, PIR and phenolic insulation materials that by common consent were not materials of limited combustibility. Mr Martin should have refused to lend his support to that guidance and should have taken it up with senior management at NHBC.
201Chapter 12: Regulation of fire risk assessors
¶12.1 The Fire Safety Order introduced a requirement for responsible persons to carry out fire risk assessments, and in many cases they engaged commercial fire risk assessors to produce such assessments on their behalf.
¶12.2 By about 2009 it had become clear to those working in the government fire safety policy team and the fire sector generally that there were significant grounds for concern about the competence of some commercial fire risk assessors. Those concerns were set out in a series of reports produced by and for the government.
The Initial Evaluation of the effectiveness of the Fire Safety Order (March 2009)
¶12.3 In March 2009, the Department for Communities and Local Government (the department) published an evaluation of the Fire Safety Order entitled Initial Evaluation of the Effectiveness of the Regulatory Reform (Fire Safety) Order 2005.1779 {HOM00046062}. By that time, the Fire Safety Order had been in force for almost three years.1780 The Fire Safety Order generally came into force on 1 April 2006. The department considered it good practice periodically to evaluate how well legislation of that kind was functioning and becoming familiar to the enforcing authorities, responsible persons and the fire safety sector.1781 Upton {Day247/15:14-23}; Louise Upton {HOM00046040/4} page 4, paragraph 14. The aim of the report was to obtain views from as broad a constituency of consultees as possible.1782 Upton {Day247/18:14-19}. It was based on a series of interviews with a range of interested organisations, including 20 enforcing authorities, representatives from bodies concerned with fire safety, consultants and 45 businesses of various kinds.1783 {HOM00046062/8} paragraph 2.
¶12.4 The report's findings revealed that some fire and rescue authorities were concerned about the work of independent consultants and other commercial fire safety organisations.1784 {HOM00046062/43} paragraph 6. The main problem was a variation in the level of competence.1785 {HOM00046062/46}; {HOM00046062/12}. By the time of the report, some organisations had set up voluntary registers of fire risk assessors, whose competence they certified.1786 Davis {Day246/136:1-11}. Although fire and rescue authorities welcomed that development, the report noted that some authorities and responsible persons thought that a national scheme of accreditation or licensing would be preferable.1787 {HOM00046062/12}.
¶12.5 Dennis Davis of the Fire Sector Federation told us that, at the time, unqualified fire risk assessors were a serious concern for the fire and rescue authorities.1788 Davis {Day246/137:10-23}. Mr Davis described a call from the sector that in the case of more complex buildings there should be some assurance that a fire risk assessor was competent.1789 Davis {Day246/138:10-20}. We conclude from that evidence that the worries about the competence of some fire risk assessors were well known to the government.
202Sir Ken Knight's report on the fire at Lakanal House (July 2009)
¶12.6 In July 2009, Sir Ken Knight produced a report for the Secretary of State for Communities and Local Government on a number of matters affecting fire safety that had emerged from the fire at Lakanal House.1790 {HOM00001092}; Sir Ken Knight {HOM00046025/5-6}, pages 5-6, paragraph 17; Knight {Day245/149:9-18}. In it he recognised that in the early years after the introduction of the Fire Safety Order there had been problems in ensuring that fire risk assessors had the necessary level of competence, particularly for assessing the risks posed by more complex buildings.1791 Knight {Day246/28:23}-{Day246/29:5}. He was aware of the concerns that had been expressed in the Initial Evaluation of the Effectiveness of the Fire Safety Order (March 2009),1792 Knight {Day246/51:8-17}. but he did not give any advice to ministers about them because he saw his role as working mainly with the fire and rescue services.1793 Knight {Day246/52:12-20}.
¶12.7 Sir Ken Knight's investigations had revealed that there was a need for some kind of formal requirement to ensure that fire risk assessors undertaking assessments of high-risk premises were competent.1794 Knight {Day246/36:2-7}. He considered that article 9 of the Fire Safety Order should be amended to include an express duty on the responsible person to use a competent person to carry out a fire risk assessment in relation to any high-risk property.1795 Knight {Day246/36:3-13}. He thought that the broad approach in the Fire Safety Order was inappropriate because in some respects high-rise buildings required a greater level of expertise, for instance if an invasive assessment was required.1796 Knight {Day246/36:23}-{Day246/37:4}; {Day246/37:16-24}. Sir Ken's report also said that it was important that both the responsible person and the enforcing authority should have confidence that any fire risk assessment, particularly one in relation to a high-risk building, had been carried out by a competent person.1797 {HOM00001092/36}.
¶12.8 However, on 28 July 2009, shortly before the report was due to be completed, Louise Upton, the official leading the fire safety policy team, discussed the proposed recommendation with Peter Wise, a fire safety engineer working with Sir Ken.1798 {HOM00011611}. He told Sir Ken that she was disinclined to recommend any revisions to the Fire Safety Order so soon after it had come into force.1799 {HOM00011611}. Ms Upton told us that she and her line manager, Sandy Bishop, had thought that it was too soon to amend article 9 and that there were other ways, such as working with the fire safety sector and introducing competence standards, to address the concerns of business.1800 Upton {Day247/34:21}-{Day247/36:18}; {Day247/38:10}-{Day247/39:2}.
¶12.9 Ms Upton proposed an alternative course, namely a broader review of how responsible persons could satisfy themselves that fire risk assessments were suitable and sufficient, particularly if the premises are higher-risk.1801 Upton {Day247/38:7-9}, and email correspondence from Peter Wise to Sir Ken Knight dated 28 July 2009 {HOM00011611}. Sir Ken adopted Ms Upton's proposal almost entirely and recommended that consideration should be given to conducting a review into how the responsible person under the Fire Safety Order can be assured that a suitable and sufficient fire risk assessment has been carried out, particularly in the case of high-risk premises.1802 {HOM00001092/37}. He also recommended that the guidance on how to comply with the Fire Safety Order should be amended, where appropriate.1803 {HOM00001092/37}.
203¶12.10 Louise Upton's intervention effectively frustrated the purpose of Sir Ken Knight's independent review. She thought that amending the Fire Safety Order would not be welcome because the government did not want to increase regulation and the department had insufficient resources to support more legislation.1804 Upton {Day247/34:18-25}; {Day247/30:22}-{Day247/31:7}. Instead, it was thought that the sector should resolve the problem itself and that the government's role was to encourage it to do so.1805 Upton {Day247/31:20-24}. That approach did not have the formal approval of ministers; it was simply adopted by Louise Upton and her policy team1806 Upton {Day247/33:10}-{Day247/34:8}. and as a result no proposal to amend the Fire Safety Order was put forward for consideration by ministers. We cannot tell whether such a proposal would have been accepted but Sir Brandon Lewis, who later served as a minister in the department from September 2012,1807 Lewis {Day257/2:22}-{Day257/3:3}. said that if he had received such advice he would not have considered it unfavourably,1808 Lewis {Day257/25:21}-{Day257/26:25}. and that he would have given a recommendation from an expert like Sir Ken Knight very serious consideration.1809 Lewis {Day257/26:20-25}.
¶12.11 Sir Ken Knight was worried that people are often unaware of their own lack of competence and thereby put other people at risk.1810 {HOM00011612}. Nevertheless, he did not press his recommendation because it was an early and short report and he felt that the recommendations he had made were there for others to take forward.1811 Knight {Day246/41:8-13}. However, he accepted that as Chief Fire and Rescue Adviser he should have ensured that the amendment of article 9 of the Fire Safety Order remained at the front of ministers' minds1812 Knight {Day246/42:16-20}. and that instead he had allowed policy officials, such as Louise Upton, to take control.1813 Knight {Day246/43:1-9}. Although he denied that he had changed his mind as a result of the discussion with officials,1814 Knight {Day246/49:20-22}. we find that difficult to reconcile with the significant change of direction following their intervention. Sir Ken said that, on reflection, he could and should have been more robust with policy colleagues.1815 Knight {Day246/56:21-25}. We agree.
¶12.12 We would go further. It was unacceptable for officials to influence the outcome of Sir Ken Knight's report and not to seek the minister's view on the merits of amending article 9 with the benefit of objective advice from the Chief Fire and Rescue Adviser. Equally, given the sector's clear concern about the lack of competence of fire risk assessors and the risks to life that posed, Sir Ken should have recognised the importance of his function as an expert adviser and should have insisted on placing his conclusions before ministers irrespective of the views of officials. His failure to do so reflects poorly on his independence of mind and frustrated the object of creating the position to which he had been appointed. The practical result was that unqualified and incompetent fire risk assessors were able to continue in practice despite mounting concern on the part of many in the sector.
204¶12.13 Following the publication of his report, Sir Ken played no further part in advising the government on the competence of fire risk assessors.1816 Knight {Day246/59:11}-{Day246/60:6}. Although he was optimistic that the sector would take the issue forward to the benefit of the industry,1817 Knight {Day246/62:19}-{Day246/63:5}. the basis of his optimism is not obvious, and it was not identified by Sir Ken in his evidence to the Inquiry.
London Assembly Report – Tall and Timber-Framed buildings
¶12.14 In December 2010, the Planning and Housing Committee of the London Assembly published a report entitled Fire Safety in London: Fire risks in London's Tall and Timber Framed Buildings.1818 {INQ00014711}. The report was prompted by a series of fires that included the Lakanal House fire.1819 {INQ00014711/11}. The investigation drew on a considerable base of evidence and 45 written submissions, including submissions from 16 London boroughs, six housing providers, seven trade organisations, four fire brigades, four consultancies and two insurers.1820 {INQ00014711/22} paragraph 1.32.
¶12.15 The committee was concerned that "the desire to remove prescriptive regulation and replace it with non-mandatory guidance may have created a situation where the fire authorities do not have sufficient capacity to ensure the risk management process is always robust."1821 {INQ00014711/35} paragraph 4.12. Its recommendation was that DCLG, with relevant bodies such as the Local Authorities' Co-ordinators of Regulatory Services and the Chief Fire Officers Association, should "draw up national guidance to ensure mandatory minimum standards of competence for training and accrediting fire risk assessors."1822 {INQ00014711/35} recommendation 7.
¶12.16 Very similar concerns were set out in a report published in December 2010 by the Fire Sector Federation following the Fire Futures review entitled Decentralisation in the fire sector: Empowering and protecting the citizen.1823 {FSF00000037}. The report had been prompted, in part, by the Federation's concern to ensure that the government involved all relevant sectors in identifying and mitigating risks relating to fire safety. It described perceived low levels of competence within the fire sector in relation to fire safety and the built environment that was not helped by the absence of a common framework of qualifications.1824 {FSF00000037/10}.
205¶12.18 The first recommendation was that the sector should take the lead in formulating standards of competence and the introduction of certification and other related measures.1828 {FSF00000037/11}. The authors also recommended that the government should ask the Federation to produce a formal plan of action. However, nothing came of that.1829 Upton {Day247/117:17-18}.
The government's initial response
¶12.19 By March 2009, government officials had become aware of the concern among some enforcing authorities and responsible persons about the competence of some commercial fire risk assessors.1830 Upton {Day247/22:12-22}. Following the publication in March 2009 of the government's initial evaluation of the effectiveness of the Fire Safety Order and the delivery of Sir Ken Knight's report in July 2009, the fire safety policy team concentrated on designing and implementing a programme of work in response to the findings.1831 Louise Upton {HOM00046040/5} page 5, paragraph 16; Louise Upton {HOM00050082/3} page 3, paragraph 7. Initially there was no settled view about how a system of accrediting fire risk assessors would work in practice.1832 Upton {Day247/22:25}–{Day247/23:3}.
¶12.20 Notably, the concerns had persisted despite the existence of certification schemes, two of which, the schemes run by British Approvals for Fire Excellence (BAFE) and Warringtonfire Testing, were accredited by UKAS.1833 Davis {Day246/136:20-25}. The aim of the schemes was to provide independent assurance of the competence of fire risk assessors,1834 Davis {Day246/136:23-25}. but it was not necessary to be a member in order to work as a commercial fire risk assessor.
¶12.21 On 11 June 2009, there was a meeting of the Chief Fire Officers Association's working group on enforcement.1835 {HOM00012153}. At that meeting it was noted that although the department recognised that many would welcome a nationally-recognised accreditation scheme for fire risk assessors, it was not something that government intended to develop.1836 {HOM00012153/2} paragraph 11. Instead, it encouraged the sector to establish a register to help businesses identify competent fire risk assessors.1837 {HOM00012153/2} paragraph 11.
Jayne Boys's review
¶12.22 In order to investigate and assess the options for developing a nationally recognised quality assurance scheme for fire risk assessors, the department engaged a consultant from the In-House Policy Consultancy Service, Jayne Boys.1838 Louise Upton {HOM00050082/3} page 3, paragraph 9; Project Specification {HOM00012290}. The fire safety policy team did not have the capacity to carry out the work itself.1839 Louise Upton {HOM00050082/3} page 3, paragraph 9. The project was managed by Louise Upton.1840 Louise Upton {HOM00050082/3} page 3, paragraph 9; Upton {Day247/53:9-17}. Consultees included businesses and fire and rescue authorities.
¶12.23 At a meeting of consultees on 14 December 2009, some of those present again described the lack of understanding among responsible persons of the nature and extent of their obligations under the Fire Safety Order and the shortcomings of the existing guidance.1841 {HOM00012752/12}.
206¶12.24 It was clear from the review carried out by Jayne Boys that some consultees wanted to establish a single nationally-recognised scheme.1842 Upton {Day247/53:3-8}. Although some (including the Institution of Fire Engineers, the Royal Institution of Chartered Surveyors, and BAFE) wanted a mandatory scheme under which responsible persons would be required to use accredited fire risk assessors, that desire was not shared by the department,1843 Upton {Day247/59:2}-{Day247/60:6}. which thought that much could be achieved by voluntary methods. That meant, however, that responsible persons were not expressly required to use competent fire risk assessors.1844 Upton {Day247/60:20}-{Day247/61:3}. Ms Upton rightly accepted that there was no evidence that voluntary methods would achieve the aim of ensuring competence among fire risk assessors.1845 Upton {Day247/61:4-9}.
¶12.25 Those present at the meeting agreed that there was a need to establish a body (referred to at the meeting as a "Fire Risk Competency Council") that could set standards of competence required for carrying out fire risk assessments in different circumstances and would be accredited by UKAS.1846 {HOM00050090/4}. Louise Upton thought that there was a benefit in bringing together a number of disparate schemes to make good the absence of a set of agreed common standards.1847 Upton {Day247/57:9-15}. The department does not appear to have opposed the proposal for UKAS accreditation at that time, but it later became concerned that to require all fire risk assessors to be certified by bodies accredited by UKAS could present a disadvantage to professional bodies that were not subject to UKAS accreditation but who considered their members to be no less competent. It feared that might distort the market, reduce choice and increase costs.1848 Louise Upton {HOM00050082/11} page 11, paragraph 37. However, no formal assessments had been carried out that supported those fears1849 Upton {Day247/66:23}-{Day247/67:9}. and no research at all had been done into the extent to which the introduction of UKAS accreditation might distort the market.1850 Upton {Day247/68:11-14}. Ms Upton accepted that a UKAS-accredited scheme represented the best available means of addressing concerns about the competence of fire risk assessors.1851 Upton {Day247/69:13-23}; {Day247/70:12-18}.
The Fire Risk Assessment Competency Council
¶12.26 On 9 March 2010, the Fire Risk Assessment Competency Council held its inaugural meeting,1852 {HOM00013530}; Upton {Day247/76:13-5}. at which the agreement to publish an overarching set of criteria by which to establish competence supported by UKAS accreditation was affirmed.1853 {HOM00013530/2} paragraph 4; Upton {Day247/77:9-17}.
¶12.27 However, the minutes fail to reflect a more contentious discussion between the members. Louise Upton acknowledged that their interests differed,1854 Upton {Day247/81:10}. which made it difficult for them to agree on the best way to ensure the competence of fire risk assessors.1855 Upton {Day247/81:11-17}. In truth, their interests were fundamentally opposed and their different views reflected their particular positions.1856 Upton {Day247/79:2-21}; {Day247/80:7-11}. The difficulties of looking to a fragmented group of organisations to produce a method of ensuring the competence of fire risk assessors are neatly illustrated by the email Jayne Boys sent to Louise Upton following the first meeting, in which her advice was to keep the note of the meeting as short as possible because every word was one more to argue over.1857 See, for instance, email correspondence between Jayne Boys, Brian Martin, and Louise Upton dated 10 March 2010 {HOM00013486/1}. That inability to reach agreement effectively thwarted the department's hope that the sector would find a way to ensure the competence of fire risk assessors. Unwisely, in our view, the department never threatened the Competency Council that, if it failed to make significant progress towards introducing an effective scheme, it would reconsider the question of regulation.1858 Upton {Day247/83:3-8}.
207¶12.28 Another question to be resolved was whether membership of the scheme should be mandatory. The view of most members of the council was that few would adopt any new scheme unless it was compulsory,1859 Upton {Day247/91:3-6}. but Louise Upton and Brian Martin did not share it.1860 Upton {Day247/91:10-14}; {CLG10004360/1-3}. In the light of the department's evaluation of the effectiveness of the Fire Safety Order in 2009, Ms Upton thought that responsible persons did not want to be compelled to use an accredited fire risk assessor1861 Upton {Day247/91:10-14}. and she maintained that view despite the findings of the report on Tall and Timber-Framed Buildings and the Fire Futures review.1862 Upton {Day247/109:1-15}; {Day247/118:11-15}. As a result, in July 2010 and February 2011 she sent submissions to Bob Neill MP, the then Fire Minister, that did not argue in favour of either a single national register or accreditation by UKAS.1863 {HOM00000884}; {HOM00001003}.
¶12.29 In the first of those submissions Ms Upton sought the minister's approval for the department's approach of encouraging the sector itself to respond to the concern of business that some form of quality assurance for commercial fire risk assessors would be helpful.1864 {HOM00000884/1} paragraph 2. She said that businesses were unlikely to welcome further regulation, but that was no more than an assumption on her part for which she had no evidence.1865 Upton {Day247/104:4-9}.
¶12.30 The second submission of 7 February 2011 sought the minister's approval to offering continued support to existing attempts to manage the risks posed by low levels of competence among fire risk assessors by exploring the options for creating one or more schemes to certify fire risk assessors.1866 {HOM00001003/3} paragraphs 11-13. The department proposed to offer continued support to the sector to allay any concerns that existing certification bodies, including the professional institutions, might have about applying for UKAS accreditation and to develop agreement on the basis of any future scheme.1867 {HOM00001003/3} paragraph 12. In reality, that meant little more than being available for discussions and attending meetings.1868 Upton {Day246/119:6-9}. Ms Upton warned that there was a risk that the sector would do nothing without the department's continued involvement, leading to criticism of the government. Although she recognised the risk that its efforts might fail, she was over-optimistic about the Competency Council's ability to tackle the problem of ensuring the competence of fire risk assessors.1869 Upton {Day247/121:25}-{Day247/122:9}.
¶12.31 By that time over a year had passed since the establishment of the Competency Council in December 2009. There had been no significant progress in agreeing standards of competence or a means of imposing them, despite repeated warnings and successive calls from industry for the introduction of a mandatory regime. That was partly because the department's policy at that time was not to become actively involved in organising schemes of that kind and partly because it did not have the resources necessary to do it.1870 Upton {Day247/120:3-9}; {Day247/121:3-5}. A similar picture was painted by others in the department responsible (at least from 2013) for reviewing and revising the Building Regulations. In our view, the minimalist approach adopted by the department between 2011 and 2017 and its antipathy to regulation enabled the risk identified by Ms Upton to eventuate. The Competency Council failed to complete its work and it left responsible persons without the means of identifying competent fire risk assessors.
208The Competency Council guides
¶12.32 On 21 December 2011, the Competency Council published Competency Criteria for Fire Risk Assessors (the "Competency Criteria").1871 {HOM00033347}. The guidance contained standards relating to various matters (for example, means of escape and fire prevention) against which fire risk assessors could be judged.1872 {HOM00033347/2} paragraph 6. Its use was entirely voluntary and to that extent reflected the government's preference to allow the industry to draw up its own guidance to assist those engaging fire risk assessors.
¶12.33 On 1 February 2013, the Competency Council published a second guide, entitled Guide to Choosing a Competent Fire Risk Assessor,1873 {HOM00025548}. which offered advice to responsible persons in relation to the appointment of specialist fire risk assessors and listed several existing competency schemes.1874 {HOM00025548/5}. Louise Upton said she had viewed the publication of the guide as a positive development and a first step towards creating a professional fire risk assessor industry.1875 Louise Upton {HOM00050082/11} page 11, paragraphs 38-39.
¶12.34 Dennis Davis said the publication of the Competency Criteria was one of the key elements needed to improve the competence of fire risk assessors.1876 Davis {Day246/142:4-11}. Together with previous guidance, it created a procedure for fire risk assessors to follow,1877 Davis {Day246/143:13-24}. but it did not provide a means of assessing the skills and thoroughness of individual fire risk assessors.
¶12.35 In our view, reliance on voluntary guidance was the wrong response to the well- documented and frequently repeated warnings about the competence of fire risk assessors. No guides of any kind could exclude the risks posed by those fire risk assessors who chose to operate outside the certification schemes or who chose not to follow the prescribed standards. Responsible persons were not required to make use of the guides, which did not prevent unqualified and unregulated fire risk assessors continuing to practise.
¶12.36 On 9 January 2013, the Fire Sector Federation agreed to take responsibility for monitoring the operation of the guides to determine whether the Competency Council needed to be reconvened to consider or respond to developments.1878 {HOM00001351/5}.
209The Lakanal House inquests
¶12.37 Following the inquests into the deaths at Lakanal House, the coroner wrote to the Fire Sector Federation on 30 March 2013 expressing the view that it was well-placed to shape national policy on the scope of fire risk assessments and how they should be carried out. She also encouraged it to consider whether it might offer further guidance on the training of fire risk assessors.1879 {HOM00004356}.
¶12.38 The Fire Sector Federation was split into groups, known as "workstreams", which concentrated on different aspects of fire safety.1880 Dennis Davis {FSF00000036/5} page 5, paragraphs 23-24. A Competency and Accreditation workstream, chaired by Dennis Davis, was formed in about April 2013 in anticipation of the coroner's letter and to build on the work of the Competency Council.1881 Davis {Day246/118:5-6}; {Day246/125:5-12}; Dennis Davis {FSF00000036/8-9} pages 8-9, paragraph 34; {FSF00000036/11} page 11, paragraph 42; {FSF00000199/1}.
¶12.39 Mr Davis told us that the guides published by the Competency Council had provided a method for carrying out fire risk assessments and had been a key element in addressing the problem of competence among fire risk assessors.1882 Davis {Day246/143:17-21}. However, he had thought that further work was required to combine the advice provided by different guides into a single set of principles and that some form of regulation of commercial fire risk assessors was required.1883 Davis {Day246/144:20-25}. In our view, that is an important point. Although guidance may have been useful for those who chose to have regard to it, there remained no regulation of fire risk assessors, including those who chose to disregard the various guides produced by the Competency Council and others.
¶12.40 At the workstream's first meeting on 12 April 2013 its members decided that the Competency Criteria needed to be extended in several respects, among which were the following:1884 Davis {Day246/146:4-20}. a new section was needed drawing attention to the risks posed by the modification or refurbishment of a building;1885 {HOM00001351/6}. greater emphasis was needed on the risks posed by the introduction of new materials, building design, modern engineering practice and building methods; and greater emphasis needed to be laid on the importance of gaining access to individual premises, rather than merely common areas, to establish whether compartmentation had been weakened, for example, by changing entrance doors or removing self-closing devices.1886 Davis {Day246/148:21}-{Day246/149:5}. {HOM00001351/6}. Mr Davis said that the second reflected in particular a concern that the sector was not keeping up with innovations in the construction industry.1887 Davis {Day246/147:12-15}. Those present also decided to review the LGA Guide and to promote its use in relation to high-rise premises.1888 {HOM00001351/6}, Davis {Day246/149:18-22}.
210¶12.41 The members decided that a "passport" scheme should be established for fire risk assessors1889 Vice Chairman's Report on Activities dated 1 May 2013 {HOM00001351/7}. with the object of creating a quality assurance body that would police compliance1890 Vice Chairman's Report on Activities dated 1 May 2013 {HOM00001351/7}. and recommended that specific recognition be offered in the nine areas of competence covered by the Competency Criteria.1891 Vice Chairman's Report on Activities dated 1 May 2013 {HOM00001351/7}. On satisfying those requirements, a fire risk assessor would receive a passport, grading competence in each area.1892 Vice Chairman's Report on Activities dated 1 May 2013 {HOM00001351/7}.
¶12.42 The intention behind those proposals was to establish an overarching system of quality assurance.1893 Davis {Day246/151:2-9}. It was recognised that fire risk assessors who had not joined one of the existing certification schemes would not be subject to its requirements,1894 Davis {Day246/151:10-18}. but it was seen as a start.1895 Davis {Day246/151:17-18}. The only way to enforce compliance was by legislation.
¶12.43 A copy of the proposal was sent to Sir Ken Knight and was circulated among the department's officials, including Louise Upton and Brian Martin.1896 {CLG00000526}. Mr Martin wrote to colleagues on 29 April 2013 saying that it appeared that the Fire Sector Federation was in danger of trying to do more than was necessary or desirable or indeed within the scope of its ability.1897 {CLG00000526}. In an email to Sir Ken Knight Louise Upton used the expression "control freakery" to describe the proposed passport scheme.1898 {CLG00000527/1}. Although it is not clear why Sir Ken had continued to be involved after his retirement as Chief Fire and Rescue Adviser in January 2013, he took a similar view and was concerned that the Federation was going beyond what was required.1899 Knight {Day246/85:1}-{Day246/86:5}.
¶12.44 On 10 October 2013, the members of the workstream met to discuss the proposed passport scheme. They identified several obstacles to its work, including the government's general opposition to regulation, continuing austerity and the existence of well-established self-certification schemes,1900 Competency Workshop, draft note of meeting dated 10 October 2013 {FSF00000407/2}. that made a scheme involving formal certification, although desirable, impractical.1901 Competency Workshop, draft note of meeting dated 10 October 2013 {FSF00000407/2}; Davis {Day246/162:24}-{Day246/163:2}. They therefore decided instead to focus their efforts on the role and competence of fire safety managers, who were the people responsible for ensuring compliance with statutory fire safety requirements.1902 Competency Criteria for Fire Safety Managers {FSF00000041}; Competency Workshop – Draft Note of Meeting {FSF00000407/2}; Dennis Davis {Day246/172:5-9}. Those who were involved in the existing certification schemes considered that the Competency Council documents and PAS 79 were sufficient.1903 Davis {Day246/163:15-20}. They considered that the problem lay not so much among fire risk assessors already covered by the existing schemes as among responsible persons who did not know when to seek advice from a competent fire risk assessor.1904 Davis {Day246/163:21}–{Day246/164:1-4}.
211¶12.45 The consequence of that decision was that the Federation offered no further guidance on the scope of fire risk assessments or how such assessments should be carried out.1905 Davis {Day246/165:10-18}. Dennis Davis said that the rationale was to direct responsible persons towards competent fire risk assessors who were members of existing schemes.1906 Davis {Day246/165:19-24}.
¶12.46 Even allowing for opposition from government and others to a regulatory regime, there was no good reason following the Lakanal House inquests not to amend the existing guidance to deal with the risks posed by refurbishment, modern methods of construction, and the importance of gaining access to individual flats when carrying out fire risk assessments. On any view, an amendment would have raised awareness within the industry of the importance of those matters.
The persisting problem
¶12.47 Concern about the competence of some fire risk assessors persisted in the years after the publication of the Competency Council guides. In August 2013 the government published a further review of the Fire Safety Order entitled Focus on Enforcement Review: Enforcement of the Regulatory Reform (Fire Safety) Order 2005,1907 {BEI00001317}. which said that businesses had reported that some fire risk assessors had been overstating the need for their services, that a number of fire professionals had questioned the quality of some commercial risk assessors, and that in practice a third-party assessment offered no guarantees to businesses.1908 {BEI00001317/19}.
¶12.48 In December 2013, Louise Upton drafted a paper to identify options in response to the review, one of which was the creation of a national regulator for fire safety with broad responsibility for setting and communicating safety standards and developing standards for fire risk assessors.1909 {HOM00046039}; Upton {Day247/174:22}-{Day247/175:3}. In that paper she discussed the possibility of additional resources to develop, or obtain from third parties, expertise in fire safety, so that the department could provide independent and high quality advice to businesses and enforcing authorities on how to discharge their duties under the Fire Safety Order.1910 {HOM00046039/4}. At that time the Fire Safety team did not have the expertise or resources to provide advice of that kind and it had become increasingly difficult to obtain it from others on anything other than a temporary basis.1911 Upton {Day247/177:8}-{Day247/178:20}.
¶12.49 At a meeting on 17 July 2013, Sir Brandon Lewis had expressed reluctance to pursue the idea of a national fire safety regulator1912 {HOM00046059/2}. because he was not attracted to the idea of introducing additional regulation.1913 Lewis {Day257/73:15-18}. He was more interested in making existing schemes more efficient1914 Lewis {Day257/72:15-25}. and devolving power away from central government.1915 Lewis {Day257/76:13-14}. However, given that the fire sector had failed to solve the problem of the competence of fire risk assessors since work on the matter had begun some years earlier, the basis of his optimism was not clear. His views appear to have been of the most general kind and not directed to the particular merits of introducing a national fire safety regulator.
212¶12.50 After that, there was very limited ministerial consideration of the risks to safety posed by the continuing problem of the lack of competence of some fire risk assessors. Louise Upton could not tell us why the proposals in her paper had not been discussed any further.1916 Upton {Day247/181:5-10}. Sir Brandon Lewis told us that the competence of fire risk assessors was not the most important matter the department had to consider1917 Lewis {Day257/86:14-17}. and that he was happy to defer to the approach suggested by officials as his focus was on other things.1918 Lewis {Day257/86:24}-{Day257/87:10}.
Further proposals: 2016 onwards
¶12.51 Mr Davis, however, remained concerned about the quality of fire risk assessments and competence of fire risk assessors.1919 Davis {Day246/186:22-25}. In January 2016, he and Neil Gibbins, then acting chief executive of the Institute of Fire Engineers, prepared a strategy note suggesting that the Fire Sector Federation establish a licensing system applicable across the sector to provide the public with an assurance that the holder was competent to perform the tasks covered by the licence.1920 {FSF00000420/1}.
¶12.52 In January 2016 responsibility for fire safety policy was transferred from DCLG to the Home Office and the team of officials responsible for fire safety policy moved to the new department.1921 Brandon Lewis {CLG00031121/5} page 5, paragraph 15. In June 2016 Sir Brandon Lewis MP became Minister of State for Policing and the Fire Service.1922 Lewis {Day257/10:25}-{Day257/11:3}. The change of department appears to have had little or no effect on policy relating to the competence of fire risk assessors and the previous concerns persisted right up to the time of the Grenfell Tower fire. On 8 June 2016, the coroner at the inquest into the death of Stephen Hunt, a firefighter who had died at a fire in Manchester in July 2013, wrote to Sir Brandon Lewis suggesting that the Secretary of State should consider measures to ensure the competence of fire risk assessors.1923 {HOM00033384}.
¶12.53 However, on 25 August 2016 a submission was sent up to Sir Brandon Lewis by officials the thrust of which was that the government had already taken action to ensure the competence and accreditation of fire risk assessors.1924 {HOM00043184/3} paragraph 7. The minister's reply to the coroner enclosed a paper written by the Chief Fire and Rescue Adviser which referred to the Competency Council guides but made no proposals for additional steps to be taken to ensure the competence of Fire Risk Assessors.1925 {HOM00043186}. The response was criticised by Matt Wrack, the General Secretary of the Fire Brigades Union, who asked why the steps taken by the department had failed to bring about an improvement and why no further proposals had been forthcoming.1926 {INQ00014699/5} section 9. He observed that, in the three years since the publication of the Guide to Choosing a Competent Fire Risk Assessor, there had been no steps to find out whether it had had any discernible effect.1927 {INQ00014699/5} section 9. That was a very fair question.
¶12.54 In his reply Sir Brandon said that the use of guidance was a recognised practice in relation to health and safety matters,1928 {INQ00014700/2}. a trite observation that failed to respond to Mr Wrack's point that, several years after the publication of the Competency Council's guidance, concerns about the competence of fire risk assessors remained. The fact was that despite those repeated concerns, the senior coroner's recommendation and Mr Wrack's pointed question, the department appears to have set its face against reconsidering whether mere guidance was capable of improving the competence of those who chose not to comply with it. That was so, even though those to whom it had looked for a cure for the problem had pointed out several years earlier that legislative intervention was required. The department gave no good explanation for its failure to act.
213¶12.55 There were further, unfortunately fruitless, attempts by the Fire Sector Federation to make progress on the problem. On 16 June 2016, the chairman, Brian Robinson, wrote to the Home Secretary expressing the Federation's concern about the competence of fire risk assessors1929 {CLG00035514/3}. and in October 2016, the Federation produced a further paper, entitled the Fire Competency Registration Scheme, which effectively repeated its earlier proposal for the introduction of a licensing scheme.1930 {HOM00043195}. Ms Upton did not recall having seen that document1931 Upton {Day248/6:3-6}. and it does not appear that the department took any action in response to it.
¶12.56 In the summer of 2016, Anthony Maude, the official from the department who had usually attended Federation meetings, retired.1932 Maude {CLG00034279/9} page 9, paragraph 36. No one from the department was sent to Fire Sector Federation meetings in his place1933 Upton {Day248/6:14-16}. and as a result regular contact with the Federation lapsed.1934 Upton {Day248/8:3-7}.
¶12.57 The weakness in the system was that although the Fire Sector Federation was active in discussing how to improve the competence of fire risk assessors, its views and recommendations were never taken seriously by the government.1935 Davis {Day246/179:7}-{Day246/180:11}. It is not surprising, therefore, that the initial enthusiasm and support for its work in that area waned over time.1936 Davis {Day246/179:9-20}. Whatever the merits of encouraging the sector to take effective steps to address a widely recognised problem, by 2016 it had become obvious that the Federation had not found any common ground with the government about the right answer to the problem of incompetence among fire risk assessors. By that time it should have been clear to the department that the Fire Sector Federation itself could not produce an answer. Given the scale of the risks resulting from the continued existence of incompetent fire risk assessors the government should have taken effective measures to regulate the industry. For no good reason, it failed to do so.
215Chapter 13: The Fire Safety Order
¶13.1 At the time of the Grenfell Tower fire, the scope of the Fire Safety Order was in some respects not clearly understood. Article 6(1) excluded from its scope "domestic premises", defined as "a private dwelling (including any garden, yard, garage, outhouse, or other appurtenance of such premises which is not used in common by the occupants of more than one such dwelling)."1937 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/6-7} Article 6(1)(a); The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/3-4} Article 2. The implication was that parts that were "used in common" were within the scope of the Fire Safety Order but the meaning of that expression was not defined. Discussion of the problem was not assisted by the preference of those involved to use related expressions, such as "common parts" or "common areas", instead of the statutory language.
¶13.2 On 11 December 2012, Ron Dobson, then the London Fire Commissioner, wrote to Sir Brandon Lewis, then Fire Minister, to make a number of recommendations about matters that had arisen in the course of the LFB's investigation into the fire at Lakanal House on 3 July 2009.1938 {CLG00000274}. The first two recommendations sought guidance on the meaning of the expression "used in common" in the Fire Safety Order.1939 {CLG00000274/1}.
¶13.3 On 6 February 2013, Louise Upton responded to Mr Dobson on behalf of the minister.1940 {LFB00032153}; Louise Upton {HOM00046040/14-15} pages 14-15, paragraphs 49 – 51. The thrust of the response was that the department did not think that the Fire Safety Order applied to the structure (i.e. the walls and roof) of a block of flats, but that guidance had been developed to help responsible persons to ensure the safety of tenants. Guidance had also been produced on risk assessment and the management of safety of residents in purpose-built blocks of flats. However, she did not suggest that the department would review or amend the existing guidance.1941 Lewis {Day257/40:3-23}; {LFB00032153}. On any view, there was at that time no clear consensus within the department about the meaning of the expression "used in common".1942 Louise Upton {Day247/131:9-22}.
¶13.4 The same uncertainty emerged in the context of the Lakanal House inquests. In her letter to the Secretary of State the coroner said that there was uncertainty about the scope of inspection for fire risk assessment purposes that should be undertaken in relation to high-rise residential buildings and in particular whether it was necessary to inspect the interior of flats to enable the fire risk assessor to identify potential breaches of compartmentation.1943 {HOM00045865/2}. She therefore recommended that the government provide clear guidance on the definition of "common parts" of buildings containing multiple domestic premises, the need for inspection of flats that had been modified internally to determine whether compartmentation had been breached and the need for inspection of a sample of flats to identify possible breaches of compartmentation. It was plain, therefore, that the coroner thought that there was uncertainty surrounding the interpretation of the Fire Safety Order, despite the existence of the guidance.1944 Louise Upton {Day247/136:1-8}; Lewis {Day257/51:24}-{Day257/52:10}.
216¶13.5 In her submission to the Secretary of State, Ms Upton said that the LGA planned to undertake a quick review with the housing sector to ensure that the existing guidance adequately addressed the matters the coroner had raised.1945 {HOM00004403/2}. She appears to have thought that the review would consider whether the phrase "used in common" needed definition.1946 Louise Upton {Day247/147:3-19}.
¶13.6 Ms Upton accepted that the department should have done more to advise ministers that the definition needed to be clarified and that by not taking the opportunity presented by the coroner the government had buried its head in the sand.1947 Louise Upton {Day247/143:3-20}. She thought that the only way to resolve the problem was by amending the legislation, but that was not practicable because of the deregulatory agenda.1948 Louise Upton {Day247/143:3-20}. She explained that informal internal discussions had made it clear that at that particular time amending the Fire Safety Order was a task that was too difficult to take on.1949 Louise Upton {Day247/154:2-6}. However, ministers were never asked whether a review of the legislation could be undertaken and none of them explicitly refused to consider a review of the Fire Safety Order.1950 Louise Upton {Day247/152:5}-{Day247/154:10}; {HOM00046067}; {HOM00004403}.
¶13.7 On 20 May 2013, the Secretary of State responded to the coroner's letter in the terms proposed in the draft enclosed with Ms Upton's submission.1951 {HOM00046077/1-2}. He said that he considered that the LGA Guide was appropriate to assist responsible persons in discharging their duties under the Fire Safety Order.1952 {HOM00046077/1-2}. He also mentioned the forthcoming review by the LGA and told the coroner that it would consider whether the matters she had raised held any implications for the guidance that might need to be included in a revised version.1953 {HOM00046077/1-2}.
¶13.8 The review conducted by the LGA did not expressly consider whether guidance on the meaning of the expression "used in common" was needed.1954 {CST00005484}. The Secretary of State's letter to the coroner had said that the department considered that the Guide provided sound advice and the Association asked consultees only whether they were satisfied that the matters raised by the coroner in her Rule 43 letters were adequately addressed by the existing guidance.1955 {CST00005484}. On any view, the terms of the consultation did not encourage a full and frank expression of views by consultees and tended to suggest that the department had already made up its mind. Consultees were given 13 days to respond.1956 {CST00005484}. In June 2013, Louise Upton was told by Eamon Lally of the LGA that the review had elicited little response from consultees but that the guidance had received very robust endorsement from its authors.1957 {HOM00046074/3-4}; Louise Upton {HOM00046040/11} page 11, paragraph 39. Ms Upton should have treated that self-serving endorsement with scepticism and should have scrutinised the review. She did not do so and was unconcerned by the absence of any significant response from the consultees.1958 Upton {Day247/157:3-16}. She assumed that, given the generally vocal nature of the sector, silence indicated satisfaction.1959 Upton {Day247/159:9-14}; Louise Upton {HOM00046040/11} page 11, paragraph 39.
217¶13.9 Given the terms of the letter and the short duration of the review, the absence of any significant response is unsurprising. On any view, it was inappropriate for Louise Upton to rely solely on the endorsement of the Guide's authors, who could not have provided the degree of independent scrutiny required to respond adequately to the coroner's concerns. The LGA review also received scant attention from ministers. Although Lord Pickles expected the matter to return to the minister responsible for fire safety,1960 Pickles {Day261/125:6-9}. Sir Brandon Lewis could not recall having been made aware of the outcome of the review.1961 Lewis {Day257/59:7-11}.
¶13.10 The members of the LFB's Lakanal House Working Group were dissatisfied with the department's response to the Commissioner's letter, which they thought had not answered his questions.1962 Dexter {Day179/145:5-11}; Dobson {Day211/17:9-25}. Rita Dexter thought that the Lakanal House inquest and the coroner's rule 43 recommendations had provided both the impetus and the opportunity to write again to the department to repeat what the LFB had discovered in its investigation of the Lakanal House fire and its concerns.1963 Dexter {Day179/149:3-13}. Accordingly, on 26 September 2013, Ron Dobson wrote again to Sir Brandon Lewis to take up the response that the department had provided in its letter of 6 February 2013.1964 {LFB00032149}.
¶13.11 In his letter the Commissioner said that the meaning of the Fire Safety Order required further attention on the part of the department.1965 {LFB00032149/2}. He told us that the LFB had encountered difficulties in bringing prosecutions where it considered the Fire Safety Order was not being complied with because of the confusion about what parts of a building were and were not within its scope.1966 Dobson {Day211/20:23}–{Day211/21:9}.
¶13.12 The department's response, sent by Sir Brandon Lewis on or around 16 October 2013, did not expressly refer to the request for guidance,1967 {LFB00058999}. but it alluded to it, saying that officials were looking again at whether the department might be able to provide greater clarity in relation to residential buildings in multiple occupation to which both the Fire Safety Order and the Housing Act 2004 applied.1968 {LFB00058999/1}. The obvious conclusion to draw from that letter was that the department had decided to shelve the matter.1969 Also see Dexter {Day179/157:21}-{Day179/158:1}. No further action was taken by government until the enactment of the Fire Safety Act 2021.
219Chapter 14: The Local Government Association Guide
¶14.1 On 29 July 2011, DCLG on behalf of the Secretary of State published the Local Government Association (LGA) guide entitled Fire safety in purpose-built blocks of flats ("LGA Guide")1970 {HOM00045964}. pursuant to his obligation under article 50 of the Fire Safety Order.1971 {HOM00045964}; {HOM00046077/1-2}. The LGA Guide was published as part of the response to the Lakanal House fire, albeit before the hearings of the Lakanal House inquests that took place some two years later.1972 {HOM00000720}. It was recognised that there was a need for guidance on ensuring fire safety in purpose-built blocks of flats. The guidance, which had not previously existed, was directed at responsible persons, fire risk assessors and enforcing authorities.1973 {HOM00000720/3-4}; {HOM00045964/2-3}. The section entitled "Preparing for emergencies" contained guidance for the evacuation and assistance of disabled persons in the event of a fire. It recognised that there is likely to be a diverse range of physical and mental capabilities among the occupants of a general needs block.1974 {HOM00045964/119-120} paragraphs 79.8 - 79.9. The needs of vulnerable occupants were addressed in paragraphs 16.11–16.13, which recognised that older people and people with certain disabilities may have particular needs in responding to a fire.1975 {HOM00045964/25-26} paragraphs 6.11 - 6.13.
¶14.2 In the Phase 1 report, the Chairman recommended that the owner and manager of every high-rise residential building be required by law to prepare personal emergency evacuation plans (PEEPs) for all residents whose ability to escape may be compromised, such as persons with reduced mobility or cognition.1976 Phase 1 Report Volume IV paragraph 33.22(f). Disabled people were particularly affected by the speed and ferocity of the Grenfell Tower fire. In Phase 2, therefore, we explored why the LGA Guide advised landlords and responsible persons that it was usually unrealistic to plan for the evacuation and assistance in the event of a fire of disabled and vulnerable residents living in general needs blocks of flats,1977 {HOM00045964/120} paragraph 79.9. such as Grenfell Tower.
¶14.3 The department engaged the Local Government Improvement and Development Agency to draft the LGA Guide1978 Todd {CTA00000012/6} page 6, paragraph 30. and the agency delegated the work to C S Todd and Associates.1979 Todd {CTA00000012/4} page 4, paragraph 14. A project group was appointed by the agency to act as a steering group to oversee the content, monitor progress and contribute technical expertise.1980 Todd {CTA00000012/11} page 11, paragraph 48. The project group was ultimately responsible for the content of the publication.1981 Todd {CTA00000012/11} page 11, paragraph 48; Project Group Terms of Reference {HOM00000990}. Louise Upton from the Fire Safety policy team, Brian Martin from the Building Regulations team and Peter Wise from the Chief Fire and Rescue Adviser's unit, as well as housing policy officials, represented the department on the project group.1982 Louise Upton {Day248/9:9-25}. No disability specialists or representatives of organisations representing disabled persons were invited to join the project group.1983 Todd {Day168/133:22-25}. For full membership of the project group, see Project Group Meeting agenda for meeting on 5 April 2011 {HOM00018117}.
220¶14.4 The members of the project group also sat on a larger "reference group" that included representatives of organisations involved in the provision of housing in the local authority and voluntary sectors as well as representatives of the fire and rescue services.1984 Terms of Reference for the Reference group {HOM00001976}. The reference group was intended to act as a sounding board for the project, to gather views and to promote consensus on the contents of the guidance.1985 Terms of Reference for the Reference group {HOM00001976}. The department maintained oversight of the whole process and was a member of the reference group.1986 Todd {CTA00000012/6} page 6, paragraph 31; Louise Upton {Day248/10:11-20}. None of those who sat on the reference group was a disability specialist or a representative of an organisation representing disabled people. That appears to have been an oversight rather than a deliberate decision,1987 Louise Upton {Day248/11:3-18}. and the reference group did contain representatives from residents' associations and landlords.1988 Louise Upton {Day248/10:21}-{Day248/11:23}.
¶14.5 The draft document was subject to a detailed and wide-ranging consultation, the responses to which were then considered by C S Todd and Associates and the project group.1989 {HOM00018928/1}. However, neither the department nor C S Todd and Associates took any steps to ensure that the views of organisations representing the disabled and the vulnerable were sought.1990 Louise Upton {Day248/13:11-20}; Todd {Day168/108:17-25}. One of the key questions that arose from the consultation, to which attention had been drawn by many of the respondents, was how people with disabilities could escape from their flats in the event of a fire.1991 {HOM00018928/2}. In its response to the consultation, the Chief Fire Officers Association said that not to include advice on the evacuation of disabled people was a fundamental error.1992 {HOM00002660/7}.
¶14.6 On 22 June 2011, the project group considered the issues raised by the consultation but it is not clear whether that particular question was discussed.1993 Louise Upton {Day248/14:21}-{Day248/16:18}. In any event, a disability specialist or someone who could represent those who were disabled and vulnerable was not appointed to assist the project group.1994 Louise Upton {Day248/17:17-25}; Louise Upton {Day248/23:1-13}. Despite the views raised by the Chief Fire Officers Association, the project group did not seek to commission any research or embark upon a further round of consultations to examine ways of helping those who were unable to escape unaided.1995 Louise Upton {Day248/18:1-6}. As is plain from paragraph 79 of the LGA Guide, its response was either considered and rejected or simply ignored.
¶14.7 Another matter that was raised by the consultation was the provision of PEEPs. Consultees appear to have accepted that they were not appropriate in general needs housing but questioned whether the guidance should identify other means of reducing the risk to vulnerable people.1996 {HOM00018928/2-3}. C S Todd and Associates sought the views of the project group, which agreed that PEEPs were impracticable because of the difficulty of collating information and keeping the document up to date and the absence of staff who could help people to escape.1997 Todd {CTA00000012/17} page 17, paragraph 78; Louise Upton {Day248/21:1-9}.
¶14.8 After the LGA Guide had been published at the end of July 2011, Elspeth Grant, a director of TripleAconsult and a fire safety consultant who had worked with disabled people, wrote to Sir Merrick Cockell, the chairman of the LGA, on 23 August 2011 saying that paragraphs 79.9 to 79.11 of the LGA Guide encouraged readers to ignore the Fire Safety Order and to breach international and domestic law on equality and fire safety.1998 Letter from Elspeth Grant to Sir Merrick Cockell dated 23 August 2011 {HOM00019844/1}. She also said that the LGA Guide reflected an outdated viewpoint and was discriminatory.1999 Letter from Elspeth Grant to Sir Merrick Cockell dated 23 August 2011 {HOM00019844/2}.
221¶14.9 A copy of that letter was sent to Caroline Bosdet, who had been the project manager responsible for drafting the LGA Guide, who in turn sent it to Colin Todd asking him to draft a response. Copies were also sent to some other members of the project group, including Louise Upton, Brian Martin and Peter Wise.2000 Email from Caroline Bosdet to CSTA Office and others dated 29 August 2011 {CLG10004907/2}. Ms Upton told Ms Bosdet that she would be very interested in hearing the views of her organisation's lawyers, including any disability discrimination specialists,2001 Email from Louise Upton to Caroline Bosdet dated 12 September 2011 {CLG10004908/1}; Louise Upton {Day248/108:22}-{Day248/110:2}. but no lawyers or disability specialists were asked to comment.2002 Email from Louise Upton to Caroline Bosdet dated 12 September 2011 {CLG10004908/1}; Louise Upton {Day248/108:22}-{Day248/110:2}.
¶14.10 In her response Ms Bosdet told Ms Grant that the particular needs of people with disabilities and vulnerable people had been taken into account but that no practical solutions had been offered for evacuating disabled people from purpose-built blocks of flats.2003 Letter from Caroline Bosdet to Elspeth Grant (undated) {CLG10004932/2}. Although the response suggested that practical solutions had been sought, Colin Todd confirmed no one on the project group had asked stakeholders to suggest solutions to the problem.2004 Todd {Day168/137:22}-{Day168/138:18}. Nor is there any evidence that the department sought legal advice on whether Ms Grant's allegation of unlawful discrimination was well-founded or not. The response of the department to Ms Grant's letter was wholly unsatisfactory; it was, in effect, simply brushed aside.
¶14.11 In December 2011, BS 9991 Fire safety in the design, management and use of residential buildings – Code of practice was published.2005 {BSI00000059/2}. BS 9991 provided recommendations and guidance on the design, management and use of dwellings, including self-contained flats, to achieve reasonable standards of fire safety.2006 {BSI00000059/21}. It included recommendations and guidance on the management of fire safety throughout the life of a building and could be used in the assessment of existing buildings.2007 {BSI00000059/21}.
¶14.12 Section 9 of BS 9991 advised that those responsible for managing fire safety should take into account the full range of people who might use the premises, paying particular attention to the needs of disabled people,2008 {BSI00000059/145-146}. and Annex E pointed out that the UK has an ageing society and that there are therefore many people living in standard residential accommodation who have a range of impairments that could affect their ability to evacuate or follow procedures.2009 {BSI00000059/175}.
¶14.13 For present purposes, it is enough to note that the guidance in paragraphs 79.9 to 79.11 was concerned with what arrangements for the evacuation of disabled people could as a matter of practicability be made in general needs blocks of flats. It was not, therefore directly inconsistent with BS 9991, which drew attention to the need to pay particular attention to the needs of disabled people, but it was couched in language that suggested a very different approach. It is surprising and disappointing, therefore, that the department failed to recognise the difference and take steps to reconcile the two documents. In our view that was a significant oversight.
¶14.14 In July 2012, the LGA conducted an evaluation of the LGA Guide to assess how widely it was being used and how useful it was.2010 {HOM00023280}; Louise Upton {HOM00046040/10-11} pages 10 – 11, paragraphs 35 – 36. On 31 July 2012, Ms Upton was sent the draft report.2011 Louise Upton {Day247/138:23}-{Day247/139:5}; {HOM00023279/2}. It indicated that those who had used it considered the guidance to have been effective in improving fire safety of residents in purpose-built blocks of flats2012 {HOM00023280}. but gaps were identified in relation disabled and vulnerable persons.2013 {HOM00023280/11}. The report referred to a failure of the government to understand that disabled people could not escape from flats without help in the event of a fire and that more guidance was needed on the provision of PEEPs for residents known to have difficulty escaping or to be unable to escape.2014 {HOM00023280/11}. Those were similar to the concerns that had been raised by Elspeth Grant in August 2011.2015 {HOM00023280}; {HOM00019844}.
¶14.15 The department did take steps to develop guidance on the evacuation of disabled people living in sheltered or specialised accommodation, but considered it too difficult to find a solution to the problem posed by vulnerable persons who could not escape from purpose-built general needs blocks of flats without assistance.2016 Louise Upton {Day248/33:25}-{Day248/34:14}. Although the department recognised the concerns, it took the view that the risks to disabled people in general needs housing were far lower than the risks to those living in specialist accommodation or sheltered housing.2017 Louise Upton {Day248/34:4}-{Day248/35:8}.
¶14.16 In her submission of 13 May 2013 to the Secretary of State Ms Upton advised the minister that the department was content that the LGA Guide provided sound advice on both the process of fire risk assessment and the matters that housing providers should consider if they are to ensure an acceptable level of fire safety.2018 {HOM00004403/2} paragraph 7. That was based on the assessment carried out by the LGA and informal reports received by the department.2019 Louise Upton {Day247/142:4-18}.
¶14.17 In the present case it is difficult to see what additional measures the TMO could have taken to assist the evacuation of disabled residents once they had entered the common parts of Grenfell Tower, but one piece of advice that in our view requires reconsideration is paragraph 79.11, which states that in the case of a "general needs" block it is not realistic to expect the responsible person to hold information relating to residents with mobility or other conditions affecting their ability to escape in a way that enables it to be made available to the fire and rescue services, for example, in a premises information box. We have covered this more fully in Part 5, Chapter 46.
¶ISBN 978-1-5286-5080-9
¶(Volume 1 of 7) 7 volumes not available separately
5Part 3: The testing and marketing of products
7Chapter 15: Introduction to Part 3
¶15.1 Safety in the built environment depends in a large measure on designers being able to assess with confidence how particular materials and products will behave when incorporated into a building. Safety from fire, therefore, depends in part on knowing how materials and products react to fire. It is therefore essential that they be tested in accordance with appropriate methods and that if manufacturers make claims about their performance they are supported by reliable information about the results of those tests.
¶15.2 In his Phase 1 report the chairman found that the principal reason why the flames spread so rapidly up, down and around Grenfell Tower was the presence of aluminium composite material (ACM) rainscreen panels with polyethylene cores that acted as a source of fuel. He also found that the presence of polyisocyanurate and phenolic foam insulation boards behind the ACM panels, and perhaps components of the window surrounds, contributed to the rate and extent of vertical flame spread.
¶15.3 One might legitimately ask how products which had such a propensity to support fire were chosen for use in the refurbishment of Grenfell Tower, whether they had been subjected to appropriate testing and, if so, whether the results of the tests had been made available to those who specified their use. In this Part of our report, therefore, we examine the way in which the products principally involved in the fire were manufactured, tested and presented to the market. We have concentrated our attention on the two products that were most heavily involved in the fire, the Reynobond rainscreen panels and the Celotex RS5000 insulation. We have also examined closely the role of Kingspan K15 insulation. Although it was not used on the building in any quantity, the way in which it was tested and marketed created conditions that encouraged unethical practices in the supply of insulation for use on high-rise buildings.
¶15.4 Two aspects of the way in which products are typically presented to the market have attracted our particular attention. One is the distribution of marketing literature of the kind produced by most manufacturers, in which the product and the uses for which it is suitable are described. Marketing material of that kind was produced by the manufacturers of both insulation products and we pay particular attention to what it contained and the effect it is likely to have had on potential purchasers.
¶15.5 The other is the use of certificates of conformity certifying that the product complies with particular standards or the requirements of legislation or statutory guidance. Such certificates are issued by commercial bodies and are used by manufacturers to provide potential customers with a form of independent assurance that their products meet appropriate standards. As such, by the time of the Grenfell Tower refurbishment they had become a powerful marketing tool. We have examined certificates of compliance issued by the British Board of Agrément in respect of Reynobond 55 PE and Kingspan K15 and by Local Authority Building Control in respect of Celotex RS5000 and Kingspan K15.
¶15.6 For completeness we have included a short chapter in which we examine the testing and marketing of the cavity barriers used in the refurbishment and a further chapter in which we examine the part played by the United Kingdom Accreditation Service in monitoring the activities of the conformity assessment bodies with which we are concerned.
8¶15.7 Finally, we express our conclusions on the extent to which these interlocking parts of the system designed to ensure the safety of buildings, in this case from fire, failed to achieve the outcome reasonably to be expected of them.
9Chapter 16: Arconic - evidential matters
¶16.1 As the chairman found in the Phase 1 report,1 Phase 1 Report Volume I, paragraphs 6.11 to 6.16. the rainscreen panels used on the external walls of Grenfell Tower were aluminium composite material (ACM) with a polyethylene (PE) core. They acted as a source of fuel and were the principal reason why the fire spread so rapidly up, down and around the building.2 Phase 1 Report Volume I, paragraph 2.13(a). The material, which consisted of a 3mm sheet of polyethylene bonded between two 0.5mm sheets of aluminium,3 Phase 1 Report Volume I, paragraph 6.12. was manufactured in France and sold in the UK by Arconic Architectural Products SAS ("Arconic")4 Previously called Alcoa Architectural Products. under the product name Reynobond 55 PE.
¶16.2 Arconic sold Reynobond in the form of flat panels with a view to their being cut to size and fixed to buildings in one of two ways. Riveted fixing, as the name suggests, involved fixing a flat panel of an appropriate size and shape to an underlying frame with rivets. Cassette fixing involved scoring and folding the material into an appropriate shape and hanging it on concealed rails. In either case any necessary cutting, drilling or folding was carried out by a specialist fabricator. In this case Arconic sold the material to CEP Architectural Facades Ltd (CEP), a specialist fabricator, which made it into cassettes and sold it to Harley for installation as a protective rainscreen for the facade of Grenfell Tower. The colour was described as Smoke Silver Metallic Gloss 5000.
¶16.3 Reynobond 55 PE ACM panels were marketed in this country from early 2008 until after the Grenfell Tower fire with the support of certificate number 08/4510 issued by the British Board of Agrément (BBA) on 14 January 2008.5 {BBA00000047}. Arconic provided a copy of the certificate to Harley on 23 April 2014 specifically to support the use of Reynobond panels on the exterior of Grenfell Tower and Harley in turn passed it on to Rydon and Studio E.6 {RYD00003932}. Although Arconic did not itself cut or shape the panels for either of the fixing systems, the panels were subjected to fire performance tests only in their fabricated form and the BBA certificate applied to the panels in a fabricated form. We have seen no evidence of any fire performance testing to British or European standards of Reynobond 55 PE in the form in which it left Arconic's factory and we are not aware of the existence of any BBA (or other) certification of Reynobond 55 PE in its unfabricated form.
¶16.4 As the chairman concluded in the Phase 1 report, the external walls of Grenfell Tower did not comply with functional requirement B4(1) of the Building Regulations in that they did not adequately resist the spread of fire over the walls.7 Phase 1 Report Volume I, paragraph 26.6. In this Part of the report we examine the history of Arconic's fire safety tests on Reynobond 55 PE, what Arconic knew about the results and how that product came to be sold in this country at the time it was specified and supplied for use on Grenfell Tower. However, before we turn to the principal events in the later chapters in this Part it is necessary to say something about the process by which we obtained evidence from Arconic. That is because that evidence was materially incomplete.
10The French Blocking Statute
¶16.5 In January 2018, DLA Piper, Arconic's solicitors, wrote to the Inquiry to raise the issue of Article 1 bis of French Law No. 68-678 of 26 July 1968 (as modified in 1980), which is more commonly referred to as the French Blocking Statute ("the FBS"). That is a French law which provides:
"Subject to international treaties or agreements and applicable laws and regulations, any individual is prohibited from requesting, seeking or disclosing, in writing, orally or in any other form, documents or information of an economic, commercial, industrial, financial or technical nature, with a view to establishing evidence in foreign judicial or administrative proceedings or in relation thereto."
¶16.6 Article 3 imposes criminal sanctions for breach of the statute, which is punishable by a maximum of six months' imprisonment or a fine or both. It extends to both natural and legal persons.
The gathering of documents and witness statements
¶16.7 Arconic asserted that the statute prevented it from disclosing a large number of relevant documents to the Inquiry. It suggested that the Inquiry should try to reach an agreement with the French government to waive the prohibition imposed by the statute. Without conceding that the statute had the effect for which Arconic contended, in April 2018 the Solicitor to the Inquiry confirmed that there was no objection to Arconic's representatives contacting the competent French authorities with a view to facilitating a discussion between the Inquiry and representatives of the French Ministry of Justice.
¶16.8 Arconic was also content that the Inquiry should work with the Metropolitan Police Service to see whether a mechanism could be found to obtain relevant documents through the concurrent criminal investigation in a way that allowed them to be shared with the Inquiry. The Inquiry team thereafter worked closely with the police to assist them in obtaining witness statements and a significant volume of relevant documents.
¶16.9 In 2017 and 2019, the police obtained two European Investigation Orders, which enabled them to obtain relevant documents held by Arconic at its offices at Merxheim, France and to obtain witness statements from its employees. The documents and witness statements were then disclosed to the Inquiry by the police. Arconic's solicitors appear to have co-operated with the police in the preparation of witness statements and the police assisted the Inquiry's investigations by putting to witnesses questions proposed by the Inquiry and by obtaining further witness statements and documents and disclosing them to the Inquiry.
Obtaining evidence from Arconic's employees
¶16.10 On 25 November 2019 the Inquiry indicated that it proposed to call six current or former employees of Arconic to give evidence, three of whom were resident in France (Claude Wehrle, Claude Schmidt and Gwenaelle Derrendinger), one of whom was resident in Germany (Peter Froehlich) and two of whom were resident in the United Kingdom (Deborah French and Vince Meakins).
¶16.11 In May 2020, Arconic told the Inquiry that it would reconsider the applicability of the French Blocking Statute to the oral evidence of those witnesses in light of the decision by the Attorney-General to extend to legal as well as natural persons her undertaking that those who gave evidence to the Inquiry would not have their evidence used against them in any future prosecution in this country.
11¶16.12 In early June 2020, however, Arconic's solicitors again asserted that the evidence of the witnesses whom the Inquiry wished to call would engage the French Blocking Statute. Those witnesses included Deborah French, Vince Meakins and Peter Froehlich, even though they were not resident in France. They suggested that the Inquiry should seek the help of Her Majesty's Government to reach an agreement with the French Government in order to overcome the constraints of French law. As a consequence, the Inquiry sought the assistance from the Foreign, Commonwealth and Development Office to explore the possibility of an agreement between Her Majesty's Government and the French Government that would permit the witnesses to attend to give oral evidence to the Inquiry without risk of prosecution in France.
¶16.13 Those discussions took a number of months and resulted in a note verbale of 7 December 2020 from the French Embassy to the Foreign, Commonwealth and Development Office, a copy of which was received by the Inquiry on 8 December 2020, which stated that it was the opinion of the French government that the proceedings of the Inquiry did not appear to fall within the scope of Article 1 bis of the French Blocking Statute and that consequently the French authorities did not consider that it constituted an obstacle to the examination of Arconic's employees before the Inquiry. However, the note verbale also said that the statute did not confer any power on the French administration to remove a prohibition thereunder, and that the French courts alone had authority to interpret the criminal law. The note verbale did not go so far as to confer immunity from prosecution under the statute on Arconic's witnesses because the French government said it had no power to provide that. Accordingly, although Arconic's witnesses would have the protection of the Attorney General's undertaking in relation to the use against them of their evidence in a prosecution in England, they would not have the benefit of any protection in respect of a prosecution in France under the French Blocking Statute, which might be infringed by the giving of any information, whether it incriminated the witness or not.
¶16.14 Arconic disputed the position taken by the French Government in the note verbale and relied on an opinion it had obtained from an eminent French lawyer and a senior member of the Paris Bar, Maitre Noelle Lenoir.8 {ARC00000793}.
¶16.15 It was not possible for the chairman to decide at that stage whether witnesses who gave evidence to the Inquiry might expose themselves to a real risk of prosecution under the French Blocking Statute. He therefore decided that in the first instance orders for their attendance to give evidence should be made. Notices under section 21 of the Inquiries Act 2005 were duly served on Deborah French and Vince Meakins within the jurisdiction. They instructed solicitors, accepted service of the notices and duly attended to give evidence without challenge.
¶16.16 Mr Wehrle, Mr Schmidt and Ms Derrendinger all live in France. Mr Froehlich lives in Germany. The position in relation to them was rather different because, having taken legal advice, the chairman was satisfied that no legal mechanism existed to compel their attendance in this country. They were all asked to attend to give evidence voluntarily, or to give evidence by video-link from abroad, but with the exception of Mr Schmidt, who gave evidence by video-link from Merxheim on behalf of Arconic rather than in a personal capacity, none of them was willing to do so, relying on the advice of their lawyers and the existence of the French Blocking Statute. It is regrettable that in the face of a disaster in which so many people died they were willing to put the debatable requirements of French law above the interests of the survivors in discovering the true cause of their terrible experience. As a result, we were deprived of the opportunity to hear from Mr Wehrle, Mr Froehlich and Ms Derrendinger but we had their witness statements, the contemporaneous documents and the oral evidence of the other Arconic witnesses. Mr Schmidt initially demanded that he be allowed to give evidence only on certain conditions relating to its use, but he eventually dropped that demand and gave oral evidence in French by video-link through interpreters.
12¶16.17 The most important by far of the absent witnesses was Claude Wehrle. As will become clear, there are many questions on which his assistance would have been of very great help to us in understanding the documents or the things he said (or chose not to say) in his witness statement, but we are satisfied that even without the benefit of hearing from him the contemporaneous documents enable us to reach clear conclusions with a high degree of confidence.
13Chapter 17: Arconic's testing of ACM panels 1997 to 2006
¶17.1 The fire testing carried out by Arconic on various forms of ACM panels between 1997 and 2006 forms an important part of the background to its application for a BBA certificate. It is also relevant to the way in which it promoted Reynobond 55 PE in the years that followed.
January 1997: Reynobond 160 PE
¶17.2 Before the early 2000s, Arconic did not produce ACM panels with polyethylene cores. It manufactured coated aluminium sheets at its factory at Merxheim, in France, which it then sent to a sister company in the United States, Arconic Architectural Products LLC, previously Reynolds Metals Company, which bonded them to a polyethylene core made in the United States to form sheets of composite material. The finished sheets were then transported back to Arconic for storage at Merxheim.9 Schmidt {Day91/35:7-13}. We understand that the product, which was sold by Arconic from Merxheim, was known as Reynobond 160 PE. It was 4mm thick and comprised a 3mm core of low-density polyethylene sandwiched between two 0.5mm aluminium sheets.
¶17.3 In January 1997, Reynobond 160 PE was tested by Warrington Fire Research Centre in accordance with BS 476 Parts 6 and 7 and achieved results which enable it to be rated Class 0.10 {ARC00000355}; {ARC00000356}; {ARC00000357}.
¶17.4 In about 2000, Arconic began producing sheets of ACM material with a polyethylene core at its Merxheim factory.11 Schmidt {Day91/13:7-15}. It was sold by Arconic under the name Reynobond 55 PE.12 Schmidt {Day91/38:17}-{Day91/39:6}. "Reynobond 55 PE" was used when the aluminium sheets were 0.5mm. Other variants, such as Reynobond 33 PE, refer to a signage product with 0.3mm aluminium sheets. The reasons for changing the name of the product are not clear. There is evidence that Reynobond 55 PE was not in all respects the same as Reynobond 160 PE, or at least that the two were not directly comparable.13 Lane, Supplemental Phase 1 Report {BLAS0000011/33} paragraph 11.9.18; Lane, Phase 1 Report, Appendix O {BLAS0000036/103} paragraph O19.1.5. In particular, the core of the product manufactured in the United States was linear low density polyethylene (LLDP), whereas the core of the material produced by Arconic in France was low density polyethylene (LDP).14 Declaration of Kevin Juedeman {INQ00014554} (declaration from the civil proceedings against Arconic in the Eastern District of Pennsylvania, Case No 219-cv-02664-MMB) paragraphs 6, 8, 11. Mr Schmidt's evidence initially was that he believed that the two products were the same but ultimately accepted that the chemical compositions of Reynobond 160 and Reynobond 55 PE were different.15 Schmidt {Day91/12:22}-{Day91/13:15}; {Day93/10:3}-{Day93/11:10}; See also declaration of Kevin Juedeman {INQ00014554} (declaration from the civil proceedings against Arconic in the Eastern District of Pennsylvania, Case No 219-cv-02664-MMB) paragraphs 6, 8, 11.
14¶17.5 There were differences between the coatings of Reynobond 160 PE and Reynobond 55 PE16 Lane, Supplemental Phase 1 Report {BLAS0000011/30} paragraphs 11.9.1-11.9.18; Lane, Phase 1 Report, Appendix O {BLAS0000036/103} paragraph O19.1.5. and as a result the test data relating to Reynobond 160 PE did not apply to Reynobond 55 PE.17 Lane, Supplemental Phase 1 Report {BLAS0000011/30} paragraphs 11.9.1-11.9.18; Lane, Phase 1 Report, Appendix O {BLAS0000036/103} paragraph O19.1.5.
¶17.6 Mr Wehrle claimed that he had no reason to suppose that there was any material difference between the fire performance of Reynobond 160 PE and that of Reynobond 55 PE,18 Wehrle {MET00053190/14} page 14, paragraph 47. but we doubt that that can be correct. There is reason to believe that both the cores and the coatings of the two products were different and we do not think that it was reasonable for him to have assumed that the reaction to fire of the product installed on Grenfell Tower was the same as that of Reynobond 160 PE, which had been tested about 20 years earlier.
¶17.7 In any event, it was not appropriate for Arconic to rely on test data obtained in relation to a different product when assessing the performance of Reynobond 55 PE. That much is clear from BS 476-1019 That addresses 'Fire tests on building materials and structures' and consists of a 'Guide to the principles, selection, role and application of fire testing and their outputs' {BSI00001757/20}. and from the wording of Warrington Fire's report, which expressly provided that its results were applicable only to the specimens tested.20 {ARC00000355/3}; {ARC00000355/5}.
July 2006: Colin Southgate's warnings
¶17.8 On 26 July 2006, Colin Southgate, then the UK sales representative for Reynobond,21 French {MET00053162/2} page 2, paragraph 7. sent an email to Guy Scheidecker (a senior executive), Gérard Sonntag, Claude Wehrle and others at Arconic about the position in relation to the fire certification of Reynobond.22 {MET00064988/19}. In it he pointed out that Reynobond 160 PE had been certified in 1997 and that the certificate was due to expire in 2007 at the latest. He also pointed out that the certificate did not apply to Reynobond 55 PE with either a PVdF or Duragloss coating. He then admitted that Arconic had provided certificates that did not apply to the products being sold to see if that would keep customers happy and expressed concern that it was misleading the market in certain respects.
¶17.9 The document shows quite clearly that by July 2006 at the latest personnel at Arconic, including senior executives, were aware that it had no valid certification of the fire performance of Reynobond 55 PE with a Duragloss 5000 finish and that its marketing materials were apt to mislead customers into thinking that some Reynobond PE products (including those with a Duragloss 5000 coating) possessed certifications that they did not have. The following day, 27 July 2006, Mr Sonntag wrote to Mr Southgate,23 {MET00064988/20}. explaining that Arconic had asked Warrington Fire to carry out tests on Reynobond 33 PE and Reynobond 55 FR. No steps appear to have been taken to organise tests on Reynobond 55 PE, although Arconic was aware that the UK construction industry almost invariably purchased panels with PE cores.24 Derrendinger {MET00053191/4} page 4, paragraph 17; French {Day87/67:19-24}; {Day88/195:15-16}.
15¶17.10 In his statement, Mr Wehrle said that the results of the tests carried out on Reynobond 33 PE in 2006 had satisfied the requirements for Class 0.25 Wehrle {MET00053190/9} page 9, paragraph 34. That gave him confidence that Reynobond 55 PE would achieve the same classification, because it had thicker aluminium skins and a proportionally lower polyethylene content.26 Arconic Module 2 Closing Submissions {ARC00000770/22} paragraph 103; Overarching Closing Submissions {ARC00000797/37} paragraph 141. However, no one at Arconic explained what, if any, steps had been taken at that time to analyse the results of the tests on Reynobond 33 PE and apply them to Reynobond 55 PE. It seems unlikely that any such steps were taken but in any event the two products were different and test results on one could not be applied to the other. As Mr Schmidt accepted, the test reports relating to Reynobond 33 PE were simply irrelevant to Reynobond 55 PE.27 Schmidt {Day91/44:20}-{Day91/45:1}.
¶17.11 On 30 June 2017, in the wake of the Grenfell Tower fire, Claude Wehrle sent an email to Diana Perriah,28 {META00001104}. the President of Arconic Building and Construction Systems in the USA, attaching what he described as a list of all relevant certifications possessed by Arconic.29 {META00001106}. The list did not contain any reference to a test carried out on Reynobond 160 PE in 1997 or to a test carried out on Reynobond 33 PE in 2006, which suggests that Mr Wehrle did not think that either was relevant to products being sold by Arconic (including Reynobond 55 PE) at that time. In our view, his assertion that historic test data relating to Reynobond 160 PE was relevant to Reynobond 55 PE was simply an attempt to justify the sale of that product.
¶17.12 Indeed, the results of the separate European tests that Arconic had carried out on Reynobond 55 PE in late 2004 made it clear how that product would react to fire. Arconic knew very well that the earlier tests on other products to which we have referred above could not be relied on to market Reynobond 55 PE. We now turn to examine those tests.
European testing: 2004 to 2006
December 2004: Tests 5A and 5B
¶17.13 In December 2004, on the instruction of Arconic, the French national testing organisation for the construction industry, the Centre Scientifique et Technique du Bâtiment ("CSTB"), conducted tests on Reynobond 55 PE in accordance with the European testing regime. The European single burning item test (EN 13823) required the product to be tested in its fabricated form, that is, in riveted or cassette form, and each test to be conducted on at least three specimens.30 {BSI00000620}. See also Part 2, Chapter 5. The classification was derived from the mean of the results of the three samples. However, if the mean of those three results did not meet the required standard, two further specimens could be tested, in which case the highest and lowest results were excluded from consideration and the remaining three results used to determine the classification.31 {BSI00000620/15} Section 7. On 2 December 2004 CSTB conducted two EN 13823 tests on Reynobond 55 PE, one on a panel which had been fabricated for riveted fixing (Test 5A), the other on a panel which had been fabricated for cassette fixing (Test 5B). It is important to note that from the outset in 2004 Reynobond PE 55 was always tested by Arconic in one of the two ways in which it was intended to be used, riveted fixing or cassette fixing, and never as a simple sheet of material in the condition in which it left the factory. That was necessary because the single burning item test is a test on a product in the form in which it is designed to be used. If Arconic had wished to test the product in the condition in which it left the factory it could have done so in accordance with BS 476-6 and 476-7, but it did not choose to do so. That is a matter of some significance in the light of the way in which Arconic described Reynobond 55 PE to the BBA and its closing statement in the Inquiry.
16Test 5A
¶17.14 In Test 5A the riveted specimen achieved results that were, or appeared to be, consistent with European classification B-s2, d0.32 {ARC00000535}; {ARC00000358}. However, in April 2013, Mr Wehrle wrote in an internal email that the tests had not been "really reflective of the riveted system in general".33 {MET00064988/121}. In June 2016, he wrote in another internal email that Arconic had achieved Euroclass B for Reynobond 55 PE in rivet form by manipulating the test (in his words, ""arranging" the system to pass").34 {MET00064988/129}. We do not know what form the manipulation of the test took, but it seems clear that, by 2013 at the very latest, Mr Wehrle did not think that a B classification was truly representative of how the product in riveted form would typically behave.
¶17.15 Mr Schmidt accepted that it appeared that Mr Wehrle had known or suspected that the Euroclass B classification had not been honestly achieved.35 Schmidt {Day91/76:5-9}. There is further support for the view that the test had been manipulated in the fact that the end use condition was a minimum air gap of 50mm,36 Test 5A classification report dated 7 January 2005 {ARC00000358/4} paragraph 4.3. whereas in later tests it was reduced to 20mm, which was more realistic.37 Wehrle {MET00053190/19} page 19, paragraph 64; Email chain between Mr Wehrle and Maxine Bauer of CSTB of 1 July 2011 {MET00053158/184}. Mr Wehrle's emails to his colleagues had become very frank by 2013 and we consider that we are justified in placing a good deal of weight on what he said. We think it more likely than not that the original Test 5A for riveted panels, which was said to justify a European Class B classification, was in some respects not representative of how the product would be used in practice. The results were therefore unreliable, as Arconic was aware.
Test 5B
¶17.16 Test 5B, in which the specimen was fixed in cassette form, was stopped after 850 seconds because the heat release rate had exceeded 400 kW.38 {ARC00000536}. The test report recorded that the results could not be used but gave an idea of the way in which the product would behave in a fire.39 {ARC00000536/7}. In his witness statement Mr Wehrle said that he understood that those words meant that Arconic could not use the result to get a classification because it "did not reflect the product's real fire performance"40 Wehrle {MET00053190/15} page 15, paragraph 52. That strikes us as an odd way to read the report. It plainly meant that the results could not be used to obtain a B classification, but that the record of what had happened during the test provided an insight into the product's actual fire performance.
17¶17.17 Neither Mr Wehrle nor anyone else at Arconic attempted to discuss the result with CSTB or carry out any further tests on the product in cassette form.41 Wehrle {MET00053190/15} page 15, paragraph 52. Mr Wehrle said that everyone at Arconic was puzzled by the result but justified the decision not to carry out further tests by treating it as a rogue result and therefore unrepresentative. That conclusion was based mainly on the expectation that the product in cassette form would perform better than in the riveted form product because it had fewer exposed edges. Mr Wehrle said that no one else in the industry had obtained similar results, although he admitted that his understanding was based only on information in the public domain and what he had picked up in conversation.42 Wehrle {MET00053190/15} page 15, paragraphs 51, 53. The outcome was that Arconic's marketing, technical and management teams decided that it was permissible to claim that Reynobond 55 PE was Class B, whether in rivetted or cassette form, and no further testing in cassette form was considered at that time.
¶17.18 In our view, Arconic had no reasonable excuse for failing to confirm by further testing that the result of the only test it had carried out on the product in cassette form was indeed unrepresentative. If it had genuinely thought that to be the case, there was every reason to carry out further tests to establish that. Moreover, the expectation that cassette-fixed panels would perform better because they had fewer exposed edges ignored the fact that the aluminium skin had to be routed in order to enable them to be bent into shape, thereby increasing the total area of the exposed core. It also took no account of other factors that had the potential to affect the product's reaction to fire in cassette form, including its tendency to trap molten polyethylene and its greater propensity to deform and expose the core to the flame front because the skins are not mechanically fixed in place.
¶17.19 Mr Schmidt accepted that Reynobond 55 PE in cassette form never achieved a Class B classification.43 Schmidt {Day91/3:12}-{Day91/4:3}. In any event, Arconic knew from early 2005 that the only available test evidence indicated that Reynobond 55 PE in cassette form had the potential to react to fire in an extremely dangerous way and had failed to obtain any classification under the European standards. Despite that, Arconic persisted in telling the market that Reynobond 55 PE had been classed B-s2, d0 regardless of the form in which it was used.
¶17.20 In the period leading up to the Grenfell Tower fire Arconic carried out reaction to fire tests on various forms of its Reynobond product. In none of them did the product satisfy the requirements of Class B and the results as a whole demonstrated clearly that Test 5B had been anything but "rogue". Even if, contrary to our conclusion, Arconic had believed in early 2005 that the result of Test 5B was unrepresentative, by 2011 it knew very well that it was not.
¶17.21 Arconic did not disclose the results of Test 5B to any testing organisation, certification body or end user in the UK at any time before the Grenfell Tower fire. Mr Schmidt accepted that if the fire had not taken place it was likely that they would have remained secret.44 Schmidt {Day91/103:9-15}.
182003 and 2006 tests on Reynobond 55 FR (Riveted form)
¶17.22 In June 2003, Arconic arranged for Reynobond 55 with a fire-resistant core to be tested by Warrington Fire under BS 476-6 and BS 476-7. Taken together, the results of those tests were capable of supporting a national Class 0 classification for that product.45 Warrington Fire Research Test Report 132317 (BS 476-6 test) {BBA00000053} and Warrington Fire Test Report 132316 (BS 476-7 test) {BBA00000050}. Reynobond with an unmodified polyethylene core was not tested at that time.
¶17.23 In October 2006, Reynobond 55 FR in rivet form with a gold-coloured coating was tested by CSTB in accordance with the EN 13823 single burning item method and achieved a classification of B-s1, d0.46 CSTB – Reaction to Fire Classification Report RA06-0372 {BBA00008288}. Unsurprisingly, that was better than its PE equivalent. There is no evidence that Reynobond 55 FR was tested in cassette form at that time.
19Chapter 18: Obtaining a BBA certificate for Reynobond 55 PE
The application to the BBA: March to August 2006
¶18.1 By the mid-2000s, it had become commercially essential for Arconic to obtain a BBA certificate to enable it to sell Reynobond in this country. Arconic's relationship with the BBA had begun in 1987, when the BBA issued a certificate for Reynolux, a solid aluminium cladding panel manufactured by the company under its former name of Alcoa Architectural Products S.A.S.47 Initially issued in 1987, reissued in 2009 {BBA00008143}; Wehrle {MET00053190/42} page 42, paragraph 146. In March 2004 Arconic approached the BBA to certify its Reynobond product,48 BBA project number S3/35071 {MET00053158_P13/137-138}; {MET00053158_P13/139-140}; {MET00053158_P13/141-144}. but it did not pursue the process for reasons of cost.49 {MET00053158_P13/155}.
¶18.2 At a meeting in Luton on 21 March 2006, Colin Southgate discussed the UK marketing strategy for various products, including Reynobond, with Didier Scheidecker, Sales Manager for Reynobond. In his report of the meeting50 {MET00053158_P13/162-165}. Mr Scheidecker noted that an increasing number of enquiries related to public and private housing developments which he thought could represent 50% of the UK market in 2006.51 {MET00053158_P13/164} Item 5 under "BBA Approval". A BBA certificate was always required for such projects. He therefore asked whether Arconic could obtain BBA certification based on the approval by CSTB of its cassette version. (Since the test by CSTB of Reynobond 55 PE in cassette form had been a complete failure, that may have been a mistake for the riveted form.)
¶18.3 It seems clear, therefore, that Arconic had recognised that there was a significant potential market for Reynobond 55 PE in the UK and was intending to exploit it. It is also clear that its senior management appreciated that a BBA certificate was required in order to do so.
¶18.4 Arconic did not pursue its application to the BBA until 2 August 2006 when Mr Wehrle wrote again. He used the same form as on the previous occasion (wrongly dated 9 March 2004) and provided very similar information.52 {MET00053158_P13/166}. The form invited Arconic to provide any available test data relating to the product and pointed out that such information could result in a reduction in the cost of the certificate and the "duration" of the contract (probably meaning the time required to produce it).53 {MET00053158_P13/173}.
¶18.5 When he completed the form, Mr Wehrle said that Reynobond was available with two cores, PE (unmodified polyethylene) and FR (fire retardant).54 {MET00053158_P13/171} Section 2.1. He also referred to the tests carried out under BS 476 Parts 6 and 7 and referred to the Warrington Fire Centre reports.55 {MET00053158_P13/169} Section 1.3. He attached to the application two test reports,56 {MET00053158_P13/173} Section 3.1. each of which related to the fire retardant version of the product.57 Warrington Fire Test Reports 132316 and 132317 {MET00053158_P13/173} Section 3.1. Mr Wehrle also cited two CSTB Technical Assessments on Reynobond 55 PE, one in cassette form and the other in rivet form. They supported structural and system performance but were not relevant to any fire performance criteria recognised in the UK.
20¶18.6 Mr Wehrle completed the application to the BBA about a week after he received Colin Southgate's note of 26 July 200658 {MET00064988/19}. and his meeting with Gérard Sonntag the following day.59 {MET00064988/20}. He must therefore have known that Arconic did not have sufficient data to make claims about the reaction to fire of all variants and forms of Reynobond 55 and that the information he was providing to the BBA was incomplete and misleading insofar as it suggested that it applied equally to the product in its cassette form.
Negotiations between Arconic and the BBA
¶18.7 On 23 August 2006 the BBA formally offered to assess Reynobond 55,60 BBA project number S3/41014 {MET00053158_P14/100-101}; {MET00053158_P14/102-103}; {MET00053158_P14/104-105}. but despite its view that that a BBA certificate was increasingly important for UK sales,61 {MET00053158_P14/115}; {MET00053158_P14/131}. Arconic did not immediately accept the offer. Following negotiations, the BBA agreed to reduce the cost of the certificate and to accept the Technical Assessments issued by CSTB as the basis for it. (The BBA and CSTB were both members of the European Union for Technical Approval in Construction ('UEAtc'), a group of certification bodies whose assessments were generally carried out to a consistent set of standards, so that data produced by one member was acceptable to all others.)62 Gregorian {BBA00011096/2} page 2, paragraphs 8-9; Gregorian {Day105/27:6}-{Day105/28:3}. However, because the fire performance analyses in the Technical Assessments issued by CSTB were directed to the French national testing system rather than the British Standards applicable under the UK testing regime, the BBA also required test reports from Warrington Fire Research on the product's fire performance. In his note of the meeting in November 2006 Mr Southgate recorded that the BBA would need certificates from Warrington Fire relating to the "PE Cores". It therefore appears that the BBA had asked for fire test data relating to Reynobond with both unmodified polyethylene and fire-resistant cores.63 {MET00053158_P14/115}.
¶18.8 At a meeting between Arconic and the BBA at the latter's premises on 2 November 2006, Colin Southgate of Arconic suggested that it might be better for the certificate to apply to Reynobond as a material rather than the rainscreen system as a whole, since (in the words of his note) that would enable a "cross connection to be put together".64 {MET00053158_P14/115}. The meaning of that part of his note is not entirely clear, but he seems to have been suggesting that the BBA should be asked to certify Reynobond 55 PE generally, without regard to the differences in fire performance between the rivet and cassette forms. By "cross- connection" we think that Mr Southgate had in mind that Arconic could use a certificate that did not refer to the method of fixing in relation to both the riveted and cassette forms without distinction, and in the event, the BBA eventually agreed to provide a certificate for Reynobond without linking it to any particular fixing system. It was envisaged that different fixing systems would simply be mentioned in the certificate.65 {MET00053158_P14/131}. It is fair to point out that at that stage the BBA had yet to embark on an assessment of the product.
21¶18.9 Warrington Fire Research had not tested Reynobond 55 PE panels in accordance with BS 476 Parts 6 or 7. It had tested only Reynobond FR in accordance with those methods, and those were the only British standard tests to which Arconic had referred in its application form.66 {MET00053158_P13/173}. See penultimate row in table of test data. Arconic possessed no relevant European standard test data in relation to Reynobond 55 PE in cassette form, apart from Test 5B carried out in December 2004, in which the product performed so disastrously that the test had to be stopped.67 {ARC00000536}.
¶18.10 There is no indication that Arconic disclosed to the BBA that Reynobond 55 PE in cassette form had performed so badly or that it had reason to believe that the fire performance of the product in cassette form was significantly worse than in riveted form. On the contrary, Arconic succeeded in persuading the BBA that the certificate could properly relate to Reynobond as a generic product without distinguishing between the different fixing systems. In doing so, it deliberately and dishonestly concealed from the BBA the fact that, as Test 5B had shown, its reaction to fire was significantly affected by the fixing system adopted.
¶18.11 At that time, some of those at the BBA knew that altering the shape of a product could materially affect its fire performance. John Albon, then Section Head of a different department at the BBA, understood that particularly well,68 Albon {Day109/143:18}-{Day109/144:9}. although he did not become responsible for the technical content of certificates until 2009.69 In 2006 John Albon was Section Head of the Materials department, but he came to be Technical Manager responsible for the technical content and correctness of all BBA certificates in 2009 and later Head of Approvals for Construction Products, Albon {BBA00010723/3} page 3, paragraphs 11-12. However, at the time of the negotiations with Arconic in 2006 the BBA agreed to assess Reynobond as a generic product in the form in which it left the factory, even though it knew that it would have to undergo fabrication to some extent before it could be used for the purpose for which it had been manufactured.70 Gregorian {Day105/58:3-20}. At that stage no thought appears to have been given by the BBA to the fact that it might perform in different ways depending on the nature of the fabrication and the system of fixing adopted, even though separate test evidence was provided on the structural integrity of the cassette and rivet versions.71 {MET00053158_P13/173}; Gregorian {Day105/59:3-20}. Nor does anyone appear to have attached any importance to the fact that it was not possible to test the product's reaction to fire in an unfabricated form in accordance with EN 13823, which would be necessary to obtain a European standard classification.
¶18.12 Mr Albon said that it was for the client to determine precisely what would be assessed as part of the certification process and that the BBA would not resist that unless it had good reason to do so.72 Albon {Day109/127:25}-{Day109/128:10}; {Day109/128:24-}-{Day109:129:2}; See also assessment flowchart which includes a step of "Suitability of product and use considered" {BBA00008042/17}. Hamo Gregorian, a Project Manager in the BBA's engineering systems department who managed the initial assessment of Reynobond 55 and attended the meetings with Arconic in November 2006 and February 2007, told us that the BBA's policy was generally to approve a product, such as a cladding panel, rather than a system, because the BBA could exercise more control over the quality of a product than a system.73 Gregorian {Day105/48:5-18}; {Day105/57:16-23}. Mr Gregorian's evidence, which we accept, was that assessment of fire performance for certification was not his area of expertise and that all such matters were checked by a fire expert or agreed in consultation with the BBA's Technical Manager, Brian Haynes, who had relevant experience and knowledge.74 Gregorian {BBA00011096/3} page 3, paragraph 10; {Day105/12:20-25}; {Day105/23:9-19}; {Day105/69:4-16}. At all events, the potential effect of the different configurations on the fire performance of the product was overlooked by the BBA at that early stage in the certification process.
22Arconic's contract with the BBA: March 2007
¶18.13 On 26 February 2007 Arconic submitted a fresh application to the BBA for certification of Reynobond 55 that was largely based on the form used in August 2006.75 {BBA00008042/13-35}. In section 3 of the form Arconic was expected to set out all data relevant to the product and its use produced during the previous three years. In relation to fire performance it referred, as it had on the previous occasion, only to the results of the tests carried out by Warrington Fire in accordance with BS 476-6 and 476-7 on Reynobond 55 with a fire-resistant core.76 Tests numbered 132316 and 132317 {BBA00008042/29}. It made no mention of the results of any test on Reynobond with an unmodified polyethylene core. Nor did it refer to the results of any fire test which showed that there might be a difference in performance between the cassette and riveted forms of the product. However, the tests on Reynobond with a polyethylene core, in both riveted and cassette forms, that had been carried out in December 2004 fell within the three-year period contemplated by the form, with reports issued by CSTB in January 2005.77 {ARC00000535}; {ARC00000358}; {ARC00000536}. Those omissions can only have been deliberate.
¶18.14 On 23 March 2007 the BBA entered into a contract with Arconic to provide certification for the product.78 BBA project number S3/41014 {BBA00008042/2-5}. In the final version of the contract handwritten amendments were made to the name of the product substituting "Reynobond Architecture" for the original reference to "Reynobond 55". The description of the product was also changed from the original "Aluminium/polyethylene composite wall cladding system" to "Aluminium/polyethylene composite wall cladding panels" (our emphasis). That amendment reflected the agreement with Arconic that the certificate would refer to the product without identifying the system of fixing to be used.79 Gregorian {Day105/64:2-21}.
¶18.15 Under the BBA's standard terms and conditions Arconic was obliged to disclose to the BBA full particulars of the product, including particulars of any test data already available and the test procedures used to obtain them.80 {BBA00008042/3} clause 7(a). Arconic was also obliged to notify the BBA immediately of any change in the particulars supplied to it and any new or additional information it obtained concerning the product or its suitability for use.81 {BBA00008042/3} clause 7(g).
¶18.16 Under its standard terms the BBA had the power to withdraw or suspend any certificate if Arconic breached the contract terms, if there were any change in the technical specification of Reynobond, if any information became available that was not at the disposal of the BBA at the time the certificate was issued or if there were any change in its description, including its physical or chemical composition.82 BBA Standard terms clause 13 (a)-(c) {BBA00008042/4}.
23Arconic's further provision of test data to the BBA: May to November 2007
¶18.17 On 15 May 2007 Hamo Gregorian asked Claude Wehrle to provide reaction to fire data for the standard PE panel, by which he meant the version with an unmodified polyethylene core, and warned him that a French national classification (as used in the CSTB Technical Assessments) was not recognised in the UK.83 Gregorian {Day105/95:5-10}. Mr Gregorian said that if such evidence was not available Arconic would need to arrange for further testing to be carried out. Mr Gregorian noted that fire test reports for the product with a fire-resistant core had been submitted with the application.84 Mr Gregorian's reference to FR product tests in this correspondence is likely to be to Warrington's BS 476-6 and BS476-7 testing reports from September 2003, numbers 132316 {BBA00008042/163-175} and 132317 {BBA00008042/177-191} which were cited in each of Arconic's applications to the BBA and probably appended to them. However, Mr Gregorian did not ask for separate test evidence relating to the cassette form of the standard product and appears to have been content to accept the results of tests on the riveted form as applicable generally, without making it clear that they had been obtained only from tests on that particular form of the product. That was despite the fact that the classification report issued by CSTB stated that the European classification B-s2, d0 applied only to the riveted form.85 {ARC00000358/4}.
¶18.18 Mr Gregorian told us that he regarded the manner of fixing as irrelevant because the BBA was assessing only the product, by which he meant the product as it emerged from the factory.86 Gregorian {Day105/98:20}-{Day105/99:2}. However, that was a fundamentally unsound approach, and not consistent with what the certificate stated. The BBA should have appreciated not only that the fire performance of the product could be tested only in one or other of the fixing configurations and might differ depending on which was adopted, but also that the proposed certificate would be making statements about fire performance which covered both fixing systems. In our view the BBA should not have been willing to give a certificate for the product in its unfabricated form because, as it was aware, that did not represent the condition in which it was designed to be used. As a result, a certificate that did not take into account the method of fixing was likely to be misleading in some, if not all, cases. The BBA should have been aware when it entered into the contract that the fire performance of the product might be affected by the method of fixing adopted, but if it did not, it should have become aware of that by the time it issued the certificate.
¶18.19 On 25 May 2007 Mr Wehrle sent Mr Gregorian a copy of the results of Test 5A.87 {MET00053158_P15/90}. He did not provide the BBA with any test data relating to Reynobond 55 PE in cassette form, let alone the results of Test 5B.
¶18.20 Mr Wehrle sought to justify the decision not to provide the BBA with test data relating to Reynobond 55 PE in cassette form on the grounds that Test 5B related to a single sample and was not a valid classification report.88 Wehrle {MET00053190/48} page 48, paragraph 177. However, Arconic's contract with the BBA required it to disclose particulars of any test data available.89 BBA Standard terms clause 7(a) {BBA00008042/3}. Mr Wehrle also suggested that Arconic relied on the BBA to ask for any additional information it required,90 Wehrle {MET00053190/17} page 17, paragraph 59. but that is no justification for ignoring the terms of the contract. In any event, we regard Mr Wehrle's suggestion as disingenuous. First, in his email of 15 May 2007 Mr Gregorian had actually asked for reaction to fire data for the standard PE panel, without distinction between riveted and cassette forms. Secondly, Arconic had not told the BBA that Arconic had tested Reynobond 55 PE in cassette form and it follows that the BBA was not aware that any such data existed. Mr Wehrle could not have understood Mr Gregorian's request as limited to test data for the riveted form. Thirdly, Mr Wehrle described the results of Test 5A that he attached to the email he sent Mr Gregorian on 25 May 2007 as "the fire reaction certificate for our product Reynobond PE", implying that there was only one test result. That was deliberately misleading. The reality is that Mr Wehrle withheld Test 5B from the BBA, despite its obvious importance both to the BBA and to the UK market, because it showed that the fire performance of the product when used in cassette form was very significantly worse than when used in the riveted form covered by Test 5A.
24¶18.21 If Mr Wehrle had given evidence in person he would have had an opportunity to respond to the suggestion that he deliberately and dishonestly misled the BBA into thinking that Arconic held no results of any test of the product in cassette form. As it is, we have not had the benefit of hearing his response. Nonetheless, the evidence we have seen, which includes his statement, leaves us in no doubt that that is what he did. Our conclusion is reinforced by the fact that in none of its lengthy written or oral statements to the Inquiry did Arconic seek to suggest otherwise.
¶18.22 On 29 November 2007, Mr Gregorian asked Mr Wehrle to provide test data in respect of the fire performance of the back face of Reynobond 55 PE panels.91 {MET00053158_P16/134}. In response, Mr Wehrle sent Mr Gregorian a report from CSTB classifying Reynolux (an aluminium sheet coated with a polyester finishing coat) under EN 13501 as Class A1.92 {BBA00008042/139}. He justified that on the basis that similar coatings were applied to the front and back skins of Reynobond 55 PE.93 {MET00053158_P16/136}. It is not clear why Mr Wehrle sought to support an application for a BBA certificate concerning Reynobond 55 PE, an ACM panel product, with test data relating to an entirely different product which was not ACM. It is possible that Arconic thought that, because BS 476-6 is the method for testing the fire propagation index of the surface of a product, there was a useful analogy between the test on Duragloss-coated aluminium and Reynobond 55 PE, or that it simply left it to the BBA to ask for further information. It is equally possible that that was another step in the deliberate concealment from the BBA of relevant fire performance test data with a view to obtaining a useful certificate from the BBA for Reynobond PE 55. We cannot reach a firm conclusion on that point, given the possibility of an innocent explanation, but it is another matter on which Mr Wehrle's assistance would have been helpful if he had chosen to give evidence.
Drafting and issue of the BBA certificate: October 2007 to January 2008
¶18.23 By September 2007, Arconic, and Mr Wehrle himself, were well aware that many in the construction industry were seriously concerned about the fire safety of ACM with an unmodified polyethylene core. That knowledge ought to have led Arconic to ensure that the text of the BBA certificate was clear, accurate and complete.
¶18.24 Several drafts of the certificate were produced before it was issued. On 22 October 2007, Mr Gregorian provided Mr Wehrle with what was described as a "working draft" and invited Arconic to comment on its contents.94 {MET00053158_P15/188}. He specifically asked Arconic to provide any information that was missing but would be helpful to the user and any proposed amendments to information that Arconic considered to be inaccurate. Claude Wehrle reviewed the certificate at least three times and asked Hamo Gregorian to include some specific wording.95 Claude Wehrle reviewed drafts of the certificate in October 2007 {BBA00008042/535}; November 2007 {BBA00008042/515-517} and December 2007 {BBA00008042/465}. On each occasion, Mr Gregorian accepted Mr Wehrle's proposed text.96 Hamo Gregorian accepted Arconic's comments in November 2007 {BBA00008042/529} and {BBA00008042/511} and in December 2007 {BBA00008042/459-61}, {MET00053158_P16/149}.
25¶18.25 On 7 January 2008, shortly before the certificate was issued, Mr Wehrle also circulated a draft to Colin Southgate and Deborah French, Arconic's UK sales representatives for Reynobond at the time.97 {MET00053158_P16/167}; {MET00053158_P16/165}. Mr Southgate proposed further text which was also incorporated into the certificate.98 {MET00053158_P16/167}; {BBA00008042/463}.
¶18.26 The BBA certificate was issued on 14 January 2008. We consider its contents in detail in Chapter 19. For present purposes it is enough to note two features: first, that it declared that "the panels may be regarded as having a Class 0 surface in England and Wales";99 {BBA00000047/3}. secondly, that it expressly covered the product when used in both forms, riveted and cassette, without distinction or qualification.100 {BBA00000047/2} Figure 1.
27Chapter 19: The BBA certificate for Reynobond 55 PE
The product
¶19.1 BBA certificate 08/4510 related to "Reynobond Architecture Wall Cladding Panels."101 {BBA00000047}. They were described as
" . . . two 0.5 mm thick aluminium alloy sheets . . . bonded to either side of a core of low-density polyethylene (LDPE)."
¶The description continued as follows:
"The panels are available either plain-edged (riveted system) or flanged (cassette system), to suit architectural requirements (see Figure 1). A Duragloss or PVDF coating available in various colours protects the exposed face. A polyester primer protects the unexposed face. The products are also available in a fire-retardant grade (FR)."
¶19.2 Figure 1 showed what were said to be typical fixing systems and depicted the riveted and cassette versions. Otherwise, however, the certificate referred to the panels without any distinction between the two forms of fixing. Any reader of the certificate would therefore naturally understand that the performance of the panels, whether FR or PE, was not affected by the fixing system adopted.
¶19.3 As will become clear, at the request of Arconic the product was described in the form in which it left the factory. That blurred the distinction between the fire performance of the panels once fabricated into either riveted or cassette forms. It was wrong to say that the panels were "available" plain-edged or flanged, which suggested that Arconic supplied them in both forms. That increased the potential for confusion.
¶19.4 It is clear from the discussions that took place in 2007 that that had been Arconic's intention. What the BBA did not know, but Arconic did, was that the choice of fixing method made a significant difference to the fire performance of the product in use, as revealed by Tests 5A and 5B.
¶19.5 Arconic had chosen to withhold the results of Test 5B from the BBA and did not disclose that a separate test of the product in cassette form had taken place. Arconic was legally obliged under the terms of its contract with the BBA to provide it with the results of Test 5B. As a result of its decision not to do so, the BBA certificate was thoroughly misleading, because it failed to draw a distinction between the two fixing systems in relation to fire performance. Mr Schmidt was constrained to accept that the failure to make clear in the certificate that the B classification was obtained only in rivet form rendered the certificate wrong and such as to lead the reader into error.102 Schmidt {Day92/73:9}-{Day92/74:14}; {Day94/59:1}-{Day94/60:1}; {Day94/63:23}-{Day94/64:17}.
28¶19.6 In both its evidence and its statements to the Inquiry, Arconic asserted that it was the responsibility of the designer in each case to ensure that Reynobond 55 PE was suitable for the use to which it was to be put and complied with any applicable regulations.103 Schmidt {MET00053187/29} page 29, paragraph 90-93; Wehrle {MET00053190/11} page 11, paragraphs 40‑41; Froehlich {MET00053197/9} page 9, paragraph 33; Derrendinger {MET00053191/16} page 16, paragraph 41; {ARC00000770}. That is obviously correct up to a point but it assumes that the information required to make the decision is available to the designer. The primary purpose of a BBA certificate is to provide the designer with confirmation that the information it contains provides a suitable basis for making that decision. In the present case Arconic's argument ignores the fact that it withheld important information from the BBA and thereby caused the certificate to misrepresent the true position. Arconic knew that a BBA certificate was required to enable it to sell Reynobond 55 PE in this country precisely because designers considered it to contain reliable information about the characteristics of the product. It also knew that a designer reading the certificate would understand from the way it was worded that Reynobond 55 PE had been classed B-s2, d0 in European fire tests regardless of the fixing system adopted.
Behaviour in relation to fire
Section 6.1
¶19.7 The second sentence of section 6.1 of the certificate read as follows:
"A fire retardant sample of the product, with a gold-coloured Duragloss finish, when tested for reaction to fire, achieved a classification B-s1, d0 in accordance with EN 13501 : 2002."104 {BBA00000047/5}.
¶19.8 The statement was supported by CSTB classification report No. RA06-0372 issued on 19 October 2006 for Reynobond FR tested in riveted form.105 Report RA06-0372 {BBA00008042/155-162}. Claude Wehrle suggested that the BBA should specifically refer to this result in the certificate and the BBA agreed.106 {MET00055859}; {BBA00008042/515}. However, like the classification report for Test 5A, the report stated in terms that the classification was applicable only to Reynobond FR in a riveted form. It is plain that it could never have been used to support a certificate for Reynobond PE, whether in riveted or cassette form.
Sections 6.2 and 6.3: Class 0
¶19.9 Section 6.2 of the certificate provided as follows:
"A fire retardant sample of the product, with a metallic grey PVDF finish, when tested in accordance with BS 476-6: 1989, achieved a fire propagation index (I) of 0 and, when tested in accordance with BS 476-7 : 1997, achieved a Class 1 surface spread of flame."107 {BBA00000047/5}.
¶19.10 Warrington Fire's test reports on Reynobond FR panels supported that statement.108 Numbered 132316 {BBA00008042/163-175}; numbered 132317 {BBA00008042/177-191}. Taken together, they established that the FR version of the panels had achieved Class 0. However, Arconic had never provided the BBA with any reports which showed that Reynobond PE had achieved or could achieve Class 0. During the assessment process, Arconic sent the BBA product literature which claimed that both Reynobond FR and Reynobond PE had achieved Class 0109 Product Information brochure dated January 2005 {BBA00008042/39-81}; fire classifications {BBA00008042/43}; Discover New Perspectives marketing brochure dated November 2005 {BBA00008042/83-104}; fire classifications {BBA00008042/101}. but Arconic had no evidence to support the claim made about the PE product. Arconic's marketing brochure dated November 2005 headed 'Discover New Perspectives' also claimed that Reynobond PE had achieved Class 0 because of tests carried out by Warrington Fire Research in 1997,110 These were tests 70707 and 70708 {BBA00008042/83-104}; fire classifications {BBA00008042/101}. but reports of those tests were never provided to the BBA and, in any event, they had been carried out on a different product, Reynobond 160 PE.
29¶19.11 At section 6.3 the certificate provided:
"As a consequence of sections 6.1 and 6.2, the products may be regarded as having a Class 0 surface in relation to the Approved Document B of The Building Regulations 2000 (as amended) (England and Wales) …"111 {BBA00000047/5}.
¶19.12 Similar wording was contained on the front of the certificate. Under the heading 'Key Factors Assessed' the certificate stated as follows:
"Behaviour in relation to fire – in relation to the Building Regulations for reaction to fire, the panels may be regarded as having a Class 0 surface in England and Wales… (see section 6)."112 {BBA00000047/1}.
¶19.13 This important part of the BBA certificate requires detailed consideration taking into account the evidence of the BBA, the statements of Mr Wehrle and the submissions of Arconic.
The BBA's evidence
¶19.14 John Albon said that the words "may be regarded as having a class 0 surface" were not intended to mean that the panels actually achieved that standard; they simply reflected the position in Diagram 40 of Approved Document B in which both Euroclass B and Class 0 materials were permitted for use on external walls of buildings over 18 metres in height. He also told us that by using those words the BBA was not intending to suggest that Euroclass B was equivalent to Class 0. It was known within the BBA that the concepts were different and could not be used interchangeably.113 Albon {BBA00010723/18-19} pages 18-19, paragraphs 66-77; Albon {Day110/6:6-17}; {Day110/7:3-6}. Brian Haynes, who had been involved in testing and technical assessment at the BBA since 1973 and who by 2008 was the very senior head of a technical group with a broad portfolio, said something similar in his evidence.114 Haynes {BBA00010784/6} page 6, paragraphs 26-28.
¶19.15 John Albon also told us, and the BBA argued,115 Albon {Day110/7:20}-{Day110/8:6}; BBA closing statement {BBA00011297/17} paragraph 52. that the certificate had to be read in full, and that a reader who considered sections 6.1 and 6.2 carefully would understand that the BBA had no evidence that Reynobond PE panels had achieved Class 0 through BS 476-6 and 476-7 testing. However, he did accept that the wording was "poor".116 Albon {Day110/7:8-11}. We think that the wording was not merely poor but misleading and (on Arconic's part) deliberately so for the reasons we have examined in earlier chapters.
30¶19.16 In the section headed "Regulations" the certificate stated that in the opinion of the BBA, the panels, if used in accordance with the provisions of the certificate, would meet or contribute to meeting functional requirement B4(1) of the Building Regulations because they were judged to meet the Class 0 requirements. Someone reading that statement and the statement on the first page of the certificate that the panels might be regarded as having a Class 0 surface might well have been led to understand that the BBA itself had considered the relevant data and had come to the opinion that Reynobond PE did achieve Class 0.
¶19.17 The expression "may be regarded as Class 0" appears in BBA certificates relating to other cladding panels. John Albon told us that the BBA had tried to ensure some consistency of expression between certificates for products with similar properties,117 Albon {Day109/111:13-22}. but it is clear that the expression was not used in the same way in all cases. In some cases the phrase "may be regarded as … Class 0" was used when the BBA had evidence of testing in accordance with BS 476 Parts 6 and 7 which satisfied the definition of Class 0 in Approved Document B.118 For example, certificate 10/4746 for Alupanel XT cladding panels {BBA00000113}. In other cases the expression was used when test evidence satisfying the definition was not available for a panel of one particular colour but was available for the same panel in another colour.119 For example, certificate 13/5022 for Stacbond PE and Stacbond FR Cladding Systems {BBA00000067}; Albon {BBA00010723/28} page 28, paragraph 111; Albon {Day110/13:4-15}; {Day110/l14:10-14}. In yet other cases the expression was used where there was evidence of classification as Euroclass B, apparently because of the equivalence implied by Diagram 40 of Approved Document B (although that was not stated in terms).120 For example, certificate 06/4367 for Bauclad External Cladding Panels {CEP00050243/5}; certificate 08/4551 for Larson and Larson FR Wall Cladding Panels {BBA00000144}; certificate 12/4901 for Vitrabond Aluminium Composite Rainscreen Cladding Panels {BBA00000074}.
¶19.18 In our view the BBA ought to have made a greater effort to avoid giving the impression that Diagram 40 indicated an equivalence between national Class 0 and Euroclass B. We note that the certificate issued in August 2017, shortly after the Grenfell fire, did not use the expression.121 {BBA00000046}.
Mr Wehrle's statements
¶19.19 Mr Wehrle said that he could not remember whether he had read through the BBA certificate but that he had not been aware of its contents in any detail until after the fire.122 Wehrle {MET00053190/16} page 16, paragraph 55. However, the evidence shows unequivocally that he was intimately involved in the negotiations with the BBA leading to its production and must have been aware of its contents in so far as they concerned matters such as fire performance.123 Claude Wehrle reviewed drafts of the certificate in October 2007 {BBA00008042/535}; November 2007 {BBA00008042/515-517}; December 2007 {BBA00008042/465}.
¶19.20 However, despite his close involvement, Mr Wehrle did not comment at the time on the statement that Reynobond 55 PE might be regarded as having a Class 0 surface.124 {BBA00000047/1} section 6.3. He said that he had no specific knowledge of the UK Building Regulations, including Diagram 40 in Approved Document B,125 Wehrle {MET00053190/16} page 16, paragraph 55. although he was prepared to say that the BBA and others regarded Diagram 40 as allowing European Class B to be treated as equivalent to national Class 0.126 Wehrle {MET00053190/16} page 16, paragraphs 55 and 56. However, there is no evidence that Mr Wehrle raised the question with the BBA.
31¶19.21 Mr Wehrle also drew attention to the results of tests on another Arconic product, Reynobond 33 PE.127 Wehrle {MET00053190/9} page 9, paragraph 34; Wehrle {MET00053190/14} page 14, paragraph 46. Arconic submitted that they were relevant because they supported the conclusion that Reynobond PE could achieve Class 0.128 Written closing submissions on behalf of Arconic {ARC00000770/22} paragraph 103. However, Reynobond 33 PE had different physical properties which makes comparison inappropriate, as is borne out by the fact that no one drew those tests to the attention of the BBA. As with most such reports, the reports of the tests on Reynobond 33 contained an explicit warning that they could not be applied to any other product.129 For example {ARC00000366/7}; {EXO00001960/7}.
¶19.22 Arconic also submitted that it could not be blamed for the BBA's decision in the absence of applicable test data to treat European Class B as equivalent to national Class 0 and to state that Reynobond 55 PE could be regarded as having a Class 0 surface.130 Written closing submissions on behalf of Arconic {ARC00000770/16} paragraph 76. Like Mr Wehrle, Arconic suggested that Diagram 40 of ADB permitted one to extrapolate national Class 0 from the existence of European Class B,131 Written closing submissions on behalf of Arconic {ARC00000770/6} paragraph 29(2). but that is not possible because the nature of the tests and the standards they apply are quite different.132 See Part 2, Chapter 5. The note to Diagram 40 states (admittedly less clearly than it might) that Class B and Class 0 are not equivalent. In any event, Arconic knew very well that there was no relevant test data under either classification system to support such a statement in relation to Reynobond 55 PE in cassette form.
¶19.23 In our view the expression "may be regarded as having a Class 0 surface" should not have been used. In the absence of test data satisfying the Class 0 requirements for the PE version of the panels the BBA ought not to have proposed it and Arconic should not have allowed it to be included in the certificate. It was not appropriate for the BBA to treat Diagram 40 in Approved Document B as permitting it to treat European Class B as equivalent to Class 0, but if that was the basis of the statement, it ought to have been clearly explained. Although we consider that any reasonably competent construction professional relying on the certificate ought to have read it in full and should not have relied on the statements about Class 0 in isolation,133 Hyett {Day64/149:2}-{Day64/150:7}; {Day64/151:8-15}; {Day64/160:1-6}. the BBA and Arconic must both bear responsibility for the inclusion in the certificate of that misleading statement.
Section 6.3: the unexposed face of the product
¶19.24 The final sentence of Section 6.3 stated:
"The unexposed side of the products may also be regarded as having a class 0 surface".134 {BBA00000047/5}.
¶19.25 That wording reflected a question which had arisen towards the latter stages of the assessment process and posed a significant problem for Arconic. The BBA considered that it needed reaction to fire test data for the back of the product as well as the face.135 {BBA00010701/5}; {BBA00010701/1}. In the event, the BBA accepted test results from Arconic's Reynolux product as evidence that the coating on the back of Reynobond panels would perform at least as well as that on the front.136 {MET00053158_P16/136-137}; {BBA00008042/525-527}; classification report RA07-0182 {BBA00008042/139-145}. Consequently the BBA agreed to state in the certificate that the unexposed face of Reynobond panels might "also be regarded as having a class 0 surface".137 {BBA00000047/5}.
32¶19.26 In coming to that conclusion, the BBA initially sought advice from Dr Sarah Colwell of BRE,138 {BBA00008042/505-507}. but before it could be provided Mr Gregorian indicated that, following the receipt of further information from Arconic, the BBA no longer required its assistance.139 {BRE00047592}; Colwell {Day233/67:12}-{Day233/68:3}. In circumstances where the BBA was dealing with claims about Reynobond's fire performance and recognised that its own expertise was limited, it should have taken advice from a body such as BRE which had expert knowledge of testing and fire performance. We consider that it was remiss of the BBA not to seek that advice when the Reynobond certificate was first drafted.
¶19.27 BS 476 Part 7 requires testing to be carried out on the complete product because the performance of the surface may be affected by the underlying material. It was wrong, therefore, for the BBA to accept results obtained from testing Reynolux, which is a solid aluminium panel, as representative of Reynobond, which is a composite panel.
Section 6.4: colour
¶19.28 Section 6.4 of the certificate drew attention to the fact that the fire performance of the products described in sections 6.1 and 6.2 might not be achieved by other colours.140 {BBA00000047/5}. Hamo Gregorian added what had become a standard warning to the certificate on the advice of John Albon.141 {BBA00010693}. It was the BBA's policy that reaction to fire testing was colour- specific, and so a BBA certificate would cover only the colours that had actually been tested.142 Albon {BBA00010723/27} page 27, paragraphs 104-109; Albon {Day110/22:15-25}; {Day110/26:2-13}. John Albon said that was because he had been advised that colour might make a difference to a product's fire performance.143 Albon {Day110/25:11-22}; {Day110/26:2-13}; {BBA00010693}. However, there is no evidence that anyone at the BBA considered whether that might be so in the case of Reynobond 55. Accordingly, the BBA considered that the certificate applied only to Reynobond with a grey/green Duragloss 5000 coating, a gold-coloured Duragloss finish, and a metallic grey PVDF finish and no others.144 BBA Closing Submissions {BBA00011297/25} paragraph 77; BBA Module 2 Closing Submissions {BBA00011296/9-10} paragraph 27-28. All other variants of the product would need a separate test or assessment. The BBA ought to have alerted Arconic to that narrow approach during the assessment process. However, the wording is sufficiently clear to have told Arconic that the certificate only covered, or might only cover, the colours and finishes specified, and that it was not able to support the sale of the product in any other colour or finish.
¶19.29 For its part, Arconic did not treat the BBA certificate as applicable only to the three colours and finishes to which it referred. In the case of Grenfell Tower, for example, Ms French on behalf of the company used it to support the sale of a wide range of colours,145 Email from Deborah French to Mark Harris of Harley dated 23 April 2014 {RYD00003932}. including those ultimately chosen, namely, "Smoke Silver" and "Pure White", neither of which was covered by the certificate.146 {ARC00000552}; {ARC00000553}. Arconic used the certificate to support the sale of all its Reynobond 55 panels in the UK without qualification as to colour. Ms French said that she had not been aware that only specific colours and finishes received the classifications stated in the BBA certificate, having never discussed the matter with Arconic.147 French {MET00053162/4} page 4 paragraph 18; French {MET00053162/16} page 16, paragraphs 56 and 57. If that is true, then Arconic must be blamed for not ensuring that its sales representative was properly informed about the narrow scope of application of the BBA certificate. If, on the other hand, she was aware of those limitations when she provided the certificate to Harley on 23 April 2014 before the colour of the panels had been chosen, she would, or at any rate should, have warned Harley that the certificate did not cover other colours, including those that she knew were being considered, such as smoke silver and white.148 {RYD00003932}. She did not do so.
33Section 6.5: resistance to fire
¶19.30 Section 6.5 of the certificate warned that with regard to resistance to fire, the performance of a wall incorporating the product could be determined only by tests carried out by a suitably accredited laboratory.149 {BBA00000047/5}. The wording, which can be found in other BBA certificates relating to cladding products,150 For example, certificate 06/4367 for Bauclad External Cladding Panel {CEP00050243/5}; certificate 08/4551 for Larson and Larson FR Wall Cladding Panels {BBA00000144/5}; {BBA00000143/6}; certificate 10/4746 for Multipanel's Alupanel XT Cladding panels {BBA00000113/5}; certificate 13/5022 for Stacbond PE and Stacbond Cladding Systems {BBA00000067/9}; certificate 15/5245 for Ash & Lacy Building systems Alucobond façade cladding systems {BBA00000120/10}. also appears to have been standard.
¶19.31 Arconic submitted that the effect of section 6.5 was that readers of the certificate were given no assurance about the product's resistance to fire when incorporated into an external wall, the performance of which would have to be assessed by full-scale testing in accordance with BS 8414.151 Module 6 closing statement {ARC00000794/16} paragraph 51; Overarching closing statement {ARC00000797/19} paragraph 68. By stating that the product had achieved European Class B-s2, d0 the BBA was merely identifying the standard to which Reynobond PE was capable of performing.152 {ARC00000797/27-28} paragraphs 99-104.
¶19.32 We were not impressed by that argument. Resistance to fire and reaction to fire are fundamentally different concepts and therefore testing resistance to fire (as addressed by testing to BS 476-20 to 476-24) necessarily involves methods different from those used to test reaction to fire.153 Namely those listed in BS 476 Part 10, Guide to Principles, Selection, Role and Application of Fire Testing and their Outputs, being BS 476 Parts 20-24 {BSI00001757/5}. Reaction to fire tests are designed to measure the ease with which a material can be ignited, surface spread of flame, the rate of heat release and the production of smoke, whereas 'resistance to fire' tests are designed to measure the ability of an element of construction to contain fire, including its ability to protect a frame from collapse and to restrict the spread of smoke.154 BS 476 Part 10, section 4 {BSI00001757/13-14}. BS 8414 is an entirely different kind of test, being designed to test the reaction of an entire wall system to fire.155 BS 476 Part 10 separates full scale tests from "resistance to fire tests" see Foreword at (b) for fire resistance tests and "Miscellaneous" for full scale testing {BSI00001757/5}; Appendix B of ADB also distinguishes between resistance to fire and reaction to fire tests; Resistance to fire is assessed by tests such as BS-476-20 and EN 13501 parts 2 to 4) {CLG00000224/119}; Reaction to fire is assessed by those tests which for example combine to make up the EN 13501-1 classification {CLG00000224/121}.
¶19.33 Section 6.5 therefore did not qualify the statements about reaction to fire made elsewhere in the certificate, including in sections 6.1 to 6.3, and there is no support for Arconic's submission that all construction professionals should have known that a separate large-scale test was necessary before the product could be used in an external wall.
34¶19.34 In any event, even if section 6.5 should be understood to mean that the fire resistance of a wall incorporating the product was outside the scope of the certificate, that was of no interest to a potential buyer of the panel who simply wanted to know whether Reynobond, as a product, complied with the guidance in Approved Document B in relation to buildings over 18 metres in height. The BBA certificate was a product certificate, and section 12.6 and Diagram 40 of Approved Document B are directed to products, not systems.
35Chapter 20: Subsequent testing and marketing of Reynobond 55 PE
The Fred-Roderick Pohl presentation: September 2007
¶20.1 In September 2007, while Arconic was in the process of obtaining a BBA Certificate for Reynobond 55 PE, Gérard Sonntag, Arconic's Marketing Manager, and Didier Felder, its Area Sales Manager, attended a number of presentations organised by a metal and plastic distributor in Oslo. They included a presentation by Fred-Roderick Pohl, who had been invited by a manufacturing company, Otefal GmbH, for which he acted as a consultant.
¶20.2 In his report of the trip, Mr Sonntag recorded that Mr Pohl had explained the extreme danger presented by the use of ACM PE on residential buildings, comparing the combustibility of 5,000m2 of ACM PE to that of a truck containing 19,000 litres of oil, and drawing attention to the fact that even greater danger was posed by the toxic smoke emitted by burning polyethylene, which could kill in two or three minutes.156 {META00001953/2}. It is quite possible that Mr Pohl was not entirely independent and was seeking to advance the benefits of pure aluminium by decrying the fire safety of ACM, but even making allowances for that, his presentation was graphic and, more importantly, was taken seriously by Mr Sonntag. Mr Sonntag had been particularly concerned by Mr Pohl's hypothetical question of what would happen if "one building made out [of] PE core is in [a] fire and will kill 60 to 70 persons, what is the responsibility of the ACM supplier?".157 {META00001953/3}. Mr Sonntag's own recommendation in the light of that presentation was that Arconic ought to assess the financial consequences of selling only Reynobond with an FR core and in that case introduce a program of cost reduction to enable the FR version to be manufactured at the same cost as the PE version.
¶20.3 We have seen the slides from the presentation given by Mr Pohl,158 {MET00081029}. which do indeed draw attention specifically to the combustibility of ACM PE159 {MET00081029/4}. and the toxicity of the fumes emitted by burning polyethylene.160 {MET00081029/14}. They also illustrate past fires in buildings covered in ACM cladding around the world, and refer specifically to the UK testing regime under BS 476.161 {MET00081029/16}. Mr Sonntag also mentioned that Mr Wehrle had shown him a copy of a similar presentation made by Mr Pohl some two months previously. We have been unable to identify that document but have no reason to doubt what he said.
¶20.4 Despite those clear warnings and Mr Sonntag's reaction and recommendation, there is no evidence that anyone at Arconic took steps to examine the safety of Reynobond 55 PE or to ascertain the financial consequences of selling only panels with a fire-resistant core. However, shortly after Mr Sonntag made his report Arconic launched a project to reduce the cost of Reynobond FR to that of Reynobond PE in response to increasing demand for a fire-resistant product.162 Schmidt {MET00053187/14} page 14, paragraph 40. Despite various efforts over the ensuing years, however, the price of the fire-resistant version was never brought down to that of the unmodified version.163 Schmidt {MET00053187/14-15} pages 14-15, paragraph 44.
36¶20.5 In the light of Mr Sonntag's report, we think it is clear that by late 2007 Arconic had become aware that there was serious concern within the industry about the safety in fire of ACM panels with an unmodified polyethylene core (ACM PE) and had itself recognised the danger they posed. However, there is no evidence that Arconic took any steps to withdraw the sale of that product in the UK in the months and years that followed. On the contrary, not only did it continue to manufacture and sell ACM PE, it also sought to exploit what it perceived to be a weak regulatory regime in the UK while withholding from the market relevant information about the product's fire performance. That contrasts with the position in other countries, such as France, where, in 2016, Arconic insisted that its sales team specify only Reynobond 55 FR.
Internal and external communications: 2009 – 2010
¶20.6 On 17 July 2009, Mr Wehrle wrote to Claude Schmidt, Guy Scheidecker and Robert Quattrocchi (Arconic's plant manager) attaching some photographs of a building in Romania clad in ACM PE panels that had suffered a serious fire.164 {MET00053158_P10/125}. Mr Wehrle wrote that the photographs demonstrated how dangerous ACM PE could be when it came to architecture.165 {MET00053158_P10/122}.
¶20.7 On 16 March 2010, a sales executive, Isabel Moyses, wrote to Mr Scheidecker and Mr Wehrle, amongst others, telling them that a competitor had had to recommend fire-resistant panels for use in Spain because its standard ACM PE product did not have the classification of B-s3, d2 required under Spanish law.166 {MET00064988/125}. She said, however, that Reynobond PE panels could still be used because they had achieved a classification of B-s2, d0. When he responded the following day, Mr Wehrle surmised that the competitor had based its view on tests of the product carried out in cassette form, which he acknowledged produced results much less favourable than those carried out on products in riveted form. He pointed out that in cassette form Reynobond PE did not meet European Class B, a matter, he said, that "we have to keep as "VERY CONFIDENTIAL!!!!".
¶20.8 Mr Scheidecker's response later the same day was much shorter: "[t]his shouldn't even have been mentioned".167 {MET00064988/125}.
¶20.9 None of those emails were exhibited to Mr Wehrle's statement and he did not refer to them in any way. Since he did not give evidence, we have not had the benefit of any explanation of their contents he might have been able to give, so we are left to interpret them at face value. In our view they demonstrate clearly that by March 2010 Arconic was aware that the fire performance of ACM PE panels in cassette form was generally considerably worse than in riveted form and that test data relating to panels in riveted form did not apply to panels in cassette form. They also support the conclusion that the results of Test 5B had not been "rogue" results and that Arconic knew that any suggestion that Reynobond PE 55 in cassette form had achieved, or could achieve, Euroclass B was false. Finally, we think they show that Arconic was deliberately and dishonestly concealing from the market the true position in relation to Reynobond PE in cassette form. We were unable to invite Mr Wehrle to respond to those inferences, but Mr Schmidt was asked to do so and agreed that that had been the case.168 Schmidt {Day93/51:8}-{Day93/55:21}.
37¶20.10 In July 2010 a customer asked Ms Moyses for certification of the fire performance of Reynobond 55 PE in cassette form.169 {MET00053158_P04/3}. She told him that Arconic had fire certification only for the riveted form, but that "soon" the cassette system would be better. Her message (written in English) is not entirely easy to understand, but when reporting to Mr Wehrle she said that she had told the customer that since the riveted form was the most unfavourable system, the certificate was acceptable for the cassette system. It seems, therefore, that her message had been intended to give the customer the impression that the cassette version performed better in fire than the riveted system. If so, that directly contradicted the results of Test 5B and the position as understood by Mr Wehrle. When the customer insisted on a certificate relating to the cassette form,170 {MET00053158_P04/2}. Ms Moyses asked Mr Wehrle to "take care of it".171 {MET00053158_P04/2}. Mr Wehrle told her that it was hard to commit anything to writing on the subject because, as he put it, Arconic was "not clean".
¶20.11 Mr Wehrle did not say in his witness statement what he had meant by the expression "not clean", but we think he must have been referring to the fact that Arconic had no certificate for Reynobond PE in cassette form and that its use of the certificate relating to riveted panels to support the use of cassette-fixed panels was not straightforward. Mr Wehrle's frankness with his own colleagues suggests that they knew as much as he did and that he had nothing to hide from them.
¶20.12 On 5 July 2010, Mr Wehrle wrote to the customer attaching what he described as "the document concerning the system we choose for the Reynobond PE fire certification".172 {MET00053158_P04/4}. It was a letter written by Mr Wehrle himself, in which he said:
"Reynobond PE, is classified B-s2, d0 in accordance with the European standard EN 13501. This test was done on the riveted system, which expose the core of the material to the flame contrary to the cassette system where the core is protected by the returns. Alcoa decided to check the behaviour of its composite panels in this worst case of system (exposed fasteners on flat panels) and to use it for all the other systems."173 {MET00053158_P04/5}.
¶20.13 The assertion that Reynobond PE in cassette form would behave better in a fire than in the riveted form tested was not only false but was known by Mr Wehrle to be false. It demonstrates his willingness to resort to deliberate dishonesty in order to support the sale of the product for use in cassette form. Mr Schmidt, who was the only person who could be asked about it, accepted that Mr Wehrle had lied to the customer.174 Schmidt {Day93/66:1-3}.
38Further testing and review
CSTB Testing: June 2010
¶20.14 CSTB performed further tests of Reynobond 55 PE in riveted form in June 2010 and reported the results in February 2011. The grey riveted specimens tested achieved a classification of B-s1, d0, which was better than the results of Test 5A in 2005.175 RA11-0032 classification report of 9 February 2011 {ARC00000383}; Test report of 9 February 2011 {ARC00000537}. However, it appears that the result was unlikely to be representative of the end use of Reynobond 55 PE, because, among other things, the sample tested included a backing board of calcium silicate to simulate a 50mm air gap behind the panel.176 {ARC00000537/6}. (Test 5A had also had an air gap of 50mm.)
¶20.15 In subsequent correspondence with CSTB, Mr Wehrle agreed that the panel should be tested with a 20mm air gap between it and the insulation to reflect the way it was used in practice177 {MET00053158/184}. and in his statement he acknowledged that variations in testing methods, such as the use of different insulation products and air gaps, were likely to influence the results.178 Wehrle {MET00053190/19} page 19, paragraph 64. We do not know who was responsible for determining the test method or how the width of the air gap might have affected the outcome. However, when Reynobond 55 PE in rivet form was tested again in later years, it failed to achieve Class B.
CSTB testing of Reynobond 55 PE in cassette form: 2011
¶20.16 In late March 2011 Mr Wehrle decided to find out what was the best classification that Reynobond 55 PE in cassette form could obtain on the basis of Test 5B. On 29 March 2011 he wrote to the CSTB enclosing Test 5B and asked whether the cassette fixing variant could be classified as European Class D.
¶20.17 In May 2011 Mr Wehrle arranged for CSTB to test Reynobond 55 PE in cassette form and classify it under EN13501. On 29 June 2011 CSTB wrote to Arconic and said that, as had happened in 2004, the single burning item test had been stopped early because the heat emitted by the sample had been too great.179 {MET00053158/172}. In response to his request for an F classification, he was told by CSTB that if the product were tested under the ISO 11925 single flame source test180 See Chapter 5. it might be granted an E classification. Arconic duly instructed CSTB to conduct a further test of the product pursuant to ISO 11925 (on a small flat sample of the panel), which, when the specimen performed adequately, necessarily led to a classification of the product as Class E.181 {ARC00000538}; {ARC00000386}.
¶20.18 Mr Wehrle said that the tests enabled him to understand that cassette-fixed panels were not safer than riveted panels because molten polyethylene from the core could collect in the internal ledges of the cassette and cause a 'flash-over'.182 Wehrle {MET00053190/18} page 18, paragraph 63. He claimed to have wanted a classification report for the product in cassette form because he had a potentially different understanding of the behaviour of the cassette variant.183 Wehrle {MET00053190/18} page 18, paragraph 63. As we have said, however, we think that Mr Wehrle was aware well before 2011 that the product performed worse in cassette form than in riveted form. On any view he certainly knew that by June 2011 at the very latest.
39The first BBA review: February – July 2011
¶20.19 The BBA certificate was due to be reviewed at three-yearly intervals and, having been issued in 2008, its first review was therefore due in 2011. The BBA opened a review project in August 2010 under a new contract with Arconic which incorporated the original terms and conditions, including one which required Arconic immediately to notify the BBA of any new or additional information concerning Reynobond or its suitability for use.184 {BBA00008042/3} clause 7(g). It was signed by Mr Schmidt for Arconic in December 2010.185 {BBA00008044/11}. It appears to have been signed by Claude Schmidt.
¶20.20 Between February and June 2011, the BBA asked Arconic for documents relevant to the review and, on 11 April 2011, Arconic provided it with a pack of documents186 {BBA00008044/33}. precisely as requested.187 {BBA00008044/79}. However, none of the documents that Arconic sent concerned the fire performance of Reynobond 55 PE in cassette form and no one at Arconic informed the BBA of the results of Test 5B. That was a striking omission in light of the contract terms, given that only two weeks earlier Mr Wehrle had sent the report of Test 5B to CSTB asking it to classify the product in cassette form as European Class D.
¶20.21 On 24 June 2011, the BBA confirmed that the certificate remained valid until 2014.188 {MET00053158_P16/174}. The report was sent to Mr Wehrle on 1 July 2011,189 {MET00053158_P16/179}. only two days after he had been informed that CSTB's most recent test of Reynobond 55 PE in cassette form had been stopped early and could not produce a classification.190 {MET00053158/172}.
¶20.22 Nonetheless, there is no evidence that Mr Wehrle or anyone else at Arconic took any steps to inform the BBA of those results or gave any thought to whether the reliability and accuracy of the BBA certificate might be affected by the latest information about the fire performance of Reynobond 55 PE in cassette form. Mr Wehrle sought to explain that omission by saying that it simply did not occur to him that it might be necessary to provide the BBA with that recent test data.191 Wehrle {MET00053190/17} page 17, paragraph59. That explanation is not plausible, however, given Mr Wehrle's keenness to re-test the product in cassette form only a few days earlier in the knowledge that it could achieve at best a European Class E. We also reject his assertion that the product would have achieved Class 0 if it had been tested again under BS 476.192 Wehrle {MET00053190/17} page 17, paragraph 59. In fact, the standard version of the panel had never been tested under BS 476 Parts 6 and 7 and had never achieved a national Class 0 classification. The chances of a product which could achieve no better than European Class E obtaining a Class 0 classification were slim.193 As is explained in Part 2 Chapter 7, the UK Government's RADAR 2 report of 26 May 2000 {CLG00000951}, which was commissioned to find the appropriate transposition point between Euro classes and UK national classes, settled on Class B. Only one product achieved both Class E and Class 0 {CLG00000951/4}. That report was not in the public domain and not available to Claude Wehrle. On any view, the results of CSTB's latest tests were plainly relevant to the BBA's review of the certificate and Mr Wehrle should have provided them to it or alerted others at Arconic of the urgent need to do so. Arconic's failure to provide the BBA with information relating to the recent testing of the product in cassette form was entirely consistent with its deliberate failure to provide the BBA with information about Test 5B when it was preparing the original certificate. It was all part of a strategy on the part of Arconic to conceal from the BBA the fact that Reynobond 55 PE in cassette form had never achieved Class B but had in fact performed significantly worse.
40¶20.23 Some months later, in November 2011, Mr Wehrle did tell a Spanish customer that Reynobond 55 PE cassettes were certified as Class E, which the customer described as being "close to spontaneous combustion".194 {MET00053158_P04/54}. If Mr Wehrle was willing to disclose to his Spanish customer the true classification of Reynobond 55 PE in cassette form, the only reason he can have had for concealing that information from the BBA was a desire to withhold it from the UK market, a conclusion that is supported by the events described below.
Concentrating on the UK market: July 2011
¶20.24 On 5 July 2011, a week after the disastrous test by CSTB and five days after receiving confirmation that the BBA certificate remained valid, Mr Wehrle attended a meeting in Freiburg, Germany, with Peter Froehlich of Arconic and Frank Ritter of Alucobond, one of Arconic's competitors.195 {MET00053158_P04/26}. In his report Mr Wehrle set out the results of the tests carried out on Reynobond 55 in riveted and cassette form (which in the case of Reynobond 55 PE in cassette form was Class E) and noted that Class B was the minimum requirement for a facade in Europe. He continued:
"For the moment, even if we know that PE material in cassette has a bad behaviour exposed to fire, we can still work with national regulations who are not as restrictive. … Some countries (Spain …) are already working with EN 13501 standards, and the PE in cassettes is no more usable there."196 {MET00053158_P04/35}.
¶20.25 He also acknowledged that it would be very difficult for Reynobond 55 PE in cassette form to pass a test under BS 8414.197 {MET00053158_P04/36}.
¶20.26 It is plain that by the summer of 2011 Arconic was well aware that Reynobond 55 PE when fabricated in cassette form performed much worse in a fire than in riveted form and was considerably more dangerous. Nonetheless, it was determined to exploit what it saw as weak regulatory regimes in certain countries (including the UK) to sell Reynobond 55 PE in cassette form, including for use on residential buildings.
¶20.27 In May 2012, Claude Wehrle attempted to discuss the European classification of Reynobond 55 PE with Claude Schmidt and Peter Froehlich with a view to deciding what information to give to the market.198 {MET00053157/287}; {MET00053157/290}. We have seen no reference to any such discussion in the documents, although in his statement Mr Wehrle said that it had been agreed that reference to Class B should be removed from marketing material as it no longer accurately reflected the position.199 Wehrle {MET00053190/28} page 28, paragraph 96. He said that the sales team in each jurisdiction was to be told that Reynobond 55 PE in cassette form was Euroclass E, but there is no evidence that anyone in the UK was told that at the time.
41¶20.28 As far as we can see, the only step that Arconic took at that time in recognition of the true fire performance of Reynobond 55 PE in cassette form was to remove from its marketing literature the claim that Reynobond 55 PE200 {ARC00000388/5}. was Class B.201 {ARC00000378/3}. We think that that almost imperceptible change was designed to ensure that Arconic no longer made any positive claim for the fire performance of Reynobond 55 PE while not alerting the market to its dangers or to the fact that earlier claims that it was Class B could no longer be relied on.
¶20.29 Arconic claimed that CSTB openly published all test results on its website,202 Arconic Module 2 closing submissions {ARC00000770/1} page 1, paragraph 5; Arconic Module 2 closing submissions {ARC00000770/15} page 15, paragraph 65; Arconic Module 2 closing submissions {ARC00000770/24} page 24, paragraph 119. but the evidence of that was limited, particularly about the time of any publication. CSTB did publish summaries of results (but not the test or rating reports which were confidential to the customer) and would always ask the manufacturer in advance of publication.203 Bonhomme {METCSTB00000105/12-13} pages 12-13. The earliest evidence we have been able to find is that on 22 July 2013, Claude Wehrle told a colleague that she could find the technical opinion relating to Reynobond on the CSTB website.204 {MET00053158_P04/130}. Having regard to that description and the link that Mr Wehrle provided, that appears to have referred to an opinion relevant to the French national classification system. The first date on which a reference to the European classifications for Reynobond PE 55 appeared on the CSTB website was 5 December 2014.205 {MET00053158_P02/62}. That is consistent with Mr Wehrle's own evidence that, in late December 2014, Arconic did not refuse CSTB's proposal to publish the results.206 Wehrle {MET00053190/21} page 21, paragraph 70. Accordingly, the earliest that European classifications were likely to have been available on the CSTB's website was late 2014. However, that does not assist Arconic. It is entirely unclear how a UK entity would know that it should consult data published by a French testing house in order to obtain current results of reaction to fire tests. In any event, none of that explains why Arconic did not provide the information to the BBA, why it did not explicitly refer to the classifications in its marketing materials, or why it did not routinely disclose the classifications of Reynobond 55 PE to all UK purchasers.
The Tamweel Tower fire: November 2012
¶20.30 On 18 November 2012, a fire occurred at the Tamweel Tower in Dubai, which was clad in ACM PE rainscreen panels. Senior representatives of Arconic discussed the fire in an exchange of emails on 28 November 2012. An Arconic product had not been used in that case, but Mr Wehrle pointed out that all polyethylene composites react in the same way.207 {MET00053157/28}. Mr Schmidt accepted that he had seen the emails at the time and that it was known within Arconic that all ACM PE products burned in the same way.208 Schmidt {Day94/14:13-16}. Nonetheless, as Mr Schmidt accepted, Arconic took no action in response.209 Schmidt {Day94/15:4-18}.
The Al Hafeet fire and the monitoring of projects
¶20.31 On 22 April 2013, there was a fire at the Al Hafeet tower in Dubai, which was clad with ACM PE rainscreen panels. In response to that fire, on 9 May 2013 Alucobond, one of Arconic's competitors, sought to allay its customers' concerns by confirming that it offered ACM with a fire-resistant core as standard.210 {MET00053157/48}. The message was sent by Richard Geater, Alucobond's sales agent for UK and Ireland,211 Richard Geater was employed by 3A Composites GmbH, the sales agent for Alucobond. and quoted a colleague's description of the extreme flammability of ACM panels with unmodified PE cores that were then widely used in Dubai in the interest of saving cost.
42¶20.32 The message was sent to Deborah French, Arconic's UK sales representative, a few minutes later. On 10 May 2013 she passed it on to Mr Froehlich, Mr Wehrle, Mr Flacon, and Mr Schmidt and asked for their comments so that she could communicate with their customers.212 {MET00053157/47}. The fact that she chose to include Mr Schmidt, Arconic's president, shows how important she regarded it. Ms French said that she had discussed with Arconic's managers whether it should make the same offer to its customers but was told that it would not do so, at least in part for commercial reasons.213 French {Day89/49:22}-{Day89/53:12}. We understand that to mean that Arconic would have had to charge more for the fire-resistant panels or would have made a smaller profit if it had sold them at the price it charged for the unmodified version. Mr Schmidt did not accept that version of events214 Schmidt {Day94/21:19-22}. but he offered no other explanation and we accept Ms French's account. Arconic did not consider phasing out ACM PE in favour of the fire-resistant version then, or indeed later, because, according to Mr Schmidt, it needed time to think about it.215 Schmidt {Day94/21:17-18}. Although Mr Wehrle continued to warn about the risks associated with unmodified ACM panels, Arconic's senior management does not appear ever to have seriously considered withdrawing the product from the UK market at any time before the Grenfell Tower fire.
¶20.33 Indeed, Arconic decided to adopt a different course. A few days later, on 13 May 2013, Ms French wrote to a number of fabricators, including CEP.216 {CEP00049717}. In 2014 CEP fabricated and supplied the Reynobond 55 PE cassette panels to Harley for installation on Grenfell Tower. She referred to the recent fire at the Al Hafeet tower and offered them the following assurance:
"Regarding the supply of Reynobond in the UK, as you know we supply both PE and FR core and can control and understand what core is being used in all projects due to the controlled supply route we have. By only supplying Reynobond to a very small group of Approved Fabricators and working very closely with them on all projects we are able to follow what type of project is being designed/developed and then offer the right Reynobond specification including the core. At this stage we will continue to offer both PE & FR core and continue the close working relationship we have with our Approved Fabricators to make sure the right technical support, Reynobond Specification and Materials are being used and installed on Reynobond Projects."
¶20.34 In her witness statement, Deborah French said that the way in which the finished product was assembled and whether it complied with the relevant regulations were matters for the customer or designer.217 French {MET00053162/12} page 12, paragraph 44. However, that was clearly not consistent with what she had said in her email of 13 May 2013, as she realistically accepted.218 French {Day88/103:3-5}. Although she said that that email did not correctly reflect Arconic's position and had been badly drafted and that we should accept what she had said in her statement,219 French {Day88/98:3-12}; {Day88/100:25}-{Day88/101:7}. we think that the truth is more complicated. Ms French's email, which may have reflected advice from Arconic personnel in Merxheim,220 Froehlich {MET00053197/20} page 20, paragraph 57.1.2; French {Day88/88:23-25}; {Day88/90:14-19}. contained clear statements that Arconic knew the details of every project on which its products were used within its controlled supply routes and would ensure that the products supplied for use on those projects were suitable for their intended purpose. It was true that Arconic often did know for which projects its Reynobond products were destined and in many cases what form they would take, since those facts were sometimes recorded on Arconic's customer database (as the sale of Reynobond 55 PE to Harley for use on Grenfell Tower shows).221 See Part 6, Chapter 55; Record of customer database for Grenfell Tower, indicating the form was to be cassette: {MET00019920/31}. Accordingly, Arconic was often in a good position to judge whether a particular product was suitable for a given project. Certainly, in the case of Grenfell Tower, Arconic did have a certain amount of relevant knowledge. However, it was not true that it intended to advise the fabricator, designer or customer whether the products were safe or suitable for use on any project. On the contrary, it expected the customer and designer to look after themselves. The purpose of Ms French's message was to persuade customers to continue to buy Reynobond PE in the expectation that it would tell them if it was unsuitable for the use to which they intended to put it, although in fact it had no intention of doing so.
43Supply by Arconic for use at Grenfell Tower
¶20.35 In Part 6, Chapter 55 we have described how Reynobond 55 PE cassettes came to be supplied for the refurbishment of Grenfell Tower. The story confirms that Arconic often knew for which UK projects its products were bound, knew how they were likely to perform and whether they were safe for the intended use, but did not offer any relevant advice or warning to the designer or customer. So far as concerns Grenfell Tower, Arconic made no attempt to ensure that Harley knew about the performance of the product it supplied for the refurbishment.
¶20.36 Ms French was aware that Grenfell Tower was a high-rise building222 French {Day88/66:21-23}. because on 24 January 2013, she was sent several drawings relating to the project that showed that it involved a tall building.223 {CEP00048962}, attaching {CEP00048966}. Moreover, during the course of the project she arranged for the supply of several samples of Reynobond 55 PE panels to Grenfell Tower, including a mock-up for the RBKC planning department.224 {MET00019919}; {SEA00014518}; {SEA00014456}; {MET00053159/161}. It was also clear to her by August 2014 at the latest that ACM PE panels in cassette form were going to be used.225 French {Day88/66:18-24}; {Day88/184:6-12}. She said that she did not think about the height of any building for which Arconic supplied its products,226 French {Day88/66:18}-{Day88/69:3}. but in the light of her email of 13 May 2013, that seems unlikely. For her, however, it was enough that the product had a BBA certificate.227 French {Day88/68:20}-{Day88/69:3}. Given that, by her own admission, that is all Ms French cared about, it was essential for Arconic, for whom she was selling Reynobond 55 PE, to ensure that the statements in the BBA certificate about fire performance and regulatory compliance were correct. That was all the more so if what she had said in her email of 13 May 2013 was to be taken at face value.
44¶20.37 Ms French accepted that in the case of the Grenfell Tower refurbishment she had worked closely with the fabricator and the installer. It was therefore exactly the kind of project that she had described in her email.228 French {Day88/183:11-23}. Despite that she said that she did not have sufficient knowledge to give advice about the risks of using the product in cassette form and did not make any recommendation about it.229 French {Day88/184:13-18}. She did not seek advice about it from anyone else at Arconic because she assumed that others involved in the project would consider them.230 French {Day89/4:2-8}.
¶20.38 Arconic itself must take responsibility for the use of Reynobond 55 PE on Grenfell Tower because it knew that the sale of the product had been obtained on the basis of the BBA certificate which it was well aware gave a misleading impression of the way in which the product in cassette form reacted to fire.
Further testing and classification: 2013 to 2014
¶20.39 By February 2013, Mr Wehrle was aware that there was potential for confusion in the market about the different fire performance classifications of Reynobond PE in cassette and riveted forms, since the former was Class E and the latter Class B.231 Wehrle {MET00053190/19} page 19, paragraph 65. The FR product was also Class B. He therefore sought to obtain a lower classification for Reynobond 55 PE in riveted form in order to differentiate more clearly between the PE and FR products to assist marketing the FR product. He asked CSTB whether the PE product in both cassette and riveted form could be given a single classification.232 Wehrle {MET00053190/19} page 19, paragraph 65; {MET00053158/189}. When testing progressed in July 2013, Claude Wehrle told CSTB that Arconic wanted both forms of Reynobond 55 PE to be classed D.233 {MET00053158_P02/10}. It is not clear whether he discussed that strategy with anyone in the senior management team at Arconic.
¶20.40 CSTB duly tested Reynobond 55 PE again in July 2013 in both riveted and cassette forms. On that occasion, the riveted specimen achieved only Class C-s2, d0. As on both previous occasions, the test of the product in cassette form had to be stopped early because of what CSTB described as "widespread ignition".234 {MET00053158_P02/38-39}. Again, CSTB advised Arconic that the cassette form could be certified as achieving only Class E. The Class C result for the riveted form was not recorded in a classification report at the time.
¶20.41 Shortly afterwards, Arconic decided that all its Reynobond 55 PE products would be certified as Class E only and that revised classification for both cassette and riveted forms of the product was reflected in a report of CSTB dated 31 January 2014.235 {MET00053158_P04/135}. That was almost exactly the time at which potential contractors were producing their final bids for the refurbishment at Grenfell Tower based on the NBS Specification which included Reynobond 55 PE as a possible rainscreen panel. All forms of Reynobond PE panel were now Class E and accordingly it was unlikely that any external wall on which they were used would comply with functional requirement B4(1) of the Building Regulations.
45Claude Wehrle's message of 3 February 2014
¶20.42 On 3 February 2014, all of Arconic's sales staff (including Ms French) were told by Mr Wehrle that all Reynobond 55 PE products had been classified Class E, that the historic Class B classification for the riveted form could no longer be used and that all previous classification reports were immediately cancelled.236 {MET00053158_P04/134}.
¶20.43 Ms French received the email and read it,237 French {Day88/138:2-3}. but did not discuss it with anyone and did not pass the information on to any of her customers.238 French {Day88/140:7-9}. She plainly should have done so, as she herself accepted,239 French {Day88/155:14-16}. and she was unable to explain why she had failed to do so.240 French {Day88/148:8-15}. She was aware that others in the sales team at Arconic had done so,241 {MET00053159/282}. and she understood that the effect of Mr Wehrle's message was that Reynobond 55 PE was not as safe as had previously been thought.242 French {Day88/149:5-9}. Ms French was clearly willing and able to consider the fire performance of Arconic's products and to discuss it with her clients or to refer any questions to Mr Wehrle's technical sales support team. Curiously, she accepted that her failure to pass on the information had not been due to an oversight, although she insisted that it had not been deliberate.243 French {Day88/155:18-19}. She said that she had not appreciated its importance because she understood that the relevant classification in the UK was Class 0 and she did not understand the relevance of European classifications to the UK market.244 French {MET00053162/13} page 13, paragraph 48.2; French {Day88/141:9}-{Day88/142:24}. Her assertion was at odds, however, with the fact that the BBA certificate contained positive statements about the product's European classification which were plainly wrong in light of Mr Wehrle's email. Moreover, even if the details of the different testing regimes had eluded Ms French, she must at least have understood that any information about the fire performance of Reynobond 55 PE was likely to be of interest to customers in the UK and that they ought to be given it.
¶20.44 We think that Deborah French took the view that the change in the European classification of Reynobond PE did not matter as far as the UK market was concerned because Class 0 was all that was required in the UK for regulatory purposes. We also think that the existence of the BBA certificate was sufficient in her eyes and that she did not consider it her responsibility to worry about whether a change in the product's European classification might affect it.
¶20.45 The BBA certificate, however, remained unchanged. Arconic did not tell the BBA about the revised classification or invite it to reconsider the certificate in so far as it related to Reynobond 55 PE. Mr Schmidt sought to explain that as an oversight,245 Schmidt {Day94/43:11-15}. but we think that unlikely. It must have been clear to some within Arconic, not least Mr Wehrle, that the change in classification was important information that undermined the existing certificate, which, as a result, would be likely to mislead anyone thinking of using Reynobond 55 PE in either form. Given the importance of the BBA certificate to sales in the UK and the close involvement of Mr Wehrle in its original production, we cannot accept that the failure to inform the BBA was the result of a simple oversight.
46¶20.46 It remains an open question why Mr Wehrle went to the trouble of telling his sales force in different countries about the change of classification and instructed them not to represent Reynobond PE 55 as being Class B, and yet took no steps to contact the BBA to ask it to qualify or amend the certificate to reflect that fact. Whatever the explanation, however, the fact is that it was risky for Arconic to leave the BBA certificate in circulation in the UK market unamended, since designers would be very likely to continue to rely on it; and Mr Wehrle must have appreciated that risk.
¶20.47 Although she had been in close communication with Harley about the supply of Reynobond panels for the Grenfell Tower project since 2013, Ms French did not tell it about the revised European classification of Reynobond 55 PE or suggest that it might use the fire-resistant version instead. On the contrary, on 23 April 2014, some two months after having received Mr Wehrle's instruction on 3 February 2014, she sent Harley a copy of the BBA certificate without comment.246 {CEP000000281}. That amounted to a clear invitation to accept everything it said at face value.
¶20.48 Ms French told us that she had not thought that the BBA certificate might be unreliable because she had not made a connection between it and Mr Wehrle's email.247 French {Day88/162:2-21}. We do not accept that. In our view, she must, or certainly should, have recognised that a significant reduction in the European classification of Reynobond 55 PE might affect the statements made in the BBA certificate. By sending Harley a copy of the BBA certificate without any qualification she led it to think that Reynobond 55 PE was classified as European Class B and might therefore be regarded as achieving national Class 0, when that was not the case.248 French {Day88/165:4-23}.
¶20.49 Deborah French was clearly at fault in failing to pass on the substance of Mr Wehrle's message to her customers in the UK and in using the BBA certificate without qualification to support the sale of Reynobond 55 PE. On receipt of that message, she should have told potential customers of the change of classification and should have drawn their attention to the availability of the fire-retardant version and the benefits of using it. Claude Wehrle, who was aware how dangerous the product could be in cassette form, was at greater fault in failing to ensure that the BBA was informed of the change in classification, as required by the contract, and in failing to instruct Arconic's sales representatives in the UK not to promote Reynobond 55 PE without drawing that change of classification to the attention of customers.
¶20.50 Arconic had initially been reluctant to recognise that Reynobond 55 PE reacted far worse to fire in cassette form than in riveted form, and was therefore much more dangerous, and had induced the BBA to issue a certificate that masked the difference in performance. As regulatory requirements in European countries became more restrictive, it sought to take advantage of jurisdictions in which regulatory requirements were less stringent to continue selling the product with an unmodified polyethylene core for use in both cassette and riveted form without distinction relying, in the case of the UK, on the support of the BBA certificate. Its commercial strategy strongly suggests that neither the failure of Ms French to pass on important information to her customers nor the failure of Mr Wehrle to give that information to the BBA was the result of an oversight. We are satisfied that they reflected a sustained and deliberate strategy by Arconic to continue selling Reynobond 55 PE in the UK based on a statement about its fire performance that it knew to be false. Deborah French's failure to pass on important information to her customers, wittingly or unwittingly, supported Arconic's strategy.
47The Lacrosse Fire: November 2014
¶20.51 In the evening of 24 November 2014 there was a fire at the Lacrosse Building in Melbourne, Australia. A report of the fire circulated among several employees of Arconic, including Alain Flacon, Claude Wehrle and Gwenaelle Derrendinger, between April and June 2015.249 {MET00053159/404}; {MET00053158_P10/183}. It is clear that Mr Wehrle read the report because, on 18 June 2015, he sent it to CSTB, describing it as "very interesting".250 {MET00053158_P11/113}.
¶20.52 The report expressed a number of concerns about the use of ACM PE in high-rise buildings. It stated that the fire was directly attributable to the facade of the building and noted the "speed and intensity of the fire spread".251 {MET00053158_P11/139}. It also included descriptions of other cladding fires around the world, including those at the Mermoz Tower in France in 2012, the three other fires in the UAE in that year, and the Torch Tower fire in Dubai on 21 February 2015,252 {MET00053158_P12/144}. all of which had been attributed to the use of ACM PE in the facade.
¶20.53 The report contained a further clear warning to Arconic of the dangers of using ACM PE in high-rise residential buildings, but although Arconic was aware that ACM with an unmodified polyethylene core was flammable, it took no action in response.253 Schmidt {Day93/33:1-7}; {Day94/14:13-16}; {Day94/15:19}-{Day94/16:1}; {Day94/16:11-19}.
The BBA review: 2013 – 2015
¶20.54 Another review of the BBA certificate began in October 2013. By January 2015 the BBA had made at least twelve attempts to contact Arconic in writing to establish whether it had any new information that might be relevant.254 {MET00053158_P17/182-186}. On 18 July 2014 Mr Wehrle was asked to provide, amongst other things, written confirmation that there was no new information that would invalidate the certificate.255 {MET00053158_P17/182}. We deal with that in more detail in Chapter 21.
¶20.55 As we have explained, Arconic was aware in July 2014 that Reynobond 55 PE was not classified as Class B in any form and that the BBA certificate was therefore no longer correct. However, Arconic failed to respond to the BBA's requests for information and allowed the existing certificate to remain in circulation. Although the classification had been extended for five years and Reynobond 55 PE in rivet form had achieved Class B in 2010, Arconic knew by early 2014 that that test could not be relied on to sell Reynobond 55 PE for use in either form, hence Mr Wehrle's message of 3 February 2014. We return to that point in more detail in Chapter 21.
48Further testing by CSTB: October to December 2014
¶20.56 Further tests were carried out on Reynobond 55 PE in late 2014. On 4 December 2014 CSTB issued a report classifying the panels in riveted form as Class C256 {ARC00000397}; {MET00053158_P05/155}. and on the same date, at the request of Arconic, it reissued a report classifying the panels in cassette form as Class E.257 {MET00053158_P02/119}; {ARC00000395}. However, Arconic did not report those test results to the BBA or ask for its certificate to be revised or withdrawn.
Testing of Reynobond 55 PE with a black core: 2015
¶20.57 In 2015, Arconic changed the colour of the core of Reynobond 55 PE from translucent to black. It then instructed CSTB to undertake a single new test of the product in riveted and cassette forms. The riveted form retained its C classification258 {ARC00000402}. and the cassette form retained its E classification.259 {ARC00000405}. The results of those tests were not provided to the BBA.
Arconic's involvement in the supply of Reynobond 55 PE for use at Grenfell Tower: 2015
¶20.58 Earlier in this chapter and elsewhere in the report260 See Part 6, Chapter 55. we have covered the events by which Deborah French dealt with CEP and Harley in selling Reynobond 55 PE for use on Grenfell Tower. Ms French left Arconic at the end of 2014 and was replaced by Vince Meakins in May 2015.261 French {MET00053162/3} page 3, paragraph 12; Meakins {MET00053164/2} page 2, paragraph 5. In the interim, Arconic's sales to the UK were managed by Peter Froehlich assisted by Gwenaelle Derrendinger, an administrative sales assistant.262 Froehlich {MET00053197/11} page 11, paragraph 39.
¶20.59 On 3 March 2015, Ms Derrendinger sent a formal quotation to CEP for the supply of Reynobond 55 PE for use on Grenfell Tower.263 {MET00053161/27}. The order was confirmed on 18 March 2015.264 {ARC00000010}; {MET00053161/28}; {MET00053161/40}; {ARC00000149}. Ms Derrendinger said that, although she could not recall whether she had discussed the type of core with CEP, unless she had been asked to quote for the FR version she would have quoted for the PE version, since it was a UK project.265 Derrendinger {MET00053191/36} page 36, paragraph 104. See also Derrendinger {MET00053191/35} page 35, paragraph 100, in connection with orders placed by Booth Murie that also resulted in quotations for panels with PE cores. Even as late as March 2015, therefore, Arconic's marketing strategy in the UK was to sell ACM with a PE core unless an FR core was specifically requested.
¶20.60 At that time the panels in cassette form had a European Class E reaction to fire classification. There can be no doubt that Arconic understood that the panels it supplied for use at Grenfell Tower would be used in cassette form: Deborah French was herself aware of that fact and, in any event,266 French {Day88/173:5-15}; {CEP000000443}. Arconic's client database had included that information from at least April 2014.267 {MET00053159/86}; {MET00019920/31}. Nobody at Arconic made any attempt to tell CEP, Harley or anyone else working on the Grenfell Tower project that the panels in cassette form were Class E.
49¶20.61 Mr Froehlich attended meetings with Harley and CEP in 2014268 Froehlich {MET00053197/9-14} page 9 and 14, paragraphs 37 and 41. at which the Grenfell Tower project was discussed and was sent several emails relating to the project, including those relating to orders for Reynobond 55 PE that were placed between March and October 2015.269 {MET00053161/28}. Mr Froehlich acknowledged that he had been aware that the product supplied to Grenfell Tower was Reynobond 55 PE.270 Froehlich {MET00053197/15} page 15, paragraph 45.
¶20.62 Mr Meakins candidly accepted in his oral evidence that he had been aware for a year before the fire at Grenfell Tower that ACM PE should not have been used on tall buildings because it was dangerous.271 Meakins {Day88/130:6-11}. Arconic had been well aware of that from the outset, particularly in relation to panels in cassette form, but failed to disclose that information to anyone working on the refurbishment. Mr Meakins himself did not play a part in the supply of ACM PE panels for the Grenfell Tower refurbishment project.
Arconic's reaction to cladding fires overseas: 2015 and 2016
Fire at the King Fahd Medical Centre in Riyadh: October 2015
¶20.63 On 10 October 2015, a fire occurred at the King Fahd Medical Centre in Riyadh, a high-rise building that was clad in Alucobond FR rainscreen panels. Mr Wehrle was told about the fire on 16 October 2015, when he was sent three photographs showing the damage to the building.272 {MET00053158_P10/168}. In response he expressed the view that the panels had performed very well and that the fire would have spread over the entire height of the tower if the panels had had an unmodified polyethylene core.
¶20.64 Mr Wehrle clearly understood that ACM PE panels were likely to contribute to the spread of flame when used on high-rise buildings and were much more dangerous than the fire-resistant version. Indeed, his comment reflects the opinion he had voiced in an internal email on 29 June 2015 that ACM PE was dangerous and that Arconic should move to selling only the FR product as a matter of urgency.273 {MET00053158_P05/14}. That warning appears to have fallen on deaf ears among Arconic's senior management.
The Address, Dubai: 31 December 2015
¶20.65 On New Year's Eve 2015, there was a fire at The Address, a hotel in Dubai. A news article and photograph were passed between Claude Wehrle, Guy Scheidecker and others in early January 2016.274 {MET00053158_P10/174}.
¶20.66 On 4 January 2016 Robert Campbell, the UK sales representative for Reynolux, wrote to Mr Wehrle and others at Arconic telling them that The Address had been clad in Alucobond ACM PE and suggested that architects were wondering whether ACM PE was safe to use.275 {MET00053158_P10/172}. Mr Wehrle said that he hoped ACM PE would be removed from the facade cladding market because it was reflecting badly on other ACM products.276 {MET00053158_P10/172}. Guy Scheidecker, a senior executive, expressed the view that ACM PE was not the only component responsible for such a fire.277 {MET00053158_P10/176}. That may have been so, but there is no evidence that Arconic then undertook any further investigation of that possibility. Rather, the Arconic management were pleased that on this occasion, a competitor's product was involved, not their own.
50Place de Hageneau: January 2016
¶20.67 In January 2016, a fire broke out at the Place de Hageneau in Strasbourg, France. The building that caught fire did not feature any ACM, but another building about 10 metres away was clad in Reynobond 55 PE. On 19 January 2016, Mr Wehrle wrote to Alain Flacon and Lionel Marconnet at Arconic expressing the view that Arconic had been very lucky that the wind had not changed.278 {MET00053158_P10/179}. He went on to say that it was time for Arconic to stop offering ACM PE for construction purposes. It was aware of the danger and should take steps to withdraw it.
¶20.68 However, yet again Mr Wehrle's warnings went unheeded internally at Arconic, and nothing appears to have been done to withdraw ACM PE from the UK market or to warn customers in the UK of the dangers of which Arconic was aware. Arconic's French sales representatives were instructed to offer only Reynobond 55 FR, regardless of the height of the building, but no similar direction was given in respect of the UK.
¶20.69 There is, therefore, clear evidence that senior managers at Arconic had been aware for many years before the Grenfell Tower fire that the statements the company was making about the fire performance of Reynobond 55 PE were inaccurate and, in particular, that the fire performance of cassette-fixed panels was significantly worse than that of riveted panels. It is equally clear that, despite what they knew, they decided not to ask the BBA to withdraw or amend its certificate and did not withdraw Reynobond 55 PE from the UK market. Arconic thus promoted and sold a product knowing that it presented a significant danger to those who might use any buildings on which it was used.
51Chapter 21: The review of the Reynobond certificate
The BBA's review processes: an overview
¶21.1 Once the BBA certificate of 14 January 2008 relating to Reynobond had been issued, it became subject to the scrutiny processes in the contract between Arconic and the BBA designed to ensure its continued validity.279 {BBA00008042/3} clause 6.
¶21.2 Although its processes changed over time, the BBA consistently monitored certificates by means of desk-based reviews carried out by Project Managers and factory inspections carried out by Technical Assessors. A desk-based review, which was carried out at least once every three years,280 Albon {BBA00000158/8} page 8, paragraph 29. involved checking that statements in the certificate continued to be valid, ensuring that the product being sold by the manufacturer continued to be the one assessed and reviewing the certificate holder's public statements about BBA certification, including how it used the BBA logo.281 Amoroso {BBA00010797/3} page 3, paragraphs 14-15; Amoroso {Day106/25:15}-{Day106/26:10}; Nkomo {BBA00010783/5} page 5, paragraph 12. Factory inspections involved inspecting and assessing factory production against a quality plan agreed with the manufacturer which set out what should be assessed in continuing surveillance,282 O'Neill {BBA00010789/3-4} pages 3-4 paragraphs 8-13; Albon {BBA00000158/8} page 8, paragraph 27; Amoroso {BBA00010797/11} page 11, paragraph 57. usually at six month intervals.283 Haynes {BBA00010784/7} page 7, paragraph 29.
¶21.3 Typically a quality plan would require the Technical Assessor to examine the manufacturing process, including checking that the raw products, suppliers and methods of production were as had been originally described by the manufacturer and examining how it maintained quality in production.284 {BBA00010870}. The process was co-ordinated with the desk-based reviews conducted by Project Managers, who agreed the quality plans with the certificate holders in advance of the inspections and considered the Technical Assessors' reports against them.285 O'Neill {BBA00010789/4-5} pages 4-5, paragraphs 17, 20 and 22. However, the desk-based review and factory inspection were separate and distinct activities on the BBA's part, aimed at reviewing different aspects of certification. In particular, it was no part of a Technical Assessor's role to review fire performance testing data or certification, which was the responsibility of the Project Manager. In turn, it was for the certificate-holder to provide any new technical performance information to the Project Manager in accordance with the contract.286 {BBA00010790}; Amoroso {Day106/37:1-6}. A Technical Assessor could not review the history of a product's fire performance testing in the limited time available for an inspection and in any event could not reasonably be expected to have the skill or experience required for that task.
52¶21.4 From time to time Arconic entered into contracts with the BBA for the review and extension of the certificate. In each case it was a term of the contract that Arconic would provide the BBA with any test data available in relation to the product and would notify it of any new information relating to Reynobond and its performance that came into its possession.287 The 2010 review contract referred to the 2007 terms {BBA00008044/11}; the 2014 reissue contract did not alter the original terms {BBA00010889}; the 2016 technical reissue contract provided for materially the same obligations of disclosure on Arconic {MET00053158_P18/141-151} clause 10.
The Agreement with CSTB
¶21.5 The initial assessment of Reynobond panels was based on data obtained from CSTB and the BBA therefore felt able to dispense with a quality plan and an initial factory inspection and to rely on CSTB's continuing monitoring of Arconic's quality standards. On 17 May 2007, Hamo Gregorian asked CSTB to confirm that it had been inspecting Arconic and, if so, whether it was satisfied that appropriate quality control had been maintained.288 {BBA00008042/123}. He also asked CSTB to inform the BBA if it identified any major failures to comply with production processes affecting quality, or if it discontinued its visits. On 21 May 2007, Laurent Plagnol of CSTB agreed that it would identify any major failures to comply with processes affecting quality non-compliances for the BBA, although he did not directly answer Mr Gregorian's question whether quality control had previously been satisfactorily maintained.289 {BBA00008042/123}. Mr Gregorian recorded that agreement on 21 April 2008.290 {BBA00008042/121}. CSTB was not asked to provide the BBA with any testing information it held relating to the Reynobond product.
Review project 2011
¶21.6 At the end of 2010, the BBA and Arconic agreed a contract for the triennial review of the Reynobond certificate,291 {BBA00008044/11}. which was conducted over the next few months by Project Manager Alpheo Mlotha.292 Project number S146895; Technical File: {BBA00008044}; Signed off by Review Report on 24 June 2011 {BBA00010810}.
¶21.7 On 11 February 2011, Mr Mlotha wrote to Arconic seeking information for the purposes of the review,293 {BBA00008044/35}. including a list of customers, current technical literature and a letter from CSTB either confirming that there were no changes in the raw materials, manufacturing process or quality control procedure, or, if there had been, stating what those changes were.
¶21.8 Arconic's Quality Manager, Brigitte Gross responded on 11 April 2011 with the information requested (and no more),294 {BBA00008044/33}. including a certificate from CSTB confirming that the technical properties of Reynobond 55 complied with the CSTB certification.295 {BBA00008044/79-91}. Mr Mlotha was apparently satisfied that there had been no changes in the method of production, since he required only a few minor changes to be made to the text of the certificate at the next issue. Accordingly, the review project was closed on 24 June 2011 with the next review scheduled to commence by 15 January 2014.296 {BBA00010810}.
53Arconic Reynobond PE testing in 2011
¶21.9 On 9 February 2011, at almost exactly the same time as Mr Mlotha made his request for documents, CSTB issued a new EN 13501 classification report for grey Reynobond PE in rivet form based on the test which had been carried out in the previous June (Test RA11‑0032).297 {ARC00000537}; {ARC00000383}; See Chapter 20. CSTB certified the fire performance as being Bs1, d0, which was better than that reported in the BBA certificate. Arconic did not give that information to the BBA, even though it was apparently an improvement, despite the fact that it was contractually obliged to do so.
¶21.10 Shortly after Mr Mlotha had completed his review in 2011, CSTB conducted further testing on Reynobond PE 55 in cassette form in accordance with European methods.298 {ARC00000538}. On 12 October 2011, it issued certificate RA11-0244 classifying Reynobond in cassette form as Euroclass E.299 {ARC00000538}; {ARC00000386}; See Chapter 20. However, Arconic did not disclose the certificate or the information it contained to the BBA. At that point, Arconic could have been in no doubt that Reynobond 55 PE in cassette form performed very badly in a fire and that the BBA certificate made no reference to that important information. Even if Arconic did not think that it was bound to disclose that information to the BBA immediately (as it was), it could have been in no doubt that it would have to disclose it at the next review in 2013.
Review project: 2013-2015
¶21.11 After the 2011 review, the BBA decided that it would no longer rely on foreign bodies (like CSTB) to conduct inspections but would use its own Technical Assessors to carry out that task. From that time until September 2017, Technical Assessor Shaun O'Neill carried out the inspection of Arconic's factory at Merxheim.300 O'Neill {BBA00010789/7} page 7, paragraph 29.
Maria Barbeito's attempts to review the certificate – October 2013-September 2014
¶21.12 In October 2013, BBA Project Manager Maria Barbeito began the second triennial review of the BBA certificate for Reynobond.301 {BBA00010741}. On 8 October 2013 she wrote to Claude Schmidt at Arconic attaching a draft quality plan for Arconic's agreement. That was the first quality plan proposed for the new certificate. In that letter she asked for documents relating to her review and asked Arconic for written confirmation that there had been no changes in the design, specification, context of use or other details that would invalidate the existing certificate, or if there had, to specify any changes.302 See her email dated 9 October 2013 {BBA00008089} attaching the letter {BBA00008090} and the draft quality plan {BBA00008091}. At the time it was customary for the BBA to use that form of words when making requests of that kind.303 Amoroso {Day106/65:11-22}; Albon {Day110/35:1-8}.
¶21.13 Between 21 October 2013 and 7 May 2014 Ms Barbeito sent emails to Arconic on six occasions304 {BBA00008085} attaching {BBA00008086} and {BBA00008087}; forwarded to Claude Wehrle {BBA00008092/1-2}; {BBA00008075} attaching {BBA00008076} and {BBA00008077}; {BBA00008095} attaching {BBA00008096} and {BBA00008097}; {BBA00008971}. seeking a response; she also attempted to telephone Arconic at least twice, but without success.305 {BBA00008075}; {BBA00008663}. In an email to a colleague in July 2014, she described her frustration at Arconic's lack of response, saying that Claude Wehrle was very nice on the telephone but never sent any information.306 {BBA00008663}. The BBA received no substantial response whatever from anyone at Arconic during that period.
54¶21.14 On 18 July 2014, Ms Barbeito managed to speak to Claude Wehrle on the telephone and then sent him an email in which she repeated her request for documents, including written confirmation that there had been no material changes that would invalidate the certificate.307 {BBA00008954} attaching {BBA00008955}. She and Mr Wehrle also discussed arranging a visit to Arconic's factory at Merxheim. Shaun O'Neill carried out the BBA's first inspection of the Merxheim factory on 10 September 2014. In his report he recorded that Claude Wehrle had told him that he had tried to communicate with the BBA several times to discuss the review but that his messages had gone unanswered and that he would like the Project Manager to contact him as soon as possible.308 {BBA00010873/2}. However, the documentary record and recollections of other witnesses does not support Mr Wehrle's assertion.
¶21.15 In the period when Ms Barbeito was attempting to obtain a satisfactory response from Arconic, several changes in the classification of Reynobond 55 PE occurred, as we have described in Chapter 20. From 31 January 2014 the product in both cassette and riveted form had been classified E,309 {MET00053158_P02/59}; {MET00053158_P04/135-138}. but by 4 December 2014, the two forms were again classified differently, with the cassette form retaining an E classification,310 {MET00053158_P02/119-124}; {ARC00000395}; See Chapter 20. and the riveted form classified as C-s2, d0.311 {MET00053158_P05/155-163}; {ARC00000397}; See Chapter 20.
¶21.16 Each one of those changes was important to the BBA's work on renewing the validity of the Reynobond certificate, but Arconic did not tell the BBA about them or attempt to discuss with it the amendment or withdrawal of the certificate.
Valentina Amoroso's review: September 2014-January 2015
¶21.17 Maria Barbeito then left the BBA, and at the end of September 2014 Valentina Amoroso joined the organisation.312 Amoroso {BBA00010797/2} page 2, paragraph 6. Ms Amoroso had a degree in materials engineering313 Amoroso {BBA00010797/2} page 2, paragraph 5. but no experience or knowledge of cladding materials or of building regulations relating to fire.314 Amoroso {Day106/10:15}-{Day106/11:2}. She started working on projects relating to cladding when she was transferred to the engineering department in November 2014 and was initially assigned to the review of existing certificates, which was thought to be simpler than a full technical assessment and more suitable for a newcomer.315 Amoroso {BBA00010797/2} page 2, paragraph 7. One of the first projects she undertook was the resumption of work on the triennial review of Arconic's Reynobond 55 certificate.
¶21.18 Ms Amoroso's training in the skills required to assess cladding products and to understand fire performance was largely, if not completely, informal and self-directed. She read the applicable standards, asked questions of her seniors in the BBA, including those with greater expertise in fire performance, and attended some conferences and full-scale fire tests of facades.316 Amoroso {Day106/10:6-11}; {Day106/13:3}-{Day106/14:4}; {Day106/14:22-25}. At one external event, she met Stephen Howard of BRE and thereafter she occasionally asked for his opinion on matters she did not understand.317 Amoroso {Day106/17:19}-{Day106/18:8}. Ms Amoroso may have taken the initiative in learning about a new area of activity, but the BBA should not have asked her to conduct even a certificate review without any training in the knowledge and skills required for understanding cladding technology or fire performance.
55¶21.19 One of the people to whom Ms Amoroso directed questions internally was Prayer Nkomo.318 Amoroso {Day106/17:4-11}. He was a civil engineer319 Nkomo {BBA00010783/2} page 2, paragraphs 4-5. who had worked at the BBA since November 2010 as a Project Manager. By the time of the 2013-2015 review he had developed some expertise in cladding technology but not in fire performance,320 Nkomo {Day107/12:15-19}; {Day107/72:5-22}; Amoroso {Day106/17:4-11}. and it was only on the former that he assisted Ms Amoroso. In early January 2015, shortly after Ms Amoroso had begun working on cladding products, Mr Nkomo was promoted to the role of Team Manager and Ms Amoroso reported to him.321 Nkomo {BBA00010783/2} page 2, paragraph 6.
¶21.20 Between the time of the first assessment of Reynobond PE and the date of the Grenfell Tower fire no one at the BBA had expertise in the reaction of materials to fire.322 Albon {Day109/88:22}-{Day109/89:8}; {BBA00010486} paragraph 3. If a question about fire performance arose, Mr Nkomo might approach Jon Denyer or John Albon,323 Nkomo {Day107/19:14-18}; {Day107/102:8-19}. who by 2012 had developed some experience in the field but who were not trained experts.324 Albon {Day109/88:17-22}. Mr Nkomo was aware that if he needed external assistance, he could ask for the matter to be referred to Exova,325 Nkomo {Day107/18:6-10}; {Day107/18:23}-{Day107/19:2}. with which the BBA had made formal arrangements for advice.326 Albon {Day109/91:7-20}; {Day109/106:17}-{Day109/107:12}; {BBA00010762/4}. However, Mr Nkomo did not routinely seek assistance and would only ask for help if he was unsure of a point relating to fire performance.327 Nkomo {Day107/20:6-10}; {Day107/20:15}-{Day107/21:14}.
¶21.21 At Ms Amoroso's request328 {BBA00010550/3}. Mr Nkomo contacted Claude Wehrle on 2 December 2014. Mr Nkomo was very clear in his subsequent email to Mr Wehrle that information provided to the Technical Assessor in the course of a factory visit was no substitute for responding to the Project Manager's request.329 {MET00053158_P18/4}. Shortly after, Ms Amoroso again asked Arconic to provide written confirmation that there were no changes that would invalidate the certificate.330 {BBA00008098}. Mr Nkomo's and Ms Amoroso's emails to Mr Wehrle arrived two days before CSTB issued new classification certificates for Reynobond 55 PE, in which the riveted form was classified C, and the cassette form E. Mr Wehrle must have been aware of those classifications at the time when Mr Nkomo and Ms Amoroso were pressing him for information.
¶21.22 Valentina Amoroso also noticed that the Reynobond certificate files contained no regular surveillance reports from CSTB about factory visits nor any arrangements for continued monitoring,331 Amoroso {BBA00010797/10} page 10, paragraph 51; {BBA00008112}. although it did contain a report prepared by Shaun O'Neill after his review visit in September 2014. The BBA decided that it should make arrangements for continued monitoring.
¶21.23 At that point the BBA had received no information about the production of Reynobond since 2007 save for a report in 2011 and Mr O'Neill's report in September 2014. That seven-year gap in the BBA's information was significant.332 Amoroso {Day106/67:1-7}. In addition, no quality plan had been agreed at the time of the initial assessment, so the BBA did not have a yardstick by which to measure whether production had changed or the product was the same as that initially assessed. Nonetheless, it was content to proceed with renewing the certificate, provided a quality plan and continuing monitoring could be agreed with Arconic.
56¶21.24 On 18 December 2014, Valentina Amoroso sent a request for information to Arconic's quality representative, Lilia Koscuk.333 {BBA00008079/3-4}. In early January 2015 Ms Koscuk replied, saying that she agreed the proposed quality plan, but failed to provide the information that the BBA had requested for the purposes of the review.334 {BBA00008079/3}. Ms Amoroso repeated her request on 7 January 2015 and again on 12 January 2015, when she imposed a deadline of 20 January 2015 for a response.335 {BBA00008079/2-3}. Ms Koscuk responded by referring Ms Amoroso to various people at Arconic whom the BBA already knew, including Mr Wehrle.336 {BBA00008079/1-2}. Her approach was entirely unhelpful, bordering on the obstructive.
¶21.25 On 22 January 2015 the BBA decided at a senior level337 Nkomo {Day107/48:1-10}; Albon {Day110:39:1-7}. to complete the review with the information Ms Amoroso already had.338 {BBA00008079/1}. The decision is inexplicable. The BBA had said that the information it was seeking from Arconic was essential to complete the review, as indeed it was. The BBA had received no confirmation of the performance of the Reynobond product from Arconic in the previous seven years and Arconic's failure to provide such information when asked was exceptional and extreme.339 Amoroso {Day106/60:2-9}; {Day106/74:8-10}; Nkomo {Day107/43:23}-{Day107/44:3}; Albon {Day110/35:25}-{Day110/36:20}. The BBA should have realised that it was a case requiring particular attention rather than summary completion.
¶21.26 The BBA could and should have threatened to suspend Arconic's BBA certificate given its lack of response340 See clause 13(a) of the BBA's standard terms {BBA00008042/3} clause 13(a). and should have done so if the information it required was not provided.341 Albon {Day110/56:23}-{Day110/57:4}. However, it does not appear that such a step was ever considered, despite Arconic's wholesale lack of co-operation. Indeed, we were told that it was not the BBA's practice at the time to suspend certificates for a failure to respond to requests for information.342 Albon {Day110/56:23}-{Day110/57:4}. We consider that to be an unsafe and unsatisfactory position, but as a result the BBA completed the review using only publicly available information, such as the information available on Arconic's website, published technical datasheets and marketing brochures.343 Amoroso {Day106/76:14-24}.
¶21.27 There is evidence that summaries of results were available in the CSTB's web database344 {MET00053158_P02/62}; Wehrle {MET00053190/21} page 21, paragraph 70. and Ms Amoroso said that in January 2015 she would have referred to the certification available on the CTSB's website.345 Amoroso {Day160/77:14-18}. Had she looked at those summaries she would, or at least should, have noticed the Cs-2, d0 and E classifications and questioned the contents of the BBA certificate. However, for whatever reason, that did not happen. In any event, according to Mr Nkomo, BBA did not consider it part of its responsibility on a review to look for fire testing data on laboratories' websites because the customer was obliged to provide information of that kind.346 Nkomo {Day107/51:7}-{Day107/52:4}. That was not an unreasonable stance to take, but it should have been supported by a refusal to renew the certificate if the customer failed to provide information that was available to it.
57¶21.28 The decision to close the review was made by Mr Nkomo to whom the matter was referred Ms Amoroso and probably also in discussion with their senior manager, the Head of Approvals.347 Nkomo {Day107/47:13}-{Day107/48:25}; {Day107/49:12-19}; Amoroso {BBA00010797/12} page 12, paragraph 63; Amoroso {Day106/78:13}-{Day106/79:6}; Albon {Day110 /39:1-7}. Mr Nkomo told us that it was common for reviews to be closed despite a failure by the certificate holder to provide information, although that was not BBA policy nor encapsulated in any formal instruction.348 Nkomo {Day107/54:23}-{Day107/55:14}; Albon {Day110/45:5-25}; Moore {Day108/7:14-21}.
¶21.29 We have seen no record of why this particular review was closed. Both Mr Nkomo and Ms Amoroso thought that it had probably been because it had become delayed,349 Nkomo {Day107/57:14-17}; Amoroso {Day106/86:14-16}. and Mr Nkomo agreed there had been a backlog of reviews at the time.350 Nkomo {Day107/57:21}-{Day107/58:9}; {BBA00008073}. A further reason appears to have been that the BBA was concentrating on agreeing a quality plan and continuing monitoring. Once that had been achieved, the BBA expected any changes in the product to be reported.351 Amoroso {BBA00010797/12} page 12, paragraph 64; Amoroso {Day106/78:14-21}; {Day106/79:17-21}; {Day106/83:19}-{Day106 /84:16}. However, neither of those was a good reason for closing the review.
¶21.30 The BBA was under the impression that a product's fire performance classification would not change as long as the product itself or the manufacturing process did not change. For that reason, it thought there was no reason to check for new testing reports, but that ignored the fact that the European classification certificates said on their face that they expired five years from the date of issue. No one at the BBA working on the review of the certificate had regard to the fact that Arconic would need to have the product tested again and would or should have new fire performance information available. That would have been plain if anyone had considered the fire test data on which the initial assessment had been based.352 Amoroso {Day106/99:5-8}; {Day106/99:21-25}; {Day106/100:10-18}. Ms Amoroso did not consider that data because the process did not require her to do so.353 Nkomo {Day107/66:4-5}; Albon {BBA00000158/16} page 16, paragraph 66; Albon {Day109/151:24}-{Day109/152:19}. That was an obvious flaw in the BBA's review process.
Arconic's submissions on the review
¶21.31 In an attempt to avoid criticism of its failure to provide information to the BBA Arconic argued that there had been no need for it to provide the BBA with any further information after it had disclosed Test 5A because, among other things, the certificate stated only that Reynobond PE panels were capable of achieving Euroclass B, depending on the configuration of the system in which they were tested.354 Arconic Module 2 closing submissions {ARC00000770/30} page 30, paragraph 143. It said that the potential variations in the European testing regime made it possible for a single product to have more than one classification.355 Arconic Module 2 closing submissions {ARC00000770/14} page 14, paragraphs 60-62; Arconic Module 6 closing submissions {ARC00000794/28} page 28, paragraph 83. Arconic also maintained that it never claimed that the panels would achieve Euroclass B in all circumstances.356 Arconic Module 6 closing submissions {ARC00000794/29} page 29, paragraph 88.
58¶21.32 In our view Arconic's arguments were wholly unrealistic. They ignored the terms of its contract with the BBA, which required it to provide any test data already available357 {BBA00008042/3} clause 7(a). and immediately to notify the BBA of any change in the particulars supplied and of any new or additional information concerning the product or its suitability for use.358 {BBA00008042/3} clause 7(g). The performance of Reynobond PE in cassette form was information available to Arconic which was highly relevant to its use, as it must have realised. If the BBA had been informed of it at any time before the completion of the review in January 2015 there can be little doubt that it would have amended the certificate to reflect such important information.359 Amoroso {Day106/109:6-15}; Albon {BBA00000158/8} page 8, paragraph 27. Nor was it appropriate for Arconic to rely on CSTB giving the data to the BBA.360 Arconic Module 2 closing submissions {ARC00000770/30} page 30, paragraph 142. Arconic's obligation was clear.
¶21.33 Furthermore, Arconic's submissions demonstrate a fundamental misunderstanding of the function of a BBA certificate. It was not, as Arconic appeared to suggest, to record the best performance that a product was capable of achieving. Its purpose was and is to provide construction professionals with independent and objective information about the nature and performance of products which can be relied on as complete and trustworthy. Those who relied on BBA certificates were entitled to expect that the description of the product concerned was complete and accurate, including any variation in performance when used in different circumstances.
¶21.34 Arconic also said that the Euroclass B classification was still valid at the time of the sale of Reynobond 55 PE for use on the Grenfell Tower refurbishment in March 2015361 Derrendinger {MET00053191/37} page 37, paragraph 107. and that therefore the BBA certificate was not incorrect.362 Arconic Module 6 closing submissions {ARC00000794/29-30} page 29-30, paragraphs 83-87. It argued that when at the end of 2014 Reynobond PE 55 in riveted and cassette forms returned to being separately classified (C-s2, d0 and E respectively), they ceased to be classified E.363 {MET00053158_P02/119-124}; {ARC00000395}; See Chapter 20. Arconic argued that, in effect, the classification in 2011 of Reynobond 55 PE in rivet form as Bs-1, d0 became effective once again and, being valid for 5 years, remained effective until February 2016. The effect of that argument is that there were two classifications for Reynobond 55 PE in rivet form in effect at the same time, one Euroclass B and one Euroclass C. That is unlikely, to say the least, and there is no evidence that that was its intention.
¶21.35 The obvious flaw in the argument is that there is no proper basis on which to read certificate RA13-0333 issue 2 dated 4 December 2014 as reinstating the result of the test carried out in 2011. The only sensible way of interpreting what occurred is that Arconic decided for a time not to rely on the Euroclass B classification and to consider all Reynobond 55 PE (whether in riveted or cassette form) to be Class E. It then decided to classify them separately again, but with the riveted form being Class C rather than B. That accords with the recollection of Mr Wehrle.364 Wehrle {MET00053190/20-21} pages 20-21, paragraphs 68-70.
¶21.36 In any event, Arconic's argument applies only to Reynobond 55 PE in its riveted form. It is therefore completely irrelevant to the material supplied for use on Grenfell Tower in cassette form.
59¶21.37 In any event, on 23 April 2014, when it sent the BBA certificate to those involved in the refurbishment to support the sale of Reynobond 55 PE for use on Grenfell Tower,365 {CEP000000281}. Arconic itself considered the correct classification of the product in either form to be Class E. On any view, the BBA certificate was at that time inaccurate. The reality is that Arconic knew that Reynobond 55 PE in cassette form was Class E and that it had been consistently classified as such since 2011. However, it did not tell the BBA, nor anyone involved in the Grenfell Tower refurbishment and it appears that only one UK supplier was ever told about the true position.366 Gwenaelle Derrendinger provided certificates showing that Reynobond 55 PE cassettes had achieved European Class E to Taylor Maxwell, a UK supplier, on 3 February 2014 {MET00053173/91} and 9 March 2015 {MET00053173/135}. On the latter occasion the certificate was sent following a request from Deborah French who by that time had left Arconic and joined Taylor Maxwell.
Reissue contract 2015
¶21.38 The BBA's closing report for the 2013-2015 review was issued on 10 April 2015. It stated that the certificate had to be reissued so that the text could be revised.367 {BBA00008135}. The report also recommended that Arconic should check that there was no contradiction between the technical information that it published and that contained in the certificate.368 {BBA00008135/6}. The BBA offered Arconic a contract for this work,369 {BBA00010889}; {MET00053158_P18/31}. which Arconic accepted,370 {MET00053158_P18/41}; {MET00053158_P18/38}. but for reasons which are unrecorded the BBA did not reissue the certificate.
¶21.39 None of the documentation closing out the review or generated when the contract for the reissue was offered referred to the fact that there had been any difficulty obtaining current information from Arconic and that a decision had been taken to rely solely on publicly available information. By the end of 2015, the BBA had introduced new documentary procedures under which information of that kind was recorded for the benefit of future reviewers. However, those procedures came too late to affect the 2015 review relating to Reynobond 55 PE.371 Nkomo {Day107/67:9}-{Day107/68:3}.
Review project 2016
¶21.40 The next triennial review of the BBA certificate for Reynobond began on 12 October 2016 and was again carried out by Valentina Amoroso.372 {BBA00010742}. That was after the certificate of practical completion had been issued for Grenfell Tower and therefore too late to make any difference to that building. It is nonetheless relevant to how Arconic and the BBA continued to communicate and conduct themselves. This time, Ms Amoroso specifically asked for confirmation that no changes had been made to raw materials, manufacturing processes or quality control procedures.373 {BBA00011051/5-6}. That was the standard form of request used by BBA Project Managers at the time374 Amoroso {Day106/134:10-12}. and Ms Amoroso did not think it necessary to ask for a broader range of information.375 Amoroso {Day106/137:5-24}.
60¶21.41 Ms Amoroso corresponded with Nicholas Remy, Claude Wehrle's junior colleague in Arconic's Technical Sales Support team, who asked for clarification of precisely what documents the BBA wanted.376 {BBA00011051/1-5}. On 24 October 2016, he provided the documents Ms Amoroso had asked for, namely, technical datasheets, commercial brochures, installation manuals and EU marking data.377 {BBA00011051/1}. Before doing so, however, he wrote to Mr Wehrle on 18 October 2016 passing on part of Ms Amoroso's request.378 {MET00053158_P18/61}. He said he felt as though he was dealing with something that was not clear cut and that what the BBA was coming to review had been "completely modified without them knowing anything about it". In response Mr Wehrle assured Mr Remy that they would talk about it to alleviate any bad impression that Mr Remy had.379 {MET00053158_P18/61}. We do not know what exactly worried Mr Remy, but as far as we can tell, Arconic did not make any further information available to the BBA beyond complying strictly with Ms Amoroso's request.
¶21.42 During this review, Ms Amoroso came to the firm conclusion that references to the product in cassette form should not be included in the certificate because Arconic did not manufacture cassettes or control their fabrication by others.380 Amoroso {Day106/150:15-19}; {Day106/151:12-15}; {Day106/153:16-20}; {BBA00011057}. However, she did not see any difficulty in retaining references to the product in riveted form, although that too required a further process of cutting to size and shape and drilling to be undertaken after the product had left the factory. She did not consider the wider implications of her conclusion so far as fire performance was concerned.
¶21.43 By late 2016, some at the BBA had become aware of cladding fires that had occurred abroad.381 Nkomo {Day107/97:18-22}. As a result, the BBA's newly formed Technical Excellence team decided that statements about height restrictions should be added to certificates for cladding products, particularly ACM panels.382 Nkomo {Day107/96:10-15}. There was also a view at the BBA at that time that the use of the word "filler" in clause 12.7 of Approved Document B was ambiguous and that the word "etc." potentially broadened the ambit of that clause so that the core of an ACM product needed to be of limited combustibility to fall within it.383 Albon {BBA00010723/36-37} pages 36-37, paragraphs 149-152. This is a subject examined in detail in Part 2 of this report. The BBA decided that holders of certificates for ACM products should either show that the core of the product was of limited combustibility, or that the panels achieved Euroclass A1 or A2, or that the cladding system when tested as a whole in accordance with BS 8414 could be shown to comply with the criteria in BR 135. The BBA decided that unless those statements could be included certificates for such products should state that they should not be used on buildings over 18 metres in height.384 Amoroso {BBA00010797/16-17} pages 16-17, paragraphs 88-90; Amoroso {Day106/167:4-23}. Those statements were to be added at the next re-issue of each certificate relating to an ACM product.385 Amoroso {BBA00010797/17} page 17, paragraph 91.
¶21.44 We are surprised that if the BBA had decided to add a statement to all certificates relating to cladding products for safety reasons, it did not take more urgent steps to revise those already in existence. Since the BBA did not publicise the change, a person relying on a certificate would not have known about the change in policy.386 Amoroso {BBA00010797/16} page 16, paragraph 86; Amoroso {Day106/172:2-11}.
61¶21.45 In February 2015, the BBA began using review checklists as part of the process leading to the completion of reviews.387 Nkomo {Day107/68:13-20}; Nkomo {BBA00010783/5} page 5, paragraph 12e. The review checklist relating to the 2016 review of the Reynobond certificate indicated that it needed to be reissued for technical reasons, that references to the cassette form of the product should be removed, that statements should be added restricting the height at which it was suitable for use and that the wording should be refreshed generally.388 {BBA00011085}.
Technical Reissue: 2016-2017
¶21.46 Valentina Amoroso began work on the technical reissue of the certificate in November 2016.389 {MET00053158_P18/144-151}. The work was in progress at the time of the Grenfell Tower fire.390 {MET00053158_P18/157-164}.
¶21.47 Almost immediately after the fire the BBA wrote to Arconic about its Reynobond certification.391 {BBA00010769/6}; {MET00053158_P18/174-180}; {MET00053158_P18/181-182}. It briefly suspended the certificate due to Arconic's failure to respond,392 {BBA00010428}; {BBA00010429}. but Arconic wrote on 17 July 2017 advising that it had stopped selling Reynobond 55 PE for use on high-rise buildings and asking for the certificate to be maintained.393 {MET00053158_P18/193-194}. The BBA was satisfied that it could continue to certify the product.394 Moore {BBA00000159/4} page 4, paragraph 8.
¶21.48 On 21 July 2017, the BBA sent Arconic a draft of a revised certificate which stated that the panels were available in two grades, denoted "ST" and "FR". ("ST" was formerly denoted "PE" and contained an unmodified polyethylene core.)395 {BBA00008221/3} clause 1.2 It also stated in clause 1.4 that the flat panels could be formed into cassettes, but that the manufacturing and use and fixing of cassettes were not covered by the certificate. Fire performance information was presented in a table which recorded that the FR version was classed B-s1, d0 and the ST version (i.e., the version with an unmodified polyethylene core) was classed B-s2, d0.396 {BBA00008221/7}. The latter statement was undoubtedly wrong and was particularly dangerous in view of the failure to include in clause 1.4 any indication that the fire performance of the product in cassette form was markedly worse than in riveted form. The draft also made clear that only Reynobond FR achieved national Class 0 and all statements in the previous certificate to the effect that the product could be "regarded as" Class 0 were removed. The draft included restrictions on the use of the product on buildings over 18 metres in height.397 {BBA00008220}; {BBA00008221}.
¶21.49 Although the draft certificate was intended only for Arconic's information,398 {BBA00008220}. on 25 July 2017 Claude Wehrle commented on it, demonstrating that he had read it.399 {MET00053158_P19/23}. He did not correct the errors in the European fire performance classification of the "ST" version, even though there was no basis on which at that stage Reynobond 55 PE could be described as Class B. Given that the certificate was being drafted by the BBA immediately after a serious fire in which many people had died involving the very product being certified, it is astonishing that it did not check that the fire performance information was correct but merely repeated old claims.400 Amoroso {Day106/189:3-10}; {Day106/189:23}-{Day106/190:2}. Against that background it is even more astonishing that Arconic failed to say anything when presented with a draft certificate that contained materially and obviously incorrect information.
62¶21.50 The BBA formally reissued the certificate on 4 August 2017.401 {BBA00000046}. It stated, wrongly, that the standard PE panel with a grey/green Duragloss coating was classed B-s2, d0.
Re-issue September 2017
¶21.51 On 8 September 2017 Claude Wehrle informed Shaun O'Neill that Arconic was no longer selling Reynobond 55 PE at all in the UK.402 {BBA00010769/16}. On 22 September 2017 the certificate was amended and reissued, removing the references to Reynobond 55 PE.403 {BBA00000049}. From that time the BBA certified Arconic's Reynobond FR product only.
The BBA's discovery of the Reynobond PE and FR test reports
¶21.52 On 29 January 2018, BBC journalist Tom Symonds met Brian Moore, then Operations Director of the BBA. Mr Symonds said that he had information that Arconic had changed the core of Reynobond 55 PE from translucent to black404 Moore {BBA00000159/4} page 4, paragraph 11. and provided some details in writing shortly thereafter.405 {BBA00008363}. On 19 February 2018 Mr Symonds sent the BBA a bundle of test reports on Reynobond 55 PE between 2013 and 2015 which showed that Reynobond 55 PE had Euroclass C and E classifications.406 {BBA00009147/2} attaching reports: RA13-0333 (Classification Report for Reynobond PE, cassette, issued 4 December 2014, Class E); RA14-0339 (Classification report for Reynobond 55 PE, riveted system, issued 4 December 2014, classification Cs2, d0); RA15-0200 (Classification Report for Reynobond 55 PE, riveted system, issued 22 September 2015, Cs2, d0); RA15-0201 (Classification Report for Reynobond 55 PE, cassette system, issued 22 September 2015, Classification E).
¶21.53 Between February and April 2018 Brian Moore made extensive inquiries of Arconic and its legal representatives about the fire performance information in its possession that it had not disclosed to the BBA.407 Moore {BBA00000159/5-13} pages 5-13, paragraphs 13-44; {BBA00010769}. On 27 April 2018 Arconic disclosed to the BBA six test and classification reports on Reynobond 55 FR dating from 2012 to 2016408 {BBA00010769/69}. on the basis that the current certificate covered that product.409 Albon {BBA00000158/14} page 14, paragraph 55. Had the BBA received those reports when they were created, no doubt it would have re-evaluated the product and reissued the certificate with more accurate and complete information. Arconic refused to provide test information about Reynobond 55 PE on the basis that the certificate no longer covered that product. By that time Arconic had become a core participant in the Inquiry.410 {BBA00010769/69}.
¶21.54 Despite the non-disclosures and the highly material matters they revealed, the BBA did not immediately suspend or withdraw the Reynobond certificate. Mr Moore said that that was because the test reports on Reynobond PE obtained from the BBC had not come from CSTB directly and the BBA wanted to know what Arconic said about them.411 Moore {Day108/83:4-16}; {Day108/84:8-15}. He also pointed out that at that time the certificate did not extend to Reynobond 55 PE.412 Moore {Day108/84:22}-{Day108/85:3}.
63¶21.55 It was only on reading Dr Lane's report to the Inquiry in November 2018413 Albon {BBA00000158/11} page 11, paragraphs 38-39; {BLAS0000036}. that the BBA became aware of the existence of Test 5B on Reynobond PE in cassette form and believed that it had the basis for taking action against Arconic.414 Moore {Day108/99:12-15}. On 17 November 2018 it suspended the certificate for material non-disclosure in breach of contract415 {MET00053158_P19/41-45}. and on 1 March 2019, it withdrew the certificate for Reynobond 55 in all forms.416 {MET00053158_P19/47}.
65Chapter 22: Kingspan K15 insulation
The use of K15 insulation on Grenfell Tower
¶22.1 Most of the insulation used on Grenfell Tower during the refurbishment was Celotex RS5000. A small amount, probably about 5% of the total, was K15 Kooltherm manufactured by Kingspan Insulation Limited and marketed for use in rainscreen cladding systems.417 Marketing literature 2001 {KIN00020720}; 2002 {KIN00009173} and {KIN00008018}; 2003 {KIN00002579}; 2006 {KIN00005071}; 2007 {KIN00002580}; 2008 {KIN00009703}; 2011{KIN00003545}; 2015 {KIN00000086}; 2016 {KIN00000070}.
¶22.2 K15 was a rigid phenolic foam board with a foil facer bonded to both faces. Phenolic foam is combustible, with a short time to ignition.418 See Phase 1 Report Volume I, paragraph 6.20 for a description of the fire properties of phenolic foam. How K15 came to be supplied in May419 {SIG00000012}. and September420 {CCF00000019}. 2015 for use in the refurbishment of the tower has been described in Chapter 56 of the report. Kingspan was not aware until after the fire that K15 had been used on the tower.421 Burnley {KIN00000554/5} page 5, paragraph 4.2.
K15 – the product
¶22.3 K15 was first manufactured at Kingspan's Pembridge site in Herefordshire in November 2002.422 {KIN00022307} Tab 2, Row 2, Column C. At that time, the foam was produced with a pentane blowing agent.423 Rochefort {KIN00008838/7} page 7, paragraph 3.10; Rochefort {Day80/50:21-22}; {KIN00022307} Tab 2, Row 2, Column C. The foil facers of the product were unperforated, with a thickness of 7.6 microns.424 Meredith {Day75/35:16-18}; Heath {Day79/13:8-10}; Rochefort {Day80/54:11}; {KIN00022307} Tab 2, Row 2, Column C.
¶22.4 Following its acquisition of a Dutch company in 2003,425 Rochefort {Day80/46:15}; Rochefort {KIN00008838/6} page 6, paragraph 3.6; Heath {Day79/11:13}; Heath {KIN00020709/9} page 9, paragraph 3.4. Kingspan began to introduce a number of changes to its phenolic foam range. They included physical changes to the structure of the foam and the introduction of different chemical ingredients and manufacturing processes to achieve better thermal performance and rates of productivity.426 Rochefort {KIN00008838/6-7} pages 6-7, paragraphs 3.6 and paragraph 3.8. In particular, Kingspan introduced the use of a mixture of pentane and isopropyl chloride as a blowing agent427 Rochefort {Day80/50:25}. and perforations were introduced to the aluminium foil facers.428 Heath {Day79/13:4-7}; Meredith {Day75/35:16-18}; Rochefort {Day80/54:6-8}. The new version of K15 came to be known within Kingspan as "new technology" or "Kesteren technology"429 Kesteren is the name of the location in the Netherlands where Marec manufactured phenolic foam. K15 and the previous version as "old technology" K15.430 Rochefort {KIN00008838/6} page 6, paragraph 3.6. Dr Rochefort said that by September 2006 the K15 available to the market was the "new technology" version of the product.431 Rochefort {Day80/34:23-24}; {Day80/48:22-23}; Rochefort {KIN00008838/9} page 9, paragraph 3.17. Ivor Meredith, who had been a Project Leader in the Technical Projects team,432 Meredith {KIN00022312/1} page 1, paragraph 1. and his line manager, Philip Heath, Technical Manager until 2010,433 Heath {KIN00020709/4-6} pages 4 and 6, paragraphs 2.8 and 2.18. both agreed, although they thought that production of "old technology" K15 had ceased in about August 2007.434 Heath {KIN00020709/13} page 13, paragraph 3.18; Meredith {Day75/124:24}-{Day75/125:3}.
66¶22.5 Phenolic foam is an organic polymer, so whatever blowing agents or methods are used to produce it, it is not a material of limited combustibility as defined in Approved Document B.435 See Chapter 5; Table A7 in all relevant editions – 2000 {INQ00014107/120}; 2002 {CLG10000740/124}; 2006 {CLG10000007/132}; 2010 {CLG00000173/132}; 2013 {CLG00000224/132}. With the exception of Dr Rochefort, who professed not to have been aware at the time of the fire performance of K15 or the existence of a definition of limited combustibility in Approved Document B,436 Rochefort {KIN00008838/23} page 23, paragraph 5.8; Rochefort {Day80/27:12-15}; {Day80/28:25}-{Day80/29:4}. all the Kingspan witnesses from whom we heard confirmed that they had been aware throughout their employment at Kingspan that K15 was not, and never could be, a material of limited combustibility.437 Meredith {Day75/25:17-21}; Millichap {Day81/25:4-10}; Pack {Day86/22:1-5}; Burnley {Day85/134:1-3}; Pargeter {KIN00000494/6} page 6, paragraph 3.4; Heath {Day78/181:7–12}; Mills {Day77/15:3-6}.
Early marketing
¶22.6 From a very early stage, even before the first test in accordance with BS 8414 in 2005, Kingspan knew that, applying the guidance in Approved Document B, K15 was not suitable for use on buildings over 18 metres in height.438 Heath {Day78/198:2}; {KIN00005054/1} where on 26 January 2004 Mr Meredith reported to Mr Heath on the work then being carried out to try to develop a K15 product "that will achieve acceptability for above 18m in facade construction by Building Regulations". However, it chose to disregard that fact when selling K15 and advising on its use. Kingspan's principal marketing literature from 2001 onwards described K15 as suitable for use in rainscreen cladding systems generally439 {KIN00020720/1}. and brochures published between 2002 and 2006 described it as a product designed for use behind rainscreen cladding systems without any qualification.440 January 2002 {KIN00009173}; November 2002 {KIN00008018}; March 2003 {KIN00002579}; June 2006 {KIN00005371}. None of those documents referred to the warning in Approved Document B about the use of combustible materials in tall buildings or of the guidance that insulation used on buildings over 18 metres in height should be of "limited combustibility". That was the case even in those sections of the documents that depicted typical design details, where no distinction was drawn between use of the product on buildings of over and under 18 metres in height.441 See for example {KIN00005371/2}.
¶22.7 In 2004 Ivor Meredith was a Technical Advisor in Kingspan's Technical Projects Team; from 2005 he was a Project Leader.442 Meredith {KIN00022312/1} page 1, paragraph 1. On 19 March 2004 he wrote to contacts at Tower Hamlets Borough Council and LABC inviting comments. His email was headed "Insulation above 18m". In it he acknowledged that K15 did not meet the criteria for limited combustibility, but he expressed confidence in its fire performance and said that it had been accepted regularly for use on buildings over 18 metres in height in ventilated facade systems. He also said that K15 had been "pigeonholed" with combustible insulation, even though the char that he said would form when it was exposed to flame limited the combustibility of the product.443 {KIN00003685}.
67¶22.8 The language of that email was liable to mislead, because as Mr Meredith well understood,444 Meredith {Day75/26:14-19}. insulation used on buildings of 18 metres or more in height had to be of limited combustibility if it was intended to follow what was known as the "linear route to compliance" in Approved Document B and K15 did not satisfy that requirement. He said that he had borrowed the language from a set of written standard answers, possibly produced by the European Phenolic Foam Association, then in circulation within Kingspan.445 Meredith {Day75/27:13-21}. Whether that is right or not, however, the message provides some insight into the methods that Kingspan was using to sell K15 at the time and how it might have come about that, as Mr Meredith told us, K15 was being accepted for use on buildings over 18 metres in height in the period before any large-scale system test in accordance with BS 8414 had been carried out.446 Meredith {Day75/28:13}-{Day75/29:3}.
Large scale testing: May 2005
¶22.9 Before the publication of the BS 8414-1 test standard in December 2002447 {CEL00001205}. Kingspan had begun to explore the possibility that it could use successful testing to BS 8414 to promote and sell K15 for use on buildings over 18 metres in height.448 K5, an identical phenolic foam to K15 with different foil facers, was tested to a draft version of BS 8414-1 as early as March 2002: Meredith {Day75/32:8-20}; {KIN00003685}. On the publication of the 2006 edition of Approved Document B in April 2007449 Reference to the use of BS 8414 test data classified in accordance with the criteria in BR 135 as an alternative to the use of insulation material of limited combustibility on buildings over 18 metres in height was first included in the 2006 edition of Approved Document B published on 6 April 2007 {CLG10000007/95}. it encouraged and celebrated the adoption of the BS 8414 test,450 Kingspan's AD B consultation response {CLG00002607/24}; {KIN00005292/9} second paragraph. which it viewed as an opportunity to create a new category of insulation products for use on buildings over 18 metres in height, namely, products that were not materials of limited combustibility but were nonetheless suitable for use above that height.
¶22.10 That was the foundation of the fundamental falsehood at the heart of Kingspan's marketing strategy in the years that followed. There was no such thing as an insulation product that was combustible and yet could be used generally on buildings above 18 metres in height while following the guidance in Approved Document B. The use of a combustible product on such a building in accordance with Approved Document B was possible only if it were incorporated in a system which had been tested in accordance with BS 8414 and had met the performance criteria in BR 135 (2003). There was therefore no "over 18 metre market" for combustible insulation products as such. Insulation materials that were not of limited combustibility could be used on buildings over 18 metres in height in accordance with the guidance in Approved Document B only on the basis of a test of the particular system it was intended to install. Nonetheless, once BS 8414 and BR 135 had become available, Kingspan treated them as a generally applicable "route to compliance" for K15 as a product, even though it could constitute only part of any such system.451 Meredith {Day75/29:21-22}.
¶22.11 Following preliminary testing,452 March 2002 test on K5 and Permarock {KIN00003685}; November or December 2004 "naked" test without cladding {KIN00022357} Row 1. See also for example {KIN00005048}; {BRE00003278}. in 2004 Kingspan began preparing for its first full test in accordance with BS 8414-1 of a system incorporating K15. The test was arranged by Ivor Meredith,453 Heath {Day78/173:8-19}; Meredith {Day75/4:19}-{Day75/5:15}. under the supervision of Philip Heath.454 Technical Manager from 2001 to 2010. See Heath {KIN00020709/4-6} pages 4 and 6, paragraphs 2.8 and 2.18. Mr Meredith was responsible within Kingspan for the planning and design of the test rig and for the sourcing, purchase and delivery of the necessary materials, as well as for liaising with BRE during preparations for the test and in connection with its design.455 Meredith {Day75/42:21}-{Day75/43:16}. Both he and Philip Heath told us that the decision to test in accordance with BS 8414-1 at that time had been taken by a wider group of managers and directors at Kingspan, as had been the choice of the components of the cladding system to be tested.456 Heath {Day78/201:14-17}; {Day78/204:19-22}; Meredith {Day75/58:9-16}. They also agreed that the purpose of the test had been to use a successful result to promote K15 as a product for use on buildings over 18 metres in height.457 Heath {Day78/202:14-15}; Meredith {Day75/58:19-20}.
68¶22.12 The test was carried out in May 2005. Kingspan decided to test a system using "old technology" K15458 {KIN00024104/2} paragraph 4; Meredith {Day75/88:19-24}; Pargeter {KIN00022610/52} page 52, paragraph 7.1. with a non-combustible cement particle or fibre cement board as the rainscreen. There was some disagreement between the witnesses about the precise nature of the rainscreen used. Philip Heath was unable to remember what it had been,459 Heath {KIN00020709/79} page 79, footnote 48. whereas Ivor Meredith said that it had been a 6mm non-combustible cement particle board manufactured by a company called UAC,460 Meredith {Day75/67:21}-{Day75/68:12}. which is the information recorded in the test report issued by BRE in December 2005.461 BRE Report (Test 220876) {BRE00002511/6} third paragraph. Mr Meredith went on to tell us that the rainscreen had been a fibre cement board marketed in the UK as 'Supalux'.462 Meredith {Day76/207:18-24}. Other Kingspan witnesses, notably Adrian Pargeter, the Head of Technical and Marketing,463 Pargeter Kingspan's Head of Marketing from November 2014 and Head of Marketing and Technical from June 2015 {KIN00000494/4-5} pages 4-5, paragraphs 2.7 and 2.8. Adrian Brazier464 Adrian Brazier replaced Ivor Meredith as Technical Projects Manager in September 2015, Brazier {KIN00008828/4} page 4, paragraph 2.7. and Adam Heath,465 Adam Heath was Kingspan's Technical Projects Leader from May 2014, with responsibility from August 2015 for large-scale fire testing. In April 2019, he moved to the role of Regulatory Affairs Manager, Heath {KIN00008834/3-5} pages 3-5, paragraphs 2.4, 2.6 and 2.9. said they thought that the rainscreen had in fact been a non-combustible fibre cement board.466 Pargeter {KIN00020824/100} page 100, paragraph 10.57; Pargeter {Day 83/175:11-19}; Heath {KIN00008834/96} page 96, paragraph 11.53; Brazier {KIN00008828/59} page 59, paragraph 11.37. None of the latter group had had any involvement in the test.467 Pargeter {KIN00020824/100} page 100, paragraph 10.55; Heath {KIN00008834/96} page 96, paragraph 11.52; Brazier {KIN00008828/58} page 58, paragraph 11.31. Their belief that fibre cement boards had been used, which was expressed with varying degrees of confidence, was based solely on investigations carried out by Kingspan in 2016 and 2019.468 In 2016, while working on the development testing of a lower lambda insulation product called K115, Kingspan began preparations to replicate the test in accordance with BS 8414 carried out in May 2005, leading it in 2016 and again in 2019 to try to ascertain the precise nature of the board used as external cladding in that test. Heath {KIN00008834/96} page 96, paragraph 11.53; Pargeter {KIN00020824/100} page 100, paragraphs 10.55-10.57. No BRE witness was able to recall the precise nature of the board beyond the description given in the test report.469 Clark {Day96/121:19-24}; Colwell {Day232/205:16-17}; Baker {Day100/50:6-11}.
69¶22.13 Mr Heath and Mr Meredith both told us that the components used in the 2005 test rig had been chosen in discussion with and on the advice of BRE.470 Heath {Day78/204:17-22}; {Day78/207:9-12}; {Day78/208:18}-{Day78/209:7}; Meredith {Day75/130:23-25}. Ivor Meredith identified Dr Sarah Colwell,471 In 2005, Dr Sarah Colwell was the joint Business Group Manager for the BRE's Passive Fire Team, Colwell {BRE00047571/3} page 3, paragraph 12. David Hoare472 From 2005 to September 2015, David Hoare was the BRE's Business Group Manager in relation to cables. He also had some involvement in the testing of composite panel systems and in the approval of fire test reports, Hoare {BRE00005622/2} page 2, paragraph 5. and Philip Clark473 Philip Clark was the Burn Hall Manager at BRE between 2004 and 2017. Mr Clark was involved in BS 8414 testing at BRE from 1999 onwards and was part of the team that developed Parts 1 and 2 of BS 8414, Clark {BRE00005768/3-5} pages 3 and 5, paragraphs 13 and 22. as the BRE staff who were involved in discussions with Kingspan both before and after the test.474 Meredith {Day75/59:8}; Colwell {Day75/20:24}; Clark {Day75/63:8-20}; David Hoare, the Senior Consultant who approved BRE's test report). See BRE Report {BRE00002511/2}. Philip Heath described the test as a "pilot test", with the particular assembly suggested by BRE.475 Heath {Day78/191:14-17}. It seems clear that the test had been intended to be the first in a series of large-scale tests.476 Meredith {Day75/59:21-25}; Heath {Day78/202:23}-{Day78/203:4}.
¶22.14 Mr Heath and Mr Meredith also told us that BRE had suggested that if Kingspan tested a system with a non-combustible rainscreen which met the criteria in BR 135, it could use the results to produce a report indicating that K15 could be used in other systems incorporating non-combustible rainscreens.477 Heath {Day78/191:18-24}; {Day78/209:1-7}; Meredith {Day75/58:21}-{Day57/59:6}. Ivor Meredith described that as a "scope of application"478 See for example, Meredith {Day75/92:24}-{Day75/93:2}. or "expanded scope of application"479 Meredith {Day75/99:19-21}. report. He said that obtaining a report of that kind from BRE was the main purpose of carrying out the test. He understood that a report of that kind based on just one test might render K15 acceptable for use on buildings over 18 metres in height with all non-combustible rainscreen materials.480 Meredith {Day75/59:3-6}. In an internal activity report written on 31 May 2005, the day of the test, Mr Meredith told his managers that a successful result that afternoon would remove any limitations on selling K15 into the high-rise market.481 {KIN00021738} first paragraph.
¶22.15 It was for that reason, as Ivor Meredith and Philip Heath agreed, that the boards chosen as the rainscreen for the system tested in May 2005 were not of a kind that would ever be installed in practice, either then or now. They were intended to represent a non-combustible rainscreen of any kind.482 Meredith {Day75/69:20}-{Day75/70:24}; Heath {Day78/207:9-15}. Dr Colwell confirmed that Kingspan had given her to understand that its aim had been to test K15 with a generic rainscreen.483 Colwell {BRE00047571/48} page 48, paragraph 299; Colwell {Day232/214:3-5}. We are satisfied that Kingspan's intention in choosing cement particle or fibre cement boards for the test was simply to represent as wide a range of non-combustible rainscreen panels as possible. Since the witnesses agreed that in either case the boards used had been non-combustible, it is not necessary for us to reach a decision on precisely which kind was used in the test.
¶22.16 The test took place at BRE's burn hall on 31 May 2005 and was successful in that BRE expressed the view that the system appeared to have met the criteria in BR 135.484 Heath {Day79/8:6-13}. The test report, written by Philip Clark and approved by David Hoare, was issued on 9 December 2005.485 {BRE00002511}. A separate report classifying the system in accordance with BR 135 was issued more than ten years later, on 28 September 2015.486 Report P101812-1000 {KIN00000134}.
70¶22.17 In the event, no "scope of application" report was produced by BRE on the basis of the test. Mr Meredith's evidence, which was consistent with Mr Heath's understanding of what had happened, was that after the test had taken place, BRE had changed its position by retracting its previous suggestion that it could produce a report providing support for the use of K15 with other types of non-combustible rainscreen materials.487 Meredith {KIN00022312/5} page 5, second paragraph; Meredith {Day75/130:21}-{Day75/131:4}; Heath {Day78/192:20}-{Day78/193:1}; {Day78/209:16}-{Day78/210:3}. In his evidence, Mr Meredith described a heated meeting with Dr Sarah Colwell and an unidentified director of Kingspan Off-Site Ltd488 Kingspan Off-Site Ltd, previously known as Kingspan Metl-Con Ltd, was part of the Kingspan group. At the time it manufactured and sold pre-fabricated building and facade systems: Stevens {MET00080972/3} page 3, second paragraph. at some stage after the test during which she had made it clear to him that no wider report could or would be produced by BRE.489 Meredith {KIN00022312/5} page 5, first, second and third paragraphs; Meredith {Day75/130:10}-{Day75/133:24}. He recorded those events in the background section of an internal summary to his managers on 7 January 2008, describing both BRE's initial advice and its later retraction.490 {KIN00008847/5} page 5, first and second paragraphs.
¶22.18 Dr Colwell denied that she had been aware of any discussions with Kingspan of the kind described by Mr Meredith either before or after the test in May 2005.491 Colwell {Day232/214:16}-{Day232/217:4}. She said she had not given any advice to Kingspan on the assembly it should use in the test492 Colwell {Day232/205:18-21}. or on how to satisfy the criteria in BR 135.493 Colwell {Day232/196:24}-{Day232/198:16}; {Day232/200:23}-{Day232/201:7}. Dr Colwell was shown an internal Kingspan document in which Mr Meredith had reported to his managers that, following a Single Burning Item test on K15 in March 2004, she had told him that K15 had a good chance of passing the BS 8414 test if the right detailing was adopted.494 {KIN00021657} ninth paragraph. In the same document Mr Meredith had recorded that in October 2004 Dr Colwell had suggested that Kingspan should carry out a preliminary "naked" test (i.e. with no rainscreen) to help it pass when it was tested in accordance with BS 8414-2.495 {KIN00021657} twelfth paragraph. Dr Colwell told us that Mr Meredith was mistaken when recording those comments496 Colwell {Day232/197:9-12}. and that she thought he was putting a particular slant on their discussions.497 Colwell {Day232/198:12-16}.
¶22.19 On 14 December 2004 Mr Meredith sent Dr Colwell an email in which he said that Kingspan had decided to follow her guidance and therefore wanted to perform a full test on K15 in accordance with BS 8414-1.498 {BRE00047572/1}. When asked about it, she said that she could not understand what he might have meant.499 Colwell {Day232/200:10-18}. She said that her discussions with Kingspan at that time about testing K15 in accordance with BS 8414 had been of a general nature,500 Colwell {Day232/198:18-22}. and had concerned the programme of tests it was planning to carry out. They had not extended beyond exploring how BRE could meet Kingspan's required programme.501 Colwell {Day232/201:2-7}.
¶22.20 We did not find Dr Colwell's evidence on these matters very convincing and have been left with the clear impression that she and other employees of BRE were doing much more to assist Kingspan than she was willing to admit. Moreover, although she initially denied that she had known anything about discussions between BRE and Kingspan during or after the May 2005 test,502 Colwell {BRE00047571/47} page 47, paragraph 295. Dr Colwell was constrained to accept that, as reflected in an email exchange between BRE and Mr Meredith in March 2006,503 {KIN00005165/2} "Further to our meeting last month". she had attended a meeting in February 2006 with him and an employee of Kingspan Off-Site, as he had described, during which they had discussed the test in May 2005. She said she could not recall any details of that discussion.504 Colwell {Day232/210:16-25}.
71¶22.21 Dr Colwell's recollection of events during the period was poor and fragmented and tended to shift in response to the documents. In contrast, Mr Meredith's account was detailed, clear and essentially unchanging. His recollection was also supported by a number of documents, including contemporaneous correspondence.505 See, for example, the report of January 2006 {KIN00020718/2} first bullet point under "Projects"; {KIN00004795}; {KIN00005165/1}. We are satisfied that in the period leading up to the test in May 2005, he thought that a successful test could lead to some kind of generic approval for the use of K15 on buildings over 18 metres in height, even if limited to other systems incorporating non-combustible rainscreens. It is more likely than not that his belief was influenced to a substantial degree, if not founded upon, advice received from Dr Colwell or others at BRE.
¶22.22 It is not clear exactly when BRE decided that it would not produce a report on K15 that would support its use in conjunction with any non-combustible rainscreen. Philip Heath could not recall506 Heath {Day78/212:20}-{Day78/213:3}. and Ivor Meredith could only say that it had occurred shortly after the test.507 Meredith {Day75/130:14}. Dr Colwell denied that any retraction had occurred. In April 2006, Kingspan was still chasing Dr Colwell for an assessment508 {KIN00005163}. and was clearly still expecting it to be one that would confirm the suitability of K15 for use on buildings over 18 metres in height generally and could be sent to all its customers.509 {KIN00004795}. Although we do not consider that the precise date of BRE's change of heart is of particular importance, it is of note that by the date of his report on 7 January 2008 at the very latest (and probably considerably earlier),510 Ivor Meredith's report of 7 January 2008 {KIN00008847/5} contained an explanation of the circumstances in which Kingspan had begun a programme of BS 8414-2 testing, the key driver being BRE's refusal to issue a report supporting a broad scope of application. The first test in the programme had taken place on 20 December 2007 but planning for it had begun early in 2006. On 7 April 2006, Dr Malcolm Rochefort noted in his diary, "K15 – do we need another 8414 test?" {KIN00024441}. Mr Meredith had understood and had made his managers aware that any claims Kingspan made about success in the test carried out in May 2005 could apply only to external walls constructed using the same components in the same configuration.511 {KIN00008847/5} second paragraph. In his report, he informed his managers that the "BRE are adamant that approval only applies to what is tested".512 {KIN00008847/5} third paragraph.
Kingspan's presentation of the 2005 test: 2005 and 2006
¶22.23 Ivor Meredith knew that a test in accordance with BS 8414 could not produce a result that would cover all possible uses of K15.513 Meredith {Day75/71:20-23}. With the exception, again, of Dr Rochefort,514 Rochefort {Day80/20:22}-{Day80/21:23}; {Day80/25:3-13}; {Day80/35:16}-{Day80/36:12}; {Day80/82:13}-{Day80/83:19}; where Dr Rochefort cited the fact that BS 8414 is a system test as the basis for his lack of action following a later unsuccessful BS 8414-2 test. every Kingspan witness from whom we heard confirmed their understanding that BS 8414 was a system test that had no generic application, still less any application for one particular component of the system tested.515 Pack {Day86/64:11-19}; {Day86/140:5-17}; Meredith {Day75/85:1-19}; Heath {Day78/196:14}-{Day78/197:2}; Mills {Day77/25:11-24}; Millichap {Day81/32:25}-{Day81/33:24}; Pargeter {Day83/113:21-25}-{Day83/114:1-3}; Burnley {KIN00022662/3} page 3, paragraph 1.10. Nonetheless, following the test in May 2005 Kingspan proceeded to claim precisely that in all its marketing and sales literature relating to K15, as well as in its correspondence with customers.
72¶22.24 By October 2005, in emails advising customers about the use of K15 on buildings over 18 metres in height, Kingspan was using variations of standard wording produced by Ivor Meredith which he acknowledged to colleagues at the time was possibly "a bit heavy in some areas".516 {KIN00003687} third paragraph. Kingspan always told customers that K15 had passed a test in accordance with BS 8414 and sometimes told them that any material claiming to be fire safe should have passed that test.517 {KIN00002575/2} third paragraph. The text produced by Mr Meredith included a statement that "To fall within the requirements of Approved Document B Kooltherm K15 can continue above 18 metres"518 {KIN00003687} sixth paragraph. and statements were also made to customers that K15 met "the criterion [sic] of BR 135 and thus the 18m rule".519 {KIN00002577/2} While we note that Mr Meredith does refer in this email to a system, he included in that system only K15 and the particular cavity barrier product used in the May 2005 test, manufactured by Promat. He represented that those two products together met the criteria in BR 135, as part of an ultimately unsuccessful attempt to encourage Promat to make representations to the market about the compatibility of the two products. See also {KIN00005172/10} first paragraph for the claim that K15 "easily meets" the criteria in BR 135. Both claims were false.
¶22.25 In January 2006 Kingspan began sending out to customers520 {KIN00005133}. a promotional document entitled "What's lurking behind your façade?"521 {KIN00005350}. which came to be referred to within Kingspan as the K15 or BS 8414 "flyer".522 For example, see {KIN00003688}; {KIN00005179}. In it Kingspan stated that K15 had been tested and "awarded certification to BS 8414-1" and had been "assessed and approved in accordance with BR 135". Both statements were false. BS 8414 is a test method which does not provide the basis for certification of any kind, much less the certification of a particular product, and a single component of a system tested in accordance with BS 8414 could not be assessed or approved in accordance with BR 135 because the performance criteria in BR 135 were applicable only to the system as a whole.
¶22.26 Kingspan withdrew the flyer after it came to the attention of BRE,523 No BRE witness was able to assist us with any details of the complaint. Despite an email copied to Dr Colwell in June 2006 in which Ivor Meredith referred to discussing the complaint with her {KIN00005180}, it was her evidence that she had no recollection of it: Colwell {Day232/223:4-15}, or indeed of ever discussing any Kingspan marketing literature with BRE colleagues {Day232/218:3-8}. who at some stage before 8 June 2006524 The date of Ivor Meredith's internal email informing technical teams that the flyer had been withdrawn {KIN00005179}. complained to Kingspan about the inaccuracy of its contents.525 {KIN00005179}; {KIN00005180}; Meredith {Day75/121:10-12}. It does not appear that there was any further complaint from BRE about Kingspan's broader misrepresentation of BS 8414 as a product test. Although the words "certified" and "approved" were eventually removed from the flyer, avowedly to "steer clear of the BRE's wrath",526 {KIN00005206}. the misleading assertion that K15 as a product had been tested and was acceptable for use above 18 metres "when assessed in accordance with BR 135" persisted in the revised text that Mr Meredith told Kingspan's technical advisors to use thereafter.527 {KIN00005179}; See draft amended text at {KIN00005194}.
73¶22.27 Meanwhile, in 2007 Kingspan began to write what Mr Meredith called "letters of suitability" for the use of K15 on high-rise projects.528 Meredith {Day76/81:15-23}; {KIN00005308}; In February 2006 Joel Clarke circulated the original BS 8414 flyer to technical staff, commenting that it would be better to send the flyer out than "write tedious letters". He recommended that the flyer should be attached to any correspondence that was being sent to sizeable architects and designers "just in case they've been fooled by the lies Celotex have been spreading about how it doesn't comply": {KIN00005179}. In emails and letters to customers Kingspan recommended K15 as a suitable product for use on buildings over 18 metres in height. That was done either by asserting that K15 was suitable for use in the particular system proposed by the customer or by representing that K15 was suitable for use in all systems on buildings over 18 metres in height, or both.529 {KIN00008954/2}; {KIN00005203/2}; {KIN00002576}; {KIN00005216/1}; {KIN00005240}.
¶22.28 Occasionally, Kingspan represented to customers not only that the use of K15 was allowed in any cladding system on a building over 18 metres in height in accordance with Approved Document B, but also that the existence of the data from the BS 8414 -1 test in May 2005 constituted an alternative route to compliance for K15 as a product.530 {KIN00002577/1}. It was also said that choosing a product that had "passed" a test under BS 8414 might in fact be a more onerous (and, by implication, safer) "route" than choosing a product that was non-combustible or of limited combustibility.531 {KIN00002577/1}. In other instances, Kingspan asserted that although K15 was not a non-combustible material, it had "been proved to perform the same as a non-combustible material" by testing in accordance with BS 8414.532 {KIN00002583/1}. Again, none of those statements were true.
¶22.29 The text drafted by Ivor Meredith and used by Kingspan's teams in that correspondence was checked by Philip Heath, who admitted not only that he had provided supervision and guidance but also that he had had the final say on the wording.533 Heath {Day79/109:5-19}; Meredith {Day76/82:6-8}. False claims about K15 were therefore not being made in error or by rogue junior employees but with the knowing approval of a senior manager.
¶22.30 Indeed, Philip Heath told us that at that time Kingspan often found itself in the position of having to explain to customers Approved Document B's alternative route to compliance through the BS 8414 test.534 Heath {KIN00020709/31-32} pages 31-32, paragraph 4.50; Heath {Day78/182:9-11}. Kingspan was keenly aware that there was a lack of detailed knowledge about BS 8414 and BR 135 among its customers, many of whom were unfamiliar with both. It relied on the fact that an unsuspecting market was itself highly likely to rely on it for advice and to accept its claims about K15's suitability for use as reliable. Kingspan was reluctant to send out its one BS 8414 test report535 BRE Report {BRE00002511}. to any of its customers (it had nothing else to send), but was lucky in that they sometimes accepted its word.536 {KIN00005380/2}; Meredith {Day76/82:11}-{Day76/83:4}.
¶22.31 Kingspan's strategy was to go after every job.537 Meredith {Day76/83:3-4}. Mr Meredith's detailed report to senior managers in January 2008538 {KIN00008847/5} third paragraph. contained an important summary of the strategy at the time, namely, that Kingspan promoted the fact that K15 had "the ability to pass" (referring to the successful May 2005 test). A similar claim appeared in various Kingspan articles for industry journals539 See for example {KIN00005198/3} third paragraph; {KIN00005219/3} second paragraph; {KIN00005262/3} second paragraph. It is not known if these articles came to be published. and in the BS 8414 flyer,540 {KIN00005350} first paragraph. in all of which Kingspan warned readers to question the use of any external cladding products that "do not have the ability" to pass the BS 8414 test. That was linguistic sleight of hand. It was a cynical misrepresentation of the nature and purpose of BS 8414 and BR 135 and of the provisions of Approved Document B relating to them.
74¶22.32 Mr Meredith told us that the strategy had been agreed between him and his senior managers as offering Kingspan's only opportunity of moving forward once it had become clear that BRE was not prepared to provide a generic report on the suitability of K15 based on the BS 8414 test in May 2005.541 Meredith {Day75/117:17}-{Day75/118:24}. The other obvious option, namely to behave honestly and with integrity by avoiding false statements, does not appear to have been considered by anyone at a senior level.
Fire Performance claims for new technology K15
¶22.33 In the period between 2005 and 14 June 2017, two important claims were made by Kingspan in relation to the fire performance of K15. The first was that K15 had achieved a classification of Class 0 through testing to Parts 6 and 7 of BS 476. The second was that K15 had been tested to BS 8414 and had met the criteria in BR 135. Kingspan gave both claims prominence, both in its marketing literature for K15542 A classification to Class 0 for K15 was claimed in all K15 product literature from 2001 onwards; reference to BS 8414 was first made in K15 product literature in May 2007 and continued thereafter. March 2001 {KIN00020720}; January 2002 {KIN00009173/1}; November 2002 {KIN00008018/1}; March 2003 {KIN00002579/1}; November 2005 {KIN00022668/1}; June 2006 {KIN00005371/1}; September 2006 amended "What's lurking behind your façade?" {KIN00000055}; May 2007 {KIN00002580/6}; November 2008 {KIN00009703/6}; March 2011 {KIN00003545/1}; July 2016 {KIN00000070/7}. and in its correspondence with customers. They also appeared in the certificates relating to K15 published by the British Board of Agrément (BBA)543 {BBA00000038/5}; {BBA00000037/5}; {BBA00000036/6}; {BBA00000040/5}. and Local Authority Building Control (LABC).544 {KIN00005705/4}; {KIN00009547/2}; {NHB00000798/1} (Class 0 claim absent from this certificate), {LABC0000997/3}; {LABC0001842/2}; {KIN00016968}; {KIN00000076}.
¶22.34 As explained above, the transition to new technology K15 involved various changes to the chemical composition and manufacturing process, as well as the introduction of perforated foil facers.545 {KIN00022307} Major Changes, Row 7; Rochefort {KIN00008838/6} page 6, paragraphs 3.7-3.10; Rochefort {Day80/50:6}-{Day80/55:1}. As a result, new technology K15 had different physical properties as well as a different chemical composition. The K15 product that Kingspan sold after September 2006, although still a phenolic foam, was without question a different product from that which it had previously been selling.
¶22.35 Following the introduction of new technology K15 in 2006, Kingspan continued to make the two principal claims about the product's fire performance without any reference to the changes that had been made to the product, which were not disclosed to the market. In relation to new technology K15 those claims were entirely false. The true position was that no test in accordance with BS 8414 had been carried out on a system incorporating new technology K15 or was carried out until 23 March 2015 and no classification in accordance with the criteria in BR 135 had been made or was made until June 2015.546 23 March 2015 BS 8414-2 test. Test report 302995 dated 14 May 2015 {BRE00002494}; BR 135 Classification Report P100769-1000 dated 8 June 2015 {BRE00002495}. Moreover, new technology K15 did not achieve results when tested in accordance with BS 476 parts 6 and 7 (which was a product test but, under Approved Document B, largely irrelevant to insulation) such as to justify a rating of Class 0 at any stage before the Grenfell Tower fire.547 Pargeter {Day84/72:13-16}. That came to light only as a result of our investigations. At no time did Kingspan inform the market that the particular fire tests on which it purported to rely had in fact been carried out on a product that was no longer available and had not been sold since 2007 at the latest.
75¶22.36 For many years Kingspan marketed and sold K15 relying heavily on tests which had been carried out on a different product. That was not the result of a mistake, as Dr Rochefort claimed,548 Rochefort {Day80/68:9-16}. or misunderstanding; it was done deliberately. The relevant test and classification reports were not withdrawn until October 2020, following the Inquiry's investigations.
Class 0
¶22.37 As has been noted, a classification of national Class 0 was claimed for K15 in all promotional literature from 2001 onwards. Some of Kingspan's marketing brochures claimed that both the K15 product and, separately, its core, were "Class 0 fire rated".549 See for example March 2011 {KIN00003545/6}. That was a nonsensical assertion when considered alongside the test standards used to achieve it. Although none of its literature ever disclosed the fact, in order to substantiate its claim, Kingspan had carried out tests in accordance with BS 476 Parts 6 and 7 at various times between 2004 and 2016 not on K15 boards as supplied to the market but on the foil facer of the product alone.550 {KIN00022205}. That was done by attaching the foil to a calcium silicate or other non-combustible substrate for the tests.551 See for example {KIN00000256/5}. Kingspan sought to justify its actions by reference to the wording of Approved Document B, which stated that Class 0 was achieved if a material or, in the case of a composite product, the surface of the product met certain criteria when tested in accordance with BS 476 Parts 6 and 7.552 {CLG10000007/122} Appendix A, paragraph 13.
¶22.38 Both Adrian Pargeter and Dr Rochefort told us, and Kingspan in its closing statement submitted, that that was a legitimate practice on the basis of the wording of Approved Document B.553 Pargeter {KIN00020824/8-10} pages 8-10, paragraphs 3.11-3.18; Pargeter {Day84/69:16-19}; Rochefort {Day80/89:7}-{Day80/90:1}; Kingspan Module 2 closing submissions {KIN00025944/32} page 32, paragraphs 84-87. Mr Pargeter defended it as a technical but common-sense interpretation of the wording in Approved Document B.554 Pargeter {Day84/82:23-25}. We disagree. In our view such an interpretation of Approved Document B is over-literal, artificial and has at least the potential to lead to absurd results. Kingspan's Arron Chalmers, who was a candid, if at times lurid, internal commentator on Kingspan's style of doing business, described it as "a bit of a cheat".555 {KIN00004168}. Neither Dr Rochefort nor Mr Pargeter had checked the test standards to ensure that it was legitimate for Kingspan to claim that K15 had achieved Class 0 by testing in that way.556 Pargeter {Day84/84:12-15}; Rochefort {Day80/89:17-21}. Had they done so, they would have discovered that the practice was at odds with both the purpose of BS 476-6 and its wording, both of which make clear that it is designed as a test of a product, not part of a product.557 {BRE00005557/18}. Kingspan had sought the advice of Frans Paap at Exova on the subject. He apparently told it that the provision could be interpreted in that way558 {KIN00004168/1}. but said that it should test the complete product before making any claim about Class 0 because the foam behind it was likely to affect the performance of the facer.559 {KIN00004168/2}. Adrian Pargeter accepted that the interpretation was neither conservative nor ideal but said that Kingspan was prepared to adopt a literal interpretation of Approved Document B that might be less safe but would facilitate sales of K15.560 Pargeter {Day84/118:10}-{Day84/119:6}.
76¶22.39 To the extent that the tests relied on to support the claim that K15 was rated Class 0 had been carried out on the foil facer alone, that claim was false. Understandably, there was evidence of some disquiet about it even within Kingspan's own ranks.561 Meredith {Day76/181:4}-{Day76/182:8}; {KIN00004168/1}. Other than for one specific and limited purpose relating to the spacing of cavity barriers,562 Lane, Phase 1 Report Section 11 {BLAR00000006/41} paragraph 11.11.18; Millichap {Day81/42:13-16}. Class 0 was not relevant to the suitability of insulation for use on buildings over 18 metres in height, as Kingspan knew. No Kingspan witness claimed otherwise. Nonetheless, in much of its correspondence Kingspan either treated Class 0 as evidence of the suitability of K15 for use on buildings over 18 metres in height or treated it as the equivalent of limited combustibility. For example, it sometimes told customers in very general terms that Class 0 was the "highest possible product fire performance classification", using language which effectively elided the two concepts. It also made recommendations that K15 be used for projects involving buildings over 18 metres in height, immediately followed by a statement that K15 had achieved Class 0, as though the two were related.563 See examples at {KIN00005363/8}; {KIN00005218/2}; {KIN00009014/1}; {KIN00002583/2}; {KIN00002882/1}.
The fire performance of new technology K15
¶22.40 At the time of the change from old to new technology K15 in 2006, and for some time after, Philip Heath and Dr Rochefort considered the properties of the two products to be very similar.564 Heath {KIN00020709/9} page 9, paragraph 3.4, "…basically the same chemistry but different production technology..."; Heath {Day78/227:2-4}; Heath {Day79/11:20-25}; Rochefort {KIN00008838/7} page 7, paragraph 3.10; Rochefort {Day80/54:23}-{Day80/55:1}. Dr Rochefort explained that the similarity between them on a chemical level was such that he had not expected their fire performance to differ significantly.565 Rochefort {KIN00008838/7} page 7, paragraph 3.10; Rochefort {KIN00008838/50} page 50, paragraph 11.22; Rochefort {Day80/67:19-22}. He did not regard the introduction of perforations to the foil facers as significant,566 Rochefort {KIN00008838/7} page 7, paragraph 3.10; Rochefort {Day80/54:18-25}. because the composition was the same567 Rochefort {Day80/53:13-17}. and the perforations represented less than 0.5% of the surface area of the board.568 Rochefort {Day80/54:1-5}. However, in an email to Philip Heath on 7 July 2005 Lamtec, the manufacturers of the foil facers, had alerted Kingspan in the clearest terms to the fact that the fire performance of the foam would be significantly different once the facers were perforated because the perforations would potentially allow gases produced by combustion to reach the atmosphere and burn.569 {MET00081264}. The warning appears to have been ignored.
77¶22.41 Despite the apparent similarities between the old and the new products, Kingspan's Product and Process Development System was engaged in order to assess any differences between various aspects of their performance.570 {KIN00022307} Major Changes, Row 7, Column N; Heath {Day79/16:7}-{Day79/17:14}; Rochefort {KIN00008838/9} page 9, paragraph 3.16. Following its completion new technology K15 was able to enter the market.571 Rochefort {KIN00008838/9} page 9, paragraph 3.16.
¶22.42 Dr Rochefort had revised the Product and Process Development System at an earlier stage to ensure that the programme for the change to new technology would include fire testing.572 {KIN00022307} Major Changes, Row 7, Column N; Rochefort {KIN00008838/9} page 9, paragraph 3.16. Responsibility for fire testing and certification fell to Philip Heath,573 {KIN00022003/2}; Heath {Day79/22:21}-{Day79/23:7}. who did not sign the section off as complete574 {KIN00022307} Major Changes, Row 7, Column N. until 21 February 2008.575 Rochefort {KIN00008838/9} page 9, paragraph 3.16. He and Ivor Meredith explained that the "sign off" of any particular section of the Product and Process Development System did not in fact indicate completion but rather that something was "in hand" and confirmed that fire testing had continued for many years after the new technology had become available to the market in 2006 and the process had been signed off by Mr Heath in February 2008.576 Meredith {Day75/39:3-13}; Heath {Day79/18:14-25}. In those circumstances, it is difficult to see what real purpose Kingspan's Product Process and Development System served in this case.
¶22.43 Philip Heath was not able to explain why Kingspan had started to sell the new form of K15 years before fire testing on it had been completed.577 Heath {Day79/21:5}. Dr Rochefort told us that it was difficult in practice to have everything signed off before a new product was sold and that as long as testing was still being carried out without any obvious problems that had been considered good enough.578 Rochefort {Day80/58:5-10}. He assumed at the time that new technology K15 had achieved European Class C for the purposes of CE marking,579 The letters "CE" are the abbreviation of French phrase "Conformité Européenne" which literally means "European Conformity". It is a marking which certifies that a product has met EU health, safety, and environmental requirements. which he had understood (wrongly) to equate to national Class 0.580 Rochefort {Day80/60:13}-{Day80/61:1}. Mr Meredith thought that testing to European standards had been undertaken before new technology K15 had been made available to the market and that a Class C had been achieved,581 Meredith {Day75/155:6-9}. but he could not recollect any other testing.582 Meredith {Day75/40:10-16}.
Testing in accordance with BS 476 parts 6 and 7
¶22.44 Neither Mr Meredith nor Dr Rochefort nor Mr Heath could recall the results of tests carried out in accordance with BS 476-6 or BS 476-7 on the new K15 product that was actually produced by Kingspan at Pembridge.583 Meredith {Day75/41:10-15}; Heath {Day79/25:12-13}; {Day79/28:21}-{Day79/29:24}; {Day79/77:12-16}; Rochefort {Day80/89:1-16}. Indeed, neither Dr Rochefort nor Mr Heath could tell us clearly what fire tests had been carried out on new technology K15 or whether any difference in fire performance between the old and the new technology products had been discovered. That was despite Mr Heath's acknowledging that he, together with Research and Development Manager Vincent Coppock584 Heath {KIN00020709/15} page 15, paragraph 3.24. and Technical Processing Manager Gwyn Davies,585 Rochefort {KIN00008838/11} page 11, paragraph 3.22. had been principally responsible for the testing586 Heath {Day79/24:18}-{Day79/25:9}. and despite Dr Rochefort's acceptance that as Technical Director (to whom Mr Heath, Mr Coppock and Mr Davies all reported)587 Rochefort {Day80/4:23}-{Day80/5:6}. responsibility for ensuring that products were fit for market, including in terms of fire safety, ultimately fell to him.588 Rochefort {Day80/8:23}-{Day80/9:2}.
78¶22.45 Quite apart from that unsatisfactory evidence, we were struck by the fact that there appeared to be no composite record of the fire testing carried out on new technology K15 or of any reported difference in fire performance between the old and the new technology formulations. Although it was difficult to discern what fire testing had actually been undertaken, what did become clear was that there had been no comprehensive programme leading to a proper understanding of the fire performance of new technology K15 before it entered the market. Mr Heath admitted as much and accepted that that should have occurred.589 Heath {Day79/21:6-12}.
¶22.46 A detailed analysis of the contemporaneous documents, including notes from internal meetings and reports written by Mr Meredith, revealed that from 2005 onwards a number of small and medium-sized tests had been carried out on the new technology K15. That included calorimetry and single burning item tests as well as repeated testing to BS 476 Parts 6 and 7. The documents also revealed that none of that testing appears, in Kingspan's view at the time, to have brought positive news about the fire performance of new technology K15. In particular, numerous internal documents between 2006 and early 2009 reveal discussions about Kingspan's inability to obtain a classification to national Class 0 for the new product and details of its continuing efforts to do so over the course of many years. The documents were widely circulated among technical staff, including Dr Rochefort and Mr Heath. During the same period, however, Kingspan claimed for all external purposes that K15 had achieved that classification.
¶22.47 In a half-yearly report prepared for Mr Heath in July 2007, Ivor Meredith identified one of the low points of the period as a failure to verify basic properties for new technology K15, including its rating as Class 0.590 {KIN00005292/11} penultimate bullet point. In the same report, he referred to numerous failed attempts to pass the BS 476-6 test and said that repeats of tests that had narrowly failed and the addition of fire retardants were being considered.591 {KIN00005292/7} first paragraph.
¶22.48 In an internal report sent to Dr Rochefort and Mr Heath on 7 January 2008 that referred to the European single burning item test, Mr Meredith reported that the introduction of perforations in the foil facers of new technology K15 had led to a reduction in the European classification. He recommended the removal of the perforations and the addition of a fire retardant, noting that the latter could also help to achieve Class 0.592 {KIN00008847/3} eighth paragraph; {KIN00022466/1} paragraph 1.1, third bullet point "BS 476 Part 6 still elusive for certain formulations…".
¶22.49 Dr Rochefort told us that Kingspan's fire focus group had done quite a lot of work to establish the effect on fire performance of the newly introduced perforations in the foil facer.593 Rochefort {Day80/64:12-17}. Mr Meredith told us that the matter had been discussed at monthly technical meetings; his hypothesis was that the perforations allowed the blowing agent in the foam to ignite more readily,594 Meredith {Day75/155:10}-{Day75/156:9}. causing a deterioration in fire performance. We note that Professor Bisby's findings about the effect of the perforations tend to support that hypothesis.595 Bisby, Phase 2 Experiments Work Package 2 Report {LBYWP200000001/120} paragraph 635. Dr Rochefort did not say what work had actually been carried out and we found no documents that shed light on any such assessment, other than a reference in the minutes of a meeting on 25 July 2008 to plans to perforate only one side of the facer. We note that at that meeting, which Dr Rochefort attended, someone stated that perforations had been shown to reduce fire performance considerably.596 {KIN00022467/1} paragraph 1.2. In any event, new technology K15 was available for sale before any such assessment had been undertaken, as Dr Rochefort acknowledged.597 Rochefort {Day80/64:18}-{Day80/65:7}.
79¶22.50 In a monthly technical report produced in April 2008, Mr Meredith reported indicative calorimeter tests comparing old and new technology K15 in which the latter had showed a faster time to ignition and double the heat output (or rate of heat output, as we understand it).598 {KIN00003698} third paragraph.
Testing under BS 8414
¶22.51 By the end of 2005, BS 8414 Part 2 had been published, containing the large-scale test method for external cladding systems supported by steel frames rather than masonry.599 October 2005 {BSI00000097}. As a result, challenges began to arise in relation to Kingspan's use of test data from its BS 8414-1 test in 2005 to support the use of K15 at height on steel-framed buildings, for which no BS 8414 test data existed.600 Heath {Day79/36:18-25}; See for example {KIN00005243/2}. In an internal report in January 2008, Ivor Meredith noted that despite Kingspan's fighting the case for each project, the absence of any BS 8414-2 test data was causing it to lose sales on a daily basis. He considered it essential to obtain such data to support the sale of K15 for use on buildings over 18 metres in height.601 {KIN00008847/2} fourth paragraph; Meredith {Day75/146:3-8}.
¶22.52 In 2007 and 2008, four tests under BS 8414-2 were carried out on systems incorporating new technology K15. Two of them, on 20 December 2007602 Test 239825{KIN00008847/2}; {BRE00032344/1-3}; {BRE00032344/121-124}; {BRE00032344/170-171}. and 24 April 2008 respectively,603 Test reference unknown. See {BRE00032344/183}; {BRE00032344/187-190}. were carried out on systems using solid aluminium rainscreen panels604 Eggington {SOT00000029/2} page 2, paragraph 9. and were undertaken in partnership with Sotech Ltd, a rainscreen manufacturer, and Voestalpine Metsec plc, a supplier of structural steel frame systems. The other two, on 9 April605 Test 241103 {BRE00011552}. and 6 June 2008 respectively,606 Test 241105 {BRE00011552}. were carried out in partnership with Kingspan Off- Site and incorporated Kingframe steel loadbearing systems607 Stevens {MET00080972/4} page 4, final paragraph. and rendered rainscreen boards.608 {BRE00011552/1}. All four systems failed to meet the performance criteria in BR 135.609 Heath {Day79/35:7-10}; Rochefort {Day80/70:4-8}. Note that during Test 241105 on 6 June 2008 (Kingspan Off Site) the heat source was extinguished early, thereby terminating the test, due to the failure of the hearth. The rig was allowed to burn for the full duration of 60 minutes for observations to be made. See {BRE00011552} paragraph 1, lines 2-3, "... the full requirements of the standard were not however complied with..."; Wilkinson {MET00080973/6-7} pages 6-7, fourth paragraph. At all times, Kingspan concealed from its three co-sponsors, including Kingspan Off-Site, the fact that its previous test in accordance with BS 8414-1 in May 2005 had been carried out on a system that incorporated the old formulation of K15.610 Dr Rochefort told us that he did not know whether Kingspan Off-Site had been told that the 2005 test in accordance with BS 8414-1 had been carried out on a different, old version of K15: Rochefort {Day80/118:7-11}. All the other witnesses who were involved in this testing confirm that Kingspan Off-Site had not been told: Stevens {MET00080972/12} page 12, second paragraph; Wilkinson {MET00080973/8} page 8; Heath {Day79/90:10-12}; Meredith {Day75/171:20}-{Day75/172:4}; {KIN00020917/1} penultimate paragraph.
80¶22.53 In January 2008, after the first test on 20 December 2007, Ivor Meredith (who had not been present at the test) sent Mr Heath, Dr Rochefort and others a report containing his detailed observations and an analysis of what had occurred.611 {KIN00008847}. Describing the result as a "raging inferno", he explained that the top fire barrier had been breached 17 minutes into the test, that the system had failed the temperature criteria in BR 135612 {KIN00008847/2} penultimate paragraph. and that the test had been terminated early because there had been a danger that the laboratory would be set alight.613 {KIN00008847/3} first paragraph.
¶22.54 Mr Meredith also recorded specific observations about the performance of the K15 insulation, as well as offering views (both his own and those of BRE) on the performance of the new K15 compared with the old, which had been tested in 2005. He included photographs of that earlier test in his report in order to demonstrate the differences he was describing.614 {KIN00008847/21-22}. He said that the new K15 had burnt ferociously "on its own steam" and that it was, in his words, "... very different in a fire situation to the previous technology ...".615 {KIN00008847/3}.
¶22.55 Mr Meredith recorded what he described in the report as "official" and "unofficial" comments from BRE.616 {KIN00008847/3}. He thought they had been provided by Philip Clark,617 Meredith {Day75/160:3-13}. who had been present at the test together with Dr Colwell and Tony Baker618 "Test witnesses" {KIN00008847/2}. and had been the most approachable on the subject of testing.619 Meredith {Day75/160:5-7}. The "unofficial" comments were that the insulation had been fully involved in the fire, that the foam core had continued to burn after the flame source had been extinguished, that surface spread of flame on the K15 was apparent and finally, that BRE had not remembered the product performing like that in the previous test. The "official line" was that the system as a whole had failed and that responsibility for the failure could not be attributed to any individual component.620 {KIN00008847/3}.
¶22.56 All three BRE witnesses denied that they had made "official" and "unofficial" comments in the way described by Mr Meredith and insisted that that was not something BRE would do.621 Clark {Day96/166:16-19}; {Day96/168:4-7}; {Day96/173:18-19}; Colwell {Day232/228:18}-{Day232/229:11}; Baker {Day100/59:8-10}; {Day100/60:4-8}. Dr Colwell acknowledged that it would have been wholly inappropriate for BRE to do that.622 Colwell {Day232/228:8-20}. However, Mr Clark told us that comments to that effect could have been made by Dr Colwell or Mr Baker623 Clark {Day96/165:1-11}. and went on to say that although he could not recall making them himself, he might have commented on how bad the burning was over the surface of the K15 and that he could not rule out having made them.624 Clark {Day96/166:2-7}. We think it unlikely that Mr Meredith had invented comments of that kind or in that detail. We prefer his evidence and are satisfied that Mr Clark did make them and that Dr Colwell was probably aware that he had done so. That is supported by Mr Meredith's contemporaneous report and by a number of other contemporaneous documents. One particularly striking example is an email sent on 9 January 2008 by Mr Meredith to Dr Colwell in which he asked her to confirm that BRE would not deviate from the "official statement" and would not state in writing that the failure was due to the flame spread across the K15 insulation.625 {KIN00003693/1} final paragraph; {KIN00020908/1} first paragraph and penultimate paragraph.
81¶22.57 Both Mr Heath and Dr Rochefort confirmed that they had read Mr Meredith's report at the time,626 Heath {Day79/38:1-7}; Rochefort {Day80/70:13-20}. including his strongly worded observations about the performance of K15 in the test in December 2007, in which he had stated that the way in which the K15 had burned was of the "most concern".627 {KIN00008847/3}. Mr Heath told us that he had been concerned by the report.628 Heath {Day79/53:6-9}. Indeed, he said that he had already been aware that Mr Meredith had concerns about the fire performance of new technology K15 and had agreed that he should write the report in order to draw the attention of more senior Kingspan personnel to them.629 Heath {Day79/38:2-13}. Save for conveying those concerns to Dr Rochefort and offering support to Mr Meredith, however, Mr Heath did not take any action.630 Heath {Day79/56:17}-{Day79/57:2}. Dr Rochefort told us that he too had been disturbed by the report631 Rochefort {Day80/76:10-14}. and that he had understood that Mr Meredith was attempting to make him and others sit up and take notice that there was reason to be worried about the fire performance of the new K15 product.632 Rochefort {Day80/77:14-25}.
¶22.58 Nonetheless, the report was effectively ignored by Dr Rochefort, despite his claim to the contrary.633 Rochefort {Day80/81:11-16}. Echoing BRE's "official line" as recorded in Mr Meredith's report,634 {KIN00008847/3}. both Mr Heath and Dr Rochefort attempted to explain Kingspan's inaction by saying that BS 8414 was a system test and that it was possible that components of the system other than the K15 might have been responsible for the failure.635 Rochefort {Day80/83:4}-{Day80/83:19}; Heath {Day79/36:14-17}. Apparently for those reasons, neither Dr Rochefort nor Mr Heath gave consideration to suspending the sale of K15.636 Rochefort {Day80/82:2-10}; {Day80/91:17-24}; Heath {Day79/68:4-20}. Dr Rochefort said that after the test in December 2007 he had considered moving back to the old technology and that he had discussed that option in a couple of internal emails,637 Rochefort {Day80/91:24}-{Day80/92:8}. but his recollection was not supported by any documents we have seen. It was also inconsistent with the minutes of the many technical meetings held at that time,638 30 January 2008 {KIN00022466}; 21 February 2008 {KIN00023870}; 25 July 2008 {KIN00022467}; 22 August 2008 {KIN00023871}; 22 October 2008 {KIN00022468}. during each of which Kingspan's plans for dealing with the fire performance of the new technology were specifically discussed, often as a "high priority" or as "urgent" business. In none of those minutes was there any mention of reverting to old technology K15.639 {KIN00022467/1} paragraph 1.2; {KIN00022468/1} paragraph 1.2, fourth bullet point. We think that Dr Rochefort's memory was unreliable on that point.
82¶22.59 On 9 April 2008, a second test of a system incorporating new technology K15 was carried out in accordance with BS 8414-2 but again it failed to meet the performance criteria in BR 135, with temperatures exceeding the required levels at around 16 minutes into the test.640 {KSO00000099/6} final paragraph; {KIN00008844/1} sixth paragraph. That test was organised by Kingspan Off-Site, whose Project and Development Engineer, Aidan Wilkinson,641 Wilkinson {MET00080973/1} page 1, final paragraph. witnessed it. He described the system as having performed "abysmally".642 Wilkinson {MET00080973/4} page 4, third paragraph. There was then a third test on 24 April 2008, which was the second test carried out in partnership with Sotech and Metsec. Various modifications had been made to the system tested in December 2007 to try to improve its performance, but again it failed to meet the performance criteria in BR 135.643 Eggington {SOT00000029/3} page 3, paragraphs 17-18. John Eggington was the Managing Director of Sotech at the time of these tests in 2007 and 2008. Despite that record of persistent failure, neither Dr Rochefort nor Mr Heath nor anyone else at Kingspan was moved to take any further action.
¶22.60 On 6 June 2008 Kingspan Off-Site carried out its second test at BRE in accordance with BS 8414-2 (the fourth in the series). After the test, Aidan Wilkinson, and Mark Stevens, his manager and Technical Team Leader,644 Wilkinson {MET00080973/1} page 1, final paragraph; Stevens {MET00080972/3} page 3, first paragraph. contacted Kingspan to share their observations about the performance of K15 during both tests and to raise questions about it. In particular, Mr Stevens and Mr Wilkinson had observed that the K15 had continued to burn for more than 30 minutes after removal of the source of ignition.645 {KIN00009031/1}; {KIN00003714/1}. Kingspan Off-Site questioned Kingspan several times both by email and by telephone about whether that was normal or to be expected for K15; they also asked Kingspan for help in identifying what else might have caused the prolonged burning.646 {KIN00003704}; {KIN00020917}. That was a pressing matter for Kingspan Off-Site, which had already arranged to carry out a series of further tests of systems incorporating K15.647 Email from Mr Stevens to Mr Meredith {KIN00009031/1}.
¶22.61 Rather than telling Kingspan Off-Site what all three by then plainly knew about the worrying fire performance of new technology K15,648 Rochefort {Day80/121:15-16}; Heath {Day79/88:5-8}; {KIN00003704/1} "The question of K15s bad fire performance is no longer just an internal one". on 2 July 2008 Dr Rochefort, Mr Heath and Mr Meredith worked together to craft a carefully worded response.649 {KIN00003714/1}. They purported to express surprise at the poor performance of the product, given what Mr Heath described as Kingspan's previous success with BS 8414, and focused on the possibility that particular details of the test rig or inconsistencies in fire testing generally might have been the cause of the problem.650 {KIN00020916}.
¶22.62 Having responded in those terms, Mr Heath sent an email to his Kingspan colleague Gwyn Davies in which he said, "I'm spinning so much I'm dizzy".651 {KIN00009031/1}. Mr Heath, to his discredit, denied before us that that was effectively a boast about being less than truthful,652 Heath {Day79/92:2}-{Day79/93:19}. but that is obviously what he meant. He later accepted that there had been gaps in the information he had provided and said that he had been trying to delay matters so that Kingspan could develop a better product for testing.653 Heath {Day79/92:6}-{Day79/94:7}. At one stage, Mr Meredith seems to have been unsure of the account he was to give Kingspan Off-Site, asking Philip Heath by email, "Are we saying that the product supplied which failed their test is the same product that we got to pass the test?".654 {KIN00020917/1} penultimate paragraph; See also text in red added by Mr Meredith to {KIN00008844/2-3}. It is clear to us that both Philip Heath and Ivor Meredith were, and knew that they were, answering Kingspan Off-Site in terms that were not simply vague but actively designed to conceal and mislead.
83¶22.63 After further questions from Kingspan Off-Site on 16 July 2008, Dr Rochefort suggested that Kingspan should say that it ought not to carry out further testing as planned while Kingspan investigated possible reasons for the failure, on the basis that the "same batch…may suffer from a similar problem".655 {KIN00003714}. As Dr Rochefort acknowledged, Kingspan well knew that the problem was not limited to any particular batch.656 Rochefort {Day80/121:9-16}.
¶22.64 The simple truth behind Mr Heath's "spin" was that Kingspan did not have a version of K15 which it considered capable of performing well enough within a system to enable the criteria in BR 135 to be met;657 Heath {Day79/83:8-13}; {Day79/92:14-16}. Kingspan was working to understand why, as Mr Meredith put it in an email to Mr Heath on 3 July 2008, old tech worked and new tech did not.658 {KIN00020917/1}. Having carefully considered all the evidence, we are in no doubt that it was that fact that drove Kingspan to conceal from Kingspan Off-Site its serious reservations about the fire performance of new technology K15, rather than reasons of confidentiality, as Mr Heath suggested,659 Heath {Day79/90:13}-{Day79/91:17}. or a desire not to cause alarm, as Dr Rochefort claimed.660 Rochefort {Day80/121:22}-{Day80/122:10}.
¶22.65 The internal correspondence from July 2008 revealed numerous discussions between the three (and others) about trials, modifications and additives which might improve the fire performance of new technology K15.661 {KIN00008844}. The contemporaneous documents show that Kingspan was becoming desperate by this time to find answers to its predicament. Mr Meredith described his request for samples of a particular version of the foam for further testing as "business critical".662 {KIN00003704/1}.
¶22.66 In an internal email on 9 June 2008, Dr Rochefort wrote to Mr Meredith and others saying, "Ivor, if you're confident that old process will pass the test, we may have no choice but to provide old process K15 for Offsite until the FR [fire retardant]663 Rochefort {Day80/110:10-16}. issue is sorted out", adding, " ... we can't carry on providing something that we know fails a fire test".664 {KIN00003704/1}. Dr Rochefort told us that despite saying "for Offsite", he meant that Kingspan might have to revert entirely to producing and supplying old technology K15 across the market.665 Rochefort {Day80/110:3}-{Day80/111:21}. That is not what either Mr Heath or Mr Meredith understood him to mean, however, and neither of them thought that changing back to old technology K15 for the market generally had been considered or discussed as an option at the time.666 Heath {Day79/81:22}-{Day79/82:2}; Meredith {Day75/197:3-7}. We saw no other document that contained a reference to any consideration of reverting to old technology K15 for general manufacture and sale and we do not believe that Dr Rochefort, or anyone else at Kingspan, gave serious consideration to stopping production of new technology K15. Instead, Kingspan simply hoped to improve the product's fire performance while continuing to sell it and claiming compliance with Approved Document B on the basis of the 2005 test.
84¶22.67 In July 2008, Mr Meredith reported that a fire retardant version of K15 was being sent to BRE for indicative calorimetry testing in the hope of finding a lower calorific output and slower time to ignition, characteristics that he said were required to maintain Kingspan's position in the high rise facade market.667 {KIN00008848/2}. He told us that this testing was being carried out in an attempt to find small scale tests in which new technology K15 demonstrated a fire performance similar to that of old technology.668 Meredith {Day75/199:7-11}.
¶22.68 Mr Meredith said that he felt a tremendous responsibility to ensure that the product Kingspan was selling was fit for the market.669 Meredith {Day75/157:20-23}. It is clear to us from the evidence that by July 2008 he was worried about the performance in fire of the K15 then being sold. He made repeated and strongly worded attempts to make it clear to his managers how grave his worries were, but his impression at the time was that even if they were listening to him, they were neither responding to, nor acting on, what he was telling them.670 Meredith {Day75/157:24}-{Day75/159:1}.
¶22.69 Both Dr Rochefort and Mr Heath told us that they had taken Mr Meredith's concerns seriously.671 Rochefort {Day80/130:8-14}; {Day 80/132:19-23}; Heath {Day79/56:10-16}. They each said that they had been concerned by what they had read in the report he had made in January 2008 and by the performance of K15 in the BS 8414 tests carried out in April and June 2008.672 Rochefort {Day80/76:10-14}; {Day80/109:22}-{Day80/110:2}; Heath {Day79/53:6-9}; {Day79/77:10-16}. Philip Heath accepted that he had been aware in 2008 that there was a "paper trail"673 {KIN00020913/4}. showing considerably better performance in fire for old technology K15 than for new.674 Heath {Day79/82:25}-{Day79/83:6}. Despite their professed concerns, however, they appear to have taken no action. In particular, no consideration was given to suspending or withdrawing sales of K15, either then or at any time.675 Rochefort {Day80/82:2-10}; {Day80/91:10}-{Day80/92:4}; Heath {Day79/65:25}-{Day79/66:23}.
¶22.70 Mr Meredith said that Kingspan's reaction to the problem had amounted to no more than hope and the suggestion that further testing might provide a better result.676 Meredith {Day75/158:11-16}. That is consistent with the evidence of Dr Rochefort, who said that Kingspan's response to the concerns expressed by Mr Meredith was that a lot of work was being done to see whether the problems could be solved.677 Rochefort {Day80/132:21-23}. It is also clearly borne out by the documents, in particular the records of Kingspan's technical meetings, which show that efforts to improve the fire performance of the new technology foam continued throughout 2008 and into early 2009,678 Minutes of meetings on 22 August 2008 {KIN00023871}; 22 October 2008 {KIN00022468/1} paragraph 1.2; 25 February 2009 {KIN00022475/1-2} paragraph 1.2. ceasing only on the instructions of Mr Heath following the publication of the LABC Type Approval certificate for K15 in May 2009.679 {KIN00005382}. Kingspan continued to sell K15 to an unsuspecting market without interruption or warning while hoping that a positive test result might turn up.
85The first BBA Certificate: October 2008
¶22.71 The first BBA certificate for K15 was issued on 27 October 2008680 Certificate 08/4582 Issue 1 {BBA00000038/1}. after several years of work by Kingspan in support of its application.681 Meredith {Day75/41:7-8}. Those involved from Kingspan were Senior Technical Adviser Gareth Mills682 Mills {KIN00022329/11} page 11, paragraph 36; Mills {Day77/5:13-24}. assisted by Ivor Meredith.683 Meredith {Day75/201:17-24}. Both were supervised by Philip Heath until 2010 and thereafter by Tony Millichap, who replaced Mr Heath as Head of Technical when Mr Heath moved to another part of the business at the end of 2009.684 Millichap {KIN00020821/3} page 3, paragraph 2.4; Mills {Day77/4:12-19}.
¶22.72 Kingspan was well aware of the importance of BBA certificates in achieving acceptance of construction products by architects and building control bodies.685 Heath {Day79/132:12}-{Day79/133:15}. Mr Mills told us that he had regarded a BBA certificate as a marketing tool that would give customers greater confidence in the product;686 Mills {KIN00022329/11} page 11, paragraph 39; Mills {Day77/33:15}-{Day77/34:20}. Mr Meredith described a BBA certificate as a "green light of acceptability".687 Meredith {Day75/201:8-11}. We agree with that characterisation. The process of obtaining the first BBA certificate and deciding its final content involved various discussions between the BBA and Kingspan, principally Mr Mills, as well as comments on drafts being sent back and forth between the two companies. Kingspan circulated drafts internally to a team of proof readers for checking and comment. Mr Mills collated the comments and sent them back to the BBA.688 Mills {KIN00022329/15} page 15, paragraph 45(H); Mills {Day77/51:12}-{Day77/52:10}.
"Will not contribute to the development stages of a fire … "
¶22.73 The first BBA certificate contained three important statements about the fire performance of K15. The first, which appeared on the first page under the heading "Key Factors Assessed", was that "… the boards will not contribute to the development stages of a fire or present a smoke or toxic hazard".689 Certificate 08/4582 Issue 1{BBA00000038/1}. No witness from Kingspan or from the BBA was able to offer a coherent explanation of the meaning of, or the basis for, that sentence or how it could properly be said to apply to K15, a combustible polymeric foam. Mr Mills did not know what it meant but said he had had no basis for disagreeing with it.690 Mills {Day77/43:1-12}. Mr Meredith agreed that it was very vague but that he had believed it was a plausible statement.691 Meredith {Day75/202:23}; Meredith {Day75/204:6-13}. Mr Heath could not tell us what it had been based on but said that he thought it had been intended to reflect the behaviour in fire of thermoset materials.692 Heath {Day79/139:11-15}. Christopher Hunt of the BBA, who had approved the certificate,693 Christopher Hunt was Head of Approvals (Physics) at the BBA and signed the certificate: Hunt {BBA00011087/3} page 3, paragraph 7; Certificate 08/4582 Issue 1 {BBA00000038/1}. told us that he was not sure what the scientific or evidential basis for the statement might have been.694 Hunt {Day108/174:21-25}. He acknowledged that it was "slightly ambiguous"695 Hunt {Day108/170:8-13}. and more confusing than helpful.696 Hunt {Day108/175:2}. John Albon, the BBA's Head of Approvals from 2013 to 2019,697 Albon {BBA00010723/3} page 3, paragraph 13. told us that he had been concerned by the statement when he read it,698 Albon {Day110/112:2-21}. describing it in his evidence as an opinion that could not be substantiated and was not appropriate.699 Albon {Day110/112:20}-{Day110/115:1}. He therefore removed it.700 Albon {Day110/112:14-18}. However, that was not until October 2015, when the fourth version of the certificate was issued.701 Certificate 14/5134 Issue 1 {BBA00000040/1}.
86Class 0
¶22.74 The second significant statement in the BBA certificate about the fire performance of K15 was that it was classified as Class 0 and could therefore be used in accordance with the provisions of paragraphs 12.5 and 12.6 and Diagram 40 of Approved Document B.702 Certificate 08/4582 Issue 1{BBA00000038/5-6} paragraph 7.2. As we have explained, that was untrue. In October 2008 Kingspan had not been able to obtain a Class 0 classification for the product it was selling and continued, internally, to discuss and report on its attempts to do so throughout 2008 and the early part of 2009.703 {KIN00022205}; {KIN00022467/1} paragraph 1.2; {KIN00022468/1} paragraph 1.2; {KIN00022475/1-2} paragraph 1.2; {KIN00022476/1} paragraph 1.2.
¶22.75 Although the BBA had requested reaction to fire and surface spread of flame test data from Kingspan at an earlier stage in the preparation of the certificate in September and December 2004,704 {BBA00011093}. it appears that the only data of that kind provided to the BBA related to tests undertaken between 1991 and 2003 on various products, some produced in Kesteren, rather than at Pembridge, but none of them tests on the new technology K15 that Kingspan was currently selling.705 See summary at Moore {Day107/175:5-24}. Adrian Pargeter told us that investigation of historic records in preparation for the Inquiry had revealed that after the change to new technology in 2006, Kingspan could only have been relying on tests carried out on separate and different products706 Pargeter {Day84/40:13-20}. These were reports of tests carried out on Kesteren-produced products: BS 476-6 on DL 2000 {BBA00011291}; Part 7 on DL3300 {BBA00011292}; Parts 6 and 7 on DL3300 {BBA00011293}. to support its claim that K15 had achieved Class 0. (It also relied on the results of tests carried out on the foil facers alone but they were not provided to the BBA).707 Pargeter {KIN00022610/29} page 29, paragraph 3.40; Pargeter {Day84/39:6-24}. Ivor Meredith and Philip Heath, as they acknowledged in their evidence, had been aware of that at the time.708 Meredith {Day75/41:10-15}; {Day79/28:21}-{Day79/29:24}; Heath {Day79/25:10-13}.
¶22.76 On 1 July 2008, Gareth Mills wrote to the BBA709 {BBA00000244}. proposing the inclusion of the statement that K15 was classified to Class 0. He sent a document listing Kingspan's comments710 {BBA00000250/1} fifth row; Mills {Day77/57:16}-{Day77/59:12}. on a BBA draft of the certificate.711 {BBA00000249}. The text he proposed was an extract from a Kingspan product marketing brochure for K15.712 Mills {Day77/58:19-24}. Mr Mills did not send the BBA any data derived from tests carried out in accordance with BS 476-6 or BS 476-7 but said that he had thought that such data existed and that it might have been sent to the BBA at some other time by someone else.713 Mills {Day77/59:7-12}; {Day77/60:1}-{Day77/61:23}. Whether or not that was his true understanding at the time, it was not correct. In effect, by dint of Mr Mills' efforts, the BBA did no more than recycle Kingspan's own false marketing literature.
87¶22.77 Neither at the time the first certificate was published nor at any time thereafter did the BBA have any evidence at all on which to base a statement that K15 had achieved Class 0, as its own witnesses accepted714 Albon {Day110/156:19}-{Day110/157:7}; Moore {BBA00011097/4} page 4, paragraph 15. and as Adrian Pargeter effectively confirmed.715 Pargeter {Day84/44:6-9}. Kingspan thus persuaded the BBA to state that the product being sold as K15 had achieved a Class 0 rating (just as it was itself doing in its marketing literature)716 {KIN00002580/6}. knowing that statement to be false.
The BS 8414 test in 2005
¶22.78 The first issue of the BBA certificate also referred to a test carried out in accordance with BS 8414-1. It provided a fairly lengthy description of the system tested but did not state the date on which the test had taken place and was imprecise about the details of key parts of it. In particular, the certificate made no mention of the masonry backing for the test rig and instead used the phrase "non-combustible substrate". Most significantly, the description of the system ended with the words, "Within the stated test time the temperature at the level 2 thermocouples did not exceed 600°C, therefore displaying limited fire spread away from the fire source and that the product meets the criteria stated within BRE 135".717 Certificate 08/4582 Issue 1{BBA00000038/5} paragraph 7.1. That assertion was fundamentally misleading, since the criteria in BR 135 relate to the performance of the system as a whole, not that of any particular component.
¶22.79 When asked about that wording, Mr Heath agreed that it was incorrect718 Heath {KIN00020709/48} page 48, paragraph 7.35. and sought to explain it away as an oversight on the part of Kingspan.719 Heath {Day79/140:22}-{Day79/141:1}. Mr Meredith at first gave a similar explanation, suggesting that Kingspan had had only a limited time to check the accuracy of the BBA's draft.720 Meredith {Day75/205:14}-{Day75/206:13}. In fact, however, it is clear that drafts of the certificate had been passing between the BBA and Kingspan for several months from June 2008 onwards before the certificate had been issued.721 Kingspan provided detailed comments on at least three BBA drafts: 1 July 2008 {BBA00000250}; 15 July 2008 {BBA00000211}; 3 October 2008 {BBA00002874}. The correspondence reveals that the statement that the product had met the criteria in BR 135 had been proposed by Gareth Mills on 3 October 2008 at a fairly late stage in the process.722 {BBA00002874/1}. That was contrary to the evidence Mr Mills had given in his witness statement, which was that the BBA, rather than Kingspan, had suggested the wording.723 Mills {KIN00022329/14} page 14, paragraph 44(L).
¶22.80 The BBA's first draft of the certificate relating to K15 dated 4 June 2008 was sent to Kingspan for comment. It included a statement in paragraph 4.7 that K15 was combustible but that it could be used in various circumstances "… where no storey is at a height of more than 18m above ground ... ".724 {BBA00000249/5} paragraph 4.7. In an email of 27 June 2008 to Mr Mills and Mr Heath, Mr Meredith expressed the view that publication of that wording would be a "disaster".725 {KIN00024474}. In the same email, he urged caution over the plan to "slip the existing BS 8414 data in at the last minute so they didn't have much time to look over it and pick holes ...", warning that it might be foolish to think that the BBA would do anything other than go over the data with a fine-tooth comb. Mr Meredith need not have worried. The BBA did no such thing and inserted Mr Mills' suggested text verbatim into the final version of the certificate.726 {BBA00002874/1}; Certificate 08/4582 Issue 1{BBA00000038/5} paragraph 7.1.
88¶22.81 Mr Mills said that he could not remember who had proposed the change from the BBA's original description of the system tested in accordance with BS 8414 as based on a "blockwork" substrate727 {BBA00000219/7} paragraph 7.1. to one with a "non combustible" substrate.728 {BBA00000211/7} paragraph 7.1. However, correspondence within Kingspan reveals that the idea had come from Philip Heath, who suggested it on the basis that "it might allow us a little spin in the future".729 {KIN00024476/1}. Kingspan had been using similarly inexact language in its correspondence with customers for some time730 {KIN00005240/2}. and went on to make use of it more widely in its K15 technical bulletins and product literature following the publication of the BBA certificate in October 2008.731 {KIN00002607/3}; {KIN00003545/6}; {KIN00009585/2}.
¶22.82 Ivor Meredith understood that the data obtained from the BS 8414-1 test in 2005 related to a system with a masonry substrate and did not apply to a system with a steel framed structure732 {KIN00020913/4}; Heath {Day79/43:21}-{Day79/44:2}; {KIN00003701}. and had made his managers aware of that. Kingspan sought to recommend K15 for use on high-rise buildings by stating (or at any rate implying) that the 2005 test data applied equally to masonry and steel-framed structures as long as the latter were sheathed with a non-combustible board.733 {KIN00002607/3}. As the correspondence reveals734 {KIN00024476}. and as Mr Meredith and Mr Mills acknowledged,735 Meredith {Day76/72:23}-{Day76/73:7}; Mills {Day77/82:10-22}. that wording was consciously designed to conceal the absence of any data derived from a test in accordance with BS 8414-2, which by 2008 had become a pressing problem for Kingspan.736 {KIN00008847/2}; {KIN00020913/4}; {KIN00003701/1}; Meredith {Day75/146:3-8}. Kingspan's advice to customers that K15 could be used on buildings over 18 metres in height with any non-combustible substrate was not based on any test evidence or the advice of any suitably qualified expert.737 Heath {Day79/47:18}-{Day79/48:6}.
"Advice should be sought from the certificate holder"
¶22.83 A few lines below the description in paragraph 7.1 of the system tested in accordance with BS 8414 the BBA certificate contained paragraph 7.3, which told the reader that, "In buildings with a floor more than 18m above ground level, advice should be sought from the certificate holder."738 Certificate 08/4582 Issue 1{BBA00000038/6} paragraph 7.3. Mr Mills told us that he could not remember how that paragraph had come to be included.739 Mills {Day77/49:7-9}. He remembered that Kingspan had asked the BBA to remove from an early draft a passage that explicitly restricted the use of K15 to buildings under 18 metres in height.740 Mills {KIN00022329/13} page 13, paragraph 44(A); Mills {Day77/50:2-16}. When questioned about that, he accepted that he had proposed the removal from the summary on the front page of the certificate of the words "up to 18m" on the basis that the BS 8414 test report demonstrated that the product could be used on buildings over 18 metres in height.741 {BBA00000219/1}; {BBA00000211/1} text in red. He said that he had offered to provide the test report to the BBA in order to support his proposal.742 Mills {Day77/31:8-13}; {Day77/49:10}-{Day77/51:11}; {Day77/67:2}-{Day69/69:2}. It could do no such thing, of course, for reasons of which Kingspan was well aware.
89¶22.84 The section of the BBA certificate that advised readers to contact Kingspan when considering the use of K15 on a building over 18 metres in height was of substantial benefit to Kingspan. When potential customers sought its advice, Kingspan almost invariably advised them that K15 was suitable for such use, either in a generic sense or for a particular proposal. When doing so, it referred them to the BBA certificate, which directed them straight back to itself. Mr Meredith acknowledged that the clause was very welcome, because it meant that customers would contact Kingspan, giving it an opportunity to sell K15 for use on their projects.743 Meredith {Day76/6:13-19}. In later internal correspondence from January 2013, it was referred to as a "get-out" clause744 {KIN00005572/4}. that Kingspan tried to avoid losing.
¶22.85 The self-serving nature of the provision thus allowed Kingspan to give direct advice to potential customers about whether to use K15 on any particular building. The plain and obvious conflict of interest which that created appears to have passed unnoticed by the BBA. NHBC, the largest private building control body in the country, continued to treat that advice as unremarkable until as late as the autumn of 2013, when the significance of the sheer volume of K15 on high-rise buildings began to dawn on it.
What the BBA did not know
¶22.86 Although the BBA was not aware of the fact,745 Albon {Day111/28:10}-{Day111/29:7}. the description in the certificate of the BS 8414 test carried out on K15 rested on a fundamental falsehood. Despite a term of the contract that obliged Kingspan to notify the BBA of any changes to the product or of any new or additional information it had acquired about its suitability for use,746 {BBA00010745/3} paragraph 7(g). Kingspan did not tell the BBA that the test in 2005 had been carried out on a version of K15 that was by then obsolete and was no longer being manufactured.747 Heath {Day79/137:3-7}; Millichap {Day81/194:13-17}. When asked about that, Mr Mills and Mr Heath told us that they had thought the BBA was aware of the change to new technology and the foil facers748 Mills {Day77/41:4-14}; Heath {Day79/136:16}-{Day79/137:17}. because of the audits and quality plans in which they had been recorded.749 Heath {Day79/136:16}-{Day79/137:17}; Mills {Day77/40:3-9}; {Day77/41:4-12}.
¶22.87 We found no reference to the changes in the composition of K15 or the introduction of perforated foil facers in any BBA document. In any event, it is difficult to see how any quality plan or audit could have recorded the change to new technology. K15 had not been subject to BBA certification at the time of the changes and there would therefore have been no audit or quality plans in which to record that information.750 Meredith {Day75/40:21}-{Day75/41:3}; Albon {Day111/28:2-7}, "Once we have accepted a report, certified the product, and then have the production under surveillance, we continue to accept that data as being representative of the performance of the product on the understanding that the formulation and specifications are, from that point onwards, unchanged". Moreover, it became clear that no initial on-site assessment of K15 had taken place before the BBA issued the first certificate, apparently because several other Kingspan products had already obtained BBA certificates and the BBA was satisfied with its quality standards.751 {BBA00000161/3} final three paragraphs; Albon {BBA00010751/22} page 22, paragraph 74; Albon {Day110/162:11} -{Day110/164:24}; Hunt {Day109/39:12}-{Day109/40:1}.
90¶22.88 Moreover, Kingspan did not tell the BBA that four tests on systems incorporating new technology K15 had failed to meet the criteria in BR 135752 Mills {KIN00022329/13} page 13, paragraph 43(H); Heath {Day79/138:5-9}; {Day79/142:12-16}. or that, even in October 2008, it had misgivings about the fire performance of the product.753 Heath {Day79/137:18}-{Day79/138:4}; {Day79/142:17-21}. Philip Heath told us that Kingspan did not consider those matters to be relevant.754 Heath {Day79/138:1-4}; {Day79/143:1-4}. Mr Mills also told us that the four BS 8414-2 test results were not relevant to the scope of approval Kingspan was seeking from the BBA.755 Mills {Day77/38:13}-{Day77/39:12}. We disagree. They were plainly relevant, since they were the only tests in accordance with BS 8414 that had been carried out on systems incorporating the product that was the subject of the certificate.
Amendments proposed by the BBA: December 2008
¶22.89 On 24 December 2008, less than two months after the BBA certificate had been issued, George Lee, the Project Manager who had drafted it,756 Lee {BBA00010794/1} page 1, paragraph 1; Albon {BBA00010751/8} page 8, paragraph 31. sent an email to Kingspan in which he set out a number of proposed amendments to the part dealing with behaviour of the product in relation to fire. He explained that the BBA had received a number of comments on the clarity of the wording of that section. In particular, he proposed that the section on the first page of the certificate headed "Key Factors Assessed" should be amended by adding the following wording: "The product has been tested to BS 8414-1 for a specific construction on masonry walls".757 {KIN00009103}.
¶22.90 Eventually, on 5 March 2009, Philip Heath responded. He expressed concern about the proposal to make changes to the wording of the certificate so soon after it had been issued and warned that there might be cost implications for Kingspan, which he would need to assess before he responded. Two minutes later, he sent the exchange to Ivor Meredith, Gareth Mills and Andrew Pack, then Technical Services Manager.758 Pack {KIN00008702/4} page 4, paragraph 2.8. His email said simply, "Let the file gather dust, guys". Plainly, as Mr Pack and Meredith admitted (but Philip Heath would not),759 Heath {KIN00020709/81}, page 81 paragraph 11.47; Heath {Day79/154:20}-{Day79/155:16}. He characterised it as an instruction "not to proactively respond". that was an instruction to put off responding to the BBA's proposed amendments for as long as possible.760 Pack {Day86/147:7-11}; Meredith {Day75/211:2-12}. Mr Meredith told us candidly that this instruction had been given because it was in Kingspan's interests for the existing BBA certificate to remain in circulation. He said that Kingspan had not been prepared to allow the BBA to make it clear to the public that there were restrictions on the use of K15 on buildings over 18 metres in height because it could limit sales.761 Meredith {Day75/212:4-12}. Mr Mills admitted that that had possibly been the reason for the instruction to delay.762 Mills {Day77/102:23}-{Day77/103:4}. Mr Heath denied that, stating that, although Kingspan was keen to extend the scope of the approval, he had simply been concerned about the implications of the amendments for marketing materials, which by that time had been produced.763 Heath {Day79/154:20}-{Day79/155:24}.
91¶22.91 We do not think that Mr Heath was telling the truth. The explanation given by Mr Meredith was strongly supported by the contemporaneous internal correspondence,764 {KIN00024474}; {KIN00024476}. which, in particular, included Kingspan's comments on drafts of the certificate. They show that it was trying to persuade the BBA to certify that K15 was suitable for use on buildings over 18 metres in height in a general and unlimited sense and that K15 as a product met the criteria in BR 135.765 {BBA00000250/1-2}; {BBA00000211/1}; {BBA00000211/7}; {BBA00002874/1}.
Marketing and challenges: 2008–2009
¶22.92 Throughout 2008, and in the early part of 2009, Kingspan continued to market K15 as a product which had met the criteria in BR 135 and was therefore suitable for use on buildings over 18 metres in height, both on masonry and metal-framed substrates. Its marketing literature included drawings of both types of construction without qualification. Kingspan's promotional literature referred to the 2005 test without giving a date and without referring to the fact that it was applicable only to masonry substrates. It made no effort to draw the attention of the reader to the fact that BS 8414 is a method for testing a system as a whole rather than an individual component or product.766 {KIN00009703/6}; {KIN00002607/3}. Under the supervision of Philip Heath767 Heath {Day79/109:5-19}; {KIN00003723}; {KIN00003718}. it did the same in its responses to customers who asked for advice about the use of K15 at height and continued to write "letters of suitability" representing that the 2005 test data was "directly applicable" to various proposed constructions when it plainly was not.768 {KIN00002589/3-4}; {KIN00009042}; {KIN00002594/2}. Once the BBA certificate for K15 had been issued, Kingspan relied on the sections describing the BS 8414 test and the suitability of the product for use on buildings over 18 metres in height which it had shaped so carefully, sometimes referring to it as constituting the BBA's approval of the product.769 {KIN00002592/3}; {KIN00003723/1}.
¶22.93 Despite those efforts to conceal the true position about K15's performance in fire, the period was marked by challenges from astute designers. One such was Wintech Group Ltd, a facade engineering consultancy,770 Taylor {WIN00000002/1} page 1, paragraph 1. which in 2006 had begun to ask questions about the suitability of K15 for use in high-rise projects and the relevance of Kingspan's 2005 test to steel-framed structures.771 {KIN00005243/2}. Both Mr Heath and Mr Meredith acknowledged that the questions it raised were valid,772 Heath {Day79/115:22}-{Day79/116:9}; {Day79/120:22}-{Day79/121:7}; Meredith {Day76/86:19-24}. but at the time Kingspan fought off the challenges as best it could. Mr Meredith told other designers that Wintech was taking a precautionary approach to following the guidance in Approved Document B.773 {KIN00024478/1} penultimate paragraph.
¶22.94 Wintech's persistence led members of the technical team to seek advice from Mr Heath. On one occasion Mr Meredith asked him for a standard answer because it was becoming difficult for him to know what he could write without risking a legal confrontation. Mr Heath's response was "Wintech can go f#ck themselves, and if they are not careful we'll sue the a#se of them".774 {KIN00005363/1}. Mr Heath forwarded the exchange to a friend outside Kingspan, calling the situation a "nightmare" and writing "I'm trying to think of a way out of this one, imagine a fire running up this tower !!!!!!!!!!!!!!!!!!".775 {KIN00009066/1}. Even if we were to accept Mr Heath's explanation that the emails were an attempt to make light of a situation which was causing him "frustration",776 Heath {Day79/118:4-25}; {Day79/124:5-19}. we think, despite his denials,777 Heath {Day79/124:11-19}. that they expose a casual disregard for public safety at a senior level in Kingspan, a determination to defend K15's position in the market at all costs and a keen awareness on Kingspan's part that it needed to find a way out of the situation it had created through its own mendacity.
92The LABC Certificate 2009
¶22.95 As has been explained elsewhere in this report,778 Chapter 23. in May 2009 Kingspan obtained an LABC System Type Approval Certificate for K15. That certificate, obtained by Andrew Pack and Philip Heath, stated that K15 could be considered a material of limited combustibility and that it was suitable for use in all situations shown in Diagram 40 of Approved Document B, including on buildings over 18 metres in height.779 {KIN00005705/5}. Philip Heath's jubilation at obtaining the certificate was clear from his contemporaneous correspondence, in which he said the document could be "GOLD".780 {KIN00024991/1}. He celebrated the formal confirmation of its issue on 7 May 2009 with the single word "FANBLOODYTASTIC".781 {KIN00024993/1}.
¶22.96 On 7 May 2009, Mr Heath circulated the "GREAT NEWS!" to various internal Kingspan mailing lists, offering special thanks to Mr Pack, summarising the benefits the certificate would bring and highlighting in bold in his quote from the certificate the words "material of limited combustibility". In the same email, Mr Heath said that the certificate had completed the "tool kit" for K15.782 {KIN00005383}. The toolkit, he explained, was the marketing information used to sell the product.783 Heath {Day79/189:8-12}.
¶22.97 In response to a question from Dr Rochefort asking what test results had been used to obtain the certificate, Mr Heath said that Kingspan had sent so much fire data to David Jones, the certificate's author, that it had "probably blocked his server" and that LABC had convinced itself that K15 was the "best thing since sliced bread" without even having "to get any real ale down him".784 {KIN00020714}. Dr Rochefort never received a proper answer to his question.785 Rochefort {Day80/146:15}-{Day80/147:7}. His suggestion that testing of which he had been wholly unaware might have been carried out in Australia, China or Singapore was simply not credible.786 Rochefort {Day80/144:23}-{Day80/146:14}. The reality is that there was no answer. As Mr Pack accepted, Mr Heath's claim was nonsense.787 Pack {Day86/135:5-16}. No fire test data at all had been provided to LABC.
¶22.98 On 11 May 2009, in an email to Mr Meredith, Dr Rochefort and others, Mr Heath repeated that the LABC certificate satisfied the requirements for K15 to be installed on buildings over 18 metres in height and gave instructions that no further fire testing was to be carried out on K15.788 {KIN00005382}. He told us that the decision to stop testing and to rely on the LABC certificate to promote the suitability of K15 for use on buildings over 18 metres in height was a collective one.789 Heath {Day79/193:11-13}. During a meeting of Kingspan's Fire Focus Group on 18 May 2009, attended by Dr Rochefort and Mr Meredith but not by Mr Heath, it was agreed that work would continue on the development of a K15 product that would be able to pass a BS 8414-2 test as a back up.790 {KIN00008845/1-2}; Meredith {Day76/58:21}-{Day76/60:20}. However, Mr Heath then reversed that decision, confirming in an email to Mr Meredith on 17 June 2009 that no further facade testing involving K15 would be carried out and that the LABC certificate would be relied on "until we are challenged".791 {KIN00005387}. It is therefore clear that at that time Kingspan accepted that it had no K15 product capable of forming part of a facade system that would meet the criteria in BR 135 when tested in accordance with BS 8414-2792 Rochefort {Day80/155:7-20}; {Day80/143:10-20}. and that it made a calculated decision to use the LABC certificate to gloss over the absence of relevant test evidence.
93¶22.99 Both Mr Heath and Mr Meredith accepted that LABC's central statement about K15's suitability for use on buildings over 18 metres in height (described in an internal presentation to Kingspan's sales teams as "the highlight")793 {KIN00009178/5}. was false and thoroughly misleading. Mr Heath accepted that he had expected it to be challenged.794 Heath {Day79/207:11-15}; Meredith {Day76/24:24}. Mr Meredith, who said that at the time he had been "drowning in inquiries" about the use of K15 on buildings over 18 metres in height, told us that he was simply following suit from his line manager that, in the absence of any relevant test evidence, the LABC certificate was the solution.795 Meredith {Day76/35:12-24}. He too expected it to be challenged. Once the certificate had been obtained, the strategy was to send it out to customers and let it do the talking.796 {KIN00005385}.
¶22.100 By August 2009, that strategy appeared to be working. In an email sent that month to others in the technical and sales teams (including Mr Heath), Mr Meredith noted that questions about the use of K15 at height had died out since obtaining the LABC System Type Approval.797 {KIN00009135/1}.
Amended BBA certificates 2010-2013
¶22.101 Meanwhile, dust had been gathering on the amendments to the certificate relating to K15 that the BBA had proposed in December 2008.798 {KIN00009103}. Although the next version of the certificate bears the date 6 April 2010,799 Certificate 08/4582 Amended Issue 1{BBA00000037/1}. that was said to be the date on which it had been amended; it is clear from later correspondence that it was not the date on which it was issued.800 {BBA00002644/7}. No Kingspan witness was able to identify the date on which it had been issued. John Albon and Jon Denyer801 Denyer {BBA00010780/4} page 4, paragraph 13. thought it had been issued on 12 July 2013, although there was some uncertainty about it.802 Denyer {BBA00010780/10} page 10, paragraph 38 (publication date inserted by Jon Denyer); Albon {Day110/109:9‑25}. We have seen no evidence to confirm or contradict that later date.
¶22.102 The amended certificate contained three significant changes to the text relating to the performance of K15 in fire. First, the section on the front page headed "Key Factors Assessed" contained the additional words that Mr Lee had suggested, namely, "The product has been tested to BS 8414-1:2002 for one specific construction on masonry walls".803 Certificate 08/4582 Amended Issue 1{BBA00000037/1}. The second change was to the description of the system tested in accordance with BS 8414 in 2005, which now stated explicitly that BS 8414-1 was a test for masonry substrates and omitted the previous assertion that "... the product meets the criteria stated within BRE135".804 Certificate 08/4582 Amended Issue 1 {BBA00000037/5-6}; See previous wording {BBA00000038/5}. Last, in the passage immediately following the statement that
94¶K15 was rated national Class 0 (which had previously said that the product could be used in accordance with the provisions of paragraphs 12.5 and 12.6 of Approved Document
¶B)805 Certificate 08/4582 Issue 1 {BBA00000038/6}. the amended version said that the product could also be used in accordance with the provisions of paragraph 12.7 of the guidance.806 Certificate 08/4582 Amended Issue 1 {BBA00000037/5};
¶22.103 That proposed draft of the amended certificate was sent to Kingspan on 8 April 2010 by Mr Hunt, who explained the reason for the amendments and sought Kingspan's agreement to them.807 {BBA00002644/7}. In his response, which was not sent until 21 June 2010, Mr Mills effectively proposed reverting to the original, i.e. the complete removal of the amended wording on the first page ("for one specific construction on masonry walls") and the addition at the end of the section describing the system tested in accordance with BS 8414 the words "… therefore meeting the criteria in BR 135".808 {BBA00002644/6}. After that, no further progress was made for many years. Kingspan failed to respond to another email from Mr Hunt on 9 July 2010 and the BBA decided that the certificate would need to be re-issued rather than amended.809 {BBA00002644/1-5}.
¶22.104 Discussions resumed in January 2013 as part of what appear to have been steps leading to the eventual issue of a new certificate in July 2013. Mr Mills, Mr Meredith and a senior technical adviser at Kingspan, Joel Clarke,810 Clarke {KIN00008790/4} page 4, paragraph 2.6. considered how best to prevent the inclusion in the certificate of wording that would indicate any restriction on the use of K15 on buildings over 18 metres in height.811 {KIN00009353}; {KIN00005570}. Tony Millichap oversaw those discussions, which showed that Kingspan was now conscious of its waning influence over the BBA in relation to the contents of the certificate. Indeed, in an email sent to the other three on 9 January 2013 Mr Clarke commented that he thought Kingspan might be "pushing our luck" in seeking to restore the advice to contact the certificate holder812 {KIN00005570/2}. and said that at a meeting the day before people had said that the BBA was "onto us".813 {KIN00005570/1}. That may have been right. When the amended certificate was issued Mr Mills' comments appear to have been ignored and Kingspan's attempts to ensure that the certificate should include wording to the effect that "the product" had met the criteria in BR 135814 Email from Gareth Mills to the BBA dated 31 May 2013 {KIN00002145/4}, "... for the section relating to BS 8414, we would want the general description of the construction tested included, i.e. similar to that is (sic) our existing certificate, along with some text stating that the result achieved met the criteria from BRE 135...". had not been successful.
¶22.105 Despite the BBA's evidence815 Albon {Day109/56:13}-{Day109/57:2}. and Kingspan's arguments to the contrary,816 {KIN00025944/34-37} paragraphs 92-101. we think that the BBA's statement that K15 could be used in accordance with the provisions of paragraph 12.7 of Approved Document B was dangerously misleading because it suggested that K15 was a material of limited combustibility, which was not the case. Apart from Mr Mills, who seems to have thought that the statement was accurate,817 Mills {Day77/109:6}-{Day77/115:4}. all the other witnesses who were asked about it, including Mr Meredith818 Meredith {Day76/3:17-20}. and Mr Millichap,819 Millichap {Day81/80:8-20}. acknowledged that the reference to paragraph 12.7 in those terms was inaccurate and misleading. Mr Albon also acknowledged in his evidence that it was misleading.820 Albon {Day110/179:15}. In its closing statement for
95¶Module 2, however, Kingspan went to some lengths to persuade us otherwise.
¶22.106 As we have explained in Chapter 48 of this report, the purpose of paragraph 12.7 was to restrict the use of combustible insulation materials at height. It did so by advising that only insulation materials of limited combustibility should be used on buildings over 18 metres in height, except where they form part of a cavity wall construction and are enclosed by two leaves of masonry.821 {CLG10000007/96}. The exception for masonry cavity wall construction reflects the fact that the insulation is protected from fire on each side by a thick layer of non-combustible material. It was clearly intended to deal with a narrowly defined type of construction wholly unlike those for which the BS 8414 test and the BR 135 criteria were designed.
¶22.107 The passage in question has to be read and understood in the context of the certificate as a whole, which states that it relates to K15 "for use to create a warm frame wall construction or for use against masonry substrates, with a ventilated cavity and a weatherproof cladding system / protective rainscreen". The accompanying illustration depicts its use with a steel frame construction. Other sections of the certificate, such as paragraphs 1.1, 4, 5.2, 8.2, 8.5 and 12, suggest that it was not directed to the use of the product as insulation inside an enclosed masonry cavity wall and we have seen no clear evidence to suggest that either Kingspan or the BBA had such a use in mind. However, the real vice of the statement lies in the apparently innocuous word "therefore", which provides the link between the phrase "Class 0 or 'low risk'" and the statement that the product may be used in accordance with the provisions of paragraph 12.7 of Approved Document B. It is clear that insulation used within a masonry cavity wall construction does not need to be Class 0 or 'low risk' or of limited combustibility. The causal link can therefore be relevant only to the first part of paragraph 12.7, thereby suggesting that K15 is of limited combustibility. We therefore think that the overall thrust of the certificate was clear in that respect and that it was both erroneous and misleading.
¶22.108 On 17 December 2013, the BBA issued a third version of the certificate for K15.822 Certificate 08/4582 Issue 2{BBA00000036}. It significantly tightened the previous language in relation to the use of K15 on buildings over 18 metres in height, in particular by explicitly stating that one specific build-up had met the criteria in BR 135 through a test in accordance with BS 8414 Part 1. In a footnote, it repeated that K15 had been tested in accordance with BS 8414 only in one specific construction and added that a separate test would be required to establish the performance of any other combination of materials. It also removed the statement containing the reference to paragraph 12.7 of Approved Document B and the section directing readers to contact Kingspan for advice on the use of K15 on buildings over 18 metres in height.823 {BBA00000036/6}.
¶22.109 In recognition that its continuing efforts to prevent any "restrictive" wording about the use of K15 at height were not going to be successful, Kingspan took comfort from the fact that those restrictions were printed in "the smallest possible font and buried deep in the certificate itself". That was celebrated internally as "significant progress" from the position in a previous draft, as was the fact that the explicit restriction no longer appeared on the front page of the certificate.824 {KIN00005870/1}.
96¶22.110 Mr Meredith and Mr Mills both agreed825 Meredith {Day76/14:5-9}; Mills {Day77/131:21-24}. that they, Mr Clarke and Mr Millichap had been working to ensure that the certificate imposed the minimum restrictions on the use of K15.826 {KIN00005570/1}. Mr Millichap told us that his team might have been asking for more than was appropriate,827 Millichap {Day82/13:3-10}. but that they had simply been keen to ensure that K15 was presented in the most positive light and had tried to extend the scope of the certificate in a way that was accurate.828 Millichap {Day82/7:12-22}. Mr Meredith went further, however, admitting that inaccurate assertions made by Kingspan had not been due to an excess of enthusiasm but to a conscious attempt to persuade the BBA to accept claims that would maximise sales of K15, whether they were true or not.829 Meredith {Day76/12:16-20}.
¶22.111 Again, we think that the evidence of Mr Meredith was more reliable. We are left in no doubt that Kingspan took advantage of the BBA's initial failure properly to investigate the characteristics of K15 and thereafter did all it could to ensure that the certificates did not include wording that restricted the suitability of K15 for use on buildings over 18 metres in height, both by putting forward wording it knew to be inaccurate and by failing to correct the BBA's own inaccurate statements. Loose language or not,830 Millichap {Day82/7:4}. Kingspan's long-running internal discussions about what it could get away with831 {KIN00009353/1}. betrayed no concern whatsoever for accuracy.
LABC, NHBC and Wintech: 2012-2013
¶22.112 By May 2012, the LABC System Type Approval certificate issued to Kingspan in May 2009 had lapsed,832 {KIN00005705/1} "Conditions of Certification", second bullet point. leading to what Mr Meredith described in an email sent to Tony Millichap on 15 October 2012 as a "major headache and potentially a lot of lost work" in relation to high-rise buildings. He suggested that without the LABC certificate new data would probably be needed and that pressure should be put on the production teams to develop a form of K15 that could be expected to enable a system to meet the criteria in BR 135.833 {KIN00005552/1}; Meredith {Day76/37:17}-{Day76/39:2}. The exchange reveals the degree of reliance that had been placed on the LABC certificate and confirms that at that time Kingspan thought that K15 was still not capable of forming part of a system that could be tested successfully in accordance with BS 8414.
¶22.113 In late 2012, Kingspan thought about continuing to rely on the certificate issued in May 2009, but its lapse had not escaped the notice of Wintech, which continued to raise questions about the suitability of K15 for use on buildings over 18 metres in height.834 {KIN00005554/2-3}; Meredith {Day76/39:5}-{Day76/41:23}. In the event, Kingspan did obtain further LABC certificates for K15, the next being published on 28 August 2013.835 {LABC0001000}; {LABC0001001}. We deal with those later certificates in Chapter 23.
¶22.114 By 31 October 2013, Wintech's efforts to draw attention to Kingspan's apparent lack of test data for K15836 {KIN00005683}. had culminated in a meeting between them attended by (amongst others) Dr Rochefort, Peter Wilson, the managing director of Kingspan,837 {KIN00022334/17}. and Paul Savidge, the managing director of Wintech.838 Savidge {WIN00000004/2} page 2, paragraph 5. At the meeting Dr Rochefort maintained his view that K15 was suitable for use on buildings over 18 metres in height,839 {KIN00003823/2}; Rochefort {Day80/172:4}-{Day80/176:21}. but accepted that
97¶Kingspan did not have any BS 8414-2 test data and told Wintech that such tests would be undertaken and made available within six months.840 Rochefort {Day80/181:22}-{Day80/186:4}; Savidge {WIN00000004/25} page 25, paragraphs 63-67; Taylor {WIN00000002/26} page 26, paragraphs 57-61. In an email sent after the meeting,
¶Paul Savidge warned Dr Rochefort that if the data were not made available within that period Wintech would publicise its concerns about the use of K15 on high-rise buildings to the industry at large.841 {KIN00003823}; Meredith {Day76/139:7-21}.
¶22.115 The contents of the LABC certificates for K15 had also come to the attention of NHBC. In November 2014, it described the expression "K15 can be considered a material of limited combustibility", as "all garbage" and the approval of K15 on buildings over 18 metres in height as "an accident waiting to happen".842 {NHB00000810/1-3}. In Chapter 26 of this report we describe the discussions between NHBC and Kingspan during the period from late 2013 onwards in relation to the use of K15 on buildings over 18 metres in height. Mr Meredith told us that NHBC had started to ask difficult questions in late 2013.843 Meredith {Day76/50:7-10}; {NHB00000645/2}. Certainly, by February 2014, and following unsuccessful efforts by NHBC to obtain test evidence from Kingspan that demonstrated the suitability of K15 for use on buildings over 18 metres in height (in particular on steel frame systems), NHBC had asked Kingspan to provide written approval for every project of that kind on a job by job basis.844 {KIN00005894/1}. The evidence that Mr Meredith had repeatedly assured NHBC he would send to support the suitability of K15 for use at height proved not to exist. Consequently, the pressure on him to resolve the situation increased.845 Meredith {Day76/97:11}-{Day76/99:11}; Evans {Day219/218:25}-{Day219/219:21}. On 16 June 2014 NHBC wrote to Kingspan saying that unless test evidence supporting the use of K15 in any construction other than that tested to BS 8414- 1 in May 2005 had been provided by 30 June 2014 NHBC would reconsider its acceptance of K15 as suitable for use on buildings over 18 metres in height.846 {NHB00000757/3}. In the event, however, neither occurred.
BS 8414 test: 2014
¶22.116 In January 2014, Kingspan embarked on a programme of testing at BRE in accordance with BS 8414-2, the first since June 2008. The tests were arranged by Mr Meredith under the supervision of Mr Millichap and Dr Rochefort.847 {KIN00022334/17}. The first test in the series, held on 7 January 2014,848 Test 291718; no report produced. incorporated Trespa high pressure laminate rainscreen boards.849 {KIN00000673}. We were not able to establish whether the test in January 2014 had incorporated K15 insulation boards of the kind that were then being sold commercially. Mr Meredith told us that he thought it had,850 Meredith {Day76/110:4-7}. but Mr Millichap thought otherwise851 Millichap {Day82/27:1-8}. and an internal Kingspan presentation from May 2015 referred to a version of K15 with an unperforated foil facer.852 {KIN00021945/17}. (By January 2014, K15 was being manufactured and sold with perforated foil facers.) A spreadsheet produced by Kingspan for the Inquiry described the type of K15 used in the test as "unknown".853 {KIN00022357/3}. Whatever kind of K15 it contained, however, the system did not meet the criteria in BR 135, the temperature exceeding the relevant limit after just under
98¶15 minutes, with flames breaching the top of the test rig before 30 minutes had elapsed.854 {KIN00000673/1}.
¶22.117 Following that test, Kingspan worked on changes in advance of the next test. It is clear that Ivor Meredith, Dr Rochefort and Tony Millichap (among others) were closely involved in the discussions about possible changes. They included a suggestion made by Mr Meredith in an email dated 13 January 2014 to produce for testing a K15 product modified with an alternative blowing agent called 'solstice'.855 {KIN00021095/2} fifth bullet point. Dr Rochefort did not agree with changing to a solstice-blown foam and asked Mr Meredith to speak to him about it. Mr Meredith subsequently told Mr Millichap that he thought Dr Rochefort would be concerned about putting too much in writing.856 {KIN00021095/1}.
¶22.118 It is apparent from the internal correspondence in January 2014 following the first test857 {KIN00021095}. that at that point Dr Rochefort, Mr Millichap and Mr Meredith all realised two important things. First, that at that time they did not think that Kingspan had a K15 product that was capable of being used in a system that, when tested in accordance with BS 8414, would meet the criteria in BR 135. That included the K15 that Kingspan was then selling. Secondly, that as a result, the next test or tests could not be carried out on the standard K15 product.858 Millichap {Day81/122:12-25}; Millichap {Day82/27:16-19}.
¶22.119 Whatever reservations Dr Rochefort might initially have had about changing to a solstice-blown version of K15, the next test on 19 March 2014859 Test 293940. Test report dated 26 June 2014 {BRE00002516}. was carried out on a system incorporating a 15 millimetre Trespa decorative rainscreen board and a "trial" version of K15 made using solstice as the blowing agent with a 50 or 100 micron unperforated foil facer.860 {KIN00022357/3}; {KIN00021945/17}. Dr Rochefort, Mr Meredith and Mr Millichap were all aware at the time of the test that those were the characteristics of the insulation tested,861 Rochefort {Day80/203:5-12}; Meredith {Day76/124:23}-{Day76/125:9}; Millichap {Day82/30:23}-{Day82/31:1}. although the K15 on the market in March 2014 had a 25 micron perforated foil facer and did not use solstice as the blowing agent.
¶22.120 Despite the use of a modified K15 product, by 31 March 2014 Kingspan had learnt from BRE that the system tested on 19 March 2014 had not met the criteria in BR 135.862 {KIN00021907/2}. Towards the end of the test flames had breached the top of the rig and the test had therefore been effectively terminated straight away.863 {KIN00010461/3}; {BSI00000097/11} clause 8.5. Kingspan immediately set about challenging BRE's decision, first by making a formal complaint864 {KIN00010461/1}; {BRE00003576}. and then by warning BRE that it was consulting lawyers.865 {BRE00015592/2}. Based on its analysis of a video recording of the test, BRE stood firm and did not produce a BR 135 classification report. Mr Meredith nonetheless made good his initial promise to Dr Rochefort and others that he would get something out of the test866 {KIN00021907/2}. by obtaining a test report.867 {BRE00002516}. The resulting test report dated 26 June 2014 was later relied on in a large number of desktop assessments produced to demonstrate that systems incorporating K15 would comply with the criteria in BR 135.
99¶22.121 Despite being aware from 31 March 2014 that the system tested on 19 March 2014 had not met the performance criteria in BR 135,868 {KIN00021907/2}. Kingspan represented on a number of occasions,869 {NHB00000703}; {KIN00002186}; Millichap {Day82/107:5-24}; {Day82/134:2-23}. even as late as February 2015,870 {KIN00002199/1}. that the test supported the suitability of K15 for use on buildings over 18 metres in height. That involved a double falsehood: the insulation tested in that system was not K15 in the form in which it was being supplied to the market and the system had not met the criteria in BR 135.
¶22.122 The next test took place on 7 July 2014. Dr Rochefort directed that terracotta tiles be used as the rainscreen.871 {KIN00021907/2}. There was some discussion in late March 2014 between Mr Meredith, Mr Millichap, Dr Rochefort and others at Kingspan about the product that should be used in the next test, standard, solstice or phosphoric.872 {KIN00021907/2}. The first was the K15 that was being sold commercially, the second was the trial version which had been tested in March 2014 and the third contained certain other chemical modifications.873 Millichap {Day82/54:10-13}. On this occasion, they decided to use a solstice-blown product with a 50 micron foil facer, perforated on one side and unperforated on the other.874 {KIN00022357/3}; {KIN00021945/17}; Meredith {Day76/158:19-21}. Mr Meredith told us that the decision to test that form of the product was taken by all those who had been involved in the discussions,875 Meredith {Day76/130/10-19}; {KIN00021907}. who included Dr Rochefort, Mr Millichap and Peter Wilson.876 {KIN00021907}. The system tested met the performance criteria in BR 135.877 Test report 297099 dated 10 September 2014 {BRE00002656}; BR 135 Classification report 291642 dated 5 March 2015 {BRE00002514}.
¶22.123 There was evidence that Mr Meredith had taken steps to ensure that labels stating "trial" were removed from the insulation supplied to BRE for the test.878 {KIN00021904/3}. He agreed that that might have been to ensure that BRE did not become aware that a trial version of K15 was being tested.879 Meredith {Day76/161:4-20}. Neither the test nor the classification report produced by BRE made any reference to the fact that the insulation was a trial version, both simply referring to it as "K15 Kooltherm insulation board".880 {BRE00002656/6}; {BRE00002514/6}. As a result, the reader would not have been able to tell from the reports that the insulation was anything other than the K15 then being sold by Kingspan.
¶22.124 Mr Pargeter, Mr Meredith, Mr Millichap and Dr Rochefort all admitted that they had been aware at the time that the test on 7 July 2014 had been carried out on a system incorporating a trial product,881 Meredith {KIN00022312/58} page 58, paragraph 120(a); Millichap {Day82/64:9-15}; Rochefort {Day80/216:13-17}; Pargeter {Day83/191:7-16}. a fact clearly borne out by the documents. Mr Millichap882 Millichap {Day82/76:15}-{Day82/77:3}. and Mr Meredith883 Meredith {Day76/157:16}-{Day76/158:2}. told us that it had been common knowledge within Kingspan.
100¶22.125 The test result was immediately celebrated internally within Kingspan,884 {KIN00010825/2}. with jubilation expressed at the effect it would have on competitors and open discussion of the pressure Kingspan had been under to achieve it.885 {KIN00010825/1}. It does not appear to have occurred to any Kingspan employee, other than Mr Millichap, whose objections appear to have been roundly dismissed886 {KIN00010825/1}; Millichap {Day82/75:21}-{Day82/76:13}. and must have been short-lived, to question any aspect of the "success" being celebrated. The test result was swiftly also celebrated externally. Kingspan informed NHBC, building contractors, designers and the wider market that it had carried out a successful test to BS 8414-2 as part of its "test portfolio".887 {KIN00002186/2}; Millichap {Day82/104:23}-{Day82/105:4}; {KIN00011049}.
¶22.126 Thereafter, in its correspondence, technical bulletins and promotional literature, Kingspan relied on the result of that test to support the use of standard K15 on buildings over 18 metres in height and that remained its position until it withdrew the test in October 2020.888 {KIN00024104/1}. Kingspan's witnesses were asked why it had relied on a test carried out on a different product, given that all those involved (including Mr Pargeter, who was promoted to Head of Marketing in November 2014)889 Pargeter {KIN00000494/4-5} pages 4-5, paragraphs 2.7 and 2.8. knew that the test had not been carried out on K15 of the kind being sold in the market. There was a conflict of evidence between Mr Meredith, who did not attempt to deny that Kingspan had done so knowingly and deliberately, and Dr Rochefort, Tony Millichap and Adrian Pargeter, who did.
¶22.127 Dr Rochefort told us that at the time he had had no idea that the test carried out in July 2014 was being used by Kingspan to support the sale of standard K15 for use on buildings over 18 metres in height. When faced with documents that tended to show that he had been aware of how the test was being used,890 {KIN00020736/2} paragraph 6; {KIN00021904/1}. he put forward various unconvincing explanations while resolutely denying that Kingspan had deliberately relied on it to promote or sell standard K15.891 Rochefort {Day80/222:9}-{Day80/224:3}; {Day80/217:9-19}; {Day80/224:17-22}. In our view the evidence clearly demonstrated that he was aware that the marketing and technical departments were making use of the test in that way.
¶22.128 Mr Millichap agreed that it was wholly inappropriate to use the July 2014 test to support the sale of standard K15892 Millichap {Day82/66:12-15}. and said that he had not known that that was being done.893 Millichap {Day82/64:19}-{Day83/65:6}. However, having seen Mr Meredith's email of 21 August 2014,894 {KIN00020736}. he accepted that he had known that letters confirming success in the test that had been sent in response to questions from contractors895 {KIN00020736/2} paragraph 6. can only have referred to the test in July 2014.896 Millichap {Day82/68:17}-{Day82/69:6}. Moreover, faced with the record of a meeting held on 15 July 2014, at which he had been instructed to produce reports and letters announcing the result of the test for use as a marketing tool,897 {KIN00020736/3}. he admitted that he had been actively involved in using the test to support the sale of standard K15.898 Millichap {Day82/72:18-24}. He also confirmed that he had known throughout his time as Head of Technical that the product Kingspan had tested in July 2014 had never been produced or sold commercially.899 Millichap {Day82/64:9-15}.
101¶22.129 In the summer of 2014 Adrian Pargeter was Kingspan's Product Development Manager; he was promoted to Head of Marketing in November 2014. It is clear from the documents to which we have referred that he was closely involved in the testing of K15 and the attempts to produce a product that was capable of forming part of a system that would satisfy the criteria in BR 135 when tested in accordance with BS 8414. He could therefore be expected to have had a detailed knowledge of the differences between the various forms of K15 that were produced for testing during that period and, towards the end of 2014, of the steps being taken by the marketing department to promote and sell the product.
¶22.130 Mr Pargeter told us that he had not known that Kingspan had relied on the test in July 2014 in order to market and sell standard K15 until February 2019, when he had discovered it in the course of preparing to give evidence to the Inquiry,900 Pargeter {KIN00022610/56-57} pages 56-57 paragraph 7.16; Pargeter {Day83/191:17}-{Day83/192:9}; {Day84/4:14-25}. although he had known that a non-standard version of K15 had been tested in July 2014. In effect, his evidence amounts to saying that until early 2019 he had thought that two separate tests had been carried out in July 2014, one on the standard product and one on a trial product.
¶22.131 Mr Pargeter told us that he had not been involved in any discussions or decisions to use the report on the test carried out in July 2014 to support the sale of standard K15.901 Pargeter {KIN00022610/28} page 28, paragraph 3.37. However, his evidence was not consistent with a series of documents created in 2014 and 2015 that he had either written, approved or read, all of which contained statements that specifically relied on that test to support the use of K15 on buildings over 18 metres in height. One of them was a technical bulletin published in August 2015 entitled "Routes to Compliance",902 {KIN00000086}. which Mr Pargeter confirmed he had read in full (including the appendices and diagrams) thoroughly903 Pargeter {Day84/15:17-24}; {Day84/17:14-15}. before he had approved it.904 Pargeter {Day84/12:21-25}. The document contained pictures of the systems used for the three BS 8414 tests on which Kingspan was relying by August 2015.905 {KIN00000086/17}. One of them was the test carried out in May 2005; another was the test carried out in July 2014. Mr Pargeter said that he had not realised at the time that it was a picture of the test carried out on development material in 2014. There was a series of other documents dating from 2015 and 2016, all of which Mr Pargeter confirmed he had read, in which the test carried out in July 2014 was described or referred to as a test carried out on K15 and was being relied on in support of the promotion, certification or sale of K15.906 {KIN00002289}; {NHB00001109/2} second bullet point; {BBA00000200/5} paragraph 8.2, {BBA00000201/5} paragraph 8.2.
¶22.132 Given the positions he had occupied within Kingspan, between 2014 and 2019, it would be surprising if Mr Pargeter had not been aware of the nature of the product involved in the July 2014 test or of how his department had been marketing a product as important as K15. We found his attempts to distance himself from the activities of the marketing department dishonest and entirely unconvincing. We have concluded that Mr Pargeter was fully aware, both before and after he became Head of Marketing, that Kingspan was relying on the results derived from a test incorporating a form of K15 that was not being produced commercially to sell standard K15 and that he actively condoned it at a very senior level.
102¶22.133 We think it highly likely that Kingspan had always intended to rely on the first successful test it could achieve, whatever form of the product had been used in the tested system. Kingspan's reliance after July 2014 on a test carried out using a development product was part of a carefully planned, carefully concealed and long-running deception.
Conclusions
¶22.134 The story of the development and marketing of K15 for use on buildings of over 18 metres in height between 2006 and 2019 is one of deeply entrenched and persistent dishonesty on the part of Kingspan in pursuit of commercial gain coupled with a complete disregard for fire safety. Unfortunately, Kingspan's dishonesty was facilitated, albeit inadvertently, by serious incompetence on the part of two bodies, the BBA and LABC, to which the industry looked for confirmation that K15 was suitable for use on buildings over 18 metres in height. Both those bodies, although supposedly independent, compromised their independence by entering into negotiations with Kingspan over the wording of their certificates and agreeing to include language that was inappropriate and in some cases misleading. They both failed to examine rigorously the material on which Kingspan's applications were based or to require the production of test data that supported its claims.
¶22.135 The effect of Kingspan's dishonest marketing of K15 was to create a spurious market for a polymeric insulation product suitable for use on high-rise buildings generally, which drew in Celotex as a competitor. Celotex found it impossible to create a similar product using polyisocyanurate foam and could not understand how Kingspan had been able to produce an organic polymeric insulation board that apparently enabled designers to follow the guidance in Approved Document B relating to buildings over 18 metres in height. It therefore embarked on its own campaign to break into the market by dishonest means. Kingspan cannot be blamed for Celotex's dishonesty, which was the choice of Celotex itself, but it did create the conditions that encouraged it and in which it was able to flourish.
103Chapter 23: Certification of Kingspan K15 by LABC
Local Authority Building Control
LABC's certification schemes
¶23.2 By the early part of the present century the informal sharing of information between local authority building control departments about the suitability of construction products had developed into a more formal system known as the Type Approval scheme909 Turner {LABC0011202/8} page 8, paragraph 30; {LABC0018747}. administered by LABC on behalf of its members. (In 2010 the name of the scheme was changed to the Registered Details scheme.)910 Turner {LABC0011202/14} page 14, paragraph 45. The purpose of the scheme was to assess and verify the compliance of construction products or systems with the Building Regulations and Approved Documents. The categories of approvals granted under the scheme included a "Product Type Approval", which verified individual products or small components, and a "System Type Approval", a very wide category covering modular building systems as well as individual elements forming part of a larger structure.911 {HBC00000049/10-11} paragraph 2.2. The intention was to assist individual local authority building control bodies making decisions on specific projects,912 Turner {LABC0011202/7} page 7, paragraph 27; Turner {Day216/24:18-25}. to promote technical consistency913 Stimpson {LABC0020158/23} page 23, paragraph 25.3. and to make it easier for applicants for approval in different local authority areas to demonstrate compliance with the Building Regulations.914 Turner {LABC0011202/7} page 7, paragraph 26. The Type Approval scheme was also intended to provide a means of securing long term business for and reinvestment into LABC.915 {HBC00000049/26} paragraph 7.3.
¶23.3 The assessment of a product or system for the purposes of granting Type Approval was carried out by the building control department of a member local authority, sometimes referred to as the "research authority"916 Stimpson {LABC0020158/24} page 24, paragraph 25.13. or "matched authority",917 {HBC00000049/5}; {LABC0002281/3}. designated by LABC (if the application was made to LABC) or as a result of a direct approach by the manufacturer to a particular local authority.918 Turner {LABC0011202/8-9} pages 8-9, paragraph 31; Stimpson {LABC0020158/23} page 23, paragraph 25.6; {LABC0020158/25} page 25, paragraphs 25.16 and 25.17; {LABC0011202/11} page 11, paragraph 39. However identified, it was the responsibility of that authority to undertake an objective and impartial technical assessment919 Turner {LABC0011202/5-6} pages 5-6, paragraph 23; Stimpson {LABC0020158/27} page 27, paragraph 25.25. of a product or system based on information and supporting certification and test results from recognised bodies provided by the manufacturer.920 Turner {LABC0011202/6} page 6, paragraph 25; {LABC0011202/10} page 10, paragraph 35. The intention was to reflect the investigation that a building control surveyor would otherwise need to carry out to determine compliance with the Building Regulations and Approved Documents,921 Turner {Day216/25:2}-{Day216/26:13}. with the additional support of an independent second check.
104¶23.4 LABC published various editions of a Type Approval Service Manual922 {HBC00000049/6-30}. that set out the framework, process and standards for issuing certificates under the scheme. The manual was intended to act as a guide to assist member local authorities undertaking assessments.923 {HBC00000049/9} paragraph 1.1; Turner {Day216/71:6-10}. Although the process was based on information provided by manufacturers and therefore depended on their honesty and good faith,924 Turner {LABC0011202/12} page 12, paragraph 42; Brennan {LABC0020135/15-16} pages 15-16, paragraphs 21.17 and 21.21; Stimpson {LABC0020158/25} page 25, paragraph 25.15; Ewing {LABC0020139/17} page 17, paragraph 21.18. the assessment of the product or system under consideration was intended to be carried out at a high level and comprehensively checked in all respects.925 {HBC00000049/16} paragraph 3.2. With a view to maintaining the quality of the assessment, the scheme provided for a second check that might take a variety of forms, including referral to a specialist agency, consultant or independent peer review group.
¶23.5 Following a successful assessment, a certificate was issued by LABC, which was intended to represent "a singular initial Building Regulation approval in respect of a standard construction matter." As such, it was intended to confirm that the product or system complied with the Building Regulations for all uses falling within the defined scope and terms of the certificate.926 {HBC00000049/9} paragraph 1.2. It was intended to fulfil a number of functions, including the elimination of the need for repetitive checking of compliance with the Building Regulations.927 {HBC00000049/9} paragraph 1.2. The manual therefore contemplated that all local authorities would accept the certificate (within its terms and limits) without further checking.928 {HBC00000049/10} paragraph 2.1.
The first certificate for K15: May 2009-May 2012
¶23.6 From 2009 onwards, Kingspan obtained a number of LABC certificates for K15.929 System Type Approval 1 May 2009 – 1 May 2012, Registered Details RD 165 28 August 2013-28 August 2014, Registered Details August 2014 – 30 November 2014, EWW165 Certificate 9 March 2015–9 March 2016, EWWS165 Certificate 24 March 2016-30 March 2019 {LABC0019607/2-3}; Ewing {LABC0020139/22-24} pages 22-24, paragraph 27. The first was a System Approval certificate dated 1 May 2009 which remained valid until 30 April 2012.930 {KIN00005705/1}. A document entitled "Summary of the System and the Main Issues Considered" accompanied and formed part of the certificate931 {KIN00005705/3-6}. and made a number of important statements about the performance of K15 in fire. In particular, having stated that K15 had been tested in accordance with BS 8414-1, and BS 476, parts 6 and 7,932 BS 8414-2:2002 (Test method for non-loadbearing external cladding systems applied to the face of a building) {CEL00001205}; BS EN 1364-1:1999 (Fire resistance tests for non-loadbearing elements – walls) {BSI00000105}; BS 476-6:1989 (Method of test for Fire propagation for products) {BRE00005557}; BS 476-7:1997 (Surface spread of flame) {CTAR00000017}. it said that "From the results, it can be considered as a material of limited combustibility and meets the criteria for Class 0 classification for surface spread of flame".933 {KIN00005705/4} under the heading "Requirement B – Fire Safety Considerations". On the next page it stated that "Since K15 can be considered a material of limited combustibility, it is suitable for use in all situations shown on Diagram 40 of Approved Document B Volume 2, including those parts of a building more than 18m above the ground.".934 {KIN00005705/5} paragraph 1.
105¶23.7 Those statements were fundamentally incorrect in every respect. K15 was not, and could not be considered, a material of limited combustibility and the tests to which it was said to have been subjected were not capable of establishing whether it was a material of limited combustibility.935 {KIN00005705/4} under the heading "Requirement B – Fire Safety Considerations". Its performance in BS 476 tests did not show that it met the criteria for Class 0. Those were matters of critical importance when considering the intended use of K15, particularly on buildings over 18 metres in height. It is therefore necessary to examine how the certificate came to include statements of that kind.
¶23.8 The representatives of Kingspan involved in obtaining the certificate were Andrew Pack, Technical Services Manager,936 Pack {KIN00008702/4} page 4, paragraph 2.8. and his line manager937 {KIN00008752}; Heath {Day79/126:12-13}; Pack {Day86/10:9-12}. Philip Heath, who until 2010 was Technical Manager.938 Heath {KIN00020709/4} page 4, paragraph 2.8. On 24 November 2008 Mr Pack contacted Barry Turner by telephone to discuss a Type Approval certificate for K15.939 {LABC0002281/4}. Following that call, Mr Turner sent an email940 {LABC0002281/3}. to LABC's Business Development Team informing them that Kingspan had asked for information about obtaining a system type approval for K15 primarily in relation to functional requirements B and C of the Building Regulations. He expressed a preliminary view that LABC could consider granting such approval on the basis that K15 had a BBA certificate and LABC could therefore add an opinion on compliance with the Building Regulations in situations to be described by Kingspan.941 {LABC0002281/3}; Turner {Day216/40:6}-{Day216/42:9}.
¶23.9 Herefordshire County Council agreed to undertake the assessment of K15 and prepare any resulting certificate. The work was given to David Jones, who was a Senior Building Control Surveyor from June 2005 until November 2011 and thereafter a Building Control Team Manager until July 2014.942 Jones {HBC00000029/3-4} pages 3-4; Jones {Day101/7:8}-{Day101/8:22}; Turner {LABC0011202/8} page 8, paragraph 31. Mr Jones told us that Herefordshire was selected to undertake the assessment not for any reasons of technical expertise but due to its proximity to Kingspan's Pembridge site.943 Jones {Day101/16:4-20}. He had never previously been involved in the Type Approval process944 Jones {Day101/26:18-24}. and believed that the work had been delegated to him because he had a specific role in the department for marketing activity. The Type Approval scheme was viewed as a way of raising the profile of the LABC brand.945 Jones {Day101/18:5}-{Day101/19:8}.
106¶23.10 Mr Jones was reluctant to undertake the assessment of K15. He could see that it involved testing and certification, which he knew were not matters within his experience or within the experience of any other members of his department.946 Jones {Day101/17:4-15}. In early 2004, Mr Jones had attended a four-day training course designed for individuals new to the Building Regulations profession. Other than this, his training was "on the job" {Day101/9-23}-{Day101/10:7}; {Day101/12:2-6}; {Day101/60:5}-{Day101/61:2}. He had not undergone any specific training on the reaction of materials to fire, the testing and certification of construction products, or on the use of materials in buildings over 18 metres in height. There were no buildings over 18 metres in height in Herefordshire, so he had not had to consider the guidance relating to them in the course of his work.947 Jones {Day101/12:2}-{Day101/13:7}; {Day101/32:9-15}.
¶23.11 Mr Jones spoke to someone at LABC, probably Philip Harrison,948 Jones {Day101/30:12}-{Day101/31:8}. to explain his concern about undertaking the assessment but was told that it would be fairly limited in scope and should involve an initial meeting with the client and a review of the information provided by it. He was also told that if third party certification was considered to be reliable, it could be accepted at face value and that he need not go behind it.949 Jones {Day101/31:24}-{Day101/32:11}; {Day101/36:1-7}.
¶23.12 The reliability of third party certification was a matter for LABC rather than the assessing authority and the BBA was regarded as the leading organisation accredited by UKAS and therefore treated with a high degree of trust.950 Jones {Day101/33:18}-{Day101/34:25}. Mr Jones specifically remembered being told during the call that he could rely on the existence of a BBA certificate for K15, which he regarded as significant.951 Jones {Day101/32:15-22}. It provided him with reassurance that he was not expected to delve into complex matters of fire testing.952 Jones {Day101/32:9}-{Day101/33:9}. He explained that he was specifically told that his assessment should be based on the BBA certificate and that because the BBA would already have examined all the test information,953 Jones {Day101/32:17-18}. he need not verify any part of its contents.954 Jones {Day101/32:15-22}; {Day101/37:5-10}; {Day101/46:1}-{Day101/47:2}, "I just remember this BBA certificate being the key factor, that, 'No it's okay, don't worry, it's got a BBA certificate' and that was it. That was the answer really".
¶23.13 LABC did not accept Mr Jones' account of the telephone call, which it said was contrary to its practice both then and now.955 {LABC0019740/24-25} pages 24-25, paragraph 64 (iv). However, none of its witnesses was able to tell us who had spoken to him or to provide us with any other information about the call he described. David Jones, on the other hand, was a straightforward, candid and credible witness who gave a clear and detailed account of it. We have no doubt that Mr Jones was assured by LABC that there was little to be done beyond checking the BBA certificate (which broadly reflects what a building control officer would have done) and that it was on the basis of that assurance, and the knowledge that there would be a second check,956 Jones {Day101/183:2}-{Day101/186:5}. that he agreed to take on the task.957 Jones {Day101/27:22}-{Day101/29:2}; {Day101/184:21}-{Day101/185:9}.
107¶23.14 Mr Jones' evidence about what was said during the call is consistent with the terms of LABC's Service Manual in relation to BBA certificates958 {HBC00000049/17} paragraph 3.3 under bullet points, "... the holding and submission by the customer of authoritative independent third party verification, particularly if it is from a UKAS accredited source or other method recommended in Approved Document 7, is likely to indicate an acceptable level of satisfaction for our approval purposes and eliminate the need for any additional checking within that aspect". and with Barry Turner's evidence that when carrying out the second level review959 {LABC0008171}. he would probably not have looked beyond the BBA certificate.960 Turner {Day216/56:11-14}; {Day216/41:18}-{Day216/42:9}; {Day216/83:13-20}. Mr Turner's internal email in November 2008 {LABC0002281/3} "…given that the product has relevant BBA certification…". That all supported Mr Jones' understanding that in practice LABC did place complete reliance on BBA certificates and expected any authority carrying out an assessment to do the same.
Mr Jones' meeting with Kingspan in December 2008
¶23.15 On 5 December 2008, Mr Jones met Mr Pack and Mr Heath of Kingspan at Kingspan's offices in order to discuss the certification of K15.961 {KIN00024987}; Jones {Day101/48:24}-{Day101/49:9}. They told him that Kingspan was keen to be associated with the LABC brand962 Jones {Day101/41:2-7}. and was aware that an LABC certificate could ease the passage of a product through building control.963 Jones {Day101/42:5-18}. Mr Jones recalled in particular that they had been enthusiastic about the fire testing that Kingspan had commissioned for K15 and the BR 135 criteria964 Jones {Day101/56:10-15}. and were keen to market its suitability for use on buildings over 18 metres in height.965 Jones {Day101/52:20}-{Day101/53:1}; {Day101/64:2-24}; Jones {HBC00000029/20} page 20, first paragraph. They emphasised that aspect of the product as a key feature966 Jones {Day101/57:21}-{Day101/58:3}. of what they were presenting to him.
¶23.16 Mr Heath could not recall being enthusiastic about Kingspan's fire testing967 Heath {Day79/167:20-25}. and denied having given Mr Jones the impression that K15 was suitable for use on buildings over 18 metres in height without qualification.968 Heath {Day79/179:7-9}. He told us that, although he had overall responsibility for obtaining the LABC certificate, Mr Pack had been the person leading the project.969 Heath {KIN00020709/59} page 59, paragraph 8.16.
¶23.17 Mr Pack denied that he had spoken enthusiastically about Kingspan's BS 8414 test970 Pack {Day86/122:15}-{Day86/123:11}. and denied that the suitability of K15 for use on buildings over 18 metres in height had been a matter of significance for him or Mr Heath.971 Pack {Day86/126:22}-{Day86/127:25}. We found that wholly implausible, however, since the ability to sell K15 as suitable for use on buildings over 18 metres in height had been uppermost in Mr Heath's mind for some time. In reality, Mr Pack could recall little about the meeting,972 Pack {Day86/120:20}-{Day86/121:7}; {Day86/124:6-8}; {Day86/130:13-17}; {Day86/149:24}-{Day86/150:12}; {Day86/156:22-24}. describing his own role in obtaining the LABC certificate as merely administrative.973 Pack {Day86/100:18}-{Day86/101:20}. In the light of Mr Pack's later involvement in discussions with Mr Jones about the contents of the certificate that was clearly not true.974 {KIN00024989}; {KIN00024996}; {KIN00024997}; Pack {Day86/170:2}-{Day86/171:24}. Both Mr Pack and Mr Heath denied having claimed that K15 was or could be considered a material of limited combustibility or having given that impression.975 Pack {Day86/148:23}-{Day86/149:9}; Heath {Day79/178:25}-{Day79/179:9}.
108¶23.18 We preferred the evidence of David Jones about the meeting to that of Mr Pack and Mr Heath. Mr Jones was careful to say that he could not be specific about the words they had used but he told us that he could say with "some certainty" that he had left the meeting with the clear impression that because K15 behaved like a material of limited combustibility it was, or could be considered to be, a material of limited combustibility.976 Jones {Day101/76:1-25}-{Day101/78:12-24}; Jones {HBC00000029/37} page 37, final paragraph; Jones {Day86/74:4-25}; {Day101/78:21-25}; {Day101/82:5-20}. (It is unlikely to have been a coincidence that Kingspan had been making essentially the same claim in correspondence with customers for some time.)977 {KIN00002588/2}, "…it has been proved to perform the same as non combustible material via testing to the full scale BS 8414 test". The impression Mr Jones had formed was that different products could be used with K15 as part of an external cladding system as long as the fire performance of those products was equal to or better than that of the products used in the tests he had been told about.978 Jones {Day101/70:10-17}; {Day101/71:3-9}. Mr Jones said he understood the parameters to be the non-combustible substrate referred to in the BBA certificate, a system of cavity barriers, and non-combustible cladding panels. That is what Mr Pack confirmed he had told Mr Jones. Pack {Day86/130:21}-{Day86/131:11}. He also left the meeting with the understanding that there was a clear business advantage to Kingspan in having a product that could be marketed for use on buildings over 18 metres in height because it was not a market that all products could enter.979 Jones {Day101/64:21}-{Day101/65:5}. In later discussions with Mr Jones Andrew Pack proposed broadening the terms of the certificate to include a reference to K15's suitability for use with various cladding products with which it had not been tested, but he did not tell Mr Jones that K15 could only be used at height as part of a system corresponding to that tested in accordance with BS 8414 in 2005.980 {KIN00024996}; Pack {Day86/163:12}-{Day86/169:25}.
¶23.19 Mr Jones was given two documents during the meeting,981 Jones {Day101/55:9-13}. Kingspan's first BBA certificate, issued on 27 October 2008,982 BBA Certificate {BBA00000038}. and Kingspan's principal marketing literature for K15 at the time, which was dated November 2008.983 Eighth issue "Kooltherm K15 Rainscreen Board" {KIN00009703}. We have considered the terms of the BBA certificate and the way in which it came to be obtained by Kingspan elsewhere in this report.984 Chapter 23. In relation to fire, it stated on its front page under the heading "Key Factors Assessed" that K15 boards would not contribute to the development stages of a fire or present a smoke or toxic hazard.985 BBA Certificate {BBA00000038/1}. It also stated that K15 was classified as Class 0986 BBA Certificate {BBA00000038/5-6} paragraph 7.2. and that in a BS 8414-1 test it had displayed limited fire spread away from the source and had met the criteria in BRE 135.987 BBA Certificate {BBA00000038/5} paragraph 7.1. That was misleading, since the criteria in BR 135 relate to systems rather than products.
¶23.20 In the same vein, Kingspan's 2008 promotional literature wrongly stated that K15 had met the criteria in BR 135 and was therefore acceptable for use on buildings over 18 metres in height in accordance with the Building Regulations. It stated definitively (again, wrongly) that K15 did not contribute to the spread of fire within a cladding system.988 {KIN00009703/6}. The documents therefore reflected each other as well as the conversation that Mr Jones said had taken place when he met Mr Pack and Mr Heath.989 Jones {Day101/66:15}-{Day101/67:4}.
109¶23.21 Mr Jones asked for no further documents and none were offered.990 Jones {Day101/108:20}-{Day101/109:5}. The certificate he drafted was therefore based on those two documents, (principally the BBA certificate) and the information Andrew Pack and Philip Heath had provided during his meeting with them.991 Jones {HBC00000029/35-36} pages 35-36, paragraph 57(a)-(h); Jones {Day101/129:4}-{Day101/149:5}. Mr Jones had not read any of the test standards992 Jones {Day101/127:16-19}. or reports of the tests993 Jones {Day101/59:24}-{Day101/60:3}; {Day101/125:20}-{Day101/126:6}. he listed in his summary before the certificate was issued.994 {KIN00005705/4} under the heading "Requirement B – Fire Safety Considerations". He explained that there would have been little point in doing so because analysing those reports was outside his expertise and would have involved an entirely different exercise from the one he had understood he had been asked to carry out.995 Jones {Day101/60:5}-{Day101/63:7}. He simply copied the list of tests from the BBA certificate.996 Jones {Day101/126:2-6}. He thought that the statement that K15 could be considered a material of limited combustibility was simply a confirmation of something that was already known.997 Jones {HBC00000029/37} page 37, first paragraph; Jones {Day101/149:20}-{Day101/150:18}.
¶23.22 In 2009, Mr Jones did not know that data derived from a BS 8414 test and any subsequent classification in accordance with BR 135 was valid only for the system tested998 Jones {Day101/104:3-19}. and neither Mr Pack nor Mr Heath told him that,999 Pack {Day86/130:21}-{Day86/131:2}; Jones {Day101/68:22}-{Day101/69:12}; Pack {Day86/73:1-6}. although they were both well aware of the fact.1000 Pack {Day86/22:15}-{Day86/23:12}; Heath {Day78/189:21}-{Day78/190:5}; {Day78/196:16}-{Day78/194:2}. Nor did he know that Class 0 was demonstrated through testing in accordance with BS 476 Parts 6 and 7, two of the tests he listed in the document accompanying the LABC certificate.1001 Jones {Day101/126:7-23}. His understanding at the time of the term "material of limited combustibility" was that it referred to a material that had the capacity to burn but was difficult to ignite and would not allow flame to spread easily through it.1002 Jones {HBC00000029/29} page 29, paragraph (a); Jones {Day101/96:9}-{Day101/97:5}. That was consistent both with the impression he had been given by Mr Heath and Mr Pack at their meeting that K15 had a limited capacity to burn1003 Jones {Day101/77:7-23}; See also Kingspan correspondence at, for example {KIN00003685/1} "Therefore it is pigeonholed with the combustible insulations even though the char that forms 'limits the combustibility' of the product" {KIN00005388/1} first paragraph. and with what he told us had been the widely held view among building control officers that Kingspan products would char slowly and stop burning when the source of ignition was removed.1004 Jones {HBC00000029/38} page 38, first paragraph; Jones {Day101/81:13}-{Day101/83:20}.
¶23.23 David Jones accepted that when he did his research he had become aware of Appendix A to Approved Document B and had thus become aware of the meaning of the expression "limited combustibility". Nonetheless, he had decided to adopt the wording in the certificate on the basis that there could be different ways of meeting the functional requirements.1005 Jones {Day101/153:13}-{Day101/156:11}. When shown the relevant tables in Approved Document B,1006 Table A7 {CLG10000007/132}; Table A6 {CLG10000007/131}; Jones {Day101/158:1}-{Day101/161:14}. however, he agreed that if he had looked at them at the time he would not have written that K15 could be considered a material of limited combustibility.1007 Jones {Day101/162:15-20}. He told us that he now appreciated that, due to his lack of experience, some of the statements in the certificate should not have been made.1008 Jones {Day101/180:10-12}. He accepted that he had not drawn a clear enough distinction between a material of limited combustibility, which has a defined meaning, and a product which has a limited capacity to burn.1009 Jones {Day101/150:13}-{Day101/151:23}. He thought his judgement might have been affected by being given the impression that K15 had already been approved for use on buildings over 18 metres in height by virtue of meeting the criteria in BR 135.1010 Jones {Day101/162:6-14}. He also accepted that his approach might have been shaped by the commercial pressure on local authority building control officers to find innovative solutions that did not rigidly follow the Approved Documents in order to win business.1011 Jones {Day101/156:7-11}; Jones {HBC00000029/40} page 40; {Day101/174:4}-{Day101/176:25}.
110¶23.24 Mr Jones understood that after he had carried out his assessment it would be checked by LABC to ensure there were no errors.1012 Jones {Day101/111:17}-{Day101/112:21}; {Day101/173:12-15}. In fact, however, the second check, carried out in March 2009 by a Type Approval Working Group made up of individuals from various local authorities, appears to have been cursory at best. The only question raised was why a system approval was being issued rather than a product approval, K15 plainly being a product rather than a system.1013 {LABC0008171/2}. It appears to have gone unanswered and remained unanswered even when Barry Turner was asked about it by LABC's Technical Administrator, Sasha Cruz, in an email sent on 21 April 2009 asking if the certificate could be issued.1014 {LABC0008171/1}. No one noticed the fundamental errors in the summary. On 1 May 2009, Ms Cruz sent the certificate to Mr Jones to issue on behalf of LABC.1015 {LABC0001882/3}.
¶23.25 Barry Turner accepted that the statement that K15 could be considered a material of limited combustibility was inaccurate and misleading.1016 Turner {Day216/36:19}-{Day216/37:2}. He could not explain how it had come to be made, telling us that he did not participate in the review process and repeatedly asserting that he was copied into various relevant emails only "as a matter of courtesy".1017 Turner {Day216/51:9}; {Day216/69:13-17}; {Day217/3:8}; {Day217/12:6-10}; {Day217/23:5}; {Day217/35:17-20}; {Day217/48:6}. We agree with LABC's acknowledgment in its closing statement that Mr Turner was an unhelpful and dismissive witness.1018 {LABC0020161/34} page 34, paragraph 138. We were left in no doubt that he was seeking throughout to minimise his own technical role, his involvement in the certification process and his responsibility for any aspect of it.
¶23.26 David Ewing, who later managed LABC's Registered Details Approval scheme,1019 Ewing {LABC0020139/4} page 4, paragraph 7.6. also accepted that the 2009 certificate's wording in relation to K15's fire performance was technically incorrect,1020 Ewing {Day217/148:1-9}. as did LABC itself in its closing statement.1021 LABC Phase 2 Module 2 Closing Submissions {LABC0019740/5-6} paragraph 17; LABC Phase 2 Module 6 Closing Submissions {LABC0020161/25} paragraph 101(a)-(b).
¶23.27 To their discredit, neither Philip Heath nor Andrew Pack was prepared to accept that he had been aware in 2009 or thereafter that the wording of the certificate was inaccurate, that it would be likely to lead readers to believe that K15 was a material of limited combustibility or that many readers would understand from it that K15 had been approved for use on buildings over 18 metres in height. Both maintained that at the time they had understood that LABC had intended the wording to mean that K15 could be suitable for use in such circumstances as part of a system that had been tested in accordance with BS 8414 and had met the criteria in BR 135.1022 Heath {Day79/161:5}-{Day79/164:11}; {Day79/174:1-7}; {Day79/176:21}-{Day79/177:23}; {Day79/182:6}-{Day79/183:20}; Pack {Day86/187:6}-{Day86/189:10}; {Day86/192:9}-{Day86/193:9}. However, that was impossible, given that only a limited amount of testing had been carried out, and that on a product that had become obsolete at least two years earlier. In reality, that was neither what the certificate stated nor what Mr Jones had intended.1023 Jones {HBC00000029/36} page 36; Jones {Day101/128:11-21}. Mr Heath added that on reflection he could see that the wording had been misleading.1024 Heath {Day79/176:21}-{Day79/177:23}. Mr Pack too told us that in hindsight, the wording could have been "slightly better",1025 Pack {Day86/188:25}-{Day86/189:1}. but said that Kingspan relied on LABC and on the wording chosen by Mr Jones.1026 Pack {Day86/188:15-16}; {Day86/191:21}-{Day86/192:2}.
111¶23.28 Both Mr Pack and Mr Heath confirmed that they had understood at all times that K15 was not a material of limited combustibility.1027 Pack {Day86/21:15}-{Day86/22:7}; {Day86/187:1-5}; Heath {Day78/181:7-20}. Both were also aware that Approved Document B did not provide that combustible insulation could be considered a material of limited combustibility if used with non-combustible or limited combustibility substrates or outer cladding.1028 Pack {Day86/190:25}-{Day86/191:18}; Heath {Day79/161:5}-{Day79/162:6}. They did not need to rely on hindsight to know that the certificate was wrong in that respect and dangerously misleading. When sent a draft of the certificate and accompanying summary by Mr Jones on 27 February 2009,1029 {KIN00024990}. neither Mr Pack nor Mr Heath corrected the wording. On the contrary, Mr Heath described the document as "GOLD"1030 {KIN00024991/1}. and Mr Pack approved the draft, asking Mr Jones to proceed to issue the certificate and summary.1031 {KIN00024990}. In his markedly more candid evidence, Ivor Meredith,1032 Meredith {KIN00022312/1} page 1, paragraph 1. told us that he and his superiors had known at the time that the wording was misleading but that it was very advantageous for Kingspan.1033 Meredith {Day76/30:14-23}. He said that Mr Heath had been thrilled with it.1034 Meredith {Day76/33:13-15}.
¶23.29 Kingspan's aim from the outset (as in the case of the BBA certificate) had been to ensure that the wording of the certificate gave as much support for the use of K15 on buildings over 18 metres in height as possible, with no regard for technical accuracy or fire safety.1035 Chapter 22. It is apparent from the triumphant tone of the emails sent by Mr Heath within Kingspan at the time1036 {KIN00005383}; {KIN00024993/1}. that his own and Mr Pack's dogged assertions that they were ignorant of the error on the face of the certificate was untruthful. It was the very wording "...can be considered as a material of limited combustibility..."1037 {KIN00005705/4-5}. that was highlighted in bold in Mr Heath's announcement to colleagues that the certificate had been obtained and for which he heartily thanked Mr Pack.1038 {KIN00005383}. That part of the certificate was also described to sales teams as the "highlight" of the document1039 {KIN00009178/5}. and led directly to Mr Heath's instruction to colleagues on 11 May 2009 that no further large-scale testing was to be carried out on K15.1040 {KIN00005382/1} "The pressure is on other component suppliers to obtain similar statements or prove their non- combustible statements". Kingspan had what it needed to maintain its position in the over 18 metre market.
112¶23.30 Worse still, neither LABC nor Mr Jones knew that K15 had not achieved results when tested in accordance with BS 476-6 and BS 476-7 that enabled it to be classed as Class 01041 Kingspan had tested to BS 476 Parts 6 and 7 the foil facer of K15 boards stapled to a non-combustible substrate {KIN00022205}; See Chapter 22. and that the sole test in accordance with BS 8414-1 that Kingspan had carried out which met the criteria in BR 1351042 BRE Report {BRE00002511} Test 220876. had incorporated an obsolete form of K15 that was different from the version being produced and sold in 2009 and thereafter.1043 See Chapter 22. Those facts were concealed from LABC and from David Jones by Mr Heath, who was aware of the true position.1044 Heath {Day79/179:10}-{Day79/180:6}.
¶23.31 We accept both David Jones' description of the assurances he was given by LABC about the scope of the work he was expected to carry out and his account of what he was told by Mr Pack and Mr Heath. He acted largely on trust, but was badly let down by LABC and deliberately misled by Kingspan.1045 Jones {Day101/182:25}-{Day101/185:9}. He had expected, as had LABC,1046 Brennan {LABC0020135/26} page 26, paragraph 39.1. that Kingspan would draw attention to any errors or inaccuracies in the draft documents because it would not wish to risk reputational damage from knowingly marketing K15 on the basis of false information.1047 Jones {Day101/171:15-21}. In fact, however, the documents which Kingspan provided1048 BBA Certificate {BBA00000038}; Eighth issue "Kooltherm K15 Rainscreen Board" {KIN00009703}. in support of its application and the statements made in the course of the meeting between Mr Jones, Mr Heath and Mr Pack were intended to mislead.1049 Jones {Day101/183:2-18}. The document Mr Jones issued was, nonetheless, an LABC approval certificate and it remains the case that LABC's second level of checks, on which he had also relied,1050 Jones {Day101/113:4-14}; {Day101/173:2-15}; {Day101/184:21}-{Day101/185:9}. were woefully inadequate.
¶23.32 Mr Jones could not remember whether he had looked at LABC's Type Approval Service Manual,1051 Jones {HBC00000051/4} page 4, paragraph 14; Jones {Day101/166:20}-{Day101/167:10}. but if he did, it is unlikely that he found it to be of great assistance. Although it called for a thorough and comprehensive assessment at a high level, it also said that certificates from authoritative independent third parties, particularly those accredited by UKAS such as the BBA, were likely to indicate an acceptable level of satisfaction.1052 {HBC00000049/17} paragraph 3.3. In the event, Mr Jones did accept the BBA certificate as sufficient evidence of the statements it contained, but he had been told that that was all that was required of him and the truth is that he was neither competent nor qualified to do more.1053 Jones {Day101/39:11}-{Day101/40:5}. It is unlikely that he would have agreed to undertake the work if he had been expected to do otherwise.1054 Jones {Day101/106:19}-{Day101/107:21}; {Day101/196:2-5}.
¶23.33 Although only Kingspan knew it (because it had largely drafted the text),1055 See Chapter 22. the 2008 BBA certificate on which David Jones relied so heavily had also been issued without proper checks having been made and was riddled with fundamental errors and misleading language. To that extent there was, therefore, a fatal flaw in LABC's Type Approval scheme. As a result, Kingspan's initial misleading of the BBA1056 See Chapter 22. combined with the failure of the BBA itself to investigate the properties of K15 with sufficient rigour led to the publication of misleading claims about K15 that were repeated and given additional credibility by the LABC certificate.
113Concerns raised about the LABC Type Approval for K15
¶23.34 The terms of the LABC certificate appear to have caused immediate concern at BRE1057 {BRE00003314}. about "misuse of data" and the broad claims that K15 was suitable for all kinds of applications in all sorts of situations,1058 Colwell {Day233/36:8}-{Day233/38:18}. though it appears that no one there mentioned those concerns to Kingspan.1059 Colwell {Day233/39:2-25}; Smith {Day238/64:17}-{Day238/67:20}. The inclusion in the certificate of misleading statements was brought to LABC's attention by Larry Cody, then a director of Rockwool,1060 Turner {LABC0011202/25} page 25, paragraph 76. Rockwool manufactured non-combustible mineral wool insulation products. who wrote to Barry Turner in September1061 {LABC0000924}. and again in October 20091062 {LABC0000853}. complaining that LABC had stated that K15 could be considered as a material of limited combustibility and pointing to life safety considerations.1063 {LABC0000853}. Mr Turner did not respond until 23 February 2010,1064 {LABC0019632/4}. following a further letter from Mr Cody on 1 February 2010 asking about LABC's complaints policy and Mr Turner's failure to answer his previous letter.1065 {LABC0010318}.
¶23.35 When he did respond to Mr Cody, Mr Turner wrote that he did not consider it a matter for discussion with a competitor, despite the fact that he had already corresponded with Kingspan about the matter.1066 {LABC0019617}. In the same response, he comprehensively defended the terms of LABC's claims, telling Mr Cody that the research authority that had undertaken the assessment of K15 had been satisfied that it met the relevant criteria.1067 {LABC0019618/1}; Turner {Day216/98:10-17}. He did so, he told us, without even checking the terms of the certificate or engaging with the substance of the complaint.1068 Turner {Day216/83:4}-{Day216/84:18}; {Day216/98:18}-{Day216/99:15}. Bizarrely, he told Mr Cody in a further email that LABC neither accepted nor denied claims made by Kingspan about what the certificate stated.1069 {LABC0019632/2}. Mr Turner was unable to explain why he had said that, suggesting only that he might have been trying to protect LABC's involvement.1070 Turner {Day216/102:14}-{Day216/103:2}.
¶23.36 Mr Turner's complete failure to investigate Mr Cody's complaint was irresponsible. Although he said that if he had understood the public safety implications he would have dealt with the matter differently,1071 Turner {Day216/101:4-13}. it is difficult to see how he can have failed to appreciate them, given the clear terms of Mr Cody's letters. We note that Mr Turner's immediate dismissal of the reasoned complaint as nothing but gripes from a rival manufacturer in which LABC should not become a referee1072 Turner {Day216/83:13-20}. was in marked contrast to the tone of his emails1073 {LABC0019617}; Turner {Day216/93:15}-{Day216/95:15}. to John Garbutt, Kingspan's Marketing Director.1074 Garbutt {KIN00024388/1} page 1, paragraph 1.2.
¶23.37 Mr Turner had no satisfactory explanation to offer for LABC's failure to follow its own complaints procedure, claiming that he had been unaware that Mr Cody had mentioned a formal complaint,1075 Turner {Day216/90:22}-{Day216/91:16}. despite having been copied into the email correspondence in which he had done so.1076 {LABC0010318}. Mr Turner also claimed not to have been aware that a formal complaint procedure existed within LABC.1077 Turner {Day216/90:2-4}. As LABC accepted in its closing statement, Mr Cody's concerns were reasonable and Mr Turner's response was inexcusable.1078 LABC Phase 2 Module 6 Closing Submissions {LABC0020161/30} paragraphs 117-118. That was an important early opportunity to correct the fundamental error that had been made. It might not have been missed if Mr Turner had followed LABC's complaints process1079 {HBC00000049/30} paragraph 8.2. when the matter was raised by Mr Cody.1080 {LABC0010318/2}.
114Later LABC Registered Details certificates for K15
¶23.38 Although Kingspan's Type Approval certificate for K15 lapsed in May 2012, it was not renewed until 28 August 2013.1081 {KIN00009546}. The assessment for the second certificate was also carried out by Herefordshire Building Control, on that occasion by Senior Building Control Surveyor Colin Davies1082 Jones {HBC00000029/47} page 47, final paragraph. under the supervision of David Jones.1083 Jones {Day101/186:24}-{Day216/187:15}; {LABC0000893}. The certificate stated in the accompanying Drawings and Documents List, which was drawn up in its final form by LABC,1084 Jones {HBC00000029/48} page 48; that K15 was suitable for use with a variety of outer claddings1085 {KIN00009547/2} Appendix A, paragraph 1. and, wholly incorrectly, that K15 could be used on buildings with stories more than 18 metres above ground level provided it was used in combination with suitably non-combustible substrates and ancillary components.1086 {KIN00009547/2} Appendix A, paragraph 3. It listed as the supporting documents on which it was based1087 {KIN00009547/1}. the Type Approval Summary of May 2009,1088 {KIN00005705/3-6}. the BBA Certificate of October 20081089 {BBA00000038}. and a Kingspan marketing brochure for K15 dated March 2011.1090 Ninth Issue {KIN00003545}. The Drawings and Documents List included two diagrams, one showing K15 used on a steel frame system and the other K15 used with a terracotta rainscreen.1091 {KIN00009547/3}. In August 2013, neither of the systems illustrated nor any similar systems had been tested in accordance with BS 8414. It remained the case that the only system incorporating any form of K15 that had been tested in accordance with BS 8414 and had met the criteria in BR 135 was the one that had been tested in May 2005 using a different formulation of K15.1092 See Chapter 22.
¶23.39 On 1 August 2013 Gareth Mills, a Senior Technical Adviser at Kingspan,1093 Mills {Day77/4:7-10}; {Day77/7:23}-{Day77/8:2}. had provided those diagrams to LABC's Technical Co-ordinator, Cathal Brennan,1094 Brennan {LABC0020135/2-3} pages 2-3, paragraph 7.2. together with a description of the uses for which K15 was suitable to which we have referred.1095 {LABC0000954}. Both the diagrams and the text were incorporated into the final document after the peer review process, which had taken place in June 2013.1096 {LABC0005132}; {LABC0000925}. At that stage the review group had been provided with an amended Type Approval Summary drafted by Mr Davies that had again stated that K15 could be considered a material of limited combustibility.1097 {LABC0000894/3}. Again, no member of the review group had noticed the mistake. David Ewing accepted that peer reviewers should have noticed that there was no test evidence to substantiate that claim.1098 Ewing {Day217/119:5-20}; {Day217/120:5-8}.
115¶23.40 Before agreeing to Mr Mills' proposed amendments, Mr Brennan asked David Ewing and David Jones for their opinions.1099 {LABC0002502/1}. Mr Ewing did not respond, leaving the matter to Mr Jones.1100 Ewing {Day217/165:6-16}. He told Mr Brennan that he saw no problem with the amendments and that he could not see anything in them that was not backed up by the technical data underpinning the certificate.1101 {LABC0000936}. As Mr Jones accepted, that was wrong. It involved a simple perpetuation of the previous error, compounded by the fact that the amendments had not been subjected to the peer review process.1102 Brennan {LABC0020135/29} page 29, paragraph 45.1. Mr Ewing said that it had not been considered necessary to subject the proposed amendments to the peer review process1103 Ewing {Day217/166:5-11}. but accepted, in hindsight, that the statement that K15 was suitable for use on buildings over 18 metres in height was significant and ought to have been reviewed.1104 Ewing {Day217/166:17-24}.
¶23.41 Mr Ewing accepted that the statements made in the 2013 certificate and its accompanying documents had not been substantiated,1105 Ewing {Day217/172:3-9}. that the two diagrams ought not to have been included, since there was no test evidence to support the use of K15 in the manner shown,1106 Ewing {Day217/172:16}-{Day217/173:3}. and that the wording wrongly implied approval of the use of K15 on buildings over 18 metres in height in general.1107 Ewing {Day217/173:5-16}. He said that each of the peer reviewers should have examined the BBA certificate or the relevant technical information to see whether it supported the statements made in the certificate but accepted that they would not have been expected to go behind them and check the test results.1108 Ewing {Day217/156:3}-{Day217/157:5}. The Registered Details process,1109 As with the Type Approval scheme, a Registered Details certificate was intended to be recognised by all local authority building control departments across England and Wales {HBC00000023/3}; Ewing {Day217/124:4-23}. The same principles applied as had applied to the Type Approval scheme, Turner {Day216/32:22}. according to the Registered Details Manual,1110 {HBC00000023}. relied just as heavily (if not more so) on the existence and accuracy of BBA certificates1111 {HBC00000023/19} third paragraph "... a BBA certificate does provide absolute assurance and materials should not then be interrogated further". {LABC0002402/1} "Most of these already have BBA certification which should greatly reduce you (sic) checking time". and was therefore as flawed as the Type Approval Scheme before it. However, Mr Ewing accepted that the statements made in the 2013 certificate went beyond those made in the 2008 BBA certificate.1112 Ewing {Day217/177:15-20}. The same was true of the statements made in the 2009 certificate.
¶23.42 On 2 July 2014 Brian Martin of DCLG sent NHBC what he described as a "friendly warning" about the use of K15 on buildings over 18 metres in height,1113 {LABC0000882/3}. which Steven Evans of NHBC passed on to Barry Turner on 11 July 2014.1114 {LABC0000882/1}. Mr Ewing understood that the revised BBA certificate for K15 was more restricted than the previous version and that LABC needed to take steps to ensure that its own certificate was consistent with the testing undertaken by Kingspan.1115 Ewing {Day217/181:22}-{Day217/182:7}. That was not done, but by August 2014, therefore, it had become clear to LABC that people were worried by the fact that Kingspan's test evidence did not appear to substantiate the claims being made about the suitability of K15 for use at height.1116 {LABC0000882/3} first paragraph "... it is just the fact that the testing carried out to date does not bear this out". Mr Ewing was aware that there was a risk to buildings on which K15 had been used but had not realised that it might be significant.1117 Ewing {Day217/183:3-22}.
116¶23.43 LABC did not take any steps to correct the false impression created by the previous certificate and never asked itself whether as a result of that certificate there might be a number of tall buildings containing combustible cladding.1118 Ewing {Day217/190:3-9}. Although Mr Ewing knew that the Registered Details certificate would need to be amended following the discovery that Kingspan did not have test evidence to support the use of K15 at height, it does not appear to have occurred to him that people might have relied on the previous LABC certificate to approve its use in those situations.1119 Ewing {Day217/187:4-10}. In our view LABC should at least have drawn its members' attention to the almost complete absence of test data supporting the use of K15 on buildings over 18 metres in height.
¶23.44 Similarly, LABC failed to take any action in response to an email sent on 16 July 2014 by Clive Everett of Europa Façade Consultants in which he asked how the Registered Details certificate for K15 could state that it was suitable for use on buildings over 18 metres in height with a steel frame if it had not been part of a system tested in accordance with BS 8414-2.1120 {LABC0000835}. Mr Ewing acknowledged that the question was similar to others LABC had heard about through NHBC.1121 Ewing {Day217/192:25}-{Day217/193:5}. Mr Ewing did not respond to Mr Everett's email.1122 Everett {CEV00000001/13} page 13, paragraph 51. He said that he had wanted to wait until he knew what steps LABC was going to take, but that it had then been overlooked.1123 Ewing {Day217/193:12-22}.
¶23.45 LABC had no evidence that any system incorporating K15 had been tested in accordance with BS 8414-2 because there was none. On 6 August 2014, Doug Basen, LABC's Head of Technical, Practice and Communications1124 Basen {LABC0020141/5} page 15, paragraphs 7.1-7.2. sent Mr Ewing an email drawing his attention to a message that he had sent to Mr Turner in which he had said that he had spoken to Mr Evans at NHBC who did not believe that Kingspan would be able to prove that K15 was acceptable across a range of construction types. Mr Basen expressed his fear that there might be many buildings incorporating K15 which did not meet the very restrictive requirement of a masonry substrate. In response, Mr Ewing said that he had been told by Kingspan at a meeting on 25 July 2014 that "testing to BS 8414 had been undertaken in line with the requirements of BR 135 for materials of limited combustibility" but that LABC had not yet been provided with the test results. Mr Ewing also told Mr Basen that he was in the course of providing Kingspan with a quotation for certificates for up to 30 other Kingspan products and that he was keen to get its custom.1125 {LABC0002690}.
¶23.46 In spite of the continuing absence of relevant test evidence, LABC's existing Registered Details certificate for K15 was extended throughout the autumn of 2014.1126 {LABC0002679}; {LABC0002700}; {LABC0002701}; {LABC0001843}; {NHB00000798}. Mr Ewing said that although that might now appear to have been foolhardy, at the time he had genuinely believed that Kingspan was seeking to co-operate with LABC by producing the relevant reports.1127 Ewing {Day218/5:8-23}. He had had no reason to think that Kingspan was being anything other than honest.1128 Ewing {Day218/6:4-7}. Mr Ewing accepted that there was a clear failure on his part to notice the inaccuracies in the certificate.1129 Ewing {Day218/7:1-15}. He could not explain why LABC had issued a certificate approving the use of a product in a configuration for which there was no supporting test evidence.1130 Ewing {Day218/10:9-17}. He accepted that by extending the certificate in that way LABC had been treating Kingspan preferentially.1131 Ewing {Day218/50:11-17}.
117¶23.47 Although from 2015 the Registered Details Certificates did not include the statement that K15 could be considered a material of limited combustibility,1132 EWW165 Certificate 9 March 2015-9 March 2016 {LABC0000855}; EWWS165 Certificate 24 March 2016-30 March 2019 {LABC0000971}. Mr Turner was well wide of the mark when on 16 February 2015 he congratulated Mr Ewing on having scrutinised the application thoroughly.1133 {LABC0005823/1}. The certificate issued on 9 March 2015 stated that K15 had been tested to comply with BR 135 for use in rain screen applications above 18 metres in height1134 {LABC0000855/1}. as did the certificate issued on 24 March 2016.1135 {LABC0000971/1}. That statement, which Mr Turner himself had drafted,1136 {LABC0000863/1}; Turner {Day217/26:1}-{Day217/27:7}. was another serious misrepresentation of the position. BS 8414 was a system test, not a product test and therefore no single component of a system tested in accordance with that method could "comply" with the criteria in BR 135. In the light of the messages that had been flying around over the previous year or so, LABC should have been well aware of that. Mr Turner said that it was unlikely that he had read BR 135 before drafting that wording.1137 Turner {Day217/28:19}-{Day217/29:14}. In any event, by March 2015, much of the damage had been done given that the certificate had been in circulation since 2009.
¶23.48 Although we accept that many of the various internal LABC emails relating to competitive pricing, bonuses and a desire to establish and maintain strong links with Kingspan1138 {LABC0002402/1}; {LABC0002021/1}; {LABC0008243/1}; {LABC0002686/1}; {LABC0008505/1}; {LABC0008506}; {LABC0002827}; {LABC0002819}. contain comments that may have been made purely in jest,1139 Taylor {LABC0020153/60} page 60, paragraph 47.23; Ewing {Day218/22:6}-{Day218/23:15}. they make it clear that raising the profile of the LABC brand was very much in the minds of various employees throughout the certification of K15. In December 2014, Mr Brennan expressed concern about losing Kingspan's business as a result of the delay in issuing a certificate1140 {LABC0002819}; {LABC0002827}. after Ivor Meredith1141 Ball {KIN00020704/3} page 3, paragraph 2.5. Technical Projects Leader from May 2014 onwards. of Kingspan had warned him that it might be difficult to obtain approval for the business if it were not issued soon.1142 {LABC0002819}. Mr Ewing said that LABC had not responded to what he saw as a threat, but accepted that it reflected well on LABC to be asked to certify Kingspan's products.1143 Ewing {Day218/17:5-19}. There was evidence from another LABC employee, Martin Taylor,1144 Taylor {LABC0020153/5} page 5, paragraph 12.1. Registered Details Manager from April 2011 to September 2012 and Technical Development Business Director from May 2015. that there was some internal pressure to increase the number of registrations.1145 Taylor {LABC0020153/60} page 60, paragraph 47.23.
118¶23.49 By January 2015, Cathal Brennan had come to regard with scepticism some of Kingspan's promises about repeat business and the certification of other Kingspan products.1146 {LABC0002852/6-7}. He was under the impression that Kingspan was trying to use the prospect of a larger order to persuade LABC to accept its proposed wording in the re-issued certificate for K15.1147 Brennan {LABC0020135/48} page 48, paragraph 93.1. He regarded that as typical behaviour on the part of Kingspan.1148 Brennan {LABC0020135/31} page 31, paragraph 50.2; Stimpson {LABC0020158/61} page 61, paragraph 101.2.
119Chapter 24: Celotex RS5000 insulation
Introduction
¶24.1 The insulation used in the cladding system at Grenfell Tower was for the most part Celotex RS5000, a polyisocyanurate (PIR) thermosetting foam product. It was not a material of limited combustibility and was therefore not capable of conforming to the guidance on the construction of external walls contained in paragraph 12.7 of Approved Document B. However, RS5000 was said by Celotex to have been tested in accordance with BS 8414‑2 in May 2014 and to have met the criteria in BR 135, thereby conforming to the guidance contained in paragraph 12.5 of Approved Document B. RS5000 was launched in August 2014. It was marketed by Celotex as "the first PIR board to successfully test to BS 8414",1149 {CEL00000012}. and as "acceptable for use in buildings above 18 metres in height".1150 {CEL00000013}. In fact, however, the test on which Celotex relied as support for that claim had been rigged by the inclusion at critical points in the construction of the system under test of fire-resistant magnesium oxide boards. Needless to say, Celotex concealed the manipulation of the test in its marketing. Moreover, BS 8414 and BR 135 did not provide for the testing and classification of individual products; they applied only to a complete system, which, if it met the criteria in BR 135, could be regarded as suitable for use in buildings over 18 metres in height. Celotex deliberately tucked that information away in the small print of its marketing literature where it was unlikely to be spotted. This part of the report describes the development and testing of RS5000 and explains what led Celotex to market its new product in a dishonest way.
Background
Key personnel and management
¶24.2 At the relevant time, the management team within Celotex was known as the management action group.1151 O'Sullivan {CEL00010027/72-73} pages 72-73, paragraph 217. It was the senior day-to-day decision-making body within Celotex.1152 Evans {Day72/64:3-5}. Paul Evans (Celotex's head of marketing from 2013 to 2018,1153 Evans {CEL00010058/6} page 6, paragraph 18. and Jonathan Roper's line manager) was a member of the management action group, as were Craig Chambers and Dean O'Sullivan (managing directors of Celotex from 2013 to 2016 and from 2016 respectively). Other management bodies included the product life cycle and planning meeting, whose function was to discuss new ideas for products and projects.1154 Warren {CEL00010043/8} page 8, paragraph 29. From May 2013, it was replaced by the Service Product Innovation Group.1155 Warren {CEL00010043/8} page 8,paragraph 30.
¶24.3 The dishonest and cynical way in which RS5000 was tested and marketed reflected a culture within Celotex stretching back to at least 2009. There are a number of striking aspects of that history that deserve examination.
120The acquisition by Saint-Gobain
¶24.4 Celotex was originally owned by AAC Capital Partners, the private equity arm of ABN Amro. In August 2012 it was acquired with effect from 31 December 2015 by BPB UK Ltd, subsequently re-named Saint-Gobain Construction Products UK Ltd.1156 O'Sullivan {CEL00010027/3} page 3, paragraph 9. The corporate culture of Celotex before its acquisition had been marked by a drive to create profits and increase the company's share price with a view to a sale,1157 Hayes {CEL00010154/6} page 6, paragraph 17; Hayes {Day74/30:9-15}; Evans {Day72/67:20-23}. and that continued to be its focus after the sale to Saint-Gobain.1158 Hayes {CEL00010154/6} page 6, paragraph 17; Evans {Day72/68:1-3}. As a consequence of the focus on sales, budgets and the business generally were very lean.1159 Evans {CEL00010058/5} page 5, paragraph 15. Following the acquisition, Saint-Gobain set an annual budget for increasing profits, of which at least 15% was expected to come from new products.1160 Hayes {CEL00010154/6} page 6, paragraph 17; Roper {Day70/124:11-16}.
Lambda values
¶24.5 As explained elsewhere,1161 Chapter 56. the lambda value of a material represents its thermal conductivity expressed in watts per metre kelvin (W/mK). The lower the lambda value, the better the performance of the product as an insulator. The relevant European and national harmonised standard applicable to PIR products is the standard for rigid polyurethane foam building products, BS EN 13165.1162 {CEL00001204/10} paragraph 3.1.1. It requires a manufacturer to declare the lambda value of a product as a limit value representing at least 90% of its production with a confidence value of 90%.1163 {CEL00001204/14} paragraph 4.2.1. The duty of ensuring conformity with the standard rests on the manufacturer, based on tests carried out at the factory.1164 {CEL00001204/24} paragraph 7.1. The standard requires the product to be tested at least once every 24 hours.1165 {CEL00001204/25} paragraph 7.3 read with Annex B; {CEL00001204/28}. It may be tested more often, but there is nothing in the standard to suggest that if the product is tested more than once every twenty four hours it is permissible to select from among the results thus obtained.
¶24.6 As well as a culture of maximising profits, there had been a history within Celotex of data manipulation and dissimulation. At least as early as 2009, it had adopted a practice of taking a number of measurements each day of the lambda value of its products and selecting for the purposes of the standards (and ultimately, of course, for the purposes of marketing) the most favourable measurement without declaring the rest.1166 {CEL00010498}. There was a drive within Celotex to produce products with a lower declared lambda value, both as a way of differentiating them from other PIR products on the market and as a way of competing with Kingspan in the market for insulation on buildings.1167 Hayes {Day74/34:3-24}; Evans {CEL00012233/2} page 2, paragraphs 10-11.
¶24.7 Even within Celotex there was an awareness at the time that the selection of data in that way1168 Evans {Day72/71:7-9}. was questionable. An internal memorandum dated 9 December 2009 described the process as involving a high degree of data management and manipulation in order to "avoid an auditor finding evidence that thermals are selected to give [a set lambda value] rather than recording the results regardless of their value".1169 {CEL00010272/1}. Not only did Celotex actively seek to conceal that practice from the British Board of Agrément (BBA), its auditors for this purpose,1170 Evans {Day72/74:17-21}; {CEL00010456}. but it also appears that the practice was not disclosed to Saint-Gobain during the acquisition and was mentioned only at a management action group meeting in November 2013.1171 {CEL00010286/2}.
121¶24.8 The lambda story is revealing. First, it is indicative of a culture in which breaking the rules and misleading external bodies was tolerated long before the advent of RS5000. It demonstrates an historic inability or unwillingness to challenge the honesty and good faith of company practices.1172 Evans {Day72/83:3-4}; Evans {Day72/83:10-14}. Second, it shows the malign influence of the competition with Kingspan: Paul Evans explained that the drive to create a product with an improved lambda value was a response to a similar development by Kingspan.1173 Evans {CEL00012233/2} page 2, paragraphs 10-11.
The change of polyol
¶24.9 A further indication of the nature of the culture at Celotex relates to FR5000 itself. FR5000 was made on two manufacturing lines, known as Hipchen and Henneke. Products manufactured on the Hipchen line were reinforced with glass fibre. Those manufactured on the Henneke line were not.1174 O'Sullivan {CEL00010027/12} page 12, paragraph 41. The products were manufactured using a polymer resin, which was mixed with a polyol and various additives before the mix was allowed to rise on the production line before being cut into shape.
¶24.10 In August 2012, Celotex changed the polyol used on the Hipchen line from ElastoPIR 501 to ElastoPIR 503. ElastoPIR 501 continued to be used on the Hennecke line.1175 {CEL00009889}. No thought appears to have been given to whether the change in formulation might affect the fire performance. Although the BBA expressly warned Celotex that it should tell it about any change in the formulation of the product, Celotex failed to do so,1176 {CEL00009516}. thereby withholding potentially material technical data.1177 Evans {Day72/93:14-17}.
The development of RS5000
Genesis of the "above 18m project": 2008-2012
¶24.11 Celotex had manufactured and marketed FR5000 for some years before 2012.1178 {CEL00000723}. It was not a material of limited combustibility and therefore could not be used in the construction of an external wall of a building over 18 metres in height by anyone who wished to follow the guidance in paragraph 12.7 of Approved Document B. Nor had it been incorporated in a system that had been tested in accordance with BS 8414 and had satisfied the performance criteria in BR 135. That was all well known within Celotex.1179 Roper {Day70/139:13-21}; Hayes {Day74/37:7-12}.
¶24.12 In November 2011, FR5000 was tested in accordance with BS 476-6 and BS 467-7 and achieved a Class 0 classification.1180 {CEL00000382}. Thereafter, Celotex marketed FR5000 as having Class 0 fire performance "throughout". The reference to Class 0 was no more than a marketing device;1181 Hayes {Day74/35:10-17}. for reasons we explain later, Class 0 had come to be understood by many in the UK construction industry as meaning that a product could be used on buildings over 18 metres in height in compliance with the Building Regulations. Kingspan was marketing its phenolic foam products in that way, and achieving Class 0 fire performance was seen as a way of demonstrating that FR5000 was as good as Kingspan's K15.1182 Evans {Day72/108:2-5}; Hayes {Day74/34:13}-{Day74/35:17}. The description of it as being Class 0 "throughout"' was intended to enable it to challenge K15, which was being marketed as having a Class 0 core.1183 Hayes {Day74/36:1-8}.
122¶24.13 That was a clear abuse of the regulatory regime. The expression "Class 0 throughout" was meaningless because Class 0 is concerned with the reaction to fire of the material forming the surface of a product. It is not concerned with the underlying material, although a product which is composed entirely of a material of limited combustibility will have a Class 0 surface (see Chapter 5). To market FR5000 as "Class 0 throughout" was not only false (because the product was combustible) but can only have been designed to mislead buyers with a poor understanding of fire classification standards. Regrettably, Celotex clearly knew that many potential customers were ignorant and credulous in relation to matters of fire safety. Its marketing of FR5000 in that way laid the ground for the more fundamental mis‑selling that was to follow with RS5000.
¶24.14 Celotex had considered developing a product for use on buildings over 18 metres in height in 2008, but had decided not to do so because the cost of testing was thought to be too high.1184 Warren {CEL00010043/8} page 8, paragraphs 31-32. By 2011, however, it had become aware that it was losing sales as a result of not having a product which could be used on high-rise buildings in accordance with the guidance in Approved Document B.1185 Warren {CEL00010043/9} page 9, paragraph 33. On 19 October 2011, Robert Warren (then a technical manager, but from 1 May 2013 head of technical)1186 Warren {CEL00010043/2} page 2, paragraph 8. sent a number of colleagues an email he had received from Adrian Friar, a specification manager at Celotex, asking them to track all enquiries it had received for insulation to be used on buildings over 18 metres in height.1187 {CEL00008564}.
¶24.15 By August 2012, the tracker was being maintained by Paul Evans.1188 {CEL00008570}. There was concern that market share was being lost to competitors and that unless action was taken soon the market for insulation suitable for use on buildings over 18 metres in height would be controlled by other manufacturers, particularly Kingspan.1189 {CEL00002892}. Mr Roper, who subsequently led the project to develop what eventually became RS5000, understood that the project was driven by a desire to compete with Kingspan in that section of the market.1190 Roper {Day70/120:10-14}.
Allocation to Jonathan Roper: 2012-2013
¶24.16 On 15 December 2012, Paul Evans, then a product manager at Celotex, met Tony Baker of BRE with a view to discussing the requirements for testing PIR insulation boards for use in external walls of buildings over 18 metres in height.1191 Evans {Day72/96:14-16}; {CEL00002544}. They discussed both the BS 8414-1 and BS 8414-2 test methods, as well as the fact that the results would have to be classified according to BR 135.1192 {CEL00002544}.
123¶24.17 Paul Evans then assigned the task of carrying forward the project to Jonathan Roper.1193 Evans {Day71/117:15-23}. Mr Roper had joined Celotex in May 2012 straight from university,1194 Roper {CEL00010052/2} page 2, paragraph 2.1. having graduated with a degree in business management.1195 Roper {Day70/110:4-10}. He had no previous experience of the insulation industry and had no relevant scientific qualifications.1196 Roper {Day70/110:13-17}. Mr Roper told us that he had been closely managed by Mr Evans,1197 Roper {CEL00010052/2-3} pages 2-3, paragraph 2.4. and that he had not done anything or said anything, at least publicly, without Mr Evans' approval.1198 Roper {Day70/112:9-11}. Mr Roper's experience, as described to us, was echoed by Jamie Hayes, a colleague of Mr Roper, who said that Mr Roper had run everything past Mr Evans.1199 Hayes {Day74/44:6-9}. Mr Evans himself accepted that he had followed what Mr Roper was doing closely.1200 Evans {Day72/120:18-25}. Given Mr Roper's relative youth and inexperience, it would be surprising if he had not been subject to a high degree of supervision.
¶24.18 Despite his relative youth and inexperience, however, or perhaps because of it, Mr Roper was given the job of developing an insulation product which could be sold for use on buildings over 18 metres in height. Completion of the project was one of his formal goals for 2013.1201 {CEL00002900}. Mr Roper stood to gain a financial benefit from achieving that goal, since gaining accreditation for FR5000 was worth 20% of his potential bonus.1202 Evans {Day72/123:23-25}. However, his own understanding was that performance indicators were primarily used to create a focus on key areas for the business and we do not think that he was motivated primarily by the prospect of a bonus.1203 Roper {Day70/113:2-8}.
¶24.19 In an introductory briefing,1204 Roper {Day70/140:20}-{Day70/141:3}. Paul Evans and Robert Warren told Mr Roper that since PIR foam was not a product of limited combustibility, the only way that Celotex could satisfy the criteria in paragraph 12.5 of Approved Document B was to be tested in a system that met the performance criteria of BR 135 following a BS 8414 test.1205 Roper {Day70/140:13-18}. In March 2013, Mr Roper prepared a paper entitled "Above 18m Action Plan",1206 {CEL00001340} in which he set out the steps required to obtain accreditation for FR5000 for use on buildings over 18 metres in height. He noted that the records showed that between August 2012 and January 2013 Celotex had lost the opportunity of selling 70,000m² of insulation as the result of not having a product that could meet that requirement.
¶24.20 Mr Roper embarked on a programme of research, reporting the results to Paul Evans. He was assisted by Mr Hayes, a member of the Technical Support team,1207 Hayes {Day74/46:19-22}. who did not himself have any technical expertise or qualifications.1208 Hayes {Day 74/5:10-14}. As recorded in the Action Plan,1209 {CEL00001340/2}. it involved looking at the recently published third edition of BR 135, which he obtained and sent to both Mr Warren and Mr Hayes.1210 {CEL00011493}. He noted the criteria and although he did not read the whole document,1211 Roper {Day70/131:18}-{Day70/132:3}. he understood that it applied only to complete systems.1212 Roper {Day70/143:6-14}. He was also aware that any classification obtained under BR 135 applied only to the system tested.1213 {CEL00000584/33}; Roper {Day70/145:5-25}. As part of his research he and Mr Hayes also looked at Kingspan's publicly available marketing material.1214 Hayes {CEL00010154//12} page 12, paragraphs 36-37.
124June 2013: business case
¶24.21 On 17 June 20131215 {CEL00001856}. Mr Roper sent Mr Evans a project plan1216 {CEL00001857}. and business case1217 {CEL00001858}. for Celotex to undertake BS 8414 testing. The business case reiterated the point made in the earlier Action Plan that the lack of a product that was suitable for use on buildings over 18 metres in height was one of the main areas in which Celotex was unable to compete with Kingspan.
Celotex's investigations during 2013
¶24.22 In order to improve his understanding of testing under BS 8414 and classification in accordance with BR 135, Mr Roper obtained assistance from a number of external bodies. Some (NHBC, the BBA and BRE) were introduced to him by Mr Evans;1218 Roper {Day70/132:17-23}. others he found for himself.
Sotech and IFC: June to October 2013
¶24.23 Celotex sought advice on how to design a test rig in order to give it the best chance of a favourable result.1219 Roper {Day71/15:17-19}. On 10 May 2013 Mr Roper contacted a firm of consultants, International Fire Consultants, seeking advice and explaining that Celotex wanted to design a wall incorporating FR5000 which would have the best chance of succeeding in a full-scale test.1220 {CEL00000589}.
¶24.24 Mr Roper also sought assistance from Sotech Ltd, a designer and manufacturer of cladding with previous experience of the BS 8414 test that he had come across at a RIBA event in June 2013. By that time Sotech had already been involved in two BS 8414 tests using Kingspan insulation, each of which, Mr Roper was told, had failed.1221 {CEL00001851}. On 20 June 2013, Mr Roper and Mr Hayes met Sotech to discuss testing. A note of the meeting dated 24 June 2013 records that Sotech's previous experience of testing had shown that aluminium railing systems and cladding panels melted and allowed fire to enter the cavity, and that therefore what had proved crucial was the resistance to fire of the outer surface and the performance of the fire barriers.1222 {CEL00001863/1}. Mr Roper said that he had understood from the meeting that the success of a BS 8414 test may depend on the cladding material used.1223 Roper {Day71/5:2-4}. They also discussed K15 and Sotech expressed surprise that K15 was used so widely based only on a single test involving the use of a cement particle board to represent a typical cladding panel.1224 {CEL00001863/1}. Both Celotex and Sotech considered the Kingspan test to be unrepresentative,1225 Roper {Day71/7:2-10}. and thought that Kingspan had taken advantage of what they regarded as a carefully worded certificate from the BBA and cleverly designed marketing literature.1226 {CEL00001863/1}.
125¶24.25 Mr Roper sent his note to Mr Evans on 24 June 2013.1227 {CEL00001865}. In response Mr Evans indicated that his preference at that stage was to test a commonly used cladding panel rather than simply copying Kingspan's use of a cement particle board.1228 {CEL00001865}. International Fire Consultants advised that it should be possible to test with a standard cladding panel using improved fire barriers.1229 {CEL00001864}.
¶24.26 Mr Roper then arranged a meeting with Peter Jackman, the technical director of International Fire Consultants, on 22 July 2013.1230 {CEL00000632}. Mr Roper could not recall what had been said at that meeting,1231 Roper {Day71/16:21-23}. but according to the handwritten notes taken by Robert Warren he was told that Approved Document B only contains guidance and was open to "interpretation".1232 {CEL00002743}. We understand that to mean that Mr Jackman thought there were ways of interpreting Approved Document B that would render the guidance less restrictive. For his part, Jamie Hayes recalled a meeting with International Fire Consultants (specifically Peter Jackman and Dr Parina Patel), although he could not recall when it had taken place. He did remember that they had told him and Mr Roper that it might be possible to obtain a field of application report, in other words, to carry out a BS 8414 test and, using the results obtained from it, produce a report which was wider in its scope of application and cover the use of some components other than those used in the test rig.1233 Hayes {Day74/72:13-17}. That reflects the view of some in the industry at the time that "desktop" assessments based on test data were a permissible way of broadening the range of components that could be used in external walls while satisfying Approved Document B.1234 See Chapter 26, and the note of the meeting on 15 November 2013 between Wintech and NHBC at {NHB00000604}.
¶24.27 Celotex then commissioned International Fire Consultants to conduct small-scale testing with a view to giving an opinion on the likelihood of meeting the criteria in BR 135 if they were to test FR5000 under BS 8414.1235 {CEL00000669}; {CEL00000670}. On 4 September 2013, Mr Jackman confirmed that he had reviewed BS 476-6 and BS 476-7 test data for FR5000 and concluded that there were grounds for thinking that FR5000 would perform well in a BS 8414 test.1236 {CEL00000673}. It is unclear on what basis he thought that it was possible to draw that conclusion from BS 476 data, but Celotex did not explore that question with him. On 24 September 2013 Celotex engaged International Fire Consultants to assist in the design of BS 8414 tests, having decided by that stage to test only to BS 8414-2 (i.e. a steel-framed construction).1237 {CEL00000679}. On 27 September 2013 David Cooper of International Fire Consultants acknowledged the proposal, commenting that the "fire barrier" at storey levels and around the opening would be critical.1238 {CEL00000688}.
126¶24.28 On 3 October 2013, Mr Roper and Mr Hayes met representatives of International Fire Consultants and Sotech.1239 {CEL00011052}. Mr Hayes' note of that meeting referred to tests using Kingspan insulation having failed twice with standard cavity barriers.1240 {CEL00001195}. Mr Hayes also recalled (although it was not mentioned in the note) that there had been discussion of those tests.1241 Hayes {Day74/80:18-23}. Mr Hayes and Mr Roper both told us that following the meeting they had both been aware that, if tested with an aluminium panel, FR5000 was unlikely to pass a BS 8414 test.1242 Roper {Day70/194:2-3}; Hayes {Day74/80:24}-{Day74/81:2}.
¶24.29 On 31 October 2013 Mr Roper sent International Fire Consultants details of two European Class A2 products he had found during his researches, namely Alucobond A2 and Marley Eternit.1243 {CEL00000714}. He explained that he saw three options for testing: a. test with an ACM panel and an improved cavity barrier system (e.g. with the double
cavity barrier discussed at the meeting on 3 October),1244 Roper {Day71/24:12-16}. although he was not particularly confident in that system following the meeting with International Fire Consultants and Sotech;1245 Roper {Day71/24:9-10}.
¶b. test with an A2 panel and standard cavity barrier, which he noted was a common system which Celotex could support if challenged; and
¶c. test using a cement particle board as the rainscreen, as he understood Kingspan had done, which he viewed as a last resort
¶24.30 Mr Roper's preference was to test using an A2 panel with standard cavity barriers, but he observed that if this failed then it would be necessary to decide whether Celotex would then want to adopt Kingspan's method or pull out altogether.1246 {CEL00000714}. What he meant by adopting Kingspan's method can be seen from what Celotex chose to do later.
Discussions with BRE: May and October 2013
¶24.31 In May 2013, Jonathan Roper asked Tony Baker of BRE which of the BS 8414 tests Celotex should be considering.1247 {CEL00000585/2}. Mr Baker advised testing under BS 8414-2, adding that obtaining the classification was likely to be commercially advantageous to Celotex.1248 {CEL00000585/2}. Mr Roper contacted Mr Baker again on 21 June 2013, asking to arrange a call with him about the purpose of testing. He said that he was sceptical of how a particular competitor of Celotex (clearly a reference to Kingspan) could have satisfied the criteria in BR 135.1249 {CEL00000617}. Mr Roper went on to ask Mr Baker for advice about designing the test and whether preventing the flame from entering the cavity altogether would be acceptable,1250 {CEL00000617}. but he could not recall having received any response to his message.1251 Roper {Day70/170:19-21}.
127¶24.32 On 18 October 2014, Mr Roper asked Stephen Howard of BRE about the possibility of extending the use of FR5000 to external wall systems similar to one that had been tested successfully under BS 8414.1252 {CEL00000708/3}. He again mentioned his concern about how the market was operating, asking how it was possible for competitors who had tested one particular system to sell its products into a variety of different systems used on buildings over 18 metres in height.1253 {CEL00000708/3}. Mr Roper confirmed to us that he was referring to Kingspan and Xtratherm (the only other company that offered a product for use on buildings over 18 metres in height at that time).1254 Roper {Day70/174:22-25}. He told us that the origin of his question lay in a controversy within Celotex between individuals, some of whom viewed BS 8414 as a system test and some of whom viewed it as what he called a "product in application" test.1255 Roper {Day70/171:16}-{Day70/172:2}. He put himself, Jamie Hayes and Robert Warren in the former category, and Paul Evans, Craig Chambers and the sales team in the latter,1256 Roper {Day70/172:13-25}. which he saw as a commercial view based on Kingspan's approach.1257 Roper {Day70/163:21-24}. The "commercial view" was not a tenable reading of the guidance in Approved Document B, not least since the third edition of BR 135 published earlier in 2013 had made it plain that the classification applied only to the system as tested and described in the classification report.1258 {BRE00005555/28} at A2, left column and {BRE00005555/32} at B2 right column. It followed that the classification could not apply to a single product forming part of the system tested when it was used in a different system.
¶24.33 Mr Howard responded a few days later on 21 October 2013, saying that the test report would set out exactly what had been tested, and that the way to extend it to other systems was by what he called an "assessment report", which he described as "fairly standard practice".1259 {CEL00000708/2}. Mr Roper understood him to mean that if he gave BRE details of a particular system they would be able to tell him whether it might pass a BS 8414 test.1260 Roper {Day70/176:8-16}.
The Roper-Evans exchange: 1 November 2013
¶24.34 At the end of October and early November 2013, there was an important internal exchange between Jonathan Roper and Paul Evans. On 31 October 2013, Mr Roper sent a message to Mr Evans saying he needed to speak to him about the "Above 18m" project, and that he would send an invitation to Mr Evans, Mr Warren, Mr Hayes and Mr Chambers because they had reached a point at which a decision had to be made.1261 {CEL00000716/2}.
¶24.35 The following day, 1 November 2013, Mr Roper sent another message to Mr Evans setting out the matters for discussion.1262 {CEL00000716/1}. He explained that they had originally contemplated testing what they regarded as a "worst case scenario with improved fire barrier" (i.e. using a less fire-resistant panel) that could then be supported by an assessment report which would extend the scope of application. However, he no longer thought that could be done because it was not possible, as he put it, "to find or design a suitable barrier in which we have enough confidence that it can be used behind a standard ACM panel which we know will melt and allow fire into the cavity." His comments about how an ACM panel would perform in a full-scale test tells us much about how well known its poor fire performance was at the time, at least among manufacturers of insulation.
128¶24.36 In his email Mr Roper made a number of important observations about the poor level of understanding in the market of the guidance in Approved Document B and how Kingspan had taken advantage of it. He doubted that Kingspan had a report which would support the use of K15 on buildings over 18 metres in height. His view was that it was being used in those circumstances because of widespread ignorance in the market, including among architects, about the applicable requirements1263 Roper {Day71/35:18-24}. and a failure to think about fire performance as opposed to thermal performance.1264 Roper {Day71/36:5-6}; {Day71/36:22}-{Day71/37:1}. He thought that the only person who might possibly challenge a product's use on buildings over 18 metres in height was the building control officer1265 {CEL00000716/1}. and that Kingspan had effectively neutralised that risk through the wording of their BBA and Local Authority Building Control (LABC) certificates.
¶24.37 The timing of his observations is uncanny. They were made exactly at the time that Kingspan was using a BBA certificate revised in July 2013 to claim that K15 complied with paragraph 12.7 of Approved Document B (i.e. that it was a material of limited combustibility), a statement that was not only self-evidently incorrect but which was causing concern at NHBC.1266 See Chapter 26. It seems that Mr Roper had tapped into a growing awareness in the cladding industry that Kingspan was taking advantage of an erroneous BBA certificate for K15, thereby mis-selling it.
¶24.38 Mr Roper concluded his report to Mr Evans with words that were as prescient as they were frank: "Trying to do the right thing requires a complete re-education of the market and this would require a huge campaign and probably a lawsuit". He told us that by "doing the right thing" he had meant selling a product that had been part of a system that had met the performance criteria in BR 135 for use only in a system which was the same as that tested, and not exploiting market ignorance in a commercially more advantageous way.1267 Roper {Day71/37:24}-{Day71/38:5}. He explained that the reason he considered re-education of the market would be necessary was because he considered it to have been distorted by Kingspan. Doing things in the right way would mean explaining to specifiers that they had been using Kingspan K15 inappropriately.1268 Roper {Day71/38:10-19}.
¶24.39 His report to Mr Evans then proceeded to set out various options: testing with an A2 panel, adopting Kingspan's device of using a cement particle board, or taking the view that, as he put it, "realistically our product shouldn't be used behind most cladding panels because in the event of a fire it will burn".
¶24.40 Mr Evans responded the same day 1 November 2013. His words are, again, worth quoting: "Great summary and shows the real merit of good research and talking to the market. We are trying not to create a 'me too' here but if we do, it will be for the right reasons".1269 {CEL00000718}. Mr Evans was unable to recall what he had meant by "the right reasons".1270 Evans {Day72/166:11-15}. Mr Roper said that he had understood "the right reasons" to be commercial reasons.1271 Roper {Day71/44:5-15}. We accept his evidence and agree that that is indeed what Mr Evans meant. Mr Evans asked Mr Roper to put the contents of his email into some slides for discussion at the meeting scheduled for 4 November 2013.
129¶24.41 It is clear that by the end of 2013, Celotex had begun to come to terms with the idea that it might follow Kingspan's lead in relation to the testing and marketing of an insulation product for use on buildings over 18 metres in height. Mr Roper's preference was still to test a system incorporating an A2 rainscreen panel rather than a cement particle board. He understood that to reflect a preference within Celotex as a whole to test a more representative system.1272 Roper {Day71/25:4-7}. However, the use of a cement particle board had not been entirely ruled out.1273 Roper {Day71/11:4-16}. There remained a general desire within Celotex to enter the market for buildings over 18 metres in height in any event and if copying Kingspan was the only way of obtaining a test result that would enable it to do so, it would act accordingly.1274 Roper {Day71/25:20-25}. In the end, Celotex did indeed adopt the same strategy as Kingspan. It neither tested a representative system nor was truthful in its marketing literature.
4 November 2013 meeting – the 5 options
¶24.42 On 4 November 2013, Mr Roper met Mr Evans, Mr Hayes and Mr Warren. The electronic invitation suggests that Craig Chambers, then managing director of Celotex, was also invited.1275 {CEL00003011}. Mr Roper,1276 Roper {Day71/52:15-23}. Mr Roper's witness statement to the effect that he himself had not attended this meeting was corrected by him in oral evidence. Mr Hayes1277 Hayes {Day74/46:11-16}; {Day74/96:1-5}. and Mr Evans1278 Evans {Day72/170:6-10}. all recalled his being there and we are satisfied that he was.
¶24.43 Mr Roper prepared slides for the meeting.1279 {CEL00011199}. The first slide set out paragraph 12.5 of Approved Document B highlighted in yellow. No one who saw it can have been under any illusion about what the guidance was or what it required.1280 Roper {Day71/47:5-9}.
¶24.44 Slide 14 set out the options available to Celotex.1281 {CEL00011199/14}. The first was "Worst case scenario with field of application report", which referred to testing a system that would enable a desktop assessment to be produced to allow FR5000 to be used in other systems.1282 Evans {Day72/172:12-21}. Mr Roper envisaged that it would incorporate ACM rainscreen panels and improved cavity barriers,1283 {CEL00000718} and see paragraph 23.29 above. but he had little confidence that he could find such a product.
¶24.45 The second was "System Route (Limits Scope – Requires Re-education)", which referred to testing a representative system and making it clear that any BR 135 classification applied only to the system tested.1284 Roper {Day71/49:6-10}. The "re-education" mentioned referred to the need to explain to the market that the industry had up to that point misunderstood the effect of full-scale testing and classification in accordance with BS 8414 and BR 135 and had wrongly allowed K15 to be used in a wider set of applications than was justified by the tests.1285 Evans {Day72/173:12-18}.
¶24.46 The third and fourth options were to test and launch FR5000 with, and without, certification by the BBA and LABC.
130¶24.47 The final option was to abandon the market for insulation suitable for use on buildings over 18 metres in height altogether. It was not discussed at any length.1286 Evans {Day72/174:9-11}.
¶24.48 The next slide assessed the prospects of successfully testing FR5000 with various combinations of other products. A system incorporating an ACM panel and an improved cavity barrier was judged to have less than a 50% chance of success, a system incorporating an A2 rainscreen panel with a standard cavity barrier an 80% chance of success and a system incorporating a cement particle board rainscreen with a standard cavity barrier a 90% chance of success.1287 {CEL00011199/15}.
The decision to proceed
¶24.49 At the meeting a decision was taken to proceed with BS 8414 testing1288 Hayes {Day74/72:15-22}. using an A2 rainscreen panel and then to apply for LABC approval.1289 Roper {Day71/54:17-20}. Mr Roper said that there had been a difference of opinion between Mr Evans and Mr Chambers on the one hand and Mr Warren on the other over what should be tested. Both Mr Roper1290 Roper {CEL00010052/10} page 10, paragraph 5.15; Roper {Day71/54:10-15}. and Mr Hayes1291 Hayes {Day74/100:6-12}. recalled that Mr Warren had thought that Celotex should adopt the "systems route" or opt out, while Mr Chambers and Mr Evans were concerned that that approach would unduly limit the commercial application of the product. Mr Evans denied that that had been his view and told us that, if the product were to be taken to market, Celotex should be clear that it had tested a particular system.1292 Evans {Day72/177:20-22}. He accepted that people might want to make use of the results to demonstrate that the product could be used in different systems, but did not believe that his and Mr Chambers' view was entirely different from that of Mr Warren.1293 Evans {Day72/177:23}-{Day72/178:2}. We have doubts about the reliability of Mr Evans' evidence on this point because, in the end, we know that Celotex chose not to be clear about what it had tested. On the contrary, it deliberately concealed from end users a vital component of the system tested, namely the magnesium oxide boards, a decision which we examine below. Mr Chambers did not recall the meeting, but in his written evidence he said that he understood that an insulation material had to be either non-combustible or pass a BS 8414 test in order to achieve compliance with the Building Regulations.1294 Chambers {CEL00010056/4} page 4, paragraph 20.
Designing the test
¶24.50 On 30 October 2013 Mr Roper was introduced by a colleague at Celotex to Graham Smith of Simco External Framing Solutions Ltd (Simco), a company specialising in the production of external framing systems.1295 Roper {CEL00010052/8} page 8, paragraph 5.7. Simco was engaged by Celotex to help design the rig for the BS 8414 test.1296 Roper {Day70/190:4-9}.
¶24.51 Following the meeting on 4 November 2013, Celotex decided to use a Marley Eternit panel classed A2. Mr Roper explained that Celotex had chosen the Marley panel because Simco had suggested that it was similar to a cement particle board, although providing a decorative facade, and because Marley was a relatively well-established brand.1297 Roper {Day71/67:9-13}.
131¶24.52 Simco produced drawings for the test rig on 22 January 2014.1298 {CEL00000806}; {CEL00000807}; {CEL00000808}; {CEL00000809}. The system to be tested comprised a steel frame, a 12mm magnesium oxide sheathing board, 100mm Celotex FR5000, Lamatherm fire barriers and 8mm Marley Eternit cladding. The components appear to have been delivered to BRE's testing centre at Watford. BRE was unable to produce a complete test file for the first Celotex test, but delivery notes for some of the components were found in the file relating to the second test carried out in May 2014, to which we return below.1299 {BRE00032372/4} delivery note for 12mm magnesium oxide sheathing board used in first test; {BRE00032372/5} delivery note for FR5100 used in first test.
The first test: 14 February 2014
¶24.53 The test was carried out on 14 February 2014. Mr Roper, Mr Hayes, Mr Warren and two representatives of International Fire Consultants, Dr Parina Patel and David Cooper, attended.1300 Roper {Day71/68:18}-{Day71/69:6}. It was overseen by Philip Clark of BRE. The test was stopped after 26 minutes when flames overtopped the rig,1301 Roper {Day71/69:7-9}. but Mr Clark allowed the rig to continue burning for a further period to enable Celotex to obtain more data.1302 {INQ00014136/3}. BRE subsequently confirmed that the test had failed and that no classification report would be issued.1303 Hayes {CEL00010154/18} page 18, paragraph 56.
¶24.54 Mr Roper said that Mr Clark had commented favourably on the performance of the system, although he understood that it had failed the test.1304 Roper {Day71/77:1-3}. In particular, he recalled Mr Clark's saying that he had "seen worse fails" and suggesting that Celotex might want to strengthen the outside of the rig in order to prevent the Marley Eternit panels cracking.1305 Roper {CEL00010052/12} page 12, paragraph 5.29. Mr Roper said that he had suggested that the panels were available in 12mm thickness and that Mr Clark had said that he thought that might suffice.1306 Roper {Day71/71:17-24}. Mr Roper thought that (possibly on a later occasion)1307 Roper {Day71/74:16-20}. he had discussed with Mr Clark the possibility of using two rainscreen panels at the level of the cavity barrier to prevent cracking and allowing the fire to bypass the barrier.1308 Roper {CEL00010052/13} page 13, paragraph 5.31. He was unable to remember the details of the conversation, however.1309 Roper {Day71/74:6-11}. Mr Clark denied that he had made any comments either about the performance of the system or possible changes to it.1310 Clark {BRE00005768/50} page 50, paragraphs 203-204; Clark {BRE00005768/66} page 66, paragraph 269.
¶24.55 Mr Roper was an exceptionally candid witness, whose recollection we generally consider to have been reliable. Moreover, a recording made by the head camera worn by Mr Clark during the test reveals that he did say that he had "seen worse"1311 {INQ00014137/2}. and that "for a first attempt it's not bad, actually".1312 {INQ00014137/3}. Mr Clark then turned off the camera. No recording was disclosed of any conversation in which Mr Clark made recommendations about the design of any future test rig,1313 Clark {Day95/101:8}-{Day95/102:15}; {Day95/104:7-16}. but the recording that was disclosed supports that part of Mr Roper's evidence. We therefore accept that Mr Clark did discuss possible changes to the design of the second test rig with Mr Roper, but there is no evidence to suggest that those discussions touched on the use of magnesium oxide boards.
132¶24.56 This episode caused us to doubt the reliability of Mr Clark's evidence where it was not supported by the contemporaneous documents. For example, after the test Mr Roper sent Parina Patel and David Cooper of International Fire Consultants thermocouple data from the test,1314 {CEL00000843}. saying that he had spoken to Mr Clark, who saw no reason why a classification report could not be issued as, in his opinion, extending the test to the full duration of 30 mins would have made little difference.1315 {CEL00000842}. Mr Clark strongly denied that any such discussion had taken place, to the point of accusing Mr Roper of having invented it at the time,1316 Clark {Day95/120:4}-{Day95/121:25}. but there was no reason for Mr Roper to have made up the conversation for the benefit of International Fire Consultants and no plausible explanation of how he had obtained the thermocouple data if not from Mr Clark. We prefer the evidence of Mr Roper.
Reaction to the failed first test
¶24.57 Mr Roper considered that the failure of the first test demonstrated the impossibility of meeting the requirements of BR 135 with a representative system1317 Roper {Day71/43:6-12}. and in view of the cost of the first test, he did not expect to be given an opportunity to run a second.1318 Roper {Day71/78:18-23}. By contrast, Mr Evans said that although it had been a disappointment, he had not considered it to have been a significant problem for Celotex.1319 Evans {Day72/182:10-14}. In the light of the importance of the project and the fact that further testing required budgetary approval,1320 Roper {Day71/82:6-22}. we do not think that can have been correct. Without passing a BS 8414 test and meeting the BR 135 criteria Celotex could not break into the market for insulation suitable for use on high-rise buildings, and there was at that time no guarantee that further testing would be possible. In reality, the failure of the test in February 2014 was a significant setback.
Decision to retest
¶24.58 After the test, there were further discussions between Mr Roper, Mr Hayes, Mr Evans and Mr Warren.1321 Roper {Day71/80:7-11}. Mr Evans could not recall them but did not dispute that they had taken place.1322 Evans {Day72/190:12-19}. Mr Mahoney (then Celotex's Head of Research and Development) was also consulted, as he had responsibility for the development budget from which a second test would be funded.1323 Roper {Day71/82:14-24}. Mr Evans indicated that the cost was such that it would also have required the approval of Craig Chambers, who was in any case interested in progress, given that it involved the first launch of a (supposedly) new product since the company's acquisition by Saint-Gobain.1324 Evans {CEL00010058/29} page 29, paragraph 102.
Design changes
¶24.59 The discussions centred on how to ensure that any further test could be designed to be successful. Mr Roper said that two main changes had been proposed: the use of thicker rainscreen panels (12mm in place of 8mm) and the use of a 6mm magnesium oxide board in the area of the level 2 thermocouples.1325 Roper {Day71/81:14-19}. Magnesium oxide is a non-combustible material and the purpose of including it was to reduce the chance that the temperature at that level would exceed 600°C, thereby failing to meet the performance criteria in BR 135.1326 Roper {Day71/97:7-12}. It was also suggested that a layer of 6mm magnesium oxide board should be used at the top of the rig to provide a firm surface against which the cavity barriers could expand to prevent flames from overtopping the rig.1327 Roper {Day71/97:13-17}. The 6mm magnesium oxide board was to be covered with 8mm Marley Eternit, rather than the 12mm used elsewhere, in order to ensure as much continuity of the rainscreen surface as possible.1328 Hayes {CEL00010154//20} page 20, paragraph 61. Celotex also decided to reduce the ventilation gaps between the rainscreen panels.1329 Roper {Day72/2:8-9}. Mr Roper believed there were some gaps but he accepted that they were minimal and less than 10mm.1330 Roper {Day72/3:10-15}. Taken collectively, those decisions reflected a conscious decision by Celotex to manipulate the design of the rig in order to ensure as far as possible that the performance criteria in BR 135 were met.1331 Roper {Day71/98:2-3}.
133¶24.60 The proposal to use a 6mm magnesium oxide board was originally made by Mr Hayes;1332 Roper {Day71/86:4-16}. Mr Roper and Mr Evans then suggested using the thinner Marley board to cover it.1333 Hayes {Day74/127:13-22}. Mr Evans told us that he could recall only the decision to revise the rig design to incorporate a thicker cladding panel.1334 Evans {Day72/192:13-15}. He was adamant, despite repeated questioning, that at no point had he known of the presence of a 6mm magnesium oxide board until he had found a reference to it on his phone in 2017, and that the only variation in design that he had been aware of at the time was the change to the thickness of the panel.1335 Evans {Day72/193:9}-{Day72/195:10}; Evans {CEL00010058/31} page 31, paragraph 114. He was equally adamant that he had not taken part in any meeting at which the use of a 6mm magnesium oxide board had been discussed,1336 Evans {Day73/2:15}-{Day73/3:5}. or that he had known that it had been used in the area of the cavity barriers.1337 Evans {Day72/199:1-13}. We did not find his evidence on those matters credible and indeed Mr Evans ultimately accepted that he had become aware of the use of the 6mm magnesium oxide boards at the latest by the time of a management action group meeting on 14 May 2014 although he maintained that he had not made the connection even by that time.1338 Evans {Day73/8:15-23}; {Day73/9:16}-{Day73/10:15}. Given his faulty memory on this point, we regard the evidence of Mr Hayes and Mr Roper as far more reliable and we conclude that Mr Evans was indeed aware of the changes to the design of the second test.
No new drawings
¶24.61 Celotex did not commission any drawings of the second test rig.1339 Roper {Day71/101:1-6}. Mr Roper said that that had been in part a financial decision.1340 Roper {CEL00010052/13}page 13, paragraph 5.35. He had also formed the view that Simco did not particularly wish to assist further.1341 Roper {Day71/100:9-20}. Although Mr Roper did not think that the decision not to produce revised drawings had been motivated by a desire to conceal the use of the 6mm magnesium oxide board,1342 Roper {Day71/101:20-25}. its failure to do so was entirely consistent with Celotex's overall desire to conceal as far as possible the introduction of that layer. The only drawings available to BRE before the test on 2 May 2014, therefore, contained the same design as had been tested in February. Moreover, although revised drawings were subsequently commissioned by Celotex at the end of June 2014,1343 {CEL00000980}. they also omitted anything to indicate the use of 6mm magnesium oxide boards.1344 {CEL00000997}.
134Source of materials
¶24.62 Cavity barriers were ordered from Siderise Insulation Ltd and were delivered to BRE on 7 April 2014.1345 {BRE00032372/2}. The cladding, which was Marley Eternit in thicknesses of 12mm and 8mm, was obtained from a company called FGF Ltd and delivered to BRE on 14 April 2014.1346 {BRE00032372/3}. The delivery note for the 8mm ruby Eternit boards that were intended to cover the 6mm magnesium oxide boards was signed by Mr Clark.1347 Clark {Day96/3:2-23}. The FR5000 was delivered on 1 April 2014, and again was signed for by Mr Clark.1348 {BRE00032372/6}.
¶24.63 The 6mm magnesium oxide boards were supplied by Euroform Products Ltd, which also supplied the 12mm sheathing board.1349 Roper {Day71/98:4-13}. Although the invoice shows the delivery as being to Celotex,1350 {CEL00001985}. Mr Roper asked for it to be delivered to BRE.1351 {CEL00001981}. Although BRE disclosed a delivery note for the sheathing board from the first test (addressed 'FAO Phil Clark', although signed for by another BRE employee),1352 {BRE00032372/4}. no delivery note for the sheathing board used in the second test has been disclosed by BRE. We return to the significance of that below.
The second test – May 2014
¶24.64 The second test was carried out on 2 May 2014. As set out above, the system comprised a steel-framed rig, 12mm magnesium oxide sheathing board, 100mm Celotex FR5000, Lamatherm fire barriers, 8mm Marley Eternit cladding over 6mm magnesium oxide boards over the level 2 thermocouples and 12mm Marley Eternit cladding over all other areas. The results met the criteria in BR 135.
BRE's knowledge of the design changes
¶24.65 As in the case of the test on 14 February 2014, the officer at BRE in charge of the test on 2 May 2014 was Phil Clark. There was a serious conflict of evidence about what, if anything, he knew about the changes in the design between the rig tested in February and the rig tested in May. Mr Clark said that he had known nothing of the changes in design other than the use of thicker external cladding,1353 Clark {BRE00005768/70} page 70, paragraph 287. but his evidence was contradicted by Mr Hayes and Mr Roper, both of whom had no doubt that he had been well aware not only of the thicker Marley panels but also of the use of the 6mm magnesium oxide boards.1354 Roper {Day71/99:11-19}; Hayes {Day74/148:11-17}. Mr Roper told us that he remembered having referred to the additional materials in the course of a telephone conversation with Mr Clark when the second test was being planned.1355 Roper {Day71/98:19-22}. Mr Hayes remembered a conversation with Mr Clark in the course of which he had referred to his experiences of working during the BSE outbreak.1356 Hayes {CEL00010154/22} page 22, paragraph 67. Mr Hayes said that during the conversation, Mr Clark had expressed the view in response to a question from Mr Roper that the test would have been successful even without the addition of the 6mm magnesium oxide boards. Mr Clark denied the conversation and sought to cast doubt on Mr Hayes' recollection challenging the description he had given of his office,1357 Clark {Day96/27:1-22}. but the description given by Mr Hayes was similar to that given by Patrick Jones of Simco, who installed the rig for both tests and we accept what he told us.1358 Jones {Day99/129:2-20}.
135¶24.66 BRE's standard procedures required the project officer to compare the drawings of the test rig with the structure handed over and if any discrepancy were noted to ask for revised drawings.1359 Clark {BRE00005768/9} page 9, paragraph 41. The senior member of staff who signed the test report was also expected to check the photographs and drawings.1360 Clark {Day95/56:4-9}. BRE's standard operating procedures dated May 2013 required all components to be checked and, if necessary, samples to be taken.1361 {BRE00005773/3}. BRE produced forms for that purpose,1362 {BRE00005773/3}. but no checklists were disclosed for the second test, and Mr Clark explained that they had not normally been used, otherwise, perhaps, than as an aide memoire.1363 Clark {Day95/156:19-25}. Had the drawings been compared to the rig as it was built, or even to the components being delivered to BRE, the discrepancy between the drawings and the rig as built would have been obvious. Indeed, Mr Clark knew that the drawings had not been revised to show the thicker Marley panels and therefore knew that the Simco drawings did not accurately describe the test rig.1364 Clark {Day95/158:12-16}.
¶24.67 In coming to a decision about whether Mr Clark knew that the second test rig contained the additional 6mm magnesium oxide boards we have carefully considered the detailed submissions made by Celotex and BRE. Having done so, we have come to the conclusion that the evidence, taken as a whole, points strongly to the conclusion that Mr Clark was aware of the presence on the test rig of the 6mm magnesium oxide boards and the 8mm Marley Eternit boards that were used to cover them. First, it is right to say that we found Mr Roper and Mr Hayes more reliable as witnesses than Mr Clark. If the question had turned on the evidence of the witnesses alone we should have accepted their accounts of their conversations with Mr Clark. However, their evidence did not stand alone.
¶24.68 The delivery notes indicate that Mr Clark took delivery of the 12mm Marley panels together with the thinner 8mm ruby panels which were used to cover the 6mm magnesium oxide boards.1365 {BRE00032372/6}. There was no rational explanation for including 8mm and 12mm Marley panels in the components unless the thinner panels were to cover the 6mm magnesium oxide boards, and Mr Clark could not explain why the different thicknesses had not been noted other than as the result of an oversight.1366 Clark {Day96/7:1-9}; {Day96/8:3-11}. Mr Roper had arranged for the delivery of all of those materials and expected Mr Clark to sign for them because, as he understood it, he took delivery of most of the materials used on the test rigs.1367 Roper {Day71/98:14-18}; Hayes {Day74/145:2-4}. It is inherently unlikely that Mr Roper would have openly arranged for the delivery of those materials to BRE, which had a proper system for recording deliveries, if he had been intending to conceal their presence from BRE, and unless Mr Clark was aware of the plan, concealment would have been essential, probably quite difficult and certainly risky. There is no reason to think that BRE's system for recording deliveries was so inefficient that Mr Roper can have expected to get the 6mm magnesium oxide boards onto the test rig without anyone's noticing.
136¶24.69 The absence from BRE's disclosure of a delivery note covering the materials supplied by Euroform has not been explained by BRE and no credible explanation for it has been provided. That it was simply lost is too much of a coincidence and does not do justice to BRE's systems. It could have been removed or destroyed deliberately, but no one at BRE other than Mr Clark was involved in the Celotex tests in a way that would provide a motive for doing that. Mr Clark initially told us that he had not had access to either the paper or electronic versions of the test files other than documents that had been provided to him by BRE,1368 Clark {Day95/182:14-21}. but we subsequently learnt that he had attended BRE's offices over the course of several days when preparing his witness statement for the Inquiry and been given unsupervised access to any documents he wished to review. Mr Clark was unable to explain satisfactorily why he had failed to mention that when he made his statement.1369 Clark {Day96/110:2-12}.
¶24.70 The use of the ruby Eternit board meant that the rig had a distinctive red band in the area of the level 2 thermocouples and at the top of the rig. Mr Clark said he had understood that the ruby board was used because there had been a shortage of panels in the other colour,1370 Clark {BRE00005768/66} page 66, paragraph 269. but that was not very plausible and he had not asked whether it had any technical significance.1371 Clark {Day95/190:18-24}. However, the absence of any attempt on the part of Celotex to divert attention from the use of that material and to forestall questions of that kind is inconsistent with any plan to deceive BRE. Clearly, any attempt to smuggle the ruby board past BRE would have been risky.
¶24.71 Patrick Jones of Simco, who constructed the test rig for Celotex, was clear that he had been given no instructions to conceal the 6mm magnesium oxide board from BRE.1372 Jones {Day99/151:19}-{Day99/152:3}. His impression was that BRE was carrying out its normal checks.1373 Jones {Day99/155:22}-{Day99/156:5}. The rig was assembled over several days and there was no attempt to prevent BRE from seeing the magnesium oxide boards, and no reason to think that they had not been observed.1374 Jones {Day99/151:19}-{Day99/152:3}. He told us that there was nothing underhand going on and that BRE was fully aware of what was on the test rig.1375 Jones {Day99/144:8-16}; {Day99/150:23}-{Day99/152:3}; {Day99/164:9-25}. Mr Jones was a patently honest witness who had no reason to be anything other than candid in his evidence.
¶24.72 Following the test, the rig remained standing for some 17 days until it was stripped down on 19 May 2014.1376 {BRE00005548/6}. That provided a further opportunity for anyone at BRE to ask questions about the use of the ruby board.
¶24.73 On 15 May 2014, during the stripping down of the rig, which was also carried out by Mr Jones, Mr Roper asked Mr Clark by email to ensure that photographs were taken of the fire barrier at the level 2 thermocouples.1377 {BRE00005548/6}. Again, that is wholly inconsistent with an intention on the part of Celotex to deceive BRE or to gamble on its staff's failing to notice the presence of the 6mm magnesium oxide boards. If Mr Roper had hoped that Mr Clark might fail to notice them, it is unlikely that he would have directed his attention to the very place in which they were being used. The photographs on BRE's files clearly show their presence.1378 {BRE00030681}.
137¶24.74 The recording made by the head camera worn by Mr Clark during the second test does not of itself demonstrate conclusively that Mr Clark was aware of the presence of the magnesium oxide board, but it contains several comments made by Mr Clark that strongly suggest that he was: a. Mr Clark referred to "changing two things at the same time".1379 {INQ00014220/2}. His explanation that
that had been a reference to the scientific principle that only one variation should be made to a system at a time was unconvincing. He was unable to explain satisfactorily why, if he thought that only one change had been made, he had referred to changing two things.1380 Clark {Day96/55:5-21}. Celotex had in fact made two significant changes to the design: the use of an increased thickness of cladding overall (12mm Marley Eternit as opposed to 8mm); and the use of the 6mm magnesium oxide board.
¶b. Mr Roper at one point drew Mr Clark's attention to the ruby board, (which he described as "the rose-coloured panel"),1381 {INQ00014220/2}. being aware, he said, that Mr Clark knew what material was behind it.
¶c. At one point Mr Clark commented, "See how that flame seems to have ceased now that the board is there, because you're losing a lot of the energy from behind it".1382 {INQ00014218/3}. Unless he was aware of the presence of the magnesium oxide board, it is difficult to understand which board he was referring to.
¶d. In response to a comment by Mr Clark that the board at the level of the fire barrier had not deformed, Mr Roper said that it was "a shame we put calcium silicate behind it" and subsequently "like I say, it's a shame commercially."1383 {INQ00014220/2}; {BRE00035419} Mr Roper said that he tended to refer to calcium silicate interchangeably with magnesium oxide, because their fire resistance properties are very similar.1384 Roper {Day71/170:12-14}. It is likely that they were referring to the 6mm magnesium oxide board because its use in that location would not be adopted commercially.
¶24.75 The way in which Celotex behaved in arranging the test was wholly inconsistent with any plan to deceive BRE. It could have acted as it did only with the knowledge of Mr Clark. We are satisfied that Mr Clark was aware of the design of the rig for the second test, including the use of the 6mm magnesium boards and the 8mm ruby Eternit boards, and the reasons for it.
¶24.76 The question remains why Mr Clark, a senior BRE burn hall technician, was willing to lend himself to a plan to a test rig that was so obviously unrepresentative and designed only to meet the performance criteria, since there was no evidence that he had anything to gain personally from a successful test. He might have thought that a customer should be allowed to test any design of rig it liked, provided the subsequent report accurately reflected its structure and the outcome of the test, but if that was his view, it is difficult to understand why he subsequently denied any knowledge of the additional material. In essence, over the years leading up to 2014 BRE had by degrees lost sight of the importance of maintaining a proper distance between itself and clients and of the need for scientific rigour and independence. Its internal controls were not the subject of regular and robust training and there was no independent supervision that ensured that conflicts of interest were properly managed. It had gradually become much closer to its clients and wanted to work with them to find solutions to their problems. Scientific rigour and independence were sacrificed in favour of financial sustainability.
138Decisions following the second test
¶24.77 On 12 May 2014, Mr Roper and Mr Evans met to discuss the outcome of the test. The meeting appears to have been held in Mr Chambers's office,1385 {CEL00010627}. and Mr Roper thought it was likely the purpose of the meeting was to brief him.1386 Roper {Day71/106:18-20}. Mr Chambers did not believe he had attended such a meeting and could not recall how or by whom he had been advised that the system had passed.1387 Chambers {CEL00010056/6} page 6, paragraph 31.
The slide show
¶24.78 At or just after that meeting Mr Roper was asked by Mr Evans to prepare a presentation which could be used to report to the management action group at their next meeting, which was scheduled for 13 and 14 May 2014. Mr Chambers, Mr Warren and Mr Evans were present on 13 May 2014;1388 {CEL00009565}. Mr Chambers and Mr Evans were present on 14 May but Mr Warren probably was not. Mr Roper appears not to have attended on either day.
¶24.79 The slides created by Mr Roper described the requirements for use of combustible insulation on buildings over 18 metres in height, referring to the text of paragraph 12.7 of Approved Document B.1389 {CEL00000933/2}. A further slide set out the conclusions drawn by Mr Roper from the results of his market research, namely,1390 {CEL00000933/11}. a. that people used K15 because there was no alternative available; b. that no one understood the BS 8414 test requirements; c. that levels of understanding among building control bodies varied widely; and d. that the market would be happy to buy an alternative to K15 if one were available.
¶24.80 Although Mr Evans denied that the slide showed that Celotex intended to capitalise on the confusion in the market,1391 Evans {Day72/206:9-16}. that is the only reason why it could have been relevant for the management action group to know that nobody understood the testing requirements or that building control officers had widely differing levels of understanding on the subject. Mr Evans could not explain those statements, other than by saying that the purpose of the slides was to acquaint everyone with the research that had been carried out,1392 Evans {Day72/207:2-14}. but that hardly explains why they were thought to be of any interest to senior management. The simplest, and we think the most likely, explanation is that the slides were put before the meeting precisely to enable it to decide whether to take advantage of that confusion, and if so, how.
139¶24.81 The slides also described the two BS 8414 tests that Celotex had carried out, including the systems tested. The description of the February test referred to 8mm Eternit cladding and Lamatherm cavity barriers.1393 {CEL00000933/12}. In the case of the May test, the description listed 12mm Eternit cladding and Lamatherm cavity barriers with 6mm magnesium oxide.1394 {CEL00000933/14}. When the slides are compared, differences are quite apparent, although there is no mention of the use of the 8mm Eternit panels that had also been used in the May test. It follows that all those present were, or should have been, aware of the presence of the 6mm magnesium oxide boards used in the May test, as well as the use of the thicker 12mm Eternit boards. Indeed, Mr Evans accepted that the presentation had provided that information.1395 Evans {Day72/211:19-21}. Mr Evans said he did not remember whether there had been any discussion about the 6mm magnesium oxide boards at the meeting,1396 Evans {Day72/214:8-10}; {Day73:4/11-16}. or whether anyone had asked how the test had passed in May after it had failed in February.1397 Evans {Day72/214:21-25}. In our view it is hard to believe that no one at the meeting asked that question, if they had not been told directly, since it was critical to their decision about what to do next. The slides show that the use of the 6mm magnesium oxide boards was openly acknowledged at that meeting.
¶24.82 The slides were presented at the meeting on 14 May 2014, at which Mr Evans was scheduled to lead a discussion on the subject at 11.30 am.1398 {CEL00009566}. There was a disagreement about who presented the slides, but it makes little difference who did so. What is clear is that they show that those attending the meeting were or should have been aware of the presence of the 6mm magnesium oxide boards and that Mr Roper did not seek to keep their use a secret from senior management.
¶24.83 The slides may also have been sent to Saint-Gobain. An email from Mr Evans to Mr Roper on 16 May 2014 about the project refers to a meeting with Jonathan Cheeseman of Saint- Gobain's legal team, which appears also to have been attended by Craig Chambers.1399 {CEL00003121}. In that email, Mr Evans told Mr Roper that his presentation could provide all the background needed to explain Celotex's approach. Mr Evans was unable to recall which set of slides he had been referring to,1400 Evans {Day73/121:5-8}. but given that this set had been used for reporting to the management action group (and that the metadata relating to the short set of slides discussed below suggests that they were not created before 30 May 2014),1401 {CEL00000961}. it is likely that Mr Evans was referring to the slides shown to the meeting on 14 May 2014.
Instruction to produce slides "for general business use"
¶24.84 Mr Roper said that after the meeting, Paul Evans had asked him1402 Roper {Day71/113:16-19}. to create "for general business use" another version of the slides which did not refer to the February test or to the 6mm magnesium oxide boards.1403 Roper {CEL00010052/14-15} pages 14-15, paragraph 6.3 He told us that Mr Evans had suggested that after the meeting a decision had been taken to launch the product and to say nothing further about the use of 6mm magnesium oxide boards.1404 Roper {Day71/114:6-10}. Mr Roper subsequently produced such a presentation.1405 {CEL00000961}. Mr Evans did not remember having given any such instruction, but was unable to provide any other explanation for Mr Roper's action.1406 Evans {Day73/13:12-19}. He was also unable to think of any reason why anyone else on the project team might have instructed Mr Roper to do that without his knowledge.1407 Evans {Day73/19:21}-{Day73/20:1}. We have little doubt that Mr Roper created the slides because he was asked to do so.
140¶24.85 Mr Roper's evidence strongly supports the conclusion that the management action group made a decision at the meeting on 13 and 14 May 2014 to market FR5000 without disclosing the fact that 6mm magnesium oxide boards had been used to improve the performance of the test rig. There was a risk that BRE might disclose the use of the 6mm magnesium oxide and the 8mm Marley Eternit panels in its test report, but it was Celotex's general practice not to release such reports1408 Roome {Day70/73:17-22}; Roper {Day71/135:19-25}. and it might therefore have hoped to maintain the deception indefinitely. It was, we think, a risk that Celotex was prepared to run, having regard to the ignorance of a substantial section of its potential customers, a point to which we return in Chapter 56.
BRE draft report
¶24.86 Mr Clark produced a first draft of the test report,1409 Clark {Day95/171:4-7}. which he sent to Mr Roper on 19 June 2014.1410 {CEL00003177}. Mr Roper was about to go into a meeting with David White and Graham Perrior of NHBC when it arrived.1411 Roper {Day71/120:21}-{Day71/121:3}. It was dated 2 June 20141412 {CEL00003178/1}. and described the system that had been tested as comprising 100mm RS5000 with 8mm Marley Eternit, but made no reference to the 6mm magnesium oxide boards.1413 {CEL00003178/6}. Mr Roper denied having asked Mr Clark to omit any reference to the 6mm magnesium oxide boards; he thought it was possible that Mr Clark had done so of his own initiative because of his view that they would not have made any difference in the light of the increase in the thickness of the cladding panel.1414 Roper {Day71/128:8-13}. Nonetheless, he said that he had been surprised by the omission.1415 Roper {Day71/131:15-24}. Mr Clark denied having consciously decided to omit any reference to the 6mm magnesium oxide boards; he said that he had simply been unaware of them, although he was unable to explain how he had overlooked them.1416 Clark {Day95/179:25}-{Day95/180:20}. He accepted that he must have seen the photograph at Figure 18 of the draft report showing the magnesium oxide board, as he had selected it for inclusion, but said that he had not studied it at the time.1417 Clark {Day96/67:23}-{Day96/68:10}.
¶24.87 It was clear from the photographs in the draft test report that at the level 2 thermocouples and at the top of the rig, exterior panels had been used that differed from the rest of the exterior of the rig. Figure 15 showed the ruby Marley Eternit panels at those levels, although it is not possible to tell from the photograph that the thickness of the ruby layer was different from that of the rest of the panels.1418 {CEL00003178/25}. However, the fact that those boards were at least of a different colour was not mentioned anywhere in the report. The report also contained a photograph of the rig in the process of being dismantled (Figure 18), which showed the white 6mm magnesium oxide boards quite clearly.1419 {CEL00003178/28}. The photograph shows the insulation layer, with one panel of the 6mm magnesium oxide still present at level 2 and the whole of it present at the top of the rig. Those were the levels which had been covered by the ruby cladding panels shown in Figure 15. A simple comparison between the two photographs would have alerted a careful reader to the fact that there was white material behind the ruby cladding but on top of the insulation layer, which called for an explanation.
141Discussion of the draft report
¶24.88 On 19 June 2014, following receipt by Celotex of the draft report earlier that morning and after the NHBC representatives had left, a discussion ensued between Mr Roper, Mr Evans and another colleague at Celotex, Paul Reid (although it appears that Mr Reid was not present throughout).1420 Roper {CEL00010052/16} page 16, paragraph 7.4. Notes were made on a whiteboard of the concerns raised by NHBC, and the conversation which had subsequently taken place about the BRE draft test report.1421 {CEL00002517}. A photograph of the whiteboard was taken by Mr Evans.1422 Evans {Day73:36/6-12}. The first five points reflected concerns that had been raised by NHBC at the meeting that morning (one of which had been that the rig had been deliberately over-engineered through the use of large 12mm cladding panels with minimal gaps)1423 Roper {CEL00010052/16} page 16, paragraph 7.4 and Celotex's potential responses. Some of the proposed responses were less than frank. In relation to NHBC's concern that the test had been over-engineered, the proposed response was to note that cladding panels were commonly available in 8mm or 12mm but that only 12mm had been available for testing, whereas in fact Celotex had deliberately chosen to use large 12 mm panels. The final entry was in different handwriting, having been added by Mr Roper.1424 Evans {Day73:37/8-17}. It recorded a concern relating to the use of a "calcium silicate board" at level 2, although, as we noted earlier, Mr Roper did not distinguish in his own mind between calcium silicate and magnesium oxide.1425 Roper {Day71/170:12-14}. If NHBC were to become aware of the existence of the 6mm magnesium oxide board, Celotex proposed to say that it had confidence in the fire barriers to expand. When examined about that Mr Roper admitted that it was a poor attempt to hide the fact that 6mm magnesium oxide boards had been used.1426 Roper {Day71/171:22}-{Day71/172:1}. He said that Mr Evans and Mr Reid had suggested that they remove Figure 18 from the report.1427 Roper {CEL00010052/18} page 18, paragraph 7.16; Roper {Day71/137:21-24}. Mr Reid denied having been involved in the conversation at that point or having had any knowledge of the discussion about the removal of Figure 18,1428 Reid {CEL00011267/11} page 11, paragraphs 57-59. and we are not able to reach any firm conclusion about the extent of his involvement.
Decision not to correct the report
¶24.89 The upshot of the discussion was that it was decided that the omission from the test report of any reference to the 6mm magnesium oxide boards would not be corrected.1429 Roper {CEL00010052/18} page 18, paragraph 7.14 Mr Evans did not recall any discussion with Mr Roper about that,1430 Evans {Day73/24:18-23}. but he did accept that the white board reflected a discussion which had taken place about removing Figure 18.1431 Evans {Day73:38/19-23}. Although he recalled its having been discussed,1432 Evans {Day73/29:3-10}. he claimed to be unsure whether he had looked at the photograph.1433 Evans {Day73/29:17}. We do not accept that. Figure 18 clearly showed the 6mm magnesium oxide board and it could not have been discussed without Mr Evans' having appreciated that fact. It is also not credible that he could have taken part in a discussion about the removal of a photograph from the report without having looked at the photograph in question.
142¶24.90 Similarly, we are not convinced by Mr Evans' assertion that he did not ask about the two orange layers shown in the photographs of the rig.1434 Evans {Day73/66:9-21}. The test represented the second attempt to succeed in what was an important project for Celotex. We do not think that Mr Evans felt as little concern as he suggested.1435 Evans {Day73/68:2-7}.
Request to remove figure 18
¶24.91 On 1 July 2014, Mr Roper replied to Mr Clark's email attaching the draft report with a number of suggested changes, including the removal of Figure 18 and its substitution by some photographs showing the condition of the insulation at the conclusion of the test.1436 {CEL00001350/2}. The email refers to a previous discussion between Mr Roper and Mr Clark about the removal of Figure 18, but Mr Clark could not remember what had been said.1437 Clark {Day96/65:19-24}. Mr Roper could not remember having specifically told Mr Clark that Celotex did not want any reference to be made to the areas of the rig where the 6mm magnesium oxide board had been used; the focus, as he recalled it, was simply on getting Figure 18 removed.1438 Roper {Day71/178:20}-{Day71/179:8}.
¶24.92 The reason Mr Roper gave for asking Mr Clark to remove Figure 18 from the test report was not the true reason, as he admitted. The truth was that Celotex wanted to ensure that a picture showing the 6mm magnesium oxide board did not appear anywhere in the report.1439 Roper {Day71/141:22}. Mr Roper said that Mr Evans and Mr Reid had told him to send the false explanation,1440 Roper {Day71/141:23}-{Day71/142: 4}. but that he had thought that Mr Clark was aware of the real reason.1441 Roper {Day71/142:20}-{Day71/143:3}. Mr Evans did not remember having asked Mr Roper to send the email,1442 Evans {Day73/33:4-13}. and he may not have done, but he was copied into it and did not express any surprise at the request. We are satisfied that he knew about it, but cannot say whether Mr Reid also knew.
¶24.93 Mr Roper also sent Mr Clark some revised drawings, which showed a ventilation gap that had not existed on the rig as built but still did not show the 6mm magnesium oxide boards.
Internal review and issue of the report
¶24.94 BRE did not reply to those requests. Internally, the final version of the report was checked by Tony Baker1443 {BRE00005851}; Baker {Day100/143:4-11}. and Stephen Howard,1444 {BRE00030677}; Howard {Day99/41:2-12}. each of whom failed to identify the discrepancy between the description of the system tested and the presence of the white layer shown in Figure 18 or the ruby Marley Eternit boards shown in Figure 15.
143¶24.95 The final test report was issued by BRE on 1 August 2014. It included the additional photographs but also Figure 18, which became Figure 19 in the final version.1445 {CEL00001109/29}. As with earlier versions of the draft, the description of the system tested contained no mention of either the 8mm ruby Marley Eternit boards or the 6mm magnesium oxide boards.1446 {CEL00001109/6}. Mr Roper said that he, Mr Evans and Mr Warren had discussed the report and had decided that it would be risky to press BRE to remove Figure 19, as it might result in their correcting the description of the system.1447 Roper{CEL00010052/18} page 18, paragraph 7.16; Roper {Day71/144:25}-{Day71/145: 7}.
Mr Clark's involvement in the BRE test report
¶24.96 As set out above, we are satisfied that Mr Clark was aware of the changes that had been made to the design of the rig tested on 2 May 2014, including the use of the 8mm ruby Marley Eternit boards and the 6mm magnesium oxide boards at two levels. We also think that he realised that the presence of the 6mm magnesium oxide board might have enabled the system to pass the test, although it would not be used in a commercial context. That being so, we have to ask ourselves why he failed to include them in the list of components in the test report, not least since the delivery note for the ruby 8mm Marley Eternit was available to him on the test file.1448 {BRE00032372/3}.
¶24.97 Mr Roper denied having specifically asked him to do so, although, as can be seen from the attempt to suppress Figure 18 in the draft report, we have little doubt that he would, if necessary, have done so. It is likely, in our view, that Mr Clark was aware of Celotex's wish to avoid any reference to the magnesium oxide boards (and therefore the 8mm ruby Marley Eternit boards) and did not need to be asked to omit any reference to them. Mr Clark denied having deliberately omitted any reference to either of those components.1449 Clark {Day96/75:6-13}.
¶24.98 In view of the length of time it took to issue the draft report (just over 6 weeks), it is possible that Mr Clark simply relied on the original drawings when drafting the description of the system. That might explain why the draft referred to 8mm Marley Eternit panels as shown in the drawings for the first test.1450 {CEL00000807}. It might also explain the omission of the 6mm magnesium oxide boards, which had also not been used in the first test. However, we do not think that is the most likely explanation. We think he was willing to leave out any reference to them in order to assist Celotex, though how he expected the report to escape the scrutiny of those who would need to approve it before it was issued is less clear. Perhaps he knew that the system for reviewing reports was not very rigorous. Mr Clark said he had not looked at Figure 18 again in light of the request to remove it, because BRE did not remove material in response to a request from a client.1451 Clark {Day96/71:17}. We think that is probably what happened.
¶24.99 Although Mr Clark did not remove Figure 18 from the report, that does not mean that his omission of a reference to the 6mm magnesium oxide boards from the list of components was an oversight. He knew, or at least suspected, that the system had only met the BR 135 performance criteria at least in part because of the presence of the 6mm magnesium oxide boards, and that such boards were not representative of a system in actual use on a real building. He therefore knew that referring to the presence of those boards in the report would significantly undermine the commercial viability of the product and therefore deliberately omitted any reference to them.
144¶24.100 The test report was subsequently peer reviewed by Stephen Howard and Mr Baker, neither of whom inquired about the white layer of magnesium oxide board or the ruby Eternit boards. However, that merely suggests a lack of curiosity and a review system that was less than robust. There is no evidence that in conducting their review either of them realised that Celotex had manipulated the test by adding a layer of magnesium oxide board behind the ruby Eternit boards, still less that they realised that Mr Clark was aware of the fact.
The RS5000 classification report
¶24.101 The classification report was issued by BRE on 4 August 2014 and reissued following typographical corrections on 11 August 2022.1452 {CEL00002133/1}. It ran to 12 pages and described the test in the same terms as the test report, omitting any reference to the 6mm magnesium oxide boards or the 8mm Marley Eternit boards.1453 {CEL00002133/4}. The classification report did not contain any photographs. Indeed, there is nothing in it to alert even a scrupulously careful reader to the possibility that the description of the components of the rig was incomplete.
The abridged report
¶24.102 The classification report contained a prominent notice that it was only to be distributed in its entirety, without amendment and that any reference to the results contained in it was to be accompanied by a copy of the full report, or a link to a copy of the full report.1454 {CEL00002133/1}. Despite that, on 11 August 2014, Mr Roper sent Paul Evans copies of the test and classification reports, asking for a discussion about which they were going to use as proof that Celotex had satisfied BR 135.1455 {CEL00009724/1}. Although his recollection of that discussion was hazy,1456 Roper {Day71/153:17-19}; {Day71/152:24}-{Day71/153:8}. he recalled that there was some reluctance to provide customers with any reports, and that they had decided that an abridged version of the classification report should be produced for customers to avoid having to provide them with details of the test rig.1457 Roper {Day71/154:3-6}. Mr Roper understood that a similar approach had been adopted by Kingspan.1458 Roper {Day71/154:14-23}.
¶24.103 The abridged report was prepared on Mr Roper's instructions.1459 Roper {Day71/155:11-18}. It contained no diagrams or photographs showing the system tested, but it did contain a list of components which omitted the 6mm magnesium oxide boards and the 8mm ruby Eternit boards.1460 {CEL00011125/2}. On 15 August 2014 a copy was sent to Jonathan Roome, again at Mr Roper's request.1461 {CEL00009725}. It was then sent by him to clients, including Harley on 27 August 2014.1462 {CEL00011960}.
¶24.104 As early as 29 August 2014, Anthony Harris of Celotex contacted Mr Roper and Mr Roome because a client to whom Celotex had provided the abridged report had complained that it was incomplete and that sections were missing.1463 {CEL00010805}. Mr Roper replied the same day providing the full classification report, but not the full test report. He told Mr Harris that the salient information was contained in the BR 135 classification report.1464 {CEL00010805}. As Mr Roper accepted, the salient information was not in fact contained in that report, not least because it did not include the photograph of the 6mm magnesium oxide boards.1465 Roper {Day71/162:12-23}.
145The marketing of RS5000
¶24.105 Preparatory work on marketing materials to support the launch of RS5000 started in July 2014. On 1 July 2014, Jonathan Roper sent Paul Evans a marketing plan1466 {CEL00001213}. which set out the objectives for RS5000, including being presented as Celotex's "primary rainscreen application offering to compete directly with Kingspan K15 & Rockwool Duo-Slab".1467 {CEL00001214/2}. It also contained a phrase that would become something of a mantra in the marketing material, "the first PIR insulation board tested and approved to BR 135 and therefore acceptable for use in buildings above 18m in height". Mr Roper and Mr Hayes then started work preparing the marketing literature which was intended to accompany the launch of RS5000.1468 {CEL00003179/4}; Roper {Day71/194:13-23}.
¶24.106 On 15 July 2014, Mr Evans replied to an email from another colleague in the marketing team, Bex Hartlebury, about a press launch for RS5000, complaining that the message that RS5000 was acceptable for use on buildings over 18 metres in height was not always prominent enough, but saying that it was necessary to exercise caution about how that message was given and how often.1469 {CEL00009674}. Mr Evans accepted in evidence that there was a risk that without qualification it might mislead people into thinking that RS5000 was generally suitable for use on buildings above 18 metres in height,1470 Evans {Day73/86:5-10}. but he denied that Celotex was trying to walk a fine line between the headline and the small print.1471 Evans {Day73/86:18-24}. In our view, however, that is exactly what it was trying to do.
The RS5000 marketing literature
¶24.107 Celotex launched RS5000 on 5 August 2014. A number of documents were prepared to assist in its marketing:
¶a. a Rainscreen Cladding Compliance Guide ("the Compliance Guide");1472 {CEL00000012}.
¶b. a Rainscreen Cladding Specification Guide ("the Specification Guide");1473 {CEL00000013}.
¶c. a Handy Guide;1474 {CEL00000437}. and
¶d. a Data Sheet.1475 {CEL00007961}.
¶They were drafted by Mr Roper with the assistance of Mr Hayes (in relation to the
¶Specification Guide)1476 Hayes {Day74/173:11-20}. and others in the marketing and technical teams1477 Evans {Day73/81:16-22}. but they were reviewed and ultimately approved by Paul Evans.1478 Evans {Day73/82:1-3}. Mr Evans told us that Celotex also sought guidance on them from Saint-Gobain, in that they had been passed to the legal team, but he was unsure whether they had been reviewed by anyone on the Saint-Gobain board.1479 Evans {Day73/82:3-17}. Mr Roper also told us that Saint-Gobain's internal lawyers had reviewed the documents and that it had been as a result of that review that the disclaimers had appeared in the documents.1480 Roper {Day71/182:5}-{Day71/183: 6}. We accept their evidence about that.
146¶24.108 We therefore turn to examine those documents.
The Compliance Guide
¶24.109 The front cover of the Compliance Guide stated that it was for use "when specifying Celotex RS5000 in buildings above 18m",1481 {CEL00000012/1}. explaining on the first inside page that it provided a step by step guide to the alternative route to compliance under Approved Document B by meeting the performance criteria in BR 135 following testing to BS 8414-1:2002 or BS 8414-2:2005.1482 {CEL00000012/2}. That was not accurate, if only because RS5000 had not been tested in accordance with BS 8414-1:2002 (masonry wall construction).1483 Evans {Day73/51:9-11}. Mr Evans was unable to explain that inaccuracy.1484 Evans {Day73/52:13-19}.
¶24.110 On page 3, it contained the following disclaimer:
"The classification applies only to the system as tested and detailed in the classification report. The classification report can only cover the details of the system as tested. It cannot state what is not covered. When specifying or checking a system it is important to check that the classification documents cover the end-use application".1485 {CEL00000012/3}.
¶24.111 The next page of the Compliance Guide contained a description of the system tested together with a diagram, Figure 4. The following components were listed:
¶a. 12mm Fibre Cement Panels;
¶b. Supporting aluminium brackets and vertical rails;
¶c. 100mm Celotex RS5000;
¶d. 12mm non-combustible sheathing board;
¶e. 100mm SFS system; and
¶f. 2 x 12.5mm plasterboard.1486 {CEL00000012/4}.
¶24.112 The description did not disclose either the presence of the 6mm magnesium oxide boards nor the 8mm Marley Eternit boards. Although the text goes on to warn that "the fire performance and classification report issued only relates to the components detailed and constructed in Figure 4" and that "any changes to the components listed and construction method set out in Figure 4 will need to be considered by the building designer",1487 {CEL00000012/4}. Figure 4 also omitted any reference to those elements. They had been omitted because, as
147¶Mr Evans admitted, any reference to them would have revealed that the system tested had been entirely unrepresentative of a commercial construction.1488 Evans {Day73/62:15-22}.
¶24.113 The failure to refer to the 6mm magnesium oxide boards or the 8mm Eternit boards completely undermined the disclaimers on pages 3 and 4. If the description of the system tested was materially incomplete, as it was, even the most rigorous attempt to reproduce it was bound to fail. In its statements to the Inquiry Celotex was at pains to point out that the statements that RS5000 was suitable for use on buildings over 18 metres in height should be read in the context of the disclaimer on page 3 of the Compliance Guide, but the disclaimer was effectively meaningless, as Celotex well knew.
The Specification Guide
¶24.114 The introduction to the Specification Guide described RS5000 as
"a premium performance PIR solution for use in rainscreen cladding applications and suitable for use in building (sic) above 18 metres in height".1489 {CEL00000013/3}.
¶and in a section headed "Fire Performance", it went on to describe RS5000 as having been
"successfully tested to BS8414-2:2005 […], meets the criteria set out in BR 135 and is therefore acceptable for use in buildings above 18m in height".1490 {CEL00000013/5}.
¶This slogan was repeated throughout Celotex's other marketing material for RS5000.
¶24.115 Almost identical wording could be found in a Technical Bulletin issued by Kingspan in 2011, in which it described K15 as "successfully tested to BS8414:2002, can meet the criteria within BR 135 and is therefore acceptable for use above 18 metres".1491 {CEL00008510}. The similarity was not coincidental. As Mr Roper confirmed, Celotex took the wording directly from Kingspan's literature.1492 Roper {Day71/184:16-17}. Celotex had identified the device by which Kingspan had for years succeeded in selling an insulation product tested in one particular configuration for general use on buildings above 18 metres in height and had decided to adopt it.
¶24.116 The Specification Guide then described the system tested in the same terms as the Compliance Guide (i.e. without mentioning the 6mm magnesium oxide or 8mm Marley Eternit boards), together with the qualification that "the fire performance and classification report for Celotex RS5000 only relates to the components detailed above".1493 {CEL00000013/5}. Unlike the Compliance Guide, there is no diagram identifying that the listed "fibre cement panels" were in fact Marley Eternit. It did refer readers to the Compliance Guide for "full" specification details and provided a draft specification clause which said that "RS5000 has been successfully tested to BS8414-2:2005 and meets the performance criteria of BR 135".1494 {CEL00000013/8}.
¶24.117 Mr Roome accepted with hindsight that the Specification Guide was a thoroughly misleading document,1495 Roome {Day69/99:10-12}. and that a reader might have interpreted the claim that RS5000 was suitable for use on buildings over 18 metres in height as meaning it could be used generally above that height.1496 Roome {Day69/100:1-9}. The document was indeed thoroughly misleading and, although Mr Roome himself may not have realised it, had been deliberately crafted to mislead the reader into buying RS5000 for use on buildings over 18 metres in height without worrying about whether the external wall of which it was to form part was the same as that which had been tested. The disclaimer on page 5 that the fire performance and classification report related only to the components listed was not only buried away in the small print but was, as we have explained, itself disingenuous because the components of the system tested had not been fully described.
148Other marketing documents
¶24.118 The Handy Guide repeated the expression "the first PIR board to meet the criteria set out in BR 135 and therefore is acceptable for use in buildings above 18m in height", without qualification, although it advised that the product should be installed in accordance with instructions supplied by Celotex.1497 {CEL00000437/8}.
¶24.119 The Product Datasheet contained the same claim prominently on the first page.1498 {CEL00007961/1}. Headers on each page included, without qualification, the words "suitable for buildings above 18m in height". Mr Roper explained that the reason for the disclaimer being placed on the third page was that certain people at Celotex wanted "to dilute that system message as much as they could".1499 Roper {Day71/205:8-10}. Mr Evans did not agree; his view was that it was not intended to be a free-standing statement but was to be read in conjunction with the description of the system that had been tested,1500 Evans {Day73/70:23}-{Day73/71:2}. but the description given on the third page of the Product Datasheet did not mention the magnesium oxide boards or the use of 8mm Marley Eternit. The section did contain a warning that the fire performance and classification report related only to the components described above,1501 {CEL00007961/3}. but that was itself misleading because the components of the system tested had not been fully described.
¶24.120 A press release prepared for the launch of RS5000 described it as a "new premium performing PIR solution for rainscreen cladding applications."1502 {CEL00009599/1}. That claim was itself false, because RS5000 was merely FR5000 under a different name. The press release repeated the claim that RS5000 was "acceptable for use in buildings above 18m in height" without qualification.
¶24.121 Taken in the round, the marketing literature for RS5000 contained two messages, both of which were false and deliberately misleading. The first, aimed at the designer or cladding specialist who did not read beyond the first page, was that RS5000 was suitable for use on any building over 18 metres in height, whereas it was not. The second was the warning aimed at the more conscientious reader that the fire performance and classification for RS5000 related only to the components described as making up the system tested, when in fact the components were misdescribed.
149Internal launch of RS5000
¶24.122 RS5000 was launched on 5 August 2014, at a regional sales meeting at which Jonathan Roper gave a presentation to the sales team about the product.1503 Roper {Day71/208:16-22}. His slide presentation1504 {CEL00008668}. included a quotation from paragraph 12.7 of Approved Document B1505 {CEL00008668/5}. as well as the historical context provided by the fires at Knowsley Heights,1506 {CEL00008668/11}. Garnock Court,1507 {CEL00008668/13}. and in Dubai.1508 {CEL00008668/14}. Although he referred to test method BS 8414 and explained in terms that BR 135 was a system classification,1509 {CEL00008668/15-16}. he repeated the assertion that RS5000 was the first PIR board to meet successfully the performance criteria in BR 135 for insulated cladding systems and was therefore acceptable for use in buildings above 18 metres in height.1510 {CEL00008668/26}.
¶24.123 Jonathan Roome was present at the launch. Although he understood from the presentation that a BR 135 classification applied only to the system as tested,1511 Roome {Day69/52:1-9}. he accepted that the words "therefore acceptable for use above 18 metres in height" gave the impression that RS5000 was generally suitable for use on high-rise buildings and could be read as a representation that it was suitable for use in any rainscreen system on buildings over 18 metres in height.1512 Roome {Day69/53:2-9}. That is consistent with the evidence of Mr Roper, who said that, although he had wanted to make it clear that the test applied to a system as a whole, he had felt that the members of the management action group present at the launch had not wanted that message to be too prominent. He agreed that the combination of an early reference to the nature of the classification and the subsequent emphasis on the sales message had been a way of satisfying the technical requirements while giving a strong message to the sales teams that RS5000 was generally acceptable for use on buildings over 18 metres in height.1513 Roper {Day71/213:2-13}.
¶24.124 The launch presentation did not describe in any detail the system that had been tested but it did contain a diagram showing the rainscreen panel as 12mm Marley Eternit over 100mm of insulation.1514 {CEL00008668/27}. Mr Roome confirmed that he understood that to have been the system tested because it matched the depiction in the Compliance Guide and Specification Guide.1515 Roome {Day69/59:1-5}. That was all that he and the rest of the sales team were given by way of information about the system tested.1516 Roome {Day69/97:2-9}. He was not aware that 6mm magnesium oxide boards had been used in the test,1517 Roome {Day69/60:2-6}. and never became aware of it during the remainder of his time at Celotex.1518 Roome {Day69/60:19-23}.
¶24.125 The failure to identify the true components of the test in May 2014 was only one of a number of ways in which the presentation was misleading. It also implied that RS5000 was a completely new product and made no mention of the first, failed, test in February 2014. Mr Roome confirmed that he had not been aware of either fact. That was the result of a deliberate choice by Celotex.1519 Roper {Day71/220:19}-{Day71/221: 9}. In similar vein, Mr Roome was provided with the 12-page classification report only when he requested it following a direct enquiry from Harley,1520 Roome {Day70/73:12-16}. and during his time at Celotex he never saw the full 32 page test report.1521 Roome {Day70/73:17-22}.
150Aftermath of the launch
Relations with NHBC
¶24.126 As we have already explained, Celotex had been in contact with NHBC since November 2013, when Mr Roper sought advice from Graham Perrior about his interpretation of the requirements for use of insulation on buildings over 18 metres in height.1522 {CEL00000748}. His approach was prompted by concerns about apparent inconsistencies in the approach being taken by NHBC.1523 Roper {Day70/198:5-15}. That was again motivated by a desire to understand how Kingspan was being widely used despite having carried out only one BS 8414 test.1524 Roper {Day70/201:20-22}.
¶24.127 On 15 May 2015 Jonathan Roper told Graham Perrior and David White of NHBC that Celotex had passed a BS 8414 test.1525 Roper {Day71/166:9-18}. We have already touched briefly on the meeting between Celotex and NHBC on 19 June 2014 which was held to discuss that test.1526 Roper {CEL00010052/15} page 15, paragraph 7.1. At that meeting NHBC raised a number of concerns which Mr Evans recorded on a white board.1527 {CEL00002517}. Celotex did not tell NHBC about the test in February 2014 which had failed or about the use of the 6mm magnesium oxide boards used in the successful test in May 2014.1528 Roper {CEL00010052/16} page 16, paragraph 7.4 Celotex deliberately misled NHBC about the true nature of the system that had been tested in order to obtain its approval of RS5000, which was seen as critical to the success of the product.1529 Roper {Day71/172:2-11}.
¶24.128 On 30 July 2014, Mr Roper sent the final draft of the test report to David White and Graham Perrior,1530 {CEL00000992}. possibly at the request of NHBC.1531 Roper {Day71/181:9-22}. That involved a certain level of risk, because the report contained the photograph showing the presence of the magnesium oxide boards. Mr Roper gave NHBC the impression that the report described exactly what had been tested,1532 {CEL00000992}. but that was not the case, since it omitted any reference to the magnesium oxide boards and the 8mm ruby Eternit panels.
¶24.129 By September 2014, NHBC was still expressing reservations about RS5000. On 5 September 2014, Jonathan Roper sent an email to Paul Evans explaining that he was aware of instances in which building control officers had refused to accept RS5000 on the basis that it had not been approved by NHBC.1533 {CEL00001020}. On the same date, a Celotex area sales manager, Michael Healey, asked NHBC to explain what problems it had with the test data.1534 {CEL00001022/3}. His request was made in response to a message from a designer on a project in which the NHBC project manager (Jon Behan) had said that there were questions about the tests that had been carried out and that the matter had been raised with Celotex.1535 {CEL00001022/4}.
151¶On 22 September 2014, Mr Behan replied to Mr Healey, telling him that at present Celotex had no relevant test certificate to show that RS5000 was suitable for use on buildings over
¶18 metres in height.1536 {CEL00001022/2}. When Mr Healey referred to the test that Celotex had undertaken,
¶Mr Behan said that NHBC had "issues" with it and that the Celotex technical department was well aware of them.1537 {CEL00001022/4}. Mr Healey sent that exchange to Mr Roper who in turn sent it on to Mr Evans.1538 {CEL00001022/1}. It was understood as an indication that NHBC would not accept the use of RS5000 on buildings over 18 metres in height.1539 Evans {Day73/126:2-6}.
¶24.130 The importance of NHBC approval to Celotex was reflected in its 2015 budget presented at Saint Gobain's headquarters at Les Miroirs in Paris on 14 October 2014, which included £20,000 for "NHBC 'buy-in' for above 18m applications".1540 {CEL00003342/21}. It is unclear what the money was actually allocated for. Paul Evans thought that it might have been for additional testing but could not recall.1541 Evans {Day73/176:17-19}. He denied, however, that it was for lobbying.1542 Evans {Day73/176:20-23}. Despite its importance to Celotex, NHBC's approval of RS5000 for use on buildings over 18 metres in height was not forthcoming. By 7 January 2015, Celotex had learned through an email sent by a client (Nigel Shields of Durkan) to another Celotex area sales manager (Nigel Waring) that NHBC would not accept Celotex fire test data because it did not represent a true test of the product in all its applications. Worse still, NHBC was very nervous of its use on high-rise buildings and had taken steps to consult fire and rescue services.1543 {CEL00003445}. Although, as Mr Evans accepted, that was an indication that NHBC regarded RS5000 as dangerous,1544 Evans {Day73/127:17-25}-{Day73:128:1-3}. it did not cause Celotex to reconsider its marketing strategy.
Problems in the market
¶24.131 At the same time as NHBC was making its disquiet clear, difficult questions were being asked by clients about the breadth of application of Celotex's BR 135 classification. On 16 January 2015, Daniel Anketell-Jones of Harley sent an email to Jonathan Roome in relation to another project,1545 {CEL00000019/2}; Roome {Day70/63:14-18}. in which he explained that a customer had asked exactly how RS5000 had been installed when it was tested, who had carried out the testing, how it had been fixed, what it had been covered with, what rainscreen had been used, what support structure, and, most importantly, what had been the results. Mr Anketell-Jones described the request as a headache for Celotex, which indeed it was, because it was seeking detailed information that Celotex did not wish to make public.1546 Roome {Day70/61:16-22}.
¶24.132 The challenges faced by Celotex from the more astute section of the market were most clearly illustrated by a complaint made by Ardmore Construction Ltd in March 2015 after NHBC had rejected the use of RS5000 that had been installed on a high-rise building at Octavius Street in Deptford, London.1547 {CEL00002193}. Ardmore's Technical Director had complained about a lack of clarity in the marketing literature and asked for evidence of the fire testing on which Celotex relied to support its claim that RS5000 was suitable for use on buildings over 18 metres in height. Mr Evans told us that the complaint had been taken seriously at Celotex,1548 Evans {Day73/166:22-25}. but the marketing literature remained unchanged. He was unable to explain why Celotex had not been concerned that it was not clear enough to avoid a problem with a major developer and why there had not been discussions within Celotex about improving it.1549 Evans {Day73/165:3-9}; {Day73/167:8-15}.
152LABC approval
¶24.133 Celotex also sought to obtain an LABC certificate for RS5000. It was seen as an important form of approval,1550 Roper {Day72/26:9-16}. in part because it would protect the use of RS5000 from the risk of challenge.1551 Roper {Day71/35:11-16}; {Day72/44:15-22}. It was also seen as a route by which Celotex could market RS5000 as being suitable for use in systems other than that tested.1552 {CEL00000735/4}; Roper {Day72/29:24}-{Day72/30:7}. Before the test in February 2014 Mr Roper had been in contact with David Ewing of the LABC, who was then responsible for managing the Registered Details scheme,1553 Ewing {Day217/95:18-22}. and had been told by him that as Kingspan K15 was described as Class 0, it could be described as a material of limited combustibility.1554 {CEL00000939/5}. Mr Roper realised that that was wrong but he did not correct the LABC's mistake because he thought it was advantageous to Celotex not to do so.1555 Roper {Day72/34:14-23}.
¶24.134 The first LABC certificate for RS5000 was issued on 21 August 2014.1556 {CEL00000010}. The accompanying drawing and document list stated that it was "for use in rainscreen wall construction including above 18m in height".1557 {CEL00000009}. The only test information provided was contained in the Advice Notes, which said that RS5000:
"had successfully tested to BS 8414:2 2005, meets the criteria in BR 135 and is therefore acceptable for use in buildings with storeys above 18m in height (subject to the board being fixed to a non-combustible substrate) alternative compliance to ADB".1558 {CEL00000009}.
¶That wording had been taken directly from an email Mr Roper had sent to Tim Bartlett of
¶West Suffolk building control, the person responsible for preparing Celotex's Registered
¶Details certificate, even to the point of including the transposition of a typographical error.1559 {CEL00001995}. However, the wording and the message it was intended to convey was untrue and misleading.1560 Roper {Day72/41:14-20}. The certificate, together with the document and drawing list, were sent by
¶Jonathan Roome to Daniel Anketell-Jones of Harley on 27 August 2014.1561 {CEL00000006}.
¶24.135 In early November 2014, Samantha Li of the LABC sent an email to Jonathan Roper explaining that the LABC was intending to change the form of its certificates and that the certificate for RS5000 would be reissued in the new style.1562 {CEL00002021/2}. Mr Ewing explained that he had decided to change the form of Registered Detail certificates because he thought that the previous version did not give enough information to local authorities considering whether to approve the use of materials.1563 Ewing {Day217/122:13-25}-{Day217/123:1-3}. He had been prompted to take that course by concerns raised in relation to the certificate relating to Kingspan's K15.1564 Ewing {Day217/123:16-20}.
153¶24.136 The new certificate was attached to Ms Li's email. It stated that it had first been issued on 21 August 2014 and was valid until 21 August 2015.1565 {LABC0000312}. It now stated on the first page that RS5000 complied with BR 135 for use in rainscreen applications on buildings over 18 metres in height, but referred the reader to the conditions of the certificate for more information. They made clear that RS5000 was acceptable for use on such buildings "subject to matching the specification criteria of the BRE fire test report 295255 carried out".
¶24.137 Mr Roper, whose role as product manager of RS5000 had by this time passed to Debbie Berger, sent the email to Ms Berger on 3 November 2014, asking her to reply to the LABC with a request that it remove references to the fact RS5000 was the same product as FR5000.1566 {CEL00002021}. Ms Berger replied to Samantha Li on 6 November 2014, attaching some suggested text which removed the reference to the test report and repeated the claim that RS5000 complied with BR 135 "subject to the board being fixed to a non-combustible substrate". She also included a reference to a BBA certificate.1567 {CEL00002022}. Ms Berger accepted that that her proposed text had been misleading,1568 Berger {Day78/75:2-8}. as it suggested that the product could be used in any system with a non-combustible substrate and not merely the system that had been tested. Furthermore, it was not true that there was a BBA certificate relating to RS5000.1569 Berger {Day78/77:5-16}.
¶24.138 Later the same day Ms Berger sent Ms Li another email, observing again that the new certificate was available on the LABC website and asking for access to it to be restricted until they had sorted out the wording.1570 {CEL00008691/2}. Ms Li replied, saying that she would check with her manager to see if they could prevent the page from being available to the public. The LABC appears to have treated that as a request for the registration to be withdrawn.1571 Phase 2 Module 2 – Written closing submission on behalf of LABC {LABC0019740/28} page 28, paragraph 73. Celotex does not appear to have been told that the registration was being withdrawn, but we accept that it was removed from the LABC's website as a result of its request.
¶24.139 Six months later Mr Ewing wrote to Celotex again, referring to concerns about the wording of certificates1572 {CEL00001286}. and attaching a further revised certificate in draft.1573 {CEL00003741}. The revised certificate was finally issued in September 2015,1574 {CEL00000389}. long after the initial orders of RS5000 for Grenfell Tower had been placed.
Handover to Debbie Berger
¶24.140 Ms Berger took over the role of product manager with responsibility for RS5000 from Mr Roper on 1 October 2014.1575 Berger {Day78/6:15-17}. On 26 September she had a handover meeting with Mr Roper during which nothing was said about the use of 6mm magnesium oxide boards during the test in May,1576 Berger {Day78/27:7-12}. although the concerns about the test raised by NHBC were mentioned.1577 {CEL00002555/2}. Ms Berger discovered that the 6mm magnesium oxide boards had been used only later when she spoke to Mr Hayes on 24 October 2014 with a view to understanding the nature of the test in greater technical detail. His demeanour on that occasion led her to think that he had concerns about the test.1578 Berger {Day78/39:17-21}. On 27 October 2014,
154¶Ms Berger obtained the full 32 page test report from Mr Roper1579 {CEL00009742}. and met Mr Hayes again, either the same day or some days later, to discuss it. Mr Hayes told Ms Berger about the
¶6mm magnesium oxide boards and using a diagram showed her where on the rig they had been placed.1580 {CEL00002686}; Berger {Day78/41:23}-{Day78/42:4}. Ms Berger also made a note on her copy of the report, next to a diagram of the system before the test, with the expression "WTF? 6mm MgO + 8mm Marley Eternit panel".1581 {CEL00008507/13}. She had clearly been shocked by what she had been told.1582 Berger {Day78/52:14-19}. Despite her shock, however, Ms Berger took no steps to alert her colleagues or anybody else to the fact that the report did not accurately describe the system tested.1583 Berger {Day78/61:19-23}.
Contact with BRE
¶24.141 On 8 October 2014 Jonathan Roome attended a CWCT conference,1584 {CEL00001255}. at which Dr Sarah Colwell of BRE was one of the speakers. Mr Roome met her and together they arranged a meeting between her and one of her colleagues to discuss, as Mr Roome put it, how Celotex might improve its approach to marketing RS5000.1585 {CEL00001255}. The meeting was planned for 4 November 2014.
¶24.142 A week later, on 17 October 2014, Stephen Howard of BRE sent an email to Mr Roper and Ms Berger referring to an earlier conversation about the content of the classification reports and the amount of technical detail they contained.1586 {CEL00002131}. Ms Berger sent the message on to Mr Roome on 20 October 2014, saying that she would set up a meeting with Mr Howard to discuss how the report on RS5000 could be structured to provide relevant commercial information without disclosing anything sensitive.1587 {CEL00002131}.
¶24.143 In the event, Mr Roome and Ms Berger met Mr Howard on 4 November 2014. Dr Colwell did not attend. Notes of the meeting prepared by Ms Berger refer to growing uncertainty in the market, which had been "burnt by K15 approvals in the past".1588 {CEL00001260}. That was a reference to an unhappy experience which NHBC had had in the latter months of 2013 and thereafter with the BBA certificate for K15 and its widespread use above 18 metres.1589 See Chapter 26 for the detailed analysis. Ms Berger noted that accreditation bodies required more information in order to give approvals and that further testing with a variety of facades was required.
155February 2015: market analysis slideshow
¶24.144 For the purpose of a meeting of the Service Product Innovation Group in February 2015 Mr Roome prepared a series of slides identifying three tiers of potential customers. (We have described the slides and what they depicted in Part 6, Chapter 56 dealing with the way in which Celotex RS5000 insulation came to be chosen for use in the refurbishment.) He denied that their implication was that the more ignorant a customer was of the restriction on the use of combustible insulation on buildings over 18 metres in height and the less well-equipped to ask difficult technical questions, the more likely it was that Celotex would be able to sell it RS5000,1590 Roome {Day 69/81:23}-{Day69/82:4}. but it is difficult to see how else they can be understood.
¶24.145 As we have said, the slides reflected a deeply cynical view that there were ignorant or reckless contractors in the market of whom advantage could be taken without any regard for the safety of occupants.
¶24.146 A very different approach to knowledgeable third parties can be seen in an email sent by Jamie Hayes to Paul Evans, Rob Warren and Louise Garlick on 25 March 2015 with advice on what to say where NHBC or LABC were involved and the client's proposed construction differed from the system tested.1591 {CEL00003597} In the case of the LABC, potential customers were to be provided with a copy of the Compliance Guide and advised that, if they were using a substantially different design from the system tested, they should discuss the position with building control. If NHBC was involved, clients were to be provided with the Compliance Guide and told that Celotex did not support the use of RS5000 unless the design of the proposed system exactly matched the description given in its literature (although that did not in fact reflect the system that had been tested). Following discussions with Mr Evans, Mr Hayes subsequently promulgated an internal instruction at Celotex that in all cases where it provided a U-value calculation, and where it was asked whether a particular design complied with the Building Regulations, a copy of the Compliance Guide should be provided and customers told that it was the responsibility of building control to judge compliance.1592 {CEL00003604}.
Desktop study (March 2015)
¶24.147 In due course a meeting took place on 20 February 2015 between Frans Paap and Andrew Evans of Exova and Debbie Berger and Rob Warren of Celotex.1593 Berger {CEL00010055/57} page 57, paragraph 213. The notes of the meeting record that Exova needed to see the full test report and the Class 0 reports and refer to the need for a "case by case basis assessment".1594 {CEL00002691}. Ms Berger said that she had not understood that to mean that a separate desktop assessment would have to be made for each project.1595 Berger {Day78/144:21-25}.
¶24.148 On 18 March 2015 Ms Berger sent Mr Paap the full 32 page RS5000 test report. Her covering email set out four systems which she said were commonly presented to Celotex at the design stage and which she wanted Exova to assess: brickwork, a ventilated cavity with terracotta cladding, a ventilated cavity with A1 cladding and a ventilated cavity with a Class 0 aluminium rainscreen.1596 {CEL00003589}. However, as she ought to have realised, any desktop study based on the test report was bound to be misleading and dangerous because the report did not correctly describe the system tested.1597 Evans {Day73/154:21}-{Day73/155:1}.
156Exova's draft report
¶24.149 Exova produced a draft report dated 7 May 2015.1598 {CEL00002040}. It set out the test evidence relied on, which had been taken from the full 32-page BRE Report.1599 {CEL00002040/5}. It did not refer to the 6mm magnesium oxide boards or the 8mm Marley Eternit boards because they did not appear in the report and Mr Paap had not been told about them.1600 Berger {Day78/149:13-24}.
¶24.150 The report concluded that all the designs set out in Ms Berger's email would pass, save for the ventilated cavity system with aluminium Class 0 cladding. In respect of any such system, Exova concluded that it could not be judged with certainty to meet the performance requirements in BR 135.1601 {CEL00002040/9}. The report was formally issued on 26 May 2015.1602 {CEL00001116}.
NHBC's reaction
¶24.151 The draft report was presented to NHBC at a meeting on 19 May 2015 attended by Debbie Berger, Paul Evans and Rob Warren for Celotex and Graham Perrior, Steve Evans, David White and John Lewis for NHBC.1603 Berger {CEL00010055/61} page 61, paragraph 230; {CEL00003682}. It was not well received by NHBC, which considered that its generic nature indicated a failure by Celotex to understand the purpose of desktop studies.1604 Berger {Day78/156:22}-{Day78/157:6}. The monthly report to the management action group described the meeting as "quite heated".1605 {CEL00003710/8}.
¶24.152 NHBC's objections were set out in greater detail in an email sent by Mr Perrior to Mr Evans on 8 June 2015, which was sent on by Mr Evans to Ms Berger and Mr Warren. In it Mr Perrior identified a number of shortcomings and concluded that it appeared that the basis of Exova's analysis did not reflect a true model of a ventilated facade or take fully into account the fact that a large part of the Marley rainscreen had caught fire.1606 {CEL00001122/2}. NHBC did not, of course, know that the description of the system in the Exova report contained material omissions; its concern was whether a system such as that described would ever be built in practice. Mr Evans told us that he had been concerned by the fact NHBC thought Celotex's position was untenable and that nothing, in effect, had changed in the year since their meeting on 19 June 2014. However, he intended to work with NHBC to understand what needed to be done to gain its acceptance.1607 Evans {Day73/195:19-25}. The report to the management action group acknowledged that at some point it would be necessary to consider another test to broaden the scope of use of RS5000.1608 {CEL00003710/8}. However, Celotex kept selling RS5000 and no further testing was undertaken before the fire at Grenfell Tower.
157Chapter 25: Certification of Celotex RS5000 by LABC
Initial contact with LABC
¶25.1 On 29 October 2013, Jonathan Roper, Celotex's Product Manager, spoke to Cathal Brennan, LABC's Technical Co-ordinator about the possibility of obtaining an LABC certificate for RS5000. Mr Brennan informed his colleague David Ewing, the manager of LABC's Registered Details Approval scheme,1609 Ewing {LABC0020139/4} page 4, paragraph 7.6. of the conversation by email, telling him that Mr Roper had asked a number of questions about a competitor (by which he subsequently confirmed he meant Kingspan) and LABC's relationship with it.1610 {LABC0008417}.
¶25.2 Celotex saw obtaining an LABC Registered Details Certificate as an important step in promoting RS5000,1611 Roper {Day72/26:9-16}. in part because it would protect its use from the risk of challenge by building control officers.1612 Roper {Day71/35:11-16}; {Day72/44:15-22}. Indeed, marketing material sent by LABC to Celotex included the claim that it could be considered a "fast track" through building control because, once it had been approved, local authority building control departments would not have to repeat the process.1613 {CEL00010021/1}.
¶25.3 Mr Roper subsequently met Mr Ewing on 18 November 2013 at Celotex's offices to discuss the process of obtaining an LABC certificate. Mr Ewing understood that Celotex wanted a certificate to enable the product to compete with Kingspan K15.1614 Ewing {Day218/143:1-11}. He was not aware at that stage that RS5000 was the same as FR5000; he had believed that Celotex had been developing a new product.1615 Ewing {Day218/143:12-20}.
¶25.4 At the meeting, Mr Roper questioned whether Kingspan K15 could be described as a material of limited combustibility (as it was in the LABC certificate then in force).1616 Ewing {Day218/147:18-20}. Mr Ewing was not able to answer that question, given his lack of knowledge at the time, so he asked David Jones, who had carried out the research leading to the issue of the certificate relating to K15.1617 Ewing {Day218/147:22}-{Day218/148:4}.
¶25.5 On 19 December 2013 Mr Ewing sent Mr Jones an email seeking his assistance with Celotex's question.1618 {LABC0005339}. On 20 December 2013 Mr Jones responded, referring Mr Ewing to section 7 of the BBA certificate relating to K15, an extract from Kingspan's technical literature and LABC's internal assessment. Mr Jones told him that as K15 was described as Class 0, it could be termed a material of limited combustibility and so was suitable for use on buildings over 18 metres in height in accordance with Approved Document B. That was a fundamental misunderstanding on his part1619 Chapter 5. and none of the material Mr Jones relied on supported that conclusion. Mr Ewing told us that he had not been sure that that answered his question, but he assumed that that was due to his own lack of understanding.1620 Ewing {Day218/150:11-24}. Nevertheless, he did not seek help from anyone else in attempting to understand it.1621 Ewing {Day218/151:5-11}. Mr Ewing passed the substance of Mr Jones's response on to Mr Roper on 2 January 2014.1622 {LABC0001706}. Mr Roper replied on 3 January 2014, stating that Celotex was confident that it could also prove that RS5000 was classified as Class 0.1623 {LABC0001706}. He realised that LABC had made a fundamental mistake but thought that it was viewed as advantageous to Celotex and therefore did not correct Mr Ewing.1624 Roper {Day72/32:15}-{Day72/33:23}.
158Registered Detail 491
¶25.6 Following the test in accordance with BS 8414-2:2005, on 2 May 2014, Mr Roper contacted Mr Ewing again on 15 May 2014 to confirm that Celotex wanted to pursue an application for an LABC Registered Details Certificate.1625 {LABC0001706}. Tim Bartlett of West Suffolk District Council had been identified by LABC as a suitable person to assess the product because he was on LABC's registration and partnerships group and regularly involved in peer reviews, but no steps had been taken to ascertain his level of understanding of Approved Document B.1626 Ewing {Day218/153:16}-{Day218/154:10}.
¶25.7 Mr Bartlett visited Celotex's office1627 {LABC0000279}. during the week of 9 June 2014 to discuss the application. Following his visit, Mr Roper provided what he called the "first batch" of information to support the application and set out the wording that Celotex was seeking to have included in the certificate.1628 {LABC0000279}. It read as follows:
" – Celotex RS5000 can be used with a variety of cladding systems (including masonry or rainscreen systems) and can be fixed back to a structural steel frame with a sheathing board or direct back to masonry. … – Celotex RS5000 has successfully tested to BS 8414:2 2005, meets the criteria set out in BR 135 and therefore is acceptable for use in buildings with storeys above 18m in height (subject to the board being fixed to a non-combustible substrate) alternative compliance to AD B. – The product has Class 0 fire performance."
¶25.8 That description of RS5000's fire performance had been taken almost directly from Appendix A to the Registered Details certificate for K15.1629 {LABC0001001/2}; Roper {Day72/41:4-24}. Mr Ewing thought he had realised at the time that Celotex was effectively seeking the same broad statements that had been made in respect of Kingspan K15.1630 Ewing {Day218/155:11-25}.
¶25.9 Mr Roper sent a further email to Mr Bartlett on 17 June 2014 providing a copy of a letter from BRE confirming that a system incorporating RS5000 had been tested in accordance with BS 8414-2 and that a test report and classification document under BR 135 was being issued.1631 {LABC0000329/3}. The letter did not give any details about the system that had been tested, nor did it say what conclusions BRE had drawn when classifying it.1632 {LABC0000285}.
159¶25.10 Notwithstanding that, on 30 June 2014 Mr Bartlett sent an email to Mr Brennan telling him that that was his last day at West Suffolk and that although he had not been able to finalise Celotex's certificate pending provision of further information, once that information was available he expected it to satisfy the requirements.1633 {LABC0000306}. Among the information that was yet to be received was the BR 135 classification report from BRE.1634 Ewing {Day218/158:3-11}. Mr Bartlett attached to his email a draft Compliance Declaration form, Drawing and Documents List and a briefing note which stated:
"Celotex RS5000 has been successfully tested to BS 8414:2 2005, meets the criteria set out in BR135 and therefore is acceptable for use in buildings with storeys above 18m in height (subject to the board being fixed to a non-combustible substrate) alternative to compliance to AD B."1635 {LABC0000345/2}.
¶That was the very wording that had been requested by Jonathan Roper and was used by Celotex as a central plank of its marketing strategy. By suggesting, and then relying on, untrue and misleading statements of that kind it hoped to avoid challenge by building control officers.1636 Roper {Day72/44:15}-{Day72/45:6}; {Day72/46:15-18}. However, a statement that Celotex RS5000 had been successfully tested to BS 8414 and met the criteria set out in BR 135 could never properly be made, since such claims could be made only in relation to the system as a whole and not in relation to individual components. It is remarkable that LABC saw fit to prepare a draft of that kind without having seen the classification report itself. Its approach was fundamentally flawed.1637 Ewing {Day218/158:12-16}. However, at the time no one at LABC challenged Mr Bartlett's approach or the claims made about the product's performance. Mr Ewing accepted that he might have been under the misapprehension at the time that if a product had formed part of a system which had obtained a classification report in accordance with BR 135, it could be used on any buildings above 18 metres in height.1638 Ewing {Day218/158:17-21}.
¶25.11 In the event, despite having left West Suffolk, Mr Bartlett continued to be involved in the assessment process for RS5000. On 24 July 2014, he sent an email to Mr Brennan (with a copy to Mr Ewing) attaching further documents for the RS5000 certificate and indicating that it was ready for peer review.1639 {LABC0000339}. Among the attachments to that email were BRE's letter of 17 June 20141640 {LABC0000342}. and a Class 0 classification report for RS5000 dated 14 July 2014.1641 {LABC0000344}. No BR 135 classification report was attached, not least since LABC had not received one. Further, none of the attachments described the system that had been tested or how it had performed against the criteria in BR 135. Mr Bartlett told Mr Ewing that Celotex was still waiting for the test report but had provided the letter from BRE in the hope that LABC would accept it as sufficient proof of compliance.1642 {LABC0005566}.
¶25.12 On the same day, Mr Brennan circulated the Compliance Declaration, Drawings and Document List and details of RS5000 to the peer review group.1643 {LABC0005564}. Mr Bartlett responded the same day, attaching a draft certificate,1644 {LABC0000369}. the wording of which stated that RS5000 was suitable for use on buildings over 18 metres in height.1645 {LABC0000370}.
160¶25.13 On 8 August 2014, Mr Ewing sent an email to Cathal Brennan and Sam Li Muller noting that Celotex had still not provided a BR 135 classification report.1646 {LABC0005598}. He observed that that was an important document as LABC was under scrutiny from NHBC regarding its certification of Kingspan K15.1647 As to that, see Chapter 23. He said that the certificate for RS5000 should not be issued until the report had been received.1648 {LABC0005598}.
¶25.14 Later that day, an LABC employee, Robert Adungo, sent an email to Mr Brennan noting that Celotex's publicity for the launch of RS5000 included the claim that it was "supported by LABC approval". That was not correct, because LABC had not issued a certificate. Nonetheless, Mr Brennan told Celotex that it could refer to LABC at the product launch, presumably in a way that implied that LABC had approved, or was going to approve, the product.1649 {LABC0005601}. Mr Brennan said that he had acted on the basis of a misunderstanding of BRE's letter of the 17 June 2014 and on the fact that RS5000 had received four votes at the peer review stage.1650 {LABC0005601}. However, the holding letter from BRE did not provide any basis for a claim of that kind and those who carried out the peer review had not themselves been provided with a classification report and so had no basis for reaching any final view about the product's compliance with the statutory guidance.1651 Ewing {Day218/175:18}-{Day218/176:9}. That was plainly not an acceptable approach.1652 Ewing {Day218/172:18-23}.
¶25.15 Mr Ewing sent an email to Mr Roper shortly after, asking for the classification report.1653 {LABC0000288/2}. Mr Roper responded, attaching a copy of the BR 135 classification report.1654 {LABC0000288}; {LABC0000289}. Mr Ewing sent it on to Mr Brennan, with the comment that it contained everything needed to satisfy the criteria in paragraphs 12.5 and 12.6 of Approved Document B. However, in saying that Mr Ewing was still labouring under the misapprehension that the classification report provided some form of general support for the use of RS5000 on buildings over 18 metres in height, which was not the case.1655 Ewing {Day218/178:15-17}. The question put to Mr Ewing referred to K15 but was clearly intended to refer to RS5000.
¶25.16 Despite having been alerted to the fact that Celotex's marketing and promotional materials included a claim that RS5000 had its approval, notwithstanding that it had not issued a certificate for the product, LABC did not attempt to make Celotex correct that statement or remonstrate with it for making a misleading claim.1656 Ewing {Day218/180:4-11}.
¶25.17 On 11 August 2014, Mr Bartlett confirmed that, having seen the classification report, everything appeared to be in order, although he noted that it related to the particular system tested rather than the use of RS5000 on buildings over 18 metres in height generally. He therefore questioned whether the certificate should be limited to the specific system tested.1657 {LABC0005608}. In response, Mr Ewing confirmed that the certificate should relate to what had been tested,1658 {LABC0005608}. but then expressed the view that the rainscreen construction was relatively standard, a comment for which, as he accepted, there had been no basis.1659 Ewing {Day218/181:21-24}. Despite that fact, the LABC issued a certificate which implied generic approval for the use of RS5000 on buildings over 18 metres in height.1660 {LABC0000360}, {LABC0000361} and {LABC0000362}. The certificate was effective from 21 August 2014 until 21 August 2015.1661 {LABC0000358} and {LABC0000359}. It was accompanied by a Drawing and Document List. The contents of the certificate are set out in detail in Chapter 24. We reiterate that it gave an untrue and misleading impression that RS5000 was suitable for use on buildings over 18 metres in height generally.
161Withdrawal and reissue of registered detail certificates for RS5000
¶25.18 In early November 2014, Sam Li Muller, a Consult and Technical Administrator at LABC, sent an email to Jonathan Roper explaining that LABC had changed the format of its certificates and attaching the certificate for RS5000 in the new style.1662 {CEL00002021/2}. The new certificate stated that it had first been issued on 21 August 2014 and was valid until 21 August 2015.1663 {LABC0000312}. It now stated on the first page that RS5000 "complies with BR 135 for use in rainscreen applications above 18 metres in height", but referred the reader to the conditions of the certificate for more information. The conditions made clear that RS5000 was acceptable for use on buildings above 18 metres in height, "subject to matching the specification criteria of the BRE fire test report 295255 carried out".1664 {LABC0000312/2}
¶25.19 Mr Roper forwarded that email to Ms Berger at Celotex,1665 {CEL00002021}. who was by then the product manager for RS5000. She responded to Ms Li Muller seeking changes to the wording and attaching suggested text that removed the reference to the test report and repeated the claim that RS5000 complied with BR 135 "subject to the board being fixed to a non-combustible substrate", referring to a BBA certificate that in fact related to FR5000.1666 {CEL00002022}.
¶25.20 Discussions about the suggested changes took place between Ms Li Muller, Mr Brennan and Mr Ewing throughout November 2014.1667 {LABC0002803}; {LABC0001780}. Meanwhile, Ms Berger had noticed on 6 November 2014 that the new-style certificate was available on the LABC website and asked the LABC to limit access to it until the wording had been sorted out.1668 {CEL00008691/2} Ms Li Muller said she would check with her manager to see if they could prevent the page from being visible to the public and as a result access to it was withdrawn.
¶25.21 On 12 May 2015 Mr Ewing sent Ms Berger an email to which he attached a revised certificate.1669 {LABC0000332}. He explained there had been concern that earlier LABC certificates implied general approval for the use of thermosetting insulation materials on buildings over 18 metres in height, which he said had never been the intention.1670 {LABC0000332}. The attached document was watermarked "Draft".1671 {LABC0000333}.
¶25.22 The revised certificate, under the heading "Description of Product", stated that RS5000 had been assessed by BRE and "complies with BR135 for use in rainscreen applications above 18 metres in height subject to the board being fixed to a non-combustible substrate *see condition of certificate for more information".1672 {LABC0000321}. The first line under the heading "Conditions of Certificate" read "For use in rainscreen wall constructions including above 18m in height". Further down and within a different sub-paragraph it read "This classification is only valid for the system specification and detailing outlined in section 2 of the BRE classification report 295255…".1673 {LABC0000321}. No one could explain why that information had not been given greater prominence. Mr Ewing accepted that the certificate could have been drafted in a much clearer way to avoid confusion.1674 Ewing {Day218/201:1-6}.
162¶25.23 The new-style LABC certificate was eventually published on 10 September 2015.1675 {LABC0000321}; Ewing {Day218/201:7-10}. A further (and final) LABC certificate was issued on 19 August 2016 in very similar terms to that which had been issued on 10 September 2015, save that it included details of the system which had been tested.1676 {LABC0000337}. That certificate was withdrawn on 16 June 2017 in the aftermath of the Grenfell Tower fire.1677 {LABC0020139/48}
¶25.24 It was Mr Ewing's understanding that there had been no certificate for RS5000 in place or available on LABC's website between November 2014 and July 2015, but he could not be sure whether Celotex had been told that or that it had been told that it should not use the certificate that had been issued.1678 Ewing {Day218/194:21}-{Day218/195:17}. He was unable to recall why he had sent an email to Ms Li Muller on 1 July 2015 asking her to check which certificate was publicly available.1679 {LABC0000330}. He could not state categorically that the certificate had been removed.1680 Ewing {Day218/203:16}-{Day218/204:5}. In its written closing statement for Module 2, LABC referred to Ms Berger's email of 6 November 2014 as a request for the registration to be withdrawn,1681 Phase 2 Module 2 Closing Submissions {LABC0019740/28} page 28, paragraph 73. to which the LABC had acceded. However, the correspondence was not expressed in that way and we have seen no evidence to suggest that Celotex was told that the certificate had been withdrawn.
¶25.25 Even if the certificate had been removed, Celotex could not reasonably have understood that to have been the case from the messages they received from LABC. Although Mr Ewing sent the 'new style' certificate to Celotex, the version held by LABC was still marked as a draft as late as May 2015. At no stage did LABC clearly state that the certificate issued in August 2014 for RS5000 was no longer valid and there was no formal process through which information of that kind could be expected to be communicated.1682 Ewing {Day218/205:2}-{Day218/206:8}.
¶25.26 In those circumstances, Mr Ewing's assumption that Celotex realised that a new certificate had been issued and would act with integrity by not relying on the old certificate, knowing it had been changed,1683 Ewing {Day218/195:11-17}. was naïve. Yet again, LABC failed to communicate properly with Celotex and failed to take proper steps to ensure that it understood that the previous certificate (which stated on its face that it was valid until August 2015) should not be used. There is no evidence that LABC took any steps to inform local authority building control departments or approved inspectors (in particular NHBC) that the old certificate could no longer be relied on. Plainly, it should have done so.
163Chapter 26: The National House Building Council
NHBC and associated organisations
¶26.1 The National House Building Council (NHBC) is the largest provider of warranties for newly built properties in the UK and (through its subsidiary) the largest private building control body in England and Wales.1684 Evans {Day219/17:5}-{Day219/18:17}. NHBC did not provide building control or warranty services for the Grenfell Tower refurbishment, but it had (and retains) a major influence over standards in the housebuilding industry.1685 Evans {NHB00003020/13} page 13, paragraph 36(c). Its dealings with Kingspan and DCLG ("the department"), in particular Brian Martin, in the period 2010 to 2016 are revealing.
¶26.2 NHBC was established in 1936 in order to respond to what was seen as the poor quality of construction provided by the housebuilding industry.1686 Evans {NHB00003020/4} page 4, paragraph 15. At the time of the Grenfell Tower refurbishment it provided warranties of the quality of construction in the form of its "Buildmark" warranty and building control services as an approved inspector under the Building Act 1984. In both contexts it occupied a dominant position in the private sector market, supplying over 80% of warranties on newly built properties1687 {NHB00003501}. and about 60% of the services provided to the residential market by approved inspectors.1688 Evans {Day219/18:4-17}.
¶26.3 NHBC is a private company limited by guarantee,1689 Evans {NHB00003020/4} page 4, paragraph 15. meaning that it retains any profits it makes rather than distributing them to shareholders.1690 Evans {Day219/19:5-25}. Warranties are issued by the company itself, whereas building control services are provided by NHBC Building Control Services Ltd (NHBC BCS), a profit-making company of which NHBC is the sole shareholder.1691 Evans {Day219/19:5-25}.
¶26.4 The "Buildmark" warranty is a policy of insurance. Although the standards required for a property to be eligible for a "Buildmark" warranty were set by the Standards department of NHBC, the wording of the policy and its underwriting were handled by a different department.1692 Evans {Day225/82:9}-{Day225/83:4}. The issue of warranties was carried out separately from the provision of building control services.1693 Evans {NHB00003020/5} page 5, paragraph 18 (b).
¶26.5 Oversight of both warranty and building control operations was provided by NHBC's Technical Services Department; Steve Evans was the Building Control Manager and John Lewis one of the specialist surveyors.1694 Evans {NHB00003020/6} page 6, paragraph 18 (c). John Lewis reported to Steve Evans who in turn reported to Diane Marshall in her role as Head of Technical Services. She in her turn reported to Ian Davis, the Operations Director, who was a member of NHBC's board of directors.1695 Lewis {NHB00003433/5} page 5, paragraph 18 (c) and {NHB00002769}; Marshall {Day225/79:9-18}. Ms Marshall occasionally reported directly to the board in respect of technical matters and the financial affairs of NHBC BCS.1696 Marshall {Day225/79:9-18}.
164¶26.6 The Technical Services Department contained a group set up specifically to deal with projects over eight storeys in height. It was called the Major Projects Team.1697 Lewis {Day223/7:9-14}. NHBC did not, however, employ any specialist fire engineers after 2008 and it was not until John Lewis completed a Masters' degree in fire and explosion engineering in 2013 that the teams had access to any internal fire safety expertise.1698 Lewis {Day223/5:24}-{Day23/6:20}. Even during that period, Mr Lewis's work was never reviewed by anyone with equivalent qualifications.1699 Lewis {Day223/7:5-8}. Mr Lewis was joined by another fire engineer, Maulik Katkoria, in 2016.1700 Lewis {Day223/6:21}-{Day223/7:1}.
The Building Control Alliance
¶26.7 The Building Control Alliance (BCA) was formed in 2008 with five member organisations, the Association of Consultant Approved Inspectors (ACAI), Local Authority Building Control (LABC), the Royal Institution of Chartered Surveyors (RICS), the Chartered Institute of Building (CIB) and the Chartered Association of Building Engineers (CABE).1701 Evans {NHB00003020/59} page 59, paragraph 164 (b). The alliance was established to promote the role of building control bodies, respond to government proposals, provide mediation services and provide a unified view on areas of uncertainty in the Building Regulations. It was, at least in part, a response to a government review of building control and opposition from building control bodies to a proposed relaxation of building control requirements.1702 Evans {Day219/38:15}-{Day219/40:5}; Turner {LABC0011202/28} page 28, paragraph 92. It was later incorporated as a limited company.1703 Evans {NHB00003020/59} page 59, paragraph 164 (f). Although the BCA published guidance for the construction industry, it had no statutory standing and was an unregulated, voluntary, professional body.1704 Evans {Day219/53:14}-{Day219/55:4}.
¶26.8 NHBC was not itself a member of the BCA, but it was a member of the ACAI, through which it was actively involved in the BCA.1705 Evans {Day219/41:22}-{Day219/42:12}. Steve Evans was a founding member of the BCA executive board and was chair of the Technical Group from 2010 until 2019.1706 Evans {NHB00003020/60} page 60, paragraph 166-167. He was involved in publishing guidance notes, including Technical Guidance Note 18 first published in June 2014.1707 Evans {NHB00003020/61} page 61, paragraph 168. Diane Marshall was a member of the BCA's executive committee from its inception in 2007.1708 Marshall {NHB00003434/4} page 4, paragraph 16; Marshall {Day225/86:4-7}.
NHBC's knowledge of Kingspan K15: 2010
¶26.9 By 2010 at the latest, NHBC was aware that combustible insulation was commonly being used in the external walls of buildings over 18 metres in height. In April of that year BRE published a report entitled Fire performance of highly insulated residential buildings and modern methods of construction: A literature review1709 {NHB00000452}. that had been commissioned by NHBC Foundation, a body established and funded by NHBC to carry out research and provide guidance to the house-building industry. During the preparation of the report, BRE consulted a group of industry professionals that included two representatives of NHBC, John Lewis and Dave White.1710 {NHB00000452/6}. Mr Lewis confirmed that he had read the report at around the time of its publication.1711 Lewis {Day223/17:8}.
165¶26.10 The report contained a detailed explanation of the principal regulatory requirements applicable to residential buildings and the materials that were commonly used to construct them. It warned that the growing prevalence of modern insulation products meant that the fire load within dwellings had increased leading to a greater risk of fire spreading through the fabric of the building.1712 {NHB00000452/5}. It concluded that the materials being used in the construction of modern buildings appeared to be resulting in increasingly large fire losses.1713 {NHB00000452/9}.
¶26.11 Mr Lewis accepted that by April 2010 at the latest he had been aware that combustible insulation was being used much more commonly in the external walls of buildings over 18 metres in height1714 Lewis {Day223/19:5-7}. and that the most commonly used product was Kingspan K15.1715 Lewis {NHB00003433/7} page 7, paragraph 26. He said that Kingspan K15 was commonly accepted by fire engineers on the basis of its BBA certificate and that NHBC relied heavily on Kingspan's own assurances concerning the way in which its products could be used.1716 Lewis {NHB00003433/7} page 7, paragraph 26; Lewis {Day223/22:21}-{Day223/23:20}. For her part, Diane Marshall said that it had been NHBC's practice until 2015 to allow the use of Kingspan K15 on buildings over 18 metres in height, again on the basis of the BBA certificate.1717 Marshall {NHB00003434/17} page 17, paragraph 72.
The BBA certificate
¶26.12 The first BBA certificate for Kingspan K15 was issued on 27 October 2008. It referred to one successful test in accordance with BS 8414 Part 1 in 2005.1718 {BBA00000038/5}. It stated that Kingspan K15 might be used in accordance with paragraphs 12.5 and 12.6 of Approved Document B,1719 {BBA00000038/5-6}. but warned that advice should be sought from the certificate holder if the product were being considered for use on buildings over 18 metres in height.1720 {BBA00000038/6}. That statement remained in the version of the BBA certificate that was amended in April 2010 and published in July 2013.1721 {BBA00000037/5}.
¶26.13 Seeking advice from the manufacturer in that way was not a route to compliance with the functional requirement of the Building Regulations indicated by Approved Document B. Kingspan could never have given any advice sufficient to satisfy the guidance in Approved Document B or the requirements of the Building Regulations other than that the system proposed for use was or was not the same as that which had been the subject of the 2005 test.1722 Lewis {Day223/152:1-19}. It should have been obvious to any properly informed reader of the BBA certificate that Kingspan's own advice could not safely be relied upon.
¶26.14 Nonetheless, NHBC did exactly that. Steve Evans told us that NHBC had been satisfied with a letter from Kingspan's technical department stating that the proposed system was acceptable without knowing anything about the knowledge or experience of the writer and without any guidance from NHBC about what technical information it should contain.1723 Evans {Day219/126:19}-{Day219/135:5}. He told us that it was for the NHBC surveyor receiving the letter to decide whether it contained enough information to enable him to approve the use of K15 on a building over 18 metres in height.1724 Evans {Day219/133:12}-{Day219/134:1}.
166¶26.15 Diane Marshall sought to justify NHBC's reliance on assurances by Kingspan by referring back to the BBA certificate itself.1725 Marshall {Day225/155:3}-{Day225/158:22}. She appeared to think that the effect of the recommendation that advice should be sought from the certificate holder was effectively to enable Kingspan to certify that its products could be used in applications which bore no relation to that on which the BBA certificate was based.
¶26.16 If that was her belief it overlooked two matters of fundamental importance: first, that reliance on the advice of the manufacturer of a product could never have been a proper way of ensuring compliance with the Building Regulations, and secondly, as Ms Marshall accepted, the advice Kingspan provided was generally no more than a bald assertion that K15 was suitable for the project, without any technical assessment or analysis.1726 See for example the Kingspan letter of 13 January 2014 to Mount Anvil in respect of its Eagle House project {KIN00002663}; Marshall {Day225/155:3-6}.
Paragraph 12.7 of Approved Document B
¶26.17 When it was revised in July 2013, the BBA certificate included a new statement that Kingspan K15 could be used in accordance with paragraph 12.7 of Approved Document B, which required insulation products used in buildings over 18 metres in height to be materials of limited combustibility.1727 {BBA00000037/5}. K15 was not a material of limited combustibility and the reference to paragraph 12.7 was therefore clearly wrong. That mistake should have been obvious to all at NHBC who knew, or should have known, that it was a phenolic foam and therefore combustible.1728 Marshall {Day225/115:15}-{Day225/116:11}; Evans {Day219/66:1-4}; Lewis {Day223/37:1-4}.
¶26.18 Despite that, no one at NHBC said anything to the BBA about the error in the certificate until July 2015. The witnesses from whom we heard sought to justify that omission by relying on the Approved Document providing guidance on regulation 7 of the Building Regulations 2010.1729 {INQ00014930}. Paragraph 1.15 of that document stated that an independent product certification scheme might indicate that a material is suitable for its intended purpose and use, but the operative word there is "might".1730 {INQ00014930/13}. Paragraph 1.18 stated that past experience, such as use in an existing building might show that a product could perform the function for which it was intended, but again, the operative word is "might".1731 {INQ00014930/14}. Neither of those paragraphs detracts from the clear requirements of functional requirement B4(1) and the guidance in Approved Document B. If those at NHBC thought they did, they were wrong. Diane Marshall ultimately accepted that the guidance in the Approved Document on regulation 7 could have no bearing on paragraph 12.7 of Approved Document B but she insisted that it provided an alternative route to compliance with functional requirement B4(1).1732 Marshall {Day225/101:4-7}.
167¶26.19 In support of that position, Ms Marshall appeared to rely on a section in Approved Document B entitled "Use of Guidance", which stated that building control bodies might accept the certification of products under approved product certification schemes as evidence that they complied with a relevant standard.1733 {CLG00000224/7}. She appeared to think that a building control body need look no further than, for example, a BBA certificate, nor examine its contents critically, when deciding whether a product was suitable for use, even when some of the statements in it were obviously wrong.1734 Marshall {Day225/114:1}-{Day225/120:13}. We cannot agree. It should have been clear to everyone at NHBC that there was nothing in regulation 7 or Approved Document B that could justify such a perverse outcome. We read regulation 7 and that paragraph in Approved Document B as saying no more than that ordinarily a building control body should be able to rely on statements in certificates issued by certification bodies accredited by UKAS, but not that they are entitled to do so in the face of ambiguity or obvious error.
Internal discussions about K15: August to November 2013
¶26.20 On 28 August 2013, Steve Cook (NHBC's Area Technical Manager for London) wrote to Steve Evans saying that the question of using what he referred to as "non-combustible cavity insulation" in buildings with a storey over 18 metres in height was causing a lot of concern to customers.1735 {NHB00000583}. He asked whether NHBC was in possession of any guidance on the issue or whether it might be able to encourage Kingspan to test its K15 and K12 products to achieve certification as non-combustible. Steve Evans replied that NHBC had no involvement in the testing carried out by Kingspan, but that he would discuss with John Lewis whether NHBC might be able to draft some guidance.1736 {NHB00000583}.
¶26.21 Mr Cook may have used the phrase "non-combustible" as shorthand for having limited combustibility, or perhaps he did not understand the difference. Either way, Mr Lewis and Mr Evans both told us that they knew at the time those emails were exchanged that Kingspan K15 was combustible and should not be used in the external walls of buildings above 18 metres in height.1737 Evans {Day219/65:1-4}; Lewis {Day223/36:15}-{Day223/37:4}. However, neither of them could recall having discussed the matter or reaching any consensus on NHBC's approach to Kingspan K15 at that time.1738 Evans {Day219/71:15}-{Day219/72:3}; Lewis {Day223/40:20}-{Day223/41:5}. Certainly, no new guidance was issued.
¶26.22 On 16 October 2013, John Lewis and Steve Cook received an email from a project surveyor in NHBC's Technical Services department. The surveyor said, in summary, that he did not think that Kingspan K15 was a material of limited combustibility but had become aware of a colleague in NHBC who believed that it was and had consequently been accepting its use on buildings above 18 metres in height.1739 {NHB00000587}. Mr Cook responded the following day, saying that any insulation used on high-rise buildings was required to be a material of limited combustibility but that Kingspan did not have test evidence to show that K15 met that requirement.1740 {NHB00000587}.
¶26.23 Although John Lewis claimed that those emails indicated confusion about whether Kingspan K15 was acceptable for use on high-rise buildings, both he and Steve Evans conceded that they had known that paragraph 12.7 of Approved Document B advised that insulation materials should be of limited combustibility and that Kingspan K15 did not meet that guidance.1741 Lewis {Day223/45:4-9}; Evans {Day219/81:2-13}. Nonetheless, NHBC was routinely accepting it for use on high-rise buildings.1742 {NHB00000587/2}; Evans {Day219/78:1}-{Day219/82:12}; Lewis {Day223/46:14}-{Day223/47:7} John Lewis sought to justify that approach, again by reference to regulation 7 of the Building Regulations. He conceded, however, that he had never checked whether regulation 7 supported NHBC's approach and could not recall anyone else at NHBC having done so.1743 Lewis {Day223/47:8}-{Day223/48:15}. Had he done so, we think he would have reached the clear conclusion that it did not.
168¶26.24 John Lewis was shown an email sent by Chris Macey of Wintech, the façade engineering consultants, to Dave White of NHBC on 4 October 2013 in which Mr Macey said that Kingspan K15 was not a material of limited combustibility.1744 {NHB00000585}. Mr Macey noted that K15 was widely used and said that Kingspan's marketing material wrongly implied that it was suitable for all applications. He expressed the view, which he said was shared by BRE, that it should not be used without supporting documentation or test data to confirm its acceptability. Mr Lewis rightly accepted that what Mr Macey had said was correct.1745 Lewis {Day223/50:20}.
¶26.25 In his email, Chris Macey offered to meet NHBC in order to explain Wintech's concerns, and Dave White began to make arrangements for a meeting.1746 {NHB00000585/1}. We return to that meeting below.
¶26.26 Meanwhile, on 31 October 2013, Brian Stevenson, Steve Cook and Paul Williams, three Area Technical Managers employed by NHBC in its Technical Services department, exchanged emails concerning Kingspan K15. Mr Williams said that he had been told that NHBC was no longer accepting K15 on the basis that it was combustible and asked whether NHBC's surveyors had been advised accordingly. Mr Cook said that most surveyors were aware of that view. Mr Stevenson responded that he was certainly not aware that it was NHBC's policy not to accept K15,1747 {NHB00000589}. which it had previously accepted on the basis that it held a BBA certificate.1748 Stevenson {NHB00003524/2} paragraphs 10-11. Mr Lewis told us that he was surprised by Mr Stevenson's ignorance of that matter.1749 Lewis {Day223/53:6-9}.
¶26.27 On 4 November 2013, Paul Williams wrote to NHBC's south-west area technical team saying that John Lewis and Steve Evans were reviewing whether K15 could be accepted for use on high-rise buildings, as NHBC had doubts about its combustibility.1750 {NHB00000594/3}. In reality, as we have said above, neither Steve Evans nor John Lewis had any such doubts: they both knew perfectly well that K15 was combustible and thus did not meet the guidance in paragraph 12.7 of Approved Document B for use in the external walls of buildings over 18 metres in height.
¶26.28 Chris Cooley, a Project Surveyor in the Technical Services Department, responded to Mr Stevenson on 8 November 2013 asking how long the promised review would take. He also asked what the alternatives were to using K15 and pointed out that there were no other foam insulation boards that were of limited combustibility and therefore mineral wool was the only material that could be used on high-rise buildings. He stressed that surveyors needed to communicate their requirements at the outset of any design process and warned that a refusal by NHBC to accept K15 would give rise to a major problem with customers who relied on foam board insulation to achieve required U-values.1751 {NHB00000594/3}. Mr Cooley warned that Mr Evans should be prepared to receive a barrage of enquiries. That message worked its way up to Steve Evans the same day.1752 {NHB00000594/1}. Mr Evans could have been in no doubt, by that point, therefore, about the serious consequences of NHBC's building control officers' having routinely accepted the use of K15 on high-rise buildings in the past and continuing to do so. However, NHBC did not immediately act on what it now knew.
169¶26.29 Although Mr Lewis candidly accepted that a change in NHBC's position on K15 would have resulted in a lot of angry customers, he denied that its failure to act was motivated by commercial considerations.1753 Lewis {Day223/60:17-22}. Likewise, Ms Marshall denied that the likely reaction of customers was a factor in its continued acceptance of K15; she said it had not been taken into consideration.1754 Marshall {Day225/161:10-19}. In our view, however, in the light of Chris Cooley's email that was not credible.
¶26.30 Ultimately, Mr Evans came to accept that the NHBC's failure to adopt a tougher stance on K15 had indeed been motivated by the likely reaction of its customers. He said that what he characterised as a "knee-jerk" reaction would have caused a lot of disruption to NHBC, which wished to get hold of all the facts before it made a decision.1755 Evans {Day219/222:3-20} He claimed that NHBC continued to permit the use of K15 because it had no information that it was not safe,1756 Evans {Day219/223:2-17; {Day219/174:11}-{Day219/175:21}. but K15 could not be regarded as safe for use on buildings over 18 metres in height since it was not a material of limited combustibility and its use did not comply with paragraph 12.7 of Approved Document B, as NHBC well knew. Furthermore, NHBC also knew that K15 had been and was still being approved for use in the external walls of high-rise buildings which were not constructed in the same way and with the same components as the system that Kingspan had tested in 2005.1757 John Lewis's email of 19 November 2013 {NHB00000604/1}. In those circumstances, NHBC had no reason to think that K15 was generally safe for use on high-rise buildings and every reason to challenge the claim in Kingspan's marketing literature that it was. NHBC's continued endorsement of its use from then on was unjustifiable and amounted to an abdication of its responsibility.
Meeting with Wintech: 15 November 2013
¶26.31 The meeting between Wintech and NHBC took place on the morning of 15 November 2013. John Lewis, Dave White and Graham Perrior represented NHBC; Stuart Taylor and David Watakabi represented Wintech. John Lewis said that meeting had been responsible for bringing concerns about K15 to the forefront of his mind.1758 Lewis {NHB00003433} page 12, paragraph 47.
¶26.32 In the hours following that meeting, Mr Lewis compiled a note of the discussions, together with a draft of what he described as an internal guidance note, which he circulated at 14.45 the same day.1759 {NHB00000604/4}; {NHB00000605}. The second paragraph of Mr Lewis' note is of particular importance. It described how Wintech had outlined the route to compliance, as recommended in Approved Document B, and set out in bullet points three ways of following it, which formed the basis of his internal guidance note. Although it was described as "internal" at that time, the guidance note eventually became (with only minor amendments) Technical Guidance Note 18, published by the BCA in June 2014.1760 Lewis {Day223/74:16-20}.
170¶26.33 One important element in the discussion was Wintech's view, apparently shared by Mr Lewis, that after the 2006 amendments paragraph 12.7 of Approved Document B required all elements of a cladding system to be of limited combustibility, including the external facing material, not only the insulation. The alternative route to compliance was to test the entire proposed system in accordance with BS 8414 and satisfy the performance criteria in BR 135. As a further alternative, a "desktop" opinion from BRE, based on test data, that the performance criteria in BR 135 would be met by the system, would also suffice.
¶26.34 When Mr Lewis was asked why he felt that he needed to recite the guidance in Approved Document B in such detail to his colleagues, he said that, although NHBC already knew it, it had not really digested it.1761 Lewis {Day223/63:20-25}. He explained that the guidance in Approved Document B was not second nature to NHBC and that it had not previously understood properly the restrictions on the use of combustible insulation in high-rise buildings.1762 Lewis {Day223/64:13-15}. For NHBC as an institution to have had such a poor grasp of the statutory guidance on a matter affecting the safety of life significantly detracted from its ability to discharge its function as an approved inspector.
¶26.35 Although Mr Lewis's notes referred to the use of desktop studies, he candidly admitted that he had never heard of them being provided but said that the representatives of Wintech had told him that other building control bodies had accepted them as demonstrating compliance with the Building Regulations.1763 Lewis {Day223/66:15}-{Day223/67:3}. The basis of that part of the guidance was, therefore, purely anecdotal, although in principle a desktop assessment was an acceptable method of demonstrating compliance, provided it was performed competently using appropriate data. However, it was unwise, in our view, to produce draft guidance of that kind, even in its most rudimentary form, without finding out whether BRE, Exova, or other testing houses were capable of producing reliable desktop studies and how widespread was the practice of building control officers' accepting them.
¶26.36 Mr Lewis's notes referred to the Class 0 classification, which it described as "solely a measure of the spread of a flame across the surface".1764 {NHB00000604/5}. In fact that was incorrect, because Class 0 refers to both the spread of flame and fire propagation. Mr Lewis said that there was a lot of misunderstanding and confusion within NHBC about Class 0 and that he was not fully aware at the time of the way in which the classification was achieved.1765 Lewis {Day223/68:19}-{Day223/69:25}. That confusion about the meaning of Class 0 was not limited to NHBC but was shared by industry generally, and had been for many years.
¶26.37 In the following days, NHBC discussed the guidance note internally. On 19 November 2013 Mr Lewis agreed to put it into a form that would enable it to be presented for consideration at a forthcoming meeting of the BCA.1766 {NHB00000604}. He also told Steve Evans in terms that Kingspan had tested K15 only once on a masonry wall construction, that K15 was acceptable only if incorporated into an identical system, and that since most of the schemes being approved by NHBC involved steel-framed constructions it should not be accepting K15, if it intended to follow the guidance in Approved Document B and BR 135.1767 {NHB00000604}. Mr Lewis told us that none of his colleagues at NHBC disagreed with that view.1768 Lewis {Day223/75:20}.
171¶26.38 Nonetheless, NHBC continued to accept K15 for use on high-rise buildings. In an email sent on 2 December 2013 Steve Evans asked John Lewis for his comments on a draft message he was proposing to send to all NHBC technical staff saying that there was some confusion about whether K15 could be treated as a material of limited combustibility but that until NHBC was in a position to say otherwise, its policy was to continue to accept the use of K15 in rainscreen and masonry construction on buildings over 18 metres in height.1769 {NHB00000615/2}. Mr Lewis responded by saying that there was no confusion and that K15 was not a material of limited combustibility. He advised in his email that staff should be told to check with Kingspan first, but that NHBC was obliged in principle to accept the statement in the BBA certificate that K15 could be used in accordance with paragraph 12.7 of Approved Document B (i.e. that it was a material of limited combustibility).1770 {NHB00000615/1}. Lewis {Day223/161:14-22}.
¶26.39 Mr Evans' draft and Mr Lewis's response betray serious flaws in NHBC's thinking. First, the language of these communications strongly suggests that Mr Evans was anxious to play down the potential threat to safety by requiring Kingspan to justify the use of K15 in each individual case and in the meantime to continue to accept it for use on buildings over 18 metres in height generally. NHBC knew that K15 could not be used in a system other than one that was identical to the system tested in 2005, which was very different from any of the systems being passed by its building control officers. Secondly, they were both quite wrong to think that NHBC was obliged to endorse the use of K15. On the contrary, as Mr Lewis clearly knew, paragraph 12.7 of Approved Document B did not apply to the product because it was not a material of limited combustibility. Mr Lewis sought to justify his statement by saying that the statement in the BBA certificate that advice should be sought from Kingspan if K15 was proposed for use on high-rise buildings indicated a route to compliance.1771 Lewis {Day223/161:14-22}. However, as he ultimately accepted, it did no such thing; the "route" it suggested was, at best, a way of circumventing the guidance in Approved Document B, rather than following it.
¶26.40 At that point, rather than issue a flimsy warning to its staff, NHBC ought to have told them to stop accepting K15 for use in the external wall of any building over 18 metres in height immediately unless and until they had evidence that that system had met the performance criteria in BR 135 following a test under BS 8414. The failure of NHBC to do so reflects a desire at the time to placate customers and manufacturers at the expense of safety.
¶26.41 The BBA certificate was subsequently amended to remove the advice to contact the manufacturer,1772 {BBA00000036/6}. but NHBC's policy in late 2013 was conceived before it had any knowledge of that change and cannot therefore be justified by reference to the amended certificate. As Mr Lewis explained, NHBC foresaw that a refusal to accept K15 would have a massive effect across the industry.1773 Lewis {Day223/165:16}-{Day223/166:12}. It also believed that any change in its position on K15 would have isolated it from the rest of the industry, as the use of K15 was endorsed by the LABC. As Mr Lewis put it, that led NHBC to ask whether there was any point in rejecting K15 when it was likely to be approved by local authority building control departments.1774 Lewis {Day224/19:10-24}. In our opinion, that was an unacceptable approach for NHBC to take.
172Dealings with Kingspan: November 2013 to April 2014
¶26.42 On 26 November 2013, Mr Lewis sent an email to Kingspan asking for advice about the use of K15 on a project involving a building over 18 metres in height.1775 {NHB00000644/5}. He noted that K15 was not a material of limited combustibility and therefore asked how the alternative route to compliance in Approved Document B, namely, testing in accordance with BS-8414 and classification in accordance with BR 135, could be achieved. Kingspan's initial response came on 12 December 2013 and merely referred Mr Lewis to the BBA certificate as the basis for the use of K15 on high-rise buildings.1776 {NHB00000644/3}.
¶26.43 Mr Lewis was, unsurprisingly, not satisfied with that response and repeated his request the same day.1777 {NHB00000644/2}. He explained that his original question had been prompted by the BBA certificate's suggestion that NHBC should seek advice from Kingspan about the suitability of K15 rather than simply reading the product literature. Mr Lewis pointed out that K15 was not a material of limited combustibility and that there had been only one test under BS-8414-1 involving K15 for which results were available. He questioned how K15 could be used as part of a differently constructed external wall or on any system attached to a structural steel frame (which required testing under BS 8414-2).
¶26.44 Mr Lewis had not received any substantive response by the following day and therefore wrote again, with copies to Steve Evans, Dave White and Graham Perrior.1778 {NHB00000644}. He said that he and his managers at NHBC wished to raise the matter with Kingspan's management team and requested a meeting in early 2014. He noted that, given the number of affected projects that it was dealing with, NHBC wished to start to advise its customers that K15 did not comply with the Building Regulations or the BBA certificate when used on a building over 18 metres in height.
¶26.45 It is clear from Mr Lewis's email that, despite what its witnesses repeatedly told us, NHBC did not in fact consider that the BBA certificate provided conclusive evidence that K15 was safe or acceptable for use in accordance with the Building Regulations. Indeed, the import of Mr Lewis's message to Kingspan of 13 December 2013 was plainly that the BBA certificate did not support the use of K15 on buildings over 18 metres in height, despite what it said. In our view, NHBC correctly thought that the BBA certificate was wrong in stating that K15 could be used in accordance with paragraph 12.7 of Approved Document B and was free to reject it as proof that K15 was suitable for use under those circumstances. However, it chose not to act on what it knew, pending receipt of an explanation from Kingspan, in order to avoid provoking protests from customers and Kingspan alike. As to that, Mr Lewis had told Mr Evans on 2 December 2013 that he doubted that Kingspan would be able to provide the evidence required to justify the use of K15 on high-rise buildings1779 {NHB00000615/2}. but admitted he feared the massive effect across the industry that a change in NHBC's position would cause.1780 Lewis {Day223/165:2}-{Day223/166:12}.
173¶26.46 As Mr Lewis conceded, his threat to advise NHBC's customers that K15 was not suitable for use on high-rise buildings was intended to prompt a response from Kingspan.1781 Lewis {Day223/125:5-13}. It achieved its aim and Steve Evans, John Lewis, Graham Perrior and Dave White of NHBC met Richard Bromwich, Kingspan's National Business Development Director, and Ivor Meredith, its Technical Project Manager, in January 2014.1782 {NHB00000652}. Mr Lewis told us that at the meeting Kingspan had not contradicted his understanding of Approved Document B1783 Lewis {Day223/125:23}-{Day223/126:5}. and had confirmed that there was currently only one successful BS 8414 test of a system incorporating K15.1784 {NHB00000652/1}.
¶26.47 At that meeting, Kingspan produced a video showing the flame from a blowlamp being applied to a sample of K15 and suggested that, in Mr Lewis' words, "it doesn't burn particularly",1785 Lewis {Day223/131:3-10}. notwithstanding the absence of any test data to justify that conclusion. Mr Lewis said he did not think that that was an acceptable, independent or robust way of verifying the suitability of K15,1786 Lewis {Day223/131:14}. but NHBC continued to accept the use of the product on high-rise buildings on the basis of an assertion that it was accepted for use on many tall buildings around the world.1787 Lewis {Day223/131:3-10}.
¶26.48 John Lewis accepted that he had been aware that Appendices A and B to BR 135 provided that the results of a BS 8414 test could be used to justify the use of a combustible material only in an external wall system that was identical to that which had been tested.1788 Lewis {Day223/155:17}-{Day223/157:8}. He also accepted that it had been clear to him that there were simply no test results available to support the use of K15 in the many external wall systems in which it had already been used.1789 Lewis {Day223/157:8}. However nobody at NHBC accepted, as they should have done, that the only advice that Kingspan could properly give to its customers was that K15 could not be used at all on buildings over 18 metres in height except as part of a system exactly the same as that tested in 2005.
¶26.49 At that point, NHBC should immediately have stopped approving the use of K15 on buildings above 18 metres in height. However, it did not. It continued to endorse the use of K15, despite the guidance in Approved Document B, because Kingspan was willing to confirm that it was suitable.1790 Lewis {Day223/126:21-22}. That approach made no sense, as Mr Lewis accepted in hindsight, but it was adopted because NHBC felt at the time that Kingspan was the only party with detailed knowledge of K15's fire performance.1791 Lewis {Day223/127:2-14}. Mr Lewis told us that he had raised concerns with his superiors in NHBC that the justification for approving the use of K15 was becoming ever flimsier but that no change had been made.1792 Lewis {Day223/131:15-24}. NHBC's approach of relying uncritically on what Kingspan itself claimed for K15, given that it cannot have been in any doubt that Kingspan was selling K15 on the basis of a self-evidently misleading BBA certificate, demonstrated weakness and a failure to live up to its responsibilities. It was all the more serious for the fact that NHBC was an institution responsible for providing building control services in respect of a large number of new buildings and for ensuring their compliance with the Building Regulations.
174¶26.50 Although NHBC realised that the BBA certificate was flawed, no one thought to ask the BBA on what basis it had been issued,1793 Lewis {Day223/129:6}; {Day223/153:24}-{Day223/155:11}; {Day223/163:5-17}. even though Mr Lewis was not aware of any other BBA certificates which advised the reader to refer to the manufacturer for advice in the same way.1794 Lewis {Day223/129:17}.
¶26.51 NHBC held a further meeting with Kingspan on 2 April 2014, attended by John Lewis and Dave White. Mr White reported the results of that meeting to NHBC's technical services managers the same day. He said that for external walls of buildings over 18 metres in height, the only system incorporating K15 for which there was full proof of fire performance was one with a masonry backing wall.1795 {NHB00000688/2}. His message was unequivocal. However, even at that point, NHBC did not stop endorsing the use of K15 on high-rise buildings. John Lewis sought to justify that failure by referring to the fact that the BBA certificate for K15 had been revised in January 2014.1796 {NHB00000853/11}. That certificate removed the reference to paragraph 12.7 of Approved Document B and the advice to consult the manufacturer, leaving the 2005 test in accordance with BS 8414 as the sole means of achieving compliance.
¶26.52 NHBC discovered the change on or around 25 February 2014.1797 {NHB00000689/3-4}. Thereafter, all projects for which an initial notice had been served before January 2014 were accepted on the basis of Kingspan's historic assurances.1798 Lewis {Day223/131:3-10}; {Day223/178:20}. NHBC intended those projects for which the initial notice had been served in or after January 2014 to be the subject of a more rigorous assessment of whether K15 could be used.1799 Lewis {Day223/134:23}-{Day223/135:5}. It was likely to be several months at least until any new projects reached the stage of completion, during which Kingspan might produce proof that K15 was acceptable for use on buildings over 18 metres in height before NHBC had to take a final position.1800 Lewis {Day223/135:20-24}. In our view, that was not a responsible approach for NHBC to adopt. It was well aware that there could be no proof of the kind envisaged because no BS 8414 test results could be applied to high-rise buildings generally, and Kingspan had not produced any desktop assessments from BRE to support such an approach.
¶26.53 On 3 April 2014, Phil Pettinger, a Special Risk Projects Manager employed by NHBC, responded to Mr White's email.1801 {NHB00000688/1}. He said that every job involving a building over 18 metres in height that Special Risk Project Managers dealt with proposed or had used K15. He made plain that K15 was being widely accepted by both NHBC and other building control bodies.1802 {NHB00000688/1}. John Lewis accepted that it had been clear to him at the time that there was an industry-wide problem with the acceptance of K15 and that Mr Pettinger's email had come as no surprise.1803 Lewis {Day223/141:1}-{Day223/142:11}. However, he said that NHBC had not raised the matter with other building control bodies or investigated whether any of them had any other understanding of how K15 could safely be used on buildings over 18 metres in height because of the pressure of time.1804 Lewis {Day223/143:1-10}. However, given that NHBC had gained time by waiting for Kingspan to justify the use of K15 on high-rise buildings, we do not understand what the pressure of time was. A simple enquiry of the LABC or the BCA was all that was required.
175¶26.54 On 25 February 2014, Steve Evans asked Mr Lewis to study the new version of the certificate and make an assessment,1805 {NHB00000689/3} but it took him until 9 May 2014 to respond.1806 {NHB00000689/1}. In the event, his conclusion was that there was no justification for NHBC to continue accepting K15.1807 {NHB00000689/1}. Mr Lewis said that NHBC had been hoping that Kingspan would produce a justification for the use of K15 on high-rise buildings but it never materialised. He said that in the meantime, a practice had developed of asking for desktop studies to justify the use of K15 on high-rise buildings,1808 Lewis {Day223/176:25}-{Day223/178:14}. but we have not seen any evidence of that.
TGN 18 (Issue 0): draft
¶26.55 The guidance note that Mr Lewis had drafted within hours of NHBC's meeting with Wintech on 15 November 2013 was presented materially unamended as a formal document by Steve Evans to the Technical Working Group of the BCA on 9 December 2013. He proposed that it should be adopted as BCA policy guidance.1809 {NHB00000604/2}; {NHB00000605}; Evans {Day219/104:7-9}. It was indeed adopted without material change and became the BCA's Technical Guidance Note 18 (TGN 18), Use of Combustible Cladding Materials on Residential Buildings Issue 0, dated June 2014. It was published in July or August 2014.1810 {NHB00000760}.
¶26.56 Like Mr Lewis's guidance note, the proposed guidance put before the BCA in December 2013 referred to three potential routes to compliance with functional requirement B4(1) for the external walls of buildings over 18 metres in height. The first was that all the elements should be materials of limited combustibility, in accordance with paragraph 12.7 of approved Document B. That included the insulation, internal lining board and the external facing material.1811 {NHB00000760/2}. That represented Mr Lewis's understanding of the position based on a discussion he had had with Tony Baker of BRE by email in November 2013.1812 {NHB00002971}. In that exchange Mr Lewis had said that he thought that the provisions of paragraph 12.7 of Approved Document B extended to external cladding panels because it seemed to him logical to expect them to perform as well as the insulation in a fire.1813 {NHB00002971/2}. Mr Baker had responded by saying that all significant elements of the cladding system should be included in any analysis.1814 {NHB00002971}.
¶26.57 That approach appears to have reflected BRE's view, at least according to what Dr Sarah Colwell told NHBC in a meeting on 27 November 2014.1815 {NHB00000829}. It did not come as a surprise to John Lewis.1816 Lewis {Day223/100:12}. However, as the evidence from David Metcalfe of CWCT shows, that was by no means the general view of the industry at the time.1817 Metcalfe {CWCT0000115} page 10, paragraph 36. In fact, as Mr Lewis accepted, Approved Document B advised in paragraph 12.7 that insulation materials should be of limited combustibility and in diagram 40 that external surfaces should have a Class 0 or Euroclass B or better classification.1818 Lewis {Day223/92:21}-{Day223/94:4}. Accordingly, by suggesting that "all elements" of the external wall should be composed of materials of limited combustibility, TGN 18 presented a restrictive and conservative view of Approved Document B that was not widely shared in the industry.
176¶26.58 The second option in TGN 18 was for the client to submit evidence that the complete cladding system had been tested in accordance with BS 8414 and classified in accordance with BR 135. TGN 18 did not refer to classifications; instead it stated that the results of a test in accordance with BS 8414 would need to be supported by proof that the acceptance criteria in BR 135 had been met.1819 {NHB00000760/2}. Mr Lewis told us that that was simply intended to mean that full test data should be supplied, because NHBC had not realised that BRE would also produce classification reports with any test data.1820 Lewis {Day223/105:4}-{Day223/106:12}.
¶26.59 The third option in TGN 18 was the production of a desktop study of the kind that Wintech had told NHBC had been accepted by other building control bodies. However, that was the first time that Mr Lewis had encountered such an approach being adopted in relation to an external wall.1821 Lewis {Day223/106:5}-{Day223/108:1}. Wintech had not provided NHBC with any details of how the process would work in practice or any examples.1822 Lewis {Day223/204:7-20}. That proposed third route to compliance was entirely theoretical, in as much as it was not based on experience of any such assessments and neither BRE nor any of the other testing houses had been asked whether they could provide desktop assessments and if so how they went about doing so.
¶26.60 Mr Lewis maintained that Appendix A of Approved Document B endorsed the use of desktop studies but he could not recall whether they had been discussed at the meeting with Wintech and there is no evidence to suggest that they had been.1823 Lewis {Day223/109:5-11}. He said that he had examined the provisions of Appendix A before drafting the guidance note,1824 Lewis {Day223/109:16-21}. but any examination he did carry out can only have been cursory because the guidance note (and accompanying email) had been produced in a matter of hours.
¶26.61 In any event, we do not think that Appendix A of Approved Document B did endorse the use of desktop studies. Paragraph 1 of the introduction, which set the context for what followed, referred to the fact that much of the guidance in the document was given in terms of performance in relation to British or European Standards for products or methods of test or design or in terms of European Technical Approvals. In such cases the guidance required the material product or structure under consideration to have been assessed from test evidence against appropriate standards or by using relevant design guides as meeting the performance required by the tests.1825 {CLG00000224/119}. In our view, that provision was clearly referring to the results of tests on the relevant material, product or structure and not to the extrapolation of data from tests on a different material, product or structure.
¶26.62 Moreover, even if it were thought that that passage supported the use of desktop assessments, that reasoning could not sensibly be applied to a complex structure such as the entire external wall of a building. Such an interpretation would undermine the express routes to compliance given in Approved Document B, which required either compliance with the "linear route" or a full-scale test in accordance with BS 8414. It would make no sense for Appendix A to permit the use of combustible materials in circumstances where the proposed structure had not been tested at all.
177¶26.63 That is not to say, however, that a desktop assessment is never acceptable as a means of demonstrating compliance with one of the functional requirements, but it must be based on sufficient accurate test evidence.1826 Torero {Day292/92:6}-{Day292/95:16}. NHBC had no basis for promoting desktop assessments as an alternative way of showing compliance with functional requirement B4(1) without identifying the test data that should be used, the method that should be employed or the qualifications that were required on the part of those who were to conduct them.
¶26.64 When Mr Lewis had spoken of the available test data for K15 in his email of 15 November 2013 setting out his draft internal guidance, he had rightly pointed out that any difference between a proposed external wall system and the system that had been tested by Kingspan would prevent any direct reliance on the test result, and that the limited test data available would make it difficult to draw any reliable conclusions about the fire performance of the proposed system.1827 {NHB00000604/4}. However, when it came to drafting TGN 18, it appears that NHBC did not consider either of those matters or make any enquiries of BRE about how desktop studies could safely be performed. Mr Lewis told us that NHBC was doing whatever it could to put a guidance note together and simply did not think about consulting BRE.1828 Lewis {Day223/111:1}-{Day223/112:19}. Nor did it give any thought to who might be responsible for conducting the desktop studies it was supporting or the qualifications they might need to hold, beyond the rather vague reference to a suitable independent testing body accredited by UKAS.1829 Evans {Day220/:47-13}-{Day220/50:19}.
¶26.65 In his witness statement, Mr Lewis said that the third option had been included because he and Mr Evans had wanted to include a route to compliance for those developers who were unable to comply with the two routes described in Approved Document B.1830 Lewis {NHB00003433/35} page 35, paragraph 133; Lewis {Day223/189:24-25}. In his oral evidence, however, he said that they were considering all the options and that it had made sense to include it. We do not agree. It was wholly unnecessary and indeed dangerous for NHBC to strive to find a way to help developers who wished to use non-compliant cladding products to do so, having applied little or no thought to that suggested route. The "desktop study" route should not have been suggested by NHBC or the BCA because NHBC had no grounds for thinking that anyone in the industry understood what data was required for a reliable desktop assessment or had the competence necessary to produce one.
¶26.66 In our view, NHBC's desire for a third route to compliance was rooted in three things. First, it had formed a view that the requirements of the "linear route" were particularly onerous. However, that view does not appear to have been shared by the industry at large and, in any event, however onerous, it was not for NHBC to seek to ameliorate the requirements of the guidance.
¶26.67 Secondly, NHBC considered that the tests required by the second option were time-consuming and expensive and were in any event of limited application because they were irrelevant if any element of the system differed from that which had been tested.1831 Lewis {Day223/190:8-15}. Again, however, it was not appropriate for NHBC to seek to circumvent or dilute the effectiveness of the guidance by suggesting another route to compliance.
178¶26.68 Finally, Mr Lewis explained that NHBC did not want to prevent the industry from achieving the high degrees of insulation performance that combustible insulation products provided.1832 Lewis {Day223/193:13} However, as a provider of building control services, it was precisely NHBC's role to ensure that unsafe products that were frequently being proposed for use were not approved by its building control officers. Its evident desire to assist the industry was wholly inappropriate. As Mr Lewis was constrained to accept, the practice of building control bodies and approved inspectors "working with" the industry rather than holding it to proper standards was corrupting, because it tended to undermine the independence of building control officers and approved inspectors.1833 Lewis {Day223/194:1}-{Day223/196:3}.
¶26.69 Mr Lewis denied that the third route to compliance proposed by TGN 18 had been devised as a means of legitimising schemes using K15 that he knew had been wrongly approved by NHBC in the past.1834 Lewis {Day223/196:4-11}. Although we accept his evidence that it arose directly from the suggestion made by Wintech at the meeting on 15 November 2013, that was all it was, a suggestion based on hearsay and anecdote. The evidence shows that NHBC clearly understood that the use of K15 could not be justified by any other means and that refusing to approve the use of K15 on high-rise buildings would have significant commercial repercussions.
TGN 18 (Issue 0): June 2014
¶26.70 TGN 18 was formally issued in June 2014.1835 {NHB00000760}. The three alternative routes to compliance were identical to those included in John Lewis's initial draft prepared on 15 November 2013, save that a sentence had been added to the second route to identify some of the requirements of BR 135. There is no evidence that the BCA itself took any steps to verify or investigate the validity and safety of the three options, in particular to examine the basis for option 3, and we infer that it did not.
¶26.71 In the result, the BCA promulgated the third route to compliance on the basis of extremely limited information, namely the second-hand assurances of Wintech, and without any independent verification or indication of how it could operate in practice. Moreover, although each of the NHBC witnesses sought to justify its inclusion by reference to Appendix A of Approved Document B, there is no evidence that it had received any consideration within NHBC or the BCA.
¶26.72 In the circumstances, the inclusion of the third option in TGN 18 was irresponsible. It was not motivated by a desire for rigour in the application of Approved Document B, nor by a desire to improve fire safety standards in high-rise buildings, but by NHBC's desire to assist developers to find a way to justify the use of non-compliant products.
Discussions with the government and industry: 2014 – 2015
¶26.73 On 2 July 2014 Brian Martin of the department sent an unprompted email to Neil Smith of NHBC to provide a "friendly warning" that PIR insulation was being used in cladding systems. He did so because, as he put it, people were under the impression that PIR was a material of limited combustibility (which was not the case) and he thought that NHBC ought to ensure that its surveyors were aware of that.1836 {NHB00000732/3}. Mr Martin's email was sent at 11.42, shortly before a meeting of the CWCT at 14.00 that day. Mr Martin attended that meeting but did not stay until the end.1837 Lewis {Day224/5:4-22}.
179¶26.74 Mr Martin's email came as no surprise to NHBC, as it had been endorsing the use of PIR insulation since at least November 2013 in the full knowledge that it was not a material of limited combustibility.1838 Evans {Day220/67:3}-{Day220:68:5}. It took NHBC until 11 July 2014 to respond and when the response came, it came from Steve Evans, to whom Mr Smith had passed Mr Martin's email. Mr Evans drafted a response and discussed it with Diane Marshall before it was amended and sent.1839 {NHB00000732/1}. He said that there was no reason to suspect that buildings which had been built with Kingspan K15 were at risk; it was just the fact that testing carried out to date did not bear that out. Kingspan, he said, was confident that the testing currently being carried out would prove the suitability of the material for use on buildings over 18 metres in height.1840 {NHB00000732/2}
¶26.75 The first sentence was clearly misconceived.1841 Evans {Day220/90:2-25} Although Mr Evans did not accept it,1842 Evans {Day220/91:1}-{Day220/93:11} the fact that there was no available test evidence to indicate that K15 was compliant was itself a reason to suspect that buildings on which it had been installed were at risk. The statement amounted to a suggestion that any untested combustible insulation material was safe for use on buildings over 18 metres in height unless testing proved otherwise. That was obviously not the case. For her part, Ms Marshall sought to explain that sentence by saying that the high-rise buildings containing K15 which NHBC had approved in the past had been accepted on the basis of the BBA certificate.1843 Marshall {Day226/16:1}-{Day226/18:4}. However, the sentence does not say that NHBC had relied on the BBA certificate and, for reasons already given, the BBA certificate for K15 was plainly unreliable. She also told us that she had placed confidence in the fact that Kingspan had told NHBC that it was going to conduct more tests,1844 Marshall {Day226/17:25}-{Day226/18:4}. but that was not a sound basis for the assertion that tall buildings with K15 in their external walls were not at risk.
¶26.76 The second sentence of Mr Evans' email merely perpetuated the falsehood, disseminated by Kingspan with the assistance of NHBC and with the inadvertent support of the LABC and the BBA, that a single successful BS 8414 test could support the generic use of K15 in external walls of buildings over 18 metres in height generally, irrespective of the construction of the system. It could only have made sense if Steve Evans had been suggesting that Kingspan would subject every external wall system in which K15 had been used (of which there were very many) to a BS 8414 test, but that was clearly not his intention. As John Lewis accepted, that would require a vast number of tests (as many as there were different external wall systems containing K15), occupying BRE for months.1845 Lewis {Day224/14:6-22}.
¶26.77 The correspondence was not sent to John Lewis until 15 August 2014 and he was not consulted on its contents.1846 Lewis {Day224/4:15}-{Day224/5:25}; {Day224/11:11-16} Mr Lewis said that NHBC did not see Mr Martin's email as a reason to change anything it was doing because it was already aware of the historic legacy of buildings containing combustible insulation, was continuing to press Kingspan for the results of tests on K15 (thus far without success), and in any event had already drafted TGN 18 as a response to the problem.1847 Lewis {Day224/9:18-25}.
180¶26.78 Steve Evans' response to Brian Martin contrasted starkly with the position he had taken in correspondence with Kingspan the previous month. On 16 June 2014, he had told Richard Bromwich of Kingspan that the change in the BBA certificate for K15 meant that NHBC had no remaining basis for accepting its use on buildings over 18 metres in height.1848 {NHB00000757/3}. He warned that unless Kingspan could produce additional test evidence supporting the use of K15 in constructions which differed from the BS 8414-1 test referred to in the BBA certificate by 30 June 2014, NHBC would need to reconsider its acceptance of K15 on such buildings. That was some six months after its meeting with Kingspan in January 2014. NHBC must have realised by that point, if not earlier, that it was being deceived by Kingspan. Mr Evans' message of 16 June 2014 simply gave Kingspan a further opportunity to keep selling K15 for use on buildings over 18 metres in height in the UK market safe in the knowledge that NHBC had not instructed its surveyors to reject it.
¶26.79 In the event, Mr Evans' deadline of 30 June 2014 came and went without any action being taken by NHBC. Instead, it continued to give Kingspan further time to produce the results of tests that it must have known could not provide a satisfactory resolution. Mr Lewis said that had been because a change in NHBC's position would have created a storm within the industry and would in any event have been futile because local authority building control officers would have accepted the use of K15 based on the LABC certificate, which stated that it could be considered a material of limited combustibility.1849 Lewis {Day224/18:3} – {Day224/19:24}. That was not a responsible position for NHBC to take.
¶26.80 By August 2014, NHBC was clearly becoming increasingly uncomfortable with Kingspan's failure to provide convincing evidence that K15 was suitable for use on high-rise buildings. On 15 August 2014, Steve Evans wrote to Ivor Meredith of Kingspan requesting a letter of comfort from BRE pending receipt of further promised test results in order to protect everyone's position in circumstances where it could be months before the further information was received and there were many designers currently using or planning to use K15.1850 {NHB00000757/1}.
¶26.81 That was itself a telling request for a number of reasons. First, it is wholly unclear what comfort Kingspan could give in relation to the use of K15 on buildings over 18 metres in height. Secondly, it revealed that NHBC knew that it was open to criticism and possibly claims for accepting K15 for use on high-rise buildings when it knew that it did not comply with the guidance in Approved Document B and could therefore not demonstrate compliance with the Building Regulations by the linear route. Thirdly, it treated Kingspan and NHBC as if they had a common interest in Kingspan's continuing to market K15 for use on high-rise buildings. That was a fundamental misconception. It was NHBC's responsibility as an approved inspector to ensure that its surveyors and building control officers applied the Building Regulations correctly and rejected the use of any materials or products that would prevent the building from complying with them. The action of NHBC provides a vivid example of a large body with substantial influence over building control officers nationwide electing to co-operate with manufacturers rather than robustly enforce regulations designed to protect life. The attitude of NHBC, as revealed by Mr Evans' message, deserves criticism in the strongest terms.
181Meeting with Arup and BRE: autumn 2014
¶26.82 On 30 October 2014, Steve Evans wrote to Dr Barbara Lane of Arup Fire seeking a meeting to discuss technical issues relating to the use of combustible materials in the external facades of high-rise buildings.1851 {NHB00000811/4}. In her response Dr Lane said that Arup believed that the use of combustible materials in residential buildings was an accident waiting to happen.1852 {NHB00000811/3}. A meeting then took place between Arup and NHBC on 25 November 2014.1853 {NHB00000829/1}. Despite Arup's clear concerns, NHBC did not think to tell Brian Martin that, contrary to the previous assurances given by Steve Evans in his letter of 11 July 2014, there was indeed a real risk to existing buildings.1854 Evans {Day220/154:15}-{Day220/158:3}. Nor did NHBC, even at that late stage, a year after the Wintech meeting, start refusing to accept K15 for use on high-rise buildings.1855 Evans {Day220/157:1-11}.
¶26.83 On 27 November 2014, Steve Evans, John Lewis, Graham Perrior and Dave White of NHBC met Dr Sarah Colwell, Steve Manchester and Stephen Howard of BRE. At that meeting, NHBC was told that the time between a BS 8414 test and the consequent BR 135 classification was usually short and learned that no classification report had been issued in relation to K15.1856 {NHB00000829/2}. Therefore, despite BRE's unwillingness for reasons of client confidentiality to answer specific questions about Kingspan's latest tests, it was clear to NHBC that at least one of them had failed.1857 Lewis {Day224/89:20}-{Day224/90:14}.
¶26.84 Dr Sarah Colwell also confirmed that BRE had agreed with NHBC's view that the provisions in paragraph 12.7 of Approved Document B applied to all major components of a cladding system, including the external finish.1858 {NHB00000829/2}. John Lewis specifically asked Sarah Colwell about that because of the resistance to that view that NHBC was receiving from customers. He wanted BRE to confirm that in its view Option 1 in TGN 18 issue 0 interpreted that paragraph correctly.1859 Lewis {Day224/69:8-12}. However, Dr Colwell did not explain how she derived that meaning from the language of paragraph 12.7.1860 Lewis {Day224/69:1-7}.
Contact with the BBA: January 2015
¶26.85 NHBC did not contact the BBA about its certification of Kingspan K15 until January 2015, some seven years after the BBA certificate had first been published and a year after the certificate had been amended to remove the instruction to seek advice from Kingspan.1861 {NHB00000895/3}. On 27 January 2015, Graham Perrior asked John Albon of the BBA to explain why the certificate had been changed, which he said had seriously affected the situations in which K15 was acceptable.1862 {NHB00000895/3}.
182¶26.86 The BBA provided a comprehensive response the following day, the essence of which was that the change to the certificate was a matter of emphasis and there had been no change in the assessment criteria or scope of approval.1863 {NHB00000898/2}. When he saw that response, Graham Perrior was unimpressed. He passed it on to Dave White and Steve Evans that day saying that the BBA's position was not correct.1864 {NHB00000899}. Regrettably, no one at NHBC had asked the BBA to explain its statement that K15 could be used in accordance with paragraph 12.7 of Approved Document B and Mr Evans could not explain why it had not done so.1865 Evans {Day221/52:15-18}. Mr Evans maintained before us that even at that stage NHBC could continue to rely on the BBA certificate to approve the use of K15 on high-rise buildings because it said that it could be used in accordance with paragraph 12.7 of Approved Document B, but we find it difficult to understand that position, given that K15 was known not to be a material of limited combustibility.1866 Evans {Day221/53:18-24}.
Reliance on TGN 18
¶26.87 On 5 February 2015 NHBC told Kingspan that it would no longer approve the use of K15 on high-rise buildings unless evidence of compliance with the Building Regulations was provided in accordance with TGN 18.1867 {NHB00000922/1}. Kingspan's response was to instruct its lawyers to allege that it was being treated unfairly and to threaten legal action against NHBC.1868 {KIN00008283}.
¶26.88 NHBC's new policy applied to all projects using K15 from 1 January 2014.1869 {NHB00000934}. However, NHBC continued to accept confirmation from Kingspan that K15 was suitable for any project for which the initial notice had been given before that date.1870 As per Steve Evans's instructions on 2 December 2013 at {NHB00000935} as set out in {NHB00000934}. John Lewis accepted that K15 was no less combustible on 31 December 2013 than it had been on 1 January 2014, and could not explain why NHBC had not changed its approach.1871 Lewis {Day223/157:25}-{Day223/158:17}. In our view, the policy adopted by NHBC in early 2015 towards the continued acceptance of Kingspan K15, despite what it knew, could not reasonably be justified.
The 2015 policy review
¶26.89 Following the adoption of its new policy towards K15, NHBC launched what it termed the "Combustible Cladding Review".1872 Lewis {NHB00003433/32} page 32, paragraph 115. In accordance with the instructions of the board,1873 Marshall {Day226/32:7-15}. the review was limited to buildings over 18 metres in height currently under construction or about to start.1874 Lewis {Day224/158:22}-{Day224/159:5}; Marshall {Day226/5:14-19}. The board also decided not to tell its previous customers that NHBC had approved external cladding systems on high-rise buildings that contained combustible insulation.1875 Marshall {Day226/33:25}-{Day226/34:7}. That decision was apparently based, at least in part, on the fact that at the time NHBC had held what it regarded as a valid BBA certificate.1876 Marshall {Day226/33:15}-{Day226/34:19}. We have no reason to doubt that that was in fact in part the basis of its decision. However, we do not accept Ms Marshall's assertion that the BBA certificate for K15 ever justified such an approach, certainly not after NHBC had become aware that it was erroneous and unreliable. The board's decision not to tell previous customers of the fact that its building control officers had approved cladding systems that were at least at serious risk of preventing the building from complying with one of the principal functional requirements of the Building Regulations, and so a potential danger to life, was irresponsible.1877 Marshall {Day226/33:25}-{Day226/34:19}. As we shall see, the scale of the problem was huge.
183¶26.90 The review categorised buildings as being either high, medium or low risk according to the materials used in their construction.1878 Lewis {NHB00003433/32} page 32, paragraph 118. Those categories had been suggested by John Lewis based on his knowledge of combustible materials and were accepted by Steve Evans.1879 Lewis {Day224/164:13-19}. Mr Lewis described the review as a screening exercise, although he conceded that some projects with ACM PE had slipped through the net.1880 Lewis {Day224/164:20}-{Day224/165:14}.
¶26.91 The results of the review were subsequently put into a table that identified in detail the projects in which NHBC had been involved that included the use of combustible materials.1881 {NHB00003038}. All the buildings in the review were ultimately accepted by NHBC, despite containing combustible materials,1882 Evans {Day221/19:3-18}. although many required remedial work to be carried out before they could be finally approved.1883 Lewis {Day224/168:7-10}. NHBC's approval was ultimately given by Steve Evans and Diane Marshall, neither of whom had any fire engineering qualifications, based on the advice and expertise of John Lewis or Maulik Katkoria as fire engineers.1884 Evans {Day221/41:18}-{Day221/43:21}.
Revision of TGN 18: June 2015
TGN 18 (Issue 1): June 2015
¶26.92 Issue 1 of TGN 18 was published by the BCA in June 2015. That revision had been drafted by John Lewis at the request of Steve Evans1885 Lewis {Day224/91:1}-{Day224/92:4}; {Day224/99:21-23}. and contained two major changes. First, the pool of people who could produce desktop studies was widened to include any suitably qualified fire specialist. Secondly, a holistic fire engineering solution was included as a fourth alternative route to compliance.
¶26.93 John Lewis1886 Lewis {NHB00003433/38} page 38, paragraph 148; Lewis {Day224/99:13}-{Day224/100:19}. and Steve Evans1887 Evans {NHB00003020/77} page 77, paragraph 200 (a). said that the first change had been prompted by responses from the three testing houses which said that they were struggling to keep up with the number of requests for desktop studies. However, we have not seen any contemporaneous documents to suggest that that was the case and it was certainly not mentioned in the minutes of the meeting between BRE and NHBC in November 2014.1888 {NHB00000829/2-3}. We think that if BRE had been inundated with requests for desktop reviews, Dr Colwell would probably have raised the matter at the meeting with NHBC on 25 November 2014, but there is no evidence that she did. Although Mr Evans recalled a discussion about it, Mr Lewis did not.1889 Lewis {Day224/111:16}-{Day224/112:18}. We prefer Mr Lewis' recollection, given the total absence of any reference to the matter in the contemporaneous documents. In our view, it is more likely that the change was motivated by a desire on the part of NHBC to make it easier for developers to obtain timely building control approval.
184¶26.94 The second change was the inclusion of a holistic fire-engineered solution. That had always been an alternative way of demonstrating compliance with functional requirement B4(1), as clearly provided by Approved Document B.1890 {CLG00000224/15}, at paragraph 0.30. It was included simply for completeness.1891 Lewis {Day224/95:6-23}.
Option 3 and desktop studies
¶26.95 As NHBC's only qualified fire engineer, John Lewis was responsible for examining the desktop studies that it received.1892 Lewis {Day224/115:21-25}. He found them to be of variable quality, those from BRE and Exova being the most comprehensive.1893 Lewis Second Statement {NHB00003433/48} page 48, paragraph 182 (b). Initially he found few problems with the studies he received, but after the publication of Issue 1 of Technical Guidance Note 18 in June 2015 the standard began to drop.1894 Lewis {Day224/123:23}-{Day224/124:19}. He did not accept, however, that those who were permitted to produce reports were not qualified to do so.1895 Lewis {Day224/124:20}-{Day224/125:7}.
¶26.96 John Lewis reported his concerns to Diane Marshall,1896 Marshall {Day226/59:2-10}. who was aware that some desktop studies submitted to NHBC often lacked proper references to relevant test data and that others applied only the requirements of diagram 40 of Approved Document B as opposed to the guidance in paragraph 12.7.1897 Marshall {Day226/60:11-22}. She nonetheless claimed to believe that desktop studies worked well so long as they were done correctly.1898 Marshall {Day226/61:6-13}. However, there was no established method for assessing whether they had been done correctly.
¶26.97 In his report Professor Luke Bisby expressed the view that the change to TGN 18 in relation to desktop studies further eroded the already weak oversight of competence in this part of the industry.1899 Bisby, Phase 2 Report - BR 135 Desktop Assessment Report {LBYP20000004/37} paragraph 277. We agree. It is clear that in 2015 the practice of producing desktop assessments was fraught with dangerous shortcomings.
Further discussions with industry: 2015–2016
Paragraph 12.7 of Approved Document B and "filler"
¶26.98 On 15 June 2015, Steve Evans wrote to Brian Martin, whom he regarded as the "guardian of Approved Document B",1900 Evans {Day221/68:15-17}; {NHB00002792/3}. to seek clarification of the meaning of "filler material etc" in paragraph 12.7 of Approved Document B.1901 {NHB00002792}. He was keen to know what the department understood "filler" to mean and whether the suggested restriction to materials of limited combustibility extended to the external surface of a cladding panel. Given that NHBC had taken the view when drafting TGN 18 that all elements of the external wall construction should be materials of limited combustibility (a view shared by BRE), it is surprising that Mr Evans felt that he had to ask those questions. However, he told us that many of NHBC's customers had been challenging its view that paragraph 12.7 required cladding panels to be composed of materials of limited combustibility rather than simply being classified Class 0.1902 Evans {Day221/55:16}-{Day221/56:15}. The key point was that contained in the last paragraph of the email. NHBC was of the view that there was little point in ensuring that insulation products were materials of limited combustibility if they could be faced with a cladding finish which, although Class 0, could contribute to the spread of fire, but there was a difference of opinion within the industry. For that reason, he was seeking clarification from the department.
185¶26.99 Despite NHBC's plea for help, Mr Martin's response was that he could not offer a formal view, because the interpretation of Approved Document B as it applied to specific projects was a matter for the relevant building control body.1903 {NHB00002792/4}. As Mr Evans said at the time, that was not an answer at all.1904 {NHB00002792/2}. Nonetheless, Mr Evans did not press Mr Martin for a clearer statement and Mr Lewis thought that his existing response might be enough to justify the position taken by NHBC in its discussions with one particular developer.1905 {NHB00002792}; Evans {Day221/72:4-23}. Although NHBC had confidence in its own view that all components of the external wall of a high-rise building should be materials of limited combustibility, large swathes of the industry disagreed. Given NHBC's powerful influence in the industry, it is regrettable that it did not press Mr Martin to adopt a clear position.
BRE and Siderise Conference: January 2016
¶26.100 On 13 January 2016, Steve Evans attended a conference on external facades organised by BRE and Siderise. He gave a presentation entitled Facades to Tall Buildings: Routes to Compliance and took questions from the audience. Among those present was Nick Jenkins of Booth Muirie, a supplier of rainscreen materials, including aluminium composite panels.1906 Murden {BLM00000004/1} page 1, paragraph 7. During the question and answer session, Mr Jenkins explained that combustible ACM panels were commonly being used on high-rise residential buildings and expressed his grave concern that they did not meet the requirements of the Building Regulations.1907 {INQ00014949/10-11}. Mr Evans' response was that an ACM panel with a Class 0 classification was considered to comply with Approved Document B.1908 {INQ00014949/12}. He referred to what he described as an anomaly in Approved Document B created by the different requirements of paragraph 12.7 and Diagram 40. Although he acknowledged that ACM panels could technically be compliant if they met the requirements of Diagram 40, he said that that was not an approach he agreed with.1909 {INQ00014949/12 -13}. The video clip is at {SIL00010066}, played at {Day 221/79:4-15}.
¶26.101 Mr Evans's own position was that NHBC could not demand higher standards than those required by the Building Regulations.1910 Evans {Day220/167:7}-{Day220/170:24} and {Day221/37:6-23}; Lewis {Day224/188:13}-{Day224/189:8}. That may be so, but it begs the question what the Building Regulations actually required. Mr Evans confirmed that NHBC's position as expressed in Option 1 of TGN 18 (both Issues 0 and 1), namely, that all elements of the external wall of a high-rise building had to be of limited combustibility, had not altered between June 2014 and January 2016.1911 Evans {Day221/89:5-7}. There was therefore an obvious inconsistency between what he told the conference and NHBC's approach at the time, which he sought to explain away by saying that his answer at the conference had been badly worded.1912 Evans {Day221/87:14}-{Day221/88:6}. He said that his claim to have discussed with the department what he called the anomaly in Approved Document B was a reference to NHBC's email exchange with Brian Martin in June 2015, although, as NHBC recognised at the time, those perfunctory discussions had not advanced matters at all.1913 Evans {Day221/90:1}-{Day221/91:9}.
186¶26.102 The significance of the conference in January 2016 was twofold. First, Mr Evans did not adopt the position set out in TGN 18, and thus publicly adopt a clear position, even though it might, on one reading of Approved Document B, be over-strict. Secondly, the discussion brought home to NHBC (if it had not realised it earlier) that there was a significant number of high-rise buildings in the UK which its building control surveyors (and others) had approved as compliant with the Building Regulations but which contained combustible materials in the external wall systems that should not have been accepted.
¶26.103 On 19 January 2016, after the conference, Mr Jenkins took the matter up with Steve Evans in email correspondence, picking up the ambiguities in some of the responses given by the panel at the conference. He asked whether the entire external wall of a high-rise building had to be of limited combustibility or whether, where ACM cladding panels were used, it was sufficient that they be classified Class 0.1914 {BLM00000211/4}. Steve Evans responded on 29 January 2016 saying that Approved Document B advised that all materials used in the external wall should comply with both paragraph 12.7 and Diagram 40, thereby contradicting the view he had expressed at the conference.1915 {BLM00000211/2}. Mr Evans fairly acknowledged before us that his position was indeed directly inconsistent with what he had said at the conference but insisted that it was what he had been trying to express.1916 Evans {Day221/100:22-23}. We are not convinced by that answer, not least because Mr Evans took ten days to respond to Mr Jenkins, during which time he had had plenty of time to think about the point carefully.
¶26.104 Although Steve Evans told us that NHBC would not have approved any buildings clad in ACM panels with unmodified polyethylene cores,1917 Evans {Day221/120:4}-{Day221/121:7}. we do not accept that. John Lewis conceded that the 2015 review had revealed a number of such buildings that had been approved by NHBC.1918 Lewis {Day225/42:17}-{Day225/45:25}. By early 2016 at the latest NHBC knew at the highest levels of its management that there were a substantial number of high-rise buildings in the UK on which ACM panels with unmodified polyethylene cores had been installed and which had been passed as compliant by NHBC's building control surveyors.1919 Lewis {Day225/42:17}-{Day225/45:25}.
The July 2016 guidance note
¶26.105 After NHBC changed its policy in February 2015 to require proof of compliance with the Building Regulations in accordance with TGN 18, it noticed that it was frequently being provided with the same desktop study amended in insubstantial ways to cater for differences between projects.1920 Lewis {NHB00003433/53} page 53, paragraph 194. As no further test data had been forthcoming from Kingspan, despite a string of promises stretching back to January 2014, NHBC realised that it was likely to continue to receive desktop studies based on the same data. It therefore decided that it could dispense with the requirement for such studies altogether for certain façade systems.1921 Lewis {NHB00003433/54} page 54, paragraph 195.
¶26.106 Accordingly, in July 2016, NHBC published a guidance note entitled Acceptability of Common Wall Construction Containing Combustible Materials in High Rise Buildings.1922 {NHB00001293}. The note was drafted by John Lewis and approved by Steve Evans, Diane Marshall, Ian Davis and the NHBC Executive Committee.1923 Lewis {NHB00003433/55-56} pages 55-56, paragraphs 204-205. The new guidance set out functional requirement B4(1) and the four options contained in Issue 1 of TGN 18, which it described as alternative ways of demonstrating compliance with the Building Regulations. It went on to say that the new guidance had been produced to provide advice to builders on some of the most common wall types in relation to which NHBC would no longer require a desktop assessment in accordance with Option 3 in TGN 18 in order to demonstrate compliance.
187¶In the appendices it described three common wall and façade types that were acceptable to NHBC without the need to provide a desktop assessment provided that the design specification and installation met the minimum requirements set out in the appendices.
¶26.107 Appendix 3 covered aluminium composite panels. The requirements for automatic approval included the use of panels with a minimum Euroclass B classification and a Class 0 classification for surface spread of flame. Also acceptable as part of the system were Kingspan K15 and Celotex RS5000 insulation boards.
¶26.108 Diane Marshall told us that NHBC had been prompted to issue the guidance partly by the poor quality of the desktop studies submitted to it and partly by the administrative burden of reviewing many assessments relating to similar systems,1924 Marshall {Day226/62:14-18}. but clearly neither of those was a good reason for NHBC to abdicate its responsibility for examining carefully the proposed structure of an external wall. Ms Marshall sought to justify NHBC's approach by reference to regulation 7 of the Building Regulations and said that it was common knowledge that past experience could be used to inform future decisions.1925 Marshall {Day226/73:9-21}. However, no one at NHBC had ever examined Approved Document B to see whether that was a permissible approach.1926 Marshall {Day226/74:18-23}. We do not think it was.
¶26.109 Paragraph 1.18 of the Approved Document supporting regulation 7 states that past experience, such as the use of a material in an existing building, may show that it can perform the function for which it is intended.1927 {INQ00014930/14}. Ms Marshall conceded that a cladding system would need to comply with functional requirement B4(1) in order to demonstrate that the same system, if installed on another building, could perform the function for which it was intended as contemplated by regulation 7. However, she appeared not to grasp the important point that a previous desktop assessment could never demonstrate compliance in the absence of relevant test data relating to the particular system being used as the exemplar.1928 Marshall {Day225/73:9}-{Day225/74:10}.
¶26.110 Both Diane Marshall and Steve Evans agreed that the guidance note published by NHBC involved drawing an inference from underlying assessments that were themselves based on inferences from some underlying data.1929 Marshall {Day226/70:14-23}. However, NHBC was not concerned by the fact that there had been no large-scale testing of any systems incorporating ACM panels,1930 Evans {Day221/138:11}-{Day221/139:25}. and the guidance note was published without any contribution from organisations such as BRE or Exova.1931 Evans {Day221/147:24}-{Day221/148:7}. That was particularly surprising given that NHBC was aware of the international cladding fires involving ACM panels in 2015 and early 2016.1932 Evans {Day220/19:14-17}; {Day220/21:20-23}; Lewis {Day225/8:18-22}.
188¶26.111 Appendix 3 did contain a warning that the use of aluminium composite panels with polythene or polythene and mineral cores which did not achieve a Euroclass B classification fell outside the scope of the guidance.1933 {NHB00000065/4}. Diane Marshall said that that had been intended to mean that all panels with polyethylene cores were prohibited in addition to those with fire retardant cores that had not achieved Class B.1934 Marshall {Day226/79:4-16}. In other words, she suggested that the clause "which do not achieve a minimum Class B combustibility classification" was to be read as if in parenthesis, so that all ACM panels with unmodified or modified polyethylene cores fell outside the guidance.1935 Marshall {Day226/83:1-24}. We are unable to accept that interpretation. First, no one at NHBC suggested that the passage was intended to have that meaning until Ms Marshall proposed it in the course of her evidence. Secondly, and more importantly, some ACM panels with fire retardant polyethylene cores can be classified Class 0 and Euroclass B. Indeed, some of Arconic's Reynobond FR core panels were. No-one at NHBC had done any research before the note was published on the fire-retardant versions of ACM panels and their corresponding Euroclass classifications, and there was therefore no basis on which to ban all panels with polyethylene cores regardless of their mineral content.1936 Lewis {Day225/35:22}-{Day225/37:4}. Thirdly, if that had been intended, it would have been easy simply to say that all ACM panels with polyethylene cores fell outside the scope of the guidance note, without referring to any classification.
¶26.112 We think it clear that the sentence meant what it says, namely, that only ACM panels with polyethylene cores that were classified Class 0 or Euroclass B were covered by the guidance, without regard to the nature of the core. Mr Lewis, who drafted the note, told us that he thought that it would effectively exclude ACM panels with unmodified polyethylene cores, but he could not explain why he had not said so plainly.1937 Lewis {Day225/33:24}-{Day225/35:21}.
¶26.113 The guidance note was silent on the size and orientation of the cladding panels, the spacing between them, the fixing method (cassette or riveted) and the width of the drained and vented cavity, all of which were capable of affecting the fire performance of the system as a whole. Steve Evans said that the guidance note was intended to apply to external wall systems that were practically identical to those in the numerous desktop studies submitted to NHBC,1938 Evans {NHB00003020/102} page 102, paragraph 251 a. but he was unable to explain what that meant.1939 Evans {Day221/147:12-22}.
¶26.114 Diane Marshall conceded that the guidance note permitted the use of external wall systems containing insulation and cladding that were not materials of limited combustibility and was therefore inconsistent with her understanding of paragraph 12.7 of Approved Document B.1940 Marshall {Day226/90:22}-{Day226/91:7}. At least if, as she thought, all elements of the cladding system had to be material of limited combustibility, as Option 1 in TGN 18 provided. Although the witnesses denied it,1941 Lewis {Day225/51:18}-{Day225/52:5}. the 2016 guidance note was clearly inconsistent with the policy NHBC had adopted in 2015 and, as Kingspan said in an internal email of 8 July 2016, eased the passage of compliance for K15.1942 {KIN00002297/1}. Given the trouble that NHBC had had with Kingspan since early 2014, the sudden blanket approval of the use of K15 in the external walls of buildings over 18 metres in height was, to say the least, surprising.
189¶26.115 The guidance note was presented to an NHBC conference in London on 7 July 2016. It is a tragic irony that that was the same date as the issue by RBKC's building control officer of the certificate of practical completion for the Grenfell Tower refurbishment, the new cladding on which was composed of Celotex RS5000, a small amount of Kingspan K15 and ACM panels with unmodified polyethylene cores that purported to hold a Euroclass B classification.
¶26.116 For NHBC building control officers the guidance note was effectively a substitute for Approved Document B. For them to accept an external wall as complying with functional requirement B4(1), it was no longer necessary for the insulation (let alone all the elements) to be of limited combustibility, or, as an alternative, to have a full system test meeting the criteria in BR 135, or a desktop assessment, or a holistic fire-engineered solution. It was sufficient for the external wall to be composed of the common products listed. It drove a coach and horses through the guidance in Approved Document B and rendered TGN 18 completely irrelevant. There is no evidence that the BCA was ever consulted about it. We agree with Mr Lewis when he said that the guidance note should never have been produced.1943 Lewis {Day225/60:1-9}.
Events after the fire at Grenfell Tower
Approach from Brian Martin
¶26.117 On 16 June 2017, two days after the fire at Grenfell Tower, Brian Martin wrote to Diane Marshall attaching a script written to rebut a newspaper article which had stated that ACM panels with polyethylene cores complied with the guidance in Approved Document B.1944 {NHB00001460/2}; {NHB00001458}. He asked whether she would be prepared to make a public statement to that effect as an independent expert. Ms Marshall told us that she did not know why Brian Martin had approached her and had not given any thought at the time to whether it was appropriate for him to do so.1945 Marshall {Day226/103:1}-{Day226/104:9}.
¶26.118 In contrast to the guidance note published by NHBC in July 2016, the script stated that only materials of limited combustibility could be used in the external walls of buildings over 18 metres in height.1946 Marshall {NHB00003434/43} page 43, paragraph 201. Nonetheless, Diane Marshall told Brian Martin that she fully agreed with the proposed text.1947 {NHB00001460/1}. She did not, however, agree to act as the required independent expert and instead suggested he approach the chairman of the BCA.1948 {NHB00001460/1}. She said that her decision had not been motivated by the obvious inconsistency between the position of NHBC and that of the department but by the fact that she did not consider NHBC's views to be representative of the industry.1949 Marshall {Day226/105:16}-{Day226/109:18}. We find that an unconvincing explanation given the influence of NHBC nationally, its role in the production of TGN 18 and the issue of its guidance note.
190Withdrawal of the guidance note
¶26.119 On 26 June 2017, Brian Martin wrote to Diane Marshall again to say that NHBC's 2016 guidance note had been raised in response to the Grenfell Tower tragedy, but he offered no further explanation. He questioned its evidential basis and asked for the test results from any BS 8414 testing which had taken place using Class B ACM panels.1950 {NHB00001465/2}.
¶26.120 On 28 June 2017, NHBC withdrew the 2016 guidance note on the basis of commercial considerations rather than any consultation with fire specialists.1951 Marshall {Day226/96:25}-{Day226/97:24}. Diane Marshall told us that the guidance relating to ACM panels with polyethylene cores was open to being misread.1952 Marshall {Day226/81:22}-{Day226/84:7}. We do not accept that and we do not accept that the guidance note was a distraction from the tragedy at Grenfell Tower. On the contrary, it is of direct relevance to the attitudes of industry and NHBC at the time.
¶26.121 Diane Marshall responded to Mr Martin on 29 June 2017,1953 {NHB00001465/1}. the day after the guidance note had been withdrawn.1954 Marshall {NHB00003434/43} page 43, paragraph 201. She was aware it had been receiving media attention but disputed that she was concerned about the department's request for evidence.1955 Marshall {Day226/110:8}-{Day226/112:13}. We do not accept that the timing was coincidental. Enquiries from government were clearly instrumental in NHBC's decision to review its policy and withdraw the note. Indeed, Ms Marshall conceded that she was aware that no relevant ACM panels had ever been part of a successful test in accordance with BS 8414.1956 Marshall {Day226/119:9}-{Day226/120:12}.
191Chapter 27: Siderise cavity barriers
Background
¶27.1 Siderise Insulation Limited ('Siderise') designs and manufactures fire, thermal and acoustic insulation products for use in curtain walling and cladding. It also supplies associated products, such as brackets, sealants and tapes for use with its products.1957 Swales {SIL00000306/3} page 3, paragraphs 11 and 13. It sells direct to customers or through distributors.1958 Swales {SIL00000306/3} page 3, paragraph 11. It is a member of various industry bodies, including the Centre for Window and Cladding Technology and the Association for Specialist Fire Protection.1959 Swales {SIL00000306/4} page 4, paragraph 14. It has contributed to the development of publications and guidance relating to external walls1960 Including the ASFP Red Book chapter "Firestopping: Linear Joint seals, penetrations & cavity barriers", Swales {SIL00000306/4} page 4, paragraph 14. and has hosted industry conferences on facades in collaboration with the Building Research Establishment (BRE).1961 Swales {SIL00000306/4-5} pages 4-5, paragraph 16. The first was on 1 November 2012 and the second on 13 January 2016.
¶27.2 As well as manufacturing cavity barriers, Siderise provided additional services to its customers,1962 Siderise Site Services dated January 2016 {SIL00002589}. including advice on the suitability of its products for particular applications1963 Swales {SIL00000306/7} page 7, paragraph 28. and guidance on installation.1964 Siderise Site Services dated January 2016 {SIL00002589}.
Product Development and Testing
¶27.3 A cavity barrier is defined in Appendix E of Approved Document B as "a construction, other than a smoke curtain, provided to close a concealed space against penetration of smoke or flame, or provided to restrict the movement of smoke or flame within such a space."1965 Approved Document B 2013 {CLG00000224/143}. The guidance in Approved Document B is that cavity barriers should provide 30 minutes' integrity and 15 minutes' insulation when tested to the relevant part of BS 476.1966 Approved Document B 2013 {CLG00000224/125} Table A1, Item 15.
¶27.4 According to Siderise's witnesses, cavity barriers were traditionally tested in accordance with the general principles set out in BS 476 Part 20,1967 Mort {SIL00000298/10} page 10, paragraph 38; {BSI00001748}. which is the British Standard containing general principles governing the method of determining the fire resistance of elements of construction.1968 {BSI00001748/1}. Part 20 was accompanied by supplementary standards for testing specific elements of construction, namely, Part 21 for loadbearing elements, Part 22 for non-loadbearing elements, Part 23 for fire-protecting suspended ceilings and Part 24 for ventilation ducts.1969 Part 21 {BSI00001745}; Part 22 {BSI00001743}; Part 23 {BSI00000074}; Part 24 {BSI00000075}. Those supplemental parts did not apply to cavity barriers, which had to be tested in accordance with the general fire resistance principles outlined in BS 476-20.1970 Mort {Day102/16:23}-{Day102/18:1}.
192¶27.5 The cavity barriers installed at Grenfell Tower were vertical "full-fill" barriers and horizontal "open-state" barriers. A full-fill barrier consisted of a solid piece of material spanning the entire cavity, thus forming a permanent vertical barrier against the horizontal spread of fire. An open-state barrier had a gap between the face of the barrier and the rainscreen panels to allow the passage of air and moisture. It had an intumescent strip on the outside edge that was designed to expand to fill the gap when exposed to heat in order to restrict the passage of fire vertically.1971 Mort {Day102/21:3-16}. The intumescent strip could be effective in sealing the cavity only if the surface against which it expanded remained in place.1972 Mort {Day102/22:13-24}. The effectiveness of a "full-fill" cavity barrier also depended on the integrity of the surfaces it abutted, in particular the rainscreen.
¶27.6 Stephen Swales, Chief Commercial Officer at Siderise, explained that from the late 1990s onwards Siderise had begun to develop open-state cavity barriers in response to demands from industry for a product that would leave a gap to allow for ventilation and the passage of moisture behind the rainscreen but which would close the gap in the event of fire.1973 Swales {SIL00000306/11-12} pages 11-12, paragraphs 44-46. From around 2002 Siderise began to evaluate a number of different intumescent materials through a programme of testing carried out with the company that later became Exova.1974 Swales {SIL00000306/12} page 12, paragraph 45.
¶27.7 Christopher Mort, the Sales and Technical Engineer for Siderise (and from 2011 their Technical Officer for Fire), was responsible for ensuring that the new product complied with the relevant statutory and regulatory requirements.1975 {SIL00002586}, {SIL00002587} and Mort {Day102/27:4-13}. At a product development meeting in July 2006 it was agreed that the aim was for the product to meet the requirements of a modified BS 476 Part 20 test.1976 {SIL00002587}. Mr Mort told us that it had been accepted within Siderise that testing to the general principles of BS 476 Part 20 was not ideal, as the standard could not be applied directly to open-state cavity barriers.1977 Mort {SIL00000298/10} page 10, paragraph 38. (There was no precedent for testing open-state cavity barriers and Siderise was the only company embarking on such testing at the time.)1978 Swales {SIL00000306/10} page 10, paragraph 39 and Mort {Day102/43:23}-{Day102/44:8}. The standard test procedure in BS 476 Part 20 was therefore modified following discussions with Exova, in particular to dispense with the requirement that there be no gaps present at the start of the test.1979 Mort {Day102/28:24}-{Day102/29:7}. The standard test procedure involved pushing a metal rod into the test specimen. If it was possible to penetrate the full width, the product failed the test.1980 Mort {Day102/29:8-13}. All open-state cavity barriers automatically failed that requirement because of the gap that was present in the cold state. Instead, Siderise agreed with Exova that it would monitor and record the closure of the gap and test the integrity of the product at that stage.1981 Mort {Day102/29:18}-{Day102/30:12}.
¶27.8 At no stage did Siderise or Exova ask any other industry bodies or anyone in government whether such a test method was appropriate. Siderise relied entirely on the advice it received from Exova.1982 Mort {Day102/44:24}-{Day102/45:13}.
193¶27.9 Between 2007 and 2011 Exova carried out four tests on open-state cavity barriers on which it produced reports.1983 February 2007 {SIL00000290}; January 2009 {SIL00000223}; August 2010 {SIL00000224}; September 2011 {SIL00000211}. During each of the tests the product was held between two concrete lintels.1984 Mort {Day102/63:7-10}; {Day102/65:14-18}; {SIL00000290/12}; {SIL00000223/4}; {SIL00000224/12}; {SIL00000211/5}. Insulation and integrity were measured only after the intumescent strip had closed the gap.1985 Mort {Day102/63:21}-{Day102/64:4}; {SIL00000290/28}; {SIL00000223/3}; {SIL00000224/23}; {SIL00000211/8}. All the reports contained important qualifications about the procedure that had been adopted. They stated that the results related only to the behaviour of the specimens under the particular conditions of the test, were not intended to be the sole criteria for assessing the potential performance of the products in use and did not reflect their behaviour in an actual fire. In addition, they stated that the results of the tests might not be applicable to situations in which the width of joints, orientation or supporting construction varied from those of the test. Since no movement was induced during the tests it was not possible to evaluate the products' performance where movement was induced under actual fire conditions.1986 {SIL00000290/28}; {SIL00000223/7}; {SIL00000224/24}; {SIL00000211/7}. They were important qualifications, because they set out clear limits on the testing that Exova had undertaken.1987 Mort {Day102/68:17-21} and {Day102/69:2-4}. Anyone reading the test reports should have appreciated that they could not be relied on to predict with any accuracy how the products would perform in a fire or, in particular, how they would perform as part of a ventilated rainscreen system. That was made particularly clear in the test report issued in 2011, which included the following paragraph drawing attention to the risk of failure of the rainscreen:
"This report does not consider the fire resistance performance of the rainscreen element or whether fire spread may occur as a consequence of collapse or failure of the rainscreen. The approving authority or regulator should decide whether it is necessary for the rainscreen to be 'fire rated', whether it is of an appropriate construction and whether separate test or assessment evidence is necessary."1988 {SIL00000211/4}.
¶27.10 In the test report dated 20 September 20111989 {SIL00000211/7}. Exova combined favourable integrity test results from tests carried out in 20101990 {SIL00000224/3}. with favourable insulation results from tests carried out in 20071991 {SIL00000290/4}. and concluded that Siderise open-state cavity barriers would achieve 60 minutes' integrity and 30 minutes' insulation respectively,1992 Mort {Day102/77:25}-{Day102/78:12}. although no one specimen had produced both results.1993 Mort {Day102/78:13-16}. Nonetheless, there is no reason to think that the product did not in fact meet those standards.
¶27.11 Siderise considered that successful testing to some, but not all, of the requirements of BS 476 Part 20 would evidence compliance with the guidance in Approved Document B, as it would demonstrate that the open-state cavity barriers met the requirement for 30 minutes' insulation and 15 minutes' integrity.1994 Mort {Day102/32:2-7}.
194Testing in accordance with BS 8414
¶27.12 According to Mr Swales, before the Grenfell Tower fire there had been a general reluctance to conduct large-scale tests in accordance with BS 8414 as they were considered too costly.1995 Swales {SIL00000306/17} page 17, paragraph 64. However some guidance relating to the use of cavity barriers suggested that it was nevertheless important to consider whether full-scale testing for reaction to fire (as opposed to resistance to fire) might provide important information on whether they could perform effectively as part of a ventilated rainscreen system. For example, Technical Report 31 of the European Organisation for Technical Approvals on "Fire Resistance Tests for Cavity Barriers" dated October 20081996 {INQ00014544}. stated that the method of testing it described was not applicable to horizontal cavity barriers in rainscreen cladding systems because it was difficult, if not impossible, to model the correct thermal exposure and boundary conditions in a test for resistance to fire. It therefore recommended that the fire resistance of horizontal cavity barriers be assessed in the context of a full-scale facade test.1997 {INQ00014544/7} section 1, paragraph 4. According to Mr Swales, Siderise was a strong advocate of BS 8414 testing and was keen to test its cavity barriers in that way, having actively sought out partners for such tests in the period before 2017.1998 Swales {SIL00000306/17} page 17, paragraph 64.
¶27.13 At the time Siderise cavity barriers were specified for use on Grenfell Tower, Mr Mort was not aware of any testing that had been undertaken by Siderise, or by anyone else using its products, that demonstrated how they would perform in conjunction with metal composite rainscreen panels.1999 Mort {Day102/122:10-22}. However, it had taken part in six BS 8414 tests between 2012 and May 2015.2000 Swales {SIL00000306/17} page 17, paragraph 63. The cladding used for those tests had been rainscreen boards or terracotta tiles but not aluminium composite material;2001 Mort {Day102/136:14-19}. the insulation had been either PIR or phenolic foam boards or mineral wool.2002 Swales {SIL00000306/17} page 17, paragraph 63. Not all of the systems tested met the criteria in BR 135. In particular, a test undertaken in conjunction with Celotex RS5000 insulation in February 2014 failed to do so.2003 {Day102/135:19}-{Day102/136:2}. For our factual findings in relation to these Celotex tests see Chapter 24. Mr Mort was aware that during the test the Marley Eternit panels had pulled away from the rig and distorted, thereby rendering the cavity barriers ineffective because they had nothing against which they could form a seal.2004 Mort {Day102/144:8-12}. Siderise was aware that the effectiveness of its cavity barriers, whether full-fill or open-state, in creating and maintaining a seal depended on the integrity of the rainscreen.2005 Mort {Day102/145:8-17}.
Industry Testing
¶27.14 Since it was not possible to test open-state cavity barriers in accordance with BS 476 Part 20,2006 Swales {SIL00000306/13} page 13, paragraph 49 and Mort {Day102/80:25}-{Day102/81:3}. Siderise worked with the Association for Specialist Fire Protection, laboratories, certification engineers, manufacturers,2007 Including Siderise, Hilti, Rockwool, Firetherm, Firestopit and Promat. members of the Comité Européen de Normalisation and the British Standards Institution to develop a new method of testing entitled "Technical Guidance Document 19" ("TG19").2008 Swales {SIL00000306/13} page 13, paragraph 49. The test, which was published by the Association in 2014, required an open-state cavity barrier to close within five minutes of the beginning of the test.2009 {SIL00001540/14}. Any failure of integrity before that was to be disregarded unless any part of the surface exhibited sustained flaming above the seal.2010 {SIL00001540/15}. In other words, the test standard permitted the response of the product during the first five minutes to be ignored, save in the event of extreme flaming.2011 Mort {Day102/123:17}-{Day102/124:1}.
195¶27.15 TG19 was specifically designed for small-scale furnace testing of open-state cavity barriers.2012 Mort {SIL00000298/11} page 11, paragraph 40. Small-scale furnace testing was considered appropriate because it demonstrated the performance of the product in isolation.2013 Mort {Day102/91:14-24}. The test did not, therefore, extend to assessing the performance of open-state cavity barriers as part of a ventilated rainscreen system.2014 Mort {Day102/101:9-21}. TG19 expressly recommended that to evaluate the performance of open-state cavity barriers as part of a cladding system, a large-scale test, such as a BS 8414 test, should be considered.2015 {SIL00001540/3}. It also referred to a warning in the second edition of BR 135 that small-scale tests had been found not to reflect the fire hazard associated with full‑scale cladding systems.2016 {SIL00001540/17}. Siderise appreciated the importance of that warning before it became involved in the Grenfell Tower refurbishment.2017 Mort {Day102/128:1-13}.
¶27.16 Technical Note 17 published by the Centre for Window and Cladding Technology in March 20112018 {CWCT0000019}. also contained a warning that cavity barriers could be tested in accordance with the principles contained in BS 476-20 (and other similar standards), but that their performance in conjunction with rainscreen panels might be different.2019 {CWCT0000019/5}. Mr Mort confirmed that he had been aware of that guidance from 2011.2020 Mort {Day102/131:7}-{Day102/132:5}.
¶27.17 The recommendation that any proposed system be tested in accordance with BS 8414 was included in TG19 because the two tests served different purposes. The test described in TG19 measured the properties of a cavity barrier, in particular the duration of insulation and integrity, in isolation but, unlike a BS 8414 test, did not measure the performance of an external wall system as a whole.2021 Mort {Day102/117:19}-{Day102/118:4}. On the other hand, a BS 8414 test did not measure the performance of individual components.2022 {SIL00001540/16}; Mort {Day102/120:3-10}. Siderise was aware before the Grenfell Tower fire that if cavity barriers were used as part of a ventilated rainscreen system, the rainscreen panels might distort or become detached and thus compromise the effectiveness of the cavity barriers.2023 Mort {Day102/120:11}-{Day102/121:20}.
¶27.18 On 15 May 2013,2024 Swales {SIL00000306/13} page 13, paragraph 50 and {SIL00000212/3}. Siderise again tested open state cavity barriers on 24 April 2014 with Chiltern International {SIL00000288}. Siderise tested an open-state cavity barrier between two concrete lintels2025 {SIL00000212/2}; Mort {Day102/92:6-16}. in accordance with a draft version of TG19.2026 Entitled "ASFP TG 3 N64, fourth draft February 2013". Exova produced a report on 23 July 20132027 {SIL00000212}. which contained warnings similar to those in the reports mentioned above. In particular, it made it clear that the test results were not to be used as the sole basis for assessing the fire performance of the cavity barriers and that the results were not applicable to situations in which the width of the joints or the depth, orientation or supporting construction was different. It also drew attention to the fact that the test did not induce movement and therefore might not represent conditions that would be encountered in a fire.2028 {SIL00000212/32}. The report also made it clear that the results were applicable only to a void of the size tested.2029 {SIL00000212/34}. Siderise staff understood those limitations, including the staff in its sales and marketing teams.2030 Mort {Day102/100:7-20}.
196¶27.19 As far as Mr Mort was aware, there were no discussions with DCLG about adding a reference to TG19 to Approved Document B.2031 Mort {Day102/134:16-23}.
Extended Application Assessments
¶27.20 Siderise also carried out extended application assessments for cavity barriers of the kind that were used at Grenfell Tower. For that purpose, it used data from previous tests to calculate whether the products could be used in situations other than those in which they had been tested.2032 Mort {Day102/174:10-16}. That enabled it to assess the ability of its open-state cavity barriers to seal voids of greater width than those that had been used for the tests.2033 Swales {SIL00000306/14} page 14, paragraph 52.
¶27.21 All the extended application assessments for the products as used on Grenfell Tower were signed by Christopher Mort and dated 23 June 2017;2034 {SIL00000204/22}; {SIL00000204/29}; {SIL00000204/35-6}; and {SIL00000204/42-43}. in other words, they post-dated the fire by a few days.2035 Mort {Day102/175:2-18}. No formal assessment had been carried out before that date, or at any rate no reference to one appeared in any document.2036 Mort {Day102/178:21}-{Day102/179:13}. Mr Mort said that informal assessments had been carried out, but he accepted that there was nothing in the documents provided to us to support that.2037 Mort {Day102/180:13}-{Day102/181:5}. At Grenfell Tower, Siderise supplied cavity barriers for voids of between 326 and 425mm without having tested its products in voids of that width and without having undertaken any formal extended application assessments.2038 Mort {Day102/180:13-21}.
¶27.22 Even when Siderise did undertake formal extended application assessments in June 2017, it did not seek any external verification for its conclusions.2039 Mort {Day102/177:8-16}. Mr Mort's explanation was that external validation was not required by Siderise or by Approved Document B.2040 Mort {Day102/177:20-23}. It did not occur to him that it might be inappropriate for Siderise to certify its own products for use in extended applications without the support of an independent expert.2041 Mort {Day102/178:4-8}.
197Marketing material
Datasheet 2110
¶27.23 In mid-2012 Siderise produced datasheet 2110 relating to Lamatherm cavity barriers for rainscreen cladding.2042 {SIL00004672}. It gave copies of it to Harley in August 2013 in connection with two projects which required rainscreen cavity fire barriers.2043 Richard Kay (Siderise) emailed it to Mark Harris (Harley) in relation to the Wayland House project on 19 August 2013 {SIL00000325/2}. Richard Kay also sent it to Tim Lovell (Harley) in relation to the 10 Trinity Square project on 5 August 2013 {SIL00000327}. The title of the datasheet was "Cavity Barriers for Rainscreen Cladding". In the introduction it stated that rainscreen cladding systems typically incorporated a ventilated air space to allow the drainage of rainwater and that, to accommodate that design feature, Siderise had developed a purpose-made solution, namely, a horizontal cavity barrier with an integral intumescent strip along the edge which "fully closes the ventilated air gap in the event of a fire".
¶27.24 The datasheet referred to the four Exova reports2044 As discussed above, February 2007 {SIL00000290}; January 2009 {SIL00000223}; August 2010 {SIL00000224}; September 2011 {SIL00000211}. and said that the product had been tested by Exova and in its opinion represented a practical solution for a particularly demanding condition.2045 {SIL00004672} section 'Introduction', second column final paragraph. However, nowhere in any of the reports had Exova expressed that opinion.2046 Mort {Day102/197:4-12}. Mr Mort told us that he had reviewed the data sheet to ensure that it was accurate,2047 Mort {Day102/193:4-6}. but he was unable to explain how it had included Exova's apparent endorsement.2048 Mort {Day102/199:11-16}. He suggested that there might have been conversations with Exova, of which he had been unaware at the time, during which Exova had expressed that opinion,2049 Mort {Day102/196:16-20}; {Day102/197:10-21}. but we think that unlikely, since as Sales and Technical Engineer, he had a leading role in arranging and attending the testing with Exova.2050 Mort {SIL00000298/2} page 2, paragraph 7(b); Mort {Day102/69:6-17}. Plainly, Siderise should not have relied in its marketing material on an endorsement that was not genuine.
¶27.25 Under the heading "Advantages", the datasheet set out the results achieved in tests conducted by Exova using the principles of BS 476-20 & BS EN 1366-4:2006.2051 {SIL00004672/1}. It stated that a technical failure of integrity and insulation was deemed to have occurred at the start of the test due to the passage of flame through the open void, but went on to state that following the rapid expansion of the intumescent strip, the gap had become fully sealed and that the product had achieved the required standards for integrity and insulation.2052 {SIL00004672/1} section "Fire Performance".
¶27.26 The datasheet did not describe the nature of the test in detail, nor did it reflect any of the qualifications set out in the test reports, including the warning that the results might not apply to situations in which the supporting construction differed from that of the test. The datasheet also failed to warn the reader that it was not possible to evaluate the product's performance in circumstances where movement of the supporting construction was induced by exposure to fire. Finally, the datasheet did not draw attention to the fact that cavity barriers might be rendered ineffective if the rainscreen became distorted or dislodged in a fire.
198¶27.27 If the construction industry is to function effectively and safely it requires products that do the job expected of them and are marketed honestly. Although there is no evidence to suggest that, unlike Arconic, Kingspan and Celotex, Siderise set out in its marketing literature deliberately to mislead, it was suggested that its datasheet was in fact misleading because it suggested that its cavity barriers were effective when used in rainscreen cladding systems of all kinds, when the tests it had carried out did not support that claim.2053 {BSR00000070/31} page 31, paragraph 9.1. We think that the datasheet should have described more fully the nature of the tests it had carried out. The unqualified statement that the horizontal cavity barrier "fully closes the ventilated air gap in the event of a fire" tended to suggest that it would do so regardless of the nature of the rainscreen panel against which it was to form a seal. On the face of it, that was misleading, because no test had been carried out in conjunction with any recognised form of rainscreen panel. However, it is unlikely that any competent designer reading the datasheet would have been misled about the suitability of the product for particular rainscreen applications.
¶27.28 The title of the datasheet, "Cavity Barriers for Rainscreen Cladding", indicated no more than that the product had been designed for use in rainscreen cladding systems, which was indeed the case. Any competent fire engineer should have been aware of the warning in the second edition of BR 135 that small-scale tests on individual products had been found not to reflect the fire hazard associated with full-scale cladding systems2054 {SIL00001540/17}. and would have realised that the effectiveness of cavity barriers in any ventilated rainscreen system depends not only on the quality of the product itself but on whether the rainscreen panels remain in place during a fire. A competent fire engineer would also have asked for the underlying fire test data2055 Siderise made those available only on request: Mort {Day102/73:8-24}. to obtain a proper understanding of the tests that had been carried out on the product.
¶27.29 We recognise, however, that this kind of marketing literature would also have been read and relied on by a wide range of construction professionals, including architects, cladding designers2056 Jonathan Sakula's evidence was that specialist cladding designers would normally have referred to the manufacturer's technical literature Sakula, Façade Expert Report {JOS00000001/49} paragraph 12.1. and building control officers, some of whom might not have been familiar with test method BS 476-20. Although Siderise argued that anyone familiar with BS 476 Part 20 or BS EN 1366-4 would have been aware that tests on cavity barriers are carried out on the product held between concrete lintels,2057 {SIL00010048/12}. its marketing literature stated only that the tests had been carried out "using the principles" of those methods.2058 {SIL00004672/1}. We do not think that some professionals, for example, reasonably competent cladding contractors, could be expected to be familiar with those fire resistance tests, although they should have appreciated that tests on cavity barriers are generally conducted with the product held between walls of fire resisting construction and that their performance in conjunction with rainscreen panels might be different.2059 Sakula {Day125/80:5}-{Day125/81:8}. However, anyone with even a basic understanding of the principles underlying the use of cavity barriers who gave the matter a moment's thought would have realised that, if the rainscreen became distorted or dislodged for whatever reason, no cavity barrier of any kind could continue to be effective.
¶27.30 Although the datasheet was intended to, and did, tell the reader that the intumescent strip would expand effectively to close the gap in a rainscreen system in the event of a fire, the description of the way in which it worked made it clear that the claim was based on an assumption that the rainscreen would retain its integrity and provide a stable surface against which the intumescent strip could expand. It may not have been clear to some readers of the datasheet that the product had been tested between two concrete lintels, but any competent designer should have appreciated that the stability of the rainscreen was essential to its effective operation, as it was to the effectiveness of the vertical full-fill cavity barriers.
199¶27.31 It has been suggested that Siderise ought to have postponed marketing its products for use in rainscreen applications until there was a body of data from BS 8414 tests which demonstrated that they were effective when used in conjunction with particular rainscreen panels, and then only for use in systems of those kinds. In our view that is unrealistic. The BS 8414 test is not designed to test individual products and the behaviour of the rainscreen in response to an actual fire may depend on many factors. It may not accurately reflect its behaviour in a test. The fact is that the cavity barriers sold by Siderise, both full-fill and open-state, met the claims made for them in relation to integrity and insulation and the open-state barriers functioned effectively when tested in accordance with the principles of BS 476-20. Design professionals must take responsibility for ensuring that the choice of rainscreen panel will not render the cavity barriers ineffective. No competent design professional could reasonably have understood the datasheet to mean that the cavity barrier would remain effective even if the rainscreen became seriously distorted or detached and no one claimed to have understood it in that way.
¶27.32 The statement that the ventilated air gap would be fully closed in the event of a fire was therefore subject to the implicit qualification that the rainscreen remained in place and retained its rigidity and integrity. That qualification would have been obvious to a competent designer or cladding contractor but not necessarily to others. Siderise could not assume that everyone who read the datasheet would be competent and would be aware of the implicit qualification. It should therefore have made the qualification explicit.
Sending the datasheet to Harley
¶27.33 When Siderise sent datasheet 2110 to Harley in August 2013 it did not provide Harley with any information about the suitability in general of cavity barriers for use in rainscreen systems or the potential limits on their effectiveness. Nor did it refer to the nature of the tests that it had carried out on its own product. However, it was for Harley and others to determine whether the combination of materials it was using on a particular project, including the external wall at Grenfell Tower, would satisfy the Building Regulations. Siderise was not asked for general advice about the suitability of its products for use at Grenfell Tower nor is there any evidence that Harley relied on datasheet 2110 for the purposes of the design of the external wall. Siderise cannot reasonably be criticised for failing to point out to Harley that if a rainscreen failed, the cavity barriers would cease to be effective.
Postscript
¶27.34 Functional requirement B3(4) of the Building Regulations requires a building to be designed and constructed so that the unseen spread of fire and smoke within concealed spaces in its structure and fabric is inhibited. Functional requirement B4(1) requires that the external wall shall adequately resist the spread of fire over the walls having regard to the height, use and position of the building. Section 9 of the 2013 revision of Approved Document B provided guidance on the use of cavity barriers. It included advice in paragraph 9.15.d2060 {CLG00000224/86}. that they should be fixed so that their performance is unlikely to be made ineffective by the failure in a fire of any material or construction which they abut. The risk that cavity barriers in the external wall construction of a building with ventilated rainscreen cladding might become ineffective if the rainscreen failed appears therefore to have been foreseen. Despite that, none of those involved in the design of the refurbishment of Grenfell Tower appears to have considered how the rainscreen was likely to react if exposed to fire or whether its behaviour might undermine the effectiveness of the cavity barriers. In our view, designers should give much more thought to the behaviour in fire of rainscreen panels intended for use in conjunction with cavity barriers in order to comply with functional requirements B3(4) and B4(1).
200 201Chapter 28: United Kingdom Accreditation Service
Role and function
¶28.1 The United Kingdom Accreditation Service (UKAS) assesses, against nationally and internationally accepted standards of accreditation, those organisations which provide conformity assessment services, such as certification, testing, inspection, calibration and verification.2061 See Ukas.com/about-us/about-ukas.
¶28.2 UKAS was established in 1995 as a company limited by guarantee.2062 Turner {UKAS0011242/4} page 4, paragraph 7(a). Throughout its existence it has operated under a memorandum of understanding with the government.2063 UKAS Memorandum of Understanding (MOU) 2006 {UKAS0011258}; UKAS Memorandum of Understanding (MOU) 2007 {UKAS0011259}; UKAS Memorandum of Understanding (MOU) 2009 {UKAS0011260}; UKAS Memorandum of Understanding (MOU) 2009 {UKAS0011261}; UKAS Memorandum of Understanding (MOU) 2013 {UKAS0011262}; UKAS Memorandum of Understanding (MOU) 2014 {UKAS0011263}; UKAS Memorandum of Understanding (MOU) 2017 {UKAS0011264}; UKAS Memorandum of Understanding (MOU) 2021 {UKAS0011251}. In 2009 it was appointed the national accreditation body for the purposes of article 4(1) of Regulation (EC) No 765/2008 under the Accreditation Regulations 2009.2064 Turner {UKAS0011242/8-9} pages 8-9, paragraph 7(g); UKAS was appointed pursuant to The Accreditation Regulations 2009 {UKAS0011250}. It was, and as at June 2017 remained, the only body exercising that function in the UK.2065 UKAS Closing Submissions for Module 6 {UKAS0011447/5} page 5, paragraph 17. It is a not- for-profit organisation2066 Turner {UKAS0011242/8-9} pages 8-9 paragraph 7(g). funded primarily by the fees it charges under contracts entered into on its standard terms2067 Turner {Day226/174:5-7}; {UKAS0011300}; {UKAS0011301}; {UKAS0011302}. with the organisations it accredits.2068 Turner {Day 226/147:5-17}. The MOUs allowed for sponsoring government departments to provide financial assistance in defined circumstances. Those circumstances were not relevant to any matters before this Inquiry. Our findings about its policies and operations are to a large extent based on the evidence of Lorraine Turner, its Accreditation Director.
¶28.3 Since the early 2000s, UKAS has accredited the BBA to certify products and systems under its Agrément certification schemes.2069 {BSI00001920}. As an accredited organisation the BBA issued a certificate for Arconic's Reynobond ACM panels.2070 {BBA00000047}. UKAS also accredited BRE. It had done so for several years before April 2002, when it first accredited BRE to perform large-scale fire tests in accordance with what became BS 8414.2071 {BSI00001726}; {BSI00001924}. As an accredited organisation BRE carried out BS 8414 tests on systems incorporating Kingspan K15 and Celotex RS5000.
Policies and procedures
¶28.4 UKAS accredited organisations to various national and international standards, in particular, a. ISO/IEC 17065, Conformity assessment – Requirements for bodies certifying products,
202processes and services,2072 {BSI00001920}. which was the standard by which it assessed the BBA's Agrément certification schemes,2073 Albon {BBA00010723/7} page 7, paragraphs 19-20. and
¶b. ISO/IEC2074 ISO/IEC stands for International Organization for Standardization/International Electrotechnical Commission. 17025, General requirements for the competence of testing and calibration laboratories2075 {BSI00001726}; {BSI00001924}. which was the standard by which it assessed BRE's performance of BS 8414 tests.2076 Howard {BRE00005771/4} page 4, paragraph 18.
¶28.5 For both of those standards the process adopted by UKAS for accrediting an organisation involved checking both the technical requirements of each accredited activity as well as that organisation's processes and safeguards, such as its management systems, internal auditing, environmental conditions and the training of its personnel.2077 Turner {Day226/174:11}-{Day226/175:16}; {BSI00001920}; {BSI00001726}.
¶28.6 In addition, its internal policies provided for a rolling programme of annual assessment visits,2078 General Principles of Assessment of Conformity Assessment Bodies by the United Kingdom Accreditation Service (GEN-1) {UKAS0011246/13} figure 1; The Accreditation Process – Policy and Associated Requirements (ACC 1000) {UKAS0011247/22-23} section 6.8.2. examining each of the organisation's accredited activities at least once over a four-year period.2079 The Accreditation Process – Policy and Associated Requirements (ACC 1000) {UKAS0011247/32-39}; Turner {Day 226/181:1-10}. If it found that improvement was needed, by identifying a failure or "non-conformity" with a relevant standard, UKAS required the organisation to propose steps known as "improvement actions" to address the deficiencies. UKAS assessed whether those improvement actions met the problem and had been performed satisfactorily and then decided whether the body had met the accreditation standard. In addition, UKAS could make extra visits, including unannounced visits, outside the rolling programme and did make extra visits to some bodies as a result of the Grenfell Tower fire. However, it rarely made unannounced visits,2080 Turner {Day226/188:21}-{Day226/189:11}. so the organisation in question almost always knew when a visit was about to take place.
¶28.7 It was not possible for UKAS to review all the activities of an organisation being considered for accreditation. Each organisation subject to accreditation was therefore required to keep detailed management records, to audit its own performance and to record its more serious non-conformities. Accredited organisations were required to report any significant non-conformities to UKAS,2081 General Principles of Assessment of Conformity Assessment Bodies by the United Kingdom Accreditation Service (GEN-1) {UKAS0011246/18} section 4.5.2; Turner {UKAS0011422/11} page 11, paragraphs 8.1-9.1. but if they failed to do so, UKAS had access to the records when carrying out the next assessment and could see how the organisation had dealt with them.2082 Turner {UKAS0011422/12} page 12, paragraph 11.1. However, that meant that the effectiveness of its oversight depended to a significant extent on the honesty and integrity of the organisation in question2083 Turner {Day226/195:25}-{Day226/197:14}. and its ability and willingness to examine its own behaviour and respond comprehensively to rigorous self-evaluation as well as criticism by UKAS.
¶28.8 UKAS formed committees to advise on technical matters.2084 Turner {UKAS0011242/13} page 13, paragraph 10(b). Members were drawn from professional bodies, regulators, customers of accredited organisations and the government.2085 Turner {UKAS0011242/13} page 13, paragraph 10(c). The only committee within UKAS that considered matters relating to construction was the Construction Industry Technical Advisory Committee.2086 Turner {UKAS0011242/14} page 14, paragraph 11. However, for years before the fire that committee's work focussed on topics relating to infrastructure, for example, building roads and bridges.2087 Turner {UKAS0011242/14} page 14, paragraph 11(b). It rarely considered matters relating to fire testing or the fire safety of products used in construction and did not do so at all after 2000.2088 {UKAS0010843/4} item 4.5; {UKAS0010844/2} item 4.2; {UKAS0010845/2} item 3.2.
203¶28.9 UKAS published accreditation schedules that listed all the activities that a particular organisation was accredited to perform. That was the principal way in which the construction industry could find out what functions a particular organisation was accredited to carry out at any time. If UKAS was satisfied that an accredited organisation was failing to meet the standards required for accreditation, it had the power to suspend or withdraw accreditation, either partially or fully.2089 General Principles of Assessment of Conformity Assessment Bodies by the United Kingdom Accreditation Service (GEN-1) {UKAS0011246/30} section 6; The Accreditation Process – Policy and Associated Requirements (ACC 1000) {UKAS0011247/24-25} section 7.2. If it had proof of fraudulent behaviour or an accredited organisation deliberately provided false information or deliberately violated accreditation rules, UKAS was obliged to initiate the process for withdrawal of accreditation.2090 The Accreditation Process – Policy and Associated Requirements (ACC 1000) {UKAS0010905/19} section 7.2.11; General Principles of Assessment of Conformity Assessment Bodies by the United Kingdom Accreditation Service (GEN-1) {UKAS0011246/30} section 6.5; Turner {UKAS0011422/14} page 14, paragraph 15.1. If UKAS suspended or withdrew an organisation's accreditation, it did not publish the reasons for doing so because it considered itself bound by the confidentiality undertaking in its standard terms.2091 Turner {Day226/206:21}-{Day226/207:9}. In cases of fraud or where there were serious concerns about safety UKAS would consider who needed to know about such matters. That might involve notifying the regulator or, if there were no regulator, might involve putting the information into the public domain.2092 Turner {Day226/210:7}-{Day226/211:10}. Since the fire UKAS has changed its standard terms to make clear that it is not bound by confidentiality in cases of fraud or a risk to the safety or health of individuals.2093 Turner {Day226/211:11-16}; UKAS closing submissions for Module 6 {UKAS0011447/13-14} pages 13-14, paragraphs 40-42. UKAS had no regulatory or enforcement powers.
Accreditation of the BBA
¶28.10 UKAS accredited the BBA to issue Agrément certificates for certain products. A schedule2094 Albon {BBA00010723/8-9} pages 8-9, paragraphs 23-29; {BBA00010722}; Randall {UKAS0011424/11} page 11, paragraphs 14.1-14.2. was agreed with the BBA, known as "BBA Document 001", setting out thirteen "Technical Specifications", each of which contained short descriptions of categories of products in respect of which UKAS agreed that the BBA could assess and, if appropriate, issue Agrément certificates. For example, Technical Specification 0012 was for "Wall and cladding products and systems", within which both cladding products and built-in cavity wall insulation products were briefly and broadly described.2095 {BBA00010722/6-7}.
¶28.11 The Technical Specifications listed core certificates for each product category, known as "Leader" certificates.2096 Haynes {BBA00010784/5} page 5, paragraphs 20-21; Randall {UKAS0011424/11-12} pages 11-12, paragraph 14.4. When a product falling within one of the categories came to be assessed, the BBA's project manager was required to follow the process that had been used to produce the Leader certificate. Those processes were not recorded in any separate document; instead, the project manager was expected to follow the steps taken to produce the Leader certificate, as set out in the contract between the BBA and the relevant manufacturer.2097 Randall {UKAS0011424/11} page 11, paragraph 14.2.
204¶28.12 We have not seen any evidence that when it assessed the BBA's competence to issue Agrément certificates UKAS carried out a critical examination of the process by which individual Leader certificates had been produced. Instead, it appears that it considered whether the BBA had followed the steps set out in the contracts with its customers. However, that did not enable it to understand what the BBA was doing to follow those steps. The appendix to the contract made in 2006 between the BBA and Arconic for the certification of Reynobond, for example, consisted merely of short and rather uninformative summaries of the aspects to be considered, such as "behaviour under fire".2098 {BBA00008042/11}. It contained no description of the steps the project manager was expected to take to assess and record the product's properties. Accordingly, when it came to assess the work of the BBA, UKAS could not tell what the project manager was supposed to have done and therefore whether it had been done properly or at all. That led to a tendency on the part of UKAS to look only at the BBA's generic documentary processes rather than examine its technical assessment of performance for each type of product to see whether it was sound. In that respect there seems to have been a gap in its assessment of the BBA's Agrément certification scheme.
¶28.13 UKAS's policy relating to the assessment of conformity to ISO/IEC 17065 was to conduct a technical review of all schemes at least once every four years.2099 {UKAS0011247/35}. It regarded each category of products (for example, wall and cladding products and systems) as a separate scheme2100 Turner {Day227/81:16}-{Day227/82:1}. and accredited the BBA on that basis. Accordingly, although UKAS assessed the Agrément process as a whole, because it was similar for every scheme, it should have assessed the scheme for each of the thirteen Agrément product types separately every four years.
¶28.14 In practice, however, it failed to do so. The BBA's Agrément certification relating to "Wall and cladding products and systems" was assessed just once between 2008 and 2016, in 2009.2101 {UKAS0000586/5-6}; Randall {UKAS0011424/13} page 13, paragraph 17.2. UKAS thus failed to meet its own requirements for assessment of the BBA during that period. It is possible that UKAS treated an assessment of one scheme as being sufficient to accredit the BBA for all thirteen Technical Specifications, but there is no evidence that it did and if that was its reasoning, it was unsatisfactory, given the very significant differences between the products and systems covered by the Technical Specifications. Overall, as Ms Turner accepted, UKAS did not pay sufficient attention to the BBA's activities for Agrément certification.2102 Turner {Day227/93:10-17}.
¶28.15 For its part, the BBA did not comply with its obligation to keep UKAS informed of important developments as part of the continuing accreditation of its certification activities. Despite becoming aware in 2014 that there had been a very serious misstatement about fire performance in the certificate relating to K15,2103 The certificate provided that K15 could be used in accordance with Approved Document B paragraph 12.7, see Chapter 22; {BBA00000178}. the BBA neither reported it to UKAS as significant non-conforming work nor recorded it as such in its own records so that UKAS could discover it on the next assessment.2104 {UKAS0000977}; There was no mention of this significant non-conforming work in UKAS's subsequent management review: {UKAS0000977/4-5}. It should have been clear to the BBA that the information was relevant to its accreditation and needed to be shared with UKAS in accordance with its publicly available principles of assessment and standard terms of contract.2105 General Principles of Assessment of Conformity Assessment Bodies by the United Kingdom Accreditation Service (GEN-1) {UKAS0011246/18} section 4.5.2; {UKAS0011300/3-4} section 2.7; Turner {Day226/193:12}-{Day226/194:6}. We note that UKAS has now put the matter beyond any doubt by amending its standard terms.2106 UKAS Closing Submissions for Module 6 {UKAS0011447/12-15} paragraphs 39-46; UKAS Phase 2 statement {UKAS0011448/8} paragraphs 34-36.
205¶28.16 The steps taken by UKAS after the Grenfell Tower fire to review its assessment of the BBA shed significant light on the efficacy of its previous practices. On 12 July 2017, UKAS made an extra visit to the BBA to consider the Reynobond certificate.2107 Randall {UKAS0011424/14-15} pages 14-15, paragraph 18.1. That visit prompted a further visit2108 {UKAS0001077/4}. on 15 August 2017 which examined the Reynobond certificate in greater depth and considered the BBA's work in reissuing several certificates relating to ACM material after the fire.2109 {UKAS0001083}.
¶28.17 At around the same time, UKAS received correspondence from a person who alleged that the Reynobond certificate was not up to date, that the BBA lacked competence, that it had failed to heed previous cladding fires and that it did not attach sufficient importance to fire performance generally.2110 {UKAS0001382}. The UKAS assessors who attended the BBA had known of those allegations before the visits in July and August 2017.2111 Randall {UKAS0011424/15} page 15, paragraph 18.2.
¶28.18 When they visited the BBA in July 2017, the UKAS assessors identified only two respects in which remedial action in relation to the Reynobond certificate was considered mandatory: changes to statements concerning the use of the material on buildings over 18 metres in height (including the removal of the picture of a tall building on the front of the certificate) and a change in the name of the holder from "Alcoa" to "Arconic".2112 {UKAS0001077/4-8}; {UKAS0001077/7}; {UKAS0001077/8}. The BBA had already identified those errors and at the time of the visit had made arrangements to correct them in the forthcoming reissue of the certificate.
¶28.19 The assessors also examined the BBA's conformity with ISO/IEC 17065, not only at the date of the visit but also over the period since the certificate relating to Reynobond had been first issued in January 2008. However, despite declaring in their report that the statements made in the certificate were supported by appropriate test data,2113 {UKAS0001077/4}. they failed to notice that the fire performance certificates provided by Arconic at the time of the initial assessment related only to the product in rivetted form, not in cassette form. They also failed to notice that the description of the product blurred the distinction between the form in which it left the factory (flat sheets) and the form it would take in use, which required that it be cut to shape and drilled for rivets or fabricated into cassettes. Those were significant failings, because in these particular assessments UKAS's specific role was to consider whether statements made by the BBA about the performance of the product were complete and accurate. The assessors noted that Arconic had failed to respond to the BBA's requests for information when the certificate was reviewed between 2013 and 2015, even though the BBA's own processes required responses,2114 Randall {UKAS0011424/20} page 20, paragraph 28.1; {UKAS0001083/6}. but failed to take any further steps to understand whether there were any problems or risks with continuing certification. Ms Turner admitted that Arconic's failure to respond should have prompted UKAS to examine more fully the merits and robustness of the BBA's decision to continue to certify Reynobond.2115 Turner {Day227/117:11}-{Day227/118:1-5}; {Day227/128:13-20}; {Day227/131:18}-{Day227/132:2}.
206¶28.20 The file that UKAS reviewed in the course of those assessments contained correspondence from which UKAS could have seen that the BBA was prepared to negotiate with Arconic about the wording of the certificate. For instance, it contained correspondence in November 2007 in which Claude Wehrle of Arconic negotiated the additions to the draft BBA certificate for Reynobond with Hamo Gregorian.2116 {MET00055859}; {BBA00008042/515-517}. It should have been plain to UKAS that, if manufacturers were allowed to influence statements made in certificates, the quality of certificates might be undermined. We consider that UKAS should have identified the willingness of the BBA to discuss the wording of its certificates with manufacturers and at least have questioned whether it affected the independence, quality and accuracy of the certificates it issued.
¶28.21 UKAS also considered the technical competence of Valentina Amoroso2117 {UKAS0001077/8}. and Prayer Nkomo, both of whom had been involved in the reviews of the Reynobond certificate. However, it did not record any assessment of the competence of Hamo Gregorian and Brian Haynes, who had worked on the original Reynobond certificate.2118 Randall {UKAS0011424/18} page 18, paragraph 23.1. That was a significant oversight, because one purpose of the visits was to assess the validity of the certificate for the whole of the period from its initial issue in 2008. That required a more thorough investigation into whether those involved in the initial certification had the necessary skills and had properly assessed the product's performance at the outset.
¶28.22 The Lead Assessor for UKAS on the visits to the BBA in both July and August 2017 was Cary Randall, who had previously been employed by the BBA on Agrément certification until 2012.2119 Randall {UKAS0011424/3} page 3, paragraph 5.1 Indeed, his own work on the BBA's certification of a cladding product had been assessed by UKAS in 2009, the only assessment of the "Wall and cladding products and systems" scheme it had carried out.2120 {UKAS0000586/5-6}. Mr Randall had also worked for a time for Geoffrey Gurney, who had provided technical approval for the Reynobond certificate.2121 {UKAS0001077/3-5}; Albon {BBA00010723/6} page 6. His appointment created a potential conflict of interest, as UKAS was aware. However, it decided that it was not inconsistent with its policy for Mr Randall to assess the BBA because five years had passed since his employment by it and its policy required only a two-year interval.2122 Turner {UKAS0011242/18} page 18, paragraph 12(a).
¶28.23 Although the potential for bias was to some extent mitigated by the fact that Mr Randall was assisted by individuals who had no connection with the BBA,2123 Mr Randall was assisted by Technical Assessor Dan Patterson (for the July review) and observed by Sam Giles (for both): Randall {UKAS0011424/15} page 15, paragraphs 19.1-19.2; {UKAS0001077}; {UKAS0001083}. we consider that the decision to use him was unwise. He was not merely assessing the BBA's current performance; his task included the assessment of previous work, some of which had been done while he was still an employee of the BBA. Although Mr Randall had no involvement in the BBA's original certification of Reynobond or in its reviews of the certificate, his involvement in similar work for the BBA and his employment by it during the period under consideration would have made it difficult for him to examine its work critically.
207¶28.24 The assessments of the BBA carried out by UKAS in 2017 resulted in almost no significant criticism. In our view UKAS should have examined the history of the BBA's work on the Reynobond certificate more critically and, given that the assessment specifically considered the entire history of the certificate from 2008 onwards, should have considered whether the BBA's work was sufficiently robust for the whole of the period from that date until the Grenfell Tower fire. That was all the more so in the light of the fact that the fire had involved a product that had been certified by the BBA and that it had received highly critical allegations about the BBA's past performance. Having noticed that the certificate had failed to state that the product was not suitable for use on buildings over 18 metres in height, the BBA should have been required as part of the assessment process to ascertain why the certificate had been wrong and why the error had been allowed to persist for so many years. UKAS should have made critical findings and should have considered suspending the BBA's accreditation until it had done so.2124 Turner {Day227/133:9}-{Day227/134:10}. The fact that UKAS failed to scrutinise the BBA's processes in that way and does not appear to have considered imposing any sanction of that kind indicates to us that its assessment of the BBA was too lenient.
Accreditation of BRE
¶28.25 UKAS accredited BRE to perform BS 8414 tests in accordance with ISO/IEC 17025. The tests of systems incorporating Kingspan K15 and Celotex RS5000 were carried out under that accreditation. It also accredited BRE under ISO/IEC 17025 to perform many other activities and each assessment generated lengthy and detailed reports covering a variety of subjects.2125 Turner {Day226/176:11-14}. Any weaknesses identified by UKAS in BRE's systems must therefore be understood in the context of the full report.2126 Turner {Day227/19:24}-{Day227/20:10}; {Day227/21:25}-{Day227/21:1-7}. However, there were some weaknesses that should have been of particular concern to UKAS but which it failed to identify and its failure to do so indicates defects in its assessment process.
¶28.26 To meet the requirements of ISO/IEC 17025, BRE was required to conduct internal audits which assessed its own performance and recorded failures and corrective action.2127 {BSI00001726/19-20} section 4.14.1-4. That was particularly important, because assessments by UKAS could only involve a sample of BRE's work.
¶28.27 Between 2012 and 2016, assessors repeatedly raised concerns about the quality of BRE's auditing. In 2012, it made several criticisms of BRE processes, principally, that its audit procedures were not recorded, that there was no comprehensive management of audits for the entire year, that the few audits of testing that had been carried out had not been reported to the Quality Manager and that no corrective action had been recorded.2128 {UKAS0004239/4}; {UKAS0004239/11}. In its report of 24 July 2012 UKAS told BRE that it would not renew its accreditation unless it was able to demonstrate at a further visit that management control was being exercised and that the management system was being implemented.2129 {UKAS0004239/6}. At the next visit BRE was able to satisfy UKAS about those matters2130 {UKAS0004253}. and in 2013 it demonstrated some improvement,2131 {UKAS0004269/8}. but in its assessments in 2014 and 2015 UKAS recorded delays in carrying out and responding to audits.2132 {UKAS0004315/3}; {UKAS0004315/11}; {UKAS0004339/3}. In 2015, in particular, UKAS reported that BRE had failed to record as non-conforming work certain deficiencies that had been noted in audits.2133 {UKAS0004339/3}; {UKAS0004339/7}. UKAS assessors noted that the BRE had not investigated the scale and effect of that non-conforming work, so it was not possible to understand whether it was necessary to take immediate action, for example, by halting work.2134 {UKAS0004339/7}; {UKAS0004353}.
208¶28.28 It is clear from the assessments made by UKAS that throughout the period BRE's internal auditing processes were inadequate and UKAS should have been aware of that.2135 Turner {Day227/20:11}-{Day227/21:15}. Although it is now not possible to determine whether there was a single root cause of that underperformance,2136 Turner {Day227/21:15-23}. UKAS should have identified the problem and required BRE to investigate it.
Assessment of BS 8414 testing
¶28.29 In the four years between 2012 and 2016, UKAS witnessed only one test in 2016 as part of its assessment of BRE's competence to conduct BS 8414 tests2137 UKAS Assessment Report 2012 {UKAS0004239}; UKAS Assessment Report 2013 {UKAS0004269}; UKAS Assessment Report 2014 {UKAS0004315}, where BS 8414 was assessed by checks on equipment and discussion only (see {UKAS0004315/28-29}); UKAS Assessment Report 2016 {UKAS0004364}. and there are no records of its having witnessed any such tests during the period between 2008 and 2011. UKAS planned to witness BS 8414 testing every year from 2011 to 20162138 Visit Plan 2011 {UKAS0004200/5}; Visit Plan 2012 {UKAS0004230/3} which planned to assess all reaction to fire tests; Visit Plan 2013 {UKAS0004265/12}; Visit Plan 2014 {UKAS0004313/7}; Visit Plan 2015 {UKAS0004329/3}. and although we accept that there might have been difficulties in arranging to observe a full-scale test, nonetheless UKAS failed to meet its own policy2139 {UKAS0011247/39}. of witnessing a live test once every four-years.2140 Turner {Day227/8:8-9}.
¶28.30 In its assessment in 2016, UKAS recorded the following findings and requirements for improvement in relation to BS 8414 testing: a. that BRE did not maintain a formal record of the procedure for carrying out BS 8414
tests, but relied on informal documents that did not form part of the quality assurance system;2141 {UKAS0004364/21}.
¶b. that the test area and control rooms in the burn hall used for BS 8414 tests were untidy and disorganised, with equipment and test materials not being stored appropriately.2142 {UKAS0004364/21}. BRE was therefore not meeting the ISO/IEC 17025 standard in those respects and improvements were required if BRE was to maintain accreditation.
¶28.31 In failing to witness BS 8414 tests for many years UKAS was depriving itself of the ability to monitor BRE's performance effectively and was unable to say if BRE was conducting the tests accurately and consistently.
209Subsequent assessments of BRE
¶28.32 As in the case of the BBA, certain events that occurred after the fire show that longstanding defects in the assessments by UKAS of BRE continued in the years after the Grenfell Tower fire and proved stubbornly resistant to correction.
¶28.33 In September 2017, Sam Giles, Head of Construction and Physics in the Operations Department, reported to his seniors on the three bodies accredited by UKAS that had been connected with the refurbishment of Grenfell Tower, the BBA, BRE and Exova.2143 {UKAS0010859}; {UKAS0010860}. The report described the additional visits and other investigations that had been conducted by UKAS by that time. In the case of BRE, they included reviewing the records of the BS 8414 tests that DCLG had commissioned in July 2017, including the tests on systems which reproduced the external wall of the tower.2144 {UKAS0004456}. Although its review was based only on the records, UKAS identified a number of deficiencies, including inadequate staff training records, the absence of any formal contract between DCLG and BRE and inconsistencies in the recording of technical findings.2145 {UKAS0004456/3-4}. Mr Giles suggested that in the light of what it had discovered UKAS needed to take a tougher approach to BRE, particularly with regard to implementing required improvements.2146 {UKAS0010860/2}.
¶28.34 However, it appears that there was no change in the existing state of affairs. On 23 October 2020, Kingspan wrote to BRE to tell it that it had withdrawn several BS 8414 test reports on K15 because the material used in the tests had not been representative of the product it was selling.2147 {KIN00024104}. Despite the fact that the letter was reported in the specialist construction press shortly afterwards,2148 On 5 November 2020, Inside Housing magazine published an article about this letter: https://www.insidehousing. co.uk/news/kingspan-withdraws-insulation-fire-test-admitting-it-is-not-representative-of-product-on-market-for- 15-years-68461. UKAS became aware of it only on 17 March 2021 when Sam Giles noticed the article and circulated it within the organisation.2149 {UKAS0011430}.
¶28.35 UKAS immediately arranged an extraordinary assessment of BRE, which was conducted in May 2021 by John Leadbeater, Senior Assessment Manager and Technical Focus Person for fire testing,2150 Leadbeater {UKAS0011426/4-5} pages 4-5, paragraphs 3.2-3.3. with responsibility for leading on fire testing.2151 Turner {Day227/33:6-13}; Leadbeater {UKAS0011426/5} page 5, paragraph 3.3. He found no evidence that the tests had been performed incorrectly, but he did find evidence of weakness in complying with documentary requirements and internal audit procedures.2152 {UKAS0004773}. He recommended that if similar non-compliances were noted on the next routine assessment, there might be grounds for partial or full suspension of the BRE's accreditation for those activities.2153 {UKAS0004773/7}.
¶28.36 BRE objected to various aspects of the report2154 {UKAS0004774}. and as a result UKAS withdrew it and replaced it with a less critical version that made it clear that the findings had no bearing on the current performance of BRE.2155 {UKAS0004778}; {UKAS0011435}; Leadbeater {UKAS0011426/20} page 20, paragraph 18.1. That was done without consulting Mr Leadbeater, who was not made aware of the decision to withdraw the original report.2156 Mr Leadbeater's annotated comments: {UKAS0011435/3}; Turner {Day227/56:13}-{Day227/57:11}.
210¶28.37 In the end UKAS decided to avoid any potential conflict by withdrawing the revised report and leaving all potential criticisms until the next assessment of BRE, which was imminent.2157 Leadbeater {UKAS0011426/20} page 20, paragraph 18.1; Turner {Day277/57:24}-{Day227/58:8}. It was conducted by Mr Leadbeater over several days in July and August 2021, as a result of which he made numerous adverse findings and identified a number of areas for improvement.2158 {UKAS0011327/35-45}; {UKAS0011314} rows 107-120.
¶28.38 One consequence of withdrawing Mr Leadbeater's first report was that his observations about the historical deficiencies of BRE were subsumed in an assessment of how BRE was performing in July 2021.2159 {UKAS0011327}. Similarly, after that assessment discussions about BRE's performance turned on how UKAS could prevent a recurrence of the failures, a matter that UKAS proposed to make the subject of requirements for improvement.2160 {UKAS0011331}. Although an organisation's current competence is, rightly, the main question for UKAS, a process that fails to take account of historic performance risks overlooking significant trends. An organisation could, and on the evidence before us did, propose measures to deal with problems as though they were of an isolated nature when they were symptomatic of more general shortcomings. BRE should have conducted a searching analysis of both the root cause of the deficiencies and their effects, and if it did not, UKAS should have required it to do so.
Conclusions
¶28.39 UKAS accepted in its closing statement that its dealings with the BBA and BRE showed that its systems were in need of improvement.2161 UKAS Closing Submissions for Module 6 {UKAS0011447/18} page 18, paragraph 56. It also told us that it had introduced a number of changes to its policies and procedures that were intended to rectify the defects that had been identified.2162 UKAS Closing Submissions for Module 6 {UKAS0011447/8-17} pages 8-17, paragraphs 25-53. In October 2022, we received further documents from UKAS indicating that it was continuing to make efforts to address weaknesses.2163 {UKAS0011454}; {UKAS0011455}; {UKAS0011456}; {UKAS0011457}. We take account of those matters when we come to make our recommendations. Nonetheless, the evidence of the way in which UKAS handled the accreditation of BRE and the BBA in the period before the Grenfell Tower fire has led us to the following conclusions: a. UKAS did not follow its own policies in relation to the frequency of assessing activities.
Its assessment of the BRE's performance of BS 8414 tests between 2008 and 2016 was inadequate, with just one test being witnessed in 2016.2164 Turner {Day 227/7:5-18}. It also failed to carry out a proper assessment of the BBA's Agrément schemes, assessing the certification of only a few categories of products sporadically between 2008 and 2015.
¶b. It failed to identify a consistent failure on the part of BRE to audit its work adequately in the years 2012-2016. UKAS should have required BRE to examine the underlying cause or causes of those repeated auditing failures. Similarly, when other failures were identified, it failed to require the BBA or BRE to complete a comprehensive investigation into their cause and possible wider effects.
¶c. When assessing the BBA after the fire it failed to identify important errors in the issuing and review of the Reynobond certificate, which resulted from a failure to examine the information available in the assessments with sufficient rigour. It was also
211unwise of UKAS, after the Grenfell Tower fire, to allow a former employee to assess the BBA's Agrément Scheme.
The relationship between UKAS and accredited bodies
¶28.40 Although we accept that UKAS took its role as national accreditation body seriously, the reliability of its assessments depended on the honesty and co-operation of the organisations it was accrediting. It was therefore left to the organisations themselves to identify weaknesses, to report them to UKAS and to implement improvements in good faith. UKAS left a great deal to trust. Although a degree of trust was essential, UKAS should have taken a more searching, even sceptical, attitude to the bodies it accredited.
¶28.41 Sam Giles identified that as a potential problem in 2017 after the Grenfell Tower fire. After an assessment of the BRE, the BBA and Exova (conducted in July and August 2017), Mr Giles concluded in September 2017 that some organisations might be displaying a degree of arrogance in dismissing findings made by UKAS.2165 {UKAS0010859}; {UKAS0010860/3}. However, despite Mr Giles' observations, his comments did not appear to prompt a reconsideration of the relationships between UKAS and some of its accredited bodies, at least at that time. For example, UKAS assessors might have been instructed to adopt a less trusting view of the organisations subjected to routine assessment and to push them to consider in greater detail the cause and effect of any critical findings that UKAS made.
¶28.42 UKAS was sometimes too willing to accept the competence of an organisation without having reviewed all the relevant documents2166 {Day227/144:25}-{Day227/145:5}. and sometimes too quick to minimise or ignore its deficiencies or to accept superficial improvements as adequate. That was demonstrated by events both before and after the fire. The effect of failing to require more thorough investigations into the causes and effects of shortcomings was that opportunities to improve the work of organisations engaged in testing and certifying products were lost.
¶28.43 UKAS's powers in the face of recalcitrant or defective bodies are surprisingly limited. The most it can do in the face of unsatisfactory conduct on the part of an accredited organisation is to suspend or withdraw accreditation. It has no legal powers or role in enforcement. Moreover, the fact that accreditation is voluntary presents a particular challenge, in that, subject to market pressures, a certification body can simply decline to be accredited by UKAS at all.
¶28.44 That seems to us to be a thoroughly unsatisfactory state of affairs. A voluntary system of accreditation, where the accrediting body has no power of enforcement other than suspension or withdrawal of accreditation, in the end simply leaves the designer and building owner having to trust the certificate or test report and classification. It deprives them of the confidence that the relevant body has itself adopted rigorous methods which are wholly free from the commercial pressures inherent in relationships with manufacturers.
213Chapter 29: Failures in the system
¶29.1 Our examination of the role played by the government and other bodies that had important parts to play in the testing and certification of construction products enable us to identify a number of respects in which the systems designed to ensure the safety of buildings in general and of high-rise buildings in particular failed to achieve the purposes for which they were established.
The government
¶29.2 As the organisation with primary responsibility for establishing and maintaining a system for the regulation of construction work in the interests of public safety the government should ensure that as far as reasonably possible regulations and guidance keep pace with developments in construction materials and techniques. It should also take reasonable steps to ensure that regulations are enforced and that any guidance it publishes is clear and easily accessible to all those in the industry.
¶29.3 In our view between 1991 and 2017 the government failed to discharge those responsibilities in a number of ways. That was primarily due to its failure to ensure that the department responsible for the Building Regulations and statutory guidance was expected to monitor the performance of the system as a whole (including the effectiveness of building control) and inform itself of developments in the methods and materials being used in the construction industry with a view to ensuring that the regulations and guidance were understood and followed and, where necessary, clarified or amended. We have criticised officials for failing to take steps of that kind, but officials can act only in accordance with the way in which the department is organised. If, as appears to have been the case, the department was not expected to ensure that the regulations were being properly followed, officials cannot be blamed for failing to make enquiries or taking active steps to discover what is going on.
¶29.4 In the period between the fire at Knowsley Heights in 1991 and the fire at Grenfell Tower in 2017 there were numerous opportunities for the department to identify the risks posed by the use of combustible insulation and cladding panels, particularly on high-rise buildings, and take action in relation to them. Of particular significance is the failure by the government to implement the recommendations of the Select Committee in December 1999, or at least keep them under review, and its failure to pay due regard to the striking results of the test in 2001 involving aluminium composite panels with unmodified polyethylene cores.
¶29.5 The report of the Select Committee warned the government in unambiguous terms that it should not take a serious fire in which people were killed before steps were taken to minimise the risks posed by some external cladding systems. Unfortunately, that warning was ignored and although a large-scale system test (which became BS 8414) was introduced as an alternative way of assessing risk, national Class 0, which was based on small-scale testing, was allowed to remain in the statutory guidance as the primary standard for external wall coverings, notwithstanding its clear and well-known limitations. On numerous occasions the department was made aware that national Class 0 was wholly inadequate as a measure of the propensity of composite panels to promote the spread of fire across an external wall but it allowed it to remain in the statutory guidance as an acceptable standard until after the Grenfell Tower fire. As soon as the obvious inadequacy of Class 0 for that purpose was demonstrated by the fire, the Building Regulations and guidance were changed. The need for that change could and should have been identified and acted upon years earlier.
214¶29.6 The failure of the government following the large-scale test in 2001 of a system incorporating aluminium composite panels with unmodified polyethylene cores to take any steps to ascertain the extent to which panels of that kind were in use or to warn the construction industry about the risks they posed represents a significant failure of the system, as was the department's failure to publish the results of the test.
¶29.7 The review of Approved Document B between 2005 and 2006 provided the department with another opportunity to clarify the guidance on compliance with functional requirement B4(1). Changes were made to paragraph 12.7 of Approved Document B but the choice of language was vague and ill thought out and the changes were slipped in at a late stage in the process with no proper consultation. The failure to follow established procedures appears to have been driven by a desire to achieve a quick solution to a previously unforeseen problem, but an absence of proper consultation and time for thought resulted in an unsatisfactory amendment that was responsible for confusion and uncertainty. Once again, there was a failure of sound policy-making and the systems designed to ensure an effective outcome.
¶29.8 In the period between 2012 and 2017 the department received warnings about the risks posed by polymeric insulation products and aluminium composite cladding products with polyethylene cores. It also became aware of several major cladding fires abroad. They should have alerted it to the dangers posed by those materials and should have led it to investigate the extent to which such materials were being used by the construction industry in this country. The department appears to have proceeded on the assumption that, because a serious high-rise cladding fire had not occurred in this country, the regulatory regime was sufficient to prevent one from occurring. That was a mistaken assumption for which there was no basis.
¶29.9 Despite those warnings, the department failed to amend or clarify the guidance in Approved Document B on the construction of external walls, which, by 2013 at the latest, it knew was unclear and not properly understood by a significant proportion of those engaged in the UK construction industry. By February 2016 it was aware that some in the industry were worried that combustible insulation and ACM PE panels were routinely being used on high-rise buildings in breach of functional requirement B4. The failure to act on that knowledge represented a serious failure on the part of the government to take seriously its responsibility for the safety of those living in such buildings.
¶29.10 If systems of government are to work well it is necessary that those who are employed to operate them are carefully appointed. It is not clear how Brian Martin was chosen to be the official with day-to-day responsibility for the Building Regulations and Approved Document B, why he was allowed to remain in that position for so long or why he was allowed to wield so much influence over the department's response to developments. His repeated failures to bring to the attention of more senior officials serious risks of which he became aware suggest that he was given a much greater degree of responsibility than was justified without suitable oversight.
215¶29.11 More senior officials must also take responsibility for what were systemic failures. Anthony Burd, Mr Martin's line manager, was directly involved in the introduction into paragraph 12.7 of the expression "filler material" and appears to have been solely responsible for the further addition at the last minute of the reference to gaskets and sealants. He should have ensured that more senior officials were told about it.
¶29.12 It was a serious weakness in the organisation of the department that Mr Martin was given too much independence in deciding how it should respond to information reaching it from the industry and elsewhere. As his Deputy Director for a significant part of the relevant period, Bob Ledsome must bear some of the responsibility for that because he did not exercise the degree of oversight that matters of such importance required. He could and should have done more to understand the potential risks involved in the use of certain products, particularly when he became aware in late 2015 of various international cladding fires. Given the extent to which matters affecting the safety of people's lives depended on Mr Martin's recognition of a serious danger and the soundness and thoroughness of his decision-making, Mr Ledsome, Mr Burd and later Mr Harral should have exercised a greater degree of supervision over him, if only to ensure that his response to events was appropriate. It was a serious failure of the system to allow an area of activity that directly affected the safety of people's lives to depend on the judgment of one relatively junior official.
¶29.13 The effective working of the system was not enhanced by the privatisation of BRE. In our view its relationship with the department became less beneficial after it was required to operate in a commercial environment. The transition from adviser to contractor meant that it did not regard itself as being under a duty to provide robust and independent advice to the government. Indeed, the department made it clear that it should not volunteer policy advice but should confine itself to providing the services described in its contracts. The flaws in the relationship between BRE and the department were epitomised by the Investigation of Real Fires contracts2167 See Chapter 8. under which BRE's contribution to discussions was restricted.
¶29.14 Once the relationship between BRE and the department had been put on a purely commercial footing, it was for the department to decide what it wanted BRE to provide. If it did not want BRE to provide policy or any other advice it was free to make that clear. However, for the relationship to work to best advantage it was desirable that the department should have the benefit of BRE's advice and experience. Unfortunately, that did not always occur. BRE's investigation into the Lakanal House fire was curtailed by the department prematurely and at every stage, including the inquests, officials displayed a short-sighted attitude towards learning the wider lessons of the fire. Lessons could and should have been learnt that might have improved the robustness and clarity of the regulatory regime before the refurbishment of Grenfell Tower was carried out.
¶29.15 The department's response to the coroner's recommendations was inadequate. No-one treated them with any sense of urgency; officials did not explain clearly to the Secretary of State the steps that were required to comply with them and at least one junior official appeared to treat the coroner with disdain. There was a lack of clarity about which of them had been accepted and which rejected and there was no system for monitoring or tracking them.
216¶29.16 The picture of a department struggling under significant pressure was reinforced by the response of ministers and officials to other external bodies. Legitimate concerns repeatedly raised by the All-Party Parliamentary Group on Fire Safety were met with a defensive and dismissive attitude by officials, reflected in the responses of ministers to correspondence. They ought to have considered whether the concerns were well-founded, and if so, what action was required.
¶29.17 In the years that followed the receipt of the coroner's recommendations the government's deregulatory agenda, enthusiastically supported by some junior ministers and the Secretary of State, dominated the department's thinking to such an extent that even matters affecting the safety of life were ignored, delayed or disregarded. Senior officials and ministers alike appeared to be almost completely unaware of the day-to-day effect of those policies on junior officials who were charged with matters of that kind. Mr Ledsome made no attempt to bring to the attention of any more senior official the negative effect on his team of the pressure to deregulate and no senior official or minister appears to have given any real thought to whether it was appropriate that the policy of deregulation should apply to the Building Regulations and statutory guidance.
¶29.18 Building control was a regulatory activity in which the department played no direct role, but senior officials and ministers ought to have ensured that arrangements were in place to monitor the system and ensure that it was working properly. From 2013 onwards there were warnings about systemic failings and risks to public safety that junior officials should have brought to the attention of those in more senior positions, but no formal process for doing so existed.
¶29.19 The effectiveness of the Building Regulations division was undermined by a failure to include among its responsibilities monitoring the effectiveness of the Building Regulations and statutory guidance and the development of new methods of construction and the use of new materials and by a lack of sufficient resources to enable it to identify and record risks to public safety arising from the use of unsuitable materials. Nor did it have sufficient resources to ensure that the guidance in Approved Document B was kept up to date and fit for its purpose. The division was not afforded the priority it deserved and was not given the resources and expertise it needed to carry out the demands on it.
¶29.20 There were serious and longstanding failings of leadership at the highest levels. Senior officials should have taken a closer interest in the working of a small, but important, part of the department that was responsible for significant matters affecting the safety of people's lives. The fact that the Building Regulations division was not expected to monitor the way in which the regulations and guidance were understood and applied created a dangerous situation, given the low levels of competence in the construction industry, the introduction of new construction materials, such as polymeric insulation and ACM panels with combustible cores, and the extent to which many in the industry regarded Approved Document B as prescribing the circumstances in which combustible materials could be used in the construction of external walls without regard to the functional requirements. Most importantly, there was a failure to create a climate in which concerns reaching the department about matters affecting the safety of life were expected to be raised with more senior officials and frank advice given.
¶29.21 In conclusion, we have come to the view that over a period of many years the department failed to recognise the importance of the Building Regulations and the accompanying statutory guidance as a system of regulation whose purpose was to ensure public safety, including the safety of those who live and work in high-rise buildings. For that reason it failed to put in place arrangements to ensure that the working of the system was properly monitored and that steps were taken as and when necessary to ensure that it remained capable of achieving its purposes. Those were systemic failings of a kind for which ministers and the senior officials responsible for the organisation of the department must take responsibility. Despite the warning from the Select Committee in 1999 that action needed to be taken on the use of combustible materials in the construction of external walls, inertia combined in later years with a drive to avoid regulation made it likely that only a major fire in a high-rise building leading to a large number of casualties would prompt it to take the necessary action. The government must take responsibility for the systemic failures that played a significant part in enabling the Grenfell Tower fire to occur.
217¶29.22 Regrettably, there was a similar failure on the part of the government to ensure that the provisions of the Fire Safety Order relating to the carrying out of fire risk assessments were capable of being implemented as effectively as the nature of the activity required. The problem lay in the competence of those who held themselves out as capable of carrying out such assessments, particularly in relation to high-risk buildings, and the government's apparent determination not to respond to repeated calls for the regulation of the industry. The need for regulation to ensure the competence of those practising as fire risk assessors was drawn to the department's attention by the Chief Fire and Rescue Adviser in 2009 and over the following years calls came from various quarters for the industry to be regulated.
¶29.23 When the matter next came before the relevant minister (then Brandon Lewis MP) in 2013, reluctance to introduce new regulations appears to have trumped the need to put the industry on a sound footing. The determination to pursue a solution based on the creation of voluntary schemes of accreditation of a kind that had not previously proved effective resulted in stalemate. Unfortunately, the government failed to pay proper attention to the voice of the fire sector whose various bodies were largely in agreement about what was needed. That may have reflected the degree of importance ministers attached to fire risk assessments, but whatever the reason, its refusal to act was in our view a serious error and a failure of the system designed to keep people safe from the effects of fire.
¶29.24 Much the same can be said of the department's response to requests for clarification of the Fire Safety Order. As early as 2012 the London Fire Commissioner asked the minister (again, Brandon Lewis MP) to provide guidance on the meaning of the expression "[parts] used in common". His call for clarification was echoed by the coroner at the Lakanal House inquests but once again, the policy of deregulation appears to have stood in the way of amending the Order to provide the necessary clarity. Despite a further request for clarification from the London Fire Commissioner, the government shelved the matter and no action was taken until the passing of the Fire Safety Act 2021, some years after the Grenfell Tower fire.
The Building Research Establishment
¶29.25 BRE held a trusted position within the construction industry and more widely. Having begun life as a government agency it was privatised in 1997, after which it was engaged to advise the department from time to time on a broad range of matters relating to fire safety under contracts for research, investigations, reports and experimental work. Senior staff, including Dr Debbie Smith and Dr Sarah Colwell, were members of a range of committees working on fire safety standards at both European and national level, sometimes acting on behalf of the government. BRE was responsible for managing public consultations on, and drafting amendments to, Approved Document B and for advising working groups formed by the department on the introduction of new classifications such as Euroclass standards in 2002. Informally, BRE staff corresponded with the department, principally Mr Martin, on inquiries relating to fire safety received both by the department and by BRE itself. Their correspondence covered a range of matters, including the interpretation of parts of Approved Document B and international cladding fires.
218¶29.26 BRE was widely recognised both nationally and internationally as a leader in fire safety. For many years before the fire at Grenfell Tower it was the only organisation in the UK capable of carrying out large-scale testing in accordance with BS 8414. BRE developed that test and published all three versions of BR 135, which set out the criteria against which data from tests carried out in accordance with BS 8414 should be assessed.
¶29.27 However, as our findings in earlier chapters demonstrate, much of the work carried out by BRE was marred by unprofessional conduct, inadequate practices, a lack of effective oversight, poor reporting and a lack of scientific rigour. In some cases we saw evidence of a desire to accommodate existing customers at the expense of maintaining the rigour of its processes. Despite its close association with the department over a long period of time and the opportunities that association provided for the informal exchange of views, BRE appears to have been reluctant to alert the department to developments of potential importance in the construction industry of which it became aware.
Testing in accordance with BS 8414
¶29.28 There were weaknesses in the way BRE carried out tests in accordance with BS 8414. It did not identify carefully the materials delivered to the burn hall for individual tests, it did not ensure that they corresponded to the drawings of the system to be tested and did not ensure that the rig as constructed and tested accurately reflected the drawings that had been provided. The periodic checks that Dr Smith told us BRE staff were expected to make on systems under construction were vague and did not contain any clear direction in relation to frequency, timing or purpose. She told us that BRE staff in the burn hall were not trained to understand architectural drawings,2168 Smith {Day237/167:17-25}. so it is difficult to see why BRE required drawings to be provided or why its staff were expected to check systems under construction against them. Mr Clark, who managed the BRE burn hall between 2005 and 2015 and was responsible for compiling BRE's standards and procedures for testing in accordance with BS 8414 in 2013,2169 {BRE00005769/295-305}; Clark {Day95/60:20-21}. told us that he thought the drawings submitted by test sponsors were not intended to represent the system tested but the system as it was intended to be constructed as part of a building.2170 Clark {Day97/72:14-18}. He also told us that drawings had sometimes not been provided until after the test had taken place,2171 Clark {BRE00005768/9} page 9, paragraph 41. as happened with the second test carried out for Celotex in May 2014. In that case Mr Clark prepared a draft report using drawings from the previous test in February 2014.2172 Clark {Day96/81:3-13}. As a result of those defects in the system, reports of tests did not always correctly describe the system tested.
¶29.29 BRE took the position, repeated in all test reports, that the configuration of the system to be tested was entirely a matter for the sponsor of the test, but that did not prevent it from carrying out proper checks to ensure that the system tested matched the description in the test reports and that the components were correctly identified and accurately recorded. We see no reason why BRE could not have kept comprehensive records of all materials delivered to the burn hall for every test, examined the drawings in advance and decided at what stage of construction checks should be made by BRE staff. Since the description of the system tested was fundamental to any subsequent report, close monitoring of the system in the course of construction was essential to ensure that the report was accurate. Nothing in BS EN ISO EIC 17025 prevented BRE from doing that. The absence of such arrangements represented a serious failure in its systems.
219¶29.30 Shortcomings of that kind enabled Celotex to manipulate the testing process by introducing materials other than those described in the report. Moreover, although BRE was aware that commercial organisations were liable to manipulate their relationship with it to gain commercial advantage,2173 {BRE00014770/6}; {BRE00041887/12}; Smith {Day235/67:8-24}; {Day236/155:18}-{Day236/156:23}; {Day238/44:21-23}. it did not take adequate steps to ensure that those of its employees who came into direct contact with clients in the course of carrying out tests understood the need to maintain their distance and avoid undue familiarity. As a result, its employees were liable to be drawn into relationships with customers that undermined the independence, objectivity and rigour of their work.
¶29.31 In 2004 Dr Colwell discussed testing with Kingspan in a way that went some way beyond providing general information about the process and amounted to giving advice on the best way to satisfy the criteria in BR 135.2174 {KIN00021657} ninth and twelfth paragraphs; {BRE00047572/1}; Meredith {Day75/20:14}-{Day75/21:1}; Heath {Day78/204:17-22}; {Day78/207:9-12}; {Day78/208:18}-{Day78/209:7}; Meredith {Day75/130:23-25}. See Chapter 22. In December 2007, BRE staff offered unofficial comments and observations to Kingspan about the performance of K15 following the disastrous result of a test on a system of which it had formed part.2175 {KIN00008847/3}; Meredith {Day75/160:3-13}. See Chapter 22. In keeping with Kingspan's strongly expressed wishes,2176 {KIN00003693/1} BRE agreed to say no more in its report than that the system as a whole had not met the criteria in BR 135, despite having commented privately to Kingspan that the insulation had been fully involved and had continued to burn even after the flame source had been extinguished.
¶29.32 Despite his denials, we have found that Mr Clark advised Celotex on more than one occasion on ways in which it could improve its system for a second test after a failed test in February 2014. We have also found that he was aware of the inclusion of additional magnesium oxide boards during the second Celotex test that were not referred to in the test report or the classification report. We also saw for ourselves a recording of Mr Clark engaging in discussions with Mr Meredith during the test of a system incorporating Kingspan K15 in March 2014 in the course of which he gave advice on the performance of the system and how to argue about what the results showed.2177 {BRE00035418}.
¶29.33 The unprofessional behaviour of some of BRE's staff was in part the result of a failure to provide them with adequate training in the performance of their responsibilities. We have been critical of Mr Clark for advising Celotex on ways in which it might improve its system following the test in February 2014, for failing to draw attention to the use by Celotex of magnesium oxide boards in the system tested in May 2014 and for giving advice to Kingspan during the test conducted for it in March 2014. However, he had received no training from BRE of any kind on what was required by way of independence and impartiality,2178 Clark {Day97/88:23}-{Day97/89:3}. nor had he had any discussion at any time with any of his managers about what might constitute impermissible advice and consultancy services.2179 Clark {Day97/89:19}-{Day97/90:2}. There was no mandatory training2180 Smith {Day237/153:11-16}. or centralised record of training within BRE and its staff were responsible for their own training records.2181 Smith {Day237/154:19-25}. Quite simply, Mr Clark did not know where to draw the line and he crossed it on various occasions. The failure to provide training of that kind represents a failure to establish proper management systems.
220Commercial interests
¶29.34 When invited to a meeting of the CWCT's Fire Group in July 2014 to discuss fire and facades, including the use of combustible insulation on high-rise residential buildings, Dr Smith's alarm at what she saw as a potential threat to BRE's pre-eminent position as an adviser on such matters betrayed a desire to put BRE's status in the industry and commercial position ahead of considerations of public safety.2182 {BRE00047459/1}; Smith {Day237/59:2-8}; Smith {Day237/61:25}-{Day237/62:8}; Smith {Day237/62:24}-{Day237/63:6}. See Chapter 11.
Investigation of Real Fires project
¶29.35 We recognise that BRE's fire investigations for the department were constrained by limited resources and time and also by the restrictive terms of its contracts, particularly after 2012. Nonetheless, the investigations it carried out for the department were characterised by a lack of analysis and were at best superficial.2183 See Chapter 8. Most reports revealed very little that would enable one to discern patterns or trends or even understand what had caused or contributed to any particular fire. The reports repeatedly confirmed the overall effectiveness of the regulations and guidance without any proper basis for that conclusion. As a result they gave false comfort to the department for many years and served only to increase the danger that important matters would be missed. BRE's reports into the major fires at Knowsley Heights (1991), Garnock Court (1999) and The Edge (2005) and its preliminary report into the fire at Lakanal House (2009) were far from comprehensive and in each case failed to identify or assess important contributory factors. Most significantly, although each of those fires was often referred to as providing important lessons for the future, no one at BRE was able to describe what those lessons actually were.
Relationship with the government
¶29.36 The status of BRE, its origins and historical links with the department, as well as the fact that for many years Brian Martin, while employed by BRE, had been seconded to the department might reasonably have been expected to foster a relationship under which BRE would alert the department to significant developments in matters affecting the safety of life that might call for amendments to the Building Regulations or statutory guidance. However, the relationship did not work in that way, to the detriment of the department and the public at large. Although BRE recognised from as early as 1991 following the fire at Knowsley Heights that small-scale testing, in particular of the kind that provided the basis for national Class 0, was inadequate to enable a proper assessment to be made of the reaction of external cladding systems to fire, we found nothing to indicate that BRE had drawn that to the department's attention, formally or informally.
¶29.37 Similarly, following its large-scale test of a system incorporating aluminium composite panels with polyethylene cores in 2001 under contract cc1924, BRE failed to draw the department's attention in clear terms, either in its report or informally, to the way in which the material had behaved and the dangers it presented, particularly if used on high-rise buildings. The department did not have access to its own scientific advice on matters affecting fire safety, as we think BRE must have been aware, and so depended to a significant extent on information of the kind that BRE was able to provide. The failure of that relationship represented a significant gap in the arrangements intended to protect the safety of the public.
221The quality of BRE's work
¶29.38 BRE was engaged regularly by the department to carry out research and provide reports, but the quality of the work it produced was in many cases poor. For example, reports produced under the cc1924 project conflated Class 0 and limited combustibility when describing the regulatory requirements and guidance.2184 {BRE00001353/14} first paragraph; See Chapter 10. That was a fundamental error that was repeated by BRE when reporting on the fire at Lakanal House2185 {BRE00005881/14} fourth paragraph. See Chapter 9. and in the work done for the department by the BRE on external fire spread in 2015.2186 {CLG00019445/3} fifth paragraph; Crowder {Day230/160:22}-{Day230/162:21}. See Chapter 10. That particular piece of work, which involved experimental testing and a background research paper, was seriously inadequate. It was deeply flawed in almost every respect, lacked any scientific value and purported to draw positive conclusions about the effectiveness of the regulations and guidance that could not sensibly have been reached on the basis of the work that had been carried out.2187 Chapter 10.
Certification bodies
¶29.39 Our investigations also uncovered serious weaknesses in two important certification bodies, the British Board of Agrément (BBA) and Local Authority Building Control (LABC).
The British Board of Agrément
¶29.40 As an organisation claiming to be one of the leading certification bodies the British Board of Agrément should have ensured that its procedures for investigating the claims made by manufacturers for their products were by nature both wholly independent and rigorous and that they were followed with equal independence and rigour. In fact, however, as our investigation of the circumstances surrounding the issue of its certificates in respect of Reynobond and Kingspan K15 have shown, there were failings of a kind which undermined their value and rendered them misleading. Moreover, we have no reason to think that the shortcomings we discovered in those certificates and the way in which they had been issued were confined to those particular cases.
¶29.41 In the case of the BBA the root of the problem lay in the conflict between the need to act as a commercial organisation, and therefore to attract customers in order to generate profits, and the need to maintain a high degree of independence and rigorous investigation in order to satisfy those who might be considering using the products in question that the contents of their certificates could safely be relied on. The BBA failed to manage effectively the conflict between the commercial and (for want of a better word) regulatory aspects of its operations in the two cases we investigated and, because that conflict was inherent in its operations, we think it likely that it failed to manage it appropriately in other cases too.
¶29.42 The BBA's scrutiny of the evidence relating to the fire performance of Reynobond was superficial. Although some within the BBA knew that the performance in a fire of a product of that kind might be affected by its configuration and method of fixing, the BBA failed to ask for any test evidence relating to the product when used in cassette form. It also failed to obtain any evidence to support the claim that the version of the product with an unmodified polyethylene core had satisfied the requirements of Class 0. Despite those important omissions, it issued a certificate for Reynobond which stated that the panels "could be regarded as having a Class 0 surface" and failed to draw any distinction between the way in which different methods of fixing affected the way in which it reacted to fire.
222¶29.43 The lack of rigour in the BBA's investigations was also exemplified by its approach to the certification of Kingspan's K15 in October 2008. No aspect of the product's manufacture, testing or fire performance was assessed by the BBA before it issued the certificate. It did not obtain any test data relating to K15 before it issued a certificate that contained a statement that the product had been classified as national Class 0, since none existed. In July 2013 the BBA issued a revised certificate stating that K15 met the requirements of paragraph 12.7 of Approved Document B, although it ought to have known that that claim was false because K15, as a phenolic product, was not a material of limited combustibility. It is clear that for some years no-one at the BBA had any real expertise in assessing the fire performance of materials or understood the need for it. Until 2016, any recourse to outside expert bodies (such as BRE) was haphazard at best.2188 Amoroso {Day106/17:19}-{Day106/18:8}; Albon {Day109/92:18-23}; {Day109/110:7}-{Day109/111:22}; Gregorian {Day105/25:12}-{Day105/27:2}; {Day105/157:19}-{Day105/160:4}.
¶29.44 Until December 2013, when it issued its third certificate for K15, the BBA effectively allowed the contents of the certificates relating to the fire performance of K15 to be dictated by Kingspan itself, accepting the text it put forward without checking its accuracy. At the suggestion of Kingspan, the first and second versions of the certificate advised designers to consult Kingspan if they were considering its use on buildings over 18 metres in height. That was a singularly foolish thing to include, as should have been obvious, because it effectively allowed Kingspan to approve the use of the product itself and bypass the certificate as independent verification of the product's compliance with the guidance in Approved Document B.
¶29.45 We accept that in the case of Arconic and Kingspan the BBA was the victim of dishonest behaviour on the part of unscrupulous manufacturers, but if it had maintained robust processes that could not have happened.
¶29.46 In these different ways the BBA demonstrated an inappropriate desire to please its customers and in order to do so accepted forms of wording proposed by them for inclusion in certificates that were wrong and misleading. It failed to recognise that the way in which Arconic described the product deliberately blurred the distinction between the form in which the product left the factory and the two forms in which it would inevitably be used. Moreover, despite imposing on customers terms of contract that required them to provide information when called upon to do so, the BBA failed to enforce them and allowed Arconic to ignore them without any sanction.2189 Chapter 21. In our view all those failures reflected an ingrained willingness to cultivate customers, certainly those of any commercial value, rather than insist on high standards and compliance with a contract that was intended to maintain them. The first two certificates issued by the BBA in relation to K15 lent substantial support to Kingspan's efforts to create a market for combustible insulation material for use on high-rise buildings.
223Local Authority Building Control
¶29.47 Over a period of some years the LABC's certificates relating to Kingspan K15 and Celotex RS5000 contained misleading statements about the fire performance and suitability of both products for use in the external walls of buildings over 18 metres in height. They also misrepresented the nature of the BS 8414 test and classification in accordance with BR 135.
¶29.48 The LABC had received, and effectively ignored, several warnings from various organisations and individuals about the contents of the certificates it had issued for K15. In the case of K15 and RS5000, it failed to scrutinise properly the claims made for the products by the manufacturers; instead, it adopted uncritically the language they suggested. In short, it was willing to accommodate the customer at the expense of those who relied on the certificates.
¶29.49 Drafts were prepared for the certificate relating to RS5000 without sight of important documents. For much of the time those involved in producing the draft certificates did not understand the nature or purpose of the BS 8414 test or classification by reference to the criteria in BR 135. Nor did they understand the difference between a material with a Class 0 surface and a material of limited combustibility, which was an important distinction for the purposes of Approved Document B. As a result, they were under the misapprehension that if an external wall system containing a particular material or product satisfied the criteria in BR 135 when tested in accordance with BS 8414, that material or product was suitable for use in the external walls of buildings over 18 metres in height generally.2190 Ewing {Day218/165:23-25}-{Day218/166:1-7}.
¶29.50 Although the LABC was not a testing house and did not ultimately determine whether a product could be used safely on any particular development, and although local authority building control officers were not obliged to accept its certificates, it remains the case that one of the main purposes of an LABC certificate was to enable the product or system in question to gain approval from building control easily and quickly. As a body that issued certificates, the LABC was necessarily aware that its certificates were relied on by manufacturers to demonstrate that their products complied with the Building Regulations2191 Brennan {LABC0020135/12} page 12, paragraph 21.3; Turner {Day216/23:16-20}. and by building control officers to satisfy themselves that they were suitable for the use to which it was proposed to put them. It should therefore have been aware that it was of the utmost importance that its processes were robust and the technical contents of its certificates accurate.
¶29.51 Like the BBA, the LABC was the victim of dishonest behaviour on the part of unscrupulous manufacturers. Kingspan and Celotex outmanoeuvred and took advantage of the LABC throughout the process of certification. Each of them set out to mislead those who were responsible for assessing the claims made in respect of their products. Like the BBA, however, the LABC should have been aware of the risk that manufacturers eager to obtain certificates for their products might be tempted to present them in an unduly favourable light, if not worse, but it did little to ensure that its processes were sufficiently rigorous to avoid its being misled, so far as that was possible.
¶29.52 The LABC was vulnerable to deception because its processes were not rigorous enough and those who were responsible for the process of certification, including those who carried out the peer review, did not take them as seriously as was required. The task of producing the initial assessment should not have been given to building control officers who did not have the degree of knowledge and experience required to make an informed assessment of the product in question. It should have been given to someone who, at the very least, was capable of understanding the properties of the product and the nature of any tests to which the certificate was expected to refer. Its procedures should have ensured that appropriate test evidence existed to support the use of the products described in its certificates.
224¶29.53 The LABC accepted that in the case of Kingspan K15 and Celotex RS5000 the approval scheme had, at least at first, failed in all respects.2192 {LABC0019740/4} paragraph 11. We agree but would go further. The LABC failed to scrutinise rigorously the information provided by Kingspan or Celotex at any stage and initial errors were repeated in later certificates. The fact that the original assessments were carried out by LABC member authorities rather than by the LABC itself does not excuse the absence of proper reviews, robust second checks or, in the case of K15, the failure to respond to warnings given by reputable organisations about the inaccurate terms of a previous certificate.
¶29.54 In the final analysis, there was a complete failure on the part of the LABC over a number of years to take basic steps to ensure that the certificates it issued for K15 and RS5000 were technically accurate. We have not examined its certification of any other products and therefore cannot tell whether those were exceptions to an otherwise satisfactory process, but having seen evidence of the system in operation, we think that unlikely. We are therefore concerned by the serious deficiencies in the operation of the certification scheme that have come to light in the course of our investigations. The way in which the Type Approval and Registered Details schemes were operated in the two cases we have examined rendered them incapable of providing the construction industry, including local authority building control departments, with the objective and reliable information they required.
United Kingdom Accreditation Service
¶29.55 The role of UKAS was to assess organisations providing testing and certification services. It accredited both the BBA and BRE for many years before the Grenfell Tower fire. However, as we have concluded in Chapter 28, it did not always follow its own policies and its assessment processes were lacking in rigour and comprehensiveness. Even when failings were identified they were not properly explored and opportunities to improve were not always taken. The assessment process relied too much on the candour and co-operation of the bodies it was assessing and too much was left to trust. UKAS should have taken a more searching, even sceptical, attitude to the bodies it accredited. The powers it had to address concerns were surprisingly limited, with no powers of enforcement; the most it could do to address unsatisfactory conduct was suspend or withdraw accreditation. That was an unsatisfactory state of affairs.
The National House Building Council
¶29.56 In this chapter we have sought to identify shortcomings that had a wider significance because of their systemic nature. NHBC, whose involvement in the approval of Kingspan K15 and the publication of guidance to the construction industry on the construction of the external walls of high-rise buildings we have described in Chapter 26, played no direct part in the refurbishment of Grenfell Tower. However, as an organisation employing a large number of Approved Inspectors through whom it provided building control services to a large part of the housing market, it was very influential. It also wielded considerable influence on the housebuilding industry through its membership of the Building Control Alliance and its publication of guidance notes. It was therefore well-placed to ensure that the requirements of the Building Regulations and Approved Document B were known about and acted upon.
225¶29.57 As we have observed elsewhere, building control is essentially a regulatory function exercised in the public interest free of commercial pressure. However, as we have described in Chapter 26, there were repeated occasions on which NHBC failed to demonstrate sufficient independence and showed itself willing to accommodate the wishes of Kingspan for commercial reasons. It also showed itself unwilling to upset its own customers and the wider construction industry by revealing the scale of the problem caused by the use of combustible insulation in the external walls of high-rise buildings and the likelihood that they did therefore not comply with the Building Regulations. Those failures struck at the heart of the system of building control. The incentive to act in that way had been created by the introduction of Approved Inspectors, who were able to operate as commercial providers of building control services. In our view there is an irreconcilable tension between the requirements of regulation and the pressures of commerce that prevents a system of that kind from effectively serving the public interest.
An overall view
¶29.58 In this chapter we have sought to look beyond the individual shortcomings to identify failings of a more systemic nature in various organisations responsible in one way or another for protecting public safety. Each of them had a part to play in a larger system that was intended to achieve that end. Unfortunately, that system lacked the degree of integration required to ensure that it operated as effectively as it should. The government made the regulations and provided the guidance but was not actively involved in monitoring their effectiveness or developments in the construction industry. BRE and other similar organisations provided information and advice to the government, but only as and when it asked for it. Certification bodies provided assurance to the market that products had certain properties and were suitable for use in certain ways but were subject to conflicting interests which in some cases they failed to manage properly. Building control was meant to exercise an important regulatory function, but local authority building control departments did not have adequate resources and the competence of their employees was variable. Moreover, following the introduction of approved inspectors, building control was exposed to the conflict between commercial interests and the regulatory function. The government did not see it as part of its function to oversee its activities in a way that would ensure that the system was discharging its intended purpose of protecting the public.
¶29.59 In our view, there was a lack of effective co-ordination between what were in substance different aspects of a single system, the purpose of which was to ensure that the built environment was safe for those who lived and worked in it and for those who might be affected by it as visitors or just passers-by. That is a task that only the government can undertake. The department responsible for making the Building Regulations and publishing guidance should also be responsible for ensuring that there is effective monitoring of the working of the system as a whole. Only if there is a greater degree of integration of the different parts of the system will the public obtain the benefits that the system as a whole is intended to provide.
5Part 4: The Tenant Management Organisation
7Chapter 30: Introduction to Part 4
¶30.1 The Tenant Management Organisation occupies a central position in the matters we have investigated. As the body appointed by RBKC to manage the whole of its housing stock it was responsible for all aspects of the management of Grenfell Tower in the years leading up to the fire, including responsibility for repairs and maintenance and, most importantly, matters affecting fire safety. Although RBKC provided the funds for the refurbishment, the TMO was responsible for organising and managing it and was the client under the design and build contract with the principal contractor, Rydon. In carrying out its operations it was allowed a large measure of autonomy under the overall supervision of the council.
¶30.2 In order to provide a context for what follows, we begin this Part of our report by describing the history and structure of the TMO and the agreement with RBKC under which it managed the council's residential properties. We also describe its internal organisation and processes and their effectiveness. At the same time, we identify those responsible for some important aspects of its operations.
¶30.3 The arrangements made by RBKC for supervising the TMO's operations were of considerable importance, both as to their structure and their implementation, so we have described them and expressed our conclusions on their effectiveness.
¶30.4 Managing a large housing stock inevitably gives rise to a considerable amount of interaction between managers and tenants and it is difficult to avoid a certain amount of friction from time to time. However, it was accepted by all concerned that for some years before the fire many tenants, including some of those who lived in Grenfell Tower, had expressed considerable dissatisfaction with the way in which they were treated by the TMO and that relationships had deteriorated to the point at which they could be described as hostile.
¶30.5 We describe the history of the relationship between the residents of the Lancaster West Estate (of which Grenfell Tower formed part) and the TMO in the years leading up to the fire, including the various local residents' associations that were formed in an effort to pursue their members' interests, because it is an important part of the context in which the refurbishment of the tower took place.
9Chapter 31: Structure and governance
Background
¶31.1 In 1991 the government pledged to increase opportunities for tenants of social housing to assume greater powers of management of the properties in which they lived, independent of the local authorities which owned the buildings. That was done by amending the Housing Act 1985 to create a right to manage, so that local authorities would be obliged to transfer their housing management functions to a tenant management organisation, provided that a majority of tenants were in favour of such a transfer and certain other conditions were met. Following a study carried out by RBKC of the feasibility of transferring its housing management functions to a tenant management organisation, a ballot of RBKC tenants was held. The necessary majority voted in favour of the proposal and following preliminary government approval the Kensington and Chelsea Tenant Management Organisation (the TMO) was incorporated on 19 April 1995.
¶31.2 Following a further ballot in which the majority of tenants again voted in favour of the transfer, the first formal management agreement came into force on 28 February 1996,1 {RBK00018516}. under which RBKC appointed the TMO as its agent to carry out some (but not all) of its housing management functions.2 The TMO's management functions under this first Management Agreement {RBK00018516} included repairs, maintenance and services provision (Chapter 2), the collection of rent and levying of service charges (Chapter 3), the granting and management of tenancies (Chapter 5). Those functions were formally delegated on 1 April 1996 when the TMO became operational3 RBKC's note on the chronology and history of the TMO {RBK00058262/4} paragraph 14. and 250 officers employed in RBKC's Housing Services Department transferred to the TMO.
Constitution
¶31.3 The TMO was set up as a company limited by guarantee and was owned by its members, all of whom were tenants or leaseholders of premises owned by RBKC. In April 1996, members of the TMO elected the first tenant and leaseholder members of the board.
¶31.4 The TMO board had 15 members consisting of eight residents (tenants and leaseholders, in which the former were in the majority), up to four members appointed by the council and three members appointed by the board itself.4 Amended Memorandum of Association of KCTMO Constitution {RBK00050806/16} Article 15, clause 15.1.
¶31.5 Throughout its life, the TMO's board comprised tenant, leaseholder, council-appointed and independent board members. Its articles of association were designed to ensure that residents' representatives made up the majority of the board's members.5 Amended Memorandum of Association of KCTMO Constitution {RBK00050806/16} Article 15, clause 15.1. In particular, the chair and the two vice-chairs were required to be residents' representatives.6 Amended Memorandum of Association of KCTMO Constitution {RBK00050806/21} Article 23, clause 23.2.
10¶31.6 The TMO's board was responsible for ensuring that the TMO's objectives were carried out and for ensuring its proper day-to-day management.7 Amended Memorandum of Association of KCTMO Constitution {RBK00050806/20} Article 22, clause 22.1. In particular, the board was responsible for the appointment and dismissal of the chief executive and other senior managers.8 Amended Memorandum of Association of KCTMO Constitution {RBK00050806/20} Article 22, clause 22.4.
¶31.7 The TMO board operated independently of RBKC except on matters relating to the Housing Revenue Account.9 Black {TMO00000888/4} page 4, paragraph 23.
¶31.8 The TMO's principal object was to manage and maintain RBKC's housing stock and ancillary properties on its behalf10 Amended Memorandum of Association of KCTMO Constitution {RBK00050806/2} Article 4, clause 4.1. and on behalf of its 5,600 members, who were either residents or leaseholders of RBKC properties.11 Black {TMO00000888/4} page 4, paragraph 21.
¶31.9 In 1996 a Management Agreement was entered into with RBKC, under which the TMO agreed to manage the residential properties owned by RBKC.
Arm's Length Management Organisations
¶31.10 Arm's Length Management Organisations (ALMOs) were introduced by the government in its 2000 Housing Green Paper Quality and Choice: A decent home for all.12 RBKC's note on the chronology and history of the TMO {RBK00058262/8} paragraph 36.
¶31.11 In 2002, RBKC applied to the government to allow the TMO to become an ALMO. The application was granted, with the result that strategic control of RBKC's housing capital programme was delegated to the TMO.13 RBKC's note on the chronology and history of the TMO {RBK00058262/8} paragraph 39.
¶31.12 In April 2002, an extraordinary general meeting of the TMO was held at which the members voted unanimously to amend its constitution to allow it to operate as an ALMO and in September 2002, the Secretary of State formally consented to the delegation of additional responsibilities to it.14 RBKC's note on the chronology and history of the TMO {RBK00058262/8} paragraph 39.
¶31.13 To give effect to the TMO's change of status, the 1996 Management Agreement was varied by a deed executed by RBKC and the TMO which came into effect on 7 November 2002. The deed appointed the TMO as an ALMO and, in particular, made the TMO responsible for developing and undertaking all major work schemes as defined in the Management Agreement as well as for the management of the capital programme.
¶31.14 In 2006, the 1996 Management Agreement and the 2002 deed were replaced by a Modular Management Agreement with effect from 1 April 2006 (the 2006 Agreement), under which the TMO continued to manage residential properties for RBKC as its managing agent. The text of the 2006 Agreement was based on a template approved by the government for agreements between local authorities and tenant management organisations. It was based on a standardised form with a chapter on each of the relevant subject areas, such as repairs and payment of rent.
11¶31.15 Over the next decade there were further minor changes to the 2006 Agreement before it was superseded by a new Modular Management Agreement in 2015 which reflected the structure and content of a revised template.15 For example, the 2006 Modular Management Agreement was varied in July 2008 to provide for implementation of an improvement plan {RBK00050380} and again in April 2010 to transfer responsibility for allocation of housing from the TMO to RBKC; RBKC's Note on the Chronology and History of the TMO {RBK00058262/11} paragraph 45. Thus, in the period leading up to the fire, the contractual relationship between the TMO and RBKC was contained in the 2006 and 2015 Agreements.16 Tenant Management Organisation Modular Management Agreement Volume 1, Chapter 1 {RBK00018796/13} clause 5.
¶31.16 The effect of the two Agreements was essentially the same. Neither agreement transferred any ownership or rights in RBKC's housing stock to the TMO, except the right to manage and maintain that stock, and neither agreement affected RBKC's legal relationship with its tenants or leaseholders. In particular, RBKC retained its statutory, contractual and common law obligations to its leaseholders and tenants. The TMO undertook to carry out management functions in accordance with RBKC's legal obligations.17 Tenant Management Organisation Modular Management Agreement Volume 1, Chapter 1 {RBK00018796/13} clause 6.2. In particular, the TMO was responsible for maintenance and repairs18 Tenant Management Organisation Modular Management Agreement Volume 1, Chapter 2 {RBK00018796/33} clause 1.1. and for proposing major works.19 Tenant Management Organisation Modular Management Agreement Volume 1, Chapter 2, {RBK00018796/34-35} clause 4.1. If the TMO decided that major works were necessary, it was obliged to prepare and approve works within the level of financial resources made available to it by RBKC.20 Tenant Management Organisation Modular Management Agreement Volume 1, Chapter 2 {RBK00018796/35} clause 4.3.
The board and its committees
¶31.17 There were three committees of the TMO board: the Operations Committee, the Finance, Audit and Risk Committee and the Appointments and Remuneration Committee. Only the first two are relevant for present purposes.
¶31.18 The Finance, Audit and Risk Committee was responsible for health and safety (including fire safety). Every March, a Health and Safety report was presented to the Finance, Audit and Risk Committee. The report was also presented to the board and to RBKC's Housing and Property Scrutiny Committee (the Scrutiny Committee) as one means by which the TMO and RBKC monitored compliance with fire safety policies.21 Matthews {TMO00873380/6} page 6, paragraph 20. The Finance, Audit and Risk committee also monitored the scope and effectiveness of the systems used to identify and assess all material financial and non-financial risks to the TMO.22 TMO Annual Health and Safety Report 2015/16 {TMO00843882/1}.
The executive team
¶31.19 The TMO's day-to-day operations were carried on by an executive team that reported to the chief executive. From May 2009, that was Robert Black. There were three executive directors at the time of the fire, Sacha Jevans (Operations), Barbara Matthews (Finance and ICT) and Yvonne Birch (People, Performance and Governance).
¶31.20 Each executive director led a senior management team responsible for the TMO's management functions. In June 2017, the team that reported to Sacha Jevans consisted of Peter Maddison, Director of Assets and Regeneration, Teresa Brown, Director of Housing, Hash Chamchoun, Director of Housing Support Services and Graham Webb, managing director of Repairs Direct Ltd, a subsidiary of the TMO which was responsible for carrying out repairs. For present purposes, it is sufficient to note that Janice Wray, who had been the Health and Safety and Facilities Manager since 2011, reported to Barbara Matthews.23 Wray {Day140/6:16-17}.
12The management of health and safety
¶31.21 The Director of Finance and ICT was responsible for ensuring the health and safety of all TMO residents, employees and contractors.24 Matthews {Day147/103:21-25}. That included responsibility for putting in place arrangements to manage the risk of fire.25 Matthews {Day147/113:8}-{Day147/114:5}. An important element of her role was to monitor the TMO's health and safety performance at a strategic level.26 Matthews {TMO10049987/2} page 2, paragraph 7. Anthony Parkes was the Director of Finance and ICT between August 2009 and June 201527 Parkes {TMO00873400/1} page 1, paragraph 3. when he was succeeded by Barbara Matthews.
¶31.22 Before joining the TMO, Barbara Matthews had not held responsibility at any organisation for health and safety or fire safety management. She had received no training in, or experience of, managing health and safety28 Wray {Day147/99:19}-{Day147/100:14}. or fire safety management. She received no training on the requirements of the Fire Safety Order, either before or during her time with the TMO,29 Wray {Day147/100:25}-{Day147/101:3}. and was not familiar with its details.30 Matthews {Day147/107:23}-{Day147/108:3}. She was not aware of the concept of the responsible person under the Fire Safety Order or of the substance of that person's duties,31 Matthews {Day147/108:23}-{Day147/109:1}. nor did she take any steps to satisfy herself of the adequacy of the TMO's arrangements to discharge its duty to take general fire precautions under Article 8 of the Fire Safety Order.32 Matthews {Day147/110:24}-{Day147/111:2}.
¶31.23 Anthony Parkes, Barbara Matthews and the wider executive team relied heavily on Janice Wray for all aspects of health and safety. Although she was not part of the TMO's senior management team, the degree of reliance placed on her by Barbara Matthews and the broad autonomy she was given within her area of operations, meant that Janice Wray was effectively acting at senior management level in relation to health and safety.33 Matthews {Day147/104:15}-{Day147/105:1}.
¶31.24 The TMO's Health and Safety Committee, chaired by Barbara Matthews, was the TMO's primary forum for discussion of health and safety matters.34 Matthews {TMO00873380/2} page 2, paragraph 8. It was the body which oversaw health and safety performance and challenged managers of services on their compliance with health and safety duties.35 Matthews {TMO00873380/2} page 2, paragraph 8. The health and safety committee was a critical element in the management of fire safety.36 TMO Health and Safety Committee Terms of Reference dated September 2015 {TMO00873368/1}.
13¶31.25 Between them Barbara Matthews and Janice Wray identified the matters that they considered should be put forward for discussion at executive team meetings and included in the annual health and safety report.37 Matthews {TMO10049987/2} page 2, paragraph 8. They typically arose out of meetings of the health and safety committee, discussions in the broader housing sector or publications brought to the TMO's attention.38 Matthews {Day147/105:7-17}.
¶31.26 The TMO maintained a "corporate risk map" that identified the various risks to its operations, the harm that might arise if they occurred and the measures that could be employed to mitigate them.39 Matthews {Day147/132:8-14}; Example of Corporate Risk Map {TMO00899699}. It had identified health and safety as a strategic risk and was aware that the consequences of a failure to manage health and safety duties properly could result in serious injury or death.40 Matthews {Day147/135:13-25}; Corporate Risk Map dated 16 March 2016 {TMO00899699/1} Risk 5. Health and safety committee meetings, involving executive and senior management teams, were held at regular intervals. At those meetings fire risk assessments and any measures required by them were discussed and remedial work monitored and audited.41 Matthews {Day147/136:5-25}.
Janice Wray
¶31.27 Janice Wray played a fundamental role in the TMO's performance of its health and safety obligations, including its obligations in relation to fire safety. Although she saw her role as essentially advisory,42 Wray {Day140/7:22-25}. it is plain from the various versions of the TMO's health and safety policy that it was broader, more substantive and covered a range of matters, including those of the Competent Person for the purposes of the Fire Safety Order that we have set out in Chapter 35.43 At paragraph 18. See also TMO Health and Safety Policy 2012 {TMO10031076/3}. This list was reproduced in the 2016 version of the policy {TMO10024402/3}. The 2010 version of the policy {TMO10031078/3} does not include the references at (i) and (j) to the Fire Safety Order. The responsibilities she was given were probably too much for one person to discharge properly without substantial assistance and effective oversight and unfortunately she had neither. Senior managers either did not realise that there was simply too much for her to do, or, if they did, they were nonetheless willing for her just to get on and do her best.
Annual health and safety reports
¶31.28 The principal means by which the TMO executive committee reported to the board and to RBKC on health and safety matters was its annual health and safety report. The document was prepared by Janice Wray and reviewed by Barbara Matthews and the executive team before it was submitted to the board.44 Matthews {TMO10049987/3} page 3, paragraph 15. The matters reported to the board were those set out in the annual health and safety report and any exceptional events, such as the Adair Tower fire.45 Matthews {Day147/105:18-25}. The TMO itself reported to RBKC's scrutiny committee46 Matthews {TMO00873380/6} page 6, paragraph 20. and to RBKC at quarterly joint management meetings, principally through Robert Black.47 Matthews {TMO00873380/9} page 9, paragraph 31.
¶31.29 From time to time Janice Wray met members of RBKC's housing team, such as Amanda Johnson and Celia Caliskan, and in the course of those meetings reported informally on what the TMO was doing.
14¶31.30 Robert Black told us that Barbara Matthews and Janice Wray raised health and safety matters with him which might then be included in the annual health and safety report.48 Black {Day149/56:14-25}. Although other TMO employees contributed to the report, it was substantially the work of Barbara Matthews and Janice Wray.49 Black {Day149/57:10-19}. As a result, Mr Black was entirely reliant on their judgement to determine whether a matter concerning fire safety or fire safety management should be drawn to the attention of the board.50 Black {Day149/57:2-8}.
Funding health and safety management
¶31.31 The TMO was funded by RBKC. It maintained three separate accounts: a management account, which covered its costs under the agreement with RBKC, a "Repairs Direct" account, which related to the cost of maintenance and repairs, and a Housing Revenue account into which rents were paid,51 Black {Day149/21:6-7}. which it maintained on behalf of RBKC.52 Matthews {TMO00873380/10} page 10, paragraph 33.
¶31.32 The TMO's annual management fee was paid by RBKC into the TMO's management account. Robert Black thought that the TMO board's decision-making was not independent of RBKC because it depended on RBKC for its income.53 Black {Day149/23:23}-{Day149/24:2}.
¶31.33 The cost of employing and running the health and safety team, including that of the fire risk assessment programme, was borne by the health and safety team budget, which was one of the departmental budgets within the Financial Services and ICT directorate.54 Matthews {TMO00873380/10} page 10, paragraph 35. That budget did not include the cost of carrying out works required as a result of a fire risk assessment, which was borne by whichever team was responsible for the work in question.
Reporting to the Board and RBKC
¶31.34 The board of the TMO was the body ultimately responsible for its affairs, including strategic decisions relating to matters affecting fire safety in the buildings it managed. It was therefore important that it be kept informed of developments as they occurred, but regrettably there were many instances in which important information was not drawn to its attention. RBKC was responsible for the oversight of the TMO which reported to its scrutiny committees. Reports to the scrutiny committees did not always contain the information that might reasonably have been expected.
¶31.35 From the start of Robert Black's tenure as chief executive in May 2009, fire safety and the adequacy of the TMO's fire safety measures were regular subjects of discussion, primarily because of the LFB's concern about the TMO's approach to fire risk assessments.55 Black {Day149/217:3-8}. The substance of those matters is discussed in Part 5, Chapter 37. At the outset the LFB was concerned that the TMO was producing its own fire risk assessments and that they were inadequate.56 {RBK00052528/3}. The LFB was so troubled that it indicated that it would serve an enforcement notice on both the TMO and RBKC.57 {RBK00052528/3}. As a result, the TMO entered into a contract with Salvus Consulting Ltd to carry out fire risk assessments in respect of all its high‑risk properties.58 Black {Day149/212:1-4}.
15¶31.36 The first fire risk assessments produced by Salvus in 2009 identified a number of risks that Janice Wray wanted to discuss with Robert Black. One concerned flat entrance doors.59 {TMO10037375}. Mr Black was aware from at least October 2009 that defects in flat entrance doors (in particular, a lack of effective self-closing devices, intumescent strips and cold smoke seals) resulting in ineffective compartmentation had been identified by the fire risk assessments as a problem that required attention across the TMO's estate.60 Black {Day150/3:18-25}. Mr Black was also aware of the Fire Safety Management report dated 22 September 2009 produced by Salvus for the TMO,61 Fire Risk Assessment for Fire Safety Policy and Procedures prepared by Salvus Consulting Ltd {SAL00000013}. which drew attention to 19 respects in which Salvus considered the TMO to be in breach of the Fire Safety Order.62 Black {Day150/4:15-19}.
¶31.37 In December 2009, Janice Wray prepared a report for a meeting of the TMO board on 10 December 2009.63 {TMO00873623}. It is likely that a copy was provided to Mr Black.64 Cover Letter to Board Member dated 4 September 2009 {TMO00881999}; Enclosure 16 {TMO00888764}; Board Action Sheet {TMO00882005/20}. In relation to the Salvus Fire Safety Management report it simply said that a management report had been received from the consultant which set out the fire safety framework within which the TMO and its contractors should be working.65 {TMO00873623/2} paragraph 4.5. It said nothing about the 19 breaches of the Fire Safety Order that had been identified and gave the board no information about the serious defects that Salvus had found in the TMO's management of fire safety across its estate. There is no evidence that Mr Black presented the report to the board and no recorded explanation or discussion of its contents. We can only conclude that he and the executive team failed to make even the most basic disclosure to the board of the widespread systemic failings in the TMO's management of fire safety that Salvus had found. Janice Wray was seriously at fault in not writing a candid report for the board; Mr Black was equally at fault in failing to inform the board about the deficiencies in fire safety management.
¶31.38 Following the board meeting, Mr Black, Laura Johnson and Jean Daintith produced a report for the meeting of RBKC's Housing, Environmental Health and Adult Social Care Scrutiny Committee on 15 March 2010, which included an item on the TMO's fire risk assessment programme.66 {RBK00030060}. Paragraph 3 of the report said that the increasingly stringent requirements of the LFB had led the TMO and RBKC to agree a new approach to fire risk assessments and carrying out any remedial work required as a result. The report did not mention that the LFB had been so concerned about the adequacy of the fire risk assessments carried out by the TMO itself that it had considered issuing an enforcement notice.67 Black {Day150/9:8-14}. Mr Black could not account for that omission,68 Black {Day150/9:21-22}. nor could he recall whether the scrutiny committee had been told of Salvus's recommendations or the TMO's response to them.69 Black {Day150/9:24}-{Day150/10:5}. Robert Black's failure to disclose those matters was part of an emerging pattern of withholding from those to whom he reported the fact that there were serious problems with the management of fire safety by the TMO.
16A fire at Grenfell Tower: 30 April 2010
¶31.39 On 30 April 2010, a fire broke out in the lift lobby on floor 6 of Grenfell Tower. On 5 May 2010 Janice Wray sent an email to Collette O'Hara of the LFB (with a copy to Robert Black) giving her report on it.70 {TMO10048221/4}. She said there had been a leakage of smoke from the extraction system into the lobbies of floors 7, 12, 13, 15, 17, 18, 19 and 20 that had led a number of residents to believe that their lobbies were smoke-logged and that they were trapped in their homes. They had therefore telephoned the LFB asking for help.
¶31.40 When Janice Wray reported the incident to the TMO board in her report of 17 June 2010,71 {TMO10037437/96-97} paragraphs 8.2 and 8.3. she did not say that smoke had leaked into the lobbies on eight floors (as described in the email to Collette O'Hara) nor did she mention the residents' belief that they had been trapped in their flats and had called the LFB. The report gave the impression that the smoke ventilation system had operated substantially as intended, but with some relatively minor leakage.72 {TMO10037437/97} paragraph 8.3. It grossly understated the extent to which smoke had spread within the tower and was seriously misleading. Mr Black accepted that it did not give the board proper information about the operation of the smoke ventilation system or, importantly, the residents' fear that they were trapped. Again, Mr Black could not explain why the board had been given a materially incomplete account.73 Black {Day150/31:11}-{Day150/32:4}. He had seen Janice Wray's original report to Collette O'Hara and should have corrected the false impression that Ms Wray's report gave.
¶31.41 In March 2014 the LFB issued a deficiency notice to the TMO because of its failure to maintain the smoke ventilation system at Grenfell Tower.74 {LFB00032101}. The system was finally replaced in 2016 as part of the refurbishment, but between 2010 and 2016 there was no fully functioning smoke ventilation system.75 Black {Day150/45:5-8}. We return to this episode later in Chapter 43 because it seems that, as Mr Black accepted, the absence of a functioning smoke ventilation system was the subject of repeated complaints by the Grenfell Tower Leaseholders' Association.
¶31.42 The next TMO board meeting took place on 22 May 2014. Robert Black prepared a report for that meeting which was circulated in advance.76 TMO Board document pack {RBK00051017}; Chief Executive's report {RBK00051017/27-28}. It made no mention of the deficiency notice. Although he accepted that it was essential information for the board to receive, Mr Black could not explain why it had not been placed before it.77 Black {Day150/101:2-24}. The omission can only have been deliberate. Yet again, Mr Black's failure to provide the board with important information relating to fire safety in the TMO's housing stock deprived it of the ability to take corrective action.
Adair Tower Deficiency Notice
¶31.43 On 12 October 2015, the LFB issued a deficiency notice in respect of Adair Tower.78 {TMO00842271}. Some of the contraventions of the Fire Safety Order identified by the LFB resulted from failures to carry out remedial works called for in fire risk assessments.79 Black {Day150/138:6-14}. Janice Wray received the notice on 22 October 2015,80 {LFB00001645}. but she did not bring it to Robert Black's attention until the morning of 31 October 2015, when a fire occurred at Adair Tower.81 Black {Day150/139:25}-{Day150/140:5}. Mr Black accepted that that had been a serious failing on her part,82 Black {Day150/140:6-8}. but it was consistent with a culture of concealment that had started at the top and filtered down to lower layers of management.
17¶31.44 In the evening of 31 October 2015, Robert Black sent an email to the members of the TMO board to tell them about the fire.83 {TMO00866480/2}. Although he emphasised the LFB's success in tackling it, he made no mention of the deficiency notice. The issue of such a notice was an obviously important piece of information, given that a fire had broken out only two weeks later in that very building. Yet again, Mr Black was unable to explain why he had not told the board about it.84 Black {Day150/143:3-7}. We can only conclude that his failure to do so was deliberate.
¶31.45 On 4 November 2015, Rebecca Burton of the LFB sent an email to Janice Wray containing a list of questions relating to the Adair Tower fire.85 {TMO00869184/3}. The email chain had originated with Janice Wray on 22 October 2015 because she had been told that the LFB was about to issue five more deficiency notices relating to other properties managed by the TMO.86 {LFB00003440}. Some of them were based on the absence of effective self-closing devices on doors in buildings that had been inspected.87 {TMO00869184/6}.
¶31.46 Janice Wray forwarded the correspondence between herself and Rebecca Burton to Robert Black and others the same day. Mr Black could not remember whether he had read it or had been made aware that the LFB was about to issue more deficiency notices, but he accepted that it was likely that he had.88 Black {Day150/147:10-17}.
¶31.47 On 5 November 2015, Mr Black attended a meeting of RBKC's Housing and Property Scrutiny Committee. The minutes of that meeting record that he provided a report on the fire at Adair Tower, in which he said that the fire doors had worked well.89 {RBK00048049/6}. He did not mention the deficiency notice that had been issued 19 days before the fire. Mr Black could not recall why the committee had not been told about the deficiency notice,90 Black {Day150/143:3-7}. but the omission cannot have been accidental.
¶31.48 The fact that a deficiency notice had been issued, not to mention its contents, was clearly a matter of some importance and should have been drawn to the attention of the scrutiny committee.91 Marshall {Day133/137:5-15}. Robert Black's failure to report those matters to the committee was a serious dereliction of duty on his part, but entirely consistent with the pattern of concealment he had established in relation to fire safety matters.
¶31.49 On 4 December 2015, Barbara Matthews sent an email to the members of the TMO board (including Mr Black) telling them that the LFB intended to serve enforcement notices in relation to Adair Tower and Hazelwood Tower.92 {TMO00902920}. Again, the email is instructive as much for what is not said as for what is. She did not mention the deficiency notice issued on 12 October 2015, nor did she mention the various enforcement measures available to the LFB, although in a draft message to the board composed only two days earlier Robert Black had identified them.93 {TMO00902919}. Neither Barbara Matthews94 Matthews {Day148/81:16}-{Day148/82:5}. nor Robert Black95 Black {Day150/164:18}-{Day150/165:22}. could explain why the fact that a deficiency notice issued on 12 October 2015 had again not been mentioned. Again, the omission can only have been deliberate.
18¶31.50 An enforcement notice dated 23 December 2015 was served by the LFB on the TMO in relation to breaches of the Fire Safety Order identified following the fire at Adair Tower.96 {TMO00840703}. The enforcement notice required the TMO to take steps to remedy the failures specified in the schedule to the notice by 23 June 2016.97 {TMO00840703/1-2}.
¶31.51 On 6 July 2016, Janice Wray spoke to Ben Dewis of the LFB. During that call he told her about the current status of the LFB's investigation into the Adair Tower fire and the possibility of enforcement action. Janice Wray sent a note of the call by email to Laura Johnson, Robert Black and Barbara Matthews.98 {RBK00001865}. In it she said that she was concerned to hear that investigations were continuing.99 {RBK00001863}. Mr Black accepted that he must have seen and read the note100 Black {Day150/206:5-7}. which made it clear that the LFB were considering taking legal action against the TMO in respect of breaches of the Fire Safety Order, including possible criminal proceedings, although, as the note recorded, Mr Dewis felt that was unlikely.
¶31.52 Robert Black reported to the TMO board on 20 July 2016. His report, which was circulated to the members before the meeting,101 {TMO10014037/68}. did not mention the possibility that criminal proceedings might be taken against the TMO. Once more, he was unable to explain why he had not told the board about a potential prosecution for failing to comply with the Fire Safety Order, which was obviously a serious matter.102 Black {Day150/209:19}-{Day150/210:18}. It was his responsibility, as he accepted, to keep the board informed about anything that might affect its legal position,103 Black {Day150/142:24}-{Day150/143:2}. but although he denied that he had deliberately withheld the information from the board, we are unable to accept that it was the result of a mere oversight.104 Black {Day150/201:2-18}.
¶31.53 On 17 November 2016, the LFB issued a deficiency notice to the TMO in respect of Grenfell Tower.105 {TMO10017254}. It was based on the absence of self-closing devices on some doors in the building, which was a potential breach of the Fire Safety Order. The notice required remedial action to be taken by 18 May 2017.
¶31.54 The events we have described lead us to conclude that although there was a satisfactory system in place within the TMO for reporting through senior management to the board and the scrutiny committee, it failed to operate effectively because of an entrenched reluctance on the part of Robert Black to inform the board and RBKC's scrutiny committees of matters that affected fire safety. It was his decision whether to report to the board what he knew about problems with fire safety at the TMO and he consistently chose not to do so. Robert Black consistently failed to tell either the board or RBKC of the LFB's concerns about the TMO's compliance with the Fire Safety Order or the various steps taken by the LFB to enforce it. His persistent failure to provide them with important information denied both the board and RBKC of the ability to exercise effective oversight of the TMO's performance of its obligations under the Fire Safety Order.
19 21Chapter 32: RBKC's oversight of the TMO
Introduction
¶32.1 This chapter considers the arrangements under which RBKC exercised oversight of the TMO in relation to health and safety matters generally and fire safety in particular.
RBKC's constitutional arrangements
¶32.2 RBKC carried on its operations partly through executive members of the council, partly through committees, including the scrutiny committees, and partly through the full council made up of 50 elected councillors.
The executive
¶32.3 The executive was composed of individual councillors each responsible for a particular area of the council's functions. It was referred to as "the cabinet" when it met collectively and individual councillors were known as "cabinet members".106 Part two, article 7 of the RBKC constitution {RBK00035010/1} paragraph 7.01(a). The cabinet could comprise up to ten councillors, including the leader, who appointed the members and decided which portfolio each would hold.107 Paget-Brown {Day132/134:22}-{Day132/135:2}. The executive carried out all those functions that were not reserved to the full council or otherwise delegated to committees, sub‑committees or officers.108 Part two, article 7 of the RBKC constitution {RBK00035010/1} paragraph 7.01(a).
¶32.4 In 2013, Councillor Paget-Brown, the leader of the council, appointed Councillor Feilding‑Mellen as the cabinet member for housing, property and regeneration. He served in that role until after the Grenfell Tower fire.109 Paget-Brown {Day132/135:3-10}; Feilding-Mellen {Day131/82:23-24}.
¶32.5 The leader of the council was responsible for all portfolios and could make any decision that may have been delegated to an individual cabinet member or to the cabinet.110 Part three, article 1 of the RBKC constitution {RBK00035007/4} paragraph 1.7. Councillor Paget-Brown said that, as leader, his responsibilities included decisions relating to housing, but not to projects such as the refurbishment of Grenfell Tower.111 Paget-Brown {Day132/144:3-20}. However, he accepted that he had been responsible for ensuring that Councillor Feilding-Mellen was properly discharging his responsibilities as the cabinet member for housing, property and regeneration,112 Paget-Brown {Day132/145:3-16}. which included the oversight of fire safety within the TMO's buildings,113 Paget-Brown {Day132/148:3-16}. communicating with the LFB,114 Paget-Brown {Day132/145:3-16}. social housing projects and the proper management of the TMO115 Paget-Brown {Day132/149:1-5}. and the welfare of those who lived in RBKC's properties.116 Paget-Brown {Day132/149:6-9}.
22¶32.6 The responsibilities of the cabinet member for housing, property and regeneration were set out in paragraph 1.8 of part 3A of RBKC's constitution. In relation to housing matters, they included responsibility for leadership, strategic planning and decision-making in respect of all social housing regeneration projects, policies on maintenance of the social housing stock and the TMO management agreement.117 Part three, article 1 of the RBKC constitution {RBK00035007/5} paragraph 1.8.
The scrutiny committee
¶32.7 RBKC had a number of scrutiny committees, but for our purposes only the Housing and Property Scrutiny Committee (the scrutiny committee) is relevant. It had 11 members, whose function was to scrutinise the provision, planning, management and performance of all housing services, social housing regeneration, the TMO, housing strategy and the financing and development of the council's housing stock,118 Part two, article 6 of the RBKC constitution {RBK00035012/3-4} paragraph 6.03(a) and (b). based on the information provided to it.119 Feilding-Mellen {Day131/91:21-24}.
¶32.8 Between 13 October 2010 and 11 May 2016, Councillor Quentin Marshall was chairman of the scrutiny committee.120 Marshall {RBK00033744/2} page 2, paragraph 9; Marshall {RBK00033744/28} page 28, paragraph 118. He was succeeded by Councillor Sam Mackover, who chaired his first scrutiny committee meeting on 13 July 2016.121 Mackover {RBK00029923/5} page 5, paragraph 20.
Scrutiny of fire safety matters
¶32.9 Fire safety fell within the scope of responsibility of both the scrutiny committee and the Cabinet and Corporate Services Scrutiny Committee. The scrutiny committee had a responsibility for it because residents of the council's housing stock were affected by arrangements relating to fire safety.122 Mackover {Day134/3:13-17}. The Cabinet and Corporate Services Scrutiny Committee also had a responsibility for it because fire safety was an aspect of community safety and emergency planning.123 Mackover {RBK00029923/9} page 9, paragraph 40. The scrutiny committee received reports from RBKC's Housing department on fire safety across the council's estate, including the buildings managed by the TMO.124 Feilding-Mellen {Day131/97:8-15}; {Day131/95:10-13}; Mackover {Day133/95:11-16}; Marshall {Day133/95:11-16}.
RBKC's fire safety policy
¶32.10 RBKC's fire safety policy dated January 2014125 {RBK00001655}. was produced in conjunction with the London Borough of Hammersmith and Fulham. It set out the strategy and organisational arrangements for the management of fire safety within RBKC126 {RBK00001655/2} final paragraph. and described how RBKC could manage fire safety effectively.127 {RBK00001655/3}.
¶32.11 The fire safety policy applied to any premises in respect of which other parties were the responsible persons by virtue of a contract or tenancy agreement, but in respect of which RBKC retained responsibilities as landlord.128 {RBK00001655/4} paragraph 2.2. Accordingly, the policy applied to the premises managed by the TMO.129 Paget-Brown {Day133/7:4-9}. It required RBKC's health and safety team to have appropriate processes in place to ensure that suitable and sufficient fire safety management systems had been established and that suitable protocols had been devised to ensure that compliance with fire safety requirements was assured.130 {RBK00001655/5} fifth paragraph.
23RBKC's arrangements for monitoring the TMO
¶32.12 Celia Caliskan was the general needs housing commissioning manager in RBKC's Housing Commissioning Team.131 RBKC organograms contained within {RBK00000278}. From 2005, she was directly responsible for managing the agreement between RBKC and the TMO.132 Amanda Johnson {Day130/136:16-18}; {Day130/144:4-6}; Caliskan {RBK00035166/3} page 3, paragraph 11. Between 2011 and 2017 she reported to Amanda Johnson.133 Amanda Johnson {Day130/137:2}-{Day130/140:7}; RBKC organograms contained within {RBK00000278}.
¶32.13 Until 2016 Celia Caliskan was one of two officers in RBKC's housing commissioning team who reported to Ms Johnson on matters relating to general needs commissioning, which had been delegated to the TMO.134 Amanda Johnson {Day130/143:25}-{Day130/144:3}. In 2016, she became the only officer dedicated to that task, because the second officer was made redundant and was not replaced in order to save costs.135 Amanda Johnson {Day130/144:12-19}. Much of the work involved in overseeing the agreement was thereafter left to Celia Caliskan.136 Amanda Johnson {Day130/149:2-4}.
¶32.14 Amanda Johnson became the permanent head of the housing commissioning team at around the end of 2010 and was then involved in overseeing the TMO.137 Amanda Johnson {Day130/133:10-12}. As Celia Caliskan's line manager, she was responsible for monitoring the performance of the TMO.138 Amanda Johnson {Day130/139:16-19}.
Annual performance reviews and performance agreements
¶32.15 Every July reports on the performance of the TMO were prepared for the scrutiny committee.139 For example {RBK00032466}. They incorporated as appendix 1140 {RBK00032466/4}. a review of the TMO's performance and (as appendix 2) the performance agreement for the coming year.141 {RBK00032466/18}. The annual performance agreement was drawn up in consultation with the TMO. It contained key performance indicators and "actions" for the TMO to take during the coming year. It also set out the annual cycle of auditing of the TMO to be carried out by RBKC.142 Amanda Johnson {RBK00033719/7} page 7, paragraph 38.
¶32.16 The stated purpose of the annual performance agreement was to set out how the performance of the TMO would be monitored by the council over the coming year in accordance with its priorities and national and local requirements.143 {RBK00032466/18}. The stated purpose of the annual review was to allow the council to assess the TMO's performance over the past year and to comment on various aspects of its activity in the borough that contributed to the council's strategic priorities.144 {RBK00032466/4}.
24Absence of fire safety as a key performance indicator
¶32.17 Although the key performance indicators evolved over the years,145 Caliskan {RBK00035166/5} page 5, paragraph 24. none related to fire safety or fire safety management, fire risk assessments, or performance by the TMO of its duties under the Fire Safety Order. Although both RBKC and the TMO were aware of the delay in completing work identified in fire risk assessments, none of the annual performance agreements contained a performance indicator based on their full and prompt completion. Although Laura Johnson conceded that fact, she said that the contents of mid-year and annual reports to the scrutiny committee did provide current information about fire risk assessments.146 Laura Johnson {Day128/220:3-11}. She also made the point that the focus of key performance indicators was on the "big six" matters147 Fire safety, legionella, asbestos, gas, electricity and lifts. and that the details of compliance were monitored by the TMO's health and safety committee.148 Laura Johnson {Day128/220:16-25}.
RBKC's oversight
¶32.18 RBKC's function was to exercise strategic oversight of the TMO's activities, not to monitor its operations on a day-to-day basis.149 Laura Johnson {Day129/38:3-16}. It had monitored fire safety in the same way as it had monitored other areas of activity requiring compliance with its legislative and regulatory obligations, and the TMO reported on its performance in respect of fire safety in the six-monthly and annual reviews.150 Laura Johnson {Day129/39:15-21}. Laura Johnson also discussed matters relating to fire safety at her monthly meetings with Robert Black.151 Laura Johnson {Day129/59:11}-{Day129/60:19}.
¶32.19 Janice Wray's understanding was that the management of health and safety at the TMO was monitored primarily by RBKC's Corporate Health and Safety Advisor and its main Health and Safety Co-ordinating Committee.152 Wray {TMO00000890/37} page 37, paragraph 164. Laura Johnson's understanding was that RBKC's Housing department had not monitored health and safety at the TMO. She admitted that she had not been aware that the annual health and safety report had been presented to the RBKC corporate health and safety manager. She conceded that, in hindsight, that had been a weakness in RBKC's governance arrangements.153 Laura Johnson {Day129/67:1}-{Day129/68:14}.
¶32.20 The annual performance agreement required reports on discrete areas, one of which was always health and safety. The health and safety reports were drafted by Janice Wray. The broad purpose of their inclusion was to draw attention to any relevant developments.154 For example {RBK00032466/23-24}.
¶32.21 Celia Caliskan said that she received information from Janice Wray, which she used for drafting the performance review.155 Caliskan {RBK00054409/5} page 5, paragraph 13. The division of labour between Celia Caliskan and Janice Wray is usefully demonstrated by a draft version of the 2016-17 annual performance review, in which the person responsible for drafting each section appears to be marked in red.156 {RBK00002395/15}. The health and safety section of the report is marked "TMO" and ''Janice''157 {RBK00002395/15}. Janice Wray confirmed that she had drafted the health and safety sections of the performance reviews.158 Wray {Day140/84:10-14}. Amanda Johnson said that Celia Caliskan relied heavily on Janice Wray for the information contained in the report.159 Amanda Johnson {Day130/209:21}. Although Amanda Johnson said that she would scrutinise the contents of Janice Wray's reports, she accepted that they contained no independently verified information about the TMO's performance.160 Amanda Johnson {Day130/210:3}-{Day130/211:4}.
25¶32.22 Laura Johnson also confirmed that the health and safety sections of the annual performance review had been drafted by Janice Wray and Celia Caliskan.161 Laura Johnson {Day129/145:24-25}. Some of them, such as the health and safety section of the annual performance review for 2013/14, contained judgments and assessments that reflected well on how fire safety was being managed by the TMO.162 {RBK00032466/15-16} paragraph 3.9. In practice, Janice Wray was effectively writing her own reference.
RBKC's audits of the TMO
¶32.23 The purpose of RBKC's audits on behalf of the TMO was to provide senior management and members of the TMO with assurance about the adequacy and effectiveness of the internal controls in the area being audited. The audits considered each service area and gave an assurance assessment rating ranging from "substantial" to "limited". Where the rating was "limited", a further exercise was usually undertaken within six to nine months to assess the effect of remedial measures.163 Patel {RBK00029884/2} page 2, paragraph 5.
¶32.24 RBKC produced an audit plan for the TMO every three to five years in order to ensure that the areas of interest were audited at least once every five years.164 Patel {RBK00029884/3} page 3, paragraph 9. The plan was approved by the TMO's Finance, Audit and Risk Committee at the beginning of each year.165 Patel {RBK00029884/2} page 2, paragraph 7. RBKC allocated a maximum of 100 audit days to the TMO a year.166 Patel {RBK00029884/3} page 3, paragraph 10.
¶32.25 A list of audits was provided for in the annual performance agreement between the TMO and RBKC.167 {RBK00030149/22}. They were carried out by RBKC's internal audit department as part of its corporate function rather than the housing department.168 Amanda Johnson {RBK00033719/9} page 9, paragraph 50. At the conclusion of an audit, the auditors would provide the TMO officers in charge of the relevant departments with a draft of their report which would be reviewed by TMO before it was formally issued. The TMO was given two weeks to provide its responses to the report's recommendations together with an indication of the time within which any necessary steps would be implemented.169 Patel {RBK00029884/3} page 3, paragraph 10.
¶32.26 The annual performance agreement forming part of the report to the scrutiny committee in July 2012 identified that an audit in relation to fire risk assessments by the TMO was due to take place in 2012.170 {RBK00030149/22}. There is no evidence that it did in fact take place.171 Amanda Johnson {Day131/32:17-25}.
¶32.27 RBKC carried out three separate audits of health and safety management at the TMO between 2013 and 2016. The first was undertaken in 2013.172 {RBK00000313}. Its purpose was to examine how health and safety policies and procedures were being implemented. The TMO received a "limited" assurance rating in respect of that audit.173 Amanda Johnson {Day131/33:3-16}. A follow-up audit was carried out in December 2013 when the TMO was given a "satisfactory" rating.174 {RBK00000320}. The final audit took place in March 2016.175 {RBK00000531}. It was a high-level audit with a budget of 10 audit days. The TMO received a "substantial" assurance rating.
26¶32.28 Two other significant reviews of the TMO specifically in respect of the management of fire safety were carried out by external parties at the request of the TMO. The first was carried out by Salvus Consulting Ltd in September 2009, which specifically considered fire safety policy and procedures.176 {SAL00000013}. The second was a safety management review carried out by Matt Hodgson in July 2013.177 {TMO10040497}. We address these in detail in Chapter 37.
27Chapter 33: The TMO's relationship with its residents
Complaints
¶33.1 In the first part of this chapter, we consider the various mechanisms by which the residents of Grenfell Tower were able to express their views about the quality of the services provided by the TMO. Those mechanisms were not confined to personal representations; they included membership of the various groups that the TMO recognised as representing residents and membership of unofficial organisations set up by residents who were concerned that their views were not being heard, or at least not being heeded, by their landlord.
The Memoli and the Butler reports
¶33.2 In July 2008, RBKC asked Maria Memoli, a retired solicitor, to investigate longstanding complaints made against the TMO by residents of its properties and to establish whether there were any common themes that could inform a plan for improvement.178 {TMO00888711/2} paragraph 1.1. Her initial report, dated 10 April 2009 (the Memoli report), made serious criticisms of the TMO's relationship with its tenants, leaseholders and some freeholders, particularly as it affected repairs, major works, management charges, service charges, customer care, probity and ethics, communications, performance and monitoring, and trust and confidence. Complaints had not been resolved, it was felt, for some years.179 {IWS00001462}. The report concluded that the TMO's board should understand better its constitutional and legal role and take collective responsibility to lead the work required by the TMO's improvement plan.180 {IWS00001462/3}. It made 34 recommendations.
¶33.3 Robert Black, who had become the TMO's chief executive officer in May 2009, said that, although he had been made aware of the Memoli report, he could not remember having been given a copy of it.181 Black {Day151/55:2}-{Day151/56:5}. He recalled a report that had made serious criticisms of the TMO's governance and its relationship with its tenants,182 Black {Day151/61:16-22}. but his impression had been that RBKC had not been particularly impressed by it.183 Black {Day151/58:16-24}.
¶33.4 A final report, dated 22 September 2009, was produced by John Butler (the Butler report), also commissioned by RBKC, which made a number of recommendations echoing Maria Memoli's proposals, such as requiring that every complaint be investigated as appropriate.184 {TMO00888711/2} paragraph 1.4. Most importantly for our purposes, the Butler report made a number of observations that are relevant to the difficulties affecting the TMO's relationship with its residents throughout the time with which we are concerned. Although the Butler report noted that governance, customer service, staff attitudes and a poor repairs service were constant themes of the investigation, it is noteworthy that it considered that the residents' lack of trust in the TMO lay at the heart of the troubled relationship.185 {TMO00888711/5-6} paragraphs 4.2 and 4.4.
28¶33.5 RBKC and the TMO responded to the 34 recommendations of the Memoli report and their responses were included in appendix 2 to the Butler report.186 {TMO00894426}. In the light of how the relationship between the TMO and the Grenfell community evolved in the years between 2010 and 2017, the following recommendations and responses are particularly relevant: a. In response to the recommendation that there be a process of mediation or
conciliation to rebuild relationships with residents of the TMO, RBKC replied that the approach to resident consultation was under review and that it would consider the results.187 {TMO00894426/2}.
¶b. In response to the recommendation that TMO staff should take a more active approach and that the TMO's contractors should share information with residents about prospective work schedules, planned maintenance and emergency works on estates, the response was that the TMO had recently published a five-year capital works programme to residents,188 {TMO00894426/3}. one purpose of which was to give leaseholders a chance to plan for their share of the cost.189 Black {Day151/67:14}-{Day151/68:10}.
¶c. In response to the recommendation that the TMO should be conscious of the diversity of its residents, the response was that it had devised an equality and diversity action plan which was intended to inform all aspects of service improvement plans.190 {TMO00894426/3}. Although Robert Black told us that he thought that the plan actively identified those with mental or physical disabilities or disadvantages, he did not appear to know whether in fact it did so.191 Black {Day151/70:16-24}.
¶d. In response to the recommendation that RBKC and the TMO should re-examine their relationship with each other to ensure openness, transparency and trust and to address an historic "them and us" culture,192 {TMO00894426/4}. it was said that the problem had been resolved by changes at executive level within RBKC and the TMO. Robert Black explained that it had involved increasing engagement between various people in RBKC and the TMO, as well as other organisational changes within the TMO.193 Black {Day151/71:3}-{Day151/73:15}.
¶e. In response to the recommendation that RBKC should be more robust in making sure that the TMO's technical services were capable of delivering an effective major works programme and cyclical repairs,194 {IWS00001462/4}. RBKC and the TMO said that the TMO had arrangements in place for managing contracts effectively. Laura Johnson told us that Robert Black acted on that recommendation before the Grenfell Tower refurbishment project began.195 Johnson {Day128/190:1-17}.
29¶33.6 Those recommendations are striking, both in their prescience and as a measure of the TMO's failure thereafter. They could just as well have been contained in this report, given what we have found. It says much about the TMO's character as an organisation that, despite those penetrating reports, eight years later it showed little sign of any change and appeared to have learnt nothing about how to treat, or relate to, its residents.
Complaints procedures and management systems from 2009
¶33.7 The TMO had a complaints policy that set out the procedure to be followed when a resident made a formal complaint.196 An earlier version dated May 2010 {TMO00831399} and a revised version dated July 2015 {TMO00879692}. It was intended to be reviewed every three years and was communicated to residents through leaflets, posters in the housing offices and on the TMO's website.197 Birch {TMO00879690/2} page 2, paragraphs 8- 9. In the event, however, the policy published in 2010 was reviewed only in 2015, when it was revised by broadening the definition of a complaint and by the introduction of a procedural hierarchy for different forms of communication from residents.198 {TMO10026197/2}.
¶33.8 Yvonne Birch was responsible for managing the complaints procedure from 2012. She received reports from Janet Seward, the TMO's policy and improvement manager, who oversaw the administration of the complaints team's work.199 Birch {TMO00879690/1} page 1, paragraph 5.
Residents' Associations
¶33.9 Between 2010 and 2017, there were, at various times, four groups and associations representing the residents of Grenfell Tower. They were the Lancaster West Residents' Association, the Grenfell Action Group, the Grenfell Tower Leaseholders' Association and the Grenfell Tower Compact.
Lancaster West Residents' Association
¶33.10 The Lancaster West Residents' Association was founded in 1977.200 Burke {IWS00001544/2} page 2, paragraph 9. Before 2015, it was a vehicle for raising residents' concerns with the TMO and providing support to members of the community more generally.201 Richer {IWS00002345/2-3} pages 2-3, paragraph 9.
¶33.11 In September 2015, the TMO called a meeting of the Association which led to the formation of a new committee and a new constitution.202 {MET00049167}. The aim was to strengthen the Association, increase active participation in its work and provide a more cohesive community by putting on social events and activities.203 Blanchflower {IWS00002072/4} page 4, paragraph 12.
¶33.12 Over the next few years, although the Association appears to have had some communication with residents' groups associated with Grenfell Tower, it had little involvement in the disputes that later arose between them and the TMO.
30Grenfell Tower Leaseholders' Association
¶33.13 The Grenfell Tower Leaseholders' Association was founded by Shahid Ahmed in 2010204 Ahmed {IWS00001335/4} page 4, paragraph 13. to give Grenfell Tower's leaseholders one voice.205 Ahmed {IWS00001335/4} page 4, paragraph 13. By 2010, the leaseholders believed that the heating system was poor and that the building in general was poorly maintained. Mr Ahmed used the Leaseholders' Association to try to improve the management of the building.206 Ahmed {IWS00001335/4} page 4, paragraph 13.
¶33.14 The constitution of the Leaseholders' Association provided that its aims were to look after the leaseholders' interests and to work with RBKC and others to do so.207 {IWS00001386}. The Association had 12 members. Mr Ahmed was the chairman and Tunde Awoderu the vice-chairman. Keith Mott was secretary and treasurer.208 Ahmed {IWS00001335/4-5} pages 4-5, paragraph 13.
¶33.15 Mr Ahmed said that he had done almost all the work for the Association after Mr Mott moved away in 2013. Mr Ahmed was worried that raising concerns would lead to reprisals from the TMO, and even the forfeiture of his lease. For that reason, although letters and emails were drafted by Mr Ahmed, they were signed in Tunde Awoderu's name with his permission.209 Ahmed {IWS00001335/5} page 5, paragraph 14. Although Mr Awoderu was a leaseholder, he did not live in the tower. He rented his flat to tenants and so, presumably, was thought to be less exposed to any risk of reprisal.
¶33.16 The Leaseholders' Association held meetings from time to time to which all members were invited. At around the time proposals for the refurbishment were being made there were more frequent meetings which all members attended.
¶33.17 When problems arose, Mr Ahmed sent emails directly to individuals at RBKC or the TMO; he did not make use of the complaints procedure, in which he said he had no faith.210 Ahmed {IWS00001335/6-7} pages 6-7, paragraph 16. He frequently sent emails first to the local ward councillors and often to Councillor Judith Blakeman. He would also copy his correspondence to many, if not all, of the other councillors and officers of RBKC and the TMO.
¶33.18 Although the concerns of the Leaseholders' Association were initially directed to the reasonableness of the service charge and the quality of services, over time they developed to encompass a broad range of matters affecting the tower, one of which was fire safety. On 30 April 2010, there was a fire on floor 6 of the tower, as a result of which smoke leaked from the smoke ventilation system into the lobbies on a number of floors, in some cases a long way from the seat of the fire.211 {TMO00847309/1}. After that, some residents complained about the efficiency of the smoke ventilation system212 Blakeman {RBK00054461/15} page 15, paragraph 76. and Mr Ahmed raised concerns about the TMO's attitude to fire safety generally.213 Burton {IWS00001661/2} page 2, paragraph 8. He said he had never received a proper response from the TMO despite repeating his concerns for several years after the fire.214 Ahmed {IWS00002369/3} page 3, paragraph 8. Mr Ahmed said that he had felt that the TMO had misrepresented the seriousness of the fire by, among other things, understating the number of people who had been injured, among whom had been his wife.215 Ahmed {IWS00002369/4} page 4, paragraph 10 c.
31Grenfell Action Group
¶33.19 Grenfell Action Group was set up in 2010 by Edward Daffarn and Francis O'Connor, both of whom lived in the tower.216 Daffarn {IWS00000169/7} page 7, paragraph 18. Mr Daffarn said that he founded the group by putting up a poster in the tower in June 2010.217 Daffarn {Day118/12:13-20}. He later met Francis O'Connor and Teresa Miles, whose husband, Keith Miles, was the chair of the Lancaster West Residents' Association. Mr Daffarn told us that the Grenfell Action Group had four members: Francis O'Connor, Teresa Miles, Peter Martindale and himself.218 Daffarn {Day118/12:1-6}. Rob Regan had also possibly been a member.219 Daffarn {Day118/12:3-6}.
¶33.20 According to Mr Daffarn, the Group was formed because of dissatisfaction with the Lancaster West Residents' Association and the moribund Estate Management Board.220 Daffarn {IWS00002109/49} page 49, paragraph 124. (The Estate Management Board had been created in or about 1993221 Caliskan {RBK00035166/4} page 4, paragraph 19. and was the precursor of the TMO, to which it later delegated most of its functions.222 Johnson {RBK00033719/23-24} pages 23-24, paragraph 115. In 2010, RBKC became concerned about its effectiveness and its ability properly to oversee the TMO. Eventually, in 2014 or thereabouts, the Estate Management Board ceased to function.)223 Johnson {RBK00033719/24} page 24, paragraphs 116-119. Mr Daffarn said that the Group intended to speak on behalf of all Lancaster West residents whose lives were to be affected by the KALC project.224 Daffarn {IWS00002109/49} page 49, paragraph 126. Indeed, the first poster that Mr Daffarn put up in 2010 concerned information that residents had received from Councillor Blakeman about the KALC project.225 Daffarn {Day118/12:13-25}.
¶33.21 From 2012 onwards, both Mr O'Connor and Mr Daffarn tried to obtain recognition by both RBKC and the TMO of a residents' association called "Grenfell Action Group". In September 2012, Mr Daffarn applied successfully to RBKC for the Group to be added to its list of recognised tenants' and residents' associations.226 {IWS00002154}. Attempts were also made to register the Group as a residents' association with the TMO, but the TMO refused to give it official recognition. In August 2012, Edward Daffarn told Janet Edwards of the TMO that the Group was in the process of being registered with RBKC as a residents' association and he asked her for the form to apply for similar recognition by the TMO.227 {TMO00845472}. For some reason it was not forthcoming.
¶33.22 On 20 August 2012, there was a meeting between Mr Daffarn, Janet Edwards and Teresa Miles,228 {TMO00845472}. at which the TMO refused to recognise the Group. Following the meeting, Mr Daffarn asked the TMO to give written reasons for its decision. In reply Ms Edwards told him that a residents' association already existed on the Lancaster West Estate and that the TMO could not recognise another one. She then suggested that Grenfell Action Group consider becoming a sub-group of the Lancaster West Residents' Association. Ms Edwards told him that she had sought advice from the Tenancy Participation Advisory Service, which discouraged landlords from supporting and recognising two residents' associations in relation to the same estate because of the risk of conflict.229 {TMO00846422}.
32¶33.23 On 3 September 2012, Jon Warnock of the Tenancy Participation Advisory Service sent an email to Janet Edwards suggesting that she should seek to find a way to support the Grenfell Action Group and establish a harmonious relationship between it and the Lancaster West Residents' Association. It was suggested that the TMO consider a tripartite agreement between the two of them and the TMO which set out their respective roles and responsibilities. However, on 8 October 2012 Yvonne Birch confirmed that, having considered that advice, the TMO still would not recognise the Grenfell Action Group.230 {TMO00845579}. Her principal reason for doing so was that the suggested agreement would require a dispute resolution process which she considered to be unworkable. In an email of 23 October 2012, Yvonne Birch repeated the objection that the Group could not be recognised because there was already a recognised residents' association for the estate as well as an elected estate management board which the TMO had a duty to involve in the estate's management.231 {TMO00845856}.
¶33.24 In late June 2012, Mr Daffarn and Francis O'Connor began publishing the Grenfell Action Group blog. Mr Daffarn said that it was intended to publicise issues that had not been picked up by the media and to document what was happening to the community.232 Daffarn {IWS00000169/7} page 7, paragraph 18. He told us that at the start he felt that the blog was a means of communicating directly with the TMO, rather than writing to it or using the established processes, and that it gave the community on the Lancaster West estate a voice to express its views about the effect on it of the KALC project.233 Daffarn {Day118/150:8}-{Day118/151:2}. He considered it a necessary response to the TMO's overbearing treatment of the tower's residents.234 Daffarn {Day118/26:1-4}.
¶33.25 Another purpose of the blog was to raise concerns about fire safety.235 Daffarn {IWS00000169/8} page 8, paragraph 20. The posts that were concerned with fire safety are discussed more fully in Chapter 42, but one particular incident discussed in the blog usefully illustrates the nature of the concerns expressed by residents about fire safety and their belief that the TMO paid insufficient regard to the risk of fire in its buildings.
¶33.26 In 2013, power surges occurred at the tower which caused damage to electrical equipment in some residents' flats. The Grenfell Action Group and the Leaseholders' Association were concerned about the incident and communicated their concerns to the TMO by emails and in a petition.236 Ahmed {IWS00002369/15} page 15, paragraphs 52 and 54. They were also the subject of a blog post in September 2013,237 {IWS00002180}. the thrust of which was that the TMO had played down the seriousness of the surges. Edward Daffarn told us that the residents had asked RBKC's Housing and Property Scrutiny Committee to consider the problems surrounding the power surges, but he felt that the matter had been covered over,238 Edward Daffarn's formal complaint {TMO00838788}. with the result that the residents lost trust in the TMO's ability to take appropriate action in respect of fire safety.239 Daffarn {Day118/118:23}-{Day118/120:3}. Councillor Blakeman told a meeting of the Scrutiny Committee in July 2013 that the TMO would find it difficult to regain residents' trust, since many believed that the TMO had failed to take the power surges seriously.240 {TMOH00004598/3}.
33The Grenfell Compact
¶33.27 The Grenfell Compact was a residents' group set up during the refurbishment of Grenfell Tower specifically to represent residents' interests. The efforts taken by the residents to obtain recognition are worthy of being recorded as an illustration of the difficulties they faced.
¶33.28 Mr Daffarn explained that the Grenfell Action Group's early efforts to form an association for the broader community changed over time to an organisation designed specifically for the residents of Grenfell Tower. When the refurbishment works were under way there were around 100 people in the tower who had expressed support for such an initiative. There was a perception that the Lancaster West Residents' Association was ineffective241 Daffarn {IWS00002109/50-51} pages 50-51, paragraph 131. and Mr Daffarn hoped that an association specifically for residents of the tower would counteract the TMO's perception that the Grenfell Action Group was a small, disgruntled minority.242 Daffarn {IWS00002109/51} page 51, paragraph 134.
¶33.29 On 22 January 2014, Mr Daffarn sent an email to Claire Williams which he copied to the Leaseholders' Association and other residents. He asked for recognition, funds and support so that a Grenfell Tower residents' group could be set up to help tenants during the refurbishment. He explained that such a group would allow leaseholders and tenants to make their views known and ensure that the TMO carried out the refurbishment in co-operation with the residents rather than simply imposing it on them. Mr Daffarn said he had spoken to both the Lancaster West Residents' Association and the Leaseholders' Association, both of which supported the request.243 {TMO00845842}. The TMO's position, however, was unchanged. It declined to recognise the proposed group because a residents' association covering the area already existed.244 {TMO00832280}.
¶33.30 On 10 September 2014, Mr Daffarn sent an email to Fola Kafidiya, the TMO's Head of Governance, to complain that residents of Grenfell Tower were being denied the opportunity to form a representative group to speak on their behalf about matters affecting the refurbishment of the tower. He said that the Lancaster West Residents' Association was moribund and that residents were therefore effectively unrepresented.245 {TMOH00004881/3}.
¶33.31 On 17 September 2014, Janet Edwards made it clear that the TMO did not object to the tenants and leaseholders of Grenfell Tower forming a group for the purposes of consultation on matters relating to the building work. She also confirmed that the group would be consulted by the TMO on matters relating to the refurbishment.246 {TMOH00004881/1}. That ought to have provided an opportunity for matters to be put on a better footing.
¶33.32 On 17 March 2015, Mr Daffarn and others organised a meeting of Grenfell Tower residents which was attended by over 100 people from more than 55 households.247 Collins {IWS00002334/6} page 6, paragraph 27. On 26 March 2015, residents from about 20 households held another meeting and agreed to form a group which they called Grenfell Community Unite.248 GAG Blog, "A collective voice for residents as 'Grenfell Community Unite' is formed!" {IWS00002239}. They agreed to ask the TMO and Rydon to meet them to discuss their concerns.
34¶33.33 The meetings on 17 March and 26 March 2015 were both reported on the Grenfell Action Group blog in forthright terms.249 GAG Blog "Minutes from the Grenfell Tower Emergency Residents Meeting (17/03/15)" {IWS00002209}; GAG Blog "A collective voice for residents as 'Grenfell Community Unite' is formed!" {IWS00002239}. On 1 April 2015, Peter Maddison sent an email to Fola Kafidiya at RBKC, saying that Mr Daffarn was continuing to agitate, attaching the blog posts and asking Ms Kafidiya to advise at what point his comments would become libellous. Mr Maddison noted that there had been no direct contact from the group and said that the TMO would continue its approach of concentrating on consulting residents individually.250 Email from Peter Maddison to Fola Kafidiya dated 1 April 2015 {TMO00845965}.
¶33.34 On 6 April 2015, David Collins asked Claire Williams to arrange a meeting between the group and the TMO, Rydon, Studio E and Max Fordham.251 {TMO10043300}. He also asked for confirmation that the TMO would acknowledge Grenfell Community Unite as a residents' group.
¶33.35 Before responding, Claire Williams consulted other TMO officers.252 Email from Claire Williams regarding ''DRAFT Grenfell Community - meeting with TMO/Rydon'' dated 8 April 2015 {TMO10043313} and Draft response to David Collins {TMO10043314}. In her response, she deflected the request and suggested that discussion with individual households was more appropriate and that a survey had indicated that residents preferred to receive information by letters, newsletters and notices rather than at public meetings.253 Response to David Collins {TMO00846124}. Siobhan Rumble suggested that the TMO should agree to meet Mr Daffarn and Mr Collins, but make it clear that it would not tolerate abusive language or threatening behaviour.254 Email from Siobhan Rumble to Claire Williams dated 8 April 2015 {TMO10043321}.
¶33.36 On 13 April 2015, Claire Williams sent David Collins' request for a meeting to Peter Maddison with a draft response declining to meet residents.255 {TMO00846102}. She noted that she had spoken to Robert Black and explained that TMO people preferred not to meet Grenfell Community Unite, since such a meeting would provide a platform for Mr Daffarn.256 {TMO00846102}. In our view, that internal message is revealing. It suggests that one reason for the TMO's reluctance to recognise the Grenfell Action Group or any new group to speak for residents about the refurbishment was because of a grave mistrust of Mr Daffarn.
¶33.37 Edward Daffarn is an intelligent, articulate and motivated individual, who was an impressive witness. Whether he ever spoke for the wider community is debatable and his language and approach in his dealings with the TMO caused resentment among its staff. One thing is clear, however: those in the TMO who were responsible for managing the refurbishment were nervous of him and allowed him to become a barrier to proper communication with the rest of the community.
¶33.38 Councillor Blakeman also took an interest in the request for a meeting with residents and asked the TMO to copy her and other ward councillors into the response.257 {TMO00845970}. After receiving Peter Maddison's comments, Claire Williams responded to David Collins and Edward Daffarn on 17 April 2015 refusing their request to recognise the Group or organise a meeting with residents.258 {TMO00846124}; {TMO00846121}. She referred to the survey citing the residents' preference to be consulted by letter, but she offered Mr Daffarn an opportunity to meet Rydon to discuss the work in his flat.
35¶33.39 Following the involvement of Councillor Blakeman, on 11 July 2015, representatives of the TMO and Rydon met residents in Flat 145259 Daffarn {IWS00002109/57} page 57, paragraph 153. and on 17 July 2015 there was a meeting with the local Member of Parliament, Victoria Borwick, at which the TMO agreed to her suggestion that it should recognise the Grenfell Compact as a representative group for the purposes of the refurbishment.260 {IWS00002194}; Daffarn {IWS00002109/58-59} pages 58-59, paragraphs 156-158; {TMO00846146}.
¶33.40 It had taken the best part of three years and the intervention of the local MP to get to that point, but by July 2015 the refurbishment was only a year from completion. The residents of Grenfell Tower had never before that been given any collective say in relation to it, as required by the agreement between the TMO and RBKC.
¶33.41 The Grenfell Compact was formally constituted on 23 September 2015.261 {TMO00846191}. An information sheet sent by the TMO to residents following its formation explained that a residents' compact was an agreement between representatives of a block or estate and the TMO which sets out how residents will be involved in decisions affecting their homes.262 {TMO10009741}. It also stated that the compact was a means of influencing decision-making.263 {TMO10009741}. The signatories to the compact were William Thompson, Edward Daffarn, David Collins, Hanan Wahabi and Marcio Gomes.264 {IWS00001711}.
Consultation with residents
¶33.42 We can now examine the extent to which the TMO consulted residents during the course of the refurbishment, its response to residents' complaints and its broader attitude to its relationship with the residents of the buildings it managed.
Consultation between the TMO and residents: 2011 to 2014
¶33.43 In September 2011, Edward Daffarn had complained to Laura Johnson that the residents of Grenfell Tower had not been consulted about the selection of Studio E as architect for the KALC project. He had felt that the KALC presentation on 13 September 2011, which had been attended by an architect from Studio E, had been a charade because Studio E had already been appointed without consulting residents.265 {RBK00030110}.
¶33.44 At a KALC forum meeting on 28 March 2012, Mr Daffarn asked why Studio E had been selected to undertake the initial work on the refurbishment of Grenfell Tower. He was told by Councillor Coleridge that it was difficult to have two architects undertaking separate projects on a single site and that there was a need for synergy between the KALC and Grenfell Tower projects.266 {LBI00000129/3}.
¶33.45 At a meeting of the TMO's Lancaster West Estate Management Board on 15 May 2012, Edward Daffarn asked if Studio E had experience of tower blocks and, if not, why it had been retained for the refurbishment.267 {TMO00848807/4}. He never received an answer to that question.268 Daffarn {Day118/21:24}-{Day118/22:1}. See also Part 6 Chapter 66. The Tenant Management Organisation
36¶33.46 Most TMO officers knew little or nothing about schedule 3 to the Modular Management Agreement, which contained detailed provisions about resident engagement in respect of refurbishments such as that of Grenfell Tower. Nevertheless, the TMO did make efforts to consult the residents of Grenfell Tower about its refurbishment. Consultation began in February 2012 and covered numerous topics, including cladding, heating, gas and the windows.269 Dunkerton {TMO00000885/11} page 11, paragraph 60. It took a variety of forms, including drop-in sessions, newsletters, telephone communications270 Dunkerton {Day51/94:11-17}. and two major questionnaires in February and May 2012.271 Dunkerton {Day51/95:19-25}. The TMO consultation strategy was set out in the Grenfell Tower engagement statement dated 22 August 2012,272 {TMO10001401/4}. which contained the responses to the wide range of questions that the residents had been asked in the questionnaires. One of the questions in the May 2012 questionnaire was "Do you wish to be involved in the development proposals for Grenfell Tower?" The responses were "Yes" 13 and "No" 1, but despite that request for involvement, no proposals were developed.
¶33.47 In July 2012, the TMO's project team for the refurbishment called for a resident focus group to be established by the TMO,273 {ART00000169/4}. but a group was never established. There is also no evidence that the residents, who in May 2012 had indicated that they wanted to be involved in the development proposals for the tower,274 {TMO10001401/10}. were ever invited to join a focus group.275 See, for example, Anderson {Day51/99:16}-{Day51/100:2}. Indeed the creation of a residents' focus group was not part of the consultation strategy.
¶33.48 In December 2013, the TMO decided that it would no longer hold public consultations with residents about Grenfell Tower. Councillor Blakeman told Councillor Feilding-Mellen that Edward Daffarn had become too disruptive to continue holding public consultations.276 {RBK00003386}. Peter Maddison agreed that that had been one of the reasons, but said that poor attendance had been another.277 Maddison {Day124/22:1-15}. At a drop-in session on 12 December 2013, a survey was undertaken and residents were asked to indicate how they would prefer the TMO to consult them.278 Williams {TMO00840364/30} page 30, paragraph 170. Most people did not want formal meetings.
¶33.49 The decision to discontinue public meetings was regrettable. Mr Daffarn perhaps should have stood back and questioned whether his preferred methods were the only, or even the most effective, way in which the voice of the community could be heard. A more conciliatory approach on his part might have been reciprocated. On the other hand, for its part the TMO ought to have reacted less defensively and, instead of retreating, should have made a greater effort to engage with Mr Daffarn, both on a personal and public level. It allowed its fear and personal mistrust of him and his methods to influence the way in which it engaged with the residents more generally. As custodian of the safety and security of its residents, it must take responsibility for the breakdown in trust.
37¶33.50 Some 65 households were recorded as attending the drop-in on 12 December 2013, at which people were asked to identify their preferred methods of consultation and 55 forms were returned.279 {TMO00828516}. Six methods to choose from were listed but they did not include consultation through a residents' group. They were all directed at giving information to residents, not hearing from them.
¶33.51 The residents of Grenfell Tower were consulted in respect of the various cladding options for the tower. In August 2012, the preference was said to be for a zinc cladding system280 {TMO00838191}; {TMO10049897/3}. but the decision eventually conveyed to residents in the newsletter circulated in October 2014 was that RBKC had approved a smoke silver metallic (grey) colour for the cladding.281 {TMO00837599/2}. Claire Williams said that she did not think the residents had ever been told that there had been a change from zinc to aluminium composite material or the reasons for the change. She thought that had been because the decision had not been made until after the project had begun.282 Williams {Day121/90:3-25}.
The petition
¶33.52 In December 2015, at Councillor Blakeman's suggestion,283 Blakeman {RBK00054461/17} page 17, paragraph 91. some 60 residents of Grenfell Tower signed a petition to the Housing and Property Scrutiny Committee of RBKC asserting that residents' views had been ignored or minimised, that their day-to-day concerns had been belittled and brushed aside and that they had been forced to endure intolerable living conditions while the work on the tower was going on.284 {RBK00000110}. It had been prompted by the frustration felt by residents that their concerns about the refurbishment had been ignored by the TMO.285 Blakeman {RBK00054461/17} paragraph 91. They asked the committee to consider their views and experiences and include them in its report.
¶33.53 The petition was presented by Councillor Blakeman to RBKC on 2 December 2015 and was then referred to Councillor Marshall and the Housing and Property Scrutiny Committee for its consideration.286 {RBK00033519}. On the same day, RBKC and the TMO held a joint management meeting, at which Peter Maddison is recorded as having said that Councillor Blakeman and Mr Daffarn were a negative force at Grenfell and that residents were going to them with problems rather than the TMO.287 {TMO10011523/2}. The minutes also record Amanda Johnson as having said that she felt that Councillor Blakeman had a conflict of interest since she was a TMO board member appointed by the council.288 {TMO10011523/2-3}. It is striking that senior officers of the TMO and RBKC appear to have been more interested in silencing Councillor Blakeman than in resolving the residents' grievances.
¶33.54 In response to the petition, the TMO's board suggested that it conduct an internal review of the refurbishment works. Laura Johnson supported the proposal while emphasising that RBKC had no desire to be involved in it. She said she would relay the proposal to Councillor Mackover so that it was supported by the Scrutiny Committee.289 {TMO00852704/3}. Clearly, the TMO hoped by that means to avoid external scrutiny of the way in which the refurbishment had been conducted.
38¶33.55 A meeting of the Scrutiny Committee was held on 6 January 2016.290 {RBK00032130}. Edward Daffarn was given an opportunity to address the committee and the request set out in the petition for a review of the TMO's management of the refurbishment was then discussed. Councillors Mackover, Berrill-Cox, Blakeman and Press proposed that a working group should be set up to investigate the management of the refurbishment and Councillors Blakeman and Press said that the reviewers should be independent of the TMO.291 Blakeman {Day135/135:1-14}. However, the Chairman, Councillor Marshall, was reluctant to establish a working group at that time.292 {RBK00032130/5}; Blakeman {Day135/136:1-5}. He suggested that the establishment of a working group should await the conclusion of existing working groups as well as the TMO's suggested review.293 {RBK00032130/5}.
¶33.56 Between January and March 2016 the TMO's board carried out a review of the refurbishment. Robert Black did not know why an independent review had not been suggested rather than one led by the board, but it was never envisaged that the review would fully address the request made in the residents' petition for an independent investigation of the TMO's management of the refurbishment, as opposed to responding to the particular complaints that had been made.294 Black {Day151/127:18-19}.
¶33.57 In January 2016, members of the TMO board were invited to express an interest in joining the review group. No residents of Grenfell Tower joined the group and there is no evidence that any of them were even invited to do so. At an initial meeting in February 2016 it was decided that the review would include, among other things, consultation and engagement with residents and responses to complaints. In March 2016, there was a presentation and a tour of Grenfell Tower and the review group was given a pack of information covering each area of the investigation.295 {RBK00003513/2}.
¶33.58 Although the review did not collect residents' views about how the refurbishment had been carried out, the TMO was required under the Modular Management Agreement to gather them after the work had been completed.296 Tenant Management Organisation Modular Management Agreement Volume 2 {RBK00019006/177} Clause 22.1. Robert Black accepted that, although the plan had been to include their opinions as part of the review,297 Black {Day151/146:19-24}. he might have overlooked the need to do so.298 Black {Day151/148:14-21}. Whether that was deliberate or not, ignoring residents' views was entirely consistent with the TMO's approach to engagement with its residents from at least February 2012, and indeed, on the basis of Maria Memoli's report, from far earlier than that.
The working group's report
¶33.59 The working group's review culminated in a report dated 31 March 2016.299 {RBK00003513}. The group found that engagement with and consultation of residents had been comprehensive and had used various methods to obtain their views. It recommended that in future details of those attending public meetings should be recorded, that minutes should be taken and that resident profile surveys should be repeated every six months when projects lasted for longer than 12 months.300 {RBK00003513/3} section 3.
39¶33.60 In response to the allegations that the contractor and the TMO had used threats, lies and intimidation, the group noted that the only detailed information was a complaint that had not been upheld at Stage 3 of the complaints procedure. A new procedure was proposed for gaining access to flats to carry out work internally which could be sent to unco‑operative residents in future to avoid any misunderstanding.301 {RBK00003513/4} section 5.
¶33.61 The group reviewed seven formal complaints and other enquiries received from ward councillors and was satisfied that the TMO had responded adequately to them.302 {RBK00003513/4} section 6.
¶33.62 The report's conclusion acknowledged the disruption and inconvenience caused by the works over an extended period of time,303 {RBK00032438}. but commended Rydon, Peter Maddison and his team on completing the refurbishment works.
¶33.63 In our view, the review was flawed in its origins, its process and its conclusions. Given the history of the matter and the lack of trust between the residents of Grenfell Tower and the TMO, the board should have realised that only an independent review of the management of the project with particular reference to the residents' complaints could fairly satisfy the requirements of the moment. As it was, the review was superficial and the group conducting it failed to carry out its investigation in a sufficiently thorough and robust manner. The report lacked balance. It gave the impression that very little, if anything, had gone wrong and that there was no substance in any of the complaints made in the petition. The Scrutiny Committee in its turn failed in its task of ensuring that the relationship between the TMO and its residents was rigorously investigated.
¶33.64 On 4 July 2016, David Collins wrote to Councillor Feilding-Mellen on behalf of Grenfell Compact to express his view that the report failed to address how the refurbishment work and resident consultation had been carried out by the TMO.304 {RBK00003501/1-2}. He thought that the report was not sufficiently critical about the lessons to be learned from the refurbishment and he set out 15 recommendations for the conduct of future refurbishment works.
¶33.65 Councillor Feilding-Mellen responded on 7 July 2016. He told Mr Collins that, although he was happy to review his recommendations, he considered that many of them had already been addressed in the TMO board's review. He went on to say that he would not advise officers to investigate new allegations which were not submitted in writing and supported by evidence.305 {RBK00003466}. See also {RBK00000136} for further emails in the same chain. Councillor Feilding-Mellen met David Collins later in July 2016,306 {RBK00030865/2}. but their meeting took matters little further forward.
¶33.66 On 6 September 2016, David Collins wrote to Councillor Feilding-Mellen again to thank him for attending the meeting in July and to ask him whether he was minded to reconsider RBKC's approach to regeneration projects or the TMO's operations.307 {RBK00030865/2}. Councillor Feilding‑Mellen sent the email on to Laura Johnson and asked her if she could think of any "small concession" he could offer David Collins. Although he told us that only a small concession was needed because the differences between them were not great,308 Feilding-Mellen {Day132/95:14}-{Day132/96:7}. what he really meant, we think, was that he was looking for something trivial he could give away.
40Conclusion
¶33.67 The overwhelming impression we have gained from the evidence, both that of the witnesses and that contained in the contemporaneous documents, is that between 2011 and 2017 relations between the TMO and many of the residents of the tower were increasingly characterised by distrust, dislike, personal antagonism and anger. Some, perhaps many, occupants of Grenfell Tower regarded the TMO as an uncaring and bullying overlord, which belittled and marginalised them, regarded them as a nuisance or worse, and simply failed to take their concerns seriously. For its part, the TMO regarded some of the residents as militant troublemakers led on by a handful of vocal activists, principally Edward Daffarn, whose style they found offensive. The result was a toxic atmosphere fuelled by mistrust on both sides.
¶33.68 In the end, however, responsibility for the maintenance of the relationship between the TMO and the Grenfell community fell not on the members of that community, who had a right to be treated with respect, but on the TMO as a public body exercising control over the building which contained their homes. The TMO lost sight of the fact that the residents were people who depended on it for a safe and decent home and the privacy and dignity that a home should provide. That dependence created an unequal relationship and a corresponding need for the TMO to ensure that, whatever the difficulties, the residents were treated with understanding and respect. We regret to say the TMO failed to recognise that need and therefore failed to take the steps necessary to ensure that it was met.
¶33.69 However irritating and inconvenient it may at times have found the complaints and demands of some of the residents of Grenfell Tower, for the TMO to have allowed the relationship to deteriorate to such an extent reflects a serious failure on its part to observe its basic responsibilities.
41Part 5: The management of fire safety at Grenfell Tower
43Chapter 34: Introduction to Part 5
¶34.1 One of the TMO's most important functions as manager of Grenfell Tower was to take appropriate steps in relation to fire safety. In this Part of our report we examine the nature of the obligations imposed by law on those who manage residential buildings and the steps taken by the TMO to comply with them in the years leading up to the fire.
¶34.2 The Fire Safety Order prescribes the duties imposed on the person who has control of premises such as Grenfell Tower, known as the "responsible person", and on every other person who has, to any extent, control of the premises so far as the requirements relate to matters within his control. In the case of Grenfell Tower it was accepted that both the TMO and RBKC were subject to those duties but for practical purposes we decided to concentrate on the TMO and examine the way in which it went about discharging its duties and the extent to which it did so effectively.
¶34.3 In this Part we have therefore considered the systems adopted by the TMO to discharge its obligations, its discussions with the LFB as the enforcing authority, the steps it took to identify the risks to which the properties it managed were subject and its response to the findings that emerged. RBKC had an important part to play because it was responsible for overseeing all the TMO's arrangements for protecting health and safety. We have therefore also examined the extent to which RBKC fulfilled its responsibility in that respect.
¶34.4 Fire risk assessments play an important part in ensuring fire safety. We therefore examined the steps taken by the TMO to obtain suitable and sufficient fire risk assessments as required by the Fire Safety Order and the way in which it responded to them.
¶34.5 Maintenance of fire protections within buildings are an important element in managing fire safety effectively. One of the most important, but often least regarded, protections against the spread of fire within a residential building is the provision and effective maintenance of fire doors at the entrance to individual flats with working self-closing devices. We have therefore examined the steps taken by the TMO to ensure that the flats in Grenfell Tower were fitted with modern fire doors and the measures put in place to ensure regular inspection and maintenance of the doors and self-closing devices.
¶34.6 When Grenfell Tower was built it included a smoke ventilation system designed to operate in the event of a fire to clear smoke from the lobby of the floor on which the flat affected by the fire was situated. Such systems require regular maintenance as part of managing fire protection, so we examined the extent to which the TMO had maintained the system and whether it was capable of operating effectively. Regrettably, by the time of the refurbishment it was not in working order and could not be renovated. We describe how that situation had come about and, in the next Part, the steps that were taken to replace it as part of the refurbishment.
¶34.7 Finally, we identify certain other matters relating to fire safety that we consider to be important to comment on, including emergency planning, the provision of fire safety information in public parts of the building and arrangements for safeguarding vulnerable residents.
45Chapter 35: The Fire Safety Order
Introduction
¶35.1 Part of our terms of reference is to investigate the fire prevention and fire safety measures in place at Grenfell Tower on 14 June 2017.309 Terms of reference, paragraph (i)(f). The starting point for any investigation of that kind is to understand the obligations of those who were in law responsible for fire safety. Article 8 of the Regulatory Reform (Fire Safety) Order 2005 (the Fire Safety Order) imposes on "the responsible person" an obligation to take such general fire precautions as will ensure, so far as is reasonably practicable, that the premises are safe.310 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/8} Article 8(1). The first question we consider, therefore, is who was, for the purposes of article 8 of the Fire Safety Order, the responsible person in relation to Grenfell Tower.
The responsible person
¶35.2 Under article 3 of the Fire Safety Order, the responsible person in relation to premises that are not a workplace is the person who has control of the premises in connection with the carrying on of an undertaking of some kind or, where the person in control of the premises does not have control in connection with the carrying on of an undertaking of some kind, the owner of the premises. By article 5(2) the responsible person must ensure that any duty imposed by articles 8 to 22 or by regulations made under article 24 is complied with in respect of those premises, so far as the requirements relate to matters within his control. Article 5(3) imposes on anyone other than the responsible person who has control of the premises the same duties as those imposed on the responsible person, so far as they relate to matters within his control.
¶35.3 In addition to the duty under article 8 to take general fire precautions, the responsible person and anyone to whom article 5(3) applies are subject to certain specific duties. The most relevant are: a. to carry out a suitable and sufficient risk assessment for the purpose of identifying what general fire precautions are necessary;311 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/8} Article 9(1).
¶b. to make and give effect to appropriate arrangements for the effective planning, organisation, control, monitoring and review of preventive and protective measures;312 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/9} Article 11(1).
¶c. to ensure, where necessary to safeguard the safety of relevant persons, that the premises are appropriately equipped with fire-fighting equipment and fire detectors and alarms and that any non-automatic fire-fighting equipment is easily accessible, simple to use and indicated by signs;313 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/9} Article 13(1).
¶d. to take measures for fire-fighting, nominate competent persons to implement them and ensure that their training and the equipment available to them are adequate;314 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/10} Article 13(3).
46¶e. to ensure that routes to emergency exits from premises and the exits themselves are kept clear at all times;315 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/10} Article 14(1).
¶f. to establish and, where necessary, give effect to appropriate procedures, including fire safety drills, to be followed in the event of serious and imminent danger;316 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/10} Article 15(a).
¶g. to ensure that the premises are subject to a suitable system of maintenance and are maintained in an efficient state, in efficient working order and in good repair;317 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/12} Article 17(1).
¶h. to appoint one or more competent persons to assist him in undertaking the necessary preventive and protective measures;318 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/12} Article 18(1). i. to ensure that his employees are provided with adequate safety training.319 The Regulatory Reform (Fire Safety) Order 2005 {INQ00011327/14} Article 21(1).
RBKC as the responsible person
¶35.4 RBKC contended that, between 1 April 2005 (when the Fire Safety Order came into force) and June 2017, the responsible person in relation to Grenfell Tower (outside the period of the refurbishment and excluding the non-residential units) had been the TMO, although it accepted that it had itself fallen within the scope of article 5(3) during that period.320 RBKC Module 1 Opening Statement {RBK00055479/8} paragraph 33. This submission is maintained in RBKC Module 3 Opening Statement {RBK00063631/9} paragraph 31. It argued that under the Modular Management Agreement (the Agreement) it had delegated to the TMO the vast majority of its housing management functions and that the TMO had been responsible for health and safety arrangements (including arrangements relating to fire safety) for the housing stock which it managed on behalf of the council. RBKC's position was based on the proposition that, as a matter of law, the Fire Safety Order seeks to identify a single responsible person for each premises.321 RBKC Module 3 Opening Statement {RBK00063631/10} paragraph 34. We do not need to resolve that question, however, because RBKC was either the responsible person in relation to Grenfell Tower or was a person to whom article 5(3) applied, as it recognised in its opening statement, and was therefore subject to the same duties.
¶35.5 Before the fire, the identity of the responsible person appeared to be uncontroversial. For example, officers of the TMO thought that both bodies were responsible persons322 Black {Day149/37:22}-{Day149/38:1}; Wray {TMO00000890/37} page 37, paragraph 166; TMO Fire Safety Strategy November 2013 {TMO00830598/1}. in relation to Grenfell Tower. Moreover, on 20 February 2012, a joint protocol was agreed between LFEPA and RBKC323 {LFB00032248}. under which RBKC undertook to discharge certain duties under the Fire Safety Order. The correspondence about the joint protocol between Kevin Thompson, Laura Johnson and Janice Wray demonstrates that there was a mutual understanding between the TMO and RBKC that they both had responsibilities under the Fire Safety Order.324 {RBK00001176}.
¶35.6 That understanding was reflected in the TMO's Fire Safety Strategy of November 2013, which expressly stated that both RBKC and the TMO were to be considered responsible persons for the purposes of the Fire Safety Order.325 {TMO00830598/1}. There is no evidence that that statement was challenged by anyone.
47¶35.7 On the other hand, Laura Johnson thought that the TMO was the only responsible person in relation to RBKC's housing stock but she could not explain why and speculated (incorrectly) that the TMO's responsibility had been set out in the Agreement. She said that, because RBKC took the view that it was not the responsible person, it had not put in place any arrangements to discharge any of the duties of the responsible person under the Fire Safety Order.326 Johnson {Day129/57:21-25}. As far as she knew, nobody in RBKC oversaw the TMO's performance on health and safety matters beyond receiving an annual health and safety report.327 Johnson {Day129/64:16-20}.
¶35.8 We found Laura Johnson's evidence on this point unconvincing. The evidence shows that while she was RBKC's Director of Housing she took an active interest in matters relating to fire safety. At no time did she say that RBKC was not the responsible person in relation to the housing managed by the TMO. We conclude that, before the fire, Laura Johnson understood that RBKC, together with the TMO, was the responsible person for the premises managed by the TMO.
The TMO as the responsible person
¶35.9 The TMO set out its understanding of the division of responsibilities under the Fire Safety Order in its annual health and safety reports to the TMO Board and to RBKC. As set out in the Annual Health and Safety Report for the year 2009-2010328 {TMO00879745/1}. it was: a. that operational compliance with the Fire Safety Order had been delegated to the TMO;
¶b. that RBKC was liable for any breach of the Fire Safety Order and subject to enforcement notices or prosecution or both;
¶c. that RBKC would monitor the TMO's actions on health and safety matters to ensure compliance with relevant statutory responsibilities and adherence to best practice;
¶d. that RBKC's corporate health and safety adviser and the health and safety adviser for housing, health and adult social care would receive minutes of the meetings of the TMO's health and safety committee and copies of the TMO's annual report on health and safety;
¶e. that the TMO's health and safety adviser would attend RBKC's six-weekly meetings of its Main Co-ordinating Committee dealing with health and safety matters; and
¶f. that it would notify RBKC of major incidents, accidents, significant near-misses and any current investigations.
¶35.10 Robert Black understood that RBKC shared the TMO's understanding of their respective responsibilities.329 Black {Day149/37:22}-{Day149/38:1}. He understood that, as a responsible person under the Fire Safety Order, the TMO was responsible for appointing competent people to ensure safety. He understood the distinction, which we explain below, between the responsible person and the competent person under the Fire Safety Order.330 Black {Day149/38:23-25}.
48¶35.11 In mid-2015, Barbara Matthews succeeded Anthony Parkes as the TMO's Director of Financial Services and ICT. Although she was unaware of the duties imposed on the responsible person,331 Matthews {Day147/108:23}-{Day147/109:1}. she believed that RBKC and the TMO were both responsible persons for the premises owned by RBKC but managed by the TMO.332 Matthews {Day147/109:2-9}. She relied on the fact that fire risk assessments and internal audits were carried out to satisfy herself that the TMO was discharging its obligations under the Fire Safety Order.333 Matthews {Day147/110:24}-{Day147/111:2}. She was unaware of RBKC's arrangements for discharging its own duties as a responsible person under the Fire Safety Order.334 Matthews {Day147/112:14-17}.
The competent person
¶35.12 Article 18(1) of the Fire Safety Order requires the responsible person to appoint one or more competent persons to assist him in undertaking the preventive and protective measures. In particular, article 18(3) obliges the responsible person to ensure that the number of competent persons appointed, the time available for them to fulfil their functions and the means at their disposal are adequate having regard to the size of the premises, the risks to which relevant persons are exposed and the distribution of those risks throughout the premises.
¶35.13 Article 18(5) provides that a person is to be regarded as competent if he has sufficient training and experience or knowledge and other qualities to enable him properly to assist in undertaking the preventive and protective measures. Janice Wray, the TMO's health and safety manager, was familiar with the concept of the competent person and undertook that role for the TMO.335 Wray {Day140/43:10-13}.
Janice Wray's responsibilities
¶35.14 Although Ms Wray saw her role as essentially advisory,336 Wray {Day140/7:22-25}. it is plain from the various versions of the TMO's health and safety policy that it was broader, more substantive and included the following:337 TMO Health and Safety Policy 2012 {TMO10031076/3}. This list was reproduced in the 2016 version of the policy {TMO10024402/3}. The 2010 version of the policy {TMO10031078/3} does not include the references at i and j to the Fire Safety Order. a. providing competent advice on health and safety matters as required by the
¶Management of Health & Safety at Work Regulations; b. formulating health & safety policy and strategy;
¶c. producing health & safety policy, procedures and guidelines and ensuring that they were regularly reviewed and kept up to date; d. providing managers and employees with specialist health and safety advice;
¶e. organising and administering the health & safety committee and communicating with and consulting safety representatives through it; f. identifying the need for health and safety training; g. monitoring, reviewing and auditing compliance with the policy;
49¶h. producing an annual Health & Safety Report for presentation to the TMO board and RBKC; i. advising on compliance with the Fire Safety Order; and
¶j. attending meetings and committees as necessary to provide information on the TMO's performance in relation to specific areas of health & safety, including compliance with the Fire Safety Order.
¶35.15 Janice Wray accepted that that was an accurate description of her responsibilities.338 Wray {Day140/39:18-22}. When asked whether she had primary operational responsibility for the TMO's compliance with the Fire Safety Order, she denied having overall responsibility for it but accepted that she was responsible for overseeing and monitoring the performance by the TMO of its fire safety obligations.339 Wray {Day140/42:11-25}.
¶35.16 Although Janice Wray may have had responsibility for monitoring the performance by the TMO of its obligations in relation to fire safety, from mid-2015 primary operational responsibility lay with Barbara Matthews. An important part of her responsibilities was to monitor the TMO's health and safety performance at a strategic level,340 Matthews {TMO10049987/2} page 2, paragraph 7. which encompassed ensuring the health and safety of all the TMO's residents, employees and contractors.341 Matthews {Day147/103:21-25}.
¶35.17 In his safety management review produced in September 2013 Matt Hodgson342 An independent consultant who was instructed by the TMO to prepare a safety management review in 2013 {RBK00055531}. identified Janice Wray as the competent person at the TMO343 {RBK00055531/23}. and considered that her qualifications were more than adequate for that role.344 {RBK00055531/23}. He noted that the TMO Health and Safety Policy named Adrian Bowman, Janice Wray's assistant, as the competent person and recommended that it be amended to name her.345 {RBK00055531/23-24}.
¶35.18 In undertaking the responsibilities of a competent person Janice Wray considered that she had access to a fire safety specialist and, if she needed further advice, was able to ask for it.346 Wray {Day140/44:5-10}. She had regular meetings with the LFB and access to various people to whom she could go for advice.347 Wray {Day140/44:15-18}. She felt that she had had sufficient training, experience and knowledge to carry out the role of competent person for the TMO.348 Wray {Day140/45:9-12}.
¶35.19 Janice Wray did not think that a shortage of funds or other resources had hindered her ability to discharge her responsibilities as the competent person.349 Wray {Day140/47:16-25}. Although she felt that she was often spread very thinly,350 Wray {Day140/48:10-20}. she felt able to discharge her fire safety responsibilities satisfactorily.351 Wray {Day140/49:23}-{Day140/50:13}.
51Chapter 36: Fire safety management at the TMO
Health and safety policies
¶36.1 The TMO maintained a policy which described the way in which it sought to comply with its obligations under health and safety legislation. We saw various versions of the policy but the witnesses were asked principally about the versions dated July 2010352 {TMO10031078}. and February 2016.353 {TMO10024402}.
¶36.2 The TMO's senior staff were familiar with the policy. Teresa Brown was familiar with the general principles in the policy, but had no reason to refer to the details.354 Brown {Day126/9:14-22}. Barbara Matthews helped to review the policy in February 2016355 Matthews {Day147/140:5-16}. and Janice Wray also contributed to it.356 Wray {Day142/152:14-16}. The policy provided that Robert Black was ultimately responsible for health and safety at the TMO.357 Matthews {Day147/141:3-5}; {TMO10024402} paragraph 1.2.
¶36.3 According to the policy, the TMO was required to make sure that staff with key roles in the management of health and safety were competent and adequately trained.358 {TMO10024402/1} paragraph 1.4. However, Barbara Matthews told us that there was no document that described standards of competence or the training required for those members of staff.359 Matthews {Day147/142:11-25}.
The TMO's fire safety strategies
¶36.4 On 18 January 2013, Janice Wray sent Carl Stokes360 {CST00001187}. a document entitled "Fire Safety Policy",361 {CST00002046}. which she had drafted to address one of the failings identified by Salvus in a report dated September 2009.362 Wray {Day140/141:20-25}. It was intended to replace the fire safety policy approved by Robert Black in 2009.363 Wray {Day140/142:2-11}. When drafting the document Janice Wray had consulted her colleagues, Cyril Morris and Adrian Bowman, and the operations division of the TMO. She may also have consulted the LFB with the intention of adopting its standards.364 Wray {Day140/142:25}-{Day140/143:13}. On 1 February 2013, Carl Stokes provided some comments.365 {CST00030180}.
¶36.5 The draft policy was discussed at a meeting of the TMO's Assets & Regeneration and Repairs, Health & Safety Group on 18 April 2013.366 Item 7.1 "Fire Safety Policy" {TMO10002648}. It was discussed again at a meeting of the Operational Health and Safety Committee on 15 November 2013. The intention was for it to be circulated by Janice Wray in draft for comments before sending it to the LFB by mid-December.367 TMO Operational Health & Safety Minutes {TMO10004726/6}.
52¶36.6 The version of the document produced in November 2013368 {TMO00830598}. (entitled "TMO Fire Safety Strategy") was given to the LFB at the bi-monthly meeting in December 2013. Janice Wray said that the LFB had not commented on it.369 Wray {Day140/151:2-3}. The draft was discussed again at the meeting of the Operational Health and Safety Committee on 17 January 2014, when it was noted that it had already been given to the LFB and that the final version could be approved at the next committee meeting.370 TMO Operational Health & Safety Meeting {TMO00840384}. In fact, there is no record of the document's having been approved at the next or any subsequent Operational Health and Safety Committee meeting. Despite that, it was in its final form, as far as Janice Wray was concerned.371 Wray {Day140/155:17-19}.
¶36.7 The minutes of the meeting on 17 January 2014 recorded that Janice Wray and Michael Lyons (the Health and Safety manager of Repairs Direct) were to meet to discuss any changes to the strategy. In the event, Michael Lyons, who had been sent a copy of the draft, sent back a different document described as a fire safety policy dated January 2014.372 {TMO10040770/1}. Janice Wray said that that document had not been adopted, however, as it did not reflect the TMO's working practices.373 Wray {Day140/151:25}-{Day140/152:12}.
¶36.8 There were various versions of that document, the earliest being dated January 2014374 See Fire Safety Policy, Issue 01, January 2014 {TMO10040770}. and the latest May 2014.375 {TMO00856458}. The former, apparently written solely by Michael Lyons, contemplated the appointment of a fire safety manager,376 {TMO10040770/6}. who would be responsible for the strategic management of fire precautions, including the formulation and revision of the TMO's fire safety plan and oversight of the process for obtaining fire risk assessments.377 {TMO10040770/6}. When she received that document from Michael Lyons Janice Wray noted the different structure for managing fire safety, including the introduction of a fire safety manager. She sent a copy of the policy to Anthony Parkes, her then line manager, who confirmed that the TMO did not intend to implement the arrangements described in the draft.378 Wray {Day140/154:13}-{Day140/155:5}.
¶36.9 The draft dated May 2014, jointly written by Janice Wray and (apparently) Michael Lyons, did not contain any reference to a fire safety manager and made it clear that responsibility for fire safety policy lay with the Health & Safety Manager. In any event, it appears that neither the January 2014 nor May 2014 draft was taken any further.379 Wray {Day140/157:13-15}.
¶36.10 Another version of a fire safety policy was identified by the RBKC auditor, Alpesh Patel, who carried out an audit of the TMO's health and safety arrangements in March 2016. Janice Wray had provided him with examples of the latest internal policies and procedures, which included a Fire Safety Policy and Strategy.380 Patel {RBK00058245/11-12} pages 11-12, paragraph 32; Exhibit AP2/38 - TMO fire safety policy and strategy {RBK00058236}. That document was presented in the same way as the January and May 2014 drafts and was in substance a revised version of the fire safety strategy dated November 2013.381 Wray {Day140/162:9-14}. It was not adopted by the TMO's health and safety committee.382 Wray {Day140/162:19}-{Day140/163:2}. Janice Wray did not know why that document had been given to the auditor.383 Wray {Day140/163:6-22}. The current fire safety strategy remained the one that had been approved in November 2013.
53¶36.11 A review of the 2013 strategy began in April 2016.384 Wray {Day140/164:4-13}. Janice Wray presented a paper385 {TMO10024351}. at a meeting of the TMO Health and Safety Committee that took place on 12 April 2016.386 {TMO10012811}. The document was entitled "Review of Fire Safety Strategy" and set out initial points to consider as part of the review. The review is likely to have been prompted by the Adair Tower fire, which had occurred on 31 October 2015.387 Wray {Day140/167:24}-{Day140/168:10}.
¶36.12 The process of reviewing the strategy continued well into 2017. The TMO Health and Safety Committee considered a draft dated June 2017388 {TMO10017036}. at its meeting on 13 June 2017, the day before the fire. Janice Wray said that the revision had taken so long to complete because the TMO wanted to review many aspects of the draft and make many minor changes and because there were many aspects on which she needed to obtain responses from others.389 Wray {Day140/171:7-20}. That may be so, but on any view, the delay speaks to an absence of proper expedition to make sure that a policy, which touched on the health and safety of residents, was completed expeditiously and kept up to date to reflect any changes in circumstances or regulatory requirements.
55Chapter 37: Development of fire safety strategies and policies
¶37.1 Before 2008 the TMO's health and safety team comprising Adrian Bowman and Janice Wray carried out fire risk assessments itself in order to save money, rather than using external fire risk assessors.390 Wray {Day140/85:17-19}; Briefing Note on Fire Safety dated 27 July 2009 by Janice Wray {TMO10037317/1} item 3; Email from Janice Wray to Robert Black and Liam Good copying in various others on 17 June 2009 about the LFB's intention to issue an enforcement notice {RBK00052535/4}. In May 2008, however, Collette O'Hara, a fire safety inspecting officer in the LFB's Kensington & Chelsea fire safety team (the LFB fire safety team), identified certain deficiencies in the TMO's fire risk assessments.391 LFEPA (LFB) Report Form on the TMO by Collette O'Hara dated 16 November 2009 {LFB00031977/22}.
¶37.2 In January 2009, the LFB fire safety team was not satisfied that the TMO's fire risk assessments had improved. It therefore sent a series of letters to the TMO, each in relation to a property in respect of which it did not consider the fire risk assessment to be suitable and sufficient as required by article 9(1) of the Fire Safety Order. That precipitated a number of meetings and discussions between Angus Sangster, the team leader, Collette O'Hara and Janice Wray about the standard expected of fire risk assessments.392 LFEPA (LFB) Report Form on the TMO by Collette O'Hara dated 16 November 2009 {LFB00031977/22}; Wray {Day140/85:10}-{Day140/86:8}.
¶37.3 Following a site visit to one of the TMO's properties with Janice Wray on 17 June 2009, Mr Sangster and Ms O'Hara concluded that the TMO was not competent to carry out fire risk assessments itself. Accordingly, Mr Sangster advised Janice Wray that the LFB would issue an enforcement notice against RBKC and the TMO requiring fire risk assessments to be carried out by a competent person.393 LFEPA (LFB) Report Form on the TMO by Collette O'Hara dated 16 November 2009 {LFB00031977/22}.
¶37.4 Later that day, Janice Wray told Laura Johnson and Jean Daintith, RBKC Executive Director of Housing, what the LFB intended to do.394 Email from Janice Wray to Jean Daintith and Laura Johnson copying in others on 17 June 2009 about the LFB's intention to issue an enforcement notice {RBK00052535/3}. Jean Daintith immediately sought advice from RBKC's building control department, which said that the TMO's fire risk assessments were not sufficiently robust and that a specialist should be engaged to carry them out.395 Email from Jean Daintith to Derek Myers cc David Prout on 17 June 2009 about the LFB's intention to issue an enforcement notice {RBK00052535/3}; Email from Jean Daintith to Derek Myers and Robert Black cc others on 18 June 2009 about the TMO's fire risk assessments {RBK00052528/1}.
¶37.5 As a result, on 18 June 2009, Alexis Correa, RBKC's health and safety advisor for the Housing, Health and Adult Social Care department, contacted Angus Sangster to explain that RBKC would provide funds to allow the TMO to appoint an external fire risk assessor and to carry out all necessary works. He sought an assurance that in those circumstances the LFB would not issue an enforcement notice. Mr Sangster agreed not to do so, subject to receiving from RBKC and the TMO a schedule for the completion of fire risk assessments.396 LFEPA (LFB) Report Form on the TMO by Collette O'Hara dated 16 November 2009 {LFB00031977/23}.
56¶37.6 On 9 July 2009, Janice Wray sent Mr Sangster a schedule of work397 LFEPA (LFB) Report Form on the TMO by Collette O'Hara dated 16 November 2009 {LFB00031977/23}. that had been agreed between RBKC and the TMO,398 Email from Alexis Correa to Pam Sedgwick cc others on 7 July 2009 about providing a schedule of works for fire risk assessments {TMO00866049/2}; Email from Alexis Correa to Janice Wray and others on 8 July 2009 describing the outcome of a meeting that day with Janice Wray, Liam Good and Ann Muchmore about fire risk assessments {TMO00865069/1}. but he did not consider it acceptable and suggested a further meeting to discuss the way forward.399 LFEPA (LFB) Report Form on the TMO by Collette O'Hara dated 16 November 2009 {LFB00031977/23}; Briefing Note on Fire Safety dated 27 July 2009 by Janice Wray {TMO10037317/3} item 5. The meeting took place on 6 August 2009400 Minutes of meeting between RBKC, TMO and LFB on 6 August 2009 {RBK00018535/1}. and was attended by representatives of the LFB fire safety team, RBKC and the TMO. During the meeting Keith Holloway, the TMO's Director of Strategic, Planning, Performance and Compliance, confirmed that fire risk assessments would be carried out by an external consultant. He and Jean Daintith also agreed that RBKC and the TMO would complete fire risk assessments for all their properties within three years, starting with high-risk properties, and carry out any work identified in them within five years.401 Minutes of meeting between RBKC, TMO and LFB on 6 August 2009 {RBK00018535/2} item 5.
¶37.7 Although RBKC and the TMO felt that, in requiring that approach to fire risk assessments, the LFB was treating them unduly harshly, they agreed to comply with its requirements.402 Minutes of TMO Executive Team meeting dated 29 July 2009 {TMO00903017/5} item 9; Minutes of TMO Executive Team meeting dated 3 August 2009 {TMO00903019/3} item 2.4; Emails between Laura Johnson and Janice Wray cc Keith Holloway dated 4-5 August 2009 about fire safety {TMO10037329}; Minutes of meeting between RBKC, TMO and LFB on 6 August 2009 {RBK00018535/1} item 1; Minutes of meeting between RBKC, TMO and LFB on 6 August 2009 {RBK00018535/4} item 10.
¶37.8 On 7 September 2009, a fire risk consultant, Salvus Consulting Ltd (Salvus), was appointed by the TMO to carry out the first phase of fire risk assessments. It covered 110 properties that were considered to pose a high risk, including Grenfell Tower. Work was due to start on 24 September 2009.403 Wray {TMO00842341/2} page 2, paragraph 9; Agreement between TMO and Salvus to appoint Salvus to carry out fire risk assessments on high-risk properties dated 7 September 2009 {TMO10037438/42}; TMO spreadsheet of potentially high-risk properties dated 1 July 2009 {TMO00842374}. There were meetings between Salvus, the LFB fire safety team, the TMO and RBKC on 16 September 2009 and 23 November 2009 to discuss the scope of the fire risk assessment programme and the method to be adopted.404 Minutes of the meeting between Salvus, LFB fire safety team and TMO on 16 September 2009 {SAL00000039}; Minutes of the meeting between Salvus, LFB fire safety team, TMO and RBKC on 23 November 2009 {SAL00000043}.
¶37.9 On 27 January 2010, Robert Black and Laura Johnson wrote to Angus Sangster confirming the joint commitment of RBKC and the TMO to achieving compliance with the Fire Safety Order. In their letter they described what had been agreed in their meetings with the LFB fire safety team in relation to the fire risk assessment programme, which by that time was already under way. The LFB was evidently satisfied with their proposal.405 Minutes of meeting between RBKC, TMO and LFB on 6 August 2009 {RBK00018535}; Minutes of the meeting between Salvus, LFB and TMO on 16 September 2009 {SAL00000039}; Minutes of the meeting between Salvus, LFB, RBKC and TMO on 23 November 2009 {SAL00000043}.
57The Salvus Management Report
¶37.10 On 22 September 2009, Steve Wain, a Salvus fire risk assessor, carried out a detailed assessment of the TMO's fire safety management systems at the request of Russell Thompson, the TMO's Head of Assets Strategy and Investment.406 Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/2}. Steve Wain set out his findings in a report of the same date entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" (known as the Salvus Management Report).407 Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/1}.
¶37.11 The Salvus Management Report was divided into two parts. Part 1 identified 25 deficiencies in the TMO's fire safety management arrangements that created hazards. It also identified where there were inadequate control measures in place in relation to those hazards and the level of risk the hazards presented.408 Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/2}. It based risk on both the likelihood of harm occurring and the likely severity of harm. A high-risk event, for example, was defined as one that was very likely or almost certain to occur and cause major injury or death and a medium-risk event as one that could occur in time and was likely to cause injury and ill health.409 Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/2}. All but two of the deficiencies were assessed as presenting a high or medium to high level of fire risk.410 Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/5-12}. Hazards included the absence of an overall fire safety policy setting out the TMO's strategic fire safety objectives, which was assessed as a high risk, the lack of policy and supporting arrangements to explain how the TMO would meet its fire safety objectives (for example, in relation to fire risk assessments and the maintenance of fire safety measures), which was also assessed as high risk and the lack of senior managerial audit of the fire safety arrangements to ensure that they were being satisfactorily implemented, which was assessed as medium to high risk.411 Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/5}.
¶37.12 Although Janice Wray did not agree with all of Salvus's conclusions, she did accept that the TMO had not adequately recorded its fire safety arrangements.412 Wray {Day140/108:18-21}. Indeed, the TMO's Health and Safety Policy dated May 2009 was the only policy relevant to fire safety in existence at the time of the Salvus Management Report.413 TMO's Health and Safety Policy dated May 2009 {TMO00870519}. It was not, however, a fire safety policy. It referred only briefly to fire safety and emergency procedures and made no mention at all of the Fire Safety Order, which had come into force in October 2006 some two and half years earlier.414 TMO's Health and Safety Policy dated May 2009 {TMO00870519/5}.
¶37.13 Part 2 of the Salvus Management Report was an action plan which set out 49 steps required to reduce the risks that had been identified.415 Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/13-19}. Salvus considered that 19 of them were required to remedy statutory breaches.416 Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/13-19}. The key to colour coding on page 19 shows that red signifies a statutory breach. The statute and statutory instruments Steve Wain probably had in mind are set out in the "Reference Material" on page 4. According to the priority ratings, Salvus required that the majority be completed within one or three months or, if a plan had been agreed, within six months.417 Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/13-19}. The "key to priority rating" on page 19 shows that "3" means "Undertake action within 1 month" and "4" means "Action within 3 months or agree plan within 6 months". There was, therefore, some urgency attached to the recommendations.
58¶37.14 Salvus strongly recommended that the TMO develop an overall fire safety policy within one month setting out its strategic fire safety objectives. It also strongly advised that the TMO introduce policy and supporting arrangements to show how it would meet its strategic fire safety objectives (for example, in relation to fire risk assessments and the maintenance of fire safety measures) within three months or, if a plan had been agreed, within six months.418 Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/13}.
¶37.15 Although we do not know exactly who received the Salvus Management Report, Janice Wray believed that copies had been sent to all those in the TMO who regularly dealt with Salvus. She mentioned Russell Thompson, Janet Rhymes, the TMO's Consultancy Services Manager, and also Ann Muchmore, RBKC's Performance and Contracts Monitoring Officer.419 Wray {Day140/105:7-11}.
¶37.16 Janice Wray did not receive the Salvus Management Report until 20 November 2009.420 Minutes of the meeting between Salvus, LFB, RBKC and TMO on 23 November 2009 {SAL00000043/4}. At item 5.4 it is recorded that Janice Wray received the email "late Thursday" which would have been 20 November 2009. See also Wray {Day140/118:4-12}; Wray {Day140/119:7-25}. We do not know why there was a delay of two months in her receiving it; on the face of it, it should have reached her much sooner. The delay may explain why she did not mention the report in her fire risk assessment report to the TMO board on 8 October 2009,421 Janice Wray's report to the TMO Board entitled "Further Update on Fire Risk Assessments" dated 8 October 2009 {RBK00053571/1}. but it does not explain why, according to her report, Salvus had said at its meeting with the TMO on 24 September 2009 that generally the TMO had good fire safety policies and procedures in place, although they had not been consistently documented.422 Janice Wray's report to the TMO Board entitled "Further Update on Fire Risk Assessments" dated 8 October 2009 {RBK00053571/2} item 3.4. That statement is difficult to reconcile with the deficiencies in fire safety policy and arrangements that Salvus had identified in the report it had made only two days before that meeting. Regrettably, we have not seen any minutes of that meeting.
¶37.17 When Janice Wray received the Salvus Management Report she should have communicated at least the substance of its findings to the executive team, which in turn should have communicated them to the board and to RBKC. We have seen no evidence that that was done and we conclude that she did not do so. That would at least have set the record straight and would have corrected the false impression that Ms Wray had given the board on 8 October 2009.
¶37.18 Janice Wray may have discussed the report with Lornette Pemberton, the TMO's Head of Human Resources and Organisational Development and her line manager at the time and if so, she probably assumed that Ms Pemberton would report the deficiencies to the executive team.423 Wray {Day140/122:16}-{Day140/123:12}; Wray {Day140/127:12-17}. Robert Black said that he could not recall the report but was sure that he had seen it.424 Black {Day149/63:9}-{Day149/67:11}; Wray {Day140/133:6-10}.
59¶37.19 In her fire risk assessment report on 10 December 2009, Janice Wray told the board that the TMO had received a report from the consultant that set out the fire safety framework within which it and any contractors should be working.425 Janice Wray's report to the TMO Board entitled "Further Update on Fire Risk Assessments" dated 10 December 2009 {TMO00873623/2} item 4.5. However, she did not mention any of the critical findings or urgent measures that needed to be taken by the TMO in relation to the management of fire safety. She could not explain that omission,426 Wray {Day140/123:7-12}. nor could she remember having told the executive team or the board about them. We have seen no evidence that she or anyone else did so and are forced to the conclusion that they were not drawn to the attention of either the executive team or the board.427 Wray {Day140/122:24}-{Day140/123:12}.
¶37.20 The report and its findings were, however, discussed by Salvus, the TMO and RBKC at a progress meeting on 26 January 2010. That meeting was attended by Janice Wray, Russell Thompson, Abigail Acosta (a TMO project manager) and Ann Muchmore.428 Minutes of the meeting between Salvus, RBKC and TMO on 26 January 2010 {RBK00052572/3-4} item 4. It is clear from the minutes of the discussion of the report that Ann Muchmore was aware of its existence, even if she had not been provided with a copy. However, we have seen no evidence that she ever shared the report more widely within RBKC. Laura Johnson had no recollection of having seen it.429 Johnson {Day129/100:25}.
Implementation of the recommendations
¶37.21 At the meeting on 26 January 2010, Janice Wray raised a number of questions about the Salvus Management Report.430 Minutes of the meeting between Salvus, RBKC and TMO on 26 January 2010 {RBK00052572/3-4} item 4. It is clear from the minutes of that meeting that many of Salvus's recommendations had yet to be implemented and indeed Janice Wray accepted that some had not been. For example, she said she had not had an opportunity to put in place policy and supporting arrangements to explain how the TMO would meet its strategic fire safety objectives.431 Wray {Day140/125:3-20}. That was despite a recommendation that it be done within three months.432 Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/13} item 1.2.
¶37.22 It appears that Janice Wray had started to implement that particular recommendation within the required time but had stopped work before it was complete. There is a document headed "TMO Fire Safety Policy", apparently signed by Robert Black and dated December 2009,433 Draft TMO Fire Safety Policy dated December 2009 {TMO00870171}. which appears to be an early draft of the fire safety policy. Although she had little recollection of it, Janice Wray thought she had probably started drafting it in response to Salvus's recommendation and had put it aside because of other work.434 Wray {Day140/131:5-25}; Wray {Day140/142:6-11}. As it was, the TMO did not produce a fire safety policy in response to that recommendation until November 2013.435 TMO Fire Safety Strategy dated November 2013 {TMO00830598}.
¶37.23 On any view, the pace at which the recommendations were implemented was glacial. Given a high or medium to high assessment of the danger posed by a recommendation's remaining incomplete, the TMO failed to act with the degree of urgency that the subject demanded. It is not clear whether the problem flowed from Janice Wray's failure to prioritise the work or whether she did not have the capacity to undertake it and failed to ask for more resources. Whatever the cause, given their importance, the TMO should have made sure that the recommendations were promptly implemented and it failed to do so.
60¶37.24 One of the other recommendations made by Salvus was that within three months (or six months if a plan had by then been produced) the TMO should introduce a senior managerial audit of fire safety arrangements. There was also a recommendation that it be reviewed as part of the TMO's Business Plan.436 Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/14} item 1.4. We have seen no evidence that the TMO had introduced such an audit before the Grenfell Tower fire on 14 June 2017 and no explanation has been given for its failure to do so.
¶37.25 The TMO Performance Agreement for 2012/13 contained a draft audit programme for the following year that included a full review of fire risk assessments by Lornette Pemberton.437 TMO Performance Agreement 2012/13 {TMO00883568/42} paragraph 3.4. It is evident, however, that the audit was intended to relate to fire risk assessments rather than the fire safety management system as a whole. It would not, therefore, have fully met Salvus's recommendation. In any event, we have seen no evidence that Lornette Pemberton, or anyone else, carried out an audit of that kind and we conclude that no one did. Robert Black could not explain why it had not been carried out.438 Black {Day149/211:14-22}. An audit of fire risk assessments did not appear again in the TMO audit programme before 14 June 2017.439 TMO Performance Agreement 2013/14 {TMO10002878/22} item 3.2; TMO Performance Agreement 2014/15 Mid-Year Review {TMO10042117/5-6} item 2; TMO Performance Agreement 2015/16 {TMO10043715/20-21} item 3.2; TMO Performance Agreement 2016/17 {RBK00000589/24-25} item 3.2.
¶37.26 In June 2013, PAS 7:2013, a publicly available specification concerning fire risk management systems, was published by the British Standards Institution.440 BSI Standards Publication PAS 7:2013 "Fire Risk Management System - Specification" {LFB00116924/2}. Paragraph 7.4.3 stated that an organisation should audit the fire risk assessment programme after the delivery of the fire risk assessments and hold review meetings at planned intervals to discuss the results of the audits of fire risk assessments and the efforts made to respond to the findings.441 BSI Standards Publication PAS 7:2013 "Fire Risk Management System" {LFB00116924/23} paragraph 7.4.3.
¶37.27 At paragraph 8.3.1, it provided that senior management should review the organisation's fire risk management system at planned intervals to ensure its continuing suitability, adequacy and effectiveness.442 BSI Standards Publication PAS 7:2013 "Fire Risk Management System" {LFB00116924/25} paragraph 8.3.1. That specification bears a striking resemblance to the recommendation made by Salvus in September 2009 for a senior managerial audit of fire safety arrangements.
¶37.28 Janice Wray was aware of PAS 7:2013.443 Wray {Day145/11:12}-{Day145/12:17}. Despite that, she made no provision in the TMO fire safety strategy that she prepared in November 2013 for an audit of the fire risk assessment programme or for a review of the fire risk management system.444 TMO Fire Safety Strategy dated November 2013 {TMO00830598}.
¶37.29 We have seen no evidence that RBKC or the TMO incorporated a specific audit of the fire risk assessment programme or a review by senior management of the fire risk management system into its policy. Nor have we seen any evidence that the management of the TMO ever implemented such an audit or review in practice. No explanation has been given for those chronic failings.
61RBKC audit of the TMO's health and safety arrangements
¶37.30 The TMO, in conjunction with RBKC, set annual audit plans, the results of which allowed senior management to assess the adequacy and effectiveness of the internal controls in any particular year.445 Patel {RBK00029884/2} page 2, paragraph 5. Audits were carried out by RBKC's audit department, whose reports gave an overview of the area of service being audited. They also provided an assurance assessment rating, which ranged from "substantial" to "limited", based on the findings and the number of recommendations made in the report. If a "limited" assurance rating was given, there was usually a review within six to nine months to assess the implementation of any recommendations.446 Patel {RBK00029884/2} page 2, paragraph 5.
¶37.31 For TMO health and safety audits, each recommendation was given a high, medium or low priority and the overall audit would be given a "limited", "satisfactory" or "substantial" assurance rating. "Limited" assurance meant that there were weaknesses that put the objectives of the system at risk of failure. "Satisfactory" assurance meant that there were some weaknesses or omissions that put the objectives of the system at risk of failure. "Substantial" assurance meant that there was a sound system of control designed to achieve its objectives with few errors of weaknesses found.447 Patel {RBK00029884/4} page 4, paragraph 12. RBKC's audit team provided an independent audit service for the TMO.448 Patel {RBK00029884/4} page 4, paragraph 14.
¶37.32 An audit of the TMO's Health and Safety department was carried out by RBKC in April 2013.449 {RBK00000313}. The report was circulated, initially in draft, to Sacha Jevans, Janice Wray, Peter Maddison and Anthony Parkes. When completed, copies of the report were sent to Robert Black and Laura Johnson.450 {RBK00000313/1}. The audit provided only limited assurance that the TMO had adequate controls and processes in place in relation to health and safety.451 {RBK00000313/4}. The report made two relevant recommendations, first, that all high priority remedial work identified in the annual health and safety inspection should be reviewed by the Health and Safety Team to ensure that it was undertaken promptly; and secondly, that appropriate performance indicators relating to health and safety inspections should be developed by management.
¶37.33 The TMO accepted that some performance indicators would be useful, including indicators relating to fire risk assessments and reviews, the service of enforcement and deficiency notices and the number of fires.452 {RBK00000313/21}.
Matt Hodgson's review
¶37.34 Following the audit in April 2013 and the finding of "limited assurance",453 Black {Day149/135:19}-{Day149/136:13}. the TMO instructed Matt Hodgson, a health and safety professional, to complete a safety management review.
62¶37.35 Mr Hodgson prepared two reports, dated 19 July 2013454 Safety management review, July 2013 {TMO10003124}. and September 2013 respectively,455 Safety management review, September 2013{TMO00873398} paragraph 2. both of which were marked for the attention of Robert Black. The reports set out to provide an independent assessment of the implementation of the TMO's health and safety policy and its supporting arrangements.456 Safety management review, September 2013 {TMO00873398/4}.
¶37.36 In his first report Mr Hodgson identified 39 matters that required attention across the broad range of the TMO's health and safety responsibilities.457 Safety management review, July 2013 {TMO10003124/9}. For example, he recommended a review of the section of the corporate policy dealing with roles and responsibilities to make sure that the management of health and safety was appropriate to the TMO. He also concluded that the designation of RBKC's chief executive as the responsible person for the purposes of the Fire Safety Order was not appropriate. He advised that someone within the TMO should be designated as the responsible person and should receive the training and resources necessary to allow the role to be performed effectively.458 Safety management review, July 2013 {TMO10003124/34} paragraph 1.
¶37.37 More fundamentally, Mr Hodgson found that the health and safety policy did not identify the risks to which the TMO was exposed and failed to explain in sufficient detail what arrangements were necessary to satisfy, among other matters, its obligations in relation to fire safety.459 Safety management review {TMO00873398/19} paragraph 5. He observed that many of the fire safety arrangements had been grouped together in a way that lacked the detail required to produce an effective planned preventative maintenance process.
¶37.38 Matt Hodgson's analysis echoed the criticism made by Salvus in 2009. The maintenance process remained reactive, which defeated the object of effective policy arrangements, namely, the clear definition of planned preventative maintenance arrangements that ensured compliance with the TMO's health and safety obligations.460 Safety management review {TMO00873398/19}. Mr Hodgson therefore recommended a full review of the policy arrangements to ensure that there was a section for each property risk in order to achieve compliance.461 Safety management review {TMO00873398/20} item 4. Robert Black was asked whether any new policies had been introduced or any existing policies revised following that recommendation. He could not remember.462 Black {Day149/141:13-16}.
¶37.39 Matt Hodgson also considered the position in relation to fire risk assessments.463 Safety management review July 2013 {TMO10003124/33}. He found that the TMO's records of fire risk assessments were not up-to-date and that it was therefore not possible to see whether and, if so, to what extent the TMO had complied with its duties. It was clear, however, that there were between 900 and 1,000 outstanding matters arising from previous fire risk assessments.
¶37.40 Following receipt of the report, Robert Black prepared a report for the meeting of the TMO's board on 5 September 2013. In it he referred to Mr Hodgson's initial report and said that an action plan was being prepared for incorporation into the final report, but he did not mention any of the shortcomings identified by Mr Hodgson, not least the fact that the TMO itself and the members of the board could be exposed to liability if some of the deficiencies that had been identified were not remedied. Nor did he mention the lack of a co-ordinated approach to risk management or a lack of leadership from the executive team. In evidence, Mr Black agreed that they were all important matters for the TMO board to know.464 Black {Day150/87:13-23}. He suggested that the reason he had not revealed those findings to the board was that at that stage the report was still in draft.465 Black {Day150/88:24}. The fact is that the Hodgson report contained a powerful criticism of the TMO's health and safety arrangements and was all the more serious for the fact that four years had passed since the Salvus report and not all of the recommendations had been carried out. If Mr Black had disclosed those matters to the board he would no doubt have been asked some very difficult questions. We can only infer that he chose not to face up to them and hoped instead to keep Mr Hodgson's conclusions away from the board and thereby avoid embarrassment.
63¶37.41 Yet again, Mr Black's decision not to inform the board about those important matters prevented it from exercising effective supervision and control over the development of adequate fire safety management policies and arrangements. That was a very serious failing on his part.
¶37.42 The result was that by the end of 2013, the TMO's executive team had received two independent reports, four years apart, on its fire safety management arrangements, each of which had made far-reaching criticisms and recommendations. Those reports went to the chief executive but not to the board. They were not acted on in any material way by the TMO, not least because Mr Black's failure to bring them to the attention of the board meant that there was no pressure on him to take action. His own failure to take responsibility for implementing the recommendations and put in place a strategy for solving the myriad of deficiencies in the management system was a further serious failing on his part. It was also a serious failing on the part of Janice Wray, who knew as much as he did and on whom he relied. Clearly neither of them regarded fire safety as a high priority, even though the TMO had gone to the trouble and expense of commissioning the reports.
Further audits
¶37.43 In December 2013, RBKC carried out a further audit of the TMO's Health and Safety department.466 Exhibit AP/3 - RBKC, TMO Health and Safety Follow up Audit Report {RBK00000320}. The report was circulated in draft to Peter Maddison, Alex Bosman and Janice Wray before the final version was sent to Sacha Jevans and Anthony Parkes. Robert Black also received it.467 Black {Day150/64:20}-{Day150/65:1}. The level of assurance had risen from "limited" to "satisfactory" because of the steps that the TMO said had been taken.468 Exhibit AP/3 - RBKC, TMO Health and Safety Follow up Audit Report {RBK00000320/2}.
¶37.44 The action said to have been taken on key performance indicators is set out on page 9 of the report.469 Exhibit AP/3 - RBKC, TMO Health and Safety Follow up Audit Report {RBK00000320/9}. Notwithstanding the clear terms of the TMO's response to the report produced in April 2013, no indicators had been prepared for fire risk assessments or reviews, the service of enforcement or deficiency notices or the number of fires. The TMO did not set up a system to monitor each indicator until January 2016.470 Black {Day150/63:3-6}. No explanation was given for that delay.471 Black {Day150/63:18}-{Day150/64:11}. The TMO did not inform RBKC of the contents of the two Hodgson reports, much less provide it with copies.
¶37.45 Another audit of the TMO's health and safety arrangements was undertaken as part of the 2015/16 audit plan. The final report, dated March 2016, was a "high level audit review". It did not identify any shortcomings in the TMO's management of fire safety. It found that appropriate procedure and guidance documents existed covering fire safety policy and had recently been revised.472 Exhibit AP/4 - RBKC, TMO Final Internal Audit Report {RBK00000531/6}. It said that fire risk assessments were carried out by a specialist consultant and were reviewed by the TMO Assistant Safety Advisor during routine inspections to ensure that any significant findings and recommendations were pursued in a timely manner and in accordance with their stated priority. Checks on the electronic database relating to ten estates had confirmed that they were up to date and that all fire equipment had been inspected within the past twelve months.473 Exhibit AP/4 - RBKC, TMO Final Internal Audit Report {RBK00000531/6-7}.
64¶37.46 That finding failed to take account of the serious backlog of remedial work required by previous fire risk assessments that existed in the months before the final audit report.474 See for example minutes from the 11 November 2015 TMO Executive Committee meeting, item 3 "Adair Tower - Responses" {TMO00843593/2}. The TMO failed to correct the auditor's mistake in thinking that all remedial work had been carried out in a timely manner and in accordance with their stated priority. None of the witnesses from the TMO could explain that failure. As a consequence, the audit report gave the misleading impression that there were no deficiencies in the TMO's management of fire safety. Nor, once again, did the TMO take the opportunity to tell RBKC about the contents of Matt Hodgson's reports or the systemic failings in its fire safety management he had identified.
65Chapter 38: Fire risk assessments
Introduction
¶38.1 Fire risk assessments lie at the heart of the arrangements by which the responsible person discharges its obligations under the Fire Safety Order. In this chapter, starting with the engagement of Salvus by the TMO in 2009, we consider how the TMO carried out fire risk assessments of the high-rise residential buildings within its housing stock, principally in relation to Grenfell Tower. In particular, we concentrate on the appointment of Carl Stokes as the TMO's preferred fire risk assessor, his qualifications and competence, the adequacy of his fire risk assessments and concerns that emerged about the quality of his work.
Fire risk assessments – background
¶38.2 Between 24 September 2009 and March 2010, Salvus carried out fire risk assessments of high-risk TMO properties for the TMO and RBKC.475 Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/3}. The programme was a joint initiative between the RBKC and the TMO for which they had joint responsibility.476 Wray {Day140/101:16-19}; Amanda Johnson {Day130/6:2-14}. Janice Wray took responsibility for identifying which blocks should take priority, the procurement, commissioning the fire risk assessments and ensuring that progress met the LFB's requirements.477 Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/1}; Amanda Johnson {Day130/6:2-14}. Valerie Sharples, and for a brief period Abigail Acosta, were the TMO's project managers.478 Minutes of Fire Risk Assessments in high rise blocks, introductory meeting between Consultant and Fire Brigade dated 16 September 2009 {TMO00842368/1}. Ann Muchmore, RBKC's performance and contracts monitoring officer, had responsibility for overseeing the contract.479 Wray {Day140/101:20}-{Day140/102:9}.
¶38.3 At the start of the contract, Angus Sangster and Steve Reade of the LFB's Fire Safety team met Janice Wray, Adrian Bowman and Abigail Acosta and Andrew Furness and Steve Wain of Salvus.480 Minutes of Fire Risk Assessments in high rise blocks, introductory meeting between Consultant and Fire Brigade dated 16 September 2009 {TMO00842368/1}. Angus Sangster repeated the LFB's requirements for the fire risk assessment programme, namely to have the entire property portfolio assessed within three years and to have the remedial work required for properties to be fully compliant with the Fire Safety Order completed within five years.481 Minutes of Fire Risk Assessments in high rise blocks, introductory meeting between Consultant and Fire Brigade dated 16 September 2009 {TMO00842368/1}.
¶38.4 Salvus employed four fire risk assessors, including Carl Stokes.482 Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/1}. Carl Stokes started working for Salvus on 24 September 2009 on a six-month contract as a sub-contractor.483 Stokes {Day136/6:5-8}; {Day136/7:19-21}; {Day136/58:6-18}.
66Carl Stokes
¶38.5 Before he started working for Salvus, Carl Stokes had been an operational firefighter.484 Stokes {CST00003063/4} page 4, paragraph 7. In 1986, he joined the Royal Berkshire Fire and Rescue Service.485 Stokes {CST00003063/4} page 4, paragraph 7. During that time, he was seconded to the Fire Safety department and carried out familiarisation visits to high-rise buildings.486 Stokes {CST00003063/5} page 5, paragraph 8; Stokes {Day136/4:22}-{Day136/5:5}. In 1994, Mr Stokes transferred to the Oxfordshire Fire and Rescue Service where he spent most of his time in the Fire Safety department.487 Stokes {CST00003063/5} page 5, paragraph 9. Following the introduction of the Fire Safety Order, he received training on it and spent a significant amount of time auditing the findings made by fire risk assessors on behalf of responsible persons pursuant to the Fire Safety Order.488 Stokes {CST00003063/5} page 5, paragraph 10; Stokes {Day136/10:14-17}. However, none of these included residential blocks of flats over 18 metres in height.489 Stokes {Day136/15:24}-{Day136/16:9}.
¶38.6 On 12 December 2007, Mr Stokes was awarded a Fire Risk Assessment Certificate by the Northern Ireland Fire Safety Panel, which enabled him to carry out fire risk assessments.490 Stokes {CST00003063/5} page 5, paragraph 11; {TMO00880581/12}. He set up C S Stokes and Associates Ltd in February 2009 and retired from the Oxfordshire Fire and Rescue Service in September 2009.491 Stokes {CST00003063/6} page 6, paragraph 13. Carl Stokes was the sole director of C S Stokes and Associates Ltd and employed no-one else. He was therefore always a "one man band".492 Stokes {CST00003063/1} page 1, paragraph 1; Stokes {Day136/5:20}-{Day136/6:3}. When he started working for Salvus, he had no experience of carrying out fire risk assessments on highrise residential blocks of flats.493 Stokes {Day136/19:7-13}. He had less than two years' experience as a certified fire risk assessor.494 Stokes {Day136/19:25}-{Day136/20:7}.
Salvus's fire risk assessment programme
¶38.7 Salvus operated a quality control process under which all fire risk assessments were reviewed and discussed by email, when required, before being approved by the managing director, Andrew Furness.495 'Background re Carl Stokes employment with Salvus Consulting Limited' dated August 2019 {SAL00000002}. Mr Furness attended sites periodically to ensure consistency of assessments.496 Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/1}. Steve Wain oversaw the team of fire risk assessors.497 Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/1}.
¶38.8 In the case of the TMO, Andrew Furness held regular monthly meetings with Valerie Sharples and Janice Wray.498 Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/3}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 16 September 2009 {TMO00842368/1}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 19 October 2009 {SAL00000044}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 23 November 2009 {SAL00000043}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 26 January 2010 {RBK00052572}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 23 February 2010 {SAL00000042}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 1 April 2010 {SAL00000041}. Ann Muchmore of RBKC and officers of the LFB Fire Safety Team often attended those meetings.499 Minutes of Fire Risk Assessments in high rise blocks meeting dated 19 October 2009 {SAL00000044/1}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 23 November 2009 {SAL00000043/1}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 26 January 2010 {RBK00052572/1}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 1 April 2010 {SAL00000041/1}.
67¶38.9 Over the course of the six months between September 2009 and March 2010 the team at Salvus carried out fire risk assessments in relation to about 110 high-risk properties managed by the TMO, including Grenfell Tower.500 Minutes of Fire Risk Assessments in high rise blocks meeting dated 16 September 2009 {TMO00842368/1}; Wray {TMO00842341/2} page 2, paragraph 9; {TMO00842374}; Minutes of the meeting between LFB, RBKC and TMO dated 20 April 2010 {TMO00873670/1}. Carl Stokes believed he had carried out between 20 and 30 of those assessments.501 Stokes {Day136/61:17-25}.
¶38.10 The fire risk assessment in relation to Grenfell Tower was completed on 30 September 2009 by Carl Stokes under the supervision of Andrew Furness.502 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128}; Stokes {Day136/70:2-16}. It identified the chief executive of RBKC and the TMO503 Under General Information the Chief Executive of the Royal Borough of Kensington and Chelsea is listed as a Responsible Person. The Tenant Management Organisation Warden is listed as a Responsible Person/contact on site: Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/5}. as the responsible persons for the purposes of the Fire Safety Order, which reflected Carl Stokes's view504 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/5}; Stokes {Day136/69:7-10}. and presumably also that of Salvus. Janice Wray was consulted during the assessment.505 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/5}. The fire risk assessment was subject to a quality control process and was reviewed by Andrew Furness on at least two occasions.506 Stokes {Day136/70:2-16}. It rated the overall risk for the building as "normal", but identified 51 defects requiring remedial measures to reduce the risk.507 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/6}; Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/15-19}. Of those 51 defects, 19 were categorised as involving statutory breaches and were marked in red. Each defect was given a "priority rating" which identified the length of time within which it was recommended that action be taken to remedy it.508 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/15-19}. Some of the measures required to remedy red defects, such as reviewing the evacuation procedure and confirming the policy and procedures for the operation of the smoke ventilation system, required action to be taken within one week.509 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/16-19}. Other defects requiring remedial measures marked in red required the TMO to take action within three months or to agree a plan within six months.510 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/19}. They included recommending that the TMO introduce and implement a system of formal checks on flat front doors to ensure that compartmentation remained fit for purpose.511 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/16}. The assessment also recommended that the TMO engage competent engineers to test the smoke ventilation system and the lifts, if testing was not being carried out in accordance with current industry best practice.512 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/18-19}.
¶38.11 The programme ended in March 2010.513 Wray {TMO00842341/2} page 2, paragraph 10; Minutes of Fire Risk Assessments in high rise blocks meeting dated 1 April 2010 {SAL00000041/1}. In February 2010, Janice Wray and Ann Muchmore evaluated the performance of Salvus in accordance with a commitment they had made to the LFB.514 Wray {TMO00000890/30} page 30, paragraph 135; Wray {Day140/172:7}-{Day140/173:14}. Although, as she explained to us, they were not unhappy with Salvus's work, on 11 February 2010 Janice Wray told Ann Muchmore that she had some concerns that Salvus were "very rule-bound" and that they had shown some reluctance to challenge the LFB on behalf of the TMO.515 {RBK00053588/3}. She noted that Salvus was not as robust as she had hoped and that Carl Stokes, who had done most of the inspections as a sub-contractor, might be willing to tender for the work in future.516 {RBK00053588/1}. Janice Wray felt that Salvus had not given her a clear indication on fire safety issues raised by the LFB and she wanted to know whether the course of action suggested by the LFB was required before she committed the budget.517 Wray {Day140/175:24}-{Day140/177:5}. They decided to invite tenders for carrying out fire risk assessments in relation to the medium – and low-risk phases of the programme.518 Wray {TMO00000890/30} page 30, paragraph 135; Wray {Day140/174:1-5}.
68¶38.12 Janice Wray's message reveals that the TMO wanted a fire risk assessor that would take its side against the LFB when debating its fire safety requirements instead of taking them entirely at face value. Given that the LFB was the enforcing authority under the Fire Safety Order, that was a mistake. It also explains why Carl Stokes, who was ill-qualified to carry out fire risk assessments of buildings on this scale, let alone to hold the entire TMO portfolio, was selected by the TMO as the sole fire risk assessor and allowed to retain that role for the best part of seven years.
Appointment of fire risk assessor for medium- and low-risk properties
¶38.13 Once the fire risk assessment programme for high-risk buildings had been completed, on 18 October 2010 the TMO started a six-month fire risk assessment programme of its medium risk properties.519 {TMO00842327}; {CST00030040}. The fire risk assessment programme for the low-risk properties started later, on 17 August 2011.520 {CST00030041}. Carl Stokes was appointed as the sole fire risk assessor for both programmes.521 {CST00030041}; {CST00030040}; Wray {TMO00842341/3-4} pages 3-4, paragraphs 12-14. He began the reviews of the fire risk assessments for the high-risk properties in about December 2010.522 Stokes {CST00003063/9-10} pages 9-10, paragraphs 25 and 26; Stokes {Day136/89:7-15}; Wray {Day140/216:14-20}; {CST00001926}. Once the medium- and low-risk programmes had been completed, Carl Stokes was retained as the TMO's sole fire risk assessor indefinitely until his contract was terminated in about November 2017.523 Wray {TMO00842341/4} page 4, paragraph 15; Stokes {Day136/89:3-6}; {Day136/8:14-17}.
¶38.14 RBKC and TMO made a commitment to the LFB to evaluate the performance of the fire risk assessor at the end of the medium- and low-risk programmes, resources permitting, and to appoint a competent fire risk assessor to complete the assessments.524 {LFB00031977/30-31}. The TMO, with the agreement of RBKC, conducted a procurement process for a fire risk assessor for the medium-risk properties in 2010.525 {TMO00842327}; Stokes {Day136/88:10-18}. It did not carry out a further procurement exercise for the review of the assessments relating to the high-risk properties or for the programme relating to the low-risk properties.526 Wray {Day144/220:12-15}; Stokes {CST00003063/9-10} pages 9-10, paragraphs 25 and 26; Stokes {Day136/89:7-15}; Wray {Day140/216:14-20}.
¶38.15 The procurement process that was carried out in 2010 and the decision to appoint Carl Stokes bears further examination.
69The decision to appoint Carl Stokes
¶38.16 On 11 February 2010, Janice Wray sought funding and approval from Ann Muchmore to invite tenders for carrying out fire risk assessments in relation to the medium-risk properties.527 {RBK00053588/3}. In May 2010, the TMO Operations Committee was told that it had been agreed between the TMO and RBKC that a new fire risk assessor should be appointed for the medium-risk programme by July 2010.528 {TMO10037422/2}.
¶38.17 On or around 6 August 2010, C S Stokes and Associates Ltd, Salvus, and three other companies were invited to tender for the medium-risk programme.529 Wray {TMO00842341/2-3} pages 2-3, paragraphs 10 and 11. The invitation included a consultants' brief, which set out the proposed terms of the contract.530 Wray {TMO00842341/2-3} pages 2-3, paragraph 10; {TMO00842371}. It provided at paragraph 1.10 that the consultant's appointment would be for a one year period with an option for the TMO to extend for a further year, subject to the consultant's satisfactory performance.531 {TMO00842371/3}.
¶38.18 There was evidence to suggest that, even before the tender process had begun, Carl Stokes was undertaking fire risk assessments for the TMO. Invoices show that he had been carrying out fire risk assessments of areas of the TMO's offices from as early as 22 June 2010 and 2 July 2010.532 {CST00030111}; {CST00030077}. There was no evidence to show that he had formally applied for that work or had taken part in any formal procurement process. Janice Wray could not explain why he had been conducting fire risk assessments for buildings in the TMO stock before the procurement process had started.533 Wray {Day141/15:19}-{Day141/17:8}. She was adamant that she had not already decided to appoint him as the fire risk assessor534 Wray {Day141/17:9-21}. and that it was to be a joint decision with RBKC.535 Wray {Day141/17:9-21}. That may be so, but the episode does suggest that in some way Carl Stokes had an advantage in the procurement process.
¶38.19 On 22 June 2010, Carl Stokes met Janice Wray.536 {CST00001887}. He sent her a letter the following day setting out the matters they had discussed, including employee fire training, personal emergency evacuation plans (PEEPs) and the lift maintenance policy for buildings over 18 metres in height.537 {CST00001887}. When he gave evidence he said that they had discussed the nature of the information that he would include in his fire risk assessments and their discussions were reflected in the assessments he subsequently produced.538 Stokes {Day136/118:3-17}; {Day136/122:7-11}; Fire Risk Assessment for Grenfell Tower dated 29 December 2010 {CST00003181}. Carl Stokes could not explain the reason for that meeting.539 Stokes {Day136/119:12-15}. Janice Wray suggested that he had only been seeking more information about the organisation and its policies and procedures.540 Wray {Day141/9:16}-{Day141/10:5}. She thought he had been trying to create a good impression.541 Wray {Day141/9:16}-{Day141/10:5}. Ms Wray did not meet any of the other applicants, nor did she tell any of them that she had provided Carl Stokes with the information set out in the letter.542 Wray {Day141/10:6-18}.
70¶38.20 On the face of it, it appears that Carl Stokes was the favoured applicant because he had already carried out work for the TMO under its contract with Salvus and had continued to carry out work for it.
¶38.21 Carl Stokes submitted his tender on 24 August 2010.543 {CST00002368}. Thereafter, interviews were held with a panel of two officers of the TMO, Janice Wray and either Janet Rhymes or Valerie Sharples, and one officer of RBKC.544 {TMO00842327/1}; Wray {Day140/189:5-22}; Carl Stokes's interview was held on 6 September 2010 {CST00003159}.
¶38.22 Clause 1.5 of the consultants' brief required the consultant to hold a current fire risk assessment qualification.545 {TMO00842371/3} paragraph 1.5. Carl Stokes held a qualification from the Northern Ireland Fire Safety Panel, having gained a Fire Risk Assessment certificate on 12 December 2007.546 Stokes {CST00003063/5} page 5, paragraph 11; {TMO00880581/12}. The consultants' brief also required applicants to submit documentary evidence of their competence to undertake the appointment, in particular, their experience in assessing residential blocks.547 {TMO00842371/3} paragraph 1.4. Carl Stokes submitted a pack of certifications but he did not provide any other details of his qualifications and experience.548 Stokes {Day 136/72:21}-{Day136/73:14}; {TMO00880581}. The only document that demonstrated his qualifications and experience was a statement in a pro forma fire risk assessment he submitted549 Stokes {Day136/73:18}-{Day136/74:21}; Stokes {CST00003063/17} page 17, paragraph 50; {CST00003071}. that read as follows:
¶"Assessment completed by:
Mr C Stokes, ACIArb, FPA Dip FP (Europe), Fire Eng (FPA), NEBOSH, FIA BS 5839 System Designer, Competent Engineer BS 5266, IFE Assessor/Auditor (FSO). 19 years Fire Safety experience with local Fire Authority, in enforcement and auditing roles, 3 years as an independent fire risk assessor. Member of the construction industry CPD certification Service. Professional Indemnity insurance cover provided by Hiscox. Enhanced C R B checked."
¶38.23 Mr Stokes accepted in evidence that he had included that statement to lead the reader to think that he possessed the formal qualifications and professional body memberships set out in it.550 Stokes {Day136/75:5-21}. The purpose of including it was to advance his application to become the TMO's fire risk assessor.551 Stokes {Day136/74:17-21}.
¶38.24 The statement was false in a number of respects. All but one of the qualifications referred to either did not exist or were irrelevant or meaningless.552 Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/55-58} paragraphs 6.45 and 6.46. The only one that was valid and correctly stated was "ACIArb", indicating he was an associate of the Chartered Institute of Arbitrators, which had no bearing on fire safety.553 Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/55-56} paragraph 6.46. Carl Stokes also claimed to hold an "FPA Dip FP (Europe)", which, although incorrect in abbreviation,554 The correct abbreviation is "CFPA(EU) Dip". was intended to convey that he had completed the Diploma in Fire Prevention awarded by the Confederation of Fire Protection Association, as indeed he had.555 Todd {Day167/66:24}-{Day167/67:7}; Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/51} paragraph 6.16; {CTA00000011/56} paragraph 6.46. Carl Stokes was neither registered nor certificated by any professional or certification body as competent to carry out fire risk assessments.556 {CTA00000011/58} paragraph 6.47. He suggested that the post-nominals were meant to evidence qualifications, training and experience required by the Fire Safety Order,557 Stokes {Day136/77:11-15}. but the fire safety training he had completed did not entitle him to invent qualifications and use them as he did in that statement.558 Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/55-58} paragraph 6.46. Mr Stokes accepted that he had known at the time that the statement was thoroughly misleading.559 Stokes {Day136/81:24}-{Day136/82:6}.
71¶38.25 His claim that at the time he had carried out the fire risk assessment on 21 August 2010 he had been an independent fire risk assessor for three years was also false. In fact, he had begun work as an independent fire risk assessor only 11 months earlier on 24 September 2009.560 Stokes {Day136/83:9}-{Day136/84:12}. He accepted that the statement about the extent of his experience had been misleading.561 Stokes {Day136/84:13-15}.
¶38.26 Each of the fire risk assessments produced by Carl Stokes stated that he was "a member of the construction industry CPD certification service", which, he explained, meant that he had attended "formal CPD designated training 2 or 3 times a year", usually lasting for one day.562 Stokes {CST00030186/7} page 7, paragraph 25(iii). As Mr Stokes was not registered or accredited by any professional body, he was under no requirement to undergo continuing professional development, but both Dr Lane and Mr Todd considered that even an unregistered fire risk assessor would be expected to undergo a certain amount of regular training.563 Lane {Day171/27:20}-{Day171/28:9}; Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/46} paragraph 5.37. Mr Todd considered it necessary in order to keep up with new developments and to ensure that competence was maintained.564 {CTA00000011/46} paragraph 5.37. As Dr Lane observed, some regular training is necessary to ensure that a fire risk assessor has sufficient skill and knowledge to do his job.565 Lane {Day171/27:20}-{Day171/28:9}.
¶38.27 There was evidence that Mr Stokes did undertake a mixture of formal and informal training which complemented his practice as a fire risk assessor, such as attending training days and lectures held by fire industry bodies, such as the Fire Industry Association.566 Stokes {CST00030186/7-8} pages 7-8, paragraphs 25-27; Stokes {CST00030186/45-49} pages 45-49, Appendix 1. He did not keep a training log or any other written record of the training he had undertaken and was not required to do so.567 Stokes {CST00030186/8} page 8, paragraph 26. We saw no evidence that Carl Stokes consistently undertook any formal training on an annual basis during the years he was employed as the TMO's fire risk assessor and we conclude that he did not.568 Stokes {CST00030186/7-8} pages 7-8, paragraphs 25-27; Stokes {CST00030186/45-49} pages 45-49; {CST00030191}.
¶38.28 Janice Wray knew that Carl Stokes had elected not to join any professional bodies.569 Wray {TMO00000890/31} page 31, paragraph 139; Wray {Day140/197:17-19}. When she raised it with him, he told her that he did not feel that he would gain anything from such memberships.570 Wray {TMO00000890/31} page 31, paragraph 139. On 1 February 2013, the Fire Risk Assessment Competency Council published A Guide to Choosing a Competent Fire Risk Assessor (the FRACC Guide) which recommended using fire risk assessment companies, including sole traders, who were "third party certificated to appropriate schemes operated by Certification Bodies which have been UKAS accredited to certificate against such schemes."571 {HOM00025548/4}. but it could not make registration or certification mandatory. The FRACC Guide listed the holders of registers, such as the British Standards Institution, the Institute of Fire Prevention Officers (IFPO), the Institute of Fire Safety Managers, the Institution of Fire Engineers and Warrington Certificated Ltd.572 {HOM00025548/5}. Carl Stokes was never registered with or certificated by any of those bodies. Janice Wray was aware of the FRACC Guide and was aware that Mr Stokes had chosen not to join any professional register,573 Wray {TMO00000890/31} page 31, paragraph 139; Wray {Day140/197:17-19}. but she was not concerned.574 Wray {Day140/199:7-14}. She thought that, as he had already demonstrated his competence in the work he had done for the TMO, the FRACC Guide did not demand that he be certificated.575 Wray {Day140/200:2-15}. However, she thought it would apply to the appointment of any future fire risk assessor.576 Wray {Day140/197:22}-{Day140/200:16}.
72¶38.29 Ms Wray said that she did not think that the interviewing panel (of which she had been a member) had considered Carl Stokes's statements about his qualifications, but she thought they might have looked at a copy of his curriculum vitae,577 Wray {Day140/190:17}-{Day140/193:22}; {CST00001895}. in which he had claimed to be a fire risk auditor and assessor accredited by the Institute of Fire Engineers, even though he had not been a member of the institute.578 {CST00001895}; Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/57} paragraph 6.46. She knew at the time that Carl Stokes used post-nominals to describe his qualifications, even though they were not genuine, but she was surprised to be told that some of the qualifications which he claimed to hold did not exist.579 Wray {Day140/196:3-9}. His deliberately misleading description of his experience and qualifications demonstrate a lack of integrity and reliability on Mr Stokes's part, but it is the failure of the TMO and RBKC to pay any serious attention to his supposed qualifications that represent the more serious failing, since it betrays a fundamental carelessness about fire safety matters in the housing stock for which they were responsible.
¶38.30 When the TMO evaluated the competing tenders Carl Stokes's was rated first for quality; he also submitted the lowest price for a six-month programme.580 {TMO00842327/2}. Overall his tender was just over £2,000 cheaper than that of his nearest competitor.581 {TMO00842327/3}. He was thought to have the knowledge, competence, experience and enthusiasm to be a good partner.582 Wray {TMO00000890/31} page 31, paragraph 137. The fact that he was already known to the TMO because of his work with Salvus also weighed in his favour.583 Wray {TMO00000890/31} page 31, paragraph 137.
¶38.31 The consultants' brief required applicants to demonstrate that they were able to satisfy the provisions of a quality management system in accordance with BS EN ISO 9001,584 {TMO00842371/5} paragraph 3.2. but Carl Stokes was not required to satisfy that provision.585 Stokes {Day136/86:2-21}. He ought to have been. He was to all intents and purposes a sole trader who had no quality management system or arrangements in place for peer reviewing his work.586 Stokes {Day136/86:2-21}; {Day136/61:9-16}. Janice Wray was not concerned about that or about the fact that his work for the TMO would not be supervised.587 Wray {Day140/201:10-13}. She said that the LFB had still been heavily involved in scrutinising the TMO's fire risk assessments and that she had expected it to raise any problems quickly.588 Wray {Day140/203:11-23}. Moreover, she claimed to have challenged Mr Stokes's fire risk assessments when she did not agree with them,589 Wray {Day140/203:11-23}. but that is of little significance, since she had no relevant expertise and was certainly not independent. In the end she was reassured by the fact that he had been recruited by Salvus and that he had been one of the principal assessors it had used to produce fire risk assessments on its high-risk buildings.590 Wray {Day140/201:10-25}. She knew that he was familiar with many of the TMO's buildings. She said he appeared to be extremely knowledgeable and she understood that everything he had done appeared to meet the requirements of the LFB.591 Wray {Day140/202:12-15}; {Day140/202:20-25}.
73¶38.32 Ms Wray's approach was not in itself contrary to the Fire Safety Order, given that there is no requirement under article 9 for the responsible person to commission an independent fire risk assessment, nor for the person carrying out a fire risk assessment to be qualified or competent,592 See Chapter 12 for the examination of the role of government in regulating standards of competence in this area. but it did create a risk that the resulting fire risk assessment would not meet the statutory requirement of being suitable and sufficient. No good reason was given to justify the failure of the TMO and RBKC to require Mr Stokes to show that he could satisfy the provisions of an appropriate quality management system in accordance with the consultants' brief.
¶38.33 By the end of September 2010, Amanda Johnson had approved the appointment and confirmed the funding of the medium-risk programme.593 {TMO00842327/2}. On 28 October 2010, Robert Black approved the appointment,594 {TMO00842327/2}. although Carl Stokes had signed the contract seven days earlier.595 {CST00030040}. Laura Johnson was aware that the TMO obtained fire risk assessments because it was required to do so,596 Laura Johnson {Day129/79:16-19}. but neither she nor anyone else in the RBKC Housing department received copies of them.597 Laura Johnson {Day129/70:16-22}. Indeed, no one in the Housing department had the experience needed to analyse them or to challenge the TMO on their contents.598 Laura Johnson {Day129/71:4-15}.
¶38.34 On 25 November 2010, Janice Wray reported to the Operations Committee the completion of the high-risk programme and the appointment of Carl Stokes as fire risk assessor for the TMO's medium risk properties.599 Minutes of TMO Operations Committee meeting dated 25 November 2010 {RBK00052563/8}. She explained that he was willing to challenge the LFB if he considered its requirements to go beyond what it could reasonably require.600 Minutes of TMO Operations Committee meeting dated 25 November 2010 {RBK00052563/8}. Clearly, Mr Stokes's willingness to be an advocate for the TMO in disagreements with the LFB was a material factor in the decision to appoint him.
The expansion of Carl Stokes's retainer in December 2010
¶38.35 From December 2010 onwards, Carl Stokes carried out fire risk assessments for the TMO on its high-risk buildings.601 Stokes {CST00003063/9-10} pages 9-10, paragraphs 25 and 26; Stokes {Day136/89:7-15}; Wray {Day140/216:14-20}; {CST00001926}. The TMO did not invite tenders for that work.602 Wray {Day140/216:14-16}. Janice Wray believed she had taken advice from colleagues dealing with procurement, her line manager (Lornette Pemberton) and possibly RBKC before appointing Carl Stokes to review the fire risk assessments carried out the year before on high-risk buildings, but we have seen no evidence to support that.603 Wray {Day140/215:7-15}; {Day140/216:14-20}; {Day140/217:15}-{Day140/218:14}. It had not originally been intended to appoint Carl Stokes to carry out that work604 Wray {Day140/218:15-20}. but the need to review the assessments of the high-risk properties and the pressure of time led to a decision not to invite fresh tenders.605 Wray {Day140/216:21}-{Day140/217:15}. Neither the TMO nor RBKC had established a programme for the regular review of the fire risk assessments on high-risk buildings at the conclusion of the first programme in March 2010. As a result, the need for the reviews had been overlooked and there was no proper recruitment or selection process.606 Wray {Day140/217:8-18}. No written contract was entered into with Carl Stokes, who took over the work on an informal basis.607 Wray {Day140/219:7-10}; Stokes {CST00003063/10} page 10, paragraph 26. Janice Wray could not recall whether the appointment had been approved by the TMO executive team or RBKC or how the funding for it had been obtained.608 Wray {Day140/218:21}-{Day140/219:5}. The TMO simply drifted unthinkingly into a broader retainer of Carl Stokes without any formalities.
74¶38.36 When the programme of fire risk assessments on medium-risk buildings had been completed, the low-risk programme began. Carl Stokes was appointed to carry it out.609 {TMO00842318}. Sacha Jevans approved his appointment610 Wray {TMO00842341/3} page 3, paragraph 14; {TMO00842378}. and Mr Stokes signed the contract on 24 August 2011.611 {CST00030041}. The programme was completed in May 2012, well before the LFB's deadline of July 2012.612 {TMO10031056/2} paragraph 3.2.
¶38.37 Once the programmes covering the medium and low-risk buildings had been completed, the TMO continued to retain Carl Stokes as its fire risk assessor but did not enter into any new contracts with him.613 Stokes {CST00003063/10} page 10, paragraph 26. He became responsible for carrying out fire risk assessments on all 650 properties managed by the TMO.614 Wray {Day140/207:20}-{Day140/208:8}. He did not work exclusively for the TMO but it was his biggest client, having more buildings under its management than any other.615 Stokes {Day136/9:8-9}. Robert Black was aware that Carl Stokes had been retained but he did not know that his continued appointment had not been subject to a further procurement process.616 Black {Day150/17:2-17}. He had assumed that a formal procurement process of some kind had taken place and accepted that the failure to keep him informed pointed to a defect in the reporting processes and governance of the TMO.617 Black {Day150/18:3-16}.
¶38.38 Carl Stokes was allowed, therefore, to drift into his role as the sole fire risk assessor for 650 properties, many of which were high-rise buildings, without any regard to formal selection or contracting processes. That was not a proper or safe way for either the TMO or RBKC to seek to discharge their duties under the Fire Safety Order and it created a risk that the standard of the fire risk assessments produced as a result might not meet the statutory requirement.
75Carl Stokes's work as the TMO's fire risk assessor
¶38.39 Part 2 of the consultants' brief set out the scope of the work in relation to fire risk assessments that Carl Stokes had undertaken to carry out. Paragraph 1.1 of Part 2 required fire risk assessments to be undertaken and reviewed as regularly as the degree of risk dictated. It also required fire risk assessments to include an examination of each communal fire door.618 {TMO00842371/6} paragraph 1.1.
¶38.40 Paragraph 1.3 of Part 2 of the brief instructed the fire risk assessor to focus on a building's compartmentation (and any possible shortcomings), the operation and adequacy of fire doors, firefighting equipment and automatic detection and other systems, the means of escape, fire safety management systems and the overall fitness for purpose of the building in relation to fire safety.619 {TMO00842371/6} paragraph 1.3.
¶38.41 Janice Wray and Carl Stokes operated on the understanding that his work was always governed by the terms of the original contract, including the consultant's brief, even after his formal contracts for the programmes of fire risk assessments in relation to medium and low-risk buildings had come to an end.620 Stokes {CST00003063/10} page 10, paragraph 26; Stokes {Day136/89:25}-{Day136/90:8}; Wray {Day140/220:1-25}.
¶38.42 The LGA Guide described four kinds of fire risk assessment: Type 1 – Common parts only (non-destructive); Type 2 – Common parts only (destructive); Type 3 – Common parts and flats (non-destructive); and Type 4 – Common parts and flats (destructive).621 {HOM00045964/44-46} paragraph 35.1. Mr Stokes told us that he had carried out 'Type 1' assessments with elements of 'Type 3'.622 Stokes {CST00003063/16} page 16, paragraph 47. (He had carried out that hybrid type of fire risk assessment before the LGA Guide was published in July 2011.)623 Stokes {CST00003063/16} page 16, paragraph 47. The LGA Guide stated that unless there was reason to expect serious deficiencies in structural fire protection, such as inadequate compartmentation, or poor fire stopping, a Type 1 inspection would normally be sufficient for most purpose-built blocks of flats.624 {HOM00045964/45} paragraph 35.1.
¶38.43 On one reading of the Fire Safety Order, Carl Stokes was required to consider only the common parts of the building when carrying out a fire risk assessment.625 Stokes {CST00003063/13} page 13 paragraph 36; Wray {TMO00000890/31} page 31, paragraph 140. In the case of purpose-built blocks of flats, like Grenfell Tower, that meant inspecting the lift-lobby areas of each floor, the refuse chute rooms, the staircase enclosure and both sides of the entrance doors to the flats, but not the interiors of individual flats.626 Stokes {CST00003063/15-16} pages 15-16, paragraphs 43 and 44; {HOM00045964/44} paragraph 34.1; Stokes {Day136/94:2-18}. It was his practice also to report any problems with access to properties.627 Wray {Day140/236:20-25}. He was not expressly instructed to consider the external walls of the properties he inspected628 Wray {Day141/1:18-22}. and there was nothing in the LGA Guide to suggest that he should do so, unless there was reason to think that they might affect the compartmentation of the building.
76¶38.44 Carl Stokes's practice in relation to Grenfell Tower was to carry out a primarily visual inspection. He also carried out some additional inspection of the inside of front doors where he could gain access.629 Stokes {CST00003063/16} page 16, paragraph 48. In those circumstances, he checked the self-closer and whether a domestic fire alarm system was fitted.630 Stokes {CST00003063/16} page 16, paragraph 48. In 2015, he was also asked to check the heat interface units.631 Stokes {CST00003063/16} page 16, paragraph 48.
¶38.45 Mr Stokes agreed that for the purposes of making a Type 1 fire risk assessment he had to gain access to some flats in order to inspect the entirety of the entrance door, including the strips and smoke seals and self-closing device, if fitted.632 Stokes {Day136/94:2-25}.
¶38.46 PAS 79:2012, published by the British Standards Institution, contained the standards for carrying out fire risk assessments as they existed at the time of the Grenfell Tower fire. Paragraph (i) of the commentary on clause 16 says that fire safety management should be regarded as of equal importance to fire protection measures.633 {CTA00000003/50} clause 16, commentary, paragraph (i). Clause 16 of PAS 79 required that, among other matters, any shortcomings in evacuation procedures should be identified.634 {CTA00000003/54} clause 16.3. Carl Stokes was familiar with those provisions.
¶38.47 Mr Stokes assessed the TMO's fire safety management systems as part of his fire risk assessments on a continuing basis and expected Janice Wray to tell him if the TMO had changed its policies or procedures.635 Stokes {Day136/164:3-15}. He was aware of the need to consider the arrangements for maintaining all the fire prevention measures required under the Fire Safety Order.636 {HOM00045964/44} paragraph 34.5; Stokes {Day136/101:25}-{Day136/102:10}.
¶38.48 Carl Stokes frequently gave the TMO advice about matters relating to fire safety. For example, he might be asked whether matters he had raised in his fire risk assessment and action plans had been remedied or to provide comments or advice on discrete issues.637 Stokes {CST00003063/10} page 10, paragraph 28. He gave advice on matters such as the TMO's programme for the replacement of flat doors, potentially non-compliant entrance doors to leaseholder's flats and work on the gas supply and was asked to inspect and assess the front doors of particular flats.638 Stokes {CST00003063/29-33} pages 29-33, paragraphs 87-94; Stokes {CST00003063/47-48} pages 47-48, paragraphs 137-141; Wray{Day140/223:5-6}; {CST00000932}. In December 2016 and July 2017 he provided training to the Estate Service Assistants.639 Stokes {CST00030186/9} page 9, paragraphs 28-32.
¶38.49 Carl Stokes was never appointed to advise on the refurbishment of Grenfell Tower, although he occasionally provided advice to the TMO and Rydon about matters relating to the refurbishment.640 Stokes {CST00003063/11} page 11, paragraph 30(iv); Minutes of Grenfell Tower Progress Meeting No.22 dated 19 April 2016 {TMO10045055/2} Item 2.6. When Janice Wray wanted his advice on a particular matter she usually asked him to produce a report, which she then provided to the Asset Management team.641 Wray {TMO00000890/9} page 9, paragraph 44. Sometimes Claire Williams instructed him directly,642 Wray {Day141/2:24}-{Day141/3:6}. for example, if she wanted a second opinion on a matter or if the project team wanted him to produce a report.643 Wray {Day141/2:12-20}. During the course of the refurbishment he provided advice in relation to the smoke vents and lifts, rights of way to Grenfell Tower, the heating interface units, floor numbering and premises information boxes.644 Wray {TMO00000890/10-14} pages 10-14, paragraphs 45-64; {CST00000894}; Stokes {CST00030186/43-44} paragraphs 167-172; Stokes {Day136/140:5}-{Day136/162:14}; {CST00003088}; {CST00003173}; {CST00001258}; {TMO10043487}.
77Frequency of fire risk assessments
¶38.50 Carl Stokes carried out fire risk assessments on the properties managed by the TMO as instructed by Janice Wray.645 Stokes {Day136/129:5-9}. Initially, she sent him a list of the properties requiring inspection in November each year and he assessed the buildings during the course of the following year.646 Stokes {CST00003063/17} page 17, paragraph 51.
¶38.51 The TMO's fire safety strategy acknowledged that fire risk assessments could not remain valid indefinitely.647 {TMO00830598/9} paragraph 14.3.1. It required fire risk assessments to be reviewed periodically in various circumstances.648 {TMO00830598/9} paragraph 14.3.1. In the case of high-risk buildings, reviews were required annually and a new assessment every three years.649 {TMO00830598/10} paragraph 14.3.4. In the case of medium or low-risk buildings, the intention was to carry out reviews on a two-yearly basis with a new assessment every four years.650 {TMO00830598/10} paragraph 14.3.5. In practice, new fire risk assessments of Grenfell Tower, which was a potentially high-risk block, were made at least every two years. Two were carried out in 2016.651 Fire Risk Assessment of Grenfell Tower dated 29 December 2010 {CST00003181}; Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084}; Fire Risk Assessment of Grenfell Tower dated 26 April 2016 {CST00003161}; Fire Risk Assessment of Grenfell Tower dated 20 June 2016 {CST00003145}.
¶38.52 The reviews of the fire risk assessments were carried out by the TMO Health and Safety team, primarily by Adrian Bowman.652 {TMO00830598/10} paragraph 14.3.3; Wray {Day140/233:6-16}. Janice Wray's "colleague" in the TMO Health and Safety team was Adrian Bowman: Wray {Day140/212:24}-{Day140/213:2}. Their purpose was to monitor whether the measures recommended by Carl Stokes had been completed and to check for obvious changes to the building. That included anything that would cause an increased level of risk, such as anti-social behaviour or work being carried out on site, of which the TMO was unaware.653 Wray {Day140/232:14-23}. Adrian Bowman used the Significant Findings and Action Plans that Carl Stokes had submitted with the fire risk assessments to record whether remedial measures had been completed.654 Wray {Day140/212:18}-{Day140/213:2}; Wray {Day140/233:6-15}.
Meetings with Carl Stokes
¶38.53 Before he started work Carl Stokes met Janice Wray on two occasions to obtain information, once on 22 June 2010 and once on 24 September 2010.
¶38.54 In a letter to Janice Wray following their meeting on 22 June 2010, Carl Stokes asked her to send him a copy of the fire safety report produced by Salvus655 {CST00001887/2}. "to back up any fire related issues that may be raised in some of the reports".656 {CST00001887/2}. On 28 September 2010 Ms Wray sent Mr Stokes a copy of the report and action plan.657 {CST00004383}; {SAL00000013}. He told us that he assumed that he had read it, but could not remember having done so.658 Stokes {Day136/176:1}-{Day136/178:18}. If he did read it, however, it appears to have made very little impression on him. He did not recall having become aware of the weaknesses in the TMO's fire safety management system or the 19 statutory breaches that had been identified in the Salvus report.659 Stokes {Day136/176:1}-{Day136/178:18}. Janice Wray, for her part, expected him to read the report and to ask her about any outstanding items and when they would be completed. However, she could not recall any such conversation with him660 Wray {Day140/127:18}-{Day140/129:5}. and there is no evidence one ever took place. Carl Stokes does not appear to have taken any steps to find out whether the TMO had resolved, or planned to resolve, the statutory breaches identified in the report. We find that very surprising, given the widespread and significant failings identified by Salvus and the effect they must have had on the risk to the TMO's properties.661 Stokes {Day136/177:11}-{Day136/179:6}.
78¶38.55 A number of matters were discussed between Carl Stokes and Janice Wray at their meeting on 24 September 2010, some of which had already been covered in the meeting on 22 June 2010.662 {CST00003061}; {CST00001887}. The information Mr Stokes obtained on that occasion did not relate to any particular building,663 Stokes {Day136/220:21-25}. but he used it to fill out the fire risk assessments relating to various buildings.664 Stokes {Day136/125:14-20}. Not once during the seven years that he subsequently acted as the TMO's only fire risk assessor did he seek or obtain current information about the matters covered in the letters of 23 and 27 September 2010.
Carl Stokes's methods
¶38.56 The method adopted by Carl Stokes for carrying out fire risk assessments reflected the Health and Safety Executive's five steps for managing risks and PAS 79665 Stokes {CST00003063/13} page 13, paragraph 35; {CTA00000003}; {RBK00036722/13}; https://www.hse.gov.uk/simple-health-safety/risk/steps-needed-to-manage-risk.htm. He explained that in his fire risk assessments for 2009 and 2010 he had kept in mind the guidance in the government's publication Fire Safety Risk Assessment – Sleeping Accommodation and, following its publication in July 2011, LGA Guide.666 Stokes {CST00003063/13} page 13, paragraph 35; {RBK00036722}; {HOM00045964}. He would apply the HM Government Guide for Offices and Shops to the office part of Grenfell Tower: Stokes {CST00003063/13} page 13, paragraph 35(iii).
¶38.57 When Carl Stokes undertook a fire risk assessment, he obtained information from Janice Wray about the nature of the common parts and the active and passive fire safety measures they contained.667 Stokes {CST00003063/18} page 18, paragraph 55(i). He asked for any reports of the testing of dry risers or any other services in the building.668 Stokes {Day136/129:12-20}. He obtained maintenance and servicing records from the TMO's management system, Keystone, or by asking the maintenance department for them.669 Stokes {CST00003063/22} page 22, paragraph 67; {TMO00859318}; Stokes {Day136/131:15}-{Day136/133:19}; Parsons {TMO00870938/2} page 2, paragraph 10. If he could not obtain the information he needed, he drew attention to its absence in the action plan.670 Stokes {Day136/133:21-24}.
79¶38.58 If Mr Stokes had completed a fire risk assessment for a building previously, he usually reviewed the last Action Plan and checked whether the remedial measures had been completed.671 Stokes {CST00003063/23} page 23, paragraph 68; Stokes {Day136/145:7}-{Day136/146:5}; For an example see: Record of Significant Findings and Action Plan for Grenfell Tower dated 26 April 2016 with handwritten notes {CST00000003}. The check did not go much beyond a tour of the building and a look at the TMO's records (including what he described as "tick sheets") which showed what had been done since his last assessment.672 Stokes {Day136/129:12-20}; {Day136/147:21}-{Day136/148:16}. Janice Wray did not recall his ever asking her for completed action plans or sending him the action plan sheets and she could not recall a tick sheet at all.673 Wray {Day140/232:25}-{Day140/233:23}. We saw no health and safety tick sheets nor any evidence that he was sent completed action plan sheets. We have concluded that when drawing up the latest fire risk assessment he had little information before him about which of the remedial measures he had recommended in his previous fire risk assessment had been completed and which had not and why.
¶38.59 When he visited a building for a fire risk assessment, Mr Stokes inspected it and spoke to anyone he met, such as residents or contractors.674 Stokes {CST00003063/18} page 18, paragraph 55(ii); Stokes {Day136/202:16-24}. In the assessment he set out the names of those he had consulted, which would often be Janice Wray, one of the Estate Service Assistants or Claire Williams.675 For example, see Fire Risk Assessment of Grenfell Tower dated 29 December 2010 {CST00003181/3}; Fire Risk Assessment of Grenfell Tower dated 26 April 2016 {CST00003161/3}. He asked for certificates and records when the opportunity to do so arose.676 Stokes {Day136/69:11-16}. If work had been carried out by third parties, he would rely on their records.677 Stokes {CST00003063/22} page 22, paragraph 67(iii). He thought that the first fire risk assessment of a building took about four hours to complete and four hours to write up; it would take him less time to carry out a review of an existing assessment.678 Stokes {Day136/66:19-20}; {Day136/185:7-15}; {Day136/186:7-10}. He then prepared his fire risk assessment and a document entitled "Significant Findings and Action Plan".679 Stokes {CST00003063/19} page 19, paragraph 55(iv); Stokes {Day136/143:8-16}. After his inspection he could request additional information but often he would draw attention to any missing information in the Action Plan.680 Stokes {CST00003063/18} page 18, paragraph 55(iii); Stokes {Day136/143:8-16}.
¶38.60 If he was concerned about a particular matter, Carl Stokes included it in his Action Plan, which identified the risk or hazard and the remedial action to be taken.681 Stokes {CST00003063/23} page 23, paragraph 68. He categorised the item of the significant findings as of high, medium or low priority. The Action Plan was set up as a checklist for the use of the TMO.682 Stokes {CST00003063/23} page 23, paragraph 68. See for example, Record of Significant Findings and Action Plan for Grenfell Tower dated 17 October 2014 {CST00003177}.
¶38.61 Carl Stokes set out his findings in a fire risk assessment that followed a standard template approved by the TMO, RBKC and the LFB before the start of work on the medium-risk properties.683 Stokes {CST00003063/16} page 16, paragraph 45; Stokes {CST00003063/9} page 9, paragraph 24(iii); Stokes {CST00003063/17} page 17, paragraph 50; {TMO00842371/6} section 1.4; {RBK00029052/2}. At the time he entered into the contract on 21 October 2010 to carry out fire risk assessments on the medium risk properties Mr Stokes understood that copies would be provided to the LFB.684 Stokes {CST00003063/17} page 17, paragraph 50.
80Carl Stokes's fire risk assessments for Grenfell Tower
¶38.62 Carl Stokes carried out fire risk assessments of Grenfell Tower on 29 December 2010,685 Fire Risk Assessment of Grenfell Tower dated 29 December 2010 {CST00003181}; Significant Findings and Action Plan dated 29 December 2010 {CST00003165}. 20 November 2012,686 Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084}; Significant Findings and Action Plan dated 20 November 2012 {CST00003083}. 17 October 2014,687 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157}; Significant Findings and Action Plan dated 17 October 2014 {CST00003177}. 26 April 2016688 Fire Risk Assessment of Grenfell Tower dated 26 April 2016 {CST00003161}; Significant Findings and Action Plan dated 26 April 2016 {CST00003098}. and 20 June 2016.689 Fire Risk Assessment of Grenfell Tower dated 20 June 2016 {CST00003145}; Significant Findings and Action Plan dated 20 June 2016 {CST00003069}. In each case he identified the chief executive of RBKC as the responsible person,690 See for example, Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/3}. although he did not provide any of his assessments directly to RBKC.691 Stokes {Day136/191:10}-{Day136/193:9}. In fact, he had no contact with anyone at RBKC.692 Stokes {Day136/193:10-13}.
¶38.63 Provided nothing had changed, Mr Stokes's practice was to copy text from one fire risk assessment of Grenfell Tower to the next.693 Stokes {Day136/187:4-17}. He also copied text from fire risk assessments of other buildings. For example, in the fire risk assessment for Grenfell Tower dated 17 October 2014, he included some text referring to balconies taken from the assessment of another building, even though there were no balconies at Grenfell Tower.694 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/1}. The passage was then repeated in his fire risk assessment dated 26 April 2016.695 Fire Risk Assessment of Grenfell Tower dated 26 April 2016 {CST00003161/1}. Similarly, in section 11 of his fire risk assessments, he always included a passage headed "Pest control". In the fire risk assessment for Grenfell Tower dated 17 October 2014 he reported on the condition of pigeon netting on the balconies,696 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/18}. although there were no balconies on Grenfell Tower. That was simply lazy and careless and undermined the authority and quality of the fire risk assessment. Thoughtless drafting of that kind was bad enough, but it was aggravated by the fact that the same inapposite information was repeated in the fire risk assessments dated 26 April 2016 and 20 June 2016.697 Fire Risk Assessment of Grenfell Tower dated 26 April 2016 {CST00003161/19}; Fire Risk Assessment of Grenfell Tower dated 20 June 2016 {CST00003145/20}. Carl Stokes explained that the information had been repeated in those assessments because he knew that nothing had changed in relation to pest control and had not read the section again.698 Stokes {Day136/190:23}-{Day136/191:4}. He did not read through those fire risk assessments before sending them to the TMO,699 Stokes {Day136/191:5-7}. which Mr Todd described as very bad practice.700 Todd {Day167/78:21-24}. We agree.
¶38.64 What is worse, nobody at the TMO noticed those inapposite observations that had clearly been transposed from fire risk assessments on other buildings. That strongly suggests that Janice Wray did not read the fire risk assessments with any degree of care. If she had too many things on her desk to read and digest, she ought to have asked for help. In her own words, she was "spread very thinly", as she had responsibility for 650 buildings across the whole of the borough.701 Wray {Day140/48:12-20}. Failing to read such important documents with due care reflected the TMO's casual approach to fire safety.
81¶38.65 Carl Stokes included a section headed "Legal statement" in every fire risk assessment for Grenfell Tower. In it he told the recipient (in this case the TMO), among other things, that it did not have to give a copy to anybody, not even the fire authority, and that, if it did so, the document could be used against it at a later date.702 See for example, the Fire Risk Assessment of Grenfell Tower dated 20 June 2016 {CST00003145/2}.
¶38.66 Mr Stokes explained that he included that statement in his fire risk assessments because it was his understanding that the Fire Safety Order required the responsible person only to record the significant findings and make them available for inspection.703 Stokes {Day136/199:5-10}; Stokes {CST00003063/24} page 24, paragraph 70. As there was no requirement to record the risk assessment itself, he considered that there was no obligation to produce it to the fire service.704 Stokes {CST00003063/24} page 24, paragraph 70(ii). He considered that a fire risk assessment that was critical of the fire safety arrangements could be used against the responsible person at a later date.705 Stokes {CST00003063/24} page 24, paragraph 70(iii). Colin Todd thought that the statement was unnecessary, confrontational and wrong in law, given that the local fire and rescue service as the enforcing authority has extensive powers under article 27 of the Fire Safety Order to obtain information and documents relating to compliance with the Order.706 Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/76} paragraph 8.15. Again, we agree.
Quality management and auditing
¶38.67 Carl Stokes did not operate a quality management system or peer review process. A one‑man company can implement a quality management system and can also be certificated under BS EN ISO 9001.707 Todd {Day167/72:2-10}; Lane {Day171/32:8}-{Day171/33:2}. The absence of a quality management system was a structural weakness in Carl Stokes's business and the absence of such a system in relation to a company that was the only fire risk assessor for the TMO's entire portfolio of 650 buildings was a structural weakness in the TMO's fire risk management system.708 Todd {Day167/73:16}-{Day167/74:20}.
¶38.68 Janice Wray placed an undue amount of trust and confidence in Mr Stokes's ability to carry out sufficient and suitable fire risk assessments. Although she claimed to have read every fire risk assessment and action plan (which, for reasons explained above, we doubt she did with any care) and although she sometimes challenged Carl Stokes when she did not agree with him, she did not monitor the technical quality of his documents709 Wray {Day140/47:10-15}; {Day140/203:11-23}; Lane, Fire Safety Investigation Module 3 Report {BLARP20000027/145} paragraph 8.4.5. and could not have done so, since she had neither the necessary technical expertise nor the time to do it. As we have already mentioned, she was overworked as it was.710 Wray {Day140/48:12-20}. However, it was a significant failure on the part of the TMO not to monitor the quality of the work done by Mr Stokes as the sole provider of fire risk assessments for its portfolio of buildings.711 Lane, Fire Safety Investigation Module 3 Report {BLARP20000027/145} paragraphs 8.4.5 and 8.4.6.
¶38.69 The Publicly Available Specification "PAS 7:2013 entitled Fire risk management system – Specification" (PAS 7), published by the British Standards Institution in June 2013, contained guidance on the requirements for establishing a fire risk management system by which an organisation can put in place the practical steps required to carry out its fire safety policy.712 {LFB00116924/1-7}. It suggested that an organisation should audit its fire risk assessment programme after fire risk assessments had been delivered and conduct review meetings at planned intervals to discuss the results of the audits.713 {LFB00116924/23} paragraphs 7.4.3 and 7.4.4.
82¶38.70 Janice Wray was familiar with the provisions of PAS 7 but she did not arrange for the fire risk assessment programme to be audited.714 Wray {Day145/12:6-21}. Her excuse was that she could not find the time to do it and that she had received a degree of reassurance from the fact that the LFB had been asking questions about some of the fire risk assessments that had led her to understand that they were of a suitable and sufficient standard.715 Wray {Day145/14:9}-{Day145/15:25}. She accepted, however, that she should have arranged an audit and that she could not rely on the enforcement authority to act as an auditor.716 Wray {Day145/14:9}-{Day145/16:6}. Ms Wray could not recall ever having raised the question of auditing the fire risk assessment programme with Barbara Matthews, although she admitted that she should have done so.717 Wray {Day145/13:15-20}. Again, we agree.
¶38.71 Robert Black never gave any thought to whether a sole trader could properly act as the fire risk assessor for 650 buildings.718 Black {Day150/19:9-12}. Nor did he ever consider specifically whether Janice Wray had sufficient resources to carry out her fire safety responsibilities properly.719 Black {Day150/19:13}-{Day150/21:12}. He simply never brought his mind to bear on how the TMO, as the responsible person with statutory obligations, was actually setting out to discharge them. That indicates a lack of interest in matters of fire safety and explains his failure to exercise sufficient control over such matters. It also goes a long way to explain the casual approach to fire safety of the TMO as an organisation.
External concerns
¶38.72 In her first witness statement Janice Wray said that, as far as she could remember, the LFB had never commented on fire risk assessments produced by Carl Stokes in such a way as to give the TMO any reason to doubt his competence or the quality of the assessments themselves.720 Wray {TMO00000890/36} page 26, paragraph 158. In fact, however, that was not the case. There were many occasions when both Mr Stokes's competence and the quality of his fire risk assessments were called into question, not only by the LFB but also by others. In the end, Janice Wray was not only constrained to admit that her statement was incorrect, but was unable to provide any credible explanation of how she had come to make it.721 Wray {Day144/200:3}-{Day144/201:2}. On this aspect of our investigations, therefore, we have been able to place little weight on her evidence.
Concerns expressed by the LFB
¶38.73 During the last quarter of 2015, two of the LFB's fire safety inspecting officers, Julie-Anne Steppings and Michelle McHugh, told Rebecca Burton, the leader of the LFB's Fire Safety Team for Hammersmith, Fulham, Kensington and Chelsea, of the concerns they had about the approach taken in fire risk assessments produced by Carl Stokes for the TMO.722 Burton {Day145/119:1-4}; Burton {LFB00084098/12-13} pages 12-13, paragraph 24. As a result, between November 2015 and September 2016, she raised the matter with the TMO on a number of occasions.
83¶38.74 Among the concerns identified by Rebecca Burton were that Carl Stokes would rely on inspections by the LFB and undocumented discussions and agreements with LFB personnel as support for his assessments.723 Burton {LFB00032331/4-5} pages 4-5, paragraph 11. She did not think that he was providing the TMO with suitable and sufficient fire risk assessments and considered that the matter needed to be addressed.724 Burton {LFB00032331/5} page 5, paragraph 11. She also highlighted a tendency on his part when carrying out a fire risk assessment to select the most convenient parts of different documents rather than identify the most suitable guide and apply it in full to the premises in question.725 Burton {LFB00084098/7-8} pages 7-8, paragraph 11; {LFB00003439/1}.
Meeting between Janice Wray and Rebecca Burton on 13 November 2015
¶38.75 On 13 November 2015, a meeting took place between Janice Wray and Rebecca Burton following the fire that had occurred at Adair Tower on 31 October 2015. Neither of them kept a contemporaneous note of their discussions, but at different times each of them described the substance of them in emails to their respective superiors.
¶38.76 On 13 November 2015, Janice Wray sent a long email to Robert Black, Barbara Matthews and Sacha Jevans, in which she described the review being carried out by the LFB for the purposes of deciding whether to issue an enforcement notice. She referred to a number of questions that had been raised by Ms Burton, none of which had been critical of the fire risk assessment. She did not mention agreeing to raise any concerns with Carl Stokes.726 {TMO10011001}.
¶38.77 On 5 May 2016, Rebecca Burton reported what had transpired in an email to her superior, Spencer Sutcliff, when discussing the review. She said that various areas of concern about fire risk assessments had been discussed with Janice Wray, including the assessor's approach to self-closing devices on flat entrance doors generally, his claim that the LFB had agreed that self-closing devices were not required on flat entrance doors and the failure of his fire risk assessment to reflect an understanding of the strategy for the building and how occupants were to be kept safe in the event of fire.727 {LFB00003445/1}. Although he is not mentioned by name, it is obvious that when she referred to the fire risk assessor she was referring to Carl Stokes. She went on to record that Janice Wray had agreed to consider each of those points and discuss with Mr Stokes what improvements could be made.728 {LFB00003445/1}.
¶38.78 The difference between the two accounts no doubt reflects the authors' different interests but is striking, nonetheless. However, any difficulty we might otherwise have had in deciding whether Ms Burton did in fact voice criticisms of the fire risk assessment was resolved by Ms Wray's admission that during the meeting Ms Burton had indeed raised the matters to which she had referred in her email.729 Wray {Day144/204:2-4}. Ms Wray said that she had raised them with Carl Stokes, but we cannot be confident that she did, since there is no record of any such discussion.730 Wray {Day144/204:9-16}. That itself is a matter for criticism, since, if the LFB had serious concerns about Carl Stokes, she ought to have made a record of when and how she had raised those matters with him.
84¶38.79 Barbara Matthews was also well aware of the LFB's views about Carl Stokes's fire risk assessments.731 Wray {Day144/206:4-17}. On 30 November 2015, Barbara Matthews had a telephone conversation with Rebecca Burton, during which they discussed the proposed enforcement notices for Adair and Hazlewood Towers. According to her note of the call, Barbara Matthews was told by Rebecca Burton that the fire risk assessments for Adair and Hazelwood Towers were not suitable and sufficient, that Carl Stokes had not considered the question of smoke ventilation and that his risk assessments were not comprehensive.732 Barbara Matthews' notebook, entry date 30 November 2015 {TMO00880324/31}. Rebecca Burton confirmed the note as an accurate record of the discussion: Burton {Day145/126:10-14}. Barbara Matthews told us that she had thought that Rebecca Burton was criticising only the particular fire risk assessments under discussion and not his overall performance733 Matthews {Day148/75:23}-{Day148/76:4}. but she had no reason to believe that the defects that the LFB had highlighted were limited to those assessments and certainly should not have assumed that that was the case without further investigation.
¶38.80 On 4 December 2015, Barbara Matthews wrote to the TMO board to provide a report on the Adair Tower fire.734 {TMO00902920}. She said that the LFB had confirmed that it would serve enforcement notices in respect of Adair and Hazlewood Towers.735 {TMO00902920/1}. She explained that the LFB had advised the TMO of what she called "key matters of concern", specifically smoke ventilation and the absence of self-closing devices on flat entrance doors, but she made no reference to the direct criticism of Carl Stokes's fire risk assessments that Rebecca Burton had made during their conversation on 30 November 2015, less than a week earlier.736 {TMO00902920/1}; {TMO00880324/31}. Nor, strikingly, did she refer to the service of the deficiency notice in relation to Adair Tower on 12 October 2015, a point which is considered elsewhere in this report.
¶38.81 Barbara Matthews could not explain why she had failed to include in her report any reference to the criticism of Carl Stokes's fire risk assessments, but in hindsight she accepted that she should have drawn it to the board's attention.737 Matthews {Day148/81:23}-{Day18/83:2}. Her failure to do so was consistent with the desire of Robert Black and the executive team as a whole to keep any bad news about fire safety away from the board.
¶38.82 Rebecca Burton again raised her concern about Carl Stokes with the TMO at their bi‑monthly meeting on 5 January 2016. The minutes record that she told the meeting that Carl Stokes was prone to making statements that were not justified or supported and that he needed to provide support for what he said. If he referred to discussions with the LFB he needed to identify with precision in each case when they had taken place, who had been parties to them and what had been the outcomes.738 Minutes of bi-monthly meeting between LFB and TMO dated 5 January 2016 {LFB00032330/3} item 8. Janice Wray agreed to raise the issues identified by Rebecca Burton with Carl Stokes. Janice Wray told us that she did speak to him,739 Wray {Day144/208:9-11}. but the outcome is not clear and there is certainly no evidence that Carl Stokes's approach improved or that he absorbed the LFB's criticisms.
¶38.83 On 31 March 2016 there was a meeting of the TMO board at which Barbara Matthews described the progress of the enforcement notices relating to Adair and Hazlewood Towers.740 Minutes of meeting of the TMO Board dated 31 March 2016 {TMO10045103/4} item 9.1. At the meeting, Jeff Zitron, a board member nominated by the council, asked why enforcement notices had been issued, given that at the time of the fire the TMO had valid fire risk assessments.741 Minutes of meeting of the TMO Board dated 31 March 2016 {TMO10045103/4-5} item 9.2. Sacha Jevans responded, telling the board that enforcement notices had been served despite the fact that Carl Stokes had not identified any problems when carrying out his fire risk assessment, and that the LFB had identified none either when it carried out its fire audit.742 Minutes of meeting of the TMO Board dated 31 March 2016 {TMO10045103/5} item 9.2. That was wrong and misleading. In fact, the LFB had served a deficiency notice relating to Adair Tower on 12 October 2015, about 2 weeks before the Adair Tower fire, which had identified contraventions of Articles 11, 17(1) and 8 of the Fire Safety Order.743 {LFB00084110/3-4}. The contravention of Article 17(1) identified referred expressly to an absence of a self-closing device on a flat entrance door, in contradiction to the statement in the fire risk assessment that flat entrance doors were fitted with a self-closing device: {LFB00084110/4}.
85¶38.84 We have already commented on this and other examples of the TMO's executive officers misleading the board or failing to disclose to it material matters relating to fire safety. The result in this particular case was that Mr Zitron did not get a straight answer to his question but it was a question that the TMO ought to have asked itself instead of resorting to deflection and concealment. By this point, however, it seems that the TMO had become so heavily reliant on Carl Stokes that any challenge to his work was disregarded, even in the wake of a serious fire.
The TMO Health & Safety Report 2015/2016
¶38.85 In June 2016, Janice Wray and Barbara Matthews produced the TMO's Health & Safety Report for the period 1 April 2015 to 31 March 2016.744 {TMO10024405/1-22}. In the section relating to fire risk assessments, it said that suitable and sufficient fire risk assessments were in place which had been produced in accordance with best practice as set out in PAS 79.745 {TMO10024405/7} paragraph 7.9. No mention was made of the concerns raised by Rebecca Burton in November 2015 and January 2016. Janice Wray was unable to explain that omission,746 Wray {Day144/217:20-25}. but she accepted that unless she included those criticisms in the report, or the matter had been raised by Barbara Matthews, neither the TMO's executive team nor the board nor RBKC would have been aware of them.747 Wray {Day144/219:4-12}. Yet again, the board of the TMO was kept in the dark about concerns expressed by the enforcing authority about the quality of the TMO's fire risk assessments. That was a particularly important matter for the board to know because it put the TMO, and indirectly the members of the board, at risk of incurring liability for breach of the Fire Safety Order, which carried serious sanctions.
¶38.86 The report referred to the TMO's intention to procure a new contract for fire consultancy and fire risk assessment services.748 {TMO10024405/18} paragraph 15.2. Janice Wray and Barbara Matthews both denied that that had been prompted by criticisms of Carl Stokes's work.749 Wray {Day144/220:17}-{Day144/221:11}; Matthews {Day148/79:23}-{Day148/80:2}. In the event, the procurement manager apparently did not think that a new contract was required at that time and no steps were taken to obtain one. The subject was not discussed further by the TMO's Health and Safety Committee, the executive team or the board.750 {TMO10047034/19}.
87Chapter 39: Response to fire risk assessments
The duty to record significant findings
¶39.1 Article 9(6) of the Fire Safety Order requires the responsible person to record certain information, including the significant findings of the assessment and the measures which have been or will be taken by that person pursuant to the order.751 Fire Safety Order {BEI00001545/8} Article 9(7).
¶39.2 Guidance on carrying out fire risk assessments was published by the British Standards Institution in the form of Publicly Available Specification 79 (PAS 79). It represented current best practice in the industry. The edition of PAS 79 relevant to the fire risk assessments carried out in relation to Grenfell Tower by Carl Stokes (other than that carried out in December 2010) was PAS 79:2012. We therefore refer mainly to that edition in this section of the report.
¶39.3 Clause 19 of PAS 79:2012 provided guidance on the formulation of an action plan.752 PAS 79:2012 {CTA00000003/59-60} clause 19; Similar guidance is provided in PAS 79:2007 {CTA00000001/55-56} clause 18. It recommended that every documented fire risk assessment should incorporate an action plan such as to ensure that, if implemented, it would reduce the fire risk to, or maintain it at, a tolerable level.753 PAS 79:2012 {CTA00000003/60} clauses 19.1 and 19.2; PAS 79:2007 {CTA00000001/56} contains identical provisions at clauses 18.1 and 18.2. The commentary on Clause 19 stated that it was normally appropriate to allocate a priority to each measure recommended and gave an example of a scheme of prioritisation.754 PAS 79:2012 {CTA00000003/59-60} paragraphs (vii) to (xiv); PAS 79:2007 {CTA00000001/56-57} contains similar provisions.
¶39.4 In addition to the guidance, the annexes to PAS 79:2012 contained model documents available for use by fire risk assessors.755 PAS 79:2012 {CTA00000003/77-99}; PAS 79:2012 {CTA00000003/106-113}; Similar templates were included in PAS 79:2007 {CTA00000001/59-80} Annex A; PAS 79:2007 {CTA00000001/85-94} Annex D. Annex B contained a template that could be used for an initial fire risk assessment and Annex E provided a shorter template for a review of an existing fire risk assessment.756 PAS 79:2012 {CTA00000003/77-99} Annex B; PAS 79:2012 {CTA00000003/106-113} Annex E; PAS 79:2007 {CTA00000001/59-80} Annex A; PAS 79:2007 {CTA00000001/85-94} Annex D. It included prompts for the assessor to record any significant changes in the management of fire safety since the previous fire risk assessment.757 PAS 79:2012 {CTA00000003/111} Annex E. At the end of each template PAS 79:2012 included a basic pro forma action plan.758 PAS 79:2012 {CTA00000003/98-99}; PAS 79:2012 {CTA00000003/112-113}; PAS 79:2007 {CTA00000001/80}; PAS 79:2007 {CTA00000001/93-94}. Both of the PAS 79:2012 action plan templates provided space for recording the actions to be taken by the responsible person in a table that contained columns for priority, the identity of the person by whom action was to be taken and the date on which it was taken. They also contained sections for the assessor to indicate the overall level of fire risk that would be achieved once all the actions identified had been completed. In addition, the template for a fire risk assessment review included a section prompting the assessor to enter details of any actions identified on a previous occasion that had not been carried out by the time of the review.759 PAS 79:2012 {CTA00000003/113}; PAS 79:2007 {CTA00000001/93}.
88¶39.5 The TMO's fire safety strategy in force from November 2013 recorded that the LFB's Fire Safety team had been told that the assessment to be produced by the TMO's consultant would be based upon the pro forma in PAS 79.760 TMO Fire Safety Strategy dated November 2013 {TMO00830598/9} paragraph 14.1.3.
¶39.6 In their fire risk assessments produced for the TMO, Salvus and Carl Stokes both included a schedule setting out their significant findings and providing a plan for any necessary remedial work. However, although the purposes of the schedules were the same, the contents and approaches differed.
¶39.7 Salvus's action plan was incorporated in the risk assessment as part of a single document.761 Salvus FRA and Action Plan for Grenfell Tower dated 30 September 2009 {CST00003128}. That was necessary, because the action plan did not repeat the findings in the assessment that required remedial action. Instead, it referred to them using the item number in the assessment. In addition to setting out the action which needed to be taken, Salvus identified the time within which it should be taken. Space was provided to record the name of the person responsible for carrying it out and the date by which it should be completed. A colour-coded column indicated whether the action related to a statutory breach, was required to conform to best practice or guidance, or was simply recommended by the assessor. A column was available to record the name of the person carrying out a re-assessment. Finally there was a column to record any change in the level of risk.762 Salvus FRA and Action Plan for Grenfell Tower dated 30 September 2009 {CST00003128/15-19}. However, the form did not make provision for recording the overall risk to the premises once all the actions had been completed, as suggested by the template in PAS 79:2012. It also did not include a section relating to actions outstanding from previous assessments.
¶39.8 The format in which Carl Stokes produced his fire risk assessments was different. The schedule of significant findings did not form part of the assessment itself but was contained in a separate document described as a "Record of Significant Findings and Action Plan".763 Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 {CST00003165}. His form differed from that used by Salvus in that, as well as cross-referring to the section of the assessment which identified necessary remedial action, it also repeated the description of the risk or hazard that had been identified. It indicated the priority to be given to each action, whether high, medium, or low, with colour-coding, although without a key to explain the classification. At the head of the document there was an indication of the time within which each category of remedial measures needed to be completed. The form also provided sections in which the identity of the person or department responsible for carrying out the work and the date by which it needed to be completed could be recorded.
¶39.9 In contrast to the pro forma at Annex E of PAS 79:2012, Carl Stokes's form did not contain a section for the assessor to record any actions that had not been completed since the last inspection, nor did it contain an indication of the level of risk to the premises once the actions identified had been completed.
¶39.10 Carl Stokes understood that his form of risk assessment and Record of Significant Findings and Action Plan had been shown to and approved by the LFB.764 Stokes {Day137/36:11-13}; Specimen FRA and Action Plan {CST00003071}; {CST00003089}.
89Carl Stokes's practice
¶39.11 Carl Stokes said that when he identified concerns in the course of a fire risk assessment, he recorded them in the schedule of significant findings and assigned a priority for their completion.765 Stokes {CST00003063/19} page 19, paragraph 55(iv); Stokes {CST00003063/23} page 23, paragraph 68. He said that the document had been set out in that way to allow the TMO to use it as a checklist to ensure that all the points raised had been dealt with.766 Stokes {CST00003063/23} page 23, paragraph 68.
Subsequent inspection of premises
¶39.12 In his written statement Mr Stokes said that when he made subsequent visits to premises in order to conduct a fire risk assessment he would take with him the schedule of significant findings produced following his previous visit, which he would use as a starting point to ensure that all the points raised had been dealt with.767 Stokes {CST00003063/23} page 23, paragraph 68. That approach, had he actually adopted it, would have been in accordance with the guidance in clause 20 of PAS 79:2012, which advises that when a fire risk assessment is reviewed, consideration should be given to the extent to which the original action plan has been implemented and work that has not been completed identified.768 PAS 79:2012 {CTA00000003/61} paragraph 20(v). Carl Stokes confirmed that he was aware of this advice, Stokes {Day137/55:20-23}.
¶39.13 However, we doubt that he did in fact adopt that approach. Although the annotated copies of his significant findings and action plans for Grenfell Tower made in October 2014 and April 2016 contain his manuscript annotations,769 Handwritten notes on 2014 FRA Significant Findings Schedule {CST00003151}; Handwritten notes on April 2016 FRA Significant Findings Schedule {CST00000003}. there is no reference in any of his fire risk assessments or action plans to any outstanding (or indeed, completed) work that he had identified as necessary during a previous assessment.
¶39.14 When he gave evidence Carl Stokes said that it was his practice to ask Janice Wray to provide him with a printed copy of the previous fire risk assessment from which to work.770 Stokes {Day139/103:22}-{Day139/104:4}. He said that by comparing the state of the premises during his inspection with the records of his previous inspection, he could see that recommendations he had made on a previous visit had not always been completed, but he did not have any idea of the total number of recommendations outstanding at any time.771 Stokes {Day139/103:16-21}. Mr Stokes told us that he had raised the importance of completing actions during meetings with Janice Wray, but there is no record of any of those meetings.772 Stokes {Day139/104:5-21}. The TMO therefore had no reliable or comprehensive record of what remedial work Mr Stokes thought it particularly important to complete.
The involvement of the TMO's Health and Safety team
¶39.15 Once the information had been put on to the relevant TMO system, it could be distributed to the teams whose responsibility it was to carry out the work. It was primarily Janice Wray's responsibility to allocate the remedial work to the appropriate team in the TMO.773 Wray {Day141/33:20}-{Day141/34:8}.
90¶39.16 The way in which the information was recorded and processed by the TMO changed over time. From October 2010, the work was recorded in electronic spreadsheets and documents.774 Wray {Day141/25:10-18}. The documents contained information which appeared to have been copied from various different Action Plans and pasted into the document.775 See Composite FRA (High Risk) Action Plan Items for response repairs for Grenfell and other TMO stock {TMO10002330}. From August 2013, the TMO began to use a computerised system for logging recommendations. This system, known as "W2", was a database in which recommendations were recorded and by which work could be assigned to the appropriate team for completion within a given time.776 Wray {TMO00000890/33-34} pages 33-34, paragraph 148. When a job was assigned to a team, it would appear in that team's general "inbox" on the W2 system, along with any other tasks assigned to it.777 Wray {TMO00873629/17} page 17, paragraph 71. When a team had completed the work assigned to it, it could mark the tasks as complete and Janice Wray or one of her assistants would then close them.778 Wray {TMO00000890/33-34} pages 33-34, paragraph 148; Wray {TMO00873629/16} page 16, paragraph 65. When the W2 system was first introduced, it ran in parallel to Janice Wray's spreadsheet tracker until all the actions recorded in the spreadsheet had been completed. At that point the spreadsheet was closed.779 Wray {Day141/27:10-20}. On 25 May 2016, the TMO launched a new system, which took over the electronic processes for recording and monitoring remedial work. However, the TMO Health and Safety team did not use that system to record remedial work until about a week before the Grenfell Tower fire.780 Wray {TMO00873629/17} paragraph 70.
¶39.17 Where remedial work was assigned to the TMO Health and Safety team, Janice Wray could give instructions herself to Repairs Direct or the relevant contractor to carry it out. Instructions of that kind were given through the Capita Housing Management System.781 Wray {Day143/197:6-15}; Bowman {TMO00842308/1-2} pages 1-2, paragraph 2.
¶39.18 The methods of recording and monitoring we have described related only to actions recorded in the schedules of Significant Findings and Action Plan produced in the course of fire risk assessments. Any necessary remedial work identified by other means, for example by the LFB in a deficiency notice, was not recorded in or monitored using the electronic systems. We describe below how they were handled.782 Wray {Day141/222:21}-{Day141/224:11}.
Access to data
¶39.19 Throughout his time as fire risk assessor Carl Stokes was not given full access to relevant fire safety information by the TMO, despite his asking for it. In particular, many of the actions identified in the Significant Findings and Action Plans referred to the need for the TMO to confirm the maintenance of certain items of equipment. For example, in the Significant Findings and Action Plan for Grenfell Tower produced in November 2012, Mr Stokes sought confirmation that the smoke ventilation system was being serviced and maintained in accordance with the manufacturer's instructions.783 Record of Significant Findings and Action Plan for Grenfell Tower dated 20 November 2012 {CST00003083/5} item 23c.
¶39.20 Between 2010, when he began his assessments for the TMO, and October 2015, Carl Stokes had to rely for information about the maintenance and servicing of equipment on records printed out for him by the TMO Maintenance Department or Janice Wray.784 Stokes {Day136/131:15-25}.
91¶39.21 From 2010, the TMO recorded information on servicing and inspection of plant and machinery on a computer programme known as "Keystone".785 Parsons {TMO00870938/1-2} pages 1-2, paragraphs 5-6. Although he had been providing fire risk assessments for the TMO since 2010, Carl Stokes did not have access to the data held on Keystone until October 2015. He was eventually given remote access to Keystone in the hope that he could check for himself that servicing had been carried out and thus reduce the number of recommendations he made in the future.786 TMO Health & Safety Committee Minutes dated 16 April 2015 {TMO10009485/2} item 4.1. In any event, Carl Stokes had access to the Keystone system by the time he carried out the fire risk assessment in April 2016, as he recorded in that assessment that he had checked the Keystone records in relation to certain items.787 Record of Significant Findings and Action Plan for Grenfell Tower dated 26 April 2016 {CST00003098/7-8} item 23a and item 23e.
¶39.22 Even with access to Keystone, Carl Stokes was reliant upon TMO staff for some information because Keystone did not contain maintenance and servicing records for some equipment that was critical to fire safety. In particular, it did not contain maintenance and servicing records for the fire control system, dry rising fire main or emergency lighting system at Grenfell Tower.788 Lane, The Management and Maintanance of Grenfell Tower, Chapter 7, Module 3 Report {BLARP20000033/220} paragraph 11.2.56. Carl Stokes told us that if he could not obtain information for himself, he asked the TMO for the information he needed.789 Stokes {Day136/133:3-19}. If he was still unable to obtain the information, he would record in the Significant Findings and Action Plan that he did not have it.790 Stokes {Day136/133:21-24}.
¶39.23 However, we doubt that he was consistently conscientious in doing so and his requests for information were patchy. Paul Steadman, who was the estates services assistant (ESA) for Grenfell Tower at the relevant time, had no recollection of having been consulted by Carl Stokes in relation to a fire risk assessment,791 Steadman {Day146/84:9-25}. despite the fact that Mr Stokes recorded having consulted him by name in connection with the fire risk assessments for Grenfell Tower carried out in 2010, 2012, and 2014.792 Fire Risk Assessment of Grenfell Tower dated 29 December 2010 {CST00003181/3}; Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084/3}; Fire Risk Assessment of Grenfell Tower dated 10 October 2014 {CST00003157/3}. Moreover, Mr Stokes was never given access to the W2 system and was therefore unable to check for himself whether actions which had been identified during his previous visit to a property had been completed. He said that he had been forced to rely on documents printed out by Janice Wray,793 Stokes {Day138/121:5-22}; Wray {Day141/153:9}-{Day141/154:5}. Janice Wray was unable to recall whether she had provided Carl Stokes with spreadsheets from W2. She thought that she had probably done so for blocks in respect of which he had been requesting information, Wray {Day141/153:24}-{Day141/154:5}. but if that was so, it is surprising that they were not mentioned in his fire risk assessments.
The TMO's management of remedial work
¶39.24 Within its sections on formulating an action plan, PAS 79 provides guidance on prioritising actions and the time to be allowed for their completion. PAS 79:2007 provided a scheme comprising three priorities: "immediate", "short term" (within three months), and "long term" (to be carried out as and when the opportunity arose).794 PAS 79:2007 {CTA00000001/55-56} clause 18. PAS 79:2012 also provided a scheme comprising four priorities, which broadly replicated the 2007 scheme publication with the addition of a "medium term" category for implementation within three to six months.795 PAS 79:2012 {CTA00000003/59-60} clause 19(ix). It is clear from the text of both editions of PAS 79 that the intention of the document was that actions were to be completed within the timescales indicated. Both the 2007 and 2012 versions of PAS 79 recognise that other systems of prioritisation could be adopted, including a system which distinguished between items which breach legislation and those which do not.796 PAS 79:2007 {CTA00000001/56} clause 18; PAS 79:2012 {CTA00000003/60} clause 19(x).
92¶39.25 There were five categories of priority for implementing the remedial measures identified in the action plan produced by Salvus for Grenfell Tower.797 Salvus FRA and Action Plan for Grenfell Tower dated 30 September 2009 {CST00003128/19}. The highest three priorities required action within a short time, ranging from 24 hours to one month. Salvus also included a colour-coded designation, indicating whether an action represented a breach of statute (red), compliance with best practice or guidance (amber) or simply a recommendation (green).798 Salvus FRA and Action Plan for Grenfell Tower dated 30 September 2009 {CST00003128/19}. As such, the colour-coding was not directly related to the priority rating or the time for completion, but it gave a useful indication of the basis of the advice. The risk presented by each item was assessed separately and the action plan included a column for a revised level of risk once the remedial work had been completed.
¶39.26 The Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 resulted from Carl Stokes's first fire risk assessment of the tower.799 Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 {CST00003165}. He identified 23 separate risks or hazards, each of which was given a priority rating for completion on the scale "High" (2 – 3 weeks), "Medium" (1 – 2 months) and "Low" (3 – 6 months). He thought that those periods had been agreed between the TMO and the LFB, but Janice Wray could not confirm that and did not believe that a detailed discussion of that kind had taken place.800 Stokes {Day137/36:11-13}; Wray {Day141/53:8-13}. Mr Stokes confirmed that the document required actions to be completed within the periods indicated.801 Stokes {Day137/35:19-25}.
¶39.27 Carl Stokes also included a colour-coded designation of priority in his action plans. The TMO's fire safety strategy of November 2013 referred to that colour-coding as a guide to the priority to be accorded to different actions and explained that, like the Salvus colour‑coding system, red referred to measures required to comply with legal requirements under the Fire Safety Order and any significant risk to life, amber to recommendations relating to good practice and green to actions that would enhance fire safety based on good practice, but of a lower priority.802 TMO Fire Safety Strategy dated November 2013 {TMO00830598/9} paragraph 14.1.3. The fire safety strategy also confirmed that remedial work would be carried out in order of risk, with priority given to items with a red or amber rating.803 TMO Fire Safety Strategy dated November 2013 {TMO00830598/9} paragraph 14.1.3. Unlike the Salvus document, in which the colour-coding indicated the basis of the action and a separate system was incorporated to indicate priority, Carl Stokes's system effectively dealt with both aspects together.804 Under a system of that kind an item identified as a breach of legislation would always be categorised red and be prioritised, regardless of the actual risk it posed. By taking such an approach he conflated the gravity of the risk and the urgency of the work. We agree with Colin Todd that it is generally better to deal separately with the degree of risk and the time for completion of remedial measures, because, for example, it may be possible to eliminate a low risk quickly.805 Todd {Day167/26:21-24}; Todd {Day167/27:9-12}.
93¶39.28 Carl Stokes's form did not include a section for an overall assessment of the risk level once all remedial measures had been carried out, as suggested in Annex E to PAS 79, nor did it include a column for a revised level of risk, as did the Salvus template.
¶39.29 The next Record of Significant Findings and Action Plan for Grenfell Tower is dated 20 November 2012, reflecting Carl Stokes's fire risk assessment of that date. In that document the time within which high priority items were to be completed remained the same as in the 2010 schedule, but the time allowed to complete medium and low priority actions were both increased. In the case of medium priority actions the period of 1 – 2 months was increased to 2 – 3 months; for low priority actions it was increased from 3 – 6 months to 6 – 12 months.806 Record of Significant Findings and Action Plan for Grenfell Tower dated 20 November 2012 {CST00003083/1}.
¶39.30 Carl Stokes thought that he had extended the periods for medium and low priority actions because of relevant guidance, but he was unable to identify it when he gave evidence807 Stokes {Day137/37:19-25}. and none has come to light in any document we have seen. His extended periods did not accord with either the 2007 or 2012 versions of PAS 79. When pressed during his evidence for the specific source of guidance he had relied on to support the change, he suggested that he had taken them from the LGA Guide,808 Referred to elsewhere in this report as the LGA Guide. but that document contained no reference to the extended periods he adopted and provides guidance on the prioritisation of remedial measures only in the broadest of terms.809 Local Government Association Guide "Fire safety in purpose-built blocks of flats" {HOM00045964/47} paragraph 37.1. No other support for his decision has been identified.
¶39.31 The time allowed for completing remedial measures was changed again in the Action Plan for Grenfell Tower dated 17 October 2014.810 Record of Significant Findings and Action Plan for Grenfell Tower dated 17 October 2014 {CST00003177/1}. Although the periods allowed for each category remained the same, there was added in parenthesis after the period of 6 – 12 months relating to low priority work the words "to start to action any works". Carl Stokes confirmed that he intended the qualification to apply to all three priority ratings.811 Stokes {Day137/41:1-5}. The effect of that amendment was that whereas previously the TMO had been required to complete the work within the prescribed periods, it was now required only to have started it within that period. No date for completion was prescribed.
¶39.32 The TMO had not asked for the action plan to be altered in that way.812 Stokes {Day137/41:14-15}; Wray {Day141/61:20-23}. Carl Stokes's explanation was that "companies" had told him that they were encountering difficulties in completing work identified in action plans where they required capital investment which could not be provided at short notice.813 Stokes {Day137/39:12-23}. His reference to "companies" suggests that he understood it to be a problem that had either been raised by a number of clients or was widespread and well-known within the industry. However, neither of the experts who considered the matter thought that the change he had made reflected a standard approach in the industry. Colin Todd considered that without any reference to specific examples of major capital works, it was too broad and was unusual.814 Todd {Day167/31:19-25}. Dr Lane considered it to be entirely incorrect.815 Lane {Day171/2:19}-{Day171/4:6}.
94¶39.33 The main problem created by the change was that it meant that in theory a responsible person could allow remedial measures to remain incomplete indefinitely, provided they had been started within the required time.816 Stokes {Day137/41:10-13}. In practice, however, Janice Wray understood the change to mean that in situations where it was not feasible to complete the work with the prescribed time, for example, because it was necessary to undertake a procurement exercise, the TMO needed to be able to demonstrate only that the necessary process had been put in hand.817 Wray {Day141/62:7-13}. She explained that the teams to which work was assigned did not see the schedule in its original form, because they received their instructions only after the action had been put onto the W2 system for completion.818 Wray {Day141/63:17-22}. In those circumstances we think that Carl Stokes's unusual and potentially dangerous approach to the completion of remedial work from 2014 onwards probably had little or no effect on how the TMO dealt with the work in practice.
The TMO's approach
¶39.34 Although Carl Stokes included priority ratings for the risks identified in his action plans, the TMO did not always accept them uncritically. On the contrary, on occasions, the management team even went so far as to challenge his professional judgement and seek to persuade him to change his findings. That was despite the fact that they had far less experience in matters of fire safety than he did. Other than Janice Wray, senior managers at the TMO were not experienced in matters relating to fire safety management and had not received training on it during their time at the TMO. Barbara Matthews, the director responsible for health and safety had no previous experience in that field and had received no fire safety training before or during her time at the TMO.819 Matthews {TMO10049987/1-2} pages 1-2, paragraphs 4 and 8; Matthews {Day147/103:15-20}; {Day147/100:6}-{Day147/102:23}. Similarly, Peter Maddison, the TMO's Director of Assets and Regeneration, had no qualifications or experience in the management of fire safety.820 Maddison {TMO00000892/14} page 14, paragraph 79. Although Robert Black had had some practical experience of health and safety, he had no relevant qualifications821 Black {Day149/7:4-17}. and had received no fire safety training.822 Black {Day149/7:18-20}.
Re-categorising actions – discussions between Janice Wray and Peter Maddison
¶39.35 On at least two occasions in 2014 and 2015, Peter Maddison and Janice Wray discussed the categorisation of deficiencies identified in fire risk assessments. The common factor in their discussions was his wish to divide the remedial measures into categories or sub-categories of priority actions.
The June 2014 intervention
¶39.36 The minutes of the TMO's Health and Safety Operational Meeting on 20 June 2014 record that during a discussion of statistics relating to fire risk assessments Peter Maddison asked Janice Wray which of the actions could be defined as absolute requirements and which were best practice.823 TMO Health and Safety Operational Meeting Minutes dated 20 June 2014 {TMO10009784/2}. Janice Wray's view was that there was nothing to clarify, other than the number of actions and which ones were "red", that is to say, urgent.824 Wray {Day141/141:17-21}. She was clear that she would not adjust the priorities but she said that she had not thought that Peter Maddison was seeking to treat some red items as having a slightly lower importance.825 Wray {Day141/142:16-19}; {Day141/142:20}-{Day141/143:3}. The upshot on that occasion was that she resisted his request. However, he did not give up.
95Peter Maddison's next request
¶39.37 The minutes of the TMO's Health and Safety Operational Meeting on 23 February 2015 record a discussion between Janice Wray and Peter Maddison in which he suggested that it would be useful to have more information about priority levels and the nature of each outstanding action.826 Health and Safety Operational Meeting Minutes dated 23 February 2015 {TMO00869479/1-2}. Janice Wray agreed to "split the outstanding actions into high, medium and low categories with targets".827 Health and Safety Operational Meeting Minutes dated 23 February 2015 {TMO00869479/2}.
¶39.38 Initially Peter Maddison told us that he had been seeking more information about what the different categories of action entailed.828 Maddison {Day122/206:1-3}. He said that his intention had been to get a better means of understanding what the actions were, the risk they presented and the urgency of remedying them.829 Maddison {Day122/206:4-15}. He thought that was the information he had asked for in June 2014 but had not received.830 Maddison {Day122/207:9-23}. However, he later conceded that by February 2015 his team did have access to spreadsheets setting out the actions and suggested that he was looking for a summary overview.831 Maddison {Day123/20:7-18}. We are not sure what Mr Maddison wanted and we are unable to place much reliance on his evidence of his intentions at the time, as it was rather confused. Janice Wray also thought that Peter Maddison, or members of his team, already had the information he wanted, but she nevertheless ran reports and produced high‑level information.832 Wray {Day141/146:18}-{Day141/147:4}.
¶39.39 It is unclear why Peter Maddison felt it necessary to ask Janice Wray for information his team already held. He was emphatic that he was not seeking to change the priorities assigned by Carl Stokes, but was seeking to address the backlog of actions as effectively as possible, although he accepted he might have been seeking to understand which of the high priority work was the most urgent.833 Maddison {Day123/24:24}-{Day 123/25:6}; {Day123/16:8-14}.
The Adair Tower fire risk assessment
¶39.40 The clearest example of the TMO's seeking to challenge Carl Stokes's risk assessments occurred after the fire at Adair Tower on 31 October 2015. Following that fire, Carl Stokes reviewed the fire risk assessment and action plan for Adair Tower which were discussed at a meeting between him and the TMO on 19 November 2015.834 Stokes {Day138/190:3-12}. The draft Record of Significant Findings and Action Plan included at item 12e a high priority recommendation that self-closing devices be fitted to all flat entrance doors that did not already have them.835 Record of Significant Findings and Action Plan for Adair Tower dated 11 November 2015 {CST00026368/3}. Carl Stokes told us that during that meeting he had advised the TMO to undertake the work set out in the action plan.836 Stokes {Day138/190:16-21}. His recollection of the meeting was that, although the TMO had suggested that there was no legal or regulatory requirement to fit self-closing devices, he had told it to fit them.837 Stokes {Day138/190:22-24}.
96¶39.41 The next day, 20 November 2015, Peter Maddison sent an email to Sacha Jevans, Janice Wray, Robert Black, Alex Bosman and Daniel Wood at 07:45 in which he questioned Carl Stokes's assignment of a high priority rating to the recommendation that self-closing devices be fitted.838 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/3-4}. He explained that he did not consider that to be justified because it was not a statutory requirement to install self-closing devices retrospectively and because the entrance doors of the leasehold flats were demised to the leaseholders. The proposed action plan would therefore require the TMO to carry out work that it could not require the leaseholders to undertake.839 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/4}. Peter Maddison could not remember how he had gained the understanding that there was no statutory requirement to fit self-closing devices.840 Maddison {Day123/135:16}-{Day123/136:17}. In his email he went on to express his concern that committing itself to carrying out work that it did not have the power to undertake would leave the TMO exposed. He suggested that the priority be reduced to "low" or "advice" and that a note be added that the TMO could not enforce the requirement in relation to leasehold properties.841 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/4}. Peter Maddison was unable to explain exactly what he was concerned the TMO would be exposed to, other than possible criticism Maddison {Day123/134:9-13}.
¶39.42 Peter Maddison's view was supported by Barbara Matthews and Robert Black.842 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/1-3}. In her response, Barbara Matthews said that Janice Wray had been instructed to raise the matter with Carl Stokes and that a revised Record of Significant Findings and Action Plan would be provided to the LFB.843 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/3}. She later confirmed that Carl Stokes had changed his categorisation to "strong advice" (as he had), which, she said, had "no regulatory requirement or defined timescale" but was "advisory only".844 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/1}.
¶39.43 It is surprising that Barbara Matthews supported Peter Maddison's view, given that she was aware that the LFB was keeping a close eye on this matter. Only a week before those email exchanges, Janice Wray had attended a meeting with Rebecca Burton to seek clarification on its response to the fire at Adair Tower.845 Correspondence between Janice Wray, Robert Black, Barbara Matthews, and Sacha Jevans, regarding Adair Tower meeting with LFB Fire Safety Team Leader dated 13 November 2015 {TMO00840415}. Following that meeting, she told Barbara Matthews that the LFB was focusing specifically on self-closing devices and smoke ventilation systems and that she thought the LFB might take a kinder view of smoke ventilation if the revised fire risk assessment recognised the need to fit self-closing devices and it was programmed to be completed swiftly.846 Correspondence between Janice Wray, Robert Black, Barbara Matthews, and Sacha Jevans, regarding Adair Tower meeting with LFB Fire Safety Team Leader dated 13 November 2015 {TMO00840415/2}. Barbara Matthews therefore decided to support Peter Maddison's suggestion that Carl Stokes be asked to downgrade the urgency of the action on self-closers despite knowing very well that the LFB was considering taking action against the TMO with a particular focus on self-closing devices on flat entrance doors.
97Carl Stokes's response to pressure from the TMO to amend his findings
¶39.44 Carl Stokes had not been included in the email conversation discussed in the previous section. On 20 November 2015, he sent an email to Janice Wray advising that the item in the action plan concerning fitting self-closing devices should continue to be rated high priority,847 Email correspondence between Carl Stokes, Barbara Matthews and Janice Wray regarding FRA for Adair Tower dated 20 November 2015 {CST00026445/2-3}. but agreed to alter that to "strong advice", partly to appease the LFB. However, he reiterated that the fitting of self-closing devices to the front doors of flats should be given a high priority.848 Email correspondence between Carl Stokes, Barbara Matthews and Janice Wray regarding FRA for Adair Tower dated 20 November 2015 {CST00026445/3}. As a result, that item was downgraded to "strong advice" and was not colour-coded.849 Record of Significant Findings and Action Plan for Adair Tower dated 11 November 2015 {CST00009046/5} item 12i.
¶39.45 When Carl Stokes was asked about his decision to alter the action plan, he said he felt able to make the change as the work was in hand.850 Stokes {Day138/200:17}-{Day138/201:9}. He also said that his reference to "appeasing" the LFB meant helping them, as it was better to be on the right side of the enforcing authority.851 Stokes {Day138/199:4-21}. Perhaps surprisingly, given his email of 20 November 2015 at 09.48, he said he thought it had been appropriate for the TMO to challenge his professional judgement and suggested that he had decided not to oppose it as the work was being undertaken in any event.852 Stokes {Day138/201:15-25}. However, when pressed he accepted that the change appeared to have been the result of pressure put on him by the TMO.853 Stokes {Day138/201:10-14}. That is exactly what had happened. The TMO, in full knowledge of risks involved, persuaded him to downgrade an important aspect of his assessment in relation to a building in which a serious fire had already occurred and in respect of which the LFB was already considering enforcement action.
¶39.46 Dr Lane and Mr Todd agreed that altering a recommendation in that way in response to pressure from a client was not consistent with the standards to be expected of a reasonably competent fire risk assessor854 Lane {Day171/9:21}-{Day 171/10:5}; Todd {Day167/40:17-24}. and we have no hesitation in saying that in doing so Mr Stokes was not acting professionally or in accordance with those standards.
¶39.47 We have analysed this episode at length not because it had any direct impact on what occurred at Grenfell Tower 20 months later but because it illuminates so well the TMO's general approach to fire safety. Its behaviour in seeking to challenge and dilute Mr Stokes's risk assessment, not for the first time, suggests that the TMO treated the demands of managing fire safety as an inconvenience rather than an essential aspect of its care for those living in the buildings under its management. It was a betrayal of its statutory obligations to its tenants.
98Remedial work
¶39.48 When she entered remedial work on the W2 system Janice Wray included a time for completion, which she took from the Record of Findings and Significant Actions. The time was treated as running from the date that she received the action plan and entered the work on the system.855 Wray {Day141/59:21-25}. She understood that the work was to be completed within the time indicated.856 Wray {Day141/60:1-3}. Janice Wray explained that she treated any work that had not been completed as "outstanding", not merely those items which had not been completed when the time allowed expired.857 Wray {Day141/86:4-17}. Over time, the number of outstanding items of work increased, but they were broadly unrelated to any particular kind of risk and do not appear to have been taken into account in assessing the overall risk affecting the TMO's properties.
¶39.49 From early 2012, various committees and groups within the TMO began to identify problems in dealing with the outstanding work. The minutes of a meeting of the TMO Health and Safety Committee on 26 January 2012 recorded that Janice Wray was continuing to chase up work arising from the assessments in relation to high-risk buildings carried out by Salvus in May 2010.858 TMO Health & Safety Committee Minutes dated 26 January 2012 {TMO10001026/3} item 8. By January 2012, therefore, the TMO was at least 12 months behind in completing some of the remedial work. Although Ms Wray was very concerned about the backlog and took steps to discover its cause,859 Wray {Day141/88:6-22}. she did not know what it was, other than that there were problems with contractors.860 Wray {Day141/91:3-8}
¶39.50 The arrears of remedial works were discussed at a meeting of the TMO Assets, Investment and Engineering Health and Safety Group on 15 March 2012. The minutes recorded that some work to put right some high – and medium-risk defects had been outstanding for as long as two years.861 TMO Assets, Investment and Engineering Health & Safety Group Minutes dated 15 March 2012 {TMO00869800/2} item 5.2. By December 2012 a significant amount of work was outstanding, which was causing concern.862 TMO Assets, Investment and Engineering Health & Safety Group Minutes dated 13 December 2012 {TMO10001903/3} item 6.2.
The Hodgson Report (July 2013)
¶39.51 In July 2013, Matt Hodgson produced the report on his review of the TMO's safety management to which we referred in Chapter 37.863 TMO Safety Management Review by Matt Hodgson dated 19 July 2013 {TMO10003124}. In a section of the report dealing with fire risk assessments he recorded that there were between 900 and 1,000 outstanding items of remedial work waiting to be completed.864 TMO Safety Management Review by Matt Hodgson dated 19 July 2013 {TMO10003124/33}. The figure is significant, first, because Matt Hodgson clearly thought it large enough to justify specific mention and secondly, because it is the earliest record of the amount of outstanding remedial work presented in that form to the TMO's executive team.
¶39.52 Although Mr Hodgson had drawn attention to the existence of that huge number of outstanding items of remedial work, Robert Black had little recollection of that part of the report and did not remember what he had done about it.865 Black {Day150/81:10-22}. He did not take any steps to find out why a backlog of that size had been allowed to accrue, because he regarded that as the responsibility of Anthony Parkes. He could not recall any discussions about it following the receipt of the report.866 Black {Day150/81:10-15}; Black {Day150/81:20-22}. As a result, there was no direction from the top and nothing to indicate that it was a serious problem that needed to be resolved urgently.
99¶39.53 Matt Hodgson's report was discussed by the TMO's executive team on 7 August 2013.867 TMO Executive Team Minutes dated 7 August 2013 {TMO00899807/1-2} item 1.4. The minutes of that meeting do not record a detailed discussion about the number of outstanding items of work as such, but do reflect concern that the Assets and Regeneration department was being bogged down with recommendations addressing the situation.868 TMO Executive team Minutes dated 7 August 2013 {TMO00899807/2} item 1.4. There is nothing to suggest that the number of outstanding items was regarded as a shocking statistic that demanded to be treated as an urgent priority.
¶39.54 Matt Hodgson produced a further report on 13 September 2013.869 TMO Safety Management Review by Matt Hodgson dated 13 September 2013 {TMO00873398} and Chapter 4A more generally. The reference to the number of remedial items outstanding had been removed from that version of the report, which instead referred only to the number of high priority items completed between 28 February and 17 July 2013.870 TMO Safety Management Review by Matt Hodgson dated 13 September 2013 {TMO00873398/31-32}. The arrears were now presented as a percentage of the total number of high priority items completed within a six-month period. It is unclear why that measure was chosen because, although the figures identified relatively low percentages of completions, for example, 34% by Assets and Regeneration Building Services and 34% by Response Repairs, the overall number of outstanding actions, and thus the scale of the backlog, was missing from the report.
¶39.55 Recommendation 16 of Mr Hodgson's report was to take steps to eliminate the backlog of remedial work.871 TMO Safety Management Review by Matt Hodgson dated 13 September 2013 {TMO00873398/12}, recommendation 16. Janice Wray was quite glad that he had made that recommendation, because she thought it would force the TMO to take the necessary action.872 Wray {Day141/118:24}-{Day141/119:3}. That was a telling admission because it suggested that her efforts to persuade the TMO's senior management to take the backlog seriously had thus far been in vain.
¶39.56 The final report also stated that the lack of sufficient information provided to the executive team relating to compliance with statutory duties had resulted in a want of leadership in making important changes or decisions needed to manage risk effectively.873 TMO Safety Management Review by Matt Hodgson dated 13 September 2013 {TMO00873398/8}. The completion of outstanding remedial work identified in fire risk assessments was given as a specific example.
¶39.57 In his original report Matt Hodgson had also referred to a breakdown in communication between the Health and Safety department and other departments in relation to remedial work.874 TMO Safety Management Review by Matt Hodgson dated 19 July 2013 {TMO10003124/8}. Janice Wray denied there had been a breakdown in communications, although she accepted that there had been some frustration,875 Wray {Day141/111:19}-{Day141/112:15}. but the fact is that Mr Hodgson's view was near enough the mark. It was on any view a clear warning that remedial work and the associated risks were not being effectively managed by the TMO and that one reason for that was structural.
100¶39.58 Between March 2012 and June 2017, the need to clear the arrears of remedial work was a constant topic of discussion by the Health and Safety Committee, but it did not consider detailed statistics until July 2015. Despite Matt Hodgson's reports in 2013 and the discussions in the various committees from 2012, the TMO was unable to keep up with the flow of remedial work. Janice Wray prepared a paper ("Paper 2") for a meeting of the TMO Health and Safety Committee on 31 July 2015 which showed the number of items of remedial work completed, partly completed and outstanding. Of the 1,850 items recorded, only 941, or about 50 percent, had been completed, leaving 909 outstanding or only partly completed.876 TMO Health & Safety Committee FRA Action Statistics Paper dated 31 July 2015 {TMO10009662/1}. That was similar to the position in July 2013 when Matt Hodgson produced his first report. At no time does the TMO Health and Safety Committee or the executive team appear to have considered the risk to life presented by the arrears.
¶39.59 Following the presentation of Janice Wray's paper in July 2015, Barbara Matthews, who had recently taken over executive responsibility for health and safety, asked her to produce a more informative breakdown of outstanding actions so that the committee could see the details better and understand what programme of work would be required to clear them.877 TMO Health & Safety Committee Minutes dated 31 July 2015 {TMO10010039/3} item 4.1. For the meeting on 29 September 2015, Janice Wray produced statistics which included a breakdown of work by priority for the contract management team and a breakdown of contract management work by category, showing how long they had been outstanding (by year).878 TMO Health & Safety Committee FRA Action Statistics Paper dated 28 September 2015 {TMO10010066/4-6}. A further paper including the breakdown of actions by priority and type was produced in November 2015.879 TMO Health & Safety Committee FRA Action Statistics Paper dated 23 November 2015 {TMO10011191}. However, when statistics were produced for the January 2016 meeting, far less detail was included (only two pages of the document related to fire risk assessment actions) and the paper no longer included information about the priority of actions, although an age profile was included.880 TMO Health & Safety Committee FRA Action Statistics Paper dated 9 January 2016 {TMO10011910}. Janice Wray was unable to explain why some of the detail had been removed, beyond saying that she thought she may have run out of time to prepare the document.881 Wray {Day141/171:14-18}. Subsequent papers containing statistics on remedial work did not provide the same level of detail as the papers produced in September and November 2015.882 See TMO Health & Safety Committee FRA Action Statistics Paper dated 6 April 2016 {TMO10012642}; TMO Health & Safety Committee FRA Action Statistics Paper dated 10 March 2017 {TMO10016217}.
¶39.60 Despite those efforts to monitor the number of items of remedial work and the progress in completing them, the TMO had not been able to bring the arrears under control by the time of the fire at Grenfell Tower. At the meeting of the TMO Health and Safety Committee on 19 January 2017, Barbara Matthews raised concern about the number of items of work that had been outstanding for more than 12 months. She required the various teams to whom the work had been assigned to explain their plans to complete it,883 TMO Health & Safety Committee Minutes dated 19 January 2017 {TMO10016020/2} paragraph 4.1. but explanations were provided by only two of the five teams.884 TMO Health & Safety Committee FRA Action Statistics Paper dated 16 March 2017 {TMO10016217/3}. Explanations received from Health & Safety Team and Neighbourhood Management South. Peter Maddison suggested that only teams with actions older than 12 months needed to provide a report, Maddison {Day123/98:14-17} however this was not Janice Wray's understanding, Wray {Day141/189:22}-{Day141/190:3}. The progress made following the meeting of the Health and Safety Committee in March 2017 was evidently insufficient and Barbara Matthews again expressed her concern at the number of outstanding actions at the next meeting of the committee on 13 June 2017, the day before the fire at Grenfell Tower.885 TMO Health & Safety Committee Minutes dated 13 June 2017 {TMO10021548/3} item 3.1.
101Interim measures: paragraph 14.4.2 of the fire safety strategy
¶39.61 The TMO's fire safety strategy made specific provision for instances where it was not possible to complete remedial work within the required time. Paragraph 14.4.2 provided that if high-priority work could not be completed within the time indicated, interim measures would be implemented to reduce the risk in the short term.886 TMO Fire Safety Strategy dated November 2013 {TMO00830598/10} paragraph 14.4.2. That was a sound attempt, in theory at least, to render the risk as low as reasonably practicable, but the TMO failed to create suitable plans to ensure that necessary interim measures were identified, documented or completed.887 PAS 79:2012 {CTA00000003/59} Clause 19 (ix); Lane, The Management and Maintenance of Grenfell Tower, Module 3 Report, Chapter 8 {BLARP20000027/141} paragraphs 8.2.37 - 8.2.39.
¶39.62 Janice Wray said that paragraph 14.4.2 had not been intended to apply in all cases in which remedial work had not been completed within the time allowed but only in those where significant delay was expected, such as where a lengthy procurement process was needed.888 Wray {Day141/75:6-10}; {Day141/76:5-10}. However, whenever it was thought that it might not be possible to complete high-priority remedial work within times indicated in the action plan, consideration should have been given to adopting interim measures, if appropriate.889 Wray {Day141/77:4-12}. In reality, however, that was only ever an aspiration. Although Ms Wray thought that over the years a number of interim measures had been implemented by the TMO,890 Wray {141/78:21-24}. she could not identify any, other than those relating to the smoke control system at Grenfell Tower.891 Wray {Day141/78:25}-{Day141/79:8}.
¶39.63 We have not been able to identify any occasion on which the TMO implemented interim measures. The TMO did not record such measures and although Janice Wray said that she would have put the details into the W2 system if she had known of them,892 Wray {Day141/79:13-16}. there was in fact no field in which information of that kind could be recorded. Although interim measures were said to have been recorded as an "update", there was no evidence from W2 of that having been done.893 Wray {Day141/79:17-24}. Indeed, Janice Wray admitted that there had been no system to record the fact that interim measures had been considered in relation to any particular high priority item or that a decision had been taken about it one way or the other.894 Wray {Day141/81:1-8}. She accepted that it would probably not be possible to find out whether in any particular case interim measures had been considered.895 Wray {Day141/80:16-19}. There was no formal system for notifying Carl Stokes of any decision to implement interim measures, although it is likely that Janice Wray discussed the matter with him first.896 Wray {Day141/81:15}-{Day141/82:7}.
Reporting on the progress of remedial measures
¶39.64 Remedial work was monitored by the TMO's Health and Safety Committee and also, before July 2015, by the TMO's Health and Safety Operational Committee.897 TMO Health & Safety Committee Meeting Minutes dated 31 July 2015 {TMO00880645/3} item 4.1. At the TMO Health and Safety Committee Meeting on 31 July 2015, Barbara Matthews is recorded in the minutes as stating that she hoped the committee would become the only Health and Safety Committee {TMO00880645/2} item 2.1. The minutes of the TMO's Health and Safety Committee were circulated for the consideration of the executive team.898 See the distribution list at the foot of the minutes of the TMO Health and Safety Committee {TMO00880645/8}.
102¶39.65 Janice Wray prepared reports on safety performance which were presented to the executive team and to TMO board meetings by members of the executive team.899 Wray {TMO00000890/37} page 37, paragraph 168. Anthony Parkes and his successor, Barbara Matthews, reported to the executive team and, to the best of Janice Wray's knowledge, presented her reports to the executive team.900 Wray {Day140/38:24}-{Day140/39:6}. During his evidence, Robert Black explained that the TMO's budget was not big enough to have someone with Health and Safety expertise on the executive team, Black {Day149/27:5-9}.
¶39.66 It appears that the TMO executive team never reported to the board on the need for remedial work or the extent of the delay in carrying it out. That is consistent with its failure to report to the board other matters of importance to fire safety. Barbara Matthews said that the only health and safety matters referred to the TMO board were those which had been included in the annual health and safety report or exceptional items, such as matters to do with the enforcement notice served following the fire at Adair Tower.901 Matthews {Day147/105:18}-{Day147/106:4}. As a result, the board lacked the information it needed to perform its function. It did not know whether the TMO was complying with its statutory duties and did not have the information it needed to make decisions that might enable its management to eradicate the arrears of remedial work.
¶39.67 The TMO's executive team itself does not appear to have been regularly and reliably provided with information about the arrears of remedial work, which, as was plain from the content of the minutes, was a chronic problem. If it had been given that information and had reported properly to the board, the board might have realised that the TMO had long-term difficulty completing remedial work.
Auditing the fire risk assessment programme
¶39.68 Although Janice Wray and the other members of the Health and Safety Committee gave frequent consideration to the question of remedial work, they never attempted to identify trends and failings in the delivery and implementation of the fire risk assessment programme. Such an audit was advised by clause 7.4 of PAS 7:2013.902 {LFB00116924/23} paragraphs 7.4.3 and 7.4.4. The failure to undertake such an exercise contributed to the TMO's lack of understanding of the underlying causes of the problem and its inability to overcome the arrears.
Resources
¶39.69 At many points in her evidence Janice Wray blamed a lack of money for her failure to act in a more efficient and effective way, but the evidence does not enable us to reach any firm conclusion on that question.
¶39.70 Robert Black was unsure whether the TMO had a specific budget or sub-budget line item for health and safety, and agreed that the TMO "probably" did not have a line item within the general budget to cover remedial work identified in fire risk assessments.903 Black {Day150/14:18}-{Day150/15:3}. However, he said that, if Barbara Matthews had asked for additional funds to eliminate the arrears of remedial work, he was sure that he would have been able to provide them, although he noted that as finance director she knew where all the money was.904 Black {Day150/120:2-10}.
103¶39.71 Barbara Matthews told us that there had been a specific budget to enable the TMO to meet its health and safety obligations. Although the budget was restricted,905 Matthews {Day147/144:2-12}. if there had been specific demands which could not be managed within the existing budget, it would have approached RBKC for additional funds.906 Matthews {Day147/144:13-24}. She could not recall any occasion on which RBKC had refused a request for additional funds.907 Matthews {Day147/144:25}-{Day147/145:9}. However, it had not occurred to her to approach RBKC to obtain funding for additional staff to support Janice Wray because she had felt that she might not have been able to make a strong enough case.908 Matthews {Day148/136:5-16}. She thus appears to have adopted a degree of self-restraint when considering whether to ask RBKC for more funds. By contrast, Janice Wray was under the impression that no additional funding was available.
¶39.72 It is difficult to tell why Janice Wray and Barbara Matthews had such divergent understandings of the position, given their shared responsibility to deliver the fire risk assessment programme. Throughout her evidence Janice Wray referred to many instances in the years 2009 until 2017 when she thought that the absence of funds was the reason why work had not been undertaken or why additional resources or assistance had not been sought. An early example of this was when she was asked about emergency plans and the recommendation by Salvus to ensure that all emergency plans were in accordance with government guidance.909 Salvus Fire Risk Assessment of TMO Fire Safety Policy and Procedures dated 22 September 2009 {SAL00000013/18} row 9.1. When asked why the TMO had not followed Salvus's advice, she said that she suspected that resources had not been available, but she could not recall asking for additional resources to enable her to do so.910 Wray {Day142/30:1-13}. It is interesting to note that neither the minutes of the TMO Health and Safety committee nor those of the regular meetings between the LFB and the TMO in those years contain any reference to difficulties caused by a lack of funds for fire safety matters. That suggests that lack of resources was not a real constraint, but in the end we do not consider that we have enough information about the TMO's finances or the extent to which RBKC was willing to make additional funds available to it to be able to reach a reliable conclusion on that question.
Failure to assess the risk posed by the arrears
¶39.73 None of Carl Stokes's fire risk assessments considered the risk posed to residents by the TMO's longstanding failure to carry out remedial work in a timely manner. As a result, he did not consider the extent to which the risk to the occupants of the building was enhanced by remedial measures not being carried out within the time required. Secondly, he failed properly to assess the effectiveness of the fire safety management system.
¶39.74 Clause 20.2 of PAS 79:2012 advised that when a fire risk assessment was reviewed, the assessor should confirm whether work previously recommended has been carried out911 PAS 79:2012 {CTA00000003/62} clause 20.2. and the template in Annex E relating to a review assessment included a section headed "Action on Previous Action Plan".912 PAS 79:2012 {CTA00000003/112}. It thus prompted the assessor to record whether remedial work required by the previous assessment had been carried out.
104¶39.75 Dr Lane considered that a fire risk assessor could not make a suitable and sufficient assessment of the risks affecting a building without identifying whether previous recommendations had been satisfactorily addressed,913 Lane {Day171/14:8-13}. and that a failure to include in a fire risk assessment information about whether previously identified remedial work had been carried out fell below the standard of a reasonably competent fire risk assessor.914 Lane {Day171/14:17}-{Day171/15:2}. Colin Todd agreed that it was important for a fire risk assessor to document in the assessment or action plan any items from previous assessments that had not been completed.915 Todd {Day167/41:20}-{Day167/42:9}. His preference was to identify deficiencies that had been found on the previous occasion and had not been rectified rather than simply treat them as new items,916 Todd {Day 167/42:6-10}. but he said approaches varied and a failure to deal with them in that way did not of itself fall below the standard to be expected of a reasonably competent fire risk assessor.917 Todd {Day167/43:4-23}. However, we are not sure why, given the standards set by PAS 79 and the self-evident risks arising from not keeping a track on the progress of previous fire risk assessments.
¶39.76 Carl Stokes's fire risk assessments and significant findings and action plans did not contain a section recording the completion or otherwise of recommendations made during a previous assessment. There is some evidence that during his inspections he looked at the previous Schedule of Significant Findings and Action Plan in order to see whether the TMO had complied with his recommendations, but even if he did so, it did not contribute to his overall assessment of the fire risk and he did not record his findings in the documents provided to the TMO. As a result, he could not tell how long individual deficiencies had remained outstanding. That was particularly important when assessing the extent to which the risk to residents was affected by arrears of remedial work.
¶39.77 However, Carl Stokes was aware that the TMO was not completing remedial work within the recommended times. a. In each of the Schedules of Significant Findings and Action Plans produced in 2010,
2012 and 2014, he asked for confirmation that the caretakers were checking and testing the installed fire protection systems and emergency lighting.918 Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 {CST00003165/4-5} items 20, 23b & 23e; Record of Significant Findings and Action Plan for Grenfell Tower dated 20 November 2012 {CST00003083/5-6} items 23b & 23e; Record of Significant Findings and Action Plan for Grenfell Tower dated 17 October 2014 {CST00003177/9} items 23b & 23d. He said that he had been challenging the absence of a record of that work, but it must have been apparent to him by 2014 that, regardless of whether the checks and tests were in fact being carried out, the TMO had not established a proper system of keeping records over that 4-year period. Mr Stokes believed that he had taken that issue up with Janice Wray but was unable to recall the outcome.919 Stokes {Day136/210:18}-{Day136/211:10}.
¶b. On 13 November 2015, Alex Bosman sent Carl Stokes a consolidated spreadsheet containing a number of questions about recommendations that he wanted him to answer.920 Alex Bosman's FRA Queries Spreadsheet {CST00002213}. This document also contains entries where Alex Bosman asked Carl Stokes to "justify" the fire risk and classification of the action as "high risk" (Row 9). The spreadsheet contained recommendations relating to a range of buildings managed by the TMO drawn from assessments made in 2013, 2014, and 2015. They included recommendations classified as "high priority" which had been
105outstanding for 20 months.921 Alex Bosman's FRA Queries Spreadsheet {CST00002213}, see in particular Row 9. Mr Stokes responded a few days later attaching a revised spreadsheet containing his own annotations. It is clear from that document that by 16 November 2015 at the latest he had been aware that the TMO had been routinely and systematically failing to complete remedial work within the recommended times.922 Email from Carl Stokes to Janice Wray dated 16 November 2015 {CST00002482}; Annotated spreadsheet {CST00002483}.
¶c. In October 2016, Carl Stokes was instructed by Janice Wray to inspect Grenfell Tower before an audit scheduled to be undertaken by the LFB.923 Letter from Carl Stokes to Janice Wray dated 19 October 2016 {CST00003137}. The outcome of that inspection, as recorded in his letter of 19 October 2016, was that he found that 23 of the 46 recommendations he had made following the fire risk assessment on 20 June 2016, 43 of which had been described as being of "high priority", were still outstanding.924 Letter from Carl Stokes to Janice Wray dated 19 October 2016 {CST00003137}; Record of Significant Findings and Action Plan for Grenfell Tower dated 20 June 2016 {CST00003069}. Indeed, the majority of the recommendations in the June 2016 action plan were themselves outstanding from an earlier assessment made in April 2016.925 The Record of Significant Findings and Action Plan for Grenfell Tower dated 26 April 2016 {CST00003098} contained 42 entries; Record of Significant Findings and Action Plan for Grenfell Tower dated 20 June 2016 {CST00003069} contained 46 entries of which 31 were identical or in close terms to a corresponding entry from the April 2016 document. Further, 14 of the recommendations described by Carl Stokes in his letter of 19 October 2016 as outstanding appear in both the April and October 2016 action plans and were unresolved, despite having been brought to the TMO's attention six months earlier.
¶39.78 Accordingly, by October 2016 at the latest, Carl Stokes was aware that the TMO was not carrying out remedial work promptly. He expressed his frustration with the failure to complete work that ought to have been carried out within two or three weeks.926 Stokes {Day138/139:25}-{Day138/140:6}. He suggested that he had contacted Janice Wray to ask her why the work had not been undertaken but he could not remember what her response had been.927 Stokes {Day138/140:18-25}. He did not record his advice and there is no other evidence to show that he gave it.
107Chapter 40: The replacement of entrance doors
¶40.1 On the night of the fire, 13 of the entrance doors to the flats had been fitted when the tower was built, 104 had had been installed by Manse Masterdor Limited between 2011 and 2012 as part of a comprehensive replacement programme implemented by the TMO, three had been replaced since 2014, either by the leaseholder or by the TMO, and nine had been fitted to new flats on the lower floors of the building. The doors installed by Manse Masterdor were Suredor GPR fire doors.
¶40.2 Fire risk assessments of high-risk properties carried out in 2009 and 2010 had drawn the TMO's attention to the need to introduce regular inspections of entrance doors to flats to ensure that they complied with regulatory requirements. They had also drawn attention to the fact that many doors did not meet current standards and needed to be modernised or replaced. A survey of fire safety features of entrance doors conducted by Rand Associates across the whole of the TMO's housing stock completed in October 2010928 {TMO00866665}; Wray {TMO00847305/1-2} pages 1-2, paragraphs 5 and 7. found that a significant proportion of entrance doors did not have fire safety features and in particular did not have the necessary 30 minute fire resistance.929 {TMO00847327}. They could not, therefore, be modernised.930 KCTMO Health and Safety Annual Report 2010-2011 {TMO00854890/7} paragraph 8.1.9. The TMO therefore embarked on a programme of replacing entrance doors to flats in many of its buildings. Funding for the replacement programme was agreed with RBKC and various properties were selected for inclusion in it, including all tenanted properties at Grenfell Tower.
¶40.3 Abigail Acosta was project manager for the replacement programme until her departure from the TMO early in 2012.931 Wray {TMO00000890/3} page 3, paragraph 13; Acosta {TMO00862539/1} page 1, paragraph 1. In the initial phase of the programme, Simon Throp, the TMO's assistant director of the Assets Investment and Engineering team, was also involved.
¶40.4 The TMO procured replacement doors through the London Housing Consortium,932 Wray {TMO00847305/2-3} pages 2-3, paragraph 9. a social housing procurement company with a framework agreement for external doorsets.933 External Doorsets Specifiers' Guide {LHC00000006/1}. Following a competition, Manse Masterdor's tender was accepted by the TMO's Operations Committee on 22 February 2011.934 Minutes of the Operations Committee meeting on 22 February 2011 {TMO00866724/2} item 3.
¶40.5 A pilot door was fitted by Manse Masterdor at Flat 16, Grenfell Tower on 11 May 2011 and the rest of the work appears to have started soon after. The final doors were installed by February 2012 or thereabouts.
Regulatory requirements
¶40.6 The standard of performance required of a door in a compartment wall separating a flat from a space in common use, such as the entrance doors to the flats in Grenfell Tower, was set out in Appendix B to Approved Document B. It called for 30 minutes' integrity when tested in accordance with BS 476-22 and an ability to meet the requirements of BS 476‑31.1 or BS EN 1634:2004 for cold smoke leakage. It also had to meet those standards when exposed to fire on each side of the door separately as part of the complete assembly of the doorset.935 Dr Lane Phase 1 Report – Appendix I – Flat Entrance and Stair Fire Doors – requirements and provisions {BLAR00000024/30-31} sections I4.3.39 – I4.3.46 and {BLAR00000024/53} section I4.7.4. If it met those requirements, it was denoted FD30S.
108¶40.7 The Inquiry has seen two fire resistance test certificates for Suredor GPR fire doors, both of which confirm 30 minutes' integrity when tested in accordance with BS 476-22.936 Building Test Centre Report on fire resistance test on single leaf composite door BS 476 {MAS00000001}; Chiltern International Fire test report {MAS00000002}. However, it appears that no fire resistance tests were carried out937 Duncan {MAS00000356/2-4} pages 2-4, paragraphs 8, 9, 11, 14 and 15; Duncan {MET00040071/2}. in accordance with the standard because the test certificates show that the doorset was tested on one side only and not, as required, on both sides.938 Building Test Centre Report on fire resistance test on single leaf composite door BS 476 {MAS00000001}; Chiltern International Fire test report {MAS00000002}. There is no evidence that the door was tested for smoke leakage as required by BS 476-31.1.
¶40.8 Dr Lane and her team examined many of the entrance doors to the flats in Grenfell Tower after the fire for the purposes of Phase 1 of the Inquiry and in Annex I of her report she identified numerous discrepancies between the construction of the doors fitted to the flats and the construction of the door that had been subjected to testing.939 Dr Lane Phase 1 Report – Appendix I – Flat Entrance and Stair Fire Doors – requirements and provisions {BLAR00000024/30} sections I4.3.42, {BLAR00000024/40-53} I4.5.29 – I4.5.88 and I4.7.4. We accept her evidence, from which it follows that in many, if not all, cases the doors installed under the replacement programme did not satisfy the requirements of Approved Document B for that reason also.
The specification
¶40.9 Simon Throp drafted the specification for the doors to be used for the replacement programme.940 Acosta {Day166/7:6-18}; {Day166/16:6-12}; {Day166/18:9-18}; Letter from Carl Stokes to Janice Wray dated 7 March 2011 updated on 10 March 2011 {CST00013074/2}; Wray {Day143/42:8-19}. Carl Stokes and Janice Wray941 Stokes {Day138/39:1-5}; {Day138/40:4-15}; Wray {Day143/40:13-15}; Acosta {Day166/17:6-18}; Wray {Day143/39:9-25}. were either consulted or provided general advice about the relevant regulatory requirements.942 Acosta {Day166/21:13-24}.
¶40.10 The tender documents required that the doors be "Security/30 min fire doors",943 Manse Masterdor Ltd Tender Documents 2011 {MAS00000035/3}; {MAS00000035/90-91}. but despite the clear requirements of Approved Document B, they did not specify that the doorsets should be rated FD30S, nor did they expressly require the inclusion of cold smoke seals or confirmation that cold smoke leakage testing had been carried out. The documents did require fire test certification to be provided on request, but there was no similar requirement in relation to cold smoke leakage.944 Manse Masterdor Ltd Tender Documents 2011 {MAS00000035/93}.
¶40.11 In its letter of 22 February 2011 conditionally accepting the bid, the TMO said that the schedule of individual door prices provided by Manse Masterdor in the tender documents would be incorporated in the contract.945 Letter from the TMO to Manse Masterdor Ltd dated 10 February 2011 {MAS00000016/1}. The schedule referred to the doors as being rated FD30S but no further details were provided.946 Manse Masterdor Ltd Tender Documents 2011{MAS00000035/7}. That was the only reference to the FD30S rating in the tender documents or product literature seen by Carl Stokes or others at the TMO.
109¶40.12 Carl Stokes referred to three documents which he said had given him some assurance that the doors were available as 30-minute fire doors:947 Stokes {CST00030186/15} page 15, paragraph 59. the Manse Masterdor "Suredor" brochure,948 {CST00000116}. a style guide949 {CST00002070}. and a specification sheet.950 Manse Masterdor specification sheet {CST00002306}. It is true that the style guide indicated that some doors were available as 30-minute fire doors, but none of them was said to be available with an FD30S rating or with appropriate testing for cold smoke leakage. It seems clear to us that the Suredor GPR door was being marketed primarily as an entrance door for ordinary domestic use, for which a fire and smoke rating was not required.
¶40.13 Although it is unclear whether the TMO received copies of the certificates relating to tests carried out in accordance with BS 476-22, no one took any steps to check whether the doors supplied corresponded to the test certificates available.951 Wray {Day143/57:13}-{Day143/58:3}; Stokes {Day138/66:8-22}, {Day138/67:3-13}; Acosta {Day166/31:15}-{Day166/32:18}; Pollard {MAS00000341/3} page 3, paragraphs 14 and 17 (certificates were provided to the TMO on two occasions).
Carl Stokes's advice
¶40.14 Carl Stokes was asked to advise the TMO on the requirements for fire doors in the relevant guidance952 Stokes {CST00030186/15} page 15, paragraph 57. and gave the TMO written advice on 7 March 2011953 Letter from Carl Stokes to Janice Wray dated 7 March 2011 updated on 10 March 2011 {CST00013074}., 23 May 2011954 Letter from Carl Stokes to Janice Wray dated 23 May 2011 {CST00000991}. and 24 June 2011955 Letter from Carl Stokes to Abigail Acosta dated 24 June 2011 {CST00003149}.. Although he correctly identified the test standard for fire resistance, BS 476-22, he made no reference to the requirement for doors to be tested for cold smoke leakage. However, he was consistently clear that self-closing devices and smoke seals were required. He understood that the entrance doors to flats were required to be FD30 doors with the addition of smoke seals956 Stokes {Day138/39:25}-{Day138/40:3}; {Day138/52:12-17}; {Day138/55:7-19}; {Day138/56:3-19}; {Day138/61:5-8}. and believed that "S" indicated that a cold smoke seal was fitted.957 Stokes {Day138/65:18-19}. He was clearly unaware of the requirement for entrance doors to flats on protected corridors to have been tested for cold smoke leakage to the standard set out in BS 476-31.1.
¶40.15 Following a meeting with Simon Throp and Janice Wray on 10 March 2011, Carl Stokes wrote to Janice Wray958 Letter from Carl Stokes to Janice Wray dated 7 March 2011 updated on 10 March 2011 {CST00013074}. asking her to obtain documentation from Manse Masterdor to confirm that the doors to be supplied would be the FD30 version and complied in all respects with the Building Regulations and the "Sleeping Guide". At the same time he pointed out the absence from the information he had seen of any references to self-closing devices or intumescent seals.
¶40.16 Carl Stokes had originally drafted the letter on 7 March 2011, three days before his meeting with Mr Throp and Ms Wray. In a note added after the meeting he recorded that Mr Throp had confirmed that the doors would have self-closing devices and cold smoke seals.
¶40.17 Carl Stokes attended the pilot installation of a Suredor GPR fire door by Manse Masterdor on 11 May 2011. He said that he had checked the sticker on the door to confirm that it was rated FD30.959 Stokes {Day138/52:11-14}.
110¶40.18 Following the pilot installation, Carl Stokes wrote to Janice Wray on 23 May 2011 telling her that on the basis of technical sheets she had given him and information provided by the installation team, the door was a fire-rated (FD30) version of the Suredor GRP fire door.960 Letter from Carl Stokes to Janice Wray dated 23 May 2011 {CST00000991/1}. It is clear that he had not seen the fire resistance test certificates for himself and that he made his assessment of the doors on the basis of the limited information provided to him961 Stokes {Day138/62:10-15}. and what he saw during the pilot installation. He said that having seen smoke seals fitted to the door frame he was satisfied that the doors were indeed rated FD30S.962 Stokes {Day138/64:9-25}. From his letter of 23 May 2011, it appears that he was satisfied that the doorset met the regulatory requirements.963 Letter from Carl Stokes to Janice Wray dated 23 May 2011 {CST00000991}. Colin Todd thought it was reasonable to infer from the presence of a seal that a door was rated FD30S.964 Todd {Day167/220:1-9}; {Day167/221:24}-{Day167/222:20}.
¶40.19 On 24 June 2011, Carl Stokes wrote to Abigail Acosta about the standards required for entrance doors to residential flats. He said that the doors should have a minimum of 30 minutes' integrity when tested in accordance with BS 476-22, be fitted with a self‑closing device and intumescent strips and a cold smoke seal, in other words that they should bear the suffix "S".965 Letter from Carl Stokes to Abigail Acosta dated 24 June 2011 {CST00001388/1}.
¶40.20 Carl Stokes did not tell the TMO that entrance doors to flats should be tested for cold smoke leakage and his advice led Janice Wray to understand that, if doors had been tested for fire resistance for 30 minutes and had self-closing devices and smoke seals, they were FD30S doors.
¶40.21 The TMO's invitation to tender did not specify, as it should have done, that FD30S doors were required.966 Manse Masterdor Ltd Tender Documents 2011 {MAS00000035}. Responsibility for that omission lies squarely with the TMO, which should have taken effective steps to make sure that it was procuring entrance doors that met the required standards. However, conditions on the night of 14 June 2017 were such that even a door rated FD30S would have provided little protection to the lobbies or the occupants of any of the flats.
111Chapter 41: Inspection and maintenance of entrance doors
¶41.1 On the night of the Grenfell Tower fire many of the self-closing devices on the front doors of flats in the block failed to work effectively and some were entirely missing. As a result, many doors remained open when the occupants left, allowing smoke to enter the lobbies, which quickly became smoke-logged. The absence of effective self-closing devices was therefore an important cause of the inability of many occupants to escape the tower at a time when the stairs were relatively free of smoke. It represents a serious defect in the management of the building in relation to fire safety.
Legislation and guidance
¶41.2 Under article 17(1) of the Fire Safety Order the responsible person must ensure that any equipment or devices provided in respect of the premises under the order are subject to a suitable system of maintenance and are maintained in efficient working order and good repair where necessary in order to protect the safety of relevant persons.
¶41.3 Among the equipment and devices that fall within article 17(1) are fire-resisting doors and self-closing devices. Part G of the LGA Guide, which is entitled "Managing fire risk – ongoing control", indicates that arrangements for managing fire safety in a block of flats should include putting in place programmes for routine inspection, testing, servicing and maintenance of fire safety systems, such as fire-resisting doors and monitoring the common parts, both through formal inspections and informally as part of day-to-day activities by staff.967 {HOM00045964/112}. It also recognises that whatever safety equipment is provided, its effectiveness will depend on proper inspection and maintenance.968 {HOM00045964/113}.
¶41.4 Section 82.3 of the LGA Guide advised that it was good practice to inspect timber fire‑resisting doorsets every six months with a view to identifying defects, such as missing or ineffective self-closing devices and doors which had been replaced with non-fire-resisting products.
¶41.5 The Guide also said that entrance doors to flats should be fitted with effective self-closing devices that should be replaced as a matter of urgency when found to be missing or damaged. It also warned of the dangers of residents' removing or disconnecting them.969 {HOM00045964/99}; {HOM00045964/105}.
¶41.6 Before the LGA Guide was published, on 30 April 2011 Carl Stokes wrote to Janice Wray about a draft version dated 18 April 2011970 {TMO00847318/1}; {CST00012483}. quoting certain paragraphs which he considered could affect the programme for the replacement of entrance doors.971 {TMO00847318/1}. Paragraph 68.2 in the draft LGA Guide was materially the same as that in the published version. Janice Wray was therefore aware by 30 April 2011, if not before, that entrance doors needed to be fitted with self-closing devices and that residents might remove or disconnect them.972 Wray {Day143/68:7}-{Day143/69:5}.
112Problems with self-closing devices
¶41.7 Shortly after Manse Masterdor began installing new entrance doors in March 2011, two problems began to emerge with the concealed self-closing devices fitted to them. One was a mechanical fault in the self-closing device which prevented the door from closing or which caused it to become stuck in the closed position. That appears to have been caused by a defect in the fixings connecting the self-closing device to the door and the doorframe. The other was that the self-closing devices were too strong for some residents, particularly those who were elderly or frail, who had difficulty opening and closing their doors. The evidence suggests that both problems were inherent in the design or manufacture of the doorsets rather than the result of defective installation. However, whether the problem was one of design, manufacture or installation, doors were proving difficult to open easily and the solution adopted by many, including the TMO's repair staff, was to remove the self‑closing devices, even though they were an important fire safety measure.
¶41.8 Our conclusions about the extent to which one or other of those problems affected the self-closing devices at Grenfell Tower and the extent to which they were remedied before 14 June 2017 depend to a significant extent on evidence provided by residents about their entrance doors and the requests for repairs sent to Manse Masterdor and the TMO. That evidence has its limitations, however. For example, there are many references to doors' not opening or closing properly that do not identify any more clearly the nature of the problem. Moreover, the lapse of six years between the start of the door replacement programme and the fire means that other factors, such as wear and tear, may have contributed to the condition of some of the self-closing devices on 14 June 2017. We have made findings about the condition of self-closing devices on 14 June 2017 where the evidence gives us sufficient confidence to do so, but it is important to acknowledge at the outset the limited nature of the information available to us.
Early discovery of failings: 2011
¶41.9 On 17 May 2011, Andy Webster, a project manager for Manse Masterdor, sent an email to fellow employees Paul Birkett and Richard Moore about the entrance doors being installed for the TMO in which he referred to a defect in concealed self-closing devices that prevented doors from closing. He recognised that the doors should not have left the factory in that state.973 {MAS00000187/82}.
¶41.10 It is unclear from Mr Webster's email what the precise nature of the fault was, except that it prevented the doors from shutting. It appears to have arisen during the design or manufacturing process, but it is unclear how. It is not clear what steps Manse Masterdor took to cure the problem, either in relation to doors that were yet to be installed or in relation to doors that had already been fitted. (At Grenfell Tower 17 entrance doors had been fitted by that date.)974 {MAS00000003}. It is clear, however, that Manse Masterdor did not tell the TMO about the problem.975 Acosta {Day166/86:3-5}. There is no record of the problem being raised and discussed in the progress meetings for the entrance door replacement programme.
113¶41.11 On 24 June 2011, Carl Stokes sent an email to Abigail Acosta about problems with two newly installed entrance doors that he had identified during an inspection of King Charles House.976 {TMO00867377/2}. He had found that the self-closing device had come out of the door of Flat 13. Abigail Acosta told Natasha Brown, resident liaison officer at Manse Masterdor, about the problem and she arranged for a fitter to repair it.977 {TMO00867377/1-2}.
¶41.12 On 21 July 2011, Carl Stokes sent another email to Abigail Acosta about the same problem affecting newly installed entrance doors at Grenfell Tower. He said that he had been told that three self-closing devices had been dislodged from the doors. He did not say which flats were affected but he suggested that the screws securing the closer inside the door were too short.978 {TMO00867783/2-3}.
¶41.13 Abigail Acosta sent the message on to Andy Webster on 26 July 2011.979 {TMO00867783/2}. He said that he was aware of the problem and explained that although the factory had used the screws recommended by the manufacturers, they had turned out not to be long enough. As a precautionary measure the size of the screws had been increased.980 {TMO00867783/1-2}. Apparently Mr Webster told Ms Acosta which other properties had also been affected, but she could not remember which ones they were.981 Acosta {Day166/87:14-18}.
¶41.14 It is clear that from the outset inadequate screws and fixings presented a systemic problem in relation to self-closing devices on the new entrance doors throughout the TMO stock, as the TMO knew. It is also clear that as a result there was a real possibility that self-closing devices would become dislodged from the doors unless the screws and fixings were changed. It is less clear whether the problem was the same as, or related to, the problem with doors not shutting that Mr Webster had referred to in his email of 17 May 2011.
¶41.15 In his response to Abigail Acosta of 26 July 2011 Mr Webster said that Manse Masterdor had started changing the fixings as necessary,982 {TMO00867783/1-2}. but it changed the screws and fixings only of the doors that were affected, not of all doors.983 Acosta {Day166/88:1-6}.
¶41.16 At Grenfell Tower, the vast majority of the new entrance doors had been installed by the end of June 2011.984 {MAS00000003}. Unless Manse Masterdor returned to change them, therefore, they retained the original fixings and did not have the larger screws and fixings that the factory apparently used from July 2011 onwards. There is in fact no evidence that Manse Masterdor replaced the fixings of the self-closing devices on any of the new entrance doors.
¶41.17 We have seen no evidence that Abigail Acosta ever received confirmation that any remedial work had been carried out by Manse Masterdor at either King Charles House or Grenfell Tower. Further, there is no evidence that she, as project manager, carried out any checks herself or that she had a system to record any remedial work that needed to be carried out. She appears to have assumed that Manse Masterdor carried out any necessary remedial work and that the problem had been resolved.985 Acosta {Day166/87:14}-{Day166/89:5}.
114¶41.18 Carl Stokes also assumed that the problem had been cured.986 Stokes {Day138/75:24}-{Day138/76:3}; {Day138/83:5-21}. He did not carry out any checks at the time or investigate whether the problem had been satisfactorily resolved when he carried out his next fire risk assessment at Grenfell Tower in November 2012.987 {CST00003084}; Record of Significant Findings and Action Plan {CST00003083}.
¶41.19 Whatever steps Manse Masterdor took to cure the problem, it is reasonably clear that it persisted, at least at Grenfell Tower, which may explain why so many self-closing devices were defective or missing on 14 June 2017.988 {MET00039807/76-80}.
¶41.20 There was evidence that during the period from 2011 to 2013 the self-closing devices on the entrance doors of a number of flats at Grenfell Tower had become dislodged or that the doors would either not close at all or else become stuck in the closed position. It is likely that those problems were caused by inadequate screws and fixings, but it is possible that in some cases there were other faults. It is also evident that various repairers, including employees of Manse Masterdor, Morrisons989 Morrisons Facilities Services Ltd provided reactive repair services for the TMO until the termination of their contract in June 2012 when Willmott Dixon was appointed by the TMO to provide those services. and Repairs Direct,990 Repairs Direct Ltd was a wholly owned subsidiary of the TMO which was established in 2013 to provide reactive repair services for the TMO in place of Willmott Dixon. as well as Seamus Dunlea (the Lancaster West Estate handyman) and residents themselves removed self-closing devices so that doors could be opened and closed freely. Self-closing devices were removed from the doors of Flat 11,991 Alison Moses {IWS00001281/4-5} pages 4-5, paragraphs 21-25 Flat 12,992 Dainton {IWS00000806/6} page 6, paragraph 33; Dainton {IWS00001974/5} page 5, paragraph 25; {RBK00053524} row 3709. Flat 25,993 Rasoul {IWS00001768/7-8} pages 7-8, paragraphs 34-35; {RBK00053524} rows 3555 and 3052. Flat 32,994 {MET00045733} row 5303. The flat was identified in that document by cross-checking the factory reference with the document showing the doors installed at Grenfell Tower {MAS00000003} row 15. Flat 41,995 Kasote {IWS00000768/5} page 5, paragraph 19; Kasote {IWS00001775/7} page 7, paragraph 23; Kasote {Day117/63:17-20}. Flat 54,996 Rawda Said {IWS00001729/2-3} pages 2-3, paragraph 4(b); Salma Said {IWS00001727/4-5} pages 4-5, paragraph 4(b). Flat 66,997 Hanan Wahabi {IWS00000074/5} page 5, paragraph 16; {TMO00899663}; {TMO00899664}. Flat 76,998 Quang {IWS00000080/3} page 3, paragraph 11; Quang {IWS00001821/8-9} pages 8-9, paragraphs 40-42; {RBK00053524} row 2851. Flat 82,999 {TMO00868337/1}; {RBK00053524} row 3745. Flat 115,1000 {MET00045733} row 5110. The flat was identified in that document by cross-checking the factory reference with the document showing the doors installed at Grenfell Tower {MAS00000003} row 62. Flat 133,1001 Hanife Macit {IWS00000904/5} page 5, paragraph 32; Sener Macit {IWS00000069/7} page 7, paragraphs 39 and 40. Flat 134,1002 Daffarn {IWS00000169/15} page 15, paragraph 47. Flat 1521003 Yahya {IWS00000498/3} page 3, paragraph 10; El-Guenuni {IWS00002034/2-3} pages 2-3, paragraph 7. and Flat 205.1004 Neda {IWS00000886/22} page 22, paragraph 132.
¶41.21 A common feature of all the flats listed above is that the self-closing device on the entrance door was missing on 14 June 2017.1005 {MET00039807/76-80}. We have seen no evidence that Manse Masterdor, the TMO or anyone else replaced the self-closing devices on those doors before 14 June 2017, except for Flat 32. In the case of that flat there is evidence that Manse Masterdor replaced the self-closing device.
¶41.22 There is positive evidence that the self-closing devices on the entrance doors of some of the flats listed above had not been replaced by June 2014. On 14 June 2014 Leon Taylor, a fire risk assessor for PSC London Ltd, carried out a fire risk assessment of Grenfell Tower on instructions from Michael Lyons, a health and safety manager employed by Repairs Direct.1006 Emails between Michael Lyons and Amelia Sales on 26-31 March 2014 {TMO00856436/1-2}; Taylor {PSC00000002/1} page 1, paragraph 2; Leon Taylor's fire risk assessment of Grenfell Tower dated 14 June 2014 {TMO10001286}. Mr Taylor inspected some of the new doors and found that their self-closing mechanisms had been disconnected; he also found that some of the old fire doors did not have self‑closing devices.1007 Leon Taylor's fire risk assessment of Grenfell Tower dated 14 June 2014 {TMO10001286} "FRA" sheet, Reference L6, rows 231-233. He took photographs of missing self-closing devices on at least three entrance doors, including Flats 25 and 76.1008 Photographs taken by Leon Taylor on 15 June 2014 of missing self-closing device at Flat 76 {PSC00000072}; Flat 25 {PSC00000082}; another flat entrance door where the number is not visible {PSC00000087}. He recommended that the entrance doors to all flats should have fully functioning, positive-action, working, self-closing devices fitted.1009 Leon Taylor's fire risk assessment of Grenfell Tower dated 14 June 2014 {TMO10001286} "Action Plan" sheet, row 9. We have seen no evidence that Repairs Direct or the TMO took any action in response to that recommendation.
115¶41.23 On 17 December 2015, Janice Wray sent an email to Siobhan Rumble to report Carl Stokes's concern that some residents of Grenfell Tower had told him that Seamus Dunlea had disconnected the self-closers on their entrance doors. Janice Wray asked Ms Rumble to tell him to stop disconnecting or removing self-closing devices, which apparently she did.1010 {TMO00859693/1}. On the face of it, that is consistent with Seamus Dunlea's own evidence.1011 Dunlea {MET00019959/6} page 6. It is not clear when he disconnected self-closing devices or on which doors, but it does indicate that by December 2015 some of the self-closing devices he had removed had not been replaced. There is no evidence that they were replaced at that point or that any investigation was carried out to determine from which flats they had been removed.1012 Janice Wray could not remember, but said she would have asked Siobhan Rumble to ask for repairs, Wray {Day143/189:5-15}-{Day143/190:6-12}. Siobhan Rumble said she took no action beyond asking Seamus Dunlea to stop disconnecting and removing the self-closing devices, Rumble {Day120/43:1-5}. Carl Stokes did not investigate whether the issue had been addressed in his subsequent fire risk assessment of Grenfell Tower in April 2016 {CST00003161}. Moreover, the TMO did not have a system for the regular inspection and maintenance of entrance doors that might have revealed that self-closing devices at Grenfell Tower were missing or defective and prompted their replacement before the fire.
¶41.24 In those circumstances, the only plausible explanation for the absence of self-closing devices from the entrance doors of the flats on the night of the fire (except Flats 32 and 53) is that they had been removed as a result of problems that had arisen shortly after the doors had been installed and not replaced before the fire. It is unclear how the self-closing devices on the doors of Flats 32 and 53 came to be missing at the time of the fire.1013 {MET00039807/76-80}.
Excessive strength of the self-closing device
¶41.25 During the summer of 2011 there were various reports that the strength of the self-closing devices on new doors caused difficulties for residents when opening and closing them. There is evidence that the self-closing devices to Flats 43,1014 Sobieszczak {IWS00001539/4} page 4, paragraphs 16 and 17. 72,1015 Roncolato {IWS00001774/2} page 2, paragraph 8. 1831016 Gomes {IWS00001078/12} page 12, paragraphs 59 and 60. and 1221017 Beadle {IWS00001872/7} page 7, paragraphs 30 and 31. were removed or disabled as a result. We have seen no evidence that they had been repaired or replaced before 14 June 2017, but they were all missing on 14 June 2017 except one (Flat 43), which was present but not working.1018 {MET00039807/76-80}. Again, it is likely that the reason for their absence is because they had been removed or disabled as a result of the problems that had arisen shortly after the doors were installed and were not subsequently repaired or replaced.
116Inspection and maintenance of entrance doors
¶41.26 The TMO was repeatedly advised, both before and after the LGA Guide was published in July 2011, that it needed to put in place a system of regular inspection and maintenance of fire-resisting doors, including the entrance doors to flats.
¶41.27 The Salvus Management Report, dated 22 September 2009,1019 See Chapter 37. identified the absence of adequate inspection and monitoring of premises and facilities as a hazard. It specifically identified that the monthly safety inspection did not include any formal checks on fire doors1020 {SAL00000013/7} item 4.1. and contained a strong recommendation that the inspection sheet be revised to include formal checks on fire doors. Salvus advised that that needed to be done within a month to remedy what it considered to be a breach of the TMO's statutory obligations.1021 {SAL00000013/15} item 4.1.
¶41.28 In his fire risk assessment of Grenfell Tower dated 30 September 2009 on behalf of Salvus Carl Stokes recommended that a system of formal checks on the entrance doors to flats and all other fire compartmentation doors be introduced by the TMO to ensure that fire compartments remained fit for their purpose. He made it clear that checks should be made on all fire doors within the building and recommended that a system of inspection be put in place within three months or that a plan for doing so be agreed within six months.1022 {CST00003128/16}.
¶41.29 Salvus repeated that recommendation in, at least, 12 other fire risk assessments on TMO properties which it carried out between September 2009 and January 2010 under the high‑risk programme. In each case, it recommended that a system of inspection be put in place within three months or that a plan for doing so be agreed within six months.1023 9 Colville Square dated 25 September 2008 {CST00003736/12}; 11 and 12 Colville Square dated 25 September 2008 {CST00003737/12}; Gillray House dated 14 October 2009 {TMO00873667/19}; Salvus fire risk assessments of Dixon House dated 16 November 2009 {CST00002006/21}; Clydesdale House dated 16 November 2009 {CST00003596/15}; Elm Park House dated 9 December 2009 {CST00003744/15}; Whitstable House dated 25 January 2010 {CST00002008/20}; Frinstead House dated 25 January 2010 {CST00003214/22}; Markland House dated 15 January 2010 {CST00003215/22}; Adair Tower dated 28 January 2010 {CST00002623/17}; Hazelwood Tower dated 28 January 2010 {CST00002626/15}.
¶41.30 On 4 November 2010, Carl Stokes advised Janice Wray that when carrying out the programme of replacing the entrance doors to flats, the TMO ought to consider introducing an inspection system to ensure that the residents did not disconnect or disable the self‑closing devices.1024 {CST00001156/1}; {CST00001155}.
¶41.31 On 8 November 2012, representatives of the LFB, the TMO, RBKC and the London Borough of Hammersmith and Fulham met to discuss responsibility for enforcing the law against leaseholders whose entrance doors were not adequately fire-resisting.1025 Jack {MET00040001/6} page 6, last paragraph; {LFB00004623}. Andy Jack, the Head of Fire Safety Enforcement at the LFB, Nicolas Comery, team leader of the LFB fire safety team, and Matthew Ramsey, a LFB fire safety inspecting officer, attended on behalf of the LFB. Janice Wray attended on behalf of the TMO. Carl Stokes also attended.1026 Jack {MET00040001/6-7} pages 6-7; Comery {LFB00032144/15} page 15, paragraph 50; Ramsey {LFB00032092/13} page 13, paragraphs 47 and 48. No minutes were made of that meeting.
117¶41.32 A further conversation took place immediately after that meeting involving, at least, Andy Jack, Carl Stokes and Nicolas Comery about the monitoring and maintenance requirements for entrance doors to flats and self-closing devices.1027 Jack {MET00040001/15} page 15. Janice Wray did not stay for the discussion but Carl Stokes told her afterwards what had been said.1028 Wray {Day143/116:24}-{Day143/117:1-7}; Stokes {Day138/167:16-25}. Andy Jack made the point that there was a need to maintain doors and self-closing devices in good working order and to carry out sufficient checks of their effectiveness.1029 Jack {MET00040001/19} page 19; Jack {Day147/68:19}-{Day147/69:24}. He also drew attention to the possibility of carrying out checks on self-closing devices during gas safety inspections.1030 Jack {MET00040001/19} page 19. It appears, however, that no agreement was reached about what form the TMO maintenance system should take.1031 Jack {Day147/75:1-7}.
The TMO's policy on inspection and maintenance of flat entrance doors
¶41.33 From late 2012 to November 2013 Janice Wray drafted the TMO's fire safety strategy with help from Carl Stokes.1032 {CST00001188}; {CST00001187}; {CST00001159}; {CST00002046}; {TMO00830598}. As it was the TMO's overarching policy in relation to fire safety, we should have expected it to contain the arrangements for complying with important aspects of the Fire Safety Order, including the inspection and maintenance of entrance doors to flats and self-closing devices. That is particularly so in view of the specific advice which had been given to the TMO between 2009 and 2012 on the need for a system of regular inspection and maintenance of entrance doors and the recommendations in the LGA Guide that had been published in July 2011. Despite that, however, the TMO's fire safety strategy, which was completed in November 2013, did not provide for such a system.
¶41.34 Section 5 of the fire safety strategy covered management arrangements for fire safety. Paragraph 5.1 provided for a programme of regular estate inspections, risk assessments and monitoring by neighbourhood and health and safety staff. It said that inspections ensured that fire doors were operating effectively. It also said that repairs to fire doors and self-closing devices were given priority.1033 {TMO00830598/2-3} paragraph 5.1, first bullet point. However, the inspection checklist covered only communal fire doors and chute room doors, not the entrance doors to flats.1034 {TMO00830598/18}.
¶41.35 The fire safety strategy also provided for the inspection, testing and maintenance of all fire safety systems and equipment in accordance with the requirements of the relevant British Standard,1035 {TMO00830598/3} paragraph 5.1, second bullet point. but did not include the entrance doors to flats or other fire doors.1036 {TMO00830598/4-7} paragraphs 5.1, 6.2, 9.1.3, 9.2, 9.4 and 10.
¶41.36 Section 17 specifically dealt with the entrance doors to flats, but although it clearly envisaged that the TMO's fire risk assessor would inspect some entrance doors as part of his fire risk assessments, it made no provision for a system of regular inspection and maintenance of entrance doors and self-closing devices.1037 {TMO00830598/11} paragraph 17.
¶41.37 We have seen no evidence that before the TMO completed its fire safety strategy it gave any consideration to Mr Jack's suggestion at the meeting on 8 November 2012 that regular inspections of self-closing devices might be combined with the annual gas safety check.
118Janice Wray's email to Matthew Ramsey, 18 December 2013
¶41.38 On 18 December 2013, Janice Wray sent an email to Matthew Ramsey about various fire safety matters affecting Elm Park House.1038 {LFB00003534}. In response to a concern he had raised about self-closing devices there, Janice Wray described the TMO's approach to entrance doors as follows: first, when replacement doors were fitted they were fire-rated and fitted with self-closing devices; secondly, when properties became vacant self-closing devices were reinstated or installed as necessary; thirdly, at other times when major work was to be undertaken in a dwelling the self-closing device would be reinstated if it had been removed or disconnected.
¶41.39 We have seen no evidence that Matthew Ramsey or anyone else in the LFB fire safety team replied to that email or otherwise commented on the approach it described. Mr Ramsey said that neither he nor Nicolas Comery had approved it.1039 Ramsey {Day147/15:12-17}. Andy Jack said that he had not approved it either.1040 Jack {Day147/78:1-8}. Janice Wray accepted that the LFB had not approved it in the past.1041 Wray {Day143/123:13-25}. None of that is surprising. The TMO's approach inevitably led to irregular and infrequent inspections of the entrance doors to flats and so was inconsistent with both the LGA Guide's recommendation for six-monthly inspections and the advice given by Andy Jack in November 2012, which Janice Wray had already accepted.1042 Wray {Day143/123:24}-{Day143/124:4}.
¶41.40 The TMO's approach to inspecting self-closing devices, as described by Janice Wray to the LFB, did not appear in the fire safety strategy. It was also absent from the document used by the TMO and Repairs Direct that described the condition that vacant properties were required to attain in order to be ready for letting (known as the "relettable standard") and was not included in the forms for recording inspections of vacant properties.1043 {TMO00905397}; {TMO00905501}; {TMOH00000805/1}; {TMO00861934}. However, a requirement to carry out a fire risk assessment inspection was added to a new version of the "relettable standard" that was produced in November 2014.1044 {TMO00905400/2}; {TMO00905535/2}. In addition, there is some evidence that the TMO and Repairs Direct were, in practice, inspecting the entrance doors to flats and their self-closing devices when vacant properties were inspected.1045 Brunning {TMO00880533/7} page 7, paragraph 34.
¶41.41 Quite apart from that, however, the policy was inadequate because it did not ensure that entrance doors were inspected on a regular and systematic basis. It could be many years before a property changed hands and was inspected. Records of repairs show that work was carried out on only 17 of the 120 flats in Grenfell Tower between the end of 2013, when the policy apparently came into existence, and 14 June 2017.1046 {RBK00053524}; {RBK00053297}. That means that the vast majority of entrance doors in Grenfell Tower had not been inspected before the fire.
¶41.42 The policy of inspecting the entrance door to a flat when major work was carried out was similarly inadequate, because it did not ensure regular inspection. It was only by coincidence that the flats in Grenfell Tower all underwent major work relatively shortly before 14 June 2017 as result of the refurbishment. Janice Wray conceded that the refurbishment provided a suitable occasion on which to visit the flats and inspect the self‑closing devices on the entrance doors,1047 Wray {Day143/123:3-11}. but in the event, that did not happen.
119Other situations in which the TMO inspected entrance doors
¶41.43 According to Janice Wray there were three other ways in which the TMO monitored entrance doors to ensure that they remained in good condition once the new doors had been installed.1048 Wray {TMO00000890/7} page 7, paragraph 31; Wray {TMO00847305/16-17} pages 16-17, paragraphs 53 and 54. First, Carl Stokes inspected a proportion of doors as part of the fire risk assessment programme. Secondly, flat entrance doors were to an extent monitored by caretakers, known as Estate Services Assistants, during their weekly and monthly inspections of the communal areas. Thirdly, the TMO expected tenants to report any problems with doors to their flats. However, that did not amount to a reliable system of regular inspection. Carl Stokes's inspections during fire risk assessments did not constitute a systematic and regular inspection of all or even a majority of entrance doors. He was required to carry out fire risk assessments at properties deemed to be high-risk only every two or three years and even less frequently at lower-risk properties.1049 Wray {Day143/95:2-6}; {CST00030042}. Moreover, he was expected to look at only a sample of entrance doors as part of his fire risk assessments.1050 These matters are addressed in detail in Chapter 38. {HOM00045964/43-45} paragraphs 33.2, 34.1 and 35.1; The TMO Consultant's Brief dated July 2009 for fire risk assessments in high-risk blocks, which became the instructions to which Salvus worked, stated at Part 2, section 1.1 that the "FRA and FRA reviews will include an individual examination of each fire door including whether it operates correctly": {TMO00865175/6}; However, at the meeting on 7 September 2009 between Salvus and TMO, Janice Wray agreed that only a random sample of doors needed to be inspected {SAL00000040/1} item 2.1; Wray {TMO00873629/2} page 2, paragraph 9. Accordingly, in a building as large as Grenfell Tower, there were likely to be many doors he had not checked even after several cycles of fire risk assessments. Moreover, it is not part of a fire risk assessor's task to inspect the entrance doors to flats as part of the responsible person's system of inspection and maintenance. His job is to assess whether that person has an effective system of inspection and maintenance in place.1051 Todd {Day168/17:21}-{Day168/18:3}; Lane {Day171/197:14}-{Day171/198:6}.
¶41.44 The inspection of entrance doors to flats was not formally one of the duties of the Estate Services Assistants and was not included in their daily, weekly or monthly inspection checklists.1052 Daily Estate Staff Inspection Checklist for daily routines appended to TMO Fire Safety Strategy dated November 2013 {TMO00830598/16-19}; Daily Inspections Routine Checklist contained in Estate Staff Quick Reference Handbook {TMO10028449/83-88}; Record of weekly health and safety checks carried out by Estate Service Assistants between 1 January 2016 and 14 June 2017 {CST00000068}; Record of monthly health and safety checks carried out by Estate Service Assistants between 1 January 2016 and 14 June 2017 {CST00000069}. To the extent, therefore, that they did carry out such inspections, they did so irregularly and there was no means for them formally to record any defects that they found. Their inspections were also limited to reporting visible damage on the outside of an entrance door.1053 Rumble {TMO10050001/2-3} pages 2-3, paragraph 9; Wray {TMO00000890/7} page 7, paragraph 32; Wray {Day143/98:14}-{Day143/106:12}.
¶41.45 Paul Steadman, the Estate Services Assistant who carried out the inspections of the communal areas at Grenfell Tower, did not inspect entrance doors to flats otherwise than by making a visual check when passing.1054 Steadman {TMO10049875/3} page 3, paragraph 13; Steadman {Day146/8:20}-{Day146/9:18}. His inspections, therefore, were not systematic nor did they include the internal aspects of the doors, including, critically, the self-closing devices. The TMO's records show that he did not identify the need for a single repair to an entrance door or any other fire door as a result of his inspections of Grenfell Tower between 1 January 2016, when the records for those inspections began, and 14 June 2017.1055 TMO spreadsheet entitled "ESA002D_Fault Report Repairs" which shows "results for all fault report (repairs) forms completed" by Estate Services Assistants between 1 January 2016 and 14 June 2017 {CST00000067} sheet 2, filter for Paul Steadman in column E and Grenfell Tower in column H.
120¶41.46 Relying on tenants to report problems with their entrance doors did not amount to a system of inspection at all,1056 Wray {Day143/107:1-18}. but in any case to be effective would depend heavily on the extent to which residents were aware of the importance of their entrance doors, particularly the self-closing device, to fire safety in the building and of the need to report any defects. Residents who had disconnected self-closing devices themselves could not be expected to report the fact. Although the residents received some information about the purpose of fire-resistant entrance doors, they were not specifically told about the purpose and importance of self-closing devices and the need to report defects in them.1057 Wray {Day143/107:20}-{Day143/110:23}. The number of self-closing devices found to have been defective or missing on 14 June 2017 (77 out of 120), for which no request for repair had been made, demonstrates the folly of relying on residents to identify and report defects.1058 {MET00039807/76-80}.
¶41.47 The TMO's arrangements for the inspection of entrance doors therefore fell far short of the six-monthly inspections recommended by the LGA Guide and the advice received from the LFB in November 2012. By any measure they fell far below acceptable standards.
The TMO's reasons for not implementing a programme of regular inspections
¶41.48 Janice Wray was familiar with the recommendation in the LGA Guide that entrance doors be inspected every six months as part of a programme of planned preventative maintenance.1059 Wray {Day143/91:20-23}. She put the failure to implement such a programme down to a lack of resources and difficulties in obtaining access to flats.1060 Wray {Day143/92:8-15}; {Day143/143:16-25}. However, she accepted that the TMO might have been able to fund the programme, but only at the expense of something else.1061 Wray {Day143/93:24}-{Day143/94:2}. She was confident that she had discussed resourcing a programme of regular inspections with her line managers, Anthony Parkes and (from June 2015) Barbara Matthews, but could not recall when.1062 Wray {Day143/94:5-13}. We have seen no evidence of any such discussions until after the Adair Tower fire on 31 October 2015. We consider that her frequent references to budget restrictions as a reason for not taking necessary action across the TMO estate in relation to fire safety were based on an assumption that any request for further funds would be refused. Neither she nor anyone else appears to have made any serious effort to obtain additional resources.
Adair Tower and the LFB's stance on self-closing devices
¶41.49 Both before and after the fire at Adair Tower on 31 October 2015 the LFB fire safety team raised concerns with the TMO about its approach and that of Carl Stokes to ensuring that self-closing devices were fitted on entrance doors to flats.
¶41.50 In early September 2015, the LFB fire safety team identified during an inspection that the entrance door to Flat 41 at Adair Tower, which had not been replaced as part of the replacement programme, did not have a self-closing device.1063 {LFB00003385/1-2}; {LFB00001613}. They also discovered that in his fire risk assessment of Adair Tower dated 20 February 2014 Carl Stokes had advised that self-closing devices were "not applicable" and that, although entrance doors to flats were not fitted with self-closing devices, he had not identified their absence as a concern and had not assessed the consequent risk or recommended remedial action.1064 Burton {LFB00084098/5-6} pages 5 and 6, paragraph 10; {LFB00024281/19}; {LFB00084107/1}. On 12 October 2015, the LFB issued a deficiency notice to the TMO in respect of Adair Tower based on the absence of self-closing devices.1065 {LFB00001613/4}.
121¶41.51 On 14 September and 22 October 2015, Janice Wray sent emails to Julie-Anne Steppings, the LFB fire safety inspecting officer who had conducted the inspection, and Rebecca Burton, the LFB fire safety team leader, respectively. She told them that the TMO's approach to self-closing devices on existing entrance doors reflected advice from Carl Stokes who had himself received clarification of the position from Andy Jack at the meeting on 8 November 2012.1066 {LFB00003385/1-2}. The meeting with Andy Jack is incorrectly referred to in that email as having taken place in November 2015. Email from Janice Wray to Rebecca Burton on 22 October 2015 {LFB00003440/1}. The LGA Guide had introduced the concept of a "nominal" or "notional" fire door to describe an existing door that does not meet current standards for fire-resistance but satisfied the previous standard and therefore did not necessarily need to be replaced.1067 {HOM00045964/98} paragraph 62.17. For the TMO, the concept applied to the doors that had not been replaced under the replacement programme, such as those at Adair Tower.
¶41.52 Although she did not say so explicitly, Janice Wray suggested that she had understood from Carl Stokes that the LFB accepted that self-closing devices were not required on "nominal" doors, despite the fact that the LGA Guide said that all entrance doors to flats and any doors leading onto a protected escape route needed to have a self-closing device.1068 {HOM00045964/99} paragraph 62.19. Janice Wray suggested that the LFB had changed its position in that respect.1069 {LFB00003440/1}. On 22 October 2015 Rebecca Burton replied to Janice Wray, telling her that she was unaware of any guidance that allowed fire doors not to be self-closing, especially those leading to the means of escape.1070 {LFB00003440/1}. We do not think that the LFB had changed its position, not least because the LGA Guide is clear on the point.1071 Burton {Day145/90:4-7}; {HOM00045964/99} paragraph 62.19.
LFB advice and enforcement action
¶41.53 After the fire at Adair Tower, Rebecca Burton sent an email to Andy Jack, Nicholas Coombe and Nicolas Comery on 1 November 2015 asking what had been agreed at the meeting with the TMO on 8 November 2012.1072 {LFB00003385/1}. Although none of them could recall the precise details of what had been discussed, each of them effectively denied that they had agreed that entrance doors did not need to be self-closing.1073 {LFB00001610}; {LFB00003463/1}. Andy Jack said in evidence that he had been shocked by the suggestion. He was also shocked that Carl Stokes, as a former fire safety officer, should have thought that entrance doors did not need to be self-closing.1074 Jack {Day147/80:7-21}. Nicolas Comery was similarly clear that there had been no such agreement.1075 Comery {Day145/181:6-10}. We accept their evidence about that.
¶41.54 On 13 November 2015, Rebecca Burton met Janice Wray to discuss the LFB's concerns about Adair Tower.1076 {TMO00869184/3-4}; {TMO00840415}; {LFB00003445}; Burton {Day145/96:13-25}; Burton {LFB00084098/9} page 9, paragraph 16. They included the suitability and sufficiency of fire risk assessments, especially in relation to self-closing devices, and the claim that the LFB had agreed that entrance doors to flats did not need to be self-closing.1077 {LFB00003445}. She told Janice Wray that Andy Jack, Nicholas Coombes and Nicolas Comery all denied that they had agreed to that and she told Janice Wray that self-closing devices were required on all entrance doors.1078 Burton {Day145/97:1-7}; {Day145/97:17}-{Day145/98:2}. Janice Wray accepted that they had discussed the need for self-closing devices to be checked regularly.1079 Wray {Day143/139:4-11}.
122¶41.55 On 23 December 2015, the LFB fire safety team served an enforcement notice on the TMO in respect of Adair Tower and sent a copy to RBKC.1080 {LFB00003383}. It described a number of matters that the LFB fire safety team considered to involve breaches of the Fire Safety Order. They included a failure to carry out a suitable and sufficient fire risk assessment for the purposes of Article 9 because the assessment carried out by Carl Stokes did not give adequate consideration to existing and required standards for self-closing devices. They also included a failure to maintain the fire resistance of the protected route because none of the doors that opened onto it were fitted with positive-action self-closing devices.1081 {LFB00003383/4-5}. The LFB issued another enforcement notice on 18 January 2016 in respect of Hazlewood Tower (Adair Tower's sister block) which included essentially the same alleged breaches in relation to self-closing devices.1082 {RBK00001020}.
¶41.56 Rebecca Burton and Janice Wray discussed the LFB's stance on self-closing devices at their regular meeting on 5 January 2016.1083 {LFB00032330}. The minutes recorded the LFB's view that landlords should ensure that self-closing devices were fitted and that effective procedures were introduced to ensure that the devices remained operational and were not disconnected or removed by residents.1084 {LFB00032330/3} item 7; {LFB00032331/4} page 4, paragraph 10. That was, we consider, a clear and unambiguous warning to the TMO.
¶41.57 Janice Wray's response was that it would be difficult to establish any other sort of maintenance regime due to problems of access and that she would need to speak to her line management to devise a programme.1085 Burton {Day145/101:23}-{Day145/102:3}. They discussed ways in which the TMO could maintain self-closing devices, including by using caretakers, Estate Services Assistants and incorporating a check of self-closing devices into the TMO's annual electricity and gas safety checks.1086 Burton {LFB00032331/4} page 4, paragraph 10; Burton {Day145/102:8-24}. Rebecca Burton in effect said that, rather than pressing for entrance doors to be inspected every six months the LFB thought that it was better that inspections actually be carried out at less frequent intervals than to be scheduled at more frequent intervals that could not be achieved.1087 Burton {Day145/103:5-19}.
The response of the TMO and RBKC
¶41.58 After her meeting with Rebecca Burton on 5 January 2016, Janice Wray told Robert Black and Barbara Matthews that Rebecca Burton had stressed that the entrance doors to all flats in the TMO's housing stock needed to be fitted with self-closing devices and that the policy of checking self-closing devices only in vacant properties was insufficient.1088 {TMO00840451}. She also reported the LFB's view that the TMO should have a procedure in place for carrying out and recording regular checking of the devices as well as her own opinion that that would be virtually impossible to achieve. In response, Barbara Matthews asked Janice Wray whether it was possible to find out what approach other housing providers, including the London Borough of Hammersmith and Fulham, were taking to self-closing devices.1089 {TMO00902946/1}.
123¶41.59 Accordingly, later the same day Janice Wray sent an email to a number of housing providers to ask whether they required all entrance doors to flats to be self-closing and, if so, how they achieved it, what procedures they adopted to ensure that self-closing devices were not removed or disconnected, and what approach the relevant fire and rescue service took to them.1090 {TMO00865995/2-3}. All those who replied said that it was their policy to ensure that entrance doors were fitted with self-closing devices. None of them said that they had a formal system of inspection of self-closing devices, but three of the five who replied had informal approaches to checking self-closing devices, although the methods varied.1091 {CST00007708/1-2}; {CST00006634/1}; {TMO00865995/1}; {CST00002902/1}; {CST00002302/1-2}. None of those who replied had encountered a challenge to their approach by the fire and rescue service, except one that had also received a number of deficiency notices and an enforcement notice.1092 {CST00002902/1}.
¶41.60 On 8 April 2016, Janice Wray circulated papers for the TMO Health and Safety Committee meeting on 12 April 2016.1093 {TMO10012661}. They included a paper dated 4 April 2016 entitled "Review of the Fire Safety Strategy",1094 {TMO10024351}; {TMO10012811/5} item 6.3. in which she said that it was time to review the strategy to make sure that the TMO's policies complied with the relevant legislation and the LFB's advice, guidance and requirements.1095 {TMO10024351}. However, for reasons which are not apparent, she did not invite the committee to consider the matters she had discussed with Rebecca Burton on 5 January 2016, namely, the need to install self-closing devices on all entrance doors and to put in place a system for the regular inspection and maintenance of self-closing devices.
James Swindells' email to Janice Wray of 1 August 2016
¶41.61 On 27 July 2016, James Swindells, an LFB fire safety inspecting officer, reported to Janice Wray, copying in Rebecca Burton, on his inspection of Lonsdale House.1096 {CST00009704/2}. He had found that a number of self-closing devices had been broken or removed by residents. Janice Wray replied on 1 August 2016 saying that the doors had been replaced as part of the entrance door replacement programme in 2012-2013 and had operational self-closing devices at that time. She said that the TMO could not control the action of residents and pointed out that, even if the self-closing devices were repaired or replaced, they could soon be removed or disabled again.1097 {CST00009704/1-2}.
¶41.62 In response Mr Swindells emphasised the obligation imposed on the responsible person by Articles 11 and 17 of the Fire Safety Order to monitor and maintain fire safety systems and suggested that residents should be reminded that the device was there to protect both them and their neighbours.1098 {CST00009704/1}.
124Review of the TMO fire safety strategy: September 2016
¶41.63 On 9 September 2016, Janice Wray circulated papers for a meeting of the TMO Health and Safety Committee on 13 September 2016.1099 {TMO00840649}. She again included a paper entitled "Review of the Fire Safety Strategy", in which she invited the committee to comment on various fire safety matters.1100 {TMO00840660/1-2}. On that occasion they included for the first time the need to install and inspect self-closing devices on entrance doors to flats as had been discussed with Rebecca Burton on 5 January 2016. Janice Wray could not explain the delay other than by saying that complying with the enforcement notices for Adair Tower and Hazlewood Tower had been time-consuming work.1101 Wray {Day143/152:17}-{Day143/153:19}. Given the obvious importance of the matter, that is scarcely a sufficient explanation.
¶41.64 Janice Wray invited the committee to consider the requirement for self-closing devices, the LFB's interpretation of the Fire Safety Order and what the TMO could do to advance the installation of self-closers.1102 {TMO00840660/2}. She suggested that one option was to create, and give priority to, a programme for installing self-closing devices, which would need approval and financial support from RBKC. She also asked the committee to consider how the TMO might implement a system of regular inspection and maintenance of self-closing devices, asking a number of questions relating to practical matters, such as the extent to which the TMO's caretakers could assist, when checks might best be carried out and whether the importance of self-closing devices could be emphasised in communications to residents.1103 {TMO00840660/2}.
¶41.65 At its meeting on 13 September 2016 the committee acknowledged the need to have a more active policy on the installation of self-closing devices in order to meet the LFB's requirements. Someone suggested that the work could be included in cyclical redecoration projects but it was decided that further work needed to be done to obtain approval and funding from RBKC.1104 {TMO00840753/5} item 6.1. We have seen no evidence that the ways in which self-closing devices might be inspected were discussed, either at the meeting or subsequently.1105 {TMO00905766}.
¶41.66 The possibility of inspecting self-closing devices when carrying out annual gas safety checks had been raised by Andy Jack in November 2012. Janice Wray said that she had instructed Alex Bosman to discuss that with the TMO's gas safety contractors, but that they had refused to do it.1106 Wray {Day143/85:20}-{Day143/86:5}; {Day143/120:2}-{Day143/121:16}. She was not able to say when that discussion had taken place, only that it had probably occurred before her meeting with Rebecca Burton on 5 January 2016.1107 Wray {Day143/120:2}-{Day143/121:16}; {Day143/141:22}-{Day143/142:7}. However, that is not easy to reconcile with the matter being raised for discussion for the first time in September 2016. We have seen no other evidence that discussions of that kind took place and on balance we do not think that they did.
The involvement of RBKC
¶41.67 The fitting of self-closing devices was discussed at a meeting of the TMO executive team on 5 October 2016 attended by Robert Black, Sacha Jevans, Barbara Matthews and Yvonne Birch. The meeting was told that the LFB was putting pressure on the TMO to fit self-closing devices to all entrance doors to flats but that that had been resisted by Laura Johnson.1108 {TMO00843861/2} item 3.2. It was also told that the fire strategy was being revised to contain a programme for the work be done over a period of five years, although it was thought likely that the LFB would expect it to be done within a shorter period. It was agreed that it would be necessary to discuss the matter with RBKC, which would need to provide the necessary funding.1109 Jevans {Day127/97:25}-{Day127/98:5}.
125¶41.68 Robert Black's view was that RBKC (in particular, Laura Johnson) was in a position to decide whether or not the TMO took the steps required by the LFB because it controlled the budget.1110 Black {Day150/211:17-20}. Laura Johnson said that she had suggested that any programme for installing self-closing devices should be spread over five rather than three years for financial and practical reasons.1111 Johnson {Day129/200:2}-{Day129/202:7}; Jevans {Day127/96:15}-{Day127/97:5}; Matthews {Day148/108:7-10}. She said that she had understood that it would probably have to be carried out within a shorter period, but that she had not wanted to set the TMO up to fail.1112 Johnson {Day129/200:2}-{Day129/202:7}; Jevans {Day127/96:15}-{Day127/97:5}.
¶41.69 It is clear that Laura Johnson was not persuaded of the need to install self-closing devices over a three-year period. The minutes make that clear. Although she was right to have in mind the need to balance the expense of the proposed programme against the risks involved, her decision failed to give sufficient weight to the advice of the LFB and the nature of the risk that self-closing devices were intended to mitigate.
The deficiency notice for Grenfell Tower: 17 November 2016
¶41.70 On 17 November 2016, the LFB issued a deficiency notice to the TMO in respect of Grenfell Tower1113 {TMO10017254}. on the grounds that the protected escape route (corridors, lobbies and stairs) was compromised by doors that did not have self-closing devices. It also identified the doors to Flats 44 and 153 as having failed to close themselves when inspected.1114 {TMO10017254/4-5}. It recommended that the deficiencies be remedied by 18 May 2017. The deficiency notice thus informed the TMO of its obligations in respect of the installation and maintenance of self-closing devices and the urgency with which they needed to be discharged.
RBKC's decision
¶41.71 On 28 February 2017, Barbara Matthews sent a report on self-closing devices to members of the RBKC and TMO Joint Management Committee in advance of its meeting on 1 March 2017.1115 {RBK00000987}. It had been drafted by Janice Wray.1116 {RBK00000988}. It set out the LFB fire safety team's requirements in relation to the installation and inspection of self-closing devices, which were based on its view of articles 11 and 17 of the Fire Safety Order. The report drew attention to the TMO's concern that even regular inspections and maintenance would not ensure that self-closing devices remained effective. It referred to the email sent by James Swindells on 1 August 2016 voicing that concern, in which he said that the TMO only needed to put in place a reasonable system of inspection to discharge its duty.1117 {TMO00869692}. The report included an estimate prepared by Graham Webb, the managing director of Repairs Direct, of the cost of carrying out a programme of installation and inspection and the assumptions underlying.1118 {RBK00000988/3}; {TMO00905766}. It did not, however, mention the recommendation in the LGA Guide that inspections be carried out every six months. Although it was estimated that 50% of the TMO's properties did not have self-closing devices fitted to the entrance doors and that 40% of those that were present needed to be repaired or replaced, the report did not touch on the effect that self-closing devices have on the safety of residents.1119 {RBK00000988/3}.
126¶41.72 At the meeting of the Joint Management Committee concern was expressed at the fact that no other housing provider had a programme for the regular inspection of self-closing devices.1120 {RBK00014072/2} item 5. There appears to have been no reference to the recommendation in the LGA Guide for six-monthly inspections, the available means of carrying out inspections or the risk to the safety of residents if a programme of installation or regular inspection was delayed or not implemented.
¶41.73 On 3 March 2017, Barbara Matthews sought to confirm with Laura Johnson and Robert Black what she understood had been agreed at that meeting, namely, that the installation of self-closing devices would be carried out over a period of between three and five years but that regular inspection would not be introduced until legal advice had been obtained about the TMO's right to obtain access if tenants or leaseholders refused it.1121 {RBK00014053/4}. Laura Johnson said that she wanted to spread the installation programme over five years because it would make funding more manageable. In respect of the proposed inspection programme, she took an uncompromisingly negative line, saying that it would impose a continuing burden on the Housing Revenue Account without any evidence that it would affect the safety of residents and that she did not think it was necessary.1122 {RBK00014053/4}.
¶41.74 Laura Johnson accepted that her message amounted to, or at least was interpreted by the TMO as, a direction to extend the period over which the installation programme was to be carried out and to not establish an inspection regime.1123 Johnson {Day129/225:1-5}. The TMO did not resist.1124 {RBK00014053/3}; {TMO00842281/1} item 3; {TMO00847312/5} item 4.2. In effect, therefore, she alone decided that the installation programme should be extended.1125 Johnson {Day129/221:20-23}. She did so without having taken any advice about the consequences for the safety of residents.1126 Johnson {Day129/221:24}-{Day129/222:2}. She effectively accepted that financial considerations were the principal, if not sole, basis for her decision.1127 Johnson {Day129/224:4-17}.
¶41.75 Laura Johnson admitted that she had not taken any steps to understand the risk to safety of not inspecting and maintaining self-closing devices1128 Johnson {Day129/225:17-20}. and she accepted that her decision not to establish an inspection system had been wrong.1129 Johnson {Day129/225:6-16}. She could not recall what her views had been on the LFB's clear advice about the need to inspect and maintain self closing devices, except that she had wanted to understand whether there was a statutory requirement to do so.1130 Johnson {Day129/225:6-16}. She said that she had not been aware of the recommendation in the LGA Guide that landlords should establish a system of inspection and maintenance of self-closing devices.1131 Johnson {Day129/226:24}-{Day129/227:3}. It is evident from the email she sent to Barbara Matthews on 6 March 2017 that money again was the driving force behind her refusal to introduce a system of inspection and maintenance.1132 {RBK00014053/4}.
127Revision of the fire safety strategy: June 2017
¶41.76 Janice Wray revised the TMO's fire safety strategy in June 2017.1133 {TMO10017036}. In paragraph 18.1.1 there was a reference to the agreement with RBKC to carry out a programme of fitting self-closing devices to the entrance doors of all flats over a period of five years.1134 {TMO10017036/12} section 18.1.1. In the same paragraph it said that the TMO had a variety of methods of ensuring that self-closing devices remained in place and operational. They included inspections when properties were vacant and sample inspections during fire risk assessments.1135 {TMO10017036/12} section 18.1.1. In short, little, if anything, in the TMO's approach had changed.
Oversight by RBKC Housing Property and Scrutiny Committee
¶41.77 The evidence indicates that neither RBKC nor the TMO fully informed the Housing Property and Scrutiny Committee ("the scrutiny committee") about the position in respect of the installation and inspection of self-closing devices after the Adair Tower fire and before the Grenfell Tower fire. The evidence also indicates that, to the extent that the scrutiny committee was made aware of the LFB's concerns about self-closing devices, it did not take adequate steps to investigate why those concerns had arisen or to ensure that RBKC and the TMO had adequately addressed them.
¶41.78 In her report for the scrutiny committee meeting on 6 January 2016, Laura Johnson warned that the LFB intended to serve enforcement notices in respect of Adair Tower and Hazlewood Tower, in part because of the lack of self-closing devices on entrance doors to flats.1136 {RBK00032439/5-6} paragraphs 4.6-4.7. Robert Black reported orally to the meeting that the LFB's requirement to install self-closing devices applied not only to Adair and Hazlewood Towers, but to all the council's properties.1137 {RBK00014534/11}. However, he did not mention that the LFB also required a system of regular inspection to be put in place. We have seen no evidence that the scrutiny committee took steps at that point to find out how the problems with self-closing devices had arisen, particularly in the light of the replacement of entrance doors only a few years earlier and the continuing programme of fire risk assessments. We find that lack of curiosity surprising.
¶41.79 In her report for the meeting of the scrutiny committee on 13 July 2016 Laura Johnson provided further information about the enforcement notices relating to Adair and Hazlewood Towers.1138 {RBK00032476/1-2} paragraphs 1.3 and 1.4. She said that the TMO and RBKC had agreed to ensure that all entrance doors to flats in both blocks were adequately fire-rated and fitted with self-closing devices.1139 {RBK00032476/1-2} paragraphs 1.3 and 1.4. At the meeting, Councillor Nicholls asked whether RBKC complied at other locations. Ms Johnson told him that self-closing devices were fitted at all properties,1140 {RBK00032473/5} paragraph A9. although at that time the TMO was still discussing internally how to remedy the lack of self-closing devices across its properties. There is no record of Robert Black, who was in attendance, correcting her. The scrutiny committee did not take any further action to satisfy itself that RBKC and TMO had fully addressed the LFB's concerns in that respect.
128¶41.80 In her report for the scrutiny committee meeting on 16 November 2016, Laura Johnson said that the works required by the Adair Tower and Hazlewood Tower enforcement notices had been completed.1141 {RBK00032461/1} paragraphs 1.1-1.3. However, she did not refer to the need to install and inspect regularly self-closing devices across the whole of the housing stock, although by that point she had begun discussing that with the TMO.1142 {TMO00843861/2} item 3.2. Nor were they mentioned in the TMO's Mid Year Review of Performance which had been prepared for that meeting.1143 {RBK00000731}; {RBK00032475/8} paragraph A16. Laura Johnson and Barbara Matthews attended the meeting. There is no record of any fire safety matters having been raised by either of them.1144 Minutes of the meeting of the scrutiny committee meeting on 16 November 2016 {RBK00032475}.
¶41.81 As we have already said,1145 See Chapter 31. we have also seen no evidence that the scrutiny committee were ever informed about the deficiency notice the LFB issued in respect of Grenfell Tower dated 17 November 2016 and the concerns it identified in relation to the maintenance of self-closing devices before the Grenfell Tower fire.
¶41.82 At the scrutiny committee meeting on 4 May 2017, following the fire at Trellick Tower on 19 April 2017, Councillor Mackover and Councillor Pascall expressed concern about the TMO's approach to the installation of fire doors on properties owned by leaseholders.1146 Mackover {RBK00029923/18} page 18, paragraph 67; {RBK00052464/7} paragraph A8; {RBK00002340/1-2}. The scrutiny committee had not been briefed about the decision only a month or so earlier to spread the installation of self-closing devices over a period of five rather than three years and not to introduce a system of regular inspection and Laura Johnson did not draw it to their attention.
¶41.83 The minutes of a TMO executive team meeting on 17 May 2017 recorded that at the meeting of the scrutiny committee on 4 May 2017 Councillor Mackover had criticised the TMO's approach to fire doors but that Laura Johnson had made it clear that RBKC did not want the TMO to inspect the front doors of flats.1147 Minutes of the TMO executive team meeting on 17 May 2017 {TMO00894337/1-2} item 2.6.
¶41.84 Laura Johnson sent an email to Robert Black the following day in response to a question he had asked about the nature of Councillor Mackover's concern and whether he should contact him.1148 Emails between Laura Johnson and Robert Black on 17-18 May 2017 {RBK00002340/1-2}. She said that it related to the entrance doors of leaseholders' flats and that there was nothing in it. She recommended not contacting him. She thought that a section in the annual report would be sufficient. Robert Black agreed.1149 Email from Robert Black to Laura Johnson on 18 May 2017 {RBK00002340/1}.
¶41.85 It is evident, therefore, that the scrutiny committee was not told about the decisions that had been made, principally by Laura Johnson, about the installation and inspection of self‑closing devices before the Grenfell Tower fire.
129The TMO's approach to the repair of entrance doors
¶41.86 Section 5.1 of the TMO's fire safety strategy dated November 2013 said that repairs to fire doors and self-closing devices were given priority.1150 TMO fire safety strategy dated November 2013 {TMO00830598/3}. Beyond that, the TMO had no policy or procedure for responding to requests for repairs to fire doors, including entrance doors to flats. For example, they were not included in the TMO's Fire Protections Systems Policy & Procedure drafted in 2017, which set out the procedure for repairing faults in a number of fire protection systems, including sprinklers, fire alarms, fire extinguishers, hose reels and automatic opening vents.1151 TMO Fire Protections Systems Policy & Procedure Version 8 dated 10 January 2017 {TMO00899324/2}.
¶41.87 Despite the terms of section 5.1, the TMO's repair records for Grenfell Tower reveal no discernible system for giving repairs to fire doors priority over other matters.1152 {RBK00053524}; {RBK00053297}. Where a need to repair a fire door was identified by Carl Stokes in the course of a fire risk assessment, it was marked as "FRA", or something similar, but we saw nothing to suggest that it was given priority.1153 {RBK00053524}; {RBK00053297}. The repair records suggest that defects of that kind were dealt with in the same way as any other kind of repair. That is consistent with a finding of a "Health Check" audit carried out on Repairs Direct after the Grenfell Tower fire that there was no structured approach to categorising repairs, which made them difficult to manage effectively.1154 {TMO00862541/11}.
¶41.88 Those sent to carry out repairs to self-closing devices at Grenfell Tower between 2011-2013 often simply removed them, so that doors could be opened and closed freely, but did not replace them. In the period up to 14 June 2017 Repairs Direct staff continued on occasions to remove, or offer to remove, self-closing devices or failed to identify the need to replace them when carrying out repairs to entrance doors. That occurred at Flat 26,1155 Dagnachew {IWS00001742/4} page 4, paragraph 4b; {RBK00053297} row 467. Flat 45,1156 Email from Glen Duggan to Janice Jones on 22 July 2015 {CST00000989/2}; Carl Stokes's letter to Janice Wray on 28 July 2015 {CST00001448}; Capita repair spreadsheet {RBK00053524} rows 686 and 1227; West {IWS00000021/3} page 3, paragraph 14; Paramasivan {IWS00001003/3} page 3, paragraph 9. Flat 126,1157 Repair records {RBK00053524} rows 30 and 163. Flat 1311158 Gashaw {IWS00001738/2-3} pages 2-3, paragraph 4b; Fletcher {IWS00001797/3} page 3, paragraph 5b; Repair record {RBK00053524} row 847. and Flat 135.1159 Daniels {IWS00000608/6} page 6, paragraph 40; Daniels {IWS00002065/3} page 3, paragraphs 13-15; Open Contractor spreadsheet {RBK00053297} row 82; Repair records {RBK00053297} row 82.
¶41.89 At each of those flats the self-closing device was found to be missing on 14 June 2017, apart from Flat 26 where the resident had refused the Repair Direct workman's offer to remove it.1160 {MET00039807/76-80}. In our view that is indicative of a broader failure by the TMO to ensure that those carrying out repairs fully understood the importance of effective self-closing devices and ensured that repairs did not undermine the protection offered by the doors.
Fire risk assessment and flat entrance doors
¶41.90 Paragraph 33.2 of the LGA Guide drew attention to the importance of ensuring that the fire resistance between flats and the common parts was considered as part of a fire risk assessment by examining at least a sample of the entrance doors to flats to ensure that they were fire-resisting and self-closing.1161 The LGA Guide {HOM00045964/43} paragraph 33.2. In a similar vein, Annex D to PAS 79:2012 stated that a fire risk assessor must consider whether all fire-resisting doors are properly self-closing.1162 PAS 79:2012 {CTA00000003/104}.
130The approach to flat entrance doors to be expected of a fire risk assessor
¶41.91 We have no doubt that a fire risk assessor considering any building containing a large number of flats should inspect a representative sample of entrance doors.1163 Lane {Day171/177:22}-{Day171/178:11}; Todd {Day168/6:5-11}. Although they expressed themselves in slightly different terms the experts agreed that the number of doors that should be expected will be a matter of judgment in each case and depend on the nature and size of the building and the assessor's familiarity with it.1164 Lane {Day171/178:20}-{Day171/179:11}; {Day171/186:19}-{Day171/187:20}. There appears to have been a general understanding at the time among fire risk assessors that 10% of the total number with a minimum of two doors was sufficient.1165 Todd {Day168/6:12-20}.
¶41.92 The experts also agreed that a fire risk assessor should inspect both sides of the door, check whether the self-closing device was working effectively,1166 Lane {Day171/178:6-11}; {Day171/184:3-9}; Todd {Day168/6:7-11}. keep a record of the doors inspected,1167 Lane {Day171/180:7}-{Day171/182:16}; Todd {Day168/9:9-23}; Todd {Day168/14:20}-{Day168/15:20}. record any defects in the fire risk assessment1168 Lane {Day171/175:19}-{Day171/176:23}; {Day171/188:13}-{Day171/189:11}; Todd {Day168/20:10}-{Day168/24:1}. and assess the adequacy of the arrangements for the inspection and maintenance of entrance doors.1169 Lane {Day171/197:3-12}; Todd {Day168/17:8-19}.
¶41.93 Salvus and the TMO had agreed in late 2009 at the start of programme of assessing high-risk buildings that its fire risk assessors would inspect a sample of the entrance doors to flats during each of their assessments, although they did not agree a specific number or percentage of doors to be inspected.1170 The TMO Consultant's Brief dated July 2009 for fire risk assessments in high-risk blocks, which was the brief for Salvus, states at Part 2 section 1.1 that the "FRA and FRA reviews will include an individual examination of each fire door including whether it operates correctly": {TMO00865175/6}; However, at a meeting on 7 September 2009 between Salvus and TMO, Janice Wray agreed that only a random sample of doors needed to be inspected {SAL00000040/1} item 2.1; Wray {TMO00873629/2} page 2, paragraph 9. When Carl Stokes was engaged by the TMO to assess medium-risk buildings in September 2010, it does not appear that he and Janice Wray discussed the need to inspect a sample of doors but they both clearly proceeded on understanding that he would.1171 Janice Wray said Carl Stokes continued to inspect flat entrance doors as part of his fire risk assessments, Wray {TMO00000890/7} page 7, paragraph 31; Stokes {Day138/84:5-7}; Stokes {Day138/149:11-15}; {CST00002861}. That expectation was ultimately recorded in the TMO's fire safety strategy dated June 2017.1172 {TMO10017036/12} section 18.1.
Carl Stokes's inspection of entrance doors at Grenfell Tower
¶41.94 In section 12 of his fire risk assessment template referring to the means of escape Carl Stokes included the questions whether fire doors were fitted with self-closing devices and whether they functioned correctly.1173 For example, Carl Stokes's fire risk assessment of Grenfell Tower dated 26 April 2016 {CST00003084/18}. It was his own addition to the model template contained in PAS 79:2012.1174 PAS 79:2012, Annex B model proforma fire risk assessment template {LFB00034866/77}.
131¶41.95 Carl Stokes said that he did not make appointments to inspect doors but knocked on doors and asked residents whether he could inspect them and, in particular, whether self-closers were fitted.1175 Stokes {CST00003063/20} page 20, paragraphs 58 and 59. He said that tried to inspect at least a handful, or about 5%, of entrance doors1176 Stokes {Day136/96:3-12}. and that if the doors in a building were of the same kind, he aimed to inspect a sample. If they differed, he aimed to inspect at least one of each kind.1177 Stokes {Day136/95:21}-{Day136/96:2}. However, even when the doors in a building were all of the same kind, inspecting only 5% of them was barely enough.1178 Lane {Day171/179:14}-{Day171/180:6}; Todd {Day168/8:24}-{Day168/9:8}.
¶41.96 Notwithstanding what he said about his approach to sample inspections, the evidence suggests that at Grenfell Tower Carl Stokes did not carry out sample inspections of entrance doors which extended to both the external and internal faces of the doors, including self-closing devices. The evidence tends to support the conclusion that he looked only at the outside of doors and that he noted only such damage as he happened to see rather than visiting a number of flats as part of an organised plan. In the course of four fire risk assessments he carried out at Grenfell Tower between November 2012 and June 2016 Carl Stokes identified defects in only four entrance doors.1179 Carl Stokes identified holes in the flat entrance doors of flats 166 and 202 in his Record of Significant Findings and Action Plan for Grenfell Tower dated 20 November 2012 {CST00003083/3} item 12b. Carl Stokes identified that the flat entrance door of Flat 24 was damaged and that the door to Flat 112 was being replaced, was not marked as fire rated and did not have a self-closing device, Record of Significant Findings and Action Plan dated 20 June 2016 {CST00003069/4-5} items 12g and 12h. Only one of them was a defect that affected the inside face of the door: a self-closing device missing from the door to Flat 112. As it happened, the door to Flat 112 was being replaced in June 2016 and had been open at the time he was carrying out his fire risk assessment. His ability to inspect the inside of the door had therefore been fortuitous rather than planned.1180 Stokes {Day138/130:17}-{Day138/131:1}.
¶41.97 Carl Stokes's failure to identify defects on the inside of doors, particularly defective and missing self-closing devices, is in stark contrast with what others who carried out sample inspections of entrance doors at Grenfell Tower found. Leon Taylor, who carried out a sample inspection of entrance doors in the course of a fire risk assessment on 14 June 2014 found at least three self-closing devices missing,1181 {TMO10001286} 'FRA' sheet, ref L6, row 232; Taylor {PSC00000002/2} page 2, paragraph 2.d. whereas Carl Stokes, who carried out a fire risk assessment on 17 October 2014, did not find any self-closing devices missing. Michelle McHugh, of the LFB fire safety team, carried out an inspection of a sample of entrance doors during her audit of Grenfell Tower on 26 October 2016 and found that three self-closing devices were defective,1182 {LFB00105489/6} penultimate paragraph under 'Observations'. but Carl Stokes did not find any devices missing during his fire risk assessments in April and June 2016 or during an inspection he carried out on 18 October 2016, only a week or so before Ms McHugh.1183 {CST00003098}; {CST00003069}; {CST00003137}.
¶41.98 Given the number of self-closing devices that were found to be missing or broken after the fire (some 77 out of 120), and in the light of Leon Taylor and Michelle McHugh's findings, we think it likely that, if Carl Stokes had inspected both the inside and outside of a representative sample of entrance doors during his fire risk assessments, he would have discovered a significant number of missing or defective self-closing devices.1184 {MET00039807/76-80}. Accordingly, we think it unlikely that he did routinely inspect the inside of doors.
132¶41.99 Carl Stokes kept no record of which flats he had visited or tried to visit as part of his fire risk assessments or of the results of any such inspections, except in relation to the four defects he identified in his action plans.1185 For example, {CST00003084/19}.
¶41.100 In each of his fire risk assessments Carl Stokes stated that the entrance doors to the flats had recently been replaced with new self-closing 30-minute fire doors but he did not say that he had inspected a sample of entrance doors.1186 {CST00003157/19}; {CST00003161/21}; {CST00003145/20}. Further, in his contemporaneous notes of the fire risk assessment he carried out on 20 June 2016, he recorded only the defects that he had identified on the outside of the door to Flat 24 and on the open door to Flat 112.1187 {CST00000003/10}. He did not include a note of any other flats he had sought to enter, nor what he had found. That has left us in some doubt whether he did, in fact, inspect a representative sample of entrance doors during any of his fire risk assessments.
¶41.101 Gaining access to flats clearly posed a problem for Carl Stokes from time to time. In his fire risk assessment of Grenfell Tower dated 30 September 2009 (when he was working for Salvus), he recorded that the entrance to each flat appeared to be a rated fire door to FR30 standard but that without being able to obtain access to all the flats he could not confirm that every door was fitted with an intumescent strip, cold smoke seals and a self-closing device.1188 Carl Stokes's fire risk assessment of Grenfell Tower dated 30 September 2009 {CST00003128/9} item 3.4. He confirmed when he gave evidence that he had not always been able to gain access to flats because, for example, the residents were out at work.1189 Stokes {CST00003063/20} page 20, paragraphs 58 and 59; Stokes {Day138/149:11-15}. However, he did not tell the TMO that he was having difficulty in inspecting the inside of entrance doors to flats because people were not at home to let him in,1190 Carl Stokes said that he considered the sample inspections he carried out to be sufficient and that he did not tell the TMO that he had been unable to obtain access to a sufficient number of doors because he was happy with the process that he had adopted. Stokes {Day138/150:11}-{Day138/151:11}. and except for the fire risk assessments he produced in 2009, he did not record that as a problem. If he could not gain access to enough flats to inspect a representative sample of doors, he ought to have told Janice Wray so that she could arrange access for him.1191 Lane {Day171/181:19-24}.
¶41.102 Carl Stokes also failed to record in his fire risk assessments for Grenfell Tower problems that he knew existed in relation to self-closing devices. For example, in the assessment he carried out in November 2012, he did not mention the recurring problem of people disconnecting self-closing devices that he had identified in July 2011.1192 {TMO00867783}; {CST00003084/19}. Similarly, in the assessment he carried out in April 2016, he did not mention the missing self-closing device at Flat 45 that he had identified in July 2015, nor the fact that Seamus Dunlea had been removing self-closing devices on entrance doors, something he had discovered in December 2015.1193 {CST00001448}; {TMO00859693}; {CST00003161}. There is nothing to suggest that he had been told that those problems had been satisfactorily resolved and he ought, therefore, to have taken steps as part of his next fire risk assessment to find out. If they had not, or if he did not get a satisfactory response, he should have taken that into account in assessing the risk.
¶41.103 We have seen no evidence that Carl Stokes ever considered the TMO's arrangements for the inspection and maintenance of entrance doors to flats, whether as part of his fire risk assessments or otherwise, much less that he advised it that they were inadequate. When he was asked to comment on the draft strategy in early 2013, he did not tell Janice Wray that it needed to include arrangements for the inspection and maintenance of entrance doors, although the LGA Guide recommended inspections every six months and Andy Jack had referred to the need for regular inspection in the course of their conversation on 8 November 2012.1194 {CST00002046}.
133¶41.104 We have seen no evidence that Carl Stokes ever drew Janice Wray's attention to the recommendation in the LGA Guide, although she said she had been aware of it.1195 Wray {Day143/71:20}-{Day143/72:14}; {Day143/91:20-23}. Nor did he mention it in his letter of 30 April 2011 when he drew her attention to other provisions of the draft LGA Guide which could adversely affect the replacement of doors, including the risk of residents' removing self-closing devices.1196 Note the letter from Carl Stokes to Janice Wray is wrongly dated as 30 April 2010 {TMO00847318/1}. He also failed to draw it to her attention after the Adair Tower fire when there were discussions about the approach the TMO should take to self-closing devices, of which he appears to have been aware.1197 For example, {CST00007708/1-2}; {CST00006634/1}; {CST00002902/1}; {CST00002302/1-2}.
¶41.105 In the fire risk assessment of Grenfell Tower he produced in April 2016, Carl Stokes referred to the TMO's policy of inspecting self-closing devices in vacant properties1198 {CST00003161/21}. but he did not comment on its adequacy. It is not clear what prompted him to refer to the policy for the first time in April 2016.
135Chapter 42: Fire safety information
¶42.1 Under the Fire Safety Order the TMO had a duty to take such general fire precautions as would ensure, so far as was reasonably practicable, that Grenfell Tower was safe for those who lived there, their visitors and its own employees.1199 Article 8. General fire precautions include measures in relation to the means of escape and the arrangements for action to be taken if a fire occurs.1200 Article 4(1). It also had a duty to establish procedures to be followed in the event of serious and imminent danger to persons present in the parts of the tower to which the Fire Safety Order related.1201 Article 15(1). As part of our investigation into the fire that occurred on 14 June 2017, therefore, we have considered it appropriate to examine the steps taken by the TMO to comply with those duties. In earlier chapters we have examined the steps taken by the TMO to carry out fire risk assessments as required by the Fire Safety Order and we have described the problems that affected the smoke ventilation system. In this chapter we consider the information given to residents relating to fire safety.
¶42.2 Before the refurbishment Grenfell Tower had been constructed entirely of concrete, apart from some internal structures and the usual internal fittings. The structure was therefore not combustible. The front door of each flat was a fire door and had originally been fitted with a self-closing device. Although a fire could spread from one flat to another up the outside of the building or through the lift lobby, that was likely to happen relatively slowly, giving time for the occupants to escape and the fire brigade to gain control before many people were affected. That was the design principle behind the "stay put" strategy for responding to fires in individual flats which had proved effective in the past.
¶42.3 The existence of a "stay put" strategy was reflected in the advice the TMO gave residents about how to respond to a fire in the building. It also affected the way in which it approached the question of evacuation.
¶42.4 The TMO provided fire safety advice to residents in letters to new tenants, in magazines distributed to residents (Link magazine and Homeowner newsletter), through fire action notices and in roadshows held by the TMO Resident Engagement team.1202 Wray {TMO00000890/53-55} pages 53-54, paragraphs 245-250. Written materials were produced in the seven major languages identified as being most likely to meet the needs of the residents.
¶42.5 Before moving into a property, new residents were given a handbook that included some fire safety advice, including instructions not to store items in communal areas or obstruct the means of escape. The TMO did not display fire safety action notices in residential buildings because it considered that it had provided the relevant information in other ways.1203 Letter from Carl Stokes to Janice Wray dated 27 September 2010 {CST00001979}; Stokes {Day136/217: 2}-{Day136/219:8}; Stokes {Day136/220:15-22}.
136The resident's handbook
¶42.6 Historically, the resident's handbook had contained some fire safety advice,1204 Tenant's Handbook {IWS00001762} and Rasoul {IWS00001768/3} page 3, paragraph 13. such as how to prevent a fire and how to make sure that a smoke detector was installed, but no advice on how to respond to a fire.1205 Tenant's Handbook {IWS00001762} and Rasoul {IWS00001768/3} page 3, paragraph 13. The original stock of handbooks ran out in 2008 or 2009. There were no plans to publish any more at that time, but later on a decision was made to produce a new version.1206 Jones {TMO00900052/3} page 3, paragraph 9; "Tenant's Handbook" was used interchangeably with "Resident's Handbook". The TMO also produced a "Homeowner's Handbook" which was intended for leaseholders and contained information which was different from that provided to tenants. By January 2010 a first draft was said to be ready for consideration,1207 {TMO10000641/2}. but in the event it had not been published by the time the coroner made her recommendations following the Lakanal House inquests in March 2013, four years later. They included a recommendation that information and guidance should be provided to residents about fire procedures.
¶42.7 In June 2013, Janice Wray told the Health and Safety Committee that residents received fire safety information on the TMO's website, in the resident's handbook, through articles in Link and in letters and LFB leaflets to new tenants. She asked the committee to consider what other opportunities there were to promote fire safety and fire procedures to residents. No one appears to have pointed out that the new resident's handbook had not been finished and so could not be distributed to residents. It is not clear why Janice Wray told the committee that information was given in the handbook. Although she may not have had direct knowledge of the matter, she told us that she had thought that by March 2013 it had been finalised.1208 Wray {Day142/185:17-23}. However, that seems unlikely.
¶42.8 When the TMO's Fire Safety Strategy was completed in November 2013, it referred to the resident's handbook as one means by which information about fire safety was communicated to residents.1209 Fire safety policy dated November 2013 {TMO00830598}. Although the strategy was submitted to the Health and Safety Committee for its views in November 2013, no one mentioned that the resident's handbook had still not been finished.1210 The meeting was attended by, among others, Sacha Jevans, Janice Wray, Peter Maddison, and Alex Bosman. Minutes of TMO Operational Health & Safety Meeting dated 15 November 2013 {TMO10004726/6}. In 2017, when the Health and Safety Committee's views were sought on the revised fire safety strategy, yet again no one raised the fact that the handbook had not been produced,1211 The meeting was attended, among others, by Barbara Matthews, Janice Wray, Peter Maddison and Teresa Brown. Minutes of Health and Safety Committee Meeting dated 13 June 2017 {TMO10021549/4}. even though it was one of the ways of communicating with residents referred to in the fire safety strategy.1212 Fire safety strategy dated June 2017 {TMO00847324/3}.
¶42.9 The delay in the production of the resident's handbook illustrates many aspects of the TMO's attitude to its fire safety obligations. Having rightly identified the need for a revised handbook in 2010, nothing had been produced by June 2017. Although the handbook had been repeatedly relied upon as a way of communicating information to residents about how to respond to a fire, no one at the TMO had noticed that supplies of the old handbook had been exhausted in 2008 or 2009 and that the new edition had never been produced. The effectiveness of the TMO's Emergency Plan depended to a great extent on residents being aware of what to do in an emergency, but the TMO's failure over such a long period of time to make it available denied residents one useful means of receiving that information. No reasonable explanation was offered for that failure.
137Letters to new residents
¶42.10 We have seen three draft letters to new residents containing fire safety advice. The first appears to date from December 2010.1213 {TMO00870665}. It advised new residents, among other things, that: a. there was a "stay put" strategy in place; b. they should not prop open fire doors; c. they must not disconnect the self-closing device on the entrance door to the flat; d. they should fit a smoke alarm, if one was not already installed; e. they should not use a lift in the event of a fire; f. they should refer to the resident's handbook for additional fire safety information; and g. they would be provided with a personal emergency evacuation plan (PEEP) if they had difficulty hearing or responding to a smoke alarm or had special requirements. The letter we were shown was a draft and we do not know whether it was sent to any new residents.
¶42.11 The letter was substantially revised in May 2013.1214 {TMO00865707}. In its new form it advised residents: a. to ensure that an operational smoke alarm was installed in their flats; b. that if there was a fire elsewhere in the building, residents were safe to stay in
their flats unless they were affected by heat, flames, smoke or the LFB or the TMO instructed them to leave; and
¶c. that the front door should be self-closing and should not be propped open. Residents were encouraged to report defective doors to the TMO. Again, it is not clear whether that letter was ever used.
¶42.12 Some minor changes were made to the letter in September 2016, but the contents remained essentially the same.1215 {TMO00865991}. We do not know why the reference to PEEPs was removed from the 2013 and 2016 drafts.1216 Wray {Day142/187:13-25}. Janice Wray thought that the housing officers who met residents took them through the induction pack and, if there were any concerns about vulnerability, came back to her so that appropriate action could be taken.1217 Wray {Day142/187:17-25}.
¶42.13 The letter was provided to residents as part of an induction pack by Moira MacDonald, the TMO officer who arranged viewings for prospective tenants.1218 Wray {Day142/187:4-11}. They could ask for a translation, but there is no evidence that they were routinely told that a translation could be provided. There was no system to record whether residents received the letter during the induction process.1219 Wray {Day142/187:1}.
138¶42.14 Daniel Lewis, a TMO Neighbourhood Co-ordinator, said that fire safety advice for new residents had not been included in the documents that formed part of the "Welcome Pack" that he had compiled and that the Neighbourhood Officer provided to new residents.1220 Lewis {TMO00899762/3} page 3, paragraph 10. Janice Jones agreed that the fire safety letter had not been included in the pack, but said that Moira MacDonald took her own paperwork to viewings, including a fire safety letter signed by Janice Wray.1221 Jones {TMO00900052/6} page 6, paragraph 24.
¶42.15 We have been left with the impression that it was largely a matter of chance whether new tenants, at whom the fire safety letter in its various versions was directed, saw it at their viewings. The point of the letter was to bring home to tenants in clear terms the fire safety arrangements in their buildings. That was important, but the TMO simply failed to ensure that the message always reached its intended recipients.
'Link' magazine
¶42.16 Link was a quarterly publication for TMO tenants. Originally it was produced only in English, but from 2012 it contained information about how it could be translated into other languages.1222 See, for example, Link Magazine dated Winter 2012 {TMO00873414}; Link magazines from 2009 did not include information about how to translate the newsletter; see, for example, Link Magazine dated Winter 2009 {TMO10048206}. TMO leaseholders received the Homeowner newsletter instead of Link.
¶42.17 Some issues of Link and Homeowner contained fire safety advice. In the Winter 2009 issue of Link the TMO announced that a fire safety consultant would carry out fire risk assessments in the communal areas and would require access to the front doors of some flats. Residents were reminded not to smoke in communal areas and to keep those areas free of items.1223 Link Magazine Winter 2009 {TMO10048206/5}.
¶42.18 Fire safety advice was also included in the June 2013, Summer 2014 and Autumn/Winter 2015 issues.1224 Link Magazine Autumn/Winter 2015 {TMO00873549}; Link Magazine Summer 2014 {TMO10031098}; Link Magazine June 2013 {TMO00873438}; Link Magazine Winter 2009 {TMO10048206}. Only the latter, published after the Adair Tower fire, gave advice about evacuation and what to do if there was a fire.1225 Link Magazine Autumn/Winter 2015 {TMO00873549/25}.
¶42.19 Some editions of Homeowner also contained information about fire safety, including advice about compliance with the requirements relating to flat entrance doors and smoke alarms.1226 Homeowner Newsletter December 2013 {TMO00873466}; Homeowner Newsletter June 2015 {TMO00873520}; Homeowner Newsletter Winter 2015 {TMO00873536}. However, only the Summer 2016 issue contained advice about what to do in the event of a fire.1227 Homeowner Newsletter Summer 2016 {TMO00873556/4}. It is clear that, as Janice Wray accepted, there had been no regular programme for the distribution of fire safety advice; it was included as and when it seemed appropriate.1228 Wray {Day142/189:2-23}. Contrary to the statements made in the fire safety strategies of November 2013 and June 2017, Link and Homeowner did not regularly contain fire safety information or information about the evacuation strategy in properties managed by the TMO.1229 Fire safety strategy dated September 2013 {TMO00830598/3}; fire safety strategy dated June 2017 {TMO00847324/3}. In any event, they were distributed to tenants in a wide range of buildings, so it was not possible to include in them advice which related to specific buildings.
139Fire safety advice leaflets
¶42.20 Carl Stokes delivered leaflets on fire safety produced by the LFB to residents of smaller TMO premises.1230 Stokes {Day139/ 99:2}-{Day139/100: 20}; Carl Stokes confirmed he distributed the leaflet {CST00017272}. He did not do that in the larger blocks, as he thought the caretakers would leave them with the concierge instead. Carl Stokes did not deliver any leaflets to the residents of Grenfell Tower because there was a caretaker or handyman who did that.1231 Stokes {Day139/ 101:9-14}.
Roadshows
¶42.21 The TMO organised regular "Roadshows" which were used informally to consult or communicate with residents. On one occasion, on 14 May 2016, Janice Wray invited the LFB to attend a roadshow in Lancaster West Green to speak to residents about fire safety.1232 Wray {TMO00000890/54} page 54, paragraph 250; Email from Janice Wray to LFB dated 13 April 2016 {LFB00001085}. However, that was no substitute for consistent, clear and regular communication of fire safety advice to residents.
Website
¶42.22 The TMO maintained a website, which included a page containing fire safety advice. A page headed "Fire and smoke alarms" provided advice on fire safety measures. It first appeared on the website on 13 February 2012.1233 {TMO00899658/18}. The website set out detailed advice on fire safety, including advice on the evacuation strategy for residential blocks with purpose-built self‑contained dwellings.1234 {TMO00899658}.
¶42.23 Apart from a minor change to its contents, the "Fire and smoke alarms" page remained available on the TMO's website until 14 June 2017.1235 {TMO00899658/17}. Again, it was not a comprehensive statement of the fire safety advice to all residents and its efficacy depended on residents' accessing, and being able to access, the website to find information for themselves. Engagement, therefore, depended on the curiosity or sensitivity to risk of the individual tenant. The disadvantages of the website as a means of communicating fire safety information are obvious.
Fire Safety Advice during the refurbishment
¶42.24 From September 2013 to May 2016, the TMO and Rydon distributed newsletters almost monthly to the residents of Grenfell Tower. Two newsletters published in July 20141236 {CST00001919/2}. and May 2016 respectively1237 {JRP00000028/4}. contained fire safety advice.
140Fire action notices
¶42.26 In September 2009, Salvus identified a number of deficiencies in the TMO's management of fire safety across its housing stock, one of which was that adequate information and instruction on fire safety was not provided to employees. It also said that fire action notices were not displayed in properties where there was no fire alarm system and that residents did not receive specific individual emergency plans based upon the layout of their buildings.1241 {SAL00000013/10} section 7.2. It recommended that fire action notices should be displayed in all properties managed by the TMO setting out the fire action procedure for the particular property.1242 {SAL00000013/17} section 7.2.
¶42.27 On 26 January 2010, fire action notices were considered at a progress meeting with Salvus on fire risk assessments in high-risk blocks.1243 {RBK00052572/1} paragraph 2.2. There was a long discussion about whether to install a notice in the main entrance of each block setting out the emergency procedure in relation to that block. It was agreed that fire action notices should be put up in each block and that letters should be sent to residents describing the evacuation procedure.1244 {RBK00052572/1} paragraph 2.4.
¶42.28 On 13 May 2010, the TMO's Operations Committee agreed to put fire action notices in each block,1245 {TMO10037437/89}; Wray {Day142/211:11-18}. but the matter was not raised again at any subsequent meetings and in September 2010 Janice Wray presented a report on fire risk assessments which said nothing about fire action notices.1246 {TMO00899839/4}; {TMO00888971/1}. Instead, she reported that the TMO would write to the residents in each block explaining the relevant evacuation procedure and summarising the fire risk assessment's findings. The decision to post fire action notices was seemingly forgotten.
¶42.29 On 27 September 2010, Carl Stokes wrote to Janice Wray, at her request, about fire safety signage in the TMO's residential buildings.1247 {CST00002701}. He told her that, as the TMO provided fire safety information to residents in other ways, fire action notices were not required. Janice Wray accepted that advice, but she did not tell the Operations Committee or the executive team that the decision to put up fire action notices would not be carried out, though she believed that she had told her line manager.1248 Wray {Day142/212:15}-{Day142/213:20}.
¶42.30 Janice Wray was of the view that the LGA Guide (which was published after Carl Stokes's advice of 27 September 2010) supported her understanding that fire action notices were not required in high-rise residential blocks.1249 Wray {Day142/212:22}-{Day142/213:4}; {Day142/214:11-25}. The LGA Guide suggested that there would rarely be a need for a more elaborate emergency plan than a simple fire action notice. It also said that it was not universally necessary to display a fire action notice and that it was common to convey the emergency plan to tenants in other ways, for example, through residents' handbooks {HOM00045964}. She told us that she had thought that the passage in which it is stated that it is not always necessary to display fire action notices in blocks of flats with simple layouts was consistent with Carl Stokes's previous advice.1250 {HOM00045964/118}. Nonetheless, neither she nor Carl Stokes assessed each block to decide whether a fire action notice was required. On the contrary, the same generic approach was taken by the TMO to all its high-rise residential buildings.1251 Wray {Day142/217:6}-{Day142/219:19}. However, the LGA Guide did not say that fire action notices are never required in a purpose-built block; on the contrary, paragraph 79.1 provided in terms that a fire action notice would usually be all that would be needed by way of emergency plan for most purpose-built blocks.1252 {HOM00045964/118}. If Janice Wray and Carl Stokes thought that it supported a blanket decision not to put up fire action notices in any of the buildings managed by the TMO, they were mistaken.
141¶42.31 The question of fire safety advice for residents was considered by the TMO again after the coroner published her recommendations following the Lakanal House inquests. The inquests had identified the need to find ways to advise residents about the fire procedure other than by the website, leaflets, magazines and letters. However, no effective alternative had yet been identified and fire action notices do not appear to have been discussed. On 2 May 2013, Janice Wray wrote a report for the Operations Committee about the TMO's fire risk assessments which summarised the coroner's recommendations following both the Lakanal House and Shirley Towers inquests, particularly as they touched upon the "stay put" strategy.1253 {TMO10031056/5}. The Lakanal House coroner's recommendations were discussed at a meeting between the LFB Fire Safety team and the TMO Health & Safety team at a meeting on 15 May 2013.1254 {TMO00844568/2-3}.
¶42.32 A further briefing note was circulated to the Health and Safety Committee about the recommendations and the implications for the TMO1255 {TMO10039112}. which included a reference to the need to provide information and guidance to residents about fire procedures. The coroner's recommendations were discussed again at a meeting of the TMO's Health and Safety Committee on 20 June 2013.1256 {TMO00880630/4}. Janice Wray asked the committee to consider other opportunities for promoting fire safety and bringing fire procedures to the attention of residents.1257 {TMO00880630/4}. There was no mention of the coroner's recommendation to put up fire action notices, however, and the committee did not identify any new ways of providing fire safety information to residents. Nor was there any discussion at the meeting of the agreement that had been reached by the committee in May 2010 to install fire action notices in each block or why that had not been done. There was no discussion either about whether the coroner's recommendations should lead the committee to reconsider the assumption that it was not necessary to put up fire action notices in any of the buildings managed by the TMO.
¶42.33 On 23 December 2015, following the Adair Tower fire on 31 October 2015, the LFB issued enforcement notices against the TMO and RBKC.1258 {RBK00029298/4}. One breach of the Fire Safety Order they identified was that the TMO's procedures in the event of serious and imminent danger were inadequate. That was because no instructions about action to be taken in the event of a fire had been displayed in the common parts of the premises where they might be seen by visitors and other relevant persons.1259 {RBK00029298/6}.
142¶42.34 Janice Wray and Rebecca Burton discussed the enforcement notice at their next regular meeting on 5 January 2016.1260 {RBK00013997/1}. Rebecca Burton confirmed that the LFB required work to be completed within six months from the date the notice had been posted, i.e. by 23 June 2016. She told Janice Wray that, although the notice related to Adair Tower, the LFB expected that the standards required in one block would be applied in others.1261 {RBK00013997/2}. Janice Wray told her that the TMO had not put up fire action notices because the buildings were not complex and a "stay put" strategy was in place. Rebecca Burton indicated that notices were required, but that it was not a priority.1262 {RBK00013997/2}. In the light of that Janice Wray did not think the requirement was pressing.1263 Wray {Day142/222:10}-{Day142/223:20}.
¶42.35 Rebecca Burton told us that in her view fire action notices were of limited use.1264 Burton {Day145/134:3-11}. When shown the wording of the enforcement order which proposed an adequate fire action notice in the common parts, she said that the LFB would suggest action but that it was for the responsible person to decide how to comply with the notice.
¶42.36 If the TMO had provided its residents with fire safety information, we can see why fire action notices might not have been required, but it did not provide them with such information. The tenancy pack included no fire safety information and had not done so for many years, and the newsletters contained no advice about what to do in the event of a fire until the Autumn/Winter 2015 issue of Link which was published after the Adair Tower fire. There was no resident's handbook.1265 {TMO00873549/25}. Nothing said by Rebecca Burton could fairly have led Janice Wray to think that it was acceptable to have no fire action notices in buildings managed by the TMO, let alone that that would be consistent with the LGA Guide. Janice Wray can fairly be criticised for seeking to justify doing the minimum in the face of the enforcement notice.
¶42.37 Shortly afterwards, on 8 January 2016, Councillor Pat Mason sent an email to Councillor Marshall expressing concern about the advice given to residents on fire procedures. The email followed a meeting of the Cabinet and Corporate Services Scrutiny Committee, which had discussed the Adair Tower fire.1266 {RBK00053869/5}. On 9 January 2016, Councillor Marshall asked Robert Black to set out the advice that was normally given to residents of high-rise residential buildings.1267 {RBK00053869}. Robert Black responded on 15 January 2016,1268 {RBK00053869/3}. saying that "stay put" advice was given to residents of high-rise buildings and was available on the website, in regular fire safety articles in Link and in LFB leaflets distributed by the fire risk assessor to some dwellings.1269 {RBK00053869/3-4}. In relation to procedures to respond to a major fire breaking out at the weekend when offices were closed, he said that Pinnacle, the out-of-hours call handling service, would activate the emergency plan. Janice Wray and Hash Chamchoun were the principal contacts and other staff were available. Estate services staff would also be called out to visit and assess the situation.1270 {RBK00053869/4}.
143¶42.38 On 14 April 2016, Councillor Pat Mason wrote to Robert Black asking whether fire safety information was provided to residents otherwise than on the TMO's website. He was concerned that not all residents might have access to the internet.1271 {TMO00865782/3}. Janice Wray responded on 15 April 2016 saying that such information was provided to residents on the TMO website, in the letter to new tenants and by regular articles in Link and Homeowner.1272 {TMO00865782/1}. However, her response tended to gloss over the defects we described earlier in the quality of the information provided by the TMO and its delivery to residents.
¶42.39 It was not until 13 September 2016 that the Health and Safety Committee considered putting up fire action notices in all buildings managed by the TMO.1273 {TMO00840753/5}. The committee expected the LFB to require notices to be placed in all buildings, having seen the position it had taken in the Adair Tower enforcement notice. The TMO therefore decided to adopt a risk-based approach and to start placing fire action notices in high-risk buildings.1274 {TMO00840753/5}. That was a far cry from what Janice Wray had understood to be required as a result of her meeting in early January 2016 with Rebecca Burton, but it was the correct approach. On 13 October 2016, Barbara Matthews asked Janice Wray to develop a programme for putting up fire action notices in all the TMO's buildings and to provide costings.
¶42.40 A month later, on 17 November 2016, the LFB issued a deficiency notice in relation to Grenfell Tower because there were no fire action notices in the common parts (among other reasons).1275 {TMO10017254}. The deficiency notice was issued a year after the Adair Tower fire, 11 months after the enforcement notice relating to Adair Tower and two months after Janice Wray had told the Health and Safety Committee that fire action notices would be installed in all properties managed by the TMO. Janice Wray was not able to say why there had been a delay in putting up the fire action notices; she thought they had been on order by that time.1276 Wray {Day143/3:7-14}; {Day143/6:24}-{Day143/7:8}. However, the evidence we have seen suggests that a quotation for fire action notices for Grenfell Tower had been requested on 23 November 2016 after Edward Daffarn and Councillor Blakeman had complained about the lack of notices.1277 {TMO00861289/2}.
The Grenfell Action Group blog - "KCTMO - Playing with fire"
¶42.41 On 20 November 2016, Edward Daffarn posted an article on the Grenfell Action Group blog entitled "KCTMO – Playing with fire". In it he criticised the TMO for failing to take fire safety seriously. He said that the Grenfell Action Group firmly believed that only a catastrophic event would expose what he described as the "ineptitude and incompetence" of the TMO.1278 {TMO00845987}. The post contained links to previous blogs on fire safety and referred to the Adair Tower fire in October 2015, saying that the LFB had found that the TMO had not looked after the safety of residents properly and had issued an enforcement notice compelling it to improve fire safety. He said that the residents of Grenfell Tower had received no proper fire safety instructions from the TMO. Residents, he said, had been informed by a temporary notice in a lift and one announcement in a recent regeneration newsletter that they should remain in their flats in the event of fire.1279 {TMO00845987/2}.
144¶42.42 The post has since gained a degree of notoriety for its apparent prescience, but it did not in fact predict the fire at Grenfell Tower, much less what turned out to be its cause. Nonetheless, based on his own experience as a resident of Grenfell Tower, Mr Daffarn was able to put his finger on something very wrong with the TMO's management of fire safety and used his forthright style to make his point. Shorn of the rhetoric, it was a message that the TMO could not afford to ignore.
¶42.43 On 23 November 2016, Councillor Blakeman saw the blog post and raised its contents with Robert Black. She agreed with Mr Daffarn's point that instructions were not permanently available on noticeboards or in letters to residents (or in appropriate languages, where required) and asked whether that could be rectified.1280 {TMO10015228/2}.
¶42.44 Robert Black asked Janice Wray to prepare a response.1281 {TMO10015214/1}. She told him that advice on fire procedures was included in newsletters, on the website, in regular articles in Link and provided to all new tenants. She said the Health and Safety Committee had been considering putting up fire action notices in all the buildings and that, although the LFB had issued a deficiency notice relating to the absence of fire action notices, its attitude to the need for them had been inconsistent. Janice Wray asked for permission to order notices for Grenfell Tower to address Mr Daffarn's concerns.1282 {TMO10015214/1}. She also said that although Mr Daffarn was challenging the "stay put" strategy, none of the professionals with whom she had discussed Grenfell Tower had suggested that there was a need to change it.
¶42.45 A quotation for the cost of obtaining fire action notices was provided on 23 November 2016, presumably in response to the issue of the deficiency notice, Mr Daffarn's blog post and Councillor Blakeman's concerns.1283 {TMO00829191}. On 14 December 2016, Janice Wray confirmed that 30 fire action notices had been put up in Grenfell Tower the previous day.1284 {TMO00861381}. They cost £328.32.1285 Quote for fire action notices for Grenfell Tower {TMO00829191}.
¶42.46 In the response that she prepared for Mr Black to send to Councillor Blakeman, Janice Wray failed to mention that on 17 November 2016 the TMO had received a deficiency notice in relation to Grenfell Tower and that one of the deficiencies identified had been the absence of fire action notices. There is no doubt that Councillor Blakeman should have been told about the notice and its substance. She was a member of the TMO board who had specifically asked about fire safety advice in response to a resident's concerns and she should have been given the full picture. Janice Wray's failure to mention the deficiency notice to Councillor Blakeman mirrored Robert Black's own failure to bring the notice to the attention of the TMO Board, a matter to which we have referred in Chapter 31.
¶42.47 On 2 December 2016, Peter Maddison asked if any of the allegations in the blog post could be considered libellous.1286 {TMO00865831/3}. Barbara Matthews responded indicating that she had spoken to Robert Black and that they agreed to take no action in response to it.1287 {TMO00865831/1}. Peter Maddison's reaction, to seek advice about whether Mr Daffarn had libelled the TMO rather than to get to the bottom of the complaint, was telling. By this point, the TMO's defensiveness and hostility towards the Grenfell community, at least as represented by Mr Daffarn, had sunk to a new low.
145¶42.48 The history of fire safety notices illustrates a reluctance on the part of the TMO to take active steps to promote fire safety. Although the need for fire action notices was first raised in 2009 by Salvus, they were not provided until the end of 2016 after the LFB had issued a deficiency notice and Councillor Blakeman had questioned the position having read Mr Daffarn's blog post. In the end, fire action notices proved a relatively inexpensive means of providing fire safety advice. Their timely installation following Salvus's advice in 2009, or even immediately after the Adair Tower fire in 2015, would have ensured that consistent advice was available to residents. That might have gone some way to reassuring them that fire safety was taken seriously by the TMO. The delay in installing fire action notices should also be understood in the context of enquiries and complaints from residents of Grenfell Tower about the evacuation strategy.
Residents' complaints about fire safety advice
¶42.49 Mr Daffarn's was not a lone voice. The blog post of 20 November 2016 was the culmination of a long history going back to 2010 of complaints about fire safety by residents of Grenfell Tower.
¶42.50 On 3 September 2010, the Leaseholders' Association wrote to Robert Black setting out 11 areas of concern that had arisen as a result of the fire on 30 April 2010.1288 {TMO10037439}. The letter said that no one in the block had been aware of the evacuation procedure and that they had not been given information about what to do in the event of a fire in the previous 36 years.1289 {TMO10037439/5}.
¶42.51 Anthony Parkes responded on Robert Black's behalf on 21 September 2010,1290 {TMO00846320}. saying that the fire alarm was functioning and the smoke ventilation system had been working at the time (although in fact it had not).1291 {TMO00846320/4}. He did not address the complaint that residents had not been informed of the evacuation procedure.
¶42.52 On 6 October 2010, the Leaseholders' Association sent another letter to the TMO making a number of complaints again.1292 {IWS00001310}. Anthony Parkes responded on 27 October 2010. Among other things, he said there was a "stay put" strategy in place, which he explained. He also said that information about fire safety was regularly published in Link and that the TMO planned to write to the residents of each block to advise on the action to be taken in response to a fire in that block.1293 {TMO00836390}. He also expressed the TMO's commitment to working with the Association and invited it to provide some dates when they could meet for a discussion.
¶42.53 In 2012, the Association made further complaints about the management of fire safety. On 14 November 2012, it sent an email to David Ward, the TMO's Home Ownership Manager, about the plan to replace the entrance doors to tenants' flats,1294 {TMO00833837}. asking why leaseholders had not been included in the programme if the replacement related to fire safety and complaining about their omission. They also complained about the lack of health and safety training or drills in case of an emergency.1295 {TMO00833837/1}. Paul Dunkerton responded on 20 November 2012 reminding the leaseholders that a "stay put" strategy was in place at Grenfell Tower, meaning that if a fire were to break out anywhere other than in their own flats they were safe to remain in their homes.1296 {TMOH00027332/2}. The existence of the "stay put" strategy was repeated in several subsequent letters responding to various points raised by the Leaseholders' Association.
146¶42.54 On 29 September 2016, the Association sent an email to Councillor Blakeman raising a number of complaints, including the failure of the TMO to organise any fire drill at Grenfell Tower since 2012. They referred to the recent fire at Shepherd's Bush and asked her to investigate their various concerns.1297 {TMO00846025/35}.
¶42.55 Robert Black circulated the email within the TMO and asked for responses.1298 {TMO00847231}. Janice Wray told him that fire drills were not required in blocks with a "stay put" fire strategy.1299 {TMO10033125}. The purpose of fire drills, she said, was to test the procedure to be followed in the event of a fire and if that was to stay put, a fire drill would conflict with the way residents were expected to respond.1300 {TMO10033125}. Peter Maddison prepared a draft response in which he explained that Grenfell Tower maintained a "stay put" fire strategy1301 {RBK00000142}. and that, if the LFB decided that an evacuation was necessary in response to a particular incident, it would organise it.1302 {RBK00000142}. It is not clear whether that response was sent to the Leaseholders' Association.
¶42.56 Grenfell Compact was formed in 2015 to voice residents' concerns during the refurbishment. Councillor Blakeman responded briefly to the Leaseholders' Association's email on 4 October 2016 attaching a list of complaints that had been prepared by Grenfell Compact in May 2016 together with the TMO's responses to them.1303 {TMO00846745}; {TMO00846746}. They did not include a complaint about the absence of fire action notices, but as mentioned earlier, fire action notices were put up in Grenfell Tower on 13 December 2016.
¶42.57 The repeated complaints by the Leaseholders' Association about fire safety advice and procedures over the years prompted responses from the TMO but not a review of the fire safety advice provided to residents. Instead, the TMO simply repeated the "stay put" advice in correspondence with the Association and took no further action. It is difficult to know, even with the benefit of hindsight, whether the earlier installation of fire action notices would have made any difference, but it might have addressed some of the concerns of the Association to have had the advice set out in accessible and publicly available notices.
147Chapter 43: The smoke ventilation system
The system
¶43.1 Grenfell Tower was equipped with a ventilation system designed to allow the passage of air through the building for ventilation and the extraction of smoke in the event of a fire. Ventilation depended entirely on natural airflow. The extraction of smoke depended on the natural convection of hot smoke but could be boosted by mechanical means. The booster fans were designed to be operated manually by the fire and rescue service.
¶43.2 The system comprised two pairs of shafts running the full height of the building with openings into each lift lobby controlled by louvred dampers. In the event of a fire the dampers were designed to open on the floor affected by the fire and close on all other floors, thereby allowing smoke to flow up the shaft to the opening at roof level without escaping into lobbies on other floors.
The fire at Grenfell Tower on 30 April 2010
¶43.3 On 30 April 2010, a fire was started deliberately outside Flat 64 at Grenfell Tower.1304 Wray {TMO00000890/43} page 43, paragraphs 195-196; LFB notifiable fire report into the fire {LFB00000201/1-2}; LFB report into the fire dated 22 December 2010 {IWS00001463/3}. During the fire, the smoke ventilation system (sometimes referred to as the automatic opening vent system or AOV) failed to operate properly.1305 Wray {TMO00000890/43} page 43, paragraphs 195-196; LFB notifiable fire report into the fire {LFB00000201/2}; LFB report into the fire dated 22 December 2010 {IWS00001463/3}. Smoke leaked into the lobbies of eight other floors, which led a number of residents to believe they were trapped and call the LFB.1306 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4} item 2; TMO spreadsheet of previous fires {TMO00873387} "fires" sheet, row 6; LFB notifiable fire report into the fire {LFB00000201/1-2}; LFB report into the fire dated 22 December 2010 {IWS00001463/3}.
¶43.4 On 5 May 2010, Janice Wray sent the results of her investigation into the fire to Collette O'Hara, an LFB fire safety inspecting officer.1307 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4-5}. She explained that the system was subject to quarterly inspections by RGE Services (RGE)1308 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4} item 3. and said that the most recent inspection had identified "incomplete sealing" of a number of dampers.1309 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4} item 3. She said that the remedial work had been delayed and had therefore not been carried out by the time of the fire.1310 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4} item 3. Janice Wray accepted, in retrospect, that the TMO should have implemented interim measures while the system was being repaired.1311 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4-5} items 3-4; TMO spreadsheet of previous fires {TMO00873387} "fires" sheet, row 6.
¶43.5 When he replied to Janice Wray on 6 May 2010,1312 Email from Spencer Sutcliff to Janice Wray on 6 May 2010 {TMO10048221/2}. Spencer Sutcliff, the leader of the LFB Fire Safety team, agreed that the TMO should implement interim measures in future.1313 Email from Spencer Sutcliff to Janice Wray on 6 May 2010 {TMO10048221/2}. He also recommended that the TMO introduce a procedure to assess faults in fire safety systems to ensure that any high-priority remedial work was completed to a strict time scale.1314 Email from Spencer Sutcliff to Janice Wray on 6 May 2010 {TMO10048221/2}. He expressed surprise about the amount of smoke leakage caused by defective sealing of the vents1315 Email from Spencer Sutcliff to Janice Wray on 6 May 2010 {TMO10048221/3}. and recommended that the entire system be tested by an engineer because of what he described as a "catastrophic failure of the system".1316 Email from Spencer Sutcliff to Janice Wray on 6 May 2010 {TMO10048221/3}.
148¶43.6 Janice Wray replied to Spencer Sutcliff on 12 May 2010.1317 Email from Janice Wray to Spencer Sutcliff on 12 May 2010 {TMO10048221/1}. She included an earlier response from the TMO's senior electrical engineer, Keith Fifield,1318 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. who had explained that the remedial work, which had been agreed before the fire, included a complete overhaul of the system1319 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. and that, when the work had been done, the system would be fully operational.1320 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. Mr Fifield did not agree that the failure had been catastrophic.1321 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. He said that, except for the incomplete sealing, the system was working properly, but that there had been a failure to activate the mechanical extract system manually during the fire.1322 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. He said that he had arranged for smoke tests to be carried out on completion of the work.1323 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}.
¶43.7 On 7 May 2010, Janice Wray told Spencer Sutcliff that the remedial work had been completed and a smoke test had been successfully undertaken.1324 Email from Janice Wray to Spencer Sutcliff on 12 May 2010 {TMO10048221/1}.
RGE's inspections of the system 2009 – 2010
¶43.8 On 28 July 2009, the TMO appointed RGE to carry out maintenance work on the fire safety equipment and systems.1325 Letter from Keith Fifield to RGE dated 28 July 2009 {RGE00000003}. At some time after, but before the fire at Grenfell Tower on 30 April 2010, RGE had carried out its first test on the system.1326 Undated RGE maintenance report on AOV system at Grenfell Tower {MAX00001414/3}. There is an undated maintenance report that refers to fire damage, suggesting that it was completed after the fire on 30 April 2010,1327 Undated RGE maintenance report on AOV system at Grenfell Tower {MAX00001414/5}. but it also refers to a "first visit" to test the system, which RGE apparently carried out before the fire. In that report RGE said that all fresh air inlet dampers were in the open position and had been for some years. As a result, most of them were seized open or so contaminated that they were impossible to close and reset.1328 Undated RGE maintenance report on AOV system at Grenfell Tower {MAX00001414/5}.
¶43.9 If the dampers were open and unable to close, smoke could spread between lobbies through the system in the event of a fire.1329 As explained by Dr Lane in her Module 3 report, The Management and Maintenance of Grenfell Tower – Chapter 7 {BLARP20000033/355} paragraph 15.4.14. It is a matter of concern that the situation had apparently existed for a number of years before RGE's inspection. Although it is not clear precisely when that first visit took place, there are records of RGE having been instructed to carry out repairs on the system on 4 January 2010 and 20 April 2010, so it was probably before then.1330 Capita Repair Spreadsheet {RBK00053524} row 4870 and row 4701; Repair order raised with RGE on 20 April 2010 {RBK00046981}. A quotation from RGE dated 20 April 2010 refers to stripping down, cleaning and lubricating each vent, which, on the face of it, relates to the problems identified during the "first visit".1331 Quote from RGE for £2,257.05 to carry out repair work to the system at Grenfell Tower {RBK00013641}. They appear to have been the repairs Janice Wray had referred to in her emails to the LFB fire safety team following the fire at Grenfell Tower on 30 April 2010, which she said had been completed on 7 May 2010.1332 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4} item 3; Email from Janice Wray to Spencer Sutcliff on 12 May 2010 {TMO10048221/1}.
149¶43.10 RGE produced another maintenance report dated 12 May 2010 that set out the results of its tests on the system after the fire on 30 April 2010.1333 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637}. It concluded that due to the spring force on the inlet dampers the actuators were not reliable and might not operate on every activation, but that the system was otherwise generally in good operational order and capable of being maintained for the next 5 years.1334 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637/7}. The report included a quotation of £27,280 for work to the inlet dampers to ensure that they automatically opened and closed without manual intervention.1335 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637/8}.
¶43.11 Janice Wray said that she had not been made aware of that report, either before she replied to Spencer Sutcliff on 12 May 2010 or after.1336 Wray {Day144/22:14-21}. She said that the TMO's Contract Management team dealt with RGE,1337 Wray {Day144/23:2-20}. but that she would have expected Keith Fifield to provide the report to her.1338 Wray {Day144/24:1-13}. We have not seen any evidence that the remedial work identified by RGE in its report dated 12 May 2010 was ever carried out.1339 There is, for example, no record of a repair corresponding with this quote in the Capita Repair Spreadsheet, whereas there are records of the repairs raised on 4 January 2010 and 20 April 2010 {RBK00053524}.
¶43.12 An RGE engineer carried out a further test on the smoke ventilation system at Grenfell Tower on 4 June 2010.1340 RGE service/maintenance sheet for smoke test to smoke ventilation system at Grenfell Tower dated 4 June 2010 {RBK00046980}. The service sheet says that the purpose was to test the fire dampers following the recent fire and remedial works.1341 RGE service/maintenance sheet for smoke test to AOV system at Grenfell Tower dated 4 June 2010 {RBK00046980}. It is likely that the sheet refers to the remedial works for which instructions were given on 20 April 2010 and which were completed on 7 May 2010, given that there is no evidence that the remedial works identified in the report dated 12 May 2010 were carried out. Despite that, the engineer stated that following the test he had left the site in full working order as witnessed by Keith Fifield and others.1342 RGE service/maintenance sheet for smoke test to smoke ventilation system at Grenfell Tower dated 4 June 2010 {RBK00046980}; Email from Janice Wray to Collette O'Hara on 7 June 2010 about the smoke test {LFB00000767}.
¶43.13 In about August 2010, the TMO started to consider the need to modernise or replace the smoke ventilation system at Grenfell Tower.1343 Minutes of the Asset Investment and Engineering Health and Safety Group meeting on 26 August 2010 {TMO10000725/3} item 2. The minutes of the meeting of the Asset Investment and Engineering Health and Safety Group on 26 August 2010 recorded that the feasibility of modernising the smoke extraction system was being examined.1344 Minutes of the Asset Investment and Engineering Health and Safety Group meeting on 26 August 2010 {TMO10000725/3} item 2. Janice Wray suggested that the need for that had been brought to the TMO's attention by the fire on 30 April 2010, which had brought to light the age of the system, rather than by RGE's report in May 2010 or the failure of the system to operate properly.1345 Wray {Day144/26:23}-{Day144/27:11}.
150The Leaseholders' Association's complaint
¶43.14 In July 2010, the Grenfell Tower Leaseholders' Association made a complaint about fire safety which included a specific concern about the operation of the smoke ventilation system. The evidence suggests that the TMO was less than full and frank in its response. In particular, it did not tell the leaseholders or other residents of the tower about the defects in the system which had been found by RGE or the heightened risk to their safety.
¶43.15 On 28 July 2010, the Leaseholders' Association wrote to Geoff Payne, the TMO's Head of Housing, making various complaints including a complaint that during the fire on 30 April 2010 smoke had entered lobbies on other floors of the tower.1346 Letter from GTLA to Geoff Payne on 28 July 2010 {IWS00001497/2}. It asked what defects had been found in the system and what action had been taken in response.1347 Letter from GTLA to Geoff Payne on 28 July 2010 {IWS00001497/2}. Daniel Wood, the TMO's Head of Home Ownership, responded on 20 August 2010,1348 Letter from Daniel Wood to GTLA on 20 August 2010 {TMO00846311}. saying that there had been a "minor fault" in the system that had been identified during the service visit before the fire.1349 Letter from Daniel Wood to GTLA on 20 August 2010 {TMO00846311/4}. He said that repairs had been put in hand and that, when completed, the system would be fully operational.1350 Letter from Daniel Wood to GTLA on 20 August 2010 {TMO00846311/4}. He said that the problem with leaking vents had been put right.1351 Letter from Daniel Wood to GTLA on 20 August 2010 {TMO00846311/4}.
¶43.16 On 3 September 2010, the Leaseholders' Association wrote to Robert Black about their complaints.1352 Letter from GTLA to Robert Black on 30 September 2010 {TMO10037439}. Among other matters it asserted that the recent fire had raised so many health and safety questions that it demanded an independent investigation into the safety of the building.1353 Letter from GTLA to Robert Black on 30 September 2010 {TMO10037439/2}. Later, when dealing with the fire, it said that if the smoke ventilation system was not working it should be considered a major rather than a minor fault as Mr Wood had described it.1354 Letter from GTLA to Robert Black on 30 September 2010 {TMO10037439/5}.
¶43.17 Anthony Parkes replied on 21 September 2010.1355 Letter from Anthony Parkes to GTLA dated 21 September 2010 {TMO00846320}. He acknowledged that the seals on some of the vents had leaked, but said that otherwise they had been working at the time of the fire.1356 Letter from Anthony Parkes to GTLA dated 21 September 2010 {TMO00846320/4}. He said that the effects of the fire would not have been so serious if the LFB fire fighters had activated the smoke extract fan manually, but that they had not known how to do so.1357 Letter from Anthony Parkes to GTLA dated 21 September 2010 {TMO00846320/4}. He also said that the system was being upgraded so that it would work automatically when the fire alarm sounded.1358 Letter from Anthony Parkes to GTLA dated 21 September 2010 {TMO00846320/4}. Mr Parkes gave an assurance that the system was regularly checked and test reports completed.1359 Letter from Anthony Parkes to GTLA dated 21 September 2010 {TMO00846320/4}.
¶43.18 Neither Daniel Wood nor Anthony Parkes referred to RGE's report of 12 May 2010, which had advised that the inlet dampers might not operate on every activation and recommended significant remedial work.1360 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637/7-8}. As set out above, we have seen no evidence that that remedial work was carried out.
151RGE's inspection of the system in 2011
¶43.19 On 9 August 2011, RGE produced a further test report on the system at Grenfell Tower.1361 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 9 August 2011 {TMO00894311}. In section 3, under the heading "Test Results / Urgent Recommendation", it said that, having maintained the system for over 12 months, it could not guarantee that it would operate as required or that it met the requirements of the fire regulations. In particular, it reported that the systems for actuating the vents in the lobbies were no longer reliable and were found to have opened at random between maintenance visits. They were no longer fit for purpose and needed to be replaced.1362 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 9 August 2011 {TMO00894311/5}.
¶43.20 Janice Wray said that she had not been made aware of that report either.1363 Wray {Day144/25:3-11}. Keith Fifield, however, was certainly aware of it. He discussed it at a meeting with RGE on 7 September 2011.1364 Minutes of RGE Contract Review meeting with the TMO on 7 September 2011 {TMO00848054/1} item 1.7. The minutes of that meeting record that he had seen the report and was aware that RGE could not guarantee that the system would work in the event of an emergency.1365 Minutes of RGE Contract Review meeting with the TMO on 7 September 2011 {TMO00848054/1} item 1.7. They also recorded that he had said that the matter was being looked into by the TMO and that RGE and other contractors would be invited to submit tenders for the necessary work.1366 Minutes of RGE Contract Review meeting with the TMO on 7 September 2011 {TMO00848054/1} item 1.7.
¶43.21 The required improvements to the system at Grenfell Tower were discussed at a meeting of the TMO Asset Investment and Engineering Health and Safety Group on 15 September 2011 attended by Keith Fifield and Janice Wray.1367 Minutes of Asset Investment and Engineering Health and Safety Group meeting on 15 September 2011 {TMO00869798/1-2} item 2.2(e). The minutes of the discussion do not refer to RGE's recent report,1368 Minutes of Asset Investment and Engineering Health and Safety Group meeting on 15 September 2011 {TMO00869798/1-2} item 2.2(e). but in our view, given Keith Fifield's knowledge of that report, it is unlikely that the modernisation or replacement of the system was discussed without mentioning the significant findings it contained.
¶43.22 Despite the reports made by RGE in May 2010 and August 2011, we have seen no evidence that the TMO gave any consideration at that time to implementing measures to mitigate the risk presented by the potential failure of the smoke ventilation system to operate in the event of a fire. That was despite the assurance Janice Wray had given the LFB Fire Safety team after the fire on 30 April 2010 that it would do so.1369 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4-5}.
Modernisation of the system
¶43.23 Even if Janice Wray was not aware of the findings made by RGE in August 2011, it is reasonably clear that she was aware of at least some of the concerns about the system that had been identified in the course of the feasibility study for its modernisation.
¶43.24 In October 2011, AECOM, a construction industry consultancy, produced a tender for the modernisation of the system.1370 AECOM tender for upgrade to fire alarm and smoke extract system dated October 2011 {MAX00017497}. In a description of the existing system it noted that some of the dampers leaked, making it possible for smoke from a fire on a lower floor to leak through the closed dampers on an upper floor into the lift lobby. It was also possible that more than one set of dampers would open at any one time, since there was no way of establishing whether dampers were open other than by visual inspection. Although the extractor fans would overcome those problems, they had to be started manually by the fire brigade.1371 AECOM tender for upgrade to fire alarm and smoke extract system dated October 2011 {MAX00017497/6-7}.
152¶43.25 Apart from the installation of an autodialler to monitor the system remotely when staff were not on site, we have seen no evidence that Janice Wray or anyone else at the TMO considered measures to mitigate the risk caused by the defects in the system pending its modernisation. Further, although the tender document was produced in October 2011, no work had been carried out by late 2013 when it was included in the refurbishment, and it was not completed until April 2016, some four and a half years later.1372 See, for example, email from Bruce Sounes to John Allen and Paul Hanson (RBKC Building Control) copying in Terry Ashton and Duncan Campbell on 23 October 2013 {TMO10040556}. It was commissioned in April 2016: PSB Above Ground Commissioning Report dated 28 April 2016 {PSB00000224/7}. Janice Wray told us that the work had been put back so that it could form part of the refurbishment.1373 Wray {Day144/46:14}-{Day144/47:4}.
The fire risk assessments 2009-2012
¶43.26 Having heard the evidence of Dr Lane and Mr Todd, we are satisfied that a fire risk assessor should assess the risk that the means of escape might be compromised by a failure of a smoke ventilation system to work.1374 Todd {Day168/24:18-22}; Lane {Day172/3:4-11}. He could not reasonably be expected to test the system, but should satisfy himself that the system had been effectively tested and maintained in efficient working order, either by checking the records or by making reasonable enquiries of the competent person.1375 Todd {Day168/24:14}-{Day168/26:14}; {Day172/3:12}-{Day172/4:5}; {Day172/5:4}-{Day172/6:17}; Lane Module 3 Report, The Management and Maintenance of Grenfell Tower, Chapter 8 {BLARP20000027/267} s.12.3.14-15. If the necessary information is not immediately available, the fire risk assessor should make a further effort to acquire it.1376 Todd {Day168/26:16}-{Day168/27:10}; Lane {Day172/14:14}-{Day172/15:7}; {Day172/15:15}-{Day172/16:1}. There may be occasions when a fire risk assessor might ask to see the equipment tested,1377 Lane {Day172/6:25}-{Day172/7:20}. but that would not be normal.1378 Todd {Day168/26:12-14}. In the absence of satisfactory information about testing and maintenance he should increase the assessment of risk until provided with information to justify reducing it.1379 Lane {Day172/15:8}-{Day172/16:1}. We agree that the absence of available information about the testing and maintenance of a system of that kind indicates a shortcoming in the responsible person's management of fire safety in relation to the building in question.1380 Todd {Day168/29:1-7}; Lane {Day172/16:2}-{Day172/17:1}.
PAS 79:2012
¶43.27 The approach of Dr Lane and Colin Todd was, in essence, the same as that set out in PAS 79:2007 and PAS 79:2012.1381 PAS 79:2007 {CTA00000001}; PAS 79:2012 {CTA00000003}. The guidance in relation to smoke ventilation systems is materially the same in the two versions. Clause 15 of PAS 79:2012, entitled "Assessment of Fire Protection Measures", states that among the systems that should be taken into account are smoke control systems, which, in some premises can be essential for the protection of the means of escape. It is often vital to ensure that there are adequate arrangements for control, testing and maintenance of such systems.1382 PAS 79:2012 {CTA00000003/45-48}; See Clause 14 in PAS 79:2007 for the equivalent paragraphs {CTA00000001/42-45}.
153¶43.28 Clause 16 says that fire safety management, which includes the testing and maintenance of fire protection systems, and fire protection measures should be regarded as of equal importance.1383 PAS 79:2012 {CTA00000003/50-53}; See Clause 15 in PAS 79:2007 for the equivalent paragraphs {CTA00000001/46-47}.
The approach of Carl Stokes
¶43.29 Carl Stokes told us that he never tested or witnessed the testing of the smoke ventilation system at Grenfell Tower during his fire risk assessments.1384 Stokes {Day139/4:14-17}. He said that in order reliably to verify that the system was functioning correctly he used the contractor's service sheets and made certain that he had one that was in date.1385 Stokes {Day139/4:18-21}. He preferred to use that information rather than ask Janice Wray about the condition and operation of the system, because she would have had to go to the same source material.1386 Stokes {Day139/4:22}-{Day139/5:12}.
The fire risk assessment in September 2009
¶43.30 In the fire risk assessment of Grenfell Tower he carried out on behalf of Salvus in September 2009, Carl Stokes reported that he could not confirm that the smoke ventilation system had been maintained and tested in accordance with current guidance and British Standards.1387 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/14}. He advised that that presented a medium to high risk and recommended that the TMO confirm within a month whether the system had been tested and, if not, that it engage a competent engineer to do so within three months.1388 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/18} item 9.2.
¶43.31 The action plan based on that assessment, which was revised by the TMO in October 2009, stated that regular maintenance was being carried out.1389 Fire Risk Assessment Action Plan for Grenfell Tower updated in October 2009 {CST00000019} rows 52-54. It is not clear precisely when RGE carried out its first test of the system.1390 Undated RGE maintenance report on AOV system at Grenfell Tower {MAX00001414/5}. If it had taken place by the time of Carl Stokes's fire risk assessment, it is not clear why the test results, which had identified defects in the dampers which had existed for possibly five years, were not provided to him or why he was otherwise unable to obtain them.1391 Undated RGE maintenance report on AOV system at Grenfell Tower {MAX00001414/5}.
The fire risk assessment in December 2010
¶43.32 Carl Stokes completed his next fire risk assessment of Grenfell Tower on 29 December 2010.1392 Fire Risk Assessment for Grenfell Tower dated 29 December 2010 {CST00003181}. In it he referred to the fire on 30 April 2010 (although he incorrectly dated it as July 2010), but he did not mention that the system had not operated as intended.1393 Fire Risk Assessment for Grenfell Tower dated 29 December 2010 {CST00003181/5}. He told us that he had not been aware that there had been a leakage of smoke during the fire.1394 Stokes {Day139/7:3-9}. He said he would have expected Janice Wray to give him that kind of information or for it to be included in the service reports for the system.1395 Stokes {Day139/7:3-13}. Janice Wray, for her part, could not remember having given him that information.1396 Wray {Day144/7:1-21}; {Day144/9:11-21}.
154¶43.33 In the Record of Significant Findings and Action Plan dated 29 December 2010, Mr Stokes noted that there were automatic opening vents in each lobby area, but that he did not know whether the system had been serviced and maintained.1397 Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 {CST00003165/5} item 23c. He sought confirmation of that as a matter of high priority.1398 Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 {CST00003165/5} item 23c. That essentially repeated the request he had made in the fire risk assessment carried out in 2009.1399 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/18} item 9.2. However, we have seen no evidence either that he sought, or that the TMO provided, the confirmation he had asked for before he completed the assessment. Carl Stokes could not remember whether he had asked for it.1400 Stokes {Day139/11:15-19}.
¶43.34 The failure to obtain that information as part of the fire risk assessment was significant because, by that stage, RGE had identified defects in the inlet dampers in their maintenance report dated 12 May 2010 and the TMO had begun to consider the need to modernise or replace the system.1401 RGE maintenance report for the smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637/7}; Minutes of the Asset Investment and Engineering Health and Safety Group meeting on 26 August 2010 {TMO10000725/3} item 2. Carl Stokes said that he had not been aware of RGE's concerns about the inlet dampers,1402 Stokes {Day139/8:1-15}. and as he did not have that information, he could not take it into account when making his assessment of the risk at Grenfell Tower. Nor could he advise on the need for measures to mitigate the risk presented by the defects in the system pending its renovation or improvement.
The fire risk assessment in November 2012
¶43.35 Carl Stokes completed his next fire risk assessment of Grenfell Tower on 20 November 2012.1403 Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084}. In section 23, he ticked the box to indicate that there was no record of monthly testing or annual servicing of the smoke ventilation system1404 Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084/28}. but did not provide any comment or observation.1405 Colin Todd explained that, where "no" was ticked in the fire risk assessment to a proforma question, the fire risk assessor should include commentary explaining the "no" in the fire risk assessment, then there should be a corresponding action in the action plan: Todd {Day168/34:5}-{Day168/36:3}. In his Record of Significant Findings and Action Plan, he referred to the presence of automatic opening vents in each lobby and asked for confirmation that they were serviced and maintained. He rated that a matter of high priority.1406 Record of Significant Findings and Action Plan dated 20 November 2012 {CST00003083/5} item 23c.
¶43.36 That was the third time that Mr Stokes had said that he did not know whether the system had been routinely tested and maintained, but we have seen no evidence that he tried to obtain the maintenance records before he completed his assessments.1407 Carl Stokes said it would have been covered in meetings with Janice Wray, but the Inquiry has seen no evidence in support of that assertion, Stokes {Day139/16:1-12}. Moreover, he made no comment about what had become a persistent and, in our view, worrying problem. Nor did he vary his assessment of the fire risk at Grenfell Tower, which he considered "tolerable", to account for the possibility that the system might not have been maintained in efficient working order.1408 Carl Stokes's Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084/10}.
155¶43.37 Carl Stokes's failure to request that information before he completed his assessment, and the TMO's failure to provide it, was especially significant in November 2012. By that stage, RGE had stated in explicit terms in its report dated 9 August 2011 that it could not guarantee that the system would work.1409 RGE maintenance report on the smoke ventilation system at Grenfell Tower dated 9 August 2011 {TMO00894311/5}. The AECOM tender of 19 October 2011 also referred to serious defects in the system.1410 AECOM tender for upgrade to fire alarm and smoke extract system dated October 2011 {MAX00017497/6-7}. That information should have been taken into account in assessing the risk and measures should have been put in place to mitigate it, pending the completion of remedial work. However, Mr Stokes did no more than renew his request for confirmation that the system had been tested and maintained.
The Leaseholders' Association's complaints in 2012
¶43.38 On 14 November 2012, the Leaseholders' Association wrote a further letter to David Ward about the concerns felt by its members about being excluded from the programme to replace flat entrance doors in 2011 to 2012.1411 Letter/email from GTLA to David Ward on 18 November 2012 {TMO00842270}. It complained that leaseholders had not been told after the fire on 30 April 2010 that their entrance doors might not comply with safety regulations and questioned whether other health and safety equipment was in working condition and fit for its purpose.1412 Letter/email from GTLA to David Ward on 18 November 2012 {TMO00842270/2}. It therefore asked for copies of all reports, conclusions or recommendations relating to any investigation into the fire.1413 Letter/email from GTLA to David Ward on 18 November 2012 {TMO00842270/2}.
¶43.39 On 22 November 2012, in preparing a response to that complaint, Janice Wray sent an email to Paul Dunkerton containing information about the fire on 30 April 2010.1414 Email from Janice Wray to Paul Dunkerton on 22 November 2012 {TMO00848792}. She said it would be inappropriate to provide the leaseholders with a copy of the email she had sent to the LFB Fire Safety team after the fire.1415 Email from Janice Wray to Paul Dunkerton on 22 November 2012 {TMO00848792}. Instead, she proposed telling them that the smoke ventilation system had removed the smoke from the lift lobby, but had not worked as effectively as it should have because of a need for remedial works that were then pending. All those works had been completed and the system continued to operate effectively.1416 Email from Janice Wray to Paul Dunkerton on 22 November 2012 {TMO00848792}.
¶43.40 Paul Dunkerton included that information in his reply to the Leaseholders' Association on 14 December 2012.1417 Letter from Paul Dunkerton to Tunde Awoderu, GTLA, on 14 December 2012 {TMOH00027328/2}. By that time, however, the TMO had for a long time been in possession of RGE's report dated 9 August 2011, which stated explicitly that it could not guarantee that the system would work, and AECOM's tender, which described its defects.1418 AECOM tender for upgrade to fire alarm and smoke extract system dated October 2011 {MAX00017497/6-7}. Even if Janice Wray had not seen those documents, she should have asked Keith Fifield for information about the maintenance of the system before responding to Paul Dunkerton.1419 Wray {Day144/36:1-7}; {Day144/39:15-18}. There is no evidence that she did so.
¶43.41 By omitting that information from its reply, the TMO failed to give the leaseholders a full and accurate account of the investigation carried out into the fire, failed to inform them, and indeed other residents, of the operational status of the system and provided them with false assurances about the protection the system would provide in the event of a fire.
156The TMO's review of the action plan dated 20 November 2012
¶43.42 In April 2013, after receiving the leaseholders' complaint, the TMO reviewed Carl Stokes's Record of Significant Findings and Action Plan dated 20 November 2012.1420 TMO review in April 2013 of Carl Stokes's Record of Significant Findings and Action Plan dated 20 November 2012 {MAX00001426}. A version of the Action Plan was produced with an additional column containing comments following a review in April 2013.1421 TMO review in April 2013 of Carl Stokes's Record of Significant Findings and Action Plan dated 20 November 2012 {MAX00001426/1}. In response to his request for confirmation that the smoke ventilation system had been regularly tested and maintained, there is a comment that the TMO had been informed that the vent needed changing and that RGE had said that it could not guarantee that in the event of an emergency the system would work.1422 TMO review in April 2013 of Carl Stokes's Record of Significant Findings and Action Plan dated 20 November 2012 {MAX00001426/7} item 23c. A report was said to have been sent to someone and additional copies were to be provided to Alex Bowman. The action was marked as completed by Ricki Sams.1423 TMO review in April 2013 of Carl Stokes's Record of Significant Findings and Action Plan dated 20 November 2012 {MAX00001426/7} item 23c.
¶43.43 Janice Wray accepted that she had seen that action plan and the findings of the review.1424 Wray {Day144/65:13-17}. The document metadata for the TMO's review of the action plan also states that it was last modified on 4 June 2013 by Janice Wray: {MAX00001426/1}. She accepted, therefore, that from at least April 2013 she had known that the system was not sure to work1425 Wray {Day144/67:4-19}. but she took no steps at that stage to put in place any measures to mitigate the risk it presented.1426 Wray {Day144/67:20-25}. She accepted that it had been her job to make sure that the relevant department was aware of its responsibility to carry out repairs, but she did not accept that she had been responsible for ensuring that the work was in fact carried out, or that she had had the ability to do so.1427 Wray {Day144/68:1-25}. That responsibility lay with the contracts management team, which had the expertise needed to determine what was required.1428 Wray {Day144/68:1-25}. We disagree. Janice Wray, as the competent person, was responsible for overseeing the TMO's compliance with the Fire Safety Order. In particular, she had a responsibility to make sure that the smoke ventilation system was either repaired or, if that was not viable, replaced and mitigating measures put in place pending its replacement.
RGE's inspection of the system in October 2013
¶43.44 RGE carried out a further test of the system on 11 October 2013, which identified the same problems as had been described in its report dated 9 August 2011.1429 RGE engineers' service/maintenance report dated 11 October 2013 {TMO00879757}. The test report stated that the dampers were still not functioning correctly and could not be guaranteed to work correctly in an emergency.1430 RGE engineers' service/maintenance report dated 11 October 2013 {TMO00879757/3}. RGE had provided a quotation for remedial work in May 2010, but the work was evidently still outstanding.1431 RGE maintenance report on the smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637/8}. It seems that no immediate action was taken to remedy the defects because of the plan to modernise the system as part of the refurbishment. No measures were put in place to mitigate the increased risk presented by those defects pending the completion of that work.
157Maintenance records
¶43.45 On 23 January 2014, Matt Smith of Max Fordham sent an email to Simon Coleman of RGE asking for the test and maintenance records for the smoke ventilation system to assist in formulating a submission to building control on the designs for the proposed new system.1432 Email from Matt Smith to Simon Coleman on 23 January 2014 {MAX00004262/3}. Later that day, Dil Singh of RGE sent him a maintenance report for the system, which, although undated, was the same as the inspection report dated 12 May 2010.1433 Email from Dil Singh to Matt Smith on 23 January 2014 {MAX00004262/1}; Undated RGE maintenance report for the smoke ventilation system at Grenfell Tower {MAX00018264}. Dil Singh told Mr Smith that RGE had told the TMO following every service visit that it could not guarantee that the system would work.1434 Email from Dil Singh to Matt Smith on 23 January 2014 {MAX00004262/1}.
¶43.46 It is not clear why Dil Singh did not give Max Fordham the test reports dated 9 August 2011 and 11 October 2013, given the more serious and recent concerns that they raised about the operation of the system.1435 RGE maintenance report on AOV system at Grenfell Tower dated 9 August 2011 {TMO00894311/5}; RGE engineers service/maintenance report dated 11 October 2013 {TMO00879757/3}. Despite a number of further requests from Matt Smith and Claire Williams between January and March 2014 for the test and maintenance records and for clarity about the current condition of the system, RGE did not provide either.1436 Email from Matt Smith to Dil Singh on 24 January 2014 {MAX00004266/1}; Email from Matt Smith to Claire Williams on 3 February 2014 {MAX00004281/1}; Email from Dil Singh to Claire Williams on 6 February 2014 {MAX00004293}; Email from Duncan Campbell to Claire Williams on 13 February 2014 {MAX00004306}; Email from Duncan Campbell to Claire Williams on 28 February 2014 {MAX00004329}; Email from Claire Williams to Duncan Campbell on 3 March 2014 {EXO00000644}; Email from Claire Williams to Dil Singh on 3 March 2014 {MAX00004330}. It is not clear why, but there is evidence that the TMO had previously experienced problems obtaining documents from RGE.1437 See, for example, email from Gary Mitchell to Peter Maddison on 21 February 2013 {TMO10002270/1}; Emails between Roger Greene and Gary Mitchell on 14 March 2013 {CST00004790}. As it was, RGE's contract came to an end on 31 March 2014.1438 Craig {RGE00000010/1} page 1, paragraph 1; RGE Maintenance Contract {RGE00000004/3} paragraph 3.2.
LFB visit to Grenfell Tower on 12 March 2014
¶43.47 On 12 March 2014, Matthew Ramsey and Ben Dewis, LFB fire safety inspecting officers, and Daniel Hallisey, the local fire station manager, visited Grenfell Tower with Claire Williams and Bruce Sounes.1439 Email from Bruce Sounes to Claire Williams and Janice Wray on 13 March 2014 {TMO10005515/3}. During the visit, consistent with RGE's previous findings, Matthew Ramsey identified that about 25-30 percent of the vents on the smoke ventilation system were not in the correct position.1440 Email from Claire Williams to Janice Wray on 12 March 2014 {TMO10005515/4-5}; Ramsey {LFB00032092/6-7} pages 6-7, paragraphs 19 and 23.2. He was sufficiently concerned about the state of the system to turn his visit into a formal audit and threatened to issue an enforcement notice requiring the TMO to demonstrate within four to six weeks that the system was fully operational.1441 Ramsey {MET00071003/4} page 4; Ramsey {LFB00032092/6} page 6, paragraphs 19-20; Email from Claire Williams to Janice Wray on 12 March 2014 {TMO10005515/5}; Email from Bruce Sounes to Claire Williams and Janice Wray on 13 March 2014 {TMO10005515/3}.
¶43.48 After the visit Claire Williams sent an email to Janice Wray, with a copy to Carl Stokes, telling her of the outcome and suggesting that Ms Wray chase up RGE for the servicing records.1442 Email from Claire Williams to Janice Wray on 12 March 2014 {TMO10005515/4-5}.
158¶43.49 Carl Stokes replied to Claire Williams' email later that day with a copy to Janice Wray. In relation to Matthew Ramsey's concern about the system, he said that the matter had been raised on numerous occasions, but that RGE had failed to provide servicing and maintenance information. He suggested that if the LFB issued an enforcement notice, it would be challenged and that the LFB should be asked to serve it on RGE as the maintenance contractor.1443 Carl Stokes email to Claire Williams on 12 March 2014 {CST00001426/1}.
¶43.50 On 17 March 2014, Carl Stokes visited the tower at the request of Claire Williams to investigate the LFB's concerns.1444 Wray {TMO00000890/10} page 10, paragraph 46. He set out his findings in a letter to her dated 18 March 2014.1445 Letter from Carl Stokes to Claire Williams on 18 March 2014 {CST00003100}. His inspection of the smoke ventilation system appears to have been limited to what he described as the "smoke extract panel", which he said was "showing healthy", and RGE's maintenance logbook, which he appended to his letter.1446 Letter from Carl Stokes to Claire Williams on 18 March 2014 {CST00003100/2}. For reasons which are not clear, the logbook did not contain entries for the tests carried out on 9 August 2011 and 11 October 2013, which Carl Stokes had not seen.1447 The logbook contained only two entries one dated 11/5/2010, which possibly relates to the test report on 12 May 2010, and the other incorrectly dated "15/15/2013", which identified a faulty relay on 15th floor: {CST00003100/14-15}. Carl Stokes interpreted that to mean "15/12/2013" so that the inspection was in date: {CST00003100/2}. There is, however, a separate record of a test to the fire alarm system associated with the smoke ventilation system on 15/05/2013 so, in our view, that is the more likely date: {RGE00000005}. Carl Stokes stated that "the previous loose page in the logbook" was full, but he did not append it: {CST00003100/2}. As a result, he concluded that the logbook showed that RGE had found the system to be generally in working order at the last service.1448 Letter from Carl Stokes to Claire Williams on 18 March 2014 {CST00003100/11}; Carl Stokes said that he understood from RGE's servicing records that the system was functional, notwithstanding Matthew Ramsey's findings, Stokes {Day139/22:19}-{Day139/23:8}.
¶43.51 Carl Stokes said that he had also inspected those parts of the system that were visible, but he did not refer to that in his letter.1449 Stokes {Day139/24:18}-{Day139/25:10}. Nor did he refer to Matthew Ramsey's finding that 25-30 percent of the vents were not working, although he said that he thought he had done so.1450 Stokes {Day139/26:23}-{Day139/27:1}. He recommended that the contractor be asked to service the system sooner rather than later.1451 Letter from Carl Stokes to Claire Williams on 18 March 2014 {CST00003100/11}. Neither Claire Williams nor Janice Wray raised with him the fact that he had not recorded Matthew Ramsey's findings or the fact that his assessment was, on the face of it, at odds with them. Janice Wray did not tell him that RGE had said that it could not guarantee the system would work in the event of the fire, a matter of which she had been aware from at least April 2013.1452 As discussed earlier in this section, see the TMO's review in April 2013 of the Record of Significant Findings and Action Plan dated 20 November 2012 {MAX00001426/7} item 23c.
Notice of deficiencies
¶43.52 On 24 March 2014, the LFB served a deficiency notice on the TMO.1453 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/1}. In summary, it stated that about a quarter of the dampers in the smoke ventilation system were not working, which indicated that it had not been maintained in effective working order.1454 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. It stated that that was a breach of Articles 11(1) and 17(1) of the Fire Safety Order1455 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. and that effective monitoring and maintenance of the system was required to remedy the breach.1456 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. It said those steps should be taken by 5 May 2014.1457 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/1}.
159¶43.53 Matthew Ramsey decided to issue a deficiency notice rather than an enforcement notice because in his experience the TMO, as a responsible person, generally acted on the LFB's advice and could be trusted to take remedial action within the time allowed and because the imminent refurbishment of the building was subject to the oversight of building control.1458 Ramsey {LFB00083855/7} page 7, paragraph 19. When they had spoken after the visit, Janice Wray had satisfied him that there was a plan to replace the system during the refurbishment.1459 Ramsey {LFB00032092/7} page 7, paragraph 23.2; Ramsey {Day147/38:16}-{Day147/39:3}. However, he expected the TMO to ensure that the existing system was working by 5 May 2014, which was necessary to protect both residents and firefighters.1460 Ramsey {Day147/38:1-4}; Ramsey {MET00071003/5} page 5.
¶43.54 In the event, that did not happen. Claire Williams said that it had not been possible to produce a temporary solution to the problem in advance of the refurbishment.1461 Williams {Day121/127:15}-{Day121/128:8}. There is evidence that she thought about that following the receipt of the deficiency notice. For example, in an email to Matt Smith and Bruce Sounes on the 25 March 2014, she said that she was looking at the possibility of fixing the dampers in the open position,1462 Email from Claire Williams to Matt Smith on 25 March 2014 {MAX00004366/3-4}. but Matt Smith advised against that because it would simply allow smoke to spread from floor to floor.1463 Email from Matt Smith to Claire Williams on 25 March 2014 {MAX00004366/3}. Claire Williams had also emailed Michael Lyons on 3 April 2014 about a "temporary option" for the smoke ventilation system: {TMO00856447}. Claire Williams subsequently sent an email to Janice Wray and Alex Bosman on 17 April 2014 suggesting they discuss the options open to the TMO before the time for remedial work allowed by the deficiency notice expired on 5 May 2014. She had already been advised by Max Fordham that the only option available was to carry out the full modernisation work.1464 Email from Claire Williams to Alex Bosman copying in Janice Wray on 22 April 2014 {TMO00856473}. It is not clear whether that discussion ever took place.
¶43.55 Despite the developing recognition that it was not possible to find a temporary solution to the problem, the TMO had the system serviced again, presumably in response to Carl Stokes's recommendation and the deficiency notice.1465 Letter from Carl Stokes to Claire Williams on 18 March 2014 {CST00003100/11}; LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. On 17 March 2014, after the LFB had visited Grenfell Tower, Alex Bosman had instructed Colt International Ltd, a company specialising in the design, supply and maintenance of smoke control systems, which serviced smoke ventilation systems in some of the TMO's other properties, to quote for servicing the system.1466 Email from Alex Bosman to Debbie Sanderson on 17 March 2014 {TMO00856389/3}. However, the proposal for servicing that Colt produced on 28 March 2014 does not appear to have been pursued, possibly because the inspection on which it had been based had not identified any of the defects noted by the LFB.1467 Colt service proposal for the smoke ventilation system at Grenfell Tower dated 28 March 2014 {TMO10005654}.
160¶43.56 On 11 September 2014, Simon Lawrence sent an email to Claire Williams asking whether the LFB had returned to check the system after the time allowed in the deficiency notice had expired.1468 Email from Simon Lawrence to Claire Williams on 11 September 2014 {TMO00856902/1-2}. The answer was that it had not. It is evident from that correspondence that almost six months after the deficiency notice, the smoke ventilation system had still not been properly inspected and serviced.
Meeting with Rydon to discuss interim measures
¶43.57 Also on 11 September 2014, Claire Williams sent an email to Janice Wray inviting her to a discussion about the smoke ventilation system on 16 September 2014.1469 Email from Claire Williams to Janice Wray on 11 September 2014 {CST00003178/1}. She explained that Rydon had been working with JS Wright to find an interim solution to the problem. Janice Wray forwarded the email to Carl Stokes and invited him to the meeting as well.1470 Email from Janice Wray to Carl Stokes on 12 September 2014 {CST00003178/1}. That appears to have been the first time the TMO had given any consideration to implementing measures to mitigate the risk presented by the defects in the existing system pending the completion of the refurbishment and the installation of a new system. However, we have not seen any minutes of the proposed meeting and neither Carl Stokes1471 Stokes {Day139/29:24}-{Day139/30:21}. He also did not mention it in his letter to Janice Wray dated 17 September 2014 {CST00030043/9} item 27-28. nor Claire Williams1472 Williams {Day121/138:18}-{Day121/139:8}. had any recollection of it. It is not clear, therefore, whether the meeting actually took place.
Meeting with the LFB fire safety team on 18 September 2014
¶43.58 A progress meeting for the Grenfell Tower project, attended by Claire Williams, was held on 16 September 2014.1473 Grenfell Tower project progress meeting no.3 on 16 September 2014 {TMO00830089}. The minutes of the meeting record that the smoke ventilation system was currently not working. Rydon was asked to try to bring it up to contracted specification as soon as possible. If that was not possible, the system would be returned to the original specification.1474 Grenfell Tower project progress meeting no.3 on 16 September 2014 {TMO00830089/4} item 9.2. The minutes recorded that Claire Williams would keep the LFB informed about the work,1475 Grenfell Tower project progress meeting no.3 on 16 September {TMO00830089/4} item 9.3. but she said that Janice Wray was the main point of contact with the LFB.1476 Williams {Day121/136:3-23}; Williams {Day121/144:9-19}. Claire Williams said that she kept Janice Wray updated as to the progress of the works to the AOV system: Williams {Day121/140:25}-{Day121/141:3}. Janice Wray thought that Claire Williams and the project team were responsible for keeping the LFB informed about the work to the smoke ventilation system.1477 Wray {Day144/54:22}-{Day144/55:10}; {Day144/56:1-7}. Neither of them had a clear understanding of their responsibilities in that respect, but they agreed that the bi-monthly meetings, which they both attended, were the time for informing the LFB fire safety team about the refurbishment. Apart from that, Rydon spoke to the local fire crews when they visited the site.1478 Williams {Day121/141:4-20}; {Day121/144:20}-{Day121/145:8}; Wray {Day144/55:2-10}; {Day144/58:21}-{Day144/59:5}.
161¶43.59 On 18 September 2014, Claire Williams and Janice Wray attended one of the regular meetings with the LFB fire safety team.1479 Minutes of bi-monthly meeting between TMO and LFB fire safety team on 18 September 2014 {TMO10023364}. Ms Williams told them that the smoke ventilation system was to be modernised as a priority. She also drew attention to the fact that while the work was going on the system would not be working at full capacity. That had also been brought to Carl Stokes's attention.1480 Minutes of bi-monthly meeting between TMO and LFB fire safety team on 18 September 2014 {TMO10023364/3} item 6.
¶43.60 According to the minutes of the meeting, neither Claire Williams nor Janice Wray told the LFB that the existing system was not working.1481 Minutes of bi-monthly meeting between TMO and LFB fire safety team on 18 September 2014 {TMO10023364/2-3} item 6. Claire Williams said that the statement that the system "would not be working at full capacity" while the work was going on did not do justice to the state of the existing system, but that the LFB should have known that it was not working because it had issued the deficiency notice.1482 Williams {Day121/149:23}-{Day121/150:7}. The minutes also suggest that the TMO thought about putting in place interim measures only during the modernisation work and did not consider taking steps to mitigate the immediate risk presented by the defects in the existing system.1483 Minutes of bi-monthly meeting between TMO and LFB fire safety team on 18 September 2014 {TMO10023364/3} item 6.
¶43.61 Later that day Claire Williams sent an email to Simon Lawrence telling him that the smoke ventilation system would not be fully operational until after Christmas.1484 Email from Claire Williams to Simon Lawrence on 18 September 2014 {TMO00851824/1}. It is evident from that email that at the meeting the LFB had also made a specific request, which was not reflected in the minutes, that the unavailability of the system during the period of the work should be taken into account in Rydon's and the TMO's fire risk assessments.
¶43.62 On 6 October 2014, Claire Williams told Janice Wray that although the ventilation system would be "in some sort of order" by Christmas, the new extractor fans in the roof plant room would probably not have been fitted, as they would be waiting for building control approval.1485 Email from Claire Williams to Janice Wray on 6 October 2014 {TMO00851844/1-2}. In her response Janice Wray asked whether any steps could be taken to reinstate the ventilation and extraction system, even partially, before it was refurbished.1486 Email from Janice Wray to Claire Williams on 6 October 2014 {TMO00851844/1}. We have not seen a direct response to that email, but it is evident from the subsequent correspondence that it was not considered possible to carry out temporary repairs to the system.
Chubb's inspection
¶43.63 On 29 September 2014, Alex Bosman instructed Chubb Fire and Security to service the smoke ventilation system at Grenfell Tower, which was said to be "out of target".1487 Email from Alex Bosman to Steve Plumridge and Adria Frith copying in Janice Wray and Siobhan Rumble on 29 September 2014 {CST00001451/3}. He also instructed Chubb to contact Carl Stokes, who wished to meet their engineer.1488 Email from Alex Bosman to Adrian Frith copying in Carl Stokes on 29 September 2014 {CST00001451/1}. Mr Stokes met Chubb's engineer at Grenfell Tower on 6 October 2014 to examine the smoke ventilation system, but it seems that he was unable to test it because a fault was showing on the fire alarm panel.1489 Email from Janice Wray to Alex Bosman copying in Carl Stokes on 6 October 2014 {TMO10007591}; Email from Carl Stokes to Alex Bosman on 7 October 2014 {CST00001451/1}. The service certificate, therefore, recorded that further investigation of the system was required.1490 Email from Janice Wray to Alex Bosman copying in Carl Stokes on 6 October 2014 {TMO10007591}. The Inquiry has not been provided with a copy of Chubb's service certificate.
162¶43.64 On 9 October 2014, Alex Bosman sent on to Claire Williams, Janice Wray and Carl Stokes an email that he had sent to Chubb that day, in which he had said that the system had been confirmed as beyond repair and scheduled for replacement shortly.1491 Email from Alex Bosman to Claire Williams, Janice Wray and Carl Stokes on 9 October 2014 {CST00001244/1}. It is not clear whether the description of the system as "beyond repair" came from Chubb's inspection or from Rydon's investigations or something else, but, in any case, in our view, it should have been clear to the recipients of that email that the existing system could neither be temporarily repaired nor maintained pending its modernisation.
¶43.65 Nonetheless, neither Claire Williams nor Janice Wray told the LFB that the existing system was beyond repair, nor did they pass on the information that the completion of the work was likely to be delayed beyond Christmas.1492 Williams {Day121/156:6-18}. When it became clear that the work would not be completed by that time, neither of them sought to implement mitigating measures or to inform the residents that the system was not operating.1493 Williams {Day121/139:10}-{Day121/140:1}; {Day121/156:19}-{Day121/159:18}. Claire Williams had suggested that her concern about the risk to residents had been allayed by the plan to have the system in some kind of working order by Christmas.1494 Williams {Day121/139:10}-{Day121/140:1}; {Day121/142:2-14}. If it was not possible, as had by then become apparent, further measures were required.
The fire risk assessment in October 2014
¶43.66 Carl Stokes carried out a fire risk assessment of Grenfell Tower on 17 October 2014.1495 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157}. In the section headed "Any other relevant information on this premises" he summarised the three requirements of the deficiency notice and stated that they had been covered in the assessment and accompanying Record of Significant Findings.1496 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/7-8}. In respect of the smoke ventilation system, he referred to the LFB's requirement that a system of monitoring should be implemented in relation to the equipment in the lobbies and a maintenance schedule put in place so that the system was kept in good working order.1497 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/8}.
¶43.67 Carl Stokes did not refer to the fact that the deficiency notice stated that about a quarter of the dampers were not working and that the system had not been maintained in effective working order.1498 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. Although he did state where the notice could be found, the omission of that information meant that his summary failed to convey the seriousness of the LFB's findings.1499 Carl Stokes disputed in his oral evidence that he had downplayed the seriousness of the situation: Stokes {Day139/42:2-6}.
¶43.68 In section 19 of his fire risk assessment, headed "Fixed Fire Systems and Equipment", he described the smoke ventilation system and recorded that it had been serviced by RGE Services on the 11 October 2013. He also recorded that it was being modernised as part of the refurbishment. However, he did not mention that RGE had said in its service report that it could not guarantee that the system would work; nor did he refer to Matthew Ramsey's findings on 12 March 2014 that 25-30% of the dampers were not working.1500 Email from Claire Williams to Janice Wray on 12 March 2014 {TMO10005515/4}; Email from Bruce Sounes to Claire Williams and Janice Wray on 13 March 2014 {TMO10005515/3}. He did not refer either to the fact that Chubb had been unable to carry out a service of the system on 6 October 2014, or to Alex Bosman's email of 9 October 2014 in which he had described the system as "beyond repair".1501 Email from Alex Bosman to Claire Williams, Janice Wray and Carl Stokes on 9 October 2014 {CST00001244/1}. In short, he failed to address any of the information before him which showed that the system was not working. Despite knowing that, he maintained his assessment that the fire risk at Grenfell Tower was tolerable.1502 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/10}. In those respects, his fire risk assessment gave the misleading impression that the system was operational, at least to the extent that it did not affect the overall risk rating for the building.
163¶43.69 Mr Stokes should have recorded in his fire risk assessment that the smoke ventilation system was not working and should have taken account of that in his assessment of the risk.1503 Todd {Day168/31:7}-{Day168/32:23}; Lane {Day172/19:7-12}. He said that he had not referred to the fact that the system was considered to be beyond repair because it was being modernised as part of the refurbishment,1504 Stokes {Day139/35:3-16}. but that did not justify ignoring the fact that it was not then working.1505 Lane {Day172/19:14}-{Day172/20:17}. He also said that, because there was a "stay put" strategy in place, the fact that the system was defective would increase the risk to residents only slightly.1506 Stokes {Day139/35:17}-{Day139/37:23}. Whatever the merits of that suggestion, however, he did not deal with it in his fire risk assessment.
¶43.70 In his accompanying Record of Significant Findings and Action Plan, Carl Stokes stated that Rydon was going to upgrade the existing smoke ventilation system in the lobbies and the refuse chute rooms.1507 Record of Significant Findings and Action Plan dated 17 October 2014 {CST00003177/8} item 19d. He asked what compensatory measures, if any were being put in place whilst the work was being done, but he did not ask whether any measures had been put in place to mitigate the immediate risk presented by the defects in the existing system, nor did he recommend any. He did not include any assessment of the extent to which there were any measures which might adequately mitigate that risk.
¶43.71 Neither Janice Wray nor Claire Williams pointed out to Carl Stokes that he had not dealt in his risk assessment with the failure of the existing system. That was despite the fact that Matthew Ramsey had specifically asked Ms Wray to ensure that Carl Stokes addressed his concerns about the system,1508 Email from Matthew Ramsey to Janice Wray on 14 March 2014 {CST00003115/1}. and despite the LFB's request at the meeting on 18 September 2014 to ensure that the unavailability of the system during the modernisation work was covered in its fire risk assessment.1509 Email from Claire Williams to Simon Lawrence on 18 September 2014 {TMO00851824/1}.
¶43.72 In section 23 of his fire risk assessment, headed "Testing and maintenance", Carl Stokes responded to the question "Is there a monthly testing and annual servicing and maintenance of any automatic opening vents along with any associated equipment/ devices, with records kept?" with the answer "No".1510 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/29}. He did not include any comment by way of explanation, even though good practice requires that in such circumstances the fire risk assessor should explain the answer and make a corresponding entry in the action plan.1511 Todd {Day168/34:5}-{Day168/36:3}. Nor did he record that Chubb had been unable to service the system on 6 October 2014,1512 Email from Carl Stokes to Alex Bosman on 7 October 2014 {CST00001451/1}. but he did record that he did not know whether the occupier's tests and inspections of the fire systems within the building were being undertaken.1513 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/30}. In his accompanying action plan he recommended that the occupier should carry out weekly tests of the system and record the results.1514 Record of Significant Findings and Action Plan dated 17 October 2014 {CST00003177/9} item 23c.
164¶43.73 That was the fourth time in as many fire risk assessments that Carl Stokes had said that he did not have any information about the maintenance of the smoke ventilation system and had asked for it to be provided. In our view, even though the system was considered to be beyond repair, that was simply not good enough. He ought to have insisted on being given that information before he completed his assessment.1515 Todd {Day168/26:24}-{Day168/27:10}; Lane {Day172/14:14}-{Day172/15:7}; Carl Stokes's Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/8}. If in October 2014 he had asked directly what had been done in response to his previous recommendations, he might have discovered the chronic nature of the failure to maintain the system and taken account of it in his assessment.
The meeting with the LFB on 13 November 2014
¶43.74 On 12 November 2014, in advance of Janice Wray's meeting with the LFB fire safety team the following day, Claire Williams sent an email to Simon O'Connor asking what it was currently thought could be done to put the smoke ventilation system at Grenfell Tower into working order.1516 Email from Claire Williams to Simon O'Connor on 12 November 2014 {TMO00852028/3}. Simon Lawrence replied the next day saying that the design team had been trying to find a solution which did not involve carrying out work that would later have to be discarded, but that one was unlikely to be available before Christmas.1517 Email from Simon Lawrence to Simon O'Connor and Claire Williams on 13 November 2014 at 08:50 {TMO00852028/1-2}.
¶43.75 Claire Williams did not pass that information to Janice Wray until after her meeting with the LFB that morning,1518 Email from Claire Williams to Janice Wray on 13 November 2014 at 13:59 {TMO00852028/1}. but apparently the subject of the smoke ventilation system had not been raised.1519 Email from Janice Wray to Claire Williams on 13 November 2014 {TMO00852028/1}. However, Ms Wray had been aware from early October that the existing system was beyond repair and that it would, at best, only be partly operational by Christmas, but she did not share that information with the LFB .1520 Email from Claire Williams to Janice Wray on 6 October 2014 {TMO00851844}; Email from Alex Bosman to Claire Williams, Janice Wray and Carl Stokes on 9 October 2014 {CST00001244/1}. Nor did she or Claire Williams pass on the information she had been given by Simon Lawrence to the LFB.1521 Wray {Day144/54:15-20}. There was evidence that the project team was keeping the local LFB operational crew informed, but Janice Wray accepted that she and Claire Williams should have kept the LFB Fire Safety team informed.1522 Wray {Day144/55:2}-{Day144/57:9}.
The Leaseholders' Association complaint, January 2015
¶43.76 On 2 January 2015, the Leaseholders' Association sent an email to Councillor Blakeman and Councillor Dent-Coad seeking confirmation that the smoke ventilation system at Grenfell Tower was going to be replaced as part of the refurbishment.1523 Email from Claire Williams to Janice Wray on 5 January 2015 {TMO00846731}. Later that day, Mr Maddison sent a draft response to Councillor Blakeman, in which he said that the system was currently beyond economic repair and that the TMO was working with building control to agree a design for a system that would meet current standards.1524 Email from Peter Maddison to Councillor Blakeman on 5 January 2015 {TMO10008422}.
165Meeting with the LFB, 20 January 2015
¶43.77 On 13 January 2015, in preparation for a meeting with the LFB on 20 January 2015 Claire Williams asked Matt Smith whether building control had approved the plans for replacing the smoke ventilation system and whether any steps were being taken in the meantime to produce an effective system.1525 Email from Claire Williams to Matt Smith on 13 January 2015 {TMO10042871/2}. Matt Smith said in reply that a technical submission had been prepared comprising a two-stage scheme under which natural ventilation would be reinstated as an interim measure before new pressure differential controls and fans were added later. However, he was unable to say when the work was likely to begin.1526 Email from Matt Smith to Claire Williams on 13 January 2015 {TMO10042871/1}.
¶43.78 The minutes of the meeting on 20 January 2015 suggest that the information obtained from Max Fordham was not passed on to the LFB.1527 Minutes of the bi-monthly meeting between the TMO and LFB fire safety team on 20 January 2015 {TMO00844037}. In the event, only Janice Wray attended the meeting on behalf of the TMO1528 Minutes of the bi-monthly meeting between the TMO and LFB fire safety team on 20 January 2015 {TMO00844037}. and although Claire Williams thought it likely that she had sent Matt Smith's email on to Janice Wray, she could not remember having done so.1529 Williams {Day121/190:3-8}. We are satisfied that she did not send it to the LFB herself.1530 Williams {Day121/190:3-8}. However, even if Janice Wray had not received the email, she was already aware that the work had not been completed and should have drawn that to the attention of the LFB.
¶43.79 On 21 January 2015, Claire Williams told Janice Wray that the first phase of the work, involving the creation of a passive system, was programmed to start on 16 March 2015 and be completed by 1 May 2015 and that the second phase, involving the installation of fans and controls, was programmed to start on 5 May 2015 and be completed by 19 June 2015.1531 Email from Claire Williams to Janice Wray on 21 January 2015 {TMO10042915/2}. It does not appear that either Janice Wray or Claire Williams passed that information on to the LFB at the time.1532 It was provided at the meeting on 23 March 2015: {RBK00013999/3} item 9.
Rydon Fire Risk Assessment, 20 February 2015
¶43.80 On 20 February 2015, Simon Camps and Simon O'Connor of Rydon carried out a project fire risk assessment in relation to Grenfell Tower.1533 Rydon Project Fire Risk Assessment dated 20 February 2015 {RYD00035553/1}.
¶43.81 They identified as a hazard that the detection and alarm systems and the smoke ventilation system did not work.1534 Rydon Project Fire Risk Assessment dated 20 February 2015 {RYD00035553/10}. Each of them was marked as high risk.1535 Rydon Project Fire Risk Assessment dated 20 February 2015 {RYD00035553/10}. Among their recommendations were that the TMO obtain a fire risk assessment that took into account current circumstances.1536 Rydon Project Fire Risk Assessment dated 20 February 2015 {RYD00035553/10}.
166¶43.82 On 18 March 2015, Simon O'Connor sent the fire risk assessment to Claire Williams.1537 Email from Simon O'Connor to Claire Williams on 18 March 2015 {RYD00035549}. She did not notice that Carl Stokes had not addressed those defects in the system in his own risk assessment, nor did she notice the criticism that was made of his assessment.1538 Williams {Day122/10:3}-{Day122/12:21}. Accordingly, she did not ask Carl Stokes to review his assessment to take account of the fact that the smoke ventilation system did not work properly, nor did she ask Janice Wray to do so.1539 Williams {Day122/12:22}-{Day122/13:4}; {Day122/14:11}-{Day122/15:2}. Indeed, she could not recall having given the document to Janice Wray at all.1540 Williams {Day122/15:3-4}.
Further updates to the LFB and delays to the upgrade work
¶43.83 The work to modernise the system did not begin until April 20151541 Emails between Simon O'Connor, Claire Williams and Matt Rawlings on 22-23 April 2015 {TMO00858424}. and the new system was not fully commissioned until 28 April 2016.1542 PSB Above Ground Commissioning Report dated 28 April 2016 {PSB00000224/7}. Janice Wray and Claire Williams kept the LFB informed of the progress of the work during that period.1543 Minutes of the bi-monthly meetings between the TMO and LFB fire safety team on 23 March 2015, 19 August 2015 and 4 March 2016: {RBK00013999/3} item 9; {LFB00000063/4} item 9.1; {TMO10014736/3} item 10.1. The TMO also implemented measures during that period intended to mitigate the risk caused by the absence of a smoke ventilation system while it was being installed. That took the form of familiarisation visits by local fire crews, increased and enhanced inspections by estate staff, health and safety visits, additional inspections by Carl Stokes and preventing contractors from carrying out hot work.1544 Record of Significant Findings and Action Plan dated 17 October 2014 {TMO10017386/9} row 41; Minutes of the bi‑monthly meeting between the TMO and LFB fire safety team on 19 August 2015: {LFB00000063/4} item 9.1.
167Chapter 44: Lifts
Introduction
¶44.1 During Phase 1 there was evidence that in the early stages of the fire the firefighters had been unable to secure control over the lifts in Grenfell Tower. That meant that the they had been unable to use the lifts in their firefighting and search and rescue operations; it also meant that some occupants of the tower were able to use the lifts in an attempt to escape.1545 Phase 1 Report Volume IV paragraph 33.13. The inability of the firefighters to bring the lifts under their control is therefore relevant to the circumstances in which some residents died1546 Phase 1 Report Volume IV paragraph 28.11. and it is therefore necessary to consider why the firefighters were not able to bring the lifts under their control on the night of the fire.
Background
¶44.2 In 2005, the lifts serving Grenfell Tower were substantially refurbished and many of their components were replaced. At that time the lifts served only the ground floor, the walkway floor (floor 2) and what became floors 4 to 23.1547 {TMO00853783/16}. As part of the refurbishment new flats were created on what became floors 1, 2 and 3. To accommodate those new flats it was necessary to extend service of the lifts to floors 1 and 3.1548 Phase 1 Report Volume I paragraphs 6.38-6.39. The extent of that work, which was carried out between 2014 and 2015, seems to have been limited to creating two new lift openings and landing entrances and associated work, such as reprogramming of the software.
¶44.3 Over the course of time there have been developments in the specifications of lifts installed in high-rise buildings. A fireman's lift is one that is designed to enable firefighters to take control of it when responding to a fire in the building. A firefighting lift has a higher specification and is designed to transport firefighters and their equipment to the scene of a fire with the minimum amount of time and effort. It is fitted with a higher level of equipment and structural protection, a communication system and a secondary back-up power supply. Much evidence was heard about whether the lifts at Grenfell Tower were fireman's lifts or firefighting lifts and, if they were fireman's lifts, whether they could or should have been upgraded to firefighting lifts. For present purposes, however, only two points need to be made: first, at no stage were the lifts firefighting lifts, as they did not possess all the features of firefighting lifts required by the relevant contemporaneous standards;1549 BS 5588-5: 1991, BS EN 81-72: 2003 and BS 5588-5: 2004. The lifts did not have many of the important features of a firefighting lift including, for example, a secondary power supply, water protection or a trap door. secondly, there is not enough evidence to enable us to determine whether it was reasonably practicable at any stage to upgrade the lifts so that they had at least those features of firefighting lifts that the physical constraints of the building would allow.
168The fire control switch
¶44.4 There were two fire control switches at Grenfell Tower, one on the ground floor and one on floor 2 (the Walkway floor). The switch on the ground floor appeared older and at the time of the fire was connected, whereas the switch on floor 2 appeared newer but was not connected.1550 {MET00019973/19-21}.
¶44.5 Email correspondence between Janice Wray and Claire Williams on 18 August 2014 showed that the entrance to the tower had been moved temporarily from the ground floor to the Walkway level.1551 {CST00001858}.
¶44.6 In his Record of Significant Findings dated 17 October 2014 Carl Stokes noted that the entrance to the building had been moved to the Walkway level and asked whether the fire service override controls for the lifts had been moved.1552 {CST00001734/7}. In his Record of Significant Findings dated 26 April 2016 he asked whether the controls for the lifts had been moved back down to street level.1553 {CST00002206/6}. A spreadsheet that appears to be dated October 2016 states that he had received confirmation the controls had been moved back down to street level.1554 {CST00000196/25-27}.
¶44.7 It is likely, therefore, that a new fire control switch was installed temporarily on floor 2 during the refurbishment in about August 2014. The switch on floor 2 was subsequently disconnected and the switch on the ground floor reconnected when the entrance was moved back to the ground floor. It is likely that that took place after April 2016, but it is difficult to be any more precise.
Maintenance and testing of the lifts
¶44.8 In the years before the fire the TMO produced various policies relating to lift safety, lift breakdowns and lift trap-ins.1555 {TMO00899279}; {TMO00899287}; {TMO00880413}; {TMO00880416}; {TMO00880418}; {TMO00880419}. Those published after 2011 required a lift engineer to carry out periodic visual checks of safety gear and other equipment, such as emergency alarms, emergency car lighting and lift machine room emergency lighting, in accordance with statutory regulations. The policies also required all lifts, hoists, disabled people's hoists and stairlifts to be inspected periodically by a competent engineer as required by statutory regulations, British Standards and manufacturers' instructions, and inspections to be recorded.1556 See, for example, clause 10.0 in {TMO00880416/6}.
¶44.9 The policies also required checks to be carried out by staff, including the TMO's senior lift engineer. He was directed to carry out checks on safety gear, emergency alarms, emergency car lighting and lift machine room emergency lighting in accordance with regulations. Monthly checks of all fireman's switches were required.1557 {TMO00880421/30}; {TMO00880422/30}; {TMO00880423/30}; {TMO00880430}; {TMO00880430/30}. Responsibility for those checks passed to the TMO's lift maintenance contractor in January 2014.1558 {TMO00880432/26}; {TMO00880430}.
¶44.10 The TMO also published a "Lift Safety (Passenger, Goods, and Fireman's) Policy and Procedure" dated 23 September 2013.1559 {TMO00880431}. It stated that lifts should be thoroughly examined by a competent person, usually an insurance engineer, every six months and that a lift maintenance contract should be established with a competent lift maintenance company. The policy also required lifts to be checked weekly or monthly to ensure that they were operating correctly.1560 TMO Lift Safety (Passenger, Goods and Fireman's) Policy Procedure Clause 3.23 {TMO00880431/3}.
169¶44.11 The TMO also produced a "Lift Safety Policy and Procedure" dated February 20141561 {TMO00880433}. which dealt with statutory inspections and maintenance. Section 4.1, relating to planned preventative maintenance, stated that the TMO should appoint a competent lift contractor to carry out monthly maintenance checks on all lifts, to record maintenance on the lift log card and to carry out maintenance identified by inspections as soon as practicable. The policy also noted that that was to be supplemented by regular inspections of the lift cars by the estate staff and health and safety staff. Section 4.2 provided that the lifts should be thoroughly examined every 6 months.1562 {TMO00880433/3-4}. Subject to various minor changes, the substance of the policy remained in place until the fire.
The PDERS maintenance contract
¶44.12 PDERS (an unincorporated trading division of Otis Ltd) was the TMO's planned preventative maintenance provider from 3 February 2014.1563 Fallis-Taylor {PDR00000050/2} page 2, paragraph 9.
¶44.13 Based on the Description of the Works contained in paragraph 2.0 of the document entitled "Service Information and Preambles for the Lift Preventative Planned Maintenance and Repair Contract",1564 {PDR00000049/43} paragraph 2.0. PDERS was expected to provide fully comprehensive servicing of the lifts throughout RBKC's estate, including routine inspection, maintenance and repairs. Breakdown response repairs due to vandalism or misuse were not included. The contract required maintenance visits to take place monthly with a minimum period between visits of not less than 21 days.1565 {PDR00000049/44} paragraph 2.1.1.
¶44.14 The contract identified the maintenance tasks and how often they should be carried out. Codes designated the frequency of a task, so, for example, "M1" indicated that a task should be carried out monthly, "M2" that it should be carried out every two months, and so on.1566 {PDR00000049/45} paragrapgh 2.1.9. Under the heading of "Landing Entrances" the contract expressly provided that fireman's control switches should be checked monthly.
¶44.15 The contract listed the lifts at Grenfell Tower (H090 and H091) and provided that a minimum of two hours should be spent each month on the maintenance of each of them.1567 {PDR00000049/82}. The evidence of Mark Wallis, a maintenance engineer at PDERS, was that a maintenance visit normally took about two hours for each lift.1568 Wallis {Day163/86:21-25}.
Maintenance by PDERS
¶44.16 The service visit reports for lift H090 covering the period from February 2014 until the fire1569 {PDR00000047}. suggest that it suffered no significant defects. The repair visit reports1570 {PDR00000048}. also reveal no noteworthy problems with it.
170¶44.17 Similarly, the service visit reports for lift H091 covering the period between February 2014 and June 20171571 {PDR00000041}. show no significant faults. The repair visit reports for lift H0911572 {PDR00000045}. also disclose no significant problems.
Testing by Bureau Veritas
¶44.18 Bureau Veritas is a testing, inspection and certification organisation which tests equipment, including lifting equipment, to assess whether it meets required technical standards.1573 Veitch {BVL00000006/1} page 1, paragraph 2.
¶44.19 Bureau Veritas was engaged by RBKC from January 2013 to carry out "thorough examinations" of all the lifts in the borough every six months, including those at Grenfell Tower.1574 Veitch {BVL00000006/8} page 8, paragraph 29. A thorough examination is a detailed examination of a lift and its associated equipment. It does not include maintenance or repairs.1575 Veitch {BVL00000006/2-3} pages 2-3, paragraph 5.
¶44.20 The reports of the inspections carried out by Bureau Veritas in 2016 and 2017 were available to us. They identified some category A defects (defects that are or could become a danger to users), some category B defects (defects that do not affect safety but usually require some maintenance) and some category C defects (defects that call for observations or recommendations only).1576 Lasisi {BVL00000015/2-3} pages 2-3, paragraphs 7-10.
¶44.21 On 7 January 2016, a Bureau Veritas engineer examined lifts H0901577 {MET00036488}. and H091.1578 {MET00036489}. He found no category A defects but several category B and C defects. On 2 June 2016, Bureau Veritas examined lift H0901579 {MET00035852}. and lift H091 again.1580 {MET00035853}. Again, no category A defects were found but several category B and C defects were identified.
¶44.22 On 2 November 2016, Isiaka Lasisi of Bureau Veritas examined lifts H0901581 {BVL00000014}. and H091.1582 {BVL00000016}. Although a category A defect was found in the latter, it did not relate to its fire safety features.1583 Lasisi {BVL00000015/5} page 5, paragraph 19. The evidence shows that on 2 November 2016 the TMO raised the category A defects with PDERS and on 3 November 2016 an engineer examined the lifts and rectified them.1584 {MET00036245}
¶44.23 Michael Arnold of Bureau Veritas examined lifts H090 and H091 on 10 April 2017.1585 {BVL00000008}. Although he identified some category B defects, he found no category A defects. As no category A defects had been identified during the visit on 10 April 2017 and there is nothing to suggest that the inspection was anything other than diligent, we conclude that there were no significant defects in the lifts at the time of the fire.
171Maintenance and testing of the fire control switch
¶44.24 Although until January 2014 the TMO's policies (in draft from August 2011 and approved in June 2012) provided that its own lift engineer would test the fireman's switch each month,1586 {TMO00880421/30}; {TMO00880430/30}. there is no evidence that the TMO did carry out any testing or maintenance of the fire control switch itself. PDERS said that the switch had been tested monthly from 2014 onwards, as the contract required. Although before that date the TMO's policies required it to be tested by its own lift engineer, it was not done regularly or, it seems, at all.1587 Cahalarn {Day164/68:12-19}; {Day164/69:1}; {Day164/70:3}.
The lift maintenance contractor - PDERS
¶44.25 Not all the lifts maintained by PDERS had fire control switches and it was therefore decided not to include the fire control switch in the report forms.1588 Fallis-Taylor {PDR00000050/6-7} pages 6-7, paragraph 25; Wallis {PDR00000036/3} page 3, paragraph 12. As a result, none of the service visit reports produced by PDERS1589 {PDR00000047}; {PDR00000041}. records testing of the fire control switch and there is no other written record of its having tested the switch.
¶44.26 From September 2016, Dave Smalley was the PDERS lift maintenance engineer for the North Kensington area, which included Grenfell Tower. He said that the fire control switch had been tested on each of his service visits in November and December 2016 and January and March 2017. He did not recall any problems with it.1590 Smalley {PDR00000029/5} page 5, paragraphs 25-28.
¶44.27 From April 2017, Mark Wallis was the lift maintenance engineer for Grenfell Tower. He carried out service visits on 12 April 20171591 {PDR00000047/34}; {PDR00000041/36}. and 9 May 2017.1592 {PDR00000047/35}; {PDR00000041/37}. He said he specifically remembered checking that the fire control switch had been in good working order on both occasions.1593 Wallis {PDR00000036/3} page 3, paragraph 12; {PDR00000036/5-6} pages 5-6, paragraphs 22-23; Wallis {Day163/115:9}-{Day163/116:5}. However, after he had given evidence, a CCTV recording made on 9 May 2017 was obtained which covered his maintenance visit. It showed clearly that, contrary to his evidence, he had not tested the fire control switch on that occasion. In the light of that recording Mr Wallis accepted that he had not tested the switch on that day.1594 Wallis {PDR00000056/1} page 1, paragraph 2. No CCTV recording of his visit on 12 April 2017 or, if he attended, of any previous visit was available, so we cannot be confident that he tested the control switch on that occasion or on any previous visit.
¶44.28 In the circumstances, there is no reliable evidence of when the fire control switch was last tested by PDERS before the fire. In fact, the weight of the evidence suggests that the fire control switch was not regularly tested before 14 June 2017.
The insurance inspections - Bureau Veritas
¶44.29 The Bureau Veritas reports from 2016 and 20171595 {MET00036488}; {MET00036489}; {MET00035852}; {MET00035853}; {BVL00000014}; {BVL00000016}; {BVL00000008}. record only defects affecting the lifts, not the testing of the fire control switch.1596 Lane, The Management and Maintenance of Grenfell Tower - Chapter 7 - KCTMO's duty to provide a suitable system of maintenance for fire protection measures {BLARP20000033/463} paragraph 19.5.47.
172¶44.30 Michael Arnold, the engineer who tested the lifts on 10 April 2017, confirmed that he had tested the fire control switch at Grenfell Tower. The outcome of the test was not separately documented, but we were told that if the switch had been defective, that would have been recorded in the Report of Thorough Examination.1597 Arnold {BVL00000017/5} page 5, paragraph 6c; Arnold {BVL00000019/2-3} pages 2-3. There is no such record. Accordingly, the insurance inspections found nothing to suggest that the fire control switch was not working effectively.
The London Fire Brigade
¶44.31 For the sake of completeness, we note that the LFB made a number of visits to Grenfell Tower.1598 {TMO00855611}; Ramsey {LFB00083855/3} page 3, paragraph 9; Ramsey {MET00071003/10} page 10; Ramsey {Day147/31:7}-{Day147/32:1}; Stokes {Day138/5:20}-{Day138/6:12}; McHugh {LFB00091787/12} page 12, paragraph 28. The last took place on 27 March 2017 and was carried out by Dean Ricketts and a crew from North Kensington fire station.1599 Ricketts {LFB00004825/4} page 4. He recalled that he had been told by one of his crew that the lifts had "fireman's lifts" controls but due to the number of people using the lifts they were unable to test them.1600 Ricketts {LFB00004825/5} page 5.
Automatic fire alarm recall
¶44.32 An automatic fire recall function was installed in about March 2006. Although there is evidence that the system was tested in 2013 and early 2014,1601 Howkins, Supplementary Report concerning the lifts at Grenfell Tower {RHO00000005/35-36} paragraphs 92-94. correspondence from September 2015 suggests that by then it had been disconnected. We do not know when that happened or who disconnected it.1602 Howkins, Report concerning the lifts at Grenfell Tower {RHO00000003/177-179} paragraphs 437-449. Investigations carried out after the fire also showed that there was no connection between the fire alarm, the smoke detection system and the lifts.1603 {MET00018469/11}; {MET00065879/34-35}; {MET00072161/12}; {MET00072161/26}.
The failure of the fire control switch
¶44.33 As set out in the Phase 1 report, the firefighters who attended Grenfell Tower on the night of the fire were not able to operate the ground floor fire control switch.
¶44.34 The first person to attempt to use the switch was CM Christopher Secrett. A CCTV recording shows him inserting a drop key into the switch at 01.01.1604 {INQ00000138}. He put the drop key into the fire control switch and felt the end of it drop down and engage but it did not work. He felt that the key was hitting some sort of stop. He turned the key several times in both directions but it did not operate the switch. He tried to turn it with more force but it made no difference. Eventually he tried to take the key out of the box but it was stuck. He left the key in place and tried to use the lifts in the normal way.1605 Secrett {MET00039598/3} page 3; Secrett Phase 1 {Day16/192:23}-{Day16/193:6}.
¶44.35 CM Secrett had bought a new drop key on 27 April 2017 on eBay. He kept it in a pocket of his tunic. He wore the tunic on the night of the fire but he could not be sure that the key he had bought on eBay was the key he had used on the night of the fire as the keys all look alike to the naked eye and it is common for keys to be switched and replaced.1606 Secrett {MET00056990/2} page 2.
173¶44.36 A CCTV recording shows that at 01.33 CM Ben Gallagher tried to use the fire control switch. A key was already in the box which CM Gallagher tried to use to take control of the lift. However, he was unable to activate the switch and left the key in place.1607 Gallagher {MET00040215}.
Evidence recovered after the fire
¶44.37 Another CCTV recording showed FF Nuttall removing the drop key from the fire control switch. He was unable to remember doing so and explained that, some two years after the fire, he had been called by a member of the LFB's investigation team and asked if he had any drop keys. FF Nuttall said that he had posted to them the one drop key that he had been able to find, although he had thought he had two. He was not able to say that the key that he had provided to the investigation team was the one that he had removed from the tower.1608 Nuttall {MET00056991/1} page 1.
¶44.38 It is not possible to say whether the key sent in by FF Nuttall had been used on the night of the fire. The period between the fire and the posting of the key was very long and FF Nuttall accepted that he might have swapped the key with another firefighter.1609 Nuttall {MET00056991/2} page 2.
¶44.39 The Metropolitan Police instructed an engineering consultant, WSP, to visit Grenfell Tower on 15 March 2018 to conduct a visual inspection of the fire control switch on the ground floor. The engineer who attended noted that it had not been damaged by fire or water and therefore recommended that it be removed for examination.1610 {MET00019973/12} paragraph 6.1. The fire control switch therefore remained in place from the date of the fire until about March 2018.
Why did the switch fail to operate?
Presence of debris
¶44.40 The first possibility is that the switch was jammed with debris. It was first tested on 18 April 2018 in the presence of professional engineers from WSP, Elan Lifts, the Metropolitan Police, the LFB and an independent lift test engineer.1611 {MET00019973}. The report of the test made by WSP recorded that the switch was difficult to operate. The faceplate was removed to determine the reason why the switch could not be operated and the mechanism was found to be seized and deformed.1612 {MET00019973/21}.
¶44.41 The report also concluded that, as the mechanism of the switch was defective, it had not been examined by the lift service company at regular intervals.1613 {MET00019973/43} paragraph 10.1.
¶44.42 The switch was tested again on 15 February 2019 at the Building Research Establishment (BRE). The test is described in two reports: the first written by Arup,1614 {RHO00000001}. the second by André Horne, an independent expert instructed by the Metropolitan Police.1615 {MET00056700}. In both reports the switch is described as Exhibit BJG/74.
¶44.43 There is no evidence that the switch was cleaned between the test on 18 April 2018 and that on 15 February 2019. However, it had been moved between locations, so it is possible that any debris that had originally been inside it had moved or had been dislodged.
174¶44.44 Arup's report is dated 1 March 2019. It stated that a visual examination of the switch disclosed a build-up of builders' material on the casing and that the micro-switch was jammed. The author's impression was that the debris was wall plaster. On examination, the micro-switch became free and worked. The cause of the jamming could not be identified, but there were plaster grains on the work bench. The author's view was that the presence of builders' material had not been the result of disturbance when the switch was extracted but from the original works.1616 Howkins, Grenfell Tower Lifts Briefing Note regarding fire control switches {RHO00000001/13}.
¶44.45 André Horne's report was based on the same test. He said that the switch frame arms were jammed because of debris on the frame which appeared to be dirt, mortar or sand, possibly from the construction of the building. Mr Horne could not say whether some of the debris had been dislodged during the removal, transportation and storage of the switch, thereby causing the jam, or if it had been jammed before its removal. After some gentle manipulation by hand, it moved freely. In Mr Horne's view, forceful manipulation of a correctly fitting key would have moved the switch frame arms.1617 {MET00056700/3}.
¶44.46 Mr Howkins was also present at the test on 15 February 2019. He provided a diagram which showed where the debris had been observed.1618 Howkins, Supplementary Report concerning the lifts at Grenfell Tower {RHO00000005/48}. He originally estimated the quantity of debris removed as about a quarter of a teaspoonful,1619 Howkins, Supplementary Report concerning the lifts at Grenfell Tower {RHO00000005/48} paragraph 161. but in his evidence he said that it had been half to three-quarters of a teaspoonful.1620 Howkins {Day165/103:5-10}. There was no way of knowing if the switch had become jammed with debris while it was still in place, during its removal, while it had been stored or in the course of transportation before testing.
¶44.47 During the test a drop key was inserted into the switch. The switch did not immediately operate but after the key had been turned left and right a few times the debris on the micro switch cleared and it was possible to operate the switch.1621 Howkins, Supplementary Report concerning the lifts at Grenfell Tower {RHO00000005/48} paragraph 159. Mr Howkins and Mr Horne agreed that the use of a reasonable amount of force would probably have cleared the debris.1622 Howkins, Supplementary Report concerning the lifts at Grenfell Tower {RHO00000005/49} paragraph 163.
¶44.48 Both Mr Horne and Mr Howkins noted another abnormality in the switch, unrelated to the debris, namely that the side wards were bent out of shape. That was not specifically noted in WSP's report, but the reference to the mechanism being "deformed" may have been a reference to the bent side wards.1623 {MET00019973} page 21.
¶44.49 The Arup briefing note also noted the deformation of the side wards and photo 13 in the report showed the damage.1624 Howkins, Grenfell Tower Lifts Briefing Note regarding fire control switches {RHO00000001/8-9}. The author concluded (and Mr Horne agreed)1625 {MET00056700/3}. that the damage to the side wards had been caused either by the use of an incorrect drop key, which deformed the side wards, or by a drop key being inserted too far into the barrel with the result that a high twisting force damaged the side wards.1626 Howkins, Grenfell Tower Lifts Briefing Note regarding fire control switches {RHO00000001/13}.
Use of an incorrect key
¶44.50 The second possibility is that the drop key used was not the right one for the fire control switch.
175¶44.51 The LFB purchased drop keys for fire stations which were made available through its internal supply system. The LFB has used the same supplier of lift keys since at least 2011.1627 Atkinson {LFB00083885/2} page 2, paragraph 6; Atkinson {LFB00083885/8} page 8, paragraph 11.
¶44.52 Drop keys are not issued to individuals but are kept on the pumps with many other keys and are used by all crew members as necessary. If a key is lost and a replacement needs to be ordered using the LFB's internal system, it can take up to four weeks to arrive. For that reason, firefighters often buy their own drop keys from suppliers such as Amazon or through eBay.1628 Secrett {MET00056990}; Secrett {LFB00091726/2-3} pages 2-3, paragraphs 7-8.
¶44.53 The drop key obtained from FF Nuttall was labelled LJH/67 by the police. It is not possible to know whether it was the one used on 14 June 2017.1629 Nuttall {MET00056991}. It was tested on 29 July 2019 at BRE Watford. In his subsequent report Andre Horne noted that because of its dimensions it could not be used in the fire control panel at the tower or in the example panel provided by the Metropolitan Police for the purposes of the examination.1630 {MET00056700/4}. The key could be inserted into the opening of the switch but could not be turned and therefore could not have caused the damage to the side wards.
¶44.54 A key supplied by Jeff Turner, a forensic locksmith, fitted the switch taken from the tower correctly. An example key provided for the purposes of the examination was also tested but did not fit correctly.1631 {MET00056700/3}.
¶44.55 Further testing took place on 7 February 2020.1632 {MET00071006/1}. For that purpose two more keys were compared. Key DER/22 was one of a set of keys provided by the LFB that had been assembled from keys left over from various appliances no longer in use and included a drop key.1633 Wilson {MET00077769/2}. It did not fit very well in the switch taken from the tower and Mr Horne noted that, even if the side wards had been straight, it would still not have fitted correctly. However, Key DER/22 did fit normally in the example panel and could operate the panel taken from the tower if sufficient force was applied.1634 {MET00071006/3}.
¶44.56 Key SJG/01 had been bought on eBay. It fitted both the switch taken from the tower and the example switch.1635 {MET00071006/4}.
¶44.57 By contrast, the key obtained from FF Nuttall could not be used to operate either switch. The only keys that functioned normally in the switch taken from the tower were the key bought on eBay (SJG/01) and the key provided by Jeff Turner. Neither the example key nor the key provided by the LFB (DER/22) fitted the switch taken from the tower correctly, but, if sufficient force had been applied, they could both have operated it. All the keys other than LJH/67 worked properly in the example fire control panel.
An unidentified fault
¶44.58 It is possible that some other unidentified cause was responsible for the failure of the fire control switch to work on the night of the fire, but there is no evidence that the switch had been damaged by smoke or fire and no other defects in it were identified.
176¶44.59 We think that the use of the wrong size of drop key is the most likely reason for the failure of the fire control switch to operate properly on the night of the fire.1636 Howkins {Day165/112:5-7}.
Conclusions
¶44.60 Two important matters emerge from this aspect of our investigations. The first is the need for regular maintenance of fire control switches. Whether debris in the switch box interfered to any significant extent with the operation of the switch on the night of the fire, the likelihood is that more foreign material was present than should have been allowed to accumulate in a piece of equipment that was supposed to be checked at regular intervals. We cannot say that a failure of regular maintenance was the cause of the switch becoming inoperable, but we can say that the evidence strongly suggests that it was not given the attention it deserved.
¶44.61 The second concerns the significant variation in the dimensions of the drop keys tested and their compatibility with different fire control switches. One might have expected fire control switches to conform to a specified pattern and that drop keys would likewise conform to a pattern known to be capable of operating the standard switch. That appears not to have been the case. As a result, it appears to have been largely a matter of chance whether the key carried by the first firefighter who tried to take control of a lift enabled the switch to be operated. That is a recipe for disaster. Part of the reason for that unsatisfactory state of affairs lies in the practice of firefighters' obtaining drop keys from various sources without appropriate guarantees of their suitability. Standardisation and control of equipment by fire and rescue services are necessary to avoid incompatibility. On 8 August 2019, the LFB notified all watch managers and crew managers that keys purchased from external sources were in circulation and instructed them to carry out an immediate physical check of all drop keys to ensure that keys of the correct pattern were stowed on all firefighting appliances at all stations.1637 Atkinson {LFB00083885}; also see {LFB00083895}. We hope that as a result the substantial variation in the keys used by firefighters has now been eliminated.
177Chapter 45: Emergency planning
Legislative framework and guidance
¶45.1 Save for the purposes of article 30 (which is not relevant for present purposes), the Fire Safety Order does not apply to domestic premises. Each flat in Grenfell Tower was occupied under a separate lease or tenancy agreement and so constituted domestic premises for the purposes of the Order. Accordingly, as far as the residents were concerned, the duties imposed by articles 8 to 22 applied only in relation to the common parts of the building, namely, the lobbies, lifts and staircase.
¶45.2 Article 14 imposes a duty to ensure that routes to emergency exits and the exits themselves are kept clear at all times; emergency routes and exits must be indicated by signs and be adequately lit (including, where necessary, by emergency lighting). Article 15(1)(a) requires the responsible person to establish, and where necessary give effect to, appropriate procedures to be followed in the event of serious and imminent danger from fire and to nominate a sufficient number of competent persons to implement those procedures in so far as they relate to the evacuation of relevant persons from the premises. The procedures must, so far as is practicable, require any relevant persons exposed to a serious and imminent danger to be informed of the nature of the hazard and of the steps taken or to be taken to protect them from it (article 15(2)(a)).
¶45.3 In practical terms the Fire Safety Order required the TMO to ensure that the lift lobbies, the lifts themselves and the staircase were kept free of obstructions, were properly lit (including by emergency lighting when necessary) and displayed appropriate signs to indicate the escape route. It appears to assume that the occupants of any flat in which a fire occurred, or which was affected by heat or smoke from a fire in a neighbouring flat, could escape into the lobby and from there make their way to safety using the stairs. It did not, however, impose a duty on either of them to devise a plan to evacuate residents from within their flats, much less a plan to evacuate the building as a whole. A "stay put" or "defend in place" strategy for responding to a fire is better viewed as a response strategy rather than an evacuation plan.
¶45.4 Publicly available guidance, in particular the guidance published by the Local Government Association specifically in relation to purpose-built blocks of flats (the LGA Guide), emphasised the need to ensure that that information about the procedure to be followed in the event of a fire should be disseminated to all residents.1638 {HOM00045964/115-117} paragraphs 77.1 to 77.6; {HOM00045964/133} Appendix 1.
¶45.5 Section 79 of the LGA Guide, under the heading "Preparing for emergencies", advised that there must be a suitable emergency plan for the premises, but that, in the case of purpose‑built blocks of flats, that would rarely require more than a fire action notice, which in most cases would be sufficient as an emergency plan. It also recognised that it was common to communicate the emergency plan to tenants in other ways, so that it was not always necessary to display a fire action notice in the building.1639 LGA Guide {HOM00045964/118} paragraph 79.1.
178¶45.6 With the approval of the LFB, both before and after the refurbishment Grenfell Tower was subject to a "stay put" strategy, under which residents were encouraged to remain in their flats unless they were directly affected by fire or smoke because that was considered to be the safest course for them to take. Any more general evacuation of the building was expected to be directed and supervised by the fire and rescue service. There was therefore no need for the responsible person to create an evacuation plan for the building as a whole. We consider below the steps taken by the TMO to inform residents of the steps to be taken in the event of a fire in the building.
The TMO Emergency Plan
¶45.7 The TMO maintained an Emergency Plan. It had been drafted in August 2004 and revised in October 2006, May 2009, November 2009 and February 2016.1640 TMO Emergency Plan – Version 1 August 2004 {TMO10013898}; TMO Emergency Plan – Revised October 2006 {TMO10048195}; TMO Emergency Plan – Revised November 2009 {TMO00841015}; TMO Emergency Plan – Revised 2016 {TMO10013898}. The 2016 version referred to revisions in May 2009 and May 2015, but these have not been disclosed to the Inquiry. Adrian Bowman was responsible for maintaining, and when necessary revising, it under the general supervision of Janice Wray.1641 Wray {Day142/34:23-25}. She was unable to say what had given rise to the various revisions, but accepted that there had been no system for reviewing it at regular intervals and making any necessary changes.1642 Wray {Day142/36:20}-{Day142/38:3}. That, of itself, was a serious failing, because, if a plan is not reviewed regularly, it may not be fully effective when an emergency occurs.
¶45.8 The chairman considered the TMO Emergency Plan in the Phase 1 report and found that it was far from adequate.1643 Phase 1 Report, Volume IV, paragraph 30.93. The evidence we have heard at Phase 2 only reinforces that conclusion. The TMO Emergency Plan was in two parts: the first was the generic plan; the second contained separate sections relating to the various properties managed by the TMO, each containing a description of a particular property.
¶45.9 The section relating to Grenfell Tower was dated 25 February 2002.1644 November 2009 TMO Emergency Plan {TMO00841015/147}. It contained estimates of the number of residents and vulnerable persons; it identified places where the emergency services could gather and identified a nearby place of shelter. There was information about the electricity, gas and water supplies and the dry riser. The location of the keys was also recorded and the means of escape. The "stay put" strategy was recorded as was the existence of automatic fire alarm and smoke extract systems, but no further information was provided about them.1645 November 2009 TMO Emergency Plan {TMO00841015/147-148}.
¶45.10 The version of the Emergency Plan dated February 2016 was current at the date of the fire. The sub-section relating to Grenfell Tower was largely the same as that which had been created on 25 February 2002, 15 years earlier. Janice Wray was unable to explain why that was the case. The number of dwellings had not been changed to reflect the new flats created in the lower floors as a result of the refurbishment, but the place of shelter had been changed to North Kensington Resource Centre. The means of escape were still described as through the stairs and onto the walkway level, which did not reflect the fact that the door to the walkway had been blocked up during the refurbishment. The section containing "other information" had only partly been brought up to date. Information about the reception desk, the creche and the boxing club had been removed as well as information about the hydraulic lift to social services on the first floor. A description of the bin stores was included and a note recorded about a fire that had affected them in 1997. However, the plan still recorded that there was an automatic fire alarm and smoke extract system, even though the former no longer existed. The plan noted that in case of fire residents were advised to remain in their homes unless affected by heat or smoke.1646 February 2016 TMO Emergency Plan {TMO10013898/145-146}.
179¶45.11 The piecemeal and inconsistent revision of the information in the Emergency Plan meant that that part of the plan could not safely be relied on in an emergency at Grenfell Tower.
¶45.12 Janice Wray told us that the Emergency Plan had been intended to deal with only minor emergencies, such as a fire, a power failure, a leak or a flood.1647 Wray {Day142/38:5-19}; {Day142/40:22}-{Day142/41:19}. That was because the TMO lacked the resources to respond to a major emergency. RBKC had a more comprehensive emergency plan and greater resources. The plan itself, however, said that it set out the roles and responsibilities of the TMO in the event of a major incident, which it defined as an incident or natural disaster resulting in death, injury or serious disruption to normal life of a magnitude that would acutely stretch the TMO's resources.1648 February 2016 TMO Emergency Plan {TMO10013898/13}.
¶45.13 Ms Wray said that the section on Grenfell Tower had been intended to collate information that the emergency services or anybody else might require for the purposes of emergency planning,1649 Wray {Day142/43:22}-{Day142/44:2}. but she appears not to have given any thought to whether it contained all the information recommended by the guidance. They referred only to the requirement to communicate the emergency plan (that is, the "stay put" strategy) which they did through the residents' handbook, Link magazine and in documents provided to residents when they signed the tenancy agreement with the TMO.1650 Wray {Day142/45:5}-{Day142/46:1}.
The fire safety strategy
¶45.14 The TMO's fire safety strategies of 2013 and 2016 did not refer to the Emergency Plan,1651 2013 TMO Fire Safety Strategy {TMO00830598}; 2017 TMO Fire Safety Strategy {TMO00847324}. but that may have been because it was understood that the Emergency Plan was intended as a response to a wide range of emergencies.
¶45.15 The 2013 fire safety strategy asserted that a "stay put" or "defend in place" strategy was "overwhelmingly" appropriate for the TMO's housing blocks. That was because compartmentation, both between flats and also between flats and the common parts, was considered to be sufficient to withstand fire for long enough to enable the fire and rescue service to attend and extinguish it. That message was said to have been communicated to residents in various ways, including in the resident's handbook, on the TMO's website and in Link magazine.1652 {TMO00830598/10-11}, paragraph 15.1; {TMO00847324/10}, paragraph 15.2.
Evacuation planning in the fire risk assessments
¶45.16 A fire risk assessment should set out in detail the fire management procedures required to respond to a fire so that they can provide the basis of an appropriate response plan.1653 Lane, Chapter 8 – The adequacy of the advice provided by the fire risk assessor Carl Stokes of CS Stokes & Associates Ltd to KCTMO Report {BLARP20000027/373}. Clause 16 of PAS 79:2012 also required a fire risk assessor to undertake an assessment of fire safety management, which included procedures for people to follow in the event of fire, including people with special responsibilities, the nomination of people to respond to fire and, where appropriate, to assist with evacuation and arrangements for liaison with the fire and rescue service, both in respect of planning for fire and at the time of any fire.1654 PAS 79:2012 {CTA00000003/50}, paragraph ii.c-e. The commentary to clause 16 said that in making a fire risk assessment there was a need to ensure that there were formal, documented procedures of an adequate kind for people to follow in the event of fire. A list of procedures considered to be adequate was included.1655 PAS 79:2012 {CTA00000003/51}, paragraph viii.
180¶45.17 Carl Stokes did, in the main, take PAS 79:2012 as his guide for making fire risk assessments, although his adherence to it was patchy and inconsistent. Each of his fire risk assessments for Grenfell Tower had a section headed "The Evacuation Strategy for this building" in which he noted that there was a "stay put" strategy in place and that the fire and rescue service or the TMO would organise a general evacuation of the building, if appropriate. He also noted that the TMO had provided information to all residents in a tenant's handbook, letters and briefing sheets and in articles in Link.1656 Grenfell Tower Fire Risk Assessment – 20 June 2016 {CST00003145/6}. Once the refurbishment of the tower was under way, he recorded that the contractors had an evacuation policy and procedure relating to areas under their control and that the nursery and boxing club had their own fire risk assessments and evacuation procedures. He did not record whether there was an emergency plan specifically for Grenfell Tower that described how the TMO would contact the LFB, residents or the nursery or boxing club in the event of a fire. Nor did he record whether there was a plan which contained relevant information specific to the tower. That part of the fire risk assessment remained substantially the same between 2010 and 2016 with minor and immaterial variations.1657 Lane, Chapter 8 – The adequacy of the advice provided by the fire risk assessor Carl Stokes of CS Stokes & Associates Ltd to KCTMO Report {BLARP20000027/376}.
¶45.18 Carl Stokes told us that in the case of Grenfell Tower the evacuation plan had been a "stay put" strategy,1658 Stokes {Day136/223:3-6}; Letter from Carl Stokes to Janice Wray of 27 September 2010 {CST00003061}. information that he admitted he had obtained at a meeting with Janice Wray on 24 September 2010.1659 Stokes {Day137/16:6-11}. In his view, that explained why his fire risk assessments for many other high-rise residential blocks contained similar language. He had been responsible for the inclusion in his fire risk assessments of the statement that the Fire and Rescue Service or the TMO would organise a general evacuation of the building. He had not been told by Janice Wray that the TMO (either alone or in conjunction with the Fire and Rescue Service) would organise a general evacuation.1660 Stokes {Day136/221:15}-{Day136/222:3}; {Day137/4:3}-{Day137/5:18}; Wray {Day142/54:10}-{Day142/55:4}; {Day142/59:2-7}. He had based it on the knowledge that under GRA 3.2 it was something for which the fire and rescue service should have contingency plans and that the TMO was aware of the needs of individual residents.1661 Stokes {CST00003063/51} page 51, paragraph 150 (i). He thought that it was always possible that a situation might arise in which the fire and rescue service would have to evacuate the building. He said that he had not contemplated that the TMO would organise an evacuation in response to an emergency; in such cases it would act under the direction of the Fire and Rescue Service.1662 Stokes {Day137/9:19-23}. It would do so only in cases where it had other reasons for evacuating the building and could do so in its own time.1663 Stokes {Day137/6:1-7}. However, those qualifications were not recorded in the fire risk assessment itself, nor were they readily apparent to anyone reading the document, which gives a quite different impression.1664 Stokes {Day137/9:24}-{Day137/10:4}.
181¶45.19 It was the TMO's responsibility to check the accuracy of the statements in Mr Stokes's fire risk assessments, since, under article 9 of the Fire Safety Order, they were its own assessments. We therefore find it difficult to understand why no one at the TMO took issue with an erroneous statement on a matter of such importance, particularly since it was repeated in fire risk assessments made in respect of other high-rise buildings, including Adair Tower, Gillray House, Hazlewood Tower and Markland House. However, as we have noted elsewhere, at no point during the seven years in which Carl Stokes carried out fire risk assessments for the TMO did Janice Wray seek to question any of his assessments whether in relation to Grenfell Tower or any other building.1665 Apart from a disagreement about whether the lifts at Grenfell Tower were fire-fighting lifts (see Chapter 44); and on his grading of remedial actions (see Chapter 39). She was clear in her own mind that the TMO had no formal role in organising an evacuation in the event of a fire, but she did not make that clear to Carl Stokes.1666 Wray {Day142/63:8-16}.
The fires at Adair Tower and Trellick Tower
¶45.20 In the two years before the Grenfell Tower fire there were two fires in high-rise residential buildings managed by the TMO. On 31 October 2015, a fire occurred in Adair Tower and on 27 April 2017 there was a fire in Trellick Tower.1667 LFB FSR Post Fire Review Report {LFB00054910}; LFB Senior Fire Safety Officers Report {LFB00001626}; Paper 3 – Adair Tower fire – 31 October (2015) dated 23 November 2015 {TMO00840431}. On both occasions, the LFB carried out a partial evacuation of the building.1668 Paper 3 – Adair Tower fire – 31 October (2015) dated 23 November 2015 {TMO00840431}.
¶45.21 Janice Wray was aware that on each occasion part of the building had been evacuated and knew that the "stay put" strategy had sometimes been departed from.1669 Wray {Day142/52:2-19}; {Day142/53:2-7}. On 23 November 2015, she drafted a note to the Health and Safety team about the Adair Tower fire in which she reported that there was a "stay put" strategy at Adair Tower, in common with most of the TMO's high-rise residential blocks. She said that the LFB would decide whether an evacuation was required and, if so, would carry it out. She also said that the LFB would be assisted by any TMO staff who were present.1670 Paper 3 – Adair Tower fire – 31 October (2015) dated 23 November 2015 {TMO00840431}. She described that as merely an observation on the response at Adair Tower rather than a plan.1671 Wray {Day142/63:2-7}.
The response of senior management to the fires
¶45.22 After the fire at Adair Tower on 31 October 2015, Robert Black asked Janice Wray and Sacha Jevans to explain the building's fire procedures and processes.1672 Email from Robert Black "re Fire Adair Tower" dated 31 October 2015 {TMO00869147}. In response Janice Wray described the "stay put" strategy and explained that, if a fire occurred, the LFB would decide whether an evacuation was necessary and, if so, whether it should be partial or total.1673 Email from Janice Wray to Robert Black dated 31 October 2015 {TMO00869159}.
¶45.23 On 1 November 2015, Robert Black sent Peter Griffiths, Teresa Brown, Sacha Jevans and Yvonne Birch some complaints that Councillor Mason had received from the press and residents. They included the absence of an evacuation plan.1674 Email from Robert Black dated 1 November 2015 {TMO00866475}.
182¶45.24 On 2 November 2015, Robert Black told the board that the TMO had responded to the fire rapidly,1675 Email from Robert Black dated 2 November 2015 {TMO00866480}; {TMO10050075}. and following an inspection of Adair Tower on 3 November 2015 Carl Stokes expressed the view that the TMO's management procedures had worked well.1676 Initial views of the fire risk assessor following his inspection of Adair Tower on 3 November 2015 {CST00025017}. Robert Black told the Housing and Property Scrutiny Committee on 5 November 2015 that the emergency planning had worked and that the fire doors had also worked well,1677 Minutes of the Housing and Property Scrutiny Committee, 5 November 2015 {RBK00048049/6}. but that was not quite the message that was conveyed in internal meetings of the TMO that followed. The incident was discussed at an executive meeting on 11 November 2015.1678 TMO executive team meeting {TMO00843593/2}. Barbara Matthews, who was co-ordinating the response to the fire, said that although RBKC had been supportive, the TMO should be more involved in RBKC's emergency planning strategy so that everyone was aware of contact numbers and roles and responsibilities. The TMO's own Emergency Plan was discussed and it was agreed that the executive team should meet Janice Wray and Hash Chamchoun to gain a better understanding of who was responsible for keeping it up to date and for applying any lessons learnt from the fire at Adair Tower.1679 TMO executive team meeting {TMO00843593/2}.
¶45.25 As a result of the Adair Tower fire, it had become apparent to the TMO that its role in an emergency was unclear and that its Emergency Plan should be reviewed in conjunction with RBKC's emergency plan and revised as necessary.1680 Matthews {Day148/122:9-15}. Barbara Matthews may have looked at the plan,1681 Matthews {Day148/122:16-18}. but she did not take any steps herself to make sure that it was brought up to date; instead, she relied on Janice Wray to do that.1682 Matthews {Day148/122:9}-{Day148/123:5}.
183Chapter 46: Vulnerable residents
The Fire Safety Order
¶46.1 Articles 14 and 15 of the Fire Safety Order set out the duties of the responsible person to ensure that there are effective emergency exits and to establish and give effect to procedures to be followed in the event of serious and imminent danger. We need not set them out in detail here. However, we make two general observations at the outset. First, the expression "relevant persons" includes anyone who is lawfully on the premises.1683 DCLG regulatory reform (fire safety) order 2005 {CLG00000094/12}, Article 2 That clearly includes all occupants of the building and any visitors, regardless of their physical or mental capabilities, who are in those parts of the building to which the Fire Safety Order applies. The Order extends to the common parts but not to individual flats. Secondly, whatever the origins of the Fire Safety Order, it cannot be read as applying only to premises where there are employees of the responsible person present at all times to provide assistance with evacuation.
¶46.2 Between 2005 and 2017 there was much guidance available to assist those who had responsibility under the Fire Safety Order for managing fire safety to understand their duties to those with disabilities.
DCLG Guidance Note No. 1: Enforcement
¶46.3 DCLG Guidance Note No.1 published in October 2007 gave general guidance to enforcing authorities on the need to ensure that the means of escape were suitable and sufficient to allow safe escape from the premises. In relation to the duties under article 14, paragraph 77 of the guidance advised that all emergency routes and exits should lead as directly as possible to a place of safety and be adequate for everyone to escape quickly and safely. It also advised that the risk assessment should identify any person for whom special evacuation arrangements might need to be made because of their age, state of health, physical or mental abilities or, in some circumstances, their location on the premises.1684 DCLG regulatory reform (fire safety) order 2005 {CLG00000094/20}. However, no specific guidance was available in relation to different types of premises, such as high-rise residential buildings, and no distinction was made between residential and commercial premises.
The Sleeping Guide (2007)
¶46.4 The guidance entitled Fire Safety Risk Assessments: Sleeping Accommodation, commonly known as the "Sleeping Guide", published by the government in 2007, was intended to assist in carrying out fire risk assessments in relation to the common parts of buildings containing flats and maisonettes, as well as premises of other kinds.1685 HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015 {RBK00036722/6}. 12 bullet points which state that the guide will address the common areas of flats and maisonettes. It was not intended to apply to domestic premises occupied as a single private dwelling, including private flats or rooms. It recommended that when carrying out a fire risk assessment steps should be taken to identify people who may be particularly at risk, such as children and people with disabilities or with a sensory impairment.1686 HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015 {RBK00036722/16-17}. In particular, it advised that the means of escape should be assessed to make sure that they are suitable for the evacuation of everyone from the premises, including vulnerable residents. It suggested that, in evaluating the risk to people with disabilities, the responsible person might need to discuss their individual needs with them.
184¶46.5 The Sleeping Guide drew attention to the Disability Discrimination Act 1995 and advised that if a disabled person could realistically be expected to use the premises, the responsible person must make any reasonable adjustments that will make it easier for that person to use and, if necessary, escape from the premises.1687 HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015 {RBK00036722/54}, paragraph 1.15. In particular, it advised that the concept of "reasonable adjustments" applied equally to fire safety, although its precise application would depend on the circumstances of each case.1688 HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015 {RBK00036722/54}. As in other aspects, the Sleeping Guide also advised that if people with special needs used the premises, their needs should so far as practicable be discussed with them.1689 HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015 {RBK00036722/54}. It recommended that effective management arrangements be put in place for those who need help to escape.1690 HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015{RBK00036722/69}.
DCLG supplementary guide "Means of Escape for Disabled People"
¶46.6 In 2007, DCLG published a supplementary guide which considered accessibility and the means of escape for disabled people.1691 Fire Safety Risk Assessment Supplementary Guide, Means of escape for disabled people {INQ00014732}. It was intended to be read with its other guides on fire risk assessment. The supplementary guide contains a "Legal Overview" in paragraph 1.1, in which it states that there should be adequate means of escape for all people, including disabled people, which do not depend on the fire and rescue service. It also points out that if an employer or a service provider does not make provision for the safe evacuation of disabled people, that may be discriminatory and a breach of the Fire Safety Order.1692 Fire Safety Risk Assessment Supplementary Guide, Means of escape for disabled people {INQ00014732/6}.
¶46.7 The guide draws attention to the disability equality duty which, since 2006, had required all public bodies to promote the equality of disabled people.1693 Fire Safety Risk Assessment Supplementary Guide, Means of escape for disabled people {INQ00014732/6}. It also sets out guidance on preparing emergency evacuation plans for disabled people who are likely to be in the building or visiting it.
The LGA Guide 2011
¶46.8 The LGA Guide was drafted following the Lakanal House fire in July 2009 specifically to provide guidance on fire safety in purpose-built blocks of flats.1694 LGA Guide, Fire safety in purpose-built blocks of flats {HOM00045964/11} paragraph 2.1. It recognises that there is likely to be a diverse range of physical and mental capabilities among the occupants of a general needs block. The needs of vulnerable occupants are addressed in paragraphs 16.11-16.13 which recognise that older people and people with certain disabilities may have particular needs in responding to a fire. The guide also recognises, however, that in many circumstances it will be impracticable in existing blocks of flats to make special provision for such occupants.1695 LGA Guide, Fire safety in purpose-built blocks of flats {HOM00045964/25}.
185¶46.9 Section 79 is concerned with "Preparing for Emergencies". Paragraph 79.9 provides that in "general needs" blocks of flats the physical and mental abilities of the residents are likely to vary but suggests that it is usually unrealistic to expect the responsible person to plan for that or to have in place special arrangements, such as personal emergency evacuation plans. We assume that is intended to reflect the fact that the responsible person's duty under the Fire Safety Order is circumscribed by what is reasonably practicable. In our view, those whose ability to evacuate the building without assistance should be provided with personal emergency evacuation plans (see the chairman's recommendations in paragraph 33.22 of the Phase 1 report), although the content of such a plan will depend in each case on what is practicable. It is difficult to see what additional measures the TMO could have taken to assist the evacuation of disabled residents once they had entered the common parts of Grenfell Tower.
¶46.10 Paragraph 79.11, on the other hand, states that the case of a "general needs" block it is not realistic to expect the responsible person to hold information relating to residents with mobility or other conditions affecting their ability to escape in a way that enables it to be made available to the fire and rescue services, for example, in a premises information box. The justification offered is the difficulty of keeping that information up to date and the risk that inaccurate information could be more harmful than no information. However, although we understand the risks involved, we do not think it is impracticable for the responsible person to make available to the fire and rescue services by digital or other means reliable information about those with chronic disabilities whose ability to evacuate the building without assistance in an emergency is known to be compromised. Again, that was the subject of a recommendation in the chairman's Phase 1 report. In our view, therefore, this paragraph of the Guide should be reconsidered.
PAS 79:2012
¶46.11 We have considered some of the provisions of PAS 79:2012 in Chapter 39. For present purposes we note that it contained very detailed guidance on how to go about ensuring that a fire risk assessment took due account of the specific needs of vulnerable persons in the relevant building. It stated in terms that it applied to blocks of flats,1696 {CTAR00000003/9}. and indeed Carl Stokes himself rightly considered that it applied to his work for the TMO generally and to Grenfell Tower in particular. Although Colin Todd, who played an important part in drafting PAS 79 in 2005, and its revisions in 2007 and 2012, said that its focus was on commercial premises, he was constrained to accept that it (or at least the 2012 edition) applied to purpose-built blocks of flats.1697 Todd {Day166/132:23}-{Day166/133:5}; {Day166/133:24}-{Day166/134:19}. He also told us that in his view a fire risk assessor would have sufficient training and experience to know that some parts of PAS 79:2012 were not intended to apply to high-rise blocks of flats and other parts were.1698 Todd {Day167/106:5-10}. We see no overt support in PAS 79 2012 itself for that view, but in any event it was not an approach actually adopted by Carl Stokes, who did, albeit idiosyncratically and unevenly, follow the guidance it contained.
¶46.12 PAS 79:2012 recommended that a fire risk assessment should consider factors that have a major effect on the risk of fire.1699 {CTA00000003/19}. They included the approximate number of occupants of the premises, the maximum number of members of the public likely to be present (unless small in number), the nature of the occupants (e.g. young or old, disabled or able-bodied), the familiarity of the occupants with the premises (e.g. fully familiar, slightly familiar or totally unfamiliar) and the state (or likely state) of the occupants (e.g. awake or asleep, alert or under the influence of alcohol or drugs). It recommended a 9-step approach to fire risk assessments. Step 1 was to obtain relevant information about the premises and their occupants, including those particularly at risk in the event of fire.1700 {CTA00000003/34} paragraph i.1. Step 6 was to make an assessment of the likely consequences to the occupants of a fire. Step 8 was to formulate a plan, if necessary, to address shortcomings in the fire precautions.1701 {CTA00000003/34} paragraphs i.6 and i.8.
186¶46.13 The commentary on clauses 12 and 15 contains guidance about assessing the risks to vulnerable persons in order to ensure that the fire risk assessment is suitable and sufficient. We draw particular attention to paragraphs viii, ix, xi, xiv and xv of the commentary on clause 12, and to paragraphs xx and xxviii of the commentary on clause 15.1702 {CTA00000003/36-44}. Tellingly, paragraph xxix of the commentary on clause 15 provides that "Disabled evacuation strategy should not rely on rescue of disabled people by the fire and rescue service",1703 {CTA00000003/44}. but then goes on to say that "assistance with their evacuation is provided by persons within the premises".
¶46.14 Standing back from the detail, PAS 79:2012 envisages that the fire risk assessment will first assess whether there are persons particularly at risk because of their personal characteristics and consider whether adequate provisions are or can be put in place to ensure their safety. That approach is necessary to ensure that as far as is reasonably practicable those who are vulnerable have a means of escape which is as good as that available to those who do not share their particular vulnerability.
BS 9991:2015 Fire Safety Code of Practice
¶46.15 The Code of Practice BS 9991:2015 considered the means of escape for disabled occupants at various points. It advised on the need to be aware of the types of people in the building (such as disabled people, elderly people, children, pregnant women, etc) and any special risks or needs they might have.1704 {BSI00000059/20} paragraph d. Paragraphs 4.6 and 54, and Annex E, in particular, advised that fire safety management of a residential building needed to take account of the needs of disabled persons with permanent or temporary impairment. High-rise residential premises and premises with a "stay put" strategy in place are not excluded.
The TMO's fire safety planning for vulnerable residents
¶46.16 The TMO had a duty in relation to each building in respect of which it was a responsible person to identify and record the presence of residents with disabilities and the nature of those disabilities. That was necessary both for the purposes of carrying out a suitable and sufficient fire risk assessment and to enable it to take all such steps as were reasonably practicable to ensure their safety in the event of a fire. The "stay put" strategy assumed that residents would leave their flats only if they were affected by fire, heat or smoke but that in those circumstances they would escape into the lobby from where they could reach the stairs, which were in a protected area. Any resident who needed help to negotiate the stairs could telephone for assistance but ultimately would have to rely on another resident or the fire and rescue service to escape from the building. The TMO was entitled to assume that if a total or partial evacuation of the building was required it would be carried out under the direction and control of the LFB.
187¶46.17 With that in mind we consider what steps the TMO took to discharge its duty to vulnerable residents.
Concern about vulnerable residents: June 2009
¶46.18 By June 2009 the LFB had become concerned about the failure of the TMO to make adequate provision for disabled people to escape from some of its buildings. On 17 June 2009, it told Janice Wray that it intended to serve an enforcement notice on the TMO and RBKC due to their failure to make suitable and sufficient fire risk assessments of the communal areas of some of their blocks.1705 {RBK00053539}. In particular, the LFB considered that the fire risk assessment for Gillray House was not suitable and sufficient because there were no procedures to enable occupants with reduced mobility to escape.
¶46.19 Janice Wray sent an email to Robert Black advising him of the LFB's intention and at his request she sent it to Jean Daintith and Laura Johnson at RBKC.1706 {TMO00901459}. It eventually reached Alexis Correa, Health and Safety Advisor in RBKC's Housing, Health and Adult Social Care Services department, and Claire Wise (then a member of the Housing Policy Team).
¶46.20 On 18 June 2009 Claire Wise sent an email to Janice Wray in which she said that there was little information on the application of the Fire Safety Order to dwellings, but that there might be duties under the Disability Discrimination Act 1995 not to treat disabled people less favourably than people without a disability. She advised Ms Wray that if an evacuation plan was in place that was unsuitable for a person with a disability, alternative provision for disabled people should be provided.1707 {RBK00052528/1-2}. She went on to say that she thought that provision for disabled people in domestic premises and communal areas had slipped through the net in legislation and guidance.1708 {RBK00052528/2}. She asked Janice Wray for a meeting to discuss progress and an action plan. She also suggested it would be an opportunity for collaborative working with the fire brigade to develop a model to be applied across the remaining TMO buildings.
¶46.21 Jean Daintith forwarded that exchange to Robert Black later that day. She told him that Alexis Correa had confirmed that the fire risk assessments were not robust enough and that a specialist would need to be engaged.1709 {RBK00052528/1}.
¶46.22 Janice Wray accepted that the LFB had recommended there should be a procedure in place to enable residents with reduced mobility to escape,1710 Wray {Day142/82:6-9}. but admitted that she had not sought advice about the TMO's duties under the Fire Safety Order or the Disability Discrimination Act 1995.1711 Wray {Day142/84:15}-{Day 142/85:24}.
¶46.23 Two points emerge from this exchange. First, that the TMO at the highest level was aware from as early as 2009 of the need to consider the arrangements for the safe evacuation of disabled people and, secondly, that RBKC was itself fully aware of the fact.
188Salvus's Advice: September 2009
¶46.24 In its report entitled "Fire Risk Assessment for Fire Safety policy and procedures" dated 22 September 2009, Salvus identified a need for the TMO to establish procedures to ensure the safety of disabled or vulnerable persons in the event of a fire.1712 {SAL00000013}. The absence of such procedures was described as constituting a breach of the statutory requirements. In the enclosed action plan, it recommended that as a high priority the TMO consider developing formal procedures to deal effectively with fire safety concerns associated with disabled or vulnerable tenants and leaseholders and also any employees.1713 {SAL00000013/18}. It marked the item as needing to be completed within three months or a plan to be agreed within six months.
¶46.25 Following receipt of the report, a progress meeting was held on 19 October 2009 attended by Salvus, the TMO and RBKC.1714 Minutes of Progress Meeting dated 19 October 2009 {RBK00047771/1}. Paragraph 4.3 of the minutes records that Salvus had been unable to confirm whether any residents had sensory impairments at the time of the fire risk assessment and the TMO was advised to tell tenants to contact it if they had a disability affecting their ability to react to an alarm.1715 Minutes of Progress Meeting dated 19 October 2009 {RBK00047771/2}. The minutes also record that the TMO had attempted to identify and record vulnerable residents. Andrew Furness of Salvus said that if the fire risk assessor had been informed about the location of vulnerable residents and the nature of their vulnerabilities in advance, the assessment would have been more comprehensive. It was agreed that an attempt would be made to obtain that information in relation to one of the TMO properties, the World's End Estate.1716 Minutes of Progress Meeting dated 19 October 2009 {RBK00047771/2-3}.
¶46.26 It seems that the effort was to some extent successful. On 19 October 2009 (the same day as the meeting), two spreadsheets were produced containing data about vulnerable persons.1717 {TMO00866618}. That is the only documentary evidence we have seen of TMO officials' attempting to gather information about vulnerable residents for the purposes of a fire risk assessment. Janice Wray confirmed that as a result of that meeting, she was aware of the need to provide fire risk assessors with information about vulnerable residents.1718 Wray {Day142/87:1}-{Day142/88:10}.
¶46.27 On 5 January 2010, Andrew Furness complained to Nicholas Coombe of the LFB that the TMO and RBKC had little or no knowledge of the occupiers of their premises and that Salvus had advised them to gather better information about their residents in order to take appropriate steps in respect of disabled or vulnerable people and, specifically, to help them prepare PEEPs.1719 {SAL00000047/2}.
¶46.28 It is not clear what Mr Furness based his report on. Janice Wray told us that he had not spoken to the Housing team at the TMO, but she did not take any steps herself to obtain information about vulnerable residents. She regarded that as a matter for the Housing team.1720 Wray {Day142/89:3}-{Day142/90:22}.
¶46.29 On 21 January 2010, there was another progress meeting attended by Salvus, the TMO and RBKC to discuss fire risk assessments for high-rise buildings at which procedures for vulnerable residents were again discussed. Andrew Furness said that a formal documented system needed to be implemented to address the needs of disabled and vulnerable people in the event of a fire.1721 Minutes of Progress Meeting dated 26 January 2010 {RBK00052572/5}. Although the recommendation was clear and well made, it was not implemented by the TMO in relation to its general needs housing stock.1722 In 2012, TMO prepared a paper on fire safety and housing which addressed fire safety in sheltered housing. This was limited to sheltered housing only and had no application to general housing {CST00005799}.
189Carl Stokes's advice to the TMO: 2010 onwards
¶46.30 Carl Stokes met Janice Wray on 22 June 2010 and on 23 June 2010 he sent her a letter confirming his advice.1723 {CST00001887}. He told her that the PEEPs she had shown him accorded with those described as best practice in the government's guidance on risk assessments. She confirmed that the intention had been to use the PEEPs documents annexed to DCLG's 2007 guide entitled "Means of Escape for Disabled People"1724 HM Government Fire safety risk assessment supplementary guide, means of escape for disabled people {INQ00014732/46-49}. for TMO residents as well as staff.1725 Wray {Day142/91:23}-{Day142/93:11}.
¶46.31 Carl Stokes and Janice Wray had a further meeting on 24 September 2010, the substance of which was reflected in a letter he wrote to her on 27 September 2010.1726 {CST00003061/1}. In it he noted that the TMO had recently introduced a comprehensive programme to gather information about residents, including any disabilities or restrictions on their ability to respond to an emergency. The information would be held on the "TP Tracker system" and used to assess whether residents required any additional devices to provide them with early warning of smoke or fire in their homes. It would also be used to inform the development of a personal emergency evacuation plan.1727 {CST00003061/3}.
¶46.32 Carl Stokes did not check the TMO's systems for recording vulnerable residents as he thought that was beyond what was expected of him as a fire risk assessor.1728 Stokes {Day137/81:10}-{Day137/85:20}. He did say, however, that Janice Wray had agreed that when carrying out fire risk assessments she would provide him with information about residents who were especially at risk.1729 Stokes {Day137/70:19}-{Day137/74:18}. She, on the other hand, could not recall whether she had agreed to provide him with that information. At all events, given that he had noted that they had discussed the identification of vulnerable residents for the purposes of preparing PEEPs and that Salvus had advised her of the need to provide fire risk assessors with information about individuals especially at risk, we think it likely that Janice Wray did agree to provide that information to him. However, there is no evidence that she did so.
¶46.33 Janice Wray thought that Carl Stokes's reference in his fire risk assessments to the residents' newsletters was a reference to the Link magazine, but no edition of Link between 2009 to 2017 made any reference to PEEPs. Janice Wray explained that she was reluctant to use the term "PEEP" because it was not generally understood; she invited those with concerns about being able to leave their homes in the event of fire to contact her or the fire brigade.1730 Wray {Day142/98:11-22}. No editions of Link from Autumn 2009 to Spring 2017 carried any article inviting residents who were worried about their ability to evacuate their homes in an emergency to contact the TMO.1731 None of the Link or Homeowner magazines disclosed to the Inquiry invited residents to contact the TMO to be evaluated for a PEEP. Fire safety advice was contained in the following Link Magazines: Autumn 2009 {TMO00901358}; Winter 2009 {TMO10048206}; June 2013 {TMO00873438}; Summer 2014 {TMO10031098}; Autumn/Winter 2015 {TMO00873549}.
190RBKC's oversight of the TMO's preparation of PEEPs
¶46.34 On 28 September 2010, Jean Daintith sent Robert Black a copy of an article written by Claire Wise about fire safety and the requirements of housing legislation relating to people living in flats in tall buildings. She invited Robert Black to respond with his observations about what lessons could be learnt.1732 {RBK00026862}; {RBK00030073}. His response on 30 September 2010 was to reassure her that the TMO had completed fire risk assessments for all its high-risk buildings, including high-rise blocks, and that the evacuation strategy was "stay put – defend in place". He told her that the TMO intended to produce PEEPs for disabled residents but had so far done so only in a small number of cases with advice from the LFB. However, fire risk assessments had identified the need to extend the work to residents known to have disabilities and that the TMO planned to work with Carl Stokes to produce generic PEEPs for larger blocks which could then be adapted to individual needs.
¶46.35 Robert Black's assurances were, however, misleading. The first of only two PEEPs to be prepared for TMO residents was still in preparation and was not completed until 18 October 2010, nearly three weeks later.1733 {CST00005610}. Plans to produce generic and individual PEEPs were not fulfilled. Even so, at a joint meeting of RBKC, TMO executives and the LFB on 20 July 2011, Janice Wray gave similar assurances that the TMO intended to identify vulnerable and disabled residents who required PEEPs.1734 Minutes of RBKC, KCTMO and LFB Meeting dated 20 July 2011 {RBK00053638/6}; Wray {Day142/119:4}-{Day142/120:3}.
¶46.36 Despite having been made aware in late 2010 and July 2011 of the TMO's supposed plans, neither Laura Johnson nor Amanda Johnson asked Robert Black whether any PEEPs had been prepared.1735 Laura Johnson {Day129/117:5-17}; Amanda Johnson {Day131/44:25}-{Day131/45:12}. Indeed, nobody from RBKC asked whether the TMO had completed any PEEPs. In its written submissions, RBKC rightly acknowledged that fact and admitted that it had been a failure of oversight on its part.1736 RBKC Module 3 Closing submissions {RBK00068069/29-30} pages 29-30, paragraph 103; Laura Johnson {Day129/117:5-17}; Amanda Johnson {Day131/44:25}-{Day131/45:12}.
¶46.37 Contrary to what had been said by Robert Black and Janice Wray, the TMO did not regularly identify vulnerable residents. Only two residents were assessed for PEEPs between 2010 to 2017,1737 Stokes {CST00030186/38} page 38, paragraph142. one in Markland House and one in Gillray house.1738 {CST00005610}; {CST00020896}. Although Janice Wray said that the Health and Safety team were prepared to receive requests for PEEPs from residents in general needs housing,1739 Stokes {CST00030186/38} page 38, paragraph 143; Wray {TMO00862589/2} page 2, paragraphs 6-7. as far as we can see, none was ever prepared by Janice Wray or her team.
191The TMO's assurances to the LFB
¶46.38 The LFB, like RBKC, received assurances from the TMO about the identification and treatment of vulnerable people. At a meeting on 20 July 2011, Janice Wray told the LFB that the TMO was gathering information about vulnerable and disabled residents in the council's properties with the intention of preparing PEEPs for those who needed them.1740 Minutes of RBKC, KCTMO and LFB Meeting dated 20 July 2011 {RBK00053638/6}; Wray {Day142/119:4}-{Day142/120:3}.
¶46.39 On 26 September 2012, Nicolas Comery, Nick Coombe and Andy Jack of the LFB met Janice Wray and Claire Wise.1741 {TMO00863422}. The LFB team asked the TMO to prepare a list of residents with additional needs to be kept close to the fire alarm control panel. They told Janice Wray and Claire Wise that the LFB's view was that the person or organisation managing a building had a duty to develop a plan to be followed in the event of a fire and to collect information on residents with additional needs. A risk assessment would also need to be reviewed if a resident's needs changed significantly or became permanent. Although the discussion was focused on sheltered housing, the LFB's advice related to general needs accommodation as well.1742 Wray {Day142/119:4}-{Day142/120:3}. The LFB's views were passed to RBKC's Housing department.1743 {TMO00863422}.
¶46.40 Notwithstanding that prompt from the LFB, the TMO did not create a system to collect information about residents with additional needs that could be made available to the LFB in the event of a fire. According to Janice Wray, that was because it was concerned about its ability to keep documents held in a premises information box up to date. It was not discussed with the LFB again.1744 Wray {Day142/122:16}-{Day142/123:8}. Critically, it does not appear that the TMO told the LFB why it was difficult to comply with its request.
Correspondence with the LFB
¶46.41 On 30 November 2012, Nick Comery asked Janice Wray for help in identifying vulnerable persons in local authority premises who might be suitable for an LFB initiative promoting sprinklers. Janice Wray passed the request to Carl Stokes who advised her to say that she was not aware of anyone. He did so in order to avoid any questions being asked about why anyone who might qualify had not been identified in the fire risk assessments or received a PEEP.1745 {CST00016416}.
¶46.42 Carl Stokes thought he had spoken to Janice Wray before responding to her email, although he could not be sure about that.1746 Stokes {Day137/128:10}-{Day137/129:4}. He said that he had not been suggesting that there were no vulnerable residents in the properties managed by the TMO, but that there were no heavy smokers. His evidence was that he had thought that the LFB were asking for people who were vulnerable because they were heavy smokers. Although automatic fire suppression systems may have been particularly suitable for use by those who were heavy smokers, we do not accept that explanation. Carl Stokes had no information about the smoking habits of TMO residents and had never sought any. The truth is that he knew that PEEPs were required for vulnerable residents, that the TMO had produced only two, and that his fire risk assessments had not recommended any additional fire safety measures for vulnerable people. His advice amounted to a suggestion that she should lie to the LFB.
192¶46.43 Janice Wray agreed that it was not possible to say that there were no vulnerable residents in the properties managed by the TMO,1747 Wray {Day142/128:14-23}. but although she said she would not lie to the LFB, she does not appear to have been unduly concerned about Mr Stokes's suggestion that she should.1748 Wray {Day142/128:24}-{Day142/130:1}.
¶46.44 Carl Stokes's reaction to the LFB's request for information about vulnerable people ought to have acted as a spur to him and Janice Wray to correct the position quickly. The TMO should have initiated a process of collecting information and should have asked him to carry out a proper risk assessment, taking into account the vulnerable people in each building.
¶46.45 Neither Carl Stokes nor Janice Wray was able to provide a clear explanation for their failure to ascertain the number of vulnerable people living in properties managed by the TMO. Janice Wray had been aware of the need to collect and maintain that information since receiving the advice from Salvus in 2009 and 2010. However, she did not take any steps to review the fire risk assessments or take any action to check whether any of them should contain any reference to vulnerable residents. She said she had had no concerns about Mr Stokes's response, and that if she had, she would have done something about it.1749 Wray {Day142/131:5-9}.
Carl Stokes's fire risk assessments of Grenfell Tower
¶46.46 As we have said in Chapter 38, Carl Stokes carried out six fire risk assessments in relation to Grenfell Tower between 30 September 2009 and 20 June 2016.1750 Fire risk assessment for Grenfell Tower dated 30 September 2009 {CST00003128}; Fire risk assessment for Grenfell Tower dated 29 December 2010 {CST00003181}; Fire risk assessment for Grenfell Tower dated 20 November 2012 {CST00003084}; Fire risk assessment and schedule of significant findings for Grenfell Tower dated 17 October 2014 {CST00003177}; Fire risk assessment for Grenfell Tower dated 26 April 2016 {CST00003161}; Fire risk assessment for Grenfell Tower dated 20 June 2016 {CST00003145}. The first, dated 30 September 2009, was carried out as a sub-contractor of Salvus and follows the Salvus template.1751 Fire risk assessment for Grenfell Tower dated 30 September 2009 {CST00003128/11}.
¶46.47 In section 5 on page 11 of that fire risk assessment, Carl Stokes described the measures in place to counter the risk that people on the premises might not be aware of the fire. In section 5.4 he identified as a hazard the possibility that if tenants and others within the building suffered from a hearing impairment they might not receive adequate warning. In relation to control measures he recorded that there was no evidence that any resident or member of staff on the premises suffered from a sensory impairment that would prevent them from hearing a shouted warning of fire. However, he also recorded that he could not confirm that that was the case or whether the TMO had any personal emergency evacuation plans available or policies in place if they were needed.
¶46.48 Mr Stokes said that he had focused on hearing impairments to the exclusion of other disabilities, including mobility and visual impairments, because there had been no communal fire alarm in Grenfell tower so residents would be affected if they could not hear someone trying to warn them of a fire.1752 Stokes {Day137/94:7-20}. However, he failed to consider the full range of impairments that could affect residents who might be required to evacuate.
193Fire risk assessments: 29 December 2010 and later
¶46.49 After Carl Stokes had been appointed by the TMO to carry out its fire risk assessments he used his own templates that were partly, but not consistently, based on PAS 79. Section 13 of his form referred to "Disabled People".
¶46.50 The 2010 fire risk assessment for Grenfell Tower stated that there was no evidence that any residents suffered from a hearing impairment that would prevent them hearing a shouted warning of fire or a warning in the form of a loud knocking.1753 Fire risk assessment for Grenfell Tower dated 29 December 2010 {CST00003181/16}. It also recorded that the TMO had introduced a programme to gather information about tenants, including any disabilities and their ability to respond to emergency situations. The information was to be recorded in the TP Tracker system and used to decide whether any residents required additional devices or PEEPs.1754 Fire risk assessment for Grenfell Tower dated 29 December 2010 {CST00003181/16}.
¶46.51 Aside from minor variations, the text remained substantively the same between 2010 and 2016.1755 Fire risk assessment for Grenfell Tower dated 29 December 2010 {CST00003181/16}; Fire risk assessment dated for Grenfell tower dated 20 November 2012 {CST00003084/20-21}; Fire risk assessment for Grenfell Tower dated 17 October 2014 {CST00003157/21}; Fire risk assessment for Grenfell Tower dated 26 April 2016 {CST00003161/22}. Janice Wray could not recall speaking to Carl Stokes about the variations in the text. She admitted that she had probably noticed that he had repeatedly used the same information in section 13 of his fire risk assessments, but she never asked him why. She did not remember being concerned that the information in section 13 might have become out of date, but she admitted that she should have been.1756 Wray {Day142/133:7-20}.
¶46.52 Although the TP Tracker was discontinued in 2013, the fire risk assessments in relation to Grenfell Tower continued to refer to its being used to identify residents in need.1757 {RBK00057527}. Janice Wray could not say why Carl Stokes had not been told that it had been discontinued in 2013. She accepted that it had been part of her responsibility to identify vulnerable residents, but she said that she had not been aware of how the Housing department was recording them. She failed to ask Carl Stokes whether he had that information when he was preparing the fire risk assessments, but she did try to clarify what information was held by the TMO when she reviewed the fire strategy in December 2016.1758 Wray {Day142/135:24}-{Day142/137:13}; {TMO00865834/2}. We return to her attempt to do so below.
Leon Taylor's fire risk assessment: June 2014
¶46.53 Leon Taylor, an independent fire risk assessor, carried out a fire risk assessment in respect of Grenfell Tower on 14 June 2014. He noted that the vulnerabilities of the occupants were unknown, but that as the building was designated as "general needs" he assumed that the occupants were typical of the general population.1759 {TMO10001286}, Cell E39.
¶46.54 In section K13 of his fire risk assessment Mr Taylor noted that the TMO Housing department should have a record of all those who had special needs in relation to evacuation and should make arrangements in accordance with the Housing Act 2004 for evacuation plans and any PEEPs that might be required. No action appears to have been taken by the TMO in response to that fire risk assessment.
194Carl Stokes's fire risk assessments relating to other TMO properties
¶46.55 A sample of Carl Stokes's fire risk assessments for other high-rise buildings managed by the TMO revealed that it was his practice not to identify vulnerable residents.1760 Fire risk assessment for Adair Tower dated 28 October 2010 {CST00004307}; Fire risk assessment for Adair Tower dated 20 February dated 2014 {LFB00027631}; Fire risk assessment for Adair Tower dated 11 November 2015 {CST00025478}; Fire risk assessment for Adair Tower dated 28 September 2016 {TMO00843943}; Fire risk assessment for Gillray House dated 19 November 2012 {TMO00854930}; Fire risk assessment for Gillray House dated 28 January 2016 {CST00025186}; Fire risk assessment for Hazlewood Tower dated 20 February 2014 {TMO10043804}; Fire risk assessment for Hazlewood Tower dated 25 November 2015 {TMO10044598}; Fire risk assessment for Hazlewood Tower dated 3 October 2016 {TMO10048023}; Fire risk assessment for Markland House dated 16 November 2010 {CST00009754}; Fire risk assessment for Markland House dated 29 November 2012 {CST00017016}; Fire risk assessment for Markland House dated 21 January 2016 {TMO10047159}; Fire risk assessment for Trellick Tower dated 11 June 2012 {CST00017807}; Fire risk assessment for Trellick Tower dated 6 March 2014 {TMO00842081}; Fire risk assessment for Trellick Tower dated 26 April 2017 {TMO00842255}. Only the fire risk assessment carried out in relation to Gillray House in 2010 recorded that there was a resident with impaired mobility.1761 Fire risk assessment for Gillray House dated 8 October 2010 {CST00012048/15}. Moreover, as he accepted, the first three paragraphs of the text in section 13 of each of his fire risk assessments for Adair Tower (2011), Gillray House (2012), Hazlewood Tower (2014), Markland House (2016) and Trellick Tower (2017) were identical to each other and to that section of the assessment carried out in relation to Grenfell Tower in 2010.
¶46.56 Carl Stokes drew up a PEEP for a resident of Gillray House on 18 October 2010.1762 {CST00005610}. The same resident asked for a copy of the PEEP in November 2013, indicating that she was still living in the property.1763 {CST00005609}. Her presence in Gillray House was reflected in the 2010 fire risk assessment but not in the assessment prepared in 2012. He also drew up a PEEP for a resident of Markland House on 8 March 2014,1764 {CST00020896}. but it was not noted in the 2016 fire risk assessment.1765 Fire risk assessment for Markland House dated 21 January 2016 {TMO10047159/21}. He was unable to explain why those two fire risk assessments did not record that PEEPs had been produced for residents of those properties.1766 Stokes {Day137/117:3}-{Day137/122:5}.
¶46.57 Janice Wray did sometimes comment on fire risk assessments,1767 On 2 December 2015, Janice Wray asked Carl Stokes to correct a sentence on page 5 of the Hazlewood fire risk assessment: email from Janice Wray to Carl Stokes dated 2 December 2015 {CST00006647}. but she does not appear to have questioned the inclusion of identical text in section 13 of the fire risk assessments relating to those five different buildings at different times over the course of some six years. It is difficult to believe that she failed to notice the fact or the fact that he continued to refer to the system used to record information on vulnerable residents years after it had been discontinued.
¶46.58 We are bound to conclude that the fire risk assessments carried out by Mr Stokes that we examined, including those relating to Grenfell Tower, were inaccurate and out of date in relation to the presence of vulnerable persons and were not suitable and sufficient for the purposes of Article 9 of the Fire Safety Order.
195TMO Policies relevant to vulnerable persons
The TMO fire safety strategy
¶46.59 The TMO had no formal fire safety strategy at all until November 2013. The strategy was later reviewed in 2016 and approved in June 2017.1768 {TMO10004485}; {TMO00832724}.
¶46.60 Although the original fire safety strategy made express provision for PEEPs for the TMO's staff,1769 {TMO10004485/14} section 24.1 ("Fire Procedures"). it contained no reference to PEEPs for vulnerable residents. Similarly, the TMO's Health and Safety Policy (dated February 2016 and in force in June 2017) referred to PEEPs only in relation to staff.1770 {TMO10024402/6} sections 7-10.
¶46.61 The 2017 version of the fire safety strategy also referred to PEEPs in relation to staff, but not in relation to residents.1771 {TMO00832724/15} section 25.1. A new section (paragraph 28) was added, to cover both hoarders and vulnerable residents. Paragraph 28.3 stated that efforts were made to collect information about a resident's vulnerability when the tenancy was signed and thereafter as part of the TMO's continuing contact with residents. The purpose of the exercise was said to be providing a service which better met the resident's needs, including fire safety. The new paragraph therefore acknowledged to some extent the TMO's obligation to identify vulnerable residents in order to meet their needs in respect of fire safety, but it did not extend to the provision of PEEPs.
¶46.62 Janice Wray was unable to explain why the 2013 and 2017 fire safety strategies did not refer to PEEPs being produced for residents and accepted that they should have done so.1772 Wray {Day142/149:23}-{Day142/152:1}. Robert Black could not remember why there had been no reference in the fire safety strategies or the Health and Safety policy to producing PEEPs for residents, but thought the TMO had probably decided not to follow Salvus's advice about that.1773 Black {Day149/169:22}-{Day149/170:1-14}. We agree that that is the most likely explanation.
¶46.63 Given Salvus's clear advice in 2009 about the need for procedures to ensure the safety of disabled or vulnerable persons in the event of a fire it is difficult to understand why none were ever included by the TMO in any of its policies.1774 {SAL00000013/18}.
The "Supporting Residents" policy and procedure
¶46.64 The TMO recognised the need to identify vulnerable residents living in its properties and to make them known to the appropriate support services. David Noble and Teresa Brown started preparing a policy for vulnerable residents in December 2014.1775 {TMO00880460}; {TMO00880458}; {TMO00880463}. The first draft of the Vulnerability Policy adopted the definitions of vulnerable persons already used by the TMO. It recorded that the process for identifying residents who required PEEPs depended on chance or a request from the relevant resident.1776 {TMO00880461/2}. In that regard, the document reflects Janice Wray's evidence, but the position was not recorded in any of the later drafts of the Vulnerability Policy or the "Supporting Residents"' policy. None of the draft policies relating to vulnerable residents dealt with fire safety.
196¶46.65 The final version of the "Supporting Residents" policy was drafted by David Noble and dated April 2016 .1777 {TMO00880481}. Neither he nor Teresa Brown was able to explain why it had taken nearly two years to complete.1778 Noble {Day119/69:12}-{Day119/70:4}; Brown {Day126/89:25}-{Day126/91:22}. The purpose of the policy was to provide an agreed approach to recognising vulnerable residents and referring them to the neighbourhood teams who could provide them with support.1779 Brown {Day126/77:5-13}. It was accompanied by the "Supporting Residents" procedure dated April 2016.1780 {TMO00880482}. The policy and procedure described certain potential indicators of vulnerability and identified steps that might be taken to provide assistance to those who required it. There was no mention of fire safety in either the policy or the procedure.
¶46.66 The senior management team discussed the "Supporting Residents" policy at a team meeting on 18 February 2016.1781 Minutes of Senior Management Team Meeting dated 18 February 2016 {TMO00866011}. Teresa Brown did not recall having discussed it with the Health and Safety team, but she noted that Barbara Matthews, who had overall responsibility for health and safety, had been present at the meeting and had not raised any concerns.1782 Brown {Day126/94:12}-{Day126/95:1}. Apparently, no one asked how fire safety procedures might apply to vulnerable residents. Although the revised policy was presented to the senior management team on 17 March 2016,1783 Minutes of Senior Management Team Meeting on 17 March 2016 {TMO00880549/1}. it was not presented to the executive team for approval.
¶46.67 In December 2016, before the final version of the policy had been circulated to the senior management team, Janice Wray asked David Noble how the TMO obtained and stored information on vulnerability, as she was reviewing the fire safety strategy.1784 {TMO00865834}. Although the review of the fire safety strategy (which culminated in the 2017 version) took place when the "Supporting Residents" policy was being completed, neither the TMO's senior management team nor Janice Wray nor David Noble thought that there were matters, such as fire safety, that ought to be covered in both documents.
Gathering information about vulnerable residents
¶46.68 The TMO's regular means of gathering information about residents' vulnerability was by talking to them at the time of granting a tenancy and during a tenancy audit. When registering a new tenant, the TMO recorded whether that person or anyone in the household suffered from any disability. Any disabilities were recorded in the tenancy agreement, Tenancy Information forms and in a data entry form that all new tenants were required to complete. The forms were all stored on the W2 system. The way in which the information was recorded was not consistent and in most cases the Neighbourhood Officers that helped to complete the forms recorded that no support was required, even if a vulnerability of some kind was recorded.1785 Lane, Module 3 Report {BLARP20000034/173} Table 10-1.
¶46.69 On 29 April 2014, David Noble and Teresa Brown told the executive team that there were gaps in some of the information held on tenants, particularly relating to disabilities.1786 Noble {Day119/51:11-23}. They suggested that the collection of information could be improved by the use of a detailed questionnaire.1787 Minutes of Executive Team Meeting dated 29 April 2014 {TMO00851128/1}. The proposal was approved; a new tenancy questionnaire was introduced and a programme of tenancy audits was put in place.
197¶46.70 From 2015 onwards, housing officers were required to carry out about 30 tenancy audits a month.1788 Jones {TMO00873924/3} page 3, paragraph 11. Janice Jones carried out tenancy audits at Grenfell Tower.1789 Jones {TMO00873924/3} page 3, paragraph 11. She collected information about residents, such as their names, contact details, ethnicity, vulnerabilities or disabilities, support needs and whether any repairs needed to be carried out to their properties.1790 Jones {TMO00873924/3-4} pages 3-4, paragraphs 13-15. Information gathered in tenancy audits was entered on the W2 system.1791 Jones {TMO00873924/3} page 3, paragraph 13. A spreadsheet dated 13 April 2016 recorded that 547 audits of TMO properties had been completed between 1 April 2015 and 1 April 2016.1792 {TMO00860130}.
¶46.71 The TMO gathered information on vulnerable residents in Grenfell Tower during the refurbishment. Rydon spoke to tenants to ask them, among other things, whether any member of the household had any health problems. The information was recorded in a report dated November 20141793 {RYD00024466}. which identified 57 residents as having a sensory, cognitive or mobility impairment.1794 Lane, Module 3 Report {BLARP20000034/177} paragraph 10.6.10.
¶46.72 The report was discussed with Rydon at Housing Management Liaison Meetings and there is some evidence that it was sent to Siobhan Rumble at the TMO.1795 Minutes of Housing Management Liaison Meeting with Rydon dated 28 January 2015 {TMO00852169}. There is no evidence, however, that it was used to revise any of the TMO's records. Most importantly, the information was not included in the spreadsheet from which attempts were made on the night of the fire to extract information about vulnerable residents.
Premises information box
¶46.73 During a visit to Grenfell Tower on 12 March 2014, representatives of the LFB fire safety team and a local fire station crew asked for a premises information box to be installed.1796 {CST00000178/2-3}. The intention was that it should contain fire safety information specific to Grenfell Tower, such as floor plans, that would assist the LFB in the event of a fire.1797 {CST00000178/2-3}; {TMO10013186/1}.
¶46.74 On 18 March 2014, Carl Stokes strongly advised Claire Williams against installing a premises information box, in essence, because he thought that the onus was on the LFB to gather the information themselves during section 7(2)d and familiarisation visits.1798 {CST00003100/4}; Stokes {CST00030186/42} page 42, paragraph 160. According to Colin Todd, it was not common at the time for premises information boxes to be installed in general needs blocks of flats, but both he1799 Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/102-103} paragraph 10.3. and Dr Lane1800 Lane, Module 3 Report {BLARP20000027/346-347} paragraphs 15.2.31-15.2.42. thought that they could be of assistance to fire and rescue services.1801 Lane, Module 3 Report {BLARP20000027/347} paragraphs 15.2.39-15.2.41; LGA Guide, Fire safety in purpose-built blocks of flats {HOM00045964/120} paragraph 79.12. We agree. In the face of a request from the LFB we can see no good reason for Carl Stokes to oppose the suggestion.
¶46.75 Following a demonstration of the smoke ventilation system at Grenfell Tower on 28 April 2016, the LFB renewed its request for a premises information box or other secure information box to be installed in the foyer of the tower,1802 {CST00001131/2}. but on 4 May 2016 Carl Stokes again told Janice Wray that the TMO had no obligation to provide an information box.1803 {CST00001131/1-2}. He may have been right, but there was no obvious reason to refuse the LFB's request and in our view his advice was foolish.1804 Wray {Day144/198:19-22}.
198¶46.76 At the regular meeting between the TMO and the LFB fire safety team on 5 May 2016, Nick Davis, the local station manager, asked Janice Wray again for a premises information box to be installed at Grenfell Tower. He agreed to confirm what information the LFB wanted to have stored in it but said that it would include at least information about the operation of the smoke ventilation system.1805 Minutes of the Bi-Monthly Meeting dated 5 May 2016 {TMO10013185/3} item 8. On 6 May 2016, he sent her a list of the information that he wanted to see made available.1806 {TMO10013186/1}.
¶46.77 At the next meeting on 13 July 2016, which was attended by Janice Wray and Rebecca Burton, the TMO told the LFB that arrangements had been made to store the documents to which the LFB needed access in a secure box in the lobby, the key to which would held in a key safe secured by a padlock in the bin room.1807 Minutes of the Bi-Monthly Meeting dated 13 July 2016 {LFB00032335/3} item 7. Despite that assurance, however, by the time of the fire no premises information box or any other secure box containing the relevant fire safety information had been installed at Grenfell Tower. Janice Wray thought that was because Claire Williams had made arrangements for the information to be kept in an existing secure box in the lobby, as contemplated by the minutes of the meeting on 13 July 2016,1808 Wray {TMO00000890/13} page 13, paragraph 60; Wray {Day144/195:20}-{Day144/198:1}. but she did not check whether the box did in fact exist or, if it did, what information it contained.1809 Wray {Day144/195:20}-{Day144/198:1}. Claire Williams said that there had been a "fire panel" at Grenfell Tower which described how to operate the smoke ventilation system, but she could not identify anything else.1810 Williams {Day122/33:13-21}. There was nothing else. The TMO simply never complied with the LFB's request for a secure box containing information about the building. There was no good reason for its failure to do so.
TMO's systems for recording data about vulnerable residents
¶46.78 Between 2010 and 2017 Carl Stokes's fire risk assessments for Grenfell Tower stated that the TMO used the TP Tracker for recording information about vulnerable residents. An entry dated 8 June 2013 recorded that one resident of Grenfell Tower had visual and hearing impairments, three had impaired mobility and one had a mental health illness, but none of those residents was recorded in the fire risk assessment made in October 2014.1811 Fire Risk Assessment for Grenfell tower dated 17 October 2014 {CST00003157}. That tends to show that, although Carl Stokes was aware of the TP Tracker, he did not take into account the information it contained when making his assessments.
¶46.79 In 2013, there were proposals for replacing the TP Tracker with the Civica W2 electronic document management system1812 {TMO00862586}. that held electronic copies of documents relating to residents. The information could then be entered manually into Capita, the housing management system maintained by the TMO.1813 Noble {Day119/54:11-18}. In 2016 the Customer Relationship Management platform (CRM) was introduced with the intention of replacing W2. By 14 June 2017, therefore, information about vulnerable residents was recorded in three different places: on documents held in W2, on the Capita housing management system and on the CRM database.1814 Noble {TMO00899669/1} page 1, paragraph 2 (a) and (b).
199¶46.80 There was some confusion about how information recorded on Capita was transferred to CRM. However, it appears that, although some of the information was transferred to CRM, most of it was not.1815 Noble {Day119/54:19}-{Day119/55:8}; {TMO00899673}. That turned out to be significant, because on the night of the fire there was some uncertainty about the reliability of the information held by the TMO about the number of vulnerable residents in the tower.
¶46.81 Of the 297 people present in Grenfell Tower on the night of the fire, 67 were children and 37 were adults with sensory, mobility or cognitive impairments.1816 Lane, Module 3 Report {BLARP20000034/237} paragraph 14.2.3. There were a further 17 residents who had a sensory, mobility or cognitive impairment that was not recorded in the tenancy records, tenancy audit documents or David Noble's spreadsheet. The TMO ought to have had a readily accessible system for collecting and maintaining information about its residents' vulnerabilities which would not only have enabled it to decide whether in any case a PEEP was necessary but would also have assisted in responding to emergencies.
PEEPs for Vulnerable Residents
¶46.82 Janice Wray said that the Health and Safety team would prepare PEEPs for residents in general needs housing if it were asked to do so, but that there was no established procedure for identifying circumstances that would result in consideration of the need for a PEEP and residents were not told that they could ask for one.1817 Wray {TMO00862589/2} page 2, paragraph 6; Wray {Day142/32:4-21}; {Day142/66:5}-{Day142/67:4}; {Day142/69:1}-{Day142/71:11}; {Day142/71:12-18}. For its part, the members of the Housing team did not know that they could refer a resident to the Health and Safety team to be assessed for a PEEP.1818 Brown {Day126/65:9}-{Day126/67:3}; Rumble {Day120/70:8-24}; Bartholomew {Day120/163:3-10}; Williams {TMO00879804/11} page 11, paragraphs 79-80; Jones {TMO00873924/6} page 6, paragraph 27.
¶46.83 Neither Siobhan Rumble nor Nicola Bartholomew was aware that she could ask for residents to be given PEEPs. Janice Wray said that was because she did not use the expression "PEEP" with the Housing team. She told them that if residents were concerned about fire safety generally, they could be referred to the Health and Safety team.1819 Wray {Day142/72:7-17}. If the Health and Safety team expected to have residents referred to them by the Housing team for assessment for a PEEP, even if described in other terms, the Housing team should have been aware of that and it should have been covered in one of the policies, such as the fire safety strategy or the "Supporting Residents" policy.
¶46.84 Residents were not told that they could ask to be assessed for a PEEP and the possibility was not drawn to their attention in any of the literature they were given. Janice Wray could not say why that was and we cannot see any reasonable explanation for it. The first draft version of the fire safety letter to new tenants dated December 2010 did include the offer of a personal emergency evacuation plan for those who were not able-bodied or had special requirements,1820 {TMO00870665}. but it is unclear whether the letter was ever finished and distributed to residents between 2010 and 2013.
200¶46.85 Janice Wray did not prepare a PEEP for any resident while working at the TMO,1821 Wray {Day142/72:18-24}. perhaps because no one in the Housing team knew that a resident could be referred to the Health and Safety team for a PEEP. Nonetheless, there is evidence that even when Janice Wray was made aware of a resident in Grenfell Tower with a particular vulnerability, she took no steps to ascertain whether that resident needed a PEEP. That was Elpidio Bonifacio in Flat 83.
¶46.86 On 4 February 2016, Charles Batterbee of the LFB and Janice Wray exchanged emails about a resident of Flat 83, Elpidio Bonifacio, whom the LFB had met during a home fire safety visit and believed to be blind.1822 {LFB00001057}. Janice Wray said that she should have asked whether he needed a PEEP or some other form of assistance in the event of a fire and could not explain why she had not done so.1823 Wray {Day142/163:4}-{Day142/165:24}. Moreover, Mr Bonifacio's disabilities were not recorded on the spreadsheet produced by David Noble on 14 June 2017.1824 {TMO00866002}.
¶46.87 Elpidio Bonifacio was the last person to escape from Grenfell Tower at 08.07 on 14 June 2017. Although he had been encouraged by his family to leave his flat from about 02.00, he had had to wait for more than six hours to be rescued by firefighters because he was blind, elderly and unable to escape without help.1825 Bonifacio {IWS00001085/5-6} pages 5-6, paragraphs 31-32. There is no reason to think that he was an isolated example or that Grenfell Tower was different from the other buildings managed by the TMO, given the deficiencies in the TMO's system of creating and maintaining accurate records of vulnerable residents.
Vulnerable residents in Grenfell Tower on 14 June 2017
¶46.88 The list of residents that David Noble produced on 14 June 2017 identified only ten residents of Grenfell Tower as having mental or physical impairments. That was only half the number recorded as vulnerable by the TMO in the tenancy creation and tenancy audit documents.1826 Lane, Module 3 Report {BLARP20000034/188-189} paragraphs 10.8.32-10.8.34. A result of its failure to maintain an adequate record of residents' vulnerabilities was that the TMO was unable to provide the LFB with an accurate list of vulnerable residents,1827 Phase 1 Report Volume III paragraphs 20.65-20.66. although by the time the list reached the LFB all those who died in the tower had already lost their lives.1828 Phase 1 Report Volume III paragraphs 20.67-20.68.
¶46.89 Of the ten residents recorded in the spreadsheet as vulnerable, three, Sakina Afrasehabi, Majorie Vital and Alexandra Atala, died in the fire.1829 {TMO00866002}. They lived on the top floors of the tower. The remaining seven lived on floors 2 and 3. They were able to escape as their flats were below the fire line. It is impossible to say what effect an accurate list of vulnerable residents would have had on the outcome of the tragedy, but it might have provided the LFB with valuable information about the locations and numbers of vulnerable residents when considering the deployment of crews.
¶46.90 On any view, the Grenfell Tower fire revealed the importance of ensuring that the responsible person collects sufficient information about any vulnerable occupants to enable PEEPs to be prepared, when appropriate, and, in the event of a fire, appropriate measures to be taken to assist their escape. The TMO's failure to collect such information illustrates a basic neglect of its obligations in relation to fire safety.
5Part 6: The refurbishment of Grenfell Tower
7Chapter 47: Introduction to Part 6
¶47.1 The refurbishment of Grenfell Tower between 2012 and 2016 lies at the heart of our investigations. We have therefore examined in some detail the course of the project from its original inception to completion. In order to provide the context in which the important decisions were made we begin with a description of the regulations and guidance relating to the construction of external walls of high-rise buildings which ought to have been uppermost in the minds of those making decisions about the nature of the work to be undertaken and the choice of materials.
¶47.2 That is followed by a brief description of the people and organisations involved in the work, which we have included to give the reader an overall understanding of the way in which individuals and organisations that appear frequently in the following chapters fit into the overall picture.
¶47.3 The story of how the refurbishment was planned and the important roles filled is of interest and importance, not only because decisions were made at that stage that affected the subsequent course of the work, but also because it sheds light on the way in which the TMO, as the client for the refurbishment, went about managing its own responsibilities.
¶47.4 Expert advice on fire safety was sought in the form of a fire safety strategy for the building, both in its existing form and following its intended refurbishment, but for reasons we describe, the latter was never completed, leaving a significant gap in the advice that should have been received by the TMO and the design team. A failure to understand the characteristics of the materials proposed for use in the refurbishment turned out to have disastrous consequences.
¶47.5 There follow several chapters in which we describe how the various materials and products used in the work came to be selected. It is a subject that calls for detailed examination because it was the decision to use aluminium composite panels with unmodified polyethylene cores in what was known as "cassette" form as the rainscreen that was primarily responsible for the rapid spread of the fire. Other products made a contribution, however, in particular the Celotex and Kingspan insulation boards, neither of which complied with the guidance on the use of combustible materials on high-rise buildings.
¶47.6 The requirement to obtain building control approval for the refurbishment should have ensured that any errors in design or the choice of materials were identified and put right before the work started. Regrettably, however, that did not happen. Given the importance of building control for the protection of the public, we have examined in some depth the reasons why the system failed to achieve the purpose for which it was designed.
¶47.7 Our investigations have disclosed that errors were made by many of those involved in the refurbishment and at many points during its course. As a result, we have found it convenient to collect our criticisms of each of the organisations principally responsible for the work in a number of individual chapters at the end of this Part.
9Chapter 48: The legislative background
¶48.1 Chapter 5 of the Phase 1 report contains a brief summary of the main legislative provisions and associated guidance that applied to the refurbishment of Grenfell Tower. However, in order to give a true picture of the context in which important decisions were taken in connection with the work, it is necessary at this stage to describe those provisions more fully and in greater detail. Given the important role played by the cladding system in the fire at Grenfell Tower, we concentrate on the statutory framework, including the statutory guidance relating to the construction of external walls, applicable during the period in which the refurbishment was carried out. In this chapter we also examine briefly the regulatory framework governing building control and the duties applicable under the CDM Regulations.
The Building Act 1984
¶48.2 The Building Act 1984 ("the Act")1 The Building Act 1984 {HOM00035068}. is the principal primary legislation governing building and buildings and related matters. Section 1(1) of the Act gives the Secretary of State the power to make regulations with respect (among other things) to the design and construction of buildings for a number of purposes, including securing the health, safety and welfare of persons in or about buildings. Regulations made under section 1(1) of the Act are known as "building regulations" and were made by way of statutory instrument. The regulations in force at the time of the refurbishment were the Building Regulations 2010 ("the Regulations").2 The Building Regulations 2010 {INQ00015098}.
¶48.3 Section 6 of the Act provides that the Secretary of State, or a designated body, may approve and issue documents for the purpose of providing practical guidance with respect to the requirements of any provision of the Regulations. At the time of the refurbishment that practical guidance was contained in a series of Approved Documents. The provisions of the Approved Documents are not mandatory; their purpose is merely to describe one or more ways in which the requirements of the Regulations can be met. Failure to comply with an Approved Document does not in itself render a person liable to any civil or criminal proceedings, but it may be relied upon in any proceedings as "tending to establish liability". Likewise, compliance with the provisions of an Approved Document, although not proof of compliance with the Regulations, may be relied on in any proceedings as "tending to negative liability".3 See Section 7 of the Building Act 1984 {HOM00035068/13}. It is important to note, however, that compliance with the Approved Documents does not ensure compliance with the Regulations.
¶48.4 Schedule 1 of the Act sets out further matters which building regulations may provide for. Paragraph 7 of Schedule 1 provides that they may make provision for (among other things) fire precautions.4 Paragraph 7(iv) of Schedule 1 of the Building Act 1984 {HOM00035068/109} states "Fire precautions including (a) structural measures to resist the outbreak and spread of fire and to mitigate its effects, (b) services, fittings and equipment designed to mitigate the effects of fire or to facilitate fire-fighting, and (c) means of escape in case of fire and means for securing that such means of escape can be safely and effectively used at all material times."
10¶48.5 Part 3 of the Regulations contains requirements for local authorities to be notified of building work. In particular, regulation 12(3) obliges a person intending to carry out building work in relation to a building to which the Regulatory Reform (Fire Safety) Order 2005 (the Fire Safety Order) applies to deposit full plans with the local authority in accordance with regulation 14. (The refurbishment of Grenfell Tower involved work on a building to which the Fire Safety Order applied and a deposit of full plans was therefore required.) By virtue of regulation 14, full plans are to consist of a description of the proposed work together with plans describing the work and demonstrating that it would comply with the Regulations.
¶48.6 The Act itself provides for the local authority's response to the deposit of full plans. Section 16 provides that, where plans for proposed work are deposited with a local authority, it is their duty to pass the plans unless a provision elsewhere in the Act requires them to be refused, or the plans are defective, or they show that the proposed work would contravene any of the Regulations. If the plans are defective or show that the work would contravene the Regulations, the local authority may reject them or (with the consent of the person by whom they were deposited) pass them subject to conditions. Within 5 weeks from the deposit of plans the local authority must give notice to the depositor stating whether they have been passed or rejected.5 Section 16(4) of the Building Act 1984 {HOM00035068/20}. The five-week limit is subject to any agreed extensions up to a maximum of two months (section 16(12) {HOM00035068/22-23}.
¶48.7 Failure to comply with the Regulations is punishable by a fine (section 35), but in addition local authorities have the power to require the owner of the building to pull down or remove any work that contravenes the Regulations or make such alterations to it as are necessary to make it comply with them (section 36).
The Building Regulations 2010
¶48.8 The Regulations prescribe the standards that building work must meet and impose on the person proposing to carry it out a requirement to obtain approval from a local authority or approved inspector. The requirements for building work are set out in regulation 4, which provides that building work shall be carried out so that it complies with the requirements contained in Schedule 1. The Regulations apply to building work as defined in regulation 3, which includes, among other things, the material alteration of an existing building. An alteration is material for these purposes if the work, or any part of it, would at any stage result in the building's ceasing to comply with any one of a number of listed requirements of the Regulations or (if it did not comply with such a requirement before the work commenced) becoming more unsatisfactory than it previously had been, but there is no requirement when work is done to an existing building to bring it up to current standards. This is sometimes known as the "non-worsening principle". The listed requirements include functional requirements B1, B3, B4 and B5 relating to fire safety.6 Section 3(3) of the Building Regulations 2010 {INQ00015098/7}. It is not disputed that the cladding work to Grenfell Tower, including the addition of insulation, and the renovation of the smoke control system constituted material alterations and that the Regulations therefore applied to them.
¶48.9 Paragraph 8(1)(e) of Schedule 1 to the Act gives the Secretary of State power to make building regulations with respect to buildings that are subject to a material change of use. A material change of use is defined in regulation 5. It occurs when, among other things, a building which contains dwellings is altered to contain a greater or lesser number of dwellings than it did previously. In the case of Grenfell Tower refurbishment, the addition of new flats in those parts of the building that had previously been put to other uses constituted a material change of use.
11¶48.10 The prescribed standards for building work are expressed in schedule 1 to the Regulations in terms of functional requirements. Although the refurbishment was required to comply with all the requirements, for the purposes of this report we concentrate on Part B.
¶48.11 Part B is concerned with fire safety and is divided into five sections: B1 Means of warning and escape. B2 Internal fire spread (linings). B3 Internal fire spread (structure). B4 External fire spread. B5 Access and facilities for the fire service.
¶48.12 Requirements B1, B3(4) and B4 are of particular relevance to the fire at Grenfell Tower and deserve to be quoted in full:
Means of warning and escape
¶B1. The building shall be designed and constructed so that there are appropriate
provisions for the early warning of fire, and appropriate means of escape in case of fire from the building to a place of safety outside the building capable of being safely and effectively used at all material times.
Internal fire spread (structure)
¶B3. (4) The building shall be designed and constructed so that the unseen spread of fire and smoke within concealed spaces in its structure and fabric is inhibited.
External fire spread
¶B4. (1) The external walls of the building shall adequately resist the spread of fire over the
walls and from one building to another, having regard to the height, use and position of the building.
¶(2) The roof of the building shall adequately resist the spread of fire over the roof and from one building to another, having regard to the use and position of the building.
¶48.13 The Regulations also contain certain energy efficiency requirements. In particular, regulation 23 provides that where renovation of a thermal element (which would include an external wall) constitutes a major renovation or amounts to the renovation of more than 50% of the element's surface area, the renovation must be carried out so as to comply with paragraph L1(a) of schedule 1 in so far as that is technically, functionally and economically feasible. Requirement L of schedule 1 is headed "Conservation of Fuel and Power" and paragraph L1(a) provides that reasonable provision shall be made for the conservation of fuel and power in buildings by limiting heat gains and losses through thermal elements and other parts of the building fabric.
¶48.14 The supervision of the proposed work by the local authority is intended to culminate in the issue of a completion certificate evidencing compliance with certain requirements of the Regulations. Those requirements include the applicable requirements of regulation 38 (discussed below) and schedule 1 of the Regulations. Once issued, a certificate is evidence (but not conclusive evidence) that the requirements specified in the certificate have been complied with.
12¶48.15 Regulation 38 is concerned with the provision of fire safety information. It applies where building work consists of or includes the erection or extension of a relevant building or is carried out in connection with a relevant change of use and when Part B of Schedule 1 imposes a requirement in relation to the work. In those circumstances the regulation obliges the person carrying out the work to give the responsible person under the Fire Safety Order not later than the date of completion of the work or the date of occupation of the building or extension, whichever is the earlier, information relating to the design and construction of the building and the services, fittings and equipment provided in or in connection with it that will assist that person to operate and maintain the building with reasonable safety.
¶48.16 The Fire Safety Order is considered in greater detail in Part 2 of this report. For the purposes of the Regulations, however, it is important to note that article 45 requires a local authority in receipt of a full plans application in relation to a building to which the order applies to consult the enforcing authority (in this case the London Fire and Emergency Planning Authority ("LFEPA") before passing the plans.7 For more detailed consideration of this provision see Menzies Module 1 Report {BMER0000004/139-140}. In practice, save for the highest risk or most complex projects, the consultation expected by building control and the LFEPA related to the B1 (means of escape) and B5 (access and facilities for the fire service) functional requirements only.
The Construction (Design and Management) Regulations 2007 and 2015
¶48.17 The Construction (Design and Management) Regulations were made by the Secretary of State under powers in the Health and Safety at Work Act 1974. They seek to protect persons against risks to health and safety arising from construction work through the establishment of a systematic framework for the assessment and management of those risks. The definition of construction work includes the construction, alteration, conversion, fitting out, commissioning, renovation, repair, upkeep, redecoration or other maintenance of any building.8 See regulations 2 and 3 of the Construction (Design and Management) Regulations 2007 {INQ00011315/1-4}. The first regulations were made in 1994 and came into force in March 1995. They were replaced in 2007 and again 2015. The 2007 Regulations remained in force until 5 April 2015 when the 2015 Regulations came into force.
¶48.18 The CDM Regulations 1994 and 2007 were each supported by guidance in the form of Approved Codes of Practice (ACOPs) published by the Health and Safety Executive, which provided practical guidance on how to comply with the law.9 See the 2007 Code "Managing health and safety in construction" at {INQ00013936}. The CDM Regulations 2015 {INQ00011316} were not supported by an ACOP. Instead, the HSE published guidance in the form of a document entitled "Managing health and safety in construction" {HSE00000003}.
¶48.19 When the CDM Regulations 2007 were superseded by the CDM Regulations 2015, a transition period from 6 April to 6 October 2015 was introduced to enable all those affected to put in place alternative arrangements.
¶48.20 The CDM Regulations 2007 are relevant to our investigation of the refurbishment because they imposed various duties on clients, designers (defined as including anyone preparing or modifying a design or instructing others to do so)10 See Regulation 2 of the 2007 Regulations {INQ00011315/2}. and contractors relating to health and safety or reinforced existing duties under health and safety legislation. We refer to these in more detail where relevant in the following chapters describing the refurbishment work at Grenfell Tower. The 2015 Regulations also imposed an obligation on the principal designer to prepare a health and safety file, keep it under review and deliver it to the client at the end of the project.11 Regulations 12(5) and 12(10) of the 2015 Regulations {INQ00011316/12}.
13Statutory guidance: Approved Documents
¶48.21 As we have set out above, section 6 of the Building Act 1984 Act provides for the publication by the Secretary of State of documents providing practical guidance with respect to the requirements of the Building Regulations. At the time of the refurbishment that practical guidance was contained in a series of Approved Documents, which themselves referred to British Standards and other guidance.
Approved Document B
¶dealt with fire safety. Before the Grenfell Tower fire, it was divided into two volumes: volume 1 dealt with dwelling houses; volume 2 dealt with all other buildings, including blocks of flats and buildings containing flats.
¶Approved Document B
¶48.22 As we have set out in Chapters 4 and 6, Approved Document B was first published in 1985 and was amended on numerous occasions thereafter. In this section of the report we have referred to the 2006 version incorporating the 2007, 2010 and 2013 amendments.12 {CLG00000224}.
¶48.23 Section 12 of Approved Document B provided guidance on the construction of external walls.13 {CLG00000224/95}. Our attention has focused most closely on paragraphs 12.5–12.8 of that guidance, which are worth setting out in full:
"12.5 The external envelope of a building should not provide a medium for fire spread if it is likely to be a risk to health or safety. The use of combustible materials in the cladding system and extensive cavities may present such a risk in tall buildings. External walls should either meet the guidance given in paragraphs 12.6 to 12.9 or meet the performance criteria given in the BRE Report Fire performance of external thermal insulation for walls of multi storey buildings (BR 135) for cladding systems using full scale test data from BS 8414-1:2002 or BS 8414-2:2005. 12.6 The external surfaces of walls should meet the provisions in Diagram 40… 12.7 In a building with a storey 18m or more above ground level any insulation product, filler material (not including gaskets, sealants and similar) etc. used in the external wall construction should be of limited combustibility (see Appendix A). This restriction does not apply to masonry cavity wall construction which complies with Diagram 34 in Section 9.14 {CLG00000224/95-96}. 12.8 Cavity barriers should be provided in accordance with Section 9."
¶48.24 Paragraph 12.5 thus provided two potential routes to compliance with the Regulations: following the guidance in paragraphs 12.6 to 12.9 (sometimes referred to as the "linear route") or meeting the performance criteria in BR 135 following testing in accordance with BS 8414. However, Approved Document B provided no more than guidance and in addition to the two routes it set out, there could be other ways of demonstrating compliance with the functional requirements of the Regulations to which we refer below. We note in passing that the majority of witnesses who gave evidence about the design of the Grenfell Tower refurbishment either thought that the "linear route" had been adopted or were not aware which route had been adopted.15 Sounes {Day7/138:2-16}; Crawford {Day9/177:3}-{Day179:23}; Ashton {Day17/138:2-3}; Lawrence {Day22/77:1-16}; Bailey {Day33/27:10-24}; Anketell-Jones {Day35/170:21}-{Day172:25}; Anketell-Jones {Day35/173:15-19}; Lamb {Day37/141:19}-{Day37/142:14}; Hoban {Day45/37:21}-{Day45/40:16}; Allen {Day47/25:22-25} {Day47/116:22-25}.
14¶48.25 Paragraph 12.6 of Approved Document B provided that the external surfaces of walls should meet the provisions in Diagram 40.16 {CLG00000224/95-97}.
¶Figure 48.1 – Diagram 40
15¶48.26 The heading of Diagram 40 (in particular the use of the words "or walls") might suggest that a distinction is being drawn between "external surfaces" and "walls" but the label in the key to Diagram 40 is concerned solely with "external wall surface classification". We think it is clear that it was intended to apply to the wall's external surface and thus to the material or product that makes up the outer surface of the wall.17 Hyett {PHYR0000029/34} section 4.2.42. That is certainly consistent with the language of paragraph 12.6 of the guidance which introduces Diagram 40 and which refers to the "external surfaces of walls".
¶48.27 Diagram 40e applied to Grenfell Tower and required that above 18 metres from the ground the external surface of the walls had to satisfy national class 0 or European class B-s3, d2 or better. We have described in Chapter 5 the tests which supported those classifications.
¶48.28 In our view the wording of paragraph 12.6 suggests that it applies to the external surface of a wall and does not include any product, such as insulation, that may have been fitted behind it. Similarly, when considering a composite product, such as an ACM panel, the paragraph naturally refers to its surface rather than to its core.
¶48.29 Paragraph 12.7 is headed "Insulation Materials/Products". It provided that in a building with a storey 18 metres or more above ground level any insulation used in the external wall construction should be of limited combustibility.18 Throughout the external wall, not just at heights above 18 metres. Limited combustibility is defined in Appendix A of Approved Document B (see Chapter 6).19 {CLG00000224/132}.
¶48.30 It has been argued that paragraph 12.7 should be understood as applying to the core of ACM cladding panels of the kind installed at Grenfell Tower.20 Team 1 Module 1 Opening Statement {BSR00000061/30} paragraph 13.16(2). The argument was put in two ways. The first relied on the use of the word "filler" in paragraph 12.7, which was said to be apt to refer to the core of a composite cladding panel. We do not agree with that. The word "filler" forms part of the expression "insulation product, filler material (not including gaskets, sealants and similar) etc. used in the external wall construction". In that context the word "filler" naturally means a material, such as compressible fibre or expanding foam, used to fill gaps of an unplanned or occasional kind rather than small apertures that are intended to be closed off by gaskets or sealants. It is not apt to refer to the core of a composite cladding panel which is an integral part of the finished product. We derive further support for our conclusion from the fact that we have not seen any evidence that the core of a composite panel was described as "filler" by anyone in the building industry before the Grenfell Tower fire.
¶48.31 The second argument was that the provisions relating to external surfaces in paragraph 12.6 and Diagram 40 were additional to the basic requirement that the external walls of a building over 18 metres in height should be composed only of materials of limited combustibility in the facade and do not override the functional requirement that they adequately resist the spread of fire.21 BSR Team 1 Module 1 Opening Submissions {BSR00000061/30} paragraph 13.16 (2). That interpretation was supported by Beryl Menzies22 Menzies {BMER0000004/126} paragraph 417. and support can also be found for it in industry guidance published by the Building Control Alliance in its Technical Guidance Note 18, which we discuss in Chapter 49.23 BCA Technical Guidance Note 18, Issue 0 {CEP00057294}. However, in neither case was any reason given for adopting that interpretation, beyond saying that it would give effect to functional requirement B4(1).
16¶48.32 We do not agree that paragraph 12.7 of Approved Document B can be read in that way. Functional requirement B4(1) sets out the standard with which external walls must comply. The purpose of Approved Document B was to provide guidance on ways in which that standard might be met, which it did by identifying certain elements of the wall and suggesting the kinds of materials that were likely to ensure compliance. There is nothing in the language of paragraphs 12.5–12.9 (including paragraph 12.7) to support the conclusion that all elements of the external wall, including the core of any composite panel, should be of limited combustibility. The only reference to "limited combustibility" is found in paragraph 12.7 which referred only to insulation products. That would naturally have been understood as referring to materials and products used for the purposes of insulation, not as referring to materials chosen for other purposes but which happen to have insulating properties.
¶48.33 Section 9 of Approved Document B provided guidance on the provision of cavity barriers to inhibit the spread of smoke and flame through concealed spaces or cavities in the construction of a building as required by functional requirement B3.24 {CLG00000224/82}. Paragraph 9.1 draws attention to the risks of fire spread within cavities and warns that "as any spread is concealed, it presents a greater danger than would a more obvious weakness in the fabric of the building."25 {CLG00000224/82}. Paragraph 9.3 makes it clear that cavity barriers should be provided to close the edges of cavities, "including around openings". Diagram 33 (reproduced below) shows where cavity barriers are required in external walls, namely, at the lines of compartment floors and compartment walls, at the top of any cavities in the walls and around openings such as those provided for doors and windows.
17¶Figure 48.2 – Diagram 33
¶48.34 Paragraph 9.13 gives guidance on the construction and fitting of cavity barriers and states that they should provide at least 30 minutes' fire resistance.26 {CLG00000224/86}. Cavity barriers should be distinguished from fire stopping, which is a seal provided to close an imperfection of fit or design tolerance between elements or components, to restrict the passage of fire and smoke.27 Approved Document B, Appendix E, definition of "Fire stop" {CLG00000224/144}.
18Comments on Approved Document B
¶48.35 Our investigations have revealed two particular problems relating to Approved Document B to which we think we should draw attention. The first relates to the guidance itself. Paragraph 2.3c on the means of escape from flats assumes that compliance with functional requirement B3 will provide a high degree of compartmentation and a low probability of fire spreading beyond the flat of origin, so that simultaneous evacuation of the building is unlikely to be necessary. In other words, it assumes that there would be no need for a partial or total evacuation of the building in the unlikely event that the fire spread beyond the compartment of origin and that a stay put strategy is therefore appropriate. That assumption holds good, however, only as long as the external wall of the building does not itself support the spread of fire.
¶48.36 Some uncertainty has arisen from the fact that functional requirement B4(1), which section 12 of Approved Document B was intended to support, requires only that the external walls should "adequately" resist the spread of fire, having regard to the height, use and position of the building. However, we assume that the word "adequately" was chosen to accommodate the full range of buildings to which the functional requirement applies. What is adequate will vary from case to case having regard to a number of matters, including the characteristics of the building.
¶48.37 It has been known for a long time that, even in the case of a fully compartmented residential building constructed entirely of non-combustible materials such as concrete (as Grenfell Tower was before the refurbishment), a fire in one compartment may spread to the compartment above as a result of the "coanda" effect. A limited degree of fire spread of that kind is not considered to undermine a stay put strategy because the extent of the evacuation required is very limited. Thus a limited degree of fire spread is acceptable, even where the building has a stay put strategy, because the ability of the external walls to resist the spread of fire is adequate.
¶48.38 However, the assumption underlying the guidance ceased to hold good when it became the practice to overclad high-rise residential buildings using materials that would support the spread of fire and to construct new buildings with steel frames with external walls composed in whole or in part of materials that would support the spread of fire. Unless all the materials used in the external wall are non-combustible, the effect in either case is to destroy the isolation of individual compartments by installing a continuous layer of combustible material on the outside of the building that would support the spread of fire across the outside of many compartments.
¶48.39 The failure to appreciate the effect of those developments introduced a fundamental flaw into the statutory guidance, which was not amended to draw the attention of designers to the need to consider the nature of the materials proposed to be used and other factors, such as access for the fire and rescue service, the nature of the occupants, the measures provided for alerting them to a fire and the means of escape if that should that become necessary, all of which have a bearing on whether the ability of the external wall to resist the spread of fire is adequate. If the external walls of a high-rise residential building support the spread of fire to any significant degree they are unlikely adequately to resist the spread of fire unless arrangements have been made to enable all those occupants who may be threatened by the fire to escape quickly and safely; but in any event it is not possible to operate a stay put strategy safely in relation to such a building.
19¶48.40 The effect of the introduction of new materials and methods of construction does not appear to have been recognised by any of the witnesses (other than the experts), including those from DCLG or BRE.28 See the examination of Dr Colwell at {Day231/175:11-24}; Debbie Smith {Day236/114:4}-{Day236/115:4}; Martin {Day251/96:19}-{Day251/98:19}; Burd {Day238/214:10}-{Day238/215:6}. There appears to have been a widely held view in the construction industry that if the surface of an external wall panel was classified Class 0, it was safe to use it on a building of any kind. There was also a widespread but erroneous understanding that if, following a test in accordance with BS 8414, an external wall system satisfied the criteria in BR 135, the building when completed would inevitably satisfy functional requirement B4(1) of the Building Regulations. Moreover, many in the industry failed to appreciate that the BS 8414 test applies only to a wall system as a whole and tells one nothing about its individual components. It is a matter of concern that no one appears to have considered whether the extent of flame spread that could occur while still satisfying the performance criteria in BR 135 was consistent with the adoption of a stay put strategy. We return to this matter in the context of our recommendations.
¶48.41 The second problem relates to the relationship between the regulations and the statutory guidance and the way in which Approved Document B is understood and applied by many in the construction industry. One striking feature of the evidence was the extent to which many construction professionals have routinely regarded the statutory guidance as containing a definitive statement of the requirements of the Building Regulations. In the absence of a clear statement to the contrary, we think that is an inevitable consequence of couching the guidance in prescriptive terms. Many construction professionals appear to be uncomfortable with the broad language of functional requirements B1 to B4 and want to be told what is expected of them and in any event many are not competent to translate the general language of the functional requirements into decisions about the choice of materials or methods of construction. That presents a particular problem for those who frame the statutory guidance, but while the functional requirements continue to set the standard which the law requires, it must be made clear in the guidance that following its provisions will not necessarily result in compliance with the regulations.
¶48.42 For reasons given elsewhere, Class 0 was never an appropriate standard for rainscreen panels, particularly panels with highly combustible polyethylene cores. In our view the guidance should explicitly have drawn the attention of those responsible for designing the cladding to the fact that Class 0 panels might not satisfy the requirements of functional requirement B4(1).
¶48.43 More generally, we think that Approved Document B requires a complete overhaul. It is out of date in many respects, not helpfully worded and does not contain the guidance that designers need. In a constantly changing environment it needs to be kept under review and revised annually or more often if circumstances demand. It should be drafted conservatively, so that those who follow the guidance can have a high degree of confidence that, if it is followed, the functional requirements will be met. Again, we return to this matter in the context of our recommendations.
21Chapter 49: Industry guidance on the construction of external walls
¶49.1 In this chapter we describe the industry guidance relevant to the refurbishment of the external wall of Grenfell Tower that was publicly available from reputable sources at and around the time of the refurbishment. In addition to the guidance contained in Approved Document B, certain bodies within the construction industry published guidance on the various aspects of the construction of external walls, particularly the walls of high-rise buildings. There were important developments in that guidance, particularly between 2012 and 2017, as more became known about the performance of certain products and materials in response to fire. In some respects the guidance contained in Approved Document B was overtaken by guidance published by the industry which suggested more rigorous requirements for the fire performance of each element of any external wall. According to Dr Lane29 Lane {Day61/195:1}-{Day61/197:19}.}. and Mr Sakula,30 Jonathan Sakula, Report of Facade Expert {JOS00000001/34} paragraphs 8.1.1-8.1.2; {JOS00000001/35-37} paragraphs 9.2-9.4; {JOS00000001/60-61} paragraphs 17.6-17.12, Sakula {Day125/29:13-20}; {Day125/94:15}-{Day125/96:12}; {Day125/101:25}-{Day125/102:22}; {Day125/108:1-5}. knowledge of the dangers posed by the use of combustible materials was developing rapidly during that time, partly as the result of a series of fires in high-rise buildings in various countries whose external walls contained insulation made from organic materials and aluminium composite material rainscreen panels with a polyethylene core ("ACM PE panels"). Those fires and the information readily available about them are discussed in more detail in Chapter 11 of this report.
Building Research Establishment: BR 135
¶49.2 In 1988 the Building Research Establishment (BRE) published guidance entitled Fire performance of external thermal insulation for walls of multi-storey buildings.31 See introduction to BR 135, 3rd Edition {CEL00003364/4}. It is generally known as "BR 135". The document was revised in 1999 and a second edition was published in 2003 following the fire at Garnock Court, Irvine in 1999.32 {BRE00005554/7}. A third edition was published in 2013.33 {CEL00003364/4}. The second and third editions are relevant to the refurbishment of Grenfell Tower. BR 135 is expressly referred to in paragraph 12.5 of Approved Document B, which adopts its performance criteria using full scale test data derived from a BS 8414 test as providing one way of demonstrating compliance with functional requirement B4(1) of the Building Regulations.34 {CLG00000224/95}. The history of BR 135 and the test methods contained in BS 8414‑1 (2002) and 2 (2005) are described in Chapter 5 of this report.
¶49.3 The second edition of BR 135 (2003) contained a series of important warnings about the risks posed by combustible external cladding systems. For example, Figure 2 illustrated the way in which fire may spread rapidly up through the building envelope itself to create secondary fires in compartments at many levels.35 {BRE00005554/9}.
22¶49.4 The guidance contained further warnings about the risks posed by external cladding systems, in particular, the risk that the existence of cavities may cause flames to become elongated and drawn up the building, possibly unseen,36 {BRE00005554/10}. to affect several stories simultaneously and how fire can spread unseen through cavities,37 {BRE00005554/17}. thus making firefighting more difficult.38 {BRE00005554/10}. The guidance also referred to the fact that non-combustible materials were typically used in such systems as it was difficult to prevent fire entering the cavity and spreading through the insulating material.39 {BRE00005554/17}. It also warned that, if exposed directly to the sustained flame envelope, metal panels, such as aluminium, might melt, generating molten debris.40 {BRE00005554/17-18}.
¶49.5 The third edition of BR 135 (2013) repeated the warnings given in the second edition41 {CEL00003364} see e.g. paragraphs 3.3.2 and 3.5. and contained further warnings about external fire spread and the use of certain materials in cladding systems. In particular, it drew attention to the rapid development of the market for cladding systems, driven by the need to construct more energy-efficient and sustainable buildings, which had resulted in increased volumes of potentially combustible materials being used in external cladding applications.42 {CEL00003364/11} paragraph 2.1. There were further important warnings about the proper use of cavity barriers and fire-stopping. The warnings about insulation and cladding panels were also more detailed. In particular, on the subject of cladding panels it said:
"These products generally have good surface spread of flame characteristics to prevent rapid fire spread across the surface of the system, but once the panels become involved in the fire, they have the potential to generate falling debris, add to the overall fire load, and provide a route for fire to propagate up the outside of the building"43 {CEL00003364/22} paragraph 6.4.1.
Building Control Alliance
¶49.6 The Building Control Alliance ('BCA') was formed in 2008 to represent the interests of those involved in carrying out building control functions, both local authorities and approved inspectors, and to promote consistency in the interpretation of the Building Regulations and statutory guidance. From time to time its Technical Group published guidance notes intended to assist building control officers in carrying out their functions.
¶49.7 In June 2014 BCA produced version 0 of its Technical Guidance Note 18 entitled Use of Combustible Cladding Materials on Residential Buildings (TGN 18).44 {CEP00057294} The purpose of the note is described as follows: "BCA technical guidance notes are for the benefits of its members and the construction industry, to provide information, promote good practice and encourage consistency of interpretation for the benefit of our clients. They are advisory in nature, and in all cases the responsibility for determining compliance with the Building Regulations remains with the building control body concerned." The introduction to TGN 18 stated that the note outlined the procedures referred to in paragraph 12.5 of Approved Document B for demonstrating compliance with functional requirement B4(1) and set out to address common misconceptions relating to combustibility and surface spread of flame ratings.45 {CEP00057294/1}.
23¶49.8 Under the heading "Key Issues", TGN 18 stated that the spread of fire by way of the external wall is exacerbated by the use of combustible materials and extensive cavities. It warned that within the confines of a cavity, flames can elongate up to ten times in search of oxygen, meaning that there is a need for robust cavity barriers, restricted combustibility of key components and the use of materials with a low spread of flame rating.46 {CEP00057294/1}.
¶49.9 Importantly, TGN18 made it clear that a surface spread of flame classification does not indicate that the material is not combustible. It went on to state that:
"Thermosetting insulants (rigid polyurethane foam boards) do not meet the limited combustibility requirements of AD B2 Table A7 and so should not be accepted as meeting AD B2 paragraph 12.7. However, if they are included as part of a cladding system being tested to BR135 & BS8414, the complete assembly may ultimately prove to be acceptable. The BR135 / BS8414 tests deal solely with the spread of fire once it has entered the cavity. Hence, the requirements for cavity barriers in accordance with Section 9 of AD B2 are required in all cases including around openings in the façade."47 {CEP00057294/1}.
¶49.10 TGN 18 went on to recommend three options for demonstrating compliance with paragraph 12.7 of Approved Document B.48 {CEP00057294/2}. Option 1 was the use of materials of limited combustibility for all elements of the cladding system both above and below 18 metres. Option 2 was to demonstrate that the entire system met the performance criteria in BR 135 when tested in accordance with BS 8414. Option 3 was to submit a desktop study report from "a suitable independent UKAS accredited testing body" based on test data already in its possession stating whether, in its opinion, the proposed system would meet the criteria in BR 135. As far as we are aware, that was the first occasion on which it had been formally suggested that a desktop study could provide a means of demonstrating compliance with functional requirement B4(1). It was not referred to in Approved Document B and was not the method adopted in connection with the refurbishment of Grenfell Tower.
¶49.11 A further edition of TGN 18 (version 1) published in July 2015 contained similar warnings about external fire spread.49 {CEL00002347}. This revised guidance made it clear that a wider group of thermosetting insulants did not meet the limited combustibility requirements of Approved Document B Table A7, including polyisocyanurate and polystyrene foam boards. When dealing with desktop study reports the guidance now said that a report from a "suitably qualified fire specialist" based on test data from a suitable independent UKAS accredited testing body was acceptable, without indicating what qualifications might be required for the purpose. The effect of that change was to increase the number of persons who might be considered suitable to carry out such a study. This version also introduced a fourth option in the form of a "holistic fire-engineered approach" taking into account "the building geometry, ignition risk and factors restricting fire spread etc."50 {CEL00002347/2}. That method was not adopted in connection with the refurbishment of Grenfell Tower.
24Centre for Windows and Cladding Technology
¶49.12 The Centre for Windows and Cladding Technology (CWCT) is an industry body comprising a broad spectrum of clients, architects, consultants, contractors, manufacturers and researchers which exists to assist its members in the construction of building envelopes and glazing.51 https://www.cwct.co.uk/pages/about-us. From time to time it publishes recommended standards and guidance for the benefit of its members and hosts meetings to discuss matters of interest to the industry. In the period 1996 to 2018, CWCT produced five documents of relevance to the Inquiry's investigations: Guide to Good Practice for Facades, 1996;52 {CWCT0000055}. Standard for Walls with Ventilated Rainscreens, 1998;53 {CWCT0000053}. Standard for Systematised Building Envelopes, 2008 ("the CWCT Standard");54 {CWCT0000046}. Technical Note 73, Fire performance of curtain walls and rainscreens, March 2011;55 {CWCT0000019}. and Technical Note 98, Fire performance of facades – Guide to the requirements of UK Building Regulations, 2017.56 {CWCT0000024}.
¶49.13 The CWCT's Guide to Good Practice for Facades (1996) stated that thermal insulation should be inert and drew attention to the fire performance of some insulating materials.57 {CWCT0000055/13} paragraph 4.10.1. The Standard for Walls with Ventilated Rainscreens (1998) made clear that any cavity behind rainscreens should not include materials which could significantly promote flame spread within the unseen cavity and therefore recommended non-combustible insulation.58 {CWCT0000053/45} paragraph 2.20.4; {CWCT0000053/46} paragraph 2.20.8. It warned that the use of any combustible material for the cladding framework and insulation needed to be carefully considered as the height of the building increased.59 {CWCT0000053/45} in the notes to the right of paragraph 2.20.4. Both of those CWCT standards were referred to in the structural performance specification for Grenfell Tower.60 Curtins Consulting, the structural engineer appointed by the TMO, wrote a specification entitled 'Structural Performance Specification for the Design, Supply and Application of Overcladding Systems to Grenfell Tower' dated March 2013 {CCL00002347}, in which section 7.0 addressed 'Overcladding' and included reference to these standards.
¶49.14 The CWCT Standard (2008) gave guidance on a range of aspects of the construction of the external envelopes of buildings61 {CWCT0000046/10}. Including, but not limited to, rainscreen cladding., with part 6 focusing on fire performance.62 {CWCT0000046/10-16}. Within part 6 the standard provided that the building envelope should not be composed of materials which readily support combustion, add significantly to the fire load, or give off toxic fumes.63 {CWCT0000046/11} section 6.2. It emphasised the importance of test evidence supporting fire performance requirements, as follows:
25"In all cases, products or elements of construction requiring a fire resistance or spread of flame performance should have the appropriate evidence of performance test based on test information. The final installation should follow the applicable test evidence in all respects."64 {CWCT0000046/11} section 6.2. It also stated in blue italic text: "The suitability of materials should be judged in relation to their conditions of use. For example, combustible insulation may give acceptable performance when used with a metal facing…" The black text in the CWCT Standard was prescriptive, while the blue italic text gave background information or guidance on interpretation of the clause which it followed, see {CWCT0000046/6}.
¶49.15 The CWCT Standard stated that aluminium envelope systems do not normally have significant resistance to fire and that most unmodified aluminium building envelopes would provide only 10–20 minutes stability and integrity resistance.65 {CWCT0000046/11} section 6.3. Under the heading "Insulation materials" it contained the same guidance as in paragraph 12.7 of Approved Document B, namely, that insulation in walls of buildings with a storey more than 18 metres above ground level should be of limited combustibility.66 {CWCT0000046/15} section 6.6.2. It also made clear that cavity barriers needed to be provided to close any cavity around penetrations through the rainscreen for windows.67 {CWCT0000046/14} section 6.4.4.2 (ii) under the heading "Cavities in rainscreen walls". The standard also expressly addressed "Composite components", providing:
"When one of the cladding elements is a composite of two or more materials (mechanically jointed, bonded or fused together) the elements as a whole must demonstrate the appropriate fire performance. Similarly it must be demonstrated that the composite will remain reasonably whole and not become prematurely separated from the building or framework."68 {CWCT0000046/16} section 6.6.3.
¶49.16 The CWCT Standard (2008) was expressly referred to in the NBS specification for the refurbishment works at Grenfell Tower (see Chapter 56).69 NBS Specification prepared by Studio E {SEA00000169/68-69} NBS Specification clauses 220/310.
¶49.17 Technical Note 73, Fire performance of curtain walls and rainscreens, was published by CWCT in March 2011.70 {CWCT0000019}. It contained warnings about fire and smoke spread within cavities and out of the top of cavities and highlighted the importance of cavity barriers to close the edges of cavities, including around window openings.71 {CWCT0000019/4-5}. Under the heading "Use of combustible material" it made it clear that "the only commonly used insulation material that will satisfy the definition of limited combustibility is mineral wool".72 {CWCT0000019/6}. It also emphasised that where testing was carried out in accordance with BS 8414, the test applied to the complete cladding system including insulation, rainscreen and cavity barriers73 {CWCT0000019/6} under the heading "Alternative approaches". and that changing any of those components might affect the ability of the walls to resist the spread of fire.74 {CWCT0000019/6}.
¶49.18 Technical Note 98 Fire performance of facades – Guide to the requirements of UK Building Regulations was published in April 2017. Although it was published too late to be taken into account in the design and construction of the refurbishment of Grenfell Tower, it provides a useful picture of the state of knowledge in the industry in the months before the fire. In particular, in the introductory section the note warnsː
26"Strict compliance with ADB does not necessarily guarantee adequate performance of a given façade in a fire. It is incumbent on the building designer to ensure that the guidance given in ADB is relevant to their building and what additional measures (if any) are required to ensure the façade achieves the required performance standard."75 {CWCT0000024/1}.
¶49.19 Technical Note 98 also stated that combustible materials may have non-combustible facings which restrict the spread of flame over the surface. It warned that combustible materials with non-combustible facings rely on the facings remaining intact and that the materials should be checked for damage.76 {CWCT0000024/3}. Appendix C of Technical Note 98 dealt with the combustibility of materials and paragraph 12.7 of Approved Document B. It stated:
"Clause 12.7 specifically refers to insulation materials and filler materials but is now being interpreted more generally (see BCA Guidance note 18). Therefore, where a building has a storey 18m or more above ground level all significant materials should be of limited combustibility (Class A2 in accordance with EN 13501). This includes but is not limited toː Rainscreen panels • Standard ACM panels do not meet these requirements. Limited combustibility ACM panels are available. Insulation materials • The only commonly used insulation material that will satisfy the definition of limited combustibility is mineral wool. …"77 {CWCT0000024/13}.
Booth Muirie Technical Guidance Note 1
¶49.20 Booth Muirie Ltd is a company which provides specialist architectural cladding services, including design, manufacturing and distribution. In March 2016 it published a guide to designing multi-layered walls using ACM rainscreen panels.78 {ARC00000559}. Like the BCA Technical Guidance Notes it set out various options for complying with the fire safety requirements for external walls of buildings over 18 metres in height. Option 1, which was described as "the most straightforward" was to restrict all the significant elements of each layer to non-combustible materials or materials of limited combustibility. Options 2, 3 and 4 were the same as those contained in Issue 1 of the BCA's TGN 18. Reynobond ACM with a polyethylene core, Celotex RS5000 and Kingspan K15 were all identified as being neither non-combustible nor of limited combustibility.
27Chapter 50: Organisations involved in the refurbishment
¶50.1 In this chapter we describe the organisations principally involved in the refurbishment of Grenfell Tower and the people who acted on their behalf. The purpose of doing so is to provide a brief introduction to those engaged on the project and the nature of their involvement. A number of other organisations, not referred to here, played minor and uncontroversial roles of a kind that do not call for discussion at this stage. Their involvement will be described in later chapters as we come to discuss particular aspects of the work.
¶50.2 The refurbishment of a major building is a complex undertaking which requires the co‑operation of many different bodies, some with specialised skills and experience. In addition to the client, who ultimately controls the budget and determines the scope of the work, they usually include (and in this case did include) an architect, quantity surveyor, the principal building contractor and several sub-contractors. In this case other consultants were employed at different times and for different purposes. They included a mechanical and electrical services ("M & E") consultant, a fire engineering consultant, an employer's agent and a CDM co-ordinator. Others, such as the local authority building control office, were also directly involved in the project, although in a different way. Building control, in particular, had a responsibility to the public to ensure that those involved in the project complied with the requirements of the Building Regulations.
The client: Kensington and Chelsea Tenant Management Organisation
¶50.3 Although Grenfell Tower was owned by the Royal Borough of Kensington and Chelsea (RBKC), it was managed by the Kensington and Chelsea Tenant Management Organisation (TMO) under a modular management agreement. Although the decision to refurbish the tower was taken by RBKC, which provided the funds required for that purpose, the TMO acted as the client and in that capacity procured the services needed to carry out the project and oversaw its execution. The circumstances in which the TMO procured the services of the architect and the main contractor are discussed in Chapters 51, 52 and 53.
¶50.4 As client the TMO also incurred certain obligations under the CDM Regulations 2007 and 2015. They included ensuring that all designers were competent and adequately resourced.79 CDM Regulations 2007{INQ00011315/4-5}Regulations 4 and 9; Approved Code of Practice to Construction (Design and Management) Regulations 2007, Managing Health and Safety in Construction (HSE) {INQ00013936/15-17} paragraphs 43 and 49-52; CDM Regulations 2015{INQ00011316/5-6} Regulation 4; Approved Code of Practice to Construction (Design and Management) Regulations 2015 {HSE00000003/16-18} paragraphs 29-36.
28¶50.5 The people principally involved in negotiating the contracts for the refurbishment on behalf of the TMO and overseeing the project were: Mark Anderson Peter Maddison Paul Dunkerton David Gibson Claire Williams.
¶50.6 Mark Anderson was an architect by profession with experience of private practice before he became involved with social housing.80 Anderson {TMO10048968/1} page 1, paragraph 6. He was appointed by the TMO as interim Director of Asset Investment and Engineering in March 2011 and following a redesignation of his role served as interim Director of Assets and Regeneration from April 2012 until January 2013.81 Anderson {TMO10048968/1} page 1, paragraph 5. Mr Anderson was not employed as an architect by the TMO. He was responsible for the early stages of the refurbishment project which he later handed over to Peter Maddison when the latter was appointed to succeed him.
¶50.7 Peter Maddison was appointed by the TMO to the post of Director of Assets and Regeneration from January 2013.82 Maddison {TMO00000892/1} page 1, paragraph 2. In that role he took over primary responsibility for organising the refurbishment project at a strategic level for the TMO, including overseeing the engagement of consultants and the selection of the main contractor.
¶50.8 Paul Dunkerton was a freelance project manager for the TMO between late 2010 and early July 2013.83 Dunkerton {TMO00000885/1} page 1, paragraph 5. He initially reported to Mark Anderson and later to Peter Maddison, taking on a more active role when he had no senior manager to whom to report.84 Dunkerton {Day51/11:4-15}.
¶50.9 David Gibson was Head of Capital Investment at the TMO from February 2013 until the end of June 2016, reporting to Peter Maddison.85 Gibson {TMO00000887/1-2} pages 1-2, paragraphs 2 and 8. As such he was responsible for assisting Mr Maddison in the development and delivery of the refurbishment project. Mr Gibson had been a registered architect between 1987 and 1991 and had had some previous experience of regeneration projects in the social housing sector.86 Gibson {Day53/11:15-23}; Gibson {TMO00000887/1-2} pages 1-2, paragraphs 5-7; Gibson {TMO00879742/1} page 1, paragraph 3.
¶50.10 Claire Williams joined the TMO in September 2013 as project manager for the Grenfell Tower refurbishment. Once the work began, she became the primary point of contact with the main contractor. One of her tasks was to communicate with the residents of Grenfell Tower,87 Williams {TMO00840364/4} page 4, paragraphs 18-19. having been appointed for her particular skill and experience in resident relations.88 Williams {TMO00840364/2} page 2, paragraph 11; Williams {Day54/87:12}-{Day54/88:1}. She considered herself to be the TMO's project manager for the refurbishment,89 Williams {Day54/80:23}-{Day54/81:9}; {Day54/101:7-12}. although there was some confusion about who, if anyone, was formally acting in that capacity.
29The architect: Studio E
¶50.11 The architectural practice known as "Studio E" was appointed by the TMO for the Grenfell Tower refurbishment and provided professional services in respect of the project from about February 2012 to July 2016.90 Kuszell {SEA00014271/9-10} page 9-10, paragraph 35; Sounes {SEA00014273/30} page 30, paragraph 58; Studio E {SEA00014232/2} page 2, paragraph 3.1. In Chapter 52 we describe the circumstances in which it came to be appointed, but for present purposes it is necessary to refer in a little more detail to the origin and structure of the practice.
¶50.12 Studio E Architects Limited ("SEAL") was founded in 1994 by Andrzej Kuszell and two others. A separate body in the form of a limited partnership, Studio E LLP ("SELLP"), was established by Mr Kuszell and his partners in 2007 but did not start trading until 2011.91 Kuszell {Day6/16:7-16}. Thereafter, between 2011 and 2014, SEAL was effectively dormant92 Kuszell {Day6/18:15-18}. but it was revived in 2014 when SELLP became insolvent and ceased trading. Throughout this report we refer to the practice simply as "Studio E", except when it is necessary to identify the particular legal entity involved.
¶50.13 After the principal contractor had been appointed Studio E's services were transferred to it under a separate agreement between them. We discuss the circumstances under which that occurred and the terms of the resulting contractual arrangements in Chapter 63.
¶50.14 Studio E was represented in relation to its work on the Grenfell Tower refurbishment principally by the following persons:93 Others at Studio E were also involved in the Grenfell Tower refurbishment from time to time. Andrzej Kuszell Bruce Sounes Neil Crawford Tomas Rek.
¶50.15 Andrzej Kuszell is a registered architect and a founding director of SEAL.94 Kuszell {Day6/10:17} – {Day6/11:2}; Kuszell {SEA00014271/2} page 2, paragraph 3. During his career he worked in various sectors, including defence, commercial development and education work with an emphasis on education, sports and leisure centres.95 Kuszell {Day6/11:3-18}. Mr Kuszell did not have day-to-day involvement with the Grenfell Tower project,96 Kuszell {SEA00014271/2} page 2, paragraph 4. although he oversaw the provision of resources and took part in design reviews. He did not have any personal experience of overcladding an occupied residential building and no personal experience of refurbishing a high-rise building.97 Sounes {Day6/173:14-16}; {Day6/11:19-22}.
¶50.16 Bruce Sounes studied architecture at the University of Natal at Durban in South Africa between 1989 and 1994. He completed the RIBA Part 3 examination and became a registered architect in 2000.98 Sounes {Day6/169:2-3}; He commenced work in the UK as an Architectural Assistant in 1998 at KSR Architects: Sounes {Day6/167:17}-{Day6/169:1}. Before 2000, his experience had been predominantly in education, sports, and leisure projects.99 Sounes {Day6/166:13-23}. He joined Studio E in the role of architect in 2000 and was promoted to the role of associate in 2005.100 Sounes {Day6/170:3-19}; Kuszell (Day6/104:21-24}. Mr Kuszell said that it was not unusual for an associate to lead a project and that for a commission with a construction value of £1 million or more either a partner or an associate would do so.101 Kuszell {Day6/105:5}-{Day6/107:13}. From July 2014, Neil Crawford took over day-to-day responsibility for the project from Mr Sounes, although Mr Sounes remained responsible for it and for supervising Mr Crawford's work.102 {SEA00014276}; Kuszell {Day6/124:5-10}; Crawford {Day9/22:15-20}. Mr Sounes did not have any experience of overcladding an occupied residential building, although he had gained some experience of an overcladding project when working on the Watford Woodside Leisure Centre.103 Sounes {Day6/174:21-25}.
30¶50.17 Neil Crawford had a degree and a post-graduate diploma in architecture104 Crawford {Day9/4:9-15}. Neil Crawford studied at the Mackintosh School of Architecture between 1991 and 1997. but was not a registered architect because he had not completed the Royal Institute of British Architects Part 3 examination.105 He had studied towards the RIBA Part 3 examination in London in 2007 but had not completed it: Crawford {Day9/5:19-22}. Between 1997 and 2009 he had worked at Foster + Partners, initially as a Part 2 graduate and later as an associate.106 Crawford {Day9/10:2-11}. He joined Studio E in 2009 and soon became an associate.107 Crawford {Day9/21:19-22}. From July 2014, he took over day-to-day responsibility for the project from Mr Sounes, although Mr Sounes continued to lead it.108 {SEA00014276/7}; Kuszell {Day6/124:5-10}; Crawford {Day9/22:15-20}.
¶50.18 Mr Crawford worked on the Grenfell Tower refurbishment on a day-to-day basis.109 Crawford {Day9/23:25}-{Day9/24:8}. } By October 2015, he had been made the project architect.110 {SEA00013508}. He had some limited experience of commercial projects involving cladding and curtain walling but had not previously been involved in the overcladding of a high-rise residential building.111 Crawford {SEA00014275/9} page 9, paragraph 21; Crawford {Day9/19:20}-{Day9/20:5}.
¶50.19 Tomas Rek was a registered architect who was employed by Studio E between December 2011 and December 2013.112 Rek {Day12/5:5-9}. Before joining Studio E he had worked mainly in the education sector.113 Rek {Day12/8:18-20}. He started work on the Grenfell Tower refurbishment project on 18 September 2013.114 Rek {SEA00014278/4} page 4, paragraph 9. Under the supervision of Mr Sounes, he developed the National Building Specification (NBS) specification for the project and the architectural drawings intended to form part of the tender documents.115 Rek {SEA00014278/5} page 5, paragraph 14; Rek {Day12/11:17-20}. (The NBS is a computerised system designed to assist architects and other building professionals in describing the materials, standards and workmanship required on a construction project.) Studio E drafted three versions of the NBS Specification dated 21 November 2013116 {SEA00000152}., 29 November 2013117 {RYD00001712}. and 30 January 2014.118 {SEA00000169}. The second and third of those were sent to tenderers.
The quantity surveyor, employer's agent and CDM co‑ordinator: Artelia
¶50.20 Appleyards Ltd had been appointed by the TMO as a consultant on the KALC project and as a result the TMO appointed it as quantity surveyor, employer's agent and CDM co‑ordinator for the Grenfell Tower project. In March 2012, Artelia Ltd bought Appleyards and thereafter Appleyards traded in the name of Artelia until 30 June 2015, when its business was formally transferred to Artelia.119 Artelia {ART00005764/2} page 2, paragraph 4. In this report we refer to both entities as Artelia, unless the context requires otherwise.
31¶50.21 A quantity surveyor is a surveyor trained in the particular skill of calculating the quantity and cost of materials required to carry out, or that have been used in carrying out, the whole or a particular part of a construction project. They may be used to estimate the cost of work, help manage costs during the course of the work and participate in agreeing the final account.120 Cash {Day48/2:9-13}. Artelia agreed to provide quantity surveying services, including preparing an initial budget to test feasibility, preparing regular monthly cost reports as the project progressed and advising the TMO of any decisions required.121 Artelia Agreement 2014 {ART00005742/55-58}. Simon Cash was its project director and had overall responsibility for the whole of Artelia's involvement in the refurbishment.122 Save for a brief period at the end of 2015 to early 2016; Cash {ART00006544/2} page 2, paragraph 4. He was a trained quantity surveyor and a Fellow of the Royal Institution of Chartered Surveyors.123 Cash {ART00006544/2} page 2, paragraph 5.
¶50.22 The function of an employer's agent is to perform on behalf of the client various administrative tasks that have to be undertaken by it in relation to a project.124 The Building Contract between Rydon and the TMO envisaged that an employer's agent would be appointed {RYD00094235/22} Articles (conformed copy). Philip Booth acted as employer's agent from about April 2013 until June 2015.125 Booth {ART00008527/3} page 3, paragraph 12; Booth {ART00008527/5} page 5, paragraph 22. He left Artelia in April 2016.126 Booth {Day49/113:7-8}. Neil Reed succeeded Philip Booth as employer's agent in March 2015.127 Reed {ART00006663/2} page 2, paragraph 8. In July 2015, Neil Reed left Artelia to start his own business, Re Sol Group Limited (Re Sol), but continued to provide the services of employer's agent under a subcontract with Artelia.128 Reed {ART00006663/2} page 2, paragraph 6; On 10 July 20215, Neil Reed for Re Sol proposed to perform the services of employer's agent, as set out in the 2015 Agreement {ART00007552}. On 28 July 2015, Artelia appointed Re Sol on the basis of that proposal to start from 1 August 2015 and continue to the issue of the certificate of Practical Completion {ART00006674}. In effect, Neil Reed left his employment at Artelia but continued working the same capacity on the refurbishment through his own consultancy business.
¶50.23 CDM co-ordinator (CDM-C) is a statutory role under the Construction (Design and Management) Regulations 2007 ("CDM Regulations 2007").129 {INQ00011315}. The regulations required the TMO to appoint a CDM co-ordinator (CDM-C) for the Grenfell Tower project because of its size.130 CDM Regulations 2007, Regulation 2(3) {INQ00011315/4}; CDM Regulations 2007, Regulation 14(1) {INQ00011315/8}. The CDM-C is required to assist and advise the client on the appointment of competent contractors, ensure that health and safety matters are properly co-ordinated during the design process, help communication and co-operation between project team members and prepare the health and safety file.131 Approved Code of Practice to the CDM Regulations 2007{INQ00013936/24} paragraph 84; CDM Regulations 2007 {INQ00011315/10} Regulation 20(1)(a); reflected in 2014 Agreement: {ART00005742/61} clause 3; CDM Regulations 2007{INQ00011315/11} Regulation 20(2)(e); reflected in 2014 Agreement: {ART00005742/62} clause 11. Keith Bushell of Artelia was appointed to that role. Following the introduction of the Construction (Design and Management) Regulations 2015 (CDM Regulations 2015), Artelia's appointment as CDM-C terminated on 6 October 2015. On 8 October 2015, Simon Cash wrote to Peter Maddison to confirm that Artelia's appointment as CDM-C had terminated.132 {ART00006244}.
32M & E consultant: Max Fordham
¶50.24 The TMO appointed Max Fordham LLP as building services engineers with effect from the summer of 2012. Andrew McQuatt was the lead project engineer.133 McQuatt {MAX00017292} page 5, paragraph 19. Matt Cross Smith was a building services engineer who worked on the Grenfell Tower project as a graduate engineer.134 Cross Smith {MAX00017304} pages 1-2, paragraph 4.
Structural engineer: Curtins Consulting Ltd
¶50.25 Curtins Consulting Limited (Curtins) was the consultant structural engineer for the Grenfell Tower project. Its contract was novated to Rydon by an agreement dated 25 April 2016 following that company's appointment as principal contractor.135 {TMO10013954}.
Fire engineer: Exova (UK) Ltd
¶50.26 Exova (UK) Ltd, trading as Exova Warringtonfire (Exova), is a company specialising in fire safety, fire engineering and related matters. It had been employed as a consultant by Studio E in connection with the KALC project,136 Sounes {SEA00014273/36} page 36, paragraph 73. and as a result, it was approached by the TMO to advise on the Grenfell Tower refurbishment.137 TMO's procurement of Exova's services in respect of the Grenfell Tower refurbishment is explored in Chapter 54. Although it was retained by the TMO, it continued to send reports to Studio E.138 Ashton {Day17/20:1-13}. There was no fresh tender or procurement exercise for fire engineering services for the Grenfell Tower project. Exova was used because it was known and trusted as a result of its work on the KALC project.
¶50.27 The TMO appointed Exova to produce a fire safety strategy for Grenfell Tower in its existing state (the "Existing Fire Safety Strategy")139 See fee proposal dated 11 June 2012 {TMO10003884}. and a fire safety strategy for the building in its refurbished condition (the "Outline Fire Safety Strategy").140 See fee proposal dated 9 May 2012 {ART00000026}. Its appointment was not novated to Rydon after that company had been appointed as principal contractor and it therefore continued as a consultant to the TMO.141 {ART00002255/4}; Ashton {EXO00001621/14} page 14, paragraphs 5.9 – 5.10; Ashton {Day16/117:2-10}; {Day17/185:2-3}; {Day16/117:2-10}; {Day17/187:7-10}. However, as discussed in Chapter 54, there was a confusion in some people's minds about Exova's position following Rydon's appointment that was never properly clarified.
¶50.28 In relation to its work on the Grenfell Tower refurbishment Exova was represented principally by the following persons: James Lee Cate Cooney Dr Clare Barker Terence Ashton Dr Tony Pearson.
33¶50.29 For a brief period, James Lee was involved with the project until he left the company in late July 2012. He attended a design team meeting on 19 April 2012142 {TMO10001143}; {EXO00001740/2} page 2, paragraph 3.3. and visited the tower briefly on 29 May 2012.143 Lee {EXO00001740/3} page 3, paragraph 3.6; {EXO00000802}. He provided Studio E with a series of marked-up drawings and comments in respect of the proposed refurbishment works144 Lee {EXO00001740/3}; page 3, paragraph 3.7; {EXO00001750}. and prepared a fee proposal for Studio E for the production of the Existing Fire Safety Strategy.145 Lee {EXO00001740/3}; page 3, paragraph 3.10; {TMO10037721}.
¶50.30 At the time Exova was appointed Dr Clare Barker was a principal fire engineer in Exova's Warrington office and a member of the Institute of Fire Engineers.146 Barker {Day15/7:1-5}. She attended a project meeting on 26 July 2012,147 Barker {EXO00001603/2} page 2, paragraph 3.4; {EXO00000242}; {EXO00001620} shortly before Exova was instructed to provide the Existing Fire Safety Strategy. She asked another employee, Cate Cooney, to prepare a first draft,148 {EXO00001620/4}; Barker {EXO00001603/3} page 3, paragraph 3.10; Cooney {EXO00001590/2} page 2, paragraph 3.3; Cooney {Day14/27:15-21}; Barker {Day15/9:20-24}; {Day15/41:20-25}. which she later reviewed.149 Barker {EXO00001603/3} page 3, paragraphs 3.13-3.14; Cooney {EXO00001590/3} page 3, paragraph 3.9.
¶50.31 Cate Cooney had joined Exova in 2011 after spending eight years working in building control. By 2012 she had reached the position of senior consultant. At the request of Dr Barker, she prepared the first draft of the Existing Fire Safety Strategy. She also provided some advice to Bruce Sounes of Studio E in relation to the refurbishment proposals.150 {EXO00000655}.
¶50.32 Terence Ashton had joined Exova in 1989 as a principal consultant after 25 years in building control. He was based at Exova's London office, where he was an associate in the fire engineering department151 Ashton {Day16/23:23-25}; {Day16/24:1-2}; {Day16/24:6-8}; Ashton {EXO00001621/2} page 2, paragraph 2.3. and acted as office manager.152 Pearson {Day19/4:5-10}. He had no formal qualifications in fire engineering. He had worked on high-rise residential buildings but had no experience of overcladding projects.153 Ashton {Day16/29:1-8}. He did not have the expertise to carry out highly technical fire engineering analyses, such as determining how particular materials are likely to behave in a fire, and would have called on his colleagues in Warrington for assistance if had he been asked to do one.154 Ashton {EXO00001621/3} page 3, paragraph 3.4; Ashton {Day17/94:7-20}. He said he would also have called on his testing colleagues within Exova if he needed further advice, for example, on a new type of insulation coming on to the market. He saw his primary role as being to ensure compliance with the Building Regulations.155 Ashton {Day16/64:7-13}. Following James Lee's departure from the company in July 2012, Terence Ashton assumed overall responsibility for Exova's work on the Grenfell Tower refurbishment.
¶50.33 In 2013, Mr Ashton was aware that Approved Document B contained an express warning that the use of combustible materials in cladding systems and the existence of extensive cavities might present a risk to health and safety in tall buildings.156 Ashton {Day17/87:3-8}; {CLG00000224/95} page 95, paragraph 12.5. Although he was aware of the existence of BR 135, he had not read it from cover to cover and it did not occur to him to read it before starting work on the Grenfell Tower project.157 Ashton {Day17/77:14-19}. Mr Ashton was aware that serious fires had occurred both in the UK and overseas as a result of the use of inappropriate materials (although he was not aware of the fire at the Lacrosse Building in Melbourne) and was therefore aware that combustible cladding should not be used on high-rise buildings.158 Ashton {Day18/82:1-10}. He had not encountered the use of composite metal panels, apart from one particular composite panel with a polyethylene core.159 Ashton {Day17/88:1-7}. However, he did not envisage that material of that kind would be used on high-rise buildings. He knew that polyethylene was a highly combustible substance and was aware, at least subconsciously, that panels containing polyethylene could exacerbate the spread of fire over the exterior wall of a building.160 Ashton {Day17/89:2-7}.
34¶50.34 Dr Tony Pearson joined Exova in 2008 as a graduate. In 2013 he was promoted to senior consultant161 Pearson {Day19/3:2-5}; Pearson {EXO00001753/2} page 2, paragraph 2.2. and remained in that role until he left the company in January 2016.162 Pearson {EXO00001753/2} page 2, paragraph 2.2. Before he started working on the Grenfell Tower project Dr Pearson had had no experience of refurbishing high-rise residential buildings and very little experience of overcladding projects.163 Pearson {Day19/7:17-25}.
Clerk of works: John Rowan & Partners
¶50.35 The TMO engaged John Rowan & Partners to provide a limited range of clerk of works services during the refurbishment. John Rowan is a construction consultancy offering a variety of services to the construction industry, including site monitoring and supervision or clerk of works services.164 Virdee {JRP00000333/2} page 2, paragraphs 7-8; Virdee {Day43/4:14-21}. Those principally involved were Gurpal Virdee, the managing partner since August 2016,165 Virdee {Day43/3:2-8}. and Jonathan ("Jon") White, who was an experienced clerk of works.
¶50.36 The functions that John Rowan were required to perform were more limited than those that would be performed by a traditional clerk of works.166 Virdee {JRP00000333/2} page 2, paragraphs 11-12; Virdee {JRP00000333/3} page 3, paragraph 17; Virdee {JRP00000333/5} page 5, paragraph 24; Virdee {JRP00000333/7} page 7, paragraph 28; Virdee {JRP00000333/8} page 8, paragraph 32; Virdee {JRP00000333/12-13} pages 12-13, paragraph 51; White {JRP00000330/2-3} pages 2-3, paragraphs 13-17; White {JRP00000330/5} page 5, paragraph 43. See also oral evidence, Virdee {Day43/19:7}-{Day43/20:1}; with which Claire Williams agreed, Williams {Day55/202:5-22}. In effect, they were employed to act as site inspectors or site monitors167 White {JRP00000330/2} page 2, paragraph 13. and were expected to focus a lot of attention on the residents.168 White {Day42/173:7-10}; Williams {Day56/35:9}-{Day56/37:14}; {Day56/45:16}-{Day56/47:9}.
The principal contractor: Rydon
¶50.37 The TMO appointed Rydon Maintenance Ltd ("Rydon") as principal contractor under a contract on the JCT Design and Build Contract form 2011 with amendments.169 {RYD00094235} (conformed copy). As principal contractor, Rydon was responsible for all aspects of the refurbishment project, including its design, compliance with the Building Regulations and other statutory requirements. The refurbishment division of Rydon, led by its Refurbishment Director, Stephen Blake, was responsible for the project. We describe the circumstances in which Rydon came to be appointed in Chapter 53.
35¶50.38 Those principally involved in the refurbishment on behalf of Rydon were: Stephen Blake, the Refurbishment Director Simon Lawrence, one of the contract managers Simon O'Connor, a project manager David Hughes, a site manager Gary Martin, a site manager Daniel Osgood, a site manager Zak Maynard, the commercial manager.
¶50.39 Stephen Blake was Refurbishment Director throughout the project.170 Blake {Day28/4:10-11}. He assumed the role of contract manager in October 2015 following the departure of Simon Lawrence to see the project through to completion and was the most senior Rydon employee to be directly involved in the Grenfell Tower refurbishment.171 Blake {RYD00094225/7} page 7, paragraph 4.8.
¶50.40 Simon Lawrence was the contracts manager responsible for the refurbishment from its inception until October 2015. As such he was the most senior Rydon employee with day-to-day involvement in and responsibility for the project.172 Lawrence {Day22/16:3-9}. When he left Rydon in 2015 Stephen Blake took over his role.
¶50.41 Simon O'Connor was project manager for the refurbishment until September 2015.173 O'Connor {RYD00094221/1-2} pages 1-2, paragraph 3. He had worked for Rydon since September 2002, progressing from foreman to site manager and then to project manager.174 O'Connor {Day26/3:19} The Grenfell Tower refurbishment was the first project for which he had taken on the role of project manager.175 Blake {Day28/29:19-22}. It was his task to manage the day-to-day running of the project on site.176 O'Connor {RYD00094221/1-2} pages 1-2, paragraph 3.
¶50.42 David Hughes was employed by Rydon as a site manager for the Grenfell Tower project from October 2015 until its completion.177 Hughes {RYD00094213/5} page 5, paragraph 22. He had worked for Rydon since November 2001, after graduating with a degree in civil engineering from Plymouth University.178 Hughes {Day27/3:19-22}.
¶50.43 Gary Martin was employed by Rydon as a site manager on the Grenfell Tower project from May 2014 until its completion. Before joining Rydon he had worked for another company as a site manager on residential refurbishment projects.179 Martin {Day30/4:4}.
¶50.44 Daniel Osgood had joined Rydon in March 2014, starting in the role of temporary site manager.180 Osgood {RYD00094212/1} page 1, paragraph 3. He was employed by Rydon as a site manager on the Grenfell Tower refurbishment from April 2015 until July 2015, when he was moved to work on a different project.181 Osgood {RYD00094212/1} page 1, paragraph 3; Osgood {Day30/100:3-5}. At the time of the Grenfell Tower project, he had worked as a site manager for over 10 years.182 Osgood {Day30/94:14-16}.
36¶50.45 Zak Maynard was Rydon's commercial manager, responsible for all financial aspects of the project,183 Maynard {Day31/7:9-14}. including the management of a team of several surveyors, the allocation of work packages to subcontractors, controlling budgets, assessing the financial implications of changes to the works and liaison with the employer's agent.184 Maynard {RYD00094346/1} page 1, paragraphs 4-6; Maynard {Day31/7:7}-{Day31/18:11}.
¶50.46 Although it took responsibility for all aspects of the design and execution of the works, Rydon did not employ within its organisation people with all the skills and expertise required to discharge its contractual obligations. As is common in the construction industry, it preferred to delegate the discharge of its responsibilities to a host of subcontractors, regarding itself as little more than the conductor of a large and varied orchestra of players. Later in the report we shall refer to the following subcontractors who were employed by Rydon on the refurbishment: Harley Curtain Wall and Harley Facades J S Wright & Co Ltd S D Plastering Ltd S D Carpentry Ltd.
The facade sub-contractor: Harley
¶50.47 Harley Curtain Wall ("Harley CW") was established in 1996 by Ray Bailey to carry on the business of designing and installing facades of buildings under construction. By 2013, Harley employed about 16 people,185 Ray Bailey {HAR00010184/3} page 3, paragraph 9. but none of them had any formal qualifications in facade engineering.186 Ray Bailey {Day32/11:16-20}. Mr Bailey had been involved in several projects on high-rise residential buildings which had used ACM rainscreen panels before Harley undertook the work on Grenfell Tower.187 Ray Bailey {HAR00010184/3} page 3, paragraph 10 and Ray Bailey {Day32/13:20}-{Day32/14:12}. Premier House, Castlemaine Tower, Clements Court, Ferrier Point, Chalcots Estate and Little Venice. It was Harley's practice to subcontract much of the work it undertook, including design, manufacture and the installation of the facade itself.188 Ray Bailey {Day32/12:11}-{Day32/13:5}.
¶50.48 Harley Facades was established in 2000, also by Ray Bailey. He had originally intended to use the two Harley companies on separate projects,189 Ray Bailey {HAR00010184/2} page 2, paragraph 7. but in the event Harley Facades remained dormant until 2015 when Harley CW went into administration. At that point it took over the work on the Grenfell Tower project.190 Ray Bailey {HAR00010184/2} page 2, paragraph 7. In Chapter 65 we describe how Harley came to be appointed and the key terms of its contract with Rydon. For present purposes it is sufficient to say that Harley was contractually responsible to Rydon for all aspects of the design and construction of the facade of Grenfell Tower, including the cladding, insulation, window frames, window infill panels, glazing and cavity barriers.
¶50.49 The people principally involved in the project on behalf of Harley were: Ray Bailey Mark Harris Mike Albiston
37¶Daniel Anketell-Jones Ben Bailey.
¶50.50 Ray Bailey was the founder of the Harley companies and was in overall control of the business. Mr Bailey graduated with a degree in civil engineering from Salford University in 1981 following which he worked for a number of companies in which he gained experience of all aspects of building envelopes, including design, manufacturing and installation.191 Ray Bailey {HAR00010184/1-2} pages 1-2, paragraph 4. He had no formal qualifications in facade engineering.192 Ray Bailey {HAR00010184/2} page 2, paragraph 5.
¶50.51 Mark Harris was a self-employed consultant in the field of commercial glazing and cladding appointed by Harley to assist with the Grenfell Tower project.193 Harris {HAR00010159/2} page 2, paragraph 7. He had been working exclusively for Harley since about 2011 and his experience lay mainly in the field of sales and developing business connections.194 Harris {Day43/9:16-20}; Harris {HAR00010159/2} page 2, paragraph 8. By the time he became involved in the refurbishment of Grenfell Tower Mark Harris had been involved in several projects on which ACM panels had been used.195 Harris {HAR00010159/2} page 2, paragraph 9; Harris {Day34/34:23}-{Day34/35:19}. Mr Harris told Bruce Sounes at Studio E in an email: "Over-cladding tower blocks is very much what we do…". He attached project information sheets for Castlemaine Tower, Chalcots Estate and Clements Court {SEA00007603} dated 25 April 2013.
¶50.52 Mike Albiston was Harley's senior estimator for the Grenfell Tower project. His main contribution was assisting in the production of Harley's tender for the work of designing and constructing the facade, which began in December 2013.196 Albiston {HAR00010151/3} page 3, paragraph 9.
¶50.53 Daniel Anketell-Jones had been engaged by Harley as a project engineer in November 2006197 Anketell-Jones {Day35/114:4-11}. and had been promoted to the role of design manager by the time Harley began work on the Grenfell Tower project.198 Anketell-Jones {Day35/114:4-11}. His main duties were to appoint a designer and monitor the progress of the design work until a project manager had been appointed. Between 2014 and 2017, while employed by Harley, he obtained an MSc in structural engineering and began studying for an MSc in facade engineering,199 Anketell-Jones {HAR00010149/2} page 2, paragraph 7. but he had not received any instruction in the fire performance of facades until after he had left Harley and his involvement in the Grenfell project had come to an end.200 Anketell-Jones {Day35/116:6-18}. During his time at Harley Daniel Anketell-Jones had been involved in a design capacity in two previous high-rise overcladding projects.201 Anketell-Jones {Day35/143:16}-{Day35/144:3} Ferrier Point and Little Venice. While working on the Grenfell Tower refurbishment he also worked on two other Harley projects.202 Anketell-Jones {Day35/125:12-14}; Anketell-Jones {HAR00010149/2} page 2, paragraph 9. Trinity Square and Compass House.
¶50.54 Ben Bailey is the son of Ray Bailey. He was employed by Harley as project manager for the Grenfell Tower refurbishment but had not been involved in that capacity on any previous project.203 Ben Bailey {HAR00010060/3} page 3, paragraph 9. He had worked for Harley from time to time while at school and university and had been taken on as a site manager following his graduation in 2013.204 Ben Bailey {Day39/3:25}-{Day39/4:6}. Until about May 2017, Ben Bailey continued to be involved intermittently in the Grenfell Tower project when maintenance requests or problems with snagging required attention.205 Ben Bailey {HAR00010060/3} page 3, paragraph 8. When he started work on the Grenfell Tower project Ben Bailey had no previous experience of managing the refurbishment of a high-rise residential building.206 Ben Bailey {Day39/12:4-9}.
38Harley's subcontractors
¶50.55 Harley engaged the following as sub-contractors: Kevin Lamb, to produce designs and construction drawings CEP Architectural Facades Ltd, to fabricate and supply ACM rainscreen cassette panels Osborne Berry Installations Ltd, to install the cladding.
¶50.56 Kevin Lamb was a self-employed designer of curtain walling and cladding, including glazing and rainscreen systems. He was engaged by Harley for the Grenfell Tower project in August 2014,207 Lamb {HAR00010419/3} page 3, paragraphs 12-15. having previously worked for it on one other project as a freelance draftsman.208 Lamb {HAR00010419/3} page 3, paragraph 12. Mr Lamb had previously produced preliminary schematic drawings for the Chalcots Estate refurbishment undertaken by Harley.209 Lamb {Day37/67:6-14}; Lamb {HAR00010419/3} page 3, paragraph 12.
¶50.57 CEP Architectural Facades Ltd (CEP) was appointed by Harley as a subcontractor to fabricate and supply the rainscreen panels and glazing units for the Grenfell Tower refurbishment. Geof Blades was a director from 2004 until 2013, when CEP was sold.210 Blades {Day41/5:12}. After that, he remained with the company as national glazing manager until 2016, when he became commercial projects manager. He retired in 2018.
¶50.58 CEP entered into six contracts with Harley between October 2014 and November 2015 for the fabrication and supply of rainscreen cladding panels and window units for Grenfell Tower.211 {CEP000000447}; {CEP000000469}; attaching {CEP000000470}; {CEP000000471}; {CEP000000472}; {CEP000000492}; {CEP000000512}; attaching {CEP000000513}; {CEP000000527}; {CEP000000528}; attaching {CEP000000529}; {CEP00053848}; {CEP000005833}; {RYD00040435}; {CEP000000616}; {CEP000000617}; {CEP000007550}; {CEP000001124}; {CEP000001168}. In addition, after Harley Curtain Wall had gone into administration, in September 2015 CEP entered into a contract with Rydon for the supply of Reynobond PE 55 panels.212 {CEP000000693}.
¶50.59 Osborne Berry Installations Ltd was established by Mark Osborne and Grahame Berry in 2002 as a corporate vehicle for their business of installing windows and cladding on buildings under construction or in the course of refurbishment.213 Berry {OSB000000084/1} page 1, paragraph 1. Osborne Berry had worked for Harley on many previous occasions and was engaged by Harley to install the facade, including the windows, cavity barriers, cavity wall insulation and the rainscreen panels.214 Berry {OSB000000084/1} page 1, paragraph 3; Ray Bailey {HAR00010184/24} page 24, paragraph 97; Berry {OSB000000084/2} page 2, paragraph 9; Berry {OSB000000084/3} page 3, paragraph 12; Berry {OSB00000091/9} page 9, paragraph 15; Osborne {OSB00000090/8} page 8, paragraph 15. Osborne Berry's package of work did not include refurbishment of the internal window reveals/internal window trimming. That work was undertaken by SD Plastering. Osborne Berry was also instructed by Harley to undertake some measurements of Grenfell Tower – see Osborne {Day43/88:14-21}; Osborne {Day43/89:1}-{Day43/90:3}; Osborne {Day43/92:11}-{Day43/93:1}; Berry {MET00019985/1-2}; Osborne {OSB00000090/4} page 4, paragraph 7. The company engaged self-employed fitters to carry out the work.
39¶50.60 There was no written contract between Harley and Osborne Berry215 Berry {OSB000000084/3} page 3, paragraph 12; Ray Bailey {Day33/178:22-25}. Osborne Berry had never had any standard terms in the past that ever formed the basis of Osborne Berry's contracts with Harley, Berry {Day44/15:6‑13}. and no document exists which sets out the terms on which Osborne Berry was engaged to carry out the work, the scope and content of that work, the standard to be applied or any programme for the works. Grahame Berry said that there may have been some conversations with Ray Bailey about a programme of works, but not about the quality or the standard of workmanship.216 Berry {Day44/13:4-19}; {Day 44/14:1-3}. Ray Bailey said that it was not uncommon for Harley to appoint subcontractors without any written contract.217 Ray Bailey {Day33/179:2-4}.
Other sub-contractors of Rydon
¶50.61 SD Plastering Limited (SDP) was incorporated in 2002. It was a company that mainly provided dry-lining services.218 Dixon {SDP00000196/2} page 2, paragraphs 6-7; Dixon {Day44/94:14-18}; Dixon {Day44/129:3-11}. Rydon sub-contracted a package of work to SDP, most of which comprised dry-lining, plastering, remodelling and ceiling works to the lower floors of the tower.219 Dixon {MET00056695}; Dixon {Day44/100:10-14}. In about February 2015, Rydon asked SDP to assist in designing the internal window linings and to carry out the work on the refurbishment of the internal window reveals.220 {RYD00032519}. Rydon subsequently sub-contracted the work on the internal window reveals of the newly refurbished windows to SDP.221 Dixon {SDP00000196/4-5} pages 4-5, paragraphs 19- 20; Dixon {SDP00000196/5}; {SDP00000189}; Cole {SDP00000220/3} page 3, paragraphs 15-16.
¶50.62 Rydon employed J S Wright & Co Ltd to carry out the mechanical and electrical works which included the design and supply of a new smoke control and ventilation system for Grenfell Tower. J S Wright employed PSB UK Limited to design and install the smoke control and ventilation system.
Building Control
¶50.63 Building control functions were carried out by RBKC's building control department. John Allen had joined RBKC as an assistant district surveyor in 1996. By the time he became involved in the refurbishment in 2012, he was Head of Special Projects and was subsequently promoted to Building Control Manager in September 2013.222 Allen {RBK00033930/1} page 1, paragraphs 2-3; He took voluntary redundancy in early June 2017 but was asked to carry on his role after the fire before leaving RBKC 2018, Allen {Day47/4:24}-{Day47/5:13}. He was directly involved in giving advice on the refurbishment in 2012 and 2013 before any application had been submitted. John Hoban took over responsibility for Grenfell Tower in about December 2013.223 {SEA00010232}. Between 2014 and 2016 as Mr Hoban's manager Mr Allen continued to be involved in the refurbishment and in due course the completion certificate for the refurbishment was issued in his name as Head of Building Control.224 Completion Certificate {RBK00018811}; Allen {Day47/187:10}-{Day47/188:2}.
¶50.64 John Hoban was a senior surveyor in RBKC's building control department between 1986 and March 2017, when he retired.225 {RBK00050415}. He holds BTEC ordinary and higher certificates in building studies. He worked as a junior technical officer in the Building Regulations division and from 1979 to 1986 as a technical assistant in the District Surveyor's office of the Greater London Council.226 {RBK00050415}; Hoban {Day45/10:7-24}. At the time of the refurbishment he was an associate member of the Chartered Association of Building Engineers.227 Hoban {Day45/12/24}-{Day45/13:9}. The refurbishment was the first project on which he had to deal with the overcladding of an occupied high-rise residential building.228 Hoban {Day45/91/3-7}.
40¶50.65 Paul Hanson was a senior building control surveyor (Fire Regulations) who acted as a consultant to the building control surveyors.
¶50.66 Jose Anon joined the building control department as a surveyor in 1989.229 Anon {RBK00029897/2} page 2, paragraph 6. In 2013 he was promoted to Deputy Building Control Manager.230 Anon {RBK00029897/2} page 2, paragraph 6. He was not involved in the refurbishment, save for one site visit on 17 April 2015.231 Anon {RBK00029897/8-9} pages 8-9, paragraphs 37-44.
41Chapter 51: The origins of the Grenfell Tower Project
Introduction
¶51.1 In this chapter we describe the background to the Grenfell Tower refurbishment project, including its origins and reasons, the establishment of the project team and the appointment of Studio E as architect.
The Kensington Aldridge Academy and Kensington Leisure Centre ("KALC") project
¶51.2 In 2009, the Royal Borough of Kensington and Chelsea (RBKC) instructed a design and planning consultant, Urban Initiatives Limited, to produce a report into options for the transformation of Notting Barns in North Kensington.232 Notting Barns South, Draft Final Masterplan Report, {IWS00002090/5}. The report proposed the demolition of Grenfell Tower due to the appearance of the building and the blight on its surroundings resulting from the way in which it met the ground and affected the area east of Latimer Road Station.233 {IWS00002090/19}. The report envisaged a new academy for the area and a new leisure centre.234 {IWS00002090/17}.
¶51.3 The report was presented to an RBKC cabinet working group in September 2009.235 {RBK00057224}. Rock Feilding-Mellen was then a backbench councillor who sat on the Public Realm Scrutiny Committee and was familiar with that report.236 Feilding-Mellen {RBK00033403/5} page 5, paragraph 18. Later, in 2012, when he held the portfolio for Civil Society,237 Feilding-Mellen {RBK00033403/5} page 5, paragraph 20. he became aware through a conversation with Cllr Timothy Coleridge of the proposal to refurbish Grenfell Tower and was concerned to know whether it would hinder or obstruct any future potential regeneration of the Lancaster West estate.238 Feilding-Mellen {RBK00054433/2} page 2, paragraph 5. Cllr Feilding-Mellen attended a meeting on 25 April 2012239 {RBK00028392}. with Cllr Coleridge and Laura Johnson, RBKC's director of housing, during which the refurbishment of Grenfell Tower and the effect of wider regeneration were discussed. Ms Johnson told Cllr Feilding-Mellen that there was an immediate need to decide whether to invest in Grenfell Tower and reassured him that such investment would not preclude the possibility of regenerating the wider estate in the future.240 Feilding-Mellen {Day131/138:15}-{Day131/139:16}.
¶51.4 In 2010 RBKC began work on the Kensington Aldridge Academy and Kensington Leisure Centre.241 Laura Johnson {RBK00034943/10} page 10, paragraph 44. The borough needed a new secondary school, for which RBKC had received a government grant. The school was to be located on the site of an existing leisure centre that was to be demolished and rebuilt as part of the same project. Together the work was known as the "KALC" project.242 Coleridge {RBK00033737/4} page 4, paragraph 21. A certificate of practical completion was issued on 13 November 2014.243 {RBK00068791}.
42¶51.5 Laura Johnson was the senior responsible officer for the project and oversaw the project managers in RBKC's property services team who managed it on a day-to-day basis.244 Laura Johnson {RBK00034943/10} page 10, paragraph 44.
¶51.6 In September 2011, Studio E won the commission advertised by RBKC in the Official Journal of the European Union ("OJEU") for the design of the KALC project.245 Kuszell {Day6/31:10-23}. This was a competitive procurement exercise. Studio E retained the services of specialist fire engineers Exova as sub-consultant.246 Kuszell {Day6/36:3-16}.
The reasons for the refurbishment of Grenfell Tower
¶51.7 RBKC recognised that the KALC project would be disruptive to residents of Grenfell Tower and consequently a KALC Residents Forum was set up, chaired by the RBKC Cabinet Member for Housing and Property, Cllr Timothy Coleridge. It first met on 18 July 2011247 Coleridge {RBK00064251/2} page 2, paragraph 5. and was usually attended by Cllr Coleridge, Laura Johnson, local residents and, on occasions, the KALC architects or contractors.248 Coleridge {RBK00033737/4} page 4, paragraph 22. The local residents who attended included some living in Grenfell Tower who were unhappy that KALC was being built while Grenfell Tower and the wider Lancaster West Estate was in need of refurbishment.249 Coleridge {RBK00033737/4-5} pages 4-5, paragraph 22.
¶51.8 In December 2011 Cllr Coleridge was invited to visit the flat of a resident of the tower, Edward Daffarn.250 Coleridge {RBK00064251/2} page 2, paragraph 4. He saw that the windows were very poor and single-glazed. Mr Daffarn told him that because the hot water was on all the time the flat was very hot in the summer but that it was very cold in the winter due to the lack of good insulation. Cllr Coleridge felt that something should be done for the residents of the tower and hoped that the rest of the Lancaster West estate could be refurbished in the long term.251 Coleridge {RBK00033737/5} page 5, paragraph 23. Grenfell Tower had seen no significant investment for 30 years.252 Coleridge {RBK00064251/3} page 3, paragraph 7.
¶51.9 At about the time the KALC project was being undertaken, RBKC developed and sold basement space at Elm Park Gardens in Chelsea. The sale resulted in surplus capital receipts initially to the value of about £6 million.253 Coleridge {RBK00033737/4} page 4, paragraph 20. In late 2011, when RBKC knew that that money would become available, Cllr Coleridge raised with Laura Johnson the possibility that the funds might be used to improve Grenfell Tower.254 Coleridge {RBK00064251/3} page 3, paragraph 8.
¶51.10 A meeting took place on 1 November 2011 between Jane Trethewey, RBKC's Housing Strategy and Regeneration Manager, and representatives of the TMO, including Mark Anderson, the TMO's Interim Director of Asset Investment and Engineering. At that meeting the effect of the KALC project on Grenfell Tower and the Lancaster West estate was discussed. In an email sent by Jane Trethewey of RBKC to Laura Johnson the following day, Ms Trethewey said that the TMO was keen to investigate the opportunity to overclad Grenfell Tower and replace its windows, which would have the advantage of improving one of its worst properties and preventing it looking like a poor cousin to the new facility being developed next door.255 See the email from Jane Trethewey to Laura Johnson on 2 November 2011, containing a summary of the discussion – {TMO10000965/3-4}. It was also suggested that a cladding design might be chosen which corresponded to the design of KALC, thereby improving the overall visual appearance of the area.256 As above.
43¶51.11 That is the first record we have found of any discussion of the possibility of cladding Grenfell Tower. In his evidence Mark Anderson said that the thermal efficiency of the building had been discussed at that time but not cladding as such,257 Anderson {Day52/44:22}-{Day52/45:2}. but the emails recording the discussion258 {TMO10000965/3}. and Laura Johnson's evidence suggest otherwise. She said that the primary motivation at that time for considering cladding had been the building's appearance259 Johnson {Day128/34:23}-{Day128/35:1}. and accepted that RBKC had no reason to think that the thermal efficiency of the tower was poor enough to justify the cost of cladding.260 Johnson {Day128/35:3-8}. Laura Johnson said that she was probably the person who first mentioned the idea of cladding Grenfell Tower to the KALC project architects, Studio E.261 Johnson {Day128/47:15-18}.
¶51.12 On 12 December 2011 Mr Anderson sent Ms Johnson an email containing indicative costings for cladding the tower.262 {RBK00002335}. The costings came from Hunters & Partners Ltd, a firm of architects, quantity surveyors and building consultants who had been recommended to the TMO by RBKC, and were intended by Mr Anderson to give an indicative budget for the overall cost of the project.263 Anderson {Day52/46:21}-{Day52 47:7}. The assumptions behind the costings included using a rainscreen cladding incorporating an insulated panel. According to Mr Anderson, that assumption originated from Hunters.264 Anderson {Day52/48:1-6}.
¶51.13 Mr Anderson prepared a report265 {TMO10001001/110-112}. for the meeting of the TMO's Operations Committee on 31 January 2012,266 {TMO10001001}. the purpose of which was to advise the committee that RBKC might make funding available for significant regeneration. In that report Mr Anderson advised the committee that cladding Grenfell Tower and providing it with new windows would address the TMO's need for investment in the building; he also told it that the KALC and Grenfell Tower projects would be procured jointly.267 {TMO10001001/112}.
¶51.14 On 9 February 2012 a housing digest meeting took place between RBKC and TMO. The purpose of such meetings was to provide an opportunity for the member of the RBKC cabinet holding the housing portfolio, at that time Cllr Coleridge, to meet the TMO and discuss important aspects of its delivery of the council's housing strategy and investment.268 Anderson {Day52/49:5-14}. At that meeting there was detailed discussion about the proposed work to Grenfell Tower and it was noted that any new windows and cladding should reflect or complement KALC. Officers were planning to appoint Studio E to draw up a detailed design plan which was intended to provide the benefit of economies of scale and ensure that the two projects complemented each other.269 {RBK00033739}.
44¶51.15 Mark Anderson said that by that stage a decision had been made that cladding Grenfell Tower was also the route to achieving greater thermal efficiency. He said that the repeated use of the words "reflect" and "complement" in relation to the KALC project indicated a genuine desire on the part of RBKC not only to improve the Lancaster West estate in general and Grenfell Tower in particular, but also to ensure there was synergy between the two projects.270 Anderson {Day52/50:21}-{Day52/51:4}. He said that there had been a desire to give a good feeling about the Grenfell Tower refurbishment project and convey a message that North Kensington was receiving some very serious investment.271 Coleridge {RBK00064251/10} page 10, paragraph 27. Mr Coleridge also said that it had been clear that any insulation for the building would require a rainscreen of some sort, which would change the look of the building and could only improve its general appearance. It had been his view that, if it were decided that Grenfell Tower needed to be insulated, a fresh look at the exterior would be welcome.272 Coleridge {RBK00064251/10} page 10, paragraph 27. He had thought it a reasonable assumption that metal sheeting would be used as a rainscreen, which would result in a clean and contemporary look.273 Coleridge {RBK00064251/6} page 6, paragraph 17.
¶51.16 In the light of that evidence, we are satisfied that the initial motive for cladding Grenfell Tower was to improve its visual appearance and to prevent its looking like a poor relation to the KALC development next door. RBKC in particular wished to ensure that the significant investment involved in the refurbishment resulted in a visible legacy. The desire to improve the thermal efficiency of the building was a later consideration, driven in part by Cllr Coleridge's meeting with Mr Daffarn in late 2011. As Laura Johnson admitted, other than residents' complaints about the windows, RBKC did not have any independent evidence that the thermal efficiency of Grenfell Tower was so poor that it needed overcladding.274 Johnson {Day128/32:15} – {Day128/33:6}.
Funding the Grenfell project
¶51.17 Mr Anderson prepared a further report on the tower for a meeting of the TMO board on 29 March 2012.275 {TMO10001095}. In it he recommended that the board approve the submission of a Housing Revenue Account (HRA)276 The Housing Revenue Account (HRA) was used by RBKC and the TMO to account for housing income and expenditure. It was used for day-to-day repairs, planned and major works and all other costs relating to RBKC properties managed by the TMO. See, for example, Johnson {RBK00034943/3} page 3, paragraph 10 and Matthews {TMO00873380/10} page 10, paragraph 36. Regeneration Bid for Grenfell Tower in the sum of £6 million (excluding VAT) together with the appointment of the members of the existing KALC design team to undertake the detailed development of the project.277 {TMO10001095/4}. He informed the board that RBKC had already appointed professionals for the KALC project and proposed that, subject to due diligence and legal compliance, they also be appointed to undertake the work on the Grenfell Tower project, subject to a dispensation from the full TMO Contract Regulations.278 See paragraphs 5.2 and 5.3 {TMO10001095/3}. The Royal Borough of Kensington and Chelsea Tenant Management Organisation Ltd Contract Regulations were approved by the TMO board on 26 May 2011 {RBK00000762}. Those Regulations provided the framework for the procurement by the TMO of goods, works and services. They were intended to ensure propriety, compliance with statutory and other regulatory frameworks, and the proper use of financial resources. They required a competitive tendering process in accordance with the regulations for any contract with a value in excess of £25,000, see {RBK00000762/7} paragraph 6.04. His recommendation was accepted by the TMO board, which unanimously agreed to the submission of the bid and the appointment of the KALC consultant team for the project. The board also agreed to dispense with the TMO Contract Regulations guidelines for that appointment.279 {TMO00847333}.
45¶51.18 Following that approval, the RBKC cabinet met on 2 May 2012 to consider a report prepared by Laura Johnson on the use of the funds derived from the sale of basements at Elm Park Gardens.280 {RBK00029027}. The report recommended that they be set aside for investment in renovation, regeneration and conversion works to Grenfell Tower.281 {RBK00029027/8} paragraph 6.3.3. The cabinet accepted that recommendation.282 {RBK00047482}. Consequently, RBKC funded the Grenfell Tower project and had oversight of how it was undertaken.283 Laura Johnson {Day128/9:5-12}.
47Chapter 52: The appointment of Studio E
¶52.1 Although the TMO appointed other professionals engaged on the KALC project to act on the Grenfell Tower project (Artelia, Curtins, Max Fordham and Exova), at this stage we concentrate on Studio E's appointment because it provides some context in which to judge its performance. It also illustrates the TMO's general approach to the appointment of its professional team, which was to prioritise saving cost over other considerations.
¶52.2 Peter Wright284 Project Manager for Capital Projects in RBKC's Corporate Property Department. met Andrzej Kuszell, one of the founding directors of Studio E and lead partner on the KALC project, on 9 December 2011 at RBKC Town Hall to discuss the Grenfell Tower refurbishment.285 Kuszell {SEA00014271/9} page 9, paragraph 34; {TMO10000965/4}. The agenda for that meeting included a review of the scope of the works to be carried out,286 {SEA00003557} at Item 2. although Mr Kuszell told us that it was not certain that the works to the tower would be commissioned and that he had understood it to be merely an exploratory meeting.287 Kuszell {Day6/43:18-25}.
¶52.3 Mark Anderson's recollection was that the TMO had formally engaged Studio E in February 2012.288 Anderson {Day52/59:16-19}. He said that RBKC had expressed a strong desire for the TMO to make use of the original KALC professional team, which included Studio E and Artelia.289 Anderson {Day52/60:2-7} Artelia was previously known as Appleyards. He said that the drive to use the KALC team had come from the portfolio holder, who at that time was Cllr Coleridge, and also from all the RBKC officers with whom he had had dealings.290 Anderson {Day52/60:17-22}. Mr Anderson said that he had not been told that the TMO was required to use that team, but there had been a very strong message that that was RBKC's earnest wish.291 Anderson {Day52/61:16-22}. Mr Anderson said that he thought the TMO would have been challenged by RBKC if it had not instructed them.292 Anderson {Day52/61:1-4}.
¶52.4 Laura Johnson said that she was aware that such a wish might have been expressed by RBKC293 Johnson {Day128/59:2-14}. and that the dominant reason for using the same professional team had been to harmonise the appearance of the two projects and co-ordinate them so that there was an understanding of how they were to work together.294 Johnson {Day128/60:6-14}. Like Mr Anderson, she accepted that the TMO would have been challenged by RBKC if it had decided not to use the KALC team.295 Johnson {Day128/63:10-14}
¶52.5 Grenfell Tower was Studio E's first residential high-rise cladding project and yet Mr Anderson told us that no steps had been taken before it was appointed to find out whether it had any experience of a project of that kind.296 Anderson {Day52/64:5-9}; Kuszell {Day6/63:16-20}. He accepted that that was an obvious question and could not explain why no one had asked it.297 Anderson {Day52/64:10-11}.
48¶52.6 The first formal communication from the TMO to Studio E, which set out the TMO's requirements for Grenfell Tower, was sent by Mark Anderson to Andrzej Kuszell on 29 February 2012.298 {SEA00000007/1-2}. Mr Anderson identified the principal objectives of the project and stated that the work would be separate from, but complementary to, the KALC project. He also said that it must not in any way compromise the KALC project, by which he meant that RBKC did not want the Grenfell project to impede the KALC project.299 Anderson {Day52/91:20-25}.
¶52.7 Mr Anderson went on to state that all commissions on the project would be paid by the TMO and were subject to OJEU limits. He accepted that his intention in saying that was to direct Studio E to produce a fee estimate that would fall below the financial threshold for services contracts300 See Regulation 8 of the Public Contracts Regulations 2006 (as amended). in order to avoid a public procurement process.301 Anderson {Day52/92:20}-{Day 52/93:4}. Mr Anderson said that no discussion had taken place at that time with Studio E regarding the OJEU limit or the effect it would have on Studio E's fees.302 Anderson {Day52/93:21}-{Day 52/94:8}. He recalled a discussion about OJEU limits with Bruce Sounes on 6 March 2012 and agreed that they effectively capped Studio E's fees, but he also said that there had been no indication from Studio E or from any other members of the professional team that they saw it as a cap or that their fees were likely to approach it.303 Anderson {Day52/96:1-8}.
¶52.8 The Studio E witnesses, on the other hand, told us that they had been concerned about the capping of their fees at the OJEU limit.304 Kuszell {Day6/71:4-24}; {SEA00003567}. Mr Anderson sent his email of 29 February 2012 to Bruce Sounes305 {SEA00000007}. as well as Andrzej Kuszell, which prompted a discussion within Studio E about the challenge which the limit on the level of fees would present for the project. Mr Sounes replied directly to Mr Kuszell that evening saying that he was concerned about the emphasis of working at risk (i.e. pending a formal agreement) while also being subject to OJEU limits.306 {SEA00003567}. On 7 March 2012 Mr Sounes mentioned to Mr Kuszell that he (mistakenly) thought the OJEU limit was £99,000, which Mr Kuszell said in his reply would be "problematic".307 Kuszell {SEA00014271/12} page 12, paragraph 44; {SEA00014272/2}. Mr Kuszell told the Inquiry that he had thought that even a limit of £174,000 would result in Studio E doing more work than the fee would cover.308 Kuszell {Day6/87:13-19}. Mr Sounes also thought the overall fee to deliver the project would be more than £174,000,309 Sounes {SEA00014273/32} page 32, paragraph 63. but there is no evidence that either he or Mr Kuszell raised their concerns with the TMO.310 Sounes {Day7/38:23}-{Day7/39:7}.
¶52.9 On 12 June 2012 Bruce Sounes sent Mr Anderson a fee proposal and draft letter of appointment.311 {SEA00004561}; Bruce Sounes chose to put forward the RIBA standard form contract terms. Sounes {Day7/56:7}-{Day7/57:4}; The covering letter {SEA00004562} attached: The RIBA Standard Conditions of Appointment for a Consultant (2010) {SEA00004571}, The Standard Conditions of Appointment for an Architect Amendment 1 (1 October 2011) {SEA00004564}, A Memorandum of Agreement {SEA00004570} and appendices A-E {SEA00004565}, {SEA00004566}, {SEA00004563}, {SEA00004567}, {SEA00004568}, {SEA00009827}. The proposal was for Studio E to provide architectural services under the Standard Conditions of Appointment for a Consultant (2010) published by the Royal Institute of British Architects (RIBA). (We refer to these as the RIBA Standard Terms.) However, no agreement was signed at that stage and in the event discussions about the terms on which Studio E was to be appointed continued until November 2013.312 Sounes {Day7/57:8-25}; {SEA00009820}. Both parties contemplated that the refurbishment would be carried out under a design and build contract and that if Studio E were appointed by the TMO as architect its services would in due course be transferred to the principal contractor by what is known as a "novation".
49¶52.10 The proposal was for a fee of £323,000 for all stages of the work (including work to be done after the novation) but only £161,000 for the work to be done before the novation that the TMO had said should be subject to OJEU limits.313 {ART00000148}. Although Mr Sounes attempted to persuade us that it was a fairly typical breakdown of fees314 Sounes {Day7/42:7}-{Day7/43:17}., Artelia advised the TMO in a meeting on 18 July 2012, attended by Mr Sounes, that working to OJEU limits would probably involve deferring some of Studio E's fees to the period after novation, when the contractor would become liable for them.315 {ART00000168}; Sounes {Day7/44:14-18}.
¶52.11 In the event, that is exactly what happened. Studio E produced a further fee proposal on 27 July 2012 which showed the fees for the pre-novation design work as £190,000.316 {SEA00007386} under the Studio E tab of the spreadsheet. However, in his covering email to the TMO Mr Sounes proposed deferring 50% of all Stage D fees to keep the total Stage D fee below £174,000.317 {ART00000981}.
¶52.12 The TMO board met on 15 November 2012. In advance of that meeting Mr Anderson prepared a report on the Grenfell Tower project,318 {TMO10001766/90}. in which he advised the board that the design team had been engaged by the TMO under its own contract regulations. He also told the board that the fees had been capped at the EU procurement threshold of £174,000 because the procurement process for the design team on KALC did not cover the Grenfell Tower Regeneration project.319 {TMO10001766/91} paragraph 5.2. That represented a change from the position he had reported to the board in March 2012.320 {TMO10001095/3} paragraph 5.2. The report went on to state that the novation of the Grenfell Tower design team to Leadbitter (the principal contractor for KALC and at that time the proposed principal contractor for the Grenfell Tower project) after the planning stage would be compliant with EU procurement rules because the Grenfell Tower project had been included in the OJEU notice relating to the KALC project.321 {TMO10001766/91} paragraph 5.3. However, that statement was wrong, as no mention of the Grenfell Tower project had been made in the OJEU Notice relating to the KALC project.322 {TMO10005215}; {RBK00068762}.
¶52.13 By December 2012, Studio E had already issued invoices totalling £174,000 and had stopped invoicing the TMO because it had, in Bruce Sounes' words, "reached the OJEU threshold".323 Sounes {SEA00014273/78} page 78, paragraph 162. It follows that Studio E's fees were always going to exceed the OJEU limit and the capping of its fees by the TMO was a way of avoiding a competitive procurement exercise for design services on the project.
¶52.14 The appointment of Studio E as architect for the project involved no element of competitive procurement whatsoever.324 Anderson {Day52/73:22-25}; Kuszell {Day6/64:22-25}. No member of the firm was interviewed as part of a competitive procurement and there was no design competition.325 Kuszell {Day6/65:1-6}. Mr Anderson said he had thought that, because the OJEU notice published for the KALC project had included the term "housing regeneration", the TMO could rely on the outcome of that exercise to appoint Studio E for the Grenfell Tower project, even though that project had not been mentioned in the notice.326 Anderson {Day52/70:15-23}. He also told us that he had asked the council's legal department and those responsible for procurement whether he could rely on the procurement process for the KALC project to appoint the same professional team for the Grenfell Tower project and was told that he could.327 Anderson {Day52/78:25}-{Day 52/79:9}. However, he did not receive confirmation of that advice in writing and in due course it changed.328 Anderson {Day52/79:10-16}. It is hard to see how Mr Anderson could possibly have thought that it was permissible for the TMO to rely on the procurement process undertaken by RBKC for the KALC project to justify its appointment of Studio E on the Grenfell Tower refurbishment, but if he did, he was obviously mistaken.
50¶52.15 On 11 November 2013, Bruce Sounes sent Peter Maddison by email a revised set of contractual documents.329 {SEA00009820}; The family of updated contract documents are {SEA00009821}; {SEA00009822}; {SEA00009823}; {SEA00009824}; {SEA00009825}; {SEA00009826}; {SEA00009827}; {SEA00009828}; {SEA00009829}; {SEA00009830}; and {SEA00009831}. The RIBA Standard Terms were not included in the attachments, but Mr Sounes confirmed that they were the terms on which he was proposing that Studio E be engaged and we are satisfied that that is how the proposal was understood by Mr Maddison.
¶52.16 By 20 November 2013 the terms of Studio E's appointment appear to have been agreed in principle330 {SEA00009993}; Sounes {Day7/58:3-12}. but Mr Sounes could not recall whether a letter of appointment had ever been signed and Studio E was unable to find a copy of an agreement.331 Sounes {Day7/58:3}-{Day7/59:4}; {Day7/60:18-21}; Sounes {SEA00014273/11} page 11, paragraph 26. Given the inability of either party to produce a signed copy of the terms of appointment, we think it very unlikely that a formal written agreement between Studio E and the TMO was ever signed. That does not matter for present purposes, because both parties accept that a contract came into existence between them incorporating the RIBA Standard Terms.332 Sounes {Day7/61:16}-{Day7/62:19}; {Day7/79:2}-{Day7/80:5}; {Day7/80:9-19}. However, it demonstrates a casual approach to the establishment of contractual relations which we have found to exist in relation to other aspects of the refurbishment and which appears to be widespread in the construction industry. In our view a more rigorous and careful approach at all levels would significantly reduce the risks of disagreement about where responsibility for important matters lies.
¶52.17 In the Schedule of Services in Appendix B to the contract documents, Studio E was designated as lead consultant and lead designer for RIBA Stages A to L of the project,333 {SEA00009824/2}. a position that was confirmed by Mr Sounes in a letter to the TMO in November 2013.334 See letter {SEA00009821} and attached contract documents {SEA00009822} and {SEA00009824/2}. In the light of the documents and Mr Sounes' evidence, it is clear to us that Studio E was appointed as lead consultant. As such, it had a duty to advise on the need for, and the scope of services to be provided by, consultants, specialists, sub-contractors or suppliers and to monitor the work of other consultants.335 See Appendix B: Schedule of Services {SEA00009824/5} sent by Bruce Sounes to Peter Maddison on 11 November 2013. The version sent to Mark Anderson on 12 June 2012 also says the same thing {SEA00004566/5}. Bruce Sounes agreed that these services were part of Studio E's role as Lead Consultant. Sounes {Day7/80:9-19}.
51¶52.18 The RIBA Standard Conditions obliged Studio E to exercise reasonable skill, care and diligence in accordance with the normal standards of the architectural profession when performing its services.336 {SEA00004571/4}. See Condition 2.1 under the subheading 'Duty of Care'. Bruce Sounes confirmed that this condition was consistent with the standard of service required by Studio E's professional indemnity insurance. Sounes {Day7/61:16} – {Day7/62:7}; {Day7/79:24}-{Day7/80:5}; {Day7/80:9-19}.
¶52.19 Studio E did not have any previous experience of providing architectural services in respect of the refurbishment and cladding of an existing residential high-rise building.337 Kuszell {MET00019989/3} page 3; Kuszell {SEA00014271/4-5} pages 4-5, paragraph 17; Sounes {SEA00014273/32} page 32, paragraph 64; Kuszell {Day6/80:5-15}. The process of appointing Studio E as architect for the Grenfell Tower project did not require it to demonstrate that it had the relevant skills, knowledge or experience for such a project.338 Kuszell {Day6/64:14-21}. Mr Sounes said that Studio E had not held itself out as having any such experience,339 Sounes {Day6/194:6-20}. but neither Mr Kuszell nor Mr Sounes could remember ever having informed the TMO or Artelia that it did not have experience of high-rise projects or cladding. Thus, by failing for purely financial reasons to follow the proper procurement process, the TMO deprived itself of the opportunity to appoint a firm of architects with relevant skills, knowledge and experience.
¶52.20 In his email to Mr Kuszell dated 29 February 2012 Mr Sounes described Studio E as a "little green on process and technicality". He therefore suggested "some rapid CPD" (i.e. continuing professional development).340 {SEA00003567/1}; Sounes {SEA00014273/32} page 32, paragraph 64. Mr Sounes said that by "green on process" he had meant to refer to the logistics of undertaking work on an occupied building.341 Sounes {Day6/185:24}-{Day6/186:4-5}. He had noted that overcladding the building formed part of the work, which had struck him as a challenge. He said the challenge lay in the fact that the building was to remain occupied during the work, rather than in the cladding work itself.342 Sounes {Day6/186:22-25}; {Day6/187:1-7}; {Day6/192:12-14}. By "rapid CPD", Mr Sounes said that he had meant nothing more than a consultation to understand the feasibility of how the work could be done, which he said he had undertaken with an employee of Max Fordham, the mechanical and electrical engineers engaged on KALC.343 Sounes {Day6/188:5-8}; {Day6/189:10-12}; {Day6/190:2}-{Day6/191:9}; {Day6/192:18-25}; Sounes {SEA00014273/32} page 32, paragraph 64. Mr Sounes said that his initial concerns about taking on the project had been allayed344 Sounes {Day6/192:15-16}. and that despite his initial uncertainty he had been satisfied that Studio E had the experience and expertise necessary to take on the work being discussed at that stage.345 Sounes {SEA00014273/32} at paragraph 64. He agreed that he had decided that it was possible for him to learn on the job as the project proceeded.346 Sounes {Day6/194:3-5}.
¶52.21 Mr Kuszell accepted that it was necessary for Studio E to carry out some continuing professional development and to conduct research to identify the various challenges the project might throw up,347 Kuszell {Day6/74:15-17}; {Day6/77:21-23}. but he said he had had no reason to believe that the firm was not competent and adequately resourced to do that.348 Kuszell {Day6/76:17-23}. He said that Studio E had experience of undertaking complex projects for the first time and that he had no reason to doubt that it would do the research necessary to do the project properly.349 Kuszell {Day6.75:15-21}; {Day6/76:2-6}; {Day6/80:21-24}.
52¶52.22 Both Mr Kuszell and Mr Sounes accepted that, given Studio E's lack of relevant experience, if a competitive procurement process for architectural services had been undertaken in relation to the Grenfell Tower project, it was unlikely that Studio E would have qualified for appointment.350 Kuszell {Day6/70:10-16}; Sounes {SEA00014273/32} page 32 paragraph 63; Sounes {Day6/196:13}-{Day6:197:23}.
53Chapter 53: Planning the refurbishment
Initial design team meeting: April 2012
¶53.1 The Grenfell Tower refurbishment began life as an independent project on 19 April 2012 with an initial design team meeting attended by Studio E, Max Fordham and Leadbitter.351 {ART00000013}. Artelia was also present as a potential consultant for the TMO, having acted as employer's agent and quantity surveyor for the KALC project.352 Cash {ART00006544/5-6} pages 5-6, paragraph 16. Simon Cash was designated project director for the refurbishment, the most senior position with overall responsibility for the delivery of Artelia's services.353 Cash {Day47/210:21-23}. The purpose of the meeting was to introduce the project, to set out in broad terms its scope and objectives and to discuss costs and funding. The TMO indicated that it would request a budget of £6m from RBKC for the full cost of the works.354 {ART00000013/4} item 5.0.
¶53.2 On 2 May 2012 Simon Cash wrote to Mark Anderson of the TMO offering to perform quantity surveying, employer's agent and CDM co-ordinator (CDM-C) services for the refurbishment.355 {ART00000301}. This letter attached documents including: the RICS standard form of Quantity Surveyor Services; the RICS standard from of Employer's Agent Services and a printed list of services stated to be a summary of the duties of a CDM-C under the CDM Regulations 2007. The letter appended RICS standard forms of contract for employer's agent and quantity surveying services356 {ART00000301/7}; {ART00000301/17}. These documents listed specific functions which Artelia selected by marking tick boxes. and a list of CDM-C services.357 {ART00000301/24} stated to be a summary of the statutory duties of CDM-C.
¶53.3 On 21 August 2012 Mark Anderson confirmed that the TMO wished to appoint Artelia to carry out those functions on the terms outlined in its proposal of 2 May 2012 under the standard RICS standard terms. Although the parties did not sign a contract at that time,358 Cash {Day47/213:24}-{Day47/214:2}. both appear to have acted on the basis that they were contractually bound on the terms set out in Artelia's proposal. Eventually, on 23 June 2014, Artelia and the TMO executed a formal deed of appointment incorporating the RICS standard terms.359 {ART00005742}. The Schedule of Services stated that Artelia would perform the roles of quantity surveyor, employer's agent and CDM co-ordinator.360 {ART00005742/23}.
Artelia's cost budget estimates in 2012
¶53.4 A second design team meeting was held on 24 May 2012.361 {ART00000038}. At that meeting Chweechen Lim, a quantity surveyor employed by Artelia, was instructed to prepare a cost budget estimate for the project.
54¶53.5 Between June and December 2012 Chweechen Lim prepared several cost budgets for the TMO under the supervision of Simon Cash.362 Lim {ART00005817/5} page 5, paragraph 15; Cash {Day48/2:5-6}. The estimates were based on information provided by the primary designers of the project, Studio E, Curtins Consulting and Max Fordham363 Cash {Day48/130:24}-{Day48/131:1}. and ranged from £7,803,000 to £9,645,000.
¶53.6 The first estimate in 2012, which costed the project at £7,803,000, was presented at the third design team meeting on 7 June 2012.364 {ART00000079}. At that meeting Mark Anderson, then interim Director of Asset Investment and Engineering at the TMO, indicated that he was content with the projected cost. He confirmed that RBKC's funding was £6 million, but that he expected further funds to be made available from the TMO's capital programme.365 {ART00000079/1} The TMO Capital Programme was an RBKC-funded investment programme for works to improve residences.
¶53.7 During 2012 the estimated total cost of the project changed several times, increasing by December 2012 to £9,645,000. The changes were attributable to a number of factors, including changes to the scope of the works and corrections of errors in measurements.
¶53.8 After June 2012, none of Artelia's estimates were within the budget available to the TMO, a fact not lost on those involved in the project. In mid-September 2012, after Ms Lim had costed the project at £9,280,000,366 In Estimate 3 Rev 1 {ART00005913}. both Artelia and Studio E told the TMO that either the budget must increase, or savings must be achieved, whether by reducing the scope of the project or through "value engineering".367 {ART00005879}; {ART00005783}; {ART00006081}. In theory, "value engineering" involves making changes to the design or specification that reduce cost without sacrificing performance,368 Hyett, Specialist Report {PHYR0000028/13} section 3.3.21 quoting the definition of value engineering in the RIBA Stage Guide 2015. but in our view it is in practice little more than a euphemism for reducing cost, because substituting a cheaper product for a more expensive one or altering the design or scope of the work in a way that reduces cost almost invariably involves a compromise of some kind, whether in content, performance or appearance. Certainly, in the present case the expression was being used by the parties simply to mean changes that would lead to a reduction in cost.
Leadbitter's proposed appointment
¶53.9 At the outset of the Grenfell refurbishment project, and throughout 2012, the TMO had planned to engage Leadbitter Group ("Leadbitter"), the principal contractor for the KALC project, using the IESE ("Improvement and Efficiency in the South East") framework agreement, which was a legitimate alternative to a full procurement exercise.369 Anderson {Day52/73:13-21}; Anderson {TMO00847334/2} page 2, paragraph 8. Accordingly, representatives of Leadbitter were present at most of the Grenfell project meetings in 2012 and were on the distribution list for the minutes. Leadbitter became involved in some activities, including preparing a programme of works370 Minutes of meeting 5 {ART00000169}, item: "Programme". and conducting site inspections.371 Minutes of meeting 10 {ART00000489}, item: "Contractor". However, retaining Leadbitter was not uncontroversial within the TMO and the minutes of a meeting of the TMO board on 24 May 2012 record that it needed to be persuaded that using Leadbitter was in the TMO's best interests.372 {ART00000038/1} item 1.00. Efforts by Mark Anderson to persuade the TMO board to appoint Leadbitter continued until at least November 2012,373 TMO Board meeting minutes, 15 November 2012, {TMO10001766/90-93}. but although it authorised the TMO to enter into a pre-construction agreement with Leadbitter,374 TMO Board meeting minutes, 15 November 2012 Part B {TMO00883922/2-3} item 2. the TMO failed to do so, probably because RBKC and Leadbitter had been unable to agree a final cost for the KALC project, as explained below.
55¶53.10 At the beginning of 2013, RBKC and Leadbitter were negotiating the final account for the KALC project, but they were finding it difficult to reach agreement.375 Laura Johnson {Day128/116:3-16}. On 3 January 2013, Laura Johnson sent an email to Cliff Thomas of Leadbitter telling him that in view of the continuing failure to agree the final account for KALC, RBKC would no longer be recommending that the TMO appoint Leadbitter on the Grenfell Tower project and would advise it to invite tenders from a list of contractors that did not include Leadbitter.376 {ART00000637}.
¶53.11 Although Ms Johnson was the senior responsible officer for the KALC project, she was not the senior responsible officer for the Grenfell Tower refurbishment. Nor was anyone else at RBKC, because the refurbishment was a TMO project and RBKC had no power to decide which contractors the TMO should appoint to deliver its projects.377 Anderson {Day52/28:11-22}. Nevertheless, that did not stop her trying to use Leadbitter's interest in the Grenfell Tower project as a means of putting pressure on it to agree the final account for the KALC project.378 Laura Johnson {Day128/118:25}-{Day128/119:1-2}. Ms Johnson took the precaution of sending a copy of her email to Mark Anderson of the TMO so that he would see that RBKC, as the TMO's funder, was seeking to apply pressure to Leadbitter in that way. Although Artelia had also received a copy of Ms Johnson's email to Leadbitter, it nonetheless continued to hold discussions with Leadbitter about the cost of the refurbishment because the TMO was Artelia's client and the TMO wanted Artelia to carry on negotiating with Leadbitter.379 Cash {Day48/152:9-19}.
¶53.12 Despite the advice from Artelia and Studio E to increase the budget or achieve savings, the estimated cost of the project continued to rise. The TMO had wanted to enter into a contract with a principal contractor for the refurbishment works by 8 January 2013380 As recorded in the minutes of the 22 November 2012 meeting {ART00006750} item 2.2. and therefore by December 2012 there was a pressing need to agree a fixed sum for the project with Leadbitter, which at that time was still expected to be the principal contractor.381 {ART00000633/4}.
Discussions between Leadbitter and Artelia: January–April 2013
¶53.13 The IESE framework provided for a two-stage mini-tender procurement process for use by public bodies in the south-east of London. The first stage of the process was the selection of a contractor from eight on the framework list; the second was negotiating with that contractor to agree a price.382 Lim {ART00009428/10} page 10, paragraph 27. As Leadbitter had already been selected at the outset of the Grenfell Tower project, the IESE process effectively began with negotiating the contract price.
¶53.14 However, even before discussions had started, Leadbitter indicated that it considered Artelia's cost estimate for the project to be £2 million too low.383 {ART00008469} item 3. In January 2013, one of its quantity surveyors, Mohit Kotecha, estimated the cost at £12.6m.384 Kotecha {LBI00003938/3} page 3, paragraph 9. Between January and April 2013, Ms Lim and Mr Kotecha exchanged assessments of the cost of the project, commenting on each other's calculations in detail. They also met in person several times.385 For example: 17 January 2013 {ART00006072/2}; Lim {ART00005817/14} page 14, paragraph 52; and 25 March 2013 {ART00006018}; {ART00006074}. Both Artelia and Leadbitter adjusted their assessments as a result, having taken into account a number of factors, including some value engineering options.386 {ART00006072}.
56¶53.15 Artelia attempted to test its cost assessments by approaching various contractors who had procurement framework agreements with RBKC.387 {ART00001005}; {ART00009101/18}. At the suggestion of Peter Maddison, Director of Assets and Regeneration at the TMO,388 Maddison {Day58/178:19}-{Day58/179:1-4}; {RYD00001115}. in April 2013 Artelia also approached Rydon, even though it was not included in any available framework agreements.389 {ART00008995}; {ART00008434}; {ART00009105}. Although it was not unusual for potential competitors to be asked to provide information for the purpose of checking costs,390 Lim {ART00009428/17} page 17, paragraph 49. none of the contractors approached for that purpose did so.
¶53.16 Leadbitter's costings drew attention once again to the main difficulty facing the TMO, namely, the inadequacy of its budget. Both Ms Lim and Mr Kotecha, the professional quantity surveyors in the best position to assess the costs, agreed that they exceeded the funds available by a significant margin.391 Cloke {MET00070907/5} page 5. Although they worked to understand the differences between their analyses, others in the design team and the TMO tried to find ways to bring the project within budget.392 {ART00006129/2}; {ART00005911}.
¶53.17 The cladding was a focal point of the discussions about savings, being described by Bruce Sounes as an obvious target.393 {ART00005911/1-2}. The TMO also asked for information on the savings that could be made, including specifically on cladding.394 On 27 February 2013 {ART00005807}; 22 March 2013 {ART00006017}. By April 2013, the cladding, together with the crown and the construction of the new windows, was assumed by all involved in the project to be a prime area in which costs could be reduced and it featured prominently in budget discussions from that point onwards.
A new procurement process considered: February 2013–April 2013
¶53.18 Peter Maddison joined the TMO in January 2013 as Director of Assets and Regeneration. Like his predecessors, he was attuned to the relationship between RBKC and the TMO and regarded RBKC effectively as TMO's client.395 Maddison {Day57/80:19-25}-{Day57/81:12}. He and Laura Johnson had several meetings about the Grenfell Tower refurbishment in the first quarter of 2013.396 See Maddison's notebook for January – May 2013 {TMO00879771} for example, at page 26 (for 13 February 2013). Ms Johnson accepted that in early 2013 she had discussed the relationship between RBKC and Leadbitter with Mr Maddison and had mentioned the difficulties she was having with Leadbitter on the KALC project.397 Laura Johnson {Day128/119:21-24}.
¶53.19 By late February 2013, Peter Maddison and Paul Dunkerton, who was working as a freelance project manager for the TMO, had become frustrated with what they perceived to be the slow progress of the negotiations with Leadbitter on the Grenfell Tower project. On 27 February 2013, Mr Dunkerton asked Alun Dawson of Artelia to produce a programme based on running a fresh procurement process for a principal contractor398 {ART00008989/4}; see also 15 March 2013 {ART00006556/2}. and from about that time work on a new procurement exercise ran in tandem with the attempt to agree a price with Leadbitter for the refurbishment. The TMO Programme Board discussed running a new procurement exercise at a meeting on 25 March 2013.399 {TMO10038870}. At that meeting Peter Maddison recommended that it should do so but noted that it might be difficult to explain that change of heart to the TMO board, which had been persuaded to use Leadbitter in the interests of efficiency.400 {TMO10038870/2}.
57¶53.20 As incoming employer's agent from March 2013, Robert Powell took over the task of considering a fresh procurement exercise.401 Powell {ART00008984/11} page 11, paragraph 43. On 10 April 2013 he proposed that Artelia produce a full report, without which he considered that the TMO could find itself in a worse situation.402 {ART00001083}. On 19 April 2013, Mr Dunkerton confirmed the TMO's instruction to Artelia to provide formal advice on how to proceed with the Grenfell Tower project.403 {ART00001116}. That was exactly a year after the first project team meeting.
Artelia's Status Report: April 2013
¶53.21 Artelia produced a Status Report dated 23 April 2013,404 {ART00009101}. the executive summary of which identified a number of factors which had contributed to the slow progress and excessive cost of the scheme. Artelia did not consider re-procurement a viable option and recommended that the TMO should retain Leadbitter as principal contractor.405 {ART00009101/18-19}. It warned the TMO that if the project were not stopped and the scope, programme and cost fundamentally reviewed, it would fail.406 {ART00009101/25}. It therefore recommended that the scheme in its existing guise be stopped immediately, pending a design team review.407 {ART00009101/25}.
¶53.22 The trenchant terms in which Artelia couched its opinion was matched by the strength of feeling of those working on the project. Philip Booth, who became involved in it in April 2013,408 Booth {ART00008527/3} page 3, paragraph 12. Philip Booth assumed the role of EA in July 2013 when Robert Powell left Artelia. recalled that the project had been in a state of distress at that time.409 Booth {Day49/128:24}-{Day49/129:15}; {Day50/113:19-21}.
¶53.23 Simon Cash repeated Artelia's advice to the TMO in a meeting on 26 April 2013.410 {TMO00830537/2} Section "Procurement" Item 8. On the same day, Peter Maddison confirmed that a budget of £8.5m for construction costs would be available for the project.411 {ART00009081} item 3. Confirmed in Powell's Draft project Brief of May 2013 {ART00006475} under header "Budget".
¶53.24 On 2 May 2013, perhaps in a bid to save a project in trouble, Robert Powell sent Paul Dunkerton a Draft Revised Project Brief,412 {ART00006475}; {ART00006383}; Powell{ART00008984/25} page 25, paragraph 77. in which he proposed that Artelia should take on the roles of project manager and employer's agent in addition to its responsibilities as quantity surveyor. He also suggested that Artelia should become the lead consultant.413 {ART00006475/2} under "Contract and Procurement". In the event, however, when a formal contract was eventually signed in July 2014 Artelia was engaged to act only as employer's agent, quantity surveyor and CDM co-ordinator.
58A change of priorities: value for money rather than maintaining programme
¶53.25 On 21 May 2013, Robert Powell sent an email to Philip Booth and Simon Cash describing a meeting he had attended with RBKC and the TMO earlier that day. He told them that Peter Maddison had been overruled by Laura Johnson, that Mr Maddison was no longer keen to appoint Leadbitter as principal contractor and that value for money was more important to RBKC and the TMO than preserving the programme. He said that it was likely, therefore, that the TMO would decide to hold a new procurement process in accordance with EU regulations.414 {ART00006252}.
¶53.26 From that moment, the TMO's attention was increasingly directed towards a new procurement exercise, either by inviting tenders through the Official Journal of the European Union (OJEU) or by making use of an existing framework agreement. Neither Laura Johnson nor Peter Maddison accepted there had been any overruling,415 Maddison {Day58/100:20}-{Day58/101:13}; Laura Johnson {Day128/145:2-11}. but, even allowing for some flamboyance in Robert Powell's turn of phrase among colleagues,416 Booth {Day50/16:8-11}. it is clear to us that Laura Johnson had exercised a decisive influence in favour of re‑procurement.417 Powell {ART00008984/27-28} pages 27-28, paragraph 85; Cash {Day48/164:10-16}. Mr Maddison told us that he had changed his mind as a result of what he had been told by Laura Johnson about problems which RBKC had encountered with Leadbitter on the KALC project, although that is not supported by any of the documents we have seen.418 Maddison {Day58/103:2-19}. Ms Johnson, for her part, accepted that her view of Leadbitter had influenced the TMO's decision to put the contract for the Grenfell Tower refurbishment out to tender again.419 Laura Johnson {Day128/120:6}-{Day128/121:1}. We think that when they gave evidence both Ms Johnson and Mr Maddison independently sought to downplay her influence over the direction of the Grenfell Tower project in order to preserve an appearance of independence from RBKC on the part of the TMO not wholly borne out by the contemporaneous evidence.
¶53.27 In his email Robert Powell said that the emphasis of the TMO's approach had changed from "programme" to "value for money". Even though the scope of works was still evolving,420 As can be seen by Laura Johnson's email on not progressing kitchens / bathrooms {ART00006252}; Booth {Day50/11:2-25}; {Day50/12:5-8}. the project was constrained by an inadequate budget. In the context of the developments that had by then taken place, it is clear to us that the email was recording the change of emphasis on the part of the TMO from one of maintaining the original programme to one of saving cost, and that what the TMO really meant by achieving value for money was finding a contractor who would do the work at a cost lower than that suggested by Leadbitter.
59Artelia reports: May–June 2013
¶53.28 On 24 May 2013, Artelia produced an Addendum to its Status Report.421 {ART00006232}. That short document stated that the TMO had made it clear that value for money was to be regarded as the key driver for the project and that it remained to be convinced that the existing arrangements with Leadbitter could provide that. It therefore believed that a new procurement process would provide best value. In the light of those observations Artelia recognised that it was necessary to reconsider its original recommendation and accept that value for money might be enhanced by seeking a principal contractor through a new procurement process.422 {ART00006232/6}.
¶53.29 When Robert Powell sent the Addendum to Peter Maddison, he commented that he hoped it gave him the support he had been looking for to proceed with a new procurement exercise for a principal contractor, in contrast with the earlier recommendation which had been based on information that had become obsolete.423 {ART00009020/2}. At the time, Robert Powell described the Addendum to Simon Cash as "political lubrication" to give the TMO justification for going against its original recommendation to keep Leadbitter involved in the project.424 {ART00006418}. It is apparent that the TMO had decided to start the project again from scratch, which required it to climb down from its position that there was a benefit to using the contractor it had employed on the KALC project. The TMO needed a professional opinion to support its change of position and Artelia, under pressure from its client, duly obliged. In our view, Artelia, as a professional consultant, should not have allowed itself to be influenced to that degree by its client.
¶53.30 That change of approach was reflected in a revised version of Robert Powell's Project Brief425 {ART00009032}. that was circulated by Philip Booth on 3 June 2013.426 Booth {ART00008527/13} page 13, paragraph 55; {ART00008529}. According to that version, the primary driver was "Cost (Value for money)". The Project Brief was presented at a meeting on 6 June 2013 and was approved by the TMO, with some adjustments.427 {TMO00833043} item 1.1.; Philip Booth made the amendments and reissued on 10 June 2013: {ART00008641}; {ART00008825}.
¶53.31 In a meeting on 6 June 2013 Peter Maddison asked Artelia to change the Addendum to demonstrate that a fresh procurement exercise would deliver better value for money,428 {TMO00833043} item 2.1. and in a further meeting on 11 June 2013, he asked Artelia to reword it.429 {ART00006473}. Accordingly, Simon Cash sent Mr Maddison a revised status report dated 18 June 2013,430 {TMO10048492}; {ART00001241}. the contents of which had been materially altered. Simon Cash noted in his covering email that he had reworded sections to "read in a better light".431 {ART00001241}. Having already changed its original advice in favour of support for a new procurement process, in this latest version of the addendum Artelia, having analysed the options, now more firmly recommended that using the EU procedure, rather than a framework agreement, would be more likely to give value for money.432 {TMO10048492/28}; Booth {Day50/19:9-18}. In addition, criticisms of the TMO were largely removed or watered down and replaced with criticisms of Leadbitter.433 Cash {Day48/191:5}-{Day48/194:7}.
60¶53.32 Simon Cash was reluctant to amend the criticisms of the TMO because they did not reflect Artelia's assessment of what had happened on the project,434 Cash {Day48/194:18-20}. but he was put under pressure to do so by Peter Maddison in the course of what he described as a "particularly strong"435 Cash {Day 48/194:15-16}. conversation. Mr Maddison did not accept that description of the conversation, but he did accept that a "frank" conversation436 Maddison {Day58/143:3-8}. had taken place between them. Later, in an email sent on 17 September 2013 to Claire Williams, the project manager in the TMO Assets and Regeneration Department, David Gibson, TMO's Head of Capital Investment, said that the TMO had had to "twist [Artelia's] arms quite hard" to obtain the revised report.437 {TMO10048490}. Mr Gibson's evidence was that he meant that the report had not been in the clear form he had wanted,438 Gibson {Day53/139:7-19}. nor had it been as positive and forward-looking as he had expected,439 Gibson {Day53/140:1-5}. but the clear meaning of the words used in that email is that Mr Gibson was aware that Artelia had been reluctant to amend its earlier report and had required some considerable persuasion to do so. In our view the evidence shows that the TMO put significant pressure on Artelia to make changes which it would not otherwise have made.
¶53.33 Peter Maddison relied on the advice expressed by Artelia in the Addendum to support his presentation to the TMO board on 20 June 2013.440 Maddison {Day58/143:16-22}; {Day58/148:13-24}; {TMO10002849}. The board agreed to hold a new procurement process, noting the then estimated cost of £9,780,000 for the project.441 {TMO10049945} item 1. In her Budget Monitoring Report for the first quarter of 2013/2014, prepared for RBKC's Management Board, Leaders Group and Cabinet, Laura Johnson reported that the estimated cost of the Grenfell Tower refurbishment was around £9,700,000, but that that was to be confirmed after the procurement process had been completed.442 {RBK00013783/6} paragraph 3.15. She recommended that the cabinet increase the total budget accordingly.443 {RBK00013783/7} paragraph 4.1; Laura Johnson {RBK00034943/14} page 14, paragraph 58. That increase was approved by RBKC's Cabinet on 18 July 2013.444 {RBK00059321/2} paragraph A5(iv).
The OJEU procurement
¶53.34 One effect of the decision to hold a new procurement process for the selection of a principal contractor under the OJEU process was to force the TMO to decide the scope of the project and the materials to be used. The details were set out in the NBS Specification, which was included in the tender packs.
¶53.35 The tender process was led by Jenny Jackson, a procurement specialist engaged directly by the TMO, with the assistance of Artelia. The TMO published a notice of its intention to award the contract on 20 August 2013.445 {ART00008871}. Despite the notice receiving 22 expressions of interest, only five potential bidders returned responses to the Pre-Qualification Questionnaire by the deadline of 20 September 2012.446 {ART00008876}. All five, namely, Mulalley & Co Limited, Keepmoat Regeneration Limited, Durkan Limited, Rydon Maintenance Limited and Wates Construction Limited, passed the Pre-Qualification Questionnaire evaluation, which was scored by Artelia and the TMO,447 {ART00008544}. and were invited to tender.448 {ART00001972}; {ART00008841}; {ART00008584}. Although Leadbitter had been informed about the process in July 2013,449 {ART00008603}. it did not tender for the project.
61¶53.36 In the end, only three of the five companies which had satisfied the Pre-Qualification Questionnaire eventually submitted tenders, Wates having pulled out on 18 December 2013450 {ART00008690}; {ART00008642}. and Keepmoat on 15 January 2014.451 {ART00008949}. The tenders were opened on 14 February 2014 and it was immediately apparent that Rydon's was significantly lower than those of the other two companies, Durkan and Mulalley.452 {ART00005886}; {ART00008976}.
Manipulation of the procurement process
¶53.37 Following their formal evaluation, Rydon's bid was confirmed as being the lowest price; it also achieved the highest score on quality.453 {ART00002167/23}. All the prices for the external facade were substantially higher than Artelia's estimate. The basis of evaluating tenders was 40% for price, and 60% for quality, of which 55% was attributed to written submissions and 5% to interview. Weighting the scoring in that way meant that the tender process slightly favoured the bidder with the highest quality rather than the lowest price. After the scores for the written submissions had been collated, Rydon's bid was identified as the most competitive.454 {ART00002167/23}.
¶53.38 Residents had some limited participation in the process.455 Williams {TMO00840364/8} page 8, paragraph 39; {TMO00840364/27} page 27, paragraph 149; Booth {ART00008527/23} page 23, paragraph 89. At the stage of the Pre‑Qualification Questionnaire in October 2013, and at the stage of the Invitation to Tender in February 2014, they contributed their assessments of the quality of the tenderers' communication and liaison with residents.456 Booth {ART00008527/23} page 23, paragraph 89; {ART00008693}; {ART00008909/3} question 10.3 only; {TMO00847721} question 7.1 only. They were not invited to contribute questions about programming or quality, even though those were matters which affected them and on which they might have had valuable insights.457 Williams {Day54/176:12}-{Day54/177:22}. On 21 February 2014, Cllr Judith Blakeman suggested to Peter Maddison that some residents should attend the interviews with those who had submitted tenders.458 {TMO10005313/4}. That required Claire Williams to find a leaseholder and a tenant at short notice.459 {TMO10005313/3}; Residents apparently attended {ART00008870}; {ART00008969}. We do not know which residents attended the interviews or what contributions they made, although Ms Williams thought that Pily Burton and Fahed Barakat had been involved when no one else had come forward.460 Williams {TMO00840364/8} page 8, paragraph 39. On any view, only very few residents were involved in the process. They marked a limited range of questions, their scores were averaged with those of the professionals and the TMO,461 Booth {ART00008527/23} page 23, paragraph 89; Booth {Day50/43:14}-{Day50/44:14}. which diluted their contribution, and, when it came to the interviews, their attendance appeared to be an afterthought. Despite the TMO's saying that it had every intention of involving residents in the process,462 Williams {Day54/166:3-6}; Williams {Day54/168:5-8}. we think that their involvement was largely symbolic, having been hastily arranged and entirely undocumented.
62¶53.39 In its final tender report, dated 12 March 2014, Artelia confirmed its view that the prices of all three bidders were "at a sustainable level".463 {ART00002167/13}. Even so, as was made clear in Artelia's Draft Tender Report, even Rydon's tender sum (the lowest) exceeded the budget then available and in those circumstances Artelia sought the TMO's permission to undertake a value engineering exercise with Rydon.464 {ART00002167/23}. By that point, however, Rydon (but no other bidder) had been told by the TMO that it was "in pole position" and would be awarded the contract if it could indicate that it could make significant reductions in its price through value engineering.
¶53.40 There then followed some days of discussions about potential areas of savings and specific amounts, in order to arrive at an agreed figure.465 See Chapter 55 The discussions culminated in a meeting on 18 March 2014, at which the TMO and Rydon agreed that if Rydon were awarded the contract it would reduce its price.466 See Chapter 55 The TMO considered internally that a reduction could be achieved through the "value engineering" clauses in the proposed building contract,467 Gibson {Day54/13:9-12}; {Day54/17:12-19}. but that was really just a euphemism for reducing the cost to enable an acceptable price to be achieved.468 Per Gibson email to Rydon {RYD00003302/1-2}.
¶53.41 The discussions between the TMO and Rydon, which took place at a time when the procurement process had not been completed, were not contemplated by the legislation relating to procurement. The meeting of 18 March 2014 was particularly significant, because Rydon was given an opportunity to amend its price in advance of the award of the contract, an arrangement for which the TMO could provide no reasonable justification. Those involved in the meeting knew or should have known that what they were doing was improper. The meeting was described in correspondence as taking place "offline",469 Chapter 55 the TMO did not invite its professional advisors, and no minutes were taken. Moreover, it had received advice from its solicitors that a meeting of that kind was not permissible.
¶53.42 Simon Lawrence explained to Mike Albiston of Harley that Rydon was alive to the risk that other prospective main contractors might challenge the procurement process on the grounds that they had not been given a similar opportunity to engage in the value engineering process.470 {HAR00010160/6}. Stephen Blake said that he never considered the potential for challenge by other contractors471 Blake {Day28/187:1}. and denied having any knowledge of Mr Lawrence's concerns,472 Blake {Day28/188:6-24}. but we do not accept that evidence. As we explain in Chapter 55,473 Chapter 55 the meeting of 18 March 2014 was organised through Mr Blake and he was the driving force at Rydon behind the early value engineering process. Mr Blake himself asserted that the TMO had been changing the basis of the tender474 Blake {Day28/185:24} – {Day 28/186:5}. and it would be surprising if he had not considered the concerns articulated by Mr Lawrence as a result.
63¶53.43 The steps that were taken to reduce the price of the works are described in Chapter 55 However, it is striking that the TMO appears to have given no thought at any stage to asking RBKC to increase the budget to meet Rydon's tender price, rather than seeking to drive down the costs to bring them within the budget. Given that in July 2013 RBKC had been amenable to an increase in the budget by about a third (from £6,000,000 to £9,700,000),475 {RBK00003316/3}; Feilding-Mellen {Day131/153:6} – {Day131/155:18}. it is possible, to put it no higher, that RBKC would have agreed. Indeed, in July 2014, it agreed to increase the budget to £10,300,000, without any apparent reluctance or obvious opposition from within the cabinet.476 Feilding-Mellen {RBK00054433/4} page 4, paragraph 11; {Day131/161:16}-{Day131/162:18}.
The contract with Rydon and confirmation of the budget
¶53.44 On 18 March 2014 Rydon was told that it had won the contract. On 27 March 2014, Peter Maddison presented a paper477 {TMO10005583}. to the TMO board478 {TMO10031040}. in which he recommended that the TMO should enter into what he called a "pre-contract arrangement" with Rydon so that the project could make progress while the possibility of reducing the price was investigated, in particular by changing the cladding material and securing government funding for improving the building's energy efficiency.479 {TMO10031040/2}. According to the minutes of that meeting, the board asked Mr Maddison whether Rydon might have submitted a low tender in order to obtain the contract, but he confirmed that he had confidence in Rydon's pricing480 {TMO10031040/3} item 3. and that any problems with the budget would be addressed during the pre-contract period.481 {TMO10031040/3} item 2. In reality, the primary focus of attention during the pre-contract period was clearly on achieving a reduction in Rydon's price; at any rate, there is no evidence that the TMO board took any steps to find out whether it was realistic. Peter Maddison conceded that that had not been the purpose of the pre-contract period and said that the minutes were incorrect to the extent that they stated otherwise.482 Maddison {Day59/71:3-21}. However, the minutes of the meeting are detailed and we consider that they probably are accurate. We think that Mr Maddison did reassure the board that the budget was sustainable and told it that any concerns that Rydon might have submitted an artificially low tender would be addressed during the pre-contract period.
¶53.45 Having received that assurance, the TMO board agreed to appoint Rydon as principal contractor for the Grenfell Tower refurbishment. Accordingly, it authorised an immediate agreement to cover preliminary work up to the value of £350,000 and thereafter a design and build contract for the works as a whole at a total price of £9,700,000, inclusive of fees.483 {TMO10031040/3}; {RYD00086702}; {RYD00094236/91} paragraph 215.
¶53.46 On 19 June 2014, Laura Johnson presented a paper to the RBKC cabinet484 {RBK00000409}. recommending an increase in the budget for the refurbishment from £9,700,000 to £10,300,000 to include a contingency.485 {RBK00000409/5-6} Item 3.2; {RBK00000409/8} item 6.2. The cabinet agreed the increase,486 {RBK00018808}; Laura Johnson {RBK00034943/14-15} pages 14-15, paragraph 58; {RBK00034943/16} page 16, paragraphs 65-66. which was noted in an executive decision issued by Cllr Feilding-Mellen in August 2014.487 {RBK00003309}.
64The influence of cost in the selection of materials
¶53.47 In response to a suggestion that it had been concerned above all things to reduce costs the TMO argued that its choice of the more expensive cassette version of the panels for the rainscreen showed that cost had not been the sole or overriding consideration in the selection of materials.488 Phase 2, Modules 1 and 2 Closing TMO submissions for TMO {TMO00903690/13} paragraph 52. However, the evidence does not support that conclusion. Peter Maddison denied that the TMO had been looking for the cheapest option; he said that it had been looking for a material that would, in his words, "achieve planning permission and ... meet the regulations".489 Maddison {Day59/90:9-23}; TMO submissions {TMO00903690/13} paragraph 53. As Mr Maddison's evidence makes clear, the need to obtain planning permission was a critical factor in the decision about which version of the product to use. Emails passing between Simon Lawrence and Claire Williams in May 2014 refer to the TMO's discussions with the planning committee about the different forms of fixing and the adverse cost implications if it were to prefer cassettes.490 Emails 6 May 2014 {TMO00851142}; 23 May 2014 {RYD00005374/1-2}. Simon Lawrence asked Ms Williams whether showing the committee examples of the panels in cassette form would be a risk.491 Email 23 May 2014 {RYD00005374/2}. He hoped to persuade it to accept riveted fixing by showing it a mock‑up.492 Email 29 May 2014 {RYD00005374/1}. Mr Maddison was informed of the efforts being made to persuade the planning committee to accept riveted fixing493 Emails 6 May 2014 {TMO00851142}; 2 June 2014 {SEA00011069}. and had a meeting with Councillor Feilding-Mellen at which the difference in cost was discussed.494 Diary of Peter Maddison {TMO00879770/46}; {TMO00879770_T}/60}. It is clear to us that Rydon and the TMO were seeking to persuade the planning committee to accept riveted fixing for cost reasons. In the event, however, the committee insisted on the cassette version.
Client design adviser
¶53.48 On 28 February 2014, Artelia had offered to act as client design adviser for the TMO, to review and advise on decisions made by the principal contractor in developing the design of the project. Following the appointment of a principal contractor under a design and build contract, the services of those engaged by the client to carry out the initial design work may be transferred to the contractor by a legal process known as novation to enable it to continue developing the design. The creation of new contractual relationships between the designers and the principal contractor creates a risk that the contractor may wish to adopt lower quality design solutions than those originally contemplated. The designers, whose client is now the contractor, are not able to advise the employer on matters of that kind. As a result, there is a risk that a design agreed with the employer before the appointment of the contractor may be watered down as a result of commercial pressures.
¶53.49 In early February 2014, Artelia and the TMO (represented by Jenny Jackson) were negotiating amendments to the terms of Artelia's appointment. The discussions eventually concluded with a variation to the contract agreed in July 2014. In the context of those discussions Philip Booth reviewed the scope of the services to be provided by Artelia as employer's agent and concluded that they would not overlap with the services that would be provided as client design adviser. Artelia proposed that Richmal Hardinge, an architect, be appointed in that capacity. She had acted as client design adviser to RBKC on the KALC project and had drafted the proposal for the Grenfell Tower project, which offered to set and safeguard design quality. She proposed that she should provide a "Design Compliance Report" before the contract was awarded, after reviewing the contractor's proposals to ensure that they were consistent with the Employer's Requirements, the NBS Specification and British, European and other statutory standards. Ms Hardinge also proposed that, once the contract had been awarded, she would review the contractor's drawings to ensure they continued to meet the Employer's Requirements and provide advice on matters of design as required by the TMO. The proposal excluded any aspects of the mechanical and electrical ("M&E") services.
65¶53.50 At a progress meeting on 15 July 2014, attended by Peter Maddison, David Gibson and Claire Williams on behalf of the TMO, it was agreed that the TMO would appoint a client design adviser. However, a few weeks later, on 29 August 2014, the TMO decided to perform the role itself. Claire Williams set out the TMO's reasons for that decision in an email sent to Peter Blythe and Philip Booth on 29 August 2014. They included the fact that the cladding and M&E elements were under guarantee, which she thought obviated the need for such an appointment. A note was later added to the minutes of the progress meeting confirming that the TMO would perform the role of client design adviser itself and stating that it would need to approve all design decisions.
¶53.51 Claire Williams told us that the TMO had come to the view that the services that would have been provided by a client design adviser role fell within the scope of the services Artelia had already agreed to provide and that she had not wanted responsibility for design to be complicated. However those are not the reasons she gave at the time, which suggest that she was more concerned about the value that a client design adviser would provide. In those circumstances we think that the TMO's decision not to appoint Artelia as client design adviser was driven by a combination of commercial considerations and an unrealistic view of the expertise available within the TMO. The TMO's rejection of that offer meant that it was unable to review effectively any of the design work carried out following the appointment of Rydon as the principal contractor. In reaching its decision the TMO significantly overestimated its ability to scrutinise the design work and chose to overlook the fact that no one within the organisation had experience of a project involving the overcladding of a high-rise residential building.
¶53.52 The TMO's decision not to appoint a client design adviser does not, of course, make it responsible for the quality of subsequent decisions affecting the design of the refurbishment or their compliance with the Building Regulations. That rested with Rydon and its contractors, including Studio E and Harley. However, the TMO's decision not to appoint a client design adviser at modest expense was foolish and reflected an over- confidence in its ability to manage the design aspects of the project itself.
67Chapter 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.495 {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.496 {TMO10037721/1}; {TMO10003885/1}. Exova had won numerous prestigious awards for its work.497 {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".498 {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.499 Sounes {SEA00014273/36} page 36, paragraph 73. As a result, it was instructed by the TMO500 {SEA00004789}; {EXO00000543}; Ashton {Day17/19:4-6}. to work on the Grenfell Tower refurbishment,501 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.502 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.503 {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 Rydon504 {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,505 {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 Inquiry506 Lane, Phase 2 Report {BLARP20000017}; Appendix A {BLARP20000018}. A document outlining corrections and addenda {BLARP20000014}. and gave evidence in person over two days.507 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.508 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.509 Exova Closing Submissions {EXO00002124/52} page 52, paragraph 27.1.
68¶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".510 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".511 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.512 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).
69¶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.513 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.514 Lane {Day61/15:10-14}.
¶d. It should explain how the building is to be managed in order to protect persons using it from fire515 Lane {Day61/19:6-23}. and identify any fire risks which have either been mitigated or which it is not possible to mitigate.516 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."
¶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.517 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,518 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.519 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",520 {INQ00011219}. dated May 2015, which she considered reflected good industry practice and had done so for many years before its publication.521 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",522 {INQ00011219/4}. "fire compartmentation requirements, including fire-stopping and cavity barriers"523 {INQ00011219/4}. and "external fire spread".524 {INQ00011219/4}. Again, Mr Ashton accepted that those were matters that ought to be included in any fire strategy.525 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.526 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,527 Lane {Day61/131:8}-{Day61/133:11}. or at least to review them and digest all aspects that were relevant to fire safety.528 Lane {Day61/177:7-19}.
70¶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.529 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 911:2007,530 {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.531 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.532 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.533 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.534 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.535 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.536 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.537 {EXO00001743}.
71¶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.538 {EXO00001744/4} sections 5 and 6. There was some discussion about the budget for the cladding.539 {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 email540 {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.541 {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 2012.542 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}.
¶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.543 {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.544 {EXO00001748}. Mr Sounes found Mr Ashton's comments "difficult to follow",545 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.546 {EXO00000685}.
¶54.19 Mr Lee visited the tower on 29 May 2012 and took a number of photographs.547 {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.548 {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.549 {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 £2,865.550 {TMO10037721/2}.
72¶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.551 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.552 {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.553 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.554 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 2012.555 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.)556 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.557 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.558 {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.559 Cooney {Day14/30:3-9}.
¶54.25 Ms Cooney said that the information she had initially been given was limited.560 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.561 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.562 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.563 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.564 {EXO00001592}. He told her that there was not.565 {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"),566 {TMO10037743}. which wrongly described the lifts as "fire-fighting lifts".567 {TMO10037743/4}. Ms Cooney noticed the inconsistency in the information before her but did not seek to resolve it,568 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.569 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 lift570 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.571 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,572 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.
73¶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.573 {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,574 {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 2012575 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.576 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 any577 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.578 Barker {Day15/37:19-22}.
¶54.29 In its fee proposal Exova had described itself as having a worldwide reputation for excellence in fire safety579 {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.580 {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.581 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,582 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}. and her involvement was limited to a cursory review of the draft Existing Fire Safety Strategy produced by Ms Cooney.
74¶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.583 {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.584 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.585 {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."586 {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.587 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.588 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.589 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.590 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,591 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.
75¶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,592 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 2012.593 {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.
¶54.35 On 17 August 2012, Cate Cooney and Bruce Sounes had a telephone conversation594 {EXO00001279}. but it is likely that their conversation related to aspects of the refurbishment other than the draft Existing Fire Safety Strategy.595 {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,596 {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 documentation597 {EXO00001224}. and check that all elements of the project had been completed satisfactorily. Dr Barker did not have a good recollection of the procedure,598 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.599 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.600 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,601 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.602 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.603 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.
76¶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"604 {ART00000404}. but when they met on 10 September 2012 they did not consider it in any detail,605 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.606 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.607 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,608 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.609 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)). The fee quoted (£2,865 plus VAT) represented about three-and-a-half days' work, which was insufficient for a task of that magnitude.610 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.611 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.612 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.613 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,614 Lane {Day61/79:3-8}. that was not the case; there were no site notes or marked-up drawings, and the photographs,615 {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.616 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.617 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.618 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.619 Lane {Day61/84:6-13}; {Day61/121:1-7}. That would have included relevant fire safety policies, fire safety management policies and maintenance records.620 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.621 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.622 Lane {Day61/120:8-14}.
77¶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.623 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.624 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 Order625 Which deals with emergency routes and exits from a building. and therefore did not provide the responsible person with practical guidance on that topic.626 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,627 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.628 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.)629 Cooney {Day14/171:20}.
¶d. No sketches or drawings were provided to enable the reader to understand how the text related to the building.630 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.631 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.
78¶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.632 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.633 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.634 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.635 {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.
79¶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.636 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.637 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.638 {SEA00000043}. Later that morning Ms Cooney sent Andrew Martyn, a senior consultant at Exova,639 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?"640 {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.
80¶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.641 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.642 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.643 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.644 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.645 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.646 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.647 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.648 Sounes {Day21/124:10}-{Day21/125:20}.
81¶54.53 Dr Lane criticised Ms Cooney for failing to draw her concerns to the attention of those responsible for the building.649 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 responsible650 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",651 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.652 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."653 {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.654 {EXO00000667}. Mr Ashton said that it had not been necessary for him to discuss the message with Ms Cooney because it "was pretty comprehensive".655 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.656 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.657 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.658 {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}.
82¶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.659 {SEA00000058}. See also Sounes {Day8/12:22-25}-{Day8/13:1-2}. Later, on 12 September 2012, a document describing itself as a Design Note660 {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"661 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 design662 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 C663 {Day16/165:7-12}. and was included in the formal reporting package for Stage C on 31 October 2012.664 {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 essential665 {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.666 {EXO00000685}. When he gave evidence he conceded that a visit would have been desirable,667 Ashton {Day16/169:7}. explaining that he failed to make one because he had "other priorities."668 Ashton {Day16/168:8-25}. He therefore became familiar with the tower only from the drawings provided by Studio E.669 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.670 Ashton {Day16/170:7-14}. He had no conversations with Mr Lee about the layout of the building671 Ashton {Day16/171:2-5}. or about the plans to overclad it.672 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.673 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.
83¶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,674 {EXO00000413}. some marked up General Arrangement plans675 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,676 {TMO10017402}. which he considered to be enough for his purposes.677 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,678 {EXO00000716}. but he did not make use of them.679 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.680 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,681 {EXO00000474}. he had not at that stage seen any specific proposals that he could comment on,682 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,683 {ART00000404/4}. Mr Ashton did not remember anything of the discussion, suggesting that he might have left early.684 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,685 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.686 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.687 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.688 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.689 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.690 Sounes {Day8/24:14-15}.
84¶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,691 {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.692 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 2012.693 {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.694 {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.695 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.696 Lane, Phase 2 Report {BLARP20000017/170} paragraph 6.3.9. It appeared to have been produced in haste in order to meet a project deadline697 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 Strategy698 {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.699 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.700 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.701 Ashton {Day17/24:4-19}.
85¶54.67 Nowhere in Issue 1 of the Outline Fire Safety Strategy did Exova state that the refurbishment included overcladding of the building.702 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.703 Ashton {Day17/101:3-20}.
¶54.68 The only reference in the document to functional requirement B4 was in section 3.1.4,704 {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.705 {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 cladding706 Ashton {EXO00001621/10} page 10, paragraph 4.9 (D). and that he had not been given any details on which he could comment.707 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.708 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."709 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 Strategy710 {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 packages711 {SEA00006395}. from Adrian Jess of Studio E on 23 October 2012712 {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,713 {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.714 Ashton {Day17/30:1}-{Day17/32:9}.
86¶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.715 Sounes {Day8/52:9-11}; See also Sounes {SEA00014273/73} page 73, paragraph 149. Mr Ashton, however, did not realise that.716 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.717 {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.718 {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.719 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,720 {SEA00006429/27}. with various options being considered for the rainscreen, including zinc721 {SEA00006429/28}; {SEA00006429/31}; {SEA00006429/32}. and aluminium.722 {SEA00006429/32}. He would also have seen that Celotex FR5000 was proposed as insulation in the external wall.723 {SEA00006429/82-83}. Mr Ashton repeatedly said that he had not been told what insulation or rainscreen was being used on the tower.724 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.725 {SEA00006666}. Mr Ashton had not previously used the site and asked for assistance.726 {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.727 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.728 Proposed Walkway +1 Floor Plan, annotated {SEA00006728}; Proposed Mezzanine Floor Plans, annotated {SEA00006727}, attached to email {SEA00006726}.
87¶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.729 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.730 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.731 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.732 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 2012.733 {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.734 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.735 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.736 {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.737 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.738 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,739 {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.
88¶54.80 Mr Ashton met building control again for the last time on 17 September 2013 to discuss the fire strategy.740 {EXO00000693/5}. He agreed that he would normally have expected to have had more meetings with them741 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,742 {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.743 Ashton {Day17/182:20-24}. Again, there is no evidence that the overcladding of the tower was discussed at that meeting.744 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 B745 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 2013.746 {EXO00000430}. It was written by Mr Ashton and reviewed by Dr Tony Pearson, a senior consultant747 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.748 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 2013.749 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,750 {SEA00008054/78}. a fact of which Mr Ashton was also unaware.751 Ashton {Day17/97:8-11}. Since he had not read the Stage D report, (or, for that matter, the Stage C report),752 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,753 {SEA00008054/22}; {SEA00008054/29}. images of cladding754 {SEA00008054/26}. and references to Celotex FR5000 as the proposed insulation.755 {SEA00008054/29}. By that time, however, Studio E was working to the Employer's Requirements – Stage E,756 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.
89¶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.757 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.758 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.759 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 2013.760 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,761 {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.762 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.763 {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,764 Pearson {Day19/105:6}; {Day19/122:12-17}. nor did he have any knowledge of the arrangements proposed at the top of the tower,765 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.766 "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.767 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,768 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.769 Pearson {Day19/171:10-14}.
90¶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,770 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.771 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;772 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.773 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.774 Pearson {Day19/125:18-22}.
¶54.88 No changes were made to the section covering functional requirement B3 (internal fire spread)775 {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.776 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.777 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.778 {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.779 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,780 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.781 {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 Note782 {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.783 {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,784 Ashton {Day17/114:14-24}. but he did not want to draw attention to it in case they said it was not acceptable.785 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.786 Ashton {Day17/112:19-20}.
91¶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.787 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.788 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",789 {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".790 {EXO00001107/6}. Mr Ashton did not seek to discuss that amendment with Dr Pearson791 Pearson {Day19/91:11-15}. and Dr Pearson appears not to have realised at the time that the words in question had been removed.792 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 2013.793 {SEA00000121}. John Allen responded on 11 November 2013,794 {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,795 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.796 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 2013.797 {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.798 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.799 Lane {Day61/188:1-23}. We agree.
92¶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.800 {EXO00000586}. Mr Ashton's response on 4 November 2013 was brief, stating simply that cavity barriers needed to have only 30 minutes' fire resistance.801 {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.802 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.803 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.804 Ashton {Day17/120:22-25}. Regrettably, Mr Rek's email did not prompt Mr Ashton, as it should have done,805 {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.806 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 2013,807 {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.808 {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.809 {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.810 Lane {Day61/221:10-15}.
93¶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.811 Sounes {Day12/147:19-23}. Mr Ashton had still not seen either the Stage C or Stage D report.812 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.813 {EXO00001107/4}. The wording of the section covering B4 (external fire spread) also remained the same.814 {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.815 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".816 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.817 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.818 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.819 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.820 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.821 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.822 Ashton {Day17/130:25}-{Day17/131:5}.
94¶54.100 Similarly, Issue 3 contained no guidance on the need for cavity barriers823 {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.824 {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.825 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,826 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.827 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.828 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.829 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.830 {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 BS5588-5:2004,831 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.832 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,833 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 2013.834 {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.835 Ashton {Day17/147:9}-{Day17/149:14}.
95¶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.836 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.837 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.838 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.839 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.840 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 project841 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.842 Ashton {Day18/165:6-9}. Exova produced nothing commensurate with RIBA Stages E or F.843 Lane, Phase 2 Report {BLARP20000017/101} paragraph 4.7.104. According to Mr Ashton, that was because Exova had not been novated to Rydon.844 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.845 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 version846 Ashton {Day 17/133:1-3}. and accepted that a detailed fire strategy would have dealt with all the functional requirements from B1 to B5.847 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 B4.848 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;849 Ashton {Day17/133:1-6}. but he never asked Studio E for that information850 Ashton {Day17/133:22-25}. and allowed the matter to drift in the absence of any request from Studio E for a complete analysis.851 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.852 Ashton {Day17/133:11-15}.
96¶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.853 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.854 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.855 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.856 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 2014.857 {SEA00000215}. Mr Ashton was not aware of that at the time, but he knew that it was standard practice to do so.858 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.859 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.860 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.861 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.862 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.863 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,864 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.865 Lane {Day61/198:14}-{Day61/202:15}.
97¶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,866 {EXO00000474}. he had attended at least one project team meeting (on 6 September 2012) at which the cladding had been discussed,867 {ART00000404}. he had been sent minutes of other project team meetings referring to it868 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.869 {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",870 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 2013.871 {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.872 {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.873 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}.
98Failure 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.874 {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.875 {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.876 {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.877 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.878 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.879 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.880 {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,881 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}. but no one on behalf of Rydon contacted Exova for that purpose.882 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 2016,883 {MAX00006093}. Exova continued to provide advice to Studio E, Rydon and its subcontractors884 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.
99¶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."885 {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."886 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 consultant887 {RYD00022280}. and the item remained on the agenda because Artelia retained it as a matter calling for decision by Rydon.888 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.889 {ART00003150}. Claire Williams did not notice that890 Williams {Day55/83:9}. and said she would have expected Artelia, as Employer's Agent, to pick it up.891 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.892 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.893 Sounes {SEA00014273/152} page 152, paragraph 372; Sounes {Day12/168:20}. Mr Lawrence did not recall that conversation,894 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.895 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.896 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 2014.897 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,898 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.899 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 consultant900 Williams {Day55/84:2-10}. and it seems that the matter then disappeared from sight. Artelia and the
100¶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.901 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.902 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.903 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.904 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.905 {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.906 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,907 Ashton {Day17/184:16-25}. See also Ashton {EXO00001621/14} page 14, paragraph 5.10. but that is not reflected in the billing procedures.
101¶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 information908 {HAR00003616}; Email attaching the RFI {SEA00011703}. he had received from Harley about the location of horizontal fire breaks within the cladding.909 {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.910 {RYD00018154}. At that stage he had not given any substantive consideration to the cladding or its implications for external fire spread.911 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 H92/776.912 {EXO00000710}, {EXO00000709}. That was the first time Mr Ashton had seen the design and specification for the cladding system.913 Ashton {Day18/31:15-22}.
¶54.131 The code H92/776 referred to a paragraph in the NBS Specification914 {SEA00000169/73}. which specified Celotex FR5000 insulation. Mr Ashton had not seen the Employer's Requirements or the NBS Specification915 Ashton {Day18/127:7-8}. and did not ask to see them.916 Ashton {Day18/31:1-14}. The code meant nothing to him917 Ashton {Day18/29:11-22}. and he did not understand that the drawings included references to the materials to be used for insulation.918 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.919 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.920 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.921 {EXO00000708}. That advice was wrong insofar as it suggested that cavity barriers were required only if the insulation were combustible.922 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.923 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 worded924 Ashton {Day18/39:1-18}. but in our view that suggests that he had not understood the significance of the nature of the insulation.
102¶54.133 The drawings provided to Mr Ashton by Studio E925 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.926 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.927 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.928 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.929 Ashton {Day18/42:19}-{Day18/43:5}.
¶54.134 Later the same day Neil Crawford sent another email to Mr Ashton930 {SEA00011724}. attaching a datasheet for Celotex RS5000.931 {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.932 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.933 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.934 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 combustible935 Ashton {Day18/67:11-15}., even if he did not know how exactly it reacted to fire.936 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.937 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.938 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 proposed939 Ashton {Day18/69:2}. or to tell him that the Outline Fire Safety Strategy needed to be revised.940 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:
103"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."941 {EXO00001430}.
¶No one responded to his comment about the extent of the external wall cavity and he did not press for further information.942 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.943 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.944 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 tower945 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 materials946 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.947 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 B4.948 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.949 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.950 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,951 Crawford {Day10/58:1}-{Day10/59:1}. an assertion which Mr Ashton equally unequivocally denied.952 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.953 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.954 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-up955 Crawford {Day10/94:1-22}; Ashton {Day18/77:5-21}. and had discussed with him the suitability of the cavity barrier strategy.956 Crawford {Day10/94:1-22}. Mr Ashton also denied that.957 Ashton {Day18/74:18}-{Day18/77:24}, {Day18/124:11}-{Day18/125:6}; Ashton {EXO00001775/3} page 3, paragraphs 3.1-3.2.
104¶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 2014.958 Crawford {Day9/179:5-7}. Mr Ashton did not recall any such conversation.959 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,960 Crawford {Day10/95:22}-{Day10/96:10}; {Day11/169:23}-{Day11/170:5}. which again Mr Ashton denied.961 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.962 Crawford {Day11/181:20}-{Day11/183:15}. Mr Ashton also denied that.963 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 2018.964 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.965 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.
105Advice 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,966 {EXO00001315}. attaching Harley's Specification Notes967 {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.968 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.969 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,970 {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.971 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".972 Ashton {Day18/92:21-22}. He did not take in the fact that aluminium rather than zinc was now being proposed.973 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,974 Lane, {Day62/52:4-12}; {Day62/61:5-11}; {Day62/62:20-24}. but regrettably it did not do so.975 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,976 {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.977 {EXO00000715}. Mr Ashton responded the same day,978 {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).979 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.980 {EXO00000715}.
106¶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.981 {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.982 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.983 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.984 Lane {Day62/60:23}-{Day62/61:4}. She considered that those and some later exchanges with the design team in September 2014985 Lane {Day62/73:4-23}. should again have led Mr Ashton to realise that the fire safety strategy needed to be revised.986 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.987 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.988 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,989 {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,990 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.
107¶54.148 Throughout the exchange Mr Ashton was careful to confine himself to the questions asked of him,991 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.992 Ashton {Day18/131:2-4}. He did not notice that the drawing993 {SEA00002499}. attached to Mr Crawford's email of 31 March 2015994 {SEA00013044}. showed cavity barriers only at the head of the window, because he did not look at it at the time.995 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.996 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 statement997 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.998 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.999 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,1000 Ashton {Day18/120:1-3}. he still did not have enough information from Studio E to enable him to do that.1001 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.1002 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.1003 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.1004 {EXO00001347}. Mr Ashton did not recall having received it1005 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.1006 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.1007 Ashton {Day18/116:1-6}.
108¶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.1008 Pearson {Day19/156:16}. He did not know what stage had been reached in the design process,1009 Pearson {Day19/157:3}. did not look back to the Outline Fire Safety Strategy,1010 Pearson {Day19/166:5-8}; {Day19/169:1-4}. did not check what materials it was proposed to use1011 Pearson {Day19/170:2-8}. and directed his mind only to the specific question asked of him.1012 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 spread1013 Pearson {Day19/169:15-17}. and that someone should have considered the materials being used in the external wall.1014 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 tower1015 {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.1016 {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.1017 Ashton {Day18/138:5-6}; {Day18/139:7-10}.
109Completing 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 recorded1018 {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.1019 Ashton {Day18/140:20}. Mr Hughes' said1020 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.1021 {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.1022 Ashton {Day18/139:11-15}.
¶54.161 Dr Pearson thought that in 2013 Exova was a "designer" within the meaning of the CDM Regulations,1023 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.1024 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.1025 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,"1026 {EXO00001279}. and by Mr Ashton's response to Dr Pearson's identification of a "rather fundamental"1027 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.1028 {EXO00001444}. The latter comment revealed an approach to fire safety that we consider irresponsible.
110¶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.1029 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 site1030 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.1031 Lane {Day61/77:18}-{Day61/78:13}; Lane, Phase 2 Report {BLARP20000017/88} paragraph 4.7.14. Insufficient time was spent drafting the reports,1032 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. 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.1033 {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.
111¶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 author1034 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 B4.1035 Lane {Day61/209:24}-{Day61/210:7}. Exova's peer review procedure also applied to emails containing technical advice,1036 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,1037 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 2015,1038 {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",1039 {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 it1040 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.1041 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.1042 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.1043 {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.1044 Ashton {Day17/168:25}-{Day17/169:13}.
¶54.168 Mr Ashton himself had no formal training in fire engineering,1045 Lane Phase 2 Report {BLARP20000017/85} paragraphs 4.6.18-4.6.19. no previous experience of overcladding high-rise buildings,1046 Ashton {Day16/28:18}-{Day16/29:8}. and very little knowledge of cladding materials.1047 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.1048 Lane Phase 2 Report {BLARP20000017/82} paragraph 4.6; Lane {Day61/51:1-25}.
112¶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,1049 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.1050 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.1051 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.
113Chapter 55: The choice of ACM PE rainscreen panels
Initial proposals
¶55.1 Although the initial motive for overcladding Grenfell Tower was to improve its appearance, it was soon recognised that doing so could also provide a significant improvement in the energy efficiency of the building. Adding insulation to the outside, protected by a rainscreen, was proposed by Studio E as a solution.1052 {SEA00000007}. Discussions with RBKC's Planning Department resulted in a proposal to use zinc panels as a rainscreen, but from the early part of 2012 Bruce Sounes began to think of aluminium as an alternative because it was light, presented a limited risk of corrosion and was available in a variety of colours.1053 Sounes {SEA00014273/88} paragraphs 206 – 207; Sounes {Day20/108:11}-{Day20/113:8}
¶55.2 At the beginning of April 2012 Mr Sounes carried out some internet searches from which he identified CEP Architectural Facades Ltd ("CEP") as a potential supplier of the rainscreen.1054 Sounes {Day20/77:4-11}. He then contacted Geof Blades of CEP seeking information about cladding systems and prices1055 {CEP00048112/1}; Sounes {SEA00014273/35} page 35, paragraph 71; {SEA00003965}. and provided him with drawings and photographs of the tower.1056 {CEP000000043}. In response Mr Blades sent Studio E details of a high-rise cladding project on which an ACM rainscreen had been used in rivet fix.1057 {SEA00003941} The project involved Rockwool insulation {SEA00003942}-{SEA00003956}. Mr Sounes met Mr Blades on 11 April 2012 to discuss potential cladding options, but they did not talk about the fire performance of any of the elements of the cladding.1058 Sounes {Day20/83:8-12}. Geof Blades did not recall the content of the conversation – see Blades {Day41/85:3-7}.
¶55.3 Later that month Mr Sounes suggested Alucobond ACM panels as a possible option for the rainscreen, although he knew that at that stage RBKC's Planning Department did not care for aluminium on aesthetic grounds.1059 {SEA00004051}; {TMO10001143/4-5}; Sounes {Day20/83:20}-{Day20/85:15}.
¶55.4 On 28 May 2012, Mr Sounes indicated to Chweechen Lim of Artelia that both zinc rainscreen and render were being considered for the external facade of the building1060 {ART00006104}. and in her first budget estimate Ms Lim priced those two options.1061 {ART00005838}. Render is a plastered finish for external walls that provides a smooth surface and protects the underlying material against the elements. During July 2012 Studio E continued to look into various options for the cladding,1062 Sounes First Witness Statement {SEA00014273/52} paragraph 111; Sounes {Day20/89:25}. but zinc rainscreen appeared to be gaining preference on aesthetic grounds.1063 {EXO00000753/2}. In July 2012, Studio E sent Paul Dunkerton at the TMO a technical data sheet on a VM Zinc composite panel with a fire retardant core,1064 {SEA00005320} and {SEA00005330}. This panel was not ultimately selected for inclusion in the NBS Specification. although Bruce Sounes had not considered whether it complied with the Building Regulations or the guidance contained in Approved Document B.1065 Sounes {Day20/89:20-25}.
114¶55.5 On 7 August 2012 at a pre-application meeting with the Planning Department, Mr Sounes suggested zinc cladding,1066 {SEA00005602}. which was considered by the planning officer present to be acceptable.1067 Sounes {SEA00014273/53} page 53, paragraph 114; {SEA00005597/1}; Sounes {Day20/92:2-8}.
The move towards Reynobond ACM PE
¶55.6 On 16 October 2012, Mr Blades arranged an introductory meeting between himself, Mr Sounes and Deborah French of Arconic.1068 Sounes {SEA00014273/65} page 65, paragraph 136.6; {CEP000003961}. Mr Sounes thought that they had discussed the fact that Grenfell Tower was a high-rise residential block,1069 Sounes {Day20/96:14-17}. but the others did not remember that. Ms French said she did not remember ever having thought about the height of the building.1070 French {MET00053162} page 21, paragraphs 72-73; French {Day88/67:1}-{Day88/69:3}. She presented the rainscreen products that Arconic offered, including a metal composite with zinc outer skins (called "ZCM") and an ACM composite which could be painted to resemble solid zinc.1071 Sounes {Day20/93:19}-{Day20/98:7}; Sounes {SEA00014273/65} page 65, paragraph 136.6; Blades {Day41/85:12}-{Day41/92:20}. Neither Mr Sounes nor Ms French could remember having discussed the composition of the cores or their reaction to fire.1072 Sounes {Day20/98:3-7}; French {Day88/52:2-11}.
¶55.7 On 31 October 2012 Studio E issued its Stage C report,1073 {SEA00006429}. which included options for rainscreen materials, including zinc composite1074 {SEA00006429/28}; {SEA00006429/31}; {SEA00006429/32}. and aluminium.1075 {SEA00006429/32}. Although the Stage C Report addressed Approved Document L (Conservation of fuel and power) in detail,1076 {SEA00006429/81}. no detailed analysis of a similar kind was included in relation to Approved Document B.
¶55.8 Mr Blades remained in contact with Studio E. On 16 November 2012, he told Ms French that Studio E was inclined towards zinc but that there was still a chance for her to promote the sale of Reynobond panels.1077 {CEP00048712}; Blades {Day41/92:21}-{Day41/93:12}. He encouraged her in her efforts because if Reynobond ACM panels were chosen for the refurbishment, there would be a chance for CEP to be engaged as fabricator.1078 Blades {Day41/93:24}-{Day41/94:3}. Studio E continued to consider other cladding options1079 {SEA00007446}; {SEA00007448}, Sounes {SEA00014273/86} page 86, paragraph 192. and on 7 December 2012 Mr Sounes suggested that aluminium might be a better choice than zinc on aesthetic grounds.1080 {ART00000584/2-3}.
¶55.9 In January 2013, Mohit Kotecha of Leadbitter emailed documents to Geof Blades for cost estimation purposes.1081 {CEP00048886}. They included an outline specification showing VMZ composite zinc panels as the rainscreen.1082 {CEP00048887/6}. Despite that specification, Mr Blades provided a quotation1083 {CEP000000138}; {CEP000000148}. pricing only Reynobond Zinc Patina finish ACM and not the specified VMZ composite zinc panels. Although the price quoted included a full facade design service,1084 Blades {Day41/96:3-6}. Mr Blades did not consider whether the panels were suitable for use on a building over 18 metres in height.1085 Blades {Day41/101:12-17}.
115¶55.10 Geof Blades immediately sent the documents received from Leadbitter to Arconic.1086 {CEP00048962}. They included an outline specification with drawings showing the height and dimensions of the tower,1087 {CEP000000075/7}; {CEP00048966}. images of the tower, which showed it to be a tall building,1088 {CEP000000076}. and a scope of works which included a specification for Celotex FR5000 insulation.1089 {CEP00048971/5}. Although Ms French said that she did not remember whether she had looked at those documents,1090 French {Day88/64:5-11}. she accepted that she had become aware that the tower was a high-rise building.1091 French {Day88/66:18-23}. At that stage CEP was promoting Reynobond because it had a commercial interest in doing so. Mr Blades did not give any thought to whether the PE version was suitable for use on a high-rise building, but at that stage the distinction between a PE and FR core had not really come to the fore. In Mr Blades' mind "Reynobond" was synonymous with Reynobond PE.
¶55.11 In January 2013 the RBKC Planning Department rejected a proposal for green and yellow panels.1092 TMO Position Statement {TMO00837466/7}; {SEA00007275}; Sounes {SEA00014273/78} page 78, paragraph 164. In discussions between Artelia and Leadbitter later that month it became clear that Leadbitter's proposed costs were substantially higher than Artelia's Stage D cost budget estimate. In a costs workshop on 18 January 2013, Leadbitter made various value engineering proposals, including substituting aluminium panels for zinc, resulting in a potential saving of £250,000.1093 {ART00006072}. On 1 February 2013, Leadbitter costed the saving to be made by using aluminium panels at £300,000.1094 {ART00006045}; {ART00005812/7}; {SEA00007298}; {TMO00879771/10}; Maddison {Day59/84:17}-{Day59/85:13}.
¶55.12 In February 2013 Artelia asked Studio E, Curtins and Max Fordham to take a radical look at the specification to identify potential opportunities for value engineering.1095 {SEA00007413}. In the view of Studio E, one obvious possibility was to change the rainscreen from zinc to a cheaper material.1096 {SEA00007415}; Sounes {Day20/102:6}-{Day20/104:7}; {SEA00007414} Studio E also identified other potential cost savings, including scaling back the crown and changing the windows. Studio E had long held a preference for a Proteus Honeycomb zinc product,1097 The core of this product was an aluminium honeycomb structurally bonded between two thin sheets of metal – see {SIG00000248/9}. but it was under significant pressure from the TMO to specify a cheaper alternative to zinc.
¶55.13 Throughout February and March 2013 CEP continued to promote Reynobond ACM panels for use on the tower.1098 Blades {Day41/117:20-24}. Pursuant to the request to consider opportunities for value engineering, on 4 March 2013 CEP and Studio E met to discuss substituting ACM panels for zinc.1099 Sounes {SEA00014273/85} page 85, paragraph 190. In advance of the meeting CEP told Arconic that it would propose the Reynobond range of products.1100 {CEP000000150}; Blades {Day41/104:14}-{Day41/108:25}. Mr Blades said that he did so out of professional loyalty to Arconic, having already introduced them to the project, and during the meeting he supported the use of Arconic's Reynobond panels.1101 Blades {Day41/116:6-12}; Blades {CEP000008838/11} page 11, paragraph 7.42; Blades {Day41/117:8-19}. In doing so, he reinforced the impression held by Studio E that Reynobond PE was a suitable material for use on Grenfell Tower, although he had only limited knowledge of the regulatory regime governing the use of such products and, at that stage, only a limited understanding of the way in which Reynobond PE reacted to fire.
116¶55.14 In our view CEP should have taken steps to ensure that a person in the position of Mr Blades understood the behaviour, particularly in response to fire, of the products it supplied and had a general understanding of the regulatory regime that applied to them. In fact, he believed, quite wrongly, that "Class 0" was synonymous with "limited combustibility".1102 Blades {CEP00064247/14} page 14, paragraph 67; Blades {Day41/58:13-24}. Both he and Neil Wilson, the general manager, were under the impression that Reynobond PE had achieved Class 0,1103 Wilson {CEP00064249/5} page 5, paragraph 21; {CEP00064249/6} page 6, paragraph 24; Blades {CEP00064247/5} page 5, paragraph 22; Blades {Day41/192:18}-{Day41/193:5}. which was not the case, although it is fair to say that BBA Certificate 08/4510 relating to Reynobond ACM panels, of which he was aware,1104 Blades {Day41/57:14-19}. stated (wrongly) that the panels might be regarded as having a Class 0 surface.
¶55.15 Following the meeting, Mr Sounes felt that it might be possible to switch from zinc to ACM1105 {SEA00007442}. and reported to Alun Dawson of Artelia that other options included insulated render and Marley "Natura" fibre cement panels.1106 {SEA00007442} see also {SEA00000547/26}; {SEA00000909}; {SEA00007563/2}; Sounes {Day20/107:11}; Blades {Day41/8:16-19}. At the request of Mr Blades, Ms French sent samples of various Reynobond panels directly to Adrian Jess at Studio E between 22 March and 8 April 2013.1107 {CEP000000151}. Further samples were sent between the beginning of March and the end of June 2014.1108 Exhibit French DF/4 List of samples provided for the refurbishment project {MET00019919}.
¶55.16 In April 2013, CGL Systems Ltd, a facade designer and manufacturer who had been visiting Studio E's offices in connection with another project,1109 Sounes {SEA00014273/89} page 89, paragraph 209. provided Studio E with the names of cladding contractors, including Harley.1110 Sounes {SEA00014273/89} page 89, paragraph 209. Harley had already become aware of the project through commercial sources and on being told by CGL that its name had been given to Studio E,1111 {HAR00005352}; Ray Bailey {Day32/131:1-6}. it contacted Studio E by email to express its interest in the project.1112 {SEA00007603}. Harley's email included details of its previous projects, all of which involved ACM rainscreen.1113 {SEA00007604}; {SEA00007605}; {SEA00007606}; Ray Bailey {Day32/134:23}-{Day32/135:2}. Studio E did not make any enquiries about Harley,1114 Sounes {Day20/118:23-25}. nor did it investigate the construction of the external walls of the buildings involved in any of those projects.
¶55.17 On 17 April 2013, Studio E gave the TMO details of a number of alternative materials to zinc that could be used as a rainscreen, most of which were ACM.1115 {SEA00007563}. By that time the project had effectively stalled while the TMO made decisions about costs and procurement. Bruce Sounes said that it had been necessary to look at the cheapest options because that was what the TMO needed.1116 Sounes {Day20/111:21}-{Day20/112:9}.
117¶55.18 By June 2013 Mr Blades had become aware that an ACM panel with a fire resistant ("FR") core was available1117 Blades {Day41/43:17-23}. and realised that it would perform better in a fire.1118 Blades {Day41/44:11-13}. However, he consistently promoted Reynobond 55 PE and accepted in evidence that he had relied on its Class 0 classification in the BBA certificate without having a working knowledge of the Building Regulations.1119 Blades {Day41/57:5}-{Day41/59:7}.
¶55.19 In June 2013, Studio E was given a copy of Artelia's Draft Revised Project Brief, which stated that the primary driver of the project was value for money.1120 {SEA00007722}; {SEA00007721}. However, despite the fact that ACM was likely to be a cheaper option, Studio E still preferred zinc.1121 Sounes {Day20/120:2-11}.
¶55.20 In July 2013, following a meeting with Councillor Rock Feilding-Mellen, Bruce Sounes prepared a document describing a range of materials and fixing methods that could be used to provide a rainscreen for insulated cladding. Both zinc and ACM panels were illustrated,1122 {SEA00002067}. but the document did not mention fire safety. Studio E submitted a revised planning application to RBKC in July 2013 in which the proposed zinc composite rainscreen remained unchanged.1123 Sounes {SEA00014273/25} page 25, paragraph 48. The changes related predominantly to the lower 4 floors. {SEA00002077}.
¶55.21 On 20 August 2013, Studio E completed a revised Stage D report which included Rheinzink panels for the rainscreen with ACM panels as an alternative.1124 {SEA00008052}; {TMO10003310}; {TMO10003310/21-26}; {SEA00014616/37}. The Rheinzink panel was not combustible.1125 SEA00014616/41} at paragraph 1.2; {SEA00014616/37}.
The Hays Galleria meeting
¶55.22 On 27 September 2013, Bruce Sounes and Tomas Rek of Studio E met Ray Bailey and Mark Harris of Harley at a coffee shop in Hays Galleria near London Bridge to discuss options, costs and technical details for the cladding of Grenfell Tower.1126 {SEA00008375}; Sounes {Day20/129:15-25}; Harris {HAR00010159/4} page 4, paragraph 15; Harris {Day34/48:13}-{Day34/52:14}. During the meeting Harley showed Studio E photographs of some of their previous projects, including Ferrier Point, a high-rise overcladding project in East London, where Harley had installed face-fixed ACM panels over mineral wool insulation.1127 SEA00003497}; {SEA00003516}. Before the meeting, Harley sent an email to Studio E attaching information sheets for three projects: Castlemaine, Clements Court and Chalcots Estate, all of which used ACM as the rainscreen material {SEA00007603}. Studio E and Harley discussed cladding options, including Zinc Proteus HR with a honeycomb core and ACM.1128 Ray Bailey Witness Statement {HAR00010184/6} page 6, paragraph 22; Ray Bailey {Day32/139:4-23}. Mark Harris said1129 Harris {Day34/51:12}-{Day34/52:16}. that Harley had indicated to Studio E that Harley's clients were frequently forced to use ACM because it was the cheapest product available and that Harley had used ACM on tower blocks more than any other product. Ray Bailey claimed not to have expressed a preference for ACM1130 Ray Bailey {Day32/146:14-18}. and Tomas Rek did not recall any particular preference being expressed by Harley.1131 Rek {Day12/68:2-15}.
118¶55.23 Throughout the discussions between Studio E and Harley, price and aesthetics were the dominant considerations;1132 Ray Bailey {Day32/174:8-11}. the fire safety of the panels was not discussed at all.1133 Bailey {Day32/142:17-19}; Rek {SEA00014278/10} page 10, paragraph 30; Rek, {Day12/133:7-9}. Mark Harris accepted that Studio E had been relying on Harley to suggest materials that were suitable for use on the tower,1134 Harris {Day34/52:20}-{Day34/53:1}. but the individuals involved at Harley and Studio E did not turn their minds to the risks involved in using ACM, particularly on a building over 18 metres in height. They simply assumed that it was safe because it had been used on a number of other projects involving tower blocks.1135 Ray Bailey {Day32/145:2}-{Day32/146:4}; {Day32/173:18}-{Day32/174:4}; Harris {Day34/53:7-17}.
¶55.24 Despite the discussions about ACM at the meeting, Mr Sounes still preferred zinc or a zinc composite material. He told Harley that Studio E was looking seriously at Nedzink (a zinc composite panel)1136 Email from Bruce Sounes to Ray Bailey and Mark Harris dated 27 September 2013, {SEA00008809} in which he states, "we are looking seriously at Nedzinc's composite panel. The small sample we have in the office looks like Alucobond but is apparently zinc." See also Sounes {Day20/138:18-25}; {SEA00008985}. but, when he reported back to the TMO with Harley's rough estimate of £3 million based on zinc rainscreen cassettes,1137 {SEA00008809}. he pointed out that in Harley's experience budgets often forced clients to adopt face-fixed ACM.1138 {SEA00008790}. Peter Maddison responded asking whether Harley had given a similar cost estimate for aluminium rainscreen.1139 {SEA00008836}.
¶55.25 On 18 October 2013 Harley provided budget costs to Studio E1140 {HAR00005515}; budget attached at {SEA00002275}. omitting the requested quotation for Nedzink1141 {SEA00008985}. and listing three alternative options for the rainscreen, including Reynobond ACM panels and Reynobond zinc-faced panels. Mr Sounes, who was still pursuing zinc,1142 {SEA00009240}. replied asking for an indication of what the cost would be for Nedzink1143 {SEA00009237}. and explaining that the Reynobond Natural Zinc (also referred to as VM Zinc "Quartz") was not an option for aesthetic reasons.1144 {Day20/145:19-25}.
¶55.26 Harley provided further costs information to Studio E in November 2013, including a quotation for Proteus HR Composite, but expressed a clear preference for ACM because it had used it on many previous projects and was confident about the costs involved.1145 {SEA00009736}; Ray Bailey {Day32/173:18}-{Day32/174:11}. However, Mr Sounes remained adamant that Studio E had set out to use zinc and that if the budget allowed it the result would be excellent.1146 {ART00001895}. In the same email he explained that the TMO would also want ACM options in the tender, despite the fact that the planners did not like the standard finish.1147 {ART00001895}. On 7 November 2013, Mr Sounes forwarded his email exchange with Harley about the cost of different cladding options to Chweechen Lim of Artelia. At that stage Artelia was preparing the OJEU tender documentation and on 11 November 2013, Ms Lim told Mr Sounes that she would include ACM in the tender contract sum analysis and ask contractors to provide an optional cost for zinc panels to ensure that tenderers provided costs for both types.1148 {ART00001895}. Ms Lim noted that Harley's quoted costs were higher than Artelia's cost plan and were also higher than the TMO's budget.1149 {ART00001895}.
119¶55.27 Mark Harris responded to Bruce Sounes some two weeks later on 21 November 2013. He failed to answer Mr Sounes' question about the rate for Nedzink, but he gave standard rates for ACM cassette and face-fixed panels. The email makes clear the close business relationship between Harley and Arconic,1150 {HAR00005509}; Harris {Day34/95:22}-{Day34/100:6}. which led Harley to press for Reynobond panels to be used.1151 Harris {Day34/68:4}-{Day34/85:12}. By December 2013 Harley was seeking prices for Arconic's Reynobond ACM panels1152 {CEP000000267/3}; Ray Bailey {Day32/183:10-15}. and by the spring of 2014 it had become committed to their use on the project.1153 Albiston {Day35/76:17}-{Day35/77:4}.
¶55.28 Planning permission for the refurbishment was granted on 10 January 2014,1154 {ART00001999}. subject to conditions, including a requirement that the materials to be used on the external face of the building be approved in writing by RBKC.1155 See condition 3 {ART00001999/2}. On 15 January 2014 Arconic provided a quotation to CEP for Reynobond 55.1156 {ARC00000083}. Although silent about the composition of the core, Deborah French accepted that as a standard product it would have been polyethylene.1157 French, {Day88/128:22-25}.
¶55.29 CEP, the only fabricator which Harley approached for the supply and fabrication of the rainscreen,1158 Albiston {Day35/46:11-16}. sent two formal quotations on 21 January 2014. These differed only in respect of the window system proposed: Metal Technology,1159 {CEP000000268}. or Wicona.1160 {CEP000000270}. In relation to the rainscreen, the only quotation was for panels manufactured using 4mm Reynobond ACM with rivet fixings. Mr Blades confirmed that Harley had asked him to quote only for Reynobond.1161 Blades {Day41/137:8}-{Day41/141:2}. Following the receipt of the quotation, Harley sent its own quotation to Rydon on 29 January 2014, which did not include VM Zinc as an option.1162 {RYD00002606}; {RYD00002607}.
The NBS Specification
¶55.30 The final version of the NBS Specification produced by Tomas Rek at Studio E was dated 30 January 2014.1163 {SEA00000169}. It specified Celotex FR5000 insulation1164 {SEA00000169/73}. and Proteus HR zinc honeycomb rainscreen panels.1165 {SEA00000169/65}. See section 3 for further details of the CWCT Standard 2008; Rek {Day12/75:23}-{Day12/76:11}. It also asked bidders to provide alternative prices for ACM rainscreen panels, including Reynobond Duragloss 5000.1166 {SEA00000169/64}. The TMO agreed to the inclusion of ACM options in the NBS Specification for two reasons: first, because it wanted priced options, as RBKC's Planning Department had not yet granted consent for any specific type of rainscreen;1167 Maddison {Day59/88:3-10}; {Day59/92:5-10}. second, because it had in mind that it might consider options that were less expensive than zinc in order to reduce the cost.1168 Maddison {Day59/93:1-12}. Peter Maddison denied that the inclusion of ACM had been driven by the TMO; he said that the TMO had included the ACM options on the advice of its professional design team and in the understanding that it was compliant with all the regulations.1169 Maddison {Day59/91:4-18}; {Day59/92:17-24}. We accept his evidence about that.
120¶55.31 Studio E, which had drafted the NBS Specification, had not checked whether the materials specified for use in the cladding complied with the requirements of the Building Regulations or reflected the guidance given in Approved Document B.1170 Sounes {Day20/173:12-24}; Rek {Day12/23:2}; {Day12/20:15-20}; {Day12/24:16-21}; {Day12/27:7-21}. It appears simply to have assumed that they did because they had been used on other projects.1171 Sounes {Day7/170:2-5}; Sounes {SEA00014273/140} page 140, paragraph 343; Sounes {Day20/93:12}{Day20:95:14}. Appearance clearly played a central part in the choice of rainscreen,1172 Sounes {Day20/135:1-7}. which was entirely reasonable, but Studio E did not ask Exova, or any other fire engineer, to review the NBS,1173 Sounes {Day20/51:2-10}. nor did it ask itself whether ACM was an appropriate material to use.1174 Sounes {Day 20/105:12-15}; {Day20/72:1-4}. It was not common practice at Studio E to carry out a full assessment of materials for compliance at RIBA Stage D or E.1175 Sounes {Day20/64:13}-{Day20/65:3}.
¶55.32 Studio E did not investigate the fire performance of any of the proposed rainscreen panels. In his witness statement, Mr Sounes claimed that research and consultations, including with Exova, had not revealed any particular concerns or fire risks associated with the proposals or the materials,1176 Sounes {SEA00014273/140} page 140, paragraph 343.2. but he was unable to identify any specific research that he had done or persons he had consulted.1177 Sounes {Day8/57:2}-{Day8/58:6}. At all events, we are satisfied that Studio E did not consult Exova on the use of ACM rainscreen panels. Until the night of the fire Mr Sounes was unaware that ACM panels could be produced with different cores, some fire retardant and some not.1178 Sounes {Day20/176:17-24}. Indeed, he was unaware that any of the materials referred to in Harley's quotation might be available in fire-rated versions1179 Sounes {Day20/144:12-18}; {RYD00003953}. and simply did not think about the fire performance of the ACM panels.1180 Sounes {Day20/135:4-7}. None of those involved in the refurbishment at Studio E or Harley scrutinised the BBA certificate relating to Reynobond 55 PE properly.1181 Sounes {Day21/16:18-21}; {Day21/19:3-24}; {Day21/23:8-15}; Ray Bailey {Day33/36:11}-{Day33/37:3}; Lamb {Day38/23:17-24}; Anketell Jones {Day37/6:10}-{Day37/7:23}; Albiston {Day35/43:6-24}: Harris {Day34/178:1-5}.
¶55.33 Following the production of the NBS Specification and throughout the discussions in early 2014 between Studio E, Harley and Rydon, everyone involved concentrated on the appearance of the rainscreen panels to the complete exclusion of their fire performance.1182 Harris {Day34/115:12-25}.
Previous projects on which ACM panels had been used
¶55.34 Between 2006 and 2011 Rydon had carried out two substantial overcladding projects on high-rise residential buildings in London, the Chalcots Estate and Ferrier Point, using Harley as sub-contractor. Chalcots Estate comprised five tower blocks, four of which were 23 storeys in height and the fifth 19 stories.1183 {RYD00094236/25} page 25 paragraph 44-47. Ferrier Point was a 23-storey tower block. In both cases a company in the Rydon group was appointed as principal contractor under a design and build contract for the refurbishment of the building1184 {RYD00094236/26} page 26, paragraph 48-50. and in both cases Rydon installed ACM rainscreen panels over mineral wool insulation.1185 {RYD00094236/51} page 51, paragraph 103. Although in each case the core of the panels was unmodified polyethylene, there was one difference: the panels used were face-fixed (i.e. riveted to the supporting rails), whereas the Reynobond panels installed at Grenfell Tower were cassette-fixed.1186 The distinction is important for the purposes of understanding the BBA certificate governing Reynobond PE 55. See in particular Chapter 19. For reasons that will become clear, that was an important distinction.
121¶55.35 Rydon and Harley remained in close contact throughout the procurement process relating to the Grenfell Tower project and it is clear that they approached it as a team, so much so that Rydon's tender included notes on the background and experience of three of Harley's employees, Daniel Anketell-Jones, Mark Stapley and Robert Maxwell.1187 {RYD00094244/44}.
¶55.36 CEP had worked with Harley on ten previous projects, including the Chalcots Estate and Ferrier Point projects,1188 Blades {MET00040323/4} page 4, paragraph 3.3; {CEP000003010}. but the Grenfell Tower refurbishment was the only project it had undertaken with Harley using ACM panels in cassette form.1189 Blades {Day41/24:6-8}. CEP had supplied ACM panels for many other high-rise residential overcladding projects in the years leading up to the Grenfell Tower refurbishment, including both panels with unmodified polyethylene cores and fire-resistant polyethylene cores.1190 {CEP000003010}; Blades {Day41/21:5} – Blades {Day41/25:7}.
Early discussions about value engineering
¶55.37 At the time of the formal procurement process Rydon also had an existing relationship with the TMO and there had been at least some discussion within Rydon of the project and its connection with Peter Maddison before 5 April 2013.1191 Email from Steve Blake to Jeff Henton of 5 April 2013: "This is the Peter Maddison scheme which is right up our street." {RYD00001115}.
¶55.38 Stephen Blake, Rydon's Refurbishment Director, had known Peter Maddison and Sacha Jevans of the TMO since about 2000, having met them at various conferences.1192 Blake {Day28/92:8} – {Day28/93:15}. Although he had not seen either of them regularly, they had kept up a direct line of contact, as Simon Cash of Artelia recorded in an email in October 20151193 {ART00006206}. and as was broadly confirmed by both Mr Maddison and Ms Jevans.1194 Maddison {Day58/161:18}-{Day58/162:1}; {Day127/172:10-19}.
¶55.39 On 6 March 2014, during the OJEU tender process, Mr Blake sent an email to Tim Shutler of Rydon, copied to Jeff Henton, Rydon's chief executive, in which he said that at a recent housing conference he had met senior representatives from the TMO and had been given to understand that Rydon was the leading contender to obtain the contract for the refurbishment.1195 {RYD00086648}. The housing conference to which Mr Blake referred took place between 4 and 6 March 2014 in Brighton. According to Mr Blake, the "senior representatives" of the TMO were either Mr Maddison or Ms Jevans,1196 Blake {Day28/100:7-11}. but both of them denied having spoken to Rydon about the tender.1197 Maddison {Day58/184:11}-{Day58/187:9}; Jevans {Day127/174:17-21}. The tender interviews for the project were due to take place on 7 March 2014 and in our view the email speaks for itself. However it came about, it is clear to us that Rydon was given an indication of the likely outcome of the tender process while it was still going on. No other contractor was afforded the same benefit.1198 Maddison {Day58/202:7-13}.
122¶55.40 When he gave evidence Mr Maddison accepted that he had telephoned Mr Henton on 10 March 2014, after the TMO had interviewed all the potential contractors, to tell him that Rydon was in first position.1199 Maddison {Day58/195:6-23}; {Day58/197:2-12}. The next day Mr Henton sent an email to Alan Sharrocks and Simon Lawrence telling them that, subject to a small amount of value engineering, he expected Mr Maddison to recommend to the TMO board the following week that Rydon be appointed as principal contractor for the refurbishment.1200 {RYD00003279}.
¶55.41 Mr Blake had not been included in Mr Henton's email and he was unable to say why that was,1201 Blake {Day28/148:16}. or how the conversation between Mr Henton and Mr Maddison had come about.1202 Blake {Day28/149:8}. He was asked whether at that time (11 March 2014) he had understood that Rydon's appointment would be conditional on its willingness to accommodate the TMO's desire for value engineering and initially told us that he had not known that at the time.1203 Blake {Day28/152:14}. However, he had in fact been sent a draft of the email on 10 March 2014 by Sandra Guest, Mr Henton's assistant, who had asked him to give her the names of the Rydon employees who had been involved in the bid.1204 {RYD00086650}. Despite his prevarication, it is clear that Mr Blake had been in direct contact with Mr Maddison on or before 10 March 2014 about the results of the tender, because at 7.10pm on 10 March 2014 he had written to Mr Henton to tell him as much.1205 {RYD00094368}. Having been shown the contemporaneous documents, Mr Blake ultimately accepted that he had been aware by 10 March 2014 at the latest that the TMO required significant reductions in the cost of the project by way of "value engineering" if it was to go ahead.1206 Blake {Day29/10:11-16}. On 12 March 2014 Mr Blake sent an email to various Rydon employees telling them that Rydon would be asked by the TMO to find some savings in addition to those identified in the tender.1207 {RYD00003295}. Mr Maddison said that he had spoken to Mr Blake to establish that Rydon was prepared to work with TMO to value engineer the project once the contract had been awarded.1208 Maddison {Day58/203:12}-{Day58/204:4}; {TMO00879770/28}.
¶55.42 When asked about that exchange Mr Blake originally denied having spoken to Mr Maddison on 12 March 2014, but having been shown the contemporaneous documents he was forced to accept that his previous evidence had been untrue,1209 Blake {Day29/15:3}. though he said he had had no recollection of the emails. He also accepted that he and Mr Henton had had personal and private access to the top decision-makers on the project at the TMO.1210 Blake {Day29/16:15}. Mr Blake insisted that their relationship with Mr Maddison and Ms Jevans had not influenced the tender process.1211 Blake {Day28/120:19-20}. Peter Maddison did not score the tenders; that was done by Artelia, Jenny Jackson and the TMO, each of whom provided their own independent scoring, and Rydon came top. However, we are satisfied that Mr Maddison and Ms Jevans played an important part in ensuring Rydon's appointment, both in providing information to Rydon about the tender and in negotiating with it so that its appointment would proceed.
123Rydon's costing error
¶55.43 While those discussions were going on with the TMO, Rydon was also attempting to make good a mistake in the preparation of its tender that had led to a shortfall of approximately £212,000 in its costing. On 11 March 2014, Katie Bachellier, one of Rydon's estimators, had written to Mr Blake to tell him of the error. Mr Blake's response was to look for a way to claw back the loss that would otherwise be made.1212 {RYD00086654}. That had significant repercussions, which we describe below.
Value engineering before Rydon's appointment
¶55.44 On 13 March 2014, Peter Maddison sent an email to David Gibson of the TMO1213 Initially the email was wrongly sent to David Burns but was then forwarded to David Gibson: {TMO00850707}. with copies to Claire Williams and Jenny Jackson, the TMO's procurement consultant, telling him that Mr Blake was confident that a gap in the budget of £270,000 could be closed. Mr Maddison intended to include Rydon's proposals for achieving that reduction in the submission he was about to make to the TMO's board seeking its approval of Rydon as principal contractor.
¶55.45 Later the same day Mr Gibson sent an email to Mr Blake attaching a spreadsheet which indicated that the TMO was looking to achieve a saving in cost of around £800,000 in total.1214 {RYD00003302}; {RYD00003301}. The spreadsheet identified the cladding as offering a saving of £243,000, that being the saving that Rydon had included in its tender submission in respect of new aluminium cladding.1215 {RYD00094244/15}. The combined result of the TMO's request for Rydon to reduce its price by about £800,000 and Rydon's own estimating error meant that Rydon needed to achieve a saving in cost of just over £1 million even before it had formally been awarded the contract.1216 Lawrence {Day23/135:1}.
¶55.46 Mr Blake responded to Mr Gibson a little over five hours later, saying that he could see no reason why the reduction in cost that Mr Gibson had asked for could not be achieved. At that stage, however, he had not taken any steps to satisfy himself that such a reduction was in fact achievable.1217 Blake {Day28/169:13-25}. Mr Blake clearly understood that if Rydon could provide savings to match the TMO's budget, it would be awarded the contract.1218 {RYD00003302}.
¶55.47 On receipt of Mr Gibson's email, Mr Blake contacted Harley more or less immediately. A log entitled "Sales/tender progress report" kept by Mark Harris recorded that he had received a call from Mr Blake who had told him that Rydon had been informed "off the record" that they were in "pole position", but that the job was over budget. Rydon had asked Harley to confirm potential cost savings for them to table in discussions with the TMO.1219 {HAR00010160/5}. Private discussions between Mr Blake and Mr Maddison revealed by Mr Maddison's diary entries for 12 and 13 March 2014 are likely to have been the occasions when Rydon was given that "off the record" indication.1220 {TMO00879770/28}.
124¶55.48 On 14 March 2014 Mark Harris sent Rydon an email giving Harley's analysis of the savings that could be achieved by changing the materials used in the construction of the facade of the tower.1221 {RYD00003315}. He attached a document entitled "Grenfell Tower, London proposed VE cost savings", which set out the cost of Harley's "compliant bid" (i.e. its bid for provision of the facade system specified in the NBS Specification) in the sum of £3,736,595, together with two alternative window systems and four alternative cladding systems, each with an associated saving.1222 {RYD00003316}. Harley indicated savings that could be achieved by using zinc and ACM rainscreen panels as follows: Zinc (cassette-fixed): £157,385 Zinc (riveted): £279,764 Cassette-fixed ACM: £419,627 Riveted ACM: £576,973
¶55.49 Stephen Blake and Simon Lawrence both said that by that time it had been accepted by Harley and Rydon that ACM panels would be used if planning permission could be obtained.1223 Lawrence {Day23/151:20}; Blake {Day28/182:14-17}.
¶55.50 A meeting took place during the evening of Tuesday 18 March 2014, attended by Mr Lawrence, Mr Blake and Ms Bachellier on behalf of Rydon and Mr Gibson, Mr Maddison and Claire Williams on behalf of the TMO, at which they discussed how the project could be brought within the TMO's revised budget.1224 Lawrence {RYD00094220/5} page 5, paragraph 22. Mr Blake said that he could not recall the meeting in any detail, but he did remember that Rydon and the TMO had discussed the need to find a significant amount of savings to enable the scheme to meet the TMO's budget.1225 Blake {Day28/171:10}.
¶55.51 We do not know exactly what was discussed at the meeting because no record was kept of it. Mr Maddison described it as an "offline conversation" that was not part of the formal process, but specifically denied that it had been a secret meeting.1226 Maddison {Day59/13:11-20}; {Day59/14:24}. However, the TMO had been advised by its solicitors in February or early March that it was bound to assess all the tenders received for the project on the basis of the price and quality criteria set out in the tender documents and that the regulations did not allow it to enter into negotiations with individual tenderers before the contract had been awarded or even to invite all tenderers to submit revised offers. It was advised that it could run value engineering exercises with its selected tenderer only after it had entered into the contract. Ms Jackson therefore suggested that the TMO enter into the contract with Rydon at its tender price and then embark on value engineering, but she noted that there would need to be some informal discussion with the preferred contractor before they entered into a contract to ensure that it understood the TMO's approach.1227 {ART00006433}.
¶55.52 Simon Cash of Artelia agreed with Ms Jackson that the TMO could have an "offline discussion" with the preferred contractor and that the TMO was entitled to look for savings and seek Rydon's agreement in principle to work with it later to achieve them. He added that some savings had been identified and others might be put forward during that conversation.1228 {ART00008594}. He told us that he had not been comfortable about the TMO's meeting Rydon in that way but had felt under pressure from the TMO to agree.1229 Cash {Day48/233:7-19}. In oral evidence, Mr Cash said he had meant that the TMO could tell Rydon what its approach to value engineering would be once the contract had been awarded,1230 Cash {Day48/225:24-25}; {Day48/226:1-4}. without indicating that Rydon was the preferred bidder.1231 Cash {Day48/224/16-17}. If that was so, however, we do not understand why Mr Cash said that suggestions for savings might be put forward before the contract had been awarded. Nor do we think that is the plain meaning of his message. As employer's agent he should not have lent his support to discussions which, in the light of the advice that he knew had been given by the TMO's solicitors, he had every reason to think might not be consistent with the procurement rules.
125¶55.53 On 23 March 2014, after the "offline" meeting had taken place, the TMO received further advice from its solicitors.1232 {TMO10005632}. They said that the procurement process could be open to challenge if a contracting authority sought to vary a price after receiving tenders or entered into negotiations with its preferred contractor. In an email sent to Sacha Jevans, David Gibson and Claire Williams on 26 March 2014 Peter Maddison summarised that advice as "Low risk of challenge and low risk of success."1233 {TMO10005632}.
¶55.54 Peter Maddison said that the "offline" meeting on the 18 March 2014 and the conversations which had preceded it were in accordance with the solicitors' advice,1234 Maddison {Day59/12:21}-{Day59/13:3}. being solely to seek agreement to value engineering in principle, and to agree a process for doing so.1235 Maddison {Day58/198:6}-{Day58/199:19}. David Gibson, however, conceded that no record had been made of the meeting because the TMO had wanted to achieve a secret understanding with Rydon.1236 Gibson {Day54/34:21-25}. He was aware that holding it had been contrary to the legal advice given to the TMO and that there was a risk that the procurement process would be challenged if other contractors found out about it. He ultimately conceded that one purpose of the meeting had been to identify changes to the specification that would reduce the overall cost of the project.1237 Gibson {Day54/30:7}-{Day54/31:18}; Gibson {Day54/43:3-11}.
¶55.55 We do not accept Peter Maddison's characterisation of the discussions. Their clear purpose, which was understood by both the TMO and Rydon, was to achieve a reduction in the cost of the project that would be reflected in the contract price. Specific areas of savings were identified and figures were discussed. Peter Maddison said that there had been a commercial risk of challenge,1238 Maddison {Day59/15:11}-{Day59/17:3}. but that the discussions had not been improper.1239 Maddison {Day58/202:19}-{Day58/203: 6}. No doubt the TMO was in a difficult position: only three tenders had been received and all exceeded the budget as it then stood.1240 {ART00002197}. Repeating the procurement process would have caused considerable delay, which would have disappointed residents who had been waiting a long time for the refurbishment, and there was no guarantee that any of the contractors would bid again, or would bid again at a lower price.1241 Maddison {Day59/16:1-24}. However, we do not accept that Peter Maddison thought at the time that the "offline" discussions were consistent with the rules governing the procurement process; indeed, in answer to a question from the Chairman he accepted that they "did not strictly comply with the letter of the process."1242 Maddison {Day59/23:5-18}. That, of course, explains why the meeting was described as "offline", i.e. secret. Secrecy was essential so far as both the TMO and Rydon were concerned because transparency might defeat its object.
126¶55.56 On 17 March 2014, Philip Booth of Artelia had drafted a letter to Rydon formally notifying it of its status as the preferred bidder.1243 {TMO10005474}. Substantial amendments were made to the wording by Ms Jackson later that evening.1244 {ART00002210}. The amended version, dated 18 March 2014,1245 {ART00008632}. was sent to Rydon at 5.55pm, some time after the "offline" meeting had ended.1246 {ART00008755}. Although Artelia had been aware of the process that the TMO proposed to adopt, there is no evidence that Artelia had been aware of the meeting itself and it is likely that it sent the letter on the instructions of Mr Gibson or Mr Maddison.1247 Williams {Day54/192:7 – {Day54/193:3}. The letter referred to certain conditions, but said nothing about value engineering or the need to find substantial (or indeed any) cost savings. Unsurprisingly, the letters sent to the unsuccessful bidders the same day did not refer to the contact between the TMO and Rydon.1248 {ART00002224}; {ART00002219}.
¶55.57 Simon Lawrence reported to Mark Harris on 19 March 2014 that Rydon had been confirmed as the preferred contractor for the refurbishment, although the decision was yet to be formally approved. Mr Harris recorded in his log that Rydon was "keen to push this job down the face-fixed ACM route with standard colour finish".1249 {HAR00006044} and {HAR00010160}. He immediately contacted Deborah French of Arconic to procure samples of ACM rainscreen that would appear similar to zinc but at a lower cost.1250 {HAR00006044}; {CEP00051117}; {RYD00003525}; {RYD00003508}; {RYD00003524}. In the weeks and months that followed, there were extensive discussions between Harley, Arconic, Studio E, Rydon and CEP about the use of ACM rainscreen cladding, but they related only to its cost and appearance;1251 {ARC00000089}; {RYD00003890}; {HAR00000931}; {HAR00005692}; {HAR00000933}; {SEA00010775}; {RYD00003964}; {CEP00051309}; {HAR00005737}. certainly, there were no discussions about its reaction to fire. Peter Maddison's diary entry for 19 March 2014 suggests that he had been advised by the TMO's solicitors to agree with Rydon that the negotiations and the contract price should both be kept confidential.1252 {TMO00879778/4}.
¶55.58 On 20 March 2014, Katie Bachellier sent Peter Maddison and others at the TMO a summary of Rydon's value engineering proposals1253 {RYD00003489}. in the form of two documents entitled "VE Options 18.03.14"1254 {RYD00003490}. and "Cladding VE Options 18.03.14",1255 {RYD00003491}. which set out the cost savings that Rydon had presented to the TMO at the "offline" meeting on 18 March 2014. The first of those documents showed a possible saving of £862,041 (enough to meet the TMO's objective) if all the suggestions were adopted.1256 Lawrence {Day23/159:4}; Blake {Day28/190:15}. The second indicated the savings that could be achieved by the use of different rainscreen materials as follows: Zinc (cassette-fixed): £100,406 Zinc (riveted): £202,372
127¶Cassette-fixed ACM: £293,368 Riveted ACM: £376,175
¶55.59 Those figures were all lower than those that Harley had given Rydon on 14 March 2014. Stephen Blake, Simon Lawrence and Zak Maynard were all asked to explain why Rydon had not disclosed to the TMO the true extent of the savings that could be achieved by changing the rainscreen. Both Mr Lawrence and Mr Maynard accepted (though not in so many words) that the purpose was to enable Rydon to retain the difference in order to make up the shortfall caused by the £212,000 error in costing.1257 Lawrence {Day23/163:18}; Maynard {Day31/91:15}-{Day31/92:2}. Mr Blake conceded that Rydon had seen the change of rainscreen as an opportunity to generate additional profit for itself1258 Blake {Day28/193:6-8}. and ultimately accepted that Rydon was showing the TMO significantly less by way of savings than it was obtaining from Harley.1259 Blake {Day28/193:12}.
¶55.60 At all events, it is self-evident that Rydon stood to make a greater profit from the refurbishment if the rainscreen were changed to ACM, particularly if a face-fixed (riveted) system was chosen rather than a cassette system. It was therefore in Rydon's interest to promote the selection of ACM panels, which goes some way to explaining its enthusiasm for choosing that material and method of fixing. The TMO was kept entirely in the dark about Rydon's financial interest in recommending ACM.
The BBA certificate
¶55.61 Arconic held a certificate issued by the BBA in respect of Reynobond Architecture Wall Cladding Panels, the most recent version of which, at the time of the refurbishment, was dated 14 January 2008.1260 {ARC00000678}. Astonishingly, at no stage of the project did anyone at Rydon, Harley or Studio E examine the certificate with any care with a view to understanding how ACM panels with unmodified polyethylene cores might react to fire.
¶55.62 Deborah French gave Mr Harris a copy of the BBA certificate on 23 April 2014 and he passed it straight on to Simon Lawrence,1261 {RYD00003932}. apparently without giving it any consideration. Simon Lawrence sent a copy to Mr Sounes the same day and also arranged for a copy to be provided to Mr Blake on or around 6 May 2014 as part of a pack of documents relating to a meeting with RBKC's Planning Department.1262 {RYD00003932}; {RYD00004142}.
¶55.63 Mr Sounes did not spend long looking at the certificate; indeed he said that it had not been his practice to read the whole of a BBA certificate for any product that he was planning to recommend for a project.1263 Sounes {Day21/12:5-7}; {Day21/13:3}. He admitted that he had never read section 6 of the Reynobond certificate, which related to the fire performance of the panels, and said that investigating their fire performance had not been a concern at that stage.1264 Sounes {Day21/19:24}; {Day21/16:20}; {Day21/17:8}; Sounes {SEA00014273/154} page 154, paragraph 381. In his view Rydon had by that time taken over responsibility for the design of the project which included responsibility for assessing the suitability of any materials that might be used. Mr Sounes was not aware of the distinction between the fire retardant (FR) and unmodified polyethene (PE) versions of the product and he never discussed the matter with Harley or CEP.1265 Sounes {Day21/24:7-13}. For his part, Neil Crawford could not remember having looked at the BBA certificate before the fire and we think it unlikely that he did so.1266 Crawford {Day10/149:22}-{Day10/150:14}. No one at Studio E sought any guidance on the meaning or effect of the BBA certificate from Exova, Rydon, Harley, Arconic or anyone else.1267 Sounes {Day21/29:11-21}.
128¶55.64 Although Simon Lawrence may have looked at the BBA certificate generally, he did not study it in any detail and did not pay any attention at all to the section relating to fire performance.1268 Lawrence {Day24/4:11-14}; {Day24/6:5-14}. He did not ask Harley to check the test evidence on which the certificate was based, nor did he ask it whether the panels being proposed for use on the tower were in all respects the same as those described in it. Rather, he appears simply to have assumed that ACM panels generally were suitable for use on the tower because Rydon and Harley had previously worked together to install similar panels on the Chalcots Estate and Ferrier Point projects.1269 Lawrence {Day24/18:14}-{Day24/19:21}.
¶55.65 Mr Lawrence could not recall having discussed the BBA certificate with Bruce Sounes or anyone else and he did not discuss the fire performance of ACM panels with anyone at any stage of the project.1270 Lawrence {Day23/179:2-7}; {Day24/21:4} – {Day24/22:6}. When he sent the certificate to Mr Blake on 6 May 2014 he specifically drew attention to the fact that it stated that the panels were rated Class 0, which might suggest that he had addressed his mind to the question of the fire performance, at least to a limited extent.1271 {RYD00004142}. However, when he was asked about that email, he said that he had merely been trying to provide Mr Blake with as much information as possible and that he had not considered that the fire performance of panels to be relevant to the meeting.1272 Lawrence {Day24/35:19}-{Day24/37:9}. Mr Blake said that there had been no discussions at all within Rydon about which, if any, of the routes to compliance for external walls in Approved Document B had been adopted.1273 Blake {Day28/86:8-12}. Furthermore, none of those who gave evidence on behalf of Rydon was aware that Reynobond 55 panels were available with a fire retardant core, despite that being clear from the wording of the BBA certificate.1274 Lawrence {Day24/14:1-14}; Blake {Day28/48:20-23}; O'Connor {Day26/27:18-24}; Hughes {Day27/53:24}-{Day27/54:1}; Martin {Day30/116:4-7}. In the circumstances, we are satisfied that no one at Rydon gave any meaningful consideration at any stage to the part of the certificate that dealt with the fire performance of the ACM panels used on Grenfell Tower.
¶55.66 As for Harley, Ray Bailey had read the BBA certificate in 2008 at the time of the Chalcots Estate project and did not read it in detail again.1275 Ray Bailey {Day32/15:11-20}. He accepted that Harley was obliged to examine certificates such as the BBA certificate in order to satisfy itself that the products that were being used on the tower were appropriate,1276 Ray Bailey {Day33/37:4-11}; {HAR00000120}; {HAR00000391/2} at clause 4.2. but he said he had only been concerned to ensure that the BBA certificate confirmed that the panels had a Class 0 rating.1277 Ray Bailey {Day32/124:16-18}; {Day33/33:14-15}. He was not aware that that classification did not extend to the smoke silver polyethylene cored panels that had been selected for use.
¶55.67 Despite Mr Bailey's evidence, it is difficult to resist the conclusion that no one from Harley gave any serious consideration at all to the current BBA certificate. Daniel Anketell-Jones did not read it1278 Anketell-Jones {Day37/7:22}. and, despite having received a copy of the email from Ms French to Mr Harris attaching it, nor did Mike Albiston.1279 Albiston {Day35/43:24}. Harley's designer, Kevin Lamb, did not consider it to be part of his job to read the certificate; indeed, it had never crossed his mind that there might be one.1280 Lamb {Day38/23:19}.
129¶55.68 We think it is clear that none of those responsible for the design of the overcladding of Grenfell Tower asked themselves whether the BBA certificate could be relied upon as evidence that the ACM panels which they proposed to use, whether in face-fixed or cassette form, would result in the creation of an external wall which complied with the Building Regulations. In her evidence to the Inquiry, Ms French, who sold the cladding for Arconic, said that this fundamental lack of curiosity in the reaction of the panels to fire was more normal than otherwise.1281 French {Day88/187:21-25}.
¶55.69 The approach of RBKC's Building Control Department was much the same. Mr Allen accepted1282 Allen {Day47/80:3-13}; {Day47/77:4-12}. scrutinising certificates such as the BBA certificate and the test data referred to within them was a core function of a Building Control officer, but Mr Hoban did not look beyond the first page of the BBA certificate with its reference to Class 0.1283 Hoban {Day46/23:14-16}; Allen {Day47/80:3-24}; Menzies {Day60/97:14}-{Day60/98:6}; {Day60/99:2-16}. The reliability of a BBA certificate was accepted without question by RBKC's Building Control Department, but it was not Mr Hoban's practice to read BBA certificates in any detail.1284 Hoban {Day46/15:20}-{Day46/16:45}.
¶55.70 Geof Blades was aware of the existence of the BBA certificate and thought (wrongly) that it stated that Reynobond 55 PE panels had achieved a Class 0 fire rating, having failed to notice that only the FR version was said to have passed both the BS476-6 and BS476-7 tests.1285 Blades {Day41/60:4-25}. He did not appreciate that the certificate did not in that respect cover panels with an unmodified polyethylene core. He also thought, quite wrongly, that Class 0 was synonymous with limited combustibility1286 {CEP00064247/14} page 14, paragraph 67; Blades {Day41/58:11-12}; {Day41/60:19-24}; {Day41/131:10-12}. and failed to consider whether the nature of the core might affect its compliance with the Building Regulations. He had no understanding of the ways in which cladding systems could be shown to comply with the Building Regulations and Approved Document B.1287 Blades {Day41/64:7-12}.
Negotiations with the Planning Department
¶55.71 From March 2014 onwards, the attention of Studio E, Rydon, Harley and the TMO turned to obtaining approval from the RBKC Planning Department for the material to be used on the external walls of the tower. From that time, the only product that was proposed for use was Reynobond 55 PE ACM panels, i.e. with unmodified polyethylene cores.1288 Williams {Day55/20:9-15}. The only remaining questions were about colour and whether the fixing system should be cassette or rivet.
¶55.72 On 1 April 2014, a meeting was held to introduce the TMO to Rydon, as the main contractor for the project. The minutes of that meeting record that the TMO was told that there was a potential saving of up to £376,175 to be made if the material used for the rainscreen were changed from zinc to ACM and if rivet fixings were used.1289 {ART00002256}; Peter Blythe asked that the minutes of this meeting be kept confidential {RYD00003682}. Rydon did not tell the TMO that Harley was willing to reduce the cost of the rainscreen by as much as £576,000 for face-fixed ACM and if, as the minutes tend to suggest, the TMO was given to understand that the sum of £376,175 reflected the full amount of the reduction available from Harley, that was clearly false and was known by Rydon to be false.1290 Lawrence {Day23/174:1-9}; Blake {Day28/193:9-12}.
130¶55.73 Artelia immediately began to discuss with Rydon, Studio E, Harley, the TMO and IBI Taylor Young, an independent planning consultant appointed by the TMO, the best strategy for obtaining planning permission for the change in design.1291 {RYD00003898}; {SEA00010720}; {SEA00010767}; {RYD00004155}. On 8 May 2014, Stephen Blake attended a meeting with the Planning Department, together with (among others) Bruce Sounes, to discuss the proposed changes to the design of the facade. In an email to Claire Williams before the meeting, Simon Lawrence listed what he described as "agenda points" for the meeting, including, in particular, a proposal for changing the rainscreen from zinc to ACM. He intended to argue that ACM was not inferior to zinc.1292 {RYD00086654}. Mr Lawrence saw Rydon as an advocate for ACM against a reluctant planning committee because it had used ACM successfully on previous occasions. He thought it was in everyone's interests for ACM to be accepted, because there was a risk that, if it were not, the project might not go ahead at all.1293 Lawrence {Day24/32:2-6}. As we have already noted, Rydon also had a powerful financial interest in the choice of ACM.
¶55.74 When Mr Lawrence briefed Mr Blake before the meeting, he told him that the ACM panels they proposed to use had a Class 0 rating, but there was no discussion about their fire performance at the meeting. Indeed, he could not remember any discussion about the fire safety of the panels at all.1294 Blake {Day29/40:8-16}. Mr Blake said that he had not been aware of any consideration having been given to the fire performance of ACM panels at any time between May and October 2014, when final planning permission was obtained.1295 Blake {Day29/43:18}-{Day29/44:21}. The appearance and cost of the cladding, together with concerns about the programme, were the only matters considered by the council, either in its internal discussions or those it held with Studio E.1296 Feilding-Mellen {Day131/188:15}-{Day131/189:22}; {Day131/191:15}-{Day131/193:14}; {Day131/195:2-17}; {Day131/199:3-6}.
¶55.75 RBKC's Planning Department was principally concerned with two matters: the colour of the panels and the method of fixing. There is no evidence that the TMO, Rydon or Harley was aware that the method of fixing might affect the reaction of the panels to fire, but it did affect the appearance of the facade and was therefore regarded as an important aesthetic consideration.1297 RBKC Planning also considered whether the face-fixing could rust: {SEA00011359}. Bruce Sounes said that his own examination of the technical documents provided by Arconic concentrated on the colour charts because the focus at that time had been on the building's appearance.1298 Sounes {Day21/11:9-20}; Sounes {SEA00014273/154} page 154, paragraph 381. When one of the councillors, Rock Feilding-Mellen, intervened in the debate in July 2014, the only issues on which he commented were fixing method and colour,1299 {RBK00033430}; {RBK00003508}. with a heavy emphasis on the latter.
131¶55.76 The Planning Department had a clear preference for a cassette rather than a riveted system. On 23 May 2014, Simon Lawrence sent an email to Stephen Blake and Zak Maynard, in which he expressed his concern that the planners would accept only cassette-fixed panels on aesthetic grounds.1300 {RYD00005064}. His concern stemmed from the fact that Rydon stood to gain far less from the use of a cassette system than a riveted system.1301 Lawrence {Day24/69:10}.
¶55.77 On 17 July 2014, representatives of the planning committee visited Grenfell Tower to view a mock-up of the cladding.1302 {RYD00012461}; {RYD00012459}. Arconic supplied Reynobond ACM rainscreen for the purpose free of charge to CEP, which fabricated it. On 31 July 2014 the TMO informed Rydon that the planning department had approved ACM rainscreen cladding using cassette fixings and formal planning permission was granted for those panels in "smoke silver" on 25 September 2014.1303 {RYD00003932} attaching {HAR00000934}; {IBI00001802}; {RYD00014150}.
Fabrication by CEP
¶55.78 Once Reynobond 55 PE ACM panels had been approved, attention turned to their fabrication by CEP. Harley placed four orders with CEP for ACM panels to be used on the facade and crown of the tower, on 13 March 2015, 6 July 2015, 8 July 2015 and 9 November 2015.1304 {CEP000000512}, attaching {CEP000000513}; {CEP000000527}; {CEP000000528}, attaching {CEP000000529}; {CEP000000616}; {CEP000000617}; {CEP000007550}; {CEP000001124}; {CEP000001168}. Harley placed separate orders for the fabrication of the windows, in October 2014 and February and May 2015.1305 {CEP000000447}; {CEP000000469}, attaching {CEP000000470}; {CEP000000471}; {CEP000000472}; {CEP000000492}; {CEP00053848}; {CEP000005833}; {RYD00040435}.
Contemporaneous knowledge of the combustibility of ACM panels
¶55.79 Although it appears that neither Harley, nor Rydon nor Studio E gave detailed consideration to whether ACM rainscreen panels complied with the requirements of the Building Regulations, many of those involved in the decision to use them had some general awareness of their combustibility, in some cases as a result of personal experience. The most significant event, in our view, was the fire which occurred on the night of 16 January 2012 at Taplow House on the Chalcots Estate. Employees of Rydon and Harley, including Stephen Blake, attended Taplow House on 17 January 2012 to inspect the damage, including the damage to the ACM panels.1306 {HAR00010169}. A report produced by Harley on 17 January 2012 found that the fire had melted the windows of the flat in which it had started and had damaged the cladding, but had been prevented from spreading more widely into the cladding system (and in turn to other flats) by the cavity barriers around the windows.1307 {HAR00010169/3}. Mr Blake was pictured in the report pointing to the cavity barrier system around the damaged window.1308 {HAR00010169/3}; Blake {Day29/121:21-23}.
¶55.80 After the initial inspection on 17 January 2012, Harley and Rydon agreed that an abseil survey should be conducted. It took place on 18 January 2012 and a further report was produced by Harley on 23 January 2012.1309 {CEP000003223}. The report stated that the purpose of the inspection had been to examine the external facade of the building to ensure that the cladding panels were safe, as the fire had caused extensive damage.1310 {CEP000003223}. The inspection revealed that the ACM panels had distorted as a result of being exposed to heat and smoke, and the report contained photographs showing that they had been seriously damaged, having melted and warped.1311 {CEP000003223/5-14}. The abseil report was circulated to, amongst others, Mr Blake, Ray Bailey and Daniel Anketell-Jones.1312 {CEP000003223/2}. Despite the contents of the report, Mr Blake appears to have told David Hughes (of Rydon) that he had no concerns about the safety of ACM panels arising from the Taplow House fire.1313 Hughes {Day27/42:1-18}. Ray Bailey told us that the fire at Taplow House had demonstrated to Harley that ACM would burn1314 Ray Bailey {Day33/143:4-5}. and he accepted that Harley's failure to implement the lessons it had learnt from Taplow House in the designs of the windows at Grenfell Tower had been an error.1315 Ray Bailey {Day33/146:11-16}.
132¶55.81 There were other events which should have made those responsible for the cladding at Grenfell Tower aware of the dangers posed by the combustible nature of ACM panels. On 13 May 2013, Deborah French of Arconic wrote to Geof Blades, Neil Wilson and Roy Fewster of CEP to alert them to press reports of a fire in a building in the United Arab Emirates that had been overclad with ACM rainscreen panels.1316 {CEP00049719}. Mr Blades knew as a result of those exchanges that ACM panels with unmodified polyethylene cores were combustible.1317 Blades {Day41/123:14-15}. Ms French's email followed a message to CEP a few days earlier from Richard Geater, the UK sales representative of Alucobond's, another producer of ACM panels, which referred to the Tamweel Tower fire in Dubai and described the problems that had been encountered there with the use of cheap ACM panels with polyethylene cores.1318 {MET00053158_P10/157}; Blades {Day41/122:15-25}. Those messages ought to have prompted Mr Blades to reconsider whether it was safe to use Reynobond PE on any high-rise building in the UK, including Grenfell Tower, but regrettably he did not do so.
¶55.82 On 7 October 2014, Daniel Anketell-Jones attended the Annual General Meeting and Members' Meeting of the Centre for Window and Cladding Technology (CWCT), at which a presentation was given by Sarah Colwell discussing the regulatory requirements and testing regimes for the construction of facades.1319 {CEL00001037}. It is clear from the slides used at that presentation that the combustibility of rainscreen facades was discussed, including the large number of cladding fires that had affected high-rise buildings in other countries.1320 {CEL00001038/3}. Daniel Anketell-Jones said that he had no specific recollection of being at that presentation; he thought he had been there but that he had not been concentrating.1321 Anketell-Jones {Day36/5:16-18}.
¶55.83 It is unlikely to be a coincidence that on 8 October 2014, the day after that meeting, Samuel Anketell-Jones, a junior design engineer at Harley and Daniel Anketell-Jones's brother, sent Deborah French of Arconic an email asking for information about Reynobond ACM panels with a fire-resistant mineral core.1322 {MET00081175}. This email was disclosed to the Inquiry by the MPS in 2022 after the conclusion of the hearings and was disclosed to core participants in April 2023. Daniel Anketell-Jones told us that when he had proposed the cladding for Grenfell Tower he had not realised that Reynobond ACM panels were available with a fire-resistant core.1323 Anketell-Jones {Day37/8:13-18}; {Day36/212:21}-{Day36/213:8}. (Ray Bailey said that he had been aware that two kinds of panel were available as a result of reading the BBA certificate but had assumed that they performed in similar ways and that neither he nor anyone else at Harley had ever asked Deborah French about it.)1324 Ray Bailey {Day33/44:4-25}. Although it is not clear to which of Harley's projects the email related, it suggests quite strongly, particularly when viewed together with the information shared at the CWCT meeting, that Harley knew more than it was willing to admit about the availability of a fire-resistant version of the Reynobond panel and the dangers of using ACM with an unmodified PE core.
133¶55.84 In March 2015, discussions took place between Siderise, Harley and Rydon about the cavity barrier requirements for Grenfell Tower. For present purposes it is not necessary to refer to the details of the debate but it is worth drawing attention to some of the things said in the course of it by Exova, Studio E, Rydon and Harley. In an email of 27 March 2015, Daniel Anketell-Jones wrote to Ray Bailey saying, "There is no point in 'fire stopping', as we all know; the ACM will be gone rather quickly in a fire!"1325 {HAR00006585}. On 31 March 2015, Terence Ashton wrote to Neil Crawford saying, amongst other things, that it was difficult to see how a fire-stop would stay in place in a fire involving external flaming as it would cause the zinc cladding to fail.1326 {EXO00001434}. Mr Crawford agreed, expressing the view that "metal cladding always burns and falls off."1327 {EXO00001434}. Later the same day, he relayed Mr Ashton's opinion to Simon Lawrence.1328 {SEA00013051}. It is clear that Mr Lawrence read Mr Ashton's comments because he responded, "Excellent. That looks positive."1329 {SEA00013051}.
¶55.85 None of the witnesses was prepared to accept that those messages showed that those concerned were aware that ACM panels were combustible. Mr Ashton said that he had meant to say that metal rainscreen would not burn, but that if windows connected to metal cladding failed, the panels themselves would fall off the building in that area,1330 Ashton {Day18/103:4-10}. not that they would actually burn.1331 Ashton {Day18/104:10-14}. We do not accept that evidence. In our view he was aware that ACM panels would burn, but at the time he was still under the impression that the panels were to be zinc.1332 See Chapter 54 and our findings about Exova's work. Similar explanations were offered by Mr Crawford and Mr Anketell‑Jones. Mr Anketell-Jones said that he had been referring to the fact that ACM panels and their fixings were made of aluminium, which would melt at a lower temperature than steel, and was not referring to the combustibility of the panel itself or to the fact that its core was made of polyethylene.1333 Anketell-Jones {Day37/20:4}-{Day37/21:24}. He told us that at the time nobody had been aware that any of the materials were combustible,1334 Anketell-Jones {Day37/27:6-8}. and went on to explain that he had meant to say that metal cladding would melt, fail and fall off.1335 Crawford {Day10/154:6-7}. He denied that he had been aware that composite panels with a polyethylene core could contribute to the spread of flame.1336 Crawford {Day10/156:2-16}. For his part, Simon Lawrence simply said that he did not give any thought to what would happen if the rainscreen were exposed to flames.1337 Lawrence {Day25/11:17}. He said that if he had been aware that ACM would quickly fail in a fire, he would have checked with Building Control that it complied with the regulations and would then have looked into it further.1338 Lawrence {Day25/12:23}-{Day25/24:1}. In the event, it is clear that he did neither of those things. We agree with the view expressed by Deborah French in a witness statement given to the Metropolitan Police that it would have been obvious to anyone that polyethylene was plastic and flammable.1339 {MET00053162/7} page 7, paragraph 28. We are satisfied that Mr Crawford and Mr Anketell-Jones knew that ACM was combustible; Mr Lawrence may not have known, but ought to have taken the trouble to find out after he had been asked about the reaction of the panels to fire by Claire Williams in her email of 12 November 2014.
134¶55.86 However, even if none of them gave any real thought to the implications of using ACM panels with polyethylene cores, those representatives of Exova, Studio E, Rydon and Harley were aware that an external wall incorporating the rainscreen panels that were to be used on Grenfell Tower would not adequately resist the spread of fire across the surface of the building. That much is clear from the exchange of emails mentioned above.1340 {HAR00006585}; {SEA00013051}.
The "Lacknall moment"
¶55.87 On 12 November 2014, Claire Williams wrote to Philip Booth and Nick Valente of Artelia asking, amongst other things, whether in the light of the fire at Lakanal House there was any requirement for materials to be flame retardant.1341 {ART00003042}. Later the same day she sent an email to Simon Lawrence referring to Lakanal House and asking him to clarify the fire retardance of the new cladding.1342 {RYD00023468}. She was familiar with the Lakanal House fire principally because she had attended a presentation by Dr David Crowder of the BRE on 10 January 2014,1343 {TMO10040126}; Williams {Day55/126:21}-{Day55/130:20}. but could not recall any specific aspect of the presentation that had caused her to make a connection between that fire and the fire performance of the cladding chosen for use on Grenfell Tower. She also included in her email extracts from the NBS Specification for the project, which Philip Booth had sent her as a reminder of what had been specified.1344 {ART00008527/52} page 52, paragraph 173; Booth {Day50/62:9-15}; Booth {Day50/64:15}-{Day50/65:6}. He had suggested that she seek clarification from Rydon about the fire performance of the cladding. Mr Lawrence accepted that it had been part of Rydon's task as principal contractor to answer questions of that kind from the TMO and that, within Rydon, he was the person to do so.1345 Lawrence {Day24/166:18-23}.
¶55.88 Mr Lawrence told us that when he read Ms Williams email he had understood her to be referring to the glass reinforced concrete ("GRC") cladding that was to be installed on the lower levels of tower,1346 Lawrence {Day24/161:12}-{Day24/168:8}. but that was not what she had said in her email and, although the information she included had referred to GRC products, it had also referred to the CWCT standard for systemised building envelopes, which applied to the whole of the tower's facade. We are unable to accept that Mr Lawrence understood that message to refer only to the GRC element of the cladding installed at Grenfell Tower.
¶55.89 Mr Lawrence said that he would not have expected to respond to an email of that kind himself but would have sent it to the project's design team for a response.1347 Lawrence {Day24/164:1}-{Day24/166:23}. However, there is no record of his having done so, or indeed of any response to it, and Ms Williams could not recall having received any response.1348 Williams {Day55/145:25}. We think that Simon Lawrence simply failed to take any action at all in response to the email, possibly because he did not understand its significance, that Ms Williams did not pursue it, and that no one in the design team gave any consideration to the question she had raised, despite the fact that it was of real importance.
135¶55.90 In both his written and oral evidence David Gibson told the Inquiry that he had raised concerns about the fire performance of the rainscreen system during a meeting chaired by Philip Booth of Artelia in March or April 2015.1349 Gibson {TMO00000887/19} page 19, paragraph 99. He said that he had become concerned when he learnt that there was to be an air gap between the insulation and the rainscreen, as he had understood that a cavity of that kind had contributed to spread of fire at Lakanal House.1350 Gibson {TMO00000887/18} page 18, paragraphs 94-98; {TMO00842310/8} page 8, paragraph 23; Gibson {Day53/177:9-22}. He said that Mr Lawrence had assured him that the rainscreen was completely inert and would not burn at all.1351 Gibson {TMO00842310/8} page 8, paragraph 23. Claire Williams supported Mr Gibson's recollection.1352 Williams {TMO00842312/15} page 15, paragraph 64; Williams {Day55/159:18}-{Day55/160:6}. Both Mr Gibson and Ms Williams said they recalled being given hard copies of the minutes of the meeting drafted by Artelia which recorded Simon Lawrence's advice, although their accounts of how they received them were not consistent. Mr Gibson believed he received a copy at the next scheduled meeting1353 Gibson {TMO00000887/19} page 19, paragraphs 101 and 103; Gibson {Day53/190:5-14}. and said he had noted that "Lakanal" had been misspelled.1354 Gibson {TMO00842310/8} page 8, paragraph 22; Gibson {Day53/180:15-18}. Ms Williams did not think that Mr Gibson had been at the subsequent meeting; she said she had been given a hard copy which she had brought back to the office and read to him.1355 Williams {Day55/163:20}-{Day55/164:6}.
¶55.91 Neither Simon Lawrence nor Philip Booth recalled any such conversation nor any such minutes.1356 Booth {ART00008527/52} page 52, paragraph 173; Lawrence {Day24/170:6-10}; {Day24/171:15-18}; Booth {Day50/77:4-11}. In particular, Mr Booth said that compliance with the fire safety requirements of the regulations had not been discussed with him, because it was an absolute requirement, not a matter for debate.1357 Booth {Day50/60:8-14}. None of those who could be expected to have received copies of the minutes disclosed them, either in electronic or paper form, and there is no reference in any of the contemporaneous documents to an assurance of that kind. In those circumstances we are unable to regard the evidence of Mr Gibson and Ms Williams on this matter as reliable. We find the evidence of Mr Booth persuasive: as employer's agent, he was required to ensure that meetings were properly and fully recorded for the benefit of the TMO. If such an important assurance had been given at the meeting, he would have noted it. We consider it very unlikely that a paper document was produced and distributed at a meeting if no paper or electronic copy of it could be found, either on Artelia's systems or among the records or documents of any other party. Contrary to the assertions of Ms Williams that there is a gap in the minutes for February 2015,1358 Williams {Day55/175:6-8}. there is none.1359 {ART00006769}, It is clear in the footer that Progress Meeting 8 was held on 13 February 2015. The body of the minutes erroneously record this as having been held on 20 January 2014, the date of Progress Meeting 7 {ART00006766}.
136¶55.92 The matter does not end there, however. Ms Williams made no reference at all to any such assurance in her first statement; it was not until she made her second statement, produced after she had seen Mr Gibson's statement,1360 Gibson {TMO00000887/19} page 19, paragraphs 99-103. that she first mentioned it.1361 Williams {TMO00842312/15} page 15, paragraphs 64-65; Williams {Day55/154:1-{Day55/155:8}; {Day55/163:13-15}. Ms Williams said that she simply had not remembered the conversation with Mr Lawrence when she made her first statement,1362 Williams {Day55/154:5-19}. but it is difficult to understand how such an important matter could have escaped her mind. Moreover, she said that she had not recalled Mr Lawrence's assurance when she became aware of the fire on 14 June 2017.1363 Williams {Day55/155:9-17}. Again, that is difficult to understand. If she had been told that ACM panels were inert and would not burn, that assurance would surely have come to mind as soon as she became aware of the disaster.
¶55.93 Finally, it is worth bearing in mind that Ms Williams sought an assurance of a similar kind in two emails sent on 12 November 2014. In the first,1364 {ART00003042}. she told Mr Booth that she wanted to ensure that the flame retardance of the ACM panels was raised. In the second, her "Lacknall moment" email to Mr Lawrence, she said that she was writing to get clarification on the fire retardance of the new cladding. If Mr Lawrence had already given her a clear assurance before 12 November 2014, we think it unlikely that either of those messages would have been sent, or, if sent for other reasons, that she would not have referred to it. If the assurance was given after 12 November 2014 (as Ms Williams and Mr Gibson suggested), we think that she would have recalled telling Simon Lawrence that she had asked for the same information some months before but had not received a response. In the light of all the evidence we do not accept that Mr Lawrence gave Mr Gibson and Ms Williams any assurance of the kind they described.
137Chapter 56: The choice of insulation
¶56.1 The purpose of adding insulation to a building is to keep it warmer in winter and cooler in summer. Laura Johnson, Head of RBKC's Housing Department, accepted that at the end of 2011 there was no evidence that the thermal efficiency of Grenfell Tower was sufficiently poor to justify the investment in cladding; she thought, at least at the outset, that the primary rationale for cladding it was to improve its appearance.1365 Johnson {Day128/32:15}-{Day128/35:1}. Bruce Sounes thought that the modernisation of the heating system, the replacement of the windows and the addition of insulation were all integral to the refurbishment of the building, but he had not been involved in RBKC's original decision.1366 Sounes {Day12/190:9-12}.
¶56.2 Two insulating products were ultimately used in the construction of the external wall of Grenfell Tower, Celotex RS5000 ("RS5000") and Kingspan Kooltherm K15 ("K15").1367 See Grenfell Tower Inquiry Phase 1 Report, Volume I, Chapter 6 for a description of the construction of the external facade. RS5000 was a polyisocyanurate ("PIR") rigid foam board insulation. K15 was a phenolic ("PUR") rigid foam board insulation. Both were combustible, with a short time to ignition.1368 Grenfell Tower Phase 1 Report, Volume I, Chapter 6, paragraph 6.20. Neither RS5000 nor K15 met the limited combustibility guidance in paragraph 12.7 and table A7 of Approved Document B; and neither of them had been tested in accordance with BS 8414 in combination with the other materials intended for use on the tower. It follows that the system had not been shown to meet the criteria set out in BR 135. No alternative way of establishing compliance with the Building Regulations, e.g. by way of a desktop report or a holistic fire-engineered solution, had been followed. The use of those products was therefore contrary to official and industry1369 For example, CWCT's Technical Note 73, Fire Performance of curtain walls and rainscreens, dated March 2011 at {CWCT0000019/6}. guidance and, as the Chairman found in his Phase 1 report, the external wall of the building as a whole, including the insulation, was combustible and did not adequately resist the spread of fire over the walls. The use of those materials was therefore a clear breach of functional requirement B4(1) of the Building Regulations. In this chapter we seek to explain how the insulation came to be chosen for use on the tower.
The initial selection of Celotex FR5000: 2012–2014
¶56.3 Celotex FR5000 was the insulation product specified in the contract between the TMO and Rydon. It was specified by Studio E in the NBS Specification in November 2013,1370 {SEA00000169/73} final version of 30 January 2014: thermal insulation was specified at item 776. which formed part of the Employer's Requirements. However, the origins of that decision can be traced back to early in the previous year.
¶56.4 On 24 May 2012, there had been a design team meeting at which insulation was discussed, but only in very general terms.1371 Minutes at {ART00000037}. In attendance at this meeting were various representatives of the TMO, Bill Watts of Max Fordham, and Bruce Sounes of Studio E. The minutes were circulated to James Lee of Exova. Some consideration was given to installing insulation internally, rather than on the outside of the building,1372 {ART00000037/2}. but that option had been quickly rejected because it would have caused too much disruption to residents.1373 McQuatt {Day42/35:17-21}. At that meeting Max Fordham was instructed to assist the design team in establishing environmental design criteria, including U-values, ventilation openings and other matters, in order to advance the design of the cladding.1374 {ART00000037/2}. U-value is a measure of the rate of heat transfer through a material or structure, measured in watts per square metre kelvin (W/m2K). The lower the U-value, the better the material or structure's thermal efficiency; that is, the more it prevents heat loss in winter and heat gain in summer. Lambda value is a measurement of thermal conductivity of a material, measured in watts per metre kelvin (W/mK). The lower the lambda value of a material, the less is needed to achieve the desired U-value. Following the meeting, Bruce Sounes understood that Max Fordham was to provide the environmental design criteria, including the U-values.1375 Sounes {Day12/192:21-24}; {Day12/193:4-6}; Sounes {SEA00014273/39} page 39, paragraph 81.
138¶56.5 On 18 June 2012, Matt Smith of Max Fordham sent an email to Bruce Sounes asking what U-value Studio E was seeking to achieve.1376 {SEA00004737}. Andrew McQuatt of Max Fordham understood that Mr Smith had written that email to prompt Studio E to suggest its own U-value, assuming that Studio E as architect was designing the whole system and that Max Fordham did not have the power to specify any of the elements of the cladding. The email was intended to stimulate a dialogue with Studio E about the overall design, including the U-value.1377 McQuatt {Day42/44:10}-{Day42/46:3}. In response, Mr Sounes instructed a colleague to send Max Fordham drawings of the likely build-up of the cladding system.1378 {SEA00004737}.
¶56.6 At a design team meeting on 25 June 2012,1379 {ART00000096}. Attended by the TMO, Studio E and Max Fordham, among others. Bill Watts of Max Fordham suggested a target U-value of 0.15 W/m2K for the walls of the tower.1380 {ART00000096/2}. Another U-value was suggested for the windows. McQuatt {Day42/38:3-11}. That was ambitious. It was to become the target U-value for walls of new buildings in the Approved Documents published in 2013,1381 {INQ00015203/39}. but in 2012 the Approved Documents required a U-value of 0.30 W/m2K only for walls of existing buildings with external insulation,1382 See Approved Document L 1B at {INQ00011283/20}, Table 3 and also Approved Document L 2B {INQ00015204/25} at Table 5. as was recorded in the minutes of the meeting.1383 {ART00000096/2}. Even greater latitude was provided in the Approved Documents, which stated that where a U-value of 0.30 W/m2K could not be achieved, the external wall should reach the best standard that was technically and functionally possible.1384 See Document L1B at {INQ00011283/20}, Section 5.9 and Document L2B at {INQ00015204/24} section 5.10.
¶56.7 Max Fordham's suggestion that the designers seek to achieve a U-value of 0.15 W/m2K was therefore twice the efficiency required by the statutory guidance for existing buildings. The purpose of doing so was, in summary, to ensure that the building would continue to perform well by future standards.1385 McQuatt {Day42/39:10-16}; {Day42/41:9-19}. See also {MAX00000412/6}. at table 2.1. In addition, Max Fordham considered that, in principle, overcladding an existing high-rise building did not differ in principle from constructing a new one.1386 McQuatt {Day42/38:12-21}; {Day42/39:6-16}. Another consideration was that the London Plan recommended reducing energy use by improving the fabric of the building first1387 McQuatt {Day42/39:17-25}. and there was also a widespread recognition in the industry of the importance of improving the fabric of buildings. Accordingly, it was environmental considerations, including energy efficiency, that lay at the heart of the U-value that was chosen.1388 McQuatt {Day42/40:1-9}.
139¶56.8 When he came to work on the project, Andrew McQuatt checked that the U-values suggested by Max Fordham were consistent with Approved Document L. He understood that if the target was not achievable, it was permissible to depart from it to a U-value that was technically and functionally feasible.1389 McQuatt {Day42/8:4-8}; {Day42/10:15-20}; {INQ00011283/20}; Bruce Sounes was not aware that Approved Document L provided that flexibility. Sounes {Day20/10:18}-{Day20/11:3}. Max Fordham did not think that the U-value it had suggested was unduly ambitious.1390 McQuatt {Day42/40:12-21}. Bruce Sounes also shared that view,1391 Sounes {Day20/33:13-15}. and realised that Max Fordham was seeking to match the statutory guidance relating to new buildings.1392 Sounes {Day20/9:21}-{Day20/10:17}; {Day20/18:4-9}. Neither Max Fordham nor Studio E checked the proposed U-value against the fire safety guidance in Approved Document B to see whether a higher U-value would have to be accepted in order to comply with the guidance on insulation contained in paragraph 12.7.1393 McQuatt {Day42/47:21}-{Day41/48:7}.
¶56.9 Following Max Fordham's suggestion, Bruce Sounes carried out some research into insulation products. On 5 July 2012, he asked Rockwool1394 Rockwool is a company manufacturing a range of mineral or stone wool insulation products for use in external cladding systems, among other applications. According to the CWCT in Technical Guidance Note 73 dated March 2011, mineral wool was the only insulation product which would satisfy the definition of "limited combustibility" in Approved Document B (see Chapter 49). to advise which mineral wool insulation product it would be appropriate to use within an external cladding system and what thickness would be required to achieve a U-value of 0.15 W/m2K.1395 {SEA00004967}. Mr Sounes sent an email to Andrew McQuatt and Matt Smith telling them that he had sent enquiries about insulation to both Rockwool and Kingspan,1396 {SEA00004973}. attaching a spreadsheet with some calculations. At that point, neither Studio E nor Max Fordham had given any consideration to using a Celotex product, or indeed any polymeric material.
¶56.10 The spreadsheet contained an analysis of the thickness of mineral wool that would be required to achieve a U-value of 0.15 W/m2K.1397 {SEA00001334}. Mr Sounes had carried out that analysis himself using various thicknesses of one of Rockwool's products, "Rainscreen Duo Slab". For each thickness of the product, he derived the corresponding U-value by extrapolation from the information in the datasheet. He calculated that 325mm of Duo Slab would achieve a U-value of only 0.20 W/m2K.1398 Sounes {Day20/15:17-22}. He concluded that to achieve a U-value of 0.15 W/m2K about 450mm of Duo Slab would be required.1399 {SEA00004973}; {SEA00004974}. It was on that basis that he said in his email to Max Fordham that the target U-value of 0.15 W/m2K looked to him "a bit aspirational" and he questioned whether it would be feasible to use Rockwool, given the thicknesses apparently required to achieve it.1400 {SEA00004973}. Mr Sounes did not ask Max Fordham or anyone else to check his calculations1401 Sounes {Day20/25:4-9} and McQuatt {Day42/65:9-14}. and he did not check Approved Document L to see what U-value the guidance required.1402 Sounes {Day20/9:11-20}.
140¶56.11 In the light of his calculations Mr Sounes might have been expected to consider whether he should abandon the proposed U-value 0.15 W/m2K in favour of a higher value that might be easier to achieve, but he does not appear to have done so. He did not think that "aspirational" meant irresponsible; it just meant trying to do the best you can.1403 Sounes {Day20/17:24}-{Day20/18:1}. He said that Max Fordham had prided itself on being an aspirational engineer and that Studio E had followed it. He had seen no reason to abandon a U-value of 0.15 W/m2K and thought that it had been in the project's interest to try to achieve it.1404 Sounes {Day20/27:9-23}. The target U-value was never rejected by Studio E as being unachievable. Sounes {Day20/4:20-21}; {Day20/16:24-25}.
¶56.12 In his email of 5 July 2012, Bruce Sounes had referred to Max Fordham's having "asked for" a target U-value of 0.15 W/m2K. Mr Sounes said in evidence that in the past Studio E had looked to Max Fordham to propose U-values and he was doing the same in connection with the Grenfell Tower project.1405 Sounes {Day20/3:23}-{Day20/4:1}; {Day20/17:20-22}. It was part of Max Fordham's role, as set out in its fee proposal, to help the architect to comply with the energy efficiency requirements in Part L of the Building Regulations.1406 {MAX00000075}.
¶56.13 In our view, although Max Fordham did first suggest a target U-value of 0.15 W/m2K for the external walls in its capacity as the building services engineer,1407 McQuatt {Day42/44:4-9}. it was Studio E's responsibility, as lead consultant and lead designer, to assess the feasibility of that U-value in the context of its initial design of the cladding system. Max Fordham did not "ask for" that U-value or specify it in such a way as to oblige the design team, including Studio E, to accept it without question. A reasonably competent lead consultant and lead designer would not have considered itself limited in any way in its selection of materials or the design of the cladding system by suggestions made by the M & E consultant. Mr Sounes accepted as much,1408 Sounes {Day20/17:15-18}. and rightly so. The services to be provided by Studio E included co-ordinating the design of all constructional elements, including work by consultants, specialists or suppliers, and determining materials, elements and components, standards of workmanship, type of construction and performance in use.1409 Appendix B: Schedule of Services {SEA00009824/7}. It was Studio E's responsibility as architect and lead designer to decide what U-value was feasible and appropriate.
¶56.14 Matt Smith replied to Bruce Sounes on 5 July 2012, probably after having discussed the matter with Andrew McQuatt.1410 McQuatt {Day42/66:3-8}; {SEA00004978}. He had done a quick calculation using the lambda value for the Rockwool product and the thicknesses proposed by Mr Sounes. It was his view that the thicknesses of Rockwool calculated by Mr Sounes were too great and he questioned whether Mr Sounes had taken thermal bridging1411 A thermal bridge is an area or component of an object which has higher thermal conductivity than the surrounding materials, creating a path of least resistance for the transfer of heat. into account.1412 {SEA00004978}. Matt Smith's calculation did not include any thermal bridging considerations, because Max Fordham did not have any more specific details of the design of the cladding to enable him to do so.1413 McQuatt {Day42/68:22}-{Day42/69:6}. It was Andrew McQuatt's own view that Mr Sounes' analysis may have been based on rather pessimistic assumptions.1414 McQuatt {Day42/69:15}-{Day42/70:7}.
141¶56.15 In the same email Matt Smith referred to a "glass fibre slab" product.1415 {SEA00004978}. It is not clear whether that was a mistake,1416 McQuatt {Day42/67:4-6}. but in any event, Andrew McQuatt said that both the mineral wool and glass fibre products were flexible and had similar lambda values, so the calculation he provided was reasonable despite any potential confusion between the two products.1417 McQuatt {Day42/67:11-23}.
¶56.16 Andrew McQuatt thought at this point that the U-value might need to be changed, given that Studio E considered that the necessary thickness of mineral wool could not be accommodated. However, he knew that the Kingspan rigid insulation board would be a thinner product and thought that it would be appropriate to wait to see what Kingspan said in response to Bruce Sounes' email of 5 July 2012 before commenting further.1418 McQuatt {Day42/49:15}-{Day42/50:9}.
¶56.17 On 6 July 2012 Bruce Sounes sent an email to Matt Smith to tell him that Kingspan had recommended 200mm of its phenolic foam product to achieve the required U-value.1419 {SEA00004986}. The calculations by Kingspan can be found at {MAX00000104}. He also attached to his email a product datasheet for a mineral wool insulation manufactured by Superglass Insulation Ltd called "Cladding Mat 37",1420 {SEA00001337}. Cladding Mat 37 is a form of mineral wool insulation, marketed as an A1 non-combustible product. but that was rejected because it was thought that too great a thickness would be required.1421 McQuatt {Day42/80:10-20}. Bruce Sounes did not consider the fire performance of that product. Sounes {Day20/36:2-6}.
¶56.18 On 24 July 2012, Ian Pritchard of Rockwool responded to Bruce Sounes' email of 5 July 2012. He said that they would normally recommend the use of Rainscreen Duo Slab for the type of construction that Mr Sounes had in mind, but that due to the low U-value required the thickness needed would be exceptionally high, probably beyond the point of sensible building practice.1422 {SEA00005276/2}. Bruce Sounes forwarded Rockwool's email to Matt Smith and Andrew McQuatt, drawing attention to his concerns about buildability and appearance if mineral wool were used.1423 {SEA00005276}. Neil Crawford could not recall any discussion about the use of a mineral wool product in the external wall facade but had understood that the thickness of the product required would have been impractical. He thought he got that understanding from Bruce Sounes. Crawford {Day10/67:12-21}. He did not ask Max Fordham to obtain from Rockwool a formal calculation of the thickness of material required, so apart from Matt Smith's "quick calculation" no attempt was made at any stage to determine precisely what thickness of mineral wool would be required to achieve a U-value of 0.15 W/m2K.
¶56.19 Andrew McQuatt understood the email from Mr Sounes to mean that he had decided that the maximum thickness for the insulation should be 200mm.1424 McQuatt {Day42/60:17-20}. He thought that Mr Sounes' calculations formed part of a bigger picture; he did not question it because he assumed that Studio E had chosen it as the best thickness for a wide range of reasons.1425 McQuatt {Day42/61:5-9}.
¶56.20 There was never any serious discussion about increasing the U-value to something greater than 0.15 W/m2K,1426 McQuatt {Day42/43:6}-{Day42/44:3}. and Studio E did not raise the possibility of doing so with Max Fordham.1427 Sounes {Day20/33:17-25}. According to Andrew McQuatt, the design team remained confident that a reasonable technical solution to the problem could be found, so there was never any resistance to adopting the ambitious U-value.1428 McQuatt {Day42/43:19-23}.
142¶56.21 Bruce Sounes sent another email to Andrew McQuatt on 15 August 2012 asking for his help in calculating the thickness of insulation required to achieve the target U-value.1429 {SEA00005818}. He attached to his email a further calculation of the thickness of mineral wool insulation required.1430 {MAX00000214}. The exchange occurred just before a report was to be made to the Planning Department in which the proposed U-value would be disclosed, so it was important to make sure the external wall could be built to produce that U-value. Mr Sounes was concerned whether the proposed U-value could be achieved over all the different elements of the wall.1431 McQuatt {Day42/53:7-22}.
¶56.22 On either 15 or 16 August 2012, there was a telephone conversation between Andrew McQuatt and Bruce Sounes during which Mr McQuatt attempted to answer Mr Sounes' concern. He undertook to do some calculations based on the different areas of the building in order to determine whether the target U-value could be achieved on average across the building as a whole and to establish the thickness of insulation required to achieve the target U-value overall.1432 McQuatt {Day42/81:21}-{Day42/82:12}.
¶56.23 On 16 August 2012 Andrew McQuatt sent Mr Sounes his calculations1433 {SEA00005840}. and attached the product datasheet for Celotex FR5000.1434 {SEA00005841}. Issue 2, January 2012. In order to do his U-value calculation, Mr McQuatt had needed to use the lambda value of an insulation product. In his mind there was little difference between the rigid board insulation products marketed by Kingspan and those sold by Celotex, so he went to the Celotex website and looked at a datasheet for a solid insulation board, FR5000. He obtained the lambda value from the datasheet and sent it to Mr Sounes so that he could see the source of the information he had used.1435 McQuatt {Day42/82:13}-{Day42/82:17}. He thought that Celotex FR5000 was the only type of product that would provide the required thermal performance at a thickness that could realistically be accommodated.1436 {SEA00005840}. When Andrew McQuatt said in this email of 16 August 2012 that Celotex FR5000 was "the only type of product that will give us the required performance", he had in mind the lambda value of the product and that, at least in his mind, FR5000 was interchangeable with a rigid insulation board marketed by Kingspan. McQuatt {Day42/85:3-9}.
¶56.24 Celotex FR5000 was a polyisocyanurate (PIR) product. The datasheet1437 {SEA00005841} Issue 2, January 2012. made no reference to its being suitable for use as part of a cladding system nor did it state that it was suitable for use on buildings with a storey above 18 metres in height. It did not say that FR5000 was a product of limited combustibility, but it did say that it had Class 0 fire performance throughout the entire product in accordance with BS 476.
¶56.25 Andrew McQuatt did not give any thought to the fire performance of Celotex FR5000 before he sent his email to Bruce Sounes on 16 August 2012.1438 McQuatt {Day42/86:20}-{Day42/87:18}. Mr Sounes had suggested both the Rockwool product and the Kingspan product and Mr McQuatt thought that the use of Kingspan had already been established.1439 McQuatt {Day42/85:3-9}. Since Studio E had proposed a Kingspan product as an option from the outset, he had thought there was nothing wrong with using it or, by extension, Celotex FR5000.1440 McQuatt {Day42/61:18-22}. He accepted that he would have been just as likely to put forward the Kingspan product if he had obtained the lambda value of one of their foam boards instead of a Celotex product.1441 McQuatt {Day42/86:2-7}.
143¶56.26 At the time, Andrew McQuatt was not aware of the guidance given in Approved Document B about insulation materials and their combustibility, nor could he recall with any certainty having heard the expression Class 0.1442 McQuatt {Day42/18:8}-{Day42/19:12}. He was not aware of industry guidance on the construction of external walls and insulation materials and had never had cause to look at the guidance published by the Centre for Window and Cladding Technology (CWCT).1443 McQuatt {Day42/21:20}-{Day42/22:4}. He was aware that there were different types of insulation and he knew that Kingspan produced a solid board rather than a mineral wool product, but that was really the extent of his knowledge.1444 McQuatt {Day42/51:9-16}. No one had suggested to him that phenolic or PIR foam insulation boards were not appropriate for use in the external walls of buildings above 18 metres in height.1445 McQuatt {Day42/91:25}-{Day42/92:4}.
¶56.27 The suggestion made by Andrew McQuatt in his email of 16 August 2012 that a PIR insulation product might be used did not give Bruce Sounes any cause for concern. He told us that PIR and phenolic insulation boards had become all but standard by that time1446 Sounes {Day20/39:2-3}. and that PIR products were widely used in the industry, which reassured him about their suitability.1447 Sounes {Day20/40:8-15}. Bruce Sounes said that every project that he had worked on involved some form of foam board in the facade, but he confirmed that those other projects had involved low-rise buildings. Sounes {Day20/39:6-14}. He said he thought he had been aware that PIR insulation had been used on high-rise buildings. Sounes {Day20/50:11-15}. Mr Sounes thought that Celotex FR5000 was suitable for use as part of the cladding system partly because it had been used in the past by Max Fordham in what he had understood to be similar circumstances, but he took no steps to find out whether Max Fordham had ever used FR5000 in the past in the external wall of a building over 18 metres in height. He could not recall having read the datasheet for Celotex FR5000 when he was working on the project, nor did he recall noting at the time that it was rated Class 0,1448 Sounes {Day12/178:4-7}; {Day12/183:14-17}. but if he had been aware of that it would have served only to increase his confidence in its use, because he understood that if a product was rated Class 0 it was, as he put it, "not hazardous".1449 Sounes {Day12/183:6-13}. Mr McQuatt did not realise that Studio E had understood his email of 16 August 2012 as a tacit endorsement of the safety of FR5000 for use on the building,1450 McQuatt {Day42/84:19-23}; {Day12/181:12-23}. but there is no reason why he should have done so, given that his expertise did not extend to fire safety and he had not been consulted about that.
¶56.28 Mr McQuatt wrote a Sustainability and Energy Statement in respect of the project dated 17 August 2012,1451 {MAX00000412/6}. which made it clear that the recommended U-value far exceeded that required by the Building Regulations.1452 {MAX00000412/6} at Table 2.1. At Tables 2.2 and 2.3 of the report, Celotex FR5000 was identified as the insulation for the spandrels and columns.1453 {MAX00000412/6}. When he received it, Bruce Sounes did not pause to consider whether mineral wool could be used to produce a U-value which, although higher, still complied with the regulations.
144¶56.29 On 10 October 2012, Max Fordham issued its RIBA Stage C report.1454 {MAX00000636}. Andrew McQuatt drafted most of it, with a contribution from Matt Smith.1455 McQuatt {Day42/92:5-12}. The information contained in the Sustainability and Energy Statement was repeated on page 12 of the report.1456 {MAX00000636/12}. Mr McQuatt explained that FR5000 had been referred to in the Stage C report solely because it delivered the U-value required at the thickness sought.1457 McQuatt {Day42/95:10-17}. He said that detailed information had been included in the report so that readers could see how the thermal conductivity value had been achieved for the insulation. If for any reason FR5000 had not been used, the technical details were available to enable a substitution to be made.1458 McQuatt {Day41/92:18}-{Day41/93:11}. He did not see it as his role to influence the design team's decision about the materials to be selected.1459 McQuatt {Day42/93:13}-{Day42/94:1}. Andrew McQuatt could not recall whether a final decision had been taken to use FR5000. Max Fordham's Stage C report makes no reference to fire safety because its practice was to advise on questions of fire safety only to the extent that they affected the work that the building services engineer was specifying.1460 McQuatt {Day42/94:16-25}. We therefore infer that, as Max Fordham was not responsible for choosing the insulation, it did not regard itself as responsible for giving advice in the Stage C report about its use, whether in relation to fire safety or otherwise.
¶56.30 Studio E issued its own RIBA Stage C report on 31 October 2012.1461 {ART00008396}; {MAX00000445}. It incorporated Max Fordham's Stage C report and referred to Celotex FR5000 as the chosen insulation.1462 {MAX00000445/82}. Before issuing the report, Bruce Sounes did not ask Exova or Max Fordham or any other specialists to advise on the suitability of using Celotex FR5000 in the cladding system or whether its use would comply with the Building Regulations.
¶56.31 In January 2013, Adrian Jess1463 Sounes {SEA00014273/59} page 59, paragraph 124. sent a draft of Studio E's Stage D report to Leadbitter, which at that stage was expected to become the principal contractor for the project. It showed EPS (expanded polystyrene) insulation at the lower levels of the tower behind rainscreen panels.1464 {MET00081283/11} under Item P10. On 21 January 2013 Juan Medina, Framework Design manager for Leadbitter, sent Mr Jess an email asking whether Studio E had checked with building control whether EPS insulation could be used on a tower of that kind. Mr Medina understood that EPS was a combustible material and was not allowed as part of a rainscreen cladding system. He suggested that phenolic insulation should be used instead.1465 {MET00081282}. The email was copied to Studio E and is therefore likely to have been seen by those at Studio E who were working on the project, including Bruce Sounes. Although the discussion concerned the lower levels of the tower, it shows that Studio E was on notice from January 2013 that building control might not allow combustible insulation to be used in a rainscreen cladding system. That warning by Leadbitter ought to have prompted Studio E to pay close attention to the fire performance of the insulation materials that it had proposed for the project. However, from the documents available to the Inquiry, it does not appear that the warning resulted in any discussion of that kind within Studio E.
145¶56.32 Studio E issued its final Stage D report on 20 August 2013,1466 {MAX00000757}. which proposed the use of Celotex FR5000.1467 {MAX00000757/29}. Between issue of its Stage C and Stage D reports there were no communications between Studio E, Max Fordham, Exova, or any other specialist about the safety of using FR5000 product or how it reacted to fire.1468 Bruce Sounes could not recall whether he had asked building control about the acceptability of using a PIR product in a high-rise building. Sounes {Day20/51:1-18}.
¶56.33 On 25 October 2013, Tomas Rek commented in an internal email to Bruce Sounes that Max Fordham's U-values were "OTT", i.e. excessive.1469 {SEA00014346/2}; {SEA00014346/2}; Rek {Day12/137:2-17}. Tomas Rek thought he had had a discussion with Mr Sounes about it, but he could not recall what Mr Sounes had said.1470 Rek {Day12/138:24}-{Day12/140:7}. Bruce Sounes did not remember any discussion of that kind.1471 Sounes {Day20/33:3-10}. In any event, no further attempts were taken by Mr Rek to address his concerns.1472 Andrew McQuatt said in his evidence that no one had ever referred to the target U-value as "over the top" to him. McQuatt {Day42/57:22}-{Day42/58:16}. Mr Sounes thus missed the opportunity properly to understand Mr Rek's concerns about the U-values and to check with Max Fordham whether they needed to be quite so ambitious.
The Hays Galleria meeting: insulation
¶56.34 As we have found when describing the discussions about the choice of cladding material, on 27 September 2013 Bruce Sounes and Tomas Rek met Ray Bailey and Mark Harris of Harley at a coffee shop in Hays Galleria in south London.1473 Near London Bridge station. The purpose of the meeting was to discuss the lay concept design drawings for the refurbishment. Ray Bailey {HAR00010184/20} page 20, paragraph 77. As well as discussing the rainscreen, they also discussed the insulation for Grenfell Tower. What was said on that matter was the subject of differing recollections and the evidence about it requires detailed consideration.
¶56.35 Ray Bailey said that Studio E had given Harley calculations relating to U-values in advance of the meeting, from which he had seen that it intended to specify a PIR insulation product.1474 Ray Bailey {Day32/149:21-25}; {Day32/150:1-22}. In his witness statement, Bruce Sounes said that at the time of the meeting he had had a lingering uncertainty about the fire safety of PIR because he was dealing with a high-rise building and had not worked on one before. He thought he had asked Ray Bailey about the acceptability of using a rigid foam insulation on such a building, but did not remember having received a clear response.1475 Sounes {SEA00014273/114} page 114, paragraph 271. Repeated in his oral evidence Sounes {Day20/49:9-12}.
¶56.36 Bruce Sounes said that insulation had been discussed in general as part of the assembly of the facade1476 Sounes {Day20/47:3-9}. and that he might not have mentioned that he had Celotex in mind.1477 Sounes {Day20/46:24-25}; {Day20/47:1-5}. Mr Sounes said that his doubt about the acceptability of a rigid foam insulation product was an afterthought and that he had not had a serious concern.1478 Sounes {Day20/50:3-4}. Indeed, he said that he had not raised the question with Exova because it was not a genuine concern.1479 Sounes {Day20/50:17-22}.
¶56.37 Bruce Sounes recalled that during the meeting he had looked at photographs of Ferrier Point under construction, in which the mineral wool insulation used in the external wall was visible. It was that, as he recalled it, which prompted him to question the use of rigid foam board insulation.1480 Sounes {Day20/47:10-15}; {Day20/50:22}-{Day20/51:1}. The photographs at {SEA00003497} and {SEA00003516} are similar to those shown by Ray Bailey to Bruce Sounes at the Hays Galleria meeting, although Bruce Sounes could not be sure that he was shown those particular photographs. Sounes {Day20/51:12-25}. Ray Bailey said that before the meeting Mark Harris had sent Studio E some photographs of buildings that Harley had previously worked on1481 Ray Bailey {Day32/152:2-6}. and agreed that it was possible that those or some similar photographs had been discussed at the meeting.1482 Ray Bailey {Day32/152:10-18}. However, he could not recall discussing whether the insulation proposed for use on Grenfell Tower was mineral wool or rigid foam, in contrast to that used on Ferrier Point.1483 Ray Bailey {Day32/152:23}-{Day32/153:1}. Mark Harris said that he did not recall having shown photographs at the meeting, but that it would not be unusual to do so and might have happened.1484 Harris {Day34/56:8-21}.
146¶56.38 There is nothing in the documents to indicate that Bruce Sounes questioned the use of PIR insulation during the meeting.1485 {ART00001487}. Mr Sounes emailed various parties at Artelia, TMO and Max Fordham with a summary of the matters discussed at the Hays Galleria meeting. Mr Sounes' remarks that Harley "pointed to Ferrier Point as being very similar to Grenfell, although it is triple glazed and super insulated". Aside from this there is no reference to any discussion regarding the insulation. Tomas Rek did not recall Bruce Sounes raising the matter with him1486 Rek {Day12/135:14-16}. and he could not recall whether the suitability of PIR or rigid foam insulation had been discussed during the meeting.1487 Rek {SEA00014278/10} page 10, paragraph 29. Mr Rek could not recall any discussions about fire safety or performance of the insulation during the meeting.1488 Rek {Day12/133:7-18}.
¶56.39 Neither Ray Bailey nor Mark Harris had any recollection of Bruce Sounes asking about the acceptability of using rigid foam products on high-rise buildings.1489 Ray Bailey {Day32/149:14-17}; {Day32/151:23}-{Day32/152:6}.,1490 Harris {Day34/54:14-17}; {Day34/55:5-7}; {Day34/56:4-7}. Ray Bailey said that the question would have struck him as odd, because PIR was a product Harley had not used on a high-rise building at that stage.1491 Ray Bailey {Day32/149:19}-{Day32/150:22}; Ray Bailey {Day32/153:7-16}. It was Ray Bailey's impression at the time that there was no flexibility in the choice of insulation and that FR5000 had already been selected.1492 Ray Bailey {Day32/153:7-16}. Ray Bailey said that no one at Studio E or Harley had asked him about the suitability of the Celotex insulation or whether its use complied with the Building Regulations.1493 Ray Bailey {Day32/153:2-6}.
¶56.40 There is little doubt that photographs of Ferrier Point were shown and discussed at the meeting and it is likely that there was some comment about the use of a mineral wool insulation on that building. We think it unlikely, however, that Bruce Sounes asked whether rigid foam insulation was acceptable for use on Grenfell Tower. If it had been sufficiently important in his mind for him to have done so, it is likely that Ray Bailey would have made some response and that he would have remembered what it was. It is also likely that there would have been some reference to it in the contemporaneous documents. Asking about the safety of PIR would not have been consistent with Mr Sounes' understanding of its suitability in general or with his lack of curiosity about the fire safety of the products he proposed to use in the cladding system.
147Celotex FR5000 in the NBS Specification
¶56.41 Studio E produced three versions of the NBS Specification for the project dated 21 November 2013,1494 {SEA00000152}. 29 November 20131495 {SEA00000153}. This was the version issued to tenderers. and 30 January 2014 respectively.1496 {SEA00000169}.
¶56.42 Studio E started work on the Employer's Requirements, including the proposed NBS Specification, early in 2013.1497 Sounes {Day7/150:18-25}. The NBS Specification was prepared largely by Tomas Rek at Bruce Sounes' direction and subject to his oversight, Adrian Jess having already done some initial work1498 Rek {SEA00014278/5} page 5; Rek {Day12/10:22}-{Day12/11:1}. Work had already begun on the NBS specification. Rek {Day12/12:7-13}. before he was made redundant in March 2013. By September 2013 the project had been developed to Stage D (the Stage D report was dated 20 August 2013). Tomas Rek was told to use Studio E's Stage D report and drawings to draw up the NBS specification and Mr Sounes gave him additional information as required.1499 Rek {Day12/10:22}-{Day12/11:1}; {Day12/15:1-9}.
¶56.43 In the case of the insulation to be applied to the external concrete walls Studio E made a proprietary specification; in other words, in all three versions of the NBS Specification Celotex FR5000 was specified as the product to be used.1500 See the "thermal insulation" section within section H92 at item 776. In the final version {SEA00000169/73}; Sounes {Day7/162:1-9}. However, that was subject to the qualification that the product could be substituted by a similar or equal alternative.1501 {SEA00000169/64}. The contract preliminaries provided that if a contractor wished to suggest an alternative product it was required to provide reasons for that substitution to the client.1502 Clause 2.2.2 {RYD00094235/64}. The NBS Specification was not unusually prescriptive and was no more detailed or prescriptive than specifications commonly written by Studio E.1503 Sounes {Day7/168:10-19}.
¶56.44 Before specifying the product, neither Tomas Rek nor Bruce Sounes had investigated whether the use of Celotex FR5000 on a building above 18 metres in height complied with either the Building Regulations or the guidance contained in Approved Document B. Mr Sounes had not asked Max Fordham that question and he did not revisit it when overseeing the writing of the NBS Specification.1504 Sounes {Day20/42:6-11}. Similarly, Mr Sounes did not seek advice from Exova about the suitability of FR5000 for use in the refurbishment before the NBS Specification was prepared.1505 Sounes {Day20/42:12}-{Day20/43:6}. Bruce Sounes said that he understood Adrian Jess and Tomas Rek to have had independent discussions with Exova, but he was not aware of their content. He said that he could not recall himself raising the use and suitability of FR5000 with CEP. Sounes {Day20/43:16-19}.
¶56.45 Bruce Sounes said that Studio E would not usually seek to satisfy itself that all materials and products complied with the regulatory requirements before submitting a full plans application to building control.1506 Sounes {SEA00014273/121} page 121. In his view it would be a waste of time to do so, because the contractor under a design and build contract might subsequently propose a change or building control might take a different view of their suitability.1507 Sounes {Day20/64:21-24}; {Day20/65:5-8}. He said it was not common practice to do a full assessment of the suitability of products at RIBA Stages D or E.1508 Sounes {Day20/65:1-3}. Mr Sounes did tell us, however, that before the submission of the full plans application to building control in August 2014, he had been reasonably confident that the materials specified in it complied with the Building Regulations and Approved Document B, because all the products had (as he believed) been used before in similar circumstances, either by Studio E itself or others.1509 Sounes {Day20/67:5}-{Day20/68:11}. However, the steps he had taken to investigate precisely what had been used and in what circumstances were negligible.
148¶56.46 Following the submission of the full plans application to building control there was no subsequent occasion on which Studio E would check whether the materials complied with the Building Regulations. Mr Sounes said that, because this was a design and build project, once the contract had been awarded the architect was, as he put it, "sidelined" so that Studio E was not policing what other people were doing.1510 Sounes {Day20/71:3-14}. That, however, ignores the role played by Studio E after it had been engaged by Rydon. For the reasons we have explained below and in Chapter 63, it should have given further consideration to whether the insulation complied with the Building Regulations, but failed to do so.
¶56.47 At the time he prepared the NBS Specification, Tomas Rek did not know that the fire performance of each of the components of the cladding would need to be considered.1511 Rek {Day12/24:16-21}. He had a general awareness of functional requirements B3 and B4, having come across them on a previous project1512 Rek {Day12/16:7-23}. which had required one part of the facade to be Class 0.1513 Rek {Day12/17:1-4}. In that context he had also had to consider diagram 40.1514 Rek {Day12/25:24}-{Day12/26:11}. It was Mr Rek's understanding that Class 0 was concerned with the external spread of flame and that if a material had that classification it would not encourage the spread of flame.1515 Rek {Day12/18:9-15}. However, it became clear during his oral evidence that his knowledge of Approved Document B was very limited. He was not familiar with the various different routes to compliance described in paragraph 12.5 of Approved Document B,1516 Rek {Day12/20:15-20}. or the definition of what would constitute a material of limited combustibility,1517 Rek {Day12/42:6-19}. or the guidance in paragraph 12.7.1518 Rek {Day12/26:20}-{Day12/27:21}. He could not recall having checked the requirements for external walls contained in Approved Document B when drawing up the specification.1519 Rek {Day12/44:10-19}; Rek {Day12/45:16-20}. Nor could he recall talking to anyone at Studio E about which route to compliance with the Building Regulations it had taken in respect of the refurbishment of the external wall.1520 Rek {Day12/22:17-23}. Mr Rek did not himself give any consideration to that question. {Day12/22:25} – {Day12/23:2}. He did not know whether the proposed cladding system had been tested to BS 8414 and met the criteria in BR 135 criteria or if a fire engineer's report had been obtained. {Day12/27:23}-{Day12/28:9}.
¶56.48 The insulation to be used as part of the cladding was specified in clause H92/776 of the NBS Specification. Within section H92/776 of the RIBA software in use at the time for compiling an NBS Specification, the details were left blank for completion. Upon selecting clause H92/776, two tabs would appear: tab G, "Guidance" and tab H, "Manufacturers". Under tab H there is a list of manufacturers available for selection derived from the NBS Plus database.1521 {INQ00011333}. At the time of drawing up the specification for the thermal insulation in November 2013, four manufacturers appeared in tab H: Kingspan with its K15 Kooltherm product, Knauf, Rockwool and Siderise.1522 {INQ00011366}. No Celotex product was listed under tab H. Accordingly, in order to specify Celotex FR5000 it was necessary for the writer to enter the product manually. When Celotex FR5000 was manually entered under clause H92/776 a message appeared informing the compiler that that product had been authorised for an alternative clause, clause P10.1523 {INQ00011342}. Clause P10 was the section covering insulation fitted between rafters.1524 {INQ00011341}. It would therefore require a conscious decision to enter FR5000 under that section of the NBS Specification despite the warning.
149¶56.49 Tomas Rek could not recall having seen that message but could recall having seen a similar notice when trying to alter clauses which were pre-filled.1525 Rek {Day12/122:9-15}; {Day12/123:1-12}. He could not, however, recall being informed that the insulation that was being specified in clause H92/776 was identified by the software as suitable for a different application.1526 Rek {Day12/123:17-21}.
¶56.50 When a person drawing up the specification for clause H92/776 clicked on the drop- down box next to the entry for "Manufacturer", the software would prompt him to select "mineral wool to BS EN 13162" as the only option and then provide a list of four manufacturers.1527 {INQ00011351}. If the writer did not wish to select a mineral wool product, that entry would have to be manually overridden.1528 Rek {Day12/127:3-8}. That is what happened here. Mineral wool was manually overridden and Celotex FR5000 was manually typed in at clause H92/776 of the NBS Specification.
¶56.51 Although he was responsible for drawing up most of the NBS Specification, Tomas Rek could not recall whether he himself had entered FR5000 or whether it had already been in the specification when he came to the project. He said that if he had entered that product he had derived that requirement from Studio E's Stage D report and probably Max Fordham's Stage C report.1529 Rek {Day12/118:10}-{Day12/119:12}; {Day12/125:1-14}. Mr Rek thought he would have spoken to Bruce Sounes about the specification of products.1530 Rek {Day12/130:20-25}. He said that he had assumed that the design of the cladding and the choice of materials had been considered by Studio E before he had started work on the project.1531 Rek {Day12/44:22}-{Day24/45:1}. Mr Rek did not recall any discussion with Bruce Sounes about the reasons for choosing FR5000 for use in the cladding system,1532 Rek {Day12/135:17-20}. nor could he recall considering whether FR5000 was combustible or non-combustible.1533 Rek {Day12/124:10-13}. He did not consult any of the product information about FR50001534 Rek {Day12/131:14-25}. and did not discuss its fire performance with anyone else at Studio E.1535 Rek {Day12/134:11-13}. He did not seek any assistance or advice about whether he should override the software and manually enter FR5000.
¶56.52 Clauses H92/220 and H92/310 of the NBS Specification stipulated that the contractor was to comply with CWCT Standard for Systemised Building Envelopes, including Part 6, which related to fire performance.1536 {SEA00000169/68-69}. It is not clear whether Mr Rek put that requirement into the NBS Specification, but he remembered having thought that it should be included.1537 Rek {SEA00014278/33} page 33; Rek {Day12/34:18}-{Day12/35:2}. Although he knew that CWCT had published guidance, he had not read it1538 Rek {Day12/19:14-18}. and was not familiar with it.1539 Rek {Day12/34:14-17}; {Day12/39:1-16}. Nor was he familiar with the guidance issued by the Building Control Alliance (BCA).1540 Rek {Day12/19:20-23}.
150¶56.53 Tomas Rek would normally have expected tenderers to check that FR5000 complied with the CWCT performance requirements, but he did not do so himself.1541 Rek {Day12/127:10}-{Day12/128:3}; {Day12/128:4-24}. He said that if the material specified did not comply with that standard there would be a conflict which would have to be resolved.1542 Rek {Day12/129:2-3}.
¶56.54 The NBS Specification was not sent to either Exova or Max Fordham for them to comment on the inclusion of FR5000 (or indeed at all). Bruce Sounes did not look to Exova to provide detailed checking of the specification because he did not consider that to be the focus of its work, which was to produce the fire safety strategy.1543 Sounes {Day20/51:2-10}.
¶56.55 Following the inclusion of FR5000 in the NBS Specification, no further consideration was given to it during the procurement process or before the award of the contract to Rydon in March 2014.
¶The "launch" of RS5000 and Harley's initial discussions with Celotex: April to August 2014
¶56.56 Jonathan Roome was a manager at Celotex whose work mainly related to sales.1544 Roome {Day69/7:6-10}. He joined Celotex in March 2014. On 28 April 2014, his colleague Jonathan Roper sent him information about the FR5000 range of products and the BS 8414 testing regime.1545 {CEL00001200}; {CEL00001201}; {CEL00001203}. Mr Roome then familiarised himself with Approved Document B and knew that there were particular requirements relating to high-rise buildings.1546 Roome {Day69/32:15-20}. He knew that if one wanted to follow the guidance in Approved Document B, a PIR product could be used in the external wall of a high-rise building only if it was of limited combustibility or formed part of a system that had undergone a BS 8414 test and met the criteria in BR 135.1547 Roome {Day69/39:16-22}. He was also aware that FR5000 and other PIR products were neither materials of limited combustibility nor had been tested in a system that had undergone a BS 8414 test and met the criteria in BR 135. They could therefore not be used in the external walls of buildings above 18 metres in height consistently with the guidance contained in paragraphs 12.5-12.7 of Approved Document B.1548 Roome {Day69/19:22-24}; {Day69/20:2-10}; {Day69/39:12-15}; {Day69/30:11-15}. He knew that there was a distinction between Class 0 materials and materials of limited combustibility1549 Roome {Day69/36:10-15}. and was aware of the tests which a material needed to pass to obtain that classification.1550 Roome {Day69/25:19-23}.
¶56.57 In about April 2014 Mr Roome became aware that Celotex was seeking to develop an insulation product that could be marketed for use in buildings above 18 metres in height.1551 Roome {Day69/43:16-25}. He understood that the new product (which was formally launched as RS5000 in August 2014) was an equivalent product to Kingspan's K15, if not better.1552 Roome {Day69/163:14-22}. As we have already explained, RS5000 was simply FR5000 re-marketed with the supposed benefit of having successfully met the BR 135 criteria in a particular wall construction, but that fact was not known to Mr Roome, who had been led to believe by his seniors in the marketing department that it was a brand new product.
151¶56.58 On 10 June 2014 Mr Roome telephoned Ben Bailey of Harley to discuss another of Harley's projects, Merit House.1553 {CEL00009874}. Ben Bailey wanted to know if Celotex had an alternative to Kingspan K15 that might be used at Merit House. Mr Roome said that because Merit House was a building above 18 metres in height Celotex did not have a suitable product, but that he would contact Harley once Celotex's 18 metre fire test was in hand. That was a reference to a BS 8414 test using RS5000 which had been carried out 2 May 2014, the results of which were awaited together with the BR 135 classification report.
¶56.59 By June 2014 Jonathan Roome was aware that Harley had been awarded two new overcladding projects in London1554 Roome {Day69/160:14-21}. and between early June and the end of August 2014 Celotex saw Harley as a potential customer for RS5000.1555 Roome {Day69/174:8-13}.
¶56.60 As a result of his conversation with Mr Roome on 10 June 2014, Ben Bailey knew that Celotex did not then have any insulation products available that could be used on buildings above 18 metres in height.1556 And he knew that there were restrictions on insulation products being used on those buildings. Ben Bailey {Day39/55:15-25}; {Day39/56:1}. When he began work on the Grenfell Tower project he read through those parts of the NBS Specification which he considered relevant to Harley's work.1557 Ben Bailey {Day39/64:21-25}; {Day39/65:1-19}. It did not occur to him, however, to question the specification of FR5000, despite knowing that Celotex did not have a suitable product.1558 Ben Bailey {Day39/66:16-21}; {Day39/68:13-25}; {Day39/69:3-7}.
¶56.61 Jonathan Roome met Ben Bailey on site at Merit House on 18 July 2014 when he was told that Grenfell Tower was one of Harley's prospective projects.1559 {CEL00009875}. Ben Bailey was under the impression by that time that Celotex was due to bring out an insulation product suitable for use above 18 metres1560 Ben Bailey {Day39/61:4-20}. which would be a competitor to Kingspan's K15.1561 Ben Bailey {Day39/58:5-13}. Mr Roome promised to be in touch when the result of the test involving RS5000 was available. According to Ben Bailey, Jonathan Roome was very keen to stay in contact about the RS5000 product and to secure two overcladding projects, including the Grenfell Tower refurbishment.1562 {CEL00009875}; Ben Bailey {Day39/61:21-25}.
¶56.62 RS5000 was launched at a meeting on 5 August 2014 attended by a number of Celotex's employees, including Jonathan Roome.1563 Roome {CEL00010031/7} page 7, paragraph 29; {CEL00009709}; {CEL00008668}. It was made clear to him that the reason RS5000 had (supposedly) been created and brought to market was for use on buildings above 18 metres in height and the communications strategy was to emphasise that it could be used on buildings of that kind.1564 Roome {Day69/48:19-24}; Roome {Day69/69:19-23}. Mr Roome was provided with documents to pass on to potential customers,1565 Rome {CEL00010031/2} page 2. including a product data sheet for RS5000, a document entitled
152¶Rainscreen Cladding Compliance Guide and a document entitled Rainscreen Cladding Specification Guide.1566 {CEL00007961}; {CEL00000012/2}; {CEL00000013}; Roome {Day69/100:23-25}; {Day69/101:1-5}. The purpose of the documents was to present RS5000 as a new product suitable for the insulation of buildings above 18 metres in height, which is what Mr Roome thought it was.1567 Roome {CEL00010031/2} page 2, paragraph 6; {CEL00001237}.
¶56.63 Having seen the documents, Mr Roome knew that RS5000 could not satisfy the requirements of paragraph 12.7 and table A7 of Approved Document B because it was not a material of limited combustibility.1568 Roome {Day69/95:16-20}. The construction of the system that had been tested on 2 May 2014, apparently successfully, was discussed at the presentation on 5 August 2014, from which he understood that the classification of RS5000 under BR 135 applied only to the system as tested and not to its individual components.1569 Roome {Day69/52:1-9}. He also knew that RS5000 could be used only in cladding systems that were identical to the system tested.1570 Roome {Day69/98:8-13}.
¶56.64 On 6 August 2014, Mr Roome sent Ben Sharman of Harley an email about RS5000 to which he attached a product comparison document, the rainscreen cladding compliance guide, the product datasheet and a rainscreen cladding datasheet.1571 {CEL00001237}; {CEL00001238}; {CEL00001239}; {CEL00001240}; {CEL00001241}. In his covering email he said,
"I have the pleasure of informing you as of yesterday we have now launched the first PIR Board To Successfully Meet The Performance Criteria in BR 135 For Insulated Rainscreen Cladding Systems, Therefore Acceptable For Use In Buildings Above 18m in Height".
¶56.65 Jonathan Roome had taken that wording from a document prepared by Celotex's marketing team. It did not include the qualification that RS5000 was suitable for use on high-rise buildings only as part of a cladding system that was identical to the system that had been tested1572 Roome {Day69/167:20}-{Day69/168:10}. and therefore was, as he accepted, potentially misleading.1573 Roome {Day69/168:7-10}.
¶56.66 In his email of 6 August 2014 Mr Roome asked to visit Harley's offices to present the new product.1574 {CEL00001237}. Neither he nor any of Harley's witnesses could recall the precise date or circumstances in which that had occurred, but various conversations took place between Mr Roome, Daniel Anketell-Jones, and Ben Bailey about RS5000.1575 Roome {Day69/190:15-25}; Ray Bailey {HAR00010184/29} page 29; Anketell-Jones {HAR00010149/6} page 6; Ben Bailey {Day39/63:14-17}; {Day39/64:4-7}; {Day39/75:15-25}; {Day39/76:1-11}.
¶56.67 Ben Bailey told us that Jonathan Roome regularly visited Harley's offices and that he might have introduced RS5000 to a number of Harley's employees at different times.1576 Ben Bailey {Day39/63:14-17}; {Day39/64:4-7}; {Day39/75:15-25}; {Day39/76:1-11}; {Day39/76:20-21}; {Day39/77:1-4}. Mr Anketell-Jones, who was at that time the design manager at Harley, recalled a representative of Celotex visiting Harley's offices on a number of occasions to discuss RS5000, and more generally that Jonathan Roome visited the office every couple of weeks and perhaps 30 times a year.1577 Anketell-Jones {HAR00010149/6} page 6; Anketell-Jones {Day36/77:6-9}. Jonathan Roome could not recall the number of visits to Harley's offices, but would visit the offices to obtain information on Harley's projects and organise his sales pipeline.1578 Roome {Day69/174:15-23}. As at August 2014, Celotex was working on two projects for Harley (neither of them high-rise buildings) and Jonathan Roome hoped that Celotex could secure more work from Harley.1579 Roome {Day69/175:2-16}.
153Harley's understanding of the fire performance of Celotex RS5000
¶56.68 Ray Bailey said that because RS5000 was a new product, Harley had wanted to be sure that it was safe1580 Ray Bailey {Day33/68:23-25}. and suitable for the Grenfell Tower project.1581 Ray Bailey {Day33/69:6-8}. He said that Celotex had been keen to emphasise that it complied with BS 8414 and was suitable for buildings over 18 metres in height.1582 Ray Bailey {Day32/16:21-24}.
¶56.69 Daniel Anketell-Jones recalled that Jonathan Roome had made a sales pitch for RS5000, the essence of which had been that it was the first product suitable for use on buildings over 18 metres in height,1583 Anketell-Jones {HAR00010149/6} page 6; Anketell-Jones {Day36/79:2-13}; {Day36/88:6-9}. as claimed in Celotex's communications strategy.1584 Roome {Day69/177:14-17}. He also recalled seeing the marketing brochures provided to him by Mr Roome and recognised the pink branding on the documents.1585 Anketell-Jones {HAR00010149/6} page 6. He did not, however, read those brochures; he simply passed them on to others.1586 Anketell-Jones {Day36/93:15-25}; {Day36/94:1-3}; {Day36/97:24-25}; {Day36/98:1-6}.
¶56.70 Ray Bailey said it had been Mr Anketell-Jones' responsibility to examine the components of the cladding shown in the NBS Specification to check that they complied with the relevant statutory requirements1587 Ray Bailey {Day32/51:4-13}. and thought that he had done so.1588 Ray Bailey {Day32/51:4-13}; {Day32/17:21}-{Day32/18:1}. Mr Bailey himself just assumed that they were compliant and did not check for himself.1589 Ray Bailey {HAR00010184/8} page 8, paragraph 31. He was aware of the guidance in Approved Document B that the insulation should be of limited combustibility and thought that Celotex's products were materials of limited combustibility because they were rated Class 0.1590 Ray Bailey {Day33/22:12-15}. He thought that a Class 0 material was safe to use on any part of a building above 18 metres.1591 Ray Bailey {Day33/6:18-25}. He was aware of the distinction between Class 0 and limited combustibility, and of the fact that additional tests were required to establish the latter,1592 Ray Bailey {Day33/9:2-9}. but he appears to have regarded them largely as interchangeable concepts.1593 Ray Bailey {Day33/10:6-8}. For example, he thought that Class 0 related to the outside of a product but that if it were described as Class 0 "throughout", that meant the product as a whole was of limited combustibility.1594 Ray Bailey {Day33/12:12-15}; {Day33/13:3-10}; {Day33/14:7-12}; {Day33/15:8-11}; {Day33/11:7-9}. He was wrong about that, as he accepted,1595 Ray Bailey {Day33/19:2}. and was therefore wrong in thinking that Celotex products were materials of limited combustibility.1596 Ray Bailey {Day33/21:3-7}; {Day33/23:2-24}.
¶56.71 Mr Anketell-Jones had no recollection of the insulation products that were used on Grenfell Tower. He did not recall that the NBS Specification had required Celotex FR50001597 Anketell-Jones {Day36/70:21-24}. and said that he had become aware of the products used only from media reports following the fire.1598 Anketell-Jones {Day36/69:1-9}; {Day36/78:3-20}. He said that he had not known what "PIR" meant but considered it to be a better performing kind of insulation.1599 Anketell-Jones {Day36/89:4-18}. He thought that Class 0 meant that a material could not catch fire.1600 Anketell-Jones {Day36/92:7-14}. He did not investigate the materials provided in the NBS Specification to see whether they complied with the Building Regulations1601 Anketell-Jones {Day36/63:19-23}. because he did not regard that as part of his job. He said that it had been his practice to send technical information about materials to a project's design team and building control for approval. He had not done so in the case of the Grenfell Tower project because he did not consider himself to be the main designer;1602 Anketell-Jones {Day36/65:9-21}. that role was being performed by Studio E and building control.1603 Anketell-Jones {Day36/71:10-22}. Mr Anketell-Jones was not aware that anyone at Harley had considered the suitability of FR5000 for the refurbishment.1604 Anketell-Jones {Day36/71:14-17}.
154¶56.72 Daniel Anketell-Jones was not aware that RS5000 had been tested as part of a particular cladding system or that the cladding system proposed for Grenfell Tower differed from that which had been tested.1605 Anketell-Jones {Day36/96:4-25}; {Day36/97:1}; {Day36/104:8-11}. He knew nothing about the BS 8414 test or BR 135 classification and did not form any view about whether testing under those regimes meant that RS5000 could be used on Grenfell Tower.1606 Anketell-Jones {Day36/95:8-25}; {Day36/96:1-3}. As a result of what he had been told by Jonathan Roome and what he had read on the front of the Celotex literature,1607 Anketell-Jones {Day36/91:6-13}; {CEL00007961}. he thought that RS5000 could be used on any building above 18 metres in height, regardless of the other components of the external wall.1608 Anketell-Jones {Day36/90:10-13}. It is likely that Mr Roome pointed out the key aspects of Celotex's marketing literature to Mr Anketell-Jones,1609 Anketell-Jones {Day36/93:15-25}; {Day36/94:1-3}; {Day36/97:24-25}; {Day36/98:1-6}. although he could not recall talking through the RS5000 specification or compliance guides with anyone at Harley or explaining the test regime.1610 Roome {Day69/174:7-10}; {Day69/177:24-25}; {Day69/178:1-7}. Certainly no steps were taken by Mr Anketell- Jones to satisfy himself independently that RS5000 was suitable for use in buildings above 18 metres in height,1611 Anketell-Jones {Day36/79:14-25}; {Day36/80:1-5}. a claim which he took at face value.1612 Anketell-Jones {Day36/80:6-10}. He did not trouble to read the RS5000 sales literature and did not see the qualifications and warnings.1613 Anketell-Jones {Day 36/98:20}-{Day36/99:12}.
¶56.73 Ben Bailey also remembered the pink branded Celotex marketing literature, but was unsure whether he had read it,1614 Ben Bailey {Day39/78:20-24}. although he did remember that the marketing literature had said that RS5000 was Class 0 throughout.1615 Ben Bailey {Day39/79:2-5}. He said he had seen the product comparison sheet or the rainscreen cladding specification guide1616 {CEL00000007}; {CEL00000013} which formed part of the package of documents sent by Jonathan Roome to Daniel Anketell-Jones on 27 August 2014 {CEL00011960}; Ben Bailey {Day39/82:10-17}; {Day39/82:1-24}. and was unsure whether he had seen the rainscreen cladding compliance guide.1617 {CEL00000012}; Ben Bailey {Day39/81:18-25}; {Day39/83:6-14}. He said that he had not been aware that RS5000 would comply with Approved Document B in relation to buildings above 18 metres in height only if it was used as part of a cladding system that corresponded exactly with the one tested.1618 Ben Bailey {Day39/83:21-25}; {Day39/84:1}.
155¶56.74 Jonathan Roome did not discuss with anyone at Harley the differences between FR5000 and RS5000, despite the fact that FR5000 rather than RS5000 had been included in the NBS Specification which Mr Anketell-Jones had seen.1619 Roome {Day69/199:18-25}; {Day69/200:1-2}. Similarly, Mr Roome did not point out to anyone at Harley that RS5000 could be used only on buildings over 18 metres in height if the cladding system corresponded exactly to the one that had been tested.1620 Roome {Day69/178:19-25}; {Day69/200:3-12}; Anketell-Jones {Day 36/97:9-20}; {Day36/98:7-22}; {Day36/99:13-24}. Harley never asked Jonathan Roome to explain the precise differences between the system as tested and the proposed cladding system for Grenfell Tower. Roome {Day69/126:22-25}; {Day69/127:1-4}. Jonathan Roome did not qualify the suitability of RS5000 on buildings above 18 metres with any caveats. Neither Harley nor Celotex made a comparison between the cladding system tested and the cladding system proposed for Grenfell Tower.1621 Roome {Day69/201:6-11}; Anketell-Jones {Day36/81:17-19}; {Day36/96:24}-{Day69/97:2}.
¶56.75 Jonathan Roome accepted that the limited relevance of the BS 8414 test involving RS5000 was important and that it was important that Harley understood it. He accepted, however, that he had not specifically drawn Mr Anketell-Jones's attention to it. His excuse was that Mr Anketell-Jones was a specialist and that he had thought he understood it from the information contained in the marketing literature Harley had been given.1622 Roome {Day69/179:4-20}; {Day69/200:13-16}; {Day69/201:3-5}; {Day69/200:13-20}; Anketell-Jones {Day36/79:4-8}. Mr Roome did not insist on seeing the composition of the cladding system proposed for Grenfell Tower to enable him to advise Harley whether RS5000 was suitable,1623 Roome {Day69/127:5-8}. nor did he point out to anyone at Harley that FR5000 might not be safe to use on buildings over 18 metres in height.1624 Anketell-Jones {Day36/79:11-13}. Harley did not ask Mr Roome for information about the BS 8414 test beyond that which was contained in the marketing literature and Mr Roome did not volunteer any.1625 Roome {Day69/192:7-18}.
Handover to Neil Crawford: August 2014
¶56.76 Neil Crawford began work on the Grenfell Tower project in about July 2014.1626 Crawford {Day9/116:19-21}. In about August 2014, Bruce Sounes had a handover meeting with him.1627 Crawford {Day9/49:23}-{Day9/50:3}. Neil Crawford was working on the project between July and August 2014, but his involvement had been minimal: Crawford {Day9/50:4-9}. It is likely that Mr Sounes gave Mr Crawford a general description of the NBS Specification during the handover.1628 Crawford {Day9/136:21}-{Day9/137:3}. When Mr Crawford started work on the project, therefore, FR5000 was the insulation product included in the NBS Specification. Neil Crawford could not recall whether Mr Sounes had told him that FR5000 had been specified as the insulation to be used within the external facade, but it is likely that he had read Max Fordham's Stage C report and had seen the reference to it there.1629 Crawford {Day9/135:15}-{Day9/136:5}. Neil Crawford said that he would probably have read that Stage C report when he came on to the project. Crawford {Day9/136:9-14}.
¶56.77 Mr Crawford accepted that it had been the architect's duty to ensure that the insulation complied with the Building Regulations1630 Crawford {Day10/124:11-20}. and told us that based on his knowledge of Bruce Sounes' work he would have expected Mr Sounes to have checked that FR5000 was suitable before completing the Employer's Requirements.1631 Crawford {Day9/140:7-11}. Mr Crawford said that although he did not have any conversations with Mr Sounes about the suitability of FR5000 for use in the external wall, he had gained the impression that Mr Sounes was firm in his view that it was suitable,1632 Crawford {Day9/139:14-24}; {Day10/51:11-14}. although he could not recall his saying it in terms.1633 Crawford {Day9/140:3-6}. Bruce Sounes, however, could not recall any conversation with Neil Crawford in which he had expressed any view about the suitability of FR5000.1634 Sounes {Day20/73:5-17}. In our view it is unlikely that by then Mr Sounes had any lingering doubts about using FR5000, and we therefore doubt that he had any reason to express a view of any kind about the suitability of FR5000 for use in the cladding system.
156¶56.78 Neil Crawford had some recollection of having seen the product datasheet for FR5000 but could not recall when he first saw it.1635 {SEA00005841}; Crawford {Day9/142:1-12}. At all events, he did not take any steps to check it when he learnt that FR5000 had been specified for use in the external wall.1636 Crawford {Day9/142:14-19}.
The change from FR5000 to RS5000: August to September 2014
¶56.79 On 27 August 2014 Jonathan Roome sent an email to Daniel Anketell-Jones attaching further information about RS5000.1637 {CEL00011960}. Mr Roome sent Mr Anketell-Jones a product comparison document, the product datasheet, the LABC Registered Details drawing and document list and certificate, a four-page version of the BRE Global Classification Report on a system which included 100mm RS5000 insulation board, the rainscreen cladding compliance guide, and the rainscreen cladding specification guide.1638 {CEL00011960}; {CEL00000007}; {CEL00000411}; {CEL00011963}; {CEL00011415}; {CEL00011965}; {CEL00011966}; {CEL00000418}. Mr Roome was not aware at that time that the full BRE report ran to 12 pages and neither he nor Mr Anketell‑Jones noticed that the four-page report was only a part of the document.1639 Roome {Day69/209:10-19}; {Day69/213:2-9}; {Day69/213:10-12}.
¶56.80 Mr Anketell-Jones said that at that time the only thing he knew about insulation was U-values,1640 Anketell-Jones {Day36/87:1-15}. but despite his lack of knowledge about the fire performance of different kinds of insulation and his assertion that he would normally send technical information to others for their consideration,1641 Anketell-Jones {Day36/93:15-25}; {Day36/94:1-3}; {Day36/97:24-25}; {Day36/98:1-6}. he did not send the package of documents he received from Mr Roome to anyone else within Harley or the wider design team because he did not regard himself as the designer.1642 Anketell-Jones {Day36/88:13-19}.
¶56.81 Shortly after receiving the documents from Mr Roome, Mr Anketell-Jones carried out U-value calculations for FR5000 using a piece of software called "BuildDesk".1643 Anketell-Jones {Day36/106:5-23}. On or around 28 August 2014 Mr Anketell-Jones and Mr Roome discussed those calculations. Mr Roome recorded their discussions in a note in which he recorded that Mr Anketell- Jones had said that the calculations had been performed using FR5000 but that he needed to use RS5000 at a thickness of 150mm.1644 {CEL00001451}. That is the first reference we have seen to the use of RS5000 in place of FR5000 at Grenfell Tower.
¶56.82 Daniel Anketell-Jones was emphatic that he had not selected RS5000 for use at Grenfell Tower.1645 Anketell-Jones {Day36/173:2-4}. He explained that the NBS Specification as drawn up by Studio E was a prescriptive specification and the insulation product, RS5000, had been prescribed by Studio E.1646 Anketell-Jones {Day36/116:13-17}; {Day36/141:13-16}; {Day36/149:18-19}; {Day36/173:2-4}. However, that was plainly wrong. Studio E had specified FR5000, not RS5000, and Mr Anketell-Jones, like others at Harley, had no reason to think that they were the same product, especially in circumstances where Mr Roome himself thought that they were not. Mr Anketell-Jones thought, without any obvious foundation, that by pressing on with RS5000 Harley was simply adhering to Studio E's specification. He believed that Studio E had already checked that RS5000 was suitable before it sent the NBS Specification to Harley1647 Anketell-Jones {Day36/102:2-12}; {Day36/93:5-13}; {Day36/141:22-25}; {Day36/142:1}. and assumed that it had been the subject of desktop studies.1648 Anketell-Jones {Day36/102:13-19}. We doubt that he did think that at the time, not least because if he had done so his mistake would have been obvious. The NBS Specification had been completed in January 2014, about eight months before the launch of RS5000. Studio E could not have checked the suitability of RS5000 before the NBS Specification had been finalised because the product did not then exist under that name. We reject Mr Anketell-Jones' evidence about his reason for adopting RS5000 in place of FR5000, although we find it impossible to know what he actually thought at the time, if indeed he turned his mind to the point at all.
157¶56.83 It is unlikely that Jonathan Roome expressly advised Harley that RS5000 was suitable for Grenfell Tower,1649 Roome {Day69/191:10-13}. but he accepted that he knew Grenfell Tower was over 18 metres in height1650 Roome {Day69/191:5-9}. and that he might well have told Mr Anketell-Jones that the product was suitable for use on such buildings because it was the only product available for that application.1651 Roome {Day69/200:3-6}.
¶56.84 Mr Anketell-Jones said that at some point he had been told that FR5000 could not be used but that RS5000 was equivalent,1652 Anketell-Jones {Day36/113:8-13}. but he could not recall when he was told that or by whom. He said that the only reason that RS5000 would have been put forward on any project was because it was appropriate for use above 18 metres and was one of the few insulation materials that were capable of achieving the high performance required.1653 Anketell-Jones {Day36/154:2-8}. In his mind, there was no difference between FR5000 and RS5000.1654 Anketell-Jones {Day36/108:1-6}. However, although he was quite right about that, he had no reason to think so. There had been no conversations between Harley and Celotex which could justify his coming to that view; indeed, quite the opposite. He thought that RS5000 was a new product,1655 Anketell-Jones {Day36/102:13-19}. not least because that was exactly what Jonathan Roome had told him. For his part, Mr Roome did not know otherwise, having been induced to think that RS5000 was indeed a new product by those at Celotex who briefed the marketing department. In circumstances where RS5000 was being marketed as a new product there is no credible basis on which Mr Anketell-Jones could have thought that it was the same as FR5000 and that there was therefore no need to investigate its fire performance.
¶56.85 Harley did not consider whether another insulation product, such as a mineral wool, might be more appropriate for use on the project. Mr Anketell-Jones explained that RS5000 had been specified by Studio E and that Harley was not considering any alternative products.1656 Anketell-Jones {Day36/119:1-7}. He was not aware whether the fact that RS5000 was rated Class 0 had affected the decision to use it,1657 Anketell-Jones {Day36/93:5-13}. but even so, a change from FR5000 to RS5000 ought to have led Harley to investigate why FR5000 had originally been specified, why RS5000 was being substituted and whether it was a suitable product for use on the tower.
158¶56.86 Daniel Anketell-Jones did not ask Rydon or Studio E whether they were happy with the use of RS50001658 Anketell-Jones {Day36/108:17-25}. because he did not consider himself to be the design manager on the project.1659 Anketell-Jones {Day36/80:15-17}. He thought that was Ben Bailey's or Kevin Lamb's job as designer1660 Anketell-Jones {Day36/108:17-25}. and assumed as a result of having worked with him before that Mr Lamb knew that was his responsibility.1661 Anketell-Jones {Day36/66:11-14}; {Day36/74:1-12}; {Day36/105:11-16}; {Day36/73:15-25}; {Day36/73:15-25}. He said that he had expected Kevin Lamb to tell Studio E about the proposed use of RS5000 so that it could check its suitability and Rydon to have then checked with Building Control,1662 Anketell-Jones {Day36/79:14-25}; {Day36/80:1-5}. but he did not tell Mr Lamb that that was his responsibility.1663 Anketell-Jones {Day36/65:20-25}; {Day36/66:1-10}. For reasons explained below, we do not accept Mr Anketell-Jones' explanation of his role at Harley; in particular, we do not accept that it was as limited as he suggested.
¶56.87 Daniel Anketell-Jones did not have any conversation with Kevin Lamb about the use of RS5000 and did not show him the Celotex documents. He could not explain how Mr Lamb could possibly have been aware of the change from FR5000 to RS5000 to enable him to check the position.1664 Anketell-Jones {Day36/109:2-7}. He did not know who at Harley was responsible for reading the Celotex specification guide for RS5000 and suggested that, if Mr Lamb had satisfied himself that RS5000 had been checked by Studio E and Building Control, he would not need to have read it.1665 Anketell-Jones {Day36/94:4-12}.
¶56.88 Kevin Lamb was told on 12 August 2014 at his initial meeting with Ray Bailey and Daniel Anketell-Jones that the insulation to be used in the external wall was a rigid PIR- type material. He could not recall whether Celotex had been specifically mentioned but assumed that a product of that kind had been selected.1666 Lamb {Day37/77:6-13}; {Day37/81:8-24}. He did not recall seeing FR5000 in the NBS Specification.1667 Lamb {Day38/33:25}. There was no discussion between Kevin Lamb and either Mr Bailey or Mr Anketell-Jones about the specification of the insulation product; he was simply told which product had been selected.1668 Lamb {Day37/78:25}-{Day37/79:22}.
¶56.89 Kevin Lamb had not previously used a product like Celotex in a rainscreen cladding system.1669 Lamb {Day37/80:5-6}. He did not see it as his responsibility to provide advice on compliance with the relevant regulatory requirements, although he said that he had had a brief look at literature relating to the use of Celotex on buildings over 18 metres in height and a brief look at the guidance published by the CWCT.1670 Lamb {Day37/130:2-13}. He knew that there was a difference between Class 0 and limited combustibility,1671 Lamb {Day38/83:9-12}. but he was not aware that limited combustibility was defined by reference to specific tests.1672 Lamb {Day38/83:22-25}; {Day38/84:1-2}. He did not consider the difference and assumed that if a material was rated Class 0 it was suitable for use.1673 Lamb {Day38/83:16-17}. He did not know that to comply with paragraph 12.7 of Approved Document B insulation materials used on buildings above 18 metres in height should be materials of limited combustibility.1674 Lamb {Day37/150:2-4}. He did not consider it part of his responsibility to review the insulation for compliance with the Building Regulations or Approved Document B.1675 Lamb {Day37/160:15-18}; {Day37/165:13-18}; {Day37/170:4-8}. He therefore read the Celotex Rainscreen Cladding Compliance Guide only to review the type of fixings it required within the cladding system.1676 {CEL00002047}; Lamb {HAR00010419/14} page 14; Lamb {Day38/36:20-25}; {Day38/37:1-5}.
159¶56.90 Ben Bailey was not familiar with RS5000 but said he had thought that it had always been intended to use it on Grenfell Tower.1677 Ben Bailey {Day39/71:13-15}; {Day39/70:19-23}; {Day39/69:6-7}. He thought (though why is not clear) that Studio E had chosen RS5000 for use on Grenfell Tower and possibly that "FR" had been a typographical error in the NBS Specification.1678 Ben Bailey {Day39/70:19-23}; {Day39/69:6-7}.
¶56.91 Ben Bailey told us that there he had had a conversation with Neil Crawford in which he had questioned the choice of FR5000 because he had been under the impression that RS5000 was to be used. He said that Neil Crawford had told him that RS5000 had been chosen, which he understood to mean that RS5000 should have been specified and that it was Studio E's intention that RS5000 rather than FR5000 be specified.1679 Ben Bailey {Day39/67:6-25}; {Day39/68:1-11}; {Day39/71:3-4}. Ben Bailey said that there had been no discussion between them about the suitability of either FR5000 or RS5000 for use in buildings above 18 metres in height.1680 Ben Bailey {Day39/69:8-23}. He said that he had not told Mr Crawford that RS5000 was a new product nor had he asked him whether it complied with the Building Regulations. Neil Crawford merely confirmed, he said, that there was a typographical error in the NBS Specification; he therefore assumed that Studio E had checked the suitability of RS5000.1681 Ben Bailey {Day39/73:6-21}. Albeit that Ben Bailey could not recall the exact words used by Neil Crawford. Ben Bailey {Day39/73:20-21}.
¶56.92 The difficulty with Ben Bailey's evidence is, again, that the last version of the NBS Specification was dated 30 January 2014, some eight months before the launch of RS5000. Studio E therefore cannot have intended to specify RS5000. In response to that difficulty, Mr Bailey said that he had misremembered the conversation and changed his evidence to say that Neil Crawford had confirmed his expectation that RS5000 should be the chosen product.1682 Ben Bailey {Day39/74:4-13}. Ben Bailey did not take any steps to amend the NBS Specification1683 Ben Bailey {Day39/74:15-20}. and he did not ask whether anyone had checked that RS5000 was suitable. He assumed that Studio E had done that.1684 Ben Bailey {Day39/72:6-17}; {Day39/72:10}-{Day39/73:2}. He did not consider whether a different kind of insulation might be more suitable for use on Grenfell Tower;1685 Ben Bailey {Day39/141:23-25}; {Day39/142:1}. nor did he consider whether the use of a PIR product rather than a mineral wool product might affect fire safety.1686 Ben Bailey {Day39/143:2-5}.
160¶56.93 If Ben Bailey did have a conversation with Neil Crawford of the kind he described, he did not tell anyone at Harley about it. Nor did he mention it in his witness statement. Neil Crawford did not mention any such conversation and there is no indication in the documents that Studio E expected RS5000 to be used. For those reasons we do not accept Ben Bailey's evidence on that matter.
¶56.94 Ray Bailey thought that RS5000 was a new product and not a rebranded version of FR50001687 Ray Bailey {Day33/65:3-10}. because that is what Celotex had told him. He told us that either Ben Bailey or Daniel Anketell-Jones had communicated the change to Studio E and that Neil Crawford had then accepted it.1688 Ray Bailey {Day33/75:2-7}. He said it had been Harley that had pointed out that there was a difference between FR5000 and RS5000 and that RS5000 needed to be accepted to enable it to be used.1689 Ray Bailey {Day33/74:16-23}; Ray Bailey {HAR00010184/8} page 8, paragraph 31. His evidence is at least consistent with the fact that Mr Roome thought that the RS5000 was a new product different from FR5000.
¶56.95 Ray Bailey was not aware of any discussions between Ben Bailey or Daniel Anketell-Jones and Studio E about the substitution of FR5000 with RS50001690 Ray Bailey {Day33/75:8-17}. and he did not himself speak to Neil Crawford or anyone else at Studio E about the change.1691 Ray Bailey {Day33/76:7-10}. None of the other Harley witnesses and none of the Studio E witnesses suggested that Neil Crawford, or anyone else at Studio E, had been informed of the change from FR5000 to RS5000 or that Studio E had accepted RS5000 for use on Grenfell Tower, as Mr Bailey maintained. We are therefore unable to accept Ray Bailey's evidence on this question. We conclude that Studio E never investigated the suitability of RS5000 for use at Grenfell Tower and did not accept its use.
¶56.96 Looking at the evidence as a whole, we are satisfied that Jonathan Roome did tell Daniel Anketell-Jones that RS5000 was suitable for use in buildings above 18 metres in height. That was consistent with Celotex's communications strategy and with the evidence given by both Mr Anketell-Jones and Mr Roome himself. We think it unlikely, however, that Mr Roome gave any assurance that RS5000 was suitable for use in the specific cladding system being proposed for Grenfell Tower. None of the witnesses could recall any conversation with Celotex about the proposed construction of the external wall and, at least in September 2014, Mr Roome had not seen any relevant drawings or specifications. He therefore had no basis for giving any specific assurance. Indeed, given the presence in the marketing literature of the warning that the BR 135 classification applied only to the system as tested, we think it unlikely that Mr Roome would have given an assurance of that kind in circumstances where there was a risk that someone in the design team might eventually read it and challenge him.
¶56.97 As it turned out, there was no discussion about that warning. No one at Harley read the marketing literature carefully or sent it to Studio E or Exova to comment on. Harley did not ask Celotex or Studio E whether a desktop study had been done to support the use of RS5000 and did not inquire whether any other members of the design team had asked for a desktop study or other assessment to support the proposed system.1692 Anketell-Jones {Day36/101:12-21}. Daniel Anketell- Jones simply accepted what Jonathan Roome had told him about the suitability of RS5000 for use on buildings above 18 metres in height and assumed that it complied with the relevant statutory requirements. On that basis he told Mr Roome that RS5000 was needed for use at Grenfell Tower.1693 {CEL00001451}.
161¶56.98 Although Jonathan Roome was canny enough to avoid giving any specific assurance to Harley that RS5000 was suitable for use on Grenfell Tower, we think he suspected that Harley had not understood the warning in Celotex's marketing literature. He certainly never drew Harley's attention to it, which was consistent with Celotex's marketing strategy to downplay it and tuck it away in the small print.1694 This is consistent with Mr Roome's internal slides of 11 February 2015 {CEL00003544}.
¶56.99 There was a design team meeting on 2 September 2014 at which U-values were discussed with Rydon. The question arose whether they needed to be rechecked from an M&E and insulation point of view.1695 {SEA00011581/4}; {RYD00017128}. A post-meeting note states that the "Max Fordham tender U-value document was shared to team via email". After a discussion everyone agreed to check their calculations. Neil Crawford did not know why Rydon had wanted to recheck the U-values; he understood that they had been derived from Max Fordham's advice but did not recall in any detail how the target had been established.1696 Crawford {Day10/66:9}-{Day10/67:4}. Daniel Anketell-Jones and Kevin Lamb also attended that meeting and Mr Anketell-Jones checked the U-values by making another calculation using the "BuildDesk" software.1697 Anketell-Jones {Day36/118:11-19}. This time he used RS5000 in the calculation,1698 {CEL00000030}. but that did not prompt him to consider its fire safety.1699 Anketell-Jones {Day36/118:23-25}.
Harley's Request for Information: September 2014
¶56.100 On 17 September 2014, Daniel Anketell-Jones sent a formal Request for Information to Rydon and Studio E about the extent to which horizontal fire breaks were required within the cladding.1700 {HAR00003638/4}; {EXO00001291}. In summary, Harley believed that horizontal firebreaks might be required at every floor level but not in the area between the windows, because there was no "chimney effect" at that location. Daniel Anketell-Jones accepted that he had drafted the request1701 Anketell-Jones {Day36/156:25}. but said that he had been asked by someone else to send it and had not fully understood the point. However, he could not remember who had asked him to send it1702 Anketell-Jones {Day36/157:6-18}. and said that he did not know what analysis had been done to support it.1703 Anketell-Jones {Day36/158:10-13}. We do not accept his evidence on this point. We think he drafted the request in his role as Harley's design manager, part of which did involve considering the fire performance of the external walls which Harley was designing.
¶56.101 Neil Crawford sent the request to Terence Ashton of Exova and asked him to comment on Daniel Anketell-Jones' "interpretation".1704 {HAR00003638/4}. Exova was then provided with some Harley drawings and Mr Ashton replied on 18 September 2014 saying that if the insulation in the cavities behind the rainscreen cladding were combustible it would be necessary to provide cavity barriers even if there was no continuous cavity from the top to the bottom of the building.1705 {HAR00003638/3}. As we have explained in Chapter 54, that advice was incorrect in so far as it implied that combustible insulation could be used provided cavity barriers were installed.
162¶56.102 Neil Crawford sent that email on to Daniel Anketell-Jones the same day.1706 {HAR00003638/2}. Mr Anketell- Jones said that he had read Mr Ashton's response but formed no view about it.1707 Anketell-Jones {Day36/162:1-3}. He did not question why Mr Ashton appeared to be linking the combustibility of the insulation to the requirement for cavity barriers.1708 Anketell-Jones {Day36/162:3-8}. Mr Anketell-Jones replied to Mr Crawford and Rydon the same day saying that because the insulation was Class 0, he thought that a fire barrier (i.e. a cavity barrier) in those locations would not be necessary and asking for confirmation.1709 {HAR00003638/1}. He attached the RS5000 product datasheet to his email.1710 {HAR00012103}; {HAR00012104}. That appears to have been the first time that Studio E had been informed of the change from FR5000 to RS5000.1711 Anketell-Jones {Day36/163:24-25}; {Day36/164:1-2}.
¶56.103 Daniel Anketell-Jones told us that his message showed that he did not understand fire classifications or know where cavity barriers were required and that he believed that it was the responsibility of the consultants to tell Harley where they needed to be installed.1712 Anketell-Jones {Day36/164:25}; {Day36/165:1-4}. We do not accept that Mr Anketell-Jones was as naïve and ignorant as he pretended. In that email, he was giving his opinion of the fire classification of the insulation (Class 0) and whether that meant that fire barriers were necessary in certain locations. It reflects his view of what was meant by Class 0. He said he had not checked his opinion with any of his colleagues or against any published guidance1713 Anketell-Jones {Day36/167:2-7}. because he was concerned only with matters of structural engineering.1714 Anketell-Jones {Day36/167:7}. It is certainly true that he did not check his opinion with anyone else or against any available guidance, but we doubt whether he made any positive decision not to do so.
¶56.104 Daniel Anketell-Jones said that he had looked at the product datasheet, had seen that RS5000 was rated Class 0, and had passed that on to Studio E and Rydon.1715 Anketell-Jones {Day36/166:18-24}. Neil Crawford then asked Mr Ashton to provide his view on whether Class 0 insulation obviated the need for cavity barriers in certain locations.1716 {HAR00003638/1}. In response Mr Ashton pointed out that a material which has a Class 0 rating is not necessarily non-combustible although the reverse is invariably true and that it was therefore necessary to prevent the spread of fire from one flat to the flat above. It was not clear from the information he had been given whether there was a continuous cavity from top to bottom in any part of the cladding, irrespective of the type of insulation.1717 {EXO00001430}.
¶56.105 Mr Anketell-Jones did not give any consideration to Mr Ashton's advice that, in summary, a Class 0 insulation may not be sufficient for fire safety.1718 Anketell-Jones {Day36/170:13-22}. Even having read that advice, it did not occur to him to question whether RS5000 was suitable, as he continued to believe that RS5000 had already been approved by Studio E, building control, and the fire engineer.1719 Anketell-Jones {Day36/171:1-5}; {Day36/171:11-12}.
¶56.106 We have already concluded that Daniel Anketell-Jones' professed understanding was wrong and that RS5000 had not been checked for suitability by Studio E, nor had Studio E confirmed that RS5000 was suitable for use at Grenfell Tower. Mr Anketell-Jones' belief that the fire engineer had already approved RS5000 makes little sense, given that Exova itself was inquiring about the type of insulation to be used in the external wall. It is clear that
163¶Exova did not know what insulation it was proposed to use and so could not have already approved it. Accordingly, we reject Mr Anketell-Jones' evidence that he thought that
¶RS5000 had already been approved by Exova. In fact, at no stage did he raise with anyone at Rydon, Studio E or Exova the combustibility of the insulation,1720 Anketell-Jones {Day36/171:13-16}. nor did he take any steps following the Request for Information to investigate whether RS5000 complied with the Building Regulations or the guidance in Approved Document B.1721 Anketell-Jones {Day36/171:5-12}.
¶56.107 Although Neil Crawford was right to refer some of those questions to Exova, he regarded himself as little more than a post-box and failed to ask himself the question whether the switch to RS5000 was appropriate for Grenfell Tower. Once Studio E had been put on notice that an apparently new product was being proposed, it should have ensured that its fire performance was appropriate. Mr Crawford admitted that he had effectively taken it on trust from Harley that it was.1722 Crawford {Day10/48:5-9}. He also said that he had read the Celotex literature and was convinced that it was suitable for use,1723 Crawford {Day10/53:5-7}. but, if he did read it, he failed to notice that the product was not of limited combustibility1724 Crawford {Day10/50:20-24}. or that the system that Celotex had tested was not the same as the one intended for installation on the tower.1725 Crawford {Day10/63:2-8}. We accept Mr Hyett's opinion that Studio E's approach fell below the standards to be expected of a reasonably competent architect exercising reasonable skill and care.1726 Hyett {Day65/16:23}-{Day65/19:20}.
¶Harley's request for technical information in respect of
¶RS5000: January 2015
¶56.108 On 16 January 2015, Daniel Anketell-Jones sent an email to Jonathan Roome seeking help with what he described as a "headache" and asking for the test results and certificates for RS5000.1727 {CEL00000019/2}. Mr Anketell-Jones said that another client1728 Daniel Anketell-Jones did not recall the client, but thought it was likely to have been a main contractor or architect on a project unconnected to Grenfell Tower. Anketell-Jones {Day36/123:23-25}; {Day36/124:1-5}. He considered that it was likely to have been in connection with a job which required Harley to put forward an insulation that would meet certain U-value requirements, Anketell-Jones {Day36/124:18-22}. wanted to know how RS5000 had been installed when it had been tested in accordance with BS 8414, how it had been fixed, what it had been covered with, and what cladding and supporting structure had been used. The client also wanted to see the certificates and results for the test to BS 476 Part 7. It did not occur to Daniel Anketell-Jones that no one at Harley had asked the same questions in relation to the Grenfell project. Mr Anketell-Jones also said that Harley had been hoping to use RS5000 on most of its other cladding projects and therefore wanted to have the information about testing to hand.
¶56.109 Mr Roome in turn sought the BS 476 test reports from a colleague at Celotex, Jamie Hayes, on 19 January 2015, saying that he could always discuss the BS 8414‑2 test report in person,1729 {CEL00000453}. and offered to visit Mr Anketell-Jones at Harley's office to do so. If that discussion had taken place, it would probably have revealed the very limited basis on which RS5000 could be used on buildings above 18 metres in height consistently with the Building Regulations and Approved Document B,1730 Roome {Day70/67:2-9}; {Day70/62:8-22}. Jonathan Roome agreed with that proposition. but that discussion did not take place.
164¶56.110 Mr Hayes told Mr Roome that he did not have access to those documents and had passed the request on to Paul Evans or Debbie Berger.1731 {CEL00000453}. Whether he had or not, the BS 476 test reports were never provided to Mr Roome, who, of course, was unable to provide them to Daniel Anketell-Jones.1732 Roome {Day70/68:18-25}.
¶56.111 Mr Roome did not tell Mr Anketell-Jones that RS5000 could not be used on any of Harley's projects unless the cladding system was, in each case, exactly the same as the one that had been tested.1733 Roome {Day70/70:20-25}. Mr Roome accepted that Mr Anketell-Jones had either not read the warnings or had misunderstood them (or even intended to ignore them), but denied that he had realised that at the time.1734 Roome {Day70/71:1-20}.
¶56.112 Mr Anketell-Jones understood that RS5000 was not suitable for all rainscreen applications and that the suitability of the product had to be determined in relation to each building individually.1735 Anketell-Jones {Day36/128:22-25}; {Day36/129:1-4}. Although he said he had not understood how the suitability of RS5000 was to be determined. Despite his professed understanding, and despite the nature of the questions being asked by the client on the other project, however, he did not consider it important to check whether the proposed system was the same as the one that had been tested. He should have known by January 2015 that whether RS5000 was suitable for use in a particular application depended entirely on whether the proposed system corresponded precisely with the one tested, but he assumed, wrongly, that it depended on how the particular fire consultant or building control officer interpreted the information.1736 Anketell-Jones {Day36/129:8-11}; {Day36/129:15-21}.
¶56.113 Daniel Anketell-Jones sent another email to Jonathan Roome on 20 January 2015 saying that he was hoping Celotex could provide the test information since otherwise they would have to change to Rockwool Duo Slab, which would satisfy "the specialists".1737 {CEL00000019/1}. Mr Roome responded on 21 January 2015, having discussed his response with his colleagues.1738 {CEL00000019}. He attached the full (12-page) BRE Classification Report, the thermocouple data from the test (showing the maximum temperatures recorded during testing) and the RS5000 product information sheet.1739 {CEL00000020} (12pp report), {CEL00000021} (thermocouple graphs) and {CEL00000022} (product information sheet). Despite their obvious importance, Mr Roome and Mr Anketell-Jones did not discuss the documents.1740 Roome {Day70/76:9}.
¶56.114 The most natural reading of the emails sent by Mr Anketell-Jones on 16 and 20 January 2015 is that he knew that the construction of the external wall was critical when assessing the suitability of RS5000 for the purposes of fire safety. That has led us to doubt his attempts to play down the extent of his knowledge about fire performance testing and the importance of his role within Harley on the Grenfell project. We are satisfied that he understood more about the technical aspects of fire safety than he was prepared to admit and as design manager he should have been responsible within Harley, together with others, for checking the fire performance of the products used in the external wall. Indeed his emails suggest that he suspected that Celotex might not have the test evidence to support the claims being made for RS5000. It is a matter of serious concern, therefore, that he made no comparable efforts to check the suitability of RS5000 for use on the Grenfell Tower project, but merely assumed it without any investigation. He said that he had not read the 12-page BRE report or the thermocouple data Mr Roome had sent to him on 21 January 2015 and had not sent it to Kevin Lamb, Studio E, or anyone else because he thought that had already been done1741 Anketell-Jones {Day36/124:23-25}; {Day36/125:1-6}; {Day36/141:5-12}; {Day36/142:2-5}. and that it was not Harley's responsibility to do it.1742 Anketell-Jones {Day36/124:7-16}.
165¶56.115 Again we cannot accept his evidence on that point. These exchanges occurred almost a year after the final issue of the NBS Specification. If he believed that RS5000 was a new product, Mr Anketell-Jones cannot have thought that the technical information he had obtained from Celotex had been in Studio E's possession when it specified the insulation material almost a year earlier. We consider that at that point, if not before, Mr Anketell‑Jones ought to have conducted his own research and, if necessary, asked Celotex, Studio E or Rydon whether RS5000 was suitable for use at Grenfell Tower.
Celotex's exploitation of Harley
¶56.116 On 11 February 2015 Jonathan Roome sent Debbie Berger and Paul Evans, a market analysis for RS5000, which split potential customers into three tiers.1743 {CEL00003543]; {CEL00003544}. Tier 1 comprised customers who were seen as being of no use to Celotex, because they used only non-combustible products or products of limited combustibility because they were not happy with current test data relating to combustible insulation products.1744 {CEL00003544/3}. Tier 2 comprised customers who were willing to consider the use of combustible insulation. By contrast, Tier 3 comprised customers who always used combustible insulation because, in some cases, they were not aware of the 18-metre restriction. In our view the existence of that document shows that Celotex was aware of the differing technical sophistication of potential buyers and that it realised that the market for RS5000 was likely to be limited to those who lacked expertise or expert advice or who did not understand, or had not bothered to investigate, the fire performance of RS5000. That reflects a deeply cynical view that there were ignorant or reckless contractors in the market of whom advantage could be taken without any regard for the safety of occupants. Certainly there is no evidence that the safety of residents played any part in Celotex's thinking on how to sell RS5000, at least when it came to Grenfell Tower.
¶56.117 Celotex regarded Harley as a Tier 3 customer and exploited its willingness to accept what it was told and its lack of interest in understanding when RS5000 could be used safely. It refrained from correcting Harley's misunderstanding and encouraged it to pursue the purchase regardless of the product's suitability for the project in hand. That was not the behaviour to be expected of an honest and plain-dealing manufacturer.
¶56.118 In our view Jonathan Roome suspected that Harley had not understood the contents of the Celotex marketing literature and in particular had failed to understand that RS5000 could not be used on a cladding project unless the proposed system as a whole was exactly the same as the one that Celotex had apparently tested in accordance with BS 8414. As noted above, Jonathan Roome accepted that Daniel Anketell-Jones had either not read the warnings to that effect or had misunderstood them or was proposing to ignore them. In our view he turned a blind eye to the failure of Daniel Anketell-Jones to ask the sort of questions in relation to Grenfell Tower that he had asked in relation to a different project in January 2015. Celotex recognised that Harley was ill-informed, or was acting recklessly, and exploited its lack of interest in the circumstances in which RS5000 could safely be used.
166¶Although it provided Harley with some technical information, it deliberately refrained from any attempt to ensure that Harley was fully informed about the suitability of RS5000, an approach that was entirely consistent with its marketing strategy.
Finalising the specification of RS5000: February to April 2015
¶56.119 Ben Bailey took over as project manager at Harley in February 2015.1745 {CEL00000024/2}; Ben Bailey {Day39/84:20-24}. He assumed that RS5000 was suitable for use on Grenfell Tower because the U-value calculations made by Daniel Anketell-Jones all referred to RS5000 and because all the conversations he had had with Jonathan Roome related to RS5000.1746 Ben Bailey {Day39/70:1-18}. He said that, although no one at Celotex had expressly confirmed or approved the use of RS5000 in combination with ACM panels, Mr Anketell-Jones had told him that a combination of RS5000 and ACM panels had been checked. He had understood that Mr Anketell-Jones had himself been told that it was suitable for use on the project.1747 Ben Bailey {Day39/79:19-25}; {Day39/80:1-12}. However, by February 2015 no one working on the project had made any assessment of the suitability of RS5000, let alone in conjunction with ACM rainscreen panels, and if Mr Anketell-Jones had told Ben Bailey that RS5000 and ACM in combination had been checked, he had no basis for doing so.
¶56.120 On 11 February 2015, Jonathan Roome sent Ben Bailey an email asking for the final construction drawings.1748 {CEL00000024/2}. He said that he had done so because if components of the external wall penetrated the insulation that could have an effect on the calculation of the U-value.1749 Roome {Day70/17:9-17}.
¶56.121 Ben Bailey responded the same day by providing a link to a folder of drawings.1750 {CEL00000024}. He did not ask Mr Roome to review the drawings and advise whether the system was safe from a fire perspective.1751 {CEL00000024}. Mr Roome did not examine all the drawings, but simply selected two which showed the insulation.1752 Roome {Day70/21:11-21}; {Day70/22:7-22}; {CEL00000456}; {CEL00000457}. He did not note that the proposed cladding panels were not made of cementitious fibreboard, as used by Celotex in the BS 8414 tests on RS5000.1753 Roome {Day70/23:10-19}.
¶56.122 Jonathan Roome asked the Celotex technical team to make U-value calculations based on the drawings and sent the information back to Ben Bailey.1754 {CEL00000029}; At that time, it appears that the specific width of RS5000 was still under consideration in order to achieve the target U-value {CEL00000025}. He did not turn his mind to the nature of the rainscreen to be used at Grenfell Tower or to whether the construction was compliant with Approved Document B.1755 Roome {Day70/33:25}; {Day70/34:1-13}. He was only concerned to check the calculations made by Mr Anketell-Jones in September 2014 to support the target U-value.1756 Roome {Day70/34:4-6}. He said that either 200mm of RS5000 or 160mm of RS5000 would be required to produce U-values of 0.15 W/m2K and 0.18 W/m2K respectively.1757 {CEL00000025}; {CEL00000027}; {CEL00000028}.
167¶56.123 Mr Bailey replied eight minutes later attaching the calculations Daniel Anketell-Jones had made on 3 September 2014 following the design team meeting the day before.1758 {CEL00000030}. Mr Roome looked at them but did not appreciate that the proposed system contemplated the use of ACM rainscreen panels.1759 Roome {Day70/25:3-25}. No one at Harley expressly told Mr Roome that the rainscreen was to be Reynobond ACM1760 Anketell-Jones {Day36/114:11-14}. and it did not occur to him that the construction of the external wall might be different from that tested in May 2014.1761 Roome {Day70/17:18-25}.
¶56.124 The system tested in 2014 had contained 100mm of RS5000 and had been classified on that basis. There was no BR 135 classification in respect of a system that included any thickness of RS5000 other than 100mm.1762 {CEL00007961/3}. Mr Roome gave no consideration to the fact that Harley thought it was permissible to use 150mm of RS5000 as opposed to 100mm and did not turn his mind to the fact that the calculations based on 200mm or 160mm of RS5000 meant that the system proposed for Grenfell Tower would not be the same as that tested and would therefore not be covered by the BR 135 classification.1763 Roome {Day70/31:1-5}. He said that at the time he had thought that the test related to the individual components of the system and that the classification was valid regardless of the quantity of material used.1764 Roome {Day70/30:7-25}. If he thought that, he was wrong, but we do not think his evidence is reliable, not least because it is inconsistent with his earlier evidence and the very warnings in the Celotex literature that he well understood.1765 He contradicted his own evidence. Roome {Day69/52:1-9}.
Did Celotex tell Harley that RS5000 was safe to use on Grenfell Tower?
¶56.125 In the course of his evidence Ray Bailey repeatedly asserted that Celotex had told Harley that RS5000 was safe to use on buildings over 18 metres in height. Initially he said that Daniel Anketell-Jones had identified the warning in the Celotex marketing literature and that Harley had taken advice from Celotex about the suitability of RS5000.1766 Ray Bailey {HAR00010184/42} page 42, paragraph 170; Ray Bailey {Day33/82:7}-{Day33/83:3}. In the course of giving evidence he told us that Harley had sent details of the construction of the external wall to Celotex so that Celotex could confirm that the use of RS5000 was safe, although it did not expressly ask that question. He said he had thought that Celotex had in effect carried out a desktop study to compare the construction intended for use at Grenfell Tower with what had been tested.1767 Ray Bailey {Day33/76:16-21}. He also insisted that Celotex had confirmed that it was safe to use it in that way.1768 Ray Bailey {Day33/91:1-2}.
¶56.126 We do not accept Ray Bailey's evidence on that point. We doubt that he was deliberately seeking to mislead us; it is more likely that he had persuaded himself of the truth of a story he had told himself ever since the fire. We are satisfied, however, that Harley did not ask Celotex for a formal assessment of the kind he described and was not given one, let alone an unqualified assurance that RS5000 was suitable for use in the external wall construction proposed for Grenfell Tower, although it certainly allowed Harley to obtain that impression, and knew it. When pressed Mr Bailey himself accepted that he did not know whether Celotex had provided any such assessment.1769 Ray Bailey {Day33/78:4-10}. He knew that the classification report based on the BS 8414 test applied only to the system tested1770 Ray Bailey {Day33/85:18-21}. and he knew that that system differed from the system proposed for Grenfell Tower.1771 Ray Bailey {Day33/86:1}-{Day33/87:6}. It is hard to understand, therefore, on what basis he could possibly have thought that RS5000 was suitable for use in the external wall system at Grenfell Tower. For its own part, Harley cannot avoid responsibility for its own failures by blaming Celotex for not telling it what it should have known or discovered for itself.
168April 2015: further discussions
¶56.127 On 8 April 2015 Jonathan Roome sent BCA Technical Guidance Note 18, issue 0 to Daniel Anketell-Jones.1772 {CEL00003628}. Mr Anketell-Jones said that he had not previously seen it and had not read through it.1773 Anketell-Jones {Day36/147:16-18}. The additional information should have led him to look again at the documentation sent to him by Celotex in August 2014, but he did not do so.1774 Anketell-Jones {Day36/127:11-14}.
¶56.128 Jonathan Roome told us that he had thought at the time that Harley was adopting the desktop study route to compliance with the Building Regulations, as set out in Approved Document B.1775 Roome {Day70/80:21-24}. However, he had not seen any desktop study relating to the proposed external wall of Grenfell Tower, or any reference to one.1776 Roome {Day 70/81:2-14}. In fact, none existed and Mr Roome had no grounds for thinking that that was Harley's chosen approach. We do not accept that he formed any view at the time about how Harley intended to demonstrate compliance with the Building Regulations or that he cared. He suspected that Harley had either not read or not understood the warning in the Celotex marketing literature and pursued the sale regardless of the consequences.
The first order of RS5000 for Grenfell Tower
¶56.129 SIG was one of a small number of major distributors of Celotex and other insulation products1777 Roome {Day69/71:19-23}. and supplied RS5000 for use at Grenfell Tower. SIG invoiced Harley for its first order of RS5000 on 1 April 2015.1778 {SIG00000022}.
Grenfell Tower as a "case study"
¶56.130 On 8 April 2015, Jonathan Roome met Ben Bailey at Harley's offices.1779 {CEL00000039}; {CEL00001443}. By then the first batch of RS5000 had been delivered to site but installation had not yet begun. Mr Roome proposed that Grenfell Tower could be used as a case study because it was one of the first major projects in which RS5000 was being used on a building above 18 metres in height.1780 Harley agreed. {CEL00000039}; Roome {Day70/38:10-21}; {CEL00001443}; Roome {Day70/40:1-25}; {CEL00000558}; {CEL00000566}. Roome {Day70/41:19-23}, and the first project for Jonathan Roome. {Day70/43:4-7}. Ben Bailey thought that any case study would focus on the U-value which could be achieved using RS5000.1781 Ben Bailey {Day39/92:9-25}; {Day39/93:15-17}. Despite intending to publish a leaflet describing the product and its use on the tower, Mr Roome did not ask Mr Bailey what the rainscreen was to be.1782 Roome {Day70/41:1-10}. Ben Bailey knew that RS5000 had not been widely used before, but he did not realise that Grenfell Tower was being treated by Celotex as a flagship project for the use of the product, although the very suggestion that it be treated as a case study might have alerted him to that fact.1783 Ben Bailey {Day 39/93:12}-{Day39/94:15}.
169¶56.131 Kingspan K15 insulation was used in substitution for RS5000 on Grenfell Tower from time to time when Harley encountered problems with the supply of RS5000. It was used in much smaller quantities than RS5000, but the amount was not insignificant. Photographs indicate that it was certainly used on the west side of the tower,1784 {RYD00055130} showing west face where Kingspan logos can be seen on some insulation panels, and see Hughes {Day27/147:19}-{Day27/148:23}. but the precise locations where it was used are not known and cannot be established given that much of the insulation was consumed in the fire.
¶56.132 K15 was not included in the NBS Specification and no substitution of materials described in the Employer's Requirements or Contractor's Proposals was permitted without the prior written consent of the TMO. It was Rydon's responsibility to obtain that consent, but it failed to do so in relation to the substitution of K15 for RS5000.
The decision to use K15: March – September 2015
¶56.133 Although Studio E was in possession of a product datasheet for K151785 {SEA00001009}; Sounes {Day12/188:2-7}. and both Bruce Sounes and Neil Crawford were aware of the product, neither of them knew until after the fire that it had been used on Grenfell Tower.1786 Crawford {Day10/139:21}-{Day10/140:10}. Sounes {Day12/189:3-11}. They are not to blame for that, since they were never consulted about it, either by Harley or Rydon, and had no other means of knowing.
¶56.134 Harley was familiar with K15, having used it before on its Merit House1787 Ben Bailey {Day39/31:23}{Day39/32:3}; {Day39/142:11-14}. and Wayland House projects.1788 Ray Bailey {Day33/19:20}-{Day33/20:7}. On 4 March 2015, Mark Stapley of Harley sent SIG an email requesting a quotation for K15 for comparison purposes with RS5000.1789 {HAR00010030}. Quotation is at {HAR00009721}; {HAR00009722}; Ben Bailey {Day39/108:3-7}. Ben Bailey could not remember having talked to Mr Stapley about it; nor could he remember why Mr Stapley wanted a price for an alternative product.1790 Ben Bailey {Day39/104:10-18}. On 9 March 2015, he sent Mr Stapley an email to which he attached a leaflet relating to a different Kingspan insulation product.1791 {HAR00009643} attaching {HAR00009644}, a brochure for Kingspan OPTIM-R which made clear, on page 7, that K15 was suitable for use in buildings over 18 metres. One can see, therefore, that K15 and other products were being considered for use on the project as early as March 2015,1792 {HAR00009721}; Ben Bailey {Day39/108:3-7}. but no K15 was ordered at that time.
¶56.135 On 26 May 2015, Ms Walker of SIG sent an email to Ben Bailey explaining that a delivery of RS5000 that had been arranged for 3 June 2015 would be delayed until 10 June.1793 {SIG00000013/2}. Mr Bailey replied, asking whether SIG held K15 in stock at the same thickness.1794 {SIG00000013/2}. He told us that before receiving that email Ms Walker had told him that SIG had problems with obtaining products from Celotex and that in the course of their conversation Ms Walker had suggested K15 as an alternative,1795 Ben Bailey {Day39/110:23}-{Day39/111:23}; {Day39/113:18-21}. as being equivalent to RS5000.1796 Ben Bailey {Day39/109:11-20}.
170¶56.136 We accept that Harley decided to substitute K15 for RS5000 because of difficulties obtaining RS5000 on time,1797 The evidence of all the relevant Harley witnesses was that the substitution was motivated by supply chain issues: Ray Bailey {HAR00010184/29} page 29, paragraph 114; Ben Bailey {HAR00010060/8} page 8, paragraph 26; Ben Bailey {Day39/113:4-6}; Lamb {Day38/38:8-25}. but we do not accept that Mr Bailey had a telephone conversation with SIG of the kind he described. Mr Bailey's response to Ms Walker's email of 26 May ("Are you joking?!")1798 {SIG00000013/2}. conveys an immediate reaction, not one that followed a telephone call during which he had already been told about the delay. Moreover, if Ms Walker had discussed with him the suitability of K15 as an alternative, it is likely that she would have referred to it in her next email. We think it much more likely that the use of K15 as an alternative to RS5000 was suggested by Ben Bailey in his reply to Ms Walker. We do not accept that she told him at any time that K15 was an equivalent product to RS5000.
¶56.137 Ray Bailey told us that K15 had been investigated and approved for use on high-rise buildings in in 2010 or 2011 by Graham Hackley, who was then Harley's Technical & Estimating Manager1799 Ray Bailey {Day32/16:6-16}; {Day32/17:10-23}; {Day32/18:3-5}; {Day33/19:6}-{Day33/20:9}. It was signed off as being "for use pretty much on all projects" {Day33/100:2-5}; {Day33/100:10-11}. and that no further checks on its suitability had been made since it had received his approval.1800 Ray Bailey {Day33/30:2-3}; {Day33/99:6-10}. However, Mr Bailey conceded that there was nothing in the documents to support the conclusion that Mr Hackley had undertaken any such investigation or provided any such approval.1801 Ray Bailey {Day33/100:10-22}. In any event, Ray Bailey described K15 as a standard insulation product throughout the industry for tall buildings.1802 Ray Bailey {Day33/98:21-25}.
¶56.138 Ben Bailey was confident about using K15 because Harley had used it on other projects.1803 Ben Bailey {Day39/124:16-18}; {Day39/124:25}-{Day39/125:5}. He shared his father's understanding that K15 could be used on high-rise buildings1804 Ben Bailey {Day39/56:4-7}. and in combination with any rainscreen.1805 Ben Bailey {Day39/102:18-21}. He did not look at the LABC certificate1806 {KIN00016733}. Ben Bailey {Day39/126:2-5}. He was not aware of the LABC as a body {Day39/126:11-13}. or the relevant BBA certificate;1807 {KIN00000454}. The 2013 version. indeed, Harley had on file only the 2008 version of the BBA certificate, which by June 2015 was more than five years old and had been superseded.1808 {BBA00000038}. Ben Bailey did not know that the BBA certificate was out of date, a second certificate having been issued in 2013 {BBA00000036}; Ben Bailey {Day39/119:5-19}.
¶56.139 Ben Bailey's evidence was that following receipt of Ms Walker's email he had checked the U-values achievable by K15 and had looked at the 2008 BBA certificate or the product literature to check that it was rated Class 0, but no more than that. He said that he had made those enquiries in the office alongside Daniel Anketell-Jones and Mark Stapley.1809 Ben Bailey {Day39/117:6-11}; Ben Bailey {Day39/117:22-25}; {Day39/118:1-16}; {Day39/119:1-4}.
¶56.140 Daniel Anketell-Jones told us that he had not been aware that K15 had been used on Grenfell Tower,1810 Anketell-Jones {Day37/1:23}-{Day37/2:2}. which, if true, casts some doubt on whether Ben Bailey really did make the enquiries to which he referred. The first purchase order for K15 appears to have been sent to SIG within an hour of Ms Walker's initial email,1811 {SIG00000012}; {SIG00000013}; Ben Bailey {Day39/116:17-18}. so any research or investigation conducted by Ben Bailey must necessarily have been very limited. He did not consider whether the cladding system proposed for Grenfell Tower was the same as that which had included K15 and had apparently met the criteria in BR 135 following a test in accordance with BS 8414.1812 Ben Bailey {Day39/127:21-25}.
171¶56.141 Ray Bailey accepted that Harley had not investigated whether there was any test evidence which showed that K15 was of limited combustibility1813 Ray Bailey {Day33/102:17-25}. and agreed that Harley ought to have made further enquiries about the combustibility of K15 before using it on Grenfell Tower.1814 Ray Bailey {Day33/103:7-18}. There was nothing in the 2008 BBA certificate1815 {BBA00000038}. to confirm that K15 was a product of limited combustibility and nothing to indicate that it was appropriate for use in any configuration of cladding system. In short, the literature did not show that K15 was safe for use on Grenfell Tower.
¶56.142 Harley placed two orders for K15: 96 units with SIG on 26 May 20151816 {SIG00000012}; {SIG00000013}. and 49 units with CCF on 10 September 2015.1817 {CCF00000019}. Hugh Bailey, a project manager at Harley, asked CCF for a further 60 units on 10 September 2015, but no purchase order or invoice was raised in respect of that quantity.1818 {CCF00000015}.
¶56.143 Ben Bailey did not consider finding an alternative supplier for RS5000 because he thought it would take too long to open a credit account with a new supplier.1819 Ben Bailey {Day39/128:10-20}. He thought that the week-long delay to the supply of RS5000 was critical to the programme and Harley was under pressure from Rydon to keep up progress in accordance with the programme of works.1820 Ben Bailey {Day39/130:12-13}; {Day39/131:13-17}.
¶56.144 Ben Bailey said that in May 2015,1821 Ben Bailey {Day39/152:6-13}. he had spoken to Simon Lawrence or Simon O'Connor about the substitution of K15 for RS5000. He said that they had discussed the U-values of both products and the fact that they were both rated Class 0.1822 Ben Bailey {Day39/129:15-21}. Ben Bailey said that Mr Lawrence had understood the reason for the substitution and had agreed to it immediately.1823 Ben Bailey {Day39/152:14-21}. There had been no mention of the need to obtain Rydon's express consent.1824 Ben Bailey {Day39/129:22-25}.
¶56.145 The recollections of Mr Lawrence and Mr O'Connor differed substantially from that of Mr Bailey. They both said that they had been unaware of the use of K151825 Lawrence {Day24/138:22-23}; {Day24/139:1-21}; {Day24/148:1-10}; {Day24/148:12-18}; {Day24/149:2-20}; {Day24/151:20-21}; O'Connor {Day26/98:8-11}. and Mr Lawrence said that he had not been aware that Harley had ever sought permission for the use of K15.1826 Lawrence {Day24/150:3-12}. Mr O'Connor also said that he had not been aware of any discussions about a substitution.1827 O'Connor {Day26/110:10-13}; {Day26/111:10-14}. They accepted that Rydon had to obtain the TMO's permission before substituting any product specified in the NBS Specification and that Harley was obliged to obtain the written approval of Rydon before any alternative insulation product could be used in the external wall envelope.1828 {INQ00011211/8} condition 2.4.1; Lawrence {Day24/147:2-5}. Simon Lawrence accepted that obtaining consent from the TMO was his responsibility during his time on the project.1829 Lawrence {Day24/147:6-17}.
172¶Mr Lawrence, Mr O'Connor and Mr Blake of Rydon said that the usual course would have been to confirm compliance with the architect before obtaining the written consent of the client to the substitution.1830 Lawrence {Day24/156:11-14}; O'Connor {Day26/111:6-9}; Blake {Day29/116:11-18}; {Day29/116:19}-{Day29/117:11}.
¶56.146 Ben Bailey said that Mr Lawrence had agreed to the substitution immediately, but that was not something he was entitled to do. He knew that the suitability of any substitute would need to be confirmed by Studio E before receiving the consent of the TMO. In those circumstances, we think it unlikely that Mr Lawrence would have agreed to the use of a new product without alerting Mr Bailey to the need to refer the proposal to Studio E for comment. If there had been such a conversation we are confident that it would have been recorded, or at any rate mentioned in some way, in one of the contemporaneous documents, but there is no such record and in those circumstances we are unable to accept Mr Bailey's account. We are satisfied that Ben Bailey acted on his own initiative to substitute K15 for RS5000 in order to avoid a delay to the programme. Harley's previous use of the product had led him to believe that K15 was suitable for use on high-rise buildings in conjunction with any rainscreen system. That assumption was, however, wrong.
¶56.147 It is not clear to us why a delay of a week was thought to make a sufficient difference to justify using a product that had not been specified and had not been considered by the design team as a substitute for one that had been prescribed in the NBS Specification and had been used extensively on the project. We think that Ben Bailey, who was a young and inexperienced site manager, succumbed to pressure, actual or perceived, from the main contractor to keep up with the construction programme. He thought that K15 was essentially the same as RS5000 and in his mind there was no reason to think that it was unsafe.
The further use of K15: December 2015
¶56.148 In December 2015 or January 2016 David Hughes of Rydon discussed the use of a Kingspan insulation product with Ben Bailey who was again having difficulty obtaining RS5000.1831 Hughes {RYD00094213/10} page 10, paragraph 55. Mr Bailey had sent him the K15 product datasheet and he read it to check that the U-value that could be achieved with K15 was similar to that which could be obtained using RS5000.1832 Hughes {Day27/58:10-19}; {Day27/63:25}; {Day27/64:1-16}. He had described it as a "like-for-like" swap.1833 Hughes {Day27/58:21-25}; Ben Bailey's evidence was that it was "a common thought" within Harley that K15 and RS5000 were equivalent products: Ben Bailey {Day39/107:1-3}; {Day39/108:11-19}. Mr Hughes thought that Mr Bailey was asking his permission to use K15 in the future1834 Hughes {Day27/59:17-24}; {Day27/60:5-9}; {Day27/63:23-25}; {Day27/66:21-22}; {Day27/71:7-11}. and agreed that he could.1835 Hughes {Day27/71:23}-{Day27/72:1}. Shortly afterwards Mr Hughes told Stephen Blake and the clerk of works, Jon White, about the substitution.1836 Hughes {Day27/66:6-18}.
¶56.149 K15 had first been ordered and supplied in May 2015, at least seven months before Mr Hughes' conversation with Ben Bailey, and again in September 2015. Mr Hughes said he had no recollection of those orders and did not know that K15 had already been used on the tower.1837 Hughes {Day27/148:12-16}. It is therefore very difficult to understand why Mr Hughes should have been asking Mr Bailey about the suitability of K15 and, at least in his mind, giving Mr Bailey permission to substitute K15 for RS5000 when K15 had been used on two occasions some months earlier.1838 Ben Bailey's explanation was that the discussion had been prompted by a change in site management. Ben Bailey {Day39/136:18}-{Day39/137:25}. For his part, Mr Bailey did not recall giving Mr Hughes the datasheet on
173¶K15, or indeed any discussion with Mr Hughes about it.1839 Ben Bailey {Day39/136:1-11}.
¶56.150 Having considered all the evidence, we have come to the conclusion that Rydon did not become aware of the use of K15 until December 2015 or January 2016, long after it had first been installed on parts of the facade. However, photographs from September and November 2015 clearly show Kingspan insulation on the building1840 {RYD00051704}; {RYD00055130}. and Rydon could have noticed that, if it had bothered to look.
¶56.151 Stephen Blake told us that he had become aware that a quantity of K15 was being used on the building towards the end of the project1841 Blake {Day29/109:12-21}. and agreed that he had discussed the matter with David Hughes. He was not able to recall that conversation in any detail, however, or when it had occurred.1842 Blake {Day29/14:14-25}; {Day29/111:1-11}; {Day29/112:8-13}. Mr Blake said that Mr Hughes had told him that the Kingspan and Celotex products were equivalent and that he had accepted that.1843 Blake {Day29/111:13}-{Day29/112:3}. Mr Blake assumed that K15 was equivalent in every respect to RS5000 and did not take any steps to establish its suitability for use on the project.1844 Blake {day29/115:7-16}. In fact, he thought that Mr Hughes was describing the same material manufactured by different companies.1845 Blake {Day29/113:3-4}. He acknowledged that he ought to have checked for himself whether the products were essentially the same.1846 Blake {Day29/113:10-14}.
¶56.152 None of the Rydon witnesses had ever seen the LABC or BBA certificates for K15 and they did not investigate the suitability of K15 for use on Grenfell Tower.1847 {KIN00016733}; {KIN00000454}. Lawrence {Day24/155:4-8}; O'Connor {Day26/109:2-6}; Hughes {Day27/59:1-6}; Hughes {Day27/64:17-21}; Hughes {Day27/65:1-6}; Hughes {Day27/147:12-17}; Blake {Day29/114:17}-{Day29/115:16}. No one at Rydon consulted Studio E about the substitution; nor did Rydon take any advice from Exova or any other fire engineer to confirm that K15 was safe for the intended use. There was, therefore, a complete failure on Rydon's part to investigate the suitability of K15 for its intended use. After it had become aware that K15 was being used, Rydon relied on Ben Bailey's assurance that K15 was an equivalent product to RS5000, which everyone assumed was suitable.1848 Blake {Day29/118:14-18}; {Day29/119:9-10}; {Day29/119:22-24}.
¶56.153 Neither Mr Hughes nor Mr Blake consulted the TMO or informed building control that a substitution was going to be, or had in fact been, made.1849 Blake {Day29/117:13-17}; Hughes {Day27/67:5-8}; Hughes {Day27/67:17}-{Day27/68:8}. Mr Hughes thought that K15 and RS5000 were very similar and that the substitution did not make any difference.1850 Hughes {Day27/68:1-8}; Hughes {Day27/70:4-5}. Building control was not provided with any document which showed that K15 was being used as insulation and no attempt was made to obtain the TMO's consent to the substitution at that or any other stage.
175Chapter 57: Cavity barriers
Introduction
¶57.1 In this chapter we examine the use of cavity barriers on the Grenfell Tower refurbishment project, including the formulation of a cavity barrier strategy by Studio E and Harley and the installation of the cavity barriers themselves by Osborne Berry. We have concluded that none of the construction professionals gave adequate consideration to the use of cavity barriers at any stage of the design process. Moreover, it was also an aspect of the design that received scant attention from building control, either in the course of reviewing the drawings or during inspections on site. Although there were a number of detailed discussions between the design professionals about cavity barriers, none of them paid sufficient attention to the need for an overall strategy or gave sufficient consideration to the purpose of cavity barriers in preventing the spread of fire. As a result, cavity barriers were not installed in the correct positions and were entirely missing around the windows. In addition, many of the cavity barriers which were fitted were poorly installed.
¶57.2 Although the failure to ensure that cavity barriers were properly installed within the cladding probably had little effect on the ultimate development of the fire,1851 Grenfell Tower Inquiry Phase 1 Report, Chapter 23, paragraph 23.60. it demonstrates a worrying lack of attention to fire safety which we think it is important to record as part of our analysis of the events which led to the tragedy. Moreover, it is possible that the absence of cavity barriers around the windows played a part in enabling the fire to escape from Flat 16 and gain unrestricted access to the combustible insulation and ACM PE cassettes.1852 Grenfell Tower Inquiry Phase 1 Report, Chapter 22, paragraph 22.40. For those reasons we explain below how it came about that the cavity barriers at Grenfell Tower were so poorly designed and installed.
¶57.3 Two types of cavity barrier were used in the external wall at Grenfell Tower. The horizontal cavity barriers were "open state", meaning that they were designed to be installed with a gap between the face of the barrier and the rainscreen to allow the passage of air and moisture. On the edge of the barrier facing the panels was an intumescent strip that expanded to close the gap when exposed to heat. The vertical cavity barriers were described as "full fill", meaning that they consisted of a solid piece of material spanning the entire cavity, thus forming a permanent vertical barrier against the horizontal spread of fire.
Consideration of Cavity Barriers at or before RIBA Stage D
¶57.4 Although Studio E began talking to building control at an early stage in the project, there was no discussion about the cladding or the requirement for the installation of cavity barriers within the facade.1853 The first meeting with building control took place on 7 November 2012. Adrian Jess' email notes of that meeting dated 7 November 2012 {SEA00006526}; Sounes {Day21/132:23}-{Day21/133:3}; there was a further meeting on 17 September 2013 but, again, there was no focus on cladding or cavity barriers: Sounes {Day21/135:1-25}; Sounes {SEA00014273/129} page 129. There was no mention of cavity barriers or of the need to maintain compartmentation in Studio E's Stage D report1854 {SEA00008054}. dated 20 August 2013,1855 Sounes {Day21/76:16-19}. nor was there any reference to the installation of cavity barriers in any version of Exova's Outline Fire Safety Strategy, including Issue 3 dated 7 November 2013.1856 See Chapter 54.
176Tender documentation: August 2013 – January 2014
¶57.5 The first person at Studio E to give any serious consideration to the need for cavity barriers was Tomas Rek. He had been asked to develop the NBS Specification and tender drawings to send to potential contractors.1857 Rek {Day12/11:17-20}. Part of that task involved revising the existing tender drawings to show the location of cavity barriers.1858 Rek {Day12/98:4-6}.
¶57.6 Although some preliminary design work on cavity barriers had been undertaken before September 2013, it was limited. Mr Rek could not recall the extent of the work that had already been done but said that the NBS Specification had not been completely blank when he started working on it.1859 Rek {Day12/12:7-17}. Mr Sounes' belief was that Studio E had done some work on cavity barriers between December 2012 and June 2013.1860 Sounes {Day21/77:5-21}.
¶57.7 At the time of his work on the tender documents, Tomas Rek was aware of Diagram 33 in Approved Document B, which set out the requirements for cavity barriers in specified locations,1861 Rek {Day12/94:7-15}. but could not remember whether he had reminded himself of it at the time.1862 Rek {Day12/95:6-7}. Although Bruce Sounes, who was supervising him, was aware of the guidance in Approved Document B he did not review Diagram 33 at any stage.1863 Sounes {Day21/70:22}-{Day21/71:3}; {Day21/71:16}-{Day21/72:3}.
¶57.8 The tender pack which Studio E prepared to send to potential contractors included several drawings depicting the "Employer's Requirements", which set out the basic principles of the design. Between 24 and 25 September 2013 Mr Rek revised one of the drawings1864 Studio E's drawing entitled "Employer's Requirements - Proposed Typical Bay Plans, Section & Elevation"; Rek {Day12/107:20}-{Day12/108:5} to show cavity barriers and their locations. The original version of the drawing (dated 24 September 20131865 {SEA00002155} with Studio E reference 1279 (06) 110 Rev 00.) contained a label which read, "Provision of cavity fire barrier TBC". The version produced by Tomas Rek the following day, 25 September 2013,1866 {SEA00002163} with the same Studio E reference. contained some information about the location of cavity barriers. In particular: a. Hatching had been applied to the Proposed Plan and Proposed Section drawings showing where cavity barriers were to be placed.
¶b. Cavity barriers were shown along the line of compartment floors, in particular, i. The sections entitled "Proposed Plan – Cill Level" and "Proposed Plan – Window
177Level" had annotations reading, "Cavity fire barrier in line with compartment wall structure. Leave no gap to cladding."
ii. The section entitled "Proposed Section – Typical Bay" contained annotations reading, "Ensure horizontal and vertical cavity barriers meet tightly" and "Cavity fire barrier in line with compartment floor structure. Leave max 25mm gap to cladding for ventilation and drainage."
¶c. Cavity barriers were not shown around the windows. Mr Crawford accepted that Studio E's cavity barrier strategy did not require the installation of cavity barriers around the windows.1867 Crawford {Day10/192:1-5}.
¶57.9 Although the drawing contained some unlabelled hatching next to the window reveal, Mr Rek was not sure whether he had intended to specify a cavity barrier in that position; the hatching was not labelled as such (unlike other cavity barriers shown in the drawing) and he accepted that a subcontractor looking at the drawing would not have interpreted the hatching as a cavity barrier in the absence of some other indication that that was intended.1868 Rek {SEA00014278/30} page 30, paragraph 126; Rek {Day12/110:2-4}; {Day12/112:1}-{Day12/113:2}. In our view, on a fair reading of the drawing it did not clearly indicate a cavity barrier in that position.
¶57.10 Neither Mr Sounes nor Mr Rek could remember what had been the source of the information about the location of cavity barriers that had been used to create those drawings.1869 Sounes {Day21/83:8}-{Day21/84:6}; Rek {Day12/100:14-23}. Mr Rek was unable to recall any discussions when he revised the drawings1870 Rek {Day12/108:19-21}. but said that it had been his practice to discuss drawings with Mr Sounes when he made any material changes.1871 Rek {Day12/108:7-10}. Mr Sounes recalled Mr Rek's having told him that he had consulted others who had specialist knowledge about such things, but he could not remember the names of any particular individuals or companies he had contacted.1872 Sounes {Day 21/82:17}-{Day21/83:3}; {Day21/73:20}-{Day21/74:6}. There is no record of any such conversations and we think it unlikely that any took place.1873 Sounes {Day21/83:4-7}.
¶57.11 The drawings that Tomas Rek revised were at 1:20 scale and he was not asked to produce more detailed drawings at a 1:5 scale. He accepted in his evidence that drawings on a 1:5 scale would have clearly shown where cavity barriers were to be located.1874 Rek {Day12/115:7-15}.
¶57.12 On 1 November 2013, Tomas Rek sent an email to Terence Ashton of Exova asking him to confirm that the rainscreen cavity barriers should have 60 minutes' fire resistance to match that of the compartmentation.1875 {EXO00000586/1}. He did not ask Mr Ashton where cavity barriers ought to be placed or send him any drawings showing where he proposed to place them. A few days later Mr Ashton replied, saying that cavity barriers needed to have only 30 minutes' fire resistance.1876 {EXO00000586/1} dated 4 November 2013. Mr Rek did not recall having spoken to Mr Ashton about the positioning of cavity barriers1877 Rek {Day12/105:3-7}. and although Mr Sounes thought that the guidance in Section 9 of Approved Document B was unclear, he did not seek advice or assistance from Exova.1878 Sounes {Day21/81:2-20}.
¶57.13 At no point did Studio E produce detailed drawings of typical elevations or sections for use at tender stage showing precisely where cavity barriers were to be positioned.1879 Sounes {Day21/84:20-24}.
178¶57.14 The tender drawings were accompanied by the NBS Specification, which contained details of the types of cavity barriers to be installed in the horizontal and vertical positions.1880 In section P10 "Sundry insulation/ proofing work" at Clause 435. All three versions of the NBS Specification (21 November 2013 {SEA00000152/263}, 29 November 2013 {RYD00001712/245} and 30 January 2014 {SEA00000169/246}) contained the same clause 435 in Section P10 in respect of ventilated cavity barriers. Although there was an inconsistency in the specification, one part requiring 60 minutes' integrity and insulation and another only 30 minutes' integrity and insulation,1881 The products specified were "Lamatherm CW-RSH60" and "Lamatherm CW-RSV60" which could have been interpreted as a reference to 60 minutes' integrity. However, the clause also stated: "Fire resistance rating: 30/30 to BS 476, Part 20:1987 and BS EN 1366-4:2006. See also the witness statement of Stephen Swales (Siderise) which sets out the coding conventions for Siderise cavity barriers at the time. Swales {SIL00000306/9-10} pages 9-10, paragraph 38. both exceeded the minimum requirement in Approved Document B of 30 minutes' integrity and 15 minutes' insulation.1882 Table A1 of Approved Document B: {CLG00000224/125}.
Studio E drawing design after tender
¶57.15 Studio E did not revise its drawings in relation to cavity barriers after the invitation to tender had been issued on 29 November 20131883 This was done by email to Studio E on 29 November 2013 {SEA00010081}. Five main contractors were invited to tender: Mullaley, Durkan, Keepmoat, Rydon, and Wates. and as a result Harley based its design for the facade on the tender drawings.1884 Lamb {HAR00010419/5} page 5, paragraph 22. Studio E continued to be involved in the project until Harley began its detailed design work in late August 2014,1885 Lamb {HAR00010419/6} page 6, paragraphs 22-24. but there is no evidence that it carried out any further work on the cavity barrier strategy during that time.
Harley's initial design
¶57.16 Harley's design work started in earnest after Kevin Lamb was appointed on 12 August 2014.1886 {HAR00010418}. Mr Lamb said that he had based his work on the plans, sections and elevations produced by Studio E for the key aspects of the external facade.1887 Lamb {HAR00010419/5} page 5, paragraph 20. He also made use of a set of preliminary drawings of a typical window detail prepared by Samuel Anketell-Jones and Ray Bailey before his involvement. They did not show any cavity barriers.1888 {HAR00010432}.
¶57.17 Kevin Lamb accepted that the requirements of the NBS Specification relating to cavity barriers took precedence over the tender drawings.1889 Lamb {Day38/123:22}-{Day38/124:21}. The NBS Specification required compliance with Approved Document B and the Standard for Systemised Building Envelopes published by the Centre for Window and Cladding Technology (CWCT).1890 Dated September 2008 {CWCT0000046}. Both documents clearly called for cavity barriers around windows.1891 Approved Document B at {CLG00000224/83} paragraph 9.3; {CLG00000224/96} paragraph 12.8; the CWCT Standard {CWCT0000046/14} section 6.4.4.2 under the heading "Cavities in rainscreen walls".
¶57.18 On 22 August 2014, Kevin Lamb produced some preliminary drawings to establish the basic principles of the design which he sent to Simon Lawrence of Rydon and copied to Studio E and Daniel Anketell-Jones of Harley.1892 {HAR00010426}. Those drawings did not indicate where cavity barriers would be placed within the facade.1893 {RYD00016100}. Neil Crawford commented on the drawings on 27 August 20141894 {HAR00010423/2}. but did not draw attention to the absence of cavity barriers.1895 Crawford {Day10/185:2-5}. He could not recall having raised the absence of cavity barriers with Harley at that time.1896 Crawford {Day10/185:11-14}.
179¶57.19 Mr Crawford provided further comments on Harley's drawings on 3 September 2014 following a design team meeting1897 {HAR00010413}. but did not refer to the absence of cavity barriers.1898 {HAR00010423/2}; {HAR00012086}. On 12 September 2014, he confirmed that he had no further comments to make.1899 {HAR00010423/1}.
The Request for Information
¶57.20 On 17 September 2014, for reasons which remain unclear, Daniel Anketell-Jones sent a formal Request for Further Information to Rydon and Studio E, with a copy to Kevin Lamb, seeking instructions on the provision of horizontal cavity barriers within the area of the cladding.1900 Email dated 17 September 2014 {HAR00003638/4}; RFI attachment {EXO00001291}. He suggested that cavity barriers were required at every floor level on the vertical columns, but not in the area between the windows because there was no "chimney" effect there so the cladding would not exacerbate the spread of fire.
¶57.21 On 18 September 2014 Mr Crawford sent the request on to Mr Ashton at Exova asking for his comments.1901 {HAR00003638/4}. In response, Mr Ashton asked for a set of drawings, which were provided to him by Mr Crawford, who told him that they represented an attempt to establish the basic approach.1902 Email: {HAR00003638/3}; Studio E Drawings attached: {EXO00000710}; {EXO00000711}; {EXO00000712}; Harley Drawing attached: {EXO00000713}. They included a drawing produced by Harley, which did not show any cavity barriers,1903 {EXO00000713} Title: Typical Bay Levels 1 to 20 West Elevation Reference: C1059-200, drafted by Kevin Lamb and dated 20 August 2014; Crawford {Day10/82:13-20}. and drawings produced by Studio E,1904 {EXO00000710}; {EXO00000711}; {EXO00000712}. which showed cavity barriers around each flat but not around the window frames.
¶57.22 Mr Ashton's response was that if the insulation in the cavities was combustible it would be necessary to provide cavity barriers in order to prevent fire from spreading from one flat to the flat above. That advice was wrong, however, because cavity barriers were required regardless of the nature of the insulation.1905 Ashton {Day18/39:1-18}. Mr Anketell-Jones did not ask Mr Ashton why cavity barriers were required only if the insulation was combustible1906 Anketell-Jones {Day36/162:4-8}. and Mr Ashton did not comment on the absence of cavity barriers from Harley's or Studio E's drawings.
¶57.23 Later that same day, Mr Crawford sent Mr Ashton's response on to Mr Anketell-Jones with copies to Simon Lawrence, Simon O'Connor and Kevin Lamb.1907 {HAR00003638/2}. In response, Mr Anketell- Jones asked Mr Ashton to confirm his own view that since the insulation was rated Class 0, a "fire barrier" was not required between the windows and attached the datasheet for Celotex RS5000.1908 {HAR00012104}. Simon Lawrence did not pay much attention to the exchange because he expected Harley to carry out the design work and Studio E to check it before it was referred to building control1909 Lawrence {Day24/124:4-13}. for approval.1910 Lawrence {Day24/123:17-22}.
180¶57.24 Mr Ashton replied to Mr Anketell-Jones on 18 September 2014 without having looked at the datasheet.1911 Ashton {Day18/46:15-23}; {Day18/47:3-19}; {Day18/49:1-8}; {Day18/55:6-8}. He pointed out that a material that had a Class 0 rating was not necessarily non-combustible, although the reverse was invariably true. He said that it was not clear from the information he had been given whether there was a continuous cavity from top to bottom in any part of the cladding, thereby inviting him to provide further information.1912 {HAR00003638}. Mr Anketell-Jones sent Mr Ashton's email on to Mr Crawford the same day asking him for his view on Mr Ashton's comments about combustibility and continuous cavity paths.
¶57.25 The matter was allowed to rest there, however. Mr Ashton did not chase Mr Anketell-Jones for further information1913 Ashton {Day18/59:5-22}. and Mr Anketell-Jones did not pursue the matter with either Mr Crawford or Mr Ashton.1914 Anketell-Jones {Day36/167:22-24}.
Harley's work on the design of the windows: September 2014–March 2015
¶57.26 On 22 September 2014 Kevin Lamb sent Simon Lawrence a set of drawings for final approval reflecting comments made by Studio E at their previous meeting.1915 {SEA00011759}; Attached drawings at {RYD00018436}. None of them contained any details of cavity barriers.1916 {RYD00000431}. Although both Bruce Sounes1917 On 22 September 2014 {RYD00018537}. and Neil Crawford1918 On 24 September 2014 {RYD00018687}. both commented on the design of the windows, neither of them referred to the absence of cavity barriers around the windows. Mr Lamb expected details of the cavity barriers to be provided at a later date,1919 Lamb {Day38/89:4-7}. so he could not have considered the drawings to be final.
¶57.27 Mr Lamb issued a revised set of drawings on 14 January 2015,1920 {RYD00027692}; Attached drawings at {RYD00027693}; {RYD00027694}; {RYD00027695}; {RYD00027696}; {RYD00027697}; {RYD00027698}; {RYD00027699}; {RYD00027700}; {RYD00027701}; {RYD00027702}; {RYD00027703}; {RYD00027704}. all of which were marked as "Approved for Construction" although they did not show any cavity barriers. No one in the design team at Harley noticed the omission, possibly because Harley did not have a fully effective procedure for reviewing the status or progress of the design at particular points in the life of the project or for reviewing the design as it developed. Mr Lamb was not directly supervised1921 Anketell-Jones {Day36/176:4-23}. and he confirmed that no one had checked the revised drawings before they had been issued.1922 Lamb {Day38/90:6-12}.
181¶57.28 Despite the fact that the drawings were marked as having been approved for construction, on 16 January 2015 Mr Crawford responded with his comments.1923 {SEA00012531}; Annotated drawings at {SEA00003040}. They had been marked using Studio E's stamp as being either "Status A: Conforms to Design Intent" or "Status B: Conforms to Design Intent subject to incorporation of comments. Revise and resubmit for Category A status." No mention was made of cavity barriers.1924 Lamb {Day38/92:5-7}; Crawford {Day10/196:13}-{Day10/197:2}; {Day10/197:15-22}. Although Mr Lamb said that there had been discussions within the design team in relation to cavity barriers, he was certain that he had never discussed the detailed guidance in Approved Document B on where cavity barriers ought to be placed to comply with functional requirement B4.1925 Lamb {Day38/92:16}-{Day38/93:9}.
The fire at Taplow House
¶57.29 On 16 January 2012 a fire occurred in a flat on floor 17 of Taplow House, part of the Chalcots Estate in Camden.1926 Ray Bailey {HAR00010184/4} page 4, paragraph 15. The facade had been installed by Rydon and Harley using mineral wool insulation (probably Rockwool) and riveted Reynobond PE 55 rainscreen panels.1927 Ray Bailey {Day33/141:13-20}; {Day33/60:15-25}. Timothy Lovell of Harley inspected the building on 17 January 2012 and prepared an initial incident report, which was distributed to Ray Bailey and Daniel Anketell- Jones, amongst others.1928 {HAR00010169}. In it he recorded that, despite the fire and the amount of flammable items in the flat, the fire breaks had still been intact and had prevented the fire spreading between flats.1929 {HAR00010169/4}. Above that paragraph was a photograph showing a "fire break" at the head of the window, although Ray Bailey thought that it was in fact a firestop rather than a cavity barrier.1930 Ray Bailey {Day33/143:20-25}.
¶57.30 Mr Lovell made a further inspection on 18 January 2012 and set out his findings in a report dated 23 January 2012, copies of which were given to Stephen Blake at Rydon, Ray Bailey and Daniel Anketell-Jones, amongst others.1931 {CEP000003223}. The report again drew attention to the containment of the fire by "fire breaks" located at the head and sill of each window.1932 {CEP000003223/2-3}. Mr Anketell-Jones said that he had not been aware that "fire breaks" had played an important part in preventing the spread of fire and did not recall anyone at Harley discussing the importance of cavity barriers or firestopping around windows following that fire.1933 Anketell-Jones {Day35/149:1-8}. He confirmed that, when Harley came to design the facade of Grenfell Tower, the fire at Taplow House appears to have been forgotten.1934 Anketell-Jones {Day35/149:14-19}. Ray Bailey accepted that Harley's failure to implement the lessons from Taplow House was an error.1935 Ray Bailey {Day33/146:11-16}.
¶57.31 Stephen Blake of Rydon agreed that the use of cavity barriers around the windows of Taplow House had been a critical factor in preventing the spread of fire.1936 Blake {Day29/126:25}-{Day29/127:8}. He also agreed that he had first-hand knowledge of the importance of cavity barriers around windows,1937 Blake {Day29/127:17-19}. but despite that, he did not think it necessary to check with Studio E or Harley that proper cavity barriers had been included in their designs.1938 Blake {Day29/130:3-10}.
182¶57.32 The experience at Taplow House ought to have made clear to Harley (and to a lesser extent, Rydon) the importance of installing fire protection measures around the windows at Grenfell Tower. But Harley and Rydon did not bear those lessons in mind when considering the design in the areas surrounding the windows of Grenfell Tower. Ray Bailey accepted that it was a mistake not to have done so.1939 Ray Bailey {Day33/146:11-16}.
March 2015 emails
¶57.33 On 3 March 2015, Kevin Lamb sent a set of drawings to Rydon which had been revised to include cavity barriers.1940 Email {SEA00012850} sent to Simon Lawrence, copying Neil Crawford, Bruce Sounes, Daniel Anketell-Jones, Mark Stapley, Mr Robert Maxwell and Mr Ben Bailey. Drawings attached: Specification Notes C1059-100 Rev A {SEA00000256}; Drawing Register {SEA00012855}; Typical Bay Levels 1 to 20 South Elevation C1059-202 Rev C {SEA00012851}; Typical Bay Levels 1 to 20 West/East Elevation C1059-201 Rev D {SEA00003155}; Typical Bay Levels 1 to 20 East & West Elevation C1059-200 Rev I {SEA00003156}; Jamb Joint Upper Levels and Typical Joint Upper Levels C1059-305 Rev C {SEA00012856}; and, Window Head Upper Levels C1059-301 Rev E {SEA00012857}. He also sent copies to various persons in Harley. Mr Lamb said that he had included cavity barriers in the drawings because the cladding was going to be installed soon and so completing the design had become urgent.1941 Lamb {Day38/97:5-14}. Mr Lamb had looked at some industry guidance in relation to cavity barriers,1942 Lamb {HAR00010419/13} page 13, paragraph 50 gives the following list of the guidance Mr Lamb recalls consulting: Approved Document B, the Centre for Window and Cladding Technology ("CWCT") Standard for Systemised Building Envelopes Part 6 – Fire Performance, the CWCT Technical Note 73 and Siderise technical literature. but only to find out what rating was required, rather than to where they should be placed.1943 Drawings 200 {SEA00003156}; 201 {SEA00003155}; 202 {SEA00012851}; 301 {SEA00012857}; 305 {SEA00012856} Lamb {HAR00010419/13} page 13, paragraph 50; Lamb {Day38/99:3-8}.
¶57.34 Each of the drawings bore a revision date of 3 March 2015. Cavity barriers were marked as broken lines surrounding compartments and were labelled as "firebreaks". Mr Lamb said that "firebreak" was a generic term and that at the time of his work on the Grenfell Tower refurbishment project he would probably not have used the term "cavity barrier".1944 Lamb {Day38/100:8-12}. There were no cavity barriers shown immediately around the heads, sills or jambs of the windows.1945 Lamb {Day38/101:7-10}. Mr Lamb's explanation for their absence was that Studio E's drawings and Harley's instructions were to show cavity barriers only around the compartment.1946 Lamb {Day38/102:4-10}. The positioning of horizontal cavity barriers above the windows and supposedly in line with compartment floors was different from that which had been shown at the tender stage by Studio E.1947 The Employer's Requirements - Proposed Typical Bay Plans, Section & Elevation drawing {SEA00002163}. Studio E's drawings showed a cavity barrier immediately at the head of the window, whereas Harley's drawings showed it at some distance from the head of the window in the spandrel section.1948 Lamb {Day38/102:11-21}. That change was never expressly brought to Studio E's attention, despite Mr Lamb's acceptance that it was a development of the design made by Harley.1949 Lamb {Day38/110:15-20}; {Day38/111:13-15}.
¶57.35 The detail of the window head1950 Harley drawing 301 {RYD00000220}. showed a horizontal cavity barrier at some remove from the window frame, marked with honeycomb hatching and labelled "Firebreak cut around cladding rails. All joints taped on top face." When he gave evidence Mr Lamb suggested that the cavity barrier was positioned above the head of the window because the window hung down below the structure and the concrete did not provide a flat surface.1951 Lamb {Day38/104:9-23}. However, he conceded that something would have to be added if the cavity barrier were positioned above the head of the window as he had suggested.1952 Lamb {Day38/106:12-18}. Mr Lamb never considered how the integrity of the horizontal cavity barrier would be maintained if it were cut to fit around the vertical cladding rail1953 Lamb {Day38/112:8-13}. and he gave no thought to whether the gaps created by the cladding rails should be filled to maintain the integrity of the cavity barriers.1954 Lamb {Day38/151:7-17}; {Day38/152:6-8}.
183¶57.36 On 3 March 2015, shortly after he had sent the drawings to the design team,1955 Lamb's email to the design team {SEA00012850} was timed at 12:58. His email to Carrick was at 13:06. Kevin Lamb sent an email to Barnaby Carrick, the Technical Applications Engineer at Siderise seeking his advice on using the horizontal barriers in a cavity which was wider than the maximum dimension shown in Siderise's literature.1956 {HAR00004013} the cavity was 316mm which was wider than the maximum cavity of 300mm shown by Siderise. Mr Carrick replied the same day,1957 {HAR00004013}. confirming that the information that Mr Lamb had provided was consistent with Siderise's recommendations and that the proposed cavity barrier fell within their standard test data.1958 The void size was less than 325mm and a 25mm air gap was present. He also confirmed that the fixing details shown in Harley's drawings1959 Drawing C1059-305 {HAR00009737}. were acceptable. Mr Lamb did not ask Siderise for any further advice on the cavity barrier strategy.1960 Lamb {Day38/95:10-15}.
¶57.37 Neil Crawford responded to Kevin Lamb's email on 6 March 2015.1961 {SEA00012906}. He confirmed that he had sought advice from Exova, but that his own interpretation was that the fire rating of the cavity barriers would have to follow that of the adjacent walls. He attached the Fire Strategy drawing.1962 {SEA00003101}. Bruce Sounes confirmed that he had not looked at the drawings that Mr Lamb or Mr Crawford had sent him as, by that stage, although he was still nominally leading the design team, Mr Crawford was "fronting it".1963 Sounes {Day21/90:13-25}. When he commented on Harley's revised drawings1964 {SEA00003160}. Mr Crawford did not draw attention to the absence of cavity barriers around the windows as, according to him, the strategy had been simply to have cavity barriers at the junctions between compartments.1965 Crawford {Day11/2:20-25}; {Day11/3:1-5}. Similarly, Mr Crawford did not comment on Harley's note that the cavity barrier was to be cut around the cladding rail because he regarded it as a specialist item and he expected Harley to know what it was doing.1966 Crawford {Day11/6:1-9}.
¶57.38 On 11 March 2015 Kevin Lamb sought further advice from Siderise about the rating of the cavity barriers.1967 Email from Mr Lamb to Mr Carrick dated 11 March 2015 {HAR00003999}. He did not ask where to place the barriers as, in his mind, it was clear where they were going to go and their positioning had been approved in discussions with Harley.1968 Lamb {Day38/118:11-22}. Christopher Mort (Technical Officer for Fire at Siderise) replied on 12 March 20151969 {SIL00000038}. advising that to meet the guidance in Approved Document B the area between the compartment wall and outer cladding needed only to be a cavity barrier (not a firestop) with just 30 minutes' integrity and 15 minutes' insulation. He included in his message a copy of Diagram 33 of Approved Document B,1970 {SIL00000038/7}. which showed cavity barriers around the windows and contained a label reading "Close around openings" with arrows pointing to the top and bottom of the window.1971 {BSD00001779}.
184¶57.39 Mr Mort did not give Mr Lamb any advice about the risks associated with using cavity barriers in a rainscreen system.1972 Mort {Day103/16:19}-{Day103/17:10}. Nor did he provide any information about the limitations of the testing that Siderise had carried out on its cavity barriers.1973 Mort {Day103/17:11-24}. Despite having Diagram 33 expressly drawn to his attention and himself noticing that cavity barriers were marked around the windows, Kevin Lamb took no steps to revise the cavity barrier strategy for Grenfell Tower.1974 Lamb {Day38/120:4-24}.
¶57.40 On 18 March 2015, Ben Bailey sent an email to Neil Crawford telling him that Siderise had given advice about the required rating of the cavity barriers that differed from that received from RBKC building control.1975 {SEA00012953} The email was copied to Daniel Anketell-Jones, Mark Stapley, Robert Maxwell, John Hoban, and Kevin Lamb. Shortly afterwards, Mr Crawford spoke to Mr Hoban, who, on 20 March 2015, sent him an email informing him that the fire rating for any new elements of structure (including the cavity barriers) should be 120 minutes' insulation and integrity and drawing attention to Diagram 33.1976 {RBK00048734}. Mr Hoban was unable to recall the content of his conversation with Mr Crawford.1977 Hoban {Day46/112:10-14}.
¶57.41 On 25 March 2015, Mr Lamb sent revised versions of Harley's drawings1978 Harley drawings 100 {HAR00017787}, 301 {HAR00008901}, 304 {HAR00017785}, 305 {HAR00017784}, 325 {HAR00017783} and 326 {HAR00017782}. to Simon Lawrence with copies to members of the design team.1979 {HAR00017781}. Bruce Sounes, Neil Crawford, Daniel Anketell-Jones, Mark Stapley, Ben Bailey and Robert Maxwell were copied in. The drawings contained revised details of the "firebreaks", the ratings of which had all been increased to 120 minutes' integrity and 60 minutes' insulation.
¶57.42 Following a discussion they had had the day before, on 26 March 2015 Ben Bailey sent an email to Richard Kay, National Facades Manager at Siderise, asking him to identify the regulations which supported Siderise's opinion that cavity barriers with 30 minutes' integrity and 15 minutes' insulation were all that was required.1980 {HAR00004002/3}. He asked Mr Kay to do that because he was not familiar with them himself and was wholly dependent on Siderise for advice.1981 Ben Bailey {Day40/61:21}-{Day40/62:3}. Mr Kay replied the following day, copying in Kevin Lamb and others at Harley.1982 {HAR00004002/2}. He included in his email an extract from Approved Document B1983 Table A1 from Appendix A. which showed that 30 minutes' fire integrity and 15 minutes' insulation were recommended. Mr Bailey was unable to recall the conversation he had had with Mr Kay.1984 Ben Bailey {Day40/61:1-5}.
¶57.43 Ben Bailey forwarded that email to Simon Lawrence and Simon O'Connor on 26 March 2015 with the comment that there was quite a large difference in cost between the cavity barriers that Siderise had recommended (and the project specification required) and the 120 minute cavity barriers suggested by building control.1985 {RYD00037117/2}. According to Neil Crawford, there was pressure from those on site not to specify cavity barriers with 120 minutes' fire resistance due, at least in part, to the additional cost and delay that might be caused.1986 Crawford {Day11/45:1-10}.
185¶57.44 Subsequently Neil Crawford referred the question of the rating of the cavity barriers back to Mr Hoban.1987 {HAR00003947/7}. On 27 March 2015, he sent the email from Siderise to Mr Hoban and asked him to review the position. However, Mr Hoban adhered to his original view and Mr Crawford reported that to the design team later that day.1988 {RYD00037117}.
¶57.45 On 27 March 2015 Ray Bailey sent an email to Simon Lawrence, Neil Crawford and Ben Bailey with copies to Simon O'Connor, Kevin Lamb and Daniel Anketell-Jones, explaining the difference between a firestop and a cavity barrier.1989 {RYD00037117}. Ray Bailey did not comment on the absence of cavity barriers around the windows in the drawings produced by Harley.
¶57.46 Later the same day Ray Bailey sent the exchange to Daniel Anketell-Jones for his comments.1990 {HAR00006585}. Mr Anketell-Jones replied:
"Just that it's ridiculous. There is no point in 'fire stopping', as we all know; the ACM will be gone rather quickly in a fire! The whole point is to stop 'unseen' fire spreading in the cavity and moving to other parts of the building."1991 {HAR00006585}.
¶We have considered that exchange in Chapter 55 where we have set out our conclusions on the choice of ACM PE rainscreen panels for use on Grenfell Tower. Mr Anketell-Jones accepted that in his email he had been expressing an opinion about the risk of fire spreading within the cavity unseen and how that affected the cavity barrier strategy,1992 Anketell-Jones {Day37/22:2-16}. but that did not lead him to think about the importance of preventing fire from spreading from a compartment into the cavity in the first place.1993 Anketell-Jones {Day37/27:9-14}.
¶57.47 On 30 March 2015 Neil Crawford sent another email to Mr Hoban, recommending that he speak to Ben Bailey,1994 {HAR00003947/7}. but he did not check whether Mr Hoban had spoken to Mr Bailey or anyone else at Harley.1995 Crawford {Day11/52:3-7}. Neither Mr Hoban nor Mr Bailey was able to recall whether a conversation had taken place.1996 Hoban {Day46/119:10-17}; Ben Bailey {Day40/70:24}-{Day40/71:15}.
¶57.48 Shortly after,1997 Mr Crawford's email suggesting Mr Ashton contact Mr Bailey was at 12:49. Mr Hoban's response was at 14:22 on the same day. on 30 March 2015, Mr Hoban replied to the project team and Mr Kay of Siderise setting out his view.1998 {EXO00000715/2}. He referred to his email of 20 March 2015 and said that in his view Diagram 33 of Approved Document B required a firestop with 120 minutes' resistance between compartment floors.
186¶57.49 The repeated references to Diagram 33 throughout the email exchanges leaves little room for doubt that all the construction professionals involved either knew or ought to have known that a cavity barrier strategy in accordance with that diagram was required, but regrettably it appears to have been ignored.
The "weak link"
¶57.50 On receipt of Mr Hoban's email of 30 March 2015, Mr Kay asked Harley to send him drawings of the build-up of the cladding so that his technical officer could evaluate the position and provide a formal response.1999 {HAR00003947/4-5}. In response Ben Bailey sent him two drawings2000 Drawing 300 showing a section of the windowsill and Drawing 301 showing a section of the window head {HAR00019402} and {HAR00019403}. with copies to Mr Mort.2001 {HAR00019401}. Mr Kay had also asked for a section drawing through the whole window to give to Mr Mort for comment,2002 As shown on Mr Mort's annotated drawing as "C-C": {RYD00037413}. but Ben Bailey was unable to provide that drawing. That struck Mr Mort as odd, because he would normally have expected to see a full section which clarified the window details.2003 Mort {Day103/29:15}-{Day103/30:13}.
¶57.51 Mr Mort replied the same day.2004 {HAR00018971}. He said:
"I have reviewed the drawings sent over and sketch a proposal to alleviate the issues raised by the BCO, also on the second page of the attachment I have highlighted the weak link so to speak in terms of fire and I think the [building control officer] would have also noticed this. The proposal requires the installation of RH25g 90/60 product in two layers one at the head of the window aligning with the compartment floor and the other at the top of the existing up stand, therefore two layers of 60 minutes protection that overall would provide if tested over 120 minutes protection, at the window locations…"
¶57.52 Mr Mort confirmed that he had prepared two sketches, one to show the proposed solution to increase the fire resistance of the cavity barriers to 120 minutes2005 {HAR00003948}. and one to identify what he called a "weak link" for fire at the head of the window.2006 {HAR00003948/2}. According to him, they were distinct sketches with distinct purposes.2007 Mort {Day103/33:9-19}. The weak link that Mr Mort had identified was a gap at the head of the window, where there was nothing to stop a fire spreading from an internal compartment into the external cavity.2008 Mort {SIL00000298/8} page 8, paragraph 31(c); Mort {Day103/34:25}-{Day103/35:10}. It was a clear error, to which Mr Mort felt he had to draw attention. It was his opinion that Harley or building control ought to have noticed it.2009 Mort {SIL00000298/8} page 8, paragraph 31(c); Mort {Day103/37:24}-{Day103/38:7}.
¶57.53 The first of Mr Mort's sketches described his proposed means of producing cavity barriers with 120 minutes' fire resistance.2010 {HAR00003948}. It showed two pairs of cavity barriers, one pair above the window head and another pair at the sill, each made up of two individual barriers rated 90 minutes' integrity and 60 minutes' insulation to achieve a total of 180 minutes' fire resistance and 120 minutes' insulation.2011 Mort {Day103/38:15-20}. Mr Mort said that it had not been clear from Harley's drawings whether there were vertical cavity barriers at the window jambs. He accepted that the cavity barriers he had added at the sill of the window in his sketch were slightly below the sill itself, but said that the drawing was a schematic rather than a detailed design.2012 Mort {Day103/39:21}-{Day103/40:19}.
187¶57.54 The second sketch which Mr Mort had prepared was based on a drawing produced by Harley, to which he had added a bubble containing the note "weak link for fire".2013 Harley drawing 301 {HAR00003948/2}. The sketch showed the new window set back from the edge of the building, exposing a gap between the window brackets, as shown below.2014 Mort {Day103/36:11}-{Day103/37:3}.
¶Figure 57.1 – Harley drawing 301
¶57.55 Ben Bailey thought that the purpose of Mr Mort's email and sketches was to provide a solution to the dispute about whether there should be cavity barriers or firestopping2015 Ben Bailey {Day40/74:12-17}; {Day40/76:4-11}. and he noticed that Mr Mort had drawn cavity barriers at the head and sill of the window in the first sketch.2016 Ben Bailey {Day40/80:17-24}. However, he did not communicate Mr Mort's views, including about the weak link for fire, to anyone at Studio E, Rydon or building control, despite Mr Mort's having said that he thought that the building control officer would have noticed the problem.2017 Ben Bailey {Day40/75:7-21}; {Day40/86:17-25}. Nor did he ask Mr Mort to clarify exactly what he meant.2018 Ben Bailey {Day40/76:20-25}; {Day40/85:17}-{Day40/86:2}; Crawford {Day11/6:11-15}. Ben Bailey's explanation was that he had read the emails together and, as Mr Hoban had changed his position shortly afterwards, he did not feel the need to refer Mr Mort's email to him.2019 Ben Bailey {Day40/76:12-19}; {Day40/76:4-11}.
188¶57.56 That explanation is far from satisfactory. It made no sense for Ben Bailey to disregard Mr Mort's concerns about the design of the window head simply because the dispute over the rating of the cavity barriers had been resolved shortly afterwards. It was foolhardy to ignore the very clear warning about the design of the window, since it should have been plain to anyone reading Mr Mort's email and reviewing his sketches that the two issues were distinct from one another.2020 {HAR00018971} In particular, Mr Mort wrote in the introductory paragraph: "I have reviewed the drawings sent over and sketch a proposal to alleviate the issues raised by the BCO, also on the second page of the attachment I have highlighted the weak link so to speak in terms of fire."
¶57.57 Later the same day Ben Bailey forwarded the email from Mr Mort to others at Harley, including Ray Bailey and Kevin Lamb.2021 {HAR00003947}. He expected them to read its contents and also the attachments.2022 Ben Bailey {Day40/92:14-20}. Ray Bailey could not recall when he first saw Mr Mort's email and accompanying sketches, but he confirmed that it was before the end of the project.2023 Ray Bailey {Day33/158:5-15}. He did not bring Mr Mort's concerns to the attention of Studio E or building control, nor did he ask Mr Mort to clarify the position.2024 Ray Bailey {Day33/159:17-19}; {Day33/160:2-5}; {Day33/160:8-12}. His explanation was that the email needed to be read in the context of the debate about the requirement for firestopping or a cavity barrier,2025 Ray Bailey {Day33/159:20-23}. but for the reasons set out above, we do not accept that explanation, even allowing for the fact that he may not have seen the email until 1 April 2015, or even later.2026 Ray Bailey {HAR00010184/17-18} pages 17-18, paragraph 69. Whenever he read the email, Ray Bailey ought to have realised that the problem of the weak link was separate and distinct from the question about firestopping. Ray Bailey eventually accepted that the only sensible thing to have done was to raise Mr Mort's concern with building control.2027 Ray Bailey {Day33/160:13-25}.
¶57.58 Mr Lamb denied having noticed Mr Mort's warning about the weak link, despite admitting that he had scanned the email.2028 Lamb {Day38/138:8-20}; {Day38/141:24}-{Day38/142:4}. Mr Lamb did not discuss the drawing with anyone at Harley or anyone else connected with the project2029 Lamb {Day38/142:21}-{Day38/143:2}; {Day38/144:3-5}. and no changes were made to either of the drawings that Mr Mort had annotated.2030 Lamb {Day38/144:6-14}. Mr Mort's email did not prompt Mr Lamb to consider whether the weak link could be rectified by some other change to the design.2031 Lamb {Day38/146:2-15}.
¶57.59 Although Harley had been alerted in that way to the presence of a potential route for fire to spread at the head of the window, it did not take any steps to make good the defect, either by referring it to the design team for discussion, or by revising its design.
The outcome: March–April 2015
¶57.60 On 31 March 2015, Mr Crawford replied to Mr Hoban's email of 30 March 2015.2032 {SEA00000265}. He noted that the subject of fire barriers was causing concern on site, not least due to the effect on programme and cost. He asked for Mr Hoban's earliest response as the matter was beginning to hold up work.
189¶57.61 Mr Crawford sent the correspondence to Mr Ashton and asked for his comment.2033 {SEA00013044}. Mr Ashton responded by email later the same day.2034 {EXO00000715}. He explained that, in his view, a cavity barrier was all that was required, since fire stopping would not stay in place in a fire which would cause the zinc cladding to fail. Mr Ashton was unaware of the type of cavity barrier that had been proposed for use at Grenfell Tower and did not think it necessary to clarify that with the design team at that stage.2035 Ashton {Day18/100:13-21}. Attached to Mr Crawford's email was a drawing produced by Studio E showing a cavity barrier at the head of the window only.2036 Studio E drawing "Proposed Typical Bay Plans, Section & Elevation" {SEA00002499}. However, Mr Ashton did not look at the drawing at the time and therefore did not know where cavity barriers were to be located.2037 Ashton {Day18/123:7}-{Day18/124-10}.
¶57.62 On 1 April 2015 Mr Hoban replied to Mr Crawford saying that he had no objection to the proposal made by the design team, which provided for a cavity barrier with 30 minutes' integrity and 15 minutes' insulation.2038 {HAR00013719/2}.
¶57.63 Mr Crawford replied on the same day2039 {HAR00013719/2}. and sent Mr Hoban two further drawings relating to the lower levels.2040 Detail Sections Sheet 2 Main Entrance 1279 (06) 121 Rev 00 {RYD00037743}; Detail Section Sheet 1 1279 (06) 120 Rev 00 {RYD00037744}. He also attached a drawing made by Harley.2041 Harley Drawing C1059-325 Revision C which was a Walkway +1 Level Section {RYD00037745}. Mr Hoban replied to that email, thanking Mr Crawford for the further drawings and confirming that he had no adverse comments.2042 {HAR00013719}. Simon Lawrence sent that email onto Ben Bailey and Ray Bailey,2043 {HAR00013719}. copying Neil Crawford and Simon O'Connor shortly afterwards and informing them that the building control officer now agreed that the fire protection in the cladding should be a cavity barrier rather a fire stop. Ray Bailey was aware that the drawings did not show cavity barriers around the windows but did not check with Rydon or Studio E whether building control had made any comments on that omission.2044 Ray Bailey {Day33/155:20}-{Day33/156:3}. Mr Crawford did not expressly seek guidance from building control about the location of cavity barriers around the windows2045 Crawford {Day11/61:24}-{Day11/62:4}. and we have seen no evidence that he asked Mr Hoban to approve or comment on Harley's cavity barrier strategy as a whole.2046 Crawford {Day11/62:10-13}. For his part, Mr Lawrence was unaware that there ought to have been cavity barriers around the windows.2047 Lawrence {Day25/13:18-22}.
¶57.64 When Mr Lawrence was asked what steps he had taken to ensure that cavity barriers were included as required in the external wall design, he said that he had used a lead designer and a specialist subcontractor and had consulted building control.2048 Lawrence {Day24/184:8-13}. He accepted he had been largely a spectator in relation to the exchange of correspondence in March 2015 emails, as did the project manager, Mr O'Connor.2049 Lawrence {Day25/8:1-4}; O'Connor {Day26/153:11-13}. Mr Lawrence's evidence, however, betrayed a failure to understand his responsibility for ensuring that the external wall of the building complied with the requirements of the Building Regulations. There were many occasions in the course of that correspondence when it was, or should have been, clear to Mr Lawrence that Harley needed assistance2050 Email from Kevin Lamb to Simon Lawrence dated 3 March 2015 {HAR00017738}. which it was not receiving from Studio E.2051 Email from Neil Crawford to Kevin Lamb, copying Simon Lawrence and others dated 3 March 2015 {EXO00001461}. Mr Lawrence was surprised that Studio E required advice on a query of this nature, Lawrence {Day24/191:20-24}; but this did not trigger him to consider Studio E's competence, {Day24/193:2-11}. It was also clear that there was a significant degree of confusion over whether and to what extent cavity barriers were required2052 Lawrence {Day24/193:2-11}. and that consideration should have been given to obtaining specialist advice. Mr Lawrence was not alive to any of these problems.2053 Lawrence {Day24/185:13-18}. He should have been.
190Further advice from Siderise
¶57.65 Harley contacted Siderise on a number of other occasions during the life of the project seeking advice about cavity barriers.2054 Emails 6 May 2015 {HAR00004238}; 17 June 2015 {HAR00019012/2}. Despite that, it did not occur to Ben Bailey to inform himself about the guidance which was available in Approved Document B.2055 Ben Bailey {Day40/110:24}-{Day40/111:9}. The correspondence demonstrates a concerning lack of knowledge and expertise within Harley in relation to the use and siting of cavity barriers, which led to undue reliance on the advice of the manufacturer. Ben Bailey was unable to explain that lack of expertise and could not recall whether he had sought advice from Mr Anketell-Jones, Mr Lamb or Studio E.2056 Ben Bailey {Day40/113:3}-{Day40/114:3}. It was reasonable to expect Harley, as a specialist cladding contractor, to possess a degree of technical knowledge about the function of cavity barriers in ensuring compliance with the Building Regulations, but the evidence shows that it did not. The piecemeal requests to Siderise demonstrate the pitfalls in failing to articulate a clear and detailed cavity barrier strategy at the design stage before construction work began.
Installation of the cavity barriers
¶57.66 The installation of the external facade, including cavity barriers, was carried out by Osborne Berry Ltd as a subcontractor.2057 Ben Bailey {HAR00010060/3} page 3, paragraph 11. Mr Osborne had no formal training in the installation of rainscreen cladding facades.2058 Osborne {Day43/72:9-12}. The company had no experience of installing cavity barriers with intumescent strips and, as far as Mr Berry was aware, it had not previously installed cavity barriers manufactured by Siderise.2059 Berry {Day44/41:4-22}. Harley did not maintain a permanent presence on site and there was no clerk of works in the traditional sense, so there were times when Osborne Berry and their workmen were unsupervised when installing the facade.2060 Ben Bailey {Day40/120:17}-{Day40/121-3}.
¶57.67 A subcontractor progress meeting was held on 28 April 2015. The minutes record that Ben Bailey was to issue elevation drawings to Daniel Osgood, a Rydon site manager, showing the position of the cavity barriers.2061 {HAR00000414}. The minutes also recorded that windows and "firebreaks" were being fitted to the north, east and west elevations.2062 {HAR00000414/3}. It therefore appears that the work of installing cavity barriers had begun before Harley had issued a full set of drawings. Mr Osgood said that he had assumed that Osborne Berry knew from experience where to place the cavity barriers.2063 Osgood {Day30/146:25}-{Day30/147:4}.
191¶57.68 Ben Bailey did not recall having given Osborne Berry any guidance on how to install the cavity barriers.2064 Ben Bailey {Day40/134:4-18} such as the Siderise document "RH and RV cavity barriers for use in the external envelope or fabric of buildings" {HAR00008668}. Mr Osborne had never seen any such guidance, nor did he ask for any while he was on site.2065 Mr Osborne confirmed he had not seen either Siderise document shown to him {SIL00000230} or {SIL00000227}. Osborne {Day43/139:5-21}. He accepted that he should have checked that he understood how to install the product, which he had not fitted before, but apparently it did not occur to him at the time to do so.2066 Osborne {Day43/140:7-11}. Mr Berry had not seen any Siderise literature containing guidance on the installation of cavity barriers during the time he was working on the Grenfell Tower project, nor had he looked for guidance on Siderise's website.2067 Mr Berry was shown the guide at {SIL00000227} and confirmed that he did not read any guide like it while he worked on the project; Berry {Day44/45:12-14}; {Day44/49:18-22}. At the time that Osborne Berry was training their fitters, only horizontal cavity barriers were available on site.2068 Berry {Day44/46:4-9}.
¶57.69 Mr Osborne confirmed that the cavity barriers above the windows had been fitted above the level shown on Harley's drawings2069 Osborne {Day43/98:6-21}. to prevent the fixing brackets penetrating the EPDM membrane.2070 Osborne {Day43/97:5-18}. He said that the change had been specifically agreed on site after Osborne Berry had produced a mock-up of a sample cladding arrangement.2071 Mr Osborne's evidence was that this was agreed by either Daniel Anketell-Jones or Kevin Lamb at an early stage in the construction process, Osborne {Day43/97:25}-{Day43/98:5}; {Day43/98:22-24}. He also said that it had been impossible to install the vertical cavity barriers under compression, as recommended in the Siderise product literature,2072 {SIL00000227/6}: "This cavity barrier is fitted vertically under compression, completely filling the void." because the method of attaching the cassettes to the supporting rails allowed the cavity barrier to push the panel away from the building.2073 Osborne {Day43/142:13-21}. Mr Osborne did not raise the problem with anyone on site nor did he investigate a solution with Harley.2074 Osborne {Day43/142:23}-{Day43/143:7}. Osborne Berry instructed their fitters to trim the cavity barriers on site as the gap between the original concrete and the facade differed at different levels on the building.2075 Berry {Day44/51:13-21}.
¶57.70 Mr O'Connor did not attempt to check the positions of the horizontal cavity barriers against the drawings, because that was not his personal responsibility, and he therefore did not notice that they had not been positioned in accordance with the drawings.2076 O'Connor {Day26/166:25}-{Day26/167:6}. However, he accepted that placing them incorrectly constituted defective workmanship, for which Rydon (amongst others) would be responsible.2077 O'Connor {Day26/167:24}-{Day26/168:15}. He would have expected that kind of poor workmanship to be picked up under Rydon's quality assurance and inspection regime and could not explain why that had not happened.2078 O'Connor {Day26/172:18-25}.
¶57.71 Ben Bailey was responsible for supervising Osborne Berry's work on site on behalf of Harley2079 Ben Bailey {HAR00010060/3} page 3, paragraphs 11-13. but he had not received any training that would enable him to ensure that the installation of the cavity barriers complied with the manufacturer's advice, directions or guidance.2080 Ben Bailey {Day40/138:15-19}. He thought it was likely that he had reviewed Siderise's product literature and installation guidance,2081 Ben Bailey {Day40/153:24}-{Day40/154:2}. but according to Mr Berry he gave Osborne Berry no specific guidance about how the cavity barriers were to be fitted.2082 Berry {Day44/55:12-16}. Ben Bailey conducted visual inspections of the windows, insulation, cavity barriers and cladding rails before the cladding panels were installed on the north, east and west elevations, but not on the south elevation.2083 Ben Bailey {HAR00010060/4} page 4, paragraph13; Ben Bailey {Day40/148:13-19}; {Day40/149:17-20}. No formal record was kept of those inspections.2084 Ben Bailey {Day40/146:15-20}. Ben Bailey's inspections involved ensuring that the components had been installed in the same way as on the previous bays; he did not check the work against the drawings.2085 Ben Bailey {Day40/150:4-17}. He did not notice any poor workmanship or flaws in the installation during any of his inspections.2086 Ben Bailey {Day40/150:19-23}.
192¶57.72 After the fire the remaining cavity barriers were inspected and found to have various defects. In particular, a. The horizontal cavity barriers were found to have been installed with air gaps in
excess of 25mm and in some places the material had been poorly cut and fitted to the surrounding structure with gaps between adjacent barriers at joints.
¶b. Gaps had been left between the vertical cavity barriers and the cladding panels. c. Incorrect fixing brackets had been used. d. In some cases the fixing brackets had been spaced too widely. e. Some cavity barriers in the area of the columns were missing or had gaps.
¶f. Horizontal cavity barriers had been used in the vertical position, with the intumescent edge installed directly against the concrete.2087 Dr Lane, Phase 1 Report {BLAS0000008/40-48}; Swales {SIL00000306/25-26} pages 25-26, paragraphs 97-101.
¶57.73 Ben Bailey said he had been very shocked when he was shown photographs of the cavity barriers taken after the fire. He said that he had not seen workmanship like that when he had been on site or when he had conducted his checks.2088 Ben Bailey {HAR00010060/10} page 10, paragraph 32. In his witness statement he sought to explain why he had not noticed the problems with the installation of the cavity barriers by saying that the insulation boards had obscured the junction between the concrete walls and the back of the cavity barriers, making it impossible to see any defects without dismantling and causing damage to the completed works.2089 Ben Bailey {HAR00010060/10} page 10, paragraph 32. However, that is in contrast with Mr Berry's evidence that there had been plenty of opportunities to inspect the cavity barriers before the insulation was fitted.2090 Berry {Day44/59:9-14}. Ben Bailey conceded that he ought to have been conducting inspections at each stage of the installation.2091 Ben Bailey {Day40/164:1-9}. If he had done so, he would have inspected the work before the insulation obscured the rear of the cavity barriers and at a time when the problems would probably have come to light. As it was, Harley's inspections of Osborne Berry's work were insufficient to ensure that the defects we have described were identified.
193¶57.74 Mr Hoban of RBKC building control also visited the site and carried out inspections. He had not received any training on the installation of cavity barriers in cladding systems,2092 Hoban {RBK00050416/11} page 11, paragraph 34g; Hoban {Day46/126:20}-{Day46/127:4}. or indeed cladding systems more generally,2093 Hoban {Day46/126:20}-{Day46/127:4}. but a building control officer could be expected to be shown on site what to look for and to be aware of the need to check the manufacturer's instructions about how the barriers should be installed.2094 Menzies {Day60/109:24}-{Day60/111:4}. Mr Hoban did not check whether cavity barriers had been installed around the windows because most of the windows had by that time been installed and therefore it was not possible to see where the cavity barriers should have been.2095 Hoban {Day46/98:4-11}. He did not ask to look behind the windows because he had seen cavity barriers being installed in other locations and so did not think it necessary to do so.2096 Hoban {Day46/98:14}-{Day46/99:5}. Mr Hoban accepted that he should have checked whether cavity barriers had been fitted around the windows but that he had failed to do so.2097 Hoban {Day46/99:20-25}.
¶57.75 Mr Hoban's evidence was that he would know through reading cavity barrier documentation how cavity barriers were to be installed.2098 Hoban {Day46/127:13}-{Day36/128:1}. However he also accepted that the lack of training meant he had been unable to detect whether the cavity barriers within the facade had been properly cut and installed or whether the right kinds of cavity barriers had been placed in the right positions.2099 Hoban {Day46/127:6-12}. He thought that the cavity barriers that he had been able to inspect when he went up the mast climbers were acceptable, and although he saw them being installed, the workmen were covering them up as they went along.2100 Hoban {Day46/128:10-20}. At no stage did he ask for a cassette to be removed so that he could check the installation of the cavity barriers.2101 Hoban {Day46/189:21}-{Day46/190:6}; {Day46/191:24}-{Day46/192:13}. Mr Hoban was unable to recall whether he had seen cavity barriers in place before they were covered by insulation.2102 Hoban {Day46/130:11-20}. He did not notice that the horizontal cavity barrier at the head of the window was being installed at a level higher than that shown on the drawings made by Studio E.2103 Hoban {Day46/130:21-25}.
¶57.76 Mr Jonathan White of John Rowan Partners, which was engaged by the TMO to provide site supervision and inspection services, told us that it was not part of his job to check for compliance with the Building Regulations.2104 White {Day42/112:11}-{Day42/113:4}. His role, as he saw it, was to find out whether building control had expressed any concerns about the work and report back to the TMO.2105 White {Day42/165:7-13}. Mr White did not see design drawings of the windows2106 White {Day42/158:2-12}. and did not notice during his inspections that there were no cavity barriers around the windows.2107 White {Day42/165:1-3}. Although he inspected the cavity barriers and insulation, he was generally concerned only with whether the installation was consistent and the work neat and tidy.2108 White {Day42/171:4}-{Day42/172:9}. He told us that he would have picked up any obviously poor workmanship, such as poorly fitted cavity barriers, but not defects such as horizontal barriers in a vertical orientation.2109 White {Day42/176:20}-{Day42/179:24}.
194Siderise inspection at Wayland House
¶57.77 In December 2014, before Harley had begun installing the cladding at Grenfell Tower, Mr Kay of Siderise inspected the work on another of its projects, Wayland House in Brixton,2110 {SIL00000321}. which involved a curtain wall refurbishment. Mr Kay inspected the firestopping following the installation of Siderise's Lamatherm system. Following his inspection, on 19 December 2014 Mr Kay reported to Harley on the quality of the work. He found a. Installation of fire barriers in the incorrect orientation. b. Areas where the fire barriers had not been installed under sufficient compression, leaving gaps or loose material in the cavity. c. Gaps between the vertical fire barriers and the structure. Mr Kay considered it shocking to see so many defects in a cladding system2111 Kay {Day103/97:17-25}. and asked Harley to arrange for him to visit the building again when remedial works had been carried out.2112 {SIL00000321/3}.
¶57.78 Mr Kay confirmed that a similar inspection service would have been provided to Harley in relation to the Grenfell Tower project,2113 Kay {Day103/106:20}-{Day103/107:23}. but that no one from Harley had asked Siderise for it.2114 Kay {Day103/175:15-17}. Ben Bailey was unaware of the email or Mr Kay's findings when he began his work on the cavity barriers at Grenfell Tower.2115 Ben Bailey {Day40/157:23-25}. Nor did he know whether anyone at Harley had communicated those findings to Osborne Berry so that lessons could be learned.2116 Ben Bailey {Day40/158:5-10}. Harley failed to learn from the experience at Wayland House and did not make use of Mr Kay's report to ensure that standards were improved at Grenfell Tower.
Cavity barriers in the crown
¶57.79 Neither the second2117 Dated 29 November 2013 {SEA00000153}. nor the third2118 Dated 30 January 2014 {SEA00000169}. version of the NBS Specification contained any detailed information about the crown; each of them simply indicated that that part of the work was still to be completed.2119 At Clause 130 in Section H92 where it stated: "Major Nonstandard Components 'Crown': Manufacturer: TBC - Product Reference: TBC. Material: TBC. Finish: TBC…" {SEA00000153/66} and {SEA00000169/67}. Mr Sounes accepted that because the details of the crown had not yet been confirmed, little consideration had been given to where cavity barriers were to be placed within it.2120 Sounes {Day 21/92:16-22}. During Mr Rek's time working on the Grenfell Tower project (September to December 2013) no detailed design work had been carried out on the crown and questions relating to the design, material, finish and fixing were left until after the NBS Specification had been sent out to tenderers.2121 Rek {Day12/86:12-17}; {Day12/87:12-16}.
¶57.80 As part of the Employer's Requirements prepared for the tender, Studio E prepared a drawing which showed a cross-section of different floors of the tower, including the top floor and roof (or "plant") level.2122 Drawing entitled "Detail Section Sheet 1" {SEA00002551} dated 26 September 2013 with reference 1279 (06) 120 Rev 00. The drawing bore a label "Design of the crown detail TBC by architect". One cavity barrier was shown at the head of the window between the top floor and the roof level. There were, however, no other indications of where cavity barriers would be located within the crown. Mr Sounes accepted that little thought had gone into the matter at that stage.2123 Sounes {Day21/92:19-22}. Studio E never produced any elevation drawings showing how the horizontal cavity barriers at the top of the building would meet the vertical cavity barriers.2124 Sounes {Day21/93:8-16}. Mr Sounes confirmed that the risk that the crown might contribute to the spread of a fire in the external wall had not been considered because no one had been aware of the risks posed by ACM panels.2125 Sounes {Day21/101:5-20}.
195¶57.81 Mr Crawford was involved in the design of the crown after Studio E had been novated to Rydon.2126 Crawford {Day11/63:1-3}. He did not consider whether cavity barriers were required over and above those that would be fitted around compartments.2127 Crawford {Day11/63:7-12}. Since there were no compartments in the crown itself, it was his view that there was no requirement for cavity barriers.2128 Crawford {Day11/63:22}-{Day11/64:8}.
¶57.82 On 29 May 2015 Mr Lamb sent Mr Crawford an email attaching drawings of the crown and asking for his approval.2129 {SEA00013221}. On 12 June 2015, Mr Crawford replied attaching his comments on the design.2130 {SEA00013221}. His annotated drawings2131 {SEA00003242}. showed vertical cavity barriers which terminated at the base of the crown but no horizontal cavity barriers at the head of the columns.2132 Crawford {Day11/66:9-11}. Harley's drawings2133 For example C1058-216 {SEA00003242}. did not show a horizontal cavity barrier at the head of the columns or at the base of the crown, unlike the drawing produced by Studio E.2134 Entitled "Detail Section Sheet 1" {SEA00002551} dated 26 September 2013 with reference 1279 (06) 120 Rev 00. Mr Crawford agreed that that represented a worsening of the design2135 Crawford {Day11/69:20-25}. but he did not mention that when he commented on the drawings.2136 Crawford {Day11/70:3-9}. There was no discussion between Harley and Studio E about the provision of a cavity barrier at the head of the columns.2137 Crawford {Day11/71:24}-{Day11/72:4}.
¶57.83 Mr Lamb intended to revisit the question of a cavity barrier in that location and left himself a note on the CAD2138 Computer Aided Design. version of the drawing to remind him to do so.2139 {HAR00010427}; Lamb {Day38/166:17}-{Day38/167:2}. However, the note appeared only on Mr Lamb's CAD file; it did not appear on the printed versions of the drawing and therefore no one else saw it.2140 Lamb {HAR00010419/10} page 10, paragraph 36. Mr Lamb said that there had been a discussion within Harley and that it had been felt that there was no need to include a cavity barrier at the head of the columns,2141 Lamb {Day38/163:23}-{Day38/164:5}. but he was unable to recall who in Harley had been involved in that discussion.2142 Lamb {Day38/164:12-13}. At any rate, the drawing was issued for the architect's comments without a cavity barrier.2143 Lamb {Day38/162:10-17}. Mr Lamb explained that the drawing had then been overlooked and that it had never been re-issued as a drawing for construction.2144 Lamb {Day38/165:7-14}. However, that did not cause him any concern because Mr Crawford had not commented on the absence of a cavity barrier in that location. In his view, therefore, there was no need to revisit the point.2145 Lamb {Day38/165:20-24}; see Mr Crawford's annotations on the drawing at {RYD00043547/4}. Despite Mr Lamb's evidence we think it unlikely that he did discuss the matter with anyone else at Harley and that he simply overlooked it.
196¶57.84 For his part, Daniel Anketell-Jones did not give any thought to whether steps needed to be taken to reduce the risk of fire spreading at the top of the building or around the crown.2146 Anketell-Jones {Day37/52:16-23}. and no discussions took place among the construction professionals about the risk of vertical or horizontal spread of fire at the level of the crown.2147 Anketell-Jones {Day37/52:25}-{Day37/53:14}. Work on the crown was left quite late because Harley was concentrating on the large area of cladding represented by the elevations of the building.2148 Lamb {HAR00010419/9} page 9, paragraph 35. As a result, Mr Lamb based his design for the crown on very brief drawings from the architect and a design team meeting on site.2149 Lamb {Day38/162:1-2}.
¶57.85 Mr Hoban's understanding was that cavity barriers were not required at the junction between the cladding and the crown because the crown did not represent a concealed space.2150 Hoban {Day46/102:10-19}. Accordingly, despite the fact that he inspected the crown,2151 Hoban {Day46/138:1-3}. he did not remark on the absence of cavity barriers or any other fire mitigation measures in that location.
197Chapter 58: Window infill panels
Introduction
¶58.1 The spaces between the vertical columns of Grenfell Tower were filled by window assemblies which were constructed as a single unit and contained both glazed sections (with opening parts) and solid sections acting as walls. The solid sections were known as window infill panels.
¶58.2 Two types of window infill panel were installed during the refurbishment of Grenfell Tower, a large panel with an insulating core, which was set between the glazed windows and a smaller panel, also with an insulating core, which housed the kitchen extractor fan.2152 Grenfell Tower Inquiry: Phase 1 Report, Chapter 6, 6.29 and 6.31. They are shown in red and orange in the following figure taken from Dr Lane's Phase 1 report.
¶Figure 58.1 – Typical elevation for three-window configuration
¶58.3 After the fire it was found that both panels contained a core of Styrofoam, held between two sheets of aluminium.2153 Grenfell Tower Inquiry: Phase 1 Report, Chapter 6, 6.29 and 6.31. Styrofoam is a form of extruded polystyrene (often referred to as "XPS") and is combustible.2154 Lane, Phase 1 Report {BLAS0000008/61-62} paragraphs 8.10.36, 8.10.4 and 8.10.42. Although in his Phase 2 experimental work Professor Bisby found that those panels made the lowest contribution to the energy available in the external wall (only about 2–3% of the total energy available per floor),2155 Bisby, Phase 2 Experiments - Work Package 1 {LBYWP100000002/5} page 5, paragraph 32. he also found that they were relatively easy to ignite and, once ignited, had a comparatively high energy heat release rate per unit area.2156 Bisby, Phase 2 Experiments - Work Package 1 {LBYWP100000002/5-6} pages 5-6, paragraphs 33-34. He concluded that although they were not a primary cause of, or contributor to, the spread of fire across the external walls, they may have played an important part in the early development of the fire in and immediately outside Flat 16.2157 Bisby, Phase 2 Experiments - Work Package 1 {LBYWP100000002/5-6} pages 5-6, paragraphs 39-40. Accordingly, in this chapter we seek to explain how that combustible material came to be incorporated into the external wall of Grenfell Tower.
198Specification at tender stage
¶58.4 In the NBS Specification, the final version of which was dated 30 January 2014, Studio E specified aluminium-faced window infill panels with insulating cores as part of the external wall. Although some thermal performance requirements were included, no particular material or product was prescribed at that stage.2158 {SEA00000169/145} clause 332. It was therefore left to others to select suitable products which met the stipulated requirements.2159 Crawford {Day9/112:14-22}; {Day9/147:5-8}; {Day9/154:17-18}. Studio E did not prescribe any minimum fire performance standards for the panels.
¶58.5 Studio E's tender drawings showed insulating panels between the areas of glazing, but they did not identify any particular product or type of insulation either.2160 {SEA00002499}; Hyett, Module 1 Report {PHYR0000029/77} page 77, paragraph 4.3.90.
Harley's specification
¶58.6 When Kevin Lamb read the NBS Specification he thought that Studio E had simply overlooked the need to identify the insulating material to be used.2161 Lamb {Day38/169:1-22}. On 25 September 2014 he produced a drawing of the window arrangement which was revised on a number of occasions culminating in Revision D issued on 3 March 2015.2162 {HAR00008886}. 25 September 2014 was revision A. "P1" appears in revision A. The final revision was D. dated 3 March 2015 in which both "P1" and "P2" appear. In his drawings the larger infill panels were designated "P1" and the smaller infill panels housing the kitchen extractor fans "P2". Mr Lamb also produced specification notes dated 15 January 2015 which identified the products he proposed to use.2163 {HAR00003866}. The P1 and P2 panels were both shown as comprising 2mm aluminium skins with a 24mm core of Kingspan TP10 rigid insulation. TP10 is a combustible insulation product manufactured by Kingspan.2164 Lane, Phase 1 Report {BLAS0000008/62} paragraph 8.10.39(b); BBA certificate {KIN00000276}.
¶58.7 When asked about his choice of insulating core material, Mr Lamb said that he had initially selected Kingspan TP10 for both panels because it was a standard product that he had used over many years and that he had put it into the specification as a starting point for discussions within Harley.2165 Lamb {Day38/173:9-10}; {Day38/173:12-18}; {Day38/178:25}-{Day38/179:2}. Based on a conversation he had had many years previously with a fabricator working for another client, he was confident that the result would be a "Class 0" panel.2166 Lamb {Day38/179:5-9}. However, he did not check the requirements of the Building Regulations or the guidance in Approved Document B before suggesting the use of TP10,2167 Lamb {Day38/174:2-5}; {Day38/175:13-17}. nor did he take any steps to investigate its fire performance, including its suitability for use on buildings over 18 metres in height. He did not discuss the matter with anyone else at Harley.2168 Lamb {Day38/178:20}-{Day38/179:18}.
199¶58.8 The BBA certificate for Kingspan TP10 states that the product had in fact achieved a national Class 1 rating,2169 {KIN00000276/6} section 7. which is inferior to national Class 0.2170 See Chapter 5. National Class 1 means it has undergone testing in accordance with BS 476-7, not 476-6, which is also necessary for a national Class 0 classification. However, Mr Lamb did not look at the certificate; instead, he went ahead on his understanding that when fabricated the panel would achieve a Class 0 rating because the outer surfaces would be aluminium.2171 Lamb {Day38/181:18}-{Day38/182:14}.
¶58.9 Mr Lamb's evidence suggests that he was not familiar with the guidance in Approved Document B that insulation products used in the external walls of buildings over 18 metres in height should be of limited combustibility. Although he was aware that there was a difference between limited combustibility and Class 0, he had never considered what the difference was and simply assumed that materials with a Class 0 classification were acceptable for use.2172 {CLG00000224/96} clause 12.7; Lamb {Day38/83:9-17}. It did not occur to him that TP10 panels might contain combustible insulation and he therefore never considered whether combustible cores could be exposed in a fire.2173 Lamb {Day38/183:25}-{Day38/184:9}. That in turn demonstrated a lack of understanding on his part about how metal panels are liable to perform in a fire, a matter to which attention had been drawn in industry guidance long before 2015.2174 See the 2nd Edition of BRE 135 dated 2003 {BRE00005554/17-18} and the CWCT Standard for Systematised Building Envelopes, 2008 {CWCT0000046/11} section 6.3.
¶58.10 Mr Lamb's specification notes relating to the P1 and P2 panels were subsequently changed. Someone added handwritten annotations in red to amend the specification of the P1 and P2 panels to show 25mm of Styrofoam held between two 1.5mm skins of aluminium.2175 {HAR00003866}. That involved a reduction in the thickness of the aluminium skins and a corresponding increase in the thickness of the insulation, as well as a change of product. Mr Lamb said that the changes had been made by Mark Stapley, Operations Director at Harley.2176 Lamb {Day38/176:9-11}. We accept that evidence and think it likely that the changes were made by Mr Stapley after he had obtained the first quotation for the supply of panels.
¶58.11 Kevin Lamb produced a revised version of the specification notes,2177 {HAR00003869/1}. which reflected the changes made by Mr Stapley, save that the insulation in the P2 panel was still shown as Kingspan TP10.2178 Now increased in thickness from 24mm to 25 mm.
¶58.12 Kevin Lamb said that he had been told by Ben Bailey to obtain the infill panels from a company called Panel Systems Ltd, but that that company had been able to supply panels only with Styrofoam cores.2179 Lamb {HAR00010419/16} page 16, paragraph 63; Lamb {Day38/167:4} – {Day38/168:25}. Ben Bailey, however, said that Mark Stapley had ordered the panels some time before he had become project manager.2180 Ben Bailey {Day39/158:2-12}; {Day39/159:19-24}. We accept Ben Bailey's evidence on this point. It is apparent from the documents that Mr Bailey did not take over as project manager until 3 March 2015. Mark Stapley made his first inquiry of Panel Systems for the manufacture and supply of the window infill panels in January 2015,2181 {PAN00000012}; {PAN00000007}. and the first invoice for the supply of panels was dated 10 February 2015.2182 {MET00040281}; {MET00040279}. It seems clear, therefore, that the decision to obtain panels from Panel Systems Ltd was not made by Ben Bailey.
200¶58.13 Mr Lamb's evidence was also at odds with the evidence given by Christopher Ibbotson, the owner and managing director of Panel Systems, which we have no reason to doubt. According to him, in 2015 the company manufactured composite panels using a range of materials and various insulation products.2183 Ibbotson {Day104/6:24}-{Day104/7:3}; {Day104/8:12-13}; {Day104/8:16-25}. If asked to do so, it would give advice on the most suitable kind of panel to meet the customer's needs. Any advice on fire performance of a product would be based on information obtained from the manufacturer.2184 Ibbotson {Day104/14:7-21}; {Day104/16:6-19}. It is worth noting that in September 2015 Ben Bailey asked Panel Systems for advice on the manufacture and supply of a panel for use in the mounting of an anti-arson letterbox at Grenfell Tower2185 {HAR00020436}; Ben Bailey {Day39/176:2}. and that two days later he was sent details of its Versafire Euroclass A1 rated non-combustible board.2186 {HAR00002853}.
¶58.14 If a customer did not specify a core material, Panel Systems offered Styrofoam as standard2187 {PAN00000017/2} page 2, paragraph 2.4. because of its thermal efficiency.2188 Ibbotson {Day104/20:15}–{Day104/21:2}. In those circumstances it would not generally inform the customer of Styrofoam's fire performance, nor would it tell the customer that it should check whether the use of that material in the particular circumstances they had in mind would comply with the Building Regulations.2189 Ibbotson {Day104/21:4-23}. Panel Systems marketed its insulating panels by reference to the fire rating of the core material, which was the primary factor in their performance. It therefore marketed panels with Styrofoam cores as European Class E.2190 Ibbotson {Day104/24:21}–{Day104/25:25}.
¶58.15 In the light of Mr Ibbotson's evidence, it is clear that panels with cores other than Styrofoam could have been obtained from Panel Systems and it follows that if Harley had wanted to do so it could probably have obtained panels with better fire performance which met the requirements for thermal efficiency. We are unable to say with confidence what led Mr Stapley to accept Styrofoam for the core, but the fact that it was a standard product combined with the reduction in the thickness of the aluminium skins leads us to think that considerations of cost may have played a part. At all events, there is no reason to think that anyone at Harley gave serious consideration to the fire performance of the panels.
¶58.16 On 19 January 2015 Mark Stapley asked Panel Systems to provide a price for the manufacture and supply of infill panels.2191 {PAN00000012}; Ibbotson {Day104/28:20-24}. For that purpose he sent a schedule of Harley's requirements2192 {PAN00000006/2}; Stapley {HAR00020574/8} page 8, paragraph 28; {HAR00010003}. and requested prices for aluminium spandrel panels with an overall thickness of 28mm, without specifying the core material to be used.2193 {PAN00000006/2}. Later that day Panel Systems gave Mr Stapley a quotation for 28mm thick Aluglaze panels with aluminium skins and 25mm Styrofoam cores.2194 {HAR00009866}; {HAR00009867}. On 20 January 2015, Mr Stapley sent a purchase order to Panel Systems for the supply of the panels set out in his original schedule.2195 Stapley {MET00040296/15} page 15. This was the same schedule as set by Mr Stapley on 19 January 2015 {PAN00000006/2}. There was no discussion about their fire performance.
201¶58.17 Mark Stapley said that Panel Systems had specified the core material to be used in the P1 and P2 panels,2196 Stapley {HAR00020574/10} page 10, paragraph 33. but we think that unlikely, save in the sense that its quotation was based on Styrofoam because that was the default product. Harley had not specified any minimum fire performance for the core and there had been no discussion about what fire performance was required. As an experienced member of Harley's team Mr Stapley must have expected Panel Systems to quote for a basic product, unless asked to do otherwise. The responsibility for ensuring that the fire performance of the core was appropriate rested with Harley, not with Panel Systems.
¶58.18 Kevin Lamb accepted that he had never considered the fire performance of the window infill panels2197 Lamb {Day38/171:15-17}; {Day38/192:16-20}. or whether the use of Styrofoam in the external wall complied with the Building Regulations.2198 Lamb {Day38/187:1-9}. He was not aware that Styrofoam was not a product of limited combustibility, nor did he take any steps to assess whether the panel was suitable for use on high-rise buildings.2199 Lamb {Day38/188:4-9}. Mr Lamb assumed it was a product that Harley had used many times before.2200 Lamb {Day38/193:1-5}.
¶58.19 When asked why his specification notes showed Kingspan TP10 for the P2 panel instead of Styrofoam, as had been indicated in Mr Stapley's amendment, Kevin Lamb said that Panel Systems could not produce panels with inside and outside faces in different colours, as was required in the case of the P2 panels, so the specification had not been changed and the core remained Kingspan TP10. However, that does not strike us as very plausible. After the fire some surviving P2 panels were found to contain Styrofoam cores and there is no evidence that those or any other P2 panels had been obtained from a different supplier. We think Mr Lamb simply overlooked that part of the amendment and failed to make the required change.
Studio E's review of the specification
¶58.20 The revised version of Mr Lamb's specification notes was sent to Studio E for review and on 26 January 2015 Mr Crawford stamped it "Conforms to design intent", subject to the incorporation of certain comments, which did not include any comment on the window infill panels. Mr Crawford told us that he had not seen the handwritten annotations on the specification notes and that he did not think that he had been aware that Styrofoam had been substituted for Kingspan TP10 in the P1 panel.2201 Crawford {Day11/110:4-24}. He maintained that he had been commenting only on architectural intent and would not necessarily have been looking at the description of the materials in the specification.2202 Crawford {Day11/111:22}–{Day11/112:5}; {Day11/115:5:13}. Mr Crawford had no recollection of discussing the use of any particular insulation material for the infill panels with anyone at Studio E, Harley, or Rydon.2203 Crawford {Day11/112:15-25}; {Day11/114:23}–{Day11/115:4}. Mr Hyett was critical of Studio E for failing to identify the unsuitability of Styrofoam in the course of its design reviews.2204 Hyett, Module 1 Report (revised) {PHYR0000029/135} paragraphs 4.4.140 – 4.4.141.
202¶58.21 On 15 July 2015, Kevin Lamb produced a further revision of the specification notes2205 {RYD00046822/1}. but the specification for the P1 and P2 panels remained as it had been in the previous version. On 17 July 2015 Mr Crawford stamped it as conforming to design intent. Again, he could not recall having noticed the specification of Styrofoam and Kingspan TP10.2206 Crawford {Day11/116:9-18}. He thought that it was for Harley to check that the use of the material complied with statutory requirements and that it was not Studio E's function to check Harley's work.2207 Crawford {Day11/117:4}–{Day11/118:23}; {Day11/120:2-13}. Mr Crawford also said that he thought that the Styrofoam would be treated with fire retardant to limit its combustibility, but he could not recall taking any steps to find out whether that had been done.2208 Crawford {Day11/116:22}–{Day11/117:3}; {Day11/119:6-12}.
¶58.22 We think it clear that Studio E had an obligation under its contract with Rydon to take reasonable steps to ensure that all designs, whether produced by itself or any sub-contractors, complied with the relevant statutory requirements, including the Building Regulations.2209 {RYD00094228/9} paragraph 8. Mr Crawford's understanding that it was not his role to check the materials specified by Harley to ensure that the external wall was compliant with the Building Regulations was therefore wrong. He ought to have applied his mind to the fire performance of the window infill panels, both as a matter of contractual obligation and in the exercise of reasonable skill and care,2210 Hyett, Module 1 Report {PHYR0000029/135} paragraphs 4.4.140-4.4.141. but he failed to do so.
Harley's understanding of the products
¶58.23 Harley placed a number of orders for aluminium panels with a Styrofoam core between February and June 2015.2211 Ibbotson {Day104/32:12-17}.
¶58.24 When Ben Bailey joined the project in March 2015 he was sent Harley's drawings and specification notes2212 {HAR00017738}; {HAR00003953}. but could not remember whether he had reviewed them.2213 {HAR00017762}; Ben Bailey {Day39/155:12-22}. He was not aware that Styrofoam was extruded polystyrene and he did not know who had specified its use in the P1 infill panels.2214 Ben Bailey {Day39/156:14-23}. He did not himself investigate whether it was appropriate to use panels with Styrofoam cores in the external wall.2215 Ben Bailey {Day39/162:21-25}; {HAR00009696}; Ben Bailey {Day39/163:14}-{Day39/164:17}.
¶58.25 Ben Bailey thought that the Kingspan TP10 product had been specified for the P2 panel by Kevin Lamb,2216 Ben Bailey {Day39/164:24}-{Day39/165:1}. but it is not clear why, since he had not discussed the choice of material with Mr Lamb.2217 Ben Bailey {Day39/165:14}-{Day39/166:1}. He did not look at the BBA certificate nor did he consider whether panels containing Kingspan TP10 would comply with the Building Regulations.2218 Ben Bailey {Day39/172:9}-{Day39/173:11}; {Day39/175:6-7}.
203¶58.26 Ben Bailey also thought that the window assemblies (which included both glazed sections and fixed insulating panels) did not fall within the guidance in Approved Document B on the construction of external walls. He therefore rejected the suggestion that Harley should have taken steps to satisfy itself that the insulation in the window infill panels was suitable for use on buildings of more than 18 metres in height. Other witnesses thought differently, however. Although we recognise that a distinction can be drawn between the concrete structure (including the columns), which plainly forms the external wall, and the window assemblies containing some glazed and some solid panels, which fill the gaps between the concrete, we think it clear that the purpose of the guidance in paragraph 12.7 of Approved Document B is to reduce the risk created by the use of combustible insulation in the walls of high-rise buildings. We therefore think it clear that the reference to "external wall construction" in paragraph 12.7 includes solid window infill panels and we do not think that a competent specialist facade contractor could reasonably have thought otherwise.
¶58.27 Simon O'Connor, Rydon's project manager between May 2014 and August 2015,2219 O'Connor {RYD00094221/7} page 7, paragraph 14; O'Connor {Day26/5:4-7}. received Harley's drawings and specification notes on 6 March 20152220 {HAR00003951}. but could not remember having looked at either the drawings2221 {HAR00003953}. or the notes.2222 {HAR00003955}; O'Connor {Day26/112:3}-{Day26/114:24}. He had not come across Styrofoam, extruded polystyrene or Kingspan TP10 before.2223 O'Connor {Day26/115:17}-{Day26/116:16}.
¶58.28 As we noted in Chapter 62, John Hoban, the building control officer at RBKC responsible for the Grenfell Tower refurbishment, also received Harley's specification notes on 6 March 2015.2224 {HAR00003955}. He did not notice that Styrofoam and Kingspan TP10 were being proposed as the insulating material in the window infill panels2225 Hoban {Day46/26:15}-{Day46/27:4}; {Day46/28:8-10}. He relied on Exova having looked at this specification. Hoban {Day46/27:16-21}. and did not look at the BBA certificates relating to either material; nor did he question the use of those materials.2226 Hoban {Day46/28:18}-{Day46/29:14}. He candidly accepted that he should have done so.2227 Hoban {Day46/29:15-17}.
¶58.29 On 24 August 2015, for the first time Ben Bailey asked Panel Systems to give him a price for supplying aluminium-faced panels with a core of Kingspan TP10.2228 {HAR00020331}; {HAR00020332}. On 27 August 2015, Panel Systems provided Harley with a quotation as requested2229 {HAR00018872}. but for panels with a PIR core, rather than Kingspan TP10. Michael Roache, a product manager at Panel Systems, said that he had advised Harley that Kingspan TP10 was not suitable for use as the core of a composite panel due to its manufacturing tolerance and uneven surface and that as a result a discussion had taken place (though between whom is uncertain) about an alternative PIR insulation.2230 Roach {PAN00000029/3} page 3, paragraph 14. Ben Bailey said that any such conversation was not with him. Ben Bailey {Day39/173:6}-{Day39/174:5}. Mr Ibbotson agreed that a TP10 core would not bond reliably to the aluminium skin. TP10 was therefore replaced with a generic PIR product.2231 Ibbotson {Day104/38:8-22}; {Day104/40:12-25}; {Day104/48:23}-{Day104/49:10}; Ibbotson {Day104/49:18-21}; {Day104/42:1-5}. Subsequently, Harley placed further orders with Panel Systems for panels with PIR cores.2232 {MET00040286}.
204¶58.30 In total Panel Systems appear to have supplied a number of larger orders between January and June 2015 for panels with Styrofoam cores, and two smaller orders between August and October 2015 for composite panels with PIR cores.
¶58.31 Although Kevin Lamb had specified Kingspan TP10 insulation for the P2 panels2233 {HAR00003869/1}. and although panels with PIR insulation had been ordered by Ben Bailey,2234 {HAR00000445/6}. the Inquiry's experts discovered after the fire that some of the P2 panels had Styrofoam rather than PIR cores.2235 Lane, Phase 1 Report {BLAS0000008/62} paragraph 8.10.41. Mr Ibbotson denied that Panel Systems had substituted Styrofoam for PIR2236 Ibbotson {Day104/48:1-22}. and Ben Bailey could not shed any light on how some of the P2 panels had come to be supplied with Styrofoam rather than PIR cores.2237 Ben Bailey {Day39/167:12}-{Day39/168:21}. He said that most of the panels had been supplied directly to CEP for fabrication and insertion into the window frames, which might explain why the problem had not been picked up at the time.2238 Ben Bailey {Day39/168:25}-{Day39/169:25}; Ben Bailey {Day39/171:12-21}. However, he could not tell the products apart by their appearance.2239 Ben Bailey {Day39/172:3-7}. Neither the Rydon witnesses, nor Mr Lamb could explain how Styrofoam came to be substituted for PIR.2240 Lamb {Day38/177:7-12}; O'Connor {Day26/117:9-13}; Hughes {Day27/76:16}-{Day27/77:6}; Martin {Day30/54:10}-{Day30/55:4}. However, neither material was suitable for use in the external wall of Grenfell Tower. Given the lack of interest shown by Harley, Rydon and Studio E in the fire performance of the insulating cores of the window infill panels, we think it unlikely that any of them would have objected to the use of Styrofoam in the P2 panels.
205Chapter 59: Window reveals
Introduction
¶59.1 The refurbishment of the windows at Grenfell Tower involved fitting new uPVC boards at the head of the window, the sill and the jambs (often referred to as the "window reveals"), in each case over a 25mm layer of insulation.2241 Phase 1 Report, Volume I, paragraph 6.28. After the fire, the insulation that had been used was identified as either Celotex TB4000 or Kingspan Thermapitch TP10.
¶59.2 In his Phase 1 report the chairman concluded that the window reveals had provided a route for fire to spread from the interior of Flat 16 into the cladding. He found that the fire had probably entered the cladding as a result of hot smoke impinging on the uPVC window surrounds causing them to deform and fall away, together with the insulation which was attached to them. That created a gap which allowed the fire to gain access to the cavity behind the ACM panels and ignite combustible materials.2242 Phase 1 Report, Volume IV, paragraph 22.38. In Chapter 110 we have reconsidered that conclusion in light of the evidence provided by BRE reconstruction evidence but we consider that it remains sound. In this chapter we examine how those materials came to be present around the windows.
The original specification
¶59.3 In the NBS Specification Studio E specified plywood window reveals2243 National Building Specification (NBS) {SEA00000169/249} clause 240. It also stipulated that the fire-rating for the window reveals should be "fire-rating Class 1 or Class C-s3, d2". together with "compressible insulation in gaps".2244 National Building Specification (NBS) {SEA00000169/243} clause P10. The compressible insulation was specified as mineral wool to BS EN 13162 manufactured by Rockwool.2245 National Building Specification (NBS) {SEA00000169/243} clause 191. (Mineral wool is inorganic and non-combustible.)2246 Bisby, Phase 2 Experiments Work Package 2 {LBYWP200000001/36} paragraphs 239-240. However, Studio E did not specify precisely which gaps were to be filled with mineral wool and the tender drawings did not do so either,2247 {SEA00002499}. although they should have.2248 Crawford {Day9/149:15}–{Day9/150:11}; Hyett, Module 1 Report {PHYR0000029/80-82} paragraphs 4.3.94, 4.3.96 and 4.3.98.
The substitution of uPVC for plywood
¶59.4 Although the NBS Specification provided for the window reveals to be constructed of plywood, Harley proposed the substitution of uPVC boards as part of Rydon's value engineering exercise.2249 {RYD00003316}. Neither Harley nor Rydon appears to have given any consideration to the relative fire performance of the two materials.2250 Dixon {Day44/171:24}-{Day44/172:5}. In general, plywood could be expected to provide a greater degree of fire resistance than uPVC, which softens and deforms at temperatures above 60°C.2251 Torero, Phase 1 Report {JTOS0000001/41} Figure 9; Dixon {Day 44/170:12-21}.
206¶59.5 Simon Lawrence of Rydon originally expected Harley to undertake the package of works that included the replacement of the window reveals,2252 Lawrence {Day25/39:22}-{Day25/40:8}; Berry {OSB00000091/10} page 10, paragraph 16 (b); Berry {Day44/14:15-18}. but that package was removed from the scope of Harley's works when Rydon needed to find savings in its price for the work as a whole.2253 {RYD00086654/1}; Lawrence {Day25/39:22}-{Day25/40:8}; Berry {OSB00000091/10} paragraph 16 (b); Berry {Day44/14:15-18}. Accordingly, Harley's detailed drawings of the window arrangements showed that the fitting of insulation around the windows would be undertaken by others.2254 {SEA00003040/5}; {SEA00003040/7}.
¶59.6 On 16 January 2015, Neil Crawford reviewed Harley's drawing dated 13 January 2015 showing the details of the window design,2255 {SEA00003040/7}. which he accepted as conforming to design intent. He was not concerned that the drawing did not specifically indicate mineral wool around the windows because, as he told us, he knew that fitting the insulation was not part of Harley's work.2256 Crawford {Day11/98:5}-{Day11/101:1}. However, he failed to take any steps to deal with the fact that there was no detailed drawing at all, whether by Harley or Studio E, which showed mineral wool around the windows in accordance with the specification. He had no explanation for that omission, which drew criticism from Mr Hyett. Mr Hyett's opinion, with which we agree, was that, in accordance with its contractual obligations,2257 Deed of appointment between Rydon and Studio E {RYD00094228/11} items 31(a)-(c). Studio E should have produced 1:5 drawings which showed in detail how the voids around the window linings would be packed with insulation and what materials were to be used.2258 Hyett, Module 1 Report {PHYR0000029/82} paragraph 4.3.96.
¶59.7 On 12 March 2015, Jason North, Rydon's site manager at the time, asked Neil Crawford where he could find details of the insulation behind the fixed panels at the side of the windows.2259 {SEA00012940}. Mr North was referring to the gap between the larger window infill panel (panel P1) and the concrete spandrel of the original building.2260 Crawford {Day11/104:21}-{Day11/105:2}. Mr Crawford did not respond to that request, but he told us that he thought he had directed Mr North to Studio E's 1:20 drawings.2261 Crawford {SEA00014275/41} page 41, paragraph 118. However, those drawings did not show any details of the insulation around the windows and therefore it is unlikely that he did so.2262 Hyett, Module 1 Report {PHYR0000029/82} paragraph 4.3.98. Bruce Sounes' evidence was that the scale of those drawings did not permit references to the type of insulation to be used in these applications: Sounes {Day21/120:16-19}.
¶59.8 The refurbishment of the window reveals was not part of Osborne Berry's work,2263 Berry {OSB00000091/10} paragraph 16 (b); Berry {Day44/14:15}-{Day44/16:25}; Osborne {Day43/174:3-17}. which was limited to the removal of the original glazed windows to enable the new double-glazed window units to be installed.2264 Berry {Day44/15:22}-{Day44/16:7}; {Day44/18:17-21}.
¶59.9 By 23 February 2015 SD Carpentry Ltd had produced for the show flat (Flat 145) an example of the window reveals showing how they were intended to appear. Various companies, including a company called SD Plastering Ltd, looked at the finished example in order to decide whether to bid for the refurbishment of the window reveals.2265 Dixon {Day44/102:25}-{Day44/103:4}; {RYD00032519}. (SD Plastering was a construction company predominantly engaged in dry-lining work and was unrelated to SD Carpentry.)
207¶59.10 SD Plastering had already been engaged to carry out remodelling work on the lower floors of Grenfell Tower when Rydon approached it to undertake the refurbishment of the window reveals.2266 Dixon {Day44/99:19}-{Day44/100:14}; Dixon {SDP00000196/3} page 3, paragraph 13. On that basis we consider that Mark Dixon's estimate that SD Plastering became involved in these works in April-May 2015 is incorrect. (A director of the company, Mark Dixon, had previously been employed by Rydon.)2267 Dixon {Day44/95:3-23}. He knew Simon Lawrence, Simon O'Connor, Daniel Osgood and David Hughes, Dixon {Day44/97:21}-{Day44/98:24}. The first email correspondence in respect of the work occurred in February 2015;2268 {RYD00032519}. a progress report by Rydon dated March 2015 referred to SD Plastering's involvement.2269 {RYD00035207}.
¶59.11 Although it had not done work of that kind before,2270 Dixon {Day44/119:3-10}; {Day44/152:6-10}. SD Plastering ultimately undertook all the work to the window reveals, including the packing of gaps behind the uPVC boards with insulation,2271 Dixon {Day44/157:6}-{Day44/164:22}. apart from putting foam insulation into a small gap at the sides of the window jambs next to the columns.2272 Dixon {Day44/172:7}-{Day44/173:8}. See this gap highlighted in red bubbles in Lane, Phase 1 Report {BLAS0000009/13} Figure 9.9 9.10. We have not been able to determine which company or individual was responsible for that.2273 Osborne Berry said it did not carry out that work: Osborne {Day43/171:13-18}.
SD Plastering's contract
¶59.12 Although SD Plastering had a formal contract with Rydon for the dry-lining work,2274 {RYD00031801}; {RYD00031811}. there was no formal contract between them for the work on the window reveals. On 17 February 2015, Adam Marriott of Rydon sent Mark Dixon in connection with the dry-lining work a copy of Rydon's standard terms,2275 {RYD00031806}. which required all workmanship to comply with manufacturers' and suppliers' instructions and recommendations and current British standards and codes of practice.2276 {RYD00031806/4} paragraph 2.18.1. Mark Dixon understood that SD Plastering was required to comply with the same terms and conditions when carrying out the work on the window reveals.2277 Dixon {Day44/137:17}-{Day44/139:4}. Mr Dixon accepted that the work had to comply with any relevant standards and it follows that it had to comply with the Building Regulations in general and functional requirement B4(1) in particular.
¶59.13 Under the contract between Rydon and the TMO, it was Rydon's responsibility to co-ordinate and complete the design of the window reveals, which included selecting the goods and materials to be used and setting the standards of workmanship.2278 {RYD00094235/63} clause 2.1.1; {RYD00094235/69} clauses 2.17.1-2.17.12. Rydon was also responsible for co-ordinating and supervising the work of its subcontractors, including SD Plastering. Rydon's responsibility extended to monitoring its work and providing it with the information necessary for it to do the work.2279 {TMO10041791/128} part 2A/44, section A32, paragraph 110. Rydon ought therefore to have provided SD Plastering with a copy of the relevant part of the NBS Specification identifying the materials to be used, and ought to have provided it with Harley's drawings relating to the work, as accepted by Studio E.
208¶59.14 Under its contract with Rydon Studio E was responsible for developing the design of the window reveals, advising on the appropriate method of construction, selecting materials and co-ordinating any design work undertaken by SD Plastering.2280 {RYD00094228/9}; {RYD00094228/10}.
Design of the window reveals
¶59.15 In February 2015 a meeting took place between Rydon and SD Plastering in the show flat, during which Simon Lawrence told Mark Dixon that he was not happy with the window reveals because, among other things, the sill was prone to bowing.2281 {RYD00032519}; Dixon {Day44/106:3-8}; Dixon {SDP00000196/4} page 4, paragraph 17; Dixon {Day44/108:20}-{Day44/110:2}; {RYD00042486/2}; Lawrence {Day25/49:5-12}; {RYD00042487}. It appears that Mr Dixon made some suggestions for improving the design and that Mr Lawrence asked for a quotation for the work.2282 Simon Lawrence's email of 23 February 2015 {RYD00032519}. In the event, Rydon instructed SD Plastering to produce an alternative design for the window reveals that was more aesthetically pleasing than the example, easy to install and which remedied the problem with bowing.2283 Dixon {SDP00000196/4} page 4, paragraph 19; Lawrence {Day25/56:1-5}; Dixon {Day44/116:18}-{Day44/117:12}.
¶59.16 At some time between February and 6 May 2015 there was another meeting in the show flat to discuss the design of the window reveals. Mark Dixon attended, together with Simon O'Connor, Daniel Osgood and James Clifton of Rydon.2284 Dixon {Day44/107:7-25}; Osgood {RYD00094212/2} page 2, paragraph 8. At that meeting Rydon and SD Plastering decided to use a rigid insulation board to fill the gaps behind the uPVC boards.2285 Lawrence {Day25/56:10}-{Day25/58:7}; {Day25/62:3-7}; Cole {SDP00000220/3} page 3, paragraph 14; Dixon {Day44/112:12-18}; {Day44/112:19}-{Day44/114:15}. However Rydon did not tell SD Plastering what materials to use or provide it with any drawings of the window reveals.2286 Dixon {Day44/117:22}-{Day44/118:4}. In effect, Mr Dixon was simply asked to reproduce the effect of the work in the show flat but with a better finish.2287 Dixon {Day44/119:25}-{Day44/120:13}; {Day44/171:15-19}.
¶59.17 SD Plastering initially tried to use plasterboard or ply packing pieces underneath the windowsill to bridge the gap and to prevent it from bowing but were unable to secure them in place. Mr Dixon said that Celotex rigid insulation board was chosen instead to achieve a better fit.2288 Dixon {Day44/123:1-6}; {Day44/182:23}-{Day44/183:10}.
¶59.18 On 6 May 2015, Mark Dixon gave Rydon a quotation in which he described the work to be carried out.2289 {RYD00088957}. After removing the existing timber structure2290 Dixon {Day44/125:10-21}. a plasterboard backing was to be applied, after which Celotex insulation would be fitted to the head, jambs and sill. Mr Dixon's intention was to use either plasterboard or Celotex 25mm insulation board or a combination of the two to cover the gaps around the windows.2291 Dixon {Day44/128:6-12}. The Celotex board was expected to achieve the correct fit, act as a support to the uPVC and confer a thermal benefit.2292 Dixon {Day44/127:14}-{Day44/128:4}. He said the quotation had been drafted in such a way as to give SD Plastering flexibility about which materials to use.2293 Dixon {Day44/126:15-20}. In the event plasterboard was not used at all.2294 Dixon {Day44/125:3}-{Day44/127:7}; {Day44/185:1-6}; {Day44/196:16-20}.
209¶59.19 Neither Simon Lawrence nor Simon O'Connor read the quotation and neither could recall any discussions about it. Mr Lawrence knew that some sort of rigid insulation board was being used around the windows, but not necessarily that it would be made by Celotex.2295 Lawrence {Day25/36:7}-{Day25/38:15}; O'Connor {Day26/212:17-22}.
¶59.20 SD Plastering was never shown the NBS Specification relating to the work on the window reveals, nor was it given any instructions about the materials to be used in the gaps around the windows.2296 Dixon {Day44/167:20-21}. It was not provided with any architectural drawings relating to the window reveals and did not discuss the design of the work or the products to be used with Studio E.2297 Dixon {Day44/133:14}-{Day44/134:9}. Neil Crawford was not told that PIR and phenolic insulation had been used to fill voids around the windows. He was not shown the work or asked to comment on it during his site visits.2298 Crawford {Day11/106:10}-{Day11/107:7}. There was no formal process within Rydon for approving the materials used around the windows.2299 Lawrence {Day25/61:19-25}-{Day25/62:7}.
¶59.21 Mark Dixon said that he would ordinarily have expected to receive more information from Rydon about the products to be used on work of that kind, but he does not appear to have asked for any.2300 Dixon {Day44/131:14-17}. SD Plastering did not itself produce any drawings relating to the work.2301 Dixon {Day44/135:12-15}.
¶59.22 Neither Simon Lawrence nor Simon O'Connor examined the NBS Specification to see whether any insulation product had been specified for use in connection with the window reveals. Both accepted that they should have done so, although Mr Lawrence said that the Rydon site managers should also have paid closer attention to that.2302 Lawrence {Day25/45:1-22}; O'Connor {Day26/213:22}-{Day26/214:16}. If Rydon had looked at the NBS Specification it would have been obvious that the use of a rigid combustible insulation board was contrary to what had been specified.2303 Lawrence {Day25/47:12-22}. Rigid combustible insulation boards were not a comparable substitute for compressible and non-combustible mineral wool.2304 Lawrence {Day25/45:23}-{Day25/46:21}.
Compliance of the design with the Building Regulations
¶59.23 Pursuant to functional Requirement B4(1) and if following the guidance in Approved Document B any insulation materials used in the external wall had to be of limited combustibility.2305 Lane, Phase 1 Report {BLAS0000011/66-67} Table 11.10; see paragraph 12.7 of Approved Document B at {CLG00000224/96}. In addition, pursuant to functional requirement B3(4) the building had to be designed and constructed so that the unseen spread of fire and smoke within concealed spaces in its structure and fabric was inhibited. The need for compartmentation and the risk of fire spread around openings was highlighted in sections 8 and 9 of Approved Document B.2306 {CLG00000224/73} section 8; {CLG00000224/83} section 9, see in particular paragraph 9.3 which specifically warns about fire spread around openings. Rydon ought to have instructed SD Plastering that any insulation used around the windows was to be of limited combustibility or better and should have made sure that insulation of that kind was used. It did neither of those things, however. There was no discussion between Rydon and SD Plastering about how the choice of material to fill the gaps around the windows might affect fire safety generally.2307 Dixon {Day44/114:16-23}. Neither SD Plastering nor Rydon gave any consideration to the fire performance of the materials used to fill the gaps around the windows2308 Dixon {Day44/149:10-12}; {Day44/152:12-23}; {Day44/170:1-4}; {Day44/176:12-15}; O'Connor {Day26/207:17-22}; Osgood {Day30/181:25}–{Day30/182:12}; Cole {SDP00000220/4} page 4, paragraph 23; Dixon {Day44/152:1-5}. and it does not appear to have occurred to either of them that putting combustible insulation around the windows might affect fire safety.2309 Dixon {Day44/118:25}-{Day44/119:2}; {Day44/131:19-25}; {Day44/149:13-16}.
210¶59.24 Mr Lawrence accepted that Rydon had been responsible for ensuring that the products selected for the work complied with the Building Regulations and that it should have checked the choice of materials with Studio E.2310 Lawrence {Day25/63:12-18}; {Day25/61:6-9}; {Day25/63:23-24}. However, neither he nor anyone else at Rydon gave any serious consideration to whether the construction of the window reveals was likely to result in a breach of the Building Regulations.2311 Dixon {Day44/153:14-19}; O'Connor {Day26/207:23}-{Day26/208:2}; {Day26/209:12-18}. He admitted that he had not been aware that the Building Regulations might be relevant to the work on the window reveals;2312 Lawrence {Day25/62:18-24}. he had thought that they were not part of the building envelope and were therefore unregulated.2313 Lawrence {Day25/60:11-21}; {Day25/62:25}-{Day25/63:9}. Mark Dixon was also unaware that the Building Regulations might be relevant to the work.2314 Dixon {Day44/142:23}-{Day44/143:3}; {Day44/144:24}-{Day44/145:24}. He was not aware of the guidance in Approved Document B that insulation materials used in the external wall should be of limited combustibility.2315 Dixon {Day44/145:25}-{Day44/146:3}.
The supply and fitting of the insulation
¶59.25 SD Plastering purchased Celotex TB4000 insulation boards from Travis Perkins Trading Co. Ltd. When it became difficult to obtain supplies of Celotex, it obtained Kingspan Thermapitch TP10 insulation boards from a company called CCF Ltd.2316 Dixon {Day44/147:25}-{Day44/148:12}; {Day44/141:17}-{Day44/142:14}. Mark Dixon told us that he had assumed that that was permissible because the boards were being used only to bridge the gap around the windows and provide support for the uPVC window reveals.2317 Dixon {SDP00000196/7} page 7, paragraph 32.2. Mr Dixon could not recall any discussions with Rydon about whether Kingspan boards could be substituted for Celotex, but he thought that he had made Rydon aware of the substitution at some point,2318 Dixon {Day44/156:17-22}. and we think it likely that he did so.
Supervision of the work
¶59.26 Daniel Osgood was a site manager for Rydon until July 2015 and was responsible for supervising SD Plastering's work on the window reveals.2319 Osgood {Day30/172:19-22}; {Day30/198:11-13}. He did not discuss the need to maintain compartmentation or the risk of fire spread around the windows with anyone else in Rydon;2320 Osgood {Day30/175:5-23}. he just assumed that everything that was being used was "100% fireproof".2321 Osgood {Day30/183:8}-{Day30/184:3}. He could not recall having reviewed the NBS Specification2322 Osgood {Day30/183:22}-{Day30/184:3}; {Day30/184:23}-{Day30/185:12}. and assumed that Rydon had sent it to SD Plastering.2323 Osgood {Day30/187:23}-{Day30/188:4}. He did not recall having noticed the use of Celotex insulation in SD Plastering's quotation.2324 Osgood {Day30/188:25}-{Day30/191:5}.
211¶59.27 Gary Martin took over from Daniel Osgood as Rydon's site manager in July 2015 and became responsible for inspecting the work on the window reveals before the uPVC surrounds were fitted.2325 Dixon {Day44/215:7-20}; Martin {Day30/43:4-18}; {Day30/44:23}-{Day30/47:5}; {Day30/48:15-19}; {Day30/34:21-23}. He said in his witness statement that SD Plastering had been fitting a fire resistant seal between the window unit and internal sill and that a "fire barrier" was fitted around the window void so there was no gap between the window unit and inner concrete sill.2326 Martin {RYD00094216/1-2} pages 1-2, paragraph 6. However, that turned out to be merely an assumption on his part. When he was shown the photographs of the internal window reveals during his oral evidence it became clear that what he had assumed to be a fire-resistant seal or a fire barrier was in fact the aluminium foil on the insulation boards that he had seen during his site visits.2327 Martin {Day30/26:6}-{Day30/29:19}; {Day30/33:8}-{Day30/34:20}.
¶59.28 Mr Martin was not aware that combustible insulation had been used around the windows2328 Martin {Day30/26:14}-{Day30/27:2}. and had not seen SD Plastering's quotations, both of which referred to Celotex insulation being fitted in that location.2329 Martin {Day30/37:8-18}. He knew that insulation was being used but did not notice any branding on it at the time.2330 Martin {Day30/37:20}-{Day30/38:13}; {Day30/52:23}-{Day30/53:4}. He did not communicate any instructions to SD Plastering about the need to preserve compartmentation, the materials to be used, or fire safety generally.2331 Martin {Day30/38:22}-{Day30/39:14}. As far as he understood it, SD Plastering was reproducing the example provided in the show flat.2332 Martin {Day30/39:14-15}.
¶59.29 Neither Rydon nor SD Plastering knew that Celotex TB4000 was a European Class F product or that Kingspan TP10 was European Class E and that their fire performance did not therefore correspond to the guidance in Approved Document B,2333 Lawrence {Day25/62:9-14}; Dixon {Day44/153:20-22}; {Day44/154:25}-{Day44/155:5}; Osgood {Day30/188:12-21}. which called for products of limited combustibility (European Class A2).2334 Lane, Supplemental Phase 1 Report {BLAS0000011/60} paragraph 11.15.18; Hyett, Module 1 Report {PHYR0000029/141} paragraph 4.4.149.
¶59.30 Since it is likely that the failure of the window reveals played an important part in allowing the fire to escape into the cladding, we think we should summarise the factors that in our view contributed to their inadequate performance. First, Studio E should have produced detailed 1:5 scale drawings clearly identifying the insulation referred to in the NBS Specification and showing where it was to be placed. Next, Rydon should not have accepted Harley's suggestion that uPVC boards, with poorer fire resistance, should be used for the window reveals in place of plywood just to cut cost, because there was a significant difference in fire performance. Next, Rydon should have sent the NBS Specification to SD Plastering or should at least have given it instructions about the fire performance of the materials to be used in the window reveals. It should not have allowed combustible Celotex or Kingspan insulation to be used instead of the mineral wool insulation specified by Studio E to be fitted around the windows. Finally, neither Rydon nor SD Plastering gave any consideration to the fire performance of the insulation or the construction of the window reveals as a whole, which was unsuitable for its purpose.
213Chapter 60: The new smoke ventilation system
¶60.1 If a fire breaks out in a residential building, it is likely that some smoke will enter the corridors or lobbies, for example, through the door of the flat on fire when the occupants open it to escape. The purpose of a smoke ventilation system is to protect the escape route. In a high-rise building that may involve preventing smoke from entering the stairs and it may also involve at the same time removing it from the corridors and lobbies, which will thereby also obtain a measure of protection.
¶60.2 There are different ways of achieving that goal. Natural ventilation systems provide a means for hot smoke to escape through its own buoyancy, typically through a shaft that is open to the atmosphere at the top and can act as a chimney.2335 Lane, Phase 1 Report, Appendix J {BLAS0000031/12}. Mechanical ventilation systems use fans, ducts, vents, shafts and other features to draw smoke away from the stair and common corridors.2336 Lane, Phase 1 Report, Appendix J {BLAS0000031/12}. In some cases mechanical means are used for both the inflow and exhaust functions (sometimes called a "push-pull" system); in others they may be used for the exhaust function alone (sometimes called a "mechanical extraction, natural inlet" system).2337 Lane, Phase 2 Module 3 Report {BLARP20000035/69} Sections 1-9 and 11.
¶60.3 The type of system originally installed in Grenfell Tower was a system based on natural ventilation, but with the addition of fans that firefighters could operate to assist the movement of air into and out of the building. If the fans were not operated, the system functioned as a natural inlet and outlet system.2338 Lane, Phase 1 Report, Appendix J {BLAR00000025/14}.
The original system
¶60.4 The original natural smoke ventilation system installed at Grenfell Tower consisted of fresh air shafts and smoke extraction shafts serving the lift lobbies on each residential floor. Each lobby had a pair of fresh air inlets at low level on the south side connected to a pair of shafts drawing air from an inlet above the Walkway level, and a pair of exhaust vents at high level on the north side connected to a pair of shafts venting to an outlet on the roof. The pair of fresh air inlet shafts each had an opening area of 0.24m2, giving a total inlet area of 0.48m2. The pair of exhaust shafts were the same size, giving a total exhaust area of 0.48m2. Each vent had a set of motorised dampers that kept the vents closed. If smoke was detected, actuators opened the dampers on the relevant floor, while the dampers on the other floors remained closed. The mechanical ventilation "boost" function was operated by means of a switch on the ground floor.
214¶60.5 The following diagram shows how the system was intended to work:2339 Lane, Phase 1 Report Appendix J {BLAS0000031/18} Figure J.5.
¶Figure 60.1 – Operation of the original smoke ventilation system on the fire floor
¶60.6 Accordingly, the system operated by ventilating the lobby area with the intention of protecting the escape route through the lobby.
¶60.7 The system did not follow the recommendations of British Standard Code of Practice CP3 1971 (the standard which appears to have been used when designing the building),2340 Phase 1 Report Volume I paragraph 5.1. section 3.4.3.1(4) of which required that for buildings with a single stairway, cross ventilation in common access areas should be provided by an opening with a free area of at least 1.5m2.2341 Lane, Phase 1 Report, Appendix J {BLAR00000025/6}. The available aggregate free area of 0.48m2 at Grenfell Tower was significantly less than that.
The decision to refurbish
¶60.8 As set out in Chapter 43 of this report, the original smoke ventilation system at the tower had fallen into disrepair and had failed to work in a previous fire in April 2010. In March 2014, following a visit to the tower, the LFB issued a deficiency notice to the TMO stating that about a quarter of the system's dampers were not working2342 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. and by October 2014 the TMO was aware that the system was beyond repair.2343 Email from Alex Bosman to Claire Williams, Janice Wray and Carl Stokes dated 9 October 2014 {CST00001244/1}.
215¶60.9 During 2011, the TMO's Assets and Regeneration Health and Safety Committee repeatedly discussed carrying out a feasibility study for the installation of a replacement smoke ventilation system.2344 Minutes of the Asset Investment and Engineering Health & Safety Group dated 3 February 2011 {TMO10000823}; Minutes of the Asset Investment and Engineering Health & Safety Group dated 31 March 2011 {TMO10000842}; Minutes of the Asset Investment and Engineering Health & Safety Group dated 26 May 2011 {TMO10000868}. At a meeting on 15 September 2011, the Asset Investment and Engineering Health and Safety Group decided that an invitation to tender for the work should be published immediately with a view to beginning work in December 2011.2345 Minutes of the Asset Investment and Engineering Health & Safety Group dated 15 September 2011 {TMO10000920/1}.
¶60.10 In October 2011 AECOM, an engineering consultancy firm, prepared a draft tender for the refurbishment of the dampers and the conversion of the manually activated mechanical boost function to a system activated automatically by the presence of smoke.2346 AECOM tender report {SEA00000004}. The existing system did not comply with the statutory guidance current at the time of the refurbishment because of the size of the shafts but the AECOM proposal would have made the existing system more robust, thereby satisfying the requirement in regulation 4(3) of the Building Regulations 2010 not to make the building any more unsatisfactory in that respect than it had previously been.2347 McQuatt {MAX00017292/19} page 19, paragraph 82.
¶60.11 At a design team meeting on 18 July 2012, the TMO instructed Max Fordham to expand the scope of the tower's refurbishment to include improving the smoke ventilation system, as AECOM had recommended.2348 Studio E Notes from Meeting 5 dated 18 July 2012 {MAX00000147}. Even if the existing smoke ventilation system had been working at that time, it would have been necessary to extend it to the new lobbies that were being created on the lower floors.2349 McQuatt {MAX00017292/17-18} pages 17-18, paragraph 71.
Exova's consideration of the smoke ventilation system
¶60.12 In the draft Existing Fire Safety Strategy for Grenfell Tower dated 16 August 2012 Exova summarised the position on smoke ventilation, noting that the existing shafts did not provide sufficient capacity to meet modern standards and recommending that they be ventilated by mechanical means.2350 Existing Fire Safety Strategy for Grenfell Tower dated 16 August 2012 {EXO00001074/10-11} section 3.4. The existing system was described as "significantly undersized".2351 Existing Fire Safety Strategy for Grenfell Tower dated 16 August 2012 {EXO00001074/11} fourth paragraph.
¶60.13 Exova also said that unless the fans of any new system were capable of producing flow rates equivalent to a compliant modern system, the improved system would not meet current standards.2352 Existing Fire Safety Strategy for Grenfell Tower dated 16 August 2012 {EXO00001074/11} fourth paragraph. It pointed out the particular importance of a smoke ventilation system in a building that had travel distances between flat entrance doors and the doors to the stairs of more than 7.5m. The maximum distance was said by Exova to be approximately 8.3m.2353 Existing Fire Safety Strategy for Grenfell Tower dated 16 August 2012 {EXO00001074/10} paragraph 3.3.6. Exova said that provision of ventilation was critical to the tower's "stay in place" evacuation principle and it therefore strongly recommended that the performance of both the existing and proposed smoke ventilation systems be assessed.2354 Existing Fire Safety Strategy for Grenfell Tower dated 16 August 2012 {EXO00001074/11} fourth paragraph.
216¶60.14 Minutes of a project meeting on 6 September 2012 record that Exova needed to understand the existing situation, including whether the LFB tested the smoke ventilation system twice a year and what lay behind the proposal to improve it. The minutes recorded that action would be taken by Exova.2355 Studio E Notes from Meeting 8 dated 6 September 2012 {MAX00000311/2} section "Fire".
¶60.15 On 10 September 2012 Cate Cooney of Exova sent an email to Terence Ashton stating that the existing smoke ventilation system was "questionable" and that adding additional residential floors to the building would make the existing condition worse. She noted that it was proposed to improve the smoke ventilation system but that it was not known what standard the new system would achieve.2356 Email from Cate Cooney to Terry Ashton dated 10 September 2012 {EXO00000388}.
¶60.16 In Issue 3 of the Outline Fire Safety Strategy dated 7 November 2013 reference to the smoke ventilation system was limited to noting that it would be overhauled as part of the refurbishment of the building and would be covered in a separate report by Max Fordham.2357 Exova Grenfell Tower Outline Fire Safety Strategy Issue 3 dated 7 November 2013 {EXO00001107/7} section "Smoke Ventilation of Lobbies, Walkway +1 Level". There was no further consideration of the system as part of the fire safety strategy.
Max Fordham's initial proposals
¶60.17 Max Fordham's initial proposals for the refurbishment of the smoke ventilation system took a similar approach to AECOM's and involved an improved version of the existing system.2358 McQuatt {MAX00017292/20} page 20, paragraph 85. In November 2012 Mr McQuatt sought advice on developing the design from Atrium Airconditioning Ltd,2359 Email from Andrew McQuatt to Atrium Airconditioning dated 8 November 2012 {MAX00003356}. which passed his enquiry to PSB, a specialist smoke ventilation company.
¶60.18 On 9 November 2012 PSB responded to Mr McQuatt saying that it did not see anything wrong with the proposed design.2360 Email from Fergus MacGregor to Andrew McQuatt and others dated 9 November 2012 {PSB00000002/2}. Following the consultation with PSB the design intent for the improved system was revised to bring it as close to the current regulations as possible within the limitations imposed by the existing shafts.2361 Cross Smith {MAX00017304/10-11} pages 10-11, paragraph 28. In addition to providing a working smoke ventilation system, it was intended to use the system to provide ventilation to the lobbies to prevent overheating.
RBKC Building Control
¶60.19 During 2013 there were continuing discussions between designers and other contractors engaged in the refurbishment of the tower about the modernisation of the smoke ventilation system. They included Max Fordham, Studio E, and Exova. Max Fordham's proposals for the new system did not undergo any changes during that period, but it proved difficult to demonstrate to building control that the new system would be an improvement on the existing system or at least would not make it any worse.2362 Cross Smith {MAX00017304/13} page 13, paragraph 36. The fact that the existing system was not in working order and the paucity of documentation surrounding its installation made it difficult for the designers to compare its performance with the expected performance of any proposed replacement.
217¶60.20 On 25 October 2013, Max Fordham repeated its proposals for the new system, stating that, as it was not possible to adapt the existing system to meet current standards, its intention was to bring the existing system up to as high a standard as possible.2363 Cross Smith {MAX00017304/10-11} pages 10-11, paragraph 28. At that stage, therefore, the proposal was still to improve the existing system rather than replace it with an entirely new one. Max Fordham acknowledged that there were no directly applicable standards that could be used as a basis for the design of the improved system but considered that it was reasonable to aim at providing 15 air changes an hour.2364 Max Fordham Grenfell Tower Smoke Control Proposals Rev A, dated 25 October 2013 {MAX00000867}. That may have been based on conversations with Exova.2365 Cross Smith {Day157/174:16-20}.
¶60.21 On 25 October 2013 Bruce Sounes of Studio E submitted Max Fordham's proposals to RBKC building control, together with the draft Outline Fire Safety Strategy for the building prepared by Exova. In his covering email Mr Sounes said that the design team thought that agreement on the smoke ventilation system was the single biggest risk to the proposals, but that they did not think it was reasonable to leave the existing system in place.2366 Email from Bruce Sounes to John Allen and Paul Hanson dated 25 October 2013 {SEA00000121}.
¶60.22 On 11 November 2013 John Allen, the building control manager at RBKC, told Mr Sounes that the information submitted by Studio E was not adequate to enable an effective consultation to be held with the LFB.2367 Email from John Allen to Bruce Sounes dated 11 November 2013 {SEA00009805}. However, he said that if it could be shown that the new system was no worse than the existing system, the design would be acceptable. He suggested that if there were no data available on the existing system, a way forward might be to measure the flow rates of the existing system and provide information about the capacity of the proposed new system. For the purpose of consulting the LFB Mr Allen suggested that information about the existing system be obtained, including the method of activation, the size of the shafts, and the powered extraction rate, that could be compared to similar information about the proposed improved system.2368 Email from John Allen to Bruce Sounes dated 11 November 2013 {SEA00009805}. In the light of that response Mr Cross Smith decided to contact PSB to obtain further specialist advice on the design of the new system.2369 Cross Smith {MAX00017304/14} page 14, paragraph 38.
¶60.23 On 6 December 2013, in a memorandum to Mr Allen, Paul Hanson, then responsible for the Means of Escape Group within RBKC building control, provided further observations on the proposals.2370 Memorandum from Paul Hanson to John Allen dated 6 December 2013 {RBK00003014}. He noted that it was not proposed to redesign the system to bring it up to modern standards, as that was likely to require larger shafts, but that building control had indicated that, provided the performance of the system was not made worse, the Building Regulations did not require it to be replaced. He suggested that a comparison of the flow rates of the system in its current and improved forms could provide a way forward. He did not think it was acceptable to base the design on a particular number of air changes an hour, as Max Fordham had proposed, as it did not correspond to any known guidance for lobby ventilation systems, being based on a generic value used for car parks.2371 Hanson {Day154/77:1-9}.
¶60.24 In his memorandum Mr Hanson also said that, if the designers wished to design the system to achieve a particular performance, they would need to provide evidence to support the proposed rate of extraction, including performance modelling. He suggested that a reasonable approximation of ventilation rates could be obtained using computational fluid dynamics (CFD) or a simpler zone model.2372 Memorandum from Paul Hanson to John Allen dated 6 December 2013 {RBK00003014}.
218The approach to PSB
¶60.25 At around the end of April 2014, Mr Cross Smith asked PSB to assist with satisfying building control's request for a revised submission. That led to a proposal for the use of a pressure differential system as a possible alternative2373 Cross Smith {MAX00017304/15-16} pages 15-16, paragraph 44. which was described in a document written by Hugh Mahoney of PSB, entitled Smoke Ventilation Technical Proposal For Stair De‑pressurisation Systems at Grenfell Tower, Regeneration Project, dated 22 April 2014.2374 Smoke Ventilation Technical Proposal for Stair De-Pressurisation Systems at Grenfell Tower, Regeneration Project {PSB00001233}. PSB also suggested a target extraction rate of 5.0m3/s for the system, which Mr Cross Smith incorporated into Max Fordham's latest proposals in May 2014. Apparently, that was the rate PSB always used for those purposes.2375 Cross Smith {MAX00017304/16} page 16, paragraph 47.
¶60.26 In late April or early May 2014, PSB and Max Fordham discussed CFD modelling, but by then there was insufficient time to carry it out, so it was not pursued.2376 Mahoney {Day155/163:20}-{Day155/164:13}; {Day155/21:5-22}; {Day155/26:10-25}; {Day155/32:14-24}. Simon Lay, one of the experts from whom we heard evidence, was of the opinion that, since the new system was being designed specifically for Grenfell Tower, Exova, Max Fordham and PSB ought to have ensured that a CFD analysis was carried out.2377 Lay {Day286/169:15-23}. He considered that in failing to do so they had fallen below the standards reasonably to be expected of them.2378 Lay {Day286/170:5-17}. Dr Lane also considered that Exova and Max Fordham should have made sure that a CFD analysis was carried out.2379 Lane {Day287/136:14-17}. She said that she would have expected PSB to advise that that should be done or to do it themselves if they had the capability, and rejected the suggestion that shortage of time was a valid reason for not doing it.2380 Lane {Day287/137:3}-{Day287/138:1}.
¶60.27 It remains unclear to us why a CFD analysis of the proposed new system was not carried out once it had become apparent that it was not possible to obtain reliable information about the performance of the existing system. If such an analysis had been carried out, it would have ensured that the performance of the new system had been ascertained with reasonable confidence and suitably documented. We agree that it should have been considered further and that PSB should have suggested it to the design team. Pressure of time was not a reasonable justification for failing to carry out such an analysis. The existing system had not been in working order for a long time and a further delay of weeks or even months was not a sufficient reason not to analyse properly the performance of the proposed replacement.
¶60.28 On 24 November 2014 at a meeting between building control, Studio E, the TMO and Max Fordham to discuss the system, PSB and JS Wright (Rydon's electrical and mechanical sub-contractor) put forward an alternative system, the outline of which was contained in a technical submission from PSB dated 12 November 2014 produced by Mr Mahoney.2381 Smoke Ventilation Technical Submission, Revision 0 dated 12 November 2014 {PSB00000207}.
219¶60.29 Mr Mahoney understood that the essential purpose of the proposed work on the smoke control system was simply to make it better than the existing system.2382 Mahoney {Day155/25:1-7}. In his view, provided it could be shown to deliver an extraction rate of 3m3/s, it would be acceptable to building control on the basis that that would be significantly better than the 1.2m3/s which was the estimated capacity of the existing system.2383 Mahoney {Day155/110:20}-{Day155/111:2}.
¶60.30 Mr Mahoney regarded the PSB design as an alternative approach. It did not follow any published guidance but would in his view be effective to protect the stairs and ventilate the lobby. He considered it impossible to install a system that complied in all respects with current standards.2384 Mahoney {Day155/86:5-12}.
The design of the new system
¶60.31 The design contained in PSB's technical submission was subsequently developed, culminating in Revision 6 issued on 15 March 2016 which contained the design of the system that was ultimately installed at Grenfell Tower. All versions except the final one were produced by Mr Mahoney.
¶60.32 It is not necessary to describe every aspect of the system's design because we are concerned only with those that could have played a part in the fire. In summary, the following are worth considering: a. The new system extracted air from the relevant lobby through all four vents and
discharged it either at the top of the building through the north shafts or at the level of Floor 2 through the south shafts. Air entered the lobby around the door to the stairs in response to the change in pressure. Mr Mahoney saw the extraction of air from the lobby at the rate of 3m3/s as the system's primary purpose,2385 Mahoney {Day155/90:21-24}. thereby moving air from the stairwell into the lobby and protecting it from the ingress of smoke. In other words, the objective was to remove smoke from the lobby to prevent it entering the stairs.2386 Hanson {Day154/135:1-7}.
¶b. According to PSB's technical submission, the system was designed to provide an average air velocity of 2m/s across an open door between the lobby and the stairs. That velocity was derived from BS EN 12101:6, which contains standards for pressure differential systems, but the system was not intended to work as a pressure differential system and was not designed in full compliance with that standard.2387 Smoke Ventilation Technical Submission, Revision 6 dated 15 March 2016 {PSB00000214/3}.
¶c. The system was activated by smoke detectors in the lobbies. When smoke was detected on a particular floor, the dampers on that floor were designed to remain open and the dampers on all other floors to close, allowing the full capacity of the system to extract air from the lobby in which smoke had been detected.2388 Smoke Ventilation Technical Submission, Revision 6 dated 15 March 2016 {PSB00000214/3}.
¶d. A new pair of smoke extraction fans were installed at Level 2 and also an environmental extraction fan.2389 Smoke Ventilation Technical Submission, Revision 6 dated 15 March 2016 {PSB00000214/4}.
220¶e. Pressure sensors were also installed on every floor to control the speed of the extraction fans in order to ensure that the reduction in the air pressure in the lobbies did not prevent the door to the stairs from being opened. According to PSB's technical submission, if the pressure differential fell below -25 pascals ("Pa") (for example, if the door to the stairs were opened), the speed of the fans would increase until the differential of -25Pa had been restored.2390 Smoke Ventilation Technical Submission, Revision 6 dated 15 March 2016 {PSB00000214/18}.
¶f. New dampers were fitted to the openings in the south and north shafts on every floor. In addition, the new system included dampers within the ductwork on Level 2 to bypass the environmental ventilation ducts when the system was in smoke extraction mode. That reflected the dual purpose of the system: smoke control when smoke was detected and environmental ventilation when the building became too warm.2391 Smoke Ventilation Technical Submission, Revision 6 dated 15 March 2016 {PSB00000214/4}. When the system was operating in environmental mode, the dampers would open on four floors at a time for 15 minutes in sequence to cool the building down to the activation temperature.2392 Lane, Phase 1 Report, Appendix J {BLAS0000031/87}.
¶60.33 Below is an illustration of the way in which the new smoke ventilation system was intended to operate. The blue lines indicate fresh air from the roof vent at the top of the stairs entering the lobby through the door to the stairs; the red lines indicate the movement of smoke and hot gases out of the shafts on the north and south sides of the lobby.2393 Lane, Phase 2 Module 3 Report, Sections 1-9 and 11 {BLARP20000035/260-261}.
¶Figure 60.2 - Design intent of the smoke extract system in Grenfell Tower for Level 2 to Level 23
221¶60.34 Mr Mahoney said that the advantage of the design was that by using four shafts rather than two to extract smoke from the lobbies, the velocity required to achieve the required rate of extraction was reduced. In his opinion, seeking to achieve a higher flow rate using only two shafts for extraction and two for the entry of air was not viable, because the higher air speed required through each shaft would have disrupted the flow. It would also have risked creating velocity jets in the lobbies where air entered the vents, which might have caused smoke to enter the stairs.2394 Mahoney {Day155/82:3-16}.
Dampers
¶60.35 Dampers are mechanical devices used to prevent air or gases from passing through ducts or from the openings of ducts into the space beyond. Typically they take the form of louvred plates that overlap slightly to provide a solid barrier when in the closed position. In the open position they allow the passage of air and other gases. They are often opened or closed by an electric motor known as an actuator. Different kinds of dampers with different performance characteristics are available. It may therefore be helpful to begin this section by describing the ways in which dampers are classified and the purposes they are designed to serve.
Fire dampers
¶60.36 Fire dampers sit within a duct or ventilation opening and are usually operated automatically. They are designed to prevent the passage of fire.2395 Approved Document B {CLG00000224/144}. A damper is classed as a fire damper if it achieves an integrity classification of at least "E" as defined in BS EN13501- 3:2005 when tested in accordance with BS EN1366-2:1999.
¶60.37 The integrity classification "E" reflects the damper's ability to prevent the transmission of fire as a result of the passage of significant quantities of flames or hot gases from the fire to the unexposed side, thereby causing ignition either of the surface not exposed to the fire or of any material adjacent to that surface.2396 BS EN 13501-3 (Fire classification of construction products and building elements – Part 3) {BSI00000810/9} paragraph 5.1.2. Its purpose is to prevent the ignition of whatever is on the other side of the damper rather than to restrict the amount of smoke adversely affecting the adjoining space. A fire damper, therefore, is expected to close in the event of a fire and remain closed during it;2397 Lane, Phase 2 Module 3 Report {BLARP20000035/86}. it is not intended to open and close repeatedly as part of a system's normal operation.
Fire and smoke dampers
¶60.38 Fire and smoke dampers are tested and classified by reference to their ability to limit the amount of smoke passing from one side to the other.2398 Approved Document B {CLG00000224/144}. Such dampers must have been tested in accordance with BS EN 1366-2:1999 and meet both the integrity and smoke leakage criteria in EN 13501-3:2005. They are then classified "ES". The function of a fire and smoke damper is also to close and remain closed during a fire,2399 Lane, Phase 2 Module 3 Report {BLARP20000035/88} Sections 1-9 and 11. but it must have a lower leakage rate than a fire damper.
222¶60.39 The ability of a damper to minimise the leakage of smoke was directly relevant to its suitability for use in the smoke ventilation system of the tower, because the vertical shafts used to extract smoke passed through the lobbies, which were part of the escape route for the occupants of the flats on those floors. A damper that prevented the passage of fire alone would not have been suitable.
¶60.40 The performance necessary to achieve the relevant classifications are set out as follows in EN 13501-3:2005:2400 BS EN 13501-3 (Fire classification of construction products and building elements – Part 3) {BSI00000810/16}. a. For the classification "E" the leakage limit is 360 m³/h∙m²; b. For the classification "ES" the leakage limit is 200m³/h∙m² (corrected to 20°C). (The limit is the same at ambient temperature and during the fire test.)
Smoke control dampers
¶60.41 Smoke control dampers are described in BS EN 1366-10:20112401 BS EN 1366-10:2011 (Fire resistance tests for service installations – Part 10: Smoke control dampers) {BSI00001777/12} paragraph 3.27. ("Fire resistance tests for service installations, Part 10 Smoke Control Dampers") rather than in Approved Document B. A smoke control damper is a similar device that can be automatically or manually opened or closed in its operational position to control the flow of smoke and hot gases into, from or within a duct.2402 Lane, Phase 2 Module 3 Report {BLARP20000035/90} Sections 1-9 and 11.
¶60.42 A smoke control damper is subject to the same performance requirements as a fire and smoke damper, but differs from the previous two types of damper in that it is capable of both opening and closing during a fire.2403 BS EN 12101-8:2011 (Smoke and heat control systems – Part 8: Smoke control dampers) {BSI00000048/7}.
The design of the system
¶60.43 The shafts and ductwork for the smoke ventilation system were required to be in a protected area, as described in Approved Document B, in order to restrict the ability of fire and smoke to spread between compartments.2404 Approved Document B {CLG00000224/73} paragraph 8.9. The effectiveness of the dampers in preventing excessive smoke leakage from the shafts into lobbies on floors other than the one affected by a fire was therefore an important feature of the system. Leakage through the dampers also adversely affects the ability of the fans to extract smoke and thus the performance of the system as a whole.2405 Lane, Phase 2 Module 7 Supplementary Report {BLARP20000043/16}.
¶60.44 The design of the new smoke ventilation system envisaged that dampers might be changed from the closed to the open position during a fire, because the manual control function allowed firefighters to change the floor from which smoke was being extracted as required by the location of the fire. Accordingly, a damper that had previously shut on one floor might later be opened manually if the fire brigade required the system to extract smoke from another floor.
¶60.45 Only a smoke control damper is designed and tested to perform in that way. The key differences between the testing of smoke control dampers and the testing of the other two kinds of damper relate to:2406 Lane, Phase 2 Module 3 Report {BLARP20000035/92-93} Sections 1-9 and 11.
223¶a. the durability of operational reliability, which is tested by carrying out a minimum number of opening and closing cycles before fire testing – 10,200 for smoke control dampers but only 50 for fire dampers and fire and smoke dampers; and
¶b. the ability to change from open to closed position and vice versa at elevated temperatures, which is not a requirement for fire dampers or fire and smoke dampers.
¶60.46 In this case durability of operational reliability was important because the dampers were part of a system that also provided environmental ventilation. They could therefore reasonably be expected to open and close many times each week. As a result of having been tested through over 10,000 cycles, smoke control dampers can be expected to be effective over a much longer operational lifetime.
¶60.47 The ability to move between an open and closed position at elevated temperatures was also of importance in this case because firefighters might need to control the system manually if the temperature on one floor rose considerably due to the fire.
¶60.48 Having regard to the properties of the three kinds of damper we have described, it is clear that only a smoke control damper could be expected to meet the requirements of the new system.
The Gilberts Series 54 damper
¶60.49 The Gilberts Series 54 damper is shown in the open and closed positions in the following photographs taken after the fire.2407 Lane, Phase 2 Module 3 Report {BLARP20000035/296}.
¶Figure 60.3 – Examples of dampers in an open and closed position
¶60.50 It is opened and closed by an actuator (a small electric motor)2408 Lane, Phase 2 Module 3 Report {BLARP20000035/297} Sections 1-9 and 11. that moves the blades. When smoke is being drawn up the shaft the damper prevents it from entering the lobbies. It therefore plays a vital role in protecting the atmosphere in the lobbies not directly affected by the fire.
224¶60.51 The damper was described in a brochure published by the manufacturer in October 20112409 Gilberts, Series 54 Smoke Evacuation Damper brochure {PSB00000201}. as a "smoke evacuation damper", a description not found in any published guidance. The brochure also stated that it had been fully tested to the requirements of EN1366 Part 2 for one hour.2410 Gilberts, Series 54 Smoke Evacuation Damper brochure {PSB00000201/2}. However, BS EN 1366-2 contains the standard for testing fire dampers and fire and smoke dampers; it does not contain the standard for testing smoke control dampers.2411 Lane, Phase 2 Module 3 Report {BLARP20000035/93} Sections 1-9 and 11. Moreover, the damper had been tested from the closed, rather than the open, position, as the notes attached to the original quotation confirmed. The statement in the brochure was therefore inaccurate and misleading, because the test method to which it referred requires testing from the open position. There was no suggestion by Gilberts in the brochure or otherwise that the damper was a smoke control damper in the recognised sense.
The choice of the Gilberts Series 54 damper
¶60.52 In January 2015 Hugh Mahoney asked Gilberts to quote for the supply of Series 54 dampers for use in a smoke ventilation system. At that stage he did not provide any information about the system in which they were to be used.
¶60.53 The quotation that Gilberts sent to Mr Mahoney on 22 January 2015 contained a note stating that the damper had undergone an EN 1366-2 test starting from the closed position which had lasted over 60 minutes for both fire integrity and smoke leakage (ES60) but that it had no formal certification.2412 Quotation provided by Gilberts to PSB for Series 54 Dampers dated 22 January 2015 {GBL00000006/3}. (As we have said, the claim in respect of smoke leakage was wrong because the test had been started from the closed position.) The information that the test had been started from the closed position would have disclosed to a reasonably knowledgeable reader that the test had not been carried out entirely in accordance with the published standard, a conclusion reinforced by the reference to the absence of formal certification.
¶60.54 Another note recommended that the purchaser discuss the specific technical requirements of the damper with the relevant authority to ensure that it was acceptable but there is no evidence that any of the contractors involved in designing or installing the smoke control system discussed the matter with RBKC building control.
¶60.55 After receiving the original quotation from Gilberts, Mr Mahoney asked for further information about the Series 54 dampers, including test results, which were sent to him by email.2413 Email from Mark Griffiths to Hugh Mahoney {GBL00000005/2}. One of the documents attached to the email was a report dated 6 October 2011 of a fire resistance test on a Series 54 damper carried out by Exova on 23 August 2011 in accordance with BS EN 1366-2.2414 Email from Mark Griffiths to Hugh Mahoney {GBL00000005/2-3}. The report showed that the damper had been subjected to an integrity test with a threshold of 360m3/h∙m2 for over 60 minutes under a pressure of about 300 Pa.2415 Email from Mark Griffiths to Hugh Mahoney {GBL00000005/42}. The damper satisfied that test, with satisfactory performance for 74 minutes, but it failed to satisfy the requirement in relation to the leakage of smoke, for which the performance criterion was not to exceed 200m3/h∙m2 under a pressure of about 300 Pa.
225¶60.56 In the Conclusions section of the report the test result for smoke leakage was recorded as "0 minutes", which represented an immediate failure to satisfy the performance requirement.2416 Email from Mark Griffiths to Hugh Mahoney {GBL00000005/43}. In the Test Procedure section,2417 Email from Mark Griffiths to Hugh Mahoney {GBL00000005/8}. Exova recorded that the specimen had been assessed on its ability to comply with the performance criteria for integrity, insulation and smoke leakage as required by BS EN 1366-2:1999 but that at Gilberts' request the damper had been in the closed position at the commencement of the test and that the test had therefore not been conducted fully in accordance with the standard. As a result, it was not possible for the damper to obtain any kind of certification.
¶60.57 In spite of the incorrect and misleading statements about certification and testing in Gilberts' 2011 brochure and its first quotation, any recipient of Exova's report who carried out even a cursory review of those results would have understood that the Series 54 damper held no certification whatsoever and had failed the smoke leakage test immediately. The recipients of that report included Mr Mahoney and, in due course, RBKC building control.
¶60.58 Mr Mahoney appears to have thought that a certified smoke control damper of a size and configuration suitable for use in the walls at Grenfell Tower was not available.2418 Mahoney {Day155/203:20}-{Day151/205:2}. He thought that the Gilbert's dampers were the best that could be found to fit within the wall of the tower.2419 Mahoney {Day155/213:20}-{Day155/214:1}. In any event, PSB chose to specify the use of the Gilberts Series 54 damper, despite the fact that it had not been classified in accordance with any of the standards mentioned earlier and had not been shown to meet the alternative specifications for dampers to be used in smoke control systems contained in the guides published by the Smoke Control Association. He could instead have specified performance criteria or a certification standard, such as ES60, against which a search of available products could have been made. Having carried out a limited internet archive search (including of the archived version of the LPCB2420 Loss Prevention Certification Board. Redbook dated 23 August 2014) for dampers available on the market at the time, Dr Lane identified two smoke control dampers that might have been suitable for use in the system,2421 Lane, Addenda and Errata Report {BLARP20000044/4-5}. although she acknowledged that she did not have access to enough information to tell whether either of them could in fact have been used.
¶60.59 Mr Mahoney was aware when he designed the system that the shafts had to be protected2422 Mahoney {Day155/198:14-23}. and he discussed with Mr Cross Smith the need to have fire-rated ductwork,2423 Mahoney {Day155/200:2-7}. but he did not do enough to ensure that the dampers he selected to separate the protected shafts from the lobbies were fit for the purpose of protecting escape routes. Apart from anything else, in the absence of test data evidencing their durability there could be no confidence that the dampers would perform properly in a fire after many months of use in a combined environmental and smoke ventilation system.
226¶60.60 In due course, as a result of changes to the sizes of some of the dampers required, J S Wright asked Gilberts for another quotation.2424 Email from David Bradbury to Mark Griffiths {JSW00003607}. Following the receipt of that quotation, J S Wright placed an order for the products which Gilberts supplied.2425 Jones {GBL00000010/3} page 3, paragraph 10. Gilberts did not provide advice on the suitability of the Series 54 dampers for the proposed system, about which it had little or no information.2426 Jones {GBL00000010/3} page 3, paragraphs 11-17; {GBL00000010/4} page 4, paragraph 21.
¶60.61 Mr Hanson said that he had checked the specification of the Gilberts Series 54 damper2427 Hanson {Day154/204:5-8}. and had concluded on the basis of the product literature that it was regarded as being of an acceptable standard by the Smoke Control Association Guide 2012.2428 Hanson {Day154/208:12-15}. He said he could see from the drawings that the ducts were adequately fire-resistant.2429 Hanson {Day154/210:1-2}. He accepted that the dampers were of a lower standard than smoke control dampers but, in his opinion, they were still of an acceptable standard.2430 Hanson {Day154/214:10-15}.
¶60.62 The Gilbert Series 54 damper had not been tested in a way that demonstrated it was capable of acting as anything more than a ventilator, which required the lowest standard of performance in the event of a fire.2431 Lane, Phase 2 Module 7 Supplementary Report {BLARP20000043/264}. It was far removed from a smoke control damper, which would have been the appropriate product to install in a complex and multi-functional system of the kind designed by PSB. Although it received a copy of the Exova report, PSB does not appear to have reviewed the specification of the dampers or to have discussed it with building control.2432 Lay, Smoke Control System Report {LAY00000001/201}. It should have done so, but we have seen nothing to suggest that the implications of Exova's report were identified or acted upon. PSB should have realised that the Gilberts Series 54 damper was unsuitable for this application.
¶60.63 We do not know whether in 2015 fire and smoke dampers were available that would have been suitable for use in the system, but we are surprised that PSB does not appear to have tried to find appropriately certified dampers. At the very least, it should have told J S Wright about the limitations of the Series 54 damper so that the risks of using it could be properly assessed.
¶60.64 Mr Lay was of the opinion that, although the Series 54 dampers were not certified and did not meet the alternative Smoke Control Association recommendations, their performance characteristics could allow them to perform adequately as part of the system.2433 Lay, Smoke Control System Report {LAY00000001/203}. However, we do not agree. The Series 54 dampers did not meet the requirements for smoke leakage, which was important for protecting routes of escape, and had not been shown to meet the durability requirements. In the absence of reliable test results (i.e. results of tests conducted in accordance with recognised standards) from which to draw inferences, we cannot safely make any findings about how a component might have performed. The point of testing standards is to provide an assurance that a product meets the specified performance criteria and no such assurance was provided in relation to the Gilberts Series 54 dampers.
227Effect on the system's performance
¶60.65 It is possible that the use of the Gilberts Series 54 dampers contributed to the breach of compartmentation by permitting more smoke to pass from the shafts into some of the lobbies than would have been the case if appropriately certified dampers had been used, but it is impossible now to tell whether that was in fact the case. However, circumstances surrounding the choice of dampers demonstrates insufficient concern for fire safety to which we think it important to draw attention as part of the events which led to the tragedy.
Other shortcomings in the design process
The lack of design records
¶60.66 A recurring theme of our investigation into the design of the smoke ventilation system was a failure to create a clear record of its objectives and how its performance characteristics related to the fire strategy for the building. The importance of creating such a record was made clear in the 2012 version of the Smoke Control Association's guide, which strongly recommended that, except perhaps in the simplest cases, the objectives of the system, the circumstances to be calculated or modelled, the modelling criteria, the expected reporting and the criteria for success should all be agreed and recorded before the commencement of design.2434 Smoke Control Association Guide 2012 {LFB00059241/5} Introduction and fifth paragraph.
¶60.67 The Smoke Control Association Guide 2012 advised that the records should include at least: i. A description of the residential area and the proposed ventilation system. ii. The design criteria and performance objectives. iii. The range of circumstance in which it was intended to operate. iv. Details of the techniques used and related information. v. The results of the analysis. vi. A statement whether the design criteria and objectives have been met.2435 Smoke Control Association Guide 2012 {LFB00059241/14-15} paragraph 5.4.
¶60.68 That information was required in this case to enable the wider design team, and ultimately the TMO as the responsible person, to understand the design of the system and its limitations but not all of it had been recorded.
¶60.69 Information relating to the design of the system should also have been incorporated in the fire safety strategy but that was not done either. Instead, Issue 3 of the Draft Outline Fire Safety Strategy discussed the smoke control system in very general terms and left it to Max Fordham to take the matter forward. We consider that Exova and the TMO, as the client, should have ensured that the Outline Fire Safety Strategy specifically described the final design of the smoke control system and explained how it supported the fire safety strategy for the building. A fire safety strategy necessarily relies on certain assumptions, which should be made explicit.2436 Torero {Day289/7:5-25}. That was particularly important in this case, since the new system did not correspond directly to any design described in the available guidance.
228Extended travel distances
¶60.70 We heard evidence about the distances between the entrance doors to flats and the door to the stairs. The guidance in Approved Document B is that the distance in an unventilated part of an escape route should not exceed 7.5 metres.2437 Approved Document B {CLG00000224/28-30} Diagram 7, flats served by one common stair and Table 1. BS9991 contains similar guidance.2438 BS 9991:2011 (Fire safety in the design, management and use of residential buildings – Code of practice) {BSI00000621/36}.
¶60.71 Measurements were made of the maximum distance between the front doors of the flats and the doors to the stairs on Floors 4 to 23. They ranged from 9.3 metres (BRE2439 BRE Grenfell Tower Fire Investigation Report {MET00039807/24} paragraph 32.) to 10.3 metres (Dr Lane).2440 Lane, Phase 1 Report, Appendix J {BLAS0000037/25}. We do not consider the difference between 9.3 metres and 10.3 metres to be material. What is significant is that, even at 9.3 metres, the maximum distances exceeded that indicated by Approved Document B.
¶60.72 Mr Hanson accepted that if the travel distance exceeded 7.5 metres, the Smoke Control Association Guide indicated that the primary objective of the system should be the protection of both the lobby and the staircase.2441 Hanson {Day154/167:16-22}. His view, however, was that for an existing building it would be unreasonable to apply the standards applicable to a new building.2442 Hanson {Day154/169:5-9}.
¶60.73 Mr Lay also thought that if the travel distances in a building were excessive, it would not be appropriate to concentrate solely on protecting the stairs and that protection would also need to be provided to the lobby.2443 Lay {Day286/52:14}-{Day286/53:11}. He referred to the LGA Guide as indicating that extended travel distances of less than 10 metres in existing residential buildings would not be considered excessive and did not require mitigation. We consider, however, that some caution should be exercised in using the LGA Guide in this context, since it is intended to provide guidance on compliance with the Fire Safety Order and the Housing Act 2004, rather than the functional requirements of the Building Regulations and is directed at housing providers and enforcing authorities,2444 LGA Guide on Fire Safety in Purpose Built Blocks of Flats {CST00014237/13-14} paragraph 4.1-4.2. rather than designers of smoke control systems. Although that does not make it irrelevant, it is significant that the context is assessing existing fire safety arrangements, rather than controlled works under the Building Regulations. Furthermore, we note that Approved Document B stated at paragraph 0.21, that guidance documents intended specifically for assessing fire safety in existing buildings will often include provisions which are less onerous than those set out in Approved Document B and are therefore unlikely to be appropriate for use in relation to work controlled by the Building Regulations.2445 Approved Document B {CLG00000224/13} section 0.21.
¶60.74 The LGA Guide itself states that the primary guidance is that maximum travel distances should not exceed 7.5 metres;2446 LGA Guide on Fire Safety in Purpose Built Blocks of Flats {CST00014237/87} paragraph 58.24. goes on to recognise that some existing blocks of flats do not comply with that guidance,2447 LGA Guide on Fire Safety in Purpose Built Blocks of Flats {CST00014237/94} paragraph 62.1. giving rise to a need to consider the overall risk.2448 LGA Guide on Fire Safety in Purpose Built Blocks of Flats {CST00014237/94} paragraph 62.2. The LGA Guide also refers to compensatory measures, such as automatic fire detection and automatic fire suppression systems, which were not present in Grenfell Tower. It suggests that the acceptance of standards that differ from current benchmarks should be subject to careful scrutiny, which may require assessment by a suitable specialist,2449 LGA Guide on Fire Safety in Purpose Built Blocks of Flats {CST00014237/94} paragraphs 62.3-62.4. in this case a fire engineer.2450 Lay {Day286/63:9-25}. The LGA Guide goes on to say that in ventilated lobbies and corridors, increases from 7.5m up to 10m are likely to be acceptable in most situations with no additional measures.2451 LGA Guide on Fire Safety in Purpose Built Blocks of Flats {CST00014237/95-96} paragraph 62.7. However, we are not persuaded that any of the parties involved in the design of the new smoke ventilation system actually relied on the LGA Guide to support its design. It was not referred to in any of the design documents, the witness statements or the oral evidence of those who were involved at the time. Nonetheless, the travel distances at the tower exceeded 7.5 metres and some thought should therefore have been given to protecting the escape route within the lobbies.
229¶60.75 Mr Hanson said that he had thought about extended travel distances at the time but had not written anything down, although he agreed that such information would have been helpful.2452 Hanson {Day154/154:8}-{Day154/156:5}. Mr Cross Smith said that he did not recall any discussion about travel distances.2453 Cross Smith {Day157/138:12-21}. Mr Whyte said that there might have been some discussion of travel distances, but he could not recall when and was not himself aware that the travel distances were more than the guidance in Approved Document B.2454 Whyte {Day158/52:12}-{Day158/53:9}.
¶60.76 In the absence of any contemporaneous evidence we are not able to accept that there was any discussion with building control about the travel distances in the tower or the possible need for mitigation measures. We would have expected to have seen at least some record of such a discussion if it had occurred. Rather, the evidence suggests that the travel distances were overlooked or that it was assumed that they did not need to be considered because the increase in distance was only around 2 metres. That was not an acceptable approach. Proper consideration should have been given to whether the extended distance required mitigation. That is particularly so because the system was being changed and the focus of protection was being shifted from the lobby to the stairs. If that had been done, the design might have been considered acceptable despite the extended travel distance, taking in account the limited additional distance and the mitigation measures in place.2455 Menzies {Day169/32:22}-{Day169/33:10}.
¶60.77 Considering the system as part of the wider fire safety strategy was not the responsibility of PSB but of those who were responsible for drafting that strategy, principally Exova.2456 PSB Module 7 written closing submissions {PSB00001380/17} paragraph 82. When it was drafting the fire safety strategy Exova should have identified the extended travel distances in the lobbies and should have recorded its view of the need for mitigating measures to be provided. When the design of the system was changed, Exova should have been asked to consider the fire strategy again to ensure that it reflected developments in the design.
Leakage
¶60.78 Little consideration appears to have been given to how the new smoke ventilation system would operate under different conditions of air leakage that were reasonably foreseeable. In order to assess the likely performance of the system there would need to be at least some consideration of the circumstances in which it was expected to function. Leakage paths were relevant, because the ability of the system to protect the stairs would be affected by the source of air entering the lobby. For example, the system could extract air from the lobby at a rate of 5.0m3/s but might not be able to maintain an air flow velocity of 2.0m/s across the door to the stairs if air was able to enter the lobby from other sources.
230¶60.79 Dr Lane and Mr Lay both carried out calculations to demonstrate the effect of different combinations of door and window openings on the velocity of air through the door to the stairs. Although their analyses differed, each demonstrated that leakage paths were potentially significant. The calculations involved retrospective attempts to quantify the performance of the system; there was no evidence that those who designed it had carried out any similar analyses at the time.
¶60.80 Mr Mahoney said that the figure of 50% that he had used in his initial proposals to allow for unforeseen losses from all sources when calculating the appropriate rate of extraction was a notional number taken from the British Standard.2457 Mahoney {Day155/98:13-15}. Mr Lay did not think that that was the right way to design a system of that kind, but acknowledged that it had become normal in the industry to make assumptions about such things.2458 Lay {Day286/151:22}-{Day286/152:6}. He said that he would not have approved PSB's specification without having calculations or a computer model indicating the leakage in the system.2459 Lay {Day286/152:7-14}.
¶60.81 Dr Lane's view was that relying on experience to justify a suitable rate of extraction without explaining what assumptions about leakage had been made or without demonstrating how the rate had been calculated was not a reasonable professional approach. She said that it was not clear how Mr Mahoney had quantified the different elements that would cause resistance in the proposed system, such as leakage through the builders' work shafts and blemishes in the ductwork. Dr Lane's view was that it would be normal to identify them.2460 Lane {Day287/130:21}-{Day287/132:5}.
¶60.82 In its closing statement PSB accepted that those were matters which, with the benefit of hindsight, could, and should, have been spelled out in more detail in its technical submission.2461 PSB Module 7 written closing submissions {PSB00001380/22} paragraph 98. However, although PSB obviously needed to rely on its previous experience when designing the system, there still needed to be some consideration of the building itself and the circumstances in which the system would be expected to operate. That required at least some consideration of the potential leakage from the building's structure and routes of escape that would counteract the rate of extraction, rather than relying on a generic figure. The 5.0m3/s rate of extraction was a key part of the proposal and the primary basis on which the new system was said to be superior to the old one. We do not understand how that figure could reasonably be put forward as appropriate (if, for example, it failed to achieve an air flow of 2m/s across the door under certain conditions) without there being at least some consideration of how the particular nature of the building might affect leakage in a fire. The absence of any such analysis represents a defect in the design process.
Air movement into the lobby
¶60.83 Dr Lane pointed out that if a door to one of the flats was left open the system might continue to operate at maximum capacity, even if the door to the stairs were closed, because the pressure difference between the lobby and the stairwell would have been lost, causing smoke to be drawn from the flat into the lobby.2462 Lane {Day287/141:18}-{Day287/143:5}. She was of the view that if the designer considered that that risk was mitigated by the presence of self-closing devices on the doors of the flats, that ought to have been made clear.2463 Lane, Module 7 Supplementary Report {BLARP20000043/94}. It would have ensured that their importance was understood by those responsible for the operation and maintenance of the building.
231¶60.84 We do not think it is possible to know how the system would have responded if a flat door had been left open. Apart from anything else, the precise circumstances could have varied widely and could have included a tendency for the reduction in the air pressure in the lobby to draw the door closed. The possibility was not fanciful, however, and it was important for the designers of the system to identify the circumstances under which it would no longer be able to perform in accordance with its design. The design criteria should have been taken into account in the overall fire safety strategy for the building.
Commissioning the system
¶60.85 Proper commissioning of a new smoke ventilation system is of critical importance in ensuring that it is capable in practice of performing the function required of it. It therefore needs to be carried out with great care and attention to detail.
¶60.86 Granville Partlow, PSB's Group Service and Engineering Manager,2464 Partlow {PSB00001309/3} page 3, paragraph 11. carried out the final commissioning of the new system between 26 and 28 April 2016.2465 Partlow {Day156/19:14-18}. He accepted that there had been errors in the commissioning method statement, which he attributed to his having adapted the document rather than preparing it from scratch.2466 Partlow {Day156/32:10-14}. He had not noticed the mistakes in the document, including in the description of the system, until he had read it again for the purposes of making a statement for the Inquiry.
¶60.87 Mr Partlow told us that during the commissioning process he had checked that all the fireman's override switches were working, but certain matters escaped him.2467 Partlow {Day156/94:21-23}. PSB's technical submission said the fireman's override switches were in the stairs, when in fact they were in the lobbies, but Mr Partlow did not notice the discrepancy. It did not occur to him, therefore, that in the event of a fire they might be affected by rising temperatures in the lobbies, potentially leading to unintended activation.2468 Partlow {Day156/177:18-24}.
¶60.88 There was also some confusion about measuring flow rates. Mr Partlow did not understand why building control was asking for readings of extraction flow rates in cubic metres per second, which suggests a failure of communication between building control and those designing the system.2469 Partlow {Day156/166:9-11}. PSB did not measure the flow in that way but Mr Partlow asked Mr Whyte to measure the area of one of the doors which he used together with the average velocity across the open door to calculate the flow in cubic metres per second.2470 Partlow {Day156/167:13-24}; Partlow {Day156/167:13-24}; Whyte {Day158/80:6-25}.
¶60.89 When building control approved the proposed system on 24 June 2015 it gave no reasons for its decision but did say that it should conform to the Smoke Control Association Guide 2012.2471 Hanson {Day154/143:11-23}. That was repeated in a memorandum sent by Mr Hanson to Mr Hoban on 26 January 2016,2472 Hanson {Day154/144:8-16}. in which he said that by saying the system was acceptable he meant that it was compliant with functional requirements B1 and B5 of the Building Regulations.2473 Hanson {Day154/145:5-9}.
232¶60.90 The need for a cold smoke test of the system was also debated. Ms Menzies said that such a test should have been carried out as part of the commissioning process in order to demonstrate to building control that the system operated effectively. In her opinion that was an important part of the commissioning and acceptance process, since without one it would not be possible to know whether the system worked under different door-opening conditions. In her view, the failure to require a cold smoke test fell below the standard to be expected of a reasonable building control body. Mr Hanson did not think that carrying out a cold smoke test was an important part of commissioning any system protecting escape routes with extended travel distances, although he accepted it could be a useful guide.2474 Hanson {Day154/151:22}-{Day154/152:6}. Mr Lay did not expect cold smoke testing to be part of commissioning; he would expect to take flow measurements.2475 Lay {Day286/160:24}-{Day286/161:3}.
¶60.91 Mr Partlow said that a cold smoke test had not been considered in this case because the building was occupied and it would have been very frightening for residents to walk out of a flat and be confronted by a lobby full of smoke.2476 Partlow {Day156/191:6-8}. However, Ms Menzies, who has many years' experience as a building control officer, said that she had never heard it suggested that a cold smoke test might be a problem in an occupied building.2477 Menzies {Day169/61:4-9}.
¶60.92 We think that unless detailed flow measurements under different conditions of door opening had been made, a cold smoke test should have been performed as part of the commissioning process. The practical challenges identified by Mr Partlow were far from insurmountable. The inconvenience to residents and the additional cost was justified by the benefit of assessing the system's operation in circumstances approaching those in which it would be expected to function and was to be preferred to measuring flow rates.
¶60.93 There were other respects in which the commissioning process had not captured all the information required to demonstrate that the system performed as intended.2478 Lane {Day287/213:7}-{Day287/214:1}. They included a failure to record the performance of the fans, the commissioning of all dampers, door opening forces, or pressure measurements.2479 Lane, Phase 2 Module 3 Report {BLARP20000035/409} Sections 1-9 and 11.
¶60.94 Mr Hanson accepted that there should have been a record of door opening forces, at least for a representative number of doors. He said that his ability to scrutinise the commissioning report was limited because the RBKC building control team no longer had an engineer. It therefore had to rely on the professionalism of the installer and designer of the system.2480 Hanson {Day154/201:19-24}. Ms Menzies did not think that was a reasonable approach for building control to take if it had not seen some evidence that the door opening forces had in fact been tested.2481 Menzies {Day169/48:14-21}. She also considered that building control could not have considered whether the system ensured an adequate means of escape without some form of testing which demonstrated that a flow rate of 2m/s through the door to the stairs could be achieved in a variety of different conditions.2482 Menzies {Day169/47:15}-{Day169/48:8}.
233¶60.95 There was another reason why, in the opinion of Ms Menzies, building control should not have accepted the commissioning report. An additional vent had been added to the system at its suggestion after commissioning had been undertaken. In her view, the entire system needed to be commissioned after all the work on it had been completed.2483 Menzies {Day169/62:5}-{Day169/64:12}.
¶60.96 Overall, we consider that the commissioning process was not sufficient for building control to be satisfied that the system would perform as intended. That was in part because it was not provided with a set of data that enabled it to be confident that the system operated correctly, but also because it did not require other forms of testing, such as a cold smoke test, to make up for that omission. More generally, the commissioning documents did not describe the performance expected of the system, details of the situations for which it was designed or how it related to the building's fire safety strategy.
Maintenance of the system
¶60.97 By the time of the refurbishment the original smoke ventilation system had fallen into disrepair, partly as a result of inadequate maintenance,2484 See Chapter 43. and the evidence suggests that maintenance remained inadequate after the system had been replaced.
¶60.98 The TMO had no formal procedures of its own for the maintenance of the smoke ventilation system, having entered into a contract with Allied Protection Ltd for the inspection and servicing of fire safety equipment, including the smoke ventilation system, which included the following: a. the annual servicing and testing of hardwired standalone and linked smoke detection equipment in communal areas in accordance with British Standards; and
¶b. the six-monthly servicing of the smoke ventilation system in accordance with the manufacturer's instructions, including checking interfaces with the fire alarm or control system panel and the checking and servicing of all damper activators and associated mechanisms.2485 Packer {LAK00000525/3} page 3, paragraph 7.
¶60.99 Although Allied Protection was required to service the system at 6-monthly intervals in accordance with manufacturer's instructions, the TMO did not provide those instructions until 14th June 2017.2486 Packer {LAK00000525/3} page 3, paragraph 8.
¶60.100 Generally accepted standards for the maintenance of smoke control systems published by the British Standards Institution2487 BS EN 12101-6:2005, BS 5839-1:2013 (withdrawn 31.08.2017 and replaced by BS 5839-1:2017) and BS 9999:2008 (withdrawn 31.01.2017 and replaced by BS 9999:2017). included the need to test each zone of a smoke ventilation system separately, ensuring that any fans and powered exhaust ventilators operate correctly and that dampers close or, where relevant, open.2488 Lane, Phase 2 Module 3 Report, Sections 1-9 and 11 {BLARP20000035/498-499}.
234¶60.101 We were provided with copies of the inspection and servicing certificates produced by Allied Protection following maintenance visits to Grenfell Tower on 17 January 20172489 {LAK00000009}. and 15 May 2017.2490 {LAK00000011}. The visit on 17 January 2017 was carried out by Karl Russell. The certificate records that the smoke detectors were not tested, although the inspection should have included an operational test of the 26 smoke detectors between the ground floor and Floor 23. Moreover, there was no record in the call history of the auto-dialler that the smoke detectors had been activated, although they should have operated if the tests had been carried out properly.2491 {THL00000019}. The evidence suggests, therefore, that either the smoke detectors did not work or that an operational test of the system was not carried out on that occasion. The latter is the more likely explanation, because if the system had been tested and had failed to operate, that would have been recorded.
¶60.102 The inspection on 15 May 2017 was carried out by Barry McAuliffe. There were 20 logged activations of smoke detectors,2492 {THL00000019}. but there should have been 26 if all the smoke detectors had been tested properly. It was not possible to identify from the auto-dialler log which smoke detectors had been activated and which had not, but Mr McAuliffe said that he had not tested the ground floor lift lobby detectors because he had been called away to carry out an urgent repair.2493 McAuliffe {LAK00000522/4} page 4, paragraph 26.
¶60.103 Mr McAuliffe recorded his arrival time on 15 May 2017 as 12:15 and his departure time as 14.15, a period of two hours.2494 {LAK00000011}. On each operational test of the system the maintenance engineer was required, as a minimum, to carry out the following steps to ensure that the system and all its components were operating correctly:
¶a. Activate the system using a smoke detector.
¶b. Inspect the position of the dampers in the lobbies on all floors.
¶c. Inspect the position of the by-pass dampers at Level 2.
¶d. Inspect the operation of the smoke extraction fans at roof level.
¶e. Inspect the operation of the smoke extraction fans at Level 2.
¶f. Inspect the control panel to check that it correctly indicated the system operation, floor activation and status of all dampers.
¶g. Reset the control panel on the ground floor once all inspections of dampers and fans had been completed.2495 Lane, Phase 2 Module 3 Report {BLARP20000035/516} Sections 1-9 and 11.
¶60.104 Mr McAuliffe described testing one floor at a time by setting off each smoke detector head using his own artificial smoke and checking that the smoke extraction system started. He then proceeded to the control panel in the ground floor lobby and reset the system. He said he had done that for each floor, using the emergency stairs for access.2496 McAuliffe {LAK00000522/4} page 4, paragraph 25.
235¶60.105 The period from the start to the end of the 20 activations on that day recorded in the auto-dialler log was about 1 hour 15 minutes.2497 {THL00000019}. That left Mr McAuliffe about 4 minutes a floor to carry out the required tests, which we do not think was long enough to carry out the tests he described.2498 Lane, Phase 2 Module 3 Report {BLARP20000035/518} Sections 1-9 and 11.
¶60.106 When he was sent to inspect the system at Grenfell Tower Mr McAuliffe had had previous experience of only more basic smoke ventilation systems. He had not been provided with information about the system before his visit and called his manager to ask if he could decline the job. However, he was told to go ahead, despite making clear his lack of expertise.2499 McAuliffe {LAK00000524/1-2} pages 1-2, paragraph 5.
¶60.107 Mr McAuliffe accepted that he had not opened the grilles on each floor to check that the dampers had activated properly during the tests2500 McAuliffe {LAK00000524/2} page 2, paragraph 9. and if the grilles had not been opened, the dampers cannot have been inspected in sufficient detail to ensure that they sealed properly when closed.2501 Lay, Smoke Control System Report {LAY00000001/315}. It was not possible for all 91 dampers to be serviced and their operation checked during the relatively short visits made by Allied Protection, so the maintenance records did not provide any assurance that the system would operate correctly if a fire were to occur.2502 Lane, Phase 2 Module 3 Report {BLARP20000035/523} Sections 1-9 and 11.
¶60.108 Overall, the maintenance documentation provided for the smoke ventilation system was poor and did not satisfy the guidance in BS 9999: 2008.2503 The Code of practice for fire safety in the design, management and use of Buildings. Neither the limited weekly test carried out by Mr Steadman (a TMO estate services assistant) or Allied Protection's checks provided clear evidence of rigorous maintenance and inspection consistent with what was recommended by the guidance.2504 Lay, Smoke Control System Report {LAY00000001/316-317}.
¶60.109 The smoke ventilation system was complex and contained many separate mechanical components. Dampers were subject to repeated wear through regular opening and closing while operating in environmental mode and therefore required regular inspection and maintenance. However, Allied Protection carried out inspection and maintenance visits without sight of the manufacturer's instructions and sent an engineer to carry out the inspection on 15 May 2017 who lacked the skill to do the job properly.
¶60.110 There is little evidence that the fans on Level 2 had been properly inspected or maintained before the fire.2505 Lane, Phase 2 Module 3 Report {BLARP20000035/516} Sections 1-9 and 11. Mr McAuliffe said that he probably had inspected the operation of the smoke extraction fans at Level 2 but could not be certain.2506 McAuliffe {LAK00000524/6} page 6, paragraph 37. We are doubtful that he had, however, given that he was not aware of all the testing requirements,2507 McAuliffe {LAK00000524/6} page 6, paragraph 35. had little experience of complex systems of this type and had not been provided with a description of the system.2508 McAuliffe {LAK00000524/1-2} pages 1-2, paragraph 5. He did not test the by-pass damper at Level 2 and could not recall having tested the smoke extraction fans at roof level.2509 McAuliffe {LAK00000524/6} page 6, paragraph 37. Moreover, it would not have been possible for him to check the operation of the fans at Level 2 given the length of his visit
236and the extent of the other work he had to carry out.2510 Lane, Phase 2 Module 3 Report {BLARP20000035/497} Sections 1-9 and 11. There is little evidence, therefore, that the smoke extraction fan at Level 2 was inspected and maintained in a way that would give one confidence that it would operate effectively if there were a fire.
Operation of the system on the night of the fire
¶60.111 The smoke ventilation system was designed to respond to a fire on one floor of the building only. It follows that the fire that occurred at Grenfell Tower on 14 June 2017 far exceeded anything that it was or could reasonably have been designed to deal with effectively. The system itself was complex and was significantly damaged by the fire. We have carefully considered the available evidence that might shed light on its performance on the night of the fire but given the nature and scale of the disaster that evidence, which is mainly derived from the condition of the dampers and fans after the fire, is inevitably of limited value. Unfortunately, it does not enable us to draw any reliable conclusions about how the system performed during the fire or how it would have performed under the circumstances for which it had been designed.
Conclusions
¶60.112 The design of a new smoke ventilation system for Grenfell Tower provides a good illustration of the difficulties that can be faced by those seeking to refurbish an old building. Time and standards move on and it may be impossible because of the constraints imposed by the existing structure to provide systems that comply in all respects with current standards. In those circumstances the choice is between doing the best you can and doing nothing at all.
¶60.113 The Building Regulations do not require a building that undergoes a material alteration to comply with the current functional requirements on completion of the work, provided that it is no more unsatisfactory in relation to any particular requirement than it was before the work was carried out (the "no-worsening" principle). There may be good reasons for retaining that principle, but it may be due for reappraisal because one consequence is that many older buildings, including some that have been refurbished, do not meet current standards in relation to one or more of the functional requirements, including those relating to fire safety. The solution adopted by PSB in the present case was to use the existing structure in a different way that enabled it to double the volume of the shafts available for the extraction of smoke and to provide protection for the stairs that represented the main escape route as well as the means of access for the fire and rescue service.
¶60.114 The criticisms that were made of the design were directed in the main to PSB's failure to record the basis for its design decisions and to ensure that certain processes and calculations, in particular a CFD analysis, were carried out, either by itself or others, that would have enabled a more rigorous assessment of the proposed system to be made. As a result, although it had good grounds for feeling confident that the new system would be considerably better than the original (and therefore satisfy the "no worsening" principle), it was difficult for PSB to provide evidence to that effect and difficult also for PSB to rebut the suggestion that it had not carried out the kind of rigorous analysis of the system that was to be expected. Its difficulty in demonstrating both to building control and to us that the new system was better than the old one was made all the more difficult by the fact that the original system was inoperable and its performance therefore incapable of being measured.
237¶60.115 The failure to record the basis for design decisions is not in itself a criticism of the system that was produced, but it may indicate a failure to take the process as seriously as required. However, designers need to bear in mind that there are others who need to understand the basis of their decisions, not least any fire engineer charged with producing a fire safety strategy for the building and the person responsible for the operation and maintenance of the building when in occupation. Proper recording of the calculations and assumptions that underpin the design of a complex system of that kind is therefore essential for the safety of the occupants in the longer term. Those are matters of which building control must be aware and in relation to which it must insist on being provided with cogent evidence.
¶60.116 The need to choose equipment and materials that have been properly tested and shown to conform to the appropriate requirements (such as the dampers for the system) should not be a contentious matter, but again it requires the careful attention of the system designer, the fire engineer and building control to ensure that appropriate decisions and choices have been made.
239Chapter 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.2511 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.2512 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.2513 {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.2514 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.2515 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.2516 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.2517 Cash {Day49/80:22-24}; {Day49/81:7-13}. In his view that was normal practice, both on refurbishment projects and new construction projects.2518 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.2519 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.2520 {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.2521 {ART00006299/1}.
240Change 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.2522 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 2015.2523 CDM Regulations 2015 {INQ00011316/41-42} Schedule 4, paragraph 4. If the client failed to do so, it automatically became the principal designer itself.2524 CDM Regulations 2015 {INQ00011316/43} Schedule 4, paragraph 6(3).
¶61.7 On 2 February 2015, Keith Bushell sent an email to Nick Valente2525 Nick Valente was an assistant employer's agent employed by Artelia - Booth {ART00008527/3} page 3, paragraph 13. and Philip Booth2526 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.2527 {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 Artelia2528 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.2529 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. Claire Williams questioned whether Artelia should be a "designer" and on 21 July 2015, Colin James2530 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 2015.2531 {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.2532 {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.2533 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 2015.2534 {ART00004725/7} item 7.3.
241¶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.2535 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".2536 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.2537 {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.2538 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 file2539 CDM Regulations 2007 {INQ00011315/11} Regulation 20(2)(e). and pass it to the client at the end of the construction phase.2540 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,2541 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,2542 {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 2015.2543 {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}. 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.
242¶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.2544 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.2545 {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 purpose2546 {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.2547 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.2548 {RYD00080302}; {TMOM00001932}. The guidance describing the information that should be contained in a health and safety file has not materially changed since 1994.2549 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.2550 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.2551 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.2552 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.2553 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 1.2554 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.2555 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.2556 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.
243¶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.2557 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 fire2558 Lane {Day62/208:13-23}. and we express no view on the matter.
245Chapter 62: Building Control
¶62.1 In Chapter 48 of this report we described the provisions of the Building Act 1984 and the Building Regulations 2010 which govern the process by which building work falling within their scope is checked by local authorities for compliance with the statutory requirements. In this chapter, we examine the role that RBKC building control played in the refurbishment of Grenfell Tower and the events leading up to the issue of a completion certificate in July 2016.
¶62.2 We have been greatly assisted in our investigations by Beryl Menzies, FCABE, PPBEng, CBuildE, CABE, MRICS, a consultant in fire safety and fire-related building services. Ms Menzies has over 40 years' experience in building control, having worked in the Building Regulations Division of the Greater London Council between 1973 and 1985 and subsequently as a Chief Engineer at the London Borough of Tower Hamlets.2559 Menzies, Building Control {BMER0000004/3}. Her evidence was not challenged by any of the core participants and we were not asked to consider evidence from anyone else with similar professional experience. We have therefore relied on her expert opinion when reaching our conclusions. RBKC also made some admissions that the work of its employees fell below the standard that could reasonably be expected of competent building control officers.2560 RBKC Module 1 Opening Submissions {RBK00055479/26-27} paragraphs 97-105; RBKC Module 1 and 2 Closing Submissions {RBK00064252/1} paragraph 4.
¶62.3 RBKC was the building control body for the Grenfell Tower refurbishment. It was first approached by Studio E for initial advice in June 20122561 {SEA00000023}. and was involved with the refurbishment until a completion certificate was issued in July 2016.2562 {RBK00018811}. Within RBKC, two surveyors were largely responsible for the project, John Allen, the special projects manager, from 2012 to late 2013, and John Hoban, a senior surveyor, from late 2013 to July 2016.2563 Allen {RBK00033930/1-2} pages 1-2, paragraph 3, 5, 7 and 12; Hoban {RBK00033934/1} page 1, paragraph 4. Paul Hanson, a fire engineer in the department, also gave advice on matters concerning functional requirements B1 and B5 of the Building Regulations.2564 Hanson {RBK00033894/23-25} pages 23-25, paragraphs 124-140.
¶62.4 Until September 2013, the building control department had been managed by John Jackson.2565 Allen {RBK00033930/1} page 1, paragraph 3. As special projects manager John Allen had been responsible for the larger, more complicated buildings that RBKC had to deal with,2566 Allen {Day47/8:12-24}; Allen {RBK00033930/1} page 1, paragraphs 3-4. including the KALC project and the Grenfell Tower refurbishment,2567 Allen {Day47/95:9-16}. (although it is not clear that the Grenfell Tower refurbishment would have been considered a special project but for its link to the KALC project.)2568 Allen {Day47/95:17}-{Day47/96:3}. In September 2013 the department was restructured and John Allen became Building Control Manager.2569 Stallwood {RBK00033910/2} paragraph 6. During the restructuring, procedures for allocating work within the department changed. Thereafter work was allocated on a "patch" system, under which a surveyor was allocated to a particular area and was expected to take whatever work came into the department from that area, regardless of its scale or complexity.2570 Anon {RBK00029897/3} page 3, paragraph 10; Allen {Day47/97:5-20}; Hoban {Day45/101:13-20}. In December 2013, John Allen handed over day to day responsibility for KALC and the Grenfell refurbishment to John Hoban, although those projects were on another officer's "patch" at that time.2571 {SEA00010232}; Hoban {Day45/100:20}-{Day45/101:6}; {Day45/100:17-24}. Mr Allen initially allocated the Grenfell project to Jose Anon, the deputy Building Control Manager, but Mr Anon did not feel he had the capacity to take on the additional work at the time. He also had friends who lived in the tower and felt a need to keep a professional distance. Anon {RBK00029897/8} page 8, paragraph 37-38; Allen {RBK00033930/2} page 2, paragraphs 7 and 10.
246Means of Escape group
¶62.5 In addition to its team of surveyors, RBKC had what was known as the "Means of Escape" group, which operated as an internal consultancy on matters relating to functional requirements B1 (means of warning and escape) and B5 (access and facilities for the fire service).2572 Hanson {RBK00033894/5} page 5, paragraph 31. At the time of the refurbishment, the Means of Escape group consisted of just one person, Paul Hanson, a qualified fire engineer. Mr Hanson did not have the power to make decisions on full plans applications and did not conduct site inspections,2573 Hanson {RBK00033894/6} page 6, paragraph 38. although in the case of Grenfell Tower he did attend some meetings on site. He also attended a demonstration of the smoke control system in 2016.2574 {RBK00002965}; {RBK00010784}; {RBK00003856} (this document is misdated, and the meeting took place on 7 January 2016, see email attaching the minutes) {RBK00003855}. Although Mr Hoban formally had overall responsibility for building control matters, Mr Hanson effectively made decisions in relation to functional requirements B1 and B5 because Mr Hoban deferred to Mr Hanson on those matters. He also sought his advice on matters affecting functional requirements B2, B3 and B4 if he needed assistance.2575 Hoban {RBK00033934/4} page 4, paragraph 36; Hoban {RBK00050416/3} page 3, paragraph 9(b); Hoban {Day45/121:25}-{Day45/124:15}; {RBK00048682}; {RBK00052478/7}. The evidence suggests that the role of the Means of Escape group within the department was not well understood, particularly by other professionals working on the Grenfell refurbishment,2576 {RBK00048682/1}; Crawford {Day11/128:3}-{Day11/130:25}; Lawrence {Day25/173:20}-{Day25/174:18}. and Mr Hoban agreed that its relationship with the surveyors could have been clearer.2577 Hoban {Day45/124:16}-{Day45/125:12}. Ms Menzies thought that the department could have made better use of the Means of Escape group generally, in particular because Mr Hanson was a qualified fire engineer.2578 Menzies, Building Control {BMER0000004/52} paragraph 208.
Records
¶62.6 At the time of the refurbishment, RBKC's building control department kept records in a number of different ways: an electronic record-keeping system called "Acolaid", hard-copy files, electronic diaries, a hard-copy office diary and individual surveyors' notebooks.2579 Hoban {Day45/85:5}-{Day45/86:13}. The department adopted a "weeding" policy in relation to hard-copy files, with the result that not all the documents originally placed on the file were retained after a job had been closed.2580 Stallwood {RBK00033910/8} page 8, paragraphs 37-38. RBKC was unable to find the hard-copy file for the Grenfell refurbishment or Mr Hoban's personal notebooks covering the relevant period,2581 Stallwood {RBK00033910/4-6} pages 4-6, paragraphs 17-24 and 27; Hoban {RBK00050416/10} page 10, paragraph 33(e). but because of the weeding policy it is not clear which documents would have been retained. Mr Hoban thought that his plan check record sheet (an A4 sheet divided into topics such as "structure", "fire", "damp-proofing" and so on that he used when checking plans)2582 Hoban {Day45/80:13}-{Day45/81:8}. and his notes would probably have been weeded out.2583 Hoban {RBK00050416/5} page 5, paragraph 18.
247¶62.7 Mr Hoban did not use a tracker to monitor the drawings that had been submitted in support of the Grenfell full plans application,2584 Hoban {RBK00050416/6} page 6, paragraph 18(b)-(d). although the department did have a tracker which was available for surveyors to use, if a client requested it.2585 Allen {Day47/55:2}-{Day47/56:6}. However, we have seen no indication that the use of a tracker in connection with the refurbishment was proposed by building control or that it was requested by Studio E or Rydon.
¶62.8 The absence of complete contemporaneous records means that in many instances we have had to rely on Mr Hoban's personal recollection. That is unsatisfactory, not least because with the passage of time his memory had become understandably hazy and in places incomplete. Having said that, we are satisfied that we have been able to make reliable findings on the most important matters relating to building control's work on the Grenfell refurbishment. While some points of detail were in dispute, the key points about what Mr Hoban and his colleagues knew about the refurbishment and how they went about their work were not contentious.2586 RBKC Module 1 Opening Submissions {RBK00055479/26-27} paragraphs 97-105; RBKC Module 1 and 2 Closing Submissions {RBK00064252/1} paragraph 4.
Initial approach
¶62.9 Mr Allen first became aware of the Grenfell refurbishment when his manager, Mr Jackson, asked him to contact Terence Ashton of Exova2587 Allen {RBK00033930/2} page 2, paragraph 12. but he could not remember when that was or exactly what they had discussed.2588 Allen {Day47/173:17}-{Day47/174:10}. On 6 June 2012 Studio E approached building control seeking an indication of the fee likely to be charged for the project2589 {SEA00000023}; {SEA00004471}; Allen {Day47/202:4}-{Day47/203:1}. and on 31 October 2012 Mr Ashton sent John Allen a copy of issue 1 of Exova's Outline Fire Safety Strategy.2590 {EXO00001368}.
¶62.10 Mr Allen told us that he had not known that the refurbishment involved overcladding the building until around the time of the full plans application.2591 Allen {Day47/176:16}. It is true that the Outline Fire Safety Strategy would not have alerted him to that fact, since cladding was not mentioned in it,2592 {EXO00000519/4}. but in 2012 Studio E had given him an estimate of the costs involved which had included overcladding as a line item. When that was shown to him Mr Allen accepted that he probably had read it and that he had seen that the project involved overcladding.2593 {SEA00004471}; {ART00000053/4}; Allen {Day47/203:11}-{Day47/204:10}.
¶62.11 On 7 November 2012 Studio E and Exova had a meeting with building control to discuss the fire safety strategy.2594 The meeting was attended by John Allen and Dave Gammon from RBKC, Terry Ashton from Exova and Adrian Jess from Studio E {SEA00006526}. However, that meeting and subsequent communications between the design team and building control focused primarily on the lower four floors of the tower and the smoke ventilation system.2595 {EXO00001371}; {SEA00009805}; {SEA00000154}; {SEA00010232}; {SEA00010369}; {SEA00002629}; {SEA00002630}; {RBK00048649}; {RBK00003854}; {RBK00003810}. We deal with the smoke ventilation system, including the involvement of building control, in Chapter 60. The proposals for overcladding the tower were not discussed with building control either at that meeting or at any time before the full plans application was submitted in August 2014,2596 Sounes {Day21/132:23}-{Day21/133:3}; {Day21/164:4-24}; Ashton {Day17/70:7-11}; Allen {Day47/175:4-11}. but by the time he took over responsibility for the project in late 2013, John Hoban had become aware that it involved overcladding, because he had seen it on the drawings.2597 Hoban {Day45/138:2-11}. He told us that he would have expected a contractor or architect to seek advice from building control on cladding proposals before it submitted a full plans application, but neither Rydon nor Studio E had done so in this case.2598 Hoban {Day45/154:13-21}. Having seen that the project included overcladding, we consider that Mr Hoban should at that stage have taken the initiative and asked for more information about the project as a whole.2599 Menzies, Building Control {BMER0000004/9} paragraph 38; {BMER0000004/96} paragraph 303.
248¶62.12 On 25 October 2013, Studio E sent building control its proposed fire safety strategy for the tower, including Issue 2 of Exova's Outline Fire Safety Strategy.2600 {SEA00009805/2}. On 11 November 2013, John Allen told Bruce Sounes that he did not think that the information on the smoke control system that had so far been submitted was adequate to enable an effective consultation to be held with the fire authority on functional requirements B1 and B5 as required by the Fire Safety Order.2601 {SEA00009805/1}. In January 2014, Studio E sent an email to building control asking them to consult the fire authority notwithstanding their concerns about the extent of the information available to them,2602 {RBK00048649}. but they did not do so at that time.2603 {RBK00003854}. There was no further contact between the design team and building control between January 2014 and July 2014.2604 {RBK00003810}; Hoban {Day45/142:23}-{Day45/143:2}.
The full plans application
¶62.13 On 4 August 2014 Studio E submitted a signed but undated full plans application to building control.2605 {RYD00014378} and {RYD00014379}. RBKC acknowledged receipt of the application on 5 August 2014{RBK00027424} and that is the date that the five-week statutory time limit for a decision started to run. Menzies, Building Control {BMER0000004/86} paragraph 274. By that time some demolition and site clearance work had already begun2606 {RYD00012259}. and Mr Hoban considered that the application had been made rather late in the day.2607 Hoban {Day45/154:22-24}.
¶62.14 The drawings supporting the application were submitted nearly two months after the application itself2608 {RYD00018742}. and were incomplete.2609 Menzies {Day60/134:7}-{Day60/135:10}; Menzies, Building Control {BMER0000004/88}. At the very least they ought to have shown that in principle the refurbishment was capable of complying with functional requirements B1 to B5 of the Building Regulations, but they did not. Indeed, on the basis of the information provided in relation to functional requirement B1 (means of escape) alone, the application ought to have been rejected.2610 Menzies, Building Control {BMER0000004/9} paragraph 37. Mr Hoban's reason for not rejecting it was that he was trying to "work with" the applicant,2611 Hoban {Day45/160:13}-{Day45/161:12}; Menzies {Day60/33:9-21}. but that does not provide a good reason for failing to follow the statutory procedures. It does, however, reflect a fundamental misunderstanding among many of those who work in the construction industry, contractors, building control bodies and others, that the function of building control is to provide a service to applicants rather than to enforce the regulations robustly for the benefit of the community at large. In this case Mr Hoban accepted, in hindsight, that he ought to have rejected the full plans application for lacking the necessary supporting documentation.2612 Hoban {Day45/161:5-12}.
249¶62.15 As we have noted, a local authority is required to make a decision on a full plans application within five weeks of the deposit of the plans, although that can be extended by agreement to two months.2613 Menzies, Building Control {BMER0000004/14} paragraph 62. However, in this case building control did not make a decision within the prescribed time and there is no evidence that any extension of time was agreed with either Rydon or Studio E. Mr Allen said that the statutory time limits did not work in the context of design and build projects and that there was little point in rejecting an incomplete application because building work could still go on.2614 Allen {Day47/168:1-22}. We found that part of his evidence rather disturbing, because it amounted to saying that in his eyes the legislation had to give way to commercial considerations and the practices of the construction industry. We do not think that is a proper approach to take to a statutory function and we are fortified in that conclusion by the evidence of Ms Menzies, who could see no reason why the statutory time limits could not be adhered to in the case of design and build projects.2615 Menzies {Day60/33:4-7}; {Day60/34:2}-{Day60/35:2}.
¶62.16 There is a note on the Acolaid system dated 5 August 2014 headed "Meaningful response", in which Mr Hoban recorded that he had asked for details of the works,2616 {RBK00044876/69}. but he does not appear to have put his request in correspondence to Studio E or Rydon, either by email or letter. Mr Allen said that if a surveyor felt the need to go back to an applicant for further information, or if there was a problem with the application, such as a missing document or drawing, that should be recorded in writing, but in this case it was not.2617 Allen {Day47/48:7}-{Day47/49:25}. Unfortunately, Mr Hoban's response to the full plans application lacked rigour and fell short of the standard to be expected of a reasonably competent building control officer.2618 Menzies {Day60/126:9}-{Day60/127:15}; Menzies, Building Control {BMER0000004/9} paragraph 37; Menzies, Building Control {BMER0000004/98-99} paragraph 317. He accepted that if he had exercised reasonable care and skill he would have asked Studio E for the information that was needed,2619 Hoban {Day45/96:10-22}. but there is no record of his having done so, save for the "meaningful response" note, which does not record what further details he asked for.2620 {RBK00044876/69}.
¶62.17 We are not persuaded that Mr Hoban made a real effort to obtain the missing information from Studio E. He told us on more than one occasion that he had asked Rydon to provide him with information and that he had obtained some information for himself by looking at things on site,2621 Hoban {Day45/167:6-28}; {Day46/30:17}-{Day46/31:23}; {Day46/70:4-9}. but very little of that is documented in his notes and those requests, if they were made at all, were not followed up by letters or emails.2622 Hoban {Day45/32:2-5}. Mr Hoban ought to have asked for further information about the cladding at the full plans stage. His failure to do so represents a serious failing on the part of building control.2623 Menzies, Building Control {BMER0000004/9} paragraph 39; Menzies, Building Control {BMER0000004/96} paragraph 303.
250¶62.18 Mr Hoban made his first visit to the site on 29 August 2014.2624 {RBK00052478/8}; Hoban {Day45/142:4}. He discussed the works with Simon O'Connor, Rydon's Project Manager, but did not discuss the overcladding in any detail and was not told that there was an outstanding planning application to change the rainscreen from zinc to ACM.2625 {SEA00000189}; Hoban {Day45/144:21}-{Day45/147:13}. Mr Crawford said that he had met Mr Hoban on site during the week of 25 August 2014 and had given him some drawings to take away,2626 Crawford {SEA00014275/65} page 65, paragraph 206; Crawford {Day11/137:12}-{Day11/139:1}. but Mr Hoban did not recall any such meeting and said that he would not normally take drawings away from a site.2627 Hoban {Day45/145:14-16}; {Day45/148:1-21}; {Day45/153:10-24}. Mr O'Connor thought that Mr Crawford might have been at the initial meeting but did not remember Mr Hoban taking away any drawings.2628 O'Connor {Day26/217:11-18}. The contemporaneous evidence does not refer to Mr Hoban meeting Mr Crawford on site at that time or to his taking drawings away.2629 {SEA00000189}. On the basis of that evidence and the evidence of others, we think it likely that Mr Crawford's recollection that Mr Hoban took drawings away with him is mistaken.
¶62.19 Studio E did not submit any drawings to building control until 24 September 2014 when Mr Crawford sent a zip file attached to an email.2630 {RYD00018742}. The contents of the zip file did not reflect the drawings listed in the covering email2631 Menzies, Building Control {BMER0000004/88} paragraph 277-281. but Mr Hoban did not question that at the time.2632 Hoban {Day45/164:9}-{Day45/165:1}. Some of the drawings were older revisions or otherwise out of date; for example, they showed zinc rainscreen despite the fact that ACM had been in contemplation for many months and that the final colour and finish had been selected in July 2014, subject to planning approval.2633 {RYD00018750}. The drawings did not show the type of cladding panel or insulation being proposed.2634 {RYD00018750}.
¶62.20 Mr Hoban was aware that insufficient information about the cladding had been provided and was waiting for more to be sent to him.2635 Hoban {Day45/166:8-21}. He could not recall whether he had directly asked anyone about the nature of the insulation,2636 Hoban {Day45/166:8-21}. although he said that he had asked for more details "on the job".2637 Hoban {Day45/167:11-18}. He said that he had repeatedly asked for information and had discovered some for himself by talking with the contractor and seeing what was being done on site.2638 Hoban {Day45/173:10-17}. However, there is no record of his asking for more information, so if he did make any such request, he probably did so in the course of an informal conversation with someone from Rydon or Studio E on site. In any event, although no further details of the cladding were formally submitted, drawings sent to building control for other purposes in November 2014 and March 2015 showed ACM rainscreen panels on the facade.2639 {RYD00024038}; {SEA00000225}; {SEA00000252}; {HAR00003955}. Mr Hoban could not remember whether those drawings had alerted him to the change from zinc to ACM.2640 Hoban {Day46/7:11-13}.
251¶62.21 On 25 September 2014 RBKC planning officers approved the use of Reynobond smoke silver cassette-fixed ACM panels but Studio E did not inform building control of that at the time and, as we have noted, the drawings submitted to building control continued to refer to zinc panels.2641 {IBI00001802}; Hoban {Day45/197:20}-{Day45/198:4}.
¶62.22 On 29 September 2014 Studio E provided building control with a copy of Issue 3 of Exova's Outline Fire Safety Strategy.2642 {SEA00000215}. Mr Hoban could not remember whether he had read it at the time2643 Hoban {Day45/167:19}-{Day45/168:12}. and when it was shown to him in the course of his evidence he could not remember whether he had seen it before.2644 Hoban {Day45/168:20}-{Day45/168:6}. However, he had read Issue 2 when that had been sent to him and he was aware of what Exova had said in it about functional requirement B4.2645 Hoban {Day45/169:2}-{Day45/170:25}. Mr Hoban did not ask Exova (or anybody else for that matter) whether a further report had been or would be provided to complete the advice on functional requirement B4 and he conceded that he might not have gone back to the file and done everything necessary.2646 Hoban {Day45/169:2}-{Day45/170:25}. His failure to do so was another serious omission.
¶62.23 The same day, 29 September 2014, Mr Hoban also asked Mr Hanson for his comments.2647 {RBK00048693}. It is not clear whether he gave Mr Hanson a copy of Issue 3 of the Outline Fire Safety Strategy, which he received shortly afterwards, although he thought he had probably given him a hard copy.2648 Hoban {Day45/174:21}-{Day45/175:7}. (Mr Hanson had already been given a copy of Issue 2 by Studio E in October 2013.2649 {RBK00027290}.) Mr Hanson responded to Mr Hoban on 10 November 2014 saying that building control was not in a position to approve the proposals due to a lack of information about the extraction rate of the smoke ventilation system.2650 {RBK00033895/3}. Notwithstanding the absence of that information, on 11 November 2014, Mr Hoban submitted a formal request to the LFB for their comments on matters affecting functional requirements B1 and B5.2651 {RBK00033896}. For further detail on the process for consulting the LFB, see Menzies, Building Control {BMER0000004/139-140} paragraphs 461-467. He did not ask for its comments on functional requirement B4. The LFB would not normally comment on requirement B4 unless it had been specifically asked to do so.2652 Menzies, Building Control {BMER0000004/139-140} paragraph 466; FSIGN 501 {LFB00054550/10-12}.
¶62.24 On 18 November 2014 Mr Hoban told Neil Crawford that a formal decision notice on the full plans application would be forwarded shortly.2653 {RBK00002974}. At that point a response from the fire authority was still outstanding. Mr Hoban said that he had completed the standard form decision notice2654 A blank copy of the standard form can be found at {RBK00052487}. with a schedule of conditions but no copy was available and there is no record of the conditions. Mr Hoban said that he had put it out for the business support group to process, but there is no evidence that a notice was actually sent out2655 Hoban {RBK00050416/4}, page 4 paragraphs 12-14. A copy of a blank pro forma can be seen at {RBK00052487}. and Mr Hoban did not check whether it had been.2656 Hoban {Day45/194:3-14}.
¶62.25 There is no written record of the review of the full plans application that led Mr Hoban to issue the decision notice. He said that he had prepared a memorandum in relation to functional requirements B2, B3 and B42657 Hoban {Day45/185:17}-{Day45/186:9}. but no copy of any such document was made available to us. When asked how he had concluded that the proposals were likely to comply with the Building Regulations, Mr Hoban said that there would have been conditions2658 Hoban {Day45/187:3-8}. and when asked how he was able to issue a decision notice when Mr Hanson had said in his comments on functional requirement B1 that building control could not approve the proposals, he again said that it would be subject to conditions.2659 Hoban {Day45/187:19-25}. Mr Hoban apparently felt able to approve the full plans application, even though it did not contain any details of the proposed insulation or rainscreen panels, because he had included a condition that the facade as a whole should comply with section 12 of Approved Document B.2660 Hoban {Day45/188:2}-{Day45/190:25}. However, he did not have a specific recollection of the conditions he had attached to the decision notice and did not know whether he had recorded them elsewhere.2661 Hoban {Day45/192:13-20}; {Day45/193:8-20}. We have not seen any documents or correspondence referring to specific conditions of any kind. Mr Allen said that he would expect any conditions applied to a full plans approval to be recorded in writing and kept on the file.2662 Allen {Day47/51:4}-{Day47/52:12}. In our view the failure to keep a formal record of a matter of that kind was a very serious omission.
252¶62.26 On 12 December 2014, the LFB sent building control an email attaching a response to the consultation,2663 {RBK00033896}. but neither building control nor the LFB has been able to find the response itself.2664 {LFB00000300}. On 5 February 2016, following revisions to the smoke control proposals, building control consulted the LFB again2665 {RBK00033897}. and on 4 March 2016 the LFB expressed itself satisfied with the proposals.2666 {LFB00000291}; {LFB00000292}; {SEA00014148}; {SEA00014149}.
¶62.27 Mr Hoban approved the full plans application despite Mr Hanson's advice that there was insufficient information in relation to functional requirement B1 to enable that to be done. He also consulted the fire authority without sufficient information2667 Menzies {Day60/191:4-10}. and did not wait for a response before making his decision.2668 Mr Hoban informed Mr Crawford that a decision notice would be issued on 18 November 2014 {RBK00002974}, five days after he submitted the consultation request to the LFB {RBK00033896}. In addition, he failed to carry out a methodical review of the documents submitted to him and failed to notice obvious errors and inconsistencies in the drawings. He either did not read version 3 of Exova's Outline Fire Safety Strategy2669 Hoban {Day45/167:19}-{Day45/168:12}. or failed to appreciate that on its own terms it was incomplete in an important respect. The only evidence we have seen of a structured review of the full plans application is the memorandum prepared by Mr Hanson on Requirement B1.2670 {RBK00033895/3}. We accept that Mr Hoban probably made some notes on the application, but, bearing in mind the evidence we heard about his working practices at the time, we think it unlikely that he made any detailed notes of his assessment of functional requirements B2, B3 or B4. RBKC's own proforma for full plans applications, the P60 form, was basic and did not assist officers in carrying out a thorough review of a full plans application or recording their decisions.2671 Menzies, Building Control {BMER0000004/65}. We do not know what, if any, conditions Mr Hoban attached to his approval of the full plans, but if, as he suggested, they included a condition that the cladding comply with section 12 of Approved Document B, that would not have been sufficient to enable him to issue a completion certificate in due course. It ought to have required Studio E to provide sufficient evidence that functional requirements B2, B3 and B4 had been met.2672 Menzies {Day60/139:2}-{Day60/140:24}.
253¶62.28 Other formal aspects of the application were also handled poorly. RBKC failed to issue a formal decision notice, which it accepted was a failing on its part.2673 RBKC Module 1 Opening Submissions {RBK00055479/27} paragraph 100. Mr Hoban accepted that he ought to have ensured that the decision notice he had prepared had been sent out, but he failed to do so.2674 Hoban {Day45/194:10-13}. All in all, RBKC's approach to the full plans application shows a consistent lack of care and disregard for the procedural requirements of the Building Regulations. RBKC accepted that it bore some responsibility for the failure of the applicant to provide sufficient information in a structured and easily accessible format,2675 RBKC Module 1 Opening Submissions {RBK00055479/27} paragraph 99. but its failings at full plans stage were far more extensive than that. Mr Hoban failed to ask for basic information about the cladding, did not carry out a proper review of the information he was provided with and gave a conditional approval in circumstances where he ought to have rejected the application altogether. Mr Hoban's willingness to accommodate Studio E led him to disregard the primary function of building control, with the result that a critical opportunity to scrutinise the design of the cladding was missed.
Building control's knowledge of the construction of the external wall
Rainscreen
¶62.29 There is no correspondence or documentation of any kind passing between building control and any of those engaged on the refurbishment which touches on the question whether the proposed composition of the external wall complied with the Building Regulations. Moreover, no comprehensive package of up-to-date drawings and information was ever provided to building control.2676 Menzies {BMER0000004/96} paragraph 303; Hoban {Day45/173:4-9}. However, Mr Hoban knew that ACM was being used because the contractor had told him so at some stage and he had seen the materials once they had arrived on site.2677 Hoban {Day45/167:2-5}. He could not say with certainty that he had noticed that ACM had been indicated on the drawings sent to him in November 20142678 Hoban {Day46/3:18}-{Day46/4:10}. or March 2015,2679 Hoban {Day46/7:6-13}. but he thought that he had become aware that ACM panels were being used in around 2015 when he met Ben Bailey on site.2680 Hoban {Day45/197:2-15}; {Day45/200:24}-{Day45/201:24}. He was not surprised when he saw ACM being installed instead of zinc as, in his words, "things change".2681 Hoban {Day45/201:10-16}.
¶62.30 Mr Hoban said that after seeing ACM panels being installed on the building he had looked at the BBA certificate to see whether Reynobond ACM was Class 0,2682 Hoban {Day45/205:1-7}. although he said that he had probably looked only at the first page, from which he had understood that it was.2683 Hoban {Day46/18:12-25}; {Day46/23:14-17}; {Day46/23:11-17}. He had not mentioned that fact in any of his witness statements, however, and we think that if he had had a genuine recollection of checking the BBA certificate he would have said something about it. As a result we feel bound to treat his sudden recollection in the witness box as unreliable.
254¶62.31 Mr Hoban was not aware of the advice in Approved Document B that test evidence should be checked carefully2684 ADB Appendix A, note 2 {CLG00000224/119}. "Any test evidence used to substantiate the fire resistance rating of a construction should be carefully checked to ensure that it demonstrates compliance that is adequate and applicable to the intended use. Small differences in detail (such as fixing method, joints, dimensions and the introduction of insulation materials etc.) may significantly affect the rating." Hoban {Day46/25:14}-{Day46/26:1}. and at the time had not been aware of the way in which the polyethylene core of an ACM panel would react to fire.2685 Hoban {Day46/21:1-14}. He did not consider himself to be qualified to interpret test evidence and said that he would have needed the assistance of a fire engineer to do that.2686 Hoban {Day46/77:9-22}. Mr Allen did not consider that to be a specialist area, however, and considered that scrutinising manufacturers' information was a core function of a building control officer. He did not train his officers in how to go about it because he expected them to be able to do it already.2687 Allen {Day47/77:4-25}. Although Mr Anon, deputy Building Control Manager at RBKC, said that building control officers do not have the technical expertise to challenge a product's certification,2688 Anon {RBK00029897/8} page 8, paragraph 36. Ms Menzies agreed with Mr Allen.2689 Menzies {Day60/98:1}-{Day60/100:6}. Given the nature of their role, we are satisfied that building control officers can be expected to examine certificates of that kind to ascertain whether materials are suitable for the use for which they are intended.
¶62.32 In view of its importance in enabling the fire to spread around the tower, it is worth noting that Mr Hoban paid little, if any, attention to the crown during his review of the drawings or his visits to the site. He was aware that it was composed of ACM panels2690 Hoban {Day46/138:11-14}. and ought to have asked for more information about it. He should have given some thought to the risk that it might provide a means whereby fire could spread from one part of the building to another, but he failed to do so.2691 Menzies Building Control {BMER0000004/123} paragraph 405; Menzies {Day60/165:18}-{Day60/168:11}.
Insulation
¶62.33 Mr Hoban's evidence about his knowledge of the use of Celotex RS5000 in the external wall system and of its characteristics was not easy to follow. In his witness statements he did not specifically mention Celotex RS5000, although he did mention "Celotex insulation".2692 Hoban {RBK00050416/16} page 16, paragraph 43. He said that he had become aware that Celotex was to be used when he saw it on site, although he thought he might have been told about it before that.2693 Hoban {Day46/30:17-24}. He said in his statements that he had looked for information about the insulation on the Celotex website2694 Hoban {RBK00033934/8} page 8, paragraph 67; Hoban {RBK00050416/16} page 16, paragraph 43(a). and that what he had found there told him that it was fit for purpose.2695 Hoban {RBK00050416/17} paragraph 43(c). When he was asked about that, however, he was unable to recall any details of his research. He could not recall which product he had looked at on the Celotex website2696 Hoban {Day46/32:18-23}. but he said he would have noted the particular brand of product in his notebook when he was on site.2697 Hoban {Day46/33:2-10}. He told us that he had also looked up Celotex RS5000 on the LABC website,2698 Hoban {Day45/39:14-15}. but he had not mentioned that in either of his witness statements. He could not say whether he had seen the LABC certificate, either on the Celotex website or that of LABC itself.2699 Hoban {Day46/33:23}-{Day46/34:3}; {Day46/34:12-23}; {Day46/35:5-20}; {Day46/39:5-22}. He could not identify the document or text he had seen online, although he said that it might have contained statements similar to those in the LABC registered details and drawing document list for RS5000.2700 {CEL00000009}; Hoban {Day46/35:6}-{Day46/36:20}. That document said that Celotex RS5000 was suitable for use in rainscreen wall construction on buildings above 18 metres in height, had been successfully tested to BS 8414:2 2005, met the criteria set out in BR 135, and achieved a "Class 0" spread of flame rating.2701 {CEL00000009}. Mr Hoban could not say whether he had had any discussions about the insulation with Rydon, Studio E or Harley before looking it up on line2702 Hoban {Day46/31:14-17}. and he could not remember whether he had asked any of them for evidence that the insulation was appropriate for use in the cladding system.2703 Hoban {Day46/31:18-23}. However, he said he had felt confident that they knew what they were doing.2704 Hoban {Day46/32:9-12}.
255¶62.34 Mr Hoban said that he had been aware at the time that in other contexts manufacturers and others would misuse common expressions such as "fire retardant"2705 Hoban {Day46/52:14}-{Day46/54:6}. and that he had been aware of the need to check that any test relied upon by a manufacturer to demonstrate a product's suitability matched the intended use of the product.2706 Hoban {Day45/56:21}-{Day45/57:3}. He agreed that he had accepted at face value the statement that Celotex RS5000 had passed a BS 8414 test2707 Hoban {Day46/58:3-8}. and that he had not been entitled to assume that the design and construction team had checked the suitability of the cladding materials for themselves.2708 Hoban {Day46/59:10-13}.
¶62.35 Mr Hoban's evidence taken in the round has left us in some doubt about exactly what he did to identify the insulation or to satisfy himself that it complied with the Building Regulations. First, and most importantly, he failed to identify the fact that it was not of limited combustibility. It is not clear what information about Celotex he looked at online, but whatever it was, he did not examine it carefully. Instead, he simply accepted the assertion that RS5000 was suitable for use on tall buildings.2709 Hoban {Day46/45:4-15}. Critically, he failed to investigate whether the design of the cladding system proposed for Grenfell Tower was the same as that which had been tested in the BS 8414 test to which the product literature referred and did not ask Studio E to obtain test reports to justify its use. He accepted that that had been a serious failing on his part.2710 Hoban {Day46/45:11-16}.
¶62.36 Mr Hoban did not become aware that Kingspan insulation was being used and no one from Rydon, Harley or Studio E told him that it had been substituted for Celotex RS5000 on occasions.2711 Hoban {Day46/167:7-9}. Mr Hoban said that if he had known that he would have looked at the BBA certificate relating to it.2712 Hoban {Day46/168:10-17}.
Infill panels
¶62.37 Mr Hoban had not been aware that the P1 window infill panels contained Styrofoam2713 Hoban {Day46/26:3-20}. and did not know one way or another whether they complied with the guidance in paragraph 12.7 of Approved Document B, although he agreed that Styrofoam was not a material of limited combustibility.2714 Hoban {Day46/28:12-20}. However, in March 2015 he had been provided with a copy of the Harley Specification which showed that the P1 panels contained Styrofoam.2715 {SEA00000252}; {HAR00003955}. When asked why he did not notice that at the time, he said that he thought that he had not read the document properly2716 Hoban {Day46/26:22-23}. and had relied on the fact that Exova had been working on the project.2717 Hoban {Day46/27:16-21}. He also had not checked whether the Kingspan TP10 insulation in the P2 window infill panels was of limited combustibility.2718 Hoban {Day46/29:3-9}. Mr Hoban accepted that he ought to have questioned the use of those materials.2719 Hoban {Day46/29:10-18}. During his site visits he ought also to have noticed that gaps around the windows were being packed with insulation and should have checked whether the material being used was of limited combustibility.
256Cavity barriers
¶62.38 The full plans application did not include a cavity barrier strategy and the drawings supplied with it did not show any cavity barriers.2720 Hoban {Day46/91:21-24} Mr Hoban said that he would have expected them to be shown on the drawings and that he believed he had chased the contractor for information about them.2721 Hoban {Day46/92:2-12}. Studio E sent drawings showing cavity barriers to building control on 6 March 2015.2722 {RYD00034134}; drawings attached to the email included {RYD00034136}; {RYD00034135}; {RYD00034137}. They showed cavity barriers in line with compartment walls and floors but not around the windows.2723 {SEA00002499}. Mr Hoban said that he had understood that the framework supporting the window (which he had thought was steel) would act as a cavity barrier2724 Hoban {Day 46/95:6-14}. but when he gave evidence he could not recall why he had thought that.2725 Hoban {Day46/95:15}-{Day46/96:15}. It is not clear to us how he could have come to such an understanding, as there is no indication in the drawings that the framework was steel2726 Hoban {Day46/102:2-9}]. and Mr Lamb's evidence was that the use of steel had not been part of the design.2727 Lamb {Day38/146:2-15}. We are sceptical of his explanation and think it likely that it was an afterthought on his part to explain his failure to notice the omission. At all events, Mr Hoban did not check the windows on site to see whether cavity barriers had been installed around them2728 Hoban {Day46/98:4-22}. because the work that he had seen had, in his view, been of an adequate standard. He accepted, however, that he should have done so.2729 Hoban {Day46/99:9}-{Day46/100:8}.
Site visits
¶62.39 Mr Hoban told us that he had tried to visit the site once a month while the refurbishment was being carried out,2730 Hoban {RBK00050416/19} page 19, paragraph 48. but he visited it much less often than that during the period when the cladding was being installed because the pressure of work had increased and he trusted the professionals working on the project.2731 Hoban {Day46/164:16}-{Day46/166:21}; Hoban {RBK00033934/9} page 9, paragraph 84. He did not visit the site between 15 May 2015 and 17 August 2015.2732 See site visit records {RBK00052478/4}. In our view he should have visited more often during that period. The primary means of checking compliance with the Building Regulations is by visiting the site and looking at the work.2733 Menzies, Building Control {BMER0000004/61} paragraph 249. That calls for careful and detailed inspection. It is clear from Mr Hoban's evidence that even when he did visit the site he did not check the installation of the cladding thoroughly and missed important defects, such as poorly installed cavity barriers.2734 Hoban {Day46/127:6-12}; {Day46/130:21-25}.
257Regulation 38
¶62.40 Regulation 38 of the Building Regulations requires the person carrying out the works to pass fire safety information to the Responsible Person for the purposes of the Fire Safety Order.2735 See Chapter 48. Under regulation 17 of the Building Regulations, if the Fire Safety Order applies to a building on completion of the work (as in the case of Grenfell Tower), the local authority has a duty to issue a completion certificate confirming that the requirements of regulation 38 have been satisfied if, after taking all reasonable steps to do so, it has been able to ascertain that that is the case.
¶62.41 The fourth edition of the Building Regulations Procedural Guidance, which was in force until March 2015, advised that a copy of the information provided under regulation 38 should be sent to the local authority.2736 Lane, Phase 2, Fire Safety Information Report {BLARP20000021/88} paragraph 12.4.2. The fifth edition, in force from March 2015 to July 2020, does not contain that guidance,2737 Lane, Phase 2, Fire Safety Information Report {BLARP20000021/92} paragraph 12.5.7. but both the fourth and fifth editions advise that local authorities should not issue completion certificates unless they have received written confirmation from the applicant that the information required by regulation 38 has been provided to the Responsible Person.2738 Lane, Phase 2, Fire Safety Information Report {BLARP20000021/89} paragraph 12.4.4; Lane, Phase 2, Fire Safety Information Report {BLARP20000021/128} paragraph 14.7.3.
¶62.42 Mr Hoban was aware of the requirements of regulation 38 of the Building Regulations.2739 Hoban {Day46/197:18-23}. The practice at RBKC building control at the time of the Grenfell refurbishment was simply for officers informally to ask contractors whether they had provided the necessary information to building owners.2740 Hoban {Day46/199:23}-{Day46/200:16}; Allen {Day47/188:3}-{Day47/189:20}. Mr Allen said that they did not take independent steps to satisfy themselves that that had been done2741 Allen {Day47/189:11-16}. and that his personal practice was just to check with the client if someone happened to be on site towards the end of a project.2742 Allen {Day47/190:6-9}. Not surprisingly, Mr Hoban adopted the same practice. He believed that he had asked David Hughes whether Rydon had sent the information to the TMO, but he did not record either the question or the answer in writing.2743 Hoban {Day46/200:18-24} {Day46/201:23}.
¶62.43 The practice adopted by RBKC did not in our view amount to taking all reasonable steps to ascertain whether regulation 38 had been satisfied and did not follow the procedural guidance in force at the time. It appears that a similar practice may have been followed by other local authority building control departments. If so, it suggests a widespread failure by building control bodies to comply with the regulations. Ms Menzies accepted in hindsight that the practice was not appropriate and we agree. It does not excuse the casual approach demonstrated by RBKC building control in this case.
258Completion certificate
¶62.44 Mr Hoban caused a completion certificate for the Grenfell refurbishment to be issued in the name of Mr Allen on 7 July 2016.2744 {RBK00018811}. He agreed that, given that the external wall did not comply with functional requirement B4 of the Building Regulations, he should not have done so.2745 Hoban {Day46/204:7-14}. We accept that when he caused the certificate to be issued Mr Hoban thought that the functional requirements of the Building Regulations had been satisfied,2746 Hoban {Day46/204:12-14}. but his failure to scrutinise the design and execution of the work with sufficient rigour meant that his confidence was entirely misplaced. In its statements to the Inquiry RBKC has rightly accepted that a completion certificate should not have been issued.2747 RBKC Module 1 Opening Submissions {RBK00055479/27} paragraph 105.
General observations
¶62.45 The two most serious errors made by Mr Hoban were, first, the failure to recognise that the presence of unmodified polyethylene cores rendered the ACM panels highly combustible, and second, the failure to recognise that the insulation, which was visible on the tower during his site visits,2748 Hoban {Day46/167:21}-{Day46/168:17}. was not of limited combustibility. For reasons we have explained elsewhere, neither of the insulation products should have been used in the overcladding of Grenfell Tower. In his statements Mr Hoban seems to suggest that the contractor might have used materials other than those that had been specified, but when he gave evidence he made it clear that he knew at the time that ACM was being used.
¶62.46 At the time of the refurbishment Mr Hoban was a senior building control surveyor and had worked at RBKC as a building control officer for over 25 years. However, part of the reason for those major errors was that he did not possess the knowledge and experience to be expected of a building control officer dealing with a project of that kind. In particular, there were some significant gaps in his understanding of the Building Regulations and important industry guidance so far as they concerned fire safety. He was an associate member of the Chartered Association of Building Engineers but understood that his grade of membership did not require him to engage in any regular professional training2749 Hoban {Day45/13:23}-{Day45/14:7}. and to a large extent it was left to him to decide what additional training he required. He attended conferences from time to time and read professional magazines,2750 Hoban {Day45/14:3-24}, {Day45/23:16-23}. but the only formal training he received was that which was provided by the department.
¶62.47 The building control department organised lunchtime seminars between four and six times a year2751 Allen {Day47/74:12-18}. (although no lunchtime seminars were held in 2016).2752 {RBK00051200}. They were generally delivered by the department's managers and were directed to specific topics relating to building control, such as the publication of a new edition of an Approved Document.2753 Hoban {Day45/17:18-21}; {Day45/20:2-25}. Training was provided on the new Approved Document B following its publication in 2010. On occasions, manufacturers or other industry professionals, such as architects or surveyors, were invited to deliver lunchtime seminars,2754 Hoban {Day45/30:1-10}. but Mr Hoban had not attended any seminars dealing with the overcladding of high-rise residential buildings.2755 Hoban {Day45/27:13-15}. Nor was he given any specific training on any other industry guidance.2756 Hoban {Day45/21:4-17}.
259¶62.48 The Grenfell Tower refurbishment was Mr Hoban's first residential high-rise overcladding project and, apart from the KALC project, for which he also assumed responsibility, his first design and build project. Surprisingly, Mr Allen was not aware of either fact,2757 Hoban {Day45/183:20-24}; Allen {Day47/133:18}-{Day47/114:7}. although we think he should have been.
¶62.49 Mr Hoban had a very limited grasp of industry guidance on rainscreen cladding, such as BR 135, which he had not read,2758 Hoban {Day45/52:12}-{Day45/53:15}; {Day45/59:15-22}; Menzies, Building Control{BMER0000004/97} paragraph 310; Menzies {Day60/81:7}-{Day60/83:4}. and was not aware of BCA Technical Guidance Note 18.2759 Hoban {Day45/66:1-6}; {Day45/67:6-12}; Menzies {Day60/80:20}-{Day60/81:1}. He should have been. His understanding of the BS 8414 tests and how they could be used to demonstrate compliance with functional requirement B4 was limited.2760 Hoban {Day45/37:21}-{Day45/40:17}; {Day45/68:6-22}; Menzies {Day60/103:21-23; {Day60/104:5-23}. None of the gaps in Mr Hoban's knowledge appear to have come to the attention of his managers and Mr Hoban himself does not appear to have taken any steps to develop his knowledge in those areas as part of his work on the refurbishment. He was aware, however, that cladding could provide a means of fire spread and that there was a need to fit cavity barriers;2761 Hoban {Day45/54:21}-{Day45/59:5}; {Day45/61:15-16}. and he was aware that cladding fires had occurred, both in this country and abroad, having seen references to them in the media.2762 Hoban {Day45/91:9}-{Day45/96:15}. He was not aware of the warnings to be found in industry guidance that some materials used in facades could generate molten or flaming debris and thereby contribute to the spread of fire2763 {BRE00005554/18}; Hoban {Day45/59:4-13}; {CEL00003364/11}; Hoban {Day45/60:4-16}; {Day45/64:7-23}. and did not seem to have a firm grasp on whether materials such as PIR insulation were of limited combustibility. Again, he should have been aware of those matters.
¶62.50 Mr Hoban was aware that manufacturers tend to present fire test data in misleading ways, but he did not regard himself as competent to examine test data for himself. He thought that was the responsibility of a fire engineer. Mr Allen and Ms Menzies both took a different view. We agree with them that a building control officer should be capable of examining manufacturers' information and test data critically and we do not understand why Mr Hoban thought otherwise. If he did not know how to read manufacturers' information or how to evaluate test data, he ought to have asked someone within the department for assistance.
¶62.51 Mr Hoban's opinion that the materials proposed for the refurbishment were suitable for their purpose appears to have been based at least in part on the fact that none of the other experienced professionals working on the project ever suggested that they might not comply with the Building Regulations.2764 Hoban {RBK00050416/10} page 10, paragraph 34(a). He trusted Studio E and Exova because he had worked with them on the KALC project and was reassured by the fact that Mr Ashton was involved in the refurbishment.2765 Hoban {Day45/202:6}-{Day46/204:10}. In his written evidence Mr Hoban said that at an initial meeting on site in November 2014 he had been told by representatives of Max Fordham, Exova and Siderise2766 Hoban {RBK00050416/17} page 17, paragraph 44. that the cladding would comply with the standards set out in Approved Document B.2767 Hoban {RBK00033934/8} page 8, paragraph 67; Hoban {RBK00050416/18} page 18, paragraph 44(c). However, no one representing Siderise was present at that meeting, which the minutes suggest concerned the smoke control system,2768 {MAX00004666}; {RBK00052478/5}. and Mr Ashton categorically denied having said anything of the kind.2769 Ashton {Day17/121:12}. There is no record of any such assurance in Mr Hoban's notes of the meeting and Mr Crawford could not recall a meeting where the compliance of the cladding system with Approved Document B had been discussed with him.2770 Crawford {Day11/186:4-8}. Mr Hoban was very confident in his recollection and it is possible that in the course of a casual conversation someone said that the cladding would comply with Approved Document B, but whatever was said, we do not accept that Mr Hoban was justified in relying on it to the extent of allowing important matters on a substantial project of this kind to go unchecked.
260¶62.52 Mr Hoban also relied on statements made to him by others that the same cladding system had been used elsewhere on buildings over 18 metres in height. He told us that he had discussed the cladding system with a person whom he described as "Harley's engineer" and had been told that it had been installed on many buildings of a similar height and construction throughout England and Wales.2771 Hoban {RBK00050416/11} page 11, paragraph 34(d); Hoban {RBK00033934/7} page 7, paragraph 66; Hoban {Day46/72:20-25}. Mr Hoban said that the person he had spoken to was probably Ben Bailey,2772 Hoban {Day46/71:20-24}. who had been introduced to him as an engineer by Simon O'Connor, Rydon's project manager.2773 Hoban {Day46/72:2-14}. Mr Hoban did not accept that that had led him to be complacent about compliance, but he did accept that it gave him confidence that the system was not new and had been used elsewhere.2774 Hoban {Day46/76:17-22}. Ben Bailey could not recall having had any conversations with Mr Hoban about the cladding system2775 Ben Bailey {Day40/23:20}-{Day40/24:9}. and doubted that he had told him that the cladding would comply with Approved Document B.2776 Ben Bailey {Day40/20:19-22}.
¶62.53 ACM rainscreen panels and PIR insulation had been used in the overcladding of other buildings over 18 metres in height and others involved in the project also felt reassured by that.2777 Crawford {Day10/148:8-19}; Rek {Day12/73:19}-{Day12/75:9}; Osgood {Day30/118:16-20}; Harris {Day34/53:2-12}; Sakula {Day125/110:3}-{Day125/111:7}. We think it quite likely that someone from Harley, possibly Ben Bailey, did tell Mr Hoban that similar materials had been used on other buildings and that that contributed to his understanding that they complied with the Building Regulations. We think he assumed that the other professionals involved in the project had satisfied themselves that the materials proposed for use in the cladding complied with Approved Document B and that he allowed himself to be lulled into a false sense of security.
¶62.54 Although Mr Hoban must bear primary responsibility for the failure of RBKC's building control department to deal properly with the refurbishment project, his ability to carry out his task effectively was hampered by an excessive workload and poor management of the department as a whole. He told us that he had been very busy at the time of the refurbishment2778 Hoban {Day46/156:4}-{Day46/157:2}; {Day46/157:20}-{Day46/158:2}. and candidly accepted that that had affected his work. That had led him to give priority to other work, particularly in 2015 and 2016.2779 Hoban {Day46/164:22}-{Day46/166:12}.
261¶62.55 The restructuring of RBKC's building control department in 2013 involved a substantial reduction in numbers.2780 Allen {Day47/99:14}-{Day47/100:4}; {Day47/101:17-22}; {Day47/102:19}-{Day47/103:6}, Hoban {Day45/107:1}-{Day45/109:16}. Both Mr Hoban and Mr Hanson said that at times after the restructuring they had experienced heavy workloads.2781 Hoban {Day45/110:7}-{Day45/113:12}. Mr Hoban's appraisal for 2015-16 refers to Mr Hoban covering the work of other colleagues {RBK00048753/3} and {RBK00048753/7}. Mr Crawford gave evidence that Mr Hoban had told him that he was overseeing "hundreds of projects" but Mr Hoban did not recall saying that, although his recollection was that he had been overseeing between 120 and 130 projects. Crawford {Day11/131:18-25}; Hoban {Day45/111:14}-{Day45/112:2}. John Allen said that with a small team there would be rare occasions on which a lot of work would come in at the same time and he would have to manage that and plug gaps,2782 {Day47/46:20}-{Day47/47:3}. but he did not accept that there had been a substantial increase in the amount of Mr Hoban's work after the restructuring.2783 Allen {Day47/121:13}-{Day47/123:20}. He also said that he had met his officers monthly to confirm that their workload was manageable and find out whether help was needed.2784 Allen {RBK00033930/3} page 3, paragraph 16; Mr Hoban agreed that he would meet Mr Allen monthly but said that his workload had not been discussed. Hoban {Day45/115:3-16}. Mr Allen could recall occasions on which he had offered Mr Hoban help and had reallocated some work to other officers.2785 Allen {Day47/120:24}-{Day47/121:12}. Mr Hoban said that he had asked for help in 2015 but his suggestions for lightening his load came at that time had come to nothing.2786 Hoban {Day46/157:20}-{Day46/158:2}. After he had left the witness box Mr Allen disclosed to the Inquiry his notes of his meetings with Mr Hoban. They show that Mr Allen had been aware that Mr Hoban had been struggling to carry out site visits between May 2014 and October 20152787 {ALL00000003/3}-{ALL00000003/9}. and that in December 2015 Mr Hoban's records were not up to date.2788 {ALL00000003/9}.
¶62.56 There is some suggestion in the documents that in 2014 the building control department was overwhelmed with work.2789 {RYD00004218}. Mr Hoban told Neil Crawford that he was working on hundreds of projects, although Mr Crawford thought at the time that he might have been exaggerating.2790 Crawford {Day11/131:18-24}. Mr Hoban told us, however, that at that time he had been coming in to work at weekends2791 Hoban {Day45/116:5-18}. and although Mr Allen did not think that the department as a whole was overstretched,2792 Allen {Day47/105:8-10}. we think that Mr Hoban clearly was. At times during the period between 2014 and 2016 he was unable to manage his workload and the quality of his work suffered as a result. He did not feel able to ask for support from his manager and there was no one else to whom he could take his concerns.2793 Hoban {Day46/158:22}; {Day46/159:12}-{Day46/160:3}; Allen {Day47/137:18}-{Day47/138:17}. As a result, he gave priority to other projects, particularly in April 2015 when an additional area or "patch" was allocated to him.2794 Hoban {Day46/156:4}-{Day46.157:2}. He said that, in hindsight, he wished that he had been given more time to deal with the Grenfell refurbishment.2795 Hoban {Day46/212:22}-{Day46/213:8}; {Day46/215:21}-{Day46/216:2}. Mr Hoban was also dealing with difficulties in his personal life during the summer of 2016, which he accepted may have meant that he did not do things as he should have done.2796 Hoban {Day45/170:18}-{Day45/171:6}.
262¶62.57 There was also a failure by RBKC's building control department to ensure that officers within the department received the training they needed to do their work properly. A building control body should provide continuing professional development for its officers,2797 Menzies {Day60/51:6-9}; {Day60/51:19}-{Day60/52:9}. as is reflected in the Building Control Performance Standards.2798 Menzies, Building Control {BMER0000004/45} paragraph 178(a). As a member of the Royal Institute of Chartered Surveyors, Mr Allen was required to undertake regular training, and in the years 2013 to 2017 he had exceeded the minimum hours required of him. He took responsibility for providing technical training to his officers on matters to do with the Building Regulations,2799 Allen {Day47/72:19-35}. but did not organise training on Approved Document B generally or on the fire safety risks posed by cladding systems on high-rise buildings. Similarly, there does not appear to have been any system for ensuring that officers had the knowledge and understanding to examine manufacturers' information critically, nor were they told that it was important to read certificates, such as BBA certificates, critically and in their entirety. Mr Allen expected his officers to possess those skills already.2800 Allen {Day47/80:1-15}. We do not think that building control officers would normally expect to receive formal training on examining product literature, but that they would normally acquire that skill through their work and from discussions with others.2801 Menzies {Day60/99:20-22}.
¶62.58 On 31 December 2013, Paul Hanson sent Mr Allen a copy of a guide published by the British Standards Institution (BSI) entitled "Don't be a flaming liability".2802 {RBK00059350}; {RBK00059351}. The covering email drew attention to confusion within the construction industry about the meaning of Class 0 and the tendency of manufacturers to make misleading statements about the fire performance of their products. The guide itself drew attention to the fact that manufacturers often wrongly refer to Class 0 as meaning "fireproof". Mr Allen was aware of confusion in the industry about the meaning of Class 0.2803 Allen {Day47/151:18}-{Day47/153:1}. Mr Hoban could not recall whether he had been aware of it2804 Hoban {Day46/47:20-24}. but he had been aware of manufacturers' propensity to use misleading terms more generally.2805 Hoban {Day46/51:18-25}, {Day46/52:14-25}, {Day46/53:23-24}.
¶62.59 In October 2015, Jose Anon (John Allen's deputy at the time) attended the London District Surveyors' general meeting where those present discussed a building in Southwark over 18 metres in height on which PIR insulation had been installed. They were told that Kingspan had confirmed that its PIR insulation was combustible. The notes of the meeting also referred to the need for cladding to be of limited combustibility.2806 {RBK00001221/4}. Mr Allen did not know whether Mr Anon had shared that information with the RBKC building control team2807 Allen {Day47/85:12-16}. but in our view Mr Anon should have ensured that information of that kind was disseminated through the department.
¶62.60 Mr Allen told us that he had regular meetings with the officers and would assess their general competence2808 Allen {Day47/78:1-11}. but we saw no concrete evidence to suggest that he actively checked the officers' skills to ensure that they had a basic knowledge and understanding of the problems that could arise. The failure to monitor the knowledge and skills of individual officers and to ensure that they received the training needed for them to carry out their function effectively was in our view a serious weakness in the way RBKC's building control department was run. It was compounded by a failure to recognise that Mr Hoban was struggling to keep up with the work allocated to him and to take steps to ensure that he had the time and knowledge needed properly to oversee a project as substantial as the Grenfell refurbishment. The absence of a quality management system meant that the defects in Mr Hoban's work were not identified.
263¶62.61 Record-keeping within the department was poor. RBKC accepted that there was no formal procedure for tracking the progress of applications for building control approval and that that was a failure on its part. In addition, Mr Hoban's own record-keeping was poor. He failed to make an electronic record of the conditions applied to the full plans approval and failed to record the full extent of his site visits on the Acolaid system. Someone ought to have noticed that at the time and taken steps to address it. Mr Allen was aware that Mr Hoban was behind in writing up site visit notes.2809 {ALL00000003/9}.
¶62.62 In addition to the electronic file the department maintained a paper file. Unfortunately, however, that file has been lost. That is itself a ground of criticism, but RBKC's practice of weeding files before they were sent for storage means that even if the paper file had been available, the information it contained about Mr Hoban's work on the refurbishment was likely to be limited. Weeding of files is to be discouraged because it carries a high risk that documents whose true significance is not appreciated at the time are likely to be lost. The department's poor record-keeping practices have hampered our investigation.
¶62.63 We have no doubt that the shortcomings in the management of the department to which we have referred played a significant part in Mr Hoban's failure to carry out his role properly.
¶62.64 In its opening and closing statements, RBKC candidly admitted that the work of its building control officers fell below the standard that could reasonably be expected of them, but in our view its admissions did not cover the full extent of its failures. Although we have found that other parties, in particular those responsible for the design of the cladding, bear considerable responsibility for the fact that following the refurbishment the external wall of Grenfell Tower did not comply with the Building Regulations and was dangerous, building control was the last line of defence and had a statutory obligation to check for compliance with the Building Regulations. It had a responsibility to protect the public and it wholly failed to perform that function. It therefore bears considerable responsibility for the dangerous condition of Grenfell Tower immediately on completion of the refurbishment.
265Chapter 63: The contribution of Studio E
Introduction
¶63.1 Studio E was the architect for the Grenfell Tower refurbishment. It provided architectural services in respect of the project between approximately February 2012 and July 2016. As architect, Studio E had primary responsibility for the design of the facade of Grenfell Tower, among other aspects of the refurbishment. We have concluded that Studio E fell well below the standard to be expected of a reasonably competent architect in respect of that work. Its failures relating to the design of the external wall and the selection of materials to be used in its construction had catastrophic consequences. Studio E therefore bears a very significant degree of responsibility for the disaster.
Paul Hyett's evidence
¶63.2 Since we could foresee that questions of architectural practice might arise in the course of our investigations, we instructed Mr Paul Hyett to prepare a written report dealing with the various aspects of the refurbishment, including the professional standards to be expected of a reasonably competent architect, and the work of Studio E.2810 {PHYR0000032}; His main report was dated October 2019 and was revised in August 2020 {PHYR0000024}-{PHYR0000037}; He also produced a supplemental report in September 2020 which provided additional commentary on the opinions set out in his original report {PHYS0000001}-{PHYS0000005}. In its closing statement Studio E suggested that Mr Hyett did not have the experience or expertise needed to express an opinion on any aspect of overcladding a high-rise building, having had little or no personal experience of such work. It also suggested that, when expressing views about the use of the materials used in the cladding, he had ignored the fact that similar materials had been used on many buildings across the country on which reputable architects had presumably been employed. He had thus chosen not to consider evidence of what a responsible body of professional architects would have done at the time of the Grenfell Tower refurbishment. We were therefore asked to place little or no weight on his evidence.2811 {SEA00014645/2} paragraph 1.5.
¶63.3 It is not in dispute, however, that Mr Hyett has had a long and distinguished career as an architect, including over 40 years of post-qualification experience in England and internationally. Between 2004 and 2020 he was a principal at HKS Architects2812 Hyett, Module 1 Report (revised) {PHYR0000026/2} paragraph 1.1.5. before retiring in 2020 to run a consultancy advising on architectural services.2813 Hyett {Day63/10:1-6}. He is a member of the Royal Institute of British Architects ("RIBA") and was its President from September 2000 to August 2002.2814 Hyett, Module 1 Report (revised) {PHYR0000026/2} paragraph 1.1.2. He also has a special interest in and experience of the education of architects. He was the RIBA Council member responsible for architectural education from 1998 to 2001, has acted as an external examiner at various universities, reported to the Burton Review of Architectural Education and later acted as deputy chair to the Stansfield Smith Review of Architectural Education. He is an honorary fellow of the American Institute of Architecture, the Royal Society of Architects in Wales and the Chartered Association of Building Engineers.2815 Hyett, Module 1 Report (revised) {PHYR0000035} Appendix 4; For discussion of Mr Hyett's previous experience on particular building projects, including high-rise overcladding projects, see Hyett {Day63/54:18}-{Day63/60:16}.
266¶63.4 Mr Hyett candidly accepted that his personal experience of overcladding projects was limited.2816 Hyett {Day63/55:2-12}. However, the breadth and depth of his career made him well qualified to advise on how an architectural practice should approach a project that is outside the scope of its primary expertise. Much of his evidence was directed to identifying the steps that a competent practice should take and the questions it should ask itself in those circumstances and did not require direct experience of overcladding projects. We have no evidence of the circumstances in which similar materials may have been used on other buildings and in any event, we do not think that the use of what may have been inappropriate materials in other circumstances can assist us. In view of Mr Hyett's professional experience we are satisfied that he was well qualified to give evidence about the standards that could reasonably be expected of a firm like Studio E when undertaking a new project such as the Grenfell Tower refurbishment. In general, we found his evidence to be thorough and careful, reflecting an awareness of what it was reasonable to expect from an architect in general practice. It is worth noting that Studio E did not ask us to hear evidence from someone whose opinions differed from his.
Studio E's experience and expertise
¶63.5 The refurbishment of Grenfell Tower was a new type of project for Studio E, which did not have any significant experience in refurbishing or overcladding high-rise residential buildings.2817 Kuszell {Day6/20:7-19}; {Day6/11:19-22}; Sounes {Day6/173:14-16}; Sounes {SEA00014273/114} page 114, paragraph 271; Hyett, Module 1 Report (revised) {PHYR0000027/15} page 15, paragraph 2.5.5; {PHYR0000027/16} page 16, paragraph 2.5.12(a). Andrzej Kuszell accepted that it is unlikely that the firm would have won the commission if it had been put out to tender because of its lack of relevant experience.2818 Kuszell {Day6/70:10-16}. Having said that, we do not think that Studio E can be criticised for accepting the appointment, because architects can be expected to take on work outside their traditional areas of specialism from time to time.2819 Hyett, Module 1 Report (revised) {PHYR0000027/17} paragraph 2.5.12(b); {PHYR0000027/18} paragraph 2.5.14. Hyett {Day63/80:5-18}; Hyett {Day63/82:7}-{Day63/83:17}. However, even before it had agreed to undertake the project, it should have been readily apparent to Mr Kuszell that none of the existing partners or employees had the relevant knowledge, experience or skills that would be needed. Indeed, Bruce Sounes appears to have recognised that some steps were required to improve existing knowledge and skills because he told Mr Kuszell in February 2012 that Studio E was "a little green on process and technicality" and proposed "some rapid CDP" [sic].2820 {SEA00003567}. However, he told us that his concerns related to the logistics of carrying out work in an occupied building rather than designing the external wall, which he considered to be straightforward.2821 Sounes {Day6/186:1-14}; {Day6/187:2-7}; {Day6/192:12-16}. In the end the "rapid CPD" consisted of nothing more than a discussion with Max Fordham and some research on the internet into overcladding high-rise residential buildings.2822 Sounes {Day6/192: 3-16}; {Day6/192:18}-{Day6/193:14}.
267¶63.6 In our view it was necessary for Studio E to engage someone who could bring to the firm specific experience of overcladding a high-rise residential building2823 Hyett {Day63/86:2}-{Day63/87:23}; {Day64/3:20}-{Day64/4:3}; Hyett, Module 1 Report (revised) {PHYR0000027/17} paragraph 2.5.12(b) and {PHYR0000027/18} paragraph 2.5.14; Hyett {Day63/80:5-18}; {Day63/82:7}-{Day63/83:17}. to ensure that it could provide the necessary services with appropriate skill and care.2824 Hyett, Module 1 Report (revised) {PHYR0000027/17} paragraph 2.5.12(b); {PHYR0000027/18} paragraph 2.5.14; Hyett {Day63/80:5-18}; {Day63/82:7}-{Day63/83:17}. However, Studio E did not do so and appears to have thought, both at the time and in hindsight, that that was unnecessary because it could acquire the necessary knowledge and skills as the project progressed.2825 Kuszell {SEA00014271/11} page 11, paragraph 41; Kuszell {Day6/77:1}-{Day6/78:14}, {Day6/79:12}-{Day6/80:24}; Sounes {Day6/199:11-17}. As a result it failed to ensure that it was properly equipped to perform its obligations to the TMO.
Studio E's role and responsibilities
¶63.7 Studio E was appointed as lead consultant and lead designer. As lead consultant it was responsible for advising on the need for, and the scope of services to be provided by, consultants, specialists, sub-contractors and suppliers and for monitoring the work of other consultants. As lead designer it was responsible for co-ordinating the design of all constructional elements, including work by consultants, specialists and suppliers and for determining materials, elements and components.2826 {SEA00009824/5}. However, Studio E appears to have laboured under a fundamental misunderstanding about the nature of its obligations. As a result, it treated sub-contractors and consultants as solely responsible for their work and assumed, without enquiry, that it met the required standards. Throughout its evidence and submissions to the Inquiry, Studio E's witnesses sought to place responsibility on others, such as Max Fordham, Exova, Harley and building control for ensuring that work was of the required standard. In particular, Studio E maintained that it was for others to ensure that materials chosen for use in the construction of the cladding were suitable and would ensure compliance with the Building Regulations. That was clearly wrong. Although others involved in the refurbishment had incurred separate obligations of their own in relation to the quality of the work and materials used, Studio E had an overriding obligation, initially to the TMO and subsequently to Rydon, to ensure that the work was carried out properly and the choices of materials were suitable.
The outline design
¶63.8 Bruce Sounes was given the responsibility of managing the project on behalf of Studio E. He said that he had been aware in a general way of the requirements of Part B of Schedule 1 to the Building Regulations and Approved Document B, but he did not take any steps to familiarise himself with it in any detail at the beginning of the project and did not take the trouble to understand its significance for the project he was taking on.2827 Sounes {Day7/132:7-21}. He occasionally referred to Approved Document B2828 Sounes {Day7/135:6-9}. but did not read the guidance relating to requirement B4 and did not appear to have any clear understanding of what it entailed.2829 Sounes {Day7/136:6-20}.
268¶63.9 Although Mr Sounes agreed that it was Studio E's responsibility to investigate any legislative requirements relating to the project at the earliest opportunity in the design process,2830 Hyett {Day64/41:4-18}; {Day64/55:12-16}; Hyett, Module 1 Report (revised) {PHYR0000027/46} paragraph 2.9.2 and 2.9.4; {PHYR0000027/47-48} paragraphs 2.9.6 and 2.9.8; Hyett {Day64/41:19-24}; Sounes {Day7/85:1-8}; {Day7/88:1-18}; {Day7/127:8-22}; {Day7/128:18-23}; {Day7/130:14}-{Day7/131:9}; {Day7/184:15-19}; {Day7/134:25}-{Day7/135:5}. he did not do so or ensure that someone else did. That was a basic error and his consequent ignorance of paragraphs 12.5 to 12.9 of Approved Document B meant that he was unaware of the guidance it contained on the risks arising from the use of certain materials and the ways in which compliance with functional requirement B4(1) could be achieved. He therefore gave no thought to the manner in which compliance was to be ensured.2831 Hyett {Day64/43:6}-{Day64/44:14}; {Day64/58:5-9}. In its opening statement Studio E suggested that, taken as a whole, its design might have been capable of complying with the Building Regulations (presumably when the work had been completed) and that projects often proceed to advanced stages with designs in relation to which the method of achieving compliance with the Building Regulations has not yet been fully considered.2832 Studio E's written opening statement {SEA00014642/20} paragraphs 9.10 and 9.11. However, that is not consistent with Mr Sounes' own evidence2833 See the references at footnote [2655] above. or with the terms of the contract between Studio E and the TMO (and subsequently Rydon), under which Studio E had an obligation to seek to ensure that all designs complied with the relevant statutory requirements.2834 Schedule of services, clause 8. In our view, in failing to review Approved Document B and to consider carefully its significance for the project Mr Sounes fell seriously below the standard to be expected of a reasonably competent architect.2835 Hyett {Day64/63:23}-{Day64/64:2}.
¶63.10 One consequence of the approach adopted by Mr Sounes was that he did not take active responsibility for the choice of the materials that were to form part of the external wall of the building. Instead of satisfying himself independently of their suitability, he assumed that, because others appeared to be satisfied that both the ACM panels and the Celotex insulation were acceptable for use in that context, there was nothing to worry about. He therefore failed to identify that both were composed of combustible materials and failed to recognise the dangers of using them in an external wall. As a consequence, the external wall did not comply with functional requirement B4(1).2836 Phase 1 Report Volume IV paragraph 26.4. Those were serious errors that had direct and catastrophic consequences.
¶63.11 Any reasonably competent architect should have known, or at any rate should have taken the trouble to discover, that paragraphs 12.5 and 12.7 of Approved Document B contained a warning against the use of combustible materials in external walls.2837 Hyett {Day64/65:14}-{Day64/66:23}. Indeed, Leadbitter warned Studio E against the use of combustible insulation behind the rainscreen in January 2013.2838 {MET00081282}. This email was only disclosed to the Inquiry by the MPS in May 2023. The Celotex FR5000 specified by Studio E was a polyisocyanurate material and as such was combustible. Any competent architect ought to have known that, or, if uncertain about its composition, should have discovered it. However, notwithstanding the clear terms of paragraph 12.7 of Approved Document B, Studio E specified Celotex FR5000 for use in the external wall without giving any consideration to whether the resulting structure would comply with functional requirement B4(1). That was a significant failure.2839 Hyett, Module 1 Report (revised) {PHYR0000029/49} paragraph 4.3.24; {PHYR0000029/93} paragraph 4.4.41.
269¶63.12 We have described in Chapter 56 how FR5000 came to be included in the NBS Specification and non-combustible insulation was ruled out. Mr Sounes accepted Max Fordham's suggestion that they should aim for a U-value of 0.15 W/m2K, but neither he nor anyone else at Studio E gave any independent thought to whether an alternative solution was available or to whether the proposed U-value was acceptable if it could be achieved only by using combustible insulation.
¶63.13 As lead designer, Studio E was responsible for deciding what U-value could reasonably be achieved and how, and Mr Sounes was at fault in failing to recognise that. Max Fordham provided him with technical data relating to Celotex FR5000 by way of an example in order to assist his calculations; it was inappropriate for him to treat that as advice from Max Fordham to use FR5000. It was even more inappropriate to accept it uncritically without taking steps to understand the nature of the product and satisfying himself of its suitability. That was a serious error on the part of Mr Sounes.
¶63.14 Similarly, Mr Sounes did not take any steps to ensure that the rainscreen panels proposed for the cladding were consistent with the guidance in Approved Document B or were likely to meet the functional requirements of the Building Regulations. He appears to have been content to include ACM PE panels in the NBS specification (albeit as an alternative) for aesthetic reasons and because he knew they had been used on other projects,2840 Sounes {Day7/170:2-5}; Sounes {SEA00014273/140} page 140, paragraph 343; Sounes {Day20/93:12}-{Day20/95:14}. rather than in reliance on any detailed information he had obtained about the nature of the product based on the manufacturer's literature or the certificate of a recognised certifying body.2841 Sounes {Day20/135:1-7}.
¶63.15 When he was first considering options for the cladding panels, Mr Sounes did not address his mind to fire performance.2842 Sounes {Day20/83:8-12}; Geof Blades did not recall the content of the conversation – see Blades {Day41/85:3-7}. He did not consider whether any of the panels he had in mind were consistent with the guidance in Approved Document B and although he did propose some panels that had a fire-resistant core2843 {SEA00005320}; {SEA00005330}. This panel was not ultimately selected for inclusion in the NBS Specification. or were non-combustible,2844 {SEA00014616/41} paragraph 1.2. that was coincidental and did not reflect a judgment based on information he had obtained about their reaction to fire.2845 Sounes {Day20/89:20-25}. Unfortunately, Mr Sounes was not aware that ACM panels could be produced with different cores.2846 Sounes {Day20/176:17-24}.
¶63.16 The production of the NBS Specification, which identified the materials to be used in the facade, was left to junior assistants at Studio E, mainly Tomas Rek and before him Adrian Jess.2847 Sounes {Day7/151:7}-{Day7/152: 3}. Bruce Sounes told us that only some of the initial draft of the specification had been discussed with him and that he had trusted them to complete it without reference to him,2848 Sounes {Day7/152:4-8}. but neither of them appears to have given any consideration to the suitability of the materials intended for use in the external wall. As the architect responsible for the project Mr Sounes should have supervised their work. In particular, he should have satisfied himself that they had properly investigated the suitability of any materials or products they had included in the specification or, if they had not, should have satisfied himself independently that they were suitable. In fact, no further consideration of the materials was undertaken after they had been included in the specification and his failure to do either of those things was a significant error.2849 Hyett {Day64/69:6-18}; {Day64/72:21}-{Day64/73:15}; {Day64/76:14}-{Day64/77:5}; {Day64/123:23}-{Day64/124:25}.
270¶63.17 Studio E produced three versions of the NBS Specification, one on 21 November 2013,2850 {SEA00000152}. one on 29 November 20132851 {SEA00000153}. This version was issued to tenderers. and one on 30 January 2014.2852 {SEA00000169}. Mr Sounes confirmed that no one at Studio E had satisfied themselves before they were drawn up that the materials referred to in any of those versions would ensure compliance with the Building Regulations.2853 Sounes {Day7/170:2-5}; {Day20/173:12-24}; Rek {Day12/20:15-20}; {Day12/22:25}-{Day12/23:2}; {Day12/24:16-21}, {Day12/27:7-21}. That was a fundamental failing on the part of Studio E which had significant consequences. Mr Sounes sought to explain that omission by telling us that Studio E would not usually expect to verify compliance of all materials and products before submitting a full plans application to building control,2854 Sounes {SEA00014273/121} page 121, paragraph 292. and that to do so would be wasted work if the contractor subsequently made a change.2855 Sounes {Day20/64:21}-{Day20/65:7}. He also suggested that building control might take a different view of the proposals and that it was not common practice to carry out a full assessment of compliance with the functional requirements of Part B of Schedule 1 at RIBA stages D or E.2856 Sounes {Day20/65:1-3}.
¶63.18 Mr Sounes was wrong in his understanding. Under its contract with the TMO, it was Studio E's responsibility to ensure that the materials included in the NBS Specification complied with the Building Regulations.2857 Appendix B: Schedule of Services {SEA00009824/7}: "co-ordinating design of all constructional elements, including work by consultants, specialists or suppliers" and "determining materials, elements and components, standards of workmanship, type of construction and performance in use". We accept Mr Hyett's evidence that if an architect specifies a particular product to be used, he assumes responsibility for making sure that its use is compatible with the functional requirements in the Building Regulations.2858 Hyett {Day64/69:6-18}; {Day64/72:21}-{Day64/73:15}; {Day64/76:14}-{Day64/77:5}; {Day64/123:23}-{Day64/124:25}. Tomas Rek and Neil Crawford assumed that Mr Sounes had satisfied himself that the products and materials included in the specification were suitable, but neither of them took steps to verify that assumption or to satisfy themselves independently that they were. When he handed the project over to Mr Crawford, Bruce Sounes did not warn him that he had not carried out any investigation into the materials to be used in the cladding to satisfy himself that they were suitable.2859 Rek {Day12/44:22}-{Day12/45:1}; Crawford {Day9/139:14}-{Day9/140:13}; {Day9/146:4-6}. In failing to satisfy itself that the materials specified would enable the refurbished building to comply with the Building Regulations, Studio E, and particular Mr Sounes, Mr Crawford and Mr Rek, fell seriously below the standard to be expected of persons in their positions.
¶63.19 Mr Sounes sought to justify the choice of materials by asserting that Studio E had asked for advice about them and that it was not for Studio E to satisfy itself that the products were suitable because it did not have the ability to do so.2860 Sounes {Day7/170:21}-{Day7/171:4}. We do not accept that. We saw no evidence that Mr Sounes had asked any specialist for advice or that he had received any advice that would satisfy a reasonably competent architect that the products specified in the proposed application were suitable for the purpose and would not result in the refurbished building contravening the Building Regulations.
¶63.20 Mr Sounes himself did not consider whether the proposed use of Celotex FR5000 above 18 metres met the guidance in Approved Document B or would result in the external wall's complying with functional requirement B4(1). He did not ask Max Fordham that question2861 Sounes {Day20/42:6-11}. nor did he seek any advice from Exova about it.2862 Sounes {Day20/42:12}-{Day20/43:6}. Nor did anyone else at Studio E discuss the matter with Exova. Similarly, Mr Sounes did not investigate whether any of the various alternative rainscreen products proposed in the NBS Specification were suitable, including the ACM panels which were included as an alternative to zinc.2863 Sounes {Day20/173:12-24}. Although he said that he had carried out research and had consulted others, including Exova,2864 Sounes {SEA00014273/140) page 140, paragraph 343.2. he was not able to point to any particular advice he had received,2865 Sounes {Day8/57:2}-{Day8/58:6}. and at no point did he ask Exova to comment on the suitability of any of the rainscreen products included in the NBS Specification.
271¶63.21 Industry guidance was available at the time which contained warnings about the dangers associated with the use of certain kinds of rainscreen panels. In particular, the Standard for Systemised Building Envelopes, Part 6, published by the Centre for Window and Cladding Technology (CWCT), which was incorporated into the NBS Specification,2866 {SEA00000169/69} Clauses 310 and 342. contained important information on the fire performance of materials to be used in the external envelope of a building and specific guidance on aluminium envelope systems to include composite components as well as insulation materials.2867 {CWCT0000046}. However, no one at Studio E was familiar with the CWCT standard or had even read it2868 Rek {Day12/19:14-18}; {Day12/34:14-17}; {Day12/39:1-16}; Crawford {Day9/146:15-17}; Sounes {Day7/164:14-18}. and no one troubled to check it at the time. Similarly, it failed to consider the warnings about use of combustible materials in cladding systems contained in BR 135, even though the publication had been included in the structural engineer's specification.2869 Crawford {Day10/69:8}-{Day10/70:5}; {CCL00001449/11} paragraph 7.1.13. As a result, Studio E specified products that did not reflect any of that guidance.
¶63.22 The fact is that Mr Sounes simply assumed that all the cladding panels included in the NBS Specification were suitable for the refurbishment because they had been used on other projects.2870 Sounes {Day7/170:2-5}; Sounes {SEA00014273/140} page 140, paragraph 343; Sounes {Day20/93:12}-{Day20/95:14, {Day20/68:5-14}. In its opening statement Studio E sought to justify the use of ACM material and PIR insulation by reference to their frequency of use by others on previous projects,2871 Studio E's Opening Submissions {SEA00014642/16-17} paragraph 8.16; {SEA00014262/24} paragraph 10.11; {SEA00014262/36} paragraph 15.17. but we do not accept that. Relying on what others have done in the past is not good enough when the practice in question affects people's safety, is inconsistent with industry guidance and, most importantly, does not withstand rational scrutiny.
¶63.23 Mr Sounes was the lead designer responsible for the project at the time the NBS Specification was compiled. It was therefore his responsibility to ensure that the materials specified in it were consistent with the requirements of the Building Regulations. He failed to do so. He also failed to make it clear to the TMO, Rydon and Harley that Studio E had not taken steps to satisfy itself by reference to testing or other data that the materials included in the specification would result in an external wall that complied with the regulations. He was at fault in not doing so.
272¶63.24 Studio E failed to devise a proper cavity barrier strategy for the overcladding system, which led to ever-increasing confusion as the project developed.2872 Hyett, Module 1 Report (revised) {PHYR0000029/66} paragraph 4.3.69 and {PHYR0000029/76} paragraphs 4.3.83 to 4.3.86. The cavity barrier strategy should have been established by the time the tender documents were published.2873 Hyett, Module 1 Report (revised) {PHYR0000029/64} paragraph 4.3.63 and {PHYR0000029/76} paragraph 4.3.86. The strategy produced by Studio E was seriously deficient in failing to include a cavity barrier at the window sill.2874 Hyett, Module 1 Report (revised) {PHYR0000029/65} paragraph 4.3.68; {SEA00002499}; {PHYR0000029/76} paragraph 4.3.83. In addition, the drawings did not place the cavity barrier above the window close enough to the head of the window,2875 Hyett, Module 1 Report (revised) {PHYR0000028/62} paragraph 3.8.12.; Figure 3.30 and 3.29 produced by reference to {HAR00003958}. there were no cavity barriers included in the bay elevations and none of the elevation drawings of the complete facade were marked to show the presence of cavity barriers.2876 Hyett, Module 1 Report (revised) {PHYR0000029/66-67} paragraph 4.3.69; figure 4.50. No cavity barriers had been included at the junction of the cladding and the crown.2877 Hyett, Module 1 Report (revised) {PHYR0000029/75} paragraph 4.3.81; {SEA00002551}. Those errors indicate that no one at Studio E had given any clear thought during the preparation of the tender documents to the strategy for dividing the cavities behind the rainscreen into fireproof compartments.
¶63.25 On the basis of Mr Hyett's evidence we are satisfied that at tender stage Studio E should have produced drawings showing all vertical and horizontal cavity barriers for all bay and column conditions for all four facade elevations at 1:20 scale and at 1:5 scale for details around the windows where they abutted the columns.2878 Hyett, Module 1 Report (revised) {PHYR0000029/68} paragraphs 4.3.71-4.3.72; {SEA00002499}; {SEA00010474}; {PHYR0000029/76} paragraph 4.3.85; {SEA00002551}. We accept his criticism that Studio E should have identified the clash between the brackets and supporting angles and sought to resolve it.2879 Hyett, Module 1 Report (revised) {PHYR0000029/69} paragraph 4.3.73; {PHYR0000029/71} paragraph 4.3.77-4.3.78; {PHYR0000029/76} paragraph 4.3.86.
¶63.26 We do not accept that the design of a cavity barrier strategy could be left entirely to Harley as the cladding sub-contractor. It was Studio E's responsibility to explore and resolve the strategy at tender stage in order that the details subsequently produced by Harley were properly based.2880 Hyett, Module 1 Report (revised) {PHYR0000028/63} paragraph 3.18.13; See also {SEA00009824/7} under the subheading "Designers, including Lead Designer". Studio E had responsibility for: determining materials, elements and components, standards of workmanship, type of construction and performance in use for the design.
Consultation with Exova
¶63.27 Although Exova became involved in the project at an early stage, Studio E's interest in obtaining its advice was directed mainly to the work involved in creating new dwellings in the lowest floors of Grenfell Tower. In April 2012 Bruce Sounes sent Exova information about the refurbishment, including some architectural drawings, and later that month a representative of Exova attended a design team meeting at which the overcladding was discussed. However, Studio E did not consult Exova about that aspect of the project and did not keep it informed of progress generally.2881 See, for example, the failure to send the Stage D report. Hyett {Day64/205:5-12}. Most importantly, Studio E failed to take a close interest in Exova's work on the Outline Fire Safety Strategy, which, as we have noted elsewhere, remained materially incomplete in the absence of advice on the fire safety of the proposed overcladding and its effect on functional requirement B4. Studio E did not notice the absence from the strategy of any reference to the cladding.2882 Sounes {Day8/65:5}-{Day8/66:5} (version 1 OFSS); {Day8/68:19}-{Day8/69:3} (version 2 OFSS); {Day12/149:13-24} (version 3 OFSS). More significantly, at no stage did Mr Sounes ask Exova to clarify its advice on functional requirement B4,2883 Sounes {Day8/51:6-24}; {Day8/69:18-24}. although he accepted that the implications of the overcladding for the spread of fire over the external walls of the building had never been discussed in writing by Exova or any other fire consultant.2884 Sounes {Day12/155:25}-{Day12/156:6}. He did not discuss it with Terrence Ashton because he did not regard it as a matter of concern.2885 Sounes {Day8/53:17-21}. Although Bruce Sounes originally expected Exova to complete its advice in a future version of the Outline Fire Safety Strategy,2886 Sounes {Day8/52:12-15}. he ought to have pressed for it to be completed when version 3 was issued just before the tender documents were published and it was clear that part of it remained outstanding.2887 Ashton {Day17/48:5-17}. However, he failed to do so. He thought it was the responsibility of the design and build contractor to ensure that the advice was completed,2888 Sounes {Day12/157:6}-{Day12/158:20}. but he failed to warn the TMO or Rydon that Exova's work had not been finished.
273¶63.28 Studio E was reassured generally by the fact that Exova had been instructed on the project, even though it did not provide Exova with the full range of information that would have enabled it to provide proper advice and did not question the limited advice that it did receive.2889 Sounes {SEA00014273/140} page 140, paragraph 343.2. For example, Neil Crawford said that he had felt confident about the choice of insulation and the design of the cavity barriers because he had understood that Exova had a wealth of knowledge of similar projects.2890 Crawford {Day9/177:6-11}. However, he had no idea on what basis Exova might have concluded that the design of the external wall complied with the Building Regulations.2891 Crawford {Day9/177:3-5}.
Design errors following the novation to Rydon
¶63.29 As had been envisaged at the outset,2892 See Chapter 52. Studio E's services were eventually transferred to Rydon following its appointment as principal contractor for the refurbishment. Although proposals relating to a formal contract were exchanged in April 2014, it was not until nearly two years later that the relationship between them was eventually encapsulated in a deed dated 3 February 2016. No satisfactory explanation for the delay was put forward, although Neil Crawford said that it was not unusual for projects to run to the end with no formal contract in existence.2893 Crawford {Day9/68:18-19}. This seems to us to be another example of a cavalier attitude to formalities which appears to have been shared by many of those involved in the project and which is liable to lead to a failure to understand where responsibilities lie.
¶63.30 Under the deed Studio E warranted that it had exercised and would continue to exercise reasonable skill, care and diligence in the discharge of the services covered by the deed to the standard reasonably to be expected of a competent professional experienced in the provision of professional services for works similar in size, scope, complexity, quality and nature to the development.2894 {RYD00094228/3} Clause 2.3. The language thus made it clear that the undertaking covered all the work on the refurbishment that Studio E had done for Rydon in the past, as well as any that it might do for it in the future.2895 And see also {RYD00094228/3} Clause 2.1 which provided that Studio E "has and will continue to perform for [Rydon] the Services in respect of the development"; Bruce Sounes understood the time that the obligation had retrospective effect: Sounes {Day7/102:15}-{Day7/103:5}. Studio E also undertook to seek to ensure that all aspects of the architectural designs complied with the Employer's Requirements,2896 {RYD00094228/9} Item 4. Bruce Sounes confirmed that he understood at the time that that was Studio E's obligation to Rydon: Sounes {Day7/105:6-25}; Neil Crawford said that in February 2016 he had not known that Studio E was under that obligation to Rydon: Crawford {Day9/53:4-10}; {Day9/60:15}-{Day9/61:3}. and that all designs complied with the relevant statutory requirements.2897 {RYD00094228/9}; Both Bruce Sounes and Neil Crawford understood that that 'statutory requirements' included the Building Regulations and the CDM Regulations: Sounes {Day7/107:8-16}; Crawford {Day9/62:8-13}. It also agreed to co-ordinate any design work done by consultants, specialist contractors, subcontractors and suppliers2898 {RYD00094228/10} Item 13. and to be responsible for co-ordinating the steps needed to obtain building control approval.2899 {RYD00094228/9} Item 7.
274¶63.31 We think it clear that the deed imposed an obligation on Studio E to take reasonable steps to ensure that all designs, whether produced by itself or sub-contractors, complied with the relevant statutory requirements, including the Building Regulations 2010. That would include identifying any obvious instances of non-compliance with the Building Regulations and the associated statutory guidance, including Approved Document B, in any drawings which were provided to Studio E for review. However, Bruce Sounes did not think that Studio E had any obligation to check the work of Rydon's subcontractors to ensure that it complied with the Building Regulations.2900 Sounes {Day7/112:15}-{Day7/113:8}. He thought that specialist sub-contractors were responsible for the design element of their work and were themselves responsible for ensuring that it complied with any statutory requirements. In his view, building control was primarily responsible for confirming compliance.2901 Sounes {Day7/124:4-11}. Neil Crawford's understanding was fundamentally the same.2902 Crawford {Day9/62:20-24}; {Day9/70:25}-{Day9/71:5}; {Day9/63:7-12}; {Day9/71:20}-{Day9/72:5}. They appear to have had their own understanding of the obligations being assumed by Studio E, which did not bear much relationship to the language used in the document.
Rainscreen panels
¶63.32 Bruce Sounes received a copy of the BBA certificate for the Reynobond ACM panels in April 20142903 Sounes {SEA00014273/153} page 153, paragraph 377; {SEA00002686}. but failed to read it in full carefully.2904 Sounes {Day21/12:5-7}; {Day21/13:1-3}. He thought that Rydon had taken over responsibility for the design and that it was not his function to assess the suitability of any material that might be used.2905 Sounes {Day21/16:22}-{Day21/18:12}. Mr Crawford, who came into the project in the summer of 2014, thought it unlikely that he had looked at the BBA certificate.2906 Crawford {Day10/149:22}-{Day10/150:13}.
¶63.33 Although Mr Hyett did not think that the dangers posed by ACM PE panels were well known to architects generally at that time, he was nonetheless critical of Studio E's failure to investigate their fire performance. In his report Mr Hyett said that he considered it reasonable for an architect reading just the first page of the BBA certificate relating to Reynobond to conclude that the product was rated Class 0 and so met the guidance given in paragraph 12.6 and diagram 40 of Approved Document B. He said that he did not consider that an architect could be criticised for taking the statement on the front of the certificate at face value and not going on to read section 6, which contained further information about the product's behaviour in relation to fire.2907 Hyett, Module 1 Report (revised) {PHYR0000029/97} paragraph 4.4.55; {PHYR0000029/106} paragraph 4.4.88; {PHYR0000029/106} paragraph 4.4.90; Hyett {Day64/137:15}-{Day64/138:23}; {Day64/144:5-13}; {Day64/145:9-14}; {Day64/148:8-16}. Mr Hyett noted, however, that the certificate related to only one colour sample and warned that other colours might not have met the same standard.2908 Hyett, Module 1 Report (revised) {PHYR0000029/57} paragraph 4.3.35(a); {PHYR0000029/96} paragraph 4.4.51 and 4.4.54; {PHYR0000029/99} paragraph 4.4.59.
275¶63.34 In the course of giving evidence, however, Mr Hyett changed his opinion. Having been asked to give further consideration to the contents and structure of the BBA certificate, he accepted that the first page was directing the reader to the various sections containing more detailed information on different characteristics. He agreed that it was directing the reader to section 6 for information about the product's behaviour in relation to fire and that a reasonably competent architect would not read the statements on the first page in isolation from the rest of the document.2909 Hyett {Day64/149:2}-{Day64/150:7}; {Day64/151:8-15}; {Day64/160:1-6}. He thought that a reasonably competent architect would conclude from section 6.4 of the certificate that the panels used at Grenfell Tower were not covered by the certificate because they were not the same colour or finish as those described in the certificate.2910 Hyett {Day64/157:4-17}. In those circumstances he was of the view that the architect ought to have investigated the fire performance of the panels with the manufacturer.2911 Hyett {Day64/157:18}-{Day64/158:3}. He was also of the opinion that a reasonably competent architect ought to have understood from reading the BBA certificate that the product was available in a fire retardant version,2912 Hyett {Day64/158:5}-{Day64/159:18}. which should have prompted him to ask for advice about the difference between the two versions of the product and whether the use of the fire retardant version would be more appropriate.2913 Hyett {Day64/159:20}-{Day64/160:6}.
¶63.35 We do not find Hr Hyett's change of heart surprising, because a formal document such as a BBA certificate is designed to be read as a whole. There would be no point in including the information contained in the later sections if it were not of potential importance to the reader. We accept Mr Hyett's opinion that once Studio E had become aware in or around March 2014 of the plan to substitute the Reynobond 55 PE for the zinc rainscreen panel originally specified,2914 Chapter 55. it ought to have conducted an urgent investigation into its characteristics in order to satisfy itself that the external wall as a whole would comply with the requirements of the Building Regulations.2915 Hyett, Module 1 Report (revised) {PHYR0000029/94} paragraph 4.4.45. Studio E as lead designer was responsible for satisfying itself that the product was suitable for use and for obtaining advice from Exova if it was in any doubt.2916 Hyett {Day64/128:25}-{Day64/130:5}; {Day64/130:15}-{Day64/131:9}. We consider that in failing to do so Studio E fell seriously below the standard of a reasonably competent architect. Mr Sounes appears to have thought that, in relation to a project being carried out under a design and build contract, the architect, having become a consultant engaged by the contractor, had no responsibility for overseeing what others were doing.2917 Sounes {Day20/71:3-14}. That was wrong, however, because after its services had been transferred from the TMO to Rydon Studio E remained responsible for ensuring the suitability of the proposed cladding panels.2918 {RYD00094228/9} item 8 and {RYD00094228/10} item 13.
276¶63.36 Mr Sounes and Mr Crawford should have read the BBA certificate in full carefully. It was a short document and plainly an important one. Even though by that time Studio E's services had been transferred to Rydon, it remained under an obligation to exercise reasonable skill, care and diligence in the discharge of its services,2919 {RYD00094228/3} clause 2.3. which included seeking to ensure that all designs complied with the relevant statutory requirements.2920 {RYD00094228/9} item 8 and {RYD00094228/10} item 13. We were troubled by Mr Sounes' practice of not reading the whole of the BBA certificate for any product he was planning to recommend for a project. His failure to do so fell very far below the standard of a reasonably competent architect.
Checking Harley's designs
¶63.37 Studio E told us that the cladding had been designed by Harley and that as specialist cladding sub-contractor it had assumed responsibility for all aspects of the design.2921 Studio E's written Opening Submissions {SEA00014642/3} paragraph 3.1.5(c). Bruce Sounes said that he did not expect Studio E to be required to check that Harley's drawings were consistent with any legislative requirements,2922 Sounes {Day7/131:21}-{Day7/132:5}. since that was not a role it had agreed to undertake in relation to the project.2923 Sounes {Day7/113:9-17}; {Day7/122:5-18}; {Day7/123:2-8}; {Day7/125:9-11}. Neil Crawford's understanding was the same.2924 Crawford {Day9/62:20-24}; {Day9/70:25}-{Day9/71:1-5}; {Day9/63:7-12}; {Day9/71:20-25}; {Day9/72:1-5}. They were both wrong about that, however, because they failed to pay attention to the obligations Studio E had assumed to the TMO and misunderstood the effect of the novation to Rydon.
¶63.38 Following the novation to Rydon, Studio E remained responsible for the design work it had already carried out for the TMO and became responsible for any further work it was required to carry out under the terms of its contract with Rydon.2925 {RYD00094228/3} paragraphs 2.2 and 2.3. Studio E's design work before novation was not confined to matters of aesthetic intent or appearance and Harley clearly assumed that Studio E had satisfied itself that the tender drawings and specifications were consistent with the relevant statutory requirements and guidance.
¶63.39 It is clear that Studio E took an unduly narrow view of its responsibilities after the novation. Neil Crawford maintained throughout that Studio E was only responsible for checking Harley's drawings and specifications for "architectural intent", by which he meant conformity with the preliminary design only.2926 Studio E's Opening Submissions {SEA00014642/31} paragraph 13.6; Crawford {SEA00014275/17-18} pages 17-18, paragraphs 41-42; Crawford {Day9/20:11-19}. His understanding was inconsistent, however, with the terms of its contract with Rydon, which included seeking to ensure that all designs complied with the relevant statutory requirements.2927 {RYD00094228/9} items 4, 5 and 8. Studio E's role in relation to Harley's work does not appear to have been the subject of any discussion with Rydon, which also appears to have assumed that Harley could be left to take responsibility for such matters. Neither Rydon nor Studio E appears to have understood properly the scope of their individual responsibilities.
¶63.40 Such a failure to understand the scope of its obligations might, perhaps, have been explicable if the terms on which Studio E had been engaged were unusual, but there is no reason to think that they were, since they were based on standard RIBA terms. Mr Hyett's understanding was that when an architect stamps a sub-contractor's drawing as complying with architectural intent it amounts to confirmation that the drawing demonstrates a proper understanding, interpretation and application of the architectural specification. He considered that Studio E had an obligation to assess Harley's designs for compliance with the employer's requirements and the applicable statutory requirements.2928 Hyett Supplemental Report {PHYS0000002/30} paragraph 2.3.21; Hyett {Day64/16:4}-{Day64/17:14}; Hyett, Module 1 report (revised) {PHYR0000029/141} paragraph 4.4.154; Hyett {Day64/19:13}-{Day64/20:13}; {Day64/26:11}-{Day64/28:9}; {Day64/29:2-10}; {Day64/25:2-9}; {Day64/27:18}-{Day64/28:2}. In the light of his evidence we think that if Studio E's work in relation to Harley's designs was intended to be as narrow in scope as has been suggested, that would have been formally recorded in some way.2929 Hyett {Day64/24:9}-{Day64/26:8}; {RYD00094228/9} item 8.
277Insulation
¶63.41 As set out at Chapter 56, Harley substituted Celotex RS5000 for the Celotex FR5000 specified by Studio E in the NBS Specification without reference to Studio E, although a copy of the datasheet for RS5000 was sent to Neil Crawford on 18 September 2014 in connection with a question about cavity barriers and insulation.2930 {HAR00012103}; {HAR00012104}.
¶63.42 Once Studio E had been made aware of the substitution, it had an obligation to satisfy itself that the use of RS5000 was consistent with the Building Regulations and approved guidance. (Since its use was not consistent with the approved guidance, Studio E should have drawn that to the attention of Rydon.)2931 Hyett {Day64/183:23}-{Day64/184:3}; {Day64/204:13}-{Day64/205:4}; {Day65/17:12}-{Day65/19:20}. That could have involved asking Exova to comment on the characteristics of RS50002932 Hyett {Day64/204:25}-{Day64/205:4}. or itself examining the suitability of RS5000 by a careful reading of the product literature.2933 {RYD00094228/9}. We agree with Mr Hyett that Studio E would not have performed its obligations to Rydon merely by relying on Harley to check the characteristics of RS5000 when the substitution was made. In fact, Mr Crawford took it on trust that, if Harley thought RS5000 was suitable, he did not need to investigate further.2934 Crawford {Day10/48:5-9}. It was a serious omission on Mr Crawford's part not to have made any independent assessment of RS5000 after he had been told that Harley intended to use it.
¶63.43 If Mr Crawford had looked into the characteristics of RS5000 he would have realised that the external wall system described in the Celotex Rainscreen Cladding Compliance Guide and the product datasheet for RS5000 was not the same as that which had been designed for Grenfell Tower.2935 Hyett {Day65/4:11-24}; {CEL00000416/3}; Hyett {Day65/6:3}-{Day65/7:1}; {Day65/7:3}-{Day65/9:14}; {Day65/14:9}-{Day65/15:18}; {Day65/19:9-23}; {Day65/22:1}-{Day65/24:19}. He would, or certainly should, therefore have realised that RS5000 was not generally suitable for use on buildings over 18 metres in height and should not have been proposed for use in the refurbishment. The failure to investigate the characteristics of RS5000 was another serious failing on Mr Crawford's part.
¶63.44 Mr Crawford also failed to notice that Harley's specification did not identify the insulation to be used in the construction of the external wall.2936 {HAR00003866}; {HAR00003869/1}; {HAR00017762}; {HAR00003955}; {RYD00046822/1}. Despite that omission, Mr Crawford stamped the specification as conforming to design intent when it did not.2937 {RYD00046822/1}; Hyett, Module 1 Report (revised) {PHYR0000029/89} paragraph 4.4.29.
Cavity barriers
¶63.45 Studio E's failure to provide a comprehensive cavity barrier strategy at tender stage was carried through into Harley's design. Most significantly, three of Harley's typical bay drawings did not include cavity barriers around the window openings, contrary to the guidance in Approved Document B. Studio E failed to notice that omission. Neil Crawford's own view was that it was not possible to place cavity barriers around the windows2938 Crawford {Day10/176:4}-{Day10/177:7}. but Mr Hyett's indicative scheme demonstrates that it was.2939 Hyett, Module 1 Report (revised) {PHYR0000028/39} paragraph 3.7.20; {PHYR0000028/40-43} figures 3.16 – 3.19 and {PHYR0000028/58-59} paragraphs 3.8.8-3.8.11. Studio E also failed to identify the fact that Harley had not provided for cavity barriers at the window head and sill level.2940 Hyett, Module 1 Report (revised) {PHYR0000029/112} paragraph 4.4.102. Ultimately, therefore, Studio E failed to recognise that the arrangement shown on Harley's drawings would not inhibit the passage of fire around the windows in a way that complied with Approved Document B.2941 Hyett, Module 1 Report (revised) {PHYR0000029/115} paragraph 4.4.105.
278¶63.46 Harley's construction drawings that were endorsed by Studio E were deeply flawed. Once fire was present within a cavity zone it could move freely up the sides of the windows and within the adjoining columns.2942 Hyett, Module 1 Report (revised) {PHYR0000029/131} paragraph 4.4.134 We agree with Mr Hyett that Studio E's failure adequately to review Harley's drawings flowed from a lack of technical knowledge and experience, exacerbated by the lack of a basic scheme design, which should have been completed at tender stage, against which Harley's work could have been competently checked.2943 Hyett, Module 1 Report (revised) {PHYR0000029/142} paragraph 4.4.155.
¶63.47 Studio E's lack of technical knowledge and experience in respect of cavity barriers is evident from Neil Crawford's approach to Harley's request for information in September 2014.2944 See Chapter 54 See also Hyett, Module 1 Report (revised) {PHYR0000029/119} from paragraph 4.4.109. Harley asked for confirmation from Rydon, through Studio E, on the placing of cavity barriers.2945 {RYD00018043}. Mr Crawford sent the request on to Exova asking for advice. We agree with Mr Hyett that questions of that kind should have been resolved by Studio E much earlier, but at that point the parties were only starting to establish the basic approach.2946 {EXO00000708}. It is clear from the email correspondence between Terence Ashton, Neil Crawford and Daniel Anketell-Jones that Mr Crawford abrogated responsibility for answering Harley's questions about cavity barriers.2947 {EXO00000714}. He simply passed information between Exova and Harley without becoming directly involved. For reasons we have already explained, it was quite wrong for Studio E to take the view that Harley alone was responsible for formulating the cavity barrier strategy.
¶63.48 Studio E also failed to notice that materials specified by Harley, including Styrofoam in the P1 window infill panel and Kingspan TP10 in the P2 panel, were not suitable for use in their intended applications.2948 See Chapter 58. Despite that, Mr Crawford accepted the specification without commenting on the choice of those materials.2949 Crawford {Day11/116:9-18}. We reject Mr Crawford's assertion that it was not Studio E's function to check that the designs complied with the statutory requirements.2950 Crawford {Day11/117:4}-{Day11/118:23}; {Day11/120:2-13}. Its contract with Rydon provided otherwise and we agree with Mr Hyett that Studio E should have noticed that unsuitable insulation products had been specified by Harley and should have challenged their use.2951 Hyett, Module 1 Report (revised) {PHYR0000029/135} paragraphs 4.4.140-4.4.141
¶63.49 Harley's construction drawings did not specify the materials to be used at the head, jamb and sill behind the window reveals. We agree with Mr Hyett that Studio E should have ensured that they did so, or should at least have referred to the NBS Specification to make it plain to whoever undertook the refurbishment of the window reveals that mineral wool (Rockwool) had been specified by Studio E.2952 {HAR00008469}; {HAR00008470}; {HAR00008880}; Hyett, Module 1 Report (revised) {PHYR0000029/139} paragraph 4.4.145; {PHYR0000029/141} paragraph 4.4.149. Studio E ought to have identified that omission on Harley's part and sought to rectify it.
279Communication with building control
¶63.50 Studio E's contract with Rydon included responsibility for co-ordinating Building Regulation approval.2953 {RYD00094228/9}. However, its full plans submission to RBKC building control contained drawings that were out of date or inaccurate2954 See Chapter 62, see also Hyett, Module 1 Report (revised) {PHYR0000030/60-64} paragraphs 5.4.29-5.4.34. and was insufficient to demonstrate compliance with the Building Regulations.2955 Menzies Module 1 Report {BMER0000004/9} paragraph 37. Further information was sent on a piecemeal basis. No complete package was ever sent to building control with clear information about the materials that were intended to make up the facade.2956 Menzies {Day60/137:9}-{Day60/138:10}. Studio E's failure to provide comprehensive and accurate information to building control made it difficult for RBKC to discharge its own functions under the Building Regulations.2957 Hyett, Module 1 Report (revised) {PHYR0000030/64} paragraph 5.4.34.
Quality control and training
¶63.51 Studio E's internal review processes and quality assurance systems were weak and contributed to the failures in design that we have described above. Although Mr Sounes recognised at the outset of the project that it was necessary for the firm to educate itself in what was involved in overcladding a high-rise building, no obvious attempt was made to do so.2958 {SEA00003567}. A reasonably competent architect undertaking a project of that kind for the first time would have researched it both from a technical and regulatory perspective.2959 Hyett, Module 1 Report (revised) {PHYR0000027/17} paragraph 2.5.14 and paragraph 2.5.12(b); Hyett {Day63/80:5‑18}; {Day63/82:7}-{Day63/84:10}. That would have included identifying and familiarising itself with any relevant regulations and guidance, including guidance published by reputable industry bodies. As far as we can see, Studio E did none of that.
¶63.52 Studio E had processes in place under which design work was intended to be subject to peer review, including in relation to matters of regulatory compliance,2960 Kuszell {SEA00014271/7} page 7, paragraph 24.2; Kuszell {Day6/119:7-18}; Sounes {SEA00014273/62} page 62, paragraph 130. but the technical and design reviews it carried out on the Grenfell Tower project fell well short of what could reasonably be expected.2961 Hyett, Module 1 Report (revised) {PHYR0000031/33-38} paragraphs 6.7.10-6.7.15 and 6.8.6. The technical review was carried out far too late2962 Only one technical review was carried out by Studio E, on 28 October 2015. That was more than a year after it had submitted the full plans application to RBKC building control and when the external facade works were 60% complete – {RYD00014378}; {SEA00013508}; Hyett, Module 1 Report (revised) {PHYR0000031/33} paragraph 6.7.11. and no senior technically experienced member of staff not otherwise involved in the project had any involvement in checking the designs, in particular for compliance with the Building Regulations.2963 As Mr Kuszell said should have happened, usually at RIBA Stage E/F – see Kuszell {SEA00014271/7} page 17, paragraph 24.2 and Sounes {SEA00014273/62} page 62, paragraph 130.
280"As-built" drawings
¶63.53 It was Studio E's responsibility under its contract with Rydon to provide a set of "as-built" drawings at the end of the project.2964 {RYD00094228/10} item 19. Although Studio E did so, the "as-built" drawings did not accurately record the structure of the building. For example, they did not contain reference to the type of insulation used2965 {SEA00003436}. and they inaccurately recorded that both zinc and ACM panels had been used in the cladding.2966 {SEA00003436}. "As-built" drawings are part of the information that should be handed over to the building owner as part of the health and safety file2967 See Chapter 61. and are clearly an important record of the construction for future users of the building.
281Chapter 64: The contribution of Rydon
Introduction
¶64.1 Rydon failed in a number of important respects properly to perform its role as primary contractor for the Grenfell Tower refurbishment. It promised the TMO that when completed the refurbishment would comply with the Building Regulations, but it did not. When co-ordinating, supervising and monitoring the work it did not give sufficient importance to the safety of the building's occupants and it displayed a casual attitude to fire safety throughout the project. As a result, Rydon bears considerable responsibility for the fire at Grenfell Tower.
The nature of Rydon's responsibilities on the project
¶64.2 Under its contract with the TMO Rydon was responsible for all aspects of the design and construction of the refurbishment2968 JCT Design and Build Contract 2011 {RYD00094235/69} clause 2.17.1.3. and was obliged to ensure, among other things, that when completed the building complied with the Building Regulations. That obligation existed whether the work was carried out by Rydon itself or by its sub-contractors, consultants or other specialists.2969 JCT Design and Build Contract 2011 {RYD00094235/69} clause 2.17.1.2.
¶64.3 Although the contract contemplated that Rydon might delegate design work to specialists,2970 JCT Design and Build Contract 2011 {RYD00094235/69} clause 2.17.1.1. it remained responsible for the quality of the work carried out by those whom it engaged for that purpose. It also had an obligation to co-ordinate, integrate, supervise and monitor the work.2971 JCT Design and Build Contract 2011 {RYD00094235/69} clause 2.17.1.2; the Preliminaries, part 2A/44, s.A32 {TMO10041791/128} paragraph 110, which provided that Rydon was obliged to: "Accept responsibility for coordination, supervision and administration of the Works, including subcontracts"; the Preliminaries part 2A/57, s.A33 {TMO10041791/141} paragraph 630, which provided that Rydon had to establish and maintain quality control procedures, including in respect of the work of sub-contractors so that it complied with specified requirements. However, many people other than Rydon and the TMO were liable to be affected by work carried out by sub-contractors and consultants, not least those who would occupy the building when the refurbishment had been completed. It is of no comfort to them to be told that Rydon remains responsible to the TMO for poor design or faulty workmanship or worse, when they have to suffer the consequences. In our view, therefore, regardless of any legal obligations, Rydon should have ensured that those it appointed as sub-contractors and consultants were sufficiently qualified to undertake the work and provide the services required of them effectively. Accordingly, Rydon cannot avoid all blame simply by relying on the engagement of specialist sub-contractors and designers, such as Studio E, Harley and Exova.2972 See, for example, Rydon's Closing Submissions for Modules 1 & 2 at {RYD00094564/9} paragraphs 1.35-1.36. Apart from anything else, Rydon itself had the important responsibility of overseeing their work and ensuring that it complied with the contract.
¶64.4 That was all the more so, given that Rydon was also the principal contractor under the CDM Regulations 2007 and 2015. Pursuant to the CDM Regulations 2007, its primary duty as principal contractor was properly to plan, manage and co-ordinate work during the construction phase in order to ensure that health and safety risks were properly controlled.2973 Regulation 22(1) of the CDM Regulations 2007 {INQ00011315/11}; Approved Code of Practice to the CDM Regulations 2007, L144 {INQ00013936/36} paragraph 146. That included ensuring that it was competent to deal with any health and safety problems that arose during the construction phase,2974 Approved Code of Practice to the CDM Regulations 2007, L144 {INQ00013936/36} paragraph 150(b). including risks from fire. It also included satisfying itself that the designers it engaged were competent and adequately resourced2975 Approved Code of Practice to the CDM Regulations 2007, L144 {INQ00013936/37} paragraph 150(h). and ensuring co-operation between contractors and designers and the co-ordination of their work.2976 Regulation 22(1)(i) of the CDM Regulations 2007 {INQ00011315/11}; Approved Code of Practice to the CDM Regulations 2007, L144 {INQ00013936/37} paragraph 151. In the event, Rydon failed to give fire safety the importance it deserved.
282Rydon's expertise
An inexperienced team
¶64.5 Rydon's team working on the Grenfell Tower project were notably inexperienced. Simon Lawrence (contracts manager), Simon O'Connor (project manager) and Zak Maynard (commercial manager) were all acting in those capacities for the first time.2977 Email from Stephen Blake on 9 May 2014 regarding changes of structure and promotions {RYD00004258}. That was not necessarily inappropriate, but Rydon should have responded to their lack of experience by taking steps to ensure they received sufficient supervision, training and support from others with greater experience. In the event, it plainly failed to do so.2978 O'Connor {Day26/179:15-23}; Blake {Day28/30:11}-{Day28/33:5}. Although Stephen Blake said that Simon O'Connor's promotion to project manager had been nominal, in the sense that his role on the project had been effectively that of a site manager, no attempt was made to explain that to him or to ensure that the position of site manager was filled by someone else with suitable experience.2979 Blake {Day28/31:12}-{Day28/33:5}.
¶64.6 Rydon's failures in that respect contributed to a general lack of clarity about the responsibilities that its employees were expected to shoulder, a confusion that extended beyond Rydon. In many cases staff did not recognise the descriptions of themselves that Rydon had included in its tender documents. For example, Simon O'Connor was described as holding an HNC2980 Higher National Certificate. in Building Studies and as being responsible for "co-ordinating design", as "lead[ing] the on-site team in terms of design" and as "contribut[ing] technical expertise during value engineering", but, when asked for his comments, he disagreed with each of those assertions. He did not have an HNC and had not been involved in any value engineering process on any project.2981 O'Connor {Day26/19:2}-{Day26/22:16}. Stephen Blake accepted that the way in which Mr O'Connor's qualifications and experience had been described was thoroughly misleading.2982 Blake {Day28/40:10-14}.
A lack of knowledge
¶64.7 Those whom Rydon employed on the project lacked even the most basic knowledge of the regulatory regime within which the refurbishment was being carried out, including the relevant statutory and industry guidance and descriptions of best practice. None of Rydon's employees had any substantive knowledge of the Building Regulations or of the approved documents that applied to the project.2983 Lawrence {Day22/71:1-4}; O'Connor {Day26/75:16-23}; Hughes {Day27/28:25}-{Day27/29:12}; Blake {Day28/63:11-13}; Martin {Day30/16:17}-{Day30/18:16}; Osgood {Day30/107:4-10}. Many of its witnesses did not even know that different kinds of rainscreen cladding panels were available, and those who did had no understanding of the ways in which the different materials reacted to fire.2984 Lawrence {Day24/21:13-23}; O'Connor {Day26/27:18-24}; Hughes {Day27/53:24} –{Day27/54:1}; Blake {Day28/48:20-24}; Osgood {Day30/141:5-7}; {Day30/184:1-3}; {Day30/185:17-24}; {Day30/188:9-11}; {Day30/115:13-15}; {Day30/141:5-7}; {Day30/110:1-6}.
283¶64.8 Rydon had no, or no effective, system for ensuring that its employees received regular training during their employment. Simon Lawrence had never discussed training with his peers or supervisors and Stephen Blake conceded that he had not undertaken any continuing professional development in the period between leaving university in 1985 and the fire in 2017.2985 Lawrence {Day22/104:22-24}; Blake {Day28/41:10-15}. Rydon thus failed to take any steps to maintain or improve the competence of its employees or its awareness as a business of matters affecting fire safety.
Reliance on third parties
¶64.9 The lack of knowledge and experience among Rydon's own employees was such that it did not have a clear understanding of fire safety matters or any way of determining for itself whether the work of its sub-contractors satisfied basic fire safety standards, let alone the requirements of the Building Regulations. Importantly, it was in no position to know whether the right questions had been asked or to evaluate the information given to it. As far as fire safety was concerned, the evidence of Rydon's witnesses showed that it was untroubled by either consideration and failed to consider even the simplest questions relating to the design of the facade from the point of view of fire safety. There was, for example, no discussion internally about the Building Regulations or Approved Document B, nor about which route to compliance was being followed for the cladding system, and it did nothing itself to find out whether the ACM panels proposed for use on the tower were suitable for that purpose.2986 Blake {Day28/86:8-12}; Lawrence {Day23/179:2-7}.
¶64.10 Although Rydon was of course entitled to expect its sub-contractors to carry out their work competently and in accordance with their own contractual obligations, that did not relieve it of its responsibility to the TMO for the quality of their work, nor did it relieve it of its responsibility to co-ordinate and supervise their work. At the very least, Rydon should have been aware of all those aspects of the design that required the attention of appropriately qualified professionals so that it could satisfy itself that people with the necessary skill and training had applied their minds to them. That is what is involved in co-ordinating and supervising the design process. Rydon was not aware of any of the questions that needed to be considered as part of the design process and so failed to exercise the degree of supervision that we consider was required.
¶64.11 Rydon conceded that in substance it had provided the TMO with nothing more than a management service.2987 Blake {Day28/66:21}-{Day28/69:1}; Email from Simon Lawrence to David Brissenden on 22 April 2015 {RYD00039525/3}; Lawrence {Day22/108:10-19}. In reality, it had organised the work being carried out by a web of sub-contractors and consultants, acting as a channel of communication between the TMO and the various persons contributing to the project in their different capacities. However, it is clear that Rydon failed in number of important respects to perform even its management role properly. It was not appropriate or safe for a contractor undertaking a project on the scale of the Grenfell Tower refurbishment to conduct its business in that manner.
284Failure to investigate the competence of sub-contractors
¶64.12 Although Rydon relied entirely on its sub-contractors and consultants to perform its own contractual obligations to the TMO, it made no serious effort to find out whether the bodies it proposed to engage for that purpose were competent.
¶64.13 Studio E had been responsible for producing the outline design for the refurbishment and the NBS Specification. Although Rydon was required under its contract with the TMO to accept Studio E as lead designer and enter into a contract with it,2988 {RYD00003489/115} clause 7F. it did not attempt to assess the quality of the work that Studio E had already done.2989 Rydon was fully responsible for the design of the works, including any design contained in the Employer's Requirements, and for any discrepancy in or divergence between the Employer's Requirements and/or the Contractor's Proposals and/or any drawings, details, documents and other information submitted by him. It was also responsible for adopting and taking responsibility for any design work carried out by professional consultants at the request of the TMO {RYD00094235/69} clause 2.17.1.2; Lawrence {Day22/132:1}-{Day22/139:5}. Instead, it relied entirely on an assumption that Harley would take the initiative by raising any concerns it had about Studio E's work. For its own part, Rydon never asked Harley to examine Studio E's work on its behalf and never asked Harley directly whether it had evaluated the work Studio E had done.2990 Lawrence {Day22/133:11} – {Day22/135:5}.
¶64.14 Rydon did not become aware that Studio E had not previously undertaken a project of that kind and never had a clear understanding of, or even a desire to understand, the extent to which Studio E was conversant with the requirements of the Building Regulations or Approved Document B in so far as they applied to it.2991 Lawrence {Day22/135:6}-{Day22/136:10}. If it had been aware of Studio E's lack of experience in overcladding high-rise buildings, it is possible that Rydon would have taken more seriously the need to instruct a fire engineer to assess the safety of the external wall.
¶64.15 Similarly, Rydon made no specific assessment of Harley's competence to undertake the refurbishment project, relying largely, if not solely, on the fact that it had previously employed Harley as a sub-contractor on other projects, including the Chalcots Estate and Ferrier Point projects.2992 Lawrence {Day23/48:17-25}.
The fire safety strategy
¶64.16 As principal contractor it was Rydon's responsibility to ensure that sufficient expertise and resources were made available to the project and that the work carried out by external consultants, such as Exova, was satisfactory. In the event, Rydon's approach to Exova, and to fire engineering generally, was alarmingly complacent.
¶64.17 Rydon appears to have had no interest in the use of a fire engineer on the Grenfell Tower project. It attended a contractor induction meeting on 1 April 2014, two weeks after it had been appointed as principal contractor, at which the involvement of Exova was discussed.2993 {ART00002255}. The minutes of that meeting record that Exova had completed the fire strategy at the tender stage and that the company's services had not been transferred to Rydon but that Mr Lawrence would contact it with a view to instructing it for the future.2994 {ART00002255/4} item 5.3. (The minutes, drafted by Artelia, were misleading because the fire strategy had not been completed at the tender stage and indeed never was completed.) Despite that commitment, however, he made no attempt to find out who was Exova's client or what were the terms on which it was acting.2995 Lawrence {Day23/51:9-15}; {Day23/53:11-21}. He had no discussions with the TMO, Studio E or Artelia about the role that Exova might play in the future of the project.2996 Lawrence {Day23/52:4-10}. He repeated his assurance that he would contact Exova at several subsequent site meetings, but failed to take any action in respect of it.
285¶64.18 Mr Lawrence explained to Bruce Sounes in March or April 2014 that Rydon did not normally appoint fire engineering consultants on the assumption that the safety of the design had been established before it had been appointed and was not its responsibility.2997 See Chapter 54; Sounes {SEA00014273/152} page 152, paragraph 372. In his view, it was the responsibility of building control to identify any defects in the design.2998 Sounes {SEA00014273/152} page 152, paragraph 372; Lawrence {Day23/65:17-24}; {Day23/74:8-12}.
¶64.19 Simon Lawrence said that Rydon had considered asking Exova to advise on the alterations to the lower four floors of the tower between April and October 2014,2999 Lawrence {Day23/63:14-20}. but there is no contemporaneous evidence that it considered using Exova or any other fire engineer for that purpose.3000 See Chapter 54; Lawrence {Day23/79:13}-{Day23/80:7}. We do not think that Rydon gave any genuine consideration to seeking the advice of a fire engineer in respect of the lower four floors, or indeed at all.
¶64.20 In the event, Rydon took a positive decision not to appoint a fire engineer, probably because it did not think that it needed to do so in order to protect its own interests. The decision was taken without consulting the TMO, Studio E, Harley or any other party that might have had an interest in receiving fire safety advice.3001 Lawrence {Day23/80:8-21}. Indeed, there is nothing in the contemporaneous evidence to indicate that Rydon told anyone that it had made a decision of that kind. Simon Lawrence professed not to know whether Rydon had told the TMO or Studio E that it was no longer considering the appointment of a fire engineer,3002 Lawrence {Day23/80:22}-{Day23/81:17}. but the complete absence of any indication that it did so suggests strongly that it did not. Rydon should have appreciated that it was ill-equipped to make an informed judgement about the need for fire engineering advice and should therefore have consulted the TMO (its client) and Studio E (its principal designer) before making any decision.
¶64.21 To the extent that Rydon investigated the quality of Exova's work at all, its actions were cursory and superficial. Rydon received Issue 3 of Exova's Outline Fire Safety Strategy as part of the tender documents3003 {TMO10007081/3} Item 115. and accepted that it contained the fire safety strategy underpinning the design work that had been carried out before its appointment.3004 Lawrence {Day23/85:4-6}; {Day23/88:4-9}. Nonetheless, it did not ask Studio E whether Exova's work had been sufficient for its purposes and did not attempt to familiarise itself with the terms on which Exova had been appointed.3005 Lawrence {Day23/85:16-25}. It does not appear to have occurred to Rydon that the title of the Outline Fire Safety Strategy itself suggested that it might not be in final form.3006 Lawrence {Day23/89:2-7}. Each of those was a serious failure on the part of Rydon.
¶64.22 Rydon's evidence was that it believed that Issue 3 of Exova's Outline Fire Safety Strategy was comprehensive and provided all the information needed to ensure that the design of the refurbishment was safe.3007 Lawrence {Day23/89:24}-{Day23/90-1-2}. That was self-evidently not the case, however, given the expressly provisional nature of the opinion provided in respect of functional requirement B4(1). Furthermore, Rydon did not ask what information Exova had used in compiling it, assuming instead that it had been prepared on the basis of all the information in the tender pack.3008 Lawrence {Day23/90:13}-{Day23/91:1}. However, Simon Lawrence did not know whether Exova had seen the NBS Specification3009 Lawrence {Day24/115:11-25}. and no one at Rydon appears to have noticed that Exova's description of the project did not include overcladding or any reference to the system it was proposed to use.3010 Grenfell Tower Outline Fire Safety Strategy {CST00000085/4}; Lawrence {Day23/91:9}-{Day23/92:1}. Mr Lawrence assumed that Exova had been involved in the design of the refurbishment from the outset, but did not ask anyone whether that had actually been the case.3011 Lawrence {Day23/92:18-24}.
286¶64.23 In fact, Issue 3 of the Outline Fire Safety Strategy contained no proper assessment of compliance with functional requirements B3 or B4 of the Building Regulations, and in the case of functional requirement B4 stated only that the provisional opinion that the proposed changes would have no adverse effect on the building in relation to external fire spread would be confirmed by an analysis in a future issue of the report.3012 Grenfell Tower Outline Fire Safety Strategy {CST00000085/9} paragraph 3.14. Although Simon Lawrence had reviewed Issue 3 of the Outline Fire Safety Strategy in late 2013 or early 2014 and again in September 2014,3013 Lawrence {Day23/84:20}-{Day23/85:2}; {Day23/94:14-16}. he failed to notice that no further issue of the report had been produced.3014 Lawrence {Day23/94:17}-{Day23/95:11}. Rydon therefore took no steps to ensure that it was forthcoming.3015 Lawrence {Day23/95:12-19}.
¶64.24 Simon Lawrence appears to have understood that part of the report to mean that the cladding would have no adverse effect on the fire safety of the tower provided Rydon ensured that it complied with functional requirement B4.3016 Lawrence {Day23/95:21-24}; {Day23/97:4-7}. However, if that had been its meaning, it would have rendered Exova's analysis pointless. There could be no reasonable basis for any such understanding.
¶64.25 Rydon appears to have thought that any defects in the design or choice of materials would ultimately be identified by building control,3017 Lawrence {Day23/94:17}-{Day23/97:21}. but that reflected a fundamental misunderstanding of the role of building control.
¶64.26 When giving evidence Simon Lawrence accepted that it was the responsibility of a design and build contractor to satisfy itself that the fire strategy for a given project was correct.3018 Lawrence {Day23/70:24}-{Day23/71:5}. It seems clear to us, however, that Rydon simply did not trouble to understand what Issue 3 of the Outline Fire Safety Strategy did and did not cover and what reliance could reasonably be placed on it. Rydon understood that it was ultimately responsible for ensuring the fire safety of the refurbished building,3019 Lawrence {Day23/83:17-25}. but it abdicated that responsibility by failing to take an interest in Exova's work.3020 Lawrence {Day23/83:2-7}. Rydon should have been aware that Exova had not provided a final opinion on compliance with functional requirement B43021 Hyett, 'Failures of Statutory Compliance' (Amended Report) {PHYR0000029/28} paragraph 4.2.22. and should have ensured that it was provided. Simon Lawrence was content for Studio E to obtain free advice from Exova but clearly decided that Rydon would not be paying for it.3022 Email from Simon Lawrence to Neil Crawford cc Simon O'Connor on 19 September 2014 at 14:25 {SEA00011754/1}; Lawrence {Day23/72:12-18}.
287¶64.27 We have concluded that the exchanges of emails in September 2014 involving Exova3023 {SEA00011754}. should have alerted Rydon to three important things. First, it should have been clear to Rydon that Exova was giving advice to the design team on the basis of incomplete information. Second, Rydon should have noticed that Harley and Studio E were unable to reach a settled view on the appropriate design strategy for cavity barriers in the facade of the tower and that they might therefore benefit from the assistance of an independent fire engineer. Third, if Rydon had been aware that in Issue 3 of its Outline Fire Safety Strategy Exova had provided only a provisional conclusion on compliance with functional requirement B4, it should have been alerted to the need to obtain a fully considered opinion to complete the work. None of those matters required Rydon to have its own specialist design or fire engineering expertise. On the contrary, they fall well within the capacity of a reasonably competent design and build contractor.
¶64.28 As we have already said, Rydon's role was to take the lead in ensuring that important issues such as fire safety were properly considered. In our view, its approach to the involvement of Exova represents a serious failing. It is telling that Simon Lawrence conceded, in hindsight, that the advice of a fire engineer is essential on any construction project with any significant degree of complexity.3024 Lawrence {Day23/48:6-9}. That Rydon did not realise that at the time indicates the extent of its general lack of concern for fire safety in relation to the project.
Failure properly to evaluate and co-ordinate design work
¶64.29 Rydon's internal system for evaluating and co-ordinating the design work was inadequate. One effective tool that it could and should have used to co-ordinate the design process effectively was a matrix of responsibilities identifying which of the many sub-contractors and consultants was responsible for particular aspects of the work. Such a matrix should ensure that everyone involved in a project knows where responsibility lies for each decision and is important for the effective management of any design and build contract.3025 Hyett, 'Failures of Statutory Compliance' (Amended Report) {PHYR0000029/87} paragraphs 4.4.17-4.4.18. In the absence of a matrix of responsibilities it was extremely difficult, if not impossible, for Rydon to ensure that its sub-contractors and consultants properly understood their separate responsibilities or that Rydon itself understood where responsibility for individual decisions lay. Its failure to establish a matrix of responsibilities resulted in a failure on the part of those responsible for the design of the cladding to recognise that they were responsible for various critical decisions affecting fire safety, including the compliance of the cladding with the Building Regulations.
Failure properly to monitor sub-contractors
¶64.30 Rydon appears to have assumed that Studio E was co-ordinating the design work. As early as April 2014, it authorised Studio E and Harley to talk directly to each other about matters of design, provided that all correspondence was copied to itself.3026 {HAR00000927}; Lawrence {Day23/167:6}-{Day23/168:12}. For such an approach to be successful, however, Rydon had to take active steps to ensure that Harley and Studio E were working effectively together and that all relevant matters of design were being considered, but it failed to do so. On the contrary, it relied on Studio E and Harley to lead the design process, which it saw as a "free flow" of information between Studio E and Harley, in which it did not need to play an active role.3027 Lawrence {Day22/181:18-23}; Lawrence {Day23/25:17}-{Day23/28:14}. It intervened only if it saw that an element of the design was missing or if one of them complained about the other's performance,3028 Lawrence {Day23/27:1-6}; O'Connor {Day26/37:16-24}. but it was ill-equipped to determine whether something was missing, given that it had no proper system for monitoring the design process and employed no one qualified to identify any defects.
288¶64.31 Rydon also failed to make use of an electronic drawing control system, which meant that it was not able to co-ordinate the exchange of drawings between Harley and Studio E or indeed to understand which drawings had been issued and which were missing.3029 Lawrence {Day22/165:9}-{Day22/167:23}. Rydon did not tell anyone at Studio E that it was expecting Studio E to co-ordinate the drawing exchange process on its behalf or that it had no proper drawing control system of its own.3030 Lawrence {Day22/168:1-9}. Moreover, Rydon had no system in place for recording design changes throughout the project, save for a tracker that Simon Lawrence started himself to monitor changes that had programme and cost implications.3031 Lawrence {Day23/31:20}-{Day23/40:17}; {ART00003086}; {ART00008861}; {RYD00022907}.
¶64.32 Design drawings produced by Harley were sent to Studio E for comment, but Studio E reviewed them only to ensure that they complied with architectural intent and contained no obvious errors. Rydon does not appear to have asked itself whether such a limited examination was sufficient to enable Studio E to discharge its contractual obligation to examine Harley's drawings and report on them, or to discharge Rydon's own obligation to the TMO to ensure that the design of the refurbishment complied with statutory requirements.3032 Lawrence {Day22/182:11}-{Day22/185:20}; Crawford {SEA00014275/78} page 78, paragraph 256; Crawford {Day9/85:11}-{Day9/92:12}. Indeed, Rydon never turned its mind to the question whether Studio E was actually considering statutory compliance when it reviewed design drawings.3033 Lawrence {Day22/185:10-20}. By failing to ask those questions Rydon failed to ensure that the design of the cladding was safe, at least as far as fire was concerned.
Undue reliance on previous projects
¶64.33 Insofar as Rydon turned its mind to the fire performance of the products used in the refurbishment at all, it assumed they were safe because it had used them on previous projects, particularly the Chalcots Estate and Ferrier Point projects, where it had worked with Harley to install ACM rainscreens.3034 Lawrence {Day22:178/11}-{Day22/179:8}.
¶64.34 However, Rydon failed to learn important lessons from the fire that took place at Taplow House on the Chalcots Estate on 16 January 2012. The fire gave it direct experience of the potential importance of fire barriers, particularly around windows, in preventing the spread of fire over the walls of high-rise residential buildings, but there is no evidence that it applied that knowledge to the Grenfell Tower refurbishment.3035 Blake {Day29/127:9-19}. Rydon had no system for sharing that experience or the learning derived from it with its employees. Nor did it have any system for ensuring that such lessons were heeded in its future work.3036 Blake {Day29/124:3-9}.
289Inappropriate reliance on building control
¶64.35 Rydon attempted to mitigate its lack of expertise by excessive and inappropriate reliance on building control, epitomised by Simon Lawrence's evidence that he saw building control as a "resource" on which he could rely because Rydon was paying a fee for it.3037 Lawrence {Day23/74:1-12}. Rydon viewed building control as the body that would ensure that its sub-contractors were complying with their contractual obligations,3038 Lawrence {Day22/68:7-15}; {Day23/2:21}-{Day23/3:12}; {Day24/192:12}-{Day24/199:10}; {Day25/12:18}-{Day25/14:1}; {Day25/18:14}-{Day25/24:9}; O'Connor {Day26/167:24}-{Day26/168:2}; Hughes {Day27/18:12}-{Day27/19:10}; Blake {Day29/70:22}-{Day29/74:1}; Sounes {SEA00014273/152} page 152, paragraph 372. but in our view it is never appropriate for a principal contractor (or any other party) to rely on building control to ensure that its designs comply with the Building Regulations.
¶64.36 In this case, it was particularly inappropriate and unsafe for Rydon to rely on building control to the extent that it did because its haphazard communications with building control meant that it could never be confident that it had given building control the information it needed properly to evaluate the design. For example, Rydon approved the substitution of Celotex RS5000 by Kingspan K15 (a product with a different chemical composition) and took no steps to conduct any investigation of its own into the suitability of the product or to ensure that building control and the TMO had been alerted to the change.3039 Blake {Day29/117:13-17}.
Failure to respond to concerns about fire safety
¶64.37 Rydon failed on at least two occasions to provide proper responses to specific enquiries about fire safety, indicating a lack of interest in the subject.
¶64.38 On 12 November 2014 Claire Williams wrote to Simon Lawrence seeking clarification on the fire retardance of the new cladding and saying that she had just had a "Lacknall moment".3040 {RYD00023468}. There is no evidence that he or anyone else at Rydon responded in any way to the email.
¶64.39 On 10 April 2015, Ms Williams wrote to Simon O'Connor and asked him for the fire rating of the cladding and fixings and to confirm their acceptance by building control.3041 {TMO00858290}. Although Ms Williams chased for a response, Rydon appears to have taken no action in response to her request.
The window reveals
¶64.40 As set out in detail in Chapter 56, Rydon failed to ensure that the non-combustible insulation material which had been specified by Studio E in the NBS Specification was used around the windows and instead allowed the use of combustible Celotex and Kingspan insulation products. Rydon also changed the internal window surrounds from plywood to uPVC without seeking the approval of the TMO or considering the fire safety consequences of doing so. The consequences were very serious because the deformation of the uPVC window surrounds in the kitchen of Flat 16 is most likely to have been the means by which fire first entered the cladding on 14 June 2017.
290Failures in site supervision
¶64.41 Rydon was responsible for inspecting the work done by Harley and other sub-contractors at Grenfell Tower,3042 {TMO10041791/141} at A33/630. but the inspections it carried out were inadequate because they failed to detect some serious defects in workmanship, particularly in relation to cavity barriers. In many cases the effectiveness of cavity barriers was reduced as a result of poor attachment to the concrete walls, fitting in the wrong orientation or installation in the wrong location.3043 Lane, 'Section 8 – The External Wall – Materials and Construction' {BLAS0000008/40} figure 8.42; {BLAS0000008/41} figure 8.44; {BLAS0000008/44} figure 8.47; {BLAS0000008/46} figure 8.50; Hughes {Day27/115:5}-{Day27/116:11}. Rydon accepted that the quality of workmanship in those cases was very poor, but could not explain how it had failed to detect it.3044 Osgood {Day30/154:17}-{Day30/158:11}; O'Connor {Day26/172:18-25}. In substance, Rydon's employees appeared to have regarded its quality control process as little more than a snagging inspection, but that fell far short of performing its obligation to ensure that the work had been properly carried out.
¶64.42 One important reason for Rydon's failure to ensure that the work done at Grenfell Tower was of proper quality was that those appointed to manage and inspect it were ill-equipped to do so. Daniel Osgood was brought onto the project between 27 April 2015 and 24 July 2015 to oversee the installation of the cladding.3045 Osgood {Day30/100:2}-{Day30/103:1}. Although he had previously worked on similar projects as a fitter, he had never worked with ACM panels.3046 Osgood {Day30/95:4}-{Day30/97:13}. He had never received any training in how to inspect cladding installations or in the requirements of the Building Regulations and he did not know that there was statutory guidance on the construction of the external walls of buildings over 18 metres in height.3047 Osgood {Day30/97:14}-{Day30/109:23}. Mr Osgood assumed that all materials installed on the outside of buildings were entirely "fireproof".3048 Osgood {Day30/110:4-6.}; {Day30/115:13-15}; {Day30/118:19-20}. He did not know of the need for cavity barriers to be installed around windows and was not aware of the difference between Rockwool (a non-combustible mineral wool insulation product) and Celotex RS5000 (a combustible PIR insulation product).3049 Osgood {Day30/141:5-7}; {Day30/184:1-3}; {Day30/185:17-24}; {Day30/188:9-11}; {Day30/115:13-15}; {Day30/110:1‑7}.
¶64.43 David Hughes was appointed in October 2015 as lead site manager, which required him to take responsibility for the inspection of Harley's work at a critical stage of the project.3050 Hughes {RYD00094213/5} page 5, paragraph 22. He had not previously worked on a project that involved fitting cladding to a high-rise building.3051 Hughes {Day27/6:7-9}. He did not understand, even in broad terms, the functional requirements of the Building Regulations, was not aware that the external walls of buildings should adequately resist the spread of fire over the surface, was not aware that guidance had been published on the construction of the external walls of buildings over 18 metres in height, was not aware of the expression "limited combustibility" and was not aware that cavity barriers should be fitted around windows.3052 Hughes {Day27/28:25}-{Day27/34:20}.
¶64.44 Rydon compounded the problem by failing to ensure that inspections were carried out in accordance with relevant guidance, such as the overcladding specification produced by Curtins Consulting and the manufacturers' instructions for the installation of insulation and cavity barriers.3053 {ART00000914}; Lawrence {Day22/58:22}-{Day22/60:19}; Hughes {Day27/21:1-22}. Rydon also exercised little, if any, meaningful control over the materials that were used on site by its sub-contractors, trusting them instead to use only those which were appropriate.3054 O'Connor {Day26/96:15-24}.
291¶64.45 It is also clear that the quality of Rydon's work and its approach to the project more generally was poor. From mid-2015, when the project was nearing completion, the TMO and Artelia repeatedly raised concerns with Rydon about the resources it had dedicated to the project and its apparent inability or unwillingness to resolve complaints about the quality of the work.3055 {ART00006206}; {TMO00859230}; {ART00006681/3}; {ART00006657}; {ART00006641/1}. In June 2015, Simon Lawrence candidly reported to Stephen Blake that they had a poorly performing site, mainly the result of poor surveying and cheap, incompetent sub-contractors.3056 {RYD00044349}. In May 2016 Neil Reed of Artelia reported to Simon Cash that he had never before worked with a contractor demonstrating such a level of nonchalance.3057 {ART00006672}. Both Simon Lawrence's and Neil Reed's statements reflect a contemporaneous perception, supported by other evidence before us, that the general quality of Rydon's work fell significantly below that which could be expected of a reasonably competent design and build contractor.
Regulation 38 and the health and safety file
¶64.46 Rydon sub-contracted the collation of information required for the purposes of complying with regulation 38 of the Building Regulations and the preparation of the health and safety file required by the CDM Regulations to All Group Holdings Ltd. However, nobody at Rydon checked the operation and maintenance manual or the health and safety file to ensure it was complete and accurate. Stephen Blake did not consider that to be Rydon's responsibility.3058 Blake {Day29/170:16}-{Day29/171:9}. Mr Hughes said that he had taken a quick look at a draft of the operation and maintenance manual3059 Hughes {Day27/205:1-2}. but had not received the final version.3060 Hughes {Day27/205:3}. Rydon ought to have checked All Group Holding's work. It is doubtful whether the information provided to the TMO satisfied either regulation 38 or the requirements of the CDM Regulations.
¶64.47 Mr Hoban said that he had asked David Hughes whether Rydon had given the TMO the information required by regulation 38 and that Mr Hughes had told him that the necessary information was being sent to the TMO. We do not understand how Mr Hughes was able to give that assurance.3061 Hoban {Day46/200:18-24}; Hughes {Day27:202:25}-{Day27/203:8}.
293Chapter 65: The contribution of Harley
Introduction
¶65.1 In July 2014 Rydon appointed Harley as a sub-contractor to carry out the design and construction of the overcladding of Grenfell Tower. On 25 July 20143062 {RYD00013524}. Zak Maynard sent an undated letter of intent signed by Simon Lawrence3063 Letter of Intent {HAR00000120}. on behalf of Rydon as an attachment to an email to Mark Harris of Harley. The letter of intent stated that Rydon intended to appoint Harley as the envelope package sub-contractor. On 16 September 2014 Zak Maynard confirmed that the scope of the letter of intent had been increased to cover the full value of the work. Although the letter of intent contemplated that the parties would enter into a formal contract for the work, Rydon did not provide a document and Harley does not appear to have pressed for one. As a result, the parties did not execute a formal written agreement and their relationship was governed at all material times by the terms of the letter of intent.3064 Letter of Intent {HAR00000120}; Maynard {Day31/44:8-17}; {Day31/51:11-20}; {Day31/54:11}-{Day31/55:1}; Bailey {Day32/57:4-25}; Harris {Day34/14:7-11}; {Day34/16:2-7}.
¶65.2 The letter of intent provided that the contract between Harley and Rydon was subject to the terms of the DOM2 Articles of Agreement3065 DOM2 2011 Sub-Contract Articles of Agreement {INQ00011295}. and Subcontract Conditions.3066 DOM 2011 2011 Sub-Contract Conditions {INQ00011211}. It described the work to be carried out and the conditions under which the contract was to be performed by reference to nine Appendices.3067 Appendix A: Scope of Works & Ascertainment of Lump Sum Price (Envelope Package) dated 25 July 2014 {HAR00000397}; Appendix B: Rydon Standard Terms and Conditions {HAR00000389}; Appendix C: The Rydon Way {HAR00000390}; Appendix D: Subcontractor Pre-Contract Interview dated 16 June 2014 {HAR00000391}; Appendix E: Traffic Management Plan {HAR00000392}; Appendix F: Schedule of Information {HAR00000396}; Appendix G: Site Protection Policy {HAR00000393}; Appendix H: Payment Schedule {HAR00000394}; Appendix P: Programme of Works {HAR00000395}. Under the contract Harley was responsible for all aspects of the design of the facade. In particular, it bore responsibility for ensuring that the design of the facade complied with all statutory requirements, including the requirements of the Building Regulations. Moreover, all the provisions of the draft building contract between Rydon and the TMO were incorporated into the letter of intent, insofar as they were relevant to the sub-contract works.3068 Letter of Intent {HAR00000120/2} clause 2(b). They included an obligation to accept full responsibility for the design of the project and the selection of materials, including the work carried out by Studio E.3069 Letter of Intent {HAR00000120/2} clause 2(b); DOM2 Subcontract Conditions {INQ00011211/8} clause 2.5.1; The Design and Build Contract {RYD00094235/69} clause 2.17. In those circumstances, Harley accepted responsibility to Rydon for the contents of the NBS Specification insofar as they related to the design of the facade.3070 Ray Bailey {Day32/85:12}-{Day32/87:10}.
¶65.3 In its closing statement Harley pointed out that it had no formal contract with Rydon, simply a letter of intent with a large number of appendices which incorporated the terms of Rydon's contracts with the TMO, not all of which it had read in full.3071 {HAR00020580/6}, paragraph 12. That was put forward as an explanation of its failure to understand the full extent of its contractual obligations and as a reason for following common practices within the industry. However, it is clear that any organisation that enters into a contract of this kind, no matter how complex its terms, has a responsibility to understand the nature of the obligations it has undertaken. Simply failing to understand the contract and following industry practices will not do. Despite that, however, Harley was aware that it had a responsibility to check that the materials described in the NBS Specification were suitable and to ensure that on the completion of the work the external walls of the tower complied with the Building Regulations, including functional requirement B4(1).
294¶65.4 It is clear that Rydon and Studio E both regarded Harley as an expert in the design and construction of ventilated rainscreen facades and expected it to bring to bear the skill and experience that could be expected of an expert sub-contractor of that kind. If it had stopped to think about it, Harley must have known that. With that in mind we obtained a report from Mr Jonathan Sakula MA, Ceng., FIStructE, FICE,3072 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001}. to help us understand what could be expected of a reasonably competent facade contractor in the period between January 2012 and June 2017. Mr Sakula also gave oral evidence.3073 Sakula {Day125}.
¶65.5 In a closing statement Harley challenged Mr Sakula's evidence on the grounds that he had limited experience of the use of ACM products on high-rise buildings and was himself a facade consultant rather than a cladding contractor, the suggestion being that he had little experience of the practical world in which companies such as Harley operate. We found that argument surprising, not only because it proceeds on the footing that Harley was not an expert in designing and installing building facades, but also because Harley accepted that it had undertaken significant responsibilities for ensuring the suitability of the materials that others had proposed using. We found Mr Sakula an impressive witness and we were not asked to hear evidence from anyone else who had experience of the cladding industry at the time in question. Although we have been mindful of the scope of his experience and of the various arguments put forward on Harley's behalf, we have generally accepted his evidence as reliable.
¶65.6 In the light of the evidence as a whole, we consider that Harley's work on the refurbishment was characterised by a failure to take its responsibilities seriously, ignorance, complacency and a failure properly to manage its staff. As the specialist contractor responsible for the external wall of the tower, the standard of Harley's work fell well below that to be expected of a reasonably competent cladding contractor and it must therefore bear a significant degree of responsibility for the fire.
Technical competence
¶65.7 We are satisfied that Harley failed to achieve the standard of a reasonably competent cladding contractor in several different aspects of its work. Many of those failures had the same root cause, namely, the inadequate technical expertise of its employees and representatives.
295The Building Regulations and Approved Document B
¶65.8 At the time of the refurbishment Ray Bailey considered himself to be as well placed as anyone in the specialist cladding industry to advise on whether materials used in the construction of an external wall complied with the applicable regulations.3074 Ray Bailey {Day32/8:2-9}. However, he conceded that he had not read through Approved Document B for some years and had then found it quite complicated.3075 Ray Bailey {Day32/6:20-21}. He considered himself to have a working, but not a detailed, knowledge of it.3076 Ray Bailey {Day32/6:21-22}.
¶65.9 Although Daniel Anketell-Jones later completed an MSc in facade engineering, at the time of the refurbishment his knowledge of the Building Regulations did not extend beyond matters relating to structural stability and he was not very familiar at all with Approved Document B.3077 Anketell-Jones {Day35/119:3-15}; {Day35/122:22-23}. Ben Bailey said that he had seen parts of Approved Document B but had never received any training to help him understand the Building Regulations, Approved Document B or any of the associated guidance.3078 Ben Bailey {Day39/18:10-24}. Both Mark Harris and Mike Albiston candidly admitted that they had not been competent to advise on any question of compliance with the Building Regulations or Approved Document B.3079 Harris {HAR00010159/8} page 8, paragraph 34; Harris {Day34/7:12-24}; Albiston {Day35/35:18-25}.
¶65.10 Before he became involved in the refurbishment, Kevin Lamb had never undertaken any formal training on the Building Regulations or the guidance in the approved documents.3080 Lamb {Day37/70:18-22}. He said that he had taken steps to refresh his memory of Approved Document B during the refurbishment3081 Lamb {Day37/130:2-5}. but did not think that it was his responsibility to look at it in any detail.3082 Lamb {Day37/131:3-5}. He did not give a second thought to which route to compliance was being adopted.3083 Lamb {Day37/142:1-14}.
¶65.11 Accordingly, Harley's own evidence was that none of those engaged on the refurbishment had any more than a passing familiarity with the relevant Building Regulations or approved documents. That, in our view, was unacceptable for an organisation which held itself out to be a specialist cladding contractor.3084 Sakula {Day125/27:16}-{Day125/30:12}; {Day125/34:1-7}.
¶65.12 Harley held itself out as a specialist cladding contractor with sufficient technical expertise to undertake what was, on any view, a large and complicated project. Under its contract with Rydon it was responsible for the design of the cladding and for ensuring that it complied with the relevant statutory requirements.3085 Undated Letter of Intent from Rydon Management Systems to Harley Curtain Wall Ltd {HAR00000120/1-2} Item 1. At the very least, therefore, it should have been familiar with the regulations and with any statutory and industry guidance that was relevant to its work. It is difficult to understand how Harley could reasonably have believed it could discharge its obligations to Rydon without having that essential technical knowledge.
¶65.13 According to Jonathan Sakula, whose expert opinion on this point we accept, at that time a reasonably competent cladding contractor would have had a system in place for checking the suitability of any products proposed for use on a refurbishment project of that kind.3086 Sakula {Day125/26:23}-{Day125/27:2}; {Day 125/26:2-12}. In order for such a system to function effectively it would have to be managed by someone with sufficient technical knowledge.3087 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/25-26}; Sakula {Day125/140:25}-{Day125/141:9}. However, Harley had no such system and does not appear to have employed anyone capable of managing one, despite its obligation to Rydon to ensure that suitable products and materials were used.
296¶65.14 In our view Ben Bailey lacked the competence and experience to act as Harley's project manager on a project of the size and complexity of the Grenfell Tower refurbishment. The project manager's responsibilities included ensuring that work was done to a high standard;3088 Ben Bailey {Day39/13:2-3}. and for that reason the project manager was the most senior person from Harley who regularly attended the site.3089 Ben Bailey {Day39/13:4-10}. However, Ben Bailey was at the time a 25 year old graduate with a foundation degree in motor sport engineering, who had not previously held the position of project manager and had no obvious qualifications for the role. We consider that, for a project of this nature, Harley ought to have appointed as project manager someone who had the training and experience required to manage a large project of that kind. It failed to do so.
Testing regime
¶65.15 It is clear from the evidence that none of those employed by Harley on the refurbishment had even a basic grasp of the fire testing regime that applied to the products used in the external wall of the tower. Ray Bailey thought that a Class 0 classification meant that a product was "difficult to ignite and if you take the source of flame away from it, it won't continue to burn".3090 Ray Bailey {Day33/6:14-17}. He also thought, quite wrongly, that a Class 0 classification meant that a product was safe to use in any application on any building over 18 metres in height.3091 Ray Bailey {Day33/6:18-25}. For the senior executive and owner of a specialist cladding sub-contractor, that was a striking misconception.
¶65.16 Daniel Anketell-Jones said that he had been unaware of the difference between "non-combustible", "limited combustibility" and "Class 0"3092 Anketell-Jones {Day35/180:23}-{Day35/181:5}. and thought that "Class 0" meant that the material could not catch fire.3093 Anketell-Jones {Day36/92:7-14}. Such ignorance on the part of the one person whom Harley regarded as having technical expertise in matters of fire safety is remarkable. Mr Lamb claimed to have understood what Class 0 meant, but he said that he had had no need to understand the tests that underpinned that classification.3094 Lamb {Day37/144:1-5}. His assertion that all major elements of an external wall cladding system would have to be Class 0 betrayed a fundamental ignorance of the basic principles underlying the testing and classification regime set out in Approved Document B. If a designer seeks to follow the guidance provided by what has been called the "linear route" in relation to a building over 18 metres in height, paragraph 12.7 requires insulation products to be materials of limited combustibility. Mr Lamb did not understand that distinction. We consider that to be inexcusable in one who was employed to carry out design work.3095 Lamb {Day37/149:22}-{Day37/150:4}.
¶65.17 Mr Anketell-Jones also claimed to be unaware of the BS 8414 test methods or the BR 135 criteria and said that he had never considered whether they were relevant to the question whether products were safe for use on high-rise buildings.3096 Anketell-Jones {Day36/95:8}-{Day36/96:3}. However, on 16 January 2016, he sent an email to Jonathan Roome of Celotex asking for the test results and certificates for RS5000 for the purposes of advising a different client on a different project altogether. In that email he made detailed references to the fire testing regime and the limitations of the BS 8414 test.3097 See Chapter 56 for further detail. We think, therefore, that he was seeking to play down his technical knowledge when giving evidence before us and that he knew more than he was prepared to admit.
297¶65.18 Mr Sakula told us that at the time of the refurbishment it had been the practice of reasonably competent cladding contractors to obtain from one source or another information about technical developments and to make arrangements for disseminating that information within their organisations.3098 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/29}. However, Harley had no such system in place and in that respect fell below the accepted standards prevailing at the time.
¶65.19 The general lack of understanding of these matters within Harley arose from its failure to take adequate steps to ensure that its employees were properly trained. Ray Bailey said that Harley's previous Estimating and Technical manager, Graham Hackley, had attended a course run by the CWCT and that it had been his responsibility to ensure that knowledge gained in that way was shared with the rest of the team.3099 Ray Bailey {Day33/19:6-9}. However, there is no evidence that Mr Hackley's role involved training other employees of Harley and it was ultimately the responsibility of Ray Bailey, not Graham Hackley, to ensure that Harley was competent to perform the work it took on. In any event, whatever Mr Hackley may have learnt of any value, it seems that it was not shared. When Mr Hackley left Harley in late 2012 or early 20133100 Ray Bailey {Day32/9:8}. his expertise, such as it was, does not appear to have been replaced. Daniel Anketell-Jones took over as technical manager but was scarcely qualified to do so given that it was not until 2014 that he began studying part time for an MSc in facade engineering (which he had still not completed when he left Harley in 2016).3101 Anketell-Jones {HAR00010149/2} page 2, paragraphs 7-8.
Other standards and guidance
¶65.20 Harley's knowledge of the industry standards and guidance that were relevant to its work was similarly weak. Ray Bailey said that he had read the CWCT Standard for Systemised Building Envelopes issued in 2008 in the past but conceded that he did not know it in detail.3102 Ray Bailey {Day32/7:15-25}. He had not seen the CWCT's Technical Guidance Note 73, published in March 2011, until after the fire.3103 Ray Bailey {Day33/2:1-13}. Even at the time of their oral evidence to the Inquiry in September 2020, neither he nor Mr Anketell-Jones could recall ever having seen the Curtins specification.3104 Ray Bailey {Day32/64:4-19}; Anketell-Jones {Day35/201:22}-{Day35/202:2}. That was a significant omission because the Curtins specification had been expressly incorporated into Harley's contract and required the facade system to comply fully with the recommendations of the BRE document "Fire performance of External Insulation for Walls of Multi Storey Buildings", 2nd ed. (2003) (BR 135). It also contained broader performance standards, such as a requirement that the system should not be a fire risk at any stage of installation, nor constitute a fire hazard after completion if for any reason the insulation were to become exposed.3105 {CCL00001449}. Harley should have read in full and complied with the documents that were incorporated into its sub-contract.3106 Sakula {Day125/151:12-17}.
298¶65.21 Daniel Anketell-Jones said that he had not been aware that the facade had to meet the requirements of the CWCT Standard for Systemised Building Envelopes3107 Anketell-Jones {Day36/67:12-15}; {Day37/37:23-25}. or the Curtins specification,3108 Anketell-Jones {Day35/201:15-21}. that he had not been familiar with BR 135,3109 Anketell-Jones {Day35/203:8-11}. and that he had not been aware of any guidance published by the CWCT or the Building Control Alliance.3110 Anketell-Jones {Day35/36:6-10}; {Day35/193:8-13}. Indeed, he said that it was not until about the end of 2015 that he had begun to appreciate that those documents existed.3111 Anketell-Jones {Day35/179:17-23}. He said he had not been aware that there was any industry guidance that emphasised the importance of closing cavities around the windows of high-rise buildings,3112 Anketell-Jones {Day35/188:1-5}. and had not been aware that window openings required protection from the spread of fire at all.3113 Anketell-Jones {Day35/188:6-9}. If the gaps in his knowledge were as wide as he suggested, he should not have been working on the refurbishment in a design capacity. If they were not, his failure to take action was all the more serious.
¶65.22 Mr Anketell-Jones said many times during his evidence that his expertise was limited to structural matters,3114 For example, Anketell-Jones {Day36/10:7-13}; {Day36/72:8-12}. but the contemporaneous evidence suggests that he knew rather more about the fire performance of some construction products than he was prepared to admit. For example: a. He was sent the abseil report on the fire at Taplow House, a Harley development on which ACM PE cladding had been used.3115 {HAR00010169/1}.
¶b. In response to a question from a client that he described as a "headache", he made a detailed request to Celotex for certificates demonstrating that RS5000 insulation had passed certain fire performance tests.3116 Email from Daniel Anketell-Jones to Jonathan Roome on 16 January 2015 {CEL00000019/2}.
¶c. He sent an email in which he expressed the view that ACM panels would disappear rather quickly in a fire.3117 {HAR00006585/1}.
¶d. He attended the Annual General Meeting of the CWCT on 7 October 20143118 {CEL00001037}. at which Sarah Colwell of the BRE gave a detailed presentation on BS 8414 and BR 135,3119 {CEL00001038/4-7}. as well as providing a list and images of previous national and international cladding fires.3120 {CEL00001038/2-3}.
¶65.23 In the light of those matters it is difficult to believe that Mr Anketell-Jones was as ignorant of matters relating to fire safety as he would have had us believe. Accordingly we can place little reliance on his protestations of ignorance or lack of expertise. We think that he knew more than he was prepared to admit about the combustibility of ACM PE and the technical requirements the cladding was required to meet. That is why he was regarded within Harley as the person who could give advice on fire safety matters.
¶65.24 Although Kevin Lamb was certain that he had reviewed the CWCT Standard for Systemised Building Envelopes during his work on the Grenfell Tower project, that had not gone beyond a brief look and he candidly admitted that he had not considered whether his designs complied with it.3121 Lamb {Day37/130:11-13}; {Day37/135:21}-{Day37/136:18}. It was not until March 2015, when a conversation took place between Harley, Exova, Rydon and building control in respect of the fire performance of the cavity barriers,3122 See Chapter 57. that he had consulted any external guidance.3123 Lamb {HAR00010419/13} page 13, paragraph 50; Lamb {Day37/162:5}.
299¶65.25 Since Mr Lamb was a sub-contractor, Harley ought to have referred him to relevant guidance documents or standards and ensured that he considered them.3124 Sakula {Day125/72:8-21}. It ought also to have had a system for checking that his work complied with the relevant statutory requirements and guidance documents.3125 Sakula {Day125/72:22}-{Day125/73:1}. Regrettably, however, it did not. Instead, neither Harley nor Kevin Lamb gave sufficient consideration to the documents which were key to their work, namely, BR 135, CWCT's Standard for Systemised Building Envelopes, CWCT's Technical Note 73 and BCA Technical Guidance Note 18 (Issue 0 and Issue 1).3126 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/38-46}. A reasonably competent cladding contractor would have been aware of those documents and would have considered them, together with the functional requirements of the Building Regulations and Approved Document B.3127 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/38-44}; Sakula {Day125/85:11-21}.
International cladding fires
¶65.26 None of Harley's staff involved in the refurbishment were aware of the many fires overseas involving ACM PE cladding, although they were well known within the cladding industry.3128 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/34} paragraph 8.1.1; {JOS00000001/36-37} paragraphs 9.2-9.5. We are satisfied that a reasonably competent contractor in Harley's position would have been aware of them and would have had them in mind when considering the suitability of ACM for Grenfell Tower.
Conclusion
¶65.27 Harley's striking lack of technical knowledge and its failure to implement any proper system to monitor and improve it fell far short of the standard of a reasonably competent cladding contractor. That fundamental failure was the cause of much of its inadequate work on the refurbishment.
¶65.28 It may be that, in the years when Harley was involved in the refurbishment, its understanding of the Building Regulations, Approved Document B, Class 0 and the concept of combustibility was similar to that of some other cladding contractors.3129 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/54} paragraph 14.11; Sakula {Day125/48:6}-{Day125/49:21}. As the evidence of government officials, BRE and the certification bodies revealed, there was some confusion about those matters. Harley may well not have been alone in 2013 in thinking that all that was required in the case of a rainscreen panel was a Class 0 classification, but in our view a reasonably competent cladding contractor should have been aware of the guidance in paragraph 12.7 of Approved Document B and of the distinction between Class 0 and limited combustibility. In any event, the position became clearer in the summer of 2014 when the Building Control Alliance published its Technical Guidance Note 18 (issue 0) which stated in terms that all elements of the external wall had to be of limited combustibility. A reasonably competent cladding contractor would quickly have become aware of that guidance note and of the clarification it offered. It would also have been aware that Class 0 was not a measure of combustibility and therefore would not have thought that it equated to limited combustibility.
300The choice of ACM panels
¶65.29 Harley bears a significant degree of responsibility for the decision to use Reynobond ACM PE panels on the tower. Between late 2013 and September 2014, Studio E continued to seek assistance from Harley in relation to the products that would be included in the NBS Specification and, ultimately, in the TMO's tender information for prospective contractors. During that process, Harley continued to promote the use of Reynobond ACM PE panels.3130 {HAR00005509}; Harris {Day34/95:22}-{Day34/100:6}. It had a strong preference for the use of ACM for the rainscreen because it was familiar with the product, having used it on many previous buildings, and could calculate its costs with confidence. It therefore encouraged the use of Reynobond PE 55 in its own interests,3131 Email from Mark Harris to Tomas Rek CC Ray Bailey, Mike Albiston, Bruce Sounes on 7 November 2013 {HAR00010172/3}. among which were maintaining its commercial relationship with Deborah French (Arconic's UK sales representative).3132 Harris {Day34/95:10}-{Day34/97:14}; {Day34/99:15}-{Day34/100:2} and {HAR00010172}. It is right to point out that Harley's involvement at that stage was entirely voluntary in the hope of being appointed to the project by whoever was appointed by the TMO as main contractor. It was under no contractual obligation to give advice to Studio E or to investigate the suitability of ACM PE, but in encouraging its use as the rainscreen Harley had a responsibility to satisfy itself that it was suitable for that purpose.
¶65.30 Mark Harris accepted that he thought Studio E was relying on Harley, as the specialist cladding contractor, to propose materials that were suitable for use on the tower,3133 Harris {Day34/52:20}-{Day34/53:1}. and although Ray Bailey did not think that Studio E was relying on Harley at all,3134 Ray Bailey {Day32/145:3-11}. he agreed that Harley would not recommend a product that it did not believe complied with the Building Regulations.3135 Ray Bailey {Day32/144:22}-{Day32/145:1}. However, the question whether ACM was suitable for use on the tower was never raised by Harley with Studio E (or indeed vice-versa). Both assumed that the product was safe because it had been used on many other buildings, but neither of them took any steps to investigate its fire performance.
¶65.31 That assumption was born of complacency and incompetence. The view of Mr Sakula, which we accept, was that no reasonably competent cladding contractor would have relied simply on the fact that ACM PE had been used on buildings for many years.3136 Sakula {Day125/109:14}-{Day125/110:16}. It is particularly surprising that Harley was able to make such an assumption, given the dramatic fires that in the previous two years had affected buildings overseas clad in ACM panels. They were well known in the cladding industry generally and, as a specialist cladding contractor, Harley ought to have been aware of them. A reasonably competent cladding contractor would have known about the combustibility of ACM PE and should therefore have known about the risks posed by the use of such material.3137 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/59}.
¶65.32 The NBS Specification was completed by Studio E on 30 January 2014. It included the use of Proteus HR zinc honeycomb rainscreen panels but required tendering contractors to provide alternative prices for other products, including Reynobond Duragloss 5000 ACM.3138 {SEA00000169/65}. At no point did Studio E and Harley ever discuss whether the Reynobond product was suitable for use on Grenfell Tower;3139 Harris {HAR00010159/6} page 6, paragraph 22; Harris {Day34/115:12-25}. they both appear simply to have assumed that ACM PE would perform well on any high-rise building.
301¶65.33 Harley's relationship with Arconic and its consequent ability to offer a significant reduction in the price of Reynobond panels was a factor which helped Rydon secure the contract, and in due course Harley was appointed by Rydon as cladding sub-contractor.
¶65.34 Once Rydon had secured the contract for the Grenfell Tower refurbishment in March 2014, there was no way back. Unless RBKC's planning department objected on aesthetic grounds, it was inevitable that Reynobond PE 55 would be chosen for the rainscreen panels simply on the grounds of cost. Harley's involvement thus made a significant contribution to the eventual use of ACM PE on Grenfell Tower.
¶65.35 The letter of intent and the DOM 2 sub-contract conditions, which in due course constituted the terms under which Harley carried out the work on the refurbishment, incorporated all the provisions of the contract between Rydon and the TMO relating to the installation of the cladding, including in relation to the choice of materials.3140 Letter of Intent {HAR00000120} paragraph 2(b); DOM2 Subcontract Conditions {INQ00011211/8}) clause 2.5.1; Design and Build Contract {RYD00094235/69} clause 2.17. As a result, Harley had an obligation to ensure that the materials chosen for the work were suitable and it is therefore not surprising that Ray Bailey accepted that Harley had an independent obligation to examine the NBS Specification to ensure that the products to which it referred complied with relevant statutory requirements.3141 Ray Bailey {Day32/85:12-{Day32/87:10}. Harley failed to do so, however, because it assumed that if a material or product had been included in the specification, someone, principally Studio E, had ensured that it was suitable for its intended purpose. Kevin Lamb, who was responsible for producing most of the drawings required for the fabrication of the rainscreen, did not think that Harley was responsible for ensuring the suitability of the materials or products identified in the NBS Specification.3142 Lamb {Day37/110:4-7}. Ray Bailey said that he had assumed that Daniel Anketell-Jones had checked that they were suitable, but Daniel Anketell-Jones said that he had not turned his mind to the question.3143 Ray Bailey {Day35/51:4-13}; Anketell-Jones {Day36/69:1-9}; {Day36/78:1-20}.
¶65.36 That evidence is surprising because on 7 October 2014 Daniel Anketell-Jones attended the CWCT Annual General Meeting, together with Mark Stapley, at which a presentation was given which expressly referred to a number of cladding fires in high-rise buildings abroad and to the availability of fire-resistant cladding panels.3144 {CEL00001038/3}. The next day Daniel Anketell- Jones's brother, Samuel Anketell-Jones, who was also employed by Harley, asked Deborah French of Arconic for information about Reynobond ACM panels with fire-resistant cores.3145 {MET00081175}. Although we did not hear evidence on the question, his email strongly suggests that he had spoken to one or both of Daniel Anketell-Jones or Mark Stapley and that Harley knew more than it was willing to admit about the availability of panels with fire-resistant cores and about the dangers posed by panels with unmodified polyethylene cores.3146 See Chapter 55.
¶65.37 The section of the NBS Specification that dealt with the design of the cladding was 11 pages long. We consider that Daniel Anketell-Jones, and indeed every other Harley employee involved in the refurbishment project, should have read and understood at least those sections and should have kept them under consideration throughout the work. In our opinion, there is no reasonable excuse for a specialist contractor in Harley's position not ensuring that they did so.
302¶65.38 Unsurprisingly, perhaps, no check on the suitability of the ACM PE panels was subsequently carried out by anyone at Harley. ACM panels were included in the "Specification Notes" produced by Kevin Lamb in early 2015 describing the products that would be used in the construction of the external facade of the tower.3147 {RYD00046822}; {HAR00010160/5}.
¶65.39 In the light of Mr Sakula's evidence, we consider that the approach demonstrated by Harley generally fell below the generally applicable standards of the time. A reasonably competent cladding contractor would have carefully considered whether ACM PE cladding panels were suitable for use on a building such as Grenfell Tower and would have ensured that all other construction professionals involved in the project were aware of their combustibility.3148 Sakula {Day125/199:12}-{Day125/200:20}.
Certifications and product literature
¶65.40 Mr Sakula thought that it was reasonable for a cladding contractor in Harley's position to rely on certificates such as those issued by the British Board of Agrément (BBA) and Local Authority Building Control,3149 Sakula {Day125/161:7}-{Day125/162:4}. but he also said that he would have expected the contractor's technical department to have looked at the details of the certificates more closely. In the light of his evidence we consider that a reasonably competent cladding contractor would have examined such certificates carefully and also the sales and technical literature produced by the manufacturer in order to understand the claims being made for the product and their relevance to the refurbishment. In that respect also, Harley failed to act appropriately.
¶65.41 On 23 April 2014 Deborah French of Arconic sent Harley a copy of the British Board of Agrément certificate for Reynobond PE 55 cladding panels.3150 {RYD00003932}. Although Harley had an obligation under its contract with Rydon to consider documents of that kind in order to satisfy itself that the products being used on the tower were suitable, no one at Harley gave it more than the most cursory examination at any time.3151 Ray Bailey {Day32/124:16-18}; {Day33/33:14}.
¶65.42 Ray Bailey had read the British Board of Agrément certificate when it was first published in 2008 but did not look at it again after that or discuss it with anyone.3152 Ray Bailey {Day33/35:15}-{Day33/36:20}. Daniel Anketell- Jones could not remember having seen the British Board of Agrément certificate during the Grenfell Tower project.3153 Anketell-Jones {Day37/6:16}-{Day37/7:22}. Kevin Lamb did not consider that it was part of his job to look at British Board of Agrément certificates relating to products that were included in his designs.3154 Lamb {Day38/24:15-18}.
¶65.43 If Harley had examined the British Board of Agrément certificate carefully, it would have recognised that it included several important qualifications, among them that it applied only to panels with a grey/green Duragloss 5000 coating,3155 {BBA00000047/5} section 6.4. and that the fire performance of a wall incorporating the panel could not be ascertained from the certificate alone.3156 {BBA00000047/5} section 6.5. In the light of Mr Sakula's evidence, we are satisfied that a reasonably competent cladding contractor would have read the certificate in full, would have had the qualifications in mind,3157 Sakula, Grenfell Tower Inquiry, Phase 2, Module 1, Report of Facade Expert {JOS00000001/49} paragraph 12.1. would have alerted the design team to its limitations,3158 Sakula {Day125/166:7-17}. and would have asked the manufacturer for more information about the tests that had been carried out on the product before deciding whether it was suitable for use.3159 Sakula {Day125/163:17}-{Day125/164:18}.
303Insulation
Celotex RS5000
¶65.44 From early June 2014, Harley was in close communication with Celotex in relation to the launch of Celotex RS5000 insulation3160 Task call record following call from Harley Facades regarding insulation {CEL00009874}. and representatives of Celotex, principally Jonathan Roome, subsequently made several visits to Harley's offices to promote the new product.3161 See Chapter 56.
¶65.45 The use of RS5000 in place of FR5000 resulted from those discussions. Since RS5000 was being promoted as a new product, Harley should have taken steps to satisfy itself that its use complied with the Building Regulations and any relevant statutory and industry guidance. However, it failed properly to do so.
¶65.46 Although Harley expected to be, and in due course was, appointed as a specialist cladding sub-contractor with responsibility for the design of the cladding, no one appears ever to have asked how functional requirement B4(1) was to be satisfied or which (if any) of the routes to compliance set out in Approved Document B it was proposed to follow. That was a serious failure, because unless it knew the answer to that question it could not tell whether RS5000 could properly be used. Indeed, Harley does not appear to have paid much attention to the fact that RS5000 was on the face of it a different product from that specified in the NBS Specification. The fact that RS5000 was in fact identical to FR5000 just means that in that respect Harley's incompetence did not result in any harm.
¶65.47 As a result of the conversations between Jonathan Roome and Ben Bailey in June 2014, Harley was well aware that Celotex did not at that time offer a product that was suitable for use on buildings above 18 metres in height.3162 Ben Bailey {Day39/55:15-25}; {Day39/56:1}. There was therefore no reasonable basis on which Daniel Anketell-Jones could have thought that the fire performance of RS5000 had been investigated by Studio E during the preparation of the NBS Specification or that it had been "checked through with desktop studies",3163 Anketell-Jones {Day36/102:13-19}. not least since RS5000 was not in the NBS Specification. Indeed, it could not have been because it did not exist as a separate brand in November 2013.
¶65.48 Ben Bailey claimed that after he had become involved in the project in February 2015 he had read the parts of the NBS Specification that concerned Harley's work.3164 Ben Bailey {Day39/64:21-25}; {Day39/65:1-19}. They clearly prescribed the use of a different Celotex insulation product, FR5000. Nonetheless, he did not question the use of RS5000 even though he must have realised that it was not the product specified. Mr Anketell-Jones said that he was not aware that anyone at Harley had considered whether Celotex FR5000 was suitable;3165 Anketell-Jones {Day36/71:10-22}. indeed, he could not remember that it had been included in the specification at all.3166 Anketell-Jones {Day36/70:21}-{Day36/71:4}.
304¶65.49 Harley also failed properly to examine the sales and technical literature relating to the Celotex RS5000 insulation. On 27 August 2014, Jonathan Roome sent Daniel Anketell-Jones a pack of information about Celotex RS5000, which included a detailed specification and testing information.3167 {CEL00011960}; {CEL00011961}; {CEL00011962}; {CEL00011963}; {CEL00011964}; {CEL00011965}; {CEL00011966}; {CEL00011967}. Mr Anketell-Jones said that his usual practice had been to pass information of that kind to others so that the suitability of the materials in question could be checked, but in that particular case he had not sent it to anyone else, nor had he taken any other steps to check whether the fire performance of RS5000 made it suitable for use.3168 Anketell-Jones {Day36/88:13-19}. His explanation was that he would have done so if he had been the designer, but that he had not considered that to be part of his responsibility.3169 Anketell-Jones {Day36/88:17-19}.
¶65.50 In fact, Mr Anketell-Jones did not know, or trouble himself to find out, whose job it was within Harley to check such matters and he appears not to have considered whether Kevin Lamb was likely to have read the information.3170 Anketell-Jones {Day36/93:4-13}. For his part, Ray Bailey did not read the literature himself; he simply assumed that Mr Anketell-Jones had read it.3171 Ray Bailey {Day33/78:4-20}. Kevin Lamb said that he had read what he described as a "compliance guide" on RS5000 produced by Celotex but did not discuss its contents with anyone or look into the suitability of the product.3172 Lamb {Day38/37:24}-{Day38/38:4-7}. If Harley had properly considered Celotex's product literature or got beyond the pink banner on the first page, it would have seen that the claim that RS5000 had been classed as suitable for use above 18 metres applied only if the product was incorporated into a cladding system identical to the one that had been tested.3173 {CEL00000012/3}.
¶65.51 Harley's Specification Notes of 15 July 20153174 {RYD00046822}. did not specify the type of insulation that was to be used. Further, although its drawings included references to insulation, they did not include a description of what product was to be used either. That deprived others who might review the drawings of the ability to identify the products and conduct their own checks.
Kingspan K15
¶65.52 As we have said,3175 See Chapter 56. Kingspan K15 was used as a last-minute substitute for Celotex RS5000 when there was a delay in obtaining supplies of that product. It was used without any proper investigation being made into its suitability for that purpose or into whether its use would result in an external wall that complied with the Building Regulations or was consistent with statutory or industry guidance. Harley must bear primary responsibility for that failure, which was the result of a decision made without consulting Rydon or Studio E.
305¶65.53 Ben Bailey was aware that K15 had not been included in the NBS Specification, but the fact that Harley had installed it on other projects led him to assume that it was suitable for use on Grenfell Tower.3176 Ben Bailey {Day39/31:23}-{Day39/32:3}; {Day39/142:11-14}. He said that he had asked around in the Harley office whether it could be substituted for RS5000, despite the fact that it was not referred to in the NBS Specification.3177 Ben Bailey {Day39/117:3-19}. He referred to the version of the British Board of Agrément certificate relating to K15 dating from 2008, rather than the more recent version, because Harley happened to have had a copy on file at the time. He was not aware that a more recent certificate had been issued.3178 Ben Bailey {Day39/118:20}-{Day39/119:7}.
¶65.54 Ben Bailey did not examine the relevant LABC or British Board of Agrément certificates for the product (indeed, Harley possessed only a copy of the British Board of Agrément certificate issued in 2008, which was long out of date3179 {BBA00000038}; Ben Bailey {Day39/119:5-19}.) and took no steps to find out whether Kingspan K15 was a material of limited combustibility.3180 Ray Bailey {Day33/102:17-25}; Ben Bailey {Day39/127:21-25}. Nonetheless, he proceeded to place orders for K15 in May and September 2015 and to install it on the tower without telling Rydon (or anyone else) that it was being used.3181 {SIG00000012}; {SIG00000013}. In both respects Harley failed to meet the standard of a reasonably competent cladding contractor.
¶65.55 It was not until December 2015 or January 2016, that Harley, facing another interruption to the supply of RS5000, sought permission from Rydon to substitute Kingspan K15 for Celotex RS5000.3182 Hughes {RYD00094213/10} page 10, paragraph 55. Permission was readily granted, but without any thought having been given to the characteristics of the material.3183 Hughes {Day27/71:23}-{Day27/72:1}. Ben Bailey assured Rydon that the products were substantially the same, although he had no basis for doing so, both because he did not have the technical expertise to make that assessment and because he had taken no steps to check that it was correct.3184 Ben Bailey {Day39/107:1-3}; {Day39/108:11-19}. Rydon failed to enquire into the suitability of the product or to inform the TMO or building control that it was being used.3185 Blake {Day29/115:7}-{Day29/117:11}; Hughes {Day27/67:5}-{Day27/68:8}; {Day27/70:4-6}.
¶65.56 Viewing the evidence in the round, it is clear to us that Harley failed adequately to examine the information it had been given about the products that it included in its designs. A reasonably competent cladding contractor would have taken steps to satisfy itself that any information it was given was relevant and reliable, but Harley failed to do so. In that respect it fell below the standard to be expected of a reasonably competent cladding contractor.
Window infill panels
¶65.57 When he first prepared Harley's Specification Notes in January 2015, Kevin Lamb proposed the use of Kingspan TP10 for the insulated panels within the window assemblies,3186 {HAR00003866}. but he did not consult Approved Document B or any other guidance to help him understand the fire performance required of materials to be used for that purpose.3187 Lamb {Day38/174:2-5}. He had not seen any certificates relating to TP10 and failed to investigate its fire performance or otherwise to check that it was suitable for that purpose.3188 Lamb {Day38/179:10-18}. The specification for the panels was ultimately changed to Styrofoam, but, again, Harley did not take any steps to find out whether the material was suitable for the use to which it was to be put.3189 Lamb {Day38/187:1-9}.
306¶65.58 The guidance given in Approved Document B was that the insulation in the window infill panels should be of limited combustibility in order to comply with the requirements of the Building Regulations. We are satisfied that a reasonably competent cladding contractor would have carried out careful and thorough checks on products of that kind each time they used them.3190 Sakula {Day125/111:18-24}. We have concluded that Harley failed to act in accordance with the standards to be expected of a reasonably competent cladding contractor in selecting those products without properly investigating their suitability.
Cavity barriers
¶65.59 Between August 2014 and May 2015, Harley produced fabrication drawings of the details around the windows of Grenfell Tower which contained a series of fundamental errors that were identified by Mr Hyett. The structures they described did not comply with the Building Regulations and did not reflect the guidance given in Approved Document B.3191 Hyett, Section 4 – Failures of Statutory Compliance {PHYR0000029/107-132} paragraphs 4.4.91-4.4.136.
¶65.60 The initial design of the cavity barriers had been produced by Studio E and passed to Harley for development in August 2014.3192 {HAR00010412/2}. Kevin Lamb first produced detailed drawings of the window arrangements on 22 August 2014,3193 {HAR00010426}. but they did not show cavity barriers within the facade. As such, they did not reflect the guidance in Approved Document B and could not be expected to produce a building that complied with functional requirements B4(1) and B3(4) of the Building Regulations. Thereafter, further versions of Kevin Lamb's designs were provided to Rydon and Studio E and were reviewed in design team meetings3194 See Chapter 57. but no one commented on the absence of cavity barriers.3195 Crawford {Day10/185:2-5}; {Day10/185:11-14}; {HAR00010423/2}.
¶65.61 Harley should have been aware of the need to install cavity barriers around windows because of its experience of the fire at Taplow House on the Chalcots Estate in January 2012. That was one of its previous overcladding projects which had suffered a fire but at which cavity barriers around the window had played a significant part in preventing the fire from spreading into the external wall. The significance of the cavity barriers had either not been properly appreciated or the lesson had been forgotten by the time Harley came to design the external wall of Grenfell Tower.
¶65.62 Nonetheless, the request for information which Daniel Anketell-Jones sent to Rydon and Studio E on 17 September 2014, in which he asked about the need for horizontal firebreaks within the cladding areas,3196 {SEA00011703}. shows that Harley had given some thought to the need for cavity barriers and that it understood that cavity barriers were required within the facade at least to some extent. However, no one at Harley appears to have considered any of the available guidance before making that request.3197 Anketell-Jones {Day36/158:10-13}, Lamb {Day38/74:5-11}.
307¶65.63 Harley asked for advice from Studio E, Exova and building control on the level of fire resistance that was required for the horizontal cavity barriers within the facade.3198 {HAR00003638/3-4}; see also Chapter 57. On 18 September 2014, Daniel Anketell-Jones asserted in an email to Neil Crawford that cavity barriers were not required in certain locations since the insulation was Class 0,3199 {HAR00012103}. but that was wrong. In his oral evidence, he accepted that in that email he had been expressing an opinion on what was required to comply with the guidance given in Approved Document B,3200 Anketell-Jones {Day36/166:2-16}. but he had not looked at it before doing so, nor had he sought any other advice to confirm that his view was correct.3201 Anketell-Jones {Day36/166:25}-{Day36/166:7}.
¶65.64 Between September 2014 and March 2015, Harley (in particular, Kevin Lamb) continued to develop the design of the windows. Further versions of Harley's drawings were circulated among the design team, none of which showed cavity barriers.3202 {SEA00011759}, attaching {RYD00018436}; {RYD00018537}; {RYD00018687}; {SEA00012531} attaching {SEA00003040}. Ray Bailey was aware of the importance of effective cavity barriers around windows but did not draw attention to the absence of cavity barriers around the windows in Harley's drawings. There appear to have been no discussions within Harley about what Approved Document B recommended in that respect.3203 Lamb {Day38/92:16}-{Day38/93:9}.
¶65.65 It was not until 3 March 2015 that Kevin Lamb included cavity barriers in his designs for the first time.3204 {SEA00012850}. His explanation for their inclusion at that stage was that completion of the designs had by then become urgent because construction had already begun and the cladding would soon be installed.3205 Lamb {Day38/97:5-14}. Even at that extremely late stage, however, Harley made no effort to satisfy itself that its designs complied with the guidance given in Approved Document B. In fact, as Mr Hyett explained, they did not. Among other things, there was still no provision for cavity barriers around the windows.3206 Lamb {Day38/101:11-14}.
¶65.66 Harley and the design team more generally were evidently deeply unsure about what was required in the way of cavity barriers, because there followed further discussions between Studio E, Exova, building control and Siderise (the manufacturer) in an effort to ascertain whether Harley's designs were acceptable.3207 {HAR00004013}; {EXO00001319}; {SEA00012906}; {SEA00000252}; {SEA00012927}; {HAR00003999}. The result of those conversations was yet further confusion and disagreement, largely because building control and Siderise differed in their view of what was required.3208 See Chapter 57. The issue was finally resolved to the satisfaction of building control in April 2015,3209 See Chapter 57. but Harley continued to seek advice from Siderise in May and June 2015.3210 {HAR00004238}; {HAR00019012/2}.
¶65.67 This episode reflects very poorly on all those involved. As a result of the fire at Taplow House in 2012, at which cavity barriers had played an important part in restricting the spread of fire, Ray Bailey and Daniel Anketell-Jones should have been aware of their importance for fire safety, but the significance of that incident appears to have been forgotten.3211 Anketell-Jones {Day35/149:14-19}.
308¶65.68 The evidence indicates that Harley was largely ignorant of the technical aspects of using cavity barriers and as a result was forced to rely too heavily on the advice of other members of the design team and the manufacturer. As the specialist cladding contractor, Harley could reasonably have been expected to possess a far greater degree of technical knowledge of the Building Regulations and Approved Document B in relation to the use and installation of cavity barriers than was the case.
¶65.69 It is particularly troubling that, although Kevin Lamb noticed that Studio E had failed to include cavity barriers around the windows3212 Lamb {Day38/54:5}-{Day38/56:24}. and told us that he had understood that Approved Document B required them in that location as an important means of ensuring the safety of residents,3213 Lamb {Day38/58:5-18}. he nonetheless failed to ask why they were missing or whether the designs complied with regulatory requirements. We do not accept his evidence that it was not his place to raise the matter.3214 Lamb {Day38/56:23-24}. He had no reason to think that others at Harley considered that cavity barriers were unnecessary or that anyone at Harley had consulted Studio E.3215 Lamb {Day38/57:25}-{Day38/58:3}.
¶65.70 Harley ought to have played an active part in the design of the cavity barriers and should have ensured that a detailed cavity barrier strategy had been established before construction work began. Even by March 2015, however, some eight months after it had been appointed by Rydon,3216 {HAR00005867}. Daniel Anketell-Jones remained unaware that Harley was working to the NBS Specification or what it contained.3217 Anketell-Jones {Day37/26:1-5}. The NBS Specification required Harley to design a system that contained fire stopping in accordance with the requirements of the Building Regulations, but Daniel Anketell-Jones did not ask himself what that meant because he failed to read it.3218 Anketell-Jones {Day37/38:10-22}. He repeatedly claimed that he did not have time to engage with the details of the NBS Specification, or design generally, because he was working on other projects.3219 Anketell-Jones {Day35/133:10-24}; {Day37/40:6-10}; Anketell-Jones {HAR00010149/3-4} pages 3-4, paragraph 14.
¶65.71 Harley's work on the architectural crown was carried out at a late stage.3220 Lamb {HAR00010419/9-10} pages 9-10, paragraph 35. Its designs for the crown omitted the cavity barrier at the top of the columns that had been included in the drawings produced by Studio E3221 {SEA00003242}; Crawford {Day11/66:9-11}; {SEA00002551}. and thus detracted from the original design.3222 Lamb {Day38/163:23}-{Day38/164:5}. Kevin Lamb said that he had intended to check whether the design required amendment to include a cavity barrier after it had been reviewed by the architect, but said that his question had ultimately been overlooked.3223 Lamb {Day38/165:7-14}. Overall it is clear that Harley failed to give any proper consideration to the fire performance of the crown. While the failure to include cavity barriers in the crown may not have contributed significantly to the spread of the fire,3224 Grenfell Tower Inquiry Phase 1 Report, Volume IV, {INQ00014817/59} paragraph 23.60. it reflects Harley's failure to give proper consideration to the fire safety of the facade.
309The design process
¶65.72 Harley's failure to produce designs for the refurbishment that complied with its contractual obligations reflected a failure properly to manage its own resources and a misunderstanding of its role in the refurbishment and the roles of other members of the design team.
Supervision and management
¶65.73 As an organisation, Harley failed to ensure that the various people engaged on the project were aware of the scope of their individual responsibilities. Ray Bailey and Ben Bailey both thought that Daniel Anketell-Jones was responsible for ensuring that designs produced by Harley (including those produced by Kevin Lamb on its behalf) complied in all respects with regulatory requirements.3225 Ray Bailey {Day32/17:21}-{Day32/18:2}; Ben Bailey {Day39/19:13-21}. For his part, although he had been designated as design manager for the refurbishment, Mr Anketell-Jones said that he had not considered supervision of the design process to be part of his responsibility.3226 Anketell-Jones {Day35/133:10-14}. We find that difficult to understand and think his evidence is probably best explained by the fact that the amount of work he had on other projects made it difficult for him to look at the designers' work.3227 Anketell-Jones {Day35/133:17-19}.
¶65.74 As we have already said, we do not think that as a witness Mr Anketell-Jones was always candid or reliable. In particular, we do not accept that his role in the design process was as limited as he suggested. His evidence was inconsistent with communications between Harley and Rydon, which indicated that he would be reviewing drawings on Harley's behalf.3228 Email dated 24 April 2014 from Mark Harris, "Our Dan will be taking a look at these on Monday" {HAR00005711}; Email dated 31 July 2014 from Mark Harris, "Lead designer will be Dan Anketell-Jones." {HAR00005916}. We prefer the evidence of Ray Bailey and Ben Bailey that he was given responsibility for checking the design work carried out by Harley, including the work done by Kevin Lamb on its behalf.
¶65.75 Mr Anketell-Jones had not read the contract between Harley and Rydon and did not accept that it was important for him to understand the nature of Harley's contractual responsibilities.3229 Anketell-Jones {Day35/195:3-15}. He thought that his responsibility as design manager was simply to ensure that the designers, in particular Kevin Lamb, were keeping up with the programme3230 Anketell-Jones {Day36/19:16-18}. and that the architect was responsible for approving the drawings Mr Lamb produced.3231 Anketell-Jones {Day35/195:3-15}. He was not aware, therefore, that Harley was contractually responsible for ensuring that the facade of the tower complied with the relevant statutory requirements3232 Anketell-Jones {Day35/195:16-21}. and did not apply his mind to the question whether the materials to be used would ensure that was the case.3233 Anketell-Jones {Day35/183:13}-{Day35/184:5}. If he did think at the time that the architect was responsible for checking the drawings produced by Mr Lamb (which we doubt), he was wrong and his responsibilities had not been properly explained to him. It was an important part of his role as design manager, and of Harley's generally, to supervise the work of Kevin Lamb in order to ensure that the designs he produced would result in a building that complied with the Building Regulations.3234 Anketell-Jones {HAR00010149/3-4} pages 3-4, paragraph 14. For his part, Kevin Lamb assumed that the suitability of the materials intended for use in the refurbishment had been considered and settled before he became involved on the project.3235 Lamb {Day38/21:2}-{Day38/22:12}.
310¶65.76 The development of the design of the windows of Grenfell Tower between September 2014 and March 2015 provides a telling example of Harley's failure properly to supervise Mr Lamb's work. During that period, Mr Lamb produced detailed drawings of the windows, none of which included cavity barriers in the required positions. The omission was not detected by Harley because it did not review the development of the design or examine with any care the drawings he produced.3236 Anketell-Jones {Day36/176:4-23}; see also Chapter 57.
¶65.77 In the light of Mr Sakula's evidence, we are satisfied that a reasonably competent cladding contractor would have established a system for supervising its sub-contractors. Such a system should have ensured that the work they carried out complied with relevant statutory requirements, industry guidance and normally accepted standards of safety.3237 Sakula {Day125/72:22}-{Day125/73:17}. In our view there were fundamental deficiencies in Harley's management which directly led to the creation of a design that did not comply with statutory guidance and could not be expected to result in a building that complied with the functional requirements of the Building Regulations. In that respect Harley fell short of the standard to be expected of a reasonably competent cladding contractor.
Relationship with Studio E
¶65.78 Harley also failed properly to manage its relationship with the other key designer, Studio E. It was content to assume that Studio E had considered and checked all those aspects of the external wall construction that had a bearing on fire safety. That was not the case, however, and it was not appropriate or reasonable for Harley to make that assumption, particularly in the face of clear evidence that Studio E had not done so.3238 For example, Harley knew that Studio E had not approved the use of Celotex RS5000, which did not appear in the NBS Specification – see Chapter 56. Harley should have taken steps to satisfy itself independently that the form of construction and the materials described in those drawings would result in a building that complied with the Building Regulations, but it failed to do so.3239 Ray Bailey {Day32/51:15}-{Day32/52:13}.
¶65.79 Daniel Anketell-Jones' belief that Studio E was checking the drawings produced by Harley for compliance with the relevant requirements was founded on nothing more than an assumption; he did not speak to Studio E or take any other steps to confirm his understanding.3240 Anketell-Jones {Day36/34:6-11}. Ray Bailey said that if Harley was not entirely clear on a question of compliance, it would ask the architect and ultimately expect building control to decide whether the design complied with the regulations.3241 Ray Bailey {Day32/53:7-12}. However, he assumed that the drawings were being checked by Studio E without ever taking steps to verify whether that was so.3242 Ray Bailey {Day32/51:15}-{Day32/52:13}. There is very little evidence, however, that Harley ever sought to resolve doubts about compliance by referring a question to a third party. The reason may not be far to seek: it regarded everyone involved in any aspect of the design, other than itself, even including building control, as responsible for ensuring fire safety. Its approach to a matter of such importance was irresponsible, regardless of its contractual obligations.
311¶65.80 Studio E considered that its obligation to review drawings produced by Harley was limited to ensuring that they conformed to "architectural intent", meaning that they were consistent with the appearance contemplated by the original design. We have already concluded that its understanding about that was wrong; it was not consistent with its contract with Rydon, nor did it reflect common practice among architects, as confirmed by Mr Hyett. However, as the specialist cladding sub-contractor, Harley should have taken steps to ensure that its own designs complied with any relevant legislation and guidance, regardless of Studio E's approach to its work.
Kevin Lamb
¶65.81 Kevin Lamb pointed out, correctly, that the decision to use ACM panels in place of the zinc originally specified by Studio E had been made before he had become involved in the work.3243 Lamb {HAR00010419/5} page 5, paragraph 20. However, he took no steps to familiarise himself with the products that were the subject of his designs, particularly their fire performance. He understood that ACM panels comprised a core material between two thin sheets of aluminium but did not know what the core was made of and made no effort to find out.3244 Lamb {Day38/19:2-14}.
¶65.82 Despite being responsible for creating Harley's drawings, Kevin Lamb gave no thought to questions of compliance with the Building Regulations and was instead content to assume that such matters were being considered by someone else.3245 Lamb {Day38/19:15-19}; {Day38/37:14}-{Day38/38:7}; {Day38/40:7-10}. He said that it had never crossed his mind to consider whether there was a British Board of Agrément certificate for Reynobond PE 55 ACM,3246 Lamb {Day38/23:17-20}. let alone to look at it.
Installation
¶65.83 Harley's failure properly to supervise and manage its own staff extended to its management of Osborne Berry, which it had engaged to install the facade. Ben Bailey described his shock at seeing photographs of the cavity barriers taken after the fire and said that he had not seen workmanship like that on site.3247 Ben Bailey {HAR00010060/10} page 10, paragraph 32. He sought to explain his failure to notice the defects by suggesting that the insulation had covered the junction between the cavity barriers and the existing concrete walls, making it impossible to identify any defects without dismantling and damaging the finished works.3248 Ben Bailey {HAR00010060/10} page 10, paragraph 32. We do not accept that explanation, however, as there must have been many opportunities to inspect the cavity barriers before the insulation was fitted.3249 Berry {Day44/59:9-14}. Ben Bailey accepted that he ought to have been carrying out inspections at each stage of the installation.3250 Ben Bailey {Day40/164:1-9}. If he had done so, he would have inspected the work before the insulation obscured the back of the cavity barriers and it is likely that at least some of the problems would have come to light. We are satisfied that Harley failed to inspect the work of Osborne Berry with sufficient frequency or care to ensure that the defects noted above were identified. In our view the defects in the installation of the cavity barriers reflect a serious lack of competence on the part of Harley itself and Osborne Berry.
312Failure to concern itself with fire safety
¶65.84 Viewing the evidence as a whole, we are left with the clear impression that Harley did not concern itself sufficiently with fire safety at any stage during the refurbishment. Its attitude appears to have been that there was no need for it to do so, because others involved in the project, and ultimately building control, would ensure that the design was safe. Its approach is reflected in its response to the following situations.
¶65.85 The first arose from the formal request for information about the incorporation of cavity barriers or fire breaks in the external wall of the tower, in the course of which Mr Ashton referred to the possibility that the insulation might be combustible.3251 See Chapter 54 and Chapter 57. That should have prompted Harley to consider whether RS5000 was combustible and whether it could safely be used in that situation. It is particularly surprising that Mr Anketell-Jones did not think it necessary to make such enquiries, given that he understood it to be a different product from FR5000 that had been specified,3252 Anketell-Jones {Day36/102:13-19}. but he did not raise the question with any other member of the design team, nor did he take any other steps to find out whether the new product was acceptable to Rydon or Studio E.3253 Anketell-Jones {Day36/171:13-16}; {Day36/108:17-25}. He said that he had expected Kevin Lamb to tell Studio E that Harley intended to use Celotex RS5000 so that Studio E could consider its suitability,3254 Anketell-Jones {Day36/79:14}-{Day36/80:5}. but he had not discussed the use of Celotex RS5000 with Kevin Lamb and had not provided any of the relevant information to him.3255 Anketell-Jones {Day36/65:20}-{Day36/66:10}.
¶65.86 The second arose out of a discussion in March 2015 about the fire resistance required of the cavity barriers to be installed in the external wall. In the course of that discussion Mr Anketell-Jones referred to the likelihood that ACM panels would disappear quickly in a fire. That did not, however, prompt him to look into the characteristics of ACM PE or to ask himself (or anyone else) whether it was suitable material for use on the tower. That is surprising because only a few months earlier, in October 2014, he had attended the Annual General Meeting of the CWCT at which a presentation had been given by Dr Colwell of BRE on the then recent spate of cladding fires in various countries.3256 {CEL00001038}. Natural curiosity, if not professional competence, might have led Mr Anketell-Jones to enquire into the nature of Reynobond 55 PE to see whether it might give rise to a similar problem, but regrettably neither caused him to make or instigate the kind of enquiries that a reasonably competent cladding contractor would have made under those circumstances.
¶65.87 The third relates to a warning given by Mr Mort of Siderise Ltd, the company which made the cavity barriers, that the design of the window fixings contained what he described as a "weak link for fire." Mr Mort identified the area of weakness on a copy of a drawing sent to him by Ben Bailey, but Ben Bailey failed to pass the comment to Studio E, Rydon or Exova and took no steps to ensure that it was removed. Mr Mort copied his email to Kevin Lamb and Ray Bailey, but neither of them took any action in response to it. Kevin Lamb said that he had not noticed the warning about a weak link at all, despite having read the email,3257 Lamb {Day38/138:8-20}; {Day38/141:24}-{Day38/142:4}. and did not raise the matter with any other member of the design team.3258 Lamb {Day38/142:21-24}; {Day38/144:3-5}. Ray Bailey could not explain why he had not pursued the matter with Mr Mort3259 Ray Bailey {Day33/160:2-7}. but he ultimately accepted that the only sensible course of action had been to raise the matter with building control to ensure that the design was safe.3260 Ray Bailey {Day33/160:13-25}. The result of their inaction was that no attempt was made to address the weak link, which became part of the external wall of the tower.
313 315Chapter 66: The contribution of the Tenant Management Organisation
¶66.1 Responsibility for the dangerous condition of Grenfell Tower following the refurbishment project, including the presence of combustible materials in the walls and around windows, rests primarily on those who designed, constructed and approved the work and some of those who manufactured and sold the materials they used. However, the TMO itself must take a share of the blame for the disaster. In Chapters 51, 53, 54 we have made a number of criticisms of the TMO in its role as client and in Parts 4 and 5 we have described certain shortcomings in its management of the building. Overall, we have concluded that as the client for the refurbishment, the TMO failed to take sufficient care in its choice of architect and paid insufficient attention to fire safety matters, including the work of the fire engineer.
The procurement of professional consultants
¶66.2 Neither Mark Anderson, the interim Director of Assets and Regeneration, who was primarily responsible for managing the project, nor anyone else within the TMO, gave proper attention to the choice of architect for the refurbishment project, being content to acquiesce in the desire of RBKC to engage the team that it had used on the KALC project in the hope of reducing both cost and delay.3261 Chapter 52. Minimising cost and delay was a laudable aim, but not one that could justifiably be pursued at the risk of appointing a firm that lacked the necessary experience.
¶66.3 As a result of the TMO's decision to appoint Studio E, there was no competitive process for the appointment of the architect and therefore no independent assessment of its experience in designing a project of the kind under consideration.3262 Chapter 52. Instead, the TMO assumed that Studio E had the skills, knowledge, experience and resources to carry out a high-rise residential overcladding project, which was fundamentally different from designing a school or leisure centre. That assumption turned out to be incorrect and led to a series of decisions which had disastrous consequences.
¶66.4 As the client under the CDM Regulations 2007, the TMO had a duty to take reasonable steps to ensure that any designer, principal contractor or contractor it appointed was competent to take on the role in question3263 {INQ00011315/4} Regulation 4(1). and had allocated sufficient time and resources to the project.3264 Regulation 9 of the CDM Regulations 2007; Approved Code of Practice L144 {INQ00013936/15} paragraph 43 (a); {INQ00013936/16} paragraph 47. There is no evidence that the TMO was aware of that obligation.
¶66.5 The TMO ought to have taken steps to satisfy itself that Studio E had, or could obtain, the right skills and resources to carry out the work efficiently. If it had done so, it would have learnt that Studio E had no experience of overcladding a high-rise residential building and in those circumstances it might have looked elsewhere for an architect or insisted that Studio E hired someone with expertise in facade engineering.3265 Hyett {Day63/86:2}-{Day63/87:23}; {Day64/3:20}-{Day64/4:3}.
316¶66.6 The failure of the TMO to concern itself with Studio E's previous experience is all the more remarkable in view of the fact that one of the residents of Grenfell Tower had raised that very question. At a meeting of the Lancaster West Estate Management Board on 15 May 2012, at which representatives of the TMO and Studio E were present, Edward Daffarn asked whether Studio E had experience of working on tower blocks and, if not, why it was proposed that it should be appointed as architect for the refurbishment.3266 Treasury Report of 15 May 2012 at {TMO00848807/4}. Although he was told by Cllr Coleridge at some stage that Studio E had been chosen in the interests of financial and practical efficiency, it does not appear that Mr Daffarn ever received an answer to his question from the TMO.3267 Daffarn {Day118/20:17}-{Day118/22:1}. It certainly never prompted the TMO to ask that question of itself or anyone else.
Avoiding the procurement rules
¶66.7 We have described in Chapter 52 how in order to avoid holding a formal competitive procurement procedure for professional services the TMO insisted that the architect's fees for work carried out before the appointment of a principal contractor be capped at £174,000.3268 Chapter 52. Since that was insufficient to cover the amount of work required to produce the tender documents, it was necessary to resort to the device of deferring part of those fees until after the principal contractor had been appointed.3269 Chapter 52. We need hardly say that it was quite improper for the TMO to resort to a scheme of that kind in order to evade the rules on procurement and, as Simon Cash implicitly accepted,3270 Cash {Day48/113:19}. Artelia, as employer's agent, ought to have made it clear to the TMO that it was in breach of procurement rules by capping the fees of its consultants. Instead, it appears that it simply acquiesced in the TMO's plan. The unfortunate practical result was that the TMO deprived itself of the opportunity to select an architect from a wider range of applicants, some of whom might have had more relevant experience.
Failure to notice that Exova's work was incomplete
¶66.8 It does not seem that anyone at the TMO read any of the versions of Exova's Outline Fire Safety Strategies, in detail or at all, even though they were produced for it as Exova's client.3271 Williams {Day55/69:14}-{Day55/70:19}. Both the draft Existing Fire Safety Strategy and the draft Outline Fire Safety Strategy should have been documents of particular interest to the TMO, both as a client which was managing works in a mixed-use occupied residential block and as the responsible person under the Fire Safety Order. The TMO should have taken care to make sure that the safety of the residents from fire had been comprehensively and finally addressed in detail. Instead, it assumed that others had considered the fire safety of the building and failed to appreciate its own responsibility for a matter of such importance.
¶66.9 David Gibson, Peter Maddison and Claire Williams should all have read Exova's fire safety strategies carefully. In our view, the draft Outline Fire Safety Strategy was not difficult to understand and they should certainly have noticed that, in relation at least to the external wall, the advice it contained was provisional only. It appears, however, that none of them read it or, if they did, that they did not take proper note of its contents.3272 Gibson {Day53/142:23}-{Day53/143:22}; Maddison {Day59/122:11}-{Day59/128:20}. If they had paid attention to what it said, they would have realised that the strategy was incomplete in relation to functional requirement B4(1) and that it required further work.
317¶66.10 There were at least two occasions during the life of the project when it was made clear to the TMO that Exova's work was incomplete. Terry Ashton told Claire Williams on 4 November 2013 (three days before Issue 3 of the Outline Fire Safety Strategy was produced) that after invoicing everything as of that date, there would be a balance remaining from the initial quotation.3273 {TMO00855925}. That should have alerted her to the fact that Exova had not by then done all that it had expected to do under its contract. By November 2013, many key design decisions had not been made, including the choice of rainscreen cladding. If anyone at the TMO had turned their minds at that stage to the point, they would have realised that the fire safety strategy had not been completed and that further work had to be done on it. Not to have done so was a serious failing on its part.
Failure to challenge Rydon's decision not to appoint a fire safety consultant
¶66.11 The TMO failed to ask why a fire engineer had not been engaged by Rydon after it had been appointed as principal contractor. The matter was raised at successive project meetings between June 2014 and October 2014 attended by the TMO and was mentioned in the minutes as requiring action by Rydon.3274 Chapter 54. After October 2014 the matter ceased to be mentioned in the minutes, but the TMO appears to have taken no steps to find out whether a fire engineer had been appointed and if not, why. The TMO ought to have obtained a clear decision from Rydon and, if Rydon was unwilling to appoint a fire engineer, an explanation for it. Although Artelia, as employer's agent, should have asked the same questions, the TMO as the employer had a responsibility of its own to monitor the work and ensure that it was being carried out effectively. In that case it failed to do so.
¶66.12 The TMO continued to retain the services of Exova, but in an unstructured way and on ill-defined terms. Members of the design team sought its advice from time to time, even though it was not a member of that team and had no insight into its thinking. The TMO paid for that advice as and when it was given but took no steps to clarify the terms of Exova's engagement or to understand what services it wanted it to provide.3275 Chapter 54.
¶66.13 In these, as in other respects, the TMO relied too heavily on its professional advisers and failed to take responsibility for ensuring that the work was being carried out properly.
Failure to resolve fire safety concerns
¶66.14 Having raised the fire performance of the cladding with Rydon in her email of 12 November 2014,3276 Chapter 55. Claire Williams ought to have insisted on receiving a written response to her question. The matter was too important to be allowed to pass without comment. The fact that it had to be asked at all, in particular at what was a relatively late stage in the project (a year after the NBS Specification had been produced), is a matter of criticism in itself. The fact that an answer was not obtained is difficult to explain, even as an oversight.
318Failure to involve residents
¶66.15 Since the refurbishment was being carried out while the building was occupied, it was particularly important for the TMO to engage with and consult the residents, both of the tower and of the surrounding area, in a meaningful and constructive way. Regrettably, however, it did not comply with the consultation and participation requirements in Schedule 3 of the Management Agreement.3277 Volume 2, Chapter 2, Schedule 3 of the 2006 Modular Management Agreement {RBK00019006/163}. No client review group3278 Paragraph 2.1 of Schedule 3 {RBK00019006/165}. was established and no one from among the residents was nominated to join the project team or take part when consultants were appointed.
¶66.16 Similarly, as we have found in Chapter 53, any engagement the residents had with the procurement process was largely symbolic. Although consultation exercises and meetings with residents did take place,3279 See for example Sounes {Day 21/34:21}-{Day21/56:4}. they were given no formal role and had no voice during the refurbishment. In particular, they were given no opportunity to question or challenge key decisions, including decisions on the appointment of consultants and matters affecting fire safety.
319Chapter 67: Conclusions
¶67.1 Having examined in the previous chapters the parts played by the main participants in the refurbishment, we are in a position to draw certain broader conclusions about the way in which they approached and carried out the project. It is appropriate to do so, because a number of common themes can be seen running through the story which, due to their nature, we think are likely to be repeated widely across the construction industry. By drawing attention to them now, we hope that we may encourage a change in the way that the various parties to large construction projects approach their work.
Creating and understanding the contract
¶67.2 As the evidence progressed it became clear that many of those engaged on the project did not properly understand the nature and scope of the obligations they had undertaken, or, if they did, failed to pay much attention to them. The terms of Rydon's contract with the TMO were lengthy and detailed, but in substance they imposed on it an obligation to carry out the whole of the design and construction work in accordance with all relevant statutory requirements. In particular, Rydon assumed responsibility to the TMO for all the design work that had previously been done by Studio E, including drawing up the NBS Specification and the Employer's Requirements.
¶67.3 It is likely that some within Rydon were aware of the nature of the obligations it was taking on, but that does not appear to have been so in the case of those who were more directly involved in the construction work. Simon Lawrence, the contracts manager in charge of the Grenfell Tower project, appeared not to realise that Rydon was contractually responsible to the TMO for any mistakes made by Studio E in the pre-contract stage and by its various consultants and sub-contractors during the construction stage. However, at least Rydon had a formal contract to which it could resort to identify its obligations should the need arise.
¶67.4 Regrettably the same cannot be said of Harley, whose work as facade sub-contractor was carried out under a letter of intent that was clearly intended to be superseded by a formal contract but never was. The letter of intent expressly incorporated into the contract between Harley and Rydon the terms of Rydon's contract with the TMO and contained a number of detailed appendices. Harley did not bother to read them, however, and in the absence of a formal contract did not concern itself with its legal obligations but set about its work following what it regarded as the standard practice in the industry.
¶67.5 Kevin Lamb was engaged to produce design drawings on behalf of Harley, but without any formal contract of any kind.
¶67.6 An even greater degree of informality affected the arrangements under which Osborne Berry was engaged to carry out the work of installing the cladding, comprising the insulation, the cavity barriers, the supporting rails and the rainscreen panels. The terms on which it was engaged were never reduced to writing; everything was done by word of mouth. It is not clear whether Mr Osborne or Mr Berry could have described in any detail the terms on which they were working.
320¶67.7 A similar absence of formality characterised the engagement of some of the consultants. Although Studio E's services were transferred from the TMO to Rydon in about April 2014, the deed containing the terms of that engagement was not executed until February 2016, when the work had been substantially completed. Exova, which had been instructed to produce fire safety strategies for the building, continued to be retained by the TMO after the appointment of Rydon, but neither the TMO nor Rydon nor Exova itself appear to have had a clear understanding of the terms on which it was acting or of its role or responsibilities, or to whom it owed them.
¶67.8 In our view, such a casual approach to contractual relations is a recipe for disaster if events take an unexpected turn. All those involved in whatever capacity in a complex project need to understand clearly what they have agreed to do and what they are responsible for. What appears to be a widespread culture of getting on with the job without waiting for terms to be formally agreed is unprofessional and likely to result in a failure by those carrying out the work on site to understand the scope of their responsibilities. It is an area in which the principal contractor has an important part to play, because it is at the level of sub-contracting and the engaging of consultants that the problem appears to be most acute. The principal contractor is the only person who can ensure that clear, documented contractual arrangements are in place before a sub-contractor or consultant begins work.
Failure to identify responsibilities
¶67.9 The failure to put clear contract terms in place at the outset was likely to result in confusion if anything went wrong, but in this case it laid the ground for what turned out to be a more serious problem. As principal contractor, Rydon saw its role as little more than the conductor of a large and varied orchestra. It did not employ any of those whose knowledge and skills were required to design or carry out the refurbishment. They were engaged as sub-contractors and consultants as and when Rydon considered it necessary to obtain their services. Rydon saw its role as being to engage and manage a body of construction professionals, not to carry out any of the tasks itself. Insofar as it understood the broad scope of its obligations to the TMO, it considered them to have been satisfied by appointing others to perform them.
¶67.10 That had a number of unfortunate consequences. First, Rydon itself was ill-equipped to oversee the work of its sub-contractors and consultants, particularly those whose skills or expertise were of a more technical nature. Secondly, it was free to decide whether to obtain expert assistance and advice or do without it. Thus, in this case, Rydon originally agreed at the first project meeting in April 2014 that it would be desirable to instruct Exova to provide advice on fire safety, but eventually failed to make the appointment, probably because it thought it could manage without it, no doubt at a saving in cost. Thirdly, and in our view most importantly, there was a failure to establish clearly who was responsible for what, including who was responsible for ensuring that the designs were compliant with statutory requirements. That eventually resulted in the unedifying "merry-go-round of buck-passing" in which the construction professionals all pointed the finger at each other as being the person whose responsibility it was to make one or other of the critical decisions.
321¶67.11 Such is the complexity of modern construction that no principal contractor, particularly under a design and build contract, can be expected to retain in its own employment people with the full range of skills required for every project it takes on. Sub-contracting has been a feature of the construction industry for a very long time and will inevitably continue. Many sub-contractors are experts in their particular field and can afford to maintain skills and expertise in relation to a relatively narrow range of work of a kind that might be required by a principal contractor only occasionally. We do not criticise Rydon, therefore, for organising the work in a way that involved engaging sub-contractors to carry out individual elements, particularly of a specialist nature. However, if a contractor is to perform its obligations to the client in an effective and responsible way, it must ensure that within its organisation it has access to sufficient knowledge and expertise to be able to monitor the work of its sub-contractors and consultants effectively and to satisfy itself that their work complies with their obligations and with its own obligations to the client. In the present case, we do not think that Rydon did have that knowledge and expertise at its disposal. Instead, it relied blindly on its sub-contractors and consultants to exercise all relevant skill and care without being in a position to assess the quality of their work.
¶67.12 Although the model adopted by Rydon cannot in itself be criticised, it does make it essential that, as part of co-ordinating the work, the principal contractor establish clearly which person or organisation is to take responsibility for particular decisions. One of the striking features of the evidence was the number of times those involved in the refurbishment told us that a particular decision had been someone else's responsibility. Rydon, as principal contractor, should have considered the various steps involved in designing and carrying out the work and identified which person, firm or company was responsible for the decisions relating to each of them. Since it undertook an obligation to the TMO for work done before it had been appointed, that should have included a retrospective examination of the preliminary design work, including the contents of the NBS Specification and the choice of materials included in it. It should also have identified clearly who was to take responsibility for the selection of materials chosen as a result of any value engineering exercise subsequently undertaken. In this case Rydon failed to do that and as a result all those involved, including Rydon itself, appears to have assumed that someone else was, or should be, taking responsibility for critical decisions, such as the choice of insulation, rainscreen panels and other materials.
Competence
¶67.13 If the construction industry is to provide an effective service to society it is essential that those engaged in it at all levels and in whatever capacity be competent to carry out their functions and exercise all reasonable skill and care in doing so. Regrettably, the Grenfell Tower refurbishment was marked by a serious lack of competence on the part of many of those engaged on it and, in the case of some manufacturers of construction products, outright dishonesty.
¶67.14 It is not necessary to repeat here what we have said about the shortcomings of individual persons and bodies engaged in the refurbishment. It is clear from the findings we have made in the earlier chapters of this part of the report that in many respects those who were directly involved in the design and construction of the refurbishment failed in significant ways to meet the standards to be expected of competent professionals. That is particularly true of Studio E, Harley and Rydon. We were surprised at the limited knowledge of the Building Regulations, the statutory guidance and indeed industry guidance displayed by their employees, for whom a working knowledge of the regulatory regime should have been a fundamental requirement. We were also surprised by their failure to inquire into the fire performance of the materials proposed for the external wall and their lack of concern about fire safety generally. None of them appears to have thought it possible that materials that had been used on previous occasions might not in fact be suitable in the context of the refurbishment and no one asked for advice or confirmation from a fire engineer. It is astonishing that none of those to whom Exova's draft Outline Fire Safety Strategy was sent noticed that it was incomplete or thought it necessary to make sure that Exova had been given details of the build-up of the external wall.
322¶67.15 The professionals' lack of competence was also demonstrated by the way in which they communicated with each other in relation to the project. Although the TMO raised the fire safety performance of the cladding with Rydon on two occasions, it simply failed to respond and so a critical question at a key moment in the life of the project was left unanswered. The provision of information to building control was piecemeal and disorganised. Studio E on behalf of Rydon submitted old versions of drawings showing key features of the external wall that were never replaced with current versions. There was no attempt properly to document and record important design changes, not least the switch from zinc to ACM PE rainscreen panels, the introduction of Kingspan insulation when Celotex became unavailable and the use of uPVC window surrounds in place of plywood. At the end of the project the documentation provided was inaccurate, incomplete and disordered, not least the Health and Safety file required by the CDM Regulations. One result of that casual approach to record-keeping was that several of those involved in the project, including Exova and building control, were not told that ACM PE had been used for the rainscreen panels.
¶67.16 The way in which the Grenfell Tower refurbishment was handled raises serious questions for the whole of the construction industry. We were not asked to investigate the industry at large and we do not know whether the shortcomings we have identified are typical, although, judging by the evidence we heard, we think they are likely to have been widespread. It is not acceptable for large projects of this kind to be undertaken without proper contractual arrangements by parties who do not concern themselves with the regulatory regime and insist instead on carrying on in what they regard as the usual way. There is nothing wrong with a desire to "make it work", provided that is not regarded as a sufficient reason for ignoring formalities and failing to keep safety high on the agenda.
¶67.17 Incompetence in the form of ignorance of the regulatory regime affecting construction has also infected both the approach of construction professionals to building control and, in some cases, the approach of building control itself. It became apparent that most, if not all, of those involved in the project regarded building control as, in effect, an additional consultant, whose function was to give advice on the design and choice of materials and act as a safeguard to ensure compliance with the Building Regulations. That contributed to a failure on the part of Rydon, Studio E and Harley to take proper responsibility for ensuring that the design of the external wall and the choice of materials it contained complied with the Building Regulations. That was bad enough, but it was compounded by the adoption of a similar attitude on the part of RBKC's building control department, which saw its function as being to "work with" employers and contractors by enabling them to complete the work, rather than to act as the custodian and enforcer of the Building Regulations in the public interest.
323¶67.18 In our view there is a great deal to be done to raise the overall level of competence of those in the construction industry. They need to have a better knowledge and understanding of the regulatory regime and how it applies to the work they are carrying out. The disaster at Grenfell Tower has shown that it is not safe to assume without question that the way things have been done in the past is safe or satisfactory. A greater degree of scrutiny is called for, as is a better understanding of the function of building control. That needs to go hand in hand with a change in the way in which building control bodies understand their function, which is to police the regulatory regime. Their role is not to advise the applicant or building professionals how to comply with the regulatory regime and they should not be regarded by building professionals as a "safety net".
The role of the client
¶67.19 Even under a design and build contract the client has an important part to play because, among other things, it appoints the architect, who carries out the preliminary design work and in many cases continues to develop the design under a contract with the principal contractor. In most cases the choice of architect is likely to be dictated, at least in part, by experience of projects of a similar kind, unless the client is satisfied from enquiries that a particular firm has the capacity to undertake a project of the kind under consideration.
¶67.20 In the present case Studio E was chosen for reasons of a different kind and no steps were taken by the TMO to satisfy itself that the firm had the ability to tackle a project of a kind that it had not previously undertaken. That was a mistake, but not necessarily a serious one. In the event the real error lay in the failure of any of those at Studio E involved in the choice of materials for the external wall to pay proper attention to their reaction to fire.
¶67.21 The TMO consistently portrayed itself as an unsophisticated client, dependent on its professional consultants for advice. We accept that to a large degree it was, but there were some respects in which it failed to act as a prudent client. One conclusion that emerges clearly from the evidence is that the TMO was unduly concerned with reducing costs. From the outset the TMO was struggling to keep the project within budget. As the costs rose, it was dependent on the council for additional funds and from time to time they were made available, but still the TMO looked for reductions in the cost of the project rather than go back to the council for more money. The decision to appoint Studio E was driven in a large measure by a desire to keep the costs down, as evidenced by the device employed to avoid a proper procurement exercise, and costs played a part in the choice of Rydon as principal contractor, as evidenced by the "off-line" discussions that took place before it was awarded the contract. The decision to choose Reynobond PE was part of a "value engineering" exercise performed at the TMO's insistence and designed to keep costs down, but responsibility for that disastrous decision cannot be laid at the door of the TMO. It is one that must be borne by those who could be expected to know, or at any rate discover, the nature of the product being recommended.
¶67.22 Cost is always an important factor in any construction project, of course, if only because clients want the maximum result for the minimum expense and contractors are usually working on narrow margins. Realism, however, is essential and a sound understanding of the nature of the exercise being undertaken. In this case, the cost of employing an independent professional project manager would have been money well spent.
¶67.23 Any substantial construction project needs to be managed by or on behalf of the client and unless the client has the necessary experience and skill to undertake that task, it will usually appoint a professionally qualified project manager. In the present case Artelia would have been willing to act as project manager, but the TMO persuaded itself that it could perform that function itself. That was a mistake because it did not have the necessary skills or experience to undertake that task and to ensure that Rydon, and through it the other professionals involved in the refurbishment, carried out their work effectively.
324¶67.24 What we have observed in the course of the evidence has led us to the conclusion that there is not only a need to improve the education and training of those involved in the construction industry but also a change in approach on the part of all concerned which prioritises safety over speed and cost and lays much greater emphasis on an understanding of the regulatory regime and its purpose.
5Part 7: Replacement of the gas riser
7Chapter 68: Replacement of the gas riser
Introduction
¶68.1 In his Phase 1 report the Chairman found that the supply of gas to the tower did not play a significant part in the outbreak or development of the fire on 14 June 2017 and that the employees of Cadent Gas Limited who attended to shut off the gas supply made appropriate decisions and executed their task admirably.1 Phase 1 Report Volume IV, paragraph 31.14. In this phase of the Inquiry we have investigated the replacement of one of the gas risers between 2016 and 2017. The works had not been finished at the time the fire occurred and we therefore thought it appropriate to consider whether they might have contributed to the spread of smoke or fire within the tower.
The supply of gas to the tower
¶68.2 On completion of the refurbishment work to the tower in 2016 gas was supplied to residents by two pipelines which entered the basement below ground level on the east side: a ten-inch steel pipe that fed the boilers supplying hot water to residents2 Hancox, Gas Engineering Report {RHX00000012/15} paragraphs 30-31 and figure 6. and a four‑inch steel pipe that supplied gas to the flats.3 Hancox, Gas Engineering Report {RHX00000012/13-14} paragraph 29 and figure 4.
¶68.3 The pipe providing gas to the flats entered the basement at a high level. Four pipes, known as "risers", ran vertically up into the tower; two of them were then split into two, making six risers in total.4 Hancox, Gas Engineering Report {RHX00000012/23} paragraph 44. These passed through the fabric of the building and directly into a cupboard in each flat. One of the risers supplied gas to all the "Flat 2s".
¶68.4 The gas supply had been installed at the time the tower was built and by the time of the fire the pipework was almost 50 years old. It did not comply in a number of respects with current regulations.
Supply to the tower following works commencing October 2016
¶68.5 On 1 October 2016, corrosion of the riser serving the "Flat 2s" made it necessary to cut off the supply of gas to all the "Flat 2s".
Cadent
¶68.6 Cadent Gas Limited ("Cadent") is a gas transporter which owns and operates the pipes and apparatus that transport gas. Cadent does not own the gas itself but is paid by suppliers to deliver it through a network of pipes in a particular area. In the case of Grenfell Tower the area was that served by Cadent's North London gas distribution network.5 Mason {CAD00003005/2} page 2, paragraphs 7-8. Cadent was responsible for the safety of the service pipework up to the point of the emergency control valve located at each customer meter; the installation pipework beyond the meter was the responsibility of RBKC as the owner of the building.6 Harrison {Day159/16:4-14}.
8¶68.7 The Health and Safety Executive monitors and oversees the health and safety of onshore gas distribution and supply7 Harrison {Day159/17:4-8}; https://www.hse.gov.uk/regulating-major-hazards/energy-division.htm. and Ofgem determines the funding and ensures the competitiveness of gas pricing.8 Harrison {Day159/18:7-16}. Since the 1990s, in common with all gas transporters, Cadent is under certain statutory obligations, including obligations to: a. Connect and maintain a connection for customers within 23 metres of a main (measured horizontally),9 Gas Act 1986 {INQ00014770/52-53} section 10; Mason {CAD00000004/2} page 2, paragraph 5. unless such a connection endangers the public;10 Gas Act 1986 {INQ00014770/53} section 10(9)(b); Harrison {Day159/19:16}-{Day159/20:8}. and
¶b. Maintain service pipelines and apparatus, such as shut-off valves, in efficient working order and in good repair.11 Pipelines Safety Regulations 1996 {INQ00014790/7} regulation 13; Pipelines Safety Regulations 1996 {INQ00014790/3} regulation 3(1)-(2).
Inspection on 30 September 2016
¶68.8 Part of Cadent's strategy to maintain service pipework for buildings in multiple occupation was to conduct a rolling programme of surveys.12 Harrison {Day159/21:12-21}. On 30 September 2016 Cadent carried out a survey on Grenfell Tower13 {CAD00000031}. and identified three significant problems: a. There was a gas leak between Flat 22 and the flat above, Flat 32, on floors 5 and
¶6 respectively;14 {CAD00000031} sheet 3: Riser Information, row 12, column AE; {CAD00000031} sheet 4: Lateral Information, row 9, column U; Hancox, Gas Engineering Report {RHX00000012/135} paragraph 310. b. The pipeline isolation valves on the east side of the tower could not be found;15 {CAD00000031} sheet 2: Supply Pipe Information, rows 11-12, column L; Hancox, Gas Engineering Report, {RHX00000012/68} paragraph 158. and c. There was severe corrosion of some laterals.16 {CAD00000031} sheet 4: Lateral Information, rows 7-12, column O; Hancox, Gas Engineering Report {RHX00000012/114-115} paragraph 248 and figures 65-66.
¶68.9 In response to the discovery of the leak Cadent immediately cut and capped the riser which supplied "Flat 2s". That was completed in the early hours of 1 October 2016.17 {CAD00000031} sheet 4: Lateral Information, row 9, column W; Hancox, Gas Engineering Report {RHX00000012/23- 24} paragraph 44 and figure 17.
¶68.10 Cadent used this and other information from the survey to calculate a building priority score18 Harrison {CAD00002985/8} page 8, paragraphs 30-32. which indicated how often a building should be surveyed. The score for Grenfell was such that Grenfell Tower was placed on the list for discussion at the regular Cadent hazard and operability meetings, known as "HAZOP" meetings. The inability to find the missing pipeline isolation valves and the severe corrosion was noted on a schedule presented at the HAZOP meetings of 5 December 2016 and 23 February 2017.19 {CAD00002984}.
9Lost pipeline isolation valves
¶68.11 Pipeline isolation valves, by which the supply of gas to a building can be shut off quickly, are the main emergency control mechanism for buildings in multiple occupation.20 Harrison {Day159/40:11-16}. They are mandatory on service pipelines to such buildings21 {RHX00000005/64} paragraph 7.3.1; Pipelines Safety Regulations 1996 {INQ00014790/7} regulation 13. and are located outside the premises so that access to them can be obtained easily through valve chambers with marked covers visible at pavement level. For obvious safety reasons, as part of making appropriate arrangements for responding to incidents and emergencies, gas transporters have a duty to maintain access to pipeline isolation valves.22 Pipelines Safety Regulations 1996 {INQ00014790/7} regulation 12; see also the duty to maintain the pipeline (including all its related apparatus) in an efficient state, efficient working order and in good repair: Pipelines Safety Regulations 1996 {INQ00014790/7} regulation 13. Notwithstanding that, we were told that it was well known in the gas industry that pipeline isolation valves are often lost, for example, as a result of being covered over by landscaping or road works.23 Hancox, Gas Engineering Report {RHX00000012/220} paragraph 470; Harrison {CAD00002985/22} page 22, paragraph 82; Harrison {Day159/108:18}-{Day159/109:1}. The survey of Grenfell Tower carried out by Cadent in 2008 showed that "fire valves" (another term for pipeline isolation valves) had been installed on the pipes supplying gas to the tower.24 {CAD00002989/5}. The fact that Cadent could not find them in 2016 was almost certainly attributable to the landscaping works completed as part of the refurbishment.25 Hancox {Day161/41:10-20}.
¶68.12 Having discovered in October 2016 that the pipeline isolation valves could not be found, Cadent should have taken steps to reinstate them immediately but it appears that the appropriate team in Cadent was not notified about the need for that to be done. Mr Harrison, one of Cadent's network directors, accepted that that had been a failure on its part which should not have occurred.26 Harrison {Day159/127:19-20}.
¶68.13 The failure to reinstate the pipeline isolation valves did not affect the course of events surrounding the fire because burning debris falling on the east side of the tower would have prevented anyone from obtaining access to them.27 Phase 1 Report Volume IV, paragraph 31.4. However, on another occasion access to them might be of critical importance and we therefore think that all gas transporters should have a legal duty to inspect these emergency valves at intervals to ensure that they are accessible and to reinstate them if they are not.
Corrosion survey
¶68.14 Although steel pipes are very strong and have a long service life under normal conditions, they are susceptible to corrosion, particularly if exposed to damp. Because corrosion causes the steel to deteriorate and lose its integrity, keeping it within acceptable levels is an important part of maintaining the safety of pipelines.
¶68.15 Cadent commissioned a corrosion survey for Grenfell Tower on 5 December 2016.28 {CAD00002984/1}. Mr Harrison explained that the survey was not completed because of problems over obtaining access to the tower. A Cadent engineer attended on two occasions but could not get into the relevant parts of the building.29 Harrison {CAD00002985/10-11} pages 10-11, paragraphs 37-39. Although a decision was made in February 2017 to try again, the full corrosion survey had not been completed by the time of the fire, some eight months after the corrosion had been discovered.30 Harrison {CAD00002985/11} page 11, paragraph 41; Harrison {Day159/137:22}-{Day159/138:7}. As Mr Harrison accepted, that was unacceptable.31 Harrison {Day159/137:22}-{Day159/138:7}; {Day159/138:22}-{Day159/139:5}; {Day159/140:8-14}; {CAD00002987/14} paragraph 5.6.3; {CAD00003001/13-15} paragraphs 6 and 9.
10¶68.16 After the fire it was found that a riser in Flat 115 had ruptured. It is possible that that was a result of a failure to keep corrosion levels within acceptable limits and occurred during the fire or later as the building continued to deform from its effects,32 Harrison {CAD00003043/13-14} pages 13-14, paragraph 43; Cadent Module 3 submissions {CAD00003047/23} paragraphs 64-65. but we do not think it is necessary for us to reach a decision on that question and in any event do not have sufficient evidence to do so with any confidence. All we can say is that several factors may have contributed to the rupture of that particular pipe, one of which may have been corrosion that weakened it at one of its threaded joints.33 Hancox, Gas Engineering Report {RHX00000012/110-111} figures 60-61 and paragraph 242.
Inaccurate maps
¶68.17 By June 2017 Cadent's map of the gas pipes running into the tower should have shown all three systems: the pipe supplying the boilers, the original pipe supplying gas to the flats and the new pipe supplying gas to the "Flat 2s". However, the maps available to the Cadent engineers who attended the fire only showed the pipe supplying the boiler.34 {CAD00002174}; {CAD00002241}. Cadent should have known that its maps were inaccurate because those available when it carried out the survey in September 2016 also showed only the pipe supplying the boilers.35 {CAD00000031} Supporting Photos sheet: row 3, column B.
¶68.18 Cadent maintained that its failure to correct the maps did not, in fact, have any material effect on the ability of its engineers to identify and isolate the gas supply pipes on the night of the fire, since they were able to obtain the correct information from other sources.36 Cadent Module 3 submissions {CAD00003047/18-19} paragraphs 50-52; Harrison {MET00018804/8} page 8, paragraph 31. That is true, but it was attributable more to luck than good organisation that the engineers concerned happened to know the true layout of the pipework and had accurate information readily available to them37 Cadent employee Jason Allday and surveyor Simon Boygle. as well as the time and the means to provide it to those who needed it.38 {MET00018309/2-4}; Phase 1 Report Volume IV, paragraph 31.3.
¶68.19 It is important that all gas transporters have accurate maps of the pipelines serving buildings in multiple occupation.39 Hancox {Day161/58:22}-{Day161/59:3}. Although Cadent has a process for revising its maps, it was not implemented in good time in the case of Grenfell Tower.40 {CAD00002957}; Hancox, Gas Engineering Report {RHX00000012/74} paragraph 174 and figure 41; Harrison {Day159/145:5-14}. Accurate maps are essential in order that operatives can locate the pipeline isolation valves and may be of critical importance in emergencies. There appears to be no good reason why the map was not revised after the 2016 survey, or, failing that, after the installation and commissioning of the new pipe in early 2017.
11Replacement gas supply: 2016-2017
¶68.20 UK designers of gas supply systems pay particular attention to the standards published by the Institution of Gas Engineers and Managers (IGEM) when planning and executing work of that kind.41 Hancox {Day161/8:23}-{Day161/9:1}; Harrison {Day159/33:8-23}; Dolan {Day160/17:20}-{Day160/18:11}. Although gas engineers should be aware of the Building Regulations,42 Dolan {Day160/17:2-18}. in 2016 there was a strong emphasis and reliance on IGEM publications and there existed within the gas industry a general understanding that if an engineer complied with that guidance, all relevant regulatory standards, including the Building Regulations, would be met.43 Hancox {Day161/20:24}-{Day161/21:16}. The IGEM publication applicable to the work to be carried out at Grenfell Tower in 2016 was IGEM/G/5, second edition.44 {RHX00000005}.
¶68.21 Having cut and capped the riser serving the "Flat 2s" on 1 October 2016, Cadent had to consider whether and, if so, how, to reinstate the supply of gas to them.
¶68.22 For that purpose it engaged tRIIO, a consortium formed by Morrison Utility Services Limited and Skanska Construction UK Limited, to design and install replacement gas pipes and connections.45 Dolan {MET00012711/2} page 2, paragraphs 7-10. tRIIO entered into subcontracts with other organisations and individuals for some of the work.46 Dolan {MET00012711/4-7} pages 4-7, paragraphs 23-28. There was plainly some urgency and it is apparent that Cadent sought to reinstate customers' gas supplies as quickly as possible.47 Dolan {Day160/29:21}-{Day160/30:2}.
¶68.23 Two options were available to it: it could either find a way to install a new riser to reconnect the "Flat 2s", or it could pay customers to replace their gas appliances with electric appliances. On 17 November 2016, Cadent rejected the latter option because only part of the building was affected.48 {CAD00000059}; Mason {CAD00003005/8} page 8, paragraph 23. It therefore decided to restore the supply of gas, provided it could do so safely.49 Gas Act 1986 {INQ00014770/53} section 10(9).
The first design
¶68.24 IGEM/G/5 provides a hierarchy of options for siting gas pipes. It states that the best option is an external network of pipes so as to give them direct ventilation to natural air.50 {RHX00000005/29-31} paragraph 4.2.1.4. In the case of Grenfell Tower however, the TMO and tRIIO agreed that installing pipes on the outside of the tower was not practicable because they would pierce the newly installed rainscreen cladding, would compromise the integrity of the facade and potentially invalidate any warranty for the cladding system.51 Dolan {MET00012711/8-9} pages 8-9, paragraph 34; Dolan {Day160/53:4-10}. In our view, that was a reasonable position for the TMO to take.
¶68.25 tRIIO commissioned Simon Boygle, a surveyor trading under the name of London Ops Gas, to find an alternative route for a replacement riser. He and tRIIO considered several options, including running the new riser in the same place as the original riser, that is, vertically through the floors and ceilings of the flats and directly into the kitchens. That idea was quickly discounted as impracticable, however, because of the difficulties involved in obtaining access to the pipes embedded in the fabric of the building.52 Dolan {MET00012711/8} page 8, paragraph 31; Dolan {Day160/62:11-23}; Hancox {Day161/112:7}-{Day161/113:7}. They also considered running the new pipe through the existing utilities shaft,53 Dolan {MET00012711/9} page 9, paragraph 35; Mason {CAD00003005/11} page 11, paragraph 39; Dolan {Day160/64:20}-{Day160/65:12}. but that option was rejected, principally because the ventilation was considered to be inadequate.54 Hancox {Day161/113:9-25}.
12¶68.26 A key consideration was that any gas pipework must be adequately ventilated so that if a leak occurs it does not cause the atmosphere to become unsafe, with the consequent risk of an explosion. While external ventilation directly to fresh air is preferred,55 {RHX00000005/52} paragraph 6.4.3.1. IGEM/G/5 allowed for any steel pipeline that had welded or screwed joints to be ventilated indirectly to outside air through an area that was "normally-occupied", meaning occupied as an individual dwelling or a common corridor or lobby.56 {RHX00000005/52} paragraph 6.4.3.5. However, IGEM/G/5 stated that mechanical ventilation should not be used to achieve the required ventilation level,57 {RHX00000005/52} paragraph 6.4.3.2; {CAD00000054/2-3}; Dolan Day160/66:21}-{Day160/67:8}. which in the case of Grenfell Tower prevented siting gas pipes in the lobbies, since they relied on mechanical ventilation. IGEM/G/5 also required ventilation to be provided at the top and bottom of every fire compartment,58 {RHX00000005/54-55} figures 18-19. consistently with the guidance in Approved Document B relating to ventilation in protected shafts.59 {CLG00000224/81} paragraph 8.41. Approved Document B also provided further guidance on the ventilation of shafts, directing the reader to BS 8313:1997 on the size of ventilation openings.60 {CLG00000224/81} paragraph 8.41.
¶68.27 It is clear that there were two requirements that had to be taken into account: ventilation for gas safety and compartmentation for fire safety. Giving appropriate recognition to each of them is a challenge for anyone seeking to supply gas to any complex building in multiple occupation.
¶68.28 On 12 October 2016 Simon Boygle proposed that a new riser should be installed in the stairwell of Grenfell Tower.61 {CAD00000054}; updated on 1 November 2016 {CAD00000038}. That was the only means by which to satisfy the twin requirements of ventilation and compartmentation.62 Dolan {Day160/55:24}-{Day160/56:14}. The new riser would travel from the basement, through the lower floors, through the stairs, and then by means of laterals restore the supply of gas to the "Flat 2s". It was envisaged that at a later date the pipework would be extended to serve all the flats in the tower and the original pipework would be decommissioned.
Firefighting stairs
¶68.29 What nobody involved in the project understood at the time was that although both IGEM/G/5 and Approved Document B allowed gas risers to be placed in protected stairs,63 {RHX00000005/52} paragraph 6.4.3.3; {CLG00000224/32} paragraph 2.42. if the stairs were also firefighting stairs, additional protections were required.64 {CLG00000224/32} paragraph 2.35. Diagram 52 in Approved Document B advised that firefighting stairs should be constructed in accordance with BS 5588-5:2004,65 {CLG00000224/116} diagram 52. which in turn advised that such a shaft should contain only services associated with fire-fighting. In other words, the guidance in Approved Document B and the British Standard to which it referred was that gas supply equipment should not pass through the same compartment as services associated with firefighting.66 Fire Precautions in the design, construction and use of buildings – Part 5: Access and facilities for firefighting {BSI00000087/23} paragraph 7.1.4. While BS 5588-5 was superseded by BS9999:2008 (and ADB therefore referred to an out of date standard), identical provisions appeared in BS9999:2008 at paragraph 27.2.7.2, to the effect that only services associated with firefighting should pass through the firefighting shaft {BSI00000064/123}. Although it is arguable that appropriate standards of safety could have been achieved by separating the riser from the firefighting stairs with fire-resisting construction, as was explicitly permitted for gas pipework in protected stairs,67 {CLG00000224/81} Note to paragraph 8.40. Neither BS 5580-5:2004 nor BS9999:2008 make any such provision. the position is not clear in the guidance document or standards in relation specifically to firefighting stairs. We note that the first design did not have any boxing protecting the riser in the stairs.
13¶68.30 That special consideration had to be given to firefighting stairs does not appear to have been widely understood in the gas industry before the Grenfell Tower fire68 Dolan {Day160/91:19}-{1Day160/92:14}; Hancox {Day161/117:7-18}. and there is no evidence that any other professional expressly considered the point.69 {TMO10015305}; {TMO10016548}; {CST00001240}.
Ventilation and compartmentation challenges
¶68.31 tRIIO's first design did not provide much detail of how the ventilation of the pipework would be achieved.70 {TRI000000263}. The riser was to be constructed of steel with welded joints, so indirect ventilation was available as a design choice pursuant to the guidance in IGEM/ G/5.71 {RHX00000005/52} paragraph 6.4.3.5. On that basis the design included the following features: a. Ventilation for the basement was to be achieved by way of pre-existing ducts that
vented to the outside air and were suitable for the gas installations that were already in the basement.72 Dolan {Day160/101:6-10}; {Day160/104:4-9}.
¶b. Between the basement and level 2, the riser passed through the south-east utilities shaft and into a storeroom adjacent to the community meeting room. The utilities shaft, which rose more than one storey, had a louvered door at low level which would have provided some ventilation73 Hancox, Gas Engineering Report {RHX00000012/30} figure 22; Thompson {TRI00002923/2} page 2, paragraph 8; Images of louvred doors {TRI00002921}; {TRI00002922}; Dolan {Day160/105:3-15}. but there was no obvious ventilation at the top of the compartment.74 Hancox, Gas Engineering Second Supplementary Report {RHX00000027/21} paragraph 44. It was not clear what ventilation strategy applied to the storeroom.75 Hancox, Gas Engineering Second Supplementary Report {RHX00000027/22} paragraph 50; Dolan {Day160/105:15- 23}; Hancox {Day161/135:5-18}. c. Through the stairs, the riser was ventilated across the whole shaft.
¶d. At each floor, the lateral pipes passed through the compartment walls between the stairwell and the communal lobbies through oversized holes. On the lobby side, the lateral pipework was to be boxed in with fire-rated materials.76 {TRI000000392}. The boxing in was necessary because the lobbies had mechanical ventilation, so the gas pipework could not ventilate directly into that space. The holes in the wall between the stairs and the lobby were left open so that any gas leaking from the pipework in the lobby would dissipate into the stairs, but the holes in the walls between the lobbies and the flats were to be fully fire‑stopped. e. At the top of the stairwell the riser vented directly to the air through the rooftop vents.
14¶68.32 No analysis was made of the ventilation available for each space through which the gas pipes were to pass.77 Dolan {Day160/102:3}-{Day160/103:9}; {Day160/103:16-22}; {Day160/148:2-14}. In our view, such a complicated design required detailed consideration of the ventilation arrangements in order to demonstrate that the pipework would be ventilated adequately and safely.78 Hancox, Gas Engineering Report {RHX00000012/191} paragraph 385; Hancox, Gas Engineering Report {RHX00000012/195} paragraph 394; Hancox {Day161/139:15-17}. tRIIO did not carry out a detailed analysis of that kind.
¶68.33 A detailed risk assessment should also have been carried out.79 Hancox {Day161/142:8-11}. According to IGEM/G/5, designers of gas pipework in buildings in multiple occupation should carry out a risk assessment to identify and mitigate hazards and maintain a written record of the results.80 {RHX00000005/28} paragraph 4.2.1.1; {RHX00000005/94-102} Appendix 3. In late 2016 tRIIO's procedure was to record risks in its CDM Design Risk Register, which took the form of a spreadsheet that generated an initial risk score. If that score was 18 or more, tRIIO would carry out a fuller assessment by responding to a list of more probing questions.81 {TRI000000369}. tRIIO completed the CDM Design Risk Register in relation to Grenfell Tower on 15 November 2016. It generated a score of 17.82 {TRI000000369}. Although the designers could have manually over-ridden the process and carried out a fuller assessment of risk, they did not do so.83 Dolan {Day160/85:14-16}.
¶68.34 We do not think that tRIIO's risk assessment process was adequate for buildings in multiple occupation.84 Hancox {Day161/150:10}-{Day161/151:9}; {Day161/172:3-16}. We note that tRIIO's own CDM Design Risk Register shows that any building of that kind would be "high risk" in and of itself85 {TRI000000369} at "MOBS" where a red "high-risk" categorisation is shown in the final column. and accordingly, the process should have required that it be the subject of a fuller assessment. That was particularly so in the case of an old building such as Grenfell Tower in circumstances where the proposed design was relatively complicated. tRIIO should therefore have overridden the scoring system and considered the risks posed by the installation in more detail. Mr Dolan, tRIIO's director of operations, accepted that it had been at fault in failing to do so.86 Dolan {Day160/89:11-23}.
¶68.35 Cadent's contract with tRIIO did not require it to check design decisions and it did not expect to do so. However, once work began, Cadent was under a statutory duty to notify the Health and Safety Executive (HSE) using the form "F10".87 The Construction (Design and Management) Regulations 2015 {INQ00011316/7} regulation 6; The Construction (Design and Management) Regulations 2015 {INQ00011316/29} regulation 6, schedule 1. tRIIO had produced an F10 covering all the work it intended to carry out during the period 2016-2017,88 {TRI000001784}. but that did not constitute an adequate notification of the work at Grenfell Tower. Cadent should have produced an F10 to notify the HSE of that work.89 Lane, Phase 2 Report Version 2 {BLARP20000016/148-149} paragraphs 11.3.1-11.3.9. A generic F10 of the kind produced by tRIIO was inappropriate for a project affecting a large building in multiple occupation.90 Harrison {Day159/84:5-14}; Dolan {CAD00003044/13} page 13, paragraphs 51-52.
¶68.36 Over the course of some months the original riser was replaced using a new pipe which entered the basement below ground level on the east side.91 Hancox, Gas Engineering Report {RHX00000012/14} paragraph 29 (c) and figure 4. From there it passed up through the lower floors and into the stairwell where it passed through holes cut in the floors of the landings.92 Hancox, Gas Engineering Report {RHX00000012/31} figure 24. If the supply of gas was to be restored to a flat, a horizontal pipe, or 'lateral' was led from the riser through the stairwell wall and into the lobby.93 {CAD00001643}; {CAD00001640}. The lateral then passed round the perimeter of the lobby just below the ceiling and a pipe from it entered the relevant flat through a hole in the wall between the flat and the lobby.94 {TRI000000263}; {TRI000001431}. The pipe was connected to a meter which had to be moved from its original position in the kitchen to the hallway near the front door.95 Hancox, Gas Engineering Report {RHX00000012/26} figure 18. Further pipework was then installed between the meter and any kitchen appliances that burned gas.
15¶68.37 After the gas pipework had been installed into the tower it was commissioned on 10 March 2017,96 Dolan {Day160/125:7-9}. even though the work in the lobbies of boxing it in had not been completed. At that stage the work did not comply with the guidance in IGEM/G/5 because a leak in the lobby would have been ventilated by mechanical ventilation, which was not permitted. It appears that tRIIO took a calculated risk and reconnected the supply of gas to customers before all the work had been completed. We understand the desire to reconnect occupants as quickly as possible, but the fact remains that tRIIO should not have introduced gas into a pipeline without all the ventilation requirements being in place.97 Dolan {Day160/125:7}-{Day160/126:10}.
A change of design
¶68.38 On 21 March 2017, tRIIO's design manager inspected the work and noted that flanged joints had been installed rather than welded joints.98 Dolan {MET00012711/11} page 11, paragraph 47. Flanged joints have a compression fitting which seals the connection between the two pipes with a gasket, as opposed to screwing or welding the pipes together.99 Dolan {Day160/140:16}-{Day160/141:10}. As a result, flanged joints are more prone to leaking and could not be used if the stairwell was to provide the necessary ventilation.100 Dolan {Day160/139:23}-{Day160/140:10}. The installation of the flanged joints compromised the ventilation strategy and the error was not noticed by tRIIO's design team before gas was reintroduced into the pipeline.101 Dolan {Day160/141:20}-{Day160/142:8}.
¶68.39 On 24 March 2017, in response to that discovery, tRIIO introduced a modification to the arrangement, under which the vertical riser (as well as the laterals) was to be fully boxed-in, both in the stairwell and also throughout the lower levels and the basement, using materials with a two-hour fire rating.102 Dolan {Day160/144:13-25}; {Day160/145:15}-{Day160/146:3}; {TRI000001223}. Intumescent vents were to be installed in the boxing in the stairwell, which would close in the event of a fire but allow for some ventilation in normal circumstances.103 {TRI000001223}.
¶68.40 The description of the modified arrangement did not show how the boxing-in was to be achieved at the lower levels, i.e. through the utility duct and in the storeroom and basement. Nor did it show how the boxing-in would be connected to the vent in the roof.104 Dolan {Day160/157:16-23}; Hancox, Gas Engineering Report {RHX00000012/194} paragraph 391. Moreover, the new design created other problems in relation to ventilation. It assumed that air would circulate within the boxing and across the pipework through the holes in the landings and the walls between the stairwell and the lobbies, but the holes through the landings had not been enlarged to allow for a flow of air within the new boxing.105 Hancox, Gas Engineering Report {RHX00000012/195-196} paragraphs 395-396; Hancox {Day161/158:3-16}. There was no evidence that calculations had been carried out to determine the size of the holes that would be required nor was it clear how an increase in the size of the holes and the boxing could be accommodated given the narrowness of the stairs.106 Hancox {Day161/161:3-13}. The use of intumescent vents was not consistent with the requirements of IGEM/G/5.107 Hancox {Day161/154:15}-{Day161/155:4}.
16¶68.41 In this case tRIIO manually over-rode its CDM Design Risk Register process and carried out a full design risk assessment that was recorded on a four-page spreadsheet identifying factors for consideration.108 {TRI000001218}. Three of those factors related specifically to buildings in multiple occupation, namely, breach of compartmentation, failure due to thermal expansion of south-facing pipes, and ventilation.109 {TRI000001218/4}. They were appropriate matters but they did not cover everything that a designer ought to consider, such as, for example, means of escape in fire, corrosion, inspection and maintenance, and valve access and security.110 Hancox, Gas Engineering Report {RHX00000012/156} paragraph 354; Dolan {Day160/171:1-15}; Hancox {Day161/173:3-9}.
¶68.42 In addition, the information tRIIO added to the Design Risk Register lacked sufficient detail. On the important question about fire compartmentation, the action recorded was simply to follow the Building Regulations and Fire Safety Order and seal the compartments accordingly. A gas engineer was to review the arrangements for ventilation, although they were not described in any detail in the design. Mr Dolan accepted that the assessment process fell below the standard required and that a more detailed consideration of matters affecting buildings in multiple occupation was needed.111 Dolan {Day160/162:10-19}; {Day160/170:15-25}.
¶68.43 Although tRIIO adopted a more formal approach to the modified arrangement, there is no evidence that anyone calculated the amount of ventilation needed for the pipework.112 Dolan {Day160/186:9}-{Day160/187:9}; Hancox {Day161/156:14-25}. That was particularly important, given that the ventilation strategy had changed and that the degree of ventilation had been reduced by the boxing-in of the entire pipeline.
Construction of the modified arrangement
¶68.44 Regrettably, tRIIO and its sub-contractors continued to make mistakes during the construction of the work. As Mr Dolan and tRIIO accepted,113 Dolan {Day160/189:21-25}. although the boxing-in of the pipework should have been carried out using two-hour fire-rated materials114 {TRI000001218}. (and although the TMO was told that it would be),115 {TMO10016548}. the sub-contractors, Express Building Contractors Ltd, in fact used materials that were rated as having a fire integrity of only 88 minutes.116 {TRI000001377}; Dolan {Day160/189:14-25}; Hancox, Gas Engineering Report {RHX00000012/196} paragraph 397.
¶68.45 A further problem also arose from the need to move the gas meters from the kitchens closer to the front doors because tRIIO's specifications required that there be no more than two metres of service pipework inside a residential property.117 Dolan {Day160/72:24}-{Day160/73:10}. As a result, a sub-contractor of K&S Pipe Contractors, Holland Gas Engineers Ltd, was obliged to place meters in or adjacent to the entrance hall, which was the only escape route.118 Hancox, Gas Engineering Report {RHX00000012/33} paragraph 61. Meter points can present a particular fire risk because if there is a fire, gas can burn freely from open meter ends. IGEM/G/5 suggests relatively easy mitigations, including installing the meter inside a 30-minute fire-rated cupboard with a self-closer or installing a thermal cut off device119 {RHX00000005/38} paragraph 5.2.3. to stop the flow of gas either before or after the emergency control valve.120 Hancox, Gas Engineering Report {RHX00000012/58-61} paragraph 133(f). However, neither of those steps were considered at Grenfell Tower.121 Hancox, Gas Engineering Report {RHX00000012/161} paragraph 364.
17¶68.46 tRIIO maintained that the meters were often sited in an alcove or cupboard adjacent to the entrance hall and that the mitigation measures mentioned above were unnecessary.122 Dolan {Day160/190:18}-{Day160/191:1}. However, we have seen examples of meters being located behind curtains123 {MET00016651}. or behind doors that had rising hinges and were not self-closing124 {MET00016558}; Hancox, Gas Engineering Report {RHX00000012/159} paragraph 362. and it is plain that in some cases the meter was sited close to the escape route from the flat. Although there is no evidence that any of the meters played a role on the night of the fire, we do not consider those arrangements to have been satisfactory.
The night of the fire
¶68.47 There is no evidence that gas leaked from any part of the new installation during the fire on 14 June 2017.125 Hancox, Gas Engineering Report {RHX00000012/117} paragraph 252. However, the works had not been completed by that time. The boxing-in in the stairs had almost been completed, with only the top floor and the connection to the roof vent outstanding, but the boxing-in of the laterals in the lobbies had not been completed, except on floor 5. Battens had been installed for the boxing-in in the lobbies on floors 4, 8, 9, 10 and 11 only. Mr Dolan estimated that the remaining work would have taken about five weeks.126 Dolan {TRI00001797/2-3} pages 2-3 paragraph 7; Mason {CAD00003005/11} page 11, paragraph 34.
¶68.48 While the work was being carried out the oversized holes between the stairwell and the lobbies were not temporarily fire-stopped. It was possible, therefore, for smoke to move from one compartment space to another. Heavy smoke staining on the internal faces of the boxing in the stairs indicates that some smoke must have travelled from the lobbies into that boxing.127 {MET00016722}; {MET00016516}. There was also evidence of staining between adjacent floors which appears to indicate that smoke had travelled between floors through the boxing of the riser.128 {MET00016516} showing smoke staining at the top of the boxed portion of gas riser on floor 17; {MET00016533} showing staining at the bottom of boxed portion of gas riser on floor 16; Hancox, Gas Engineering Report {RHX00000012/178-179}. It is possible, therefore, that during the fire smoke may have travelled from one lobby into the boxed-in riser and out into lobbies on other floors higher up the tower, thereby compromising the compartmentation between the lobbies. It is not possible, however, to know how much smoke may have travelled in that way or at what stage in the fire. We think it is likely to have been a much less significant route of smoke spread than open fire doors between the lobbies and the stairs.
¶68.49 In March 2017 Cadent expressed concern to tRIIO about the oversized holes between the lobby and the stairwell, which it thought might create an unsafe situation in the event of a fire.129 {TRI000000985/3}. In those circumstances we think that tRIIO should have made sure that those holes were temporarily fire-stopped while the work remained incomplete,130 Hancox {Day161/166:8}-{Day161/170:6}. as Mr Dolan accepted.131 Dolan {Day160/175:15}-{Day160/176:20}. We are unable to tell whether the failure to do so had any adverse consequences on the night of the fire, but we think it important to record that the risks should have been identified and mitigated during the work.
18The involvement of building control
¶68.50 One question we thought it appropriate to consider is whether the work involved in the replacement of the gas riser required building control approval. In 2016, the gas industry did not routinely consult building control in relation to reinstatement work.132 Hancox, Gas Engineering Report {RHX00000012/187} paragraph 375. In this instance, although Carl Stokes advised that the work was notifiable,133 Stokes {CST00003063/47} page 47, paragraph 138; {TRI000000405}. tRIIO did not consult building control because it thought that the work did not require approval, despite the material changes to compartmentation that the riser design entailed.134 Dolan {Day160/110:20}-{Day160/111:8}. In March 2017 Janice Wray told John Allen, the head of RBKC's building control department, that the new riser had been installed in the staircase and invited him to send a team to the site to look at the work.135 {TMO10016428/1}. However, he told her that the riser works were regarded as a repair and were a matter for a fire risk assessment.136 {TMO10016546}. tRIIO, for its part, appeared to believe that, if carried out in accordance with IGEM/G/5, the work would comply with the Building Regulations but that the TMO would make any necessary application for building control approval.137 {TRI000000405}; Dolan {Day160/111:1-8}.
¶68.51 Whether the work of replacing the gas riser required building control approval is a difficult question on which the evidence does not enable us to express a clear conclusion. However, we think that in cases where the structure of a building on which effective compartmentation depends is affected by the replacement of existing services, careful consideration should be given to the need to obtain building control approval as well as complying with any relevant industry guidance.
19Part 8: The London Fire Brigade
21Chapter 69: Introduction to Part 8
¶69.1 In chapter 7 of his Phase 1 report the chairman described the statutory responsibilities, structure and organisation of the London Fire Brigade (LFB). In particular, he described in some detail the operation and management of the control room, the systems and procedures employed in it and the method of handling emergency calls. Later in the same chapter he described operations at the incident ground, with particular emphasis on the role and responsibility of the incident commander and support available from monitoring officers and command units. It is not necessary for us to repeat any of that in this report.
¶69.2 In that report the chairman expressed the view that there had been significant shortcomings in the way the LFB had responded to the fire at Grenfell Tower, both in the control room and on the incident ground, many of which were the result of a failure to provide its control room officers and firefighters at all levels with the skills, preparation and training needed to enable them to respond effectively to the situation they faced. He therefore considered it necessary in this second phase of the Inquiry to examine the organisation and training of the LFB in the years preceding the fire with a view to understanding how that situation had come about and how it might be avoided in the future.
¶69.3 We begin this Part of our report with a brief description of the way in which the management of the LFB is organised to enable the reader to understand the complicated structure that existed in the years immediately before the Grenfell Tower fire. That structure is of importance only because it sheds light on the way in which the organisation functioned during that period. We follow that with a description of the way in which training was organised and training packages obtained from the LFB's provider, Babcock. It was essential to train officers at all levels in order to meet the challenges of incident command and to ensure that operations were conducted effectively. In view of the criticisms of the LFB made by the chairman in his Phase 1 report we considered it appropriate to pay particular attention to that aspect of the brigade's management, particularly since it had been the subject of a specific recommendation by the coroner who conducted the inquests following the Lakanal House fire.
¶69.4 Although the fire at Lakanal House in 2009 emphasised the dangers posed by the use, especially in high-rise buildings, of certain kinds of materials and methods of construction, the sources of that knowledge had been available for some years. We therefore decided that we should investigate the extent to which the LFB had been aware of those dangers and, if so, how widely the information had been shared within the organisation. We have also considered other sources of information that were available to it in order to understand why the dangers of a loss of compartmentation and the rapid spread of fire were not understood or recognised by operational station crews.
¶69.5 One important aspect of preparation is gathering information about buildings that may present particular challenges. The LFB is unusual in having a large number of high-rise buildings in the area for which it is responsible, many of which pose particular challenges. We have therefore examined and report on the steps taken by the LFB to collect information about buildings, particularly those that may present particular challenges in the event of a fire.
22¶69.6 The response of the control room to the huge volume of information it received as a result of the fire made it necessary for us to examine the quality of the training delivered to control room staff during the years leading up to it. That in turn required us to examine the way in which the control room had been managed and the importance attached to the delivery of regular training, particularly in handling calls from or about people trapped in high-rise buildings. In this Part, therefore, we set out our findings on those matters.
¶69.7 There are other aspects of the response to the fire that in our view called for examination. One significant obstacle encountered by the firefighters who entered the tower was the difficulty of maintaining effective radio communication. We have therefore considered the nature of the equipment then in use, the source of the difficulties in maintaining communication with the bridgehead and the steps that might be taken to overcome them in future.
¶69.8 Maintaining an adequate supply of water also presented difficulties. We have therefore examined the means by which water is made available for firefighting and the steps that were taken by the water undertaker, Thames Water, to improve the supply while the fire was being fought. We have also considered the equipment available to firefighters to deliver water at the fireground and the way in which it was used during the course of the fire.
23Chapter 70: Organisation
¶70.1 This chapter provides a broad overview of the organisational structure of the LFB in the period leading up to June 2017. It is necessary to be aware of the key elements of that structure in order to understand which departments and individuals were responsible for different aspects of its functions before and at the time of the Grenfell Tower fire.
¶70.2 On 1 October 2007, Ron Dobson was appointed LFB Commissioner, a position which he held until his retirement on 31 December 2016.138 Dobson {LFB00032157/2} page 2, paragraph 5. Following a period of handover from September to December 2016, Dany Cotton was appointed interim Commissioner on 1 January 2017 and subsequently appointed to the substantive rank on 14 June 2017.139 Dobson {LFB00032737/2-3} pages 2-3, paragraph 5. The permanent appointment on 14 June had been planned and was unrelated to the Grenfell Tower fire.140 Phase 1 hearing: {Day50/10:3-12}.
¶70.3 The London Fire and Emergency Planning Authority (LFEPA) was abolished on 1 April 2018 and replaced by the London Fire Commissioner, who became the fire and rescue authority for Greater London. The London Fire Commissioner assumed responsibility for LFEPA's statutory obligations under the Fire and Rescue Services Act 2004 outlined above.141 Section 1(2)(c) of the Fire and Rescue Services Act 2004, which came into force with effect from 1 April 2018 under The Policing and Crime Act 2017, section 9 and The Policing and Crime Act 2017 (Commencement No. 7) Regulations 2018, regulation 4 On 31 December 2019, Ms Cotton retired as Commissioner and was succeeded by Andrew Roe on 1 January 2020.
¶70.4 As an organisation the LFB was divided into three directorates, the heads of which reported directly to the Commissioner and were responsible for a number of different departments. The internal structure of the directorates was complex and subject to frequent changes, most notably in 2015 following a wide-ranging reorganisation of the LFB as a whole. In the following paragraphs we give a broad and simplified description of the LFB's structure before and after 2015, focusing on the departments and functions which are most relevant to the Inquiry's investigations.
Before 2015
¶70.5 Before 2015, the LFB's three directorates were the Deputy Commissioner's directorate, the Directorate of Operational Resilience and Training (together sometimes known as the two operational directorates) and the Directorate of Financial and Contractual Services.
The Deputy Commissioner's directorate
¶70.6 Rita Dexter served as Deputy Commissioner between November 2009 and March 2015.142 Dexter {LFB00032363/2} page 2, paragraph 4. In addition to deputising for the Commissioner, the Deputy Commissioner was responsible for the following departments within her directorate: Operational Prevention and Response, Fire Safety Regulation, Strategy and Performance, Communications, and Legal and Democratic Services.143 Dexter {LFB00032363/2} page 2, paragraph 5. The first three of those departments are relevant to the Inquiry's work.
24The Operational Prevention and Response department
¶70.7 The Operational Prevention and Response department144 Also later known as 'Operations and Mobilising'. was responsible for the planning, direction and delivery of the LFB's operational service, mobilising crews and community safety,145 Brown {LFB00032166/3} page 3, paragraph 7. including overall responsibility for the control room, fire stations and the collection, management and use of operational risk information.146 Brown {Day186/7:17}-{Day186/8:1}; Brown {Day186/5:2-21}. At all relevant times, the LFB's 102 fire stations were grouped by the 33 London boroughs in which they were located,147 Brown {LFB00032166/23} page 23, paragraph 74. each headed by a Borough Commander. The boroughs were in turn grouped into four Areas (North East, North West, South East and South West) each headed by an Area Deputy Assistant Commissioner (DAC). Before 2012, many of the department's responsibilities were split geographically between North London and South London, each headed by an Assistant Commissioner (AC). However, from June 2012 the role and responsibilities for the whole of London were brought together under a single Head of Operational Prevention and Response.
The Fire Safety Regulation department
¶70.8 The Fire Safety Regulation department had two broad functions: Regulatory Fire Safety and Community Safety. The Regulatory Fire Safety arm of the department was headed by two DACs, who filled the roles of Head of Fire Safety Delivery and Head of Fire Engineering and Specialist Fire Safety.148 Daly {Day183/13:24}-{Day183/16:19}.
¶70.9 Fire Safety Delivery included the department's fire safety teams, which had responsibility for managing the LFB's audit and enforcement activities under the Regulatory Reform (Fire Safety) Order 2005 (the Fire Safety Order). As with the Operational Prevention and Response department, the Fire Safety Delivery arm of the department was split into the same four geographical London areas, each headed by an Area Fire Safety Manager, and further divided by boroughs.149 Jack {LFB00032244/3} page 3, paragraph 7. Fire Safety Delivery was responsible for the LFB's programme of fire safety audits carried out by fire safety inspecting officers, who could be from either operational or non-operational backgrounds.150 Daly {LFB00032306/3} page 3, paragraph 9. Some fire safety inspecting officers received additional training to enable them to act as fire engineering liaison officers, who provided support to the more specialist fire engineering teams in relation to building control consultations.151 Daly {Day183/29:12-22}; Daly {Day183/39:4-21}. Fire Safety Delivery included the Fire Safety Enforcement team, headed by Andrew Jack, which was responsible for reviewing enforcement notices produced by inspecting officers, interpreting legislation and overseeing enforcement prosecutions.152 Daly {Day183/18:1-20}.
¶70.10 Some senior operational officers were also senior fire safety officers. Senior fire safety officers were typically station managers or group managers who were not part of the Fire Safety department but who would be mobilised to attend incidents requiring four or more pumps to provide support to the incident commander.153 Daly {MET00077774/16}. They undertook a relatively broad, short training course in the basic principles and practice of fire safety to enable them to fulfil that role.154 Daly {Day183/51:8-21}. In practice, and as happened at Grenfell Tower,155 Cohen-Hatton {Day185/59:18}-{Day185/61:14}. it was common for officers who were mobilised to incidents as senior fire safety officers to be assigned different roles by incident commanders.156 Daly {MET00077774/16-17}; Daly {Day183/58:23-25}. AC Daly, sometime Head of Fire Safety, said that, in his view, this practice of re-assigning senior fire safety officers to operational roles reflected a failure to give priority to fire safety expertise on the incident ground.157 Daly {Day183/61:24}-{Day183/62:5}.
25¶70.11 The Fire Engineering and Specialist Fire Safety arm of the department included its more technical fire safety teams, such as the Fire Investigation and Fire Engineering teams. Fire Engineering, also known as the Fire Engineering Group, comprised a team of around 10 specialist fire engineers who held, or were studying for, degree-level qualifications in fire engineering.158 Daly {Day183/32:7-10}. Led by two Senior Fire Engineers, the group's main function was to consider complex references from building control bodies that were beyond the experience of inspecting officers.159 Daly {Day183/29:12-22}. Most of the group's work consisted of providing support to external bodies, though the group also contributed to the development of LFB policy as part of the standard process of internal consultation.160 Daly {Day183/35:1-8}. Fire Engineers were not involved in the development of operational training unless they were specifically asked to contribute their expertise.161 Daly {Day183/38:2-15}.
¶70.12 The Fire Investigation team was made up of watch-based operational personnel whose function was to attend incidents to investigate the cause of the fire. The team used the information collected from such inspections to identify trends with a view to informing activities within the LFB and to advance the work carried out by the LFB with external bodies, including those in industry, to improve fire safety across the built environment.162 Daly {Day183/28:2-22}.
¶70.13 The other arm of the Fire Safety department, Community Safety, concentrated on actions designed to prevent fires (such as home safety visits), on people at particular risk and on community behaviour.163 Daly {Day183/14:7-18}.
The Strategy and Performance department
¶70.14 The Strategy and Performance department led the LFB's work relating to the integrated risk management plan (the London Safety Plan), its internal risk management planning, and performance reviews.164 Dexter {Day178/30:1-24}. Despite its name, the department was not in fact central to the strategy or performance of the LFB's core operational responsibilities.
26The Directorate of Operational Resilience and Training
¶70.15 AC Gary Reason was appointed Director of Operational Resilience and Training in January 2012.165 Reason {LFB00032747/2} page 2, paragraph 7. On his retirement in January 2015, he was succeeded by AC James Dalgleish.
¶70.16 The Directorate of Operational Resilience and Training comprised the following departments: Operational Procedures, Operational Assurance, Operational Resilience, and Human Resources and Development.
The Operational Procedures department
¶70.17 The Operational Procedures department was responsible for the creation and maintenance of the vast majority of the LFB's operational policies,166 Reason {Day180/93:3-7}; Cowup {LFB00032784/3} page 3, paragraph 10. subject to certain exceptions, such as the Incident Command policy, for which Operational Assurance was responsible.
The Operational Assurance department
¶70.18 The Operational Assurance department was primarily concerned with ensuring effective incident command, the safety of operations and the management of risks on the incident ground.167 Cotton {Day208/10:8-11}. Dany Cotton, who headed the department from its inception in 2012 before her term as Commissioner, said that it was designed to provide combined and streamlined leadership of two existing LFB functions, the Operational Review team's quality assurance of incident ground operations, and the Health and Safety team's learning from incidents to identify risks to LFB staff.168 Cotton {Day208/10:12}-{Day208/11:3}; Cotton {Day208/8:3-13}. The department was responsible for producing six-monthly reports which identified risks and trends from an analysis of a wide range of sources, including the LFB's Incident Monitoring Process Database (IMPD), significant incidents, incident accident reports, fire investigation reports, training and sources from outside the LFB.169 Cotton {Day208/30:16}-{Day208/32:1}; {Day208/33:24}-{Day208/34:4}; {LFB00067840} is an example of the reports produced by the department. The department was also responsible for overseeing the production of articles for Operational News, the LFB's internal circular, by which it sought to draw the attention of staff to some of the risks it had identified and any lessons to be learnt.170 Cotton {Day208/12:21}-{Day208/13:10}. The functions of the Operational Assurance department were such that it was ultimately responsible for ensuring the operational effectiveness of the LFB and for ensuring that LFB staff were aware of, and adequately prepared to deal with, operational risks which might affect their safety.
¶70.19 Key teams within the Operational Assurance department included the Incident Management Policy Group (also known as the Incident Command Policy Group), which was responsible for collating the information from the sources mentioned above and producing the six-monthly reports for the Operational Directorates Co-ordination Board (the co-ordination board),171 Cotton {Day208/31:2-12}. and the Operations Review Team, which provided oversight of the LFB's operational activities and routine training designed to maintain and develop operational skills.172 Cohen-Hatton {LFB00110660/2} page 2, paragraph 10.
27The Operational Resilience department
¶70.20 The Operational Resilience department included contingency planning and a special operations group focused on policies, procedures and the provision of equipment related to terrorism.
The Human Resources and Development department
¶70.21 The Human Resources and Development department, previously the Training department, was responsible for the management of the LFB's contract with its external operational training provider, Babcock Training Limited (Babcock), as well as the LFB's human resources function.173 Reason {Day180/93:8-15}. The LFB's operational training structure and the adequacy of particular aspects of the operational training that existed at the time of the Grenfell Tower fire, is covered in more detail below. The training of control room staff, which was not included in the Babcock contract, is covered separately in Chapter 78.
The Directorate of Finance and Contractual Services
¶70.22 The Directorate of Finance and Contractual Services, led by Sue Budden, carried out the LFB's non-operational functions, including Financial Services, Information and Computer Technology and Procurement. It is, on the whole, not relevant to the work of the Inquiry.
The Third Officer
¶70.23 Before 2015, the title of Third Officer was held by a senior operational officer in addition to their day-to-day responsibilities. Its purpose was to ensure that there were three senior uniformed officers (the Commissioner, the Director of Operational Resilience and Training, and the Third Officer) able to provide operational cover for serious incidents. From 2010, the position of Third Officer was held by David Brown, who was then an Assistant Commissioner.174 Brown {Day186/10:7-21}.
The 2015 restructuring
¶70.24 In 2015, the LFB underwent an internal reorganisation and the rank of Deputy Commissioner was dropped. Commissioner Dobson said that the position was no longer required as the directors were able to deputise for him within their own areas of responsibility. In broad terms, the Deputy Commissioner's directorate was reorganised into a new Directorate of Operations. The former Directorate of Operations, Resilience and Training was renamed the Directorate of Safety and Assurance, and the Directorate of Finance and Contractual Services continued as before. In addition to some internal restructuring within each directorate, some departments and functions were moved between directorates.
¶70.25 The separate role and title of Third Officer also ended, as there were now three senior uniformed officer positions: the Commissioner, the Director of Operations and the Director of Safety and Assurance.
28Directorate of Operations
¶70.26 The newly created Directorate of Operations retained responsibility for many of the departments which had previously reported to the Deputy Commissioner.
¶70.27 The Fire Safety Regulation department, now simply called "Fire Safety", continued to incorporate the LFB's fire safety (including Fire Safety Enforcement and Fire Investigation), fire engineering and community safety functions.
¶70.28 The operational firefighting and control functions of the previous Operations, Prevention and Response department were divided between two new departments: Fire Stations and Central Operations and Control and Resource Management.175 {LFB00000010}.
¶70.29 AC Brown was appointed Director of Operations in April 2015. When he retired on 31 March 2017, he was succeeded by DAC Philip Thomas George (known as Tom George).176 Brown {LFB00032166/4} page 4, paragraph 9; George {LFB00032823/2} page 2, paragraph 6.
Directorate of Safety and Assurance
¶70.30 The newly renamed Directorate of Safety and Assurance continued to include Operational Procedures (re-named Operational Policy), Operational Assurance, and Operational Resilience. The Human Resources and Development department was renamed Development and Training, with its human resources functions moved to the Legal and Democratic Services department within the Directorate of Finance and Contractual Services. Health and Safety and the Operational Review Team, previously sub-departments of Operational Assurance, now reported directly to the Director.
¶70.31 Following the restructuring, on 1 December 2015 AC James Dalgleish assumed the position of Director of Safety and Assurance on an interim basis before Dany Cotton's appointment as Commissioner.177 Groves {Day177/11:4-13}. Upon Ms Cotton's appointment, AC Stephen Apter became Director of Safety and Assurance in December 2016. He was in post on 14 June 2017.178 Apter {LFB00067794/2} page 2, paragraph 4.
Principal LFB boards and committees
¶70.32 This section describes the principal LFB boards and committees which existed before and after the 2015 restructuring.
The Corporate Management Board
¶70.33 The Corporate Management Board was the LFB's highest-level committee, with a membership comprising the Commissioner, the three directors and some heads of department, with other officers and advisers attending when required. The Corporate Management Board held regular meetings and provided a forum for the LFB's most senior officers to discuss operational, managerial and strategic matters. It also reviewed key papers and reports before they were submitted to the LFEPA Strategy Committee for oversight.179 Dobson {Day210/59:20-25}; {Day210/63:4-25}.
29The Commissioner's Group
¶70.34 There was also a smaller, informal leadership group known as "the Commissioner's Group", consisting of the Commissioner, the three directors and, before the 2015 restructuring, the Third Officer. The Commissioner's Group met about once a week for informal meetings, which were not minuted, to share information with the aim of improving communications between the Commissioner and the directors.180 Dobson {Day210/62:1-10}; {Day210/64:25}-{Day210/65:6}. Commissioner Dobson said that his day-to-day management and oversight of the directors was not exercised through the Commissioner's Group, but by daily individual meetings and, more formally, at the Corporate Management Board.181 Dobson {Day210/64:21}-{Day210/65:11}.
The Operational Directorates Co-ordination Board
¶70.35 The Operational Directorates Co-ordination Board (the co-ordination board) comprised the directors and most of the senior officers and heads of department in the LFB's two operational directorates. It comprised the heads of Operational Prevention and Response, Fire Safety Regulation, Operational Procedures, Operational Resilience and Human Resources and Development (the training department). The control room was not represented. Until 2015 the co-ordination board was chaired by the Deputy Commissioner, Rita Dexter; following the restructuring in 2015 it was chaired by AC Brown in his capacity as Director of Operations. The Commissioner was not a member of the co-ordination board and did not attend its meetings.182 {LFB00040625/2}; Dexter {Day178/53:19}-{Day178/55:6}.
¶70.36 The primary function of the co-ordination board was to provide a forum in which the two operational directorates183 Operational Resilience and Training and the Deputy Commissioner's directorate before the 2015 restructuring; Operations and Safety and Assurance following the restructuring. could discuss and co-ordinate their activities, identify risks to operational staff and identify and recommend training required in response to such risks.184 Cotton {Day208/27:10-18}. Trends and lessons identified by the Operational Assurance department were brought to the co-ordination board for discussion. The co-ordination board would then select the most significant operational topics for development into paper or computer-based training.
¶70.37 In late 2016, the name of the co-ordination board was changed to the Operational Professionalism Board185 Brown {LFB00084020/19} page 19, paragraph 50; {LFB00040652/1} paragraph 2. but that had no effect on its working.
31Chapter 71: Training
¶71.1 In the Phase 1 report, the chairman found various shortcomings in the LFB's training, which were revealed in its response to the fire, both on the fire ground and in the control room.186 Phase 1 Report Volume IV, pages 589-590, paragraphs 27.16-27.20. In this phase of the Inquiry, therefore, we have examined the way in which the LFB identified training needs (particularly those arising from incidents), its approach to the procurement and provision of training and its systems for monitoring the effectiveness of training.
The dynamic and intelligent operational training process
¶71.2 The LFB had a complex system for identifying the need for training and delivering training to staff at various levels. A process known as the dynamic and intelligent operational training (DIOT) process was central to the operation of that system. Its purpose, as described in Policy No. 825 (PN825), was to monitor operational, health and safety and training performance, to identify trends and provide mechanisms to support the maintenance of competence on the part of operational staff.187 {LFB00012695/2} page 2, paragraph 1.5. As Deputy Commissioner Dexter agreed, that somewhat complex description could fairly be summarised as learning from mistakes made in fighting fires and promoting good practice.188 Dexter {Day178/69:21}-{Day178/70:3}. Its principal purpose, and that of the co-ordination board more generally, was to identify risks to operational staff and to provide appropriate training.189 {LFB00055171/2} page 2, paragraphs 1.2 and 1.5; Dexter {Day178/75:17}-{Day178/76:3}. The process could also, in theory, result in the amendment of an existing policy or the introduction of a new policy, but PN825 described that outcome as rare.190 {LFB00055171/8} page 8, paragraph 3.41. Ensuring that the objectives of the process were achieved was the main responsibility of the co-ordination board.191 Dexter {Day178/69:1-5}.
¶71.3 Central to the process were the arrangements for monitoring incidents and the creation of the associated database described in PN825. The database was used to record comments on the performance of operational personnel or the brigade as a whole during incidents and training.192 {LFB00055171/4} page 4, paragraphs 3.1-3.2. Such comments, often referred to as "development points",193 Cohen-Hatton{LFB00110660/16} page 16, paragraph 58. typically emerged from meetings held after operational incidents or training exercises specifically to consider the quality of the response and the performance of the incident commanders.194 Dexter {Day178/78:5}-{Day178/79:12}. PN825 made it clear that entries should be made on the database only in cases where the performance of an individual, team, piece of equipment or the organisation as a whole had fallen below the required standard or had exceeded expectations.195 {LFB00055171/4} page 4, paragraph 3.3.
32¶71.4 Except in the case of monitoring officers, who were required to post comments on the database in certain cases, firefighters of all ranks could post comments if they wished to draw attention to something they considered to be of importance in relation to the operational response. (Comments made as a result of meetings to consider the performance of incident commanders were posted on the database in all cases.)
¶71.5 The Incident Management Policy group, which was part of the Operational Assurance directorate, was responsible for analysing the database and producing six-monthly reports to the co-ordination board identifying significant trends and matters that required attention.196 Dexter {Day178/105:25}-{Day178/106:3}. "IMPD report" refers to the six-monthly reports presented to the co- ordination board. "IMP report" refers to the individual reports produced following meetings to review operational responses and incident command. which provided material for the database.
¶71.6 Although the system could be used by firefighters of all ranks, DC Dexter and Commissioner Cotton agreed that few firefighters made use of the opportunity to make comments.197 Dexter {Day178/82:20-24}; Cotton {Day208/38:9-12}. One biannual incident monitoring report in 2014 shows that entries were made in respect of only 4% of the 47,105 incidents recorded198 {LFB00067840/5-6}. and it follows that 96% of incidents during that period generated no comments at all. The report indicated that those figures represented an increase on previous quarters, when the use of the system must have been even lower.
¶71.7 Commissioner Cotton and Dr Sabrina Cohen-Hatton, head of the Operational Review Team in June 2017, said that operational staff, especially incident commanders, saw development points as negative.199 Cotton {Day208/40:12}-{Day208/41:16}; Cohen-Hatton {Day184/205:14-22}. Ms Cotton also said that both firefighters and officers found it difficult to accept criticism of their operational performance200 Cotton {Day208/40:21}-{Day208/41:6}. and Deputy Commissioner Dexter said that some staff had voiced fears that they might get into trouble if they admitted having done something wrong.201 Dexter {Day178/82:20}-{Day178/83:7}.
¶71.8 Commissioner Cotton said that she saw no connection between the negative perception of development points and the less than enthusiastic use of the system.202 Cotton {Day208/41:17}-{Day208/43:23}. On the other hand, Deputy Commissioner Dexter told us that the negative perception of development points was the main reason given for not posting comments.203 Dexter {Day178/91:8-25}. That is the most plausible explanation we were given for the significant under-use of the system. The LFB did attempt to improve the use of the database by seeking to reassure staff that development points were not intended to be punitive and by informing officers of the importance of posting comments, but its efforts were unsuccessful.204 Dexter {Day178/83:8-25}; Cotton {Day208/44:2}-{Day208/45:10}.
¶71.9 The low use made of the monitoring process and the very low proportion of incidents which gave rise to development points (even allowing for the fact that many of them were very minor) meant that the database was very narrow and could provide the co‑ordination board with only a limited picture of operational trends or training needs. The process concentrated too much on identifying long-term trends, with the result that a serious problem disclosed by a single significant incident could be missed.205 Spooner {MET00078859/4} page 4, paragraph 4. For example, the database entry for the Shepherd's Court fire in 2016, a significant incident involving the spread of fire across the combustible facade panels of a high-rise residential block and a partial evacuation, failed to identify the spread of fire across external walls or the use of combustible panels as matters to be considered.206 {LFB00120998}.
33¶71.10 Deputy Commissioner Dexter accepted that the incident monitoring process fundamentally relied on the willingness of individual officers on the ground to provide information and that, in the context of a falling number of incidents, the amount of information available to it was steadily diminishing.207 Dexter {Day178/165:6}-{Day178/166:6}.
Operational News
¶71.11 On receipt of a six-monthly database report, the co-ordination board considered whether any training was required in response to what it disclosed. Training was delivered primarily in the form of articles published in Operational News, the LFB's internal information circular, some of which were accompanied by computer-based training packages. Indeed, Operational News and its associated training packages were the main focus of the co‑ordination board's work.208 Groves {Day177/29:3-4}; Dexter {Day178/72:10-15}. Commissioner Cotton estimated that only half to two thirds of the operational trends identified in the database reports were in fact chosen as subjects for articles in Operational News.209 Cotton {Day208/55:2-11}.
¶71.12 The Incident Management Policy group was responsible for producing articles for publication in Operational News, although the articles themselves were drafted by experts from the relevant departments before being reviewed and approved by Operational Assurance.210 Dexter {Day178/111:9-16}; Cotton {Day208/61:17}-{Day208/62:9}. They typically took the form of a summary of an existing policy, drawing firefighters' attention to its contents. Babcock produced reports every six months, in conjunction with the Human Resources and Development department, telling the co‑ordination board how the training it was providing had been, or was being, improved to support the topics covered in the previous edition of Operational News. In many of those reports Babcock simply stated that the topics in question were already adequately covered.211 {LFB00036796/4} for example, in relation to Fire Survival Guidance policy.
Station-based training
¶71.13 Commissioner Cotton said that summarising an existing policy in Operational News did not amount to training but had been intended to raise awareness and provide personnel with links to the associated training delivered through fire stations.212 Cotton {Day208/72:3}-{Day208/73:2}. Initial training was provided to firefighters by Babcock, but the subsequent development and maintenance of operational skills was mainly carried out at station level in accordance with the Policy No. 427 (PN427) by means of computer-based training packages and lectures delivered by watch managers, attendance at which was recorded on crews' training records.213 {LFB00032798/2} page 2.
¶71.14 Watch managers were not provided with any centralised training materials for their lectures (apart from the policies themselves); instead, it was the responsibility of each watch manager to develop their own lectures and deliver them to crews.214 Cotton {Day208/73:21}-{Day208/75:7}. For at least five years preceding the Grenfell Tower fire watch managers were given no guidance on how to deliver training and there was no process to ensure that officers who provided training were competent to do so.215 Cotton {Day208/77:25}-{Day208/79:5}; Groves {Day177/100:18-22}. Station-based training was monitored by Training Review Information Officers, who were responsible for ensuring that training was provided and that training records were complete and accurate.216 Groves {Day177/88:25}-{Day177/89:15}. But we have seen no evidence that any assessment of the quality of station-based training was carried out by those officers or anyone else.
34¶71.15 This station-based training was separate from the centralised training that was commissioned by the Human Resources and Development department (later known as the Training and Development department) and provided by Babcock. For ease of reference and consistency, we shall refer to the department simply as "the Training department". The Training department made no contribution to the substance of station-based training and played no part in ensuring that adequate station-based training was provided.217 Groves {Day177/94:22}-{Day177/95:5}. Nor did the Training department have any process by which to ensure that station-based training was consistent with the training provided by Babcock, which the LFB's Head of Training, Peter Groves, accepted created an obvious risk of injury.218 Groves {Day177/84:11}-{Day177/85:12}. Mr Groves said that responsibility for identifying and assessing any omissions from station-based training lay with the individual borough commanders to whom stations reported, but he accepted that, since 2012, borough commanders had not been trained in how to make such assessments.219 Groves {Day177/94:17}-{Day177/96:15}.
¶71.16 The Training department's limited involvement in supporting, monitoring or assessing the quality of station-based training is surprising and difficult to justify. The importance of Operational News to the delivery of training meant that the LFB was heavily reliant on local crews, local station managers and particularly local watch managers for creating and providing the associated lectures. That clearly created a significant risk that the training that crews at different stations received differed in content and quality.
Effectiveness of the system
¶71.17 Commissioner Cotton accepted that articles in Operational News could never provide more than a high-level, cursory exploration of an operational topic.220 Cotton {Day208/80:25}-{Day208/81:3}. She also agreed that the quality of station-based training depended entirely on the skills of individual watch managers.221 Cotton {Day208/82:4-16}. The co-ordination board's principal method of evaluating the effectiveness of that training was to see whether a particular problem featured in later incident monitoring reports.222 Dexter {Day178/149:25}-{Day178/151:15} Many of the reports considered by the co-ordination board indicated that it was difficult to teach some lessons, as evidenced by the fact that some problems kept recurring.223 Dexter {Day178/157:6}-{Day178/158:19}. Although the reports occasionally noted improvements resulting from certain steps that had been taken (presumably because the number of development points relating to that topic had reduced), there was no system by which the co-ordination board could assess the effectiveness of articles published in Operational News or station-based training.224 Dexter {Day178/152:3-13}. The co-ordination board's approach, which lacked any active assessment of the effectiveness of its training interventions, was wholly inadequate. It was foreseeable that it might fail to identify or resolve significant problems and in any event could identify problems only after they had occurred with sufficient frequency or severity to be noted in one or more incident monitoring reports.
35¶71.18 At a meeting held on 14 October 2013, the co-ordination board decided to carry out a fundamental review of the system, because it realised that the same shortcomings were repeatedly occurring. The review was to examine whether the right tools were available to the brigade for monitoring the effectiveness of training and what systems were used by other organisations. It was envisaged that it might lead to a review of the way in which the LFB responded to incidents. Ms Cotton, then AC Operational Assurance, was asked to lead the review.225 {LFB00067818/2}. In the event, however, it was not as fundamental or far-reaching as had originally been intended or as was required, and although it led to a number of recommendations, it did not result in any significant changes to the system for monitoring the effectiveness of training.226 {LFB00123806}. No one was able to explain why the stated aim of the review had not been met or why the opportunity to reform the existing arrangements had not been seized.227 {LFB00040719/2}; Cotton {Day208/88:10}-{Day208/90:9}.
Centralised training courses
¶71.19 In April 2012, the LFB engaged Babcock to provide centralised training to operational firefighters but retained responsibility for training non-operational officers, including the control room and the Fire Safety department. Shortly after being appointed as training provider, Babcock agreed to undertake a review of all the LFB's training courses within the first three years of the contract. The LFB's course review board, chaired by Director Reason, was responsible for considering and approving Babcock's proposals.228 Reason {Day180/100:12}-{Day180/103:22}.
¶71.20 Although Babcock was responsible for creating and providing operational training packages, the LFB alone determined learning objectives and in practice provided much, if not all, of the expertise necessary for the production of the content. At all times it retained ultimate responsibility for training its staff and no training package could be provided by Babcock unless it had been approved by the LFB.229 Groves {Day177/12:14-20}; {Day177/52:6-11}. The systems and structures relating to the training provided by Babcock were entirely separate from those relating to station-based training.
¶71.21 Responsibility for managing the LFB's relationship with Babcock lay with the Training department. The Training department had no role in identifying training needs, recommending new training or requesting changes to existing training. Those were the responsibility of other departments, known as "commissioning departments". The Training department's role was essentially administrative: it collated training needs and requirements received from other departments and organised the process by which they were ultimately translated into training by Babcock.230 Groves {Day177/14:7}-{Day177/15:3}.
36¶71.22 The Training department had two teams. The Learning and Development Strategy team was responsible for managing the development of training packages and communicating with Babcock and the commissioning departments.231 Groves {Day177/8:16}-{Day177/9:7}. The Training Assurance and Business Relationship team was responsible for ensuring that Babcock provided the training that had been agreed and that it met the LFB's learning and training objectives.232 Groves {Day177/8:3-13}.
¶71.23 Training was commissioned in accordance with a process known as the "training commissioning and alterations process" (TCAP). When a training requirement had been identified, the commissioning department completed a form identifying in broad terms what was needed.233 Groves {Day177/20:12}-{Day177/21:4}. Project managers in the Training and Professional Development team, in consultation with the commissioning department, then completed what was known as a "TCAP form" which built on the basic information provided in the training request by addressing practical aspects of both substance and implementation.234 Groves {Day177/21:8-19}. When the team was satisfied that it was correct, the form was submitted to a group consisting of representatives of both Babcock and the LFB's Training department to check that the training would not have a detrimental effect on operational services.235 Groves {Day177/22:20}-{Day177/23:22}. Babcock could suggest additions or changes to training but did so only once in the period before the Grenfell Tower fire.236 Groves {Day177/35:8-23}; Groves {MET00071103/11}.
¶71.24 The next stage of the process was the development of the substantive training. Babcock proposed and designed the content of the training package to meet the identified learning objectives, subject to the approval of the commissioning department.237 Groves {LFB00102138/29} page 29, paragraph 49. Although it managed the commissioning process, the Training department did not play a part in designing the training itself.238 Groves {Day177/45:3-14}. Babcock usually produced three options for providing the training for consideration by the LFB, which then made a choice.239 Groves {LFB00102138/22} page 22, paragraph 32.
¶71.25 When the training materials had been assembled, a pilot training course was developed (except for some computer-based training), which was attended by experts and representatives of the commissioning department to ensure that it met the LFB's needs.240 Groves {LFB00102138/23} page 23, paragraph 33; Groves {Day177/65:25}-{Day177/66:11}. If the pilot course was considered satisfactory, it was necessary to obtain the commissioning department's approval, confirmation from Babcock that the design was complete and approval from the Head of Fire Stations and the Training department for the provision of the training to operational staff.241 Groves {Day177/65:12-24}; {Day177/67:18-25}. At that point the training could be rolled out. Some training packages were either delayed or not released at all following the completion of a TCAP form.
¶71.26 A consistent theme of the evidence was that Babcock lacked the expertise required to develop appropriate training. As a result, the LFB frequently had to provide experts from within its own ranks to assist it, which was a significant drain on resources.242 Graham Ellis {LFB00118230/15} page 15, paragraph 69; Reason {Day181/30:16-23}. The problem was most acute at the start of the contract in 2012, particularly in relation to incident command training. It was therefore forced to rely on LFB officers to provide the necessary expertise, with the result that it was not always possible to implement much-needed changes to incident command training with sufficient urgency.243 Groves {Day177/47:16}-{Day177/48:9}; {Day177/48:20-25}. Babcock's reliance on the LFB for expertise also delayed other areas of training, including training on the use of breathing apparatus and real fire training.244 Groves {Day177/55:2-19}.
37¶71.27 Although Mr Groves considered that it was Babcock's responsibility to secure the expertise it needed, he rightly accepted that, whatever its contractual arrangements with Babcock, the LFB ultimately remained responsible for ensuring that firefighters were adequately trained.245 Groves {Day177/52:6-11}.
¶71.28 A report by Ribband Starr Ltd, commissioned by the LFB after the Grenfell Tower fire, found that many within the LFB regarded the commissioning process as cumbersome and capable of causing significant delay in the design and delivery of new courses.246 {LFB00067786/33}. All the LFB witnesses who gave evidence about training were of that view.247 Groves {Day177/56:17}-{Day177/57:5}; Reason {Day180/106:10-22}; Cotton {Day208/65:7-8} and Dexter {Day178/125:6-8}. We agree with their assessment.
¶71.29 We were told that all training courses referred to in the annual statement of training requirements produced by the Training department were audited separately at least once a year by the LFB and Babcock and that the results were discussed at monthly meetings between Babcock and the Training department to decide whether any change to a particular training course was needed.248 {LFB00055127/23} page 23, paragraph 7.1; Groves {Day177/68:15}-{Day177/69:23}. The Inquiry has not seen any evidence of audits or discussion of their findings. In particular, there is no evidence that audits resulted in the creation or amendment of any training packages. If audits were carried out, they appear to have had no effect on the content of training.
¶71.30 PN825 refers to four levels of evaluation used by the LFB to assess the effectiveness of training. Level 1 involves the use of questionnaires seeking the opinions of those who have attended courses,249 Groves {Day177/70:2}-{Day177/71:8}. Level 2 gauges what trainees have learnt, Level 3 assesses whether trainees have been able to apply their new skills and knowledge to the workplace, and Level 4 considers the effect of the training on the organisation as a whole.250 {LFB00055171/13} page 13, paragraph 6.10. We were told that training courses, apart from computer-based training, had been subject to Level 1 evaluation but that no formal Level 3 or Level 4 evaluations had been carried out.251 Groves {Day177/71:21}-{Day177/73:7}.
¶71.31 There was no system in place for evaluating the performance of staff who had attended training courses by reference to previously agreed criteria. Once a training package had been developed by Babcock and approved by the commissioning department it was assumed to be suitable.252 Groves {Day177/74:16-25}. That might have been a reasonable approach if the LFB had implemented adequate arrangements to review the effectiveness of training courses, but it is plain that it had made no such arrangements. The approach was particularly unsound in circumstances where there was no process at all by which the Training department was able to review the overall effectiveness of a training programme.253 Groves {Day 177/82:8-12}.
38¶71.32 We have been left with the clear impression that, instead of adopting a system which measured the effectiveness of training by reference to previously agreed criteria, the LFB simply waited to see what, if any, problems subsequently arose at incidents. Such an approach might or might not reveal any deficiencies in training, but if it did, it was by then likely to be too late. The obvious weaknesses of that approach were aggravated by the fact that, as the number of incidents declined, progressively less confidence could be placed in a system that relied on problems being identified at incidents.254 McGuirk, Firefighting Expert Report {SMC00000046/47-50} pages 47-50, paragraphs 123-126.
Conclusions
¶71.33 The procedure adopted by the LFB for commissioning training in the years leading up to the Grenfell Tower fire placed much emphasis on ensuring that the right courses were produced and that training did not interfere with operational requirements. Both were laudable aims. However, the process was very cumbersome and inevitably led to excessive delay in providing new courses. There was also a disturbing absence of any system for evaluating the effectiveness of courses once they had been introduced. At a local level too much responsibility was placed on watch managers to devise and deliver training, with insufficient support and oversight. Since the quality of training at that level depended to a considerable extent on the skills of individual watch managers, the quality was bound to be variable.
¶71.34 In the Phase 1 report the chairman found that the incident commanders who were present during the early stages of the fire had not received sufficient training to enable them to understand the nature of the fire that confronted them and how it was likely to develop. We do not think that the deficiencies in the system for commissioning training or the arrangements for delivering training at station level that we have identified were responsible for that shortcoming, although we cannot be confident that, if there had been sufficient understanding of the need for training in the risks of cladding fires in high-rise buildings, it would have been delivered promptly and effectively. In the next chapter we examine why the LFB failed to ensure that those who acted as incident commanders were properly trained for the task.
39Chapter 72: Incident command training
¶72.1 It became apparent during the course of the Grenfell Tower fire that few, if any, of those who were called upon to act as incident commanders in the early stages of the fire had received training in how to recognise a fire in the external wall of a high-rise residential building or to understand its likely consequences. Nor had they received any training in the principles of evacuation from high-rise residential buildings when a "stay put" strategy was no longer tenable, in how to decide whether evacuation was necessary or in how to carry it out safely and efficiently.255 Phase 1 Report Volume IV paragraph 27.16. It was therefore necessary for us to examine the way in which the LFB trained those who might be expected to assume the responsibility of incident commander and in doing so we must assess its response to the recommendations on incident command made by the coroner in March 2013, following the Lakanal House inquests.
The coroner's recommendations
¶72.2 There appears to be little doubt that before the Lakanal House fire in July 2009 only a small number of officers in the LFB were aware of the dangers posed by combustible materials when used in external walls of buildings or could recognise and understand the significance of a fire of the kind that broke out in Grenfell Tower in June 2017. Those who could and did were almost entirely confined to the Fire Safety department and did not include any of those who could be expected to act as incident commanders.
¶72.3 The Lakanal House fire should have changed that for ever, because operational firefighters at many levels witnessed at first hand the effects of fire spreading across an external wall as a result of the presence of combustible panels. They also witnessed the extensive loss of compartmentation caused in part by the spread of fire both externally and internally, the latter as a result of the use of unsuitable materials in the refurbishment of the interior, in particular some of the corridors. That should have been enough to prompt the LFB to take urgent steps to ensure that in future incident commanders were able to recognise a rapid loss of compartmentation and the spread of fire on the exterior of a building, if it occurred, and knew how to respond, almost certainly by evacuating the whole or part of the building. However, the need for such training should have been put beyond doubt by the coroner's rule 43 letter, written over three years after the fire.
¶72.4 In her rule 43 letter to the LFB the coroner recommended that consideration be given to the training of incident commanders to enhance their performance in a number of respects, including their ability to understand and react quickly to changing circumstances and to anticipate that a fire might behave in a manner inconsistent with the compartmentation principle.256 {LFB00032158/2-3}.
40The LFB's response
¶72.5 AC Cotton, who was head of the department responsible for incident command policy and training at the time, was asked to respond to the coroner's recommendations.257 Reason {Day180/169:1}-{Day180/170:8}; Cotton {Day208/157:10}-{Day208/159:10}; {Day208/160:5}-{Day208/162:7}. Her suggested response, which was ultimately adopted by the Commissioner's Group, was that the LFB should work with Babcock to ensure that all the points raised by the coroner were covered in its current review of incident command training in the period up to 2015 and to create a case study training package which would teach the lessons to be learnt from the Lakanal House fire and other high-rise fires, such as the one at Shirley Towers. The suggestion ultimately resulted in the Lakanal House case study, to which we will refer later. However, as noted there, the case study did not provide adequate training for incident commanders facing a widespread failure of compartmentation of the kind experienced at Lakanal House, nor did it specifically address the coroner's incident command recommendations.258 {LFB00034062/22}.
¶72.6 The LFB accordingly instructed Babcock to incorporate the coroner's recommendations into its review of incident command training, which by then was already in progress. In addition, the LFB instructed Babcock to conduct a separate review to confirm that all the coroner's recommendations relating to incident command were fully covered by existing training courses.259 {LFB00067820/13-14}, action 3; {LFB00003716/5}; {LFB00038170}; Reason {Day181/28:7}-{Day181/55:13}. That review was carried out in mid-September 2013 and the results were provided to the Operational Assurance department.260 {LFB00038170}. The results of Babcock's review were not considered by Director Reason.261 Reason {Day181/49:2}-{Day181/50:21}; {Day181/54:14-23}.
¶72.7 Babcock concluded that the existing training explicitly or implicitly covered all the areas identified by the coroner. Some were the subject of both theoretical and practical training; in other cases the extent to which the areas identified by the coroner were covered and the performance of trainees assessed depended on the exercises they undertook. Babcock recommended that the LFB revise its existing exercises in order to implement the coroner's recommendations and identified 16 exercises which could provide starting points for new exercises which would fully implement those recommendations.262 {LFB00038170}; {LFB00115289}.
¶72.8 In Chapter 74 we describe how in June 2013 LFEPA had set up a working group to monitor the LFB's response to the Lakanal House fire. The LFB's report to the working group on 30 September 2013 gave a different impression from that indicated by Babcock in its review. It said that Babcock had confirmed that all the coroner's recommendations were covered by the existing training on incident command, although there might be opportunities for emphasising the experience obtained from the Lakanal House fire in some cases.263 {LFB00067820/13-14}. That was inaccurate. Babcock had concluded that further work was required on the existing exercises and had identified the fact that some candidates for incident command might not have taken part in any of the relevant exercises.264 {LFB00038170}; {LFB00115289}. In such cases they would not have received any training on matters covered by the coroner's recommendations. However, the fact that some incident commanders would not receive training on matters falling within the coroner's recommendations was an important fact that was omitted from the LFB's report.
41¶72.9 In the LFB's report to the working group in November 2013 that task was marked as having been completed. For reasons explained below, that too was inaccurate, since the work was by then far from complete.265 {LFB00067832/24-25}. Director Reason accepted that the reports did not disclose that Babcock had found that some individuals were not receiving training in the areas identified by the coroner, that incident command training therefore required enhancement, and that the work to develop training exercises was continuing.266 Reason {Day181/84:3-18}. He said that he had relied on the information he had received from the co-ordination board's monitoring of the response to the recommendations and that it had been the responsibility of AC Cotton and her commissioning department to ensure the accuracy of the information.267 Reason {LFB00067846/13-14} pages 13-14, paragraph 17; Reason {Day181/48:12}-{Day181/50:21}; {Day181/82:11}- {Day181/84:18}. He told us that he had provided the working group with the information that AC Cotton's department had collated for the co-ordination board.268 Reason {Day180/150:11}-{Day180/151:8}; {Day180/157:1-7}.
¶72.10 AC Cotton considered that the reports were misleading but said that she was puzzled why the tasks had been marked as completed, because at that stage they were very far from completing the enhancement to the training programme that Babcock was going to undertake.269 Cotton {Day208/224:21}-{Day208/226:12}; {Day208/235:7-25}. She said that she could not recall ever having seen a report to the co‑ordination board indicating that the task had been completed; if she had, she would have challenged it.270 Cotton {Day209/17:17}-{Day209/21:21}.
¶72.11 AC Cotton disputed Director Reason's evidence that he had depended on reports emanating from the co-ordination board. In her view, he had a far better understanding of the position than his evidence suggested. She thought he had been fully aware that a number of tasks were outstanding because he was a member of the co-ordination board and had seen the progress reports. She said that the reports on incident command training had been discussed at length in directorate management board meetings and in her meetings with him. She added that Director Reason was not the sort of person who would accept what was given to him at face value. He would explore the detail.
¶72.12 In January 2014 Director Reason asked Adrian Bevan, a health and safety manager in the LFB,271 Hayward {Day201/30:1-10}. to provide him with a document to support the paragraph in the report to the working group which stated that all seven recommendations were adequately covered by the existing training exercises. Having made some enquiries, Mr Bevan reported that the position was not as clear as had been thought because there had been some confusion between current training exercises and the new exercises that Babcock were developing. At that point, if not before, therefore, Director Reason must have been aware that the position was not as had been reported to the working group. However he did not attempt to correct the reports.272 {LFB00094806/2}; {LFB00118750}; Reason {Day181/101:11}-{Day181/109:18}; {Day181/141:14}-{Day181/148:5}. Director Reason should have ensured that his reports to the Lakanal House Working Group accurately reflected the delay to the new incident command training programme.
42Additional training
¶72.13 Babcock's initial proposal to revise and refine 16 command training exercises was not carried out. First the number was reduced to six and in the end only one, the Holcroft House exercise, was developed. The reasons for that are not entirely clear.273 {LFB00003716}; Reason {Day181/62:16}-{Day181/75:20}; Cotton {Day209/2:10}-{Day209/3:10}; {Day209/13:11-18}.
¶72.14 The Holcroft House exercise became available in 2016. It centred on a fire at a high-rise residential block in Battersea which was undergoing decorative and remedial building works. The overview of the exercise described it as increasing in complexity to involve persons reported as trapped and needing rescue, fire survival guidance calls, significant fire growth and the need for mass evacuation, compounded by the hazards and risks associated with the remedial building works. It was intended to create significant challenges for crew managers and watch managers. A detailed description of the exercise and its potential variations disclosed that it involved only two fire survival guidance calls (at the Lakanal House fire there had been five) and the spread of fire from the original compartment only to the communal corridor, rather than to other floors. The training guide stated that trainees were expected to consider partial or full evacuation of the block, but there was nothing in the course materials designed to help them understand why they might need to consider an evacuation or how they might organise one.274 {BAB00000011}; Reason {Day181/110:10}-{Day181/129:21}. For all those reasons, as Director Reason accepted, that particular training package was not an adequate response to the coroner's recommendations.275 Reason {Day181/128:18}-{Day181/129:21}. Director Reason was not involved in the development of that package but did have ultimate responsibility for changes to the LFB's incident command training in response to the coroner's recommendations until his retirement on 2 January 2015.
¶72.15 There was conflicting evidence about whether it was intended to make the Holcroft House exercise available to all potential incident commanders,276 {LFB00004801/29}, action 3b; Groves {Day177/123:12}-{Day177/127:13}. but in the event, it was restricted, for reasons which are not clear, to Level 1 incident commanders (crew managers and watch managers), rather than being provided to all four levels of incident commander as had been envisaged by Babcock's initial proposal.277 {LFB00003716}; {LFB00115289}; Reason {Day181/73:4-22}. As a result, a significant number of incident commanders did not receive the training which had been designed to implement the coroner's recommendations.
¶72.16 Director Reason told us that the LFB was likely to have partially implemented the coroner's recommendations before August 2016 through Babcock's making simple adjustments to existing courses and by changing the procedures for assessing suitability for senior officer positions.278 Reason {Day181/76:2}-{Day181/77:12}. However, apart from a report which stated that assessments of suitability for incident command covered the challenges of managing incidents affecting high-rise buildings,279 {LFB00067812/5}. there was no contemporaneous evidence that changes to training courses or to the assessment procedures had been made to reflect the coroner's recommendations. If changes of that kind had been made, we think they would almost certainly have been recorded, if only informally. We are therefore unable to accept what Director Reason said on that matter.
43¶72.17 We have no doubt that the LFB intended to incorporate the coroner's seven incident command recommendations into Babcock's review of incident command courses,280 {LFB00042089}; {LFB00067832/25}; {LFB00003716/8}. which should have ensured that from 2015 the recommendations were reflected in new incident command courses. However, the evidence clearly shows that they were not considered in any detail by either Babcock281 {LFB00042089}; {LFB00073973}. or by the LFB during its review of the courses.282 {LFB00043552}; Reason {Day181/130:1}-{Day181/138:10}; Cotton {Day209/40:6}-{Day209/47:23}. That was a significant failing by the LFB, which should have ensured that the lessons to be learnt from the Lakanal House fire were at the heart of the review that it had instructed Babcock to undertake.
¶72.18 Director Reason told us that the LFB's Course Review Board and Babcock's review of the training courses were separate from the recommendations of the Lakanal House Board and those made by the coroner.283 Reason {Day180/100:12}-{Day180/103:22}. Although they may have had separate origins, however, it was clear that the LFB intended to incorporate the coroner's recommendations into Babcock's review of training, as indeed had been conveyed to the coroner.284 {LFB00042089}. That was also confirmed by AC Cotton, who was involved in the review of training courses relating to incident command that was overseen by the Incident Command Project Board.285 Cotton {Day208/208:3}-{Day208/210:17}; Cohen-Hatton {Day185/69:9-14}. Both AC Cotton and Director Reason could and should have ensured that the incident command recommendations were taken into account in that course review.
¶72.19 Even if the new incident command courses adequately reflected the lessons to be learnt from the Lakanal House fire, most of them had not been made available to operational personnel by the time of the Grenfell Tower fire. Courses for Level 1 incident commanders were made available between 2016 and 2017, but courses for Level 2 (station managers and group managers), Level 3 (Deputy Assistant Commissioners) and Level 4 (Assistant Commissioners and above) were either yet to be made available or were still being worked on at the time of the Grenfell Tower fire.286 Groves {Day177/140:16}-{Day177/141:18}; Cotton {Day209/73:21}-{Day209/76:23}. That was almost three years after the LFB had received Babcock's report on its review of training courses and over two years after the revisions should have been completed.287 Groves {Day177/142:11}-{Day177/143:7}; Cotton {Day209/75:22}-{Day209/76:4}. AC Cotton described that rate of progress as "worse than slow". She said that she had regularly reported her frustrations and serious concern about the lack of progress that was being made.288 Cotton {Day209/76:5}-{Day209/77:15}.
¶72.20 We heard forthright evidence from a number of witnesses about the difficulties that Babcock had experienced in providing incident command training, which they attributed to its lack of expertise (which required a greater contribution from the LFB than had been expected), delay in creating training packages and difficulty translating proposals for training into courses.289 Ellis {LFB00118230/15} page 15, paragraphs 69-71; Groves {Day177/46:3}-{Day177/55:19}; {Day177/116:7}- {Day177/120:24}; Reason {Day181/30:16-23}; {Day181/70:5}-{Day181/73:3}; Cotton {Day208/205:21}- {Day208/206:3}; {Day208/206:19}-{Day208/207:3}; {Day209/15:23}-{Day209/17:7}; {Day209/26:4-13}; {Day209/76:5}- {Day209/78:11}; {LFB00118213/11}; Dobson {Day211/186:24}-{Day211/188:21}; {Day211/190:6}-{Day211/192:9}. AC Cotton described Babcock's inability to develop incident command training as one of her greatest frustrations. She said that the LFB could not take back control of training because it had lost the teams that it had previously relied on for developing courses.290 Cotton {Day209/76:5}-{Day209/79:12}.
44¶72.21 Babcock's lack of expertise clearly contributed to the significant delay in the development and release of the revised incident command training. Peter Groves told us that it should normally take no more than a year to produce a new course but that the complexity of training for incident command and Babcock's lack of expertise had delayed the process. He agreed, however, that a lapse of three years between the receipt of the coroner's recommendations and the release of the Holcroft House exercise was unduly long. He attributed the delay to Babcock's lack of expertise,291 Dobson {Day211/127:19}-{Day211/128:14}. but the LFB was ultimately responsible for the protection of life and property and of its own staff and had a duty to ensure that adequate training was provided to its crews for that purpose. Although we heard evidence that Commissioner Dobson had raised the delay with the chief executive of Babcock, they appear to have concluded that neither Babcock nor the LFB was at fault and to have confined themselves to repeating the importance of complying with the coroner's recommendations.292 Dobson {Day211/185:23}-{Day211/192:9}. The discussions had little or no effect on the delay. We do not think that the steps taken by the LFB to remedy the problems with Babcock were sufficiently robust.
¶72.22 Some senior LFB officers thought that the coroner's recommendations did not require any substantive revisions to the LFB's existing incident command training. For example, Commissioner Dobson told us that the LFB had not needed to revise its incident command training; all that was needed, he thought, was for the seven recommendations to be enhanced and properly embedded.293 Dobson {Day211/178:12-23}. Similarly, AC Cotton said that the recommendations were not inconsistent with existing policy and procedures294 Reason {Day181/36:5-17}. and Director Reason did not think that the recommendations reflected the existence of a systemic problem.295 Reason {Day181/137:1-13}. We think that views of that kind held by senior officers are likely to have undermined the importance attached to the training packages and to have added to the delay.
Incident command revalidation
¶72.23 Another aspect of incident command training that was under development at the time of the Grenfell Tower fire was a programme of continuing assessment of competence to undertake incident command, known as incident command revalidation. The purpose of the programme was to ensure that operational officers of crew manager rank and above maintained the required level of competence as incident commanders throughout their operational careers. That contrasted with the position under the LFB's incident command training arrangements existing at the time of the Grenfell Tower fire, under which competence to undertake incident command was assessed by way of an exercise undertaken only when an officer was being considered for promotion. Under those arrangements no further assessment took place unless and until that officer was being considered for further promotion. None of the continuing incident command training that existed immediately before the Grenfell Tower fire contained any form of assessment, and officers who undertook that training continued in their existing rank regardless of their performance during training.
45¶72.24 Proposals for an incident command revalidation programme had first been put forward to the Commissioners' Group by Dr Sabrina Cohen-Hatton, then a DAC and the LFB's Head of Development, in a report dated 17 November 2015.296 {LFB00118186}. She referred to the declining number of incidents in the years preceding the report, which had resulted in a reduction in operational experience across the board and, in particular, a reduction in the number of opportunities for officers to undertake command roles. Her department had consulted five other fire and rescue services, all of which were operating a revalidation system of some kind involving a formal assessment of competence to undertake incident command roughly every 18 to 24 months.297 The FRSs consulted were Tyne and Wear, Greater Manchester, Hampshire, Derbyshire and Hertfordshire.
¶72.25 The report to the Commissioners' Group also referred to the remarkably low pass rates for the LFB's existing incident command promotional exercises, in which just 25% of station managers and group managers and 36% of Deputy Assistant Commissioners were successful. Dr Cohen-Hatton said that the low pass rates were likely to be explained by the fact that candidates received no training in how to command an incident of the scale and complexity that they were required to tackle as part of the promotional exercise, meaning that the first time that many of them had encountered such an environment was at the assessment itself.298 Cohen-Hatton {Day185/125:4-15}.
¶72.26 The report recommended a revalidation programme consisting of three elements: a test to assess levels of technical and procedural knowledge, another test to assess command skills by means of an incident command exercise, and the demonstration by means of a continuing professional development (CPD) log that incident command skills had been consistently and effectively applied on the incident ground. Dr Cohen-Hatton proposed that the three elements should be assessed every two years, with provision for additional training to be undertaken by those who scored below a minimum threshold, or, in the most serious cases, removal from operational duties.
¶72.27 The proposed revalidation programme was developed separately from the work being carried out on the coroner's recommendations, but its implementation depended on the delivery of the new incident command training exercise being developed as part of Babcock's wider review. Since the LFB lacked the necessary resources to provide and assess a separate exercise just for the revalidation programme, the incident command exercise to be used for the revalidation process had to form part of the new incident command refresher training.299 Cohen-Hatton {Day185/145:11-16}; {Day185/147:1-15}. The delay in the development of the new course therefore delayed the progress of the incident command revalidation programme.
¶72.28 The original timetable for the revalidation programme had been set out in a report to the Corporate Management Board dated 16 December 2015, which recorded that the knowledge tests and the incident command exercise were to be launched in April 2016 and the use of CPD logs in April 2017.300 {LFB00118193}. However, by the time that Dr Cohen-Hatton reported to the Corporate Management Board on 8 June 2016 those dates had been pushed back to some indeterminate time in 2016 or 2017, in the case of the knowledge tests and incident command exercise, and 2017 or 2018 in the case of the CPD logs.301 {LFB00118189}. At a meeting of the Incident Command Project Board on 23 February 2017, Dr Cohen-Hatton expressed her concern that the implementation of a revalidation programme was being pushed back as a result of the delay in the broader review of incident command training.302 Cohen-Hatton {LFB00110660/24} page 24, paragraph 87; {LFB00118192/2}. A briefing note prepared for the Corporate Management Board in March 2017 stated that pilots of some of the knowledge tests would be carried out in May 2017 and indicated that a draft policy was in the final stages of development.303 {LFB00118187}; Cohen-Hatton {Day185/163:1-17}. By that stage Dr Cohen-Hatton's team had done most of what they could do pending the delivery of the incident command training being developed in response to the broader review.304 Cohen-Hatton {Day185/164:4-8}.
46¶72.29 The revalidation programme had still not been implemented at the time of the Grenfell Tower fire, nor by the time of the inspection of the LFB by Her Majesty's Inspectorate of Constabulary and Fire and Rescue Service (HMICFRS) in May and June 2019, which identified the lack of any revalidation system as a cause for concern requiring immediate action by the LFB.305 {INQ00014796/39}.
47Chapter 73: Modern materials and methods of construction
¶73.1 In the Phase 1 report, the chairman found that the absence of any training for incident commanders in how to recognise the need for evacuation reflected a failure to recognise the risk of fire taking hold on the outside of modern buildings.306 Phase 1 Report Volume IV paragraph 27.9. He expressed the view that it was a surprising failure, given the long history of fires involving cladding on high-rise buildings both in this country and abroad, a history of which some people within the LFB had been aware for some time.307 Phase 1 Report Volume IV paragraph 27.10.
Knowsley Heights and Garnock Court
¶73.2 Before the Lakanal House fire in July 2009, there had already been two significant fires in the UK which had involved the extensive spread of fire through combustible external panels. On 5 April 1991, a fire was started deliberately in a rubbish compound outside Knowsley Heights, an 11-storey residential building in Liverpool. The fire spread rapidly through a 90mm gap between the building's concrete outer wall covered with rubberised paint and rain screen panels which had recently been installed. The fire spread to the highest floor and seriously damaged the outer walls and windows of all the upper floors.308 {LFB00031816/5-6}.
¶73.3 On 11 June 1999, a fire started on the fifth floor of Garnock Court, a 14-storey residential building in Irvine, Scotland. The fire spread rapidly to the higher floors through a vertical strip of external cladding, resulting in one fatality.309 {LFB00031816/6}.
¶73.4 The fire at Garnock Court was the subject of a report by the Environment, Transport and Regional Affairs Committee entitled Potential Risk of Fire Spread in Buildings via External Cladding Systems.310 {CLG00019478}. The report, published in December 1999, drew attention to the risk of the unexpectedly rapid spread of fire through cladding systems, which could lead to disproportionate difficulties in firefighting and a shorter period available for escape from the building, potentially endangering life.311 {CLG00019478/8} paragraph 10. The committee concluded that the evidence before it did not suggest that the majority of external cladding systems in the UK posed a serious threat to life or property in the event of fire, but went on to say that, notwithstanding that conclusion, it did not believe that it should take a serious fire in which many people were killed before all reasonable steps were taken towards minimising the risks. It recommended that all external cladding systems be required to be either entirely non-combustible or proved through full-scale testing not to pose an unacceptable level of risk from the spread of fire.312 {CLG00019478/9-10} paragraphs 18-20.
48¶73.5 Apart from a passing reference to the Garnock Court fire in a presentation on the spread of fire across the facades of tall buildings created in 2016, the LFB failed to create any training materials which communicated to operational staff the key lessons to be learnt from those two fires. Deputy Commissioner Dexter said that she had been aware of the Knowsley Heights and Garnock Court fires during her time at the LFB position;313 Dexter {Day179/94:9-18}. Commissioner Dobson said that he had been aware of the Knowsley Heights fire but not the Garnock Court fire.314 Dobson {Day210/102:19}-{Day210/103:12}. Both agreed that those fires contained lessons for the LFB.315 Dexter {Day179/94:19-23}; Dobson {Day210/103:9-20}. Commissioner Dobson's recollection was that the fires had been considered by the Operations and Fire Safety departments, which had concluded that the lessons from those incidents had already been learnt by the LFB or were not relevant to it.316 Dobson {Day210/103:21}-{Day210/104:16}.
The letter to London Boroughs and social housing landlords
¶73.6 Also on 23 March 2009, AC Stephen Turek, then in charge of Fire Safety Regulation, wrote to London Boroughs and social housing landlords about fire safety in social housing.317 {LFB00001805}. In his letter he said that it had been written in the light of a number of recent fires in social housing blocks,318 {LFB00001805/1}. and drew attention to several aspects of construction that could present dangers. They included the following: a. Replacement windows, particularly uPVC window units, installed in a way that created
gaps that had been covered with non-fire-resisting materials which, in the event of a fire, distorted and allowed fire to enter the wall cavity;
¶b. Panels on the exterior walls of flats replaced with non-fire-resisting uPVC panels as part of replacement window units, which might have contributed to the total failure of windows during a fire, allowing the fire to pass upwards across the exterior wall and enter the windows of flats above;
¶c. A lack of fire-stopping in wall cavities, allowing the unrestricted rapid spread of fire through the building;
¶d. A lack of fire-stopping in service riser ducts allowing fire to spread rapidly through blocks of flats, trapping some residents due to smoke-logging and high temperatures in the escape routes;
¶e. A lack of fire-stopping between routes of escape and individual flats, which led to residents becoming trapped in smoke-filled flats and requiring rescue.
¶73.7 The letter had apparently been based on fire investigation reports relating to premises where such defects had been noticed following inspections by fire safety regulation officers.319 Dobson {Day210/117:9-16}.
49Conclusions
¶73.8 The evidence as a whole, but particularly the letter of 23 March 2009, shows that by that date some senior officers within the LFB had become aware: a. that non-fire-resisting panels which could contribute to the spread of fire had been used on the external walls of some blocks of flats;
¶b. that a failure of compartmentation caused by a lack of fire-stopping could lead to an unrestricted, rapid spread of fire through a building;
¶c. that such defects created a risk of residents' becoming trapped in areas of the building in which they should have been safe; d. that those hazards had already been encountered at some incidents; and
¶e. that the Building Regulations could not be relied upon to prevent buildings being exposed to risks of that kind.
51Chapter 74: The response to the Lakanal House fire
¶74.1 As the chairman explained in Chapter 8 of the Phase 1 report, Lakanal House was a high‑rise residential tower block in Camberwell, South London. On 3 July 2009, a fire broke out in a flat on the ninth floor of the building. Within 30 minutes it had spread down to the fifth floor and up to the twelfth floor as well as to communal areas, including corridors and the building's single staircase. Six people lost their lives and 15 people were taken to hospital suffering from smoke inhalation. The incident involved a widespread failure of compartmentation and extensive spread of fire and smoke.320 Dobson {Day210/73:6-10}. The fire was able to spread across the external wall (both upwards and downwards) as a result of the presence of combustible window panels that did not comply with the Building Regulations.321 Dobson {Day210/75:8-20}. The incident was also characterised by an unusually high number of fire survival guidance calls (five in total),322 The LFB's Lakanal Control Report, produced for the purpose of the Lakanal inquests, identified five calls to the control room during which fire survival guidance advice was given {HOM00001124/35-37}. Two of those calls were from the same flat and three of the calls were in progress at the same time. poor communication between the control room and the incident ground, difficulties with radio communications generally and confusion among firefighters about the layout of the building and the locations of flats.323 Dobson {Day210/75:21}-{Day210/76:13}.
¶74.2 The Lakanal House fire in July 2009 was a watershed moment for the LFB and was undoubtedly the most significant residential fire in which it had been involved in the years immediately preceding the Grenfell Tower fire. It is of particular importance because it marked a milestone in the history of the LFB's response to fires in high-rise residential buildings and the handling of emergency calls. It prefigured in many respects the Grenfell Tower fire some eight years later and it is therefore appropriate to consider how the LFB responded to the experience and the extent to which it learned from it.
The Lakanal House Board
¶74.3 In October 2009, Commissioner Dobson set up the Lakanal House Board to oversee the LFB's internal investigation into the fire and its response to it. It was chaired by the Commissioner and attended by a wide range of senior officers. The board was responsible for identifying the lessons to be drawn from the incident and for making any recommendations for organisational change that were thought necessary.324 {LFB00039696} Lakanal House Board Terms of Reference; Dobson {Day210/79:3}-{Day210/80:15}. It met monthly and provided a forum for senior officers to discuss matters arising from the LFB's investigation into the fire, to agree a response and to allocate responsibility for action to relevant departments and officers.325 Dobson {Day210/86:21}-{Day210/87:3}.
¶74.4 The Lakanal House Board identified 34 steps that could be taken to improve the LFB's operational response. They were set out in an action plan agreed at a meeting of the Board on 15 September 2010. Each step was assigned to an officer who was responsible for its implementation.326 {LFB00084031/7-10}. At subsequent meetings those officers provided regular reports on progress which were reflected in a rolling plan of action.327 {LFB00084032/5-8}. The 34 steps became known internally as the "pre-inquest actions", or simply "pre-actions". They covered a wide range of subjects, from the development of a policy relating to the risk of falling cables to writing to the government to obtain clarity on aspects of national guidance. They included a review of the LFB's existing policies on firefighting in high-rise buildings and the management of emergency calls. Although some are of no relevance to our investigations, others are of central importance, such as the review of the LFB's policy on firefighting in high-rise buildings and the provision of training to control room officers in handling fire survival guidance calls. However, the pre-inquest actions failed to include any response to what should have been the principal concerns arising from the Lakanal House fire, namely, the widespread failure of compartmentation and the spread of fire across external walls due to the use of combustible construction materials.
52The Lindridge Review
¶74.5 In September 2012, more than three years after the fire and in preparation for the Lakanal House inquests, Commissioner Dobson asked the Operational Assurance department, then headed by AC Cotton, to review the pre-actions to identify those which had been completed and those which had not.328 Dobson {LFB00032157/10} page 10, paragraph 38; Reason {LFB00032747/18} page 18, paragraph 53; Dobson {Day211/153:12-24}. Director Reason (to whom AC Cotton reported) delegated the task of carrying out the review to GM David Lindridge,329 Lindridge {LFB00083925/4} page 4, paragraph 17. subject to the oversight of AC Cotton.330 Cotton {LFB00032737/6} page 6, paragraph 21.
¶74.6 GM Lindridge understood that his review was to involve no more than identifying which pre-actions had been carried out and which had not. He did not express a view on whether the actions taken were sufficient to meet the expectations of the board; he simply described the steps that had been taken so that others could make that assessment for themselves.331 Lindridge {LFB00083925/3} page 3, paragraph 12.
¶74.7 In January 2013, GM Lindridge produced a report of his findings entitled Review of the Lakanal Action Plan (the Lindridge Review).332 {LFB00033943}. He found that 16 of the 34 tasks were still being worked on in one way or another and was unable to confirm that another 13 had achieved their expected outcomes.333 {LFB00033943/4-5} pages 4-5, paragraphs 5.2 and 5.3. GM Lindridge attached to his report a list of the pre‑actions together with his findings on each of them. He also set out a list of his key findings in relation to ten of the pre-actions for the attention of the Commissioner's Group. Most of them related to the control room.
¶74.8 GM Lindridge produced a revised version of his report in November 2013, in which he found that 8 actions had still not been completed (although in all but one of those cases the LFB was awaiting action by another organisation).334 {LFB00083988}. They included actions concerning the training of control room supervisors, pre-planning and correspondence with the government relating to aspects of fire safety.335 {LFB00083988/6-23}.
53¶74.9 After receiving the Lindridge Review, neither AC Cotton nor anyone else appears to have considered whether the implementation of the Lakanal pre-inquest actions had been effective. Commissioner Cotton said that she had not been sufficiently qualified in a number of the areas being audited to express an opinion. In her view, it was the function of the Lakanal House Board to satisfy itself that the work had been done. She did not see it as part of her role as Head of Operational Assurance to be concerned with the detail of the actions referred to in the Lindridge Review.336 Cotton {Day208/110:10}-{Day208/111:6}.
¶74.10 In the event, the Lindridge Review was never presented to the Lakanal House Board, which held its last meeting in September 2013 (though it was never formally disbanded). Commissioner Dobson said that his intention had been to have a final meeting formally to review and accept the revised Lindridge Review, but that it had been overlooked.337 Dobson {Day211/171:3}-{Day211/172:7}. Nor was the Lindridge Review ever presented to the Lakanal House Working Group, referred to below, because the working group was directing its attention to the steps required in response to the findings made by the coroner.338 Reason {Day180/130:19-25}; Dobson {Day211/172:8-25}.
¶74.11 Although Commissioner Dobson said that responsibility for overseeing the progress of outstanding pre-inquest actions had been taken over by the co-ordination board,339 Dobson {Day210/88:15}-{Day210/89:5}; {Day211/171:24}-{Day211/172:4}. we have seen no evidence of any such oversight in the minutes of its meetings. The Lindridge Review was, however, circulated to the Commissioner's Group and discussed at a meeting in November 2013.340 Reason {Day180/130:15-18}. Director Reason's recollection was that he and Deputy Commissioner Dexter had each accepted responsibility for the outstanding actions that fell within their respective directorates.341 Reason {LFB00032747/19} page 19, paragraph 58; Reason {Day180/132:4}-{Day180/133:6}.
¶74.12 After the Lakanal House Board effectively ceased to exist in September 2013, the LFB was left with no means of ascertaining whether the outstanding pre-inquest actions had been completed. Nor did it carry out any systematic inquiry to find out whether the work that had been done had been successful in making good the deficiencies the fire had uncovered. As a result, by 14 June 2017 significant steps that were relevant to dealing with the hazards that were later to confront the LFB at Grenfell Tower had not been taken. The LFB's failure effectively to oversee the progress and completion of the changes in training and procedure it had identified as necessary in the light of the Lakanal House fire was a significant failing which prevented it from responding more effectively to the fire at Grenfell Tower.
¶74.13 Commissioner Cotton told us that monitoring the work on the Lakanal pre-inquest actions had not been the responsibility of the Operational Assurance department.342 Cotton {Day208/114:5-19}. Although that may be true, it is unfortunate that the department responsible for ensuring the operational effectiveness of the LFB (and with learning from significant incidents) did not have, and did not seek, that responsibility, especially as no other department of the LFB did. Operational Assurance was the department to which the Commissioner had assigned responsibility for the review of the 34 pre-inquest actions in the first place and Commissioner Dobson should have ensured that there was no doubt about where responsibility for overseeing the implementation of the Lakanal pre-inquest actions lay. Ms Cotton had also been a member of the Lakanal House Board and she continued to sit on the co-ordination board, two key boards attended by the heads of service responsible for implementing the various changes. The Operational Assurance department was best placed to oversee the necessary changes, with the assistance of relevant experts where required, and to monitor the progress of any that remained outstanding. The Commissioner's failure to assign responsibility clearly to the Operational Assurance department was a significant error.
54¶74.14 There is no evidence that the LFB subsequently reviewed the 34 pre-inquest actions in the light of the Lakanal House coroner's recommendations to see whether further changes might be required.343 Cotton {Day208/139:1-22}.
The Lakanal House inquests and the coroner's rule 43 letter
¶74.15 The Lakanal House inquests were conducted by Her Honour Frances Kirkham CBE between January and March 2013. The coroner heard evidence from a number of LFB witnesses, including Commissioner Dobson.
¶74.16 Rule 43 of the Coroners Rules then in force allowed the coroner to make such recommendations as she considered necessary, based on the evidence heard during the inquest, to eliminate or reduce the risk of further deaths. On 28 March 2013, she sent Commissioner Dobson a letter pursuant to that rule (a rule 43 letter).344 {LFB00032158}. She also wrote to the Department for Communities and Local Government, the London Borough of Southwark and the Fire Sector Federation.
¶74.17 In her letter to the Commissioner the coroner acknowledged the work that the LFB had already carried out and recommended further action in five areas: public awareness of fire safety, visits made pursuant to section 7(2)(d) of the Fire and Rescue Services Act 2004, incident command, the control room, and communications. The substance of those recommendations will be considered in later chapters.
¶74.18 Following receipt of that letter, Commissioner Dobson instructed Director Reason to put together an action plan in response to the coroner's recommendations.345 Reason {LFB00032747/5} page 5, paragraph 19. In April 2013, Director Reason held a meeting with the heads of service responsible for the activities in question and asked each of them to produce a draft plan of action on the recommendations affecting their areas of responsibility.346 Reason {Day180/139:2}-{Day180/140:21}. Draft plans, referred to internally as "pro formas", were produced by four heads of service, AC David Brown (Head of Operations, Procedures and Response), AC Stephen Turek (Head of Fire Safety Regulation), AC Dany Cotton (Head of Operational Assurance), and AC James Knighton (Head of Operational Procedures). They contained an analysis of the recommendations and proposed responses.347 {LFB00073406}; {LFB00034062}. The pro formas were submitted to the Commissioner's Group, which used them to draft the LFB's response to the coroner's letter.348 Reason {Day180/141:5}-{Day180/142:16}. That response was discussed and approved at a meeting of the Commissioner's Group and the heads of service on 14 May 2013. The meeting was not minuted, but Director Reason's recollection was that it had been concerned principally with the Commissioner's review of the proposals and the time required to implement them.349 Reason {Day180/142:9}-{Day180/143:7}.
55¶74.19 On 23 May 2013, Commissioner Dobson sent the LFB's response to the coroner.350 {LFB00042089}. The letter set out the action which the LFB proposed to take in response to each recommendation and the time within which it would be completed. The Commissioner estimated that all the proposed actions would be completed by the end of 2013.
¶74.20 Responsibility for overseeing the progress of the steps that the LFB proposed to take was allocated to the co-ordination board and the Lakanal House Working Group.351 Reason {LFB00032747/6} page 6, paragraph 22. (One of the co-ordination board's existing functions was to monitor the progress of proposals for responding to rule 43 recommendations.)352 Reason{Day180/145:6}-{Day180/146:8}. At a meeting of the board on 3 June 2013 it was agreed that AC Cotton would develop a plan to monitor the progress of the response to the coroner's recommendations.353 Cotton {LFB00032737/7} page 7, paragraph 25. A consolidated plan combining the response to the coroner with the LFB's reaction to some rule 43 recommendations made by the Hampshire coroner following a fire at Shirley Towers in Southampton in which two firefighters had died was therefore produced for a meeting of the co-ordination board on 4 July 2013.354 {LFB00089127}.
¶74.21 Commissioner Dobson told us that he took personal responsibility for overseeing the response to the coroner's letter, which, in addition to his role on the working group, he exercised in the course of meetings with individual directors and through the Commissioner's Group.355 Dobson {LFB00032157/7} page 7; Dobson {Day210/100:14}-{Day210/101:3}.
¶74.22 Overall, the response of the LFB to the Lakanal House fire was slow and ineffective. Although it soon established a process for identifying the lessons to be learnt and the steps needed to implement them, it took the best part of a year for it to identify those steps, several of which had not been implemented by the time that the first Lindridge Review was delivered two years later. Some had still not been implemented by the time that GM Lindridge produced his revised review in November 2013. The Lakanal House Board appears to have been allowed to lapse without any proper consideration of the extent to which the recommendations had been implemented, much less whether they had been successful. In our view, senior officers failed to provide the energetic and effective response that was required to an incident of such significance, for which Commissioner Dobson must bear primary responsibility.
The Lakanal House Working Group
¶74.23 The Lakanal House Working Group was established by LFEPA in June 2013 to review and oversee the LFB's actions following the fire at Lakanal House and to provide regular information and any additional recommendations to LFEPA's Strategy Committee.356 {LFB00032156/3}. It consisted of three elected members of the authority, Valerie Shawcross, Maurice Heaster and Peter Truesdale.357 Dobson {LFB00032157/7} page 7, paragraph 23; {LFB00032156/3}. The working group was intended to provide political oversight, scrutiny and accountability for the LFB's response to the coroner's recommendations.358 Reason {Day180/148:18-23}; Dobson {Day210/96:7-18}. Although membership of the working group was formally limited to the three elected members, its meetings were also attended by Commissioner Dobson, Deputy Commissioner Dexter, Director Reason and other senior LFB officers as required in order to provide information on progress and answer members' questions.
56¶74.24 The outstanding pre-inquest actions were never brought to the attention of the working group, nor did it receive a copy of the Lindridge Review. When Director Reason was asked whether the working group might have benefited from seeing the review or from being told about the items that remained outstanding, he said that the elected members would probably not have wanted that level of information.359 Reason {Day180/131:6}-{Day180/132:3}; {Day180/133:7-22}.
¶74.25 Director Reason was responsible for presenting a report on the progress of the response to the coroner's rule 43 letter at each meeting of the working group and reporting the current position in each case.360 Reason {LFB00032747/7-8} pages 7-8, paragraphs 27 and 30. He said that his reports had been based on those that had been provided to the co-ordination board, presented in a slightly different way.361 Reason {Day180/151:4-8}. In reality, the difference was more than slight. The reports submitted to the working group did not provide its members with an accurate summary of the LFB's incomplete progress in responding to the rule 43 letter. Most notably, as we have set out in detail in Chapter 72, some reports provided to the working group were misleading because they indicated that important changes to incident command training had been completed, when that was far from the case.
¶74.26 The Lakanal House Working Group met six times between July 2013 and March 2014. LFEPA's Strategy Committee was told about the LFB's actions on only two occasions, once in November 2013,362 {LFB00089117}. when work was still continuing, and once in July 2014.363 {LFB00029746}. That was clearly at odds with the working group's objective of providing information to the Strategy Committee regularly.364 {LFB00032156/3}.
¶74.27 At its meeting in July 2014, the Strategy Committee received a report from Deputy Commissioner Dexter and Director Reason. The report summarised the LFB's work in response to the coroner's recommendations, recorded that the members of the working group were satisfied that they had fulfilled its original purpose and recommended that it be wound up.365 {LFB00067819/1}, {LFB00067819/5}. That recommendation was accepted and the working group was formally closed. However, the report failed to disclose that a number of important items remained outstanding and the closure of the working group gave the misleading impression that all the proposed changes had been made.
¶74.28 Director Reason said that he had not intended to mislead the Strategy Committee and that it had not been the purpose of the report to rehearse all the information that had been put before the working group, merely to give a flavour of the subjects that had been covered.366 Reason {Day181/143:6}-{Day181/144:11}. He also told us that the members of the working group had been less interested in the details of operational procedures, policy and training than in wanting to understand broadly what the LFB had been doing.367 Reason {Day181/144:12-18}. We found his explanation unconvincing. The report presented to the Strategy Committee was not merely short on detail; it was, for the reasons summarised above and set out in greater detail in Chapter 72, misleading. With the closure of the working group, the report also ended active scrutiny by LFEPA of the outstanding responses to the rule 43 letter.368 Reason {Day181/147:15-25}. Director Reason said that it had not been the LFB but the members of the working group who had decided that it should be closed down, because, based on the information they had been given, they were satisfied that they had completed what they had set out to achieve.369 Reason {Day181/144:3}-{Day181/146:13}. However, for the reasons we have given, that information was incomplete and therefore misleading. Although we accept that was not Director Reason's intention, it was the practical effect of providing incomplete reports.
57¶74.29 In fact, certain steps identified by the LFB as necessary in response to the coroner's rule 43 letter remained outstanding at the time of the Grenfell Tower fire. In July 2014, the Lakanal House Working Group could and should have been given an accurate summary of the extent to which the LFB had implemented the various changes required in response to the Lakanal House fire. If it had been given that information, it would have been obvious to the working group that the LFB had not responded fully to the coroner's recommendations. By failing to provide it the LFB denied members of the working group the opportunity to challenge the Commissioner about the LFB's dilatory and incomplete progress and, more broadly, prevented them exercising their public duty of holding the LFB to account. We are satisfied that the closure of the working group and the consequent lack of active scrutiny by LFEPA contributed to the LFB's failure to implement the coroner's recommendations fully. That lack of scrutiny was compounded by the LFB's failure to complete its own pre-inquest actions. Not only did the LFB fail to learn from the Lakanal House fire, the premature end of the Lakanal House Working Group ensured that its failure properly to oversee the progress and completion of the steps that it had itself identified as necessary went unremedied.
The lessons – Spread of fire over external walls
¶74.30 The Lakanal House fire demonstrated, if not for the first time then beyond any lingering doubt, that combustible facade panels could enable fire to spread through the external wall of a high-rise building and that a failure of effective compartmentation, whether resulting from combustible facade panels or otherwise, could lead to the rapid total failure of a building. Understanding those risks, which were later to be exemplified in the Grenfell Tower fire, was essential, given the increasing prevalence of modern materials and methods of construction. We have therefore considered it appropriate to examine the extent to which the LFB understood the significance of the Lakanal House fire and how it affected its understanding of the hazards posed by combustible facade panels.
¶74.31 By December 2009, the LFB was aware that other buildings in London might be constructed of materials that would allow fire to spread rapidly across the external walls and result in a consequent widespread failure of compartmentation. Indeed, the exchange between Commissioner Dobson and Sir Ken Knight during December 2009 was prompted by the LFB's belief that the regulatory regime was inadequate or was being widely ignored.370 {LFB00123737/11} page 11, paragraph 26.
¶74.32 When Commissioner Dobson was asked why the LFB had not taken steps at the time to advise its operational crews how to respond to the spread of fire across the external wall of a building, he said that he did not think that the way in which the fire had spread at Lakanal House had been unusual and that firefighters would not have been surprised to see the fire spread in the way it did, although they might have been surprised by the speed at which it had happened. He did not think there had been anything particularly unusual about the Lakanal House fire that crews needed to be notified of.371 Dobson {Day210/131:18}-{Day210/132:9}; {Day210/132:16}-{Day210/133:5}.
58¶74.33 We do not agree with the Commissioner's assessment. Other witnesses told us that the spread of fire downwards at Lakanal House had been unusual. For example, Dr David Crowder described it as very unusual and not something that had been encountered commonly, if at all, previously.372 Crowder {Day230/4:15-21}. Sir Ken Knight said that it had been almost unique.373 Sir Ken Knight {Day245/187:11-13}. Furthermore, it is clear that the crews at Lakanal House were surprised by both the speed and the direction in which the fire had spread.374 This was clear from firefighters' evidence at the inquests following the Lakanal House fire: https://www.lambeth. gov.uk/about-council/transparency-open-data/lakanal-house-coroner-inquest. Given that the LFB knew about the use of combustible panels in external walls and the risks associated with them, crews should have been expressly warned about the danger of fire spreading across them and the consequent risk of compartmentation failure.
The lessons - Failure of compartmentation
¶74.34 National operational guidance on firefighting in high-rise buildings is to be found in Generic Risk Assessment (GRA) 3.2 issued by the DCLG. The version of GRA 3.2 in force at the time of the Lakanal House fire, published in September 2008, had identified the failure of compartmentation and the potential need for multiple rescues as an event for which contingency plans ought to be developed.375 {HOM00002128/12}. At the Lakanal House inquests, however, Commissioner Dobson told the coroner that under normal circumstances operational firefighters would expect a fire in a high-rise residential building to remain within the compartment of origin and not to enter communal areas before crews could reach the compartment and attack the fire.376 Johnson, Expert Communications Report {CWJ00000010/83} page 83. He said that crews would have been aware that the fire might spread to flats immediately above the fire flat, but would not expect it to spread to flats that were adjacent to the flat of origin.377 Johnson, Expert Communications Report {CWJ00000010/35} page 35. Peter Holland, who was the Chief Fire and Rescue Adviser at the time of the Lakanal House inquests, told the coroner that, although the compartmentation of a building was sometimes not as good as it was designed to be, a failure of compartmentation was an infrequent rather than a regular occurrence.378 {HOM00045826/34-35} page 34-35.
¶74.35 On 9 July 2009, six days after the Lakanal House fire, Commissioner Dobson sent a letter to the housing departments of all London boroughs, housing associations and other social housing providers referring them to AC Turek's letter of 23 March 2009.379 {LFB00001232}. In his letter he reminded recipients about certain fire safety matters, including the need for a suitable and sufficient risk assessment, which the letter said should include consideration of compartmentation, particularly where it protected escape routes. He also reminded them that a risk assessment should be reviewed if any material change was made to the premises, including any changes to the compartmentation arrangements or refurbishment.
¶74.36 In that letter the Commissioner drew attention to the need to have an evacuation strategy appropriate to the circumstances of the individual premises, but he emphasised that it should be safe for residents to remain in their flats if a fire occurred elsewhere in the building, providing that the premises complied with both the Building Regulations and the Fire Safety Order and suitable management and maintenance procedures were in place.
59¶74.37 Commissioner Dobson agreed that when that letter had been written the early indication from the LFB's own investigations had been that a failure of compartmentation had been one of the primary reasons for the spread of fire at Lakanal House and that he had been concerned that other buildings in London might suffer from the same defect.380 Dobson {Day210/119:17}-{Day210/120:1}. However, he said that the reference to strategies for evacuating buildings had not been intended to suggest that a "stay put" strategy might not be appropriate for such buildings; rather, it had been prompted by the LFB's understanding that the escape balconies at Lakanal House had not been used by residents because they had not been aware of their purpose.381 Dobson {Day210/120:11-21}.
¶74.38 The widespread failure of compartmentation at Lakanal House was also identified in the action plan drawn up by the Lakanal House Board. Item 20 required the LFB's Fire Safety department to carry out a review of high-rise fires involving the spread of fire beyond the compartment of origin to identify those incidents which could have provided opportunities for learning before 3 July 2009.382 {LFB00004801/16} page 16, action 20; {LFB00033943/15} page 15, action 20. DC Dexter said that that had been a response to both the spread of fire that had occurred at Lakanal House and to emerging findings reported by the Fire Safety team.383 Dexter {Day179/82:21-25}. Given the contents of AC Turek's letter, it is surprising that a search of the LFB's incident management system had not revealed any record of a high‑rise incident at which fire had spread by mechanisms similar to those identified at Lakanal House.384 {LFB00004801/16} page 16, action 20, {LFB00051803/135}; see also {LFB00033943/15} page 15, action 20. DC Dexter later questioned that finding with the LFB's Information Management department, which was responsible for collating and managing data of that nature.385 {LFB00096647}. In response, Clive Eustice, a member of the department, expressed doubt about the absence of any such records, which he thought reflected a very lazy response. Mr Eustice said that on being given the relevant criteria the department could provide a report setting out the relevant incidents, but no such report was made available to us.
¶74.39 When she was asked why she had raised the matter with the Information Management department, DC Dexter said that, having read a number of fire investigation reports, she could see that there had been breaches of compartmentation or the spread of fire beyond the compartment of origin and thought it unlikely that no incidents of that kind could be identified.386 Dexter {Day179/86:12-23}. There is evidence that she did in fact obtain some data as a result of her inquiries and that she questioned whether Item 20 had been clearly defined.387 {LFB00083970}. Ultimately, however, the LFB concluded that there was no record of a high-rise incident at which fire had spread in ways similar to those at Lakanal House.
¶74.40 The conclusion that there had been no similar incidents before the Lakanal House fire was inconsistent with AC Turek's letter of 23 March 2009. It was also inconsistent with concerns that were being discussed both within the LFB itself and by the LFB with outside bodies soon after the Lakanal House fire. On or around 21 April 2010, there was a meeting at the LFB's headquarters between Commissioner Dobson and representatives of the construction industry, local authority building control, and representatives of the DCLG, including Brian Martin. AC Turek wrote a briefing note for the Commissioner in advance of the meeting which said that its purpose was to discuss the LFB's concerns about the quality of construction and checking of newly built and newly refurbished residential properties.388 {LFB00025654/13-14}. Those concerns resulted from a significant number of fires during the previous two years which had exhibited an unusual spread of smoke or fire. The note stated that the causes had often been identified as breaches of the Building Regulations, either during construction or refurbishment, and that the fires had led to people becoming trapped and requiring rescue, the collapse or other unnecessary damage to buildings and to firefighters' being placed at unnecessary risk. There had been about 50 significant cases in the London area, most of which were said to have involved major construction companies. The note referred to the concern felt within the LFB about whether the regulations covering the construction and approval of building work were being enforced with sufficient vigour to ensure that new residential buildings in London were fit for their purpose, as well as to concern about how many such buildings there might be in the city.
60¶74.41 The briefing note did not provide details of any of those significant cases in London, but other evidence suggests that the fire at Bush House on 2 February 2007 had prompted the meeting. Bush House was a six-storey, newly constructed residential block. A fire had started in the basement parking area and entered a service shaft, through which it spread vertically to all floors of the building, including the building's only escape route, resulting in residents having to be rescued by the fire brigade from the balconies of their flats.389 {LFB00025654/3} page 3. As a result of the concerns raised by that and other similar incidents, those present at the meeting agreed that the National House Building Council (NHBC), in conjunction with the Chief Fire Officers Association, would provide training to raise awareness of the need for effective fire stopping. That training was provided in 2011.390 {LFB00025654/3} page 3, paragraph 18.
¶74.42 Commissioner Dobson was unable to recall any details of the meeting, but he agreed that by April 2010 the LFB had identified the risk across the built environment of failure to comply with the Building Regulations and was aware that it had resulted in a significant number of fires in London.391 Dobson {Day210/135:13-24}. He told us that the way in which the fire had spread at those incidents had been predictable, given the defects in the buildings,392 Dobson {Day210/135:24}-{Day210/136:2}. and he agreed with DC Dexter that the failure of compartmentation was common, although for a wide range of reasons.393 Dobson {Day210/136:4-9}. Nonetheless, the LFB did not seek to communicate the existence of those defects or their concerns about defective buildings to operational crews. Commissioner Dobson said that he had had concerns about the proliferation of guidance and information given to operational crews, because complaints had been made in the past that guidance notes often duplicated or conflicted with one another.394 Mr Dobson was referring to observations made by Mr Justice MacDuff, the judge who presided over the trial of the incident commanders at the Atherstone-on-Stour fire in November 2007 and was critical of the large volume of operational guidance notes and other materials considered during the trial, Dobson {Day210/140:4-25}; see also {LFB00046278/21}. Mr Dobson also told us that in any event, the spread of fire as a result of inadequate compartmentation would generally not be a surprise to operational firefighters.395 Dobson {Day210/141:1-22}.
¶74.43 Although the Commissioner's concern not to over burden operational crews with excessive guidance was understandable, we think it would have been possible to communicate to crews in a simple way that the LFB was coming across a significant number of buildings that did not comply with the Building Regulations and that crews therefore needed to be ready for smoke and fire to spread in unusual ways as a result of a failure of compartmentation. That would have sent a clear message that was consistent with national guidance and, more importantly, would have reflected the dangers that the LFB was encountering on the ground. If there was an unhelpfully large amount of operational guidance in circulation, the LFB should have taken steps to reduce it, but that was not a good enough reason not to draw the attention of operational personnel to concerns about inadequate compartmentation that were very much in the minds of those at senior management level.
61¶74.44 Inadequate compartmentation in residential high-rise buildings continued to be a concern to the LFB throughout its investigations into the Lakanal House fire. On 11 December 2012, Commissioner Dobson wrote to Brandon Lewis MP, then Parliamentary Under-Secretary of State with responsibility for fire and resilience,396 {LFB00032154}, Brandon Lewis {Day257/3:4-7}. setting out seven recommendations that the LFB thought should be considered by the government. The first was that the government should provide further guidance on which parts and areas of buildings containing multiple domestic premises could be described as 'parts used in common' for the purposes of the Fire Safety Order and how that order was intended to operate in relation to premises where the responsible person did not necessarily have control over features affecting the common parts or common fire precautions. Commissioner Dobson said that the recommendation had been identified by the LFB following the failure of compartmentation that had occurred at Lakanal House and, in particular, the fact that the fire had spread from the flat of origin into the adjacent corridor much faster than it would have expected.397 Dobson {Day210/152:23}-{Day210/153:5}. We consider the other recommendations in the letter elsewhere.398 See Part 2, Chapter 9.
¶74.45 In her rule 43 recommendations the coroner at the Lakanal House inquests also identified a failure of compartmentation as a matter that required greater consideration by both the LFB and DCLG. In her letter to the LFB, she recommended that consideration be given to the training of incident commanders and potential incident commanders to enhance their performance in seven specific respects, including the ability to recognise that a fire might behave in a manner inconsistent with the principle of compartmentation.399 {LFB00032158}. The LFB's response to that recommendation is considered below. In her letter to DCLG, the coroner recommended that consideration be given to reviewing GRA 3.2 to provide consolidated national guidance on four particular matters, including awareness that insecure compartmentation can permit the transfer of smoke and fire between a flat or maisonette and common parts of high-rise residential buildings, which has the potential to put the lives of residents and others at risk.400 {CLG00000401/2}. In the event, the LFB effectively took charge of the review of GRA 3.2 following the Lakanal House fire.
¶74.46 It is clear from her rule 43 letter that the coroner considered that operational crews, and incident commanders in particular, needed to be prepared for the risk that compartmentation within a high-rise residential building might fail, even though Commissioner Dobson had told her that in his view it remained appropriate to base plans for firefighting and rescue operations on the assumption that compartmentation would be effective. The coroner did not find that the LFB should have reversed the "stay put" advice to residents or that it should have evacuated the building, but in the DCLG's response to the rule 43 letter sent to the coroner on 20 May 2013 by the Rt. Hon. Eric Pickles MP, Secretary of State for Communities and Local Government, there was explicit recognition of the possibility that "stay put" might no longer be a tenable strategy if there were a failure of compartmentation. Referring to the pending review of GRA 3.2, the letter confirmed that the revised guidance would include advice to incident commanders to inform decisions on evacuation, should it become clear during an incident that the "stay put" principle was no longer tenable.401 {HOM00047743}.
62¶74.47 In contrast, it appears that no-one within the LFB gave any serious thought to the potential limitations of the "stay put" strategy either before or after the Lakanal House fire, notwithstanding the concerns expressed within the organisation about inadequate compartmentation and the rapid spread of smoke and fire that had occurred at Lakanal House. AC Daly, the head of the Fire Safety department at the time of the Grenfell Tower fire, rightly acknowledged that the "stay put" strategy is absolutely dependent on effective compartmentation.402 Daly {Day183/157:3-4}. The LFB's own documents, even those which pre-dated the Lakanal House fire, such as AC Turek's letter of 23 March 2009, referred to breaches of compartmentation that were significant and posed a real threat to residents' safety. Those concerns should have prompted an analysis by the LFB of the circumstances in which a "stay put" strategy would need to be kept under review, and potentially abandoned, during the course of an incident.
¶74.48 It is not clear why the LFB failed to undertake such an analysis following the Lakanal House fire. On the one hand, there was sufficient concern within the organisation about inadequate compartmentation for it to call a meeting with government and industry in April 2010; on the other, senior officers appear to have assumed that operational personnel were accustomed to dealing with failures of compartmentation when they occurred. Consequently, no serious thought was given to sharing with station-based crews the concern of senior officers about the prevalence of inadequate compartmentation in London or the potentially very serious consequences that could follow if compartmentation were to fail.
The response – The Lakanal House Case Study
¶74.49 In the light of the Lakanal House inquests it became clear to the LFB that there was a need to provide additional training to firefighters and more senior officers in responding to events of the kind that had occurred at that fire. A training package was therefore produced known as the Lakanal House Case Study.403 {LFB00004801/29} page 39, action 3c. It was commissioned in June 2013, but staff did not start to receive training until July or August 2014, over a year later and five years after the fire.404 Reason {Day181/14:18-19}. The case study consisted of a computer-based training package for station-based staff and a half-day presentation for those of station manager rank and above.405 {BAB00000073}; {LFB00030044}.
¶74.50 In 2018 the LFB produced a report for the Inquiry containing a review of the action it had taken in response to the Lakanal House fire.406 {LFB00004801}. Both that report and several LFB witnesses407 {LFB00004801/13} page 13, action 6; {LFB00004801/15} page 15, action 14; {LFB00004801/17-18} pages 17- 18, actions 21-23; Reason {Day180/177:9}-{Day180/178:6}, {Day180/208:10}-{Day180/209:8}, {Day181/37:16}- {Day181/38:17}, {Day181/88:18}-{Day181/89:13}; Daly {Day184/11:11-17}, {Day184/126:5-19}; David Brown {Day187/73:23}-{Day187/75:16}; Cowup {Day195/116:11-20}; Cotton {Day208/194:13-17}; Dobson {Day211/6:6-11}, {Day211/11:24}-{Day211/12:4}. suggested that a wide range of measures that had been taken in response to the fire had been covered in the case study, but that was not correct, because it dealt with only a relatively narrow range of operational topics, in particular:
63¶a. the confusion caused by the unusual layout of the flats at Lakanal House and the need for effective pre-planning;
¶b. the unusual downward spread of fire caused by falling burning debris and the resulting need to move the bridgehead to a lower floor;
¶c. the difficulties arising from the large amount of information that had been received from residents, as well as information relating to fire survival guidance calls, and the need for clear two-way communication between the control room and the incident ground; and d. the consequent difficulties in carrying out search and rescue operations.
¶74.51 The case study did not provide any or adequate training in the following important operational matters in respect of which the Lakanal House fire had exposed weaknesses: a. recognising when a fire might behave in a manner inconsistent with the principle of compartmentation;
¶b. understanding the dangers arising from a widespread loss of compartmentation or the spread of fire across an external wall (apart from drawing attention to the possible need to move the bridgehead due to downward fire spread, as had occurred at Lakanal House);
¶c. understanding the dangers arising from the use of combustible panels in external walls, whether cladding panels or, as was the case at Lakanal House, window infill panels; and d. the correct handling of fire survival guidance calls by control room staff.
¶74.52 Director Reason said that the risk of a failure of compartmentation had been implicit in the training,408 Reason {Day180/208:17}-{Day180/209:8}. that the whole package had been concerned with recognising when compartmentation had failed,409 Reason {Day180/209:3-4}. and that the graphics and all the material used in the package had been self-evident410 Reason {Day180/210:11-16}. or otherwise should have been obvious to firefighters.411 Reason {Day180/196:4}-{Day180/197:8}; {Day180/205:16)-{Day180/206:24}; {Day180/208:10)-{Day180/211:10}; {Day181/3:5}-{Day181/8:16}; Cotton {Day208/192:3}-{Day208/193:8}; {Day208/194:13}-{Day208/195:23}. However, the contents of the package do not, in our view, bear that out. They did not make it clear that compartmentation could not always be relied on and did not provide guidance on how to identify or deal with a failure of compartmentation. Those omissions, together with the emphasis on the Lakanal House fire being highly unusual, tended to perpetuate the assumption that compartmentation in high-rise buildings could be relied on.
¶74.53 The omission of any reference in the package to the dangers arising from the use of combustible panels in external walls is particularly surprising in view of the fact that Commissioner Dobson had written to the government in December 2009 expressing the LFB's concern about compliance with the Building Regulations in general and the particular risks posed by certain kinds of external cladding. By that time the LFB had discovered that other buildings in London might be constructed from materials that could result in the rapid or unusual spread of fire across or through external walls.
¶74.54 The present Commissioner, Andrew Roe, suggested that the case study was more sophisticated than might appear from the slides that had been put to certain LFB witnesses. He pointed out that the computer-based package had been accompanied by a training guide and that use had been made of the radio messages sent during the incident as well as interviews with principal officers who had attended the fire.412 {LFB00123737/47} page 47, paragraph 131. Although they may have made the training more engaging and provided an insight into the attending officers' experience, they did not make up for the omissions identified above.
64¶74.55 Commissioner Roe rightly accepted that the case study should have dealt with the failure of compartmentation on a widespread scale and the danger of external fire spread, both of which had played a critical part in the Lakanal House fire. He accepted that knowledge held by one part of the organisation should have been shared widely and included as part of the package.413 Roe {Day212/155:2-12}.
¶74.56 Director Reason said that the training package had been seen by the Commissioner, Deputy Commissioner and the Directors and that, to his recollection, no concerns had been raised about its general content or whether it covered the coroner's recommendations effectively.414 Reason {Day181/9:3-22}. The training package was not subsequently reviewed to ensure that it dealt with them adequately,415 Reason {Day181/11:3-9}. other than by identifying any deficiencies in operational responses identified through routine IMP database reports submitted to the co-ordination board.416 Reason {LFB00067846/28} page 28, paragraph 61; Reason {Day181/20:2}-{Day181/22:1}.
¶74.57 Although a number of senior LFB witnesses regarded the case study as a key element of its response to the Lakanal House fire,417 Reason {Day181/88:18}-{Day181/89:13}, {Day180/177:9}-{Day180/178:6}, {Day181/37:16}-{Day181/38:17}; David Brown {Day187/73:23}-{Day187/75:16}; Cowup {Day195/116:11-20}; Dobson {Day211/6:6-11}, {Day211/11:24}- {Day211/12:4}. it fell far short of what was required. The delay of five years between the fire and the release of the training package emphasises the LFB's failure to identify quickly the important lessons to be learnt from the incident and provide the necessary training as quickly as possible. That failure was compounded by the fact that the training package failed to address the most important aspects of the Lakanal House fire. It was primarily a narrative account of the incident, which limited its value as training for crews. Director Reason said that the package had not been intended for use in isolation, but together with other training packages, although he accepted that it was necessary for officers themselves to find the relevant packages or policies to study.418 Reason {Day181/3:23}-{Day181/5 -18}. Given the nature and potential scale of the dangers revealed by the Lakanal House fire, it was not appropriate to rely on individual officers to take the initiative to that extent. The situation was further worsened by the failure of other LFB training programmes to cover all the coroner's recommendations.
¶74.58 The LFB's knowledge about the risks posed by combustible panels should have been communicated to operational crews through appropriate additions to the training programme in late 2013 after it had become clear from correspondence with DCLG about the meaning of functional requirement B4(1) that the government would not take any steps (at least in the short term) to address the problem. Regrettably, however, that did not happen. There were no relevant changes in training and the information was not adequately communicated to operational crews. When asked about the failure to inform crews about these risks, Commissioner Dobson said they were matters that concerned the Fire Safety and Enforcement arms of the LFB, rather than the operational crews.419 Dobson {Day211/4:16}-{Day211/6:19}; {Day211/26:19}-{Day211/27:14}. That view was both wrong and short-sighted. Although compliance with the Building Regulations was no doubt a primary concern of the Fire Safety and Enforcement departments, the consequences of an extensive failure of compartmentation resulting from the use of combustible materials which allowed fire to spread rapidly across the external wall of a building would directly affect operational crews. They had particular implications for incident commanders implementing a "stay put" strategy that was still regarded within the LFB as underpinning the approach to fighting fires in high-rise buildings at the time of the Grenfell Tower fire.
65Conclusions
¶74.59 The Lakanal House fire should have alerted the LFB to the possibility that ineffective compartmentation throughout a high-rise residential block might result in a rapid total failure of the building. LFB witnesses maintained in their evidence to us that the risk of a failure of compartmentation was an important lesson taken from the Lakanal House fire and referred to training initiatives subsequently introduced, including the case study, as having enhanced operational crews' understanding of that risk and how to respond to it.420 Cowup {Day195/49:1-8}, {Day195/163:5-7}, Dobson {Day211/11:16}-{Day211/12:8}, {Day211/44:15-23}, {Day211/6:6- 11}, Cotton {Day208/178:5-19}. However, that was far from the case. In fact, the important subject of how to identify and respond to a failure of compartmentation remained strikingly absent from LFB training and policy following the Lakanal House fire. It was not mentioned in the revised edition of GRA 3.2 published in 2014, which the LFB was largely responsible for drafting, or in the incident command training that the LFB introduced in response to the coroner's recommendation.
¶74.60 The LFB's response to the Lakanal House fire placed undue reliance on process. Plans were made, boards were established and reviews were commissioned, but the process failed to ensure that the organisation fully understood and acted on the different aspects of its experience at the Lakanal House fire, in particular the danger of relying on compartmentation, the risk of fire spreading across external walls and the importance of being able to handle many fire survival guidance calls simultaneously. The LFB's failure to understand the importance of those matters is illustrated by their omission from the training package. The truth is that the LFB failed to consider in a systematic and rigorous way whether the outcome of the process provided an effective response to the questions raised by the fire.
67Chapter 75: Existing sources of information
¶75.1 By the summer of 2016, the Lakanal House fire was not the only source of information available to the LFB about the risk of rapid external fire spread and the consequent loss of compartmentation associated with the use of modern building materials and the problems to which that can give rise. In this chapter, we consider other sources of information about the dangers posed by the use of combustible materials in external walls and the experience of the LFB at other fires in high-rise buildings in London.
¶75.2 First, we consider a fire that occurred in a building called Madingley in Kingston-on‑Thames in July 2010 and certain correspondence between the LFB and DCLG about the effect of functional requirement B4 that took place between February 2011 and October 2013. We then consider in this context fires in high-rise buildings abroad, to which we referred in Chapter 11. Finally, we consider two fires that broke out in high-rise residential buildings in London, Adair Tower in October 2015 and Shepherd's Court in August 2016. Both incidents illustrated the LFB's practical approach, following the Lakanal House fire, to the risks posed by combustible cladding (in particular, the prospect of a complete failure of compartmentation), the need to evacuate parts of a high-rise building and how best to carry out an evacuation.
The Madingley fire
¶75.3 Not long after Commissioner Dobson's exchange of correspondence with DCLG at the end of 2009, another incident occurred in London involving the spread of fire through combustible materials in a building's façade. The fire at Madingley, a 17-storey residential building in Kingston-upon-Thames, occurred on 12 July 2010. It started in a flat on floor 12, spread rapidly through a plastic rainwater pipe system to flats on floors 13, 14 and 15 and thence to the roof of the building. Smoke entered the building's escape stairs on floor 15. Twenty fire appliances attended the incident. About 80 people evacuated the building; no‑one was injured.421 {LFB00028515}.
¶75.4 Tests carried out by both Bureau Veritas and the LFB established that the rainwater pipe system was the principal means by which the fire had spread, but other materials forming part of the balconies and the edge of the roof were also examined. It was found that glass‑reinforced plastic fascia panels and polystyrene insulation on the balconies were easily ignited and, once ignited, continued to burn and spread flames rapidly, producing large amounts of black smoke. A castellated roof fascia panel was found to behave in the same way. Bureau Veritas concluded that those elements could contribute significantly to the overall intensity of a fire and its combustion products.422 Bureau Veritas report {LFB00028515/91-94}; LFB report {LFB00028515/95-102}.
¶75.5 Messages passing between some of those in the LFB who were investigating the Madingley fire show that they considered the possibility that the other three blocks on the estate could contain similar materials and discussed whether it would be appropriate to implement an "early evacuation" strategy rather than "defend in place" if there were another fire.423 {LFB00028515/64}. The evidence we have seen, however, suggests that the change was not made and that crews were not given any warning about those risks.424 {LFB00028515/117-122}.
68Correspondence about the meaning of functional requirement B4(1)
¶75.6 Between February 2011 and October 2013, the LFB entered into correspondence with DCLG in an attempt to obtain clarification of the effect of functional requirement B4(1) (the requirement that the external walls of a building shall adequately resist the spread of fire over the walls and from one building to another, having regard to the height, use and position of the building). Following the receipt of advice from a retired building surveyor, the Commissioner had become concerned that the language used did not make it clear that the ability adequately to resist the spread of fire over external walls was a requirement in its own right. Indeed, the person from whom the Commissioner had taken advice thought it was not. As the LFB recognised at the time, that was an incorrect interpretation, but it suggested that there might be widespread misunderstanding about the effect of functional requirement B4(1) that was shared even by some building control officers. That was potentially a matter of national importance.
¶75.7 The attempt to obtain a definitive interpretation of the regulations failed because DCLG was unwilling to provide formal clarification of the effect of functional requirement B4(1), but the correspondence clearly shows that senior officers in the LFB were aware that there was considerable uncertainty in the construction industry about its meaning and that there was a potentially widespread failure to comply with the requirements of the Building Regulations in relation to the external walls of high-rise buildings. They expected the problems to increase in the absence of effective regulatory intervention.425 Dobson {Day211/26:11-18}. The LFB did all it reasonably could to persuade the government that action was required, but its concerns were not properly addressed. Nonetheless, the episode had served to draw the attention of the LFB to the uncertainty in the construction industry surrounding the meaning of functional requirement B4(1), and provided it with an opportunity to consider what, if any, changes were required to existing training, operational policies and procedures.
¶75.8 The LFB's knowledge of the risks posed by combustible panels should have been communicated to operational crews through appropriate additions to the training programme in late 2013 after it had become clear that the government would not take any steps (at least in the short term) to address the problems identified in the correspondence. Regrettably, however, that did not happen. There were no relevant changes in training and the information was not adequately communicated to operational crews. When asked about the failure to inform crews about those risks, Commissioner Dobson said that they were matters that concerned the Fire Safety and Enforcement arms of the LFB, rather than the operational crews.426 Dobson {Day211/26:19}-{Day211/27:14}. That view was both wrong and short-sighted. Although compliance with the Building Regulations was no doubt a primary concern of the Fire Safety and Enforcement departments, the consequences of an extensive failure of compartmentation resulting from the use of combustible materials which allowed fire to spread rapidly across the external wall of a building would directly affect operational crews. They had particular implications for incident commanders following a "stay put" strategy, which was still regarded within the LFB as underpinning the approach to fighting fires in high-rise residential buildings.
69International fires
¶75.9 In Chapter 11 we have referred to the information available about fires in high‑rise buildings in other countries, all of which involved to a greater or lesser degree the spread of fire across external walls. Before the Grenfell Tower fire occurred, the LFB had no system for recording fires of that kind, for investigating why or how they had occurred, or for considering whether they contained any lessons for fire prevention or high-rise firefighting in London. The main reason for that omission appears to have been a widely‑held assumption that fires of that kind could not occur in this country because the Building Regulations did not allow buildings to be constructed in a way that would allow the spread of fire over the external walls. There was also a prevalent view that the UK's regulatory regime was superior to, and more robust than, those in other countries.427 Dexter {Day179/95:21}-{Day179/97:19}; Reason {Day182/101:2}-{Day182/102:25}; Daly {Day183/117:22}- {Day183/136:9}; {Day183/163:8}-{Day183/164:8}; Cotton {Day209/231:10}-{Day209/232:11}; Cotton {Day209/233:11- 21}; Dobson {Day211/33:4}-{Day211/36:1}. Two examples demonstrate the shortcomings of this approach to the gathering and analysis of information from fires outside this country.
The Lacrosse fire, Melbourne, Australia (November 2014)
¶75.10 The Lacrosse fire caused the authorities to carry out an audit of Melbourne's high-rise buildings. In March 2016, the LFB was provided with the results of that audit, which revealed that 51% of the buildings surveyed did not comply with the regulations. AC Daly was asked whether that ought to have alerted the LFB to the possibility that the position in London might be similar. It was a relevant question, because, as we have pointed out, the LFB's reliance on the existence of a robust regulatory system in the UK necessarily depended on compliance with it. His response was that it was likely that the question had been raised within the LFB at the time, but that there was no evidence that there were buildings in London that used external wall cladding that did not comply with the Building Regulations.428 Daly {Day183/170:12}-{Day183/178:17}. The explanation was unsatisfactory, first, because there is no evidence that the question had actually been considered in that way, and secondly, because the purpose of any investigation would have been to discover whether there had been a widespread failure to comply with the regulatory requirements. In our view, the unexpectedly high rate of non-compliance found in Melbourne was a compelling reason for the LFB to consider whether the same problem existed in London.
The Address fire, Dubai, UAE (December 2015)
¶75.11 Information about the fire at the Address building in Dubai reached senior officers of the LFB through DAC Graham Ellis who sent an email to two of his LFB colleagues containing a link to an article about flammable polyurethane and aluminium cladding involved in a fire in Dubai.429 {LFB00024217}. He copied his message to AC Cotton in her capacity as Head of Operational Assurance. The article said that the fire had resurrected fears about the widespread use of highly combustible materials on skyscrapers across the UAE. It also said that a fire safety expert had estimated that up to 70% of Dubai's high-rise buildings could be clad in polyurethane and aluminium composite cladding, notwithstanding the requirement in the UAE that buildings over 30 metres in height be constructed from non-combustible materials. Towards the end of the article the author referred to the regulatory position in Britain, which he said did not permit any surface spread of flame.430 {INQ00014890}.
70¶75.12 Responding to the email from DAC Ellis, GM Biles made a flippant comment about paragraph 12.7 of Approved Document B, which provided by way of guidance that insulation products and filler materials should be of limited combustibility. AC Cotton replied to his comment, also in flippant terms. Neither paragraph 12.7 nor the broader requirements of Approved Document B had been mentioned in the body of the article, but they had been mentioned in a comment made by an online user who drew attention to the distinction between a Class 0 surface and a combustible core and asserted that there were large schemes still being constructed in the UK for which similar panels were being incorrectly specified due to a fundamental misunderstanding of the regulations.
¶75.13 AC Cotton said that she had not read the comments below the main body of the article,431 Cotton {Day210/9:12-13}. but the reference to clause 12.7 in his comment shows that, at the very least, GM Biles had. We think it surprising that none of those who received the email thought it necessary to draw the attention of the Fire Safety department to the article or the online comment, given that the comment suggested that there was a fundamental misunderstanding within the construction industry about the requirements of the Building Regulations relating to materials used in external walls. The exchange also revealed a failure by senior officers adequately to probe and question information they did not fully understand. Most importantly, the LFB should have been alert to the risk that there might be many buildings in London with dangerous cladding, but it was too complacent to discover the existence and extent of any problem in London before it was too late.
NHBC seminar – 'Facades to Tall Buildings'
¶75.14 On 7 July 2016 members of the LFB's Fire Safety department attended a seminar organised by the NHBC entitled "Facades to Tall Buildings". One presentation contained images of fires in high-rise buildings both in the UK and abroad, including the Address Tower fire in 2015 and the Tamweel Tower fire in 2012, both in Dubai, and the Garnock Court fire in Glasgow in 1999.432 {LFB00032916/2-4}. It also contained diagrams depicting different mechanisms of external flame spread taken from BR135 Fire performance of external thermal insulation for walls of multi-storey buildings (3rd ed., 2013) and relevant extracts from Approved Document B and Building Control Alliance Technical Guidance Note 18.433 {LFB00032916/5-9}. The content of the seminar was subsequently used to create the LFB's own presentation entitled "Tall Buildings Facades".
¶75.15 AC Daly said that the conference had been seen as providing reassurance about conditions and regulations in this country.434 Daly {Day183/135:12}-{Day183/136:9}; {Day183/145:16}-{Day183/146:13}. However, we draw exactly the opposite conclusion. First, in the course of the seminar the NHBC warned about the dangers of highly combustible polythene-cored ACM products, the omission of cavity barriers around openings, unrealistic assumptions about the fire resistance of glazing and confusion between the fire resistance of a wall assembly and fire spread across or within it.435 {LFB00032892/10-11}. Secondly, the Building Control Alliance, in a presentation on demonstrating compliance with the Building Regulations, had separately sounded a warning about a number of matters, including the absence of any tests using lightweight metal claddings, desktop assessments by fire engineers being based on opinion rather than fact, and the substitution of materials.436 {LFB00032891/14}. Thirdly, Brian Martin's presentation on regulatory requirements contained a diagram taken from BR135 which showed how combustible cladding systems could contribute to the spread of flame and the risk of secondary fires.437 {LFB00032895/6}. Fourthly, the BRE explained the mechanisms of external fire spread involving combustible materials and stated that the BS 8414 test method was being used in the same or a substantially similar way in the UAE, Australia and China.438 {LFB00032922/21-22}.
71¶75.16 The LFB was well aware of those warnings. It should, therefore, have been aware of the importance of understanding the risk of rapid external fire spread in buildings in London. The LFB's own "Tall Buildings Facades" presentation439 {LFB00032916}. It was produced in draft in July 2016 and finalised in October 2016 after the fire at Shepherd Court. carried a number of relevant warnings. First, it warned that although it was a general principle that the external envelope of a building should not contribute to the spread of fire, new construction materials and methods of construction were being used in facades with a limited understanding of their behaviour when exposed to fire. The same slide warned that such materials could affect the way that fires develop and spread in a building. Secondly, it warned of the importance of the facade's not contributing significantly to the spread of fire. Thirdly, it identified combustible materials in the facade as likely to lead to the spread of fire. Fourthly, it reproduced the diagrams in BR135 depicting the mechanisms of external fire spread. Finally, it concluded that the construction of the facade of Shepherd's Court might have contributed to the fire spread. There was, therefore, nothing in the various presentations to justify an unqualified assumption that the risk of rapid external fire spread was, in some way, restricted to methods of construction used abroad.
¶75.17 The evidence from fires abroad and the warnings and concerns expressed about building methods used in this country partly reflected, but certainly confirmed, the LFB's knowledge of, and longstanding anxiety about, a widespread failure to comply with the Building Regulations in London and, in particular, about modern construction materials which caused or permitted the unusual spread of smoke and fire. That knowledge and those worries pre-dated the Lakanal House fire in July 2009 and were reinforced by the Shepherd's Court fire in August 2016, discussed below.
¶75.18 Commissioner Cotton said she was unaware that anyone in the LFB had ever brought the risk of failure to comply with the Building Regulations to the attention of senior officers.440 Cotton {Day209/233:22}-{Day209/234:5}. She told us that neither she nor the Operational Assurance department had been made aware that the LFB knew about problems caused by poor compartmentation (and the implications for a "stay put" strategy) until April 2017, when a letter raising the question had been drafted by the LFB's Fire Safety department and sent in her name (as Commissioner) to Gavin Barwell MP and Brandon Lewis MP (Minister for Housing and Minister for Policing and the Fire Service respectively).441 Cotton {Day210/3:18}-{Day210/4:17}; {Day210/19:4}-{Day210/28:17}. She said that the Operational Assurance department had never been asked to consider the risks resulting from failure to comply with the Building Regulations or the spread of fire resulting from an inappropriate choice of materials, which had never been brought to its attention.442 Cotton {Day210/5:3}-{Day210/6:13}.
¶75.19 It is clear to us that communications between the different departments of the LFB were very limited and that as a result there was a significant failure to ensure that important information, in this case information about threats to the built environment, was shared with departments which really needed to receive it. The Fire Safety department should have worked much more closely with the Operational Assurance department to investigate significant fires in other countries and to understand whether there was anything important to be learnt from them. Instead, there is no evidence that either of those departments, or indeed any other department, used them as a means of improving their understanding of the risks associated with modern and refurbished buildings and their ability to fight fires in high-rise buildings. That reflected both a failure of organisation and management and a failure on the part of individual officers to display the breadth of vision to be expected of them.
72The Adair Tower and Shepherd's Court fires
¶75.20 Two other fires in high-rise residential buildings occurred in London following the Lakanal House fire, both of which gave rise to challenges similar to those that had been encountered at that fire and were to be encountered again at the Grenfell Tower fire. The first was the fire at Adair Tower; the second was the fire at Shepherd's Court.
The Adair Tower fire
¶75.21 Adair Tower is a 14-floor residential building. On 31 October 2015, a fire was started by a lighted firework being put through the letterbox of a flat on the third floor. When the first crews arrived, they reported a fully developed fire that had spread into the adjoining lobby. Neighbouring flats were affected by smoke and heat, as were the main stairwell and communal lobbies on higher floors. There were no self-closing devices on the doors of the flats, which made it easier for smoke to spread. 19 pump appliances attended the fire.443 {LFB00001708}.
¶75.22 A considerable number of calls were made by residents of Adair Tower to the control room during the course of the incident, including calls during which fire survival guidance was given. The LFB's records were not consistent in recording the number of fire survival guidance calls.444 Contemporaneous documents referred variously to 9 and 24 fire survival guidance calls: {LFB00001711}; {LFB00031757}. Up to six fire survival guidance calls (depending on how they were characterised) were received between 08.54 and 09.08, together with 15 other calls.445 {LFB00035092/5}; FSG database {LFB00031757}; Smith {Day202/201:1-20}. In any event, the total number of fire survival guidance calls made during the Adair Tower fire exceeded the five received during the Lakanal House fire.446 {HOM00001124}. The incident commander, GM Anthony Biles, who had 34 years of operational experience, said that it was the highest number of fire survival guidance calls that he had dealt with in his career.447 {MET00080605/13}. Fifty residents were helped to escape the building, either by firefighters or by control room officers (CROs) who provided advice and guidance.448 {LFB00001708/2}; {LFB00035109}.
¶75.23 When GM Biles arrived at the incident ground, he realised that many people were trapped and needed to be rescued, or believed that they did, so he obtained additional crews with extended duration breathing apparatus (EDBA) to conduct search and rescue operations on higher floors and hand over residents they had rescued to firefighters wearing standard breathing apparatus on the lower floors. GM Biles did not formally revoke the "stay put" strategy, but he briefed crews to clear the building.449 Biles {MET00080605/7-8} pages 7-8.
¶75.24 The incident monitoring process report recorded that there had been good handling of a large volume of fire survival guidance information with finite resources. There was no reference to the evacuation of residents or the "stay put" strategy.450 {MET00080621}.
73The Shepherd's Court fire
¶75.25 Shepherd's Court is a 20-floor residential building in Shepherd's Bush. On 19 August 2016, a fire started in a faulty appliance in a flat on floor 7. It spread to floors 8, 9, 10 and 11 through external facade panels and entered some of the flats on those floors through open windows. The block's single stairwell had a good level of compartmentation and individual flats had good fire doors with self-closing devices. Twenty appliances attended the fire, which was ultimately extinguished.451 {LFB00118245}; {LFB00000084}.
¶75.26 SM Charles Hanks was the second incident commander, having assumed command about 34 minutes after the first crews had arrived.452 {LFB00060951/8}. He remained in command for about ten minutes until GM Richard Ogden arrived.453 Hanks {LFB00032724/2} page 2, paragraph 5. During that ten-minute period he saw that the fire had spread to the floor above the flat of origin, which he recognised indicated a possible failure of compartmentation. Soon after, SM Hanks was told that a third floor had become involved in the fire. He became concerned that there was a risk that the fire might spread further externally and also a risk that it might spread in the interior of the building.454 Hanks {LFB00032724/2-3} pages 2-3, paragraph 6. He described the spread of fire as "exceptional", although there had been very little spread of smoke and flame in the interior and the stairwell had not been affected.455 Hanks {LFB00032724/3} page 3, paragraph 7.
¶75.27 Once SM Hanks had become aware that three floors had become involved in the fire, he decided that he needed to ensure that the flats immediately above the fire were empty and that any occupants were moved to safety when possible. (He said that, if necessary, he would have carried out a controlled evacuation of the occupants from the flats on the 9 floors immediately above because the fire was spreading vertically but not sideways.) At the same time, he directed crews to begin a systematic search from the top of the building, moving downwards to obtain information about the conditions within the building rather than to carry out search and rescue operations or to evacuate flats on those higher floors. His strategy was not intended to undermine the "stay put" policy, which in his view was maintained throughout, but was in his view a sensible precaution for one or two flats when conditions allowed, given that fires can occasionally jump a compartment boundary.456 Hanks {LFB00032724/4-5} pages 4-5, paragraph 8. The LFB's Fire Investigation report records that approximately 50 people had been evacuated from the building.457 {LFB00000084/8} paragraph 4.26.
¶75.28 The LFB has rightly accepted that, before the Grenfell Tower fire, it had failed to train its incident commanders to understand when and how to carry out an evacuation of a high‑rise residential building with a "stay put" strategy in the absence of an existing plan.458 Roe {LFB00060655/9} page 9, paragraph 21; Roe {LFB00083834/7-8} pages 7-8, paragraph 28; Closing statement for Modules 5 and 6 {LFB00123737/14} paragraph 35; {LFB00123737/35} paragraph 93. It was a failing which had the most serious consequences for the residents of Grenfell Tower on the night of 14 June 2017.459 Phase 1 Report Volume IV {INQ00014817/87} paragraph 27.3.
¶75.29 It must also be acknowledged, however, that the LFB was not alone in this failing. At the time of the Grenfell Tower fire there was no national operational guidance on how to evacuate a residential high-rise building460 McGuirk Report {SMC00000046/35} paragraph 83. and it does not appear that any other fire and rescue service in the United Kingdom had included in their operational policies or training any guidance on the practical aspects of carrying out an evacuation, beyond saying that it should be considered, as in PN63. On that basis, we agree with DAC Cowup's description of evacuation as a blind spot for the LFB. There is also some evidence to suggest that it may be a blind spot for other fire and rescue services, although we have not heard evidence about current firefighting practice outside London and Kent.461 Cowup {Day195/63:20}-{Day195/67:21}.
74¶75.30 Nonetheless, the operational responses to the Adair Tower and Shepherd's Court fires demonstrate that, although the LFB was not training its commanders on the evacuation of high-rise residential buildings, nor providing for it in its policies, it contained officers who were capable of carrying out some form of successful evacuations in high-rise residential buildings and, when circumstances required, did so. Commissioner Roe referred to incidents within his own knowledge where there had been a partial failure of compartmentation and where the incident commander had made a decision to evacuate the floors above and below the fire, while the rest of the residents remained in their flats. Commissioner Dobson also agreed that evacuation was not an unusual occurrence and that firefighters were well acquainted with evacuating all sorts of buildings, including high-rise buildings.462 Dobson {Day211/127:10-12}. DAC Cowup similarly told us that evacuation was a fairly routine and intuitive process, though he accepted that before the Grenfell Tower fire the LFB had not understood the need to provide firefighters with specific guidance on it.463 Cowup {Day195/66:1-22}.
¶75.31 It is important to note that evacuation is not necessarily inconsistent with a "stay put" strategy. If residents are being adversely affected by heat, fire or smoke, their evacuation is entirely consistent with such a strategy. However, the evacuation of flats which are not adversely affected by heat, fire or smoke does involve a revocation, at least in part, of a "stay put" strategy. There was no reference to the "stay put" strategy or to the partial evacuation of residents in the IMP reports on either the Adair Tower or the Shepherd's Court fires,464 {MET00080621}; {LFB00120998}. but we are satisfied that in practice some incident commanders have carried out emergency evacuations, including the evacuation of flats not adversely affected by smoke or fire, of some kinds of residential high-rise buildings with "stay put" strategies without recording the fact. It is not possible to say with confidence how frequently they have done so, but Adair Tower and Shepherd's Court do not appear to have been isolated incidents. The incident commanders at both fires appear to have acted intuitively, without notifying the control room, and no one appears to have regarded their actions as particularly significant. That suggests that the approach taken at both those incidents was not out of the ordinary. Indeed, Commissioner Roe referred to incidents within his own knowledge where there had been a partial failure of compartmentation and where the incident commander had made a decision to evacuate the floors above and below the fire, while the rest of the residents remained in their flats.465 Roe {Day213/147:15-23}.
¶75.32 The evidence suggests that before the Grenfell Tower fire evacuations of high-rise residential buildings had been partial rather than total.466 Roe {Day213/147:5-23}. (At any rate, we have not been provided with any evidence of a total evacuation of a residential high-rise building in London or elsewhere in the United Kingdom.) As was the case at Adair Tower and Shepherd's Court, such evacuations were probably carried out without discussion with the control room and perhaps without the commander necessarily considering whether the "stay put" strategy had been revoked. In such instances, it was the individual commander who made the decision based on his or her own judgement, deploying such practical strategies for the implementation of the evacuation as he or she saw fit. Before the Grenfell Tower fire, it was, ultimately, a matter of chance whether the officer acting as incident commander at any given time had sufficient experience and confidence to evacuate a high‑rise residential building, despite the absence of any training on when and how to do so.
75¶75.33 None of this undermines the conclusion in the Phase 1 report that "stay put" had become an article of faith for the LFB.467 Phase 1 Report Volume IV {INQ00014817/108} paragraphs 28.53 and 28.54. Institutionally, it was indeed so and the response at Grenfell Tower reflected that fact. However, the evidence heard in Phase 2 identified an inconsistency of approach and whether the incident commander considered evacuation owed nothing to established policy.
¶75.34 Another aspect of the Shepherd's Court fire that prefigured the hazards encountered at Grenfell Tower was the use of combustible facade panels, in that case containing polystyrene insulation. On his arrival at the incident AC Daly, who was the most senior incident commander to attend the fire, saw fire spreading over the walls, which he thought was unusual because he would not have expected exterior panels to support combustion.468 Daly {MET00077774/4}; Daly {Day183/206:11-18}. He thought it was the same phenomenon as had been observed at the Lakanal House fire.469 Daly {Day183/205:17}-{Day183/206:13}. AC Daly consulted SM James Flin, who was in attendance as a fire safety officer and was also a fire engineer, and the two of them agreed that it was necessary to find out why the spandrel panels appeared to have spread the fire.470 Daly {Day183/210:24}-{Day183/211:20}.
¶75.35 On 29 August 2016, sample panels were duly sent to Bureau Veritas for testing which was witnessed by personnel from the Fire Engineering team in the LFB's Fire Safety department.471 {LFB00052135/6}. The panels contained a blue polystyrene foam insulation mounted on a plywood board. One of the samples had a steel facing sheet; the steel sheet of the other had become detached during the fire, exposing the foam beneath. The sample panels were exposed to three flame tests. In the case of the panel without a steel facing sheet, the blue foam was rapidly destroyed, creating flaming droplets and sustaining burning even after the removal of the flame source. One of the tests had to be stopped due to concerns about the height of the flames. In its report of 30 November 2016 Bureau Veritas confirmed that the panels were likely to have assisted the fire in spreading up the outside of Shepherd's Court.472 {LFB00000091/2-4} paragraphs 3.5 and 3.6.
¶75.36 On receipt of those findings, Charles Elie-Romeyer, a fire engineer in the LFB's Fire Safety department who had witnessed the tests, revised the "Tall Buildings Facades" presentation to reflect the Shepherd's Court incident so that it could be used at a training day for senior fire safety officers.473 Green {LFB00032917/1-2} pages 1-2, paragraphs 3-5; Green {LFB00032917/5} page 5, paragraphs 23-26. In the section on the Shepherd's Court fire added by Mr Elie-Romeyer, the results of the Bureau Veritas tests were set out, including photographs of the burning sample panels together with the observation that the facade might have contributed to the spread of fire.474 {LFB00032916/15-20}.
¶75.37 AC Daly confirmed that the presentation had not been shared with anyone outside the Fire Safety Department, and, in particular, that it had not been shared with operational crews because of what he described as the very technical nature of the information relating to quite a complex area which operational personnel could not be expected to grasp or understand.475 Daly {Day183/138:24}-{Day183/139:11}; {Day183/142:9}-{Day183/143:16}. The Commissioner accepted that the presentation reflected the Fire Safety department's knowledge of the potential for modern construction materials to promote the rapid spread of fire, and that there had been a failure to ensure that that information was communicated to the rest of the LFB, including operational staff.476 Closing statement in Modules 5 and 6 {LFB00123737/19} paragraphs 44 and 45.
76The Parkin-Coates report: November 2015
¶75.38 The Fire Safety Department's continuing concern about compartmentation had previously been reflected in a report by Ms Adreena Parkin-Coates entitled Compartmentation Issues within the Built Environment published on 26 November 2015. Ms Parkin-Coates was a qualified fire engineer and a business support manager in the Fire Safety Department.477 {LFB00025654}; Daly {Day184/85:3-5}. Like the later Jack report of August 2016, the Parkin-Coates report referred to the importance of adequate compartmentation in defining a building's evacuation strategy. It also asserted that instances of inadequate compartmentation were widespread. In her summary of the report Ms Parkin-Coates noted that the success of many evacuation strategies, particularly "stay put" strategies, depended on adequate compartmentation, but that fire safety officers were becoming increasingly aware of defects in fire-stopping in new and refurbished buildings. She concluded that defects in compartmentation were widespread due to poor workmanship or a lack of oversight by building control bodies and contractors and that an overall strategy to address them was needed.478 {LFB00025654/1}.
¶75.39 In her report Ms Parkin-Coates accepted a view expressed by others that there was an endemic problem of sub-standard fire-stopping.479 {LFB00025654/2} paragraph 1. AC Daly thought that the use of the word "endemic" was likely to reflect the frequency with which defects in compartmentation had been identified in the pool of buildings that had been found not to comply with the Building Regulations during fire safety audits conducted by the LFB. (He said that about 70% of premises were found to be broadly compliant.) He accepted, however, that within that smaller pool of buildings, defects in compartmentation were identified reasonably regularly. He did not agree that sub-standard compartmentation was endemic across the built environment as a whole.480 Daly {Day184/88:2-14}.
¶75.40 Ms Parkin-Coates also referred to the Bush House fire in 2007, which had prompted a meeting with the government and other interested parties in 2010, and to the NHBC training initiatives that had been implemented in association with the Chief Fire Officers Association in 2011.481 {LFB00025654/3-4}. She also referred to and annexed a separate report entitled Structural Fire Safety Failures – Quarterly/Annual Reporting dated March 2015, which was provided to the Performance Management Board with her report because it was said to identify a number of other fires at which structural defects had been found.482 {LFB00025654/10}. The quarterly report for the period April to December 2014 recorded that 25 fires had occurred, three of which had exhibited possible defects in structural fire safety features that might have contributed to the development of the fire. All three of those fires, which included the fire at Holcroft House, had occurred in residential blocks of flats.483 {LFB00025654/11-12}. As noted earlier, the report recorded that some of the structural defects affecting fire safety identified at those incidents ought to have been recorded on the relevant building's ORD entry, but had not been.484 {LFB00025654/12} paragraphs 11 and 13.
77¶75.41 AC Daly told us that the Parkin-Coates report, with all its appended reports, had been waiting for his attention when he took over as Head of Fire Safety in March 2016.485 Daly {Day184/92:12-13}. He told us that the material had given him cause for concern and that it had indicated that there were systemic issues that needed to be addressed.486 Daly {Day184/94:9-13}. He accepted that his concerns suggested that there were things that operational firefighters as well as the Fire Safety department needed to learn and accepted that the LFB had not always gained as much from the work of the Fire Safety department as it could have, in particular by involving operational crews in its thinking.487 Daly {Day184/94:22}-{Day184/95:20}. It is notable that, in the revised version of the Parkin‑Coates report prepared in December 2016 for presentation to the Corporate Management Board, the range of suggestions for action related to the Fire Safety department and Fire Safety personnel alone. There was no suggestion that operational personnel should be involved in any way in the measures proposed for remedying inadequate compartmentation.488 {LFB00000155/6} paragraph 37. We accept that it was not a deliberate omission,489 Daly {Day184/112:13-24}. but it is significant for what it tells us about the nature and extent of the collaboration between the fire safety and operational sides of the LFB.
The Jack report: August 2016
¶75.42 In late 2016, at the time that the Fire Safety department was discussing its concerns about the misinterpretation of functional requirement B4, it was also doing work on compartmentation in residential blocks of flats.490 Jack {LFB00120308/18} page 18, paragraph 61; {LFB00120296}. As it had in relation to the exterior walls of such properties, the department continued to question whether its enforcement powers under the Fire Safety Order extended to the fire-resisting walls between individual flats. That was not a new issue. It had featured in discussions between the LFB and DCLG in 2012, which had culminated in Louise Upton's advice of 6 February 2013 that the Fire Safety Order did not extend to the external walls of a building.491 {LFB00032153}. In August 2016, Andrew Jack produced a report entitled Fire Resisting Compartmentation – Flats (the Jack report) that was presented to the Principal Management Board, a departmental management board chaired by AC Daly and attended by the heads of the different teams in Fire Safety.492 {LFB00120301}; Daly {Day184/65:14-22}. The report refers to the "Performance Management Board", which Dan Daly clarified in his evidence was likely to be a typographical error: {Day184/67:2-15}. The Jack report described the benefits of taking enforcement action, where necessary, in respect of inadequate compartmentation, even though its power in law to do so was considered to be unclear. It noted that compartmentation between flats was of vital importance to prevent the spread of fire through a building containing multiple dwellings and was essential if an evacuation strategy based on "defend in place" was to be employed.493 {LFB00120301/2}. ("Defend in place" is essentially the same as a "stay put" strategy.)
78¶75.43 Mr Jack observed that fire risk assessments rarely consider compartmentation in areas of the building away from the means of escape and that there was therefore scant factual basis to justify the use of a "stay put" emergency plan.494 {LFB00120301/3}. That reflected the fact that a "stay put" strategy for any building is fundamentally dependent on compartmentation being effective and that, in order to rely on "stay put" as a strategy, the building's compartmentation must be sound. It also follows that, from an operational perspective, it cannot be assumed that compartmentation will in fact be effective.
¶75.44 The Jack report contained examples of buildings whose compartmentation had been found to be inadequate, including Lakanal House, and noted that more examples were likely to be discovered as a result of fire risk assessments.495 {LFB00120301/3}; {LFB00120301/8}. AC Daly said that a great deal of the LFB's enforcement work concerned breaches of compartmentation and that his own operational experience had been that it was often possible to find products of combustion where you would not expect them.496 Daly {Day184/74:1}-{Day184/75:1}. However, he did not accept that the LFB had reason to think that inadequate compartmentation was a widespread problem.497 Daly {Day184/78:19-24}. It is also clear that no thought was given by the LFB at that stage to the potential combination of inadequate compartmentation and combustible facade systems, even though the report was being written while Bureau Veritas was carrying out tests on the panels taken from Shepherd's Court.498 Daly {Day184/76:10}-{Day184/77:4}. The Fire Safety department did not take the opportunity to raise its concerns about inadequate compartmentation in the letter it sent to chief executives on 6 April 2017. This might have been due to the fact that compartmentation had been effective at Shepherd's Court, thereby keeping the single staircase clear of smoke and fire and enabling the partial evacuation of residents.
¶75.45 On 3 April 2017, Commissioner Cotton wrote to the then Gavin Barwell MP, Minister of State for Housing and Planning and Minister for London, requesting a meeting to discuss the LFB's concern about inadequate compartmentation in residential blocks of flats.499 {CLG10009016}. In her letter she pointed out that effective compartmentation is essential to the operation of the "stay put" policy that applies to most residential buildings. She expressed concern that since the beginning of 2017 the LFB had identified, on average, at least one residential property (or development) a month in London that had significant defects in compartmentation and that there were many other cases that had not come to the LFB's attention.
¶75.46 Commissioner Cotton told us that the letter had been drafted by AC Daly and that she had not been aware of the problems to which it referred before he had spoken to her about the draft.500 Cotton {Day210/28:5-17}. She did not take any steps to check what training was being provided to operational personnel about the risks posed by failures of compartmentation or their effect on a building's "stay put" strategy.501 Cotton {Day210/26:21}-{Day210/27:15}.
79Conclusions
¶75.47 By the end of 2016, the LFB as an organisation was well aware of the dangers posed by some kinds of modern construction materials and techniques and of the particular dangers presented by various kinds of combustible materials, mainly those used for their insulating properties. That included sandwich panels, insulation boards made of organic materials and, most importantly for present purposes, external panels containing organic materials intended to provide rigidity as well as insulation, all of which had the propensity to lead to a loss of compartmentation in a major fire. Regrettably, however, that knowledge was almost entirely confined to the Fire Safety department and was not shared with those who were responsible for operations. As a result, those who were deployed to fight fires were not trained to deal with situations which could become catastrophic both for them and, in the case of residential buildings, their occupants. In particular, incident commanders were not sufficiently aware that a "stay put" strategy may not be reliable in all circumstances and that evacuation may be necessary.
81Chapter 76: Operational planning
Introduction
¶76.1 In his Phase 1 report the chairman found that the information available to the first crews mobilised to attend the Grenfell Tower fire was incomplete and in some respects inaccurate.502 Phase 1 Report Volume IV, paragraph 27.30 He also found that the LFB had failed properly to train its crews in how to obtain information when visiting premises for that purpose and had a narrow understanding of its obligations under section 7(2)(d) of the Fire and Rescue Services Act 2004 (the 2004 Act).503 Phase 1 Report Volume IV, paragraphs 27.36. He said that the reason for those failures would be investigated in the next phase of the Inquiry. We have therefore examined the LFB's approach to operational planning, with particular reference to fighting fires in high-rise residential buildings.
¶76.2 Section 7(2)(d) of the 2004 Act requires fire and rescue authorities to make arrangements for obtaining information needed for the purpose of extinguishing fires and for protecting life and property in the event of fires in their areas. Traditionally, visits by station-based staff to premises in their areas have been regarded as the primary means of discharging that duty and was the method adopted by the LFB.504 Phase 1 Report Volume IV, paragraphs 27.22, 27.24 and 27.37.
¶76.3 Information gathered from visits to premises and other sources was entered on the Operational Risk Database (ORD) which was intended to act as the main source of information for incident commanders and other officers responding to an incident. In his Phase 1 report the chairman considered the entries on the ORD for Grenfell Tower, which indicated that the LFB had failed to obtain relevant information from the manager of the building, the TMO, including information relating to the building's cladding system.505 Phase 1 Report Volume IV, paragraphs 27.35 and 27.37. Contrary to the plain meaning of the words of Appendix 1 of PN633, it was not the practice for operational personnel responsible for conducting visits to high-rise premises to consider the full list of items set out there.
¶76.4 In Phase 2 of the Inquiry we have considered what information section 7(2)(d) requires fire and rescue services to gather and how the LFB sought to discharge its duty, including the type of information it thought it needed to obtain, particularly about high-rise residential buildings. We have also considered whether the LFB's policies and practices that were designed to discharge the duty under section 7(2)(d) were appropriate.
Duty to obtain information
¶76.5 The duty to obtain information for the purpose of fighting fires was originally contained in section 1(1)(d) of the Fire Services Act 1947, which was to all intents and purposes the same as section 7(2)(d) of the 2004 Act. Steve McGuirk, the former Chief Executive and County Fire Officer of Greater Manchester Fire and Rescue Service, who was called to give expert evidence on fire-fighting, explained that the duty had originally been interpreted by fire and rescue authorities as requiring the collection of simple information that would be readily and quickly accessible to the first crews attending an incident,506 McGuirk {Day190/11:18-23}; {Day190/12:2-11}; {Day190/13:12-23}; {Day190/15:7-24}. and that had remained their approach to discharging the duty under section 7(2)(d) of the 2004 Act.507 McGuirk {Day190/14:9}-{Day190/15:2}.
82¶76.6 In April 2012, the government issued guidance to fire and rescue services on the collection and management of operational risk information, that is, the information they are required to collect under section 7(2)(d).508 {HOM00045364}. It contained a model approach entitled Provision of Operational Risk Information System, or PORIS for short. It was the first substantive national guidance on the management of operational risk information since the 2004 Act had come into force.509 McGuirk {Day190/16:7-16}. Mr McGuirk said that PORIS had marked a change in what was expected of fire and rescue authorities because it required a much more sophisticated system for managing information about risks, but he doubted whether it had brought about a widespread change in the way that most fire and rescue authorities went about gathering information. That may have been because the guidance was released with little publicity, but in any event, there has been no monitoring of whether any, and if so, how many, authorities have adopted the model.510 McGuirk {Day190/18:5}-{Day190/19:14}; {Day190/37:7-25}.
¶76.7 The PORIS model involved five steps: (1) review existing information; (2) where necessary, collect additional information by way of a site visit; (3) use that information to assess the risk presented by the particular building or site; (4) determine the appropriate risk management process; (5) provide the relevant information for use by incident commanders in a timely manner. The guidance provided a template "data capture" form, to be used for the collection of information, including information collected during visits to premises.511 McGuirk {Day190/20:1-8}. It is notable that the form included a section entitled "cladding and roof" and invited the user to select from a number of different alternatives, including "sandwich panel", "metal sheet" and "uPVC".512 {HOM00045364/85}.
¶76.8 It is immediately apparent when looking at the data capture form (which is almost 20 pages long, extremely broad in scope and in parts very technical) that the guidance issued in 2012 envisaged a process for the collection and management of operational risk information very different from the simple and practical approach that had previously been adopted by fire and rescue authorities. Mr McGuirk described the guidance as prescribing a much more expansive approach which required a significant amount of additional training.513 McGuirk {Day190/25:25}-{Day190/26:23}. Following the introduction of PORIS, as Mr McGuirk put it, operational firefighters were intended to become "more rounded risk assessors, capable of assembling and evaluating a much greater range of information."514 McGuirk, Firefighting Report {SMC00000046/15} paragraph 21.
Collection and management of operational risk information by the LFB
¶76.9 The LFB policies for the management of operational risk information were PN800, which applied to all properties, and PN633, which related specifically to high-rise buildings. Appendix 1 of PN633 contained a list of 22 items to be considered by crews during section 7(2)(d) visits.515 {LFB00083849}; {LFB00001256}. In addition, PN784 governed the sharing of information relevant to operational planning between the LFB's Fire Safety department and fire stations.
83¶76.10 In broad terms, the version of PN800 in force in June 2017 mirrored the five stages of the PORIS model. In particular, it required crews to carry out a premises risk assessment based on the risks identified during section 7(2)(d) visits using the form in Appendix 1 of the policy. That resulted in the premises achieving a certain risk score, which determined the frequency of further visits, the need for exercises on the premises and whether a tactical plan was required. Grenfell Tower had been placed in the medium- to low-risk category by the risk assessment carried out at the last visit before 14 June 2017. As a result, it qualified for at least one visit by a local crew every three years and a tactical plan. An exercise on the premises was not required unless the local station manager thought it necessary.516 {LFB00003596}. No tactical plan was ever put in place for Grenfell Tower.517 Phase 1 Report Volume IV, paragraph 27.30.
¶76.11 PN800 recognised the role of the LFB's Fire Safety department in the collection, management and analysis of operational risk information. In particular, the policy noted that one of the ways in which premises giving rise to certain hazards or risks were identified was by notification from the Fire Safety department. PN800 also directed crews to consider whether the risk assessment process required specialist knowledge, including knowledge available from the Fire Safety Regulation department.518 {LFB00083849/4}; {LFB00083849/7} paragraph 7.20.
¶76.12 PN784 governed the way in which information was to be shared between the Fire Safety team and operational crews.519 {LFB00012734}. In short, PN784 set out a procedure under which officers in the Fire Safety department were to communicate to station-based personnel information likely to be relevant when planning for operational incidents, and vice versa. Such information was to be communicated in a prescribed form and, on receipt, the station manager or Fire Safety team leader was to decide what action was appropriate, which might include a joint visit.
¶76.13 In practice, the procedure for sharing information between the Fire Safety department and fire stations was not consistently followed. Reports were compiled by the Director of Operations on a quarterly basis showing the number of "risk notifications" made by the Fire Safety department to stations during that period and the action taken by the relevant stations in response. We have been provided with a copy of one of those reports, dated 12 May 2015.520 {LFB00122962}. It records that in Kensington and Chelsea, where Grenfell Tower was situated and which contained three fire stations,521 North Kensington, Kensington and Chelsea fire stations. the Fire Safety department had made a total of six notifications to fire stations in the previous year and just two notifications had been made by fire stations to the Fire Safety department. More generally, the proportion of notifications in respect of which follow-up action was recorded varied from station to station, with some recording 100% and others as low as 40%. The report noted that the Fire Safety department sent more notifications to the stations than the stations sent to the department, which could have been the result of the stations not being fully aware of the administrative recording process, alternative channels of communication for recent team management changes or differences of opinion about the level of information that should be referred. The Fire Safety department made similar observations.522 {LFB00025654}.
¶76.14 The picture recorded in the report of 12 May 2015 was consistent with the evidence of AC Daly. He said that on the whole, the flow of information between the Fire Safety department and the fire stations did not work well and was patchy, in the sense that it worked better in some areas than others.523 Daly {Day183/46:10}-{Day183/47:11}; {Day184/107:17}-{Day184/108:7}. Both Commissioner Dobson and Commissioner Roe agreed with that assessment.524 Dobson {Day211/210:14-19}; Roe {Day213/122:10-19}. The LFB's Director of Operations, Dave Brown, said that the LFB had put measures in place to address the shortcomings in the system which had led to improvements.525 Brown {Day187/38:8-14}; {Day187/40:8-14}. Whatever measures had been implemented, they were ineffective, because the sharing of information between the Fire Safety department and fire stations remained unsatisfactory at the time of the Grenfell Tower fire. AC Daly was a frank and reliable witness, who had much closer contact with the day-to-day management of the Fire Safety department than Director Brown. On this point, we prefer AC Daly's evidence. Indeed, Grenfell Tower was a tragic illustration of the failings in the LFB's arrangements for sharing information. The North Kensington crews who carried out section 7(2)(d) visits to the tower did not obtain from the TMO information relating to the building's cladding system or even basic floor plans showing the layout and numbers of individual flats. Under the LFB's own policies and procedures that information should have been obtained by the local crews.
84Application to high-rise buildings
¶76.15 Neither PN800 nor PN784 provided any direction or guidance on the management of operational risk information relating specifically to high-rise buildings, which at the time of the Grenfell Tower fire was contained in PN633, the LFB's policy on firefighting in high‑rise buildings. PN633 was considered in some detail in Phase 1 of the Inquiry. Appendix 1 of PN633 transposed national guidance on firefighting in high-rise buildings, contained in GRA 3.2, into the LFB's local policy, insofar as the collection of operational risk information was concerned. Specifically, the LFB's list of items to be considered during visits to high-rise buildings broadly corresponded to that prescribed by GRA 3.2, apart from the omission from Appendix 1 of any reference to cladding.526 {LFB00001255/18}.
¶76.16 Mr McGuirk thought that it would take an operational crew at least two hours properly to consider all 22 items listed in Appendix 1 of PN633.527 The full list is set out in the Phase 1 Report Volume IV, paragraph 27.23. He disagreed with Commissioner Cotton's characterisation of the list as being, in parts at least, unrealistic or incorrect. In his view, it was necessary and appropriate for crews in London to be directed to consider all 22 items as well as the information required by the PORIS model. He did not think it was beyond the capacity of station-based operational crews to undertake risk assessments of that scope and level of detail, provided they were given appropriate training. In his opinion, the practical simplicity of the former approach to management of operational risk information can still be maintained, thereby preserving the need for essential information to be readily available to the first responding crews, if measures are taken to filter the information properly as it is provided to those on the incident ground.528 McGuirk, Firefighting Report {SMC00000046/33-34} paragraphs 79 and 80.
¶76.17 The LFB's policy documents did not make it clear whether all high-rise buildings should be the subject of section 7(2)(d) visits and have an entry on the operational risk database or only some. AC Brown said that ideally every high-rise building in London would be visited and subject to a risk assessment, a view with which Commissioner Dobson agreed.529 Brown {Day211/197:22}-{Day211/198:8}. However, that might or might not have led to their being recorded on the ORD, since PN800 prescribed a minimum threshold risk score for that purpose.530 Brown {Day186/54:15-20}. PN800 required all premises that scored 150 or above on the risk assessment to be recorded on the ORD {LFB00083849}. AC Brown accepted that he had faced considerable difficulties in achieving that ideal during his time in the brigade, not least because the LFB did not know, and had no obvious means of finding out, how many high-rise buildings there were in London and where they were situated.531 Brown {Day186/55:4-22}; {Day186/101:5-15}.
85¶76.18 The figures that have been provided to us indicate that the LFB was a long way from achieving AC Brown's ideal. The Lakanal Assurance Report, a review carried out by the LFB in August 2018 of the action taken in response to the Lakanal House fire, recorded that in October 2017 approximately 1,700 high-rise buildings had been subject to a risk assessment out of a total of about 6,900 such buildings in London.532 {LFB00004801/28}. The LFB has since confirmed that the total number is in fact about 8,500.533 Roe {Day213/125:8-20}.
¶76.19 The reason why such a low number of high-rise buildings appeared on the ORD might have been the apparent confusion within the LFB over whether crews were expected to visit all high-rise buildings on their ground and, if not, which ones they were expected to visit. AC Brown sent an email to station managers in April 2009 directing them to ensure that crews visited all the high-rise buildings on their ground every year.534 {LFB00032161}. His recollection was that, at that time, he had felt that that was not an unreasonable expectation, because he had not been quite sure how many there were. At a later stage, however, when the magnitude of the task became more apparent, a more risk-based approach was adopted.535 Brown {Day186/59:16-25}.
¶76.20 It appears that AC Brown's instructions still stood in 2010, when PN633 underwent one of the several reviews that were carried out following the Lakanal House fire. Peter Cowup, who was then a DAC in the LFB's Operational Policy department and was leading the review of PN633, sent an email on 1 August 2010 to various senior officers within the LFB noting that the feasibility of crews visiting all high-rise buildings on their station's ground required further consideration, because of the size of the task, especially for stations in central London.536 {LFB00082695}.
¶76.21 In November 2011, the LFB published Operational News 20, which contained an article on high-rise firefighting. In that article personnel were told that any high-rise buildings which posed a particular risk should be the subject of section 7(2)(d) visits.537 {LFB00047224}. AC Brown denied that the article reflected a departure from his earlier direction that all high-rise buildings should be visited. He said that the article had been intended to refer to the fact that high-rise buildings would be subject to regular section 7(2)(d) visits in future only if they were considered to pose a particular risk after they had been subject to an initial risk assessment.538 Brown {Day186/69:19}-{Day186/70:1}. We do not accept that. The text of the article in Operational News is clear and is not qualified in the way he suggested. The article is a straightforward guide for station-based crews on the LFB's statutory obligations in relation to high-rise buildings. We think that it illustrates the lack of a consistent approach to whether section 7(2)(d) of the 2004 Act required the LFB to visit all high-rise buildings or only those deemed on some undefined basis to present a high risk.
86¶76.22 As has been noted, Appendix 1 of PN633 listed 22 items which crews were required to consider during section 7(2)(d) visits to high-rise buildings. Mr McGuirk and Commissioner Cotton expressed different views about the practicability of complying with Appendix 1 to the letter. From around 2012 until his retirement in March 2017, Director Brown had ultimate oversight of the LFB's fire stations and responsibility for discharging its obligations under section 7(2)(d).539 Brown {Day186/7:17}-{Day186/18:1}. His evidence was therefore of particular help in understanding the nature of the information the LFB expected its operational crews to gather.
¶76.23 AC Brown expected crews to use the list in Appendix 1 to PN633 as an aide memoire and to consider the items where practicable. He accepted that that was not reflected in its language, which required crews to ensure that they were familiar with the various items contained in the list.540 Brown {Day186/29:17}-{Day186/32:4}. However, he did not think that station-based crews had the technical knowledge to look in depth at factors that might give rise to breaches of compartmentation, despite that being one of the items mentioned in the list. He said that, leaving aside obvious problems, such as an open vent in a communal stairwell, it was beyond the skill and knowledge of operational crews to identify defects likely to have that effect.541 Brown {Day186/32:15}-{Day186/33:7}. Similarly, when asked whether he would expect crews to identify features of a building that might promote the rapid or abnormal spread of fire (another item in the list) AC Brown said that that was at the extreme of the knowledge to be expected of a firefighter and that the LFB would rely on a member of the Fire Safety department to identify features of that kind.542 Brown {Day186/37:13}-{Day186/38:3}. Commissioner Dobson was similarly sceptical. He said that some of the items in the list would have required very specialist training to enable crews to carry them out properly. He doubted the likely benefit of such training in any event.543 Dobson {Day211/208:15-24}.
¶76.24 AC Brown did not expect crews to look at a building's cladding system during a section 7(2)(d) visit or to decide whether it should be taken into account in the risk assessment.544 Brown {Day186/40:11-21}. Again, he thought that was beyond the ability and training of operational personnel.545 Brown {Day186/43:13-19}. There was no discussion internally following the Lakanal House fire about whether to direct crews to consider cladding systems,546 Brown {Day186/46:25}-{Day186/47:4}. despite the fact that Commissioner Dobson had been sufficiently concerned about unsuitable panels to write to Sir Ken Knight on the subject in December 2009.547 {LFB00104291}. AC Brown told us that other steps had been taken to deal with that, which did not involve operational firefighters in that level of detail.548 Brown {Day186/45:6-22}. Nor was any consideration given to requiring crews to collect information about cladding systems of high-rise buildings following the fire at Shepherd's Court in August 2016.549 Brown {Day186/47:6-10}.
¶76.25 The lack of any advice or direction to crews about how to carry out visits to high-rise premises for the purposes of section 7(2)(d) is clear from the operational risk information training materials that were provided to the Inquiry, which were limited to a single, interactive computer-based training programme produced by Babcock in around May 2013.550 Stills from the programme are at {LFB00123288}; the accompanying trainer guide dated May 2013, is at {BAB00000058}. AC Brown confirmed that that was the first time crews had received formal training on how to conduct such visits,551 Brown {Day186/146:17-24}. and we are satisfied that it was the only time. The package was not directed specifically to high-rise buildings and did not contain any reference to PN633. Although it did provide some commentary on what to look for on such a visit, that commentary did not address the risk of fire spreading beyond the compartment of origin or the existence of features of construction that might promote the rapid or abnormal spread of fire, both of which are included in the list contained in Appendix 1. Perhaps unsurprisingly, the training did not ensure that crews understood the purpose of their visits, nor what information they were expected to obtain and record. That is apparent from the deficiencies in the ORD entry for Grenfell Tower, considered in detail in the Phase 1 report.552 Phase 1 Report Volume IV, paragraph 27.30. Although AC Brown and DAC George sought to suggest otherwise,553 Brown {Day186/202:22-25}; George {Day205/186:2-9}. Commissioner Roe confirmed that such deficiencies were not confined to Grenfell Tower, as might be expected.554 Roe {Day213/108:6-22}. He told us that a review of the entries on the ORD carried out after the Grenfell Tower fire had revealed a range of inconsistencies, poor information and a misunderstanding of risk.555 Smith {Day203/108:11-22}.
87¶76.26 The LFB's failure, following the Lakanal House fire, to instruct operational crews visiting premises pursuant to section 7(2)(d) to consider the potential for widespread compartmentation failure and the rapid or abnormal spread of fire was significant. It is not sufficient for it to point to measures that might have been taken by the Fire Safety department if the concerns of senior officers had been brought to its attention. Operational crews were not provided with the direction or training to enable them to identify the matters that should have been reported and largely disregarded the system for sharing such information.
The LFB's response to PORIS
¶76.27 The publication of PORIS in April 2012 provided another opportunity for the LFB to review and consider the effectiveness of its processes for the management of operational risk information. On 27 February 2013, a report by Susan Ellison-Bunce, Head of Strategy and Performance, was submitted to the Corporate Management Board, which considered the new guidance and the extent to which the LFB complied with it.556 {LFB00091785}. She concluded that the existing processes were robust and largely complied with national guidance and that it was not necessary or practicable to make significant adjustments to the current arrangements.557 {LFB00091785/20}.
¶76.28 Ms Ellison-Bunce also noted that the national guidance referred to the importance of periodic audits as a means of monitoring whether operational risk management systems had been properly implemented and maintained and were effective in meeting their objectives. She found that there were inconsistencies in the approaches taken by stations to what was included on the ORD and that the quality of the work done in obtaining and using information varied. Ms Ellison-Bunce therefore recommended that the Head of Operational Assurance (then AC Cotton) review how stations identified sites and buildings that might present a risk and whether they adopted an approach consistent with PN800.558 {LFB00091785/15}. AC Brown told us that that review had not been carried out.559 Brown {Day186/150:5}-{Day186/153:10}.
88The rule 43 recommendations on section 7(2)(d) visits
¶76.29 In her Rule 43 letter to the LFB the coroner recommended that it review its procedures for sharing information obtained pursuant to section 7(2)(d) with crews both within the station in question and at other local stations.560 {LFB00032158/2}. In response the LFB created a regime for inspecting what Commissioner Dobson had referred to in his letter to the coroner of 23 May 2013 as "high priority" buildings, with a view to increasing the number of premises in respect of which information was available on the ORD.561 {LFB00042089/4}. The term "high priority" did not appear in either PN800 or PN633. AC Brown told us that he did not know where it had come from and thought it had caused some unnecessary confusion.562 Brown {Day186/175:16}-{Day186/176:3}. The purpose of the new regime was to identify buildings that had not been the subject of a risk assessment but should have been.563 Brown {Day186/176:13-22}. It was not specifically aimed at high-rise buildings, but they were regarded as a priority.564 Brown {Day186/179:5-9}. AC Brown wanted to create an inspection regime that resulted in more entries on the ORD and was concentrated on those that presented higher risks.565 Brown {Day186/176:13}-{Day186/177:2}; {Day186/182:6-23}.
¶76.30 In November 2013 AC Brown asked DAC Tom George to set up the new regime, but he immediately delegated the task to GM John Elwell.566 George {LFB00032823/17}, page 17, paragraph 69. DAC George provided GM Elwell with little guidance on what was required, apart from telling him that he needed to strengthen the inspection programme and increase the number of entries on the ORD.567 {LFB00042252/2}.
¶76.31 On 11 December 2013, GM Elwell produced a careful and considered report for DAC George and AC Brown,568 {LFB00032825}. in which he identified the following questions that he thought were raised by the concern that there were too few entries on the ORD:
¶"a) Is the existing guidance (PN800) fit for purpose to achieve the desired outcomes?
b) What other Brigade data could be deployed to identify relevant premises for inclusion on the ORD. c) Are the 7000 we have all relevant and in compliance with the guidance in PN800? d) Which premises are 'missing' from the ORD given the guidance in PN800? e) What is the capacity of a station/watch in terms of the number of ORD entries that can be effectively entered and revisited with the existing guidance. A pertinent point, given the disparity of the numbers, risk and types of premises on different stations ground. f) Is the quality of existing ORD entries providing data to underpin safe systems of work? g) Are our staff competent to carry out the 72d visits and enter meaningful data and professional tactical plans? h) What are the existing Performance Evaluation Tools to monitor performance? i) What Service Standard is in place to Quality Assure the relevant extant policies?"
¶76.32 The questions identified by GM Elwell demonstrated a perceptive understanding of the difficulties that beset the LFB's systems for the collection and management of operational risk information. Indeed, they foreshadowed many of the concerns that have been raised during this Inquiry, in particular, about the capacity of individual stations to manage the number of premises on their grounds effectively, the quality of the existing entries on the ORD and the competence of operational staff to carry out visits and record relevant information.
89¶76.33 When he came to deliver his report569 {LFB00032825}. and recommendations GM Elwell concentrated on the following: a. The importance of the direct involvement of operational crews and their managers in
meetings and workshops to reinforce the provisions of PN800 and make clear what it expected of them. In particular, he warned that the then current practice of announcing new policies by email would not be adequate to explain effectively the requirements of PN800, a revised edition of which was due to be published soon after the report.
¶b. The need for a feasibility study to be carried out in relation to the use of existing data held by the LFB for the purpose of risk assessments, including the information recorded on the "Farynor" database, which held information collected on fire safety inspections. (The Farynor database had preceded and was separate from the ORD, but crews had access to it).570 Brown {Day187/35:11}-{Day187/36:5}.
¶c. The need to review the disparity in the number and nature of the risks across different station grounds and the development of a means of determining the optimal number of ORD entries for stations with a large number of high risk properties.
¶d. The need for further training to be provided to all personnel with a role in the process of creating the ORD to ensure that they had the necessary skills.
¶e. The need to be able to measure the number and quality of the entries on the ORD to determine whether they complied with the requirements of PN800.
¶76.34 AC Brown's response to the report was that, although it was interesting and helpful, it did not amount to the creation of a high priority inspection regime.571 Brown {Day186/190:21}-{Day186/191:7}. He accepted that the report had raised some significant broader concerns about the adequacy of the LFB's existing arrangements, but he told us that some of the recommendations had either been implemented already, were in the course of being implemented, or were within GM Elwell's power to implement. He thought that one or two were very aspirational and, although desirable in principle, would not work in practice.572 Brown {Day186/191:8-18}; {Day187/4:6-11}.
¶76.35 AC Brown thought that discussions between managers about section 7(2)(d) visits were an established part of normal business and that nothing further needed to be done in that respect.573 Brown {Day186/192:9-15}; Brown {LFB00123276/7} pages 6-7, paragraph 19. He said that work had already been done by the LFB's Information Management department to link information obtained from previous section 7(2)(d) visits with data available from other internal sources, including the Fire Safety department. He did not think that there could be a review of the varying levels of risk across different stations because the LFB did not have the necessary information. It could therefore not determine an optimal number of entries on the ORD for any individual station; all it could do was to direct crews that in due course all premises should be inspected to determine their suitability for inclusion on the database. He was satisfied that training on section 7(2) (d) visits had recently been given to crews (meaning, the training package distributed in May 2013)574 {LFB00123288}; {BAB00000058}. and considered that the LFB needed first to assess the results of that training in order to determine whether more was required. When asked about the need to monitor the quality as well as the quantity of the entries on the ORD, he said that it was incredibly difficult to measure quality in any meaningful way.575 Brown {LFB00123276/8} page 8, paragraph 24.
90¶76.36 We are unable to accept that AC Brown carefully considered each of GM Elwell's recommendations when the report was presented to him in late 2013. The weight of the evidence shows that he was concentrating on the introduction of an inspection regime aimed at "high priority" buildings, however defined. We think that he rejected the recommendations because they were not directly related to the creation of such a regime. In so doing, he did not properly reflect on the very real concerns that had been raised by GM Elwell.
¶76.37 We gained the strong impression that AC Brown did not wish to become involved in considering the complexities of an inspection regime, a problem which deserved more careful consideration than he was willing or able to give it. If the letter and spirit of the coroner's recommendation were to be satisfied and more effective inspection arrangements introduced, the matters raised by GM Elwell required proper consideration. AC Brown failed to give them that consideration and, as far as we can see, there was no good reason for that. If GM Elwell's recommendations had been implemented, they could have gone some way towards remedying the deficiencies in the LFB's arrangements for gathering and managing operational risk information.
¶76.38 On 22 January 2014, following AC Brown's effective rejection of GM Elwell's report, DAC George compiled a list of different types of property for inspection in order of priority that he proposed should be given to station managers and borough commanders.576 {LFB00083388}. High‑rise residential buildings of six floors and above appeared on the list second only to sites such as industrial plants of a kind which present major accident hazards. A list of that kind was exactly what AC Brown wanted.577 Brown {Day187/9:19}-{Day187/10:3}. DAC George said, however, that in his view and that of his colleagues, a satisfactory banding system was not entirely achievable and that he had reservations about such a simplistic approach.578 George {LFB00032823/20} page 20, paragraphs 75-76; George {Day206/17:1-14}. In particular, he was concerned that the system was more concerned with numbers than quality and that it would be virtually impossible for crews to carry out meaningful inspections of such a large number of premises.579 George {LFB00083884/19} page 19-20, paragraph 74. AC Brown did not agree with DAC George's reservations580 Brown {Day187/12:13-16}; {Day187/13:7-13}. and on 24 May 2014 he sent an email to all operational crews directing them to have regard to the priority banding system when conducting section 7(2)(d) visits.581 {LFB00032160}; Brown {Day187/15:2-6}; {Day187/15:18-25}.
¶76.39 The priority banding system was never formally incorporated into any policy,582 Brown {Day187/18:21-24}. but DAC George told us that he had monitored its implementation by watch managers through regular meetings with the borough commanders beneath him in the LFB's organisational structure. AC Brown had no further involvement in the inspection regime and did not ask to be provided with any further information about its success in increasing the number of entries on the ORD or its progress generally.583 George {Day206/29:15}-{Day206/30:20}; {Day206/32:1-13}.
91Communications
¶76.40 The references in PN800 to factors liable to affect communications were confined to circumstances likely to be encountered underground or in other places which may have alternative communications infrastructure, including fixed radio repeaters. However, the list of matters in Appendix 1 to PN633 on high-rise firefighting that were to be considered on visits to high-rise buildings did include potential problems with communications.584 {LFB00001256/19}.
¶76.41 The evidence given in Phase 2 about the practical application of those policies was inconsistent and uncertain. In particular, senior officers did not clearly understand whether there was a need to test the performance of radios when visiting a high-rise building.585 Documents created during and immediately after the Lakanal House inquests give conflicting views on whether radio testing formed a standard part of every s.7(2)(d) visit: {LFB00036836} and {LFB00098636/2}. PN633 contained no guidance for crews on how to identify potential difficulties with communications or how to test radio reception reliably.586 Brown {Day187/26:4}-{Day187/32:4}. Although WM Ricketts from North Kensington fire station tested the transmission of radio signals between the basement and the ground floor using his handheld UHF radio during a visit to Grenfell Tower immediately before the fire, that could have given only a limited indication of the performance of radios in the tower under operational conditions.587 Johnson, Communications Report {CWJ00000119/110} paragraphs 5.4.4-5.4.5; Johnson {Day189/153:15}- {Day189/154:24}. Professor Johnson suggested that a more detailed test, using validated procedures, may be needed in structures known to pose a particular risk of deteriorating communications.588 Johnson {Day189/155:2}-{Day189/156:1}; {Day189/156:13}-{Day189/157:16}.
93Chapter 77: High-rise firefighting: policy and guidance
Introduction
¶77.1 The Generic Risk Assessments were published by the Chief Fire and Rescue Adviser in conjunction with DCLG to provide operational guidance to fire and rescue authorities. In his Phase 1 report the chairman described the purpose of Generic Risk Assessment (GRA) 3.2, which contained the national guidance on firefighting in high-rise buildings, as being to assist fire and rescue services in drawing up their own assessments of risk to meet their statutory obligations under the relevant Health and Safety at Work legislation.589 Phase 1 Report Volume IV paragraph 27.1. The provisions of GRA 3.2 that are most relevant to the hazards encountered at Grenfell Tower were identified in the Phase 1 report.590 Phase 1 Report Volume IV paragraph 27.3. In summary, they relate to planning, training and competence, and the provision of fire survival guidance.
¶77.2 Individual fire and rescue services are obliged to have regard to national guidance when carrying out the risk assessments which underpin their operational policies.591 {LFB00001255/7}. The LFB's policy on high-rise firefighting was PN633; the version published in June 2015 was in force at the time of the Grenfell Tower fire.592 {LFB00001256}.
The review of Generic Risk Assessment 3.2
¶77.3 The second version of GRA 3.2 had been published in 2008, and in 2010 a review of the full GRA series was commissioned by DCLG and the Chief Fire and Rescue Adviser.593 {LFB00032783/6} paragraph 2.2.1. Although DCLG in conjunction with the Chief Fire and Rescue Adviser had final editorial control of the series as a whole, DCLG retained particular responsibility for the contents of GRA 3.2.594 Cowup {Day195/24:4-8}; Knight {Day245/146:10}-{Day245/148:11}. The review process began in 2010 and culminated in a revised version published in 2014.595 {HOM00002128}. DCLG delegated the management of the review to Surrey Fire and Rescue Service under the terms of a memorandum of understanding,596 {HOM00050078}. but oversaw the process through a strategic management board established for the purpose.
¶77.4 The review of GRA 3.2 was given priority over the work on other Generic Risk Assessments because it was thought that important insights had been gained into fighting fires in high-rise buildings as a result of the experience at Lakanal House.597 Cowup {Day195/22:23}-{Day195/23:6}; {Day195/39:20}-{Day195/40:25}. In March 2011 the LFB was appointed to lead the work on GRA 3.2; no other fire and rescue service was involved in the drafting.598 Cowup {Day195/20:9-19}. The LFB was seen as the appropriate organisation to take on that role because much of the learning that needed to be incorporated into the guidance had been derived from the Lakanal House fire.599 Cowup {Day195/41:16-24}. The close involvement of the LFB in the revision of GRA 3.2 gave it a unique opportunity to gain a deep understanding of the risks to which firefighters and members of the public may be exposed in such situations, particularly in buildings that have been constructed using novel products and modern materials and methods of construction. It is therefore worth considering in a little detail the way in which the revision of GRA 3.2 proceeded and the extent to which the guidance it contained was reflected in the revision of the LFB's own policy on fighting fires in high-rise buildings.
94¶77.5 Within the LFB, DAC Cowup was given primary responsibility for producing the revised version of GRA 3.2 with support from members of the Operational Policy department.600 Cowup {Day195/91:4-16}. In December 2011, he and his team produced a draft revised version of GRA 3.2,601 Cowup {LFB00119849/37} page 37, paragraph 82. which was then the subject of a regional and national consultation until September 2012.602 Cowup {LFB00119849/51} page 51, paragraph 115. The draft was revised during the course of that process to reflect some of the responses that had already been received. At that stage, DAC Cowup was confident that it fully reflected the lessons to be learnt from the Lakanal House fire, subject to the findings of the inquests which were due to start in January 2013.603 Cowup {Day195/133:20}-{Day195/134:3}.
¶77.6 The draft produced during the consultation period contained new sections on evacuation and handling fire survival guidance calls. It contained the same direction to the incident commander to follow any evacuation plan devised as part of the occupier's fire risk assessment,604 {LFB00033886/25}. but there was no express reference to the potential need to carry out an evacuation of a residential building with a "stay put" strategy. In particular, the oblique reference to the "stay put" principle did not accurately reflect the national guidance that residents are usually safest remaining in their property unless affected by fire, heat or smoke (whatever the source).605 {LFB00033886/25}; {HOM00001124/4}; {LFB00001257/2} paragraph 2.2. There was also no reference to the need to re-evaluate the advice being given to callers during the course of an incident or to the possibility that "stay put" advice might have to be reversed.
¶77.7 DAC Cowup did not accept that he and his team had failed to consider the potential need to revoke "stay put" advice during the course of an incident at a residential high-rise building. On the contrary, he said that they had recognised that it was one of the lessons of the Lakanal House fire. Although he accepted that the draft was not as explicit as it might have been, he thought that people would have understood that to be necessary, having seen the reference to the need to change the evacuation strategy if and when the situation made it appropriate.606 Cowup {Day195/113:4-18}.
¶77.8 Following the Lakanal House inquests, DAC Cowup was provided with copies of the coroner's rule 43 letters to the LFB and DCLG, which contained recommendations relating to section 7(2)(d) visits and incident command training. He examined them to ensure that all the points raised in the letters had been covered in the draft revision of GRA 3.2.607 Cowup {Day195/182:20-25}. That exercise resulted in further changes to the text, but he did not think that any substantial amendments were required.608 Cowup {Day195/187:7-19}; {LFB00102462}.
¶77.9 The section relating to handling fire survival guidance calls was changed, however, by the addition of a direction to re-evaluate the caller's situation from time to time to ensure that the balance of risk between leaving the building and remaining in place was reconsidered as circumstances changed.609 {LFB00102462/2}. Those amendments had in fact been suggested by GM Michael Curran, in an email sent to DAC Cowup on 18 March 2013 {LFB00090754}. An amendment to that effect was ultimately included in the published version of GRA 3.2 and was also incorporated into the edition of PN633 published in 2015.610 {LFB00001255/20}; {LFB00001256/14}. The oblique reference to the "stay put" principle was also changed so that it was consistent with the advice contained in national guidance and PN790,611 {LFB00102462/3}. but no reference was made to the potential need to carry out an evacuation of a high-rise residential building with a "stay put" strategy.
95¶77.10 In his response to the coroner's rule 43 letter to his department, the Secretary of State for Communities and Local Government had given a clear undertaking that the revised version of GRA 3.2 would include advice to incident commanders to help them make decisions on evacuation if it became clear during an incident that a "stay put" strategy was no longer tenable.612 {HOM00047743/2}. DAC Cowup could not recall having seen the Secretary of State's letter.613 Cowup {Day195/191:3}-{Day195/192:22}. None of the witnesses who gave evidence to the Inquiry, including those who had worked for DCLG at the time, was able to explain why that was so, despite the letter's obvious relevance to the work on GRA 3.2.
¶77.11 After the Lakanal House inquests ended in March 2013, DCLG officials became involved in the review of GRA 3.2 at what was intended to be the final stage of the preparation of the revised version for publication. Their involvement led to the incorporation of much of the significant new content, including provisions on the need for an evacuation plan and for incident commanders to be able to evacuate buildings with "stay put" strategies.
¶77.12 On 19 June 2013, representatives of the LFB and DCLG met to put the finishing touches to the draft. No one raised any concerns about the text.614 Cowup {Day195/195:18-23}. The draft GRA 3.2 was sent by Les Britzman, who was part of the Chief Fire and Rescue Adviser's team, to Louise Upton, Peter Holland, Brian Martin, Dawn Eastmead, and others within DCLG, on 9 May 2013 {CLG00001921/2}. Following that meeting, however, the draft was reviewed by other officials within DCLG and significant comments were made by Louise Upton, the Head of Fire Safety Policy. In her evidence, Ms Upton said that she had previously known nothing about the review of GRA 3.2, apart from the commitment made in the Secretary of State's letter and having occasionally received various versions of the draft.615 Upton {Day248/61:22-24}; {Day248/100:4-7}. Possibly as a result of her distance from the subject matter, Ms Upton drew attention to significant defects in the treatment of the "stay put" principle and other important aspects of firefighting in high-rise buildings. In an internal email sent to a number of her colleagues on 1 July 2013 she concentrated on the extent to which the document satisfied the Secretary of State's undertaking that the revised version of GRA 3.2 would include advice to incident commanders to help them make decisions about evacuation.616 {CLG00000624}. In a later internal email sent on 29 July 2013 she expressed the view that a more fundamental review of the document was required. She referred to the work done by the LFB since the Lakanal House fire to revise its own operational guidance and considered it odd that the revised draft GRA 3.2 did not appear to reflect the lessons learnt by the LFB as a result of that fire.617 {CLG10005807}. In saying that, she clearly thought that the LFB had given consideration to the potential need to evacuate a high-rise residential building.618 Upton {Day248/85:3-19}.
96¶77.13 Another meeting took place on 30 July 2013 to discuss Louise Upton's concerns. It was attended by DAC Cowup and Philip Morton from the LFB, Les Britzman (a member of the Chief Fire and Rescue Adviser's team) and Anthony Maude of DCLG and Leigh Brinton, an employee of Surrey Fire and Rescue Service, who was also involved in the review of GRA 3.2.619 Cowup {Day196/10:11-16}; {Day195/151:19}-{Day195/152:6}. Louise Upton did not attend the meeting because she did not consider that she could contribute on matters relating to operational firefighting. She believed that her concerns would be voiced by Les Britzman.620 Upton {Day248/86:3-15}.
¶77.14 At the meeting Mr Britzman led the discussion, which concentrated on the treatment of the "stay put" principle.621 Cowup {Day196/12:1-11}. According to DAC Cowup, that was the first time that questions of that kind had been raised by DCLG and he had been deeply frustrated by the fact that substantive changes were being proposed at such a late stage.622 Cowup {Day196/12:15-25}; {Day196/13:11-20}. Nonetheless, his understanding was that the changes were minor rather than fundamental; DCLG did not tell him that he needed to start again.623 Cowup {Day196/14:2-19}. He said that he had not become aware of DCLG's concern that the draft did not meet the Secretary of State's commitment to the coroner until he was preparing to give evidence.624 Cowup {Day196/86:22}-{Day196/87:3}. Although the point may not have been made to DAC Cowup with the same clarity as it had been made in Ms Upton's emails, the correspondence following the meeting on 30 July 2013 made clear the department's desire for greater clarity about, and greater emphasis on, the advice to incident commanders about evacuation in order to fulfil the commitment given by the Secretary of State to the coroner.625 {LFB00102486/2}.
¶77.15 Following the meeting on 30 July 2013, DAC Cowup and his team made further changes to the draft626 {LFB00052471}. by adding passages on the need to re-evaluate "stay put" advice during the course of an incident and to change it if circumstances made that necessary (both points that had been identified by DAC Cowup in his response to the coroner's rule 43 letters).627 {LFB00034198/29}; {LFB00057988}. However, the draft still did not mention the need for incident commanders to understand when to carry out an evacuation of a building with a "stay put" strategy or to the need for there to be an evacuation plan if a "stay put" strategy became untenable.
¶77.16 Notwithstanding those revisions, DCLG continued to have misgivings about the draft. On 15 October 2013, Louise Upton said in an email to Les Britzman and others at DCLG that her earlier concerns appeared not to have been particularly well addressed in the revised version.628 {CLG00002780}. She sent a large number of comments on the draft document to Mr Britzman, including a reference to the need for contingency plans to provide for evacuation,629 {CLG00002781/16}. but they were not sent on to DAC Cowup.630 Cowup {Day196/60:6-9}. The substance of Ms Upton's comment on the need for an evacuation strategy was ultimately retained in the published version of GRA 3.2.
97¶77.17 Ms Upton's comments also included a reference to the need for training to give incident commanders an understanding of when a full or partial evacuation of a residential building subject to a "stay put" strategy might be necessary.631 {CLG00002781/19-20}. Again, her comment ultimately appeared in the published version of GRA 3.2 in substantially the same terms.
¶77.18 Following various discussions, and notwithstanding DCLG's reservations, the decision was taken to publish the revised GRA 3.2 without any further substantive amendments. The decision followed a conversation between Commissioner Dobson and Peter Holland,632 Cowup {Day196/106:2-10};{Day196/108:21}-{Day196/109:2}; {HOM00043991/3}. Chief Fire and Rescue Adviser, who, DAC Cowup recalled, had also been of the view that they should move towards publication.633 Cowup {Day196/107:15-19}. Within DCLG, however, the document was described by some as a wasted opportunity and "not fit for purpose".634 {HOM00043991/2}.
¶77.19 Be that as it may, GRA 3.2 in its final form clearly contemplated that the total evacuation of a high-rise building should be an important part of any fire and rescue service's contingency plan for a building and that incident commanders should not assume that compartmentation would invariably be maintained.635 Phase 1 Report Volume IV paragraphs 27.2 and 27.3.
Review and amendment of PN633
¶77.20 In November 2011, the LFB published a revised version of PN633 which reflected changes to the policy considered necessary in the light of the Lakanal House and the Shirley Towers fires.636 {LFB00102306}. DAC Cowup described it as a comprehensive revision.637 Cowup {LFB00119849/84} page 84, paragraph 187. However, the revised policy contained no reference to the need to make contingency plans for evacuating the whole building, although crews visiting buildings pursuant to section 7(2)(d) of the 2004 Act were directed to have regard to the risk of fire spreading beyond the compartment of origin and the possible need for multiple rescues.638 {LFB00102306/15}. There were references to evacuation throughout the policy, including a direction that the incident commander should follow the evacuation plan devised as part of the occupier's fire risk assessment unless the situation dictated otherwise,639 {LFB00102306/12}. but there was no reference to the possibility that a building with a "stay put" strategy might need to be evacuated or indeed any explicit reference to the "stay put" principle at all.
¶77.21 The LFB's review of PN633 to bring it in line with the revised GRA 3.2 began in early 2013. DAC Cowup asked GM James A'Court, then part of the Operational Policy department, to co-ordinate it.640 {LFB00085313}. GM A'Court asked SM Patrick Utting, then part of the Incident Management team, to take the lead on drafting the revised policy.641 {LFB00086677}. DAC Cowup expected GM A'Court and SM Utting to keep him informed about any revisions to the draft GRA 3.2 as work went on and take them into account. He also expected them to have regard to any lessons arising out of the Lakanal House inquests, which had recently begun.642 {LFB00085313}; Cowup {Day196/143:8}-{Day196/141:15}.
98¶77.22 DAC Cowup told SM Utting that transposing the relevant elements of GRA 3.2 into LFB policy was likely to be a relatively straightforward task.643 Cowup {Day196/146:18}-{Day196/147:9}; Utting {Day198/12:23}-{Day198/13:4}. He did not recall specifically asking SM Utting to consider the coroner's rule 43 letters and SM Utting confirmed that he had not been asked to consider them as part of his work.644 Cowup {Day196/147:15-20}; Utting {Day198/16:9-18}. SM Utting was similarly unaware of the contents of the Secretary of State's response to the coroner or of his commitment to including in the revised GRA 3.2 advice to incident commanders to inform decisions on evacuation.645 Utting {Day198/55:17}-{Day198/57:6}.
¶77.23 The version of PN633 produced in 2015 was neither as clear nor as comprehensive as GRA 3.2. In particular, both the risk assessment and the gap analysis that SM Utting had produced for the purpose of his review of PN633 were based on an earlier draft of GRA 3.2 that pre-dated Ms Upton's comments in relation to "stay put" and evacuation.646 Utting {LFB00121173/2} page 2, paragraph 5; {LFB00121174}; {LFB00030368}; Utting {Day198/94:21}- {Day198/95:19}. Further, neither of them contained any reference to cladding as a feature that crews should consider when gathering information, despite its being referred to in both the 2008 and the 2014 editions of GRA 3.2. There was no satisfactory explanation why the revised PN633 did not fully or accurately reflect the 2014 edition of GRA 3.2 on these important points.
¶77.24 In the section dealing with competence and training GRA 3.2 advised that incident commanders should understand when an evacuation strategy might become necessary in a residential building where a "stay put" strategy is normally in place. That was transposed into paragraph 7.46 of PN633 and to that extent, therefore, the policy did reflect a recognition that compartmentation may fail and that the incident commander may need to carry out a partial or total evacuation of a building subject to a "stay put" strategy.647 Phase 1 Report Volume IV paragraph 27.6. However, no guidance was provided about when or how a decision of that kind should be made. SM Utting doubted whether it was feasible to include in a policy advice that would apply in all situations.648 Utting {Day198/47:21}-{Day198/48:16}. That may be so, but it does not explain why no attempt was made to identify factors that might indicate to an incident commander that "stay put" advice should be withdrawn and an evacuation of some nature carried out. In those circumstances, it is not surprising that PN633 did not refer to the need to train incident commanders to recognise the need to withdraw "stay put" advice and carry out an evacuation.649 Utting {Day198/66:3-12}. but no request for training was initiated in conjunction with the revision of PN633.650 The Inquiry received no evidence to indicate that any training had been developed for the 2015 edition of PN633, and neither DAC Cowup nor SM Utting were able to confirm otherwise: Cowup {Day197/29:18-23}; Utting {Day198/91:2-18}. As Commissioner Roe accepted, at the time of the Grenfell Tower fire the LFB did not provide any guidance or direction in either its training or its policies about when and how a "stay put" strategy should be reversed.651 Roe {LFB00083834/7-8} pages 7-8, paragraphs 28 and 29.
¶77.25 The guidance in GRA 3.2, to the effect that contingency plans for individual premises should cover the spread of fire beyond the compartment of origin and the possible need for multiple rescues, found its way into paragraph 4.8 of PN633, but without any specific reference to the need for a contingency plan. There was no reference to the need for an operational evacuation plan that could be implemented if a "stay put" policy became untenable.652 {LFB00001255/19}. SM Utting was unable to explain why that particular aspect of GRA 3.2 had not been incorporated into PN633.653 Utting {Day198/60:13-25}-{Day198/61:2}. DAC Cowup told us that he had understood the phrase "contingency plans" in GRA 3.2 to relate only to high-risk premises, such as national heritage sites or landmark high-rise buildings, and that it would not be practicable to have individual contingency plans for every high-rise building in London.654 Cowup {Day195/55:9-25}; {Day195/56:16-25}. SM Utting expressed a similar view.655 Utting {Day198/58:3-15}. However, that is not the natural meaning of the expression as it appears in GRA 3.2, where it appears to refer to all high-rise buildings. Although it might not have been practicable to require crews to draw up individual contingency plans for all high-rise buildings, GRA 3.2 required fire and rescue services to consider generally whether and how contingency plans could assist crews and incident commanders. The stark conclusion is that PN633 did not properly reflect the requirements of GRA 3.2 in that respect.
99Conclusions
¶77.26 The history of the revision of GRA 3.2 and the review of PN633 is of interest primarily for the light it sheds on the attitude of the LFB to the need to prepare for the evacuation of high-rise residential buildings subject to a "stay put" policy. The need to prepare contingency plans for an evacuation was included in GRA 3.2 as a result of the insistence of officials at DCLG rather than at the instigation of the LFB. The review of PN633 failed fully to reflect the current version of GRA 3.2, possibly because those at the LFB responsible for it did not think that the LFB needed such detailed advice and guidance or possibly because they did not attach sufficient importance to it. Whatever the reason, the close involvement of the LFB in the revision of GRA 3.2, coupled with the critical intervention of officials at DCLG, should have made it clear that producing contingency plans for a full evacuation was an essential part of fighting fires in high-rise buildings. Regrettably, however, that message was not properly absorbed by senior managers, and as a result operational firefighters were not properly prepared to deal with another major failure of compartmentation when it eventually occurred at Grenfell Tower.
101Chapter 78: The control room
¶78.1 The Grenfell Tower fire presented the control room and all those who worked there with a challenge of unprecedented proportions. All those present on that night did what they could to deal with the huge volume of emergency calls and to pass vital information to the incident ground. However, mistakes were made, as described in the Phase 1 report, mainly as a result of inadequate training. It was therefore important for us to examine the way in which the control room had been run and its staff trained in the years immediately preceding the fire, to ensure, as far as possible, that a similar situation does not arise in the future.
Structure and management
¶78.2 The control room lies at the heart of the LFB's response to fires and other unexpected events as a result of which people's lives are at risk. It takes emergency calls from the public, despatches fire appliances to incidents and maintains communications with the incident ground. A description of its organisation and method of operation at the time of the Grenfell Tower fire is contained in chapter 7 of the Phase 1 report.
¶78.3 It is important to note at the outset that control room officers (CROs) are not merely call-handlers. As part of responding to emergency calls, they provide fire survival guidance when circumstances require. When providing fire survival guidance, a CRO becomes a first responder, giving critical advice to someone facing a life-threatening situation. Their role is, therefore, complex and proper performance of their functions is critical to the effective operation of the LFB. It depends on effective management of the organisation and the maintenance of critical skills through regular training.
¶78.4 Before 2015, responsibility for the operation of the control room lay with the Operational Prevention and Response department, itself part of the Deputy Commissioner's directorate.656 Dexter {LFB00032363/2} page 2, paragraphs 4 and 5. When in 2015 the Deputy Commissioner's directorate was abolished, that responsibility was transferred to the newly formed Directorate of Operations.657 Brown {LFB00032166/3-4} pages 3-4, paragraphs 5 and 9; George {LFB00032823/2} page 2, paragraph 6. From 2015 until 2017, the Director of Operations was AC Brown. From March 2017, AC George took over as Director of Operations.
¶78.5 Until 2011, CROs were divided into four watches covering two shifts within a 24-hour period.658 Lakanal Control Report {HOM00001124/7} paragraph 21. Each watch comprised 16 CROs and seven senior control officers under the command of a control commander.659 Lakanal Control Report {HOM00001124/8} page 8, Chart 1. Two senior operations managers (SOMs) managed two watches each and held certain other responsibilities which are discussed below. From 2010, the two SOMs were SOM Joanne Smith and SOM Lindsay Turner.660 Smith {LFB00121219/2-3} pages 2-3, paragraph 7. Following the fire, Joanne Smith was promoted to the rank of Deputy Assistant Commissioner and gave her evidence while holding that rank. At all material times she was a Senior Operations Manager and so, for clarity and consistency with the contemporaneous documentation, she will be referred to in that rank in this report. They were supported by assistant operations managers (AOMs). In overall command of the control room was the principal operations manager (POM), Scott Hayward.
102¶78.6 In addition to the watches staffing the control room, there were two support teams, each led by one of the SOMs. SOM Smith led the Technical Support Group, made up of one OM and two AOMs. SOM Turner led the Training team, made up of one OM and three AOMs. The Technical Support Group was responsible for ensuring that the systems used by the control room, including the mobilising system, were suitable for their purpose and capable of carrying out the functions required to enable CROs to do their work.661 Smith {LFB00121219/2-3} pages 2-3, paragraph 7, Smith {Day202/9:2-16}; Hayward statement {LFB00055191/17} page 17, paragraph 49. The Training team was responsible for developing core training and delivering it to CROs.662 Hayward {LFB00055191/17} page 17, paragraph 49; Lakanal Control Report {HOM00001124/8} paragraph 22. Its members were full-time trainers, although they were not trained as such. All of them were experienced CROs.663 SM Kelly's training audit report {LFB00055220/4} paragraph 9.
¶78.7 In April 2011, the shift pattern was changed. Instead of operating two shifts over 24 hours, CROs worked one of four shifts: a 12-hour day or night shift, or one of two overlapping 'short' shifts of eight hours.664 The operation of the shifts and the impact of the shift system on the time available for training is covered in more detail below. The shift times and watch numbers, together with the minimum staffing numbers, are set out in tabular form in POM Hayward's first witness statement: {LFB00055191/5} page 5, paragraphs 15-17
¶78.8 At about the time that the shift pattern was changed, the Technical Support Group and the Training team were merged to form a single team known as the Operational Support Team.665 Hayward {LFB00055191/17-18} pages 17-18, paragraph 49. Smith {LFB00121219/3} page 3, paragraph 7. Although the rest of the control room operated a shift system, the Operational Support Team, as a support body, operated only during the day shift.666 Smith {Day202/13:22-24}. The Operational Support Team trained CROs while the latter were 'on watch', i.e. when their watch was on duty, but during periods when they were not required to undertake control room duties.667 Hayward {LFB00055191/18} page 18, paragraph 52. Training was occasionally provided to CROs outside normal working hours.
¶78.9 The newly formed Operational Support Team contained five AOMs, later reduced to four.668 Hayward {LFB00055191/17-18} pages 17-18, paragraph 49. Within the Operational Support Team, the members of the former Technical Support Group retained their previous responsibilities and continued to report to SOM Smith.669 Smith {LFB00121219/3} page 2-3, paragraph 7. Those officers responsible for training reported to SOM Turner.670 Smith {LFB00121219/3} page 2-3, paragraph 7. SOM Smith said that following the merger no one person had been formally placed in charge of the Operational Support Team and that she and Lindsay Turner had shared that responsibility.671 Smith {Day202/15:15-18}.
¶78.10 In September 2012, SOM Smith was seconded to the Chief Fire Officers Association.672 Smith {LFB00121219/3} page 3, paragraph 8. At around the same time, SOM Turner left the control room for medical reasons.673 Hayward {Day200/189:11-21}. As a result, Victor Bagnelle and Keith Diamond were temporarily promoted to SOMs, replacing SOM Smith and SOM Turner respectively.674 Bagnelle {LFB00122821/2} page 2, paragraph 6; Smith {LFB00121219/3} page 3, paragraph 8.
¶78.11 In 2015, the LFB changed its mobilising system from one known as 'ProCAD' to a system known as 'Vision 4DS'. The introduction of a new mobilising system meant that between 2013 and 2015 the Operational Support Team had to design, prepare and deliver intensive training to enable the CROs to use it.675 Hayward {LFB00055191/19-20} pages 19-20, paragraph 56-60.
103¶78.12 In January 2015, SOM Smith returned from her secondment and assumed overall responsibility for the Operational Support Team.676 Smith {LFB00121219/4} page 4, paragraph 9. She continued to hold that responsibility until January 2020.677 Smith {LFB00121219/4} page 4, paragraph 9.
Senior officers and lines of responsibility
¶78.13 POM Hayward was in day-to-day command of the control room and reported directly to an Assistant Commissioner. Inevitably, the position held by that Assistant Commissioner within the LFB structure varied over time.678 Lakanal Control Report {HOM00001124/7} page 7, paragraph 19. For present purposes, it is sufficient to say that between 2009 and 2016 (apart from the period between May 2012 and October 2013 when the control room was commanded by its own Assistant Commissioner, AC Richard Chandler) POM Hayward usually reported to AC Brown, who had a broad range of other responsibilities. It was not until the appointment of AC George as Head of Operational Response in March 2016 that the control room once again had the benefit of its own Assistant Commissioner.
¶78.14 In December 2015, a few months before his appointment as Assistant Commissioner and Head of Operational Response, AC George was asked by AC Brown to lead what he described as a "cultural review" of the control room and its position within the organisation.679 George {Day205/10:1-2}; George {LFB00032823/4} page 4, paragraphs 13 and 15. In his role as Head of Operational Response, AC George was also responsible for the operation of the control room and mobilising, the operation of the Resource Management and Logistics Centre and the UK Fire and Rescue Services' National Co-ordination Centre.680 George {Day205/11:3-16}. He was also POM Hayward's line manager. AC George agreed that during that period POM Hayward had run the control room on a day-to-day basis, although he knew that AC George wanted to be kept informed about the type of decisions he was making.681 George {LFB00032823/4} page 4, paragraph 16; George {Day205/15:6-11}. AC George was also ultimately responsible for the delivery of training to CROs.682 George {Day205/22:1-5}. AC George knew that POM Hayward had delegated responsibility for training to SOM Smith and was content with that.683 George {Day205/21:2-10}. He explained that he had satisfied himself that it was an appropriate and effective step and had considered SOM Smith a very professional and experienced officer.684 George {Day205/21:11-23}. As Head of Operational Response, AC George reported directly to AC Brown.685 George {Day205/4:20-22}.
¶78.15 In April 2017, AC George succeeded AC Brown as Director of Operations.686 George {LFB00032823/10} page 10, paragraph 39. He was not replaced as Head of Operational Response, a position that ceased to exist.687 George {LFB00032823/10} page 10, paragraph 39. Although AC George retained responsibility for managing POM Hayward, he delegated all matters relating to the management of the control room to him.688 George {LFB00032823/10} page 10, paragraphs 39 and 42.
¶78.16 Following the Grenfell Tower fire, the management structure of the control room changed. In late 2018 or early 2019, AC George decided that a more senior officer needed to take over the day-to-day management of the control room.689 George {Day205/108:19-23}. POM Hayward was made redundant and Commissioner Cotton appointed AC Jonathan Smith as a new AC Operational Resilience and Control.690 George {Day205/108:21}-{Day205/109:4}. Hayward said that he left Brigade Control in July 2019: Hayward {Day199/5:1-3} and Hayward {LFB00086213/2} page 2, paragraph 7. Jonathan Smith {LFB00121171/4} page 4, paragraph 7. On 1 January 2021, SOM Joanne Smith was promoted to the newly created position of DAC for Control and Mobilising, reporting to AC Jonathan Smith.691 Smith {LFB00121219/2} page 2, paragraph 6; Smith {Day202/6:8-15}.
104Management meetings
¶78.17 Control room staff held regular meetings, usually monthly, which were attended by all staff other than the CROs.692 Hayward {Day199/27:20-23}. Although AC Chandler regularly attended those meetings, AC Brown and AC George did not.693 AC Chandler is recorded as attending or sending apologies to at least 6 meetings between 8 July 2012 and 9 November 2013. AC George is recorded as attending only part of the meeting on 8 March 2016 {LFB00123152/1} by way of an introduction to the staff. AC Brown considered that, as they were meetings of middle managers, it was for the POM and SOMs to manage them.694 George {Day205/13:2-5}.
¶78.18 POM Hayward regarded the meetings as an opportunity to discuss matters generally and inform the watch managers about any changes in the work.695 Hayward {Day199/27:16-19}. He also said that he would use them as a barometer to gauge whether there were any negative comments about training.696 Hayward {Day199/32:19} – {Day199/33:1} and Hayward {Day199/50:20} – {Day199/51:13}.
¶78.19 For a long time, POM Hayward reported to AC Brown as his line manager. AC Brown said that he used a variety of methods to monitor the performance of the control room and the way in which it was being managed. As Director of Operations he chaired a monthly Principal Management Board meeting of the area DACs, which he encouraged POM Hayward to attend,697 Brown {Day206/42:19-25}. but it appears that matters relating to the control room arose only occasionally and even then represented a relatively small part of what was discussed.698 See for example Principal Management Board Meeting draft minutes, 18 December 2013 {LFB00032168/5} where there the only involvement of Brigade Control is in relation to item 3.7 concerning the Lakanal Rule 43 Letter and item 4.3 regarding a report on a Radio MDT trial. He also met Scott Hayward once between each of those meetings, so that they met about every two weeks.699 Brown {Day206/42:25}-{Day206/43:4}. They also saw each other at meetings relating to one of the other areas for which AC Brown had strategic responsibility, if the subject matter affected the control room.700 Brown {Day206/43:4-10}. As an example, AC Brown referred to meetings concerning the Vision mobilising system.
¶78.20 AC Brown did not exercise any particular oversight over the training of CROs701 Hayward {Day199/37:16-18}; Brown {Day207/22:11-12}. because he considered that they were highly managed, in the sense that the control room contained approximately the same number of staff as a large fire station but a much higher proportion of managers.702 Brown {Day207/22:13-21}; Brown {Day207/11:4-20}.
The identification of remedial measures
¶78.21 The Lakanal House fire was a particularly significant event for the control room. The Lakanal House Board identified 13 pre-inquest actions relating to the control room, the most important of which for present purposes were those concerning a review of national guidance and LFB policy on providing fire survival guidance,703 The actions are set out in detail in the Lakanal Assurance Report {LFB00004801/12-15} Pre-Inquest actions 5 and 13. the training of CROs and their supervisors,704 Lakanal Assurance Report {LFB00004801/13-16} Pre-Inquest actions 8, 11, 12, 16 and 17. amendments to LFB Policy No. 539 (PN539) on emergency call-handling,705 Lakanal Assurance Report {LFB00004801/14} Pre-Inquest action 10. the creation of a policy (Policy No. 790 (PN790)) on handling fire survival guidance calls,706 Lakanal Assurance Report {LFB00004801/15} Pre-Inquest action 14. and amendments to the Reference Information Files (RIFs).707 Lakanal Assurance Report {LFB00004801/13} Pre-Inquest action 9.
105¶78.22 AC Brown was given responsibility for carrying out the pre-inquest actions,708 Hayward {Day199/146:2-7}; Minutes of Lakanal House Board on 15 September 2010 {LFB00055192/7-8} Appendix 1; Brown {LFB00032166/5-6} pages 5-6, paragraph 14. a task which he delegated to POM Hayward, although he provided him with support and met him from time to time to monitor progress.709 Brown {Day206/72:23-25}; Brown {LFB00084020/6} page 6, paragraph 10; Brown {Day206/73:6-16}. He was also received reports from DAC Cutbill who was a part of the Lakanal House action team: Brown {Day206/73:6-16}. POM Hayward did not ask AC Brown for additional resources to carry out the work.710 Brown {Day206/73:17-24}.
Policy and guidance – the gap analysis
¶78.23 Action 5 of the pre-inquest actions was the production of a gap analysis to identify any differences between national guidance on handling fire survival guidance calls and PN539.711 Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/12}; Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/7-24}. The analysis was fundamental to shaping the control room's response to the Lakanal House fire.
¶78.24 The gap analysis had been completed by April 2010. It was produced by POM Hayward in conjunction with SOM Smith, DAC Cutbill, who was leading the investigation into the Lakanal House fire, and Thomas Davies, a member of the LFB's legal department.712 Hayward {LFB00055191/6} page 6, paragraph 20, first bullet point; Hayward {LFB00086213/2-3} pages 2-3, paragraphs 10-12; Smith {LFB00121219/9} page 9, paragraph 20; Email from SOM Smith to DAC Cutbill, POM Hayward, Thomas Davies and GM Zymanczyk on 2 February 2010 {LFB00118272}. SOM Turner, SM Hams and GM Zymanczyk also contributed to the first draft.713 Email from SOM Turner to DAC Cutbill and SM Hams copying in POM Hayward on 17 November 2009 {LFB00082629}; Email from SOM Turner to SM Hams on 19 November 2009 {LFB00075090}; Email from SOM Smith to DAC Cutbill, POM Hayward, Thomas Davies and GM Zymanczyk on 2 February 2010 {LFB00118272}. The analysis involved a comparison between two national guidance documents on the training of control room staff and the LFB's policy on emergency call management and its training materials on fire survival guidance.714 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/7-24}; Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/12}. The report made recommendations designed to address deficiencies identified in both national guidance and LFB policy and training.715 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/7-24}.
¶78.25 Although it is not clear whether the recommendations in the gap analysis were formally approved by the Lakanal House Board, some of the gaps that had been identified and some of the resulting recommendations gave rise to further pre-inquest actions intended to address them.716 Brown {Day206/79:5-9}; POM Hayward recalled that the gap analysis recommendations were accepted by the Lakanal House Board: {Day199/170:19-24}. However, the minutes of the meetings on 7 April, 5 May 2010 and 22 June 2010 do not make that clear: {LFB00060782/2}; {LFB00084028/3}; {LFB00055208/2-3}. That was certainly the case for the following recommendations:
106¶a. To include contributions from fire safety officers in training on handling fire survival guidance calls to make it consistent with national guidance.717 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/12} see 'Recommendations'. b. To amend PN539 to ensure that it reflected or complied with national guidance.718 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/8}; {HOM00001125/16} see 'Recommendations'. c. To carry out refresher training on handling fire survival guidance calls.719 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/23} see 'Recommendations'.
¶d. To improve certain points in national guidance on training on handling fire survival guidance calls.720 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/8}; {HOM00001125/11-20}; {HOM00001125/24}.
¶e. To establish a procedure for continuous communication between the control room and firefighters.721 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/21}. f. To audit training arrangements for the control room.722 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/24}.
¶g. To review LFB policy to ensure that it recognised the need to train supervising officers to provide support for CROs handling fire survival guidance calls.723 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/23}.
¶78.26 Although the RIFs used by CROs when handling fire survival guidance calls were not specifically addressed in the gap analysis, SOM Smith said that they had used the findings of the gap analysis to revise the RIFs after the Lakanal House fire.724 Smith {Day202/105:22-25}; Action Plan appended to the minutes of the meeting of the Lakanal House Board on 15 September 2010 {LFB00084031/8}; Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/13-14}.
¶78.27 On 8 December 2004, the government issued Fire and Rescue Service Circular 54-04 on 'Emergency Call Management' (FSC 54-04).725 FSC 54/04{LFB00055201/1}. It provided advice and a description of good practice developed jointly by the Chief Fire Officers Association and HM Fire Service Inspectorate to assist effective emergency call‑handling by fire and rescue services.726 FSC 54/04{LFB00055201/1}. It was produced following a review of emergency call‑handling which they had commissioned jointly in 2001.727 FSC 54/04{LFB00055201/2-3}. One of the review's objectives was to review existing guidance on handling emergency calls (including fire survival guidance calls).728 FSC 54/04{LFB00055201/2-3}.
¶78.28 The document summarised, in the form of national guidance, a three-stage approach to handling emergency calls with the objective of improving the way in which they were managed.729 Annex A of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/10}. Annex A set out a generic three-stage approach to call‑handling called the "Emergency Call Management Protocol".730 Annex A of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/7-12}. In summary, stage 1 involved obtaining information to assist the mobilising decision,731 Annex A of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/7-8}. stage 2 involved obtaining information to support continuous assessment and ensure the safety of everyone involved,732 Annex A of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/8-9}. and stage 3 was directed to ensuring the safety of the caller and members of the public.733 Annex A of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/9-10}.
107¶78.29 Annex D contained "Fire call prompts", which included various 'prompts' in relation to fire survival guidance calls to be used at stage 3 of the call-handling approach, as well as a warning that stages 1 and 2 might need to be revisited during stage 3.734 Annex D of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/16-17}.
¶78.30 FSC 54-04 did not supersede FSC 10-93, so the available national guidance was to be found in a combination of the two documents.735 Emails between Michele McHugh (LFB) and Howard Jones (CLG) on 17 February 2010 {LFB00056548}. The minutes of the meeting of the Lakanal House Board on 5 May 2010 record that "It has been confirmed with CLG it is not intended that 54/04 supersede 10/93. However, it was noted that 10/93 was not on the CLG's website, although it has now been confirmed as an extant document." {LFB00084028/3}. Despite that, the LFB excluded FSC 54-04 from the scope of its gap analysis.736 Hayward {Day199/158:25} – {Day199/159:1-2}; Smith {Day202/102:14-23}; Smith {LFB00121219/9} page 9, paragraph 21; Brown {Day206/82:14-18}. POM Hayward told us that FSC 54-04 had been discussed with DAC Cutbill and Thomas Davies at the time and that they had all considered that it did not need to be included737 Hayward {Day199/158:25}-{Day199/159:1-2}. because it was concerned with the use of scripts, which the control room did not use at that time.738 Hayward {Day199/158:9-18}. He also said that he did not think that FSC 54-04 added anything to the training described in FSC 10-93.739 Hayward {Day199/158:9-18}. SOM Smith said the same.740 Smith {Day202/102:14-23}. AC Brown did not believe that the decision had been discussed with him and he did not recall approving it.741 Brown {Day206/82:19-24}; Brown {Day206/88:18-21}; Dobson {Day211/140:12-20}.
¶78.31 Notwithstanding the view of PO Hayward that FSC 54-04 added nothing of substance to FSC 10-93, it is hard to reconcile the decision to exclude FSC 54-04 either with the purpose of the gap analysis or with the contents of FSC 54-04 itself. One of the stated aims of the emergency call‑handling review had been to review FSC 10-93 and the training package 'Keeping People Safe' which the Home Office had issued to complement it. ('Keeping People Safe' described the training requirements for CROs and set out a recommended programme of training).742 Lakanal Control Report {HOM00001124/14} paragraph 61. The express purpose of issuing FSC 54-04 had been to improve the handling of emergency calls.743 FSC 54/04{LFB00055201/2-3}; Annex A of FSC 54/04 entitled 'Emergency Call Management Protocol'{LFB00055201/10}. Moreover, it was expressly intended to provide national guidance.744 Annex A of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/10}. It is surprising, therefore, that it was excluded from an analysis which was specifically aimed at comparing LFB policy and training with existing national guidance. Nor was it simply about using scripts or prompts, as suggested by POM Hayward. It provided general guidance on managing emergency calls, including fire survival guidance calls.745 Hayward {Day199/158:9-18}. Finally, and most significantly, FSC 54-04 went beyond the guidance in FSC 10-93 and 'Keeping People Safe' in a number of important respects. For example, it advised CROs that when taking fire survival guidance calls they should positively assess the age, gender, ethnicity and any mental and physical disability of the caller.746 Annex D of FSC 54/04 entitled 'Emergency Call Management Protocol' {LFB00055201/17}. Although 'Keeping People Safe' referred to the possibility that a caller might be incapacitated, or unable to communicate effectively because of language difficulties or confusion, it did not encourage CROs to explore those matters as part of their assessment.747 'Keeping People Safe' training {LFB00118948/5}. Further, FSC 54-04 encouraged CROs continually to assess the caller's situation and review their initial assessment in the light of changing circumstances.748 Two of the stated objectives of stage two of the emergency call‑handling protocol were to "review assessment in light of further information" and to "continue to assess the call" {LFB00055201/8}. Annex D warned CROs that they might need to revisit stage one and two of the emergency call-handling protocol {LFB00055201/17}. Neither FSC 10-93 nor 'Keeping People Safe' provided or reflected that guidance.749 FSC 10/93{LFB00084051}; 'Keeping People Safe' training {LFB00118948/5}.
108¶78.32 FSC 54-04 should therefore have been included in the gap analysis. The fact that it had not been included was noticed in November 2012, when those drafting the Lakanal Control Report realised that the guidance in FSC 54-04 on handling fire survival guidance calls had been omitted from training materials. It was noticed again in January 2013 when GM Lindridge drew attention to it in his review of the pre-inquest actions. Yet, for no obvious reason, no action was taken to ensure that all relevant national guidance had been incorporated into LFB policy and training.
¶78.33 The Lakanal Control Report (dated November 2012) noted that, although some CROs handling fire survival guidance calls had tried to find out what was happening at different stages of the call, the importance of continual re-assessment had not been included in LFB training materials. Despite that finding, the Lakanal Control Report did not recommend that FSC 54-04 should be specifically referred to in the gap analysis or that a reference to the need continually to reassess the caller's situation should be incorporated into LFB training and policy.
¶78.34 On 14 January 2013, DC Dexter forwarded a copy of GM Lindridge's review to AC Brown, to which she had added her comments, and invited his response.750 Email from DC Dexter to AC Brown on 14 January 2013 {LFB00085853/1}. She asked why the gap analysis did not include any reference to FSC 54-04.751 GM Lindridge's review dated 4 January 2013 with DC Dexter and AC Brown's comments {LFB00085854/5}. On 16 January 2013, AC Brown provided her with his response, which he said he had discussed with GM Lindridge.752 Email from AC Brown to DC Dexter on 16 January 2013 {LFB00085853/1}. He said that, as FSC 54-04 only partially addressed fire survival guidance calls, and then only in relation to age, gender and disability, the analysis had concentrated on the requirements of FSC 10-93. However, he said that AC Chandler had been instructed to remedy the omission in November 2013.753 GM Lindridge's review dated 4 January 2013 with DC Dexter and AC Brown's comments {LFB00085854/5}.
¶78.35 In evidence AC Brown accepted that, because age, gender and disability were factors that might affect a caller's ability to escape from a fire, FSC 54-04 should have formed part of the original gap analysis.754 Brown {Day206/83:17-23}. However, it was also important that the guidance it provided in relation to those factors be included in LFB policy and training. In those respects, AC Brown's reply to DC Dexter understated the relevance and importance of FSC 54-04. His reply also failed to draw her attention to the guidance in FSC 54-04 that a CRO should continually reassess the caller's situation, guidance that had been identified in the Lakanal Control Report as missing from LFB training.755 Lakanal Control Report dated November 2012 {HOM00001124/50} paragraph 295. AC Brown said he believed that he had brought it to DC Dexter's attention during one of their regular meetings,756 Brown {Day206/85:4-10}. but in common with many similar assertions, we have seen no independent evidence that he did so.
109¶78.36 AC Brown said that the purpose of his reply to DC Dexter was just to confirm that he had asked AC Chandler to consider FSC 54-04 when GM Lindridge's review was revised.757 Brown {Day206/85:9-15}. AC Chandler was absent from work from late 2012 until April 2013. AC Brown said he could not remember whether AC Chandler had told him that POM Hayward would carry out the task in his absence or whether he had himself asked POM Hayward to do so,758 Brown {Day206/86:9-20}. but either way POM Hayward could not recall having received any such request.759 Hayward {Day199/164:5}-{Day199/165:1}.
¶78.37 When he revisited his review in November 2013 and May 2014, GM Lindridge again noted that FSC 54-04 had not been included in the gap analysis. He sought to justify its omission primarily on the basis that it did not seek to provide a full account of how fire survival guidance calls should be handled.760 GM Lindridge's review dated November 2013, as amended in May 2014 {LFB00083988/8}.
¶78.38 Although the exclusion of FSC 54-04 was apparently reconsidered, the gap analysis was not revised to include a comparison between LFB policy and training and FSC 54-04, despite AC Brown's assurance to DC Dexter that the omission would be remedied. The reasons given for not doing so are clearly unsound, because the purpose of the gap analysis was to compare LFB policy and training with national guidance and the guidance in FSC 54-04 on handling fire survival guidance calls clearly went beyond that contained in FSC 10-93 and 'Keeping People Safe'.
¶78.39 The failure to consider FSC 54-04 created a real risk that the guidance it contained, especially on assessing any impairments which might affect a caller's ability to leave and on continually reassessing the caller's situation, was not effectively reflected in LFB policy and training. As was found in the Phase 1 report, that risk materialised when PN539 was produced.761 Phase 1 Report Volume IV, paragraphs 29.45.e and 29.45.h.
¶78.40 The gap analysis was defective in two other significant respects: first, it failed to identify the fact that PN539 did not include the warning contained in FSC 10-93 about the dangers of offering false reassurance to a caller; secondly, despite having noted that FSC 10-93 and the LFB's training material did not emphasise the need for continual reassessment of the caller's situation, it failed to identify the fact that that guidance had also been omitted from PN539. We explore those defects and the likely consequences of them in relation to the revision of PN539 below.
¶78.41 FSC 10-93762 FSC 10/93 {LFB00003617/1}. and 'Keeping People Safe'763 'Keeping People Safe' training {LFB00118948/6}. both contained warnings that providing calming reassurance to callers trapped in buildings or otherwise exposed to danger could itself be dangerous. The gap analysis noted that FSC 10-93 acknowledged the possibility that an emotional bond might be formed between CROs and callers as calls progressed and emphasised that the relationship might be unhelpful because it might lead to callers' giving answers that they think CROs want to hear. CROs were therefore advised to exercise caution when offering reassurance to avoid giving callers a false sense of security. The gap analysis also noted that the LFB's training programme tended to encourage a strong attachment between callers and CROs by encouraging the use of reassuring phrases, which might have that effect.764 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/11}. It therefore recommended that LFB training reflect more closely the guidance in FSC 10-93 to prevent an emotional link being formed and false reassurance being given.765 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/11}.
110¶78.42 The gap analysis did not state whether PN539 dealt with the need for caution when offering reassurance to callers and therefore did not identify a gap or make any recommendation to amend PN539 in that respect. As it was, the version of PN539 dated 14 November 2007, which was current at the time, did not include a warning similar to that found in FSC 10-93 or 'Keeping People Safe'.766 PN539 dated 14 November 2007 {LFB00028382/20-21}. SOM Smith thought that that was because that guidance was to be delivered by the LFB through training rather than by policy,767 Smith {Day202/119:13-20}. but if that was the LFB's position, it was unreasonable. First, it does not explain why consideration of that aspect of PN539 was entirely omitted from the gap analysis. Secondly, it does not explain why the version of PN539 dated 14 November 2007 actively encouraged CROs to provide reassurance, including by the use of phrases such as "the firefighters will be with you very soon" and "I'm going to talk to you until the firefighters arrive", both of which might well promote a false sense of security.768 PN539 dated November 2007 {LFB00028382/21}. Thirdly, it ignored, or at least underestimated, the importance of PN539's stating clearly and fully the objectives and principles of, as well as the correct approach to, handling fire survival guidance calls. The clear and full expression of those principles would ensure that they would not be lost on anyone reading the policy (such as a CRO) and would provide a clear and comprehensive framework for training.
¶78.43 The failure to amend PN539 in those two respects was significant. As the chairman found in the Phase 1 report, PN539 had not been amended by the time of the Grenfell Tower fire and CROs invariably told callers that firefighters were on their way without having a sound basis for doing so.769 Phase 1 Report Volume IV, paragraph 29.45.f; Phase 1 Report Volume IV, paragraph 29.54.c. As a result, some callers were lulled into a false sense of security, remained in their flats and did not attempt to leave with sufficient vigour, or at all, despite the fact that escape was possible.770 Phase 1 Report Volume IV, paragraph 29.54.c.
¶78.44 The gap analysis also recommended that any revision of national guidance should contain advice to CROs to reassess the situation continually in order to be aware of changing conditions in the building and the caller's state of mind.771 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/14}. The basis for that recommendation is not entirely clear. The analysis failed to identify the fact that the current version of PN539 did not contain guidance that a CRO should continually reassess the caller's situation,772 PN539 dated 14 November 2007 {LFB00028382/20-21}. so it did not include an analysis of that aspect of the policy. POM Hayward said that it had been intended to amend PN539 in that way, but he could not explain why, if that had been the case, the gap analysis had not said so.773 Hayward {Day199/182:2-11}. SOM Smith could also not explain why: Smith {Day202/135:16-22}. That may explain why PN539 advised CROs to reassess the caller's situation, but did not emphasise the need for continual reassessment.774 PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737}; Phase 1 Report Volume IV, paragraph 29.45.e. We discuss below the reasons for the deficiencies in the version of PN539 that was current at the time of the Grenfell Tower fire.
111The Lakanal Control Report
¶78.45 The LFB also undertook a detailed internal review of the part that the control room had played in the LFB's response to the fire at Lakanal House.775 Lakanal Control Report {HOM00001124/4} paragraph 1. The outcome was contained in a report entitled Fire at Lakanal, Havil Street, SE5 on 3 July 2009 – Role and Actions of the LFB Control published in November 2012 (the Lakanal Control Report).776 Lakanal Control Report {HOM00001124/4}. It was informed by the gap analysis, completed in April 2010, which had identified differences between national guidance and LFB policy and training on handling fire survival guidance calls.777 Lakanal Control Report {HOM00001124/4} paragraph 3. It set out the policy framework relating to the control room, the arrangements for training of CROs, and the working practices of the control room.778 Lakanal Control Report {HOM00001124/4} paragraph 1. It examined the Lakanal House fire from the perspective of the control room and identified numerous lessons.779 Phase 1 Report Volume I, paragraphs 8.5-8.8. The report included nine recommendations and points for further action.780 Lakanal Control Report {HOM00001124/51-55} Chapter G.
¶78.46 Of particular interest to us is the fact that the report suggested improvements to national and LFB policy on the training of CROs in handling fire survival guidance calls and managing the performance of control room staff.781 Lakanal Control Report {HOM00001124/51-53}, paragraphs 303 to 309, Recommendations 1, 2, 3, 4, 5. The report identified some recommendations that had already been completed, with some subject to a continuing process of review and implementation.782 Lakanal Control Report {HOM00001124/51-53}, paragraphs 303 to 309, Recommendations 1, 2, 3, 4, 5. The Lakanal Control Report was submitted to the coroner and on the basis of its contents she decided not to make any recommendations about handling fire survival guidance calls or training for CROs.783 Hayward {Day199/147:13} – {Day199/148:4}; Rule 43 Letter to Mr Ron Dobson, London Fire Commissioner dated 28 March 2013 {LFB00032158}. In her rule 43 letter she noted that the LFB had already undertaken extensive work to learn from its experience at Lakanal House.784 Rule 43 Letter to Ron Dobson, London Fire Commissioner dated 28 March 2013 {LFB00032158/1}. The striking similarities between the failings of the control room in handling fire survival guidance calls during the Lakanal House fire and those which were later seen in its response to the Grenfell Tower fire led us to examine whether the assurances given to the coroner about policy and training relating to handling fire survival guidance calls had been properly implemented and met their objective.785 Phase 1 Report Volume IV, paragraph 29.5. The short answer is that they had not and did not. We shall need to return to the Lakanal Control Report more than once in this chapter.
Review of PN539
¶78.47 The LFB's policy on emergency call management is contained in Policy No. 539. Pre-inquest action 10 was to review PN539 to ensure that it complied with national guidance.786 Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/14}. That was a response to the identification in the gap analysis that PN539 did not reflect current guidance, particularly the appendix on fire survival guidance calls.787 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/8}; {HOM00001125/11-12}; {HOM00001125/16}; {HOM00001125/20}.
112¶78.48 Responsibility for carrying out the action was assigned to AC Brown,788 Action Plan appended to the minutes of the meeting of the Lakanal House Board on 15 September 2010 {LFB00084031/8}. The action was assigned to 'AC/SD', which meant "AC Service Delivery", who was AC Brown at the time. who had overall responsibility for PN539 as Head of Service Delivery & Mobilising.789 In both the version of PN539 dated 14 November 2007 that was current at the time of the Lakanal House fire {LFB00028382/1} and the version reviewed as current on 3 September 2010 {LFB00004735}, the 'owner' was designated as 'Head of Service Delivery & Mobilising'. However, he was not involved in reviewing and revising PN539, which he had delegated to POM Hayward.790 Brown {Day206/91:2-6}. Hayward {Day199/193:10-13}; Brown {LFB00084020/6} page 6, paragraph 10; Brown {LFB00084020/11} page 11, paragraph 23. POM Hayward, in turn, said that SOM Lindsay Turner and the Operational Support Team had carried out the task,791 Hayward {LFB00055191/7} page 7, paragraph 20. although in fact both he and SOM Smith were involved in and oversaw the work.792 Smith {LFB00121219/14} page 14, paragraph 34; Hayward {LFB00086213/5} page 5, paragraph 24; Emails between and Amelia Reynolds, Brigade Control Training Team Leader, POM Hayward, SOM Turner copying in SOM Smith between 13-21 July 2010 {LFB00057934}; Emails between SOM Smith and Amelia Reynolds between 2-3 September 2010 {LFB00109145}; Hayward {Day199/189:5}-{Day199/190:5}.
¶78.49 The initial review and revision of PN539 was completed by 3 September 2010,793 PN539 reviewed as current on 3 September 2010 {LFB00004735}. as POM Hayward and SOM Smith reported to the Lakanal House Board on 15 September 2010.794 Minutes of the Lakanal House Board meeting on 15 September 2010 {LFB00055192/2} item 5.15(1). However, they did not present the revised version of PN539 to the board,795 Smith did not recall the reviewed version of PN539 being presented to the Lakanal House Board: Smith {Day202/113:22}-{Day202/114:17}. There is no record of the updated policy being presented for approval at the meetings of the Lakanal House Board on 15 September 2010 {LFB00055192/2-3}, 8 November 2010 {LFB00084032/1} or 22 December 2010 {LFB00084033/2}, when the action was marked as completed. It ceased to be an agenda item thereafter. which never formally approved it.796 SOM Smith did not think anyone had approved it: Smith {Day202/112:21-23}. Nor did AC Brown,797 Brown {Day206/91:5-6}. who told us that it was not normal practice for managers in his position to read through a policy and approve the changes.798 Brown {Day206/91:15-24}. SOM Smith said that the owner of the policy had ultimate responsibility for approving it, but in practice she did not think that had happened: Smith {Day202/111:22}-{Day202/112:1}. As a result, the revisions made to PN539 after the Lakanal House fire were not subjected to any form of approval process and were not examined by the senior manager responsible for them.799 SOM Smith did not think that anyone had approved it: Smith {Day202/112:21-23}. She said that she was not aware of anyone whose authority was required to make changes to PN539: Smith {Day202/110:23}-{Day202/111:6}.
¶78.50 PN539 was amended nine more times before the Grenfell Tower fire, most significantly Appendix 3, which covered fire survival guidance calls. It was amended on 3 February 2011 and 28 March 2014.800 As shown by the audit trail to PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737/22}. The version of PN539 that was in force at the time of the fire had last been amended on 6 April 2017.801 PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737}. The Phase 1 report found that the policy was significantly defective in many respects. In particular, it failed to state clearly that the four principles of "escape, assess, protect and rescue" required continual reassessment of the caller's situation,802 Phase 1 Report Volume IV, paragraph 29.45.e. it did not contain a warning that it is not always safe to assume that the fire and rescue service is on its way to rescue the caller,803 Phase 1 Report Volume IV, paragraph 29.45.f.8. it did not make it clear that, if a fire survival guidance call required a CRO to remain on the line, the number of simultaneous fire survival guidance calls could never exceed the number of CROs available,804 Phase 1 Report Volume IV, paragraph 29.45.b.7. it contained no advice or guidance to assist CROs and senior managers when handling a large number of fire survival guidance calls concurrently805 Phase 1 Report Volume IV, paragraph 29.45.g. and it did not require CROs to find out whether the caller was, or had with them, a person who, for whatever reason, would require help to evacuate.806 Phase 1 Report Volume IV, paragraph 29.45.h. We explore the reasons for those defects below.
113¶78.51 The exclusion of FSC 54-04 from the gap analysis created a risk that the guidance it contained on the need continually to reassess the caller's situation would not be reflected in PN539. Curiously, however, the version of PN539 dated 3 September 2010, which was the result of the first revision following the Lakanal House fire, did add advice to CROs to reassess continually the caller's situation,807 PN539 dated 3 September 2010 {LFB00004735/16}; PN539 dated November 2007 {LFB00028382/20}. but it was replaced in the version dated 3 February 2011 with advice to reassess the caller's situation, providing some example questions.808 PN539 dated 3 February 2011 {LFB00028601/16-17}. The clear and unambiguous emphasis on continual reassessment had thus been removed and the policy remained in that form until the Grenfell Tower fire.809 PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737/16-17}.
¶78.52 It is evident from the version of PN539 that SOM Smith sent to POM Hayward on 3 February 2011 with tracked changes that she was the person who removed the requirement for continual reassessment.810 Email from SOM Smith to POM Hayward on 3 February 2011 {LFB00109464}; Version of PN539 with tracked changes made by SOM Smith attached to her email to POM Hayward on 3 February 2011 {LFB00109465/17}. When asked, she could not account for that,811 Smith {Day202/137:5-8}. but she suggested that the amendments amounted to the same thing and that the training made that clear.812 Smith {Day202/137:8-12}. She told us that the need for continual reassessment, although not stated explicitly, was implied in the revised version813 Smith {Day202/137:12-15}. and that training emphasised the need for continual reassessment.814 Smith {Day202/137:8-17}. AC Brown said essentially the same.815 Brown {Day206/99:3-22}. However, those explanations ignored, or at least underestimated, the vital importance of ensuring that PN539 stated clearly and comprehensively the objectives, principles and approach for handling fire survival guidance calls.
¶78.53 As set out above, the Lakanal Control Report, dated November 2012, which post-dated the removal by SOM Smith of the passage emphasising the need for continual re-assessment, found that the guidance in FSC 54-04 was not included in LFB training and that there might be a tendency among CROs to limit reassessment due to a desire to keep the caller safe.816 Lakanal Control Report dated November 2012 {HOM00001124/50} paragraph 295. It recommended that PN539 should be revised to ensure compliance with national guidance and to reflect the lessons identified in the report.817 Lakanal Control Report dated November 2012 {HOM00001124/52} paragraph 304. However, it also recorded that PN539 had already been revised in February 2011,818 Lakanal Control Report dated November 2012 {HOM00001124/52} paragraph 304. implying that no further action was required. There is nothing to suggest that the recommendation prompted any further consideration of PN539 to ensure that it reflected in full the experience of the Lakanal House fire. AC Brown confirmed that he had not asked for any further work to be done on it.819 Brown {Day206/102:4}-{Day206/103-4}.
114¶78.54 In his review dated 4 January 2013, GM Lindridge found that PN539 did not incorporate the guidance in FSC 54-04,820 GM Lindridge's review dated 4 January 2013 {LFB00085854/6}. a conclusion which he said had been reported to AC Brown as AC Operations, Prevention and Response. GM Lindridge understood that his observations would be considered in a forthcoming review of policy on handling fire survival guidance calls,821 GM Lindridge's review dated 4 January 2013 {LFB00085854/6}. but no such review was undertaken, as AC Brown confirmed.822 Brown {Day206/95:6-18}. AC Brown said that he had asked AC Chandler and then POM Hayward, in AC Chandler's absence, to review the gap analysis in relation to FSC 54-04 and to apply any resulting recommendations,823 Brown {Day206/94:22}-{Day206/95:5}. but that was not done and no good explanation was given for the omission.
¶78.55 Those were yet more missed opportunities to ensure that PN539 contained the important requirement for continual reassessment.
¶78.56 The version of PN539 dated 3 September 2010, which was the result of the initial revision following the Lakanal House fire, actively encouraged CROs to offer callers reassurance,824 PN539 dated 3 September 2010 {LFB00004735/16}. suggesting the use of phrases such as "the firefighters will be with you very soon" and "the firefighters know where you are".825 PN539 dated 3 September 2010 {LFB00004735/16}. It also referred the CROs to the RIFs to assist them in providing reassurance to the caller that help was on its way.826 PN539 dated 3 September 2010 {LFB00004735/16}. However, the version dated 3 February 2011 largely removed that guidance, apart from the reference to the RIFs.827 PN539 dated 3 February 2011 {LFB00028601/16}. It simply included advice to reassure the caller.828 PN539 dated 3 February 2011 {LFB00028601/16}. It would seem that those carrying out the review of PN539 in 2011 had in mind, to an extent, the guidance in FSC 10-93 and 'Keeping People Safe'. SOM Smith confirmed as much when she said that the emphasis on reassurance had been removed because of the warning in FSC 10-93 and the investigation into the Lakanal House fire.829 Smith {Day202/124:12-22}.
¶78.57 In those circumstances, it is hard to understand why those who updated PN539 in February 2011, a group which included SOM Smith and POM Hayward, did not include an explicit warning to CROs, as set out in the national guidance, against providing reassurance to callers which might promote a false sense of security.830 Email from SOM Smith to POM Hayward on 3 February 2011 {LFB00109464}; Version of PN539 with tracked changes made by SOM Smith attached to her email to POM Hayward on 3 February 2011 {LFB00109465}; Emails between SOM Smith and POM Hayward on 3 February 2011 {LFB00058030}.
¶78.58 SOM Smith said that training had included clearer instructions on the warning and there might also have been advice in the RIFs.831 Smith {Day202/125:13}-{Day202/126:3}. That was certainly not so in the case of the RIFs, as the chairman found in the Phase 1 report. In any event, it ignored or, at least, underestimated the important role of the policy and placed too much reliance on training.832 Phase 1 Report Volume IV, paragraph 29.49.c.
¶78.59 The Lakanal Control Report dated November 2012 noted that CROs handling fire survival guidance calls during the Lakanal House fire expected fire crews to arrive quickly (as they usually did) and advised callers to remain in their flats and wait to be rescued rather than helping them to assess whether escape was possible.833 Lakanal Control Report dated November 2012 {HOM00001124/50} paragraph 293. The implication was that an assumption that firefighters would rescue a caller promptly, or at all, was not always well founded. That echoed the warning in FSC 10-93 and 'Keeping People Safe' against providing reassurance to a caller which might produce a false sense of security.834 FSC 10/93 {LFB00003617/1} paragraph 2; 'Keeping People Safe' training {LFB00118948/6}. However, despite the recommendation in the Lakanal Control Report, that aspect of PN539 was not reconsidered and the policy was not amended to include an appropriate warning.
115¶78.60 Further, in his review dated 4 January 2013, GM Lindridge found that PN539 had been reviewed and did not contradict FSC 10-93, but that it might be said not to contain all the information in the national guidance.835 GM Lindridge's review dated 4 January 2013 {LFB00085854/13}. In a comment on the draft DC Dexter asked whether PN539 complied with national guidance, to which AC Brown replied that it did and that the action had been completed, both in word and spirit,836 GM Lindridge's review dated 4 January 2013 {LFB00085854/13}. but that was wrong because PN539 did not include a warning against providing false reassurance.837 PN539 dated 3 February 2011 {LFB00028601/16}; FSC 10/93 {LFB00003617/1} paragraph 2; 'Keeping People Safe' training {LFB00118948/6}. It appears that, as a result, no action was taken to investigate and deal with this particular aspect of GM Lindridge's review.
¶78.61 The failure to include FSC 54-04 in the gap analysis created a real risk that the guidance it contained about assessing any impairments which might impede a caller's ability to escape would not be reflected in LFB policy and training. In fact, the version of PN539 dated 14 November 2007 did include a requirement for CROs to assess whether callers had any relevant disabilities,838 PN539 dated 14 November 2007 {LFB00118944/20}. but for no obvious reason that requirement was removed from later versions and was not reinstated before the Grenfell Tower fire.839 PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737/16-17}. SOM Smith could not explain why.840 Smith {Day203/13:24}-{Day202/14:4}. She told us that she had not been involved in the revision of PN539 in 2010,841 Smith {Day203/14:3-5}. but email exchanges at the time reveal that she, together with POM Hayward, SOM Turner and Amelia Reynolds, had all contributed to it.842 Emails between and Amelia Reynolds, Brigade Control Training Team Leader, POM Hayward, SOM Turner copying in SOM Smith between 13-21 July 2010 {LFB00057934}; Emails between SOM Smith and Amelia Reynolds on 2-3 September 2010 {LFB00109145}; Hayward {Day199/189:5}-{Day199/190:5}. SOM Smith said that she was not aware of any positive decision to omit the advice on assessing disability843 Smith {Day203/14:13-16}. and could not say whether it had been omitted accidentally.844 Smith {Day203/15:3-7}. She said that she had made sure that the questions on disability were included in the training and the RIFs,845 Smith {Day203/14:5-9}; Smith {Day203/14:20-22}. but that was not the case as far as the RIFs were concerned.
¶78.62 The RIF for Operators dated 12 March 2007 had contained a prompt to ask whether a caller had a disability and whether their mobility was impaired, but that prompt was removed from the revised version approved by SOM Smith on 23 February 2011.846 RIF for Operators approved on 12 March 2007 {LFB00121224/2}; RIF for Operators approved on 23 February 2011 {LFB00121240}. However, unlike PN539, a later version of the RIF for Operators approved by SOM Bagnelle on 3 April 2014 reinstated a prompt that did effectively address the requirement to assess disability, albeit with rather less emphasis than previously.847 RIF for Operators approved on 3 April 2014 {LFB00122837/2} paragraph 1.5. That was included following a report from a command unit training workshop with the control room: Bagnelle {LFB00122821/5} page 5, paragraph 15 and report {LFB00122833/2}.
116¶78.63 SOM Smith's evidence was that she had thought that the reason why the requirement to assess disability had not been reinstated in PN539 in February 2011 and thereafter was because it had been covered by training and in the RIFs and it was felt that that was sufficient.848 Smith {Day203/16:14-22}. However, the RIFs were not amended until April 2014 and we do not consider that training could adequately compensate for its omission from the policy, since that leaves too much to the discretion of the individual trainer. SOM Smith told us that it was not unusual for a CRO to assess the caller's age and ability to leave the building,849 Smith {Day203/16:22-25}. She effectively accepted that much depended on what information the caller provided.850 Smith {Day203/17:1-13}. If so, that was not consistent with national guidance, because FSC 54-04 clearly required CROs to carry out a positive assessment of a caller's age, gender, ethnicity and mental or physical disability.851 FSC 54/04 {LFB00055201/17}. SOM Smith accepted that the LFB was not following the guidance in FSC 54-04;852 Smith {Day203/17:14}-{Day203/18:3}. she also accepted that, if it were left to the caller to volunteer information, there was a risk that it might not be given, which is exactly what happened in some cases during the Grenfell Tower fire.853 Smith {Day203/17:14}-{Day203/18:3}; Phase 1 Report Volume IV, paragraph 29.76.
¶78.64 In his review dated 4 January 2013 GM Lindridge found that PN539 did not include the guidance called for by FSC 54-04.854 GM Lindridge's review dated 4 January 2013 {LFB00085854/6}. That omission might, therefore, have been made good if some action had been taken in response to his finding. However, it was not.
¶78.65 A further opportunity to remedy the omission came in the form of GRA 3.2, published in February 2014,855 GRA 3.2 'Fighting fires – In high rise buildings' dated February 2014 {LFB00001255}. which introduced new requirements for handling fire survival guidance calls.856 GRA 3.2 {LFB00001255/20}; GRA 3.2 {LFB00001255/29-31}; Cowup {Day195/64:4-8}; Cowup {Day195/99:1-5} AC Brown was involved in the consultation process which preceded the document.857 Email from Michele Kunneke to AC Brown and others on 10 May 2012 {LFB00093616}. However, it is reasonably clear that he did not discuss it with anyone else responsible for the operation of the control room.
¶78.66 GRA 3.2 introduced a requirement for fire and rescue authorities to have effective arrangements in place for handling fire survival guidance calls from those who believe they are unable to leave a building due to disability, poor mobility, illness or the effects of fire. However, AC Brown admitted that he had taken no specific steps following the publication of GRA 3.2 to ensure that the LFB had such arrangements in place because he was satisfied that CROs would obtain that information and that adequate arrangements were therefore already in place.858 Brown {Day206/153:22}-{Day206/154:4}. He had not considered asking anyone responsible for the control room to review PN539 to ensure that it was consistent with GRA 3.2.859 Brown {Day206/154:24}-{Day206/155:10}. Unsurprisingly, in the light of their ignorance of GRA 3.2, POM Hayward and SOM Smith did not carry out any such review themselves, nor did POM Hayward ask anyone else to do so.860 Smith {Day203/20:9-16}; Hayward {Day200/54:2-17}.
¶78.67 The direct result of this cluster of failings was that the LFB did not introduce, or reintroduce, into PN539 a provision for CROs to enquire positively whether callers had disabilities or other impairments of a kind that might affect their ability to leave the building.
117¶78.68 A further, and perhaps final, opportunity to remedy that particular deficiency was by way of an equality impact assessment, which ought to have been undertaken in order to consider the likely effect of the policy on different groups of people. However, it is evident from the audit trail in the version of PN539 which was current at the time of the Grenfell Tower fire that no one carried out such an assessment after 17 September 2008.861 PN539 reviewed as current on 28 March 2014 and amended on 6 April 2017 {LFB00000737/22}.
¶78.69 AC Brown accepted that it had been his responsibility to ensure that an equality impact assessment was carried out,862 Brown {Day206/109:20}-{Day206/110:2}. but he said that such an assessment was carried out only when changes were made that required one.863 Brown {Day206/110:13-16}. He did not think that they had decided it was necessary to carry out an equality impact assessment when PN539 had subsequently been reviewed after 2008.864 Brown {Day206/110:3-25}. However, he acknowledged that in hindsight one should probably have been carried out at some point.865 Brown {Day206/110:19-21}.
¶78.70 In our view, the warning signs were there at the time for all to see. AC Brown simply did not heed them. It is surprising that he took no steps to alert the LFB's senior management to the existence, let alone the contents, of GRA 3.2 or to recognise the need for an equality impact assessment. We regard those as serious failings on his part.
The Reference Information Files
¶78.71 Pre-inquest action 9 was to revise the Reference Information Files (RIFs) used by CROs when giving fire survival guidance in order to ensure that they complied with national guidance.866 Lakanal Assurance Review dated August 2018 {LFB00004801/13}. There were two RIFs: a RIF for Operators, which was a prompt sheet or script to assist with handling fire survival guidance calls, and a RIF for Supervisors, which described their role in supporting CROs during fire survival guidance calls and passing information to the incident ground.867 Lakanal Assurance Review dated August 2018 {LFB00004801/14}.
¶78.72 SOM Turner, SOM Smith and the Operational Support Team carried out the revisions to the RIFs in discussion with POM Hayward.868 Hayward {LFB00055191/7} page 7, paragraph 20; Smith {LFB00121219/11} page 11, paragraph 26; Smith {Day203/26:11}-{Day203/28:7}. SOM Turner undertook the initial review;869 Smith {Day203/26:11-24}. SOM Smith then proposed further revisions.870 Smith {LFB00121219/11} page 11, paragraph 26; Smith {Day203/26:11-24}. They were completed by January 2011 and circulated to control room staff on 23 February 2011.871 Smith {LFB00121219/12} page 12, paragraph 27; Email from SOM Smith to all Brigade Control Staff on 23 February 2011 {LFB00121237}; RIF for Operators approved on 23 February 2011 {LFB00121240}; RIF for Supervisors approved on 23 February 2011 {LFB00111192}.
¶78.73 SOM Smith said that the primary reason for revising the RIFs following the Lakanal House fire was to prepare for the next large-scale incident.872 Smith {LFB00121219/12} page 12, paragraph 28. Senior management wanted to ensure that the RIFs contained clear advice in relation to fires in high-rise residential buildings.873 Smith {LFB00121219/12} page 12, paragraph 28. The RIF for Operators was, therefore, amended so that there were sections on different types of buildings, with a separate section on purpose-built blocks of flats.874 Smith {LFB00121219/12} page 12, paragraph 28; RIF for Operators approved on 23 February 2011 {LFB00121240/10-19}. SOM Smith said that she had also used the findings of the gap analysis to amend the RIFs.875 Smith {Day202/105:22-25}.
118¶78.74 SOM Smith approved the revisions to the RIFs.876 RIF for Operators approved on 23 February 2011 {LFB00121240/24}; RIF for Supervisors approved on 23 February 2011 {LFB00111192/5}; Smith {Day203/26:25}-{Day203/27:4}. Although she discussed some of them with POM Hayward, it is reasonably clear that he did not review or approve the revisions, even though responsibility for final approval lay with him.877 Smith {Day203/27:5}-{Day203/28:17}. Further, although POM Hayward and SOM Smith informed the Lakanal House Board on 15 September 2010 and 4 February 2011 of the fact that the RIFs had been revised, they did not describe the substance of the revisions.878 Minutes of Lakanal House Board meeting on 15 September 2010 {LFB00055192/2} item 5.6; Minutes of Lakanal House Board meeting on 4 February 2011 {LFB00055215/2} item 5.5; Smith {Day202/28:14-20}. As a result, the Lakanal House Board did not formally review and approve the changes.
¶78.75 On 27 June 2011, AOM Bonnett sent an email to SOM Smith, SOM Turner, AOM Sharp and AOM O'Shea in which he criticised the training relating to fire survival guidance as being inconsistent with the revised RIF for Operators.879 Email from AOM Bonnett to SOM Smith, SOM Turner, AOM Sharp and AOM O'Shea on 27 June 2011{LFB00028381/1-2}. He concluded that, because the RIF had been specifically designed to assist CROs during fire survival guidance calls, it should be central to, and consistent with, training.880 Email from AOM Bonnett to SOM Smith, SOM Turner, AOM Sharp and AOM O'Shea on 27 June 2011{LFB00028381/3}. He also suggested that training exercises should be carried out to test the suitability of both the RIF for Operators and the RIF for Supervisors.881 Email from AOM Bonnett to SOM Smith, SOM Turner, AOM Sharp and AOM O'Shea on 27 June 2011{LFB00028381/3-4}.
¶78.76 SOM Smith forwarded the email to POM Hayward, expressing her agreement with AOM Bonnett's findings.882 Email from SOM Smith to POM Hayward on 27 June 2011{LFB00028381/1}. Despite her agreement, however, no training was provided on the RIFs, nor were they subject to a test exercise.883 Smith {Day203/29:16}-{Day203/30:24}; Smith {Day203/34:3}-{Day203/35:8}; Smith {LFB00121219/13} page 13, paragraphs 30-31; Smith {MET00080606/20}. Control room staff were simply notified that the RIFs had been revised and told to familiarise themselves with their contents.884 Email from SOM Smith to all Brigade Control Staff on 23 February 2011 {LFB00121237/1}. SOM Smith said that was because staff could look at the RIFs at any time they wished and because, contrary to AOM Bonnett's opinion, they were consistent with the fire survival guidance training.885 Smith {Day203/30:25}-{Day203/32:5}.
¶78.77 We do not understand how senior management could have satisfied themselves that CROs and supervisors understood the nature and extent of the changes to the RIFs that had been brought about as a consequence of the Lakanal House fire without providing them with any formal training. As it was, the training records we have seen show that no staff reviewed the RIFs in 2011 and that only two did so in 2012.886 Brigade Control training records 2011-2018 {LFB00041763} columns Y, Z and AA.
119¶78.78 The RIFs were revised again in early 2013 following discussions with GM Lindridge.887 Bagnelle {LFB00122821/5} page 5, paragraphs 14-15; Email from AOM Bonnett to SOM Bagnelle on 10 January 2013 {LFB00122822/2-3}. SOM Vic Bagnelle instructed AOM Bonnett and AOM Pope of the Operational Support Team to carry out the revisions, which he then reviewed and approved on 18 February 2013.888 Bagnelle {LFB00122821/5} page 5, paragraph 15; RIF for Operators approved on 18 February 2013 {LFB00122835}; RIF for Supervisors approved on 18 February 2013 {LFB00122836}. The primary aim of those revisions was to reduce the length of the RIFs to make them more manageable.889 GM Lindridge's Review dated 4 January 2013 {LFB00085854/5}; Email from GM Lindridge to SOM Bagnelle, POM Hayward, AC Brown and others on 9 January 2013 {LFB00118958/1}; Email from SOM Bagnelle to OST on 11 January 2013 {LFB00122822/2}; Email from AOM Bonnett to all Brigade Control staff on 18 February 2013 {LFB00055234/1}; Bagnelle {LFB00122821/6} page 6, paragraph 17. As a result, the separate sections on different building types, including purpose-built blocks of flats, were removed.890 Smith {LFB00121219/12} page 12, paragraph 28; RIF for Operators approved on 18 February 2013 {LFB00122835}; RIF for Supervisors approved on 18 February 2013 {LFB00122836}.
¶78.79 Although SOM Bagnelle reported to POM Hayward and AC Brown on the progress of their work, we have not seen any evidence that POM Hayward or the Lakanal House Board reviewed or approved the revised versions.891 Bagnelle {LFB00122821/5} page 5, paragraph 15.
¶78.80 AOM Bonnett circulated the revised RIFs to control room staff on 18 February 2013.892 Email from AOM Bonnett to all Brigade Control staff on 18 February 2013 {LFB00055234/1}; RIF for Operators approved on 18 February 2013 {LFB00122835}; RIF for Supervisors approved on 18 February 2013 {LFB00122836}. As before, they were simply instructed to familiarise themselves with the contents.893 Email from AOM Bonnett to all Brigade Control staff on 18 February 2013 {LFB00055234/1}. The training records indicate, however, that most staff did not review the RIFs in 2013 and there are no records of any staff having done so thereafter.894 Brigade Control training records 2011-2018 {LFB00041763}; Hayward {LFB00055191/27} paragraph 77.
¶78.81 SOM Sharp made further amendments to the RIFs in 2014, which were approved by SOM Victor Bagnelle on 3 April 2014.895 Bagnelle {LFB00122821/5-6} pages 5-6, paragraph 14-16; RIF for Operators approved on 3 April 2014 {LFB00003542}. That then remained the version of the RIF for Operators in force at the time of the Grenfell Tower fire.896 RIF for Operators approved on 3 April 2014 {LFB00003542}. The RIF for Supervisors, however, was revised once more before the Grenfell Tower fire in April 2016, although the revisions do not appear to have been formally approved.897 Bagnelle {LFB00122821/5} page 5, paragraph 14; RIF for Supervisors approved on 3 April 2014 and updated on 2 April 2016 {LFB00003541}. The version in force at the time of the Grenfell Tower fire had, therefore, been approved on 3 April 2014 and subsequently amended on 2 April 2016.898 RIF for Supervisors approved on 3 April 2014 and updated on 2 April 2016 {LFB00003541}.
¶78.82 In his Phase 1 report the chairman found that the RIF for Operators was unsatisfactory in a number of respects.899 Phase 1 Report Volume IV, paragraph 29.49. It contained no clear guidance on what was meant by "affected" by heat, smoke or fire or how it was to be assessed, it contained no clear guidance on how to assess the safety of escape routes if the caller was, or claimed to be, affected by heat, smoke or fire, or simply felt unsafe, it did not tell CROs that assurances that firefighters would rescue callers should be based on information from the incident ground rather than expectations or assumptions, it contained no guidance on what information CROs should gather in order to assist the control room supervisor or incident commander to decide whether a partial or total evacuation of the building should be carried out and it contained no guidance on what advice CROs should give to a caller once a decision had been made to carry out a full or partial evacuation of the building. He also found that the RIF for Supervisors contained similar defects. In particular, it contained no guidance on how supervisors should gather information from CROs to enable them to form an overall assessment of the situation in order to assist incident commanders to decide whether to revoke "stay put" advice.900 Phase 1 Report Volume IV, paragraph 29.50. We consider the reasons for those defects below.
120¶78.83 The section of the RIF for Operators dated 23 February 2011 that dealt with giving fire survival guidance to a person trapped in a purpose-built flat, advised the CRO to ask the caller whether the flat was being "affected" by heat or smoke. If the caller said it was not, the advice was to say that it would usually be safer to stay in the flat, but that if the situation changed, or the caller felt unsafe, the better course was to get out and stay out.901 RIF for Operators approved on 23 February 2011 {LFB00121240/14}.
¶78.84 SOM Smith had been responsible for drafting that advice.902 Smith {Day203/70:17-20}. She said that she had taken the word "affected" from FSC 10-93, although that word is not used in the circular.903 Smith {Day203/70:21}-{Day203/71:1}. She understood it to mean that heat or smoke was entering the flat and directly affecting the caller in some way, such as interfering with their breathing;904 Smith {Day203/71:2-14}. in effect, that compartmentation had been breached.905 Smith {Day203/71:2-14}. When preparing the RIFs, SOM Smith had asked John Bradbury, DAC Fire Safety Regulation Delivery, and AC James Knighton, AC Operational Policy, what information it would be helpful to obtain from a caller to enable a CRO to determine whether the person was affected by fire, heat or smoke,906 Smith {LFB00121219/15} page 15, paragraph 36. but they had not given her any help.907 Smith {Day203/69:24}-{Day203/70:6}. However, despite her own understanding and her difficulty in obtaining assistance, she did not consider including in the RIF an explanation of what "affected" meant or further prompts to guide a CRO when giving advice.908 Smith {Day203/70:3-10}; Smith {Day203/71:15}-{Day203/72:8}.
¶78.85 The RIF for Operators also suggested that, if a caller was, or felt themselves to be, "affected" by fire, heat or smoke, CROs should ask about possible escape routes.909 RIF for Operators approved on 23 February 2011 {LFB00121240/14-15}. It then set out questions aimed at finding out whether an alternative escape route was available.910 RIF for Operators approved on 23 February 2011 {LFB00121240/15}. However, the RIF did not suggest how to assess the safety of any potential escape route. SOM Smith said that when she drafted the RIF she must, at some point, have considered whether such guidance was needed, given the questions on exploring alternative escape routes that she had included.911 Smith {Day203/73:1-3}. If so, it must follow that she decided not to include such guidance.
¶78.86 The revised versions of the RIFs for Operators dated 18 February 2013 and 3 April 2014 contained the same defects.912 RIF for Operators approved on 18 February 2013 {LFB00122835}; RIF for Operators approved on 3 April 2014 {LFB00003542}. The revision in 2013 concentrated principally on reducing its length and making it easier to use rather than on making substantive changes.913 GM Lindridge's Review dated 4 January 2013 {LFB00085854/5}; Email from GM Lindridge to SOM Bagnelle, POM Hayward, AC Brown and others on 9 January 2013 {LFB00118958/1}; Email from SOM Bagnelle to OST on 11 January 2013 {LFB00122822/2}; Email from AOM Bonnett to all Brigade Control staff on 18 February 2013 {LFB00055234/1}; Bagnelle {LFB00122821/6} page 6, paragraph 17. It is not surprising, therefore, that SOM Bagnelle and SOM Sharp do not appear to have considered providing guidance on the meaning of being "affected" by fire, heat or smoke or on assessing the safety of an escape route. However, SOM Bagnelle said that the amendments made in April 2014 had included additional questions for CROs to use following comments made by command unit staff during training workshops914 Bagnelle {LFB00122821/5} page 5, paragraph 15. to the effect that finding out how far the caller's flat was from the nearest stairwell would help a CRO decide whether the caller could reach it.915 Reports from command unit training workshops {LFB00122833/1}. It was suggested that a conversation of that kind might cause the caller to consider the layout of the property and realise that escape was possible916 Report from command unit training workshops {LFB00122833/1}. and that a prompt might be included in the RIF to that effect.917 Report from command unit training workshops {LFB00122833/2}.
121¶78.87 Despite that, when they revised the RIF for Operators in April 2014 neither SOM Sharp nor SOM Bagnelle included a prompt of that kind.918 RIF for Operators approved on 3 April 2014 {LFB00003542}. Moreover, it is reasonably clear that the comments from the workshops did not cause either of them to consider whether guidance on assessing the safety of escape routes, beyond the distance to the stairwell, should be included.
¶78.88 The failure to include such guidance was significant because, as the chairman found in the Phase 1 report, CROs failed properly to assess escape routes on the night of the Grenfell Tower fire and advised callers to stay put, even though they may not in fact have been trapped, with the result that some callers may have stayed in their flats when they could have escaped to safety.919 Phase 1 Report Volume IV, paragraph 29.54.c and paragraph 29.60.
¶78.89 The gap analysis drew attention to the warnings in both FSC 10-93 and 'Keeping People Safe' about forming an emotional bond with a caller and providing false reassurance.920 Gap Analysis {LFB00004750/10-11}. It identified that the training of CROs encouraged the creation of a strong attachment between the caller and the CRO and that it recommended using reassuring phrases that might promote a false sense of security.921 Gap Analysis {LFB00004750/11}. Accordingly, the gap analysis recommended that training be changed in those respects.922 Gap Analysis {LFB00004750/11}.
¶78.90 SOM Smith used the findings of the gap analysis to revise the RIFs,923 Smith {Day202/105:22-25}. but despite that, the revised RIF for Operators she approved on 23 February 2011, like PN539, actively encouraged CROs to reassure the caller.924 RIF for Operators approved on 23 February 2011 {LFB00121240/17}. It suggested the use of phrases such as "the firefighters are on the way" and "the firefighters know where you are".925 RIF for Operators approved on 23 February 2011 {LFB00121240/17}. However, the RIF included no warning to the CROs against providing false reassurance nor did it make it clear that such statements must be made only if based on information received from the incident ground.926 RIF for Operators approved on 23 February 2011 {LFB00121240/17}.
122¶78.91 On 3 January 2011, SOM Smith had emailed AOM Bonnett and AOM Suarez with a draft of the revised RIF for Operators.927 Email from SOM Smith to AOM Bennett and AOM Suarez copying in POM Hayward on 3 January 2011 {LFB00033220}. Anticipating the concerns of the Lakanal House Board that it did not appear in national guidance, she had removed the word "bonding".928 Email from SOM Smith to AOM Bennett and AOM Suarez copying in POM Hayward on 3 January 2011 {LFB00033220/1}. It is evident, therefore, that SOM Smith had the gap analysis and national guidance in mind when she was revising the RIF.929 See also Smith {LFB00121219/16} page 16, paragraph 39. In those circumstances, it is hard to understand why she did not include the explicit warning against providing a false sense of security or why she felt it was sufficient to remove only the word "bonding" from the RIF and not the associated statements which had been designed to reassure and create a bond with the caller.930 Draft RIF for Operators dated 16 November 2010 as edited by SOM Smith {LFB00083530/15}.
¶78.92 SOM Smith said she had not included a warning against providing false reassurance because it was guidance on what should be done rather than what should not be done, so it had not occurred to her or the Operational Support Team to include it.931 Smith {Day203/78:10-24}. Even if that were right, however, it presented no bar to including positive guidance in the RIF that a CRO should provide reassurance to callers only if it were based on information received from the incident ground. The suggestion by SOM Smith that it was a matter covered in training932 Smith {Day203/78:22}-{Day203/79:2}. placed too much reliance on training and ignored, or at least underestimated, the importance of ensuring that the RIFs stated accurately and comprehensively the correct approach to handling fire survival guidance calls in accordance with national guidance.
¶78.93 The work on revising the RIFs should have included a comparison with the guidance contained in FSC 10-93 and 'Keeping People Safe' in order to ensure that they were compatible and that nothing had been omitted. However, that was not done and all the later versions of the RIFs suffered from the same defect.933 RIF for Operators approved on 18 February 2013 {LFB00122835}; RIF for Supervisors approved on 18 February 2013 {LFB00122836}; RIF for Operators approved on 3 April 2014 {LFB00003542}; RIF for Supervisors approved on 3 April 2014 and updated on 2 April 2016 {LFB00003541}. Again, that was significant because CROs invariably told callers on the night of the Grenfell Tower fire that firefighters were on their way without having a sound basis for doing so. The tragic result was that some callers remained in their flats despite the fact that escape may have remained possible.934 Phase 1 Report Volume IV, paragraph 29.54.c.
¶78.94 SOM Smith and SM Utting were together responsible for drafting PN155 (which later became PN790), the policy on fire survival guidance calls.935 See, for example, email from SOM Smith to SM Utting on 23 January 2011 {LFB00028301}; Email from SOM Smith to POM Hayward on 24 January 2011 {LFB00058020}; Utting {LFB00118918/3} page 3, paragraph 8; Smith {Day203/128:20}-{Day203/129:7}. The draft version of PN155 dated 10 February 2011 included a warning that in exceptional circumstances the incident commander might tell the control room to advise callers seeking fire survival guidance to do their best to leave their properties.936 Draft version of PN155 dated 10 February 2011 {LFB00083447/4} paragraph 6.6. SOM Smith said that she had recommended the inclusion of that paragraph, although she had not been responsible for drafting it.937 Smith {LFB00121219/26} page 26, paragraph 69; Smith {Day203/91:4}-{Day203/92:12}. The wording suggests that the incident commander was responsible for any decision to revoke "stay put" advice. SOM Smith, however, said that she had it in mind that the decision would be made jointly by the control room and the incident commander.938 Smith {Day203/92:22}-{Day203/93:12}. Indeed, in its final form PN790 stated that the decision would be made by agreement between the incident commander and the officer in charge of the control room.939 PN790 issued on 23 February 2012 and reviewed as current on 17 April 2014 {LFB00001257/5} paragraph 8.7.
123¶78.95 SOM Smith does not appear to have given any thought to what might constitute "exceptional circumstances" sufficient to justify the revocation of "stay put" advice.940 Smith {Day203/94:19}-{Day203/95:7}. Nor did she consider providing guidance, whether to the CROs handling fire survival guidance calls or those supervising them, on what information to look out for or gather in order to help decide whether exceptional circumstances requiring an evacuation existed.941 Smith {Day203/94:19}-{Day203/95:7}. Nor, it appears, did POM Hayward,942 Hayward {Day199/220:8-21}. with the result that no such guidance was included in the RIFs.
¶78.96 Perhaps more importantly, SOM Smith did not consider including in the RIFs guidance about what a CRO should tell a caller if the decision had been made to revoke the "stay put" advice.943 Smith {Day203/96:9-16}. SOM Smith said that had been because the advice would differ depending on the particular circumstances, so that, in effect, it could not be the subject of generic guidance.944 Smith {Day203/96:17}-{Day203/97:6}. However, she also said that they did not think that such extreme circumstances were likely to occur.945 Smith {Day203/97:20-25}; Smith {MET00080606/13}. POM Hayward said much the same,946 Hayward {Day199/221:10-23}. but their position makes little sense, given that the policy specifically envisaged that the "stay put" advice might need to be revoked. It is also regrettable, given what was said about it in GRA 3.2,947 GRA 3.2 {LFB00001255/19}. which AC Brown unfortunately failed to pass on to POM Hayward or SOM Smith.
¶78.97 On 13 April 2011, a draft of PN155 was sent to all Assistant Commissioners, including AC Brown, with a request that they assess its effect on their respective departments.948 Email from Michele Kunneke to all ACs on 13 April 2011 {LFB00033332/1}. AC Brown thought that CROs would need guidance on the implementation of the provision relating to the revocation of "stay put" advice,949 Brown {Day206/120:9-22}. in the form of policy, RIFs and training, but he did not consider what form that guidance should take.950 Brown {Day206/120:9}-{Day206/121:4} He assumed that those working on the policy and the RIFs would do that, but it is clear, not least from the absence of any guidance, that he did not take steps to ensure that it was done.951 Brown {Day206/121:2-4}
¶78.98 The failure to include guidance of that kind in the RIFs was significant because, as the chairman found in the Phase 1 report, on the night of the Grenfell Tower fire SOM Smith and DAC Fenton had to make the difficult decision to revoke the "stay put" advice without the benefit of any established guidance. Moreover, many CROs struggled to deliver clear advice to callers that they must leave the building.952 Phase 1 Report Volume IV, paragraph 29.99
124Letter to DCLG about handling fire survival guidance calls
¶78.99 Pre-inquest action 13 was to draft a letter to DCLG seeking clarification of the national guidance on handling fire survival guidance calls in order to ensure a consistent approach among fire and rescue services.953 Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/15}. The letter was also intended to recommend a review of national guidance on the subject.954 Lakanal House Assurance Review dated 7 August 2018 {LFB00004801/15}.
¶78.100 By April 2010 POM Hayward and SOM Smith had produced a draft letter to DCLG.955 Hayward {Day199/194:8-11}; Smith {LFB00121219/10} page 10, paragraph 24. However, on 20 April 2011 the Lakanal House Board decided not to pursue the matter until the Lakanal Control Report had been completed.956 Minutes of Lakanal House Board meeting on 20 April 2011 {LFB00084035/1} item 4.4. Notwithstanding that decision, on 20 November 2011, after the letter had been reviewed by the LFB legal team, POM Hayward asked for it to be sent to DCLG.957 Minutes of Lakanal House Board meeting on 30 November 2011 {LFB00084038/2} item 8.1. On 12 December 2011, Commissioner Dobson confirmed that it should be sent and asked for a copy to sign.958 Minutes of the Lakanal House Board meeting on 12 December 2011 {LFB00084039/2} item 8.1; Dobson {Day211/143:19}-{Day211/144:1}.
¶78.101 On 3 February 2012, a draft of the letter dated 23 December 2011 was sent by Linda Armstrong, Deputy Head of Legal Service, by email to Sue Marshall, Commissioner Dobson's secretary, for final approval and signature by the Commissioner with a request that it be addressed to Sir Ken Knight, then Chief Fire and Rescue Adviser.959 Email from Linda Armstrong to Sue Marshall copying Commissioner Dobson and DAC Cutbill dated 3 February 2012 {LFB00100551}. Draft Letter to DCLG dated 23 December 2011 {LFB00004744}. There is another version of the letter dated 3 February 2012 addressed to Sir Ken Knight.960 Letter from Ron Dobson to Sir Ken Knight dated 3 February 2012 {LFB00004728}.
¶78.102 The letter suggested that the relationship between FSC 10-93 and FSC 54-04 should be reviewed and that in any review of the provision of fire survival guidance there were seven areas to which particular consideration should be given. They included better guidance on engaging with callers when assessing their situation and exploring possible means of protection and escape, continual reassessment of changing conditions and the caller's physical and mental condition, guidance on effective communications between the control room and the incident ground and training on the role of supervisors in the control room.961 Letter from Ron Dobson to Sir Ken Knight dated 3 February 2012 {LFB00004728}.
¶78.103 SOM Smith said that she had felt that national guidance needed to be revised in that way because of the LFB's experience at the Lakanal House fire and because a lot had changed since FSC 10-93 had been published.962 Smith {Day202/143:17-24}. She had felt that it was necessary that someone with that degree of experience should investigate whether there were new practices that could help control room staff.963 Smith {Day 202/144:1-11}. She had assumed that other fire and rescue services might make the same mistakes as the LFB had made at the Lakanal House fire and would benefit from what the LFB had learnt.964 Smith {Day202/144:22}-{Day202/144:3}.
125¶78.104 Despite SOM Smith's view and the decision in December 2011 to send the letter to DCLG, it was not in fact sent. A later decision was made in July 2012, apparently by DC Dexter, to defer once again sending the letter until work on the Lakanal Control Report had been completed.965 Minutes of the Lakanal House Board meeting on 2 July 2012 {LFB00084043/1} item 5.1; Minutes of Lakanal House Board meeting on 7 September 2012 {LFB00084044/1} item 4.1; Minutes of Lakanal House Board meeting dated 17 October 2012 {LFB00084045/2} item 6.1; Hayward {Day199/194:17-25}.
¶78.105 The version of the Lakanal Control Report dated November 2012 was unequivocal in recommending that Commissioner Dobson should write to DCLG to prompt a review of national guidance on handling fire survival guidance calls.966 Lakanal Control Report dated November 2012 {HOM00001124/51} paragraph 303. However, despite that recommendation, Commissioner Dobson decided on 19 November 2012 not to send the letter.967 Minutes of the Lakanal House Board meeting on 19 November 2012 {LFB00084046/1} item 6.1. His decision was reconsidered at the meeting of the board on 14 December 2012, however, when he decided that it would be reviewed after the conclusion of the Lakanal House inquests.968 Minutes of the Lakanal House Board meeting on 14 December 2012 {LFB00040033/1}; Dobson {Day211/144:23}- {Day211/145:1}. Commissioner Dobson thought that decision had been discussed at the Lakanal House Board.969 Dobson {Day211/145:2-6}. He said that he had been persuaded that it was better to wait for the coroner's conclusions.970 Dobson {Day211/145:7-15}. However, in September 2013, he decided that the letter was no longer required and had been dealt with by the outcomes of the inquest.971 Minutes of Lakanal House Board meeting on 30 September 2013 {LFB00050644/1} item 5.1. He said that he had taken that decision on the advice of the Lakanal House Board.972 Dobson {Day211/148:15-19}.
¶78.106 However, the coroner's rule 43 letters did not deal with the matters raised in the draft letter to the DCLG,973 There is nothing dealing with those issues in the coroner's rule 43 letter to DCLG dated 28 March 2013 {CLG00000401} nor in her rule 43 letter to the LFB dated 28 March 2013 {LFB00032158}. so it is not clear why Commissioner Dobson thought that the matters it raised had been dealt with by the outcome of the inquests. The consequence of the decision not to send the letter in September 2013 was that, almost three and half years after the pre-inquest action had been raised and the letter to DCLG had been drafted, it had still not been sent. As a result, the respects in which national guidance on the handling of fire survival guidance calls needed to be improved were not considered by DCLG. It also meant that the recommendation in the Lakanal Control Report was not carried out. The coroner was not informed of that, an omission which Commissioner Dobson described as an oversight.974 Dobson {Day211/148:3}-{Day211/149:5}.
¶78.107 In his review dated 4 January 2013 GM Lindridge found that the gap analysis had identified areas in which national guidance could be improved which had not been incorporated into LFB policy.975 GM Lindridge's review dated 4 January 2013 {LFB00085854/5}. DC Dexter asked why that had not been done. AC Brown said that all the suggestions had been adopted where relevant.976 GM Lindridge's review dated 4 January 2013 with DC Dexter and AC Brown's comments {LFB00085854/5}. However, AC Brown's confidence was misplaced because not all GM Lindridge's recommendations for improvement in national guidance had been considered and adopted. In particular, the gap analysis had recommended that national guidance be improved to emphasise the need for continual reassessment of the caller's circumstances,977 Annex B to Lakanal Control Report entitled 'Comparison between national guidance and LFB policy and training' {HOM00001125/14}; {HOM00001125/17}. but PN539 did not emphasise that, although AC Brown thought it was implicit.978 Brown {Day206/99:6-13}.
126¶78.108 AC Brown said that when AC Chandler had returned to work he had asked him to review the audit and satisfy himself that everything had been done.979 Brown {Day206/100:4-12}. It is clear, however, from the terms of AC Brown's instructions that he did not ask AC Chandler to check whether all the recommendations to improve national guidance had been covered by LFB policy.980 Email from AC Brown to AC Chandler on 4 April 2013 {LFB00028942/1}. It is equally clear that AC Chandler did not deal with it in his response.981 Email from AC Chandler to AC Brown on 28 June 2013 {LFB00060701}. POM Hayward could not recall whether any other action had been taken in response to the recommendation.982 Hayward {Day199/200:2-5}.
¶78.109 We have come to the conclusion that no action was taken in response to that particular recommendation and that as a result, an opportunity was missed to correct some of the defects in PN539, including the absence of the important emphasis on the need for continual reassessment of the caller's situation.
Handling multiple fire survival guidance calls
¶78.110 In the Phase 1 report the chairman identified the need to examine whether, when, and to what extent the LFB was aware of the deficiencies that existed in its policy and training for fires that gave rise to a large number of concurrent fire survival guidance calls.983 Phase 1 Report Volume IV, paragraph 29.42. He found that PN539 was defective, in part because it did not recognise the important fact that, because a fire survival guidance call (as defined) requires the continued presence of a CRO on the line, the number of calls that could be handled concurrently could not exceed the number of CROs available.984 Phase 1 Report Volume IV, paragraph 29.45(b).
¶78.111 The definition of a fire survival guidance call in PN539 was introduced after the Lakanal House fire because the LFB had wanted something more robust than had previously existed.985 Smith {Day202/153:4} – {Day202/154:25}. It was formulated by those working in the control room, together with DACs Tim Cutbill and Tom Davies, and was agreed by the Lakanal House Board.986 Smith {Day202/154:7-13}. It did not come from national guidance.987 Smith {Day202/154:14-15}. SOM Smith said that people had realised at the time that the number of simultaneous fire survival guidance calls could not exceed the number of CROs and supervisors available, but that in the past the control room had never received more fire survival guidance calls than it could handle.988 Smith {Day202/156:18} – {Day202/157:12}.
¶78.112 In PN539 a fire survival guidance call is defined as
"a call to Brigade Control where the caller believes that they are unable to leave their premises due to the effects of fire, and where the Control Room Officer remains on the line providing appropriate advice until either the caller is able to leave by their own means, is rescued by the Fire brigade or the line is cleared".
¶78.113 It became apparent during the evidence, particularly that of SOM Smith, that the definition is open to different interpretations,989 Smith {Day202/183:18} – {Day202/185:22}. since it depends on an exercise of judgement by the relevant CRO about the content of the call.990 Smith {Day202/183:18} – {Day202/185:22}. As a result, the precise number of fire survival guidance calls reported at any one incident could itself be a matter of debate.991 For example, see Smith {Day202/183:18} – {Day202/185:22}. For example, evidence about the Marriott Hotel fire on 11 November 2010, a ten-pump fire in a hotel and private residential block of 32 floors in Poplar, East London,992 Daily Bulletin {LFB00109347/3}. variously suggested that the control room had received between four and seventeen fire survival guidance calls.993 SOM Smith reported that four fire survival guidance calls had been received {Day202/185:14-22}; the 'End of Incident Report' suggested that approximately eight fire survival guidance calls had been received because of the number of fire survival guidance messages transferred from the control room to the incident ground {LFB00123671/3-8}. The figure of 17 fire survival guidance calls was contained in a comment to a draft of PN155 at paragraph 6.2 {LFB00109485/3}. The LFB's contemporaneous documentary evidence from the Adair Tower fire on 31 October 2015, an eight-pump fire in a high-rise residential block of flats located in the Royal Borough of Kensington and Chelsea, suggested that nine fire survival guidance calls had been received,994 Debrief proforma for Adair Tower {LFB00035092/3}; FSG Database {LFB00031757} rows 20 to 28. but SOM Smith told us that when she had listened to the calls before giving evidence, she had reached the conclusion that only six could properly be described as fire survival guidance calls.995 Smith {Day202/201:1-20}.
127¶78.114 It is difficult to understand how the identification of a fire survival guidance call could have remained a source of debate within the LFB after the Lakanal House fire, particularly when handling three fire survival guidance calls concurrently was a complex and intense experience. If the LFB could not consistently and accurately identify a fire survival guidance call, it could not tell how many had been generated by any particular incident, making it impossible to draw reliable conclusions or plan for future incidents. We have therefore sought to examine what lessons for handling fire survival guidance calls the LFB learned from the Lakanal House fire, which gave rise to five fire survival guidance calls, three of which were being dealt with at the same time.996 Lakanal Control Report {HOM00001124/35-37}, Table 4, rows 4, 28, 31, 38 & 43.
¶78.115 Before the Grenfell Tower fire, there had been a consensus among senior managers that the Lakanal House fire had been an exceptional event and that under normal circumstances the control room was unlikely to receive more than two or three fire survival guidance calls from any incident.997 Hayward {LFB00121176/16} page 16, paragraph 66; Bagnelle {LFB00122821/2} page 2, paragraph 6 and {LFB00122821/6} page 6, paragraph 19. Although SOM Smith initially said that the expression "multiple fire survival guidance calls" was not used within the LFB or nationally,998 Smith {LFB00121219/12-13} pages 12-13, paragraph 29. it is clear that the LFB had made preparations for the receipt of two simultaneous calls, which could be viewed as "multiple" fire survival guidance calls.999 Smith {Day202/162:5} – {Day202/163:12}.
¶78.116 One striking aspect of the senior managers' evidence was their common belief that the control room's experience with the Lakanal House fire would not be repeated and that it was highly unlikely that more than three fire survival guidance calls would ever be received during one incident.1000 Hayward {LFB00121176/16} page 16, paragraph 66; Bagnelle {LFB00122821/2} page 2, paragraph 6 and {LFB00122821/6} page 6, paragraph 19; Smith {LFB00121219/17} page 17, paragraph 43. That belief should have been questioned following a number of major fires attended by the LFB which involved a significant number of fire survival guidance calls, and certainly more than two or three.
¶78.117 The first such incident was the fire at the Marriott Hotel in Poplar, London, on 11 November 2010.1001 Smith {Day202/183:18-24}. SOM Smith was in attendance that night as control duty manager.1002 Smith {Day202/183:18-24}. On that occasion the control room received between four and seventeen fire survival guidance calls (depending on how one defines them) during the course of the incident, which led to seven or eight messages being passed to the incident ground about persons trapped in their flats.1003 SOM Smith reported that four fire survival guidance calls had been received {Day202/185:14-22}; the end of incident report suggested that between seven and eight fire survival guidance calls had been received {LFB00123671}; the figure of 17 fire survival guidance calls was recounted in a comment to a draft of PN155 at paragraph 6.2 {LFB00109485/3}. SOM Smith thought that there had been two concurrent fire survival guidance calls which had lasted for 45 minutes and one hour respectively.1004 {Day202/185:14-22}. After the incident, AC Hickmott sent an email to Commissioner Dobson,
128¶Deputy Commissioner Dexter, AC Cowup, AC Brown and POM Hayward, in which he described the particularly challenging nature of many of the fire survival guidance calls, some of which had lasted for more than an hour.1005 Email from Andy Hickmott to Scott Hayward, Dave Brown, Peter Cowup, Rita Dexter and Ron Dobson titled "FW: Daily Bulletin.12-11-10.doc" dated 12 November 2010 {LFB00110785/2}. By contrast, AC Brown saw the incident as little more than a normal, if busy, day,1006 Brown {Day206/126:9-16}. a remark which we consider revealed a degree of insouciance about the magnitude of the problem.
¶78.118 Although the incident generated more fire survival guidance calls than the Lakanal House fire, their number did not prompt any discussion about the control room's capacity to handle multiple fire survival guidance calls.1007 Brown {Day206/126:1-7}. According to AC Brown, that was because the control room had handled them very well.1008 Brown {Day206/126:8-9}. Be that as it may, it did not prompt any consideration of the need to plan or train for an incident which generated eight simultaneous fire survival guidance calls.1009 Brown {Day206/126:17} – {Day206/127:11}. According to AC Brown that was because the LFB was already taking the steps identified in the Lakanal Control report by developing PN790 and had started giving training on handling fire survival guidance calls.1010 Brown {Day206/126:17} – {Day206/127:11}.
¶78.119 On 16 June 2011, the LFB carried out an eight-pump exercise called the Heygate Challenge.1011 Email from Andy Roe to numerous LFB participants {LFB00033345/1-4}. It was developed to test the proposed amendments to the high-rise firefighting policy and the new draft policy on fire survival guidance calls.1012 Email from Andy Roe to numerous LFB participants {LFB00033345/1-4}. POM Hayward and SOM Smith representing the control room were involved as observers and facilitators.1013 Email from Andy Roe to numerous LFB participants {LFB00033345/1-4}. As part of the exercise the control room simulated a live incident, allocating specific pumps and passing information from mock fire survival guidance calls to the incident ground.1014 Smith {Day202/171:3-10}; Hayward {Day199/210:11-20}. The exercise included four fire survival guidance calls, although it is unclear whether they were concurrent.1015 'Feedback: High Rise and FSG Policies Test Exercise 16 June 2011 Southwark' {LFB00033384/11}; Smith {Day202/172:1-18}. It is unclear why only four fire survival guidance calls were chosen, given that five calls had been received at the Lakanal House fire.1016 Smith {Day202/176:23} – {Day202/177:10}; Hayward {Day199/212:21} – {Day199/214:7}.
¶78.120 After the exercise, a debriefing meeting was held.1017 Minutes of debrief meeting {LFB00056628}. SOM Smith could not recall attending it or being involved in any discussion or meeting after the exercise.1018 Smith {Day202/173:20} – {Day202/173:24}; Feedback: High Rise and FSG Policies Test Exercise 16 June 2011 Southwark' {LFB00033384/11}. Although POM Hayward thought that he had attended the meeting, the minutes do not record any contribution from the control room.1019 Hayward {Day199/212:7-12}; Feedback: High Rise and FSG Policies Test Exercise 16 June 2011 Southwark {LFB00033384/10}; Minutes of debrief meeting {LFB00056628}. Later reports from the command units recorded a consensus that the form used by staff in the command units had worked adequately for four flats as simulated in the exercise, but that the process would have been unmanageable for 20 or more calls, as one command unit had experienced at a previous incident.1020 Feedback: High Rise and FSG Policies Test Exercise 16 June 2011 Southwark {LFB00033384/10-11}. No witness was able to identify that incident.
129¶Further analysis noted that recording fire survival guidance calls was hard enough with four flats involved, but would be almost impossible if 60 flats were involved.1021 Minutes of debrief meeting {LFB00056628/4}.
¶78.121 Although the Heygate Challenge involved only four fire survival guidance calls, the reports on that exercise show that the LFB was aware that multiple fire survival calls could arise from a single incident and that in those circumstances an efficient flow of information to the command units could not be maintained. Despite that, no attempt was made to plan for an incident that could generate as many as 60 fire survival guidance calls,1022 Hayward {Day199/215:12-21}. probably because the LFB had never experienced an incident involving 60 flats.1023 Hayward {Day199/215:12-21}. At all events, it seems clear that there was no discussion among those responsible for the operation of the control room about how it would handle more than four concurrent fire survival guidance calls. It is also clear that by mid-2011 a picture was developing that showed that incidents could give rise to more (and conceivably many more) than two or three calls of that kind.
¶78.122 As we noted earlier, during 2011, PN155 was being drafted predominantly by SM Utting and SOM Joanne Smith.1024 Utting {Day198/103:10-25}; Smith {LFB00121219/26} page 26, paragraph 69. Paragraph 7.10 of one draft specifically contemplated that the control room might receive multiple fire survival guidance calls, because it suggested that the incident commander should consider calling for an additional command unit to help managing a large number of such calls .1025 Draft PN155 issue date 10 February 2011 {LFB00111471/5} However, there was no consensus between SM Utting and SOM Smith, or indeed between other senior managers of the LFB, on what a large number of fire survival guidance calls might mean or about how many fire survival guidance calls might be generated by any one incident.1026 Brown {Day206/122:23} – {Day206/123:11}; Smith {Day202/198:3} – {Day202/199:7}; Patrick Utting could not recall having discussed or even having considered the possibility of more than 5 fire survival guidance calls being generated by a single incident or how the control room would manage such an occurrence: Utting {Day198/118:17} – {Day198/119:18}. It is unclear why no consensus had been reached on that, given that the policy was specifically directed to handling multiple fire survival guidance calls, or why officers had up to five calls in mind when it had already become apparent from the Marriott hotel fire and the Heygate Challenge that it was possible for a single incident to generate many more calls.
¶78.123 In February 2014, GRA 3.2 was published.1027 GRA 3.2 {LFB00001255/3}. It included a section entitled "Fire Survival Guidance" which emphasised that numerous fire survival guidance calls could be received during a single high-rise incident.1028 GRA 3.2 {LFB00001255/30}. The guidance was relevant to the control room's ability to handle numerous fire survival guidance calls, but none of those responsible for its operation appears to have been asked to review GRA 3.2 or even to have been consulted about its contents. Although it contained advice on handling fire survival guidance calls, neither POM Hayward nor SOM Smith had been aware of it before the Inquiry brought it to their attention because of its focus on operational matters.1029 Smith {Day202/199:8-19} and {Day203/20:3-8}; Hayward {Day200/53:13} – {Day200/54:22}. The result was that there was no discussion about how the control room would handle multiple fire survival guidance calls as GRA 3.2 contemplated.1030 Smith {Day202/199:20} – {Day202/200:3}; Hayward {Day200/53:13} – {Day200/54:22}.
130¶78.124 During Phase 1 the chairman heard evidence about a tactical decision exercise training programme involving seven fire survival guidance calls that SM Peter Johnson had devised in 2014. Its purpose was to ascertain the maximum number of fire survival guidance calls that the control room and incident ground could handle satisfactorily at any one time. He also expected it to demonstrate that the procedures for handling fire survival guidance calls were inadequate.1031 Phase 1 Report Volume IV, paragraph 29.40. In Phase 2, we have investigated why the LFB did not proceed with SM Johnson's programme. His exercise was sent to borough commander Terence Harrington on 27 February 2014 and presented to the fire survival guidance policy group on 12 March 2014.1032 Harrington {LFB00102245/8} page 8, paragraph 18; Withers {LFB00084123/5} page 5, paragraph 16; Minutes of Fire Survival Guidance Meeting on 12 March 2014 {LFB00084124}. At that time, GM Harrington was trying to develop a practical exercise involving the structured delivery of training to impart knowledge, clarify roles and responsibilities and better understand the complexities of handling fire survival guidance calls arising from a small-scale incident that escalates to something larger.1033 Harrington {LFB00102245/12} page 12, paragraph 31. He decided that SM Johnson's training programme did not meet that aim and it was therefore not implemented.1034 Harrington {LFB00102245/12} page 12, paragraph 31. However, even though SM Johnson's proposal was not taken any further, it demonstrates that there was some recognition in 2014 that more than four or five concurrent fire survival guidance calls might arise from a single incident, that the systems might not be capable of managing them and that preparations should be made to deal with them. Unfortunately, that view was neither shared nor discussed more widely within the LFB.1035 Withers {LFB00084123/5} page 5, paragraph 16.
¶78.125 The last significant incident before the Grenfell Tower fire which gave rise to fire survival guidance calls was an eight-pump fire at Adair Tower on 31 October 2015.1036 FSG Database {LFB00031757}. Between six and nine fire survival guidance calls were received between 08.54 and 09.08, together with 15 other calls.1037 Debrief proforma for Adair Tower {LFB00035092/5}; FSG Database {LFB00031757}; Smith {Day202/201:1-20}. The incident made it clear that the control room could receive more than two or three fire survival guidance calls during a single high-rise fire. Although SOM Smith described the incident as manageable,1038 Smith {Day202/205:6-18}. she was able to shed little light on why senior officers continued to believe that a single incident would be unlikely to give rise to more than two or three fire survival guidance calls and that more than five such calls was unthinkable.
¶78.126 Even though the control room had received an exceptional number of fire survival guidance calls during the Adair Tower fire, the incident did not prompt any consideration of how so many calls should be managed.1039 Smith {Day202/206:18} – {Day202/207:14}. The FSG Database did not record any lessons to be learnt or systems to be reviewed {LFB00031757}. The Incident Debrief form did not record any learning about fire survival guidance management {LFB00035092}. The IMP report for the incident did not record any learning about fire survival guidance management {MET00080621}. It was not just the number of calls that should have prompted a review. A novel practice of recording information relating to calls on a whiteboard, which was not provided for in policy, was adopted at that incident.1040 {LFB00035092/5}. It should be noted that on 20 December 2016, following a command unit training exercise, Liz Hymns expressed concern that a whiteboard had not been set up for managing multiple fire survival guidance calls to enable the control room to manage the information, even though she considered that to be standard practice: {LFB00052219/1}. More importantly, most of the calls were taken by CROs who had less than two years' experience and for some it was their first fire survival guidance call. The incident should, therefore, have prompted careful consideration about how best to manage multiple fire survival guidance calls.
131¶78.127 Regrettably, we have come to the conclusion that despite all the indications that a large number of calls seeking fire survival guidance could be generated by a single incident, particularly one involving a large or high-rise residential building, the LFB failed to recognise that possibility and therefore failed to take any steps to prepare for it by training its staff or putting in place systems and procedures to respond to such an eventuality. The result was that when faced with an unprecedented number of callers from Grenfell Tower seeking fire survival guidance, the control room and those at the fireground were unable to rely on tried and tested systems and were forced to resort to various improvised methods of varying reliability to handle the large amount of information generated. That represents a major failing on the part of the LFB.
133Chapter 79: Fire survival guidance: training and management
Background
¶79.1 Taking emergency calls from the public, particularly those who are directly affected by a fire or other life-threatening event, and passing essential information quickly and accurately to those who need to receive it requires reserves of character and effective training. Control room staff receive training when they are recruited, but they also need regular training to ensure that their skills are kept up to date and that they benefit from any advances in learning. In the Phase 1 report the chairman was critical of some of the ways in which CROs handled emergency calls. He also identified various deficiencies in the Reference Information Files (RIFs) provided for the assistance of control room staff.1041 Phase 1 Report Volume IV paragraphs 29.49-29.50. We have therefore examined the way in which the LFB managed the training of control room staff in the years preceding the Grenfell Tower fire.
¶79.2 Ultimate responsibility for control room training lay with the senior officers, primarily AC George and AC Brown,1042 Hayward {Day199/36:21}-{Day199/37:15}; George {Day205/12:3-6}; Brown {Day206/156:13-17}. but none of them exercised very much oversight of it.1043 Hayward {Day199/37:16}-{Day199/38:3}; George {Day205/152:5}-{Day205/153:24}. AC Brown delegated to POM Hayward responsibility for monitoring control room training and ensuring that the training needs of control room staff had been properly identified and effectively met.1044 Brown {Day206/156:10-17}. POM Hayward in turn delegated that responsibility to the SOM in charge of the Operational Support Team,1045 Hayward {LFB00086213/7} page 7, paragraph 38; Hayward {Day199/38:4-8}. who was responsible for identifying the training required, deciding its content and ensuring that it was delivered effectively.1046 Hayward {Day199/33:21}-{Day199/34:1}; Hayward {LFB00055191/17} page 17, paragraph 48; Smith {LFB00121219/6} page 6, paragraph 15. The SOM took full responsibility for training and did not need to obtain the approval of POM Hayward for training packages that were developed.1047 Hayward {Day199/34:2-7}. The Operational Support Team was responsible for creating, organising and delivering all training documents and training packages for new entrants to the control room and existing staff.1048 Hayward {LFB00055191/7} page 7, paragraph 20; {LFB00055191/17} page 17, paragraph 47; Hayward {Day199/38:9- 13}. In the period between 2009 and 2019 the SOMs responsible for training were Lindsay Turner (2009–2012), Victor Bagnelle (2012–2015) and Joanne Smith (2015–2019).1049 Hayward {LFB00086213/8} page 8, paragraph 39.
¶79.3 POM Hayward generally adopted a laissez-faire style of management under which he did not expect to receive reports on matters relating to training unless there was a problem.1050 Hayward {Day199/32:6-14}; {Day199/51:6-24}. He therefore did not actively monitor training; he expected the SOM to tell him if there was a problem of some kind.1051 Hayward {Day199/51:6-24}. Otherwise, he assumed that the Operational Support Team was carrying out its job properly.1052 Hayward {Day199/32:15-21}; {Day199/51:6-24}. In practice, POM Hayward's monitoring of training was confined to discussions with the SOM about problems as they arose and the observation of some training.1053 Hayward {Day199/32:15-21}; {Day199/34:5-14}. He did not regularly inspect the training records, despite the provisions of PN164, which contemplated that he would do so.1054 Hayward {Day199/118:17-19}; PN164 amended on 28 January 2009 {LFB00084054/3} paragraph 2.5; PN164 reviewed as current on 6 May 2015 {LFB00084054/8} paragraphs 2.5-6. He made none of the decisions about the content of control room training, nor did he consult AC Brown, AC Chandler or AC George about it.1055 Hayward {Day199/34:19}-{Day199/35:3}. He expected any problem with training to be raised at Brigade Control Management meetings or in his meetings with the SOMs,1056 Hayward {Day199/32:19}-{Day199/33:17}; {Day199/50:20-24}. but apparently none ever had been.1057 Hayward {Day199/32:19}-{Day199/33:1}; {Day199/51:6-13}. In the absence of any problems he felt confident that the SOMs were managing training properly.1058 Hayward {Day199/32:19}-{Day199/33:1}. For their part, neither AC Brown nor AC Chandler nor (to a lesser extent) AC George, exercised any active supervision of his oversight of training or monitored what he was doing to keep abreast of it.
134¶79.4 In our view, such a detached approach to training should never have been allowed. Although POM Hayward was entitled to delegate the delivery of training to senior managers whom he knew and trusted, he had a personal responsibility to satisfy himself that the training programmes were suitable and were being delivered appropriately. He also had a personal responsibility to satisfy himself that the training was effective. As far as we can see, he did none of those things.
¶79.5 Most of the training was delivered to staff on watch. Accordingly, if during training there was a significant incident or a significant increase in the number of calls, staff could be recalled to their positions in the control room.1059 Hayward {LFB00055191/18} page 18, paragraph 52. Generally, training took place in a side room of the premises at Merton where the control room was located.1060 Hayward {LFB00055191/17} page 17, paragraph 49. When training had been completed, it should have been recorded manually by the Operational Support Team in a spreadsheet. From April 2019 it was recorded electronically in a system called System Training Evaluation and Performance (STEP).1061 Hayward {LFB00055191/17} page 17, paragraph 48; Hayward {LFB00055191/25} page 25, paragraph 72; Training Spreadsheet {LFB00055223}.
Fire survival guidance training after the Lakanal House fire
¶79.6 The Lakanal House Board was responsible for the introduction of a programme of fire survival guidance training introduced in response to the Lakanal House fire.1062 Hayward {LFB00055191/24} page 24, paragraph 68. The relevant pre-inquest actions were action 8 (involvement of fire safety officers in training), action 11 (ensure that initial training on handling fire survival guidance calls complied with national guidance) and action 12 (provide refresher training on handling fire survival guidance calls).1063 Lakanal Assurance Report {LFB00004801/13-14}.
¶79.7 National guidance on fire survival guidance training for CROs was published by the Home Office in 1993 and 1994 respectively in the form of FSC 10-93 and 'Keeping People Safe',1064 Lakanal Control Report {HOM00001124/13-16} paragraphs 49-74. to which we have referred. FSC 10-93 provided that recruits with between 8 and 12 weeks of service should be given fire survival guidance training to enable them, when dealing with callers trapped in domestic accommodation, to make a proper assessment of the situation, give appropriate advice where necessary and otherwise assist in minimising the danger to the caller.1065 Fire Service Circular {LFB00003617/1} paragraph 6. FSC 10-93 also recommended that continuation training be provided to CROs, which should include the fire survival guidance training set out in Appendix B.1066 Fire Service Circular {LFB00003617/2} paragraph 7. Appendix B recommended that fire survival guidance training should be presented by a fire safety officer and a fire control officer jointly and should comprise a lecture lasting one to one- and-a-half hours followed by a practical role-play session.1067 Fire Service Circular {LFB00003617/6}.
135¶79.8 One of the key recommendations of 'Keeping People Safe' was that fire survival guidance refresher training should be undertaken at intervals of no more than 12 months.1068 Lakanal Control Annexures {LFB00004750/37}. The training emphasised the need for an assessed role-play session in which CROs should actively participate.1069 Lakanal Control Annexures {LFB00004750/28}; Hayward {Day200/120:14}-{Day200/121:25}. Its purpose was to test the ability of CROs to establish whether a caller can leave the building, recognise unusual responses, determine the caller's location and provide appropriate guidance by following a sequence of prompts.1070 Lakanal Control Annexures {LFB00004750/28}.
¶79.9 After the Lakanal House fire, the LFB created an initial fire survival guidance training package in 2010 for all control room staff which consisted of three training presentations1071 Hayward {LFB00121176/3-4} pages 3-4, paragraphs 13 and 14; Lakanal House Assurance Review {LFB00004801/14}. Further training was developed for new entrants {LFB00107484}. entitled Building Types and Concepts,1072 Refresher training presentation on building types and concepts (2011) {LFB00086228}. Fire Survival Guidance1073 Fire Survival Guidance presentation {LFB00028265}. and Fire Survival Training: Introduction to Fire and Human Behaviour.1074 Fire Survival Training: Introduction to Fire and Human Behaviour presentation, dated March 2010 {LFB00119961}. SOM Lindsay Turner was responsible for drafting the new training package, although the senior management team as a whole was involved in decisions about it.1075 Smith {LFB00121219/18} page 18, paragraph 47; Smith {Day203/191:10-16}.
¶79.10 In 2010, fire survival guidance training was delivered to all control room staff, except those on long-term absence.1076 Hayward {LFB00055191/25} page 25, paragraph 74; Minutes of Lakanal House Board Meeting of 15 September 2010 {LFB00055192/1}. A full day was allocated for it, off the watch. It was delivered by one of the trainers and included opportunities to ask questions.1077 Hayward {Day200/79:9}-{Day200/80:16}; {Day200/80:19-23}; Hayward {LFB00055191/24} page 24, paragraph 69. Half of the training was delivered by the Fire Safety team, in accordance with national guidance.1078 Minutes of Lakanal House Board Meeting of 15 September 2010 {LFB00055192/2} item 5.6; Hayward {LFB00055191/6-7} pages 6-7, paragraph 20. At a meeting on 15 September 2010, the Lakanal House Board was informed that all control room staff had received refresher fire survival guidance training which had been fully in accordance with FSC 10-93.1079 Minutes of Lakanal House Board Meeting of 15 September 2010 {LFB00055192/1} item 5.4.
¶79.11 In February 2010, before the fire survival guidance training package had been provided to staff, POM Hayward asked for role-play to be introduced as part of an assessment at the end of the week to consolidate the training and to give CROs an opportunity to practise giving fire survival guidance in a controlled environment.1080 Email from Scott Hayward to Chris Sharp, Lindsay Turner, Joanne Stibbards and Robin Hannan dated 23 February 2010 regarding Fire Survival Planning Meeting 22nd February 2010 {LFB00028258/1}. As a result, the fire survival guidance training in 2010 included active role-play, in which the trainer would act as the caller and a CRO would take the call.1081 Hayward {LFB00121176/6} page 6, paragraph 20. The trainer would improvise a situation based on their own experience and act out a fire survival guidance call to which the CRO would be expected to respond.1082 Hayward {LFB00121176/6} page 6, paragraph 20; Hayward {Day200/127:22}-{Day200/128:19}. No specific responses were required but the trainer was expected to ensure that the trainee followed the structure set out in the fire survival guidance RIF.1083 Hayward {LFB00121176/6} page 6, paragraph 20.
136¶79.12 The initial fire survival guidance training package was outdated, being based on a fatal fire in the West Midlands in 1990 which had prompted the dissemination of FSC 10-93 and the 'Keeping People Safe' training. It was flawed in a number of respects. First, none of the initial training presentations referred to the Lakanal House fire or to the rapid spread of fire that had occurred on that occasion and the dangers involved.1084 2010 FSG Training {LFB00028265}; 2011 FSG Training {LFB00086214}; Hayward {Day200/96:12} – {Day200/97:11}; Building Types and Concepts presentation {LFB00086228}; Hayward {Day 200/107:3-20}; Fire and Human Behaviour Training presentation, dated March 2010 {LFB00119961}; Hayward {Day200/111:2}-{Day200/112:7}. SOM Smith could not explain why that was the case1085 Smith {Day203/202:7-11}. and the 2011 training did not remedy the omission.1086 2011 FSG Training {LFB00086214/1}.
¶79.13 Secondly, none of the training presentations enabled CROs to understand significant features of modern buildings, such as cladding systems, and how they could contribute to a rapid and unusual spread of fire.1087 Hayward {Day200/112:9-14}. It was a serious oversight not to have referred to the Lakanal House fire and modern methods of construction to ensure that control staff understood the relevance and importance of the training.
¶79.14 Thirdly, neither the 2010 nor the 2011 presentations complied fully with national guidance. FSC 10-93 warned that, in situations where the caller was prevented from escaping, CROs needed to be aware that reassuring the caller might not be appropriate and in some circumstances might even be dangerous.1088 Fire Service Circular {LFB00003617/1} paragraph 2. Yet the 2010 training presentation told CROs to reassure the caller, to remain positive in order to create a bond and to provide reassurance by saying that the firefighters were on their way and would be there very soon.1089 2010 FSG Training {LFB00028265/19-28}. SOM Smith was "extremely surprised" that the fire survival guidance training provided to CROs in 2010 included that advice and accepted that it reinforced bad practice.1090 Smith {Day203/200:5}-{Day203/201:25}. The advice to create a bond with the caller was removed from the 2011 training package, but that version still encouraged CROs to reassure the caller by telling them that the firefighters were at the scene.1091 2010 FSG Training {LFB00028265}; 2011 FSG Training {LFB00086214/21}. POM Hayward accepted that that was contrary to national guidance but could not explain why it had been included.1092 Hayward {Day200/102:2-24}; {Day200/108:13}-{Day200/110:1}.
¶79.15 Fourthly, neither the 2010 nor the 2011 training presentations addressed some of the problems that CROs had encountered in connection with the Lakanal House fire, such as difficulty in identifying a safe room or problems in understanding the layout of the flat caused by the caller's moving between rooms or even between flats.1093 Hayward {Day200/104:2-16}; FSG Refresher Presentation {LFB00086214/15-16}; 2010 FSG Training {LFB00028265}.
¶79.16 Fifthly, neither the 2010 nor the 2011 presentations referred to FSC 54-04 or the need to ask specifically about the caller's age, gender, ethnicity or mental or physical ability.1094 2010 FSG Training {LFB00028265}; 2011 FSG Training presentation {LFB00086214/21}.
137¶79.17 In August 2011, POM Hayward asked SOM Smith to review the fire survival guidance training packages to ensure that they were consistent with FSC 10-93.1095 Hayward {Day200/116:24}-{Day200/118:1}. SOM Smith did not review the role-play exercise,1096 Smith {Day204/49:20}-{Day204/50:2}. but she did review the 2011 version of the fire survival guidance training presentation and concluded that it was materially incomplete, in particular, because it used neither the definition of a fire survival guidance call found in PN539 nor that found in current national guidance.1097 Comments on FSG {LFB00083547/1}. However, her criticisms, which were bluntly expressed, were not acted on. SOM Smith could not explain why, in August 2011, more than two years after the Lakanal House fire, fire survival guidance training for CROs still contained the errors she had identified.1098 Smith {Day204/65:11-15}.
¶79.18 A new fire survival guidance training presentation was created in 2012, but most of SOM Smith's comments were not acted on and the contents of the presentation were substantially similar to those of the 2011 version.1099 FSG Brigade Control Training presentation (2012) {LFB00086226}; Smith {Day204/42:4}-{Day204/48:12}. SOM Smith could not explain why that was the case.1100 Smith {Day204/42:4-19}. She thought she had discussed her criticisms with POM Hayward but there is no record of any such discussions having taken place.1101 Smith {Day204/42:4-19}.
¶79.19 The history of this matter only reinforces our view that POM Hayward failed to exercise proper control over the development and delivery of training. The fault does not lie solely with him, however, since more senior officers should have been taking responsibility for ensuring that a matter of such importance was being properly managed.
SM Kelly's audit of control room training
¶79.20 On 3 August 2010, SM Stephen 'Ned' Kelly completed an audit of the Training team's systems for managing the quality of training courses and assessing the performance of trainees, using the fire survival guidance refresher training course as an example.1102 Audit of Quality Management Systems Fire Survival Training Course dated 3 August 2010 {LFB00109082}. Having witnessed some practical role-play exercises, he noted that each candidate was exposed to a single fairly simple fire survival guidance call lasting between 90 seconds and two minutes, during which their performance was monitored.1103 Audit of Quality Management Systems Fire Survival Training Course dated 3 August 2010 {LFB00109082/6} paragraph 40. He made a number of criticisms, noting in particular that each trainee took part in only one fairly straightforward exercise and that the assessment of their individual performances was very informal, there being no documented note of what was expected of them or any record kept of their performance. He therefore recommended that the role-play element of the training be reviewed and that a robust assessment process be implemented.1104 Audit of Quality Management Systems Fire Survival Training Course dated 3 August 2010 {LFB00109082/11}.
¶79.21 POM Hayward told us that the control room had implemented some, though not all, of SM Kelly's suggestions to improve the assessment of trainees' performance.1105 Hayward {Day200/131:22}-{Day200/132:22}. Four fire survival guidance role-play exercises were produced in 2011, for which a document was provided to enable CROs' performance to be recorded and assessed.1106 Hayward {LFB00055191/26} page 26, paragraph 75; 2011 FSG Role Play scenario 1 {LFB00055226} 2011 FSG Role Play scenario 2 {LFB00055227}; 2011 FSG Role Play scenario 3 {LFB00003788}; 2011 FSG Role Play scenario 4 {LFB00003682}. However, the control room did not implement any of his other recommendations because they considered that the course was already long enough.1107 Hayward {Day200/131:22}-{Day200/132:22}.
138Fire survival guidance refresher training
¶79.22 The Lakanal Control report noted that at the time of the Lakanal House fire there had been a lack of structured, regular fire survival guidance training.1108 Lakanal Control Report {HOM00001124/52} paragraph 308. The Lakanal House Board decided, therefore, by way of pre-inquest action 12, that a recurring programme of fire survival guidance refresher training should be established for all control personnel in accordance with national guidance.1109 Minutes of Lakanal House Board Meeting 15 September 2010 {LFB00055192/2}; Minutes of Lakanal House Board Meeting 15 November 2010 {LFB00055213/1}. At a meeting of the Board on 15 September 2010, Commissioner Dobson noted that one of the areas that needed to be considered was to ensure that refresher training for the control room on handling fire survival guidance calls was maintained and recorded on STEP.1110 Minutes of Lakanal House Board Meeting 15 September 2010 {LFB00055192/2}. Despite his comment, however, nothing appears to have been done, either to maintain refresher training or to record it on STEP.
¶79.23 National guidance required that refresher training on fire survival guidance calls should take place at least every 12 months and should include the training described in Appendix B of FSC 10-93. It recommended that training be delivered jointly with a fire safety officer and include active practical role-play.1111 Fire Service Circular {LFB00003617/6}; Lakanal Control Annexures {LFB00004750/37}. FSC 10-93 also recommended that refresher training be given systematically on the watch to all CROs, and should be scheduled and monitored.1112 Fire Service Circular {LFB00003617/3} paragraph 11. It emphasised that such training should cover little-used procedures and areas of weakness.1113 Fire Service Circular {LFB00003617/3} paragraph 11. AC Brown and SOM Smith accepted that fire survival guidance was a little-used procedure and SOM Smith accepted that the LFB's response to the Lakanal House fire had demonstrated that it was an area of weakness.1114 Smith {Day204/13:23}-{Day204/14:6}. For those reasons AC Brown accepted that the need for fire survival guidance refresher training should have been made clear to CROs.1115 Brown {Day207/59:8-11}.
¶79.24 The programme of fire survival guidance refresher training was approved at the Lakanal House Board. In the second half of 2010, it was decided that there should be a two-year refresher training programme, under which a full day of classroom training would be delivered in the first year and a computer-based training package in the second.1116 Hayward {LFB00055191/24} page 24, paragraph 68. Minutes of Lakanal House Board Meeting of 22 June 2010 {LFB00055208}; Minutes of Lakanal House Board Meeting of 15 September 2010 {LFB00055192}; Minutes of Lakanal House Board Meeting of 8 November 2010 {LFB00055213}. It was always intended that the full day of refresher training would include active role-play and would be delivered jointly with the fire safety team.1117 Hayward {Day200/143:8-19}; Smith {Day204/19:6-12}. The plan was that in alternate years CROs would complete the computer-based training package on their own,1118 Hayward {Day200/147:16}-{Day200/148:3}. the intention being for them to be allocated time to complete it while on the watch.1119 Hayward {Day200/157:3-6}. There was no plan to provide role-play exercises in the years when the computer-based training package was delivered; instead, CROs would be asked to complete a questionnaire designed to test their understanding of the principles involved.1120 Hayward {Day200/147:16}-{Day200/148:3}. The intention was to deliver the first computer-based training package in 2011.1121 Hayward {Day200/154:24}-{Day200/155:2}.
139¶79.25 The two-year programme did not comply with national guidance because it did not provide for annual fire survival guidance training delivered jointly by a fire control officer and a fire safety officer and did not include an annual role-play exercise. Although the Lakanal House Board formally approved it,1122 Brown {Day207/64:7-17}. there was no discussion at its meetings about whether the programme complied with national guidance.1123 Minutes of Lakanal House Board Meeting of 22 June 2010 {LFB00055208}; Minutes of Lakanal House Board meeting of 15 September 2010 {LFB00055192}; Minutes of Lakanal House Board Meeting of 8 November 2010 {LFB00055213}; Hayward {Day200/148:19-23}. At the meeting of the Lakanal House Board on 8 November 2010 action 12 was marked as "complete" because a system for delivering training had been established.1124 Minutes of Lakanal House Board Meeting of 8 November 2010 {LFB00055213/6}; Brown {Day207/64:1}- {Day207/65:8}. The Board did not continue to exercise oversight of the action despite the continuing nature of refresher training.
¶79.26 AC Brown thought that the biennial programme was a reasonable and efficient approach to training.1125 Brown {Day207/61:16}-{Day207/63:4}. He regarded delivering a full day of classroom training every year as a significant workload for a team that was already delivering other training.1126 Brown {Day207/62:8-21}. SOM Smith, on the other hand, did not think that a two-year training programme was appropriate and expressed her concerns to Scott Hayward and Lindsay Turner.1127 Smith {Day204/21:8-25}. POM Hayward said that a two-year programme had been adopted to allow other training to take place.1128 Hayward {Day200/149:3-11}. SOM Smith also pointed to the need for CROs to continue working while training was being provided.1129 Smith {Day204/23:20-24}.
¶79.27 Although we understand the difficulty of making CROs available for training, we do not think that it was sufficient to justify a two-year programme, given the weaknesses in providing fire survival guidance exposed by the Lakanal House fire and the fact that SM Kelly's audit had revealed the need to strengthen the role-play element of training. The training required would take one day and SOM Smith accepted that it was possible to arrange shift patterns in a way that would allow training when staff were off duty, as had been done with training for the Vision system.1130 Smith {Day204/25:4-12}. In the circumstances, we do not think that POM Hayward was right to conclude that a one-day training course each year would exclude other important training.
¶79.28 Finally, in the Lakanal Control report the LFB told the coroner that a two-year refresher training plan, which had an active role-play element to it, had been put in place.1131 Lakanal Control Report {HOM00001124/53}. However, by the time of the inquests in January 2013, it is clear that training of the kind that had been described was not in fact being provided. The LFB failed to notify the coroner that, in this respect at least, its intentions had not been realised, and no satisfactory explanation was given for that failure.
140¶79.29 In the event, refresher training on fire survival guidance was not delivered as intended. In 2011 the computer-based training package that it had been intended to deliver to CROs that year was still under development and was therefore unavailable.1132 Hayward {Day200/154:24}-{Day200/155:5}. As a result, POM Hayward approved the use by staff of the materials they had used in their initial fire survival guidance training.1133 Email from Scott Hayward to Lindsay Turner and Joanne Stibbards dated 31 May 2011 regarding Fire Survival Refresher Package {LFB00058087/1}; Hayward {Day200/180:15-25}.,1134 Hayward {Day200/154:24}-{Day200/155:25}; Hayward {LFB00055191/10} page 10, paragraph 21.8. The course was not led by trainers but was designed for CROs to study alone for about an hour to an hour and a half.1135 Hayward {Day200/155:6}-{Day200/157:15. It is likely that staff undertook the training on the watch during the four-hour rest period that became available after the shift patterns had changed.1136 Hayward {Day200/167:6-16}; FSG Training Record {LFB00041763}. The training plan for 2011 did not include active role-play, but CROs used call scripts and the RIF1137 Hayward {Day200/162:17}-{Day200/163:3}; Hayward {LFB00055191/26} page 26, paragraph 75; Hayward {Day200/184:14-17}. to confirm their understanding of procedures.1138 Hayward {Day200/162:10-16}. However, the exercise did not involve active role-play and the performances of the CROs were not assessed.1139 Hayward {Day200/162:17}-{Day200/163:3}; Hayward {LFB00055191/26} page 26, paragraph 75.
¶79.30 POM Hayward provided us with information about the number of CROs who had undergone fire survival guidance training between 2011 and 2017.1140 Hayward {LFB00055191/26} page 26, paragraph 74. He accepted that the figures might not be entirely accurate and AC George and AC Brown both cast doubt on their reliability. However, we think they provide a helpful indication of the numbers who had received fire survival guidance training during that time. The evidence indicates that 94% of the available control room staff received training in 2011,1141 Hayward {LFB00055191/26} page 26, paragraph 75. but when compared to later years the figure looks very high. POM Hayward could not explain it and we have some doubt about its accuracy.1142 Hayward {Day200/168:16-22}.
¶79.31 In 2012 CROs should have received a full day of fire survival guidance refresher training, including active role-play.1143 Hayward {Day200/171:15-17}. However, in that year the provision of training was much reduced. The role-play element of the fire survival guidance refresher training was changed to a passive exercise in which staff were required to listen to pre-recorded simulated fire survival guidance calls and discuss their positive and negative aspects.1144 Hayward {LFB00086213/14} page 14, paragraph 73; Email from Chris Sharp to Natalie Bagnelle, Vic Bagnelle, Sam Coaker, Scott Hayward, David Hughes, Steve Perry, Joanne Stibbards and Lindsay Turner dated 27 September 2012 {LFB00060696}. Either SOM Turner or SOM Bagnelle (it is not clear which) approved the change,1145 Hayward {LFB00086213/14} page 14, paragraph 73; Hayward {LFB00055191/24} page 24, paragraph 69; Hayward {Day200/190:6-11}. which was made in response to indications from staff that they felt very uncomfortable taking part in that element of the training.1146 Hayward {LFB00086213/14} page 14, paragraph 74; Email from Victor Bagnelle to Scott Hayward regarding Control Report {LFB00122840/1}. POM Hayward told us that he had not been consulted about the change and had not been aware that it had happened. He did not think that embarrassment was a sufficient reason for abandoning role-play, which he thought was an effective way of confirming CROs' understanding of the training.1147 Hayward {Day200/192:8-15}. This episode only goes to reinforce our criticisms of POM Hayward's management of the control room.
141¶79.32 At about the same time, the length of fire survival guidance refresher training was reduced.1148 Hayward {LFB00055191/24} page 24, paragraph 70. Instead of a whole day off the watch, the training took place during a four-hour short shift.1149 Hayward {LFB00055191/24} page 24, paragraph 70. The decision to reduce the length of the training was made by SOM Bagnelle without reference to POM Hayward.1150 Hayward {Day200/195:24}-{Day200/196:6}. POM Hayward said that the same training had been delivered but that by reducing the number of breaks and the number of staff involved, it could be condensed into a four-hour period.1151 Hayward {Day200/196:10-24}. However, that ignores the fact that the content was much reduced because there was only a brief discussion about difficult calls, as opposed to the one and half hour discussion originally included, and the element of active role-play was removed.1152 Hayward {LFB00055191/24-25} pages 24-25, paragraph 71. Passive role-play reduced the time it took to complete that part of the training because a group discussion was substituted for individual participation.1153 Hayward {Day200/197:4-10}.
¶79.33 In addition, fire safety officers were withdrawn from delivering the training. From 2012 onwards, fire survival guidance training for control room staff was intermittent and did not comply with national guidance. As a result, the refresher training that had been approved by the Lakanal House Board was not implemented.
¶79.34 POM Hayward said that he had become aware of the change to the training only during the Lakanal House inquests,1154 Hayward {Day200/195:24}-{Day200/196:6}; Hayward {LFB00055191/24} page 24, paragraphs 69-71. but the evidence suggests that AOM Sharp had told the control room senior management team, including POM Hayward, about the change to the fire survival guidance role-play in September 2012.1155 Email from Chris Sharp to Natalie Bagnelle, Vic Bagnelle, Sam Coaker, Scott Hayward, David Hughes, Steve Perry, Joanne Stibbards and Lindsay Turner dated 27 September 2012 {LFB00060696}. POM Hayward did not recall either having received her message or having discussed the proposal with AOM Sharp.1156 Hayward {Day200/218:1}-{Day200/219:5}.
¶79.35 When on 5 February 2013 POM Hayward discovered that the duration and content of the fire survival guidance training had been changed, he asked SOM Bagnelle, who was by then the SOM in charge of training, how it had come about.1157 Hayward {LFB00055191/24} page 24, paragraph 69; Email from Thomas Davies to Scott Hayward dated 5 February 2013 {LFB00060872/4}; Email from Scott Hayward to Vic Bagnelle dated 7 February 2013 {LFB00039935/1-2}; Bagnelle {LFB00122821/12} page 12, paragraphs 41-43. AOM Sharp and SOM Bagnelle told him that the reason for the change was to prevent staff from being taken off duty1158 Hayward {LFB00055191/24-25} pages 24-25, paragraph 71. and because there were not enough staff on duty between 08.00 and 14.00 to allow training to take place before the afternoon.1159 Email chain with Scott Hayward, Chris Sharp, Nicola O'Shea and Vic Bagnelle dated 6 February 2013 {LFB00122840/3-4}. POM Hayward said that nobody had told him that staffing difficulties prevented training taking place for a whole day.1160 Hayward {Day200/205:19}-{Day200/206:14}. He had been aware generally that there were staff shortages and had understood that there were often no staff available to carry out training,1161 Hayward {Day200/205:19}-{Day200/206:14}. but said he had never thought that training might need to be cut back as a result.
142¶79.36 On or about 7 February 2013, during the course of the Lakanal House inquests, POM Hayward spoke to AC Brown about the changes to fire survival guidance training.1162 Email from Scott Hayward to Vic Bagnelle dated 7 February 2013 {LFB00039935/1}; Hayward {Day200/208:9}- {Day200/209:19}. AC Brown told him that he was very unhappy about the changes, particularly as the Lakanal Control report had said that the LFB was carrying out a full day's training with active role-play.1163 Email from Scott Hayward to Vic Bagnelle dated 7 February 2013 {LFB00039935/1}. Although AC Brown intended to provide the coroner with information about the changes to fire survival guidance training,1164 Brown {Day207/82:4}-{Day207/83:3}. it is unclear what, if anything, was done.
¶79.37 AC Brown expected the biennial plan for fire survival guidance training to be reinstated with a full day of training every other year and a half day of computer-based training in alternate years.1165 Email from Dave Brown to Scott Hayward dated 9 February 2013 {LFB00060872}; Brown {Day207/78:7-14}. On the instructions of AC Brown, POM Hayward directed SOM Bagnelle to ensure that the active role-play was reinstated in accordance with SM Kelly's recommendation in August 2010.1166 Hayward {LFB00055191/24} page 24, paragraph 69; Bagnelle {LFB00122821/12} page 12, paragraphs 41-43; Email from Scott Hayward to Vic Bagnelle dated 7 February 2013 {LFB00122840/2}; Hayward {Day200/209:16-25}; Brown {Day207/78:7-14}. However, POM Hayward did not instruct SOM Bagnelle to change the duration of training from four hours to a full day as AC Brown had expected.1167 Hayward {LFB00055191/24} page 24, paragraph 69; Bagnelle {LFB00122821/12} page 12, paragraphs 41-43; Email from Scott Hayward to Vic Bagnelle dated 7 February 2013 {LFB00122840/2}; Hayward {Day200/209:16-25}; Brown {Day207/78:7-14}.
¶79.38 Despite AC Brown's instruction, active role-play was not reinstated.1168 Hayward {LFB00055191/26-29} pages 26-29, paragraphs 67.5 and 69; Hayward {Day201/15:20}-{Day202/16:8}. The episode illustrates our broader concerns about the LFB's management systems at the time. POM Hayward should have been made aware of the change to the role-play exercise.1169 Hayward {Day200/188:7-25}. Equally, once he had become aware of that change, it should have caused him to question the effectiveness of his supervision and monitoring of training.1170 Hayward {Day200/190:22}-{Day200/191:10}. Had he done so, the failure to reinstate an element of active role-play in fire survival guidance training might have been identified and cured in time to make a significant difference to the performance of the control room in response to the Grenfell Tower fire.
¶79.39 In early 2012, AC Brown and AC Turek decided that fire safety officers did not need to deliver fire survival guidance refresher training.1171 Brown {LFB00032166/21} page 21, paragraph 65; Brown {LFB00084020/10} page 10, paragraph 20; Brown {Day207/43:21-24}. Email chain between Scott Hayward, Lindsay Turner and Joanne Stibbards dated 22 February 2012 {LFB00058256/1-2}. The decision was inconsistent with both national guidance (FSC 10-93) and pre-inquest action 8.1172 This was accepted by AC Brown. Brown {LFB00084020/10} page 10, paragraph 20. AC Brown explained that the decision coincided with a restructuring of the brigade (including the Fire Safety department)1173 Brown {Day207/43:21-24}; Brown {Day207/48:25} – {Day207/49:8}; Brown {LFB00032166/21} page 21, paragraph 65. and reflected the view that using fire safety officers to provide training on fire survival guidance was an unnecessary use of resources. There was a dedicated control room training team to provide that training and fire safety officers could be better employed inspecting premises.1174 Brown {LFB00032166/21} page 21, paragraph 65.
¶79.40 AC Brown and AC Turek were satisfied that the fire safety officers had had sufficient involvement in the design and content of the new fire survival guidance training and they continued to be involved in the training of new control room staff.1175 Brown {LFB00032166/21} page 21, paragraph 65; Brown {LFB00084020/10} page 10, paragraph 20. AC Brown also appears to have thought that as fire safety officers had been involved in a full day of fire survival guidance training in 2010, that was sufficient.1176 Brown {Day207/46:13-21}. However, national guidance required the contribution of a fire safety officer to each refresher training session and the longer CROs remained in their roles, the greater the importance of refresher training. At all events, the training team subsequently provided training without any contribution from a fire safety officer.1177 Brown {LFB00032166/21} page 21, paragraph 65. AC Brown may have had confidence in the competence of the trainers, as he said he did, but we find it difficult to identify any steps that he had taken to satisfy himself of their ability to teach matters relating to fire safety.1178 Brown {LFB00084020/10} page 10, paragraph 20. Although AC Brown said that he had relied on his personal knowledge of the members of the team and information obtained from senior managers, POM Hayward did not remember ever having discussed the withdrawal of fire safety officers with him.1179 Brown {Day207/47:25}-{Day207/48:18}; Hayward {Day201/8:15}-{Day201/9:7}.
143¶79.41 Between 2013 and the Grenfell Tower fire, existing control room staff did not receive the full day of fire survival guidance refresher training that had been planned and approved by the Lakanal House Board and promised to the coroner.1180 Hayward {LFB00055191/26-29} pages 26-29, paragraphs 77 to 78.4; Hayward {Day201/16:6-8}; Smith {Day204/87:19}-{Day204/88:4}. Some of the CROs were given training relevant to fire survival guidance, such as reviewing the RIF for Operators. They were also given some informal training and were involved in command unit training exercises, but none of that reflected the training that national guidance recommended.1181 Hayward {LFB00055191/26-29} pages 26-29, paragraphs 77 to 78.4; Hayward {Day201/16:6-8}; Joanne Smith {LFB00121219/23} page 23, paragraph 60; Smith {Day204/110:23}-{Day204/111:16}.
¶79.42 The command unit training exercises involved units attending the control room at Merton and carrying out exercises to test activities such as two-way communication between the control room and the incident ground.1182 Hayward {LFB00055191/28} page 28, paragraph 78.2.2. The exercises had an element of role-play because CROs were required to take calls on the mobilising system and ensure that the information was passed to the command unit.1183 Smith {Day204/123:7-20}; Brown {Day207/109:10-24}. However, the training was not designed for control room staff and those who took part did little more than help train the crews of the command units.1184 Hayward {LFB00055191/28} page 28, paragraph 78.2.2; Smith {Day204/123:7-25}; {Day204/132:1-9}; Minutes of Operational Review Team Meeting on 11 January 2017 {LFB00040541/2}; Brown {Day207/109:10-24}.
¶79.43 Some computer-based training was available, but not all CROs were able to take advantage of it due to technical problems that had not been resolved by the time of the Grenfell Tower fire.1185 Smith {LFB00121219/24} page 24, paragraph 62; Smith {Day204/113:23}-{Day204/116:12}. Moreover, the content of the fire survival guidance presentations used in the computer-based training was out of date, not having changed between 2013 and 2017.1186 Hayward {LFB00055191/29} page 29, paragraph 78.3; Hayward {LFB00086213/7} page 7, paragraph 35; Hayward {Day201/80:13}-{Day201/84:8}. As POM Hayward accepted, the system for delivering them deteriorated as the presentations improved.1187 Hayward {Day200/110:24-25}. The Operational Support Team did not create an alternative training opportunity for CROs who could not obtain access to computer-based training.1188 Smith {Day204/116:17-23}. SOM Smith's preference was to introduce a computer-based training package because of the shortage of staff, particularly due to the introduction of Vision,1189 Smith {Day204/117:11-22}. but that made little sense in the face of the long-standing technical problems. Sessions led by trainers without the need for computer resources had been tried previously with only partial success. AC Brown said he had been taken by surprise to discover in 2016 that computer-based training had still not been implemented, but he refused to accept that the failure to implement the recommendation made in 2010 to introduce computer-based training for all control room staff on fire survival guidance reflected a chronic failure of management.1190 Brown {Day207/105:15}-{Day207/106:25}.
144¶79.44 Assuming that the statistics produced by POM Hayward are broadly correct, the number of control room staff involved in fire survival guidance training, such as it was, between 2013 and 2017 was strikingly low. In 2013 and 2014, only 28% and 29% respectively of control room staff received any form of training.1191 Hayward {LFB00055191/26} page 26, paragraph 74. In 2015, no fire survival guidance training was carried out at all because of the introduction of Vision.1192 Hayward {LFB00055191/26} page 26, paragraph 74. In 2016, only 46% of control room staff received fire survival guidance training, and by the time of the Grenfell Tower fire in 2017, no fire survival guidance training at all had been delivered to any existing control room staff member that year.1193 Hayward {LFB00055191/26-29} pages 26-29, paragraph 74 and paragraph 78.4; Smith {Day204/91:13-21}.
¶79.45 POM Hayward explained that in 2013 the LFB's priority had been to ensure that its new mobilising system, Vision, was working, as they had initially been given less than 14 months to deliver it.1194 Hayward {Day201/16:9-22}. We shall return to Vision, but it is sufficient for present purposes to note that its introduction was a significant undertaking, which diverted attention from chronic problems affecting the management of fire survival guidance calls and related training. The control room also suffered from significant staffing problems and underwent restructuring between 2009 and 2017.1195 Hayward {LFB00055191/30} page 30, paragraph 79; Hayward {Day201/17:12-18}. During that period, none of the senior control room managers sought to take stock of training needs or take steps to ensure that all necessary training was given.1196 Hayward {LFB00055191/30} page 30, paragraph 79; Hayward {Day201/17:12-18}.
¶79.46 In January 2015, when SOM Smith returned from her secondment to the Chief Fire Officers Association, she assumed responsibility for the Operational Support Team and control room training.1197 Smith {LFB00121219/6} page 6, paragraph 15. She asked for a list of CROs who had fire survival guidance training outstanding. She thought she must have received one, but had no specific recollection of it.1198 Smith {LFB00121219/22} page 22, paragraph 56; Smith {Day204/79:22}–{Day204/80:15}. We were not shown any such list.
¶79.47 On returning to her position in the control room SOM Smith had a handover discussion with SOM Bagnelle, but it did not touch on the numbers of control room staff who had received fire survival guidance training during her time on secondment (i.e., from September 2012 to January 2015).1199 Smith {Day204/79:9-20}. She was not told that the number of staff receiving fire survival guidance training had collapsed in 2013 and 2014,1200 Smith {Day204/78:3-18}. nor was she told about the changes that had been made to the training or that active role-play had been changed to passive role-play in 2012.1201 Smith {Day204/81:13}-{Day204/82:10}. She was unaware that in 2013 and 2014 fire survival guidance training had been limited to CROs reviewing presentations and being involved in command unit training sessions.1202 Smith {Day204/83:1-6}. She was told that fire survival guidance training had been reduced from a full day to four hours,1203 Smith {Day204/81:17-20}. but she did not ask why training had not been delivered as originally planned. She assumed that appropriate training had been provided while she had been away.1204 Smith {Day204/84:1-15}.
145¶79.48 In 2015, SOM Smith discovered that there were not enough trainers to provide fire survival guidance training in the way that had been intended in 2011.1205 Smith {LFB00121219/25} page 25, paragraph 68; Smith {Day204/96:7-21}. Although she asked POM Hayward to make additional resources available to the Operational Support Team and two or three members of staff were seconded from the watch, they were required for training on Vision and were not available for fire survival guidance training.1206 Smith {Day204/96:22}-{Day204/98:9}.
¶79.49 From the latter part of 2016, SOM Smith monitored fire survival guidance training because she was trying to revise the computer-based training packages and resolve the problems with access.1207 Smith {Day204/91:22}-{Day204/92:7}. It is not clear why she had not been doing that from the time she returned in January 2015. During 2017, she worked with the training team to create a new fire survival guidance refresher training package which was due to be delivered in September 2017,1208 Smith {Day204/92:4-7}. but it did not lead to an increase in the number of CROs being trained in fire survival guidance or to any improvement in the content of the training.
¶79.50 Although the LFB could not reasonably have foreseen the considerable difficulties that were encountered in implementing Vision, that does not excuse the failure of the senior officers responsible for the operation of the control room, namely, SOM Smith, POM Hayward and AC Brown, to keep fire survival guidance training under close review and, in particular, to decide how to deliver such training once it became clear that the problems flowing from the introduction of Vision were dominating the control room's attention, time and resources.
¶79.51 Despite the failure to deliver fire survival guidance refresher training, neither POM Hayward nor AC Brown informed the Lakanal House Board, the Lakanal House Working Group or the co-ordination board that training had fallen far short of that which had been approved and promised to the coroner.1209 Brown {Day201/21:22}-{Day201/22:4}; Hayward {Day201/73:12-25}. It seems that no one in senior management was aware of the true scale of the failure to provide fire survival guidance training between 2012 and 2017. For example, in January 2013, AC Brown told AC Dexter that 94 out of 104 staff had been given fire survival guidance refresher training.1210 Draft LFB Report 'Review of the Lakanal Action Plan' {LFB00085854/14} and {LFB00085854/26}. See comment "d10". That figure, which amounted to 90.4% of staff, was far in excess of the figure of 61% provided by POM Hayward in his witness statement,1211 Draft LFB Report 'Review of the Lakanal Action Plan' {LFB00085854/14} and {LFB00085854/26}. See comment "d10"; Hayward {LFB00055191/25} page 25, paragraph 74. but although the basis of his figure of 90.4% could not be identified, AC Brown remained confident that training had been taking place. He thought that any apparent shortfall in numbers was attributable to poor record-keeping.1212 Brown {Day207/72:14-22}; Brown {LFB00032166/21} page 21, paragraph 66.
146¶79.52 In his review of the Lakanal pre-inquest actions in June 2013, AC Chandler said that the refresher training programme had been put in place and that no further action was required.1213 Email from Chandler to Brown dated 28 June 2013 regarding Lakanal Audit {LFB00060701/1}. The Chandler review was sent to AC Brown and POM Hayward for information,1214 Email from Chandler to Brown dated 28 June 2013 regarding Lakanal Audit {LFB00060701/1}. but POM Hayward did not correct him and provide the true picture.1215 Email from Chandler to Brown dated 28 June 2013 regarding Lakanal Audit {LFB00060701/1}; Hayward {Day201/29:8-19}.
¶79.53 In 2014, Adrian Bevan, an LFB health and safety manager,1216 Hayward {Day201/30:1-10}. asked for information from AC Brown about control room training to enable him to answer a request from the Health and Safety Executive for information on control room practices, procedures and training following the Lakanal House inquests.1217 Email from Brown to Bevan copied to Scott Hayward, Philip Evans and Danielle Cotton dated 3 July 2014 regarding HSE info – control training {LFB00037428/1-2}. On 3 July 2014, AC Brown told Mr Bevan that between February 2011 and June 2014 277 individual fire survival guidance training sessions had been delivered by senior control room officers in addition to the regular watch training sessions.1218 Email from Brown to Bevan copied to Scott Hayward, Philip Evans and Danielle Cotton dated 3 July 2014 regarding HSE info – control training {LFB00037428/2}. However, although the source of that particular statistic is not clear,1219 Hayward {Day201/31:8}-{Day201/32:16}. it is plain that POM Hayward did not tell AC Brown that by July 2014 fire survival guidance refresher training was being given to less than a quarter of control room staff.1220 Hayward {Day201/35:11-22}. It is also notable that the Health and Safety Executive was not told that since 2012 fire survival guidance training had not met national guidance in some material respects.1221 Email from Brown to Bevan copied to Scott Hayward, Philip Evans and Danielle Cotton dated 3 July 2014 regarding HSE info – control training {LFB00037428/1-2}.
¶79.54 AC Brown accepted that he did not know how many CROs were actually being trained in fire survival guidance at the time, but he said that after his discussions with POM Hayward and the CROs he had been left with the impression that fire survival guidance refresher training was being delivered where practically possible.1222 Brown {Day207/92:1-14}; Brown {LFB00084020/13} page 13, paragraph 29. However, at no stage did POM Hayward ever provide AC Brown with a reliable record of fire survival guidance training, which would have enabled it to be effectively monitored, and AC Brown never asked for one.1223 Hayward {Day201/55:6-24}. Nevertheless, AC Brown was aware of periods during which fire survival guidance refresher training was not being provided as had been agreed – for example, between 2015 and 2017, when the training of control room staff concentrated on the Vision mobilising system.1224 Brown {LFB00084020/13} page 13, paragraph 30; Hayward {Day201/55:22}-{Day201/57:14}; Brown {Day207/94:15- 20}. Although he accepted in the light of the Lakanal House fire and the findings of the Mayor's Office for Policing and Crime1225 Email chain between Scott Hayward and Karen Mason dated 17-18 November 2014 regarding Brigade Control Audit {LFB00030108}; Hayward {Day201/42:1-4}; Internal Audit – Progress Report Quarter 3 2014/2015 dated 9 March 2015 {LFB00044640/1}. (to which we refer later) that fire survival guidance training was of critical importance, AC Brown sought to justify its absence on the grounds that all available resources had been taken up by the need to train staff on Vision. He maintained that the quality of the control room's response to fire survival guidance calls had been kept under continuous review.1226 Brown {Day207/94:10}-{Day207/95:16}.
147¶79.55 The introduction of Vision clearly made great demands on the resources available for training, but the fact remains that there was a chronic, systemic failure to ensure that effective fire survival guidance refresher training was consistently provided to all control room staff. Such quality assurance as existed had signally failed to identify the fact that, from 2012 onwards, the number of CROs receiving such training was low. There was a consistent failure to comply with national guidance or with the assurances given to the coroner.
¶79.56 In July 2016, at the instigation of AC Brown, AC George carried out a review of the control room, but did not identify fire survival guidance training as an area of concern.1227 Review of Brigade Control Report dated July 2016 {LFB00032826}; George {LFB00083884/11} page 11, paragraph 34; George {Day205/55:6}-{Day205/57:6}. It had not been included in his terms of reference,1228 Review of Brigade Control Terms of Reference {LFB00032827/1}. which had been informed by discussions with staff between September and November 2015.1229 Review of Brigade Control – the issues raised by staff prior to the review commencing {LFB00032831/3}; George {Day205/36:13-20}; George {LFB00032823/4} page 4, paragraphs 12 and 13. In these discussions, CROs had not expressed concern about the lack of fire survival guidance training1230 George {Day205/55:6-14}. or about their readiness to handle fire survival guidance calls.1231 George {Day205/57:3-6}. AC George himself was not concerned about fire survival guidance training because when he started his review AOM Sharp had given him a schedule of planned training.1232 George {Day205/65:4-8}. He was not aware of the changes that had been made to the fire survival guidance refresher training by the Lakanal House Board;1233 George {Day205/65:9}-{Day205/67:3}. nor was he aware that in 2015 and 2016 training on Vision had, to say the least, placed severe restrictions on it.1234 George {Day205/80:8-19}.
¶79.57 AC George was confident that fire survival guidance training was taking place because he witnessed it in 2016 and early 20171235 George {Day205/151:6-25}. and he was assured by AOM Sharp, POM Hayward and SOM Smith that it was being delivered.1236 George {Day205/151:6-25}; George {Day205/153:16-24}. However, the training he witnessed was command unit training, which was not aimed at CROs, and he did not attend the training sessions himself, having simply seen from his office window a number of people and command units gathered outside.1237 George {Day205/151:20}-{Day205/153:5}. AC George did not examine the content of the fire survival guidance training packages and he had no direct knowledge of the extent to which they had been delivered in 2016 and 2017.1238 George {LFB00032823/8} page 8, paragraph 31; George {LFB00083884/14} page 14, paragraph 49.
¶79.58 In the report of his review that he presented to the Corporate Management Board in February 2017 AC George said that additional familiarisation training on fire survival guidance had been given to all staff.1239 CMB report on Review of Brigade of Control for CMB, dated 15 February 2017 {LFB00032824/6}. Insofar as that gave the impression that additional fire survival guidance training had been provided to all CROs since his first report in July 2016,1240 Hayward {Day201/75:2}-{Day201/76:3}. it was misleading. AC George accepted that, as head of the Operational Response department and, from March 2017, Director of Operations, he should have been aware of the consistent failure to provide fire survival guidance training to CROs in 2016 and 20171241 George {Day205/165:9-22}. and that that failure was both chronic and systemic.1242 George {Day205/165:9-22}. He said that POM Hayward and SOM Smith had regularly told him about the problems being encountered with Vision, which had crowded out other training,1243 George {Day205/165:23}-{Day205/166:10}; {Day205/169:23}-{Day205/170:2}. but there is no evidence that he made any effective effort to ensure that regular and structured fire survival guidance training was provided.
148¶79.59 The importance of fire survival guidance refresher training cannot be over-stated. The senior officers responsible for the control room plainly understood the need to give priority to such training, particularly because of the weaknesses in handling emergency calls exposed by the Lakanal House fire in 2009. At that time no structured or regular fire survival guidance refresher training was being conducted by the LFB and at the time of the Grenfell Tower fire in June 2017 that remained the case. The failure to provide CROs with regular fire survival guidance refresher training is undoubtedly a serious indictment of the LFB. Even allowing for the difficulties resulting from the introduction of Vision, there is no justification for such a longstanding failure to address a vital element of the control room's work that was well known to senior management.
¶79.60 Even though the Lakanal House fire demonstrated the real danger to life posed by the failure to provide effective fire survival guidance training, the fact is that none of senior officers responsible for the operation of the control room ever tackled the challenge of providing the necessary training with the seriousness or dedication it deserved.
Monitoring the quality of responses to fire survival guidance calls
¶79.61 The need to monitor and manage the performance of CROs, particularly in relation to handling fire survival guidance calls, was identified in the Lakanal Control Report, which recommended the introduction of a policy identifying the standards that staff were expected to reach and how performance would be assessed and monitored, particularly in relation to calls where fire survival guidance was given.1244 Lakanal Control Report {HOM00001124/53}; Lakanal Control Report {HOM00001124/31} paragraphs 161-163. That recommendation was said to have been implemented by senior managers' undertaking a review of all high-rise or fire survival guidance calls and amending the RIFs and training packages to ensure that they reflected FSC10-93 and 'Keeping People Safe'.1245 Lakanal Control Report {HOM00001124/53}; Lakanal Control Report {HOM00001124/31} paragraphs 161-163. Although it did not give the impression that a new policy of the kind envisaged by the recommendation had been introduced, the statement was misleading insofar as it gave the impression that the omissions and flaws that we identified earlier had been put right.1246 Brown {Day207/28:5-20}. AC Brown explained the failure to introduce a policy of the kind contemplated by the recommendation by the fact that those with responsibility for the control room had revised the existing materials in a way that met the substance of the recommendation.1247 Brown {Day207/28:21}-{Day207/29:5}.
¶79.62 In late 2009, after the Lakanal House fire, a quality assurance system known as 'Call Coach' was introduced. At the suggestion of SOM Smith it was supplemented by a review of fire survival guidance calls to check whether the training introduced after the Lakanal House fire had been effective.1248 Smith {Day202/49:11-15}.
¶79.63 Call Coach was a structured system of reviewing and learning from the way in which CROs handled calls coming into the control room. In summary, a supervisor would choose at random from a short list of three calls at least one call a month for each call-handler and one call every three months for each team leader.1249 Call Coach Management Note {LFB00121231/6}; Smith {Day202/31:10}-{Day202/32:23}. The supervisor would listen to the call and assess the call‑handler using a prescribed standard which included a scoring system.1250 Call Coach Management Note {LFB00121231/2-3}; Smith {Day202/34:1-23}. After the assessment, a meeting would be held between the call-handler (or team leader) and the supervisor to discuss and review the assessment.1251 Call Coach Management Note {LFB00121231/2-3}. The supervisor assessing the call was then responsible for coaching the call-handler or team leader and monitoring the results obtained from successive assessments.1252 Call Coach Management Note {LFB00121231/4}. SOM Smith was responsible for introducing the system,1253 Smith {LFB00121219/7} page 7, paragraph 17. which had been operated monthly between 2010 and November 2015.1254 Smith {Day202/35:10-14}; {Day202/45:10}-{Day202/47:11}.
149¶79.64 However, fire survival guidance calls were not included in the Call Coach assessments.1255 Smith {Day202/38:1-18}; The detail required to assess a fire survival guidance call was not included in the call‑handling excellence standard, Call Coach Management Note {LFB00121231} Appendix B; Smith {Day202/38:11- 18}. The decision to exclude them appears to have flowed from an agreement between DAC Payton, then Deputy Assistant Commissioner for Control and Mobilising, and the trade unions.1256 Smith {Day202/39:4-13}; {Day202/59:15-21}. The reason for any such agreement is unclear, but it meant that supervisors did not have an opportunity to assess the quality of the response to fire survival guidance calls except when they supported a CRO handling such a call or during the fire survival guidance review process described below.1257 Smith {Day202/38:19-22}. Since assessment was not the purpose of the supervisor's involvement, supporting a CRO during a fire survival guidance call did not amount to an effective form of monitoring and managing performance.
¶79.65 Call Coach provided supervisors with a degree of reassurance about CROs' ability to handle calls, but POM Hayward did not think it was a particularly good system.1258 Hayward {Day199/56:22}-{Day199/57:17}; see SOM Smith's comments on the draft training audit report prepared by SM Kelly {LFB00109082/9}; Smith {Day202/41:25}-{Day202/43:13}. However, partly because of the money that had been spent acquiring it and partly because of the time spent bringing it into operation, POM Hayward was not inclined to look into other ways of assessing those skills.1259 Hayward {Day199/58:1-10}. SOM Smith was not aware of Operational Support Team's analysis of the CROs' performance and AC Brown did not ask her to consider the outcome of reviews.1260 Smith {Day202/37:3-16}; Brown {Day207/27:9-17}.
¶79.66 In November 2015, when Vision was introduced, Call Coach became obsolete and was replaced by a new system called Neptune Intelligence Computer Engineering (Neptune).1261 Hayward {LFB00055191/39} page 39, paragraph 96. However, Neptune was not used to review call-handling by CROs and no formal arrangements were made to make up for the loss of Call Coach.1262 Hayward {LFB00055191/39} page 39, paragraph 97; Hayward {Day199/59:15-19}. No quality assurance review process was therefore in place to monitor CROs' call-handling in the years leading up to the Grenfell Tower fire.1263 Smith {Day202/47:10-12}.
150¶79.67 Following an incident, however, it was standard practice for senior managers on duty to review fire survival guidance calls.1264 Smith {Day202/50:15-25}. There was no policy or guidance document available to direct their reviews so they relied on their own experience and training.1265 Smith {Day203/9:2-21}. A description of the circumstances in which each call had been made and a summary of its contents were recorded in an electronic database, but the database did not include any comments critical of the call-handler.1266 Smith {Day203/10:13-19}; FSG Database {LFB00031757}. Although SOM Smith said that the database was of some value, for example, in identifying causes of concern or examples of good practice, the process did not amount to a systematic appraisal of the performance of CROs.1267 Smith {Day203/11:6-14}. There was no evidence of how the review was used or how it contributed to their training or development.1268 The FSG Database did not record any lessons to be learnt or systems to be reviewed {LFB00031757}.
¶79.68 In addition to the review carried out by senior managers, SOM Smith reviewed every fire survival guidance call and every call from a high-rise building on the system1269 Smith {LFB00121219/8} page 8, paragraph 18; Smith {Day202/50:13}-{Day202/51:12} and {Day202/52:20-23}. to check that the correct advice had been given in accordance with FSC 10-93, and later, PN539.1270 Smith {LFB00121219/8} page 8, paragraph 18; Smith {Day202/54:4}-{Day202/55:6}; {Day202/54:7}-{Day202/57:6}. If deficiencies were found, the CRO's line manager would take the necessary action.1271 Smith {LFB00121219/8} page 8, paragraph 18; Hayward {Day199/64:16}-{Day199/65:5}; Smith {Day202/49:16-20}. POM Hayward said that he and SOM Adam Crinion had also listened to the calls.1272 Hayward {Day199/62:21-25}; SOM Smith also thought that Peter Suarez, Control Commander in the Technical Support Group, also listened to the call {Day202/52:15-19}. However, the findings of SOM Smith's review were not recorded anywhere and we have seen only a few of the reports that were provided to OMs and CROs about the handling of fire survival guidance calls.1273 Hayward {Day199/63:22-24} and {Day199/65:10-12}. The only email about feedback after a fire survival guidance call review provided to the Inquiry was: Email from Joanne Stibbards to Keith Diamond dated 22 October 2011 {LFB00121235}. Those that we have seen are all positive and do not identify any mistakes in the way that calls were handled.1274 Email from Joanne Stibbards to Keith Diamond dated 22 October 2011 {LFB00121235}.
¶79.69 Although SOM Smith told us that the obligation to review fire survival guidance calls fell to the person on duty at the time a call was received,1275 Smith {Day202/62:21-24}. SOM Keith Diamond and SOM Bagnelle assumed that task after she had been seconded to the Chief Fire Officers Association in September 2012.1276 Hayward {Day199/64:3-7}.
¶79.70 When SOM Smith returned to the LFB in January 2015, she did not ask SOM Diamond or SOM Bagnelle for a report on the fire survival guidance reviews they had undertaken in her absence,1277 Smith {Day202/64:10-24}. but she did resume her review of all fire survival guidance calls, relying on her expertise rather than PN539.1278 Smith {LFB00121219/8} page 8, paragraph 19; Smith {Day202/66:7-17}. By that time she found it had become impossible to review all the calls from high-rise buildings because the number of calls typically received by the LFB during high-rise incidents had become too great and her workload had increased with the introduction of Vision.1279 Smith {LFB00121219/8} page 8, paragraph 19; Smith {Day202/69:3-14}. She did not delegate the task to anyone else and was confident that the Operational Support Team had not had the capacity to take it on because its workload had also increased as a result of the introduction of Vision.1280 Smith {Day202/69:15-18}. Given that Call Coach had become obsolete at the same time, there was no review of CROs' call‑handling after 2015, apart from the limited and uncritical review described above. SOM Smith told us that a structured debriefing process had been in place since 2011 to enable CROs, supervisors and OMs to share and discuss their experiences following an incident.1281 Smith {Day202/69:19}-{Day202/70:9}. On any view, however, that was not the kind of independent review of call-handling that she had previously undertaken.
151¶79.71 The absence of any effective arrangements for undertaking a critical review of the quality of responses to fire survival guidance calls compounded the pre-existing problem surrounding the correct description of a fire survival guidance call that the LFB had failed to resolve effectively. After Call Coach became obsolete in 2015, the LFB failed to introduce an alternative system for critically reviewing fire survival guidance calls to make sure that CROs were meeting the standard required by PN539. No good explanation was provided for that failure, which provides another example of the LFB's continuing inability to recognise the importance of fire survival guidance calls in ensuring the safety of people affected by fire and smoke.
Policy No. 790
¶79.72 On 23 February 2012, the LFB issued a new policy, Policy No. 790 (PN790) 'Fire survival guidance calls' to replace PN155.1282 Fire Survival Guidance Calls (PN790) {LFB00001257}; It was designed to complete Pre-Inquest action 14, Lakanal Assurance Report {LFB00004801/15}; For the Phase 1 findings in respect of PN790, Phase 1 Report Volume IV paragraphs 29.18 – 29.23, 29.47 and 29.48. It was an operational policy designed for use by firefighters and covered the exchange of fire survival guidance information between the control room and the incident ground.1283 Utting {LFB00118918/3} page 3, paragraph 8; Smith {Day203/129:12-14}; {Day203/155:16-23}; Smith {MET00080606/13}. It was not designed for use by the control room itself, even though it had a significant bearing on the handling of fire survival guidance calls.1284 Smith {MET00080606/13}. It was developed primarily by SM Patrick Utting, working closely with SOM Smith throughout the drafting, consultation and approvals process.1285 Utting {LFB00118918/3} page 3, paragraph 8; Smith {Day203/128:20}-{Day203/129:7}.
¶79.73 Although PN790 recognised that a large number of fire survival guidance calls could be received during a single incident,1286 Fire Survival Guidance Calls (PN790) {LFB00001257} paragraphs 4.1, 5.13, 6.2, 7.6 and 9.4, and Appendix 3. it offered no guidance to control room staff on how best to respond to such a situation.1287 Brown {Day206/124:3-19}. Neither AC Brown nor any other senior officer asked POM Hayward to assess the effect of the new policy on the control room or to determine what training might be required as a result. AC Brown sought to justify that omission on the basis that the control room was used to handling many different incidents at the same time and that although fire survival guidance calls were different and not received very often, CROs used the same knowledge, skills and experience as they used on a daily basis when handling them.1288 Hayward {Day206/124:3-19}. We cannot accept that. The seriousness of fire survival guidance calls and the fact that incidents giving rise to multiple fire survival guidance calls occurred relatively infrequently make it difficult to see how he could reasonably have considered them to be a part of normal business. The various failures in handling fire survival guidance calls identified by the LFB itself following the Lakanal House fire required a more considered approach to making sure that CROs were given as much help as possible in responding to the challenges presented by the need to handle several fire survival guidance calls at the same time. We do not understand why that never occurred to AC Brown or any other senior officer responsible for the control room.
152¶79.74 Following its introduction, supervisors discussed PN790 with CROs to ensure that they were generally familiar with its contents, but no formal or structured training was provided.1289 Hayward {LFB00121176/6} page 6, paragraph 21: Hayward {Day199/223:3}-{Day199/224:10}. The training records indicate that only some of the control room supervisors themselves received any training on it.1290 Training Spreadsheet {LFB00055223}; AOM Christine Sharp and AOM Gary Court were provided with training "Fire Survival Guidance calls – 790" but there is no other training recorded about PN790 in respect of any other control staff member. There was no training for PN790 recorded on the Control FSG Training Record {LFB00041763}. Although that may reflect poor record-keeping, that fact alone meant that the LFB had no accurate note of who had received training on the new policy and who had not.1291 Training Spreadsheet {LFB00055223}; AOM Christine Sharp and AOM Gary Court were provided with training "Fire Survival Guidance calls – 790" but there is no other training recorded in respect of PN790. There was no training for PN790 recorded on the Control FSG Training Record {LFB00041763}; Hayward {Day199/224:25}-{Day199/225:7}.
¶79.75 Paragraph 8.7 of PN790 recognised that in exceptional circumstances an incident commander might consider informing control that the "stay put" advice to callers should be changed and that they should try to leave their property. At the same time, it warned the incident commander that such advice might be contrary to national policy for control staff engaged on fire survival guidance calls and that it would be necessary to communicate with the officer in charge at the control room to get agreement for such a change.1292 Fire Survival Guidance Calls (PN790) {LFB00001257/5} paragraph 8.7.
¶79.76 In the context of the Grenfell Tower fire that was an important provision. SOM Smith was the principal author of paragraph 8.7, so after the Lakanal House fire she was aware that "stay put" advice might have to be changed.1293 Smith {MET00080606/13}. However, even though she and POM Hayward were aware of that paragraph, they gave no consideration to training CROs on how to explain to a caller that the advice previously given had been changed.1294 Hayward {Day199/221:10-14}; Smith {MET00080606/13}. SOM Smith's explanation for that failure was that the LFB did not think that in practice it would be necessary to do that.1295 Smith {MET00080606/13}; Smith {Day203/97:7-25}. POM Hayward's evidence echoed that of SOM Smith. He said that the LFB had not expected "stay put" advice ever to be withdrawn, so no training had been given on how best to respond to that situation.1296 Hayward {Day199/221:15-23}.
¶79.77 It is impossible to reconcile the attitude displayed by POM Hayward and SOM Smith with the clear terms of paragraph 8.7. In effect, they simply ignored it and by doing so deprived those who worked in the control room, and thereby the LFB as a whole, of the training designed to prepare them for the challenges they would face if "stay put" advice had to be revoked. That was a very serious failure for which no plausible excuse has been offered. Moreover, the procedures that the control room would rely on if multiple fire survival guidance calls were received were never properly tested in a training exercise. After the Lakanal House fire a few training exercises were held to test the handling of fire survival guidance calls, and in particular, the arrangements for passing information to the incident ground, but none of them tested the effectiveness of the control room's own procedures.
¶79.78 The first of those tests was the Heygate Challenge, held on 16 June 2011, which was designed to test the proposed amendments to the high-rise firefighting policy (PN633) and the new fire survival guidance policy (then PN155).1297 Email from Andy Roe to numerous LFB participants {LFB00033345/1-4}. Four fire survival guidance calls were used in the exercise.1298 Minutes of the Heygate Estate high-rise exercise de-brief meeting {LFB00056628/4}; Feedback: High Rise and FSG Policies Test Exercise 16th June 2011 Southwark {LFB00033384/11}. POM Hayward explained that the exercise had been designed to test communications rather than to assess the capacity of the control room to deal with a significant number of fire survival guidance calls.1299 Hayward {Day199/213:24}-{Day199/214:7}. In other words, the focus was not on the training of CROs. No-one representing the control room appears to have had any influence on the number of fire survival guidance calls used. As we have noted in chapter 78, neither POM Hayward nor SOM Smith could explain why the exercise had assumed the existence of only four fire survival guidance calls, given that five had been received at the Lakanal House fire.1300 Hayward {Day199/213: 24}-{Day199/214:7}; Smith {Day202/172:1-16}.
153¶79.79 Although the magnitude of the challenge presented by multiple fire survival guidance calls was identified in the exercise, the LFB never organised an exercise specifically to test the number of calls that the control room could effectively handle.1301 Feedback: High Rise and FSG Policies Test Exercise 16th June 2011 Southwark {LFB00033384/11}; Minutes of the Heygate Estate high-rise exercise de-brief meeting {LFB00056628/4}; Hayward {Day199/214:15-23}. In view of the difficulties experienced by CROs in handling the five calls generated by the Lakanal House fire, no good reason was given for that failure.
¶79.80 The second exercise, held on 20 December 2012, was Exercise Florian, which simulated a fire on the seventh floor of a 15-floor purpose-built block of maisonettes, generating three fire survival guidance calls involving four persons, three of whom were rescued and one of whom escaped without assistance.1302 Exercise Florian Facilitator Briefing {LFB00122827/5}; Bagnelle {LFB00122821/15} page 15, paragraph 55. The aim of the exercise was to find out how well PN790 worked in practice and whether it contained any defects.1303 Hayward {Day200/4:16}-{Day200/5:2}; Fire Survival Guidance Calls (PN790) {LFB00001257/1}.
¶79.81 However, the exercise did not focus on all aspects of PN790. For example, it did not practise the revocation of "stay put" advice or consider the consequences that might flow from that.1304 Brown {Day206/134:9-18}. Nor did it use the same number of fire survival guidance calls as had been received during the Lakanal House fire, although AC Brown thought that the three calls that formed the basis of Exercise Florian had reflected the three calls received simultaneously at the Lakanal House fire.1305 Brown {Day206/135:8-15}. He said that no consideration had been given to including more than five fire survival guidance calls in order to test the arrangements in PN790 because there was an unspecified exercise going on in the background in the control room, which simulated other incidents. AC Brown believed that together they would have put the control room under the same pressures.1306 Brown {Day206/135:16}-{Day206/136:9}. Even if that were so, however, the exercise did not address the important function of rigorously testing the arrangements for handling multiple fire survival guidance calls.
¶79.82 Unfortunately, Exercise Florian did not test the control room's ability to handle a growing number of fire survival guidance calls.1307 Brown {Day206/134:9-18}; Exercise Florian Facilitator Briefing {LFB00122827/5}. As with the Heygate Challenge, its focus was on the response of operational crews rather than the control room's ability to handle multiple fire survival guidance calls. The CROs' function appears to have been to assist in the exercise and act as observers rather than undergo training.1308 This is also recognised by Vic Bagnelle in an email dated 5 November 2013 regarding Exercise Penfold {LFB00050721/1}. Given the failings in handling fire survival guidance calls later identified in the Lakanal Control Report, appropriate training for the CROs should have been included in the exercise. One of the suggestions made following that exercise was that someone should turn the documents created for the exercise into a regular training programme.1309 Email from David Lindridge to Dave Brown, Patrick Utting, Martin Corbett, Scott Hayward and Victor Bagnelle dated 9 January 2013 {LFB00118958/1}. POM Hayward said that regular training took the form of training with the command units, which ran from mid-2013 until 2015 and again from mid-2016,1310 Hayward {Day200/14:11}-{Day200/15:24}. but again, that training was not designed for the benefit of CROs.1311 Hayward {LFB00055191/28} page 28, paragraph 78.2.2. It appears, therefore, that no training was introduced for CROs following Exercise Florian.
154¶79.83 The third exercise was Exercise Penfold, which was held on 14 November 2013.1312 Brief for Exercise Penfold {LFB00122841}; Bagnelle {LFB00122821/14} paragraphs 51-53. It simulated a ten-pump high-rise fire with several seats of fire and persons trapped on various floors.1313 Email chain between Paul Trew and Scott Hayward and Vic Bagnelle dated 27 June 2013 {LFB00050487/2}. The exercise involved four fire survival guidance calls, to which the CROs were expected to respond using the RIF for guidance.1314 Bagnelle {LFB00122821/14} page 14, paragraph 52. An AOM was available to assist the CROs.1315 Bagnelle {LFB00122821/14} page 14, paragraph 52. Again, it is unclear why the decision was taken to limit the exercise to four fire survival guidance calls, given that five had been received at Lakanal House, or why the LFB did not seek to test the limits of PN790 by using more than five calls.1316 Scott Hayward could not assist, Hayward {Day200/42:9-24}. After the exercise, it was suggested that AOMs and the OM be more directly involved in an exercise of that kind in order to practise their roles within fire survival guidance procedures, such as communicating directly with the fire survival guidance command unit.1317 Feedback from N O'Shea following Exercise Penfold {LFB00122826/2}. POM Hayward could not say whether that suggestion had been pursued.1318 Hayward {Day200/48:1-4}. Following Exercise Penfold, no further exercise or training on PN790 was organised for CROs. At most, they were asked to assist at and observe command unit training exercises which practised communicating fire survival guidance information from the control room to the incident ground. Such exercises were not designed to benefit them.
Fire survival guidance training for supervisors
¶79.84 Pre-inquest action 17 in the Lakanal Control report recommended that an enhanced fire survival guidance training package be developed for control room supervisors to enable them to provide support to CROs handling fire survival guidance calls to ensure a standard commensurate with national guidance.1319 Lakanal Assurance Report {LFB00004801/16}. In June 2011, the Operational Support Team produced a training package for supervisors in response to that recommendation, supported by a slide presentation.1320 Hayward {LFB00055191/8} page 8, paragraph 20; Hayward {Day201/94:18-23}; Supervisor FSG Training Presentation {LFB00086222}. The presentation stated that the supervisors' main function was to support CROs taking fire survival guidance calls and to make sure that the information they gathered was passed to the incident commander or the command unit.1321 Supervisor FSG Training Presentation {LFB00086222/7}. It suggested ways in which a supervisor could support a CRO taking a fire survival guidance call, including ways of gathering relevant information from the caller.1322 Supervisor FSG Training Presentation {LFB00086222}. It also suggested ways in which a supervisor could assist in passing information to the incident ground, for example, by appointing a supervisor to act as the sole contact between the control room and the incident ground.1323 Supervisor FSG Training Presentation {LFB00086222/7-10}. The presentation contemplated that multiple fire survival guidance calls might be received but did not include any advice about how a supervisor should collate the relevant information and transmit it to the incident ground.1324 Hayward {Day201/99:16-22}; Supervisor FSG Training Presentation {LFB00086222/13}. The presentation included a list of prompts for information that should be collected and passed immediately to the incident ground, but did not refer to the need to remind the CRO to obtain information about any vulnerabilities the caller or others with them might have.1325 Supervisor FSG Training Presentation {LFB00086222/9}. POM Hayward said that CROs normally asked for information of that kind but that in any event they expected callers to volunteer it without needing to be asked.1326 Hayward {Day201/98:8-16}. The training did not include any reference to the Lakanal House fire, nor did it identify any lessons to be learnt from it.1327 Supervisor FSG Training Presentation {LFB00086222/9}; Hayward {Day201/99:23}-{Day201/102:25}. Notwithstanding SOM Smith's evidence to the contrary, the training does not appear to have been revised after November 2012 to reflect the reasoning and conclusions of the Lakanal Control report, despite its relevance to any supervisor who might need to manage the control room during an incident of that kind.1328 Smith {Day204/150:18}-{Day204/153:1}.
155¶79.85 In 2014, the Operational Support Team developed another short training exercise for control room supervisors lasting between 30 and 60 minutes.1329 Bagnelle {LFB00122821/17} page 17, paragraph 62; Supervisor FSG Training Powerpoint {LFB00122832}. It partly remedied one of the defects in the previous training by reminding supervisors that CROs should ask whether the caller was disabled, used a wheelchair or whether they were ill and used oxygen,1330 Supervisor FSG Training Powerpoint {LFB00122832/5}. but it did not tell supervisors to remind CROs that such information should be passed to the incident ground.1331 Supervisor FSG Training Powerpoint {LFB00122832/13}.
¶79.86 It is not clear whether the training we have described was provided to all supervisors.1332 There is no reference to it in Scott Hayward's witness statements or in the Control FSG Training Record {LFB00041763}; Training Spreadsheet {LFB00055223} does record that a number of supervisors received various forms of fire survival guidance training between 2014 and 2017. It seems clear, however, that they were not trained how to manage the control room during a large incident that gave rise to multiple concurrent fire survival guidance calls.1333 Hayward {Day201/103:21}-{Day201/104:6}; Real {MET00080520/6-9}; May {MET00080506/16-17}. Nor were they trained in how to deal with a major incident.1334 Hayward {Day201/118:21}-{Day201/119:9}. That was another serious failure for which no satisfactory explanation was given.
Isolation of the control room
¶79.87 There were a number of other causes, mainly of an organisational nature, that contributed to the failure of the LFB to provide the training and guidance needed by control room staff. One clear and consistent theme that emerged from the evidence was the existence of a perception within the control room and the wider LFB that the control room was a separate entity distinct and different from the rest of the brigade.1335 Smith {Day202/174:24-25}. That was reflected in the opinion of AC Jonathan Smith when he was instructed by the then Commissioner in July 2019 to undertake a root and branch review of the brigade's control function.1336 Jonathan Smith {LFB00121171/9} page 9, paragraph 24. He concluded that the control room needed to be more closely integrated into the brigade, rather than exist as a separate and distinct part of the organisation, as it had become over time. In his view there needed to be a fundamental reappraisal of the position of the control room to ensure that it was given an importance equal to that enjoyed by other sections of the brigade.1337 Jonathan Smith {LFB00121171/10} page 10, paragraph 30; AC Smith's 'Control: Overview and Control Improvement Plan' {LFB00084097/11}.
156¶79.88 The reasons for the isolation of the control room are complex, but were essentially historical, geographical and technological.
¶79.89 Originally, there had been a number of area control rooms across London, each located within an operational fire station. At some point they were consolidated and became based centrally at LFB headquarters in Lambeth.1338 George {Day205/17:16-19}; AC George recalled the control centres being located at Wembley, Croydon and Lewisham. Throughout both those periods, therefore, control room staff were able to meet their operational colleagues on a daily basis.1339 George {Day205/17:19-24}.
¶79.90 In April 2004, the control room moved from Lambeth to Greenwich View Place on the Isle of Dogs and in January 2012 it moved again to a purpose-built London Operations Centre in Merton, which is its current location.1340 LFB Lakanal Control Report {HOM00001124/26} paragraph 132. George 'Review of Brigade Control' July 2016 {LFB00032826/4} paragraph 13. When the control room moved to Greenwich View Place, CROs became physically separated from other staff within the organisation.1341 George {Day205/18:7-9}.
¶79.91 Technology also played a part in the separation. Over the course of time systems were introduced in other parts of the organisation which could not be used by the control room or were not properly adapted to its needs. The most significant examples are the Staff Attendance Recording System (StARS) and the STEP system.1342 George {Day205/75:6-8}; LFEPA Self-assessment 2015 – LGA Peer Challenge {LFB00047742/56}. STEP, which was linked to StARS, was designed to enable a senior officer to review the training undertaken by junior officers and plan for future training needs.1343 George {Day205/82:11-18}. Although the rest of the LFB used STEP to record training, the control room was unable to do so because StARS could not accommodate its shift patterns. It was therefore obliged to use a spreadsheet to record information about training which was then added to STEP manually.1344 Training Audit Recommendations 15 January 2013 {LFB00106102/2}. In contrast to the live tracking available to operational staff on STEP, the information on the control room's spreadsheet was added at monthly or quarterly intervals.1345 Smith {Day202/93:5-8}. It is not clear to us why the adjustment to StARS required to accommodate the control room's shift patterns was not made before it was introduced.
¶79.92 AC George said that when he had started working with the control room in 2016 it was like going back in time ten years. The systems were out of date.1346 George {Day205/82:21-23}. He concluded that the control room had not kept pace with the rest of the organisation because managers had not ensured that the LFB's systems operated as effectively for it as they did for fire stations.1347 George {Day205/85:7-9}. POM Hayward said that changes to the programming of STEP and StARS had been needed to accommodate the control room's shift patterns, but that things had moved slowly.1348 Hayward {Day199/125:5-18}. He said that he had asked for changes to be made, but had been told that other requirements took priority.1349 Hayward {Day199/127:22}-{Day199/128:1}.
¶79.93 There was also a marked difference between the control room and the operational departments in the way that training was organised and procured. As set out above, in April 2012, the LFB entered into a contract with Babcock for most of its training requirements,1350 LFB Report 'How Training Works' {LFB00055127/5} paragraph 2.7. but that contract did not extend to the training of control room staff. Their training was provided by the Operational Support Team1351 LFB Report 'How Training Works' {LFB00055127/5} paragraph 2.7. and, as POM Hayward confirmed, there were no arrangements for assessing the quality of the training it provided.1352 Hayward {Day201/123:10-12}. When SM Kelly reviewed the Training team's quality assurance systems in 2010 he found that there was no general plan for ensuring that training was of the appropriate quality, but he identified various systems which enabled the team to assess the quality of the training it had provided. Among them was Call Coach, described above, which he considered to be a very effective tool.1353 SM Kelly report {LFB00055220/9} paragraphs 63-64 and 66-68. However, although his audit was based on fire survival guidance training, SM Kelly was apparently not aware that fire survival guidance calls were not monitored using Call Coach or any other system.1354 Smith {Day202/38:1-7}. As a result, he appears not to have appreciated that fire survival guidance calls were not subject to any quality review or assurance process.
157¶79.94 In June 2013, AC Chandler reviewed the progress made by the control room in carrying out the Lakanal pre-inquest actions. He concluded that the training syllabus needed to be entirely refreshed and recommended that a fundamental review of training should be undertaken in 2015 or 2016.1355 Email from AC Chandler to AC Brown, 28 June 2013 {LFB00060701/2} item 16. However, no such review was undertaken1356 Brown {Day207/121:2-3}. because of the overriding focus on implementing Vision.1357 Hayward {Day201/129:16-22}. Although AC George covered aspects of training in his review of the control room, it did not amount to the fundamental reappraisal which AC Chandler had called for.1358 Review of Brigade Control July 2016 {LFB00032826/11-13} paragraph 49; Brown {Day207/120:25}-{Day207/121:12}.
¶79.95 In the report into his review of the control room AC George had recommended that responsibility for control room training should be transferred to Babcock.1359 Review of Brigade Control July 2016 {LFB00032826/11} paragraph 49(b). Although that was considered, AC George and Angela Hale, the LFB's Training Commissioning manager,1360 George {LFB00083884/7} page 7, paragraph 29(b). subsequently agreed that the nature of the training required by control staff was so specific that there was limited value in employing Babcock and that it should be retained by the LFB.1361 George {LFB00083884/12} page 12, paragraph 40 and George {LFB00083884/6} page 6, paragraph 29(b). It was also decided that the Operational Support Team should continue to deliver that training, apart from certain computer-based training packages.1362 George {LFB00083884/13} page 13, paragraphs 41-42. As a result, control room training was not subject to any regular audit by either the LFB's training department or any other organisation.
¶79.96 The Operational Support Team was in practice the only body within the LFB responsible for the development and delivery of control room training and for ensuring that it was of an appropriate standard. However, its members were not recruited as specialist trainers; they were all staff who had previous experience as CROs.1363 SM Kelly's Report of Training Audit {LFB00055220/4} paragraph 9. Until 2016 or 2017, when they received a "train the trainers" course from Babcock, its members did not receive any formal training on how to create and deliver training packages.1364 Hayward {Day199/28:25}–{Day199/29:9}.
158¶79.97 SOM Smith had not received any training or preparation before assuming responsibility for the training function of the Operational Support Team and had not asked for any.1365 Smith {Day202/73:2-18}. In particular, she received no training in quality assurance,1366 Smith {Day202/98:17-18} which is a cause for concern, given the absence of any regular or formal process for assessing the quality of training.1367 LFB Report 'How Training Works' {LFB00055127/23} paragraphs 7.1; Groves {LFB00102138/44} page 44, paragraph 81.
¶79.98 The control room's isolation was increased by the marginalisation of its senior managers in brigade meetings. POM Hayward attended monthly Departmental Management Board meetings, at which AC David Brown met the DACs to discuss current matters affecting the brigade.1368 Hayward {Day199/20:7-12}. POM Hayward said that the meetings had been mainly concerned with operational matters, to the point at which he did not always understand the subject-matter and did not contribute greatly to discussions.1369 Hayward {Day199/20:10-17}. That was unfortunate for a number of reasons: first, because POM Hayward clearly felt isolated and ill-equipped to participate, and secondly, because they were one of the points of contact with POM Hayward on which AC Brown relied to be informed about the running of the control room.1370 Brown {LFB00032166/5} page 5, paragraph 13. If POM Hayward did not participate effectively in the meetings, there was a risk that AC Brown would not have sufficient information to enable him to exercise effective management oversight of the control room.
The introduction of Vision
¶79.99 The mobilising system enables CROs to carry out their core role of despatching crews to fight fires. As mentioned earlier, in 2015, the LFB changed the mobilising system used by the control room from ProCAD to Vision,1371 Hayward {LFB00055191/11} page 11, paragraph 26. a system which had been developed and delivered by a commercial company, Capita. Since the effective despatch of crews is the primary function of the control room, at least in the initial stages of the response, it was vital that staff received adequate training on the new system before it entered service.1372 Hayward {LFB00055191/12} page 12, paragraph 29.
¶79.100 Vision had been due to enter service in 2014, but the complexity of the LFB's requirements meant that Capita was unable to deliver the system on time.1373 Hayward {LFB00055191/111-12} pages 111-112, paragraph 27. From early 2013 the Operational Support Team started to prepare for its introduction.1374 Hayward {LFB00055191/19} page 19, paragraph 56. Initial training on Vision for existing control room staff took place between 24 June 2013 and 14 January 2014 and following further delays, tailored training for CROs continued to be delivered until the system eventually entered service on 17 November 2015.1375 Hayward {LFB00055191/20} page 20, paragraphs 59-60; George {Day205/7:4-5}.
¶79.101 The introduction of Vision resulted in a reduction in response times, with the result that appliances reached their destinations about 10 seconds earlier than had been the case when the control room had been using ProCAD.1376 George {Day205/19:16-19}. That was no doubt an improvement in performance, but, as AC George told us, the introduction of Vision had been extremely difficult for the control room.1377 George {Day205/19:19-22}.
159¶79.102 For a number of years after its introduction, Vision continued to be plagued by significant system failures. More than 500 faults were reported to Capita in the first six months.1378 Hayward {LFB00055191/13} page 13, paragraph 35. There were also six occasions during the first year when the system failed altogether for periods of between 40 minutes and three hours, requiring the use of contingency measures.1379 Hayward {LFB00055191/13} page 13, paragraph 33. AC George described instances when the mobilising system slowed to the point of stopping completely, causing the CROs to resort to a secondary mobilising system that he described as "basically pen and paper".1380 George {Day205/20:4-12}. That was extremely stressful for staff, who had occasionally left the control room in tears.1381 George {Day205/20:12}; {Day205/20:2-4}. The scale of the difficulties was such that in the period from 2016 to 2017 the Operational Support Team spent about 60% of its time reporting problems with Vision, revising training packages to reflect changes to the system and training staff on ways to circumvent problems. During the first two years in which Vision was in use, ways were devised to circumvent about 100 problems.1382 Hayward {LFB00055191/21} page 21, paragraph 63. Put briefly, between 2013 and 2017, the introduction of Vision generated a very substantial amount of additional work for the control room and the Operational Support Team in particular.
¶79.103 It was accepted by LFB officers that the task of implementing Vision had been all- consuming and had completely swamped the control room.1383 Brown {Day207/89:8}; Hayward {Day201/56:12-25}. One of the most significant consequences was its effect on training, which manifested itself in a number of ways.
¶79.104 One immediate consequence of the introduction of Vision was that all the control room's training capacity was directed towards training staff on the new system. When SOM Smith returned from the Chief Fire Officers Association she was asked to create a plan to train all 100 staff in the control room on Vision,1384 Smith {Day202/74:12-15}. which was regarded as a priority. That meant arranging 2,000 hours of training on Vision before it went into service.1385 Smith {Day 202/74:22-25}. Inevitably, resources were directed to ensuring that the system was effective as soon as possible.1386 Smith {Day204/93:19-24}. Between 2015 and 2017, most, and sometimes all, of the Operational Support Team's resources were devoted to that task, because it was essential that the brigade had an effective mobilising system.1387 Smith {LFB00121219/23} page 23, paragraph 61. POM Hayward said that the control room had been unable to plan any training until Vision was fully operational and officers could see how it performed.1388 Hayward {Day201/63:21-24}. That applied even to areas where annual training was expected, such as fire survival guidance refresher training.1389 Hayward {Day201/63:25}-{Day201/64:2}.
¶79.105 In order to cope with the pressure of work expected to result from the introduction of Vision, from 2014 and throughout its implementation the number of AOMs in the Operational Support Team was increased from four to six.1390 Hayward {LFB00055191/18} page 18, paragraph 49. The increase was originally expected to be temporary, but throughout 2016 the amount of work produced made any reduction impossible and the increase was made permanent by AC George in 2016.1391 Hayward {LFB00055191/18} page 18, paragraph 51.
160¶79.106 The training requirements imposed by Vision did not cease when the system entered service. Minutes of a Brigade Control Management meeting on 8 December 2015 (about three weeks later) refer to a list of problems that Capita had already been asked to resolve and referred to staff having to work around problems with the paging system.1392 Brigade Control Management Meeting Minutes 8 December 2015 {LFB00123099/2}. From that point on, the minutes of Brigade Control Management meetings and the Joint Committee for Control Staff record concerns about the performance and stability of Vision.1393 JCC Meeting Minutes {LFB00123113/7}.
¶79.107 The problem was not simply one of confidence in the system, because faults needed to be corrected as they were identified. Accordingly, it was necessary to make changes to the system, which in turn made it necessary to train CROs urgently on the revised version. Frequent amendments were very disruptive. On many occasions staff returned from their rest days to find that a change had been made to the system that required them to undergo immediate further training.1394 George {Day205/95:12-21}. The burden of training was both substantial and, until at least 2017, constant.1395 George {Day205/20:19-23}. The inevitable consequence was that other areas of training, including training on fire survival guidance, were delayed or deferred indefinitely. POM Hayward said that no fire survival guidance training at all had been given in 2015 because of the introduction of Vision.1396 Hayward {LFB00055191/26} page 26, paragraph 74 (table). In 2015, the control room had been concentrating entirely on implementing Vision and therefore no other training had been given.1397 Hayward {Day201/52:2-5}.
¶79.108 POM Hayward told AC Brown that there were occasions when fire survival guidance refresher training had not been delivered in accordance with the agreed programme, for example, between 2015 and 2017 while the CROs were being trained on Vision.1398 Brown {LFB00084020/13} page 13, paragraph 30. The explanation AC Brown gave us for allowing that situation to continue was that Vision was a critical project and that it had been essential to deliver it on time.1399 Brown {LFB00084020/13} page 13, paragraph 30. He did not agree, however, that all other training had ceased as a result.1400 Brown {Day207/93:7-17}. AC George had also been aware of the general adverse effect that Vision was having on control room training, although he too said that he had not been specifically informed of its effect on fire survival guidance training.1401 George {Day205/80:8-14}.
¶79.109 Training on Vision also put a temporary halt to the command unit training on fire survival guidance in which the control room had been involved. POM Hayward said that that training, which had run since mid-2013, had been stopped in 2015 because of the demands of Vision, although it had been resumed to a limited extent in mid-2016.1402 Hayward {Day200/15:7-15}. Staff training and development as a whole was adversely affected.1403 George {LFB00032823/11} page 11, paragraph 46; George {LFB00083884/14-15} pages 14-15, paragraph 50.
¶79.110 It is not clear what, if anything, was done to mitigate the effect on other areas of training of introducing Vision. AC George said that the sheer volume of work needed to implement Vision made it extremely difficult to devote resources to other training.1404 George {Day 205/173:16-20}. It does not appear that consideration was given to evaluating the competing priorities of training on Vision and other forms of training, including training on fire survival guidance, until after Vision had become operational in 2015.1405 Hayward {Day201/16:23}–{Day201/17:2}. POM Hayward said that at that point the control room had taken stock of the training needs of staff and had examined how they could run more general training as well as the continuing training on Vision.1406 Hayward {Day201/17:12-18}.
161¶79.111 The fundamental review of training proposed by AC Chandler in June 2013 did not take place because of the overriding concentration on getting Vision into service.1407 Hayward {Day201/129:16-22}. Although AC George covered aspects of training in his review of the control room, it did not amount to the fundamental reappraisal for which AC Chandler had called.1408 Review of Brigade Control, July 2016 {LFB00032826/11-13} paragraph 49; Brown {Day207/120:25}-{Day207/121:12}.
¶79.112 It is clear that the introduction of Vision was a significant challenge for the LFB, particularly for the control room, and required a substantial amount of work to stabilise the system. Its success in reducing the average time taken for an appliance to arrive at an incident together with other operational benefits came at the cost of a reduction in the ability of the control room to provide broader training to CROs, including fire survival guidance refresher training. Given the endless cycle of faults, revisions and need for further training created by Vision, it is unsurprising that the Operational Support Team struggled to deliver fire survival guidance training.
¶79.113 Although it was obviously of the first importance that CROs should be able to mobilise appliances quickly, the LFB should not have allowed training on Vision to squeeze out other forms of training so completely during the four years between 2013 and 2017. For a number of years, but particularly in 2015 and 2016, the introduction of Vision was treated as a reason for ignoring or deferring essential training and even the reappraisal of training proposed by AC Chandler, despite the fact that the "Vision Training Plan" contemplated that training on handling fire survival guidance calls would take precedence and might cause delay to training on Vision.1409 {LFB00058876/2}. The failure of senior managers to ensure that training on fundamental skills required by CROs was maintained during that period reflects a failure to establish proper priorities and a weakness of organisation. When AC Brown was told that essential training was not taking place or had been severely curtailed, he should have required POM Hayward to ensure that the Operational Support Team provided essential training to the control room.
¶79.114 His failure to do so was particularly acute in the case of fire survival guidance training. Following the fire at Lakanal House and the LFB's subsequent investigations, the importance of fire survival guidance training ought to have been clear to those responsible for the operation of the control room, including the Operational Support Team. It was a significant failure on the part of the LFB that fire survival guidance training was allowed to lapse during the introduction of Vision.
Training "on the watch"
¶79.115 One longstanding problem affecting the control room was the perception that it was too difficult to arrange for CROs to undertake training while maintaining operational capability in the control room. A number of witnesses said that training on the watch was regularly interrupted by the need to recall staff to the control room to respond to incoming calls.1410 Real {MET00080520/14} page 14, paragraph 4; Hayward {LFB00055191/18} page 18, paragraph 52; Hayward {Day199/50:2-6}; Smith {Day202/95:9-13}; George {Day205/111:10-12}; Brown {Day206/160:3-7}.
162¶79.116 That was not a problem peculiar to the LFB or one which arose shortly before the fire at Grenfell Tower. The Fire Service Manual Volume 1: Fire Service Technology, Equipment and Media Communications and Mobilising, published in 1998, noted that training for control personnel had always been hindered by the small numbers of staff available and the need to maintain cover in the control room. Training was usually organised by watches and delivered at the place of work, thereby ensuring that the maximum number of personnel were available. Brigades were therefore advised to consider appointing a Training Officer and organising training days away from the control room.1411 Fire Service Manual Volume 1: Fire Service Technology, Equipment and Media Communications and Mobilising {INQ00014945/129}. That document, published nearly 20 years before the Grenfell Tower fire, makes it clear that the difficulties posed by training at work were, or should have been, well known to fire and rescue authorities throughout the country. It is equally clear that it also proposed a solution to the problem.
¶79.117 In the Phase 1 report the chairman described the shift pattern operated by the control room, which was staffed by six watches. From the introduction of the new shift system in 2011 there had been a four-hour overlap between the early and late short shifts, which provided sufficient cover to enable training to take place during that period,1412 Review of Brigade Control, July 2016 {LFB00032826/9} paragraph 39; Hayward {LFB00055191/18} page 18, paragraph 52. but in 2014 the shift pattern had been altered, with the result that the short shifts overlapped by only two hours. It had been intended that staff on duty during one of the short shifts would undertake training during the hours with overlapping cover,1413 Review of Brigade Control, July 2016 {LFB00032826/11} paragraph 49. but in his review AC George expressed the view that the shift pattern did not allow enough time for supervisors to provide regular effective training to their watches outside the control room.1414 Review of Brigade Control, July 2016 {LFB00032826/9} paragraph 39. AC Brown had been heavily involved in consideration of the shift change in 2011 and had asked AC George to see how it could better accommodate training.1415 Brown {Day206/66:18-24}; {Day206/157:19-20}. In the report into his review AC George recommended that the control room should revert to the original shift pattern to allow four hours overlap between the short shifts that could be used for training.
¶79.118 Although the problem had been identified by AC George in 2016, the LFB had not tackled the reduction in the overlap between the two short shifts by the time of the Grenfell Tower fire. Indeed, it remained a contentious subject when AC Jonathan Smith produced his own review of the control room in 2019.1416 Control - Overview and Control Improvement Plan, dated 22 July 2019 {LFB00084097/4}. He found even then that the use of the short shift was not providing the structured training that was required.1417 Control - Overview and Control Improvement Plan, dated 22 July 2019 {LFB00084097/4}.
¶79.119 The importance of an adequate overlap between the two short shifts lay in the level of cover available for responding to the demands of the control room. In essence, the more staff present in the building, the lower the likelihood of the training watch needing to be called to control room duty.1418 Tables setting out the minimum numbers of staff required from 2011, Hayward {LFB00055191/5} page 5, paragraphs 15-17. If there were a short increase in the number of calls to the control room, CROs could resume training, but if a significant incident occurred, a new date for their training had to be arranged by the Operational Support Team.1419 Smith {Day202/95:9-13}. The concern about the interruption of training is understandable, but to an extent misplaced. The evidence does not suggest that there was a frequent need to redeploy staff from training to the control room. On the contrary, POM Hayward said that it happened only infrequently1420 Hayward {Day199/43:19-21}. and he was unable to recall being aware of any problems arising from the fact that staff were unable to complete their training because they had been recalled to the control room.1421 Hayward {Day199/49:9}-{Day199/50:1}. There were other problems, however. For example, a shortage of staff in the control room meant that staff from the short shift were often needed to fill gaps in the duty watch.1422 George {Day205/111:23-25}. That inevitably reduced their availability for training.
163¶79.120 As mentioned above, the Fire Service Manual recommended that brigades should consider appointing a Training Officer and arranging training days away from the control room.1423 Fire Service Manual Volume 1: Fire Service Technology, Equipment and Media Communications and Mobilising {INQ00014945/129}. As a general rule, however, the LFB did not organise training "off-watch" or away from the control room.
¶79.121 It is clear from the evidence of control room staff that there was a commonly held belief that it was simply not possible to organise training "off-watch". SOM Smith considered that the difficulty of making control room staff available for training at work was common to all fire and rescue services because it was not possible for them to go "off the run,"1424 Smith {Day204/23:12-24}; Real {MET00080520/14} page 14, paragraph 4. i.e. to be unavailable for duty. POM Hayward said that he had been unable to use overtime to provide training because he could not require staff to work overtime for that purpose and because he had already been making excessive use of overtime to maintain the necessary number of CROs on duty.1425 Hayward {Day199/47:1-8}. However, in our view senior managers did not give sufficient consideration to delivering fire survival guidance training off-watch, given that in some other cases training was indeed delivered off-watch. For example, POM Hayward recalled that in August 2006, shortly after he had joined the LFB, staff had been trained on the ProCAD mobilising system off watch following a major revision.1426 Hayward {Day199/43:2-5}. He thought that had been the only time staff had received training "off-watch",1427 Hayward {Day199/43:6-7}. but in 2010 the initial one-day fire survival guidance training had also been delivered "off‑watch".1428 Hayward {Day200/80:19}-{Day200/81:1}. POM Hayward said that although at that time it had been possible to deliver training in that way, the introduction of the new shift patterns in 2011 and staff losses in 2012 had made training "off-watch" "problematic."1429 Hayward {Day200/81:2-10}. Despite that, SOM Smith told us that training "off-watch" had been provided in 2015 for the introduction of the new Vision mobilising system.1430 Smith {Day202/97:23}-{Day202/98:5}. CROs needed to receive a number of hours of training on Vision, which had been delivered to most of them "off-watch".1431 Smith {Day204/24:4}-{Day204/25:3}. It is also the fact that in 2016 and 2017 some CROs worked overtime to support the command unit training exercises.1432 Smith {Day204/127:20}-{Day204/128:16}; Hayward {LFB00055191/28} page 28, paragraph 78.2.
¶79.122 Those examples suggest that the belief that training could not be delivered "off-watch" was unjustified and unreasonable. They also suggest that fire survival guidance training was not considered by the LFB to be necessary to enable CROs to perform their role effectively. It is telling that although the introduction of Vision was considered to be of sufficient importance to justify "off-watch" training, the delivery of refresher fire survival guidance training was not. In view of the number of fire survival guidance calls the LFB had received during the Lakanal House fire and the lessons that it had itself identified, as well as the critical nature of the advice provided by CROs taking fire survival guidance calls, the failure to make any obvious effort to provide refresher fire survival guidance training "off-watch" was a serious error of judgment.
164¶79.123 The shortage of staff to which POM Hayward referred had an obvious effect: in order to maintain the minimum number of staff in the control room, training would sometimes have to be cancelled.1433 Review of Brigade Control - the issues raised by staff prior to the review commencing {LFB00032831/2} paragraph 3a; George {Day205/52:7}-{Day205/53:6}. A shortage of staff, together with sickness and a need for breaks, was one reason why it had not been possible to train watches away from the control room during the short shift.1434 Review of Brigade Control {LFB00032826/11} paragraph 49. However, the shortage of staff, its causes and consequences were well known. Between 2011 and 2012 the LFB was considering a proposal to enter into a contract with a third party for the provision of control room services, which resulted in a temporary halt to recruitment.1435 Hayward {Day199/47:4-6}; Hayward {Day199/87:11-13}; Brown {Day206/40:25}-{Day206/41:1}; George {Day205/53:25}-{Day205/54:3}. That remained the position until 2016, when AC George asked for recruitment to resume after he had assumed responsibility for the control room.1436 George {Day205/114:5-7}. During his time as a director, AC George also increased the number of CROs and supervisors on each watch.1437 George {Day205/114:22-25}.
Planning and recording control room training
¶79.124 Following the Lakanal House fire, the Lakanal Control report identified serious deficiencies in the provision and recording of fire survival guidance training over the long period between 1981 and 2009.1438 Lakanal Control Report dated November 2012 {HOM00001124/26} paragraphs 130 and 134 and {HOM00001124/31} paragraph 167. In his report following the audit of the training arrangements SM Kelly observed that, if fire survival guidance and other control room training were to be provided effectively, systems had to be established for planning training and recording its delivery.1439 Gap Analysis dated 7 April 2010 {HOM00001125/23}; SM Kelly's draft audit of Brigade Control training dated August 2010 {LFB00055203/7} paragraphs 46-49. Yet, it is clear that, in the years following the Lakanal House fire, senior managers failed to establish such systems, so that the problems persisted up to, and indeed well beyond, 14 June 2017.1440 AC Jonathan Smith's briefing note titled 'Control – Overview and Control Improvement Plan' dated 22 July 2019 {LFB00084097/3}.
¶79.125 The need for fire survival guidance training to be structured and planned had been identified in FSC 10-931441 Fire Service Circular {LFB00003617/3} paragraph 11. and in the Fire Service Manual published in 1998.1442 Appendix 1 of the Fire Service Manual 1: Fire Service Technology, Equipment and Media, Communications and Mobilising (Published 1998) entitled 'Control Staff – Training, Competence and Promotion' {INQ00014945/129}. Although national guidance was silent on keeping adequate records of training, the LFB's own policy, PN164, issued on 29 September 1994 and amended on 28 January 2009, included detailed requirements on training records. In particular, paragraph 2.5 required a clear record to be kept of the contents of the training, together with details of dates, the trainers and any relevant notes,1443 PN164 as issued on 29 September 1994 and amended on 28 January 2009 {LFB00084054/3}. but it was not complied with. Moreover, PN164 did not require training plans to be produced for individual officers or watches or for the control room more generally.1444 That was the case for all of its subsequent revisions. PN164 reviewed as current on 6 May 2015, which was the version in force on 14 June 2017 {LFB00084054/11}. Those requirements ought to have been added to PN164 after the Lakanal House fire.
165¶79.126 The LFB had originally intended that records of control room training should be brought into the StARS and STEP systems used by the rest of the brigade.1445 Hayward {Day199/77:16}-{Day199/79:11}; Hayward {Day199/121:22-25}; Brown {Day207/4:15-25}; Minutes of the Lakanal House Board Meeting on 22 June 2010 {LFB00055208/3} item 8.8; Minutes of the Lakanal House Board Meeting on 21 July 2010 {LFB00055210/3} item 7.5; Minutes of the Lakanal House Board meeting on 15 September 2010 {LFB00084031/2} item 5.10. In that way they would be automatically entered on STEP without the need for manual intervention1446 Hayward {Day199/77:16}-{Day199/79:11}. and control room managers would easily be able to check what training each CRO had received and plan future training.1447 George {Day205/82:7-20}. The training records, as they existed at the time, were entered on STEP by 8 November 2010.1448 Minutes of the Lakanal House Board Meeting on 8 November 2010 {LFB00055213/1}; Hayward {Day199/123:8-23}.
¶79.127 AC Brown accepted that, although he considered the biennial plan for fire survival guidance training to be robust, it did not amount to an all-encompassing training plan which met SM Kelly's recommendation that an adequate system be introduced for planning training.1449 Brown {Day206/163:2-17}. However, neither he nor POM Hayward took any steps at the time to put such a plan in place.
¶79.128 At a Brigade Control Management meeting on 18 July 2012, AC Chandler discovered that there was no single document, such as a training matrix, which recorded what training had been delivered to control room staff and what was needed in the future. He therefore asked the OMs to collate that information for their own watches and present it in the form of spreadsheets. He also asked the Operational Support Team to produce a training matrix.1450 Minutes of the Brigade Control Management Meeting held on 18 July 2012 {LFB00113237/7-8} item 5. It is clear, therefore, that SM Kelly's recommendation to introduce an adequate system for planning training had still not been carried out almost two years after he had reported and that training records were still not being entered automatically on the StARS and STEP systems. It is also clear that after he became Head of Mobilising and Control in May 2012, AC Chandler recognised the importance of an effective system of planning training and took some steps to improve the position.1451 Brown {LFB00032166/3-4} pages 3-4, paragraph 7. POM Hayward could not explain why a training plan had not been established before July 2012.1452 Hayward {Day199/85:23}-{Day199/86:2}.
¶79.129 At the meeting on 18 July 2012 OM Victor Bagnelle referred to the system of record-keeping introduced by the Operational Support Team as a temporary solution while adjustments were being made to the StARS and STEP systems to enable them to accept information relating to the control room.1453 Hayward {Day199/78:13}-{Day199/79:2}; Hayward {Day199/123:1-3}. It involved recording information on a spreadsheet which was sent to the information management team once a month to be manually entered on STEP.1454 Hayward {Day199/126:6-9}; {Day199/78:23}-{Day199/79:2}; George {Day205/86:22}-{Day205/87:5}. The system was cumbersome and subject to human error, because different staff recorded training in different ways.1455 Hayward {Day199/126:12-22}. Moreover, information about watch-based training was not always sent to the Operational Support Team for inclusion in the spreadsheet.1456 Hayward {Day199/126:12-22}.
166¶79.130 Training was discussed at the following Brigade Control Management meeting held on 12 September 2012, but no conclusion was reached.1457 Minutes of the Brigade Control Management Meeting on 12 September 2012 {LFB00113402/6} item 5. Obviously, therefore, no agreement had been reached on a training plan at that stage.1458 Hayward {Day199/96:17-21}. AC Chandler recognised that the LFB would not have a robust defence if anything went wrong in the control room, but although another meeting was due to be held in October 2012 to discuss training,1459 Minutes of the Brigade Control Management Meeting on 12 September 2012 {LFB00113402/6} item 5. no training plan was in fact put in place.
¶79.131 In January 2013, GM Lindridge found that the control room was still recording all training on a spreadsheet to be entered on STEP manually.1460 GM Lindridge's Review dated 4 January 2013 {LFB00033943/14}. He also found that the technology made it impossible for control room managers to create a training plan on STEP and therefore recommended that a two-year rolling plan should be set out on a spreadsheet by January 2013.1461 GM Lindridge's Review dated 4 January 2013 {LFB00033943/14}. It is clear, therefore, that almost two and half years after SM Kelly's report and six months after AC Chandler's request for a training matrix, no training plan had been put in place and that StARS and STEP could still not be used to create training records for the control room.
¶79.132 POM Hayward could not explain why no training plan had been introduced by that point.1462 Hayward {Day199/104:15-17}. Nor could he recall whether a training matrix had ever been produced.1463 Hayward {Day199/104:18-23}. Apparently one reason why training records still had to be entered manually on StARS was because the programme still did not recognise the control room's short shift patterns.1464 Hayward {Day199/125:3-18}; {Day199/126:24}-{Day199/127:15}; {Day199/131:9-18}; Hayward {LFB00055191/23} page 23, paragraph 67; Brown {Day207/6:23}-{Day207/7:14}. He said that there had been competing priorities for attention, in the form of an amendment to StARS to accommodate a change in operational shifts and the introduction of Vision.1465 Hayward {Day199/127:16-24}; {Day199/131:5-8}; Hayward {LFB00055191/23} page 23, paragraph 67. He said that, because there had already existed a method of recording control room training, the necessary amendment had been moved down the list of priorities.1466 Hayward {Day199/127:16}-{Day199/128:3}.
¶79.133 AC Brown agreed that there had been competing priorities, but he did not accept that operational demands routinely trumped the demands of the control room.1467 Brown {Day207/8:6-14}. He accepted that, although he had tried to push matters along, greater pressure could have been exerted to ensure that the control room's training needs were given priority.1468 Brown {Day207/7:18-23}; {Day207/8:15-25}. He also suggested that the fact that the control room was based in Merton and was not a presence within the LFB's headquarters probably made it difficult for its managers to make their case to senior officers.1469 Brown {Day207/8:15-25}.
¶79.134 On 4 April 2013, when AC Chandler returned from leave, AC Brown asked him to satisfy himself that the pre-inquest actions had been completed. He also asked AC Chandler to talk him through the training plan for the control room.1470 Email from AC Brown to AC Chandler on 4 April 2013 {LFB00028942/2}. AC Brown said that he had asked for that to be done because he remained dissatisfied with progress towards a training plan, which by then was overdue.1471 Brown {Day206/170:15-24}. He said that AC Chandler had told him that it was in hand.1472 Brown {Day206/170:25}-{Day206/171:2}. He also said that he had asked AC Chandler for the training matrix, but had not received it.1473 Brown {Day206/171:3-9}.
167¶79.135 On 9 May 2013, POM Hayward sent an email to OM Victor Bagnelle expressing concern that the training database did not provide an accurate picture of the current state of training or the programme for future training.1474 Email from POM Hayward to OM Vic Bagnelle on 9 May 2013 {LFB00042081/1}. It is evident, therefore, that the planning of training was still not fully under control at that time. However, on 28 June 2013, AC Chandler reported to AC Brown on progress in completing the pre-inquest actions.1475 Email from AC Chandler to AC Brown on 28 June 2013 {LFB00060701/1}. In relation to action 16 he reported that the planning and recording of general control room training had improved.1476 Email from AC Chandler to AC Brown on 28 June 2013 {LFB00060701/2}. In light of the continuing problems with planning and recording training, the basis for that statement is unclear.
¶79.136 Very little happened until a year later, when on 22 July 2014, POM Hayward sent an email to SOM Bagnelle, SOM Diamond and SM Ajimal expressing concern at the absence of a robust system of recording control room training.1477 Email from POM Hayward to SOM Bagnelle, SOM Diamond and Tejinder Ajimal on 22 July 2014 {LFB00051294}. His concerns were well-founded, and it is disquieting that in July 2014, although work had started, still no robust records existed and the objective of a training programme that was considered, planned and delivered to a measured outcome had not been met.
¶79.137 When SOM Smith took charge of the Operational Support Team and control room training in January 2015, she did not ask whether a training plan had been developed.1478 Smith {Day204/160:2-5}. She told us that POM Hayward had asked her to deliver a training plan for Vision.1479 Smith {Day204/160:2-10}; {Day204/161:1-4}. Although they had discussed delivering other training after Vision had been implemented, at that time attention was clearly concentrated on Vision.1480 Smith {Day204/160:2-10}; {Day204/161:1-4}; {Day204/166:1-6}. Accordingly, there had been a training plan for Vision but not for other training, such as training on handling fire survival guidance calls.1481 Smith {Day204/165:13-19}. SOM Smith told us that at that time the training plan had taken the form of large calendars displayed on a wall of the Operational Support Team's office on which entries were made following discussions by email within the team.1482 Smith {Day204/162:23}-{Day204/163:4}; {Day204/166:25}-{Day204/167:3}. As she accepted, that did not constitute a detailed formally documented training plan.
¶79.138 In November 2014, the Directorate of Audit, Risk and Assurance in the Mayor's Office for Policing and Crime audited the LFB's arrangements for the management of the control room.1483 Email chain between Scott Hayward and Karen Mason dated 17-18 November 2014 regarding Brigade Control Audit {LFB00030108}; Hayward {Day201/42:1-4}; Internal Audit – Progress Report Quarter 3 2014/2015 dated 9 March 2015 {LFB00044640/1}. It was the first time such an audit had been carried out.1484 Hayward {Day201/42:1-4}. One of the matters that interested the auditor was how the training team ensured that all staff received fire survival guidance training annually.1485 Email from Karen Mason to SOM Bagnelle on 14 November 2014 {LFB00030108/3}.
168¶79.139 The audit identified a number of risks, including:
¶a. intentional or unintentional alteration of the training spreadsheet, affecting the monitoring of training and reporting to senior management;
¶b. inconsistent and inaccurate completion of the spreadsheet, leading to inappropriate decisions;
¶c. ineffective monitoring of fire survival guidance training, leading to reputational damage if serious incidents were dealt with by inadequately trained staff; and
¶d. inadequate training, resulting in inappropriate responses to incidents.1486 Summary of MOPAC Audit of Brigade Control dated February 2015 {LFB00044640/25-26}.
¶79.140 It recommended that an independent record of fire survival guidance training be maintained and monitored for all control staff to ensure that all staff were in receipt of training at least annually and that a monthly report be produced by the Operational Support Team setting out the position in relation to training for the current year.1487 Summary of MOPAC Audit of Brigade Control dated February 2015 {LFB00044640/25-26}.
¶79.141 Both POM Hayward and AC Brown acknowledged that the risks identified in the audit had existed and that a failure to ensure that staff received adequate fire survival guidance training could result in serious injury or death,1488 Hayward {Day201/45:19}-{Day201/47:2}; Brown {Day207/87:6-18}. and we have no reason to think that they were not aware of those matters at the time. Yet, neither of them took effective steps to ensure that the auditor's recommendations were implemented. AC Brown probably used the report as the basis for a discussion with POM Hayward to satisfy himself that everything was working correctly, but did not go further than that.1489 Brown {Day207/88:18-25}. It is unlikely that POM Hayward did anything beyond asking SOM Smith to check that the Operational Support Team was maintaining training records, because at that time they were concentrating entirely on training for the introduction of Vision.1490 Hayward {Day201/51:17}-{Day201/52:18}. We do not consider that the drain on personnel resources caused by problems with Vision excuses the failure by senior management to give the auditor's findings and recommendations the importance they deserved. That was a significant failure.
¶79.142 When he conducted his review of the control room in 2016 AC George found that training to maintain skills was irregular, not robustly planned and often not recorded on an individual's training record. Staff often failed to record training and were seldom instructed to do so.1491 AC George Review of Brigade Control dated July 2016 {LFB00032826/11} paragraph 47. He recommended that each OM ensure that an appropriate, robust, annual training plan was put in place for their own watch, agreed by their SOM and made available to all watch members and managers, and that training be recorded on an individual's training record. He also recommended that senior managers should work with the LFB's information management team to produce a solution similar to the training diaries used by station staff and make effective use of the brigade's systems, including StARS.1492 AC George Review of Brigade Control dated July 2016 {LFB00032826/12} paragraphs 49 c-f.
¶79.143 SOM Smith was given the task of implementing AC George's recommendations,1493 Appendix 2 to AC George's Review of Brigade Control dated July 2016 {LFB00032826/31}; George {Day205/105:15- 25}. although he accepted that he had been ultimately responsible for ensuring that that was done.1494 George {Day205/100:23}-{Day205/101:1}. He said that he had monitored progress through POM Hayward,1495 George {Day205/101:2-19}. but despite the force of his findings, StARS and STEP were not fully adapted to accommodate the control room until December 2018, nearly 18 months after the Grenfell Tower fire.1496 George {LFB00083884/6} page 6, paragraph 29(b); George {Day205/104:12}-{Day205/105:7}; Hayward {Day199/133:16-18}; Hayward {Day199/143:23-25}. It is also reasonably clear that although some work had been done, robust training plans for individual watches had not been put in place by the time of the fire.1497 Email from POM Hayward to AC George on 7 November 2016 {LFB00083865/9}; George {LFB00083884/6} page 6, paragraph 29(b); Smith {Day204/182:12}-{Day204/184:17}; Hayward {Day199/113:13}-{Day199/114:1}; George {Day205/106:7-14}.
169¶79.144 The failure to adapt StARS and STEP to accommodate the control room was the root cause of the difficulties encountered with planning and recording training.1498 Brown {Day206/173:6-17}; George {Day205/82:7}-{Day205/84:14}; {Day205/86:6-15}; Hayward {Day199/110:2-24}. AC George expressed surprise that previous managers had not made sure that the systems had been adapted to include the control room.1499 George {Day205/83:3-4}. Commissioner Dobson attributed the failure to a decision not to contract out the training of control room staff in 2012. He thought that, if that had been done, as it had for operational firefighters, the problems with training generally, and record-keeping in particular, would have been identified earlier. Regardless of the merits of Mr Dobson's view, however, it is not a good excuse for the failure to plan, record and provide training after 2012.
¶79.145 When he carried out his review of the control room in July 2019, AC Jonathan Smith found that the current provision of training, assurance and professional development required a complete and systematic overhaul. Training was irregular and lacking in structure, there was no system of quality assurance and the recording of training was inconsistent. Those criticisms were linked to wider concerns relating to culture, accountability and leadership.1500 AC Smith's briefing note entitled 'Control – Overview and Control Improvement Plan' dated 22 July 2019 {LFB00084097/3-4}.
The management of fire survival guidance training
¶79.146 The failure to deliver regular fire survival guidance training after the Lakanal House fire represents a significant omission on the part of those responsible for the management of the control room. When senior officers were warned in the years after the Lakanal House fire that fire survival guidance training was not taking place, they should have taken effective action to make sure that it was provided. The management of fire survival guidance training was lacking in two other important respects: first, no objective criteria had been established by which to evaluate and monitor training or the quality of emergency call-handling; secondly, fire survival guidance training was not subject to consistent reporting or monitoring.
¶79.147 The LFB monitored only three aspects of the control room's performance,1501 Review of Brigade Control, July 2016 {LFB00032826/5} paragraph 22. all of which reflected performance indicators relating to the control room in the London Safety Plan.1502 George {Day205/69:14-17}; London Safety Plan 2014 {LFB00032107/70}. They were:
¶a. the average time taken to answer an emergency call;
¶b. the percentage of emergency calls answered within 7 seconds; and
¶c. the average time taken to deal with an emergency call.1503 Review of Brigade Control, July 2016 {LFB00032826/5} paragraph 22.
170¶79.148 As far as the control room itself was concerned, it was for the AC and the POM to decide which aspects of performance should be monitored, but no discussion appears to have taken place between them about whether any other aspects of performance should be considered.1504 Hayward {Day199/15:22}-{Day199/16:7}; Brown {Day206/47:2-13}. That may have been because AC Brown thought that performance indicators were relevant only to things that can easily be measured.1505 Brown {Day206/46:24-25}. He thought that it was difficult to monitor quality because that required the evaluation of a process.1506 Brown {Day206/46:21-24}. There was no key performance indicator relating to training, although he took the view that, if the three indicators mentioned above were moving in the wrong direction, that would be a clear sign that training was not effective. For that reason, he thought that the three existing indicators provided some assurance that training was taking place.1507 Brown {Day206/45:23}-{Day206/46:15}. That was not the case, of course, because they related only to response times and did not reflect the content or quality of responses to calls, particularly fire survival guidance calls. It is, therefore, unreal to suggest that the key performance indicators could be treated as indicating the overall quality of training. It was a significant failure on the part of senior management not to recognise that there were no effective means of assessing the quality of responses to fire survival guidance calls.
¶79.149 AC George said that the three aspects of the control room's performance to which we have referred reflected the information that LFEPA, as the LFB's supervising authority, required.1508 George {Day205/71:9-21}. He thought that LFEPA was interested only in numbers and quantities, which effectively dictated their scope.1509 George {Day205/71:11-21}. Although he had reservations about that approach, there is no evidence that he or any other senior officer ever suggested that some other objective standard might be adopted by which to assess the quality of the control room's responses to emergency calls generally or the quality of its responses to fire survival guidance calls in particular.1510 George {Day205/71:23}-{Day206/72:3}.
Arrangements for reporting and monitoring control room training
¶79.150 We referred earlier to POM Hayward's laissez-faire style of management. He treated the absence of any reports of difficulties as an indication that the SOMs were managing training effectively, but the fact that fire survival guidance refresher training was not being consistently or effectively provided from 2012 onwards without his apparent knowledge demonstrates the weakness in his approach. There should have been a mechanism by which the SOMs or the Operational Support Team reported to him regularly about training generally and fire survival guidance training in particular. Together with a proper training plan and reliable training records that would have enabled him to monitor the provision of training against established criteria and satisfy himself and more senior managers that the LFB's duty to train control room staff was being properly discharged.1511 Summary of MOPAC Audit of Brigade Control dated February 2015 {LFB00044640/25}.
¶79.151 It is significant that when AC Chandler was Head of Control and Mobilising, he recognised the need for improved arrangements for planning and recording control room training and was taking action to put them in place so that they could be easily audited.1512 Minutes of Brigade Control Management Meeting on 18 July 2012 {LFB00113237/7-8} item 5; Minutes of Brigade Control Management Meeting on 12 September 2012 {LFB00113402/6} item 5; Email from POM Hayward to OM Vic Bagnelle dated 9 May 2013 {LFB00042081/1}.
171¶Some improvements had been made by June 2013,1513 Email from AC Chandler to AC Brown dated 28 June 2013 {LFB00060701/2}. but it is clear that progress came to a halt when he left the LFB in October 2013,1514 Email from POM Hayward to SOM Bagnelle, OM Diamond and SM Ajimal on 22 July 2014 {LFB00051294}. because, when AC George carried out his review in July 2016, he discovered that planning and recording training was still a problem.1515 AC George's Review of Brigade Control dated July 2016 {LFB00032826/11-12} paragraphs 47-49.c. It is also clear that he did not address the problem effectively before he became Director of Operations in April 2017.1516 AC Jonathan Swift's conclusions in respect of the planning and recording of Brigade Control training in July 2019 {LFB00084097/3}.
¶79.152 On any view, as AC Brown rightly accepted, the involvement of the assistant commissioner was important in the management of the control room.1517 Brown {Day206/56:19-21}; {Day206/58:2-7}. The consequences of leaving POM Hayward without effective supervision between October 2013 and March 2016 are clear from our description of how matters developed during that period.1518 George {LFB00032823/2}; Performance Information Folder: Operations, Prevention and Response for Performance CMB dated 12 February 2014 {LFB00042326/73}.
¶79.153 AC Brown requested the appointment of an assistant commissioner to join the management of the control room as Head of Control and Mobilising in May 2012 precisely because he needed someone senior to manage it more closely than he could himself.1519 Brown {Day206/53:5-17}. He said that his position, which at that time was AC Operations, Prevention and Response and Third Officer, effectively combined two important functions, each previously performed by an assistant commissioner, with a significant increase in his responsibilities.1520 Brown {Day206/43:25}-{Day206/44:10}; {Day206/53:8-17}; Brown {LFB00032166/3} page 3, paragraph 5. POM Hayward said that as a result, his scheduled meetings with AC Brown would sometimes be cancelled or curtailed and he found it difficult to contact him.1521 Hayward {Day199/14:3-9}; {Day199/19:2-5}. AC Brown accepted that, but said that meetings would be rearranged and that even if POM Hayward had not been able to get hold of him when he wanted to, there had been ample opportunity to discuss matters.1522 Brown {Day206/44:4-10}; {Day206/52:12-17}. He did accept, however, that when he had become Director of Operations in April 2015 the extent of his responsibilities had adversely affected his capacity to manage the control room generally and POM Hayward in particular.1523 Brown {Day206/60:12-20}. In an echo of AC George's observation, AC Brown thought that the geographical separation of the control room had also contributed to difficulties in managing it, because when the control room had been moved to Merton, it had become both more difficult and more time-consuming to visit it.1524 Brown {Day206/49:21-25}. The net effect, according to POM Hayward, was that AC Brown did not actively supervise the management of control room training.1525 Hayward {Day199/37:16}-{Day199/38:8}. POM Hayward made similar comments about AC Chandler and AC George, although it is evident that AC Chandler did exercise a greater degree of oversight.1526 Hayward {Day199/37:19}-{Day199/38:8}; {Day199/95:17-20}; {Day199/100:21-25}; Brown {Day206/56:8-15}.
¶79.154 AC Brown did not think it was his responsibility to examine the control room training records personally to ensure that fire survival guidance refresher training was being delivered properly. He relied on POM Hayward to schedule and monitor it and checked on the position at monthly management meetings. He could not remember having received any complaints about the response of CROs to fire survival guidance calls after the introduction of the regular training that followed the Lakanal House fire and therefore had not had any reason to question whether refresher training was taking place.1527 Brown {LFB00032166/21} page 21, paragraph 66.
172¶79.155 We accept that an officer of AC Brown's seniority could not be expected to review details of training records personally, but the failures affecting the provision of training (and fire survival guidance training in particular) were longstanding and were well known to him and other senior officers responsible for the control room. As the various audits carried out between 2010 and 2016 consistently made clear, nothing effective had been done to remedy them. The responsibility for that failure must ultimately lie with AC Brown.
¶79.156 The criticisms of the way in which fire survival guidance calls were handled during the Lakanal House fire provided a powerful reason for senior management to satisfy themselves that fire survival guidance refresher training was taking place.1528 Lakanal Control Report dated November 2012 {HOM00001124/49-50}. Moreover, the discovery in February 2013 that the Operational Support Team had both reduced the time allocated for fire survival guidance training and removed the active role-play element1529 Brown {Day207/78:2-6}; {Day207/80:2-14}; Hayward {Day200/188:7-23}; {Day200/193:4}-{Day200/194:2}; {Day200/196:4-6}; {Day200/208:2-7}; {Day200/209:10-15}; Hayward {LFB00055191/24-25} pages 24-25, paragraphs 69-70; Emails between POM Hayward and SOM Bagnelle on 7-8 February 2013 {LFB00055221/1-3}. should have sounded a clear warning that fire survival guidance training was not being provided as agreed in the wake of the Lakanal House fire. It should also have alerted him to the fact that positive action and close and regular scrutiny was required. In fact, although both POM Hayward and AC Brown demanded that fire survival guidance training be delivered as promised, neither of them did anything effective to ensure that it was.
¶79.157 The failure to provide the fire survival guidance training agreed by the Lakanal House Board should have prompted AC Brown to question the effectiveness of POM Hayward's oversight of training, particularly given his more general concern about his day-to-day management of the control room.1530 Brown {LFB00084020/12-13} pages 12-13, paragraph 28; Brown {Day206/50:19}-{Day206/52:5}. Although AC Brown said that he had raised his concerns with POM Hayward directly and had taken action to address them, POM Hayward said that the only concern that AC Brown had ever raised with him was that he did not communicate with him enough.1531 Brown {Day206/50:19}-{Day206/52:5}; Hayward {Day199/18:20}-{Day199/19:17}. Whatever the truth of the matter, the practical result was that AC Brown did not act on his concerns about POM Hayward's management of fire survival guidance training. His failure to do so was serious, given the obvious risks to public safety.
Conclusion
¶79.158 The history of fire survival guidance training is long and complex, but the evidence gives rise to clear and consistent themes that reflect and confirm the broader failings of the LFB identified in this report. The control room was inadequately managed by POM Hayward who, in turn, was ineffectually led by senior managers, most notably AC Brown. The latter, in particular, was ultimately responsible for ensuring that CROs received the fire survival guidance training that they needed and also for ensuring that it reflected national guidance and the LFB's experience at the Lakanal House fire. As is plain from what we have said above, AC Brown failed to do that, leaving CROs ill-prepared to meet the admittedly exceptional challenges of the Grenfell Tower fire.
173Chapter 80: Communications
¶80.1 In his Phase 1 report, the chairman found that from the earliest stages of the incident the deployment of firefighters inside the tower was hampered by generally ineffective communications, that communication difficulties significantly limited the efficiency of search and rescue operations1532 Phase 1 Report Volume IV {INQ00014817/133} paragraph 28.130. and that it was well known within the LFB that BARIE sets performed badly in concrete high-rise buildings. He concluded that greater efforts should therefore have been made to establish and maintain effective communications inside the tower on the night.1533 Phase 1 Report Volume IV {INQ00014817/133} paragraph 28.131. In this phase of the Inquiry we have examined the communication equipment used by the LFB in order to identify the source of the problems and have considered whether sufficient steps were taken to solve them.
¶80.2 A general description of the communication equipment used by the LFB on 14 June 2017 can be found in paragraphs 7.66–7.69 of the Phase 1 report, but for the purposes of this chapter it is necessary to describe it in a little more detail.
Overview
¶80.3 At the time of the Grenfell Tower fire the LFB relied on radio for communication between the control room and the fireground and between firefighters, both at the fireground and more widely. It used two kinds of radio equipment:1534 Christopher Johnson {Day189/8:14}. ultra-high frequency (UHF) analogue radios and Airwave digital radios. ("Airwave" is the name of the network and of the network services provider.) In broad terms, UHF radios were used for localised, personal, operational use, principally on the fireground; Airwave radios were used for tactical functions, including communication with the control room and other emergency services.
¶80.4 The primary method of using UHF radio was by operation of a handset which acted as both transmitter and receiver. In addition, however, breathing apparatus radio interface equipment (BARIE) was used with the helmets and masks of many breathing apparatus sets.
¶80.5 UHF radio communications can be enhanced by radio repeaters, which receive and re‑broadcast a radio signal, and by "leaky feeders", which are cables that connect radio repeaters to form a series while simultaneously 'leaking' the radio signal to improve its reception between repeaters.1535 Christopher Johnson {Day189/45:1-11}; {Day189/45:12-25}; Policy 700 {LFB00001762}. Repeaters can be portable or fixed in buildings, tunnels and similar environments, or on LFB appliances.
¶80.6 Airwave digital radio, sometimes referred to within the LFB as the "main scheme radio", was also mainly operated using handsets. In addition, however, all LFB appliances contained a fixed digital radio in the vehicle's cab, which allowed crews to use the Airwave system to communicate with the control room and senior officers.
174¶80.7 The central LFB policy on communications was Policy No 488 on Incident Communications.1536 {LFB00000736}: this policy was extant at the time of the Grenfell Tower fire. The Inquiry does not have a copy of the policy in place at the time of the Lakanal House fire. It set out the intended uses of each UHF channel as well as the responsibilities of a communications operator and command unit staff. A number of other policies that we do not need to mention here governed the deployment and use of specific items of communication equipment.
Analogue (UHF) radio equipment
¶80.8 The LFB's UHF radios had 10 channels, which were used for the following purposes:1537 As summarised in Ellis {LFB00089131/7-9} pages 7-9, paragraph 26. a. Channel 1: the primary incident command and control channel. b. Channel 2: a back-up incident command and control channel, which could be used only with a radio repeater.1538 Radio repeaters are explained further below but, in summary, they are items of equipment intended to extend the range of a radio signal.
¶c. Channel 3: a channel used by specific teams for particular activities, for example, organising the supply of water or dealing with fire survival guidance calls.
¶d. Channel 4: a back-up channel, which offered additional capacity, but was not routinely used.
¶e. Channel 5: a back-up channel for communicating with BA wearers, which could be used only with a radio repeater. f. Channel 6: the primary channel for communicating with BA wearers.
¶g. Channel 7: a channel which had previously been used by the police, but had been assigned to the LFB. It provided additional capacity, but was not routinely used.
¶h. Channel 8: another channel made available by the police which provided additional capacity but was not routinely used. It required a radio repeater.
¶i. Channel 10: a channel used by command unit crews for communications relating specifically to their work.
¶j. Channel 11: for communications between the LFB and the Airport Fire Service at Heathrow Airport. This channel was loaded only on to radios at the Heathrow fire station.
¶80.9 UHF radios are intended for use locally, usually within the area of a particular incident. The signals travel a finite distance which, without interruption or interference, is determined primarily by the power of the transmitting handset.1539 Christopher Johnson {Day189/9:22}-{Day189/10:1-3}. Professor Chris Johnson, a communications expert retained by the Inquiry, pointed out that the limited and localised range of UHF signals could be used to an organisation's advantage by restricting the number of people who can receive a transmission to a localised team.1540 Johnson, Communications Expert Report {CWJ00000119/142} paragraph 6.6.5; Christopher Johnson {Day189/16:1}- {Day189/17:12}. However, that was not a relevant consideration in this case because of the almost complete loss of communications in the tower on the night of the fire.
175¶80.10 The LFB's handheld radios operated at a maximum power of 4 watts, but when transmitting on many channels were limited for historical reasons to 2.3 watts. BARIE sets, on the other hand, operated at only 1 watt. As a result, when crews were operating in the confines of a building, voice communications using BARIE sets might not reach their intended recipients without distortion or interference, or at all.1541 Christopher Johnson {Day189/25:14}-{Day189/26:16}.
¶80.11 The LFB deliberately restricted the power of its BARIE sets to make them what is known as "intrinsically safe", that is, of sufficiently low power to minimise the risk of creating a source of ignition when operating in a dangerous environment. Generally speaking, an increase in the power of a radio increases the risk of creating a source of ignition.1542 Johnson, Communications Expert Report {CWJ00000119/42} paragraph 3.2.5 - 3.2.13; Christopher Johnson {Day189/26:17}-{Day189/29:4}. For that reason, the LFB was reluctant to allow the use of more powerful radios in BARIE sets, particularly in environments that posed a risk of explosion, such as compartments or tunnels where gas might collect, and certain kinds of industrial premises. However, the need for intrinsic safety is less pressing in some circumstances, for example, when a fire has already started in a residential building. Although even in those circumstances there remains a risk that a radio might cause a gas explosion,1543 Reason {Day182/39:18}-{Day182/40:13}; {Day181/204:12}-{Day181/205:9}. the justification for not using intrinsically safe devices is that the risk is lower than in other environments in which flammable gas is likely to be encountered.
¶80.12 For similar reasons, the use of handheld radios by those wearing breathing apparatus was generally prohibited,1544 Policy No. 458 {LFB00013039/2} fourth bullet point. The general prohibition may be lifted where BARIE radios are unavailable and, following a risk assessment, the incident commander consents to the use of UHF radios. but there were also practical reasons for not using them, principally the difficulty of operating them when wearing personal protective equipment. Nonetheless, the use of handheld radios was one way of trying to achieve better communications.1545 Christopher Johnson {Day189/44:4-20}; Ellis {LFB00089131/7} page 7, paragraph 21. It had therefore become common practice for firefighters wearing breathing apparatus to use their handheld radios without the incident commander's approval and some certainly did so on 14 June 2017.1546 Johnson, Communications Expert Report {CWJ00000119/55} paragraph 4.2.7. As each team wearing breathing apparatus had only one BARIE set between them, one member of the team would be obliged to use a handheld radio if they became separated.1547 Christopher Johnson {Day189/38:5}-{Day189/39:9}. There was also evidence that the earpieces in BARIE sets frequently became loose or dislodged, thereby preventing effective communication.1548 Johnson, Communications Expert Report {CWJ00000119/151} paragraph 6.9.4. In the event, therefore, BARIE sets were not a reliable means of communication in the difficult circumstances confronting firefighters in the tower.
¶80.13 As had become clear to the LFB during its investigations into the Lakanal House fire, the distance over which UHF signals travel is affected by surrounding objects and the built environment. It is common for nearby objects or materials to block, distort or reflect signals, thereby interfering with transmissions. That, in turn, can distort the message received by the recipient or block the signal entirely.1549 Johnson, Communications Expert Report {CWJ00000119/43} paragraphs 3.2.15 - 3.2.16; Christopher Johnson {Day189/14:1}-{Day189/15:10}. As a result of the complex interactions between radio signals and objects in the built environment, Professor Johnson was unable to give a reliable estimate of the distance over which either the handheld radios or the BARIE sets would operate effectively in practice.1550 Christopher Johnson {Day189/21:5}-{Day189/22:2}. However, he considered that the LFB's estimated range of 500 metres or more using a 4 watt transmitter (assuming that the signals were unobstructed) was plausible.1551 Christopher Johnson {Day189/97:1}-{Day189/98:7}; {Day189/100:2-21}. He was unable to estimate the range of signals transmitted at 1 watt (e.g., from a BARIE set), but was of the view that it would be significantly lower.1552 Christopher Johnson {Day189/100:2-21}.
176¶80.14 In fact, by 2017 it had been well known for some time that some kinds of construction materials (including metals, thick concrete, insulation, foil-backed materials and energy efficient windows) can interfere significantly with UHF radio signals, particularly if there is an accumulation of obstructions.1553 Christopher Johnson {Day189/103:4}-{Day189/104:5}; {Day189/107:10-14}. As a result, UHF signals cannot travel to their full potential range between the floors of a high-rise building,1554 Christopher Johnson {Day189/97:1}-{Day189/98:7}. given the distances involved, the materials used in their construction and other forms of obstruction. Those limitations are particularly important when considered against the backdrop of the limited transmission power of BARIE sets and the congestion in radio traffic caused by many users.1555 Christopher Johnson {Day189/99:6-20}.
¶80.15 Congestion, which arises when more people attempt to use the system than it can handle at any one time, can affect both analogue and digital systems. In the case of an analogue system, only one person can transmit at a time,1556 Johnson, Communications Expert Report {CWJ00000119/181} paragraph 7.4.2. which means that firefighters need to wait for others to complete their transmissions before they can send their own messages. At a large incident there may be a lot of people waiting to send a message, which in turn can delay urgent or critical messages, as happened on 14 June 2017. If one person attempts to interrupt a message in the course of transmission that is likely to interfere with both signals.1557 Christopher Johnson {Day189/11:3-20}. Those effects are likely to have been one cause of the communication difficulties experienced in and around the tower on 14 June 2017.
¶80.16 A rudimentary solution to the problem of congestion is to reduce the number of people using any given channel. That reduces the time a user has to wait for an opportunity to transmit, as well as the chances of users interrupting one another and causing signal interference. Using a larger number of channels for different groups of firefighters, or for specific activities,1558 In the way that channel 3 was used to relay fire survival guidance information on the night of the fire: Johnson, Communications Expert Report {CWJ00000119/149} paragraph 6.8.9. can go some way towards achieving that aim.
¶80.17 Radio signals can be enhanced by the use of portable radio repeaters and leaky feedercables but both pieces of equipment have a limited power to propagate signals and leaky feeders are typically effective only within sight of the cable,1559 Johnson, Communications Expert Report {CWJ00000119/176} paragraph 7.2.4; Christopher Johnson {Day189/51:12}-{Day189/52:19}; Dobson {Day212/45:23}-{Day212/46:4}. which significantly limits the value of deploying them in the stairwell of a high-rise building. Professor Johnson told us that he had seen no evidence to suggest that portable radio repeaters in combination with leaky feeders would restore communications in the majority of high-rise buildings in London.1560 Christopher Johnson {Day189/136:1-12}. It should be noted that the Inquiry is not concerned with and has not considered the advantages of leaky feeders that are embedded within a building.
177¶80.18 Commissioner Dobson and AC Reason said that the LFB resorted primarily to radio repeaters and leaky feeders as the fallback mechanism to combat difficulties with communications because they were understood to be effective and were the best solution available at the time of the Grenfell Tower fire.1561 Dobson {Day212/45:1}-{Day212/46:11}; Reason {Day182/24:16-22}; {Day182/50:3-14}. However, that approach failed to take account of the following points: a. First, the equipment is not intrinsically safe,1562 Christopher Johnson {Day189/54:14-25}. so its use was inconsistent with the use
of intrinsically safe radios in the BARIE sets. There is no evidence that firefighters were warned about that.
¶b. Secondly, the equipment is time-consuming to install and is therefore likely to be deployed only after communications have deteriorated significantly. Furthermore, the cables can pose a trip hazard to firefighters and residents.1563 Lakanal House Inquest – Day 42 Transcript {CWJ00000010/73-74}. Commissioner Dobson accepted that neither radio repeaters nor leaky feeders would be an incident commander's first choice.
¶c. Thirdly, radio repeaters and leaky feeders can only be as effective as their deployment. The LFB provided training on the use of this equipment to Extended Duration Breathing Apparatus (EDBA) wearers only,1564 Johnson, Communications Expert Report {CWJ00000119/193}. leaving the majority of firefighters with insufficient training on how to use it.1565 Training packages on communications were developed following the Lakanal House fire as part of TCAP 0039, but were not released before the Grenfell Tower fire. In any event, those packages gave only a description of the operation and set up of repeaters and leaky feeders and did not distinguish between the two {LFB00122846}; {LFB00122844}. That failure was exemplified by the inability of crews at the Grenfell Tower fire to identify the correct equipment. As a result of their lack of training, crews mistook portable telemetry repeaters for radio repeaters.1566 Ashman {LFB00102269/3} page 3, paragraphs 11-12.
¶d. Finally, as stated earlier in this chapter, radio repeaters and leaky feeders operated on dedicated channels. Deploying radio repeaters and leaky feeders therefore required a change of channel. At the time of the Grenfell Tower fire, the LFB had no policy, training or strategy in place for co-ordinating a change of that kind.
¶80.19 Although it was reasonable for the LFB to use radio repeaters and leaky feeders to alleviate difficulties with communications, given the limitations outlined above, it was not reasonable for it to rely on such equipment as its primary fallback mechanism for solving the problem of poor communications when operating in a high-rise residential building.
Digital radio equipment
¶80.20 In Phase 1, there was evidence to suggest that at the Grenfell Tower fire digital radios had performed to a higher standard or provided better coverage than UHF radios. Digital devices essentially encode soundwaves into digital values and, in doing so, enable the signal to be encrypted.1567 Christopher Johnson {Day189/8:9-23}. Digital radios can operate in two modes: direct mode (which is much like UHF radio in that the user communicates directly with another handset) and trunk mode, in which the radio transmission is sent via a base station, similar to a mobile telephone signal. When communicating in trunk mode, users join Airwave talk groups (equivalent to channels). The national Airwave network hosts a large number of talk groups; a document produced by the LFB in 2015 indicates that at that time it had access to about 70 talk groups but used only a handful at any given time.1568 {LFB00084685/25} paragraph 85; Reason {Day182/87:7-15}. Because of their national coverage, talk groups can be assigned to a specific incident, location or activity, which provides an incident ground with more flexibility than the UHF system of separate channels.1569 Christopher Johnson {Day189/177:18-23}; {LFB00033375/2}.
178¶80.21 Professor Johnson attributed the superior coverage of Airwave radios to their national, trunk mode operation,1570 Christopher Johnson {Day189/57:11-23}; Christopher Johnson {Day189/58:9-12}. but it is important to note that, as in the case of analogue radio, digital radio signals are susceptible to blocking, degradation and interference.1571 Christopher Johnson {Day189/58:14}-{Day189/59:4}. Although it is possible to enhance digital signals with repeaters,1572 Christopher Johnson {Day189/59:5-10}. we have not seen any evidence that the LFB used, or contemplated using, such equipment in conjunction with digital radios.
¶80.22 Digital radios offer additional benefits, including the ability to compress data, enabling it to be transmitted using less bandwidth and thus reducing the chances of the network reaching the limit of its capacity.1573 Christopher Johnson {Day189/59:11}-{Day189/60:9}. However, congestion can affect digital radios, although in a different way. Large numbers of people communicating over a talk group can result in Airwave reaching the limit of its capacity, which, in turn, prevents a signal from being transmitted.1574 Christopher Johnson {Day189/93:20}-{Day189/94:12}. It follows that it is important to observe radio discipline, whichever technology is being used.
¶80.23 Most firefighters who attended the Grenfell Tower fire had only analogue radios (whether handheld or as part of a BARIE set). The LFB's handheld digital radios were reserved for officers of the rank of station manager and above.1575 {LFB00089144/2} paragraph 3.1.
¶80.24 The use of handheld Airwave radios was subject to stringent security requirements due to their ability to gain access to encrypted radio channels used by the police and ambulance services and for reasons of cost.1576 Christopher Johnson {Day189/159:11-20}; {LFB00012913/10} section 13. However, it is not clear that the security concerns surrounding the use of Airwave radios were insurmountable. The police and ambulance service use Airwave radios at all levels of seniority.1577 Christopher Johnson {Day189/181:5-24}.
Awareness of the limitations of radio equipment
¶80.25 Even at the time of the Lakanal House fire in July 2009, the limitations of radio equipment of the kind used by the LFB were by no means unknown, having been demonstrated at several previous large-scale incidents.1578 Dobson {Day212/8:24}-{Day212/9:4}. The following provide particularly clear examples. a. The King's Cross Fire, 1987. At the King's Cross fire radio communications were hindered
179by underground tunnels because the thick concrete walls obstructed signals. Officers could not communicate by radio unless they could see each other. Following the fire, fixed repeaters were installed in a number of underground stations and it was recommended that the LFB deploy radio repeaters and leaky feeders. However, that had not been done by the time of the London bombings on 7 July 2005.1579 Johnson, Communications Expert Report {CWJ00000119/59-60}; Johnson, Communications Expert Report {CWJ00000119/183}.
¶b. The World Trade Center incidents, 1993 and 2001. The attacks on the World Trade Center in New York are significant because they provided early warning signs that low- powered UHF radios used by emergency responders might have difficulty penetrating high-rise buildings constructed of large amounts of concrete and steel or other metal.1580 Johnson, Communications Expert Report {CWJ00000119/60-61}. The attacks also demonstrated that repeaters (whether fixed or portable) did not always provide an answer to that problem, particularly if they became damaged or unavailable during an incident.1581 Johnson, Communications Expert Report {CWJ00000119/183-185}. The 2001 World Trade Center attacks prompted DCLG to undertake research into the problems with communications that emerged during those incidents because of their importance to fire and rescue services in the United Kingdom.1582 Incident Communications Final Report {CWJ00000092}. Consideration was given to requiring developers or owners of large buildings to restrict the use of materials which limit the efficiency of radio equipment or to provide fixed radio infrastructure to assist fire and rescue services. Consideration was also given to reassigning UHF channels to minimise technical limitations and interference and to replacing analogue systems with digital systems. As far as we are aware, however, no action was taken in response to that exercise.
¶c. The Bethnal Green Road Fire, 2004. A failure of radio communications was identified as part of the circumstances which resulted in the deaths of two firefighters. At the subsequent inquests into those deaths, the coroner expressed surprise that it had been standard practice in the LFB for a team of two firefighters wearing breathing apparatus to be committed with only one BARIE set between them and recommended that the LFB revise its allocation of BARIE equipment. However, at the time of the Grenfell Tower fire it was still the LFB's practice to provide one BARIE set for each team of two wearing breathing apparatus, although Commissioner Dobson told us that every firefighter was issued with a fireground (UHF) radio and that an instruction has been given that all teams committed to an incident should have a BARIE set.1583 Johnson, Communications Expert Report {CWJ00000119/64-66}; Dobson {Day212/9:21}-{Day212/11:24}.
¶d. The London Bombings, July 2005. This incident again revealed difficulties with UHF communications underground, particularly as fixed radio repeaters had been damaged during the attacks. As a result, the Review Committee appointed by the Greater London Assembly to identify lessons to be learnt from the incident recommended that the LFB, the Metropolitan Police Service and the London Ambulance Service give it information about the provision of digital radio systems. In the meantime, it recommended an emergency underground communications system which could be put in place more quickly than a leaky feeder cable. The committee noted that no serious consideration had been given to using alternative technologies pending the provision of CONNECT (a radio communications project developed under the aegis of London Underground) and Airwave or as a backup measure in the longer term.1584 London Assembly's Report of the 7th July Review Committee {CWJ00000007/22} paragraph 2.30; cited in Johnson, Communications Expert Report {CWJ00000119/70-71} paragraph 4.9.12. The force of those observations was demonstrated at the Grenfell Tower fire, at which most LFB crews did not have access to an Airwave radio.1585 Johnson, Communications Expert Report {CWJ00000119/68-71}; Johnson, Communications Expert Report {CWJ00000119/185-187}.
180¶80.26 The evidence showed that various people within the LFB held a substantial amount of technical knowledge about how construction materials of different kinds could attenuate or block radio signals,1586 {LFB00001843/61} paragraph 9.3.11; Dobson {LFB00110652/3} page 3, paragraph 11; {LFB00041759}; {LFB00110654}; {LFB00001256/3} paragraph 2.9. but that those who held that knowledge did not share it widely, with the result that the organisation as a whole did not make appropriate use of it. Although national guidance could have provided a clearer explanation of why high-rise buildings cause interference with radio signals, it did draw attention to the problem and recommend that fire and rescue services have contingency plans in place to ensure the safety of firefighters. For example, GRA 3.2, issued in February 2014, pointed out that high-rise buildings may cause difficulties with radio reception, including the creation of "blind spots".1587 {LFB00001255/9}. The National Operational Guidance on Breathing Apparatus gave the same message when it warned that crews wearing breathing apparatus should be aware of the potential for limited penetration of radio signals through buildings and structures below ground and either make other arrangements or put contingency plans in place.1588 {LFB00029438/55} paragraph 6B3.24.
The Lakanal House fire
¶80.27 At the Lakanal House fire in July 2009, problems with the UHF radio signal made it difficult for the breathing apparatus entry control officer1589 An entry control officer manages the deployment of firefighters wearing breathing apparatus. For more information, see the Phase 1 Report Volume I, paragraphs 7.70 - 7.71. to communicate with crews relying on BARIE sets. Communications were also adversely affected by the volume of radio traffic at the incident.1590 Dobson {Day212/12:24}-{Day212/13:10}.
¶80.28 Despite not being a new problem,1591 Reason {Day182/6:21-25}. the difficulties were serious enough to prompt the LFB to investigate their cause. The LFB's Lakanal House Investigation Team, led by DAC Cutbill, was charged with that investigation. In April 2010, a radio expert, Roger Tuckley, produced a report for the LFB on the effect that steel-framed buildings can have on radio signals. It is unclear why the LFB focused attention on steel-framed buildings, since the purpose of the report was to provide answers to questions that might arise during the Lakanal House inquest.1592 {LFB00110657}.
¶80.29 Mr Tuckley's report, a one-page note entitled "In Building Radio User Difficulties",1593 {LFB00110659}. described a number of inherent restrictions affecting the use of UHF radio in the built environment, including the attenuating effect that buildings and objects within them can have on signal propagation. He also described the particular effects of certain construction materials, notably concrete, metal, solid foam insulation and insulation with foil backing. UHF radios operate best in situations where there is nothing between the transmitter and the receiver, which is typically not the case when they are used by BA crews. In view of its importance for understanding the performance of BARIE sets, the report was essential reading for the senior managers of the LFB's operational departments. Despite that, it was not brought to the attention of AC Reason when he became Director of Operations, Resilience and Training in January 2012 or when he joined the Lakanal House Board in February 2012.1594 Reason {Day182/3:15-23}; {Day182/4:18}-{Day182/5-22}.
181¶80.30 Despite the fact that Mr Tuckley had exposed significant limitations on the LFB's UHF radios and had provided an explanation for the poor radio communications at the Lakanal House fire, the evidence suggests that little was done in response to his report beyond including it as an appendix to the LFB's Lakanal House Operational Response Report.1595 {LFB00034805/59}. That report recorded only that most of the radios deployed at the Lakanal House fire had not been defective and that an unidentified report (which can only have been Mr Tuckley's report) had advised that the height and construction of the building may have contributed to some of the comments made by crews. Mr Tuckley's report did not prompt the LFB to consider how it might improve the resilience of its UHF radios or otherwise make up for their inherent limitations.
¶80.31 After the Lakanal House fire, the LFB's Incident Communications department suggested that the power of handheld radios be reviewed and that the need for intrinsically safe radios in some circumstances be re-examined, but those suggestions were not passed to AC Reason1596 {LFB00098635}; {LFB00098636}; Reason {Day181/208:8-11}. and neither he nor Commissioner Dobson could recall having given them any detailed consideration when preparing the LFB's response to the coroner's rule 43 recommendations. They both said that the limited power of the BARIE radios reflected national guidance, from which the LFB was unlikely to depart.1597 Reason {Day181/207:20}-{Day181/208:20}; {Day182/41:7-10}. However, national guidance on breathing apparatus published by DCLG in January 20141598 {LFB00031268}. had recommended that the level of intrinsic safety should be appropriate to the hazards likely to be encountered and should take account of other equipment being deployed by those wearing breathing apparatus. It also stated that electrical equipment other than that which was intrinsically safe might be considered appropriate for all normal operational requirements where it would confer a significant benefit to the safety and effectiveness of teams wearing breathing apparatus.1599 {LFB00031268/83-84}. We are not persuaded by Commissioner Dobson's evidence that no steps were taken to implement that guidance because of disruption caused by industrial action. It was clear from his evidence that he was not familiar with it and there was no evidence within the LFB's documents that it had been considered at all, let alone of any decision to delay its implementation between January 2014 and June 2017.1600 Dobson {Day212/40:2}-{Day212/41:14}. In our view it is better understood as another example of the LFB's reluctance to depart from established practices.
¶80.32 Improving radio communications was not one of the LFB's pre-inquest action points (see Chapter 74). Commissioner Dobson could not account for that omission, but thought that it might have been because the problems with communications encountered at Lakanal House were not unusual and because advice had been received from technical experts that it was not possible to overcome some of them, given the circumstances in which radios were used.1601 Dobson {Day212/13:17}-{Day212/15:7}. However, we have seen no evidence that the LFB's senior officers were told that the problems were insurmountable, or that any consideration was given to whether they could be overcome or at least mitigated. Indeed, Commissioner Dobson's evidence was that there was no review, let alone a root and branch review, of the existing technology following the Lakanal House fire.1602 Dobson {Day212/47:16-21}.
182¶80.33 We find that surprising. Given the importance of the observations made by Mr Tuckley, the LFB should have taken steps to investigate the practicability of mitigating or eliminating the problems he had identified. We have been left with the strong impression that the LFB viewed the kinds of communications difficulties experienced at the Lakanal House fire as an unavoidable incident of firefighting, particularly in modern high-rise buildings. A consequence of that attitude was that nothing was done between the Lakanal House fire in July 2009 and the Grenfell Tower fire in June 2017 properly to investigate the nature, extent and causes of those well-known difficulties to see whether it might be possible to mitigate or eliminate them. No satisfactory explanation has been offered for the LFB's failure to pursue an enquiry into a matter of such importance to effective firefighting and the protection of crews.
Another review of the problem: 2013
¶80.34 In February 2013, during the course of the Lakanal House inquests, the LFB looked again at why its incident ground radios had not been wholly effective. DAC Cutbill asked GM A'Court (who was a member of the Incident Communications team) to consider the matter, but it is unclear why he did so, since, as DAC Cutbill knew, the LFB had already received detailed advice from Roger Tuckley which it had not taken seriously into account.
¶80.35 In his response dated 28 February 2013 GM A'Court explained once again that UHF radios work best in the absence of obstructions which reduce the propagation of signals and the distance over which they are effective.1603 {LFB00106755}. He explained that steel-framed buildings are more difficult for radio signals to penetrate than simple brick or timber-framed buildings and that the transmission strength of a signal has a bearing on its propagation. He described the signal strengths of the different channels used at incident grounds and noted that the transmission strength of BARIE radios was limited to 1 watt for safety reasons. Again, however, there was no evidence that anyone made use of that valuable description of the current equipment and the factors affecting its performance to consider the possibility of making changes to the LFB's communications policies, equipment or practices. It is surprising, to say the least, that GM A'Court's email was not brought to the attention of AC Reason, who by then was Director of Operational Resilience and Training.1604 Reason {Day182/15:3-14}.
¶80.36 At the conclusion of the Lakanal House inquests, the coroner recommended that the LFB consider whether it would be beneficial to use additional breathing apparatus radio communication channels and personal radio channels at major incidents to reduce the amount of traffic on each channel.1605 {LFB00032158/3}. In his response to the coroner of 23 May 2013 Commissioner Dobson explained that the LFB had considered doing so but had decided that using separate channels might make it difficult for crews to maintain an overview of an incident and might adversely affect operations, for example, by delaying the exchange of critical information and adversely affecting co-ordination between teams.1606 {LFB00042089}. The LFB concluded that the need to pass information across several channels might negate any apparent benefit because of the need to transmit the same information across all channels in use, thus reducing radio capacity and creating a risk of duplication and confusion.1607 {LFB00042089/8}. The Commissioner also said that the LFB had introduced breathing apparatus telemetry (a system which enables the entry control officer to monitor the air consumption of those wearing breathing apparatus),1608 For a more detailed explanation of this process and the equipment involved, see the Phase 1 Report Volume I, paragraphs 7.70 - 7.71. which reduced the amount of radio communication at incidents. He said that the LFB would ensure that the constraints on communication were covered in operational training, but he did not refer to the use of additional personal radio channels.
183¶80.37 Responsibility for drafting the LFB's response to the coroner's recommendations on communications rested with the Incident Communications team, which was part of the Operational Policy department.1609 Reason {Day181/166:7}-{Day181/167:9}. The draft identified some potential improvements to communications which went beyond the coroner's recommendation relating to the use of additional radio channels.1610 {LFB00034062/9}. The improvements suggested were sound and, if adopted, would have forestalled some of the concerns that have arisen during this Inquiry. They included: a. Raising crews' awareness of problems with communications at incidents and explaining how to identify and overcome them; b. Using a dedicated UHF channel for passing fire survival guidance information; c. Using additional UHF channels which had been vacated by the police; and
¶d. Using Airwave radios to provide additional incident command channels if communication difficulties occurred at larger incidents.
¶80.38 For the sake of completeness, we note that an earlier draft of the document,1611 {LFB00098636}. which GM A'Court sent only to AC Knighton (then the Head of Operational Procedures)1612 {LFB00098635}; Reason {Day181/208:8-11}. also suggested the following: a. Carrying out a detailed risk assessment of the need to use intrinsically safe radios and equipment;
¶b. Including the effectiveness of UHF radios in the information to be gathered during section 7(2)(d) visits; and c. Training command unit staff to provide communications advice to incident commanders.
¶80.39 The Commissioner's Group rejected the suggestions. Neither Commissioner Dobson nor AC Reason could remember why they had done so, beyond referring to a general (but not obviously well-founded) belief that the LFB's systems were adequate.
¶80.40 Following the Grenfell Tower fire, the Operational Policy and Assurance department reviewed the specifications for fireground and breathing apparatus radios in advance of procuring new equipment. The review recommended that a single specification providing a transmitting power of 4 watts should be adopted for all UHF radios, but that a stock of radios with a higher intrinsic safety rating should be retained for specialist operational use.1613 {LFB00105466/1}. That approach could have been taken earlier in response to the national operational guidance on breathing apparatus issued by the DCLG in January 2014.
184Communications training: the failure to implement TCAP 0039
¶80.41 The LFB's response to the coroner's rule 43 letter was that it would ensure that the constraints on communications at incidents were covered in current operational training. In May 2013, however, the LFB provided very little training on the use of radio equipment beyond the initial training given to recruits as part of their firefighter development programme.1614 Groves {Day177/191:22}-{Day177/198:1}. The estimated completion date for the enhanced incident communications training was December 2013.
¶80.42 AC Reason said that he had understood that the new training would cover subjects such as using the correct equipment, using the correct channel, the availability of alternative channels, highlighting potential interference with the propagation of radio signals, the effect that certain kinds of buildings can have on the propagation of signals, options for circumventing problems and the equipment available for that purpose.1615 Reason {Day182/43:1-15}; {Day182/44:3-9}. The view within the LFB was that its communications procedures had broken down at Lakanal House because of the immense pressure under which firefighters were operating and that training might help to ensure that the procedures required to communicate more effectively were fixed in the minds of firefighters.1616 Dobson {Day212/20:19}-{Day212/21:8}.
¶80.43 The process for commissioning that training was initiated by TCAP No. 0039,1617 {LFB00004729}. which was first issued on 27 July 2012, a date which indicates that the need for such training had been identified even before the Lakanal House inquests had begun. The training requirement was described in the form as being to ensure that all operational personnel had the knowledge and understanding required to use radio communication equipment in accordance with LFB policy to ensure effective communication at incidents.1618 {LFB00004729/7}. The final version, dated 10 March 2015, did not refer to the problems with communications experienced at Lakanal House or to the coroner's recommendation. AC Reason said that he would have expected it to have done so, but plainly it did not.1619 Reason {Day182/58:8-15}. The absence of any reference to the LFB's experience at the Lakanal House fire or to the coroner's recommendation meant that the substance of the training programme was not informed by the matters it was intended to address. Once more, no senior LFB officer was able to explain that omission and there is no contemporaneous, or indeed any, document that explains it.
¶80.44 The resulting training packages were examined in detail during the oral evidence. Although the training package for station-based staff (that is, firefighters up to and including the rank of watch manager) described LFB radio equipment and radio enhancing equipment, it failed to explain how to use it or how to overcome communication failures. It did not explain the effect that the built environment can have on the propagation of radio signals, although that had emerged clearly from the Lakanal House fire and the LFB's own investigations.1620 Reason {Day182/60:9}-{Day182/63:17}; Groves {Day178/3:2-13}; {Day178/4:13-17}. Although the package for senior officers (station managers and above) provided more detailed information about the LFB's radio equipment, it too failed to provide advice on how to overcome communications difficulties or information about the effect of the built environment on radio signals.1621 Reason {Day182/63:18}-{Day182/67:13}. Neither training package suggested the use of Airwave radios as a way of overcoming communication difficulties,1622 Reason {Day182/83:5-21}; {Day182/88:9-11}; {Day182/92:15}-{Day182/93:7}. nor did either of them distinguish between radio repeaters and telemetry repeaters, which became a source of confusion on the night of the Grenfell Tower fire.1623 Reason {Day182/67:14}-{Day182/68:3}. In short, the substance of the training packages did not adequately address the problems that had been clearly identified by both the LFB itself and the Lakanal House coroner. We have seen no evidence to suggest that anyone reviewed the content of the packages to see whether they covered those matters adequately.
185¶80.45 However, the shortcomings of both training packages are completely overshadowed by the LFB's failure to deliver them. Although they were approved, after some delay, in May 2015, they were not delivered to staff. The LFB attributed that failure to problems with its computer training system, which at many stations could not support training packages containing videos.1624 Groves {Day177/174:15}-{Day177/176:7}. However, only the package designed for senior officers contained video; the package designed for station-based crews was not affected by the limitations of the system. Peter Groves, the former Head of Development and Training, explained that a number of attempts had been made to solve the problem, none of which had been successful, and accepted that the videos could easily have been provided to stations by other means, such as CDs. That solution was apparently not considered, although it had been adopted for other training packages.1625 Groves {Day177/179:2}-{Day177/181:3}; {Day177/197:7}-{Day177/198:1}.
Management failures
¶80.46 The story of communications is one of a succession of senior management failures to take active steps to improve what was known to be an unsatisfactory position. The rejection of GM A'Court's proposals and the absence of any record of the reasons for rejecting them illustrate the LFB's defeatist attitude towards the difficult task of providing effective communications. Our overriding impression is that the LFB's senior officers saw the difficulties with communications as an intractable problem not amenable to any solution and for that reason nothing was ever done about them. However, given the obvious importance to firefighting operations of effective communications, such an attitude also suggests an unjustified complacency about the LFB's ability to fulfil its role effectively without reliable communications.
¶80.47 The decision of the Commissioner's Group not to adopt GM A'Court's proposals is even more striking in the light of the publicity then being given to the problems with communications that had been encountered by the Hampshire Fire and Rescue Service during the Shirley Towers fire and were being investigated by the Hampshire coroner. The Hampshire Fire and Rescue Service's report into that fire had been published on 8 April 2013, a few weeks before the Commissioner's Group met in May 2013. It recorded that the handheld radios used by Hampshire Fire and Rescue Service did not always operate effectively in high-rise buildings and that the problem of poor radio communications in high-rise buildings was well known.1626 {LFB00107130/53}.
¶80.48 The report of the investigation into the Shirley Towers fire was released a week after the coroner at the Lakanal House inquests had made her rule 43 recommendations. AC Reason said that he had read the report when it was released and that it had been the subject of a report to the co-ordination board.1627 Reason {Day182/16:24}-{Day182/17:8}; {Day182/18:10}-{Day182/19:8}. In his evidence he agreed with the report's conclusion that it had been well known that radio communications within high-rise structures could present problems, a matter of which the LFB had already been aware,1628 Reason {Day182/19:10-18}. but he had no clear recollection of the extent to which, if at all, the report had affected the LFB's response to the coroner's rule 43 recommendations.1629 Reason {Day182/19:19}-{Day182/22:2}. The LFB did produce a draft plan, dated 8 October 2012, for responding to various aspects of the operations at Shirley Towers, which included reviewing the meaning of a prolonged breakdown in radio communications referred to in materials such as procedures and training materials. The task was given to Operational Procedures,1630 {LFB00100307} item 23. but we saw no evidence that any review had been carried out. AC Reason did not know whether any action had been taken in response.1631 Reason {Day182/100:9-25}.
186¶80.49 The problems identified by the investigation into the Shirley Towers fire echoed problems which were well known to the LFB and the reaction of its senior officers reflected their defeatist response to the problems experienced during the Lakanal House fire. Although the causes of those problems had been identified by some within the organisation, the LFB failed to consider how best to address them. In essence, the Shirley Towers report did not prompt the LFB to reconsider its communications practices or policies, or, importantly, its response to the Lakanal House coroner's recommendations on radio communications. As the Shirley Towers fire was yet another high-rise incident at which difficulties had been encountered using UHF radios, it should have elicited a more energetic response. Senior officers were unable to provide a satisfactory explanation for why nothing had been done.
¶80.50 In 2014, the LFB's Operations, Resilience and Training Directorate had intended to replace the existing BARIE sets with more modern equipment, but the purchase of the new equipment was deferred because the current equipment was still available and was thought to operate effectively.1632 {LFB00088188} first row. That decision was unfortunate, given the wealth of evidence that many firefighters regarded the existing BARIE sets as unsatisfactory due to their limited range and the difficulties encountered in using them.
¶80.51 Apart from the BARIE sets, whose transmission power was limited to 1 watt, handheld radios could transmit at up to 4 watts. However, although channel 1 (the default incident command channel) operated at the full 4 watts, for historical reasons related to the previous generation of equipment, radios were set to transmit on other channels at 2.3 watts.1633 {LFB00106755}. Although that must have been known to some people in the LFB, by June 2017 no steps had been taken to increase the transmission power of handheld radios to 4 watts on all channels following the introduction of the current equipment in about 2007.1634 In his statement to the MPS, Dominic Ellis explained that the LFB's working assumption was that the wattage of the other channels was based on previous radios held by the LFB, known as the Maxon radio. Director Reason's evidence was that the Maxon radios were replaced by the HX series in 2007/2008, following the Bethnal Green fire in 2004: Reason {Day182/57:1-6}. There is no evidence, whether in this statement or elsewhere, that the issue of restricted wattage had been rectified by 14 June 2017: Ellis {MET00077839/9} page 9.
¶80.52 The story of TCAP No. 0039 is one of incompetence and inefficiency. The aim of the training packages was to address the kind of problems with communications that had been experienced at the Lakanal House fire, but their contents owed little to the LFB's consideration of those problems or to the coroner's recommendation and did not deal with them adequately. The LFB had access to three 'spare' UHF channels (channels 4, 7 and 8), but in June 2017 it was not its policy or practice to use them.1635 Johnson, Communications Expert Report {CWJ00000119/48} paragraphs 3.5.8 and 3.5.9. The Incident Communications department drew attention to the possibility of using those additional channels,1636 {LFB00034062/10}. but senior officers decided against doing so, on the grounds that the benefits were likely to be outweighed by a lack of oversight of communications, a lack of co-ordination, and the possibility of delay in sending critical information.1637 {LFB00042089/8}. However, that reasoning is not consistent with the policy that firefighters wearing breathing apparatus should transfer from channel 6 to channel 5 if radio repeaters or leaky feeders have been deployed.1638 Christopher Johnson {Day189/88:20}-{Day189/89:22}.
187¶80.53 AC Reason told us that interference between channels had been a factor in the decision not to bring one of the available spare channels (channel 4) into regular use.1639 Reason {Day181/179:18}-{Day181/180:7}. Although that may be the case, we agree with Professor Johnson's view that it might have been possible to persuade the government to reallocate the channels to maximise the use of the available frequencies.1640 Christopher Johnson {Day189/80:13}-{Day189/81:4}. The fact that the LFB has brought some of those channels into regular use following the Grenfell Tower fire suggests that the problems of interference were not insurmountable.
¶80.54 An increased number of radio channels adds complexity to an incident and requires a robust system to ensure that the incident commander is made aware of all important communications. However, that should not represent an unduly onerous burden for a fire and rescue service responding to a large incident. A system of that kind is required at any incident where more than one radio channel is used, because an incident commander cannot be aware of all the communications generated, as LFB policy recognises.1641 Johnson, Communications Expert Report {CWJ00000119/50} paragraphs 3.5.10 - 3.5.15. That complexity, and the potential need for a communications officer to oversee communications at larger incidents, will often be justified by the resilience that additional radio channels bring to fireground communications.
¶80.55 The LFB knew that the transmitting power of a radio and the surroundings in which it is being used both have a direct effect on the range of the signal. It should, therefore, have increased the transmitting power of handheld UHF radios and considered providing more powerful BARIE sets for use at residential fires, particularly those in high-rise buildings. A good start would have been to make a detailed assessment of the level of risk that wearers of breathing apparatus are exposed to using equipment with different levels of power, how frequently such risks arise, the effect of using more or less powerful radios and how the quality of communications could be improved in situations in which it was considered necessary for BARIE sets to remain intrinsically safe. AC Reason said that no such assessment had been carried out during his time.1642 Reason {Day182/40:22-25}-{Day182/41:1-10}; Christopher Johnson {Day189/32:12}-{Day189/33:21}.
¶80.56 The abundance of concrete, steel and more modern construction materials in Grenfell Tower is likely to have contributed to the significant deterioration of radio communications experienced by firefighters and officers in and around the tower on 14 June 2017. After the fire, the LFB tested radios at Grenfell Tower and found that they performed better than on the night of the fire. As a result, it attributed the problems it had experienced to congestion.1643 Johnson, Communications Expert Report {CWJ00000119/159} paragraph 6.14.1. We agree with Professor Johnson that that is an oversimplification.1644 Christopher Johnson {Day189/108:5-9}; {Day189/115:1}-{Day189/122:3}. Although congestion is likely to have played a part in the failure of effective communications, we think it likely that the significant changes to the structure of the building brought about by the fire itself (including the destruction of most of the facade) explain most of the difference between the test results and the conditions experienced by firefighters on 14 June 2017.1645 This was acknowledged by the LFB in its testing methodology {LFB00084087/3}. We also accept Professor Johnson's opinion that signal propagation can be influenced by factors such as the weather and the presence of fire itself,1646 Johnson, Communications Expert Report {CWJ00000119/43} paragraphs 3.2.15 – 3.2.18; Christopher Johnson {Day189/15:11-18}. and that those factors must also be borne in mind when considering the results of the LFB's tests.
188Conclusions
¶80.57 Notwithstanding its experience at the Lakanal House fire, the LFB did not teach firefighters or officers that the structure of a building and the materials from which it is made can interfere with radio signals, beyond giving them a broad indication that there can be blind spots within high-rise (or indeed other) buildings.1647 Groves {Day177/192:6}-{Day177/194:4}; Reason {Day182/60:9}-{Day182/63:17}; {Day182/63:18}-{Day182/67:14}. More significantly, the LFB did not provide sufficient guidance to firefighters and incident commanders on how best to overcome difficulties with communications encountered in high-rise buildings. Such training may also have helped crews identify the risk of poor radio communications during section 7(2)(d) visits.
¶80.58 The LFB's communications at the Grenfell Tower fire were generally ineffective.1648 Phase 1 Report Volume IV {INQ00014817/133} paragraph 28.130. That was the result of many different failings and shortcomings, but in summary, the equipment deployed by the LFB on 14 June 2017 was inadequate, firefighters were not trained to identify and mitigate well-known and frequently encountered problems and LFB policies did not contemplate a widespread loss of communications or provide guidance on how they could be effectively restored.1649 Although Commissioner Dobson thought that wholesale loss of communications was covered in training Dobson {Day212/49:18}-{Day212/50:6}, it was clear from Mr Groves' evidence that that was not the case: Groves {Day177/192:6}-{Day177/194:4}.
¶80.59 Occasional failures of equipment are only to be expected and major incidents will always suffer from obstacles to consistently effective communications. However, that makes it all the more important to have contingency arrangements in place that can function cohesively to ensure the effective transmission of information. The LFB's communication system on the night of the Grenfell Tower fire fell well short of achieving that objective.1650 Christopher Johnson {Day189/198:3}-{Day189/199:6}.
¶80.60 In our view, the LFB's approach to communications was to do the best it could with what it had available. As a result, it failed to make sufficient efforts to modernise its equipment and eliminate well-recognised defects in its systems.1651 Christopher Johnson {Day189/202:2}-{Day189/208:1}. The LFB's senior management concentrated almost exclusively on congestion as the primary cause of problems at large incidents, but for reasons given earlier, although a contributory factor, that was not the real difficulty. Senior managers appear to have accepted that communication problems were only to be expected and since little was done to challenge that conclusion and the suggestions made by the incident communications team were not implemented, no improvements were made. As a result, the LFB's operational efficiency was significantly impaired.
189¶80.61 The history of this matter neatly encapsulates the chronic defects in the LFB's approach to well-known problems with incident ground communications. It consistently failed to accord to radio communications the significance and attention that they deserved, to address the problems that had been clearly identified and to train its personnel on how to deal with them when they arose. None of the senior officers who gave evidence was able to explain satisfactorily why the LFB had persistently failed to make a serious effort to solve problems which, although undoubtedly complex, were critically important for effective firefighting operations. For example, it is possible to set up a number of temporary Airwave talk groups for specific incidents or aspects of incidents, which is how the police and ambulance service use the system.1652 Christopher Johnson {Day189/95:2}-{Day189/96:2}. There was no evidence to suggest that the LFB had considered using talk groups in that way, other than for training exercises, which may be a reflection of the limited number of officers who had personal Airwave radios. The broader adoption of digital radios (whether Airwave or otherwise), combined with the effective use of talk groups or channels, should have received more active consideration by the LFB before the Grenfell Tower fire. That might have improved the poor quality of communications inside the tower on 14 June 2017.
191Chapter 81: The supply of water
¶81.1 There were understandable concerns that there might have been a failure on the part of the utility company to make as much water available as possible on 14 June 2017 for firefighting purposes or a failure by the LFB to make the most effective use of the water that was available. We therefore considered it appropriate to investigate the supply and use of water in order to find out whether there had been any shortcomings and, if so, how they might be avoided in the future.
Regulatory requirements
¶81.3 Due to the vast volume of water available in the Barrow Hill and Willesden reservoirs and accessible through the Thames Water Ring Main, there was more than enough water available to meet the demand for firefighting at Grenfell Tower.1655 Stoianov, Water Expert Report {ISTRP00000008/229} paragraphs 3-5.
¶81.4 The minimum water pressure in the network at the location of the hydrants used by the LFB was about 25 metres (2.5 bar),1656 Stoianov, Water Expert Report {ISTRP00000008/237}. which exceeded both the minimum regulatory pressure of 7 metres (0.7 bar)1657 Regulation 17G(1) of the Water Supply and Sewerage Services (Customer Service Standards) Regulations 2008. and the 15 metres (1.5 bar) recommended by Ofwat.1658 Stoianov, Water Expert Report {ISTRP00000005/48} paragraph 2; Stoianov, Water Expert Report {ISTRP00000008/234-5} paragraph 29. There is no minimum pressure requirement applicable to the provision of water for firefighting.
Water companies and the water distribution system
¶81.5 The water used for firefighting at Grenfell Tower was drawn from the general water distribution system, a complex network of pipes and valves used to transport water from storage (such as reservoirs and water towers) to customers and hydrants. The function of the water distribution network is to deliver an appropriate quantity and quality of water at a suitable pressure with minimal leakage, which it achieves using the force of gravity and the use of pumps.1659 Stoianov, Water Expert Report {ISTRP00000003/5}.
¶81.6 Thames Water Utilities Limited (Thames Water) is the company which supplies water to London, including the Barrow Hill Zone in which Grenfell Tower is located. The Barrow Hill Zone is supplied by water from the Barrow Hill and Willesden reservoirs and has access to additional capacity provided by the Thames Water Ring Main.1660 Stoianov, Water Expert Report {ISTRP00000008/229}.
192¶81.7 When fire and rescue authorities require water for firefighting, they connect fire hoses to hydrants to deliver water to pump appliances, which in turn pump it through hoses to firefighting equipment.1661 Stoianov {Day288/12:4-12}; Stoianov, Water Expert Report {ISTRP00000003/8-9}.
¶81.8 The three most important factors affecting the supply of water from a distribution network to firefighting equipment are:1662 Stoianov, Water Expert Report {ISTRP00000003/17-18}. a. The quantity of water available, that is, the volume of water in the distribution network
that can be made available through hydrants, which determines the time for which water can be provided to appliances.
¶b. The rate at which water can be extracted from fire hydrants for delivery to pump appliances. The flow rate describes the volume of water passing through a pipe or hose in a given time.1663 Stoianov, Water Expert Report {ISTRP00000003/20}. The flow rate provided by any particular hydrant is dependent on many factors, including the water pressure in the pipe supplying it, the hydrant's flow coefficient (a measure of the flow rate the hydrant can provide given the pressure of water it receives),1664 Stoianov {Day288/19:3-9}. and the energy losses between the hydrant and the pump appliance (such as those caused by gravity or by kinks in the hose).
¶c. The flow rate and water pressure at the discharge point of the firefighting equipment itself. There is a maximum flow rate and pressure at which any piece of equipment can safely be operated that are determined by the manufacturer.1665 Stoianov, Water Expert Report {ISTRP00000006/3}; Stoianov {Day288/23:17}-{Day288/24:18}. Supplying water to equipment at less than its maximum rated flow rate or pressure reduces the size of the water jet produced. The flow rate and pressure of water at the firefighting equipment depends on the flow rate and pressure of water pumped out of the pump appliance and on the extent of energy losses between the appliance and the firefighting equipment.
The use of water at Grenfell Tower
¶81.9 At the Grenfell Tower fire the LFB used fire hoses to draw water from the four hydrants shown in Figure 81.1 below: H1, a fire hydrant located to the south-east of the tower under Grenfell Walk,1666 Stoianov, Water Expert Report {ISTRP00000008/76}. H3, a fire hydrant located at the intersection of Grenfell Road and Bomore Road,1667 Stoianov, Water Expert Report {ISTRP00000008/78}. H8, a fire hydrant located on Bramley Road1668 Stoianov, Water Expert Report {ISTRP00000008/86}. and H5, a wash-out hydrant located next to the Kensington Leisure Centre, which was wrongly labelled as a fire hydrant. (Wash-out hydrants are used by water companies for operational and maintenance purposes to flush out sediment and stagnant water, generally at significantly lower flow rates than fire hydrants. They are not designed to supply water for firefighting.)1669 Stoianov, Water Expert Report {ISTRP00000008/79}.
193¶Figure 81.1: The four hydrants, highlighted in yellow, used to supply water at Grenfell Tower on 14 June 2017.
¶81.10 On 14 June 2017, between the first deployment of water at 01.15 and about 13.00,1670 Stoianov, Water Expert Report {ISTRP00000006/8}. the LFB projected water on to the external face of the tower using aerial appliances, ground monitors and handheld branches.
¶81.11 Aerial appliances are fire engines with extendable ladders or cages from which water can be directed onto buildings.1671 Stoianov {Day288/30:16-19}. Three aerial appliances were deployed at Grenfell Tower: turntable ladder A213 TL (from 01.47 to 02.05),1672 Stoianov, Water Expert Report {ISTRP00000006/7} 'Jet B'. aerial ladder platform A245 (for less than a minute at 02.13, from 03.28 to 06.47 and from 07.14 to 09.45)1673 Stoianov, Water Expert Report {ISTRP00000006/7} 'Jet D'. and Surrey Fire and Rescue Service's aerial ladder platform S13A1 (from 10.47 onwards).1674 Stoianov, Water Expert Report {ISTRP00000006/7} 'Jet E'.
¶81.12 Ground monitors are water nozzles which sit in a frame, enabling them to be placed on the ground and aimed in a particular direction without needing to be held by firefighters.1675 Stoianov {Day288/31:3-10}. Two ground monitors were used, albeit intermittently, at Grenfell Tower. One was sited on Grenfell Walk to the south-east of the tower (from 02.41 to 11.30)1676 Stoianov, Water Expert Report {ISTRP00000006/7} 'Jet C'. and another on the terrace of the Kensington Aldridge Academy to the north-west of the tower (from 02.43 to 10.52).1677 Stoianov, Water Expert Report {ISTRP00000006/8}; {ISTRP00000006/26} 'Jet H'.
¶81.13 Branches are nozzles attached to fire hoses held by firefighters.1678 Stoianov {Day288/28:14-16}. Many handheld branches, including the first jet projected towards the window of Flat 16 from 01.15, were used at different times to project water onto the tower.1679 Stoianov, Water Expert Report {ISTRP00000006/7-8} 'Jet A', 'Jet H', 'Jet I', 'Jet J'. Many were also used to extinguish burning debris on the ground surrounding the building.1680 Stoianov, Water Expert Report {ISTRP00000006/7-8}; {ISTRP00000006/25-26} Jet F', 'Jet G', 'Jet I', 'Jet J'.
194¶81.14 Water for firefighting inside the tower was supplied through the building's dry rising main from 01.06,1681 Stoianov, Water Expert Report {ISTRP00000006/18}. and through an additional improvised fire hose into the south-west corner of the building from about 03.30.1682 Stoianov, Water Expert Report {ISTRP00000006/8} 'Supply K'.
¶81.15 None of the aerial appliances or ground monitors deployed at the incident was supplied at its maximum capacity due to restricted flow rates at the hydrants.1683 Stoianov, Water Expert Report {ISTRP00000006/236} paragraph 2. That had three consequences. a. First, it limited the vertical reach of the water jets directed onto the exterior of the
building.1684 Stoianov, Water Expert Report {ISTRP00000006/236} paragraph 2. Appliance A213 produced a jet with a maximum vertical reach of 50–52 metres (floors 18–19).1685 Stoianov, Water Expert Report {ISTRP00000006/20} lines 31-32. Appliance A245 reached a maximum height of approximately 35 metres (floor 13).1686 Stoianov, Water Expert Report {ISTRP00000006/24} lines 8-9. Appliance S13A1 reached a maximum height of approximately 47 metres (floor 17).1687 Stoianov, Water Expert Report {ISTRP00000006/174} lines 26-28. If supplied at their maximum rated flow and pressure, each of them was capable of projecting a water jet reaching the full height of the tower (approximately 65 metres).1688 Stoianov, Water Expert Report {ISTRP00000006/238} paragraph 3; Stoianov {Day288/42:12}-{Day288/43:23}.
¶b. Secondly, the rate at which water was supplied to the pump appliances did not always match that at which it was being pumped out to firefighting equipment, which in turn resulted in periodic interruptions in the use of some equipment.1689 Stoianov {Day288/62:1}-{Day288/63:3}. c. Thirdly, some firefighting equipment could not be used as intended.
¶81.16 In the light of the report produced for the Inquiry by Dr Stoianov, the LFB carried out a series of tests to determine the maximum height of the jet that could be practically achieved by aerial appliances and ground monitors of the kind used at Grenfell Tower.1690 {LFB00123672}, 'Flow tests conducted on aerial appliance types used at Grenfell Tower fire'. The maximum heights achieved during the tests were (with one exception) higher than those achieved on 14 June 2017, but not high enough to reach the top of the tower.1691 {LFB00123672/16}, 'Conclusions'' {ISTRP00000006/236-238}. In his supplementary report1692 Stoianov, Water Expert Supplemental Report {ISTRPS00000001/21-28}. and oral evidence to the Inquiry,1693 Stoianov {Day288/53:4}-{Day288/56:20}. Dr Stoianov made strong, and in our view, persuasive, criticisms of the testing method used by the LFB, most significantly, that it had failed to supply the appliances with water at their maximum rated flow rates or pressures. For that reason, he did not accept its conclusion that the aerial appliances were unable to project a water jet to a height of 65 metres.
¶81.17 Although Dr Stoianov's calculations provide some helpful indication of the maximum height that aerial appliances could reach in optimal conditions, he rightly accepted that there were matters beyond his knowledge and expertise that could limit the height to which a water jet could be projected in practice. They included weather conditions,1694 Stoianov {Day288/57:7-19}. the performance of pump appliances1695 Stoianov {Day288/58:8}-{Day288/59:4}. and, most significantly, operational factors affecting the use, siting or angle of the jet.1696 Stoianov {Day288/59:6-14}. Examples include obstructions impeding the siting of appliances, including burning debris falling from a building,1697 Stoianov {Day288/59:6-14}. and a possible reduction in the firefighting effectiveness of a jet when operated at the limit of its vertical reach.1698 Stoianov {Day288/59:15-25}.
195¶81.18 For these reasons, we cannot safely make any finding about the height to which aerial appliances might have been able to project water on 14 June 2017 if they had been supplied at their maximum rated flow and pressure. However, we have no hesitation in accepting Dr Stoianov's opinion that the height of the jets produced by the aerial appliances at Grenfell Tower was limited by the low flow rates at which water was supplied to the pump appliances.
¶81.19 An example of periodic interruptions in the use of equipment caused by low flow rates can be seen in the operation of appliance A213 from 01.47 to 02.05. The tank of the pump appliance supplying it repeatedly became empty after less than a minute, requiring A213's water jet to be interrupted for about 20 seconds to allow the tank to refill before it could be started again. Firefighter Raymond Keane improvised a partial solution by turning down the settings of the pump supplying A213, resulting in a continuous, but less powerful, jet.1699 Stoianov, Water Expert Report {ISTRP00000006/20} lines 20-28. Similarly, the initial operation of appliance A245 at 02.13 lasted for only 47 seconds until the tank of the pump supplying it became empty.1700 Stoianov, Water Expert Report {ISTRP00000006/23} lines 17-24. The same problem affected the ground monitor on Grenfell Walk and aerial ladder platform S13A1, resulting in repeated stoppages throughout their operation.1701 Stoianov, Water Expert Report {ISTRP00000006/22} lines 24-29; {ISTRP00000006/24} line 30 -{ISTRP00000006/25} line 2.
¶81.20 Aerial ladder platform A245 was one piece of equipment that could not be deployed as originally intended. Following its redeployment at 03.28, the flow rate delivered to A245 was too low to enable its monitor to be used effectively. Firefighters therefore improvised by strapping a smaller 22 mm high-pressure hose to the cage of A245 to produce a jet which could reach the tower,1702 Stoianov, Water Expert Report {ISTRP00000006/23} lines 25-30. the equivalent of pinching the opening of a garden hose to produce a longer but narrower stream of water.1703 Stoianov {Day288/64:22}-{Day288/65:7}. Similarly, the flow rate delivered to S13A1 was insufficient to make use of its built-in monitor without interruption and firefighters tried using a smaller diameter hose to produce a jet that could reach the tower. However, that was unsuccessful and they reverted to using the monitor of S13A1 for 20 seconds and then waiting about a minute for the tank of the pump supplying it to refill.1704 Stoianov, Water Expert Report {ISTRP00000006/24-25}.
¶81.21 One significant factor contributing to the low flow rates delivered at the outlets was a loss of pressure in the hoses between the hydrants and the pump appliances.1705 Stoianov, Water Expert Report {ISTRP00000006/238} paragraph 6; Stoianov {Day288/91:14-19}. Some pressure loss is unavoidable, but on the night of the fire this was exacerbated by the long distance from the hydrants to the tower (about 95 metres and 125 metres for hydrants H3 and H8 respectively). Those losses were partially redressed by using pumps in relays (i.e. two pump appliances deployed in series) for hydrant H8 and, from about 06.00 onwards, for hydrant H3.1706 Stoianov, Water Expert Report {ISTRP00000006/11}lines 32-37; {ISTRP00000006/239} paragraph d. The main cause of the problem, however, was the low flow rates delivered by the hydrants themselves,1707 Stoianov {Day288/91:14-19}. which were caused principally by the following three factors:1708 Stoianov, Water Expert Report {ISTRP00000006/238} paragraph 6; Stoianov {Day288/91:7-11}.
196¶a. the low flow coefficients of the fire hydrants; b. the use in one case of a wash-out hydrant instead of a fire hydrant; and
¶c. the continued use of pressure reduction mechanisms in the water distribution network and a lack of efficient co-ordination between the LFB and Thames Water.
¶81.22 Water companies have a statutory duty to keep all fire hydrants attached to their pipes in good working order and to replace any hydrant when necessary.1709 Section 57 of the Water Industry Act 1991. British Standard 750:20121710 "Specification for underground fire hydrants and surface box frames and covers". (BS 750) states that fire hydrants should have a flow coefficient of not less than 92.1711 {BSI00001767/13} paragraph 10.2. BS 750 does not state whether that relates to a simple hydrant tested under factory conditions or to a hydrant installed in the pipework necessary to connect it to the water network. The distinction is relevant because the flow coefficient of a hydrant installed in a pipework system will necessarily be lower than (or, at best, equal to) that of a simple hydrant due to pressure losses introduced by the connecting pipework.1712 Stoianov {Day288/69:20-24}.
¶81.23 Paragraph 10.2 of BS 750 requires the flow coefficient of a fire hydrant to be specified in the manufacturer's literature. If the flow coefficient of a hydrant installed in a pipework system may be affected by pressure losses introduced by the particular characteristics of the connecting pipework, as Dr Stoianov told us was the case, its performance in service will, or may, depend to some extent on the system into which it has been incorporated, which is inherently variable and not something of which the manufacturer could be aware. We therefore think that the requirement in BS 750 must be understood as relating to the hydrant tested under factory conditions. However, it would avoid confusion if the British Standards Institution were to make the position clear.
¶81.24 Testing carried out by Dr Stoianov showed that the flow coefficients of the fire hydrants used at Grenfell Tower ranged between 31 and 74.1713 Stoianov, Water Expert Report {ISTRP00000008/100}; Dr Stoianov also tested three other hydrants in the vicinity of Grenfell Tower. All three had similar flow coefficients of between 32 and 58. As the hydrants were installed in the network, he was unable to test their factory standard flow coefficients. We have not had access to the manufacturers' literature relating to those hydrants and do not know whether their flow coefficients under factory conditions were 92, as required to conform to BS 750. However, Dr Stoianov told us that he would expect the installation of hydrants to be carried out in such a way as to maximise their flow coefficients and that he would have expected the flow coefficients of the hydrants used at the Grenfell Tower fire to be higher.1714 Stoianov {Day288/77:9}-{Day288/78:5}. If that had been the case, they would have provided greater flow rates to firefighting appliances and equipment.
¶81.25 Hydrant H5, which was used to supply aerial appliances A245 and S13A1, is not a fire hydrant but a wash-out hydrant, which is not designed to supply water for firefighting. It had a flow coefficient of 31, lower than the flow coefficients of the other three hydrants used at the Grenfell Tower fire, which ranged between 50 and 74.1715 Stoianov, Water Expert Report {ISTRP00000008/100}. Hydrant H5 had been wrongly labelled as a fire hydrant. The labelling of the hydrant was the responsibility of Thames Water.1716 Section 42 of the Fire and Rescue Services Act 2004.
197¶81.26 On 14 June 2017, neither the LFB nor Thames Water realised that H5 was a wash-out hydrant, although its status was indicated on Thames Water's Geographical Information System,1717 Stoianov, Water Expert Report {ISTRP00000009/21} paragraph 2. to which its technicians and the staff of its Network Management Centre referred during the incident.1718 See {THA00000036}. Having been mislabelled as a fire hydrant, there was no practical way for firefighters to tell that H5 was in fact a wash-out hydrant.1719 Stoianov {Day288/85:8}-{Day288/86:13}.
¶81.27 In his evidence to the Inquiry, Dr Stoianov said that he had notified Thames Water of the mislabelling of H5 while undertaking hydraulic testing in 2018.1720 Stoianov {Day288/87:16-21}. At some point between September 2018 and July 2019, Thames Water then replaced the metal frame of the wash‑out chamber and the metal lid of H5 with a correctly labelled "W" plate.1721 Stoianov, Water Expert Report {ISTRP00000008/79} lines 24-26; {ISTRP00000008/81} figure 6-37.
Thames Water's interventions in the network
¶81.28 The LFB contacted Thames Water's Network Management Centre by telephone at 01.28 on 14 June 2022 to ask for the attendance of a water technician and an increase in the water pressure.1722 {THA00000012/2}. Two water technicians attended the incident at 02.15 and two more at 04.15, followed by two more at approximately 07.30. After the initial call and subsequent confirmation from Thames Water that technicians were on their way, there was no further direct contact between the LFB's control room and Thames Water. Communications between the LFB and Thames Water took place between firefighters and water technicians at the incident ground. They included two requests from the LFB to increase the supply of water, one from WM Beale at about 02.30 and one from SM Payton at about 10.05.1723 Stoianov, Water Expert Report {ISTRP00000009/91-92}.
¶81.29 Thames Water made two changes to the water distribution network in an attempt to increase the amount of water available for firefighting. Technicians opened two boundary valves, at 03.091724 Stoianov, Water Expert Report {ISTRP00000009/85} paragraph 1(a). and 11.051725 Stoianov, Water Expert Report {ISTRP00000009/85} paragraph 1(b). respectively, with the aim of increasing the water pressure in the area around Grenfell Tower by connecting it to different parts of the water network and so spreading any pressure losses across a larger area.1726 Stoianov, Water Expert Report {ISTRP00000009/26} lines 12-17; Stoianov {Day288/94:16}-{Day 288/95:1}. However, that did not significantly increase the pressure at the hydrants being used by the LFB. It therefore had no significant effect on the flow rate at those hydrants1727 Stoianov, Water Expert Report {ISTRP00000009/85} paragraph 2; Stoianov, Water Expert Report {ISTRP00000008/213-214}. and caused no material improvement in the supply of water to the firefighting equipment.1728 Stoianov {Day288/95:24}-{Day288/96:8}.
¶81.30 Technicians from Thames Water also provided assistance at the incident ground. Between 06.00 and 06.30 they helped to clear blocked drains that were causing flooding around the tower and hindering firefighters' access to the building. At approximately 06.30, a technician opened fully the valve on a hydrant which had previously been only partially opened, resulting in an increased flow.1729 Stoianov, Water Expert Report {ISTRP00000009/86} paragraph 4.
198¶81.31 Water companies commonly use pressure reduction valves at certain points in the network to minimise water leaks and burst pipes, which are more likely to occur at higher pressures.1730 Stoianov, Water Expert Report {ISTRP00000005/8} section 4.1.2.1. During normal operations in June 2017, Thames Water operated a pressure reduction scheme in the Grenfell Tower area, which was implemented by the use of pressure reduction valves which it could operate remotely.1731 Stoianov, Water Expert Report {ISTRP00000008/47-48}; {ISTRP00000008/224} lines 9-13. On 14 June 2017, the pressure reduction valves remained open throughout the incident, which Dr Stoianov estimated resulted in a reduction in water pressure of between 0.7 and 1.3 bar.1732 Stoianov, Water Expert Report {ISTRP00000008/231} paragraph 13. At 03.55, the Thames Water's Network Management Centre told the technicians at the incident how to switch off the pressure reduction valves, but the technicians decided against doing so because they were concerned that if the pressure became too high it might burst the pipes, a decision with which the Network Management Centre appears to have agreed.1733 Stoianov, Water Expert Report {ISTRP00000009/103-104} paragraph 52. If a pipe had broken, it could have led to the loss of a substantial amount of water and a widespread loss of pressure, putting the entire water supply to Grenfell Tower at risk.1734 Stoianov {Day288/111:12-20}.
¶81.32 We think it likely in the light of Dr Stoianov's evidence that the pressure reduction system could have been switched off to produce an increase in water pressure of 0.7 to 1.3 bar, with only a minimal risk of a broken pipe,1735 Stoianov, Water Expert Report {ISTRP00000009/106} section 7.8.7. although that would have provided only a modest increase in the flow rate from the hydrants of between about 180 and 420 l/ min.1736 Stoianov, Water Expert Report {ISTRP00000008/236} paragraph (iii); Stoianov {Day288/107:6-21}. A single handheld firefighting branch requires a flow rate of 400 l/min.
¶81.33 Another feature of the day-to-day operation of the water distribution system at Grenfell Tower was the automatic cycle of the Hammersmith pumping station. The Hammersmith pumps operated to increase water pressure in the area during the day, when demand from customers was higher, and were automatically switched off between 00.30 and 05.30, when demand was lower. On 14 June 2017, the pumps operated as normal.1737 Stoianov, Water Expert Report {ISTRP00000008/11} paragraph 1. At 02.59, Thames Water appears to have decided against switching on the pumping station, again due to the risk of bursting a pipe.1738 Stoianov, Water Expert Report {ISTRP00000009/30}. In the light of Dr Stoianov's evidence we think that the Hammersmith pumps could have been switched on before 05.30 to increase the pressure available in the network with a minimal risk of breaking a pipe,1739 Stoianov, Water Expert Report {ISTRP00000009/102-103}; {ISTRP00000009/106} paragraph 59. but again, that would have provided an increase in the flow rate at the hydrants of only about two to three litres per minute.1740 Stoianov {Day288/104:12}-{Day288/105:14}. Given the scale and intensity of the fire, it is difficult to see that that would have made any significant difference to the LFB's firefighting efforts.
¶81.34 We should note that Dr Stoianov was critical of the level of technical and engineering support provided by the Thames Water's Network Management Centre during the incident. In particular, he thought that better use of available data, modelling and information about the network might have allowed it to recommend more efficient arrangements for the supply of water.1741 Stoianov, Water Expert Report {ISTRP00000009/99-102}. However, it seems unlikely that they would have secured a significantly greater supply.
199Misunderstandings about the water network
¶81.35 Dr Stoianov drew our attention to several misunderstandings and incorrect assumptions made by firefighters and Thames Water personnel on 14 June 2017 about the water network. Most notably, they included: a. confusing flow rate, pressure and volume;1742 Stoianov, Water Expert Report {ISTRP00000009/97} paragraph b; Stoianov, {ISTRP00000009/91} paragraph 19(a). b. an incorrect assumption that the water supply from a hydrant was reduced because water was being drawn from other hydrants, or as a result of "overuse";1743 Stoianov, Water Expert Report {ISTRP00000006/239-240} paragraph 8(a); Stoianov, Water Expert Report {ISTRP00000009/89} paragraph (b). and
¶c. a misunderstanding by technicians that it was possible by opening the boundary valve to give firefighters more flow to work with without increasing the water pressure, whereas increasing the pressure in the network was the only way to increase the flow rate from the hydrants.1744 Stoianov, Water Expert Report {ISTRP00000009/98} paragraph (e); see also {ISTRP00000009/101} paragraph (c).
201Chapter 82: Aspects of firefighting at Grenfell Tower
¶82.1 The operational firefighting response to the Grenfell Tower fire was investigated in Phase 1. In this chapter we address two particular topics relating to operational firefighting which the chairman considered called for further consideration in Phase 2: a. the effectiveness of the equipment used by the LFB on the night of 14 June 2017,
including aerial ladder platforms, ground monitors, positive pressure ventilation systems and lightweight portable pumps; and
¶b. the benefits offered by items of equipment that were not used at the Grenfell Tower fire, but which were available to fire and rescue services at the time, including smoke hoods and smoke curtains.
Aerial appliances, ground monitors and handheld branches
¶82.2 In the Phase 1 report the chairman made findings about the deployment of the principal items of equipment used by the LFB as part of its operational response to the fire. They included findings, to the extent that the evidence allowed, about the times and locations at which equipment was used during the course of the incident. In Phase 2, we have considered the effectiveness of that equipment and its deployment on the night of the fire, as contemplated in the Phase 1 report.1745 Phase 1 Report Volume IV paragraph 28.132.
¶82.3 The aerial ladder platform brought to the incident by Surrey Fire and Rescue Service (S13A1) could deploy water from a height of 42 metres, in contrast to similar vehicles operated by the LFB, which could project water from a maximum height of 32 metres.1746 Phase 1 Report Volume IV paragraph 28.133. Given that S13A1 was not used until after the last casualty had been rescued, the effectiveness of that aerial appliance has not been considered as part of our investigations.
¶82.4 In Mr McGuirk's opinion the LFB was successful in applying water to all four sides of the building, based on his own appraisal of the contemporaneous evidence and Dr Barbara Lane's analysis of the extent to which fire spread over the external walls on each side of the tower.1747 McGuirk, Firefighting Expert Report {SMC00000046/68-69} paragraph 183. The available images show a clear inverse correlation between the deployment of external firefighting equipment and the downward spread of fire, which was more limited on the south and east faces of the tower (down to floors 10 and 18 respectively) than it was on the north and west faces (down to floors 9 and 7 respectively). The images also show that a higher reach was achieved by the equipment deployed against the south and east faces of the tower, namely the ground monitor on the south side walkway and aerial ladder A245 on the east side. A213 contributed to the external firefighting on the east side, but to a much more limited degree, given the relatively early stage at which it needed to be moved away from the tower.
202¶82.5 It is clear that water was applied to the external faces of the north and west sides of the tower, albeit to a lower height, either by ground monitors or handheld jets or, more likely, a combination of the two, and appears to have been effective in limiting the downward spread of fire. That is consistent with Dr Stoianov's assessment of the application of water to the tower over the course of the incident.1748 Stoianov, Water Expert Report {ISTRP00000006/7-8}.
¶82.6 It is indisputable that the operators of the two aerial appliances on the east side of the tower, CM Daniel Harriman and FF Christopher Reynolds (who were in charge of A213) and CM Christopher Frost and FF Jason King (who were in charge of A245, overseen by WM Stuart Beale), demonstrated considerable courage and ingenuity on the night of 14 June 2017. CM Harriman and FF Reynolds operated their appliance for as long as practicable in very difficult circumstances, putting their own safety at risk from the burning debris that began falling from the tower soon after the appliance had been set up. CM Frost and FF King were successful in setting up A245 on the grass by the tower, although that was not in accordance with established procedure.1749 Policy 822: Operational use of aerial appliances {LFB00000189}. As Mr McGuirk said, that was a calculated risk and an appropriate exercise of initiative.1750 McGuirk, Firefighting Expert Report {SMC00000046/64} paragraph 170. CM Frost and FF King, overseen by WM Beale, also successfully devised a system that enabled their aerial to apply water up to floor 13 of the tower by strapping a high-pressure hose on to the cage of the platform.1751 Stoianov, Water Expert Report {ISTRP00000006/24} lines 8-9. That measure ensured an effective supply of water at the top of the appliance, despite the problems that the crew had initially experienced when trying to operate the monitor built into the cage of A245.1752 McGuirk, Firefighting Expert Report {SMC00000046/64} paragraph 170. That was pure improvisation on the crew's part and, again, it was an appropriate and considered use of initiative, which assisted in the external firefighting efforts on the east side of the tower.
¶82.7 Taking all that into account, the LFB personnel who were responsible for external firefighting acted diligently and professionally in extremely difficult circumstances, including the fact that the ability of each of the aerial appliances to project water was limited primarily by the low water flow provided by the hydrants. That was particularly so in relation to A245, the water for which was supplied by the incorrectly labelled wash-out hydrant.1753 Stoianov, Water Expert Report {ISTRP00000006/238} lines 20-22. To a great extent, those factors were outside the control of the LFB personnel managing the appliances. It was not the LFB's responsibility to ensure that hydrants were correctly labelled1754 Stoianov, Water Expert Report {ISTRP00000006/67} lines 14-16; {ISTRP00000006/69}. and we therefore make no criticism of the firefighters who used that hydrant.
¶82.8 There are, however, two points that should be made. First, it is unfortunate that the information on the Mobile Data Terminal about the location and operational status of hydrants in the vicinity of Grenfell Tower was inaccurate. Hydrant H1, which was used to supply appliance G272, was not identified at all and Hydrant H4 was incorrectly labelled as defective,1755 Stoianov, Water Expert Report {ISTRP00000006/65}; {ISTRP00000008/73} lines 18-24; {LFB00024354}. but it is unlikely that those inaccuracies made any material difference to the effectiveness of the operational response. However, it is yet further evidence of more general problems with the LFB's systems for the collection and management of operational risk information.
203¶82.9 Secondly, we agree with Dr Stoianov's view that the communications between firefighters on the incident ground and Thames Water's technicians, who relayed information to the Network Management Centre,1756 Stoianov, Water Expert Report {ISTRP00000009/4}; {ISTRP00000009/7}. were essentially casual in nature causing relevant information to be lost or not communicated at all. We recognise that the firefighters who spoke to Thames Water either in person or by telephone were operating under enormous pressure and were doing their best to improve the effectiveness of the equipment being used. Nonetheless, there is no record of any clear and explicit request having been received by the Network Management Centre to make water available in accordance with the requirements of the main appliances in use at the incident.1757 Stoianov, Water Expert Report {ISTRP00000009/93}. WM Beale said that he had asked one of the technicians on the incident ground for more water, but in the absence of any formal or consistent system for passing requests to Thames Water, it is not surprising that the request was not received or formally noted at the Network Management Centre.1758 Phase 1 hearings: {Day34/84:9-19}; Stoianov, Water Expert Report {ISTRP00000009/93}. In any event, it was not the responsibility of operational personnel, who were trying to carry out or oversee firefighting operations, to ensure that the specific requirements of those appliances were communicated to the Network Management Centre. In the first instance, that should have been the responsibility of a bulk media adviser.
¶82.10 Subject to those qualifications, the firefighters involved in the firefighting operations outside the tower did all that they reasonably could to extinguish the fire and to protect the lives of those inside the building.
Other equipment
¶82.11 Positive Pressure Ventilation fans (PPVs) provide forced ventilation which can be used to clear smoke-filled environments or to prevent smoke from entering a clear space. The fan increases the pressure of the air in the area in which it is placed, thereby causing air to flow into the adjacent space. The technique is commonly used in multi-storey buildings.1759 McGuirk, Firefighting Expert Report {SMC00000046/73} paragraphs 199-201.
¶82.12 At the Grenfell Tower fire a PPV fan was requested at 02.57 and again at 03.07. Two PPV fans arrived at the incident ground at about 04.00 and were used for a very short time in the lobby of the tower, before being stopped because they were increasing, rather than reducing, the amount of smoke in the lobby.1760 Phase 1 Report Volume III paragraph 16.87; Wilson {MET00019953/3-4}, pages 3-4.
¶82.13 Mr McGuirk explained that, when fighting a fire in a high-rise residential building, a PPV fan needs to be sited in the first instance at the entrance to the stairwell where it can direct fresh air into the stairwell to clear it of smoke.1761 McGuirk, Firefighting Expert Report {SMC00000046/73} paragraphs 199-201; McGuirk {Day190/140:3-5}. There may be an opening at the top of the stairwell through which air and smoke can escape, but fans can still be deployed effectively even if there is no opening.1762 McGuirk, Firefighting Expert Report {SMC00000046/73} paragraph 201.
¶82.14 It is clear that PPV fans could not have been used effectively at the Grenfell Tower fire, primarily because of the layout of the ground and mezzanine floors. For example, positioning them in the lobby area on the ground floor, as was done, would only have pressurised that area because of the door that led to the stairwell on the mezzanine on floor 2. They could have been moved into the stairwell, but would then have been able to draw air only from within and not from outside the building. The effect would have been to recirculate the smoke that was already in the stairwell,1763 McGuirk {Day190/140:11}-{Day190/141:10}. which was precisely the problem encountered by the firefighters who tried to use them. It is highly unlikely, therefore, that the fans that were brought to the tower could ever have reduced the spread of smoke within the stairwell or anywhere else in the building outside the lobby area.
204¶82.15 A light portable pump is a small, purpose-built, petrol-powered pump capable of providing a water supply from sources that are not accessible to standard pump appliances (for example, a lake). Pumps of that kind are normally used in rural locations and are designed to deliver small quantities of water. They have a limited pumping capacity of no more than 1,000 litres per minute and can produce relatively limited pressure. They require regular refuelling and, because they emit exhaust fumes, are suitable for use in the open air rather than inside buildings.1764 McGuirk, Firefighting Expert Report {SMC00000046/76} paragraph 207; ORR v0.7 {LFB00032988/501}.
¶82.16 There is some evidence that a light portable pump was brought to Grenfell Tower in the later stages of the incident, but it is unclear whether it was used.1765 McGuirk, Firefighting Expert Report {SMC00000046/76} paragraph 207. It is unlikely, however, to have made any material difference to the supply of water or indeed the operations that the LFB was able to carry out inside or outside the tower. In particular, the limited pumping capacity and pressure achievable by a pump of that kind meant that it was not capable of providing any significant increase in the supply of water for firefighting. It would also have been unsuitable for use inside a residential high-rise block due to the emission of exhaust fumes.
Equipment not used on 14 June 2017
¶82.17 The Inquiry heard evidence in Phase 1 about two other pieces of equipment that were potentially available, but which were not used at Grenfell Tower: smoke hoods and smoke curtains.
¶82.18 Smoke hoods are used to protect members of the public from smoke and noxious fumes for a limited period while they are being helped by firefighters to leave the building.1766 McGuirk {Day190/157:144}-{Day190/158:11}. Smoke hoods were not commonly used before the Grenfell Tower fire, but they have since been adopted by a number of fire and rescue services, including the LFB and Kent Fire and Rescue Service.1767 McGuirk {Day190/158:13}-{Day190/159:7}.
¶82.19 We think that smoke hoods could certainly have helped in the rescue of some residents of the tower, as is illustrated by the rescue by CM Tillotson's crew of two residents from floor 9 of the tower with the aid of two additional breathing apparatus sets that they had collected from the bridgehead to be worn by the residents as they were helped out of the building.1768 Phase 1 Report Volume II paragraphs 12.3-12.5, 13.18-13.19, 13.69-13.70 and 14.112-14.114.
¶82.20 Smoke curtains are sheets of fire-resistant material attached to a frame that is designed to be inserted into an existing door frame. A small opening in the base of the curtain allows firefighters to pass in and out through the door, while preventing or minimising the passage of smoke.1769 Grimwood {Day188/54:12}-{Day188/55:16}. The function of the curtain is to protect the integrity of the smoke-free area on the other side (typically the stairwell) while allowing firefighters to enter the smoke-filled area to carry out firefighting or search and rescue operations.
205¶82.21 Like smoke hoods, smoke curtains were not commonly used before the Grenfell Tower fire but have since been introduced by a number of fire and rescue services,1770 McGuirk, Firefighting Expert Report {SMC00000046/85} paragraph 235; McGuirk {Day190/163:9-16}. including the LFB.
¶82.22 Smoke curtains may be a useful way of preventing or minimising the spread of smoke within a building where there has not been widespread compartmentation failure. We think they could have been used in the first hour or so of the incident to reduce the amount of smoke entering the stairwell and thereby help residents escape. However, we do not think they would have been likely to help much after that time because of the extent to which the smoke had spread and the number of compartmentation failures.
207Chapter 83: Conclusions
¶83.1 In the Phase 1 report the chairman recognised that the firefighters who attended the Grenfell Tower fire displayed enormous courage and selfless devotion to duty.1771 Phase 1 Report Volume IV paragraph 28.1. We echo that finding, but their bravery and commitment to duty is only a part (albeit a significant part) of the picture. Another part is the inescapable fact that the systemic failings of the LFB on the night of the Grenfell Tower fire relating to training, incident command, communications and the operation of the control room had all been foreshadowed by previous fires, most particularly, the Lakanal House fire on 3 July 2009.
¶83.2 The LFB did not fail to identify or understand the lessons to be learnt from the Lakanal House fire and other major fires involving high-rise buildings constructed using modern materials and methods of construction. On the contrary, its response to the Lakanal House fire in particular showed that it understood its significance immediately. The LFB quickly analysed the incident and identified the appropriate lessons including the broader implications of the increasing use of modern materials and their role in promoting external fire spread. In that regard, Commissioner Dobson's correspondence with DCLG in December 2012 showed commendable foresight in anticipating many of the questions that have been investigated in Phase 2.
¶83.3 The LFB's failure lay in its inability to implement any effective response. That failure had many causes, but it is possible to identify in the evidence summarised in previous chapters a number of distinct but closely related aspects of the way in which the LFB was managed which, in our view, account for it. The evidence clearly shows that the LFB's failure was attributable to a chronic lack of effective leadership, combined with an undue emphasis on process and a culture of complacency. Senior officers appear to have thought that establishing bodies to review and report would inevitably lead to action without the need for effective monitoring of progress and further action being taken as necessary to ensure completion. Complacency led to a failure to ensure that knowledge of the dangers presented by the increasing use of combustible materials were reflected in operational policies and procedures.
¶83.4 Ron Dobson and Dany Cotton, as former Commissioners, bear ultimate responsibility for the LFB's inability to take effective action after the Lakanal House fire. It is to their credit that neither of them shirked nor sought to qualify that responsibility. However, their acknowledgment should not obscure the failures of other senior officers who were directly responsible for the efficiency and effectiveness of their departments. In the decade before the Grenfell Tower fire, Dave Brown, as Third Officer and Director of Operations, oversaw a broad range of the LFB's activities which have featured heavily in Phase 2.
208¶83.5 Two failings, in particular, illustrate AC Brown's approach to command and management and explain in part why recommendations were not carried out effectively. The first concerns the inspection of high-risk high-rise residential buildings. That function was (and remains) a necessary and important means of making sure that the LFB discharges its duties under the 2004 Act and the Health and Safety at Work Act 1974. AC Brown did not wish to become involved in considering the complexities of an inspection regime, a problem which deserved more careful consideration than he was willing or able to give it. If the letter and spirit of the Lakanal House coroner's recommendation were to be met and more effective inspection arrangements introduced, GM Elwell's recommendations required proper consideration. AC Brown failed to give them that consideration and, as far as we can see, there was no good reason for that. If those proposals had been implemented, they could have gone some way towards remedying the deficiencies in the LFB's arrangements for gathering and managing operational risk information.
¶83.6 The second example relates to the control room. The importance of fire survival guidance refresher training for CROs is obvious. The senior officers responsible for the control room (including AC Brown and POM Hayward) plainly understood that importance, particularly because of the weaknesses in handling calls exposed by the Lakanal House fire. In 2009, no structured or regular fire survival guidance refresher training was provided by the LFB and this was still the case at the time of the Grenfell Tower fire in 2017. The failure to give CROs regular fire survival guidance refresher training is a serious shortcoming, particularly by those officers who were responsible for making sure that effective training was provided. Even allowing for the difficulties flowing from the introduction of Vision, there is no justification for such a longstanding failure to address a vital element of the control room's work and one which touched directly upon public safety.
¶83.7 An aggravating feature is that even though the Lakanal House fire demonstrated the real danger to life posed by the failure to provide effective fire survival guidance training, none of senior officers responsible for the operation of the control room ever tackled the challenge of providing the necessary training with the dedication it deserved.
¶83.8 Although individuals undoubtedly had a role in the failings which have been examined here, it is important to stress that they were committed in the context of broader structural and cultural problems. It is clear that the LFB's response to the Lakanal House fire placed undue reliance on process. Boards were established, plans were made and reviews were commissioned, but no effective steps were taken to ensure that recommendations had been effectively implemented, particularly in relation to the danger of relying uncritically on compartmentation, the risk of fire spreading across external walls and the ability to handle many fire survival guidance calls simultaneously. Because those matters were not addressed in the resulting training packages, the recommendations were not fully implemented and so the defects that had been identified were not remedied.
¶83.9 The root cause of the problem was that the LFB's senior officers lacked the necessary degree of managerial competence to recognise and correct problems. One stark illustration of that shortcoming is the failure to translate its longstanding knowledge of the dangers posed by modern materials and methods of construction into operational policies that recognised and reflected those dangers. Another is the failure to ensure effective management of the control room, particularly in relation to training. Commissioner Dobson was alert to the danger posed by the use of combustible materials and in December 2012 recommended certain measures to DCLG that might have alleviated it. However, in the eight years between the Lakanal House fire and the Grenfell Tower fire neither he nor his successor took any steps to review and revise the LFB's operational policies, procedures and training to make sure that firefighters (and incident commanders in particular) understood how best to respond to a fire that had taken hold in the external wall of a high-rise building. Nor did they take any effective steps to ensure that control room staff received essential training.
209¶83.10 The managerial weaknesses we have identified resulted in part from the historic separation between the departments responsible for operational matters and those responsible for support functions and a lack of effective communication between them. Historically, the Fire Safety department, like the control room, had become isolated from the operational departments, leading to a failure to communicate information about the dangers of combustible materials and a corresponding failure to ensure that they were taken into account in the policies and training. For a long time that failure was compounded by an entrenched but unfounded assumption that the regulatory regime in the Building Regulations was sufficient to prevent such dangers from arising in this country. After the Lakanal House fire senior officers recognised that compliance with the regulations could not be guaranteed, but no one appears to have thought that firefighters needed to be trained to recognise and deal with the consequences. That was partly because senior officers were confident that existing training and operational practices were comprehensive and that the additional measures identified following the Lakanal House fire had been implemented. The Grenfell Tower fire showed, however, the extent to which that confidence was misplaced.
¶83.11 Confidence in existing practices and procedures manifested itself in other ways. When a problem arose which called for careful and detailed consideration, on too many occasions the LFB's response was that change was unnecessary or too difficult, even in matters which touched upon operational or public safety. The problems with radio communications in high-rise concrete buildings provide one example. Although they were well known and regularly encountered, no effective steps were taken to investigate them to identify reliable and effective solutions. The problems were simply considered too intractable. That attitude to perennial communications difficulties was unsustainable, primarily because they were a recurring feature of inquests into the deaths of both firefighters (as at the Shirley Towers fire) and members of the public (pre-eminently, at the Lakanal House fire). Given the evident danger to the life and safety of its personnel and the public, there were compelling reasons for the LFB to invest considerable effort in seeking to resolve the problems that had afflicted radio communications for so long, but regrettably nothing effective was done.
¶83.12 There is one further point that we need to address in this context. Although we acknowledge the strength of opinion held by some that the approach to funding public services adopted by the government between 2010 and 2015 and by the Mayor of London between 2012 and 2016 constrained the LFB's operational effectiveness, none of the witnesses from whom we heard told us that insufficient financial or other resources had caused or contributed to the failings that occurred on the night of the Grenfell Tower fire. In that respect, it is telling that the LFB did not suggest that budgetary constraints had been responsible for any of its shortcomings and it is worth noting that the report of Her Majesty's Inspectorate of Constabulary and Fire and Rescue Services on the LFB, published after the Phase 1 report on 17 December 2019, stated that, although the brigade was inefficient in its spending, it was not under-funded.1772 "Effectiveness, efficiency and people 2018/19 – London Fire Brigade" pages 30-33.
210¶83.13 The tragic conclusion is that the Lakanal House fire in July 2009 forewarned the LFB about the existence of the shortcomings which revealed themselves once more on the night of 14 June 2017. Those shortcomings could have been avoided if the LFB had been more effectively led in a number of respects, particularly in its response to the Lakanal House fire, and if use had been made of its knowledge of the dangers flowing from modern materials and methods of construction. On any view, that is a serious indictment of an organisation whose principal purpose is to protect the public and of the quality of its leadership.
5Part 9: The deceased
7Chapter 84: Introduction to Part 9
¶84.1 In the preceding chapters we have examined the circumstances in which the fire at Grenfell Tower came about. Most of the facts we have found and the conclusions we have drawn are relevant to all the deaths that occurred that night. The only exceptions are our findings about the treatment of those who for one reason or another were vulnerable and in respect of whom we have identified particular shortcomings. In this Part of the report, we set out our findings about the circumstances in which each person who died came to lose his or her life, a matter which it is the coroner's duty to investigate. We begin by explaining our purpose in doing so.
¶84.2 Grenfell Tower is in an area of London which falls within the jurisdiction of Professor Fiona Wilcox, His Majesty's Senior Coroner for London (Inner West). Between 20 June and 22 November 2017, Professor Wilcox opened 70 separate inquests into the deaths of those who died in the fire. She subsequently suspended those investigations pending the conclusion of this Inquiry and, if necessary, the police investigation. An inquest was not opened for Logan Gomes, the son of Marcio Gomes and Andreia Perestrelo, who was delivered stillborn following his mother's escape from the tower. Professor Wilcox concluded that Logan did not have a life independent of his mother and so was outside her jurisdiction. We have, however, included in this Part of our report findings relevant to Logan. Maria del Pilar (Pily) Burton survived the fire but died in January 2018. The cause of her death was not found to be related to the fire. Pily Burton died within the jurisdiction of a different coroner and no inquest has been opened into her death. Nonetheless, in recognition of the regard in which she was held by the community at Grenfell Tower, we have included in this Part of our report the facts concerning her experience on 14 June 2017.
¶84.3 An inquest, whether conducted by a coroner alone or with a jury, is required to answer the four questions set out in section 5 of the Coroners and Justice Act 2009: who the deceased was and how, when and where the deceased came by his or her death. When the inquest is one in which article 2 of the European Convention on Human Rights (the Convention) is engaged, the question "how" is to be interpreted as including the circumstances in which the deceased came by his or her death.
¶84.4 At an early stage of the Inquiry, the chairman decided that, in discharging its Terms of Reference and insofar as it was properly permissible to do, the Inquiry would investigate the deaths caused by the fire to the same extent as would be required of the coroner. The chairman's hope was to minimise the need for Professor Wilcox to conduct further detailed investigations, so sparing the relatives of those who died the stress of prolonged proceedings.1 Phase 1 Report Volume I paragraph 1.9; Fegan-Earl {Day298/4:9-17}.
¶84.5 Subsequently, the chairman issued a direction in which he said that, on the material then available, he saw no significant difficulty in making findings sufficient to meet the requirements of article 2 of the Convention. He proposed that while the Phase 1 report was being written the Inquiry would hold an oral hearing in which those representing the bereaved families could present the evidence relating to those who had died in order to enable him to make the appropriate findings in that report. In the end, however, it did not prove necessary to hold such a hearing. As is evident from the Phase 1 report, the Inquiry obtained a considerable amount of material, in particular the written and oral evidence of the firefighters, the bereaved and those who had survived the fire, that was analysed and presented in that report. Further, there were some aspects of the circumstances in which people had died, principally the physiological causes of death, that called for more detailed examination than was possible at that stage. Accordingly, further consideration of the circumstances of the deaths was deferred to Phase 2. The chairman made it clear that it remained his intention in Phase 2 to make the findings necessary to assist the coroner.2 Fegan-Earl {Day298/4:18-24}; Phase 1 Report Volume IV paragraph 34.2.
8¶84.6 Following further submissions and correspondence in 2019 and 2020, we concluded that the facts that we should investigate and record in relation to each deceased were: 1. Their name, gender and age. 2. The number of the flat in which they lived and the floor number. 3. The background and composition of their household. 4. What messages, if any, passed between them and the emergency services or
between them and others and what information about them was held by the emergency services.
¶5. Whether the firefighters tried to rescue them. 6. Where they died. 7. The time of death, as far as it could be ascertained. 8. Their movements between the outbreak of the fire and their death. 9. The medical cause of death. 10. Whether they had any vulnerabilities and if so, whether they were known to the TMO or RBKC.
¶84.7 We began hearing evidence about those matters on 4 July 2022. The hearings took a slightly different form in that, although Counsel to the Inquiry retained responsibility for adducing evidence, the greater part of them were taken up by a series of presentations of the essential circumstances surrounding the individual deaths by those representing the bereaved.
¶84.8 Those presentations were very helpful, not only in assisting us to identify the essential facts to be found in each case but also in reminding all those present and those watching the proceedings remotely of the personalities of the deceased and the lives they had led until the night of the fire. Our findings are based in part on evidence that had not been considered in any detail at the time the presentations were delivered, as well as on findings made in the Phase 1 report, none of which were disputed.
¶84.9 We have borne in mind throughout that we are not conducting an inquest; that remains the responsibility of the coroner. For that reason we have refrained from expressing any view about the conclusions a coroner might record. However, we continue to hope that our findings about the circumstances in which each of the deceased died will assist her in fulfilling her statutory obligations. It will be for her to decide what to make of our findings.
9¶84.10 The Inquiry opened in May 2018 with a public commemoration of the deceased through the voices of their relatives and friends. Those reflections and memories are recorded in Chapter 32 of the Phase 1 report. As the Inquiry began, so it ended, by remembering those who lost their lives that night. It is of the utmost importance that our description of the circumstances in which people died are placed in the larger context of their lives and the pictures of them painted at the memorial hearings. Only in that way can they be remembered as the people they really were.
¶84.11 Many of those who died on 14 June 2017 were found in their own homes; others had sought shelter elsewhere in the tower or were overcome while trying to leave the building and were found in the lobbies or on the stairs. Three fell from the tower. Our findings are set out floor by floor and deal in turn with each of those who died on, or fell from, the particular floor. For those who died on the stairs we have described the circumstances relating to the floor on which their flat was located. None of the occupants of floors 12 or 13 died in the fire.
¶84.12 In making our findings we have relied on the following: a. the evidence of survivors; b. transcripts of emergency calls; c. the way in which fire and smoke spread around and through the building; d. the accounts of those who spoke to the deceased in the period before their deaths; e. the record of communications between the LFB control room and the fire ground and within the fire ground, including the building; f. the evidence of individual firefighters; g. telemetry data recording the deployment of firefighters within the tower; h. the evidence of the expert witnesses.
¶84.13 Almost all of that evidence was heard in Phase 1 and was the subject of findings made in chapters 9 to 20 of the Phase 1 report.
¶84.14 In some cases the deceased could be identified only by scientific means but in each case the coroner was satisfied that identification had been correctly established and was therefore able to issue an interim certificate of the fact of death. In those cases we have not thought it necessary to describe in detail the way in which the identity of the deceased was established.
11Chapter 85: The expert evidence
¶85.1 In making our findings on the circumstances surrounding the deaths of those who lost their lives in the Grenfell Tower fire we have drawn heavily on the evidence of a number of eminent experts in a variety of fields. Their evidence may be conveniently described under the following headings: a.
The recovery and identification of the remains
¶of the deceased. b. The determination of the medical cause of death. c. The effects of the smoke and gases produced by the fire.
¶The recovery and identification of the remains
¶85.2 In respect of each deceased person the coroner, Professor Wilcox, issued an interim certificate of the fact of death pursuant to regulation 9 of the Coroners (Investigations) Regulations 2013. She was able to do so because she was satisfied in each case that the remains in question were those of the particular deceased. That resolves conclusively the doubts that at one time were aired about how many people died in the fire and who they were. However, we think it appropriate to describe in general terms the careful and painstaking process by which the remains of those who died were recovered and their identities confirmed. The procedure adopted followed the guidance contained in the Disaster Victim Identification (DVI) Guide published by Interpol in 2014, which set the standards for the identification of victims of disasters and was used in conjunction with protocols developed by the archaeologists and anthropologists working with police officers trained in identifying victims of disasters.3 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/13}; Harrison {Day302/18:5}-{Day302/19:3}; {KHA00000001/3} page 3, paragraphs 9-12; Harrison {Day302/12:18}; {Day302/19:4}; {Day302/19:21} -{Day302/20:7}.
The recovery of human remains
¶85.3 The task of recovering the human remains was led by Dr Karl Harrison MSc PhD DSc, the lead forensic archaeologist. Dr Harrison had 20 years' experience as an expert forensic archaeologist, including working on police investigations.4 Harrison {KHA00000001/1} page 1, paragraphs 1 - 4. Together with Dr Deborah Ryder PhD, he co-ordinated a team of 36 forensic archaeologists with expertise in the identification of human remains.5 Harrison {KHA00000001/2} page 2, paragraphs 5, 6 and 8. Archaeologists were attached to teams instructed to search individual flats, each of which was treated as a closed fire scene to prevent the mixing of debris and to maximise the opportunity to identify any human remains.6 Harrison {Day302/11:4}. Those search teams included DVI officers and licensed search officers (LSOs). It was the responsibility of the DVI officers to maintain the continuity of the evidential chain in order to minimise the possibility of a fragment of human remains being missed or wrongly attributed. The LSOs had a more general search function.7 Harrison {Day302/15:8} -{Day302/17:1}.
12¶85.4 Forensic archaeologists arrived at the tower on Friday 16 June 2017 and carried out their work over the next five months.8 Harrison {KHA00000001/1} page 1, paragraph 5. They worked in different places at different times in response to the requirements of the police.9 Harrison {Day302/9:23}. Dr Harrison divided the work of his team between June and December 2017 into three phases,10 Harrison {KHA00000001/3} page 3, paragraph 7 and Table 1; Harrison {Day302/21:3}. the first two of which concentrated on those flats which were thought likely to contain human remains.11 Harrison {Day302/22:2} {Day302/23:10}.
¶85.5 The first phase, which began on 16 June 2017 at a time when the team of archaeologists was smaller and the number of deceased was still unknown, had four elements. The first involved a visual assessment of the flats that were suspected to contain human remains. The search teams noted the significant volume of debris in those flats and assessed the challenges to the recovery and recording of human remains. The fragility of the remains that were visible led to a decision to search the debris in each flat in situ rather than remove it to another site. That avoided the risk of damaging the remains or mixing them up in circumstances where more than one person had died in a relatively small space.12 Harrison {KHA00000001/4} page 4, paragraph 15; {KHA00000001/5} page 5, paragraph 17; Harrison {Day302/23:13}-{Day302/27:24}.
¶85.6 The second element was the early development of search strategies. Given the extensive fire damage to the flats, with internal walls almost entirely destroyed, each flat to be searched was divided into sectors. It was decided at the outset that all spaces within the tower that had been destroyed by fire would be searched to the same extent.13 Harrison {KHA00000001/5} page 5, paragraph 18; {KHA00000001/6} page 6, paragraph 20; Harrison {Day302/21:1}-{Day302/34:23}.
¶85.7 The third element took place on 15 and 16 June 2017 and before archaeologists had become involved in searching the tower's interior. Archaeologists assisted officers using victim recovery dogs to search the base of the tower and the area around it for human remains, since it was known at that stage that at least one person had fallen from the building.14 Harrison {KHA00000001/6} page 6, paragraph 21; Harrison {Day302/34:25}-{Day302/37:9}. At that time the area remained under the control of the LFB and debris was still falling.
¶85.8 The fourth and final element of the initial phase also began on 16 June 2017. That was the recovery of visible remains from flats and bodies from the communal areas and the stairwell. That operation was undertaken at a time when the authorities were still responding to an emergency and the debris in the flats remained hot enough to present a risk of re-ignition. The structural integrity of the tower was also being assessed at that time, which required additional safety measures, including a limit on the number of people entering a flat at any one time. In the circumstances, emphasis was placed on the speed of recovery.15 Harrison {KHA00000001/8} page 8, paragraph 23; {KHA00000001/9} page 9, paragraph 25; Harrison {Day302/37:10}-{Day302/41:3}.
¶85.9 The initial phase allowed areas of particular interest to be identified. They included flats where fragments of human remains might be found because people had been reported as missing or witnesses believed they had seen people at the windows, even if there was no obvious sign of remains.16 Harrison {KHA00000001/9} page 9, paragraph 27. Acrow props were installed in flats to maintain structural stability. That made it necessary to move debris, which, wherever possible, was retained in the sector in which it had been found. If it was necessary to move debris out of a sector, it was not moved beyond the flat or lobby in which it had originated.17 Harrison {KHA00000001/9} page 9, paragraph 28; Harrison {Day302/43:6} -{Day302/48:13}.
13¶85.10 The second phase involved the careful excavation of debris to preserve any remains, which could then be lifted out. The debris was then left in situ. A record was made of the location of remains as well as of the position of any fixtures and fittings. Personal effects such as jewellery were recovered.18 Harrison {KHA00000001/9} page 10, paragraph 29; {KHA00000001/12} page 12, paragraph 36; {Day302/50:21}-{Day302/53:25}.
¶85.11 The third phase began in August and continued until November 2017. It involved the comprehensive searching and sieving of the debris in all areas which had been subjected to burning to recover any other human remains, to identify and retain any material that might assist in understanding the spread of the fire and fire protection within flats and in identifying individuals, and to locate valuable or sentimental items, which could then be returned to the family.19 Harrison {KHA00000001/12} page 12, paragraph 37; Harrison {Day302/62:3}.
¶85.12 The stairwell, part of the flats from floor 4 to floor 9 and all flats and lobbies from floor 10 to floor 23 were searched sector by sector. All debris in those areas of the tower was searched by hand by teams of DVI officers and LSOs led by a team leader and under the supervision of an archaeologist. Sieved material was bagged. The DVI officers and LSOs were given training in advance in recognising burnt bone, but the supervising archaeologist made a second check of any material that might be fragments of bone or tissue. In that way, any human remains as well as other items of potential significance, such as personal effects, medical implants or identification documents, were located and retained.20 Harrison {KHA00000001/12} page 12, paragraph 37; {KHA00000001/17} page 17, paragraph 45; Harrison {Day302/55:2}-{Day302/57:24}; {Day302/59:5}; {Day302/62:13}-{Day302/57:24}; {Day302/64:17}.
¶85.13 A quality assurance process was adopted through the introduction in search areas of a foreign control object. There were no occasions on which a DVI or LSO team failed to find that object.21 Harrison {KHA00000001/19} page 19, paragraphs 47-48; Harrison {Day302/72:1}-{Day302/73:23}. A system was put in place to ensure that all the debris had been searched and sieved and then retained in labelled bags. Each searched area went through two inspection stages. The second stage required an inspection panel comprising Dr Harrison or Dr Ryder as the lead archaeologist, the DVI co-ordinator, and the Scene Evidence and Recovery Manager to certify that all required steps had been taken.22 Harrison {KHA00000001/19} page 19, paragraph 49; {KHA00000001/20} page 20, paragraph 51; Harrison {Day302/68:21}-{Day302/71:15}; {Day302/78:1}-{Day302/80:25}.
¶85.14 Once a certificate had been issued, the bagged debris was removed from the tower so that no extraneous material was left in the flat.23 Harrison {KHA00000001/20} page 20, paragraph 52.
¶85.15 In accordance with DVI protocols, when human remains were located, they were given a Unique Reference Number (URN) and placed in a sealed bag before being taken under secure conditions from the site of recovery to a holding area and then to the Westminster mortuary. The steps involved in this process were documented. A parallel system was followed in relation to items recovered from the building, such as identification documents and valuables, all of which were handed over to an exhibits officer.24 Harrison {KHA00000001/39} page 39, paragraphs 87-91.
14¶85.16 Following arrival at the mortuary, each bag was scanned and a preliminary assessment of the remains carried out.25 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/68}; {GMK00000001/15-16}. Forensic pathologists conducted an initial post mortem examination, which was attended by forensic anthropologists when necessary.26 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/16}.
¶85.17 Dr Gaille MacKinnon, BA MSc MCIfA FRAI (ChFA) was a director of Alecto Forensic Services Ltd with over 24 years' experience, including working on major terrorist incidents.27 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/85-87}. She led the team of forensic anthropologists instructed to identify the human remains recovered from the tower.28 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/20}.
¶85.18 Working with DVI-trained police officers, forensic pathologists and experts in DNA analysis, forensic odontology (a branch of forensic science that assists with identification of remains through the examination of dental records and dental remains) and fingerprints,29 MacKinnon {Day298/65:22}‑{Day298/66:22-1}; {Day298/71:10-23}; MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/15}. the role of Dr MacKinnon's team was to construct a biological profile for each victim.30 MacKinnon {Day298/63:9-14}. Following the initial post mortem examinations, they conducted a detailed anthropological examination of each of the 17 separate locations in the tower from which remains had been recovered, working on each flat or communal space separately.31 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/16}.
¶85.19 The remains were carefully documented, mapped and reconstructed, if possible.32 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/28}. An individual biological profile was constructed according to internationally recognised standards accepted in the wider scientific community.33 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/34}. It included looking at age at death, sex, ancestry and any features or variations that differ from one person to another.34 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {Day298/63:9-14}; MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/35}; {GMK00000001/37}.
¶85.20 The purpose of the anthropological examinations was to ensure that all human remains were attributed to the individual deceased to whom they belonged.35 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/38}; {GMK00000001/41}. A particular challenge was the commingling of remains where a number of victims had died in the same location. That challenge was met by using standard operating procedures and by undertaking examinations of each flat or communal space individually.36 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/21} Dr MacKinnon's team worked alongside experts in DNA analysis (which could be used to confirm identification)37 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {Day298/82:22-25}; MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/23-24}. and odontology.38 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/21-22}.
¶85.21 On completion of the forensic anthropology and odontology examinations for each deceased recovered from a particular flat or communal space, the human remains and documentation were reviewed in a procedure called "Anthropology Grand Rounds" involving Professor Wilcox, Detective Chief Inspector Andrew Chalmers (Deputy Senior Investigating Officer and Scene Senior Identification Manager), the Post Mortem Coordinator, Andrew Langley (Operational Forensic Manager (OFM), Metropolitan Police Service), and the lead anthropologists and odontologists.39 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/42}.
15¶85.22 Dr MacKinnon confirmed that, based on her examination and having regard to the rigour with which the recoveries and clearance of the flats had been undertaken, she was very confident that the remains of all the victims had been recovered and correctly identified.40 MacKinnon {Day298/90:5-14}; {Day298/77:7-6}; {Day298/78:5-6}; {Day298/124:16-25}; {Day 298/125:4-10}.
¶85.23 The information reviewed during the Anthropology Grand Rounds procedure informed the deliberations of the Identification Commission, conducted under the direction of Professor Wilcox.41 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/18}. The identification of an individual deceased also drew upon other sources including comparative DNA and odontology.42 MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/22}. At the Identification Commission, Professor Wilcox reached a final decision on the identity of the deceased whose remains had been recovered from the tower.
The medical cause of death
¶85.24 We have already referred to the involvement of forensic pathologists. Dr Ashley Fegan‑Earl BSc (Hons) MB BS DMJ(Path) FRCPath FFFLM RCPathME led a team of 12 Home Office registered forensic pathologists who conducted post mortems on those who died in the fire and provided an opinion on the medical cause of death.43 Fegan-Earl {AWF00000001/2} page 2; Fegan-Earl {Day298/19:17-21}-{Day298/27:16}.
¶85.25 Dr Fegan-Earl explained that although the work of experts in other disciplines could assist in determining the cause of death, it was for the pathologist, as the registered medical practitioner, to certify the medical cause of death.44 Fegan-Earl {Day298/42:14}-{Day298/43:2}. The certification system uses a form which has two parts. The first gives the primary cause of death, which can be subdivided into two, Ia and Ib. For example, a doctor might record cardio-respiratory arrest as cause Ia and carbon monoxide poisoning as cause Ib, thereby indicating that cardio-respiratory arrest was due to carbon monoxide poisoning. Part II is used to record conditions that may have contributed to death, for example, heart disease.45 Fegan-Earl {Day298/43:3-23}.
¶85.26 The destructive nature of the fire meant that a full post mortem was not possible in every case. Where a full post mortem could be conducted, a toxicology examination to ascertain whether there was carbon monoxide in the blood and an histology examination to ascertain whether there was soot in the airways was also undertaken, where possible. However, if a deceased's body had been subject to extensive heat damage, a full post mortem was not possible.46 Fegan-Earl {AWF00000001/2} page 2; {AWF00000001/3} page 3; Fegan-Earl {Day298/25:11}-{Day298/40:25}.
¶85.27 The results of the post mortems were reviewed by other members of the team.47 Fegan-Earl {Day298/28:8}. The medical cause of death for many of those who died as a result of the fire was recorded as "Inhalation of fire fumes", "Inhalation of the products of combustion" or "Consistent with the effects of fire". Dr Fegan-Earl explained that the first two were essentially the same and had been used where there was pathological evidence to show that the deceased had inhaled fire fumes.48 Fegan-Earl {Day298/46:142}-{Day298/47:8}. The third formulation had been adopted where it had not been possible to conduct a full post mortem.49 Fegan-Earl {AWF00000001/4-5} pages 4-5; Fegan-Earl {Day298/44:15}-{Day298/46:5}.
16¶85.28 Dr Fegan-Earl agreed with Professor Purser's opinion that those who died in the tower had very probably been rendered unconscious by inhalation of poisonous gases, including carbon monoxide and hydrogen cyanide. One possible description of the cause of death, therefore, was inhalation of asphyxiant gases. In his opinion it was overwhelmingly likely that the deaths were the result of the inhalation of fire fumes rather than burning.50 Fegan-Earl {AWF00000001/4} page 4; Fegan-Earl {Day 280/49:2}-{day298/51:3}. Nonetheless, while not disputing Professor Purser's opinion, Dr Fegan-Earl maintained that it was appropriate to use the expression "Consistent with the effects of fire" as the medical cause of death if it was not possible to confirm with certainty that the death was caused by inhalation of asphyxiant gases, although that conclusion might be strongly supported by scientific evidence and pathological experience.51 Fegan-Earl {Day298/51:5}-{Day298/52:11}.
¶85.29 We have given careful consideration to the evidence of Dr Fegan-Earl and understand why he and his colleagues felt the need to show caution when ascertaining the medical cause of death. We keep in mind that it will be for the coroner to decide what to find as the cause of death in each case. However, as Dr Fegan-Earl acknowledged, we have the benefit of the evidence of a range of witnesses, including the expert evidence of Professor Purser. It is because of that additional evidence, and in particular the work done by Professor Purser, that we have reached the conclusion that, save for those who fell from the tower, we can safely find that death was due in each case to the inhalation of asphyxiant gases.
The analysis and conclusions of Professor Purser
¶85.30 Professor David Purser CBE BSc PhD DipRCPath was instructed to give expert evidence on toxicology. In broad terms, he considered the causes of the incapacitation and death of those who died in the tower,52 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005}; Purser, Phase 2 Report, Section 5 {DAPR0000011}; Purser, Phase 2 Report, Section 6 {DAPR0000006}; Purser, Phase 2 Report, Appendix A {DAPR0000007}; Purser, Phase 2 Report, Appendix B {DAPR0000008}; Purser, Phase 2 Report, Appendix C {DAPR0000009}; Purser, Phase 2 Report, Appendix D {DAPR0000010}. building on the preliminary conclusions he had reached in the report he provided for Phase 1.53 Purser {Day296/4:13-17}; {Day296/5:12-15}.
¶85.31 We found Professor Purser's evidence helpful and it has informed our findings about the individual deceased in the following chapters. Having considered his evidence, we regard him as a reliable expert on whose evidence we can rely in drawing conclusions about the circumstances of the individual deaths.
¶85.32 Professor Purser's expertise includes the physiological effects on the human body of the inhalation of toxic smoke and gases.54 Purser {Day296/11:25}-{Day296/12:4}. At the time he gave evidence, he was a visiting professor in the Centre for Fire and Hazards Science at the University of Central Lancashire.55 Purser {Day296/12:11-15}. His extensive experience is described in his report. He has wide practical experience of investigating the effects of major fires in this country and abroad, including taking part in an investigation by the French authorities into a fire inside the Mont Blanc tunnel.56 Purser, Phase 2 Report, Appendix D {DAPR0000010/5]; Purser {Day296/15:2-13}.
17¶85.33 In order to reach a conclusion on the cause of the incapacitation and death of each deceased,57 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/64-103}; Purser, Phase 2 Report, Appendix A {DAPR0000007}. Professor Purser examined the changing conditions in the flats, lobbies and stairs throughout the night of the fire, relying on medical records of survivors, transcripts of emergency calls, photographs of the exterior of the tower, the evidence of other experts and the chairman's findings in the Phase 1 report.58 Purser {Day296/40:18}-{Day296/41:5}.
¶85.34 To estimate the exposure of an individual to irritant smoke and its effect Professor Purser estimated the fuel load and range of materials involved in the fire to calculate the average composition of the asphyxiant gases entering the tower. For that purpose he relied upon a study published by BRE in March 2003 entitled The potential for including fire chemistry and toxicity in fire safety engineering59 {DAP00000002}. which contained the results of two experiments measuring yield and concentrations of various gases produced when certain products were burned.60 Purser {Day296/47:3}-{Day296/49:7}. He also relied on tests carried out by Professor Anna Stec61 Stec, Assessment of the toxicity and extent of penetration of smoke from combustible products on the Grenfell Tower Report {AASR0000010}. to determine the composition of smoke particulates and the yield of toxic gases obtained from burning samples taken from Grenfell Tower itself.62 Purser {Day296/49:15}-{Day296/50:8}. Professor Purser used descriptions given by witnesses of conditions in the tower and medical records of survivors to estimate the extent of smoke obscuration and irritancy.63 Purser {Day296/50:11-16}.
¶85.35 The mechanism of death from exposure to asphyxiant gases is twofold: first, the carbon monoxide bonds with haemoglobin to form carboxyhaemoglobin.64 Purser {Day296/168:22}-{Day296/169:5}. That prevents the haemoglobin from carrying oxygen65 Purser {Day296/167:15-21}. which deprives the brain and heart of oxygen.66 Purser {Day296/168:5-21}. Second, the carboxyhaemoglobin impairs the ability of the rest of the haemoglobin to deliver oxygen to tissues.67 Purser {Day296/169:6-14}. Ultimately that causes a lack of oxygen to the heart and brain.68 Purser {Day296/168:22}-{Day296:169:5}. Cyanide also prevents the tissues from metabolising.69 Purser {Day296/169:10-15}. Both can cause hypoxia.70 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/107}. He agreed that in describing the cause of death, the effect of carbon monoxide in combination with hydrogen cyanide would appropriately be termed, "asphyxia from asphyxiant gases".71 Purser {Day296/171:15-18}.
¶85.36 Professor Purser's study of conditions in the tower and information obtained from survivors added to the conclusions he drew from the toxicology and pathology reports on the deceased. The forensic data derived from those reports that record the concentration of carboxyhaemoglobin in the blood are important for measuring the toxicological effects of asphyxiant gases.72 Purser {Day296/164:17-20}.
¶85.37 Professor Purser's study enabled him to reach with some confidence a conclusion on the production of toxic gases in the tower, how those who died were overcome and the causes of their deaths. In most cases he was also able to provide an opinion about the time when death occurred.73 For Professor Purser's range of time in each individual case, see Purser, Phase 2 Report, Section 6 {DAPR0000006}. His conclusions were necessarily approximate due to the number of factors involved,74 Purser {Day296/33:6}-{Day296/39:5}. but we think that in each case they offer the most reliable estimate available.
18¶85.38 Professor Purser reached a number of conclusions that are applicable to all the deceased and have informed the findings made in the following chapters. However, he accepted that they were subject to a number of qualifications. First, it was not possible to measure exact concentrations of smoke and toxic gases during the fire, so his conclusions were estimates based on the available evidence.75 Purser {Day296/32:16-20}. Second, the concentration of carboxyhaemoglobin sufficient to cause incapacitation and ultimately death depends on the particular characteristics of the individual concerned.76 Purser {Day296/34:19}-{Day296/35:18}; {Day296/164:10-20} and {Day296/39:13}-{Day296/40:9}. Third, if the amount of carboxyhaemoglobin in the blood of the deceased could not be measured, an estimate had to be made and it was not always possible to be confident about the level persisting at the time of death.77 Purser {Day296/39:8-12}. Fourth, Professor Purser drew information from a wide range of sources, as mentioned above. Fifth, in some cases there was very sparse information available about the person in question, which limited the confidence that could be placed in his conclusion.78 Purser {Day296/41:10-15}.
¶85.39 Moreover, the rate at which asphyxiant gases are absorbed depends on an individual's personal characteristics.79 Purser {Day296/107:3-10}. Infants and children absorb gases at about twice the rate of adults, which hastens the time to collapse and death.80 Purser {Day296/107:11-15}. If infants and young children were sheltering with their parents, it is likely that they lost consciousness and died before their parents.81 Purser {Day296/109:2-9}. Respiratory conditions, such as asthma, also affect any response because they make people more susceptible to irritant particles in smoke82 Purser {Day296/112:5-11}. and those with the condition are generally more sensitive to their effect.83 Purser {Day296/113:10-14}. If people were unable to leave their flats or descend the stairs, their prospects of escape were reduced.84 Purser {Day296/120:19}-{Day296/122:23}.
¶85.40 Professor Purser identified three groups of material that contributed to the smoke within the tower: the external cladding and insulation and the window infill panels, the window surrounds and the contents of the flats.85 Purser, Phase 2 Report, Section 5 {DAPR0000011/4}. During the early stages of the fire it is likely that the cladding, the window infill panels and the window surrounds were the main contributors to the smoke.86 Purser {Day297/166:5}-{Day297/167:6}. The smoke from the fire on the outside of the building entered the tower87 {DAPR0000015/2}; Phase 1 Report Volume IV paragraph 24.8. and the contents of the flats became involved in the fire at different times as it progressed.88 Purser {Day297/168:24}-{Day297/170:17}. The contribution made by the different materials to the smoke varied.89 {DAPR0000015/2}. We are satisfied that the cladding, insulation, window surrounds and window infill panels made a significant contribution90 Purser, Phase 2 Report, Section 5 {DAPR0000011/5}; Purser {Day297/186:18-21}. but we are unable to say how much of a contribution each of them made at different times and in different places.
19¶85.41 From the descriptions of dense, irritant smoke in the lobbies, the very limited visibility described by the witnesses and the general fire conditions, Professor Purser estimated that the concentration of carbon monoxide and hydrogen cyanide was likely to have been high and in the lobbies sufficient to cause a person to collapse within about three-to-five minutes of exposure.91 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/49}.
¶85.42 He estimated that moderate concentrations persisted in the stairs,92 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/50}. which would have led to collapse (assuming no prior exposure) in approximately 15 to 30 minutes, if one were walking, or between 30 minutes and one hour, if static.93 Purser {Day296/67:17}-{Day296/68:16}.
¶85.43 Having studied data collected from 21 survivors, Professor Purser concluded that their exposure to asphyxiant gases had occurred mainly during their descent of the stairs, rather than while they were sheltering in their flats.94 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/153}; Purser {Day296/214:17}-{Day296/215:4}. When considering the density of smoke in the stairs, and therefore the risk of inhaling a large enough dose to cause collapse while on the way down, Professor Purser drew a distinction between conditions up to about 01.49 and those thereafter.95 Purser, Phase 2 Report {DAPR0000005/95} Sections 1-4; Purser {Day296/159:11-20}. Professor Purser relied on the accounts of Petra Doulova, floor 20, who exited the tower at 01:41:26 and Branislav Lukic, floor 11, who exited the tower at 01:49:09. Phase 1 Report Volume III Annex A. He considered that until about 01.49 it was still possible to descend the stairs without danger of collapse.96 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/96}. After that it was still possible to escape by the stairs, but was more hazardous due to the dense smoke and absence of visibility in both the lobbies and the stairs.97 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/96}.
¶85.44 Most of those who left the tower after 01.49 used cloths or towels to avoid inhaling smoke. The greatest danger was of collapse due to the inhalation of asphyxiant gases, which causes breathlessness, dizziness, light-headedness and weakness, followed by collapse and loss of consciousness.98 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/97}. Continued inhalation of those gases causes death from asphyxia.99 Purser, Phase 2 Report, Sections 1-4 {DPAR0000005/97}.
¶85.45 Based on Professor Purser's evidence we find that:100 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/109}. a. Anyone whose blood contained between 20% and 40% carboxyhaemoglobin had
almost certainly inhaled enough smoke and carbon monoxide to be unconscious at the point of death, even if their remains showed signs of severe burns.101 Purser {Day296/165:22}-{Day296/166:3}.
¶b. Anyone whose blood contained more than 40% carboxyhaemoglobin died from smoke inhalation and if serious burns were present, they were most likely to have occurred after death.102 Purser {Day296/166:4-9}.
¶c. A person whose blood contained less than 40% carboxyhaemoglobin but whose body showed no signs of burns probably died as a result of inhaling carbon monoxide and other toxic gases, such as hydrogen cyanide.103 Purser {Day296/166:10-15}.
¶85.46 In the light of Professor Purser's evidence we think it likely that those who died in the tower after having left their flats inhaled most of the carbon monoxide that killed them while they were descending the stairs. The time it took them to do that was therefore a significant factor.104 Purser {Day296/214:17}-{Day296/215:4}. If people left their flats before they were overcome, they had a good chance of being able to escape from the tower successfully.105 Purser {Day296/27:4-9}. Those who did not survive the journey down the stairs had inhaled a significant amount of asphyxiant gases while in their flats and before entering the stairs.106 Purser {Day296/217:23}-{Day296/218:1}. Those who remained in their flats until the fire arrived but were then able to escape successfully had probably not been exposed to a large amount of asphyxiant gases.107 Purser {Day296/25:19}-{Day296/26:2}.
20¶85.47 People were inhaling an increasing quantity of asphyxiant gases while they remained in their flats108 Purser {Day296/218:2-5}. and the longer they did so, the greater the danger of their accumulating enough to cause collapse and death.109 Purser {Day297/7:18}-{Day296/8:2}. However, in most cases they had inhaled a dose of asphyxiant gases sufficient to impede escape by the time the fire on the outside of the building reached the flats in which they were sheltering.110 Purser {Day296/218:6-10}. The key distinction between those who survived and those who died is that those who survived left before the fire spread to the outside of their flats or the rooms in which they were sheltering.111 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/153}. In some individual cases, personal characteristics affected both their ability to escape and their vulnerability to asphyxiant gases.112 Purser {Day296/218:19-23}.
¶85.48 When the fire reached the outside of the rooms in which people were sheltering, conditions deteriorated very rapidly and they were exposed to a large amount of asphyxiant gases.113 Purser {Day296/28:4-12}. When they then tried to evacuate, they had already accumulated a significant dose and collapsed quickly when exposed to further gases in the lobby or stairs.114 Purser {Day296/28:15-22}. Those who remained in their flats and did not leave were rapidly overcome.115 Purser {Day296/28:23-25}.
¶85.49 Almost all those who died in the tower had concentrations of carboxyhaemoglobin in their blood consistent with death from asphyxia rather than from heat or burns.116 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/124} figure 18. The two bodies with concentrations of less than 50% carboxyhaemoglobin that were recovered from the flats had heart disease which explained the lower result.117 Purser {Day296/182:15-18}. For eight of those who died in the lobbies or stairs, all except one had very high carboxyhaemoglobin concentrations and did not have significant burns.118 Purser {Day296/182:20}-{Day296/183:2}.
¶85.50 From those findings we conclude that all the deceased were comatose, and in most cases dead, before they were exposed to significant heat.119 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/138}; Purser {Day296/183:18}-{Day296/184:16}. The severe burning of bodies was likely to have occurred in all cases sometime after death when the fire entered the flats and consumed all the combustible contents.120 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/139}; Purser {Day296/229:1-8}.
¶85.51 Professor Purser was unable to say whether any of those who died had inhaled enough hydrogen cyanide to make a significant contribution to incapacitation and death.121 Purser {Day296/197:22}-{Day296/198:17}. He was of the opinion, which we accept, that it had made some contribution but that the dominant toxic gas causing incapacitation and death had been carbon monoxide.122 Purser {Day297/51:14-17}; {Day297/52:4-17}.
21Chapter 86: Floor 10
¶86.1 By 01.21 on 14 June 2017, the fire had spread up the east face of Grenfell Tower to reach the outside of Flat 76 on floor 10.123 Phase 1 Report Volume II paragraphs 10.115-10.116; Phase 1 Report Volume IV paragraph 24.18. All the flats on floor 10 were still occupied at that time, but none of the occupants had contact with those who died on that floor.
¶86.2 Hoang Khanh Quang, who lived in Flat 76, and her former husband, Van Quang Ho, who was there that night, were the first to leave floor 10. Having been woken by a smoke alarm, Hoang Khanh Quang saw flames at the kitchen window. Both she and Van Quang Ho then became aware of black smoke filling the hallway. Leaving at speed and in obviously difficult circumstances, neither of them closed the front door of the flat, which did not have an effective self-closing device. They left the tower together at 01.26.124 Phase 1 Report Volume II paragraphs 10.197-10.202; Phase 1 Report Volume IV paragraph 24.31.
¶86.3 Flat 76 rapidly filled with smoke, which then entered the floor 10 lobby. Within five minutes the lobby became so full of smoke that when the north lift unexpectedly stopped at that floor it was already dark and full of smoke. Some of the smoke penetrated the closed lift doors. More came in when the doors opened. The volume and density of the smoke that entered the lift made Nadia Jafari, who was in the lift, think that the lights had gone out. In the ensuing panic, three of the five people in the lift, Ali Yawar Jafari, Mohamednur Tuccu and Khadija Khalloufi, stumbled out and became trapped in the lobby of floor 10.125 Phase 1 Report Volume II paragraphs 10.215 and 10.221-10.225.
¶86.4 The lift then continued its descent, reaching the ground floor at 01.26. Only Nadia Jafari and Rhea Rojo emerged. The extent of the smoke billowing from the lift as they left it, seen on CCTV, gives an indication of the amount of smoke on floor 10.126 Phase 1 Report Volume II paragraphs 10.94 and 10.215-10.219; Phase 1 Report Volume IV paragraph 25.6. Nadia Jafari said that the smoke had been much thicker when the lift was at floor 10. At 01.28, in a call to the emergency services, the occupants of Flat 73, located in the south-west corner of the tower, reported smoke coming through their front door.127 Phase 1 Report Volume II paragraph 10.203.
¶86.5 Nagawa (Prossy) Nalukwago, who was staying in Flat 71, next to Flat 76, left the tower at 01.35. On leaving Flat 71, she had been confronted by thick black smoke which felt hot. Despite the conditions, she was able to make her way to the stairwell. While doing so, she stumbled over what she thought were three bodies.128 Phase 1 Report Volume II paragraph 11.114. They were the bodies of Ali Yawar Jafari, Mohamednur Tuccu and Khadija Khalloufi, all of whom had by then been overcome by the conditions in the lobby. That none of them had been able to reach the stairs shows how disorientating conditions on floor 10 were.
¶86.6 Clarita Ghavimi was woken at around 01.30 by a smoke alarm. She saw flames from her bedroom window. When she opened her front door, she found the lobby dark and smoky. She made her way to the stairwell door by touch because the lobby was too thick with smoke for her to see her way.129 Phase 1 Report Volume II paragraphs 11.115 and 12.40-12.43. She was then rescued by another resident, Branislav Lukic, and carried down. They left the tower at 01.49.130 Phase 1 Report Volume II paragraphs 12.41-12.43.
22¶86.7 Between 01.40 and 01.42 a group of five firefighters led by CM Guy Tillotson began searching the tower to rescue anyone they could find. They went to floor 10 but found it so full of thick, black smoke that CM Tillotson decided that the firefighters could not enter the lobby without water.131 Phase 1 Report Volume II paragraphs 12.3-12.5 and 12.29.
Ali Yawar Jafari
¶Date of birth: 1 January 1936 (81 years). Place of birth: Kandahar, Afghanistan. Gender: Male. Occupation: Retired jeweller. Usual address: Flat 86, floor 11, Grenfell Tower, London. Place of death: Lobby of floor 10, Grenfell Tower, London. Time of death: By about 01.37 on 14 June 2017. Cause of death: la. Inhalation of asphyxiant gases.
¶II. Coronary and hypertensive heart disease.
Background and composition of household
¶86.8 Born on 1 January 1936 in Kandahar, Afghanistan, Ali Yawar Jafari was an 81-year-old retired jewellery maker. He lived in Flat 86 on floor 11 of Grenfell Tower with his wife, Fatima Jafari, and their two adult daughters, Maria and Nadia Jafari. The family had lived there since 2003.132 Phase 1 Report Volume II paragraph 10.204; Phase 1 Report Volume IV paragraph 32.293.
Vulnerability
¶86.9 Ali Yawar Jafari suffered from diabetes and heart disease.133 Phase 1 Report Volume II paragraph 10.204. Rydon's survey of residents, prepared in November 2014 and provided to the TMO, recorded that he suffered from diabetes.134 Rydon Residents Survey {RYD00024466/33}. On the night of the fire, David Noble, a policy and diversity advisor with the TMO,135 Noble {TMO00000884/1} page 1, paragraph 3. produced a spreadsheet listing the residents of the tower which was designed to record any known vulnerability or disability.136 Noble {Day119/75:19-22}. That spreadsheet was compiled from information held on the TMO's Capita Insight system.137 Noble {Day119/77:17}-{Day119/82:5}. It did not identify Ali Yawar Jafari as a vulnerable resident.
Events of 14 June 2017
¶86.10 Ali Yawar Jafari was last seen entering the tower at 19.40 on 13 June 2017.138 O'Riordan {MET00013136/3} page 3. He remained in his home preparing to break the Ramadan fast with his family.139 Nadia Jafari {IWS00000683/3} page 3, paragraph 10.
23¶86.11 By 01.22 the fire had reached the top of floor 11 outside the kitchen of Flat 86.140 Phase 1 Report Volume II paragraph 10.116; Phase 1 Report Volume IV paragraph 25.6. By then the Jafari family were already aware of it and Fatima and Maria Jafari had started to make their way out of the building. Before doing so, Fatima asked Nadia to wake her father and help him outside. Nadia and her father were still in the flat when she saw flames push through the extractor fan of the kitchen window, the glass in that window shatter and the frame fall out. She shut the kitchen door and together with her father left the flat.141 Phase 1 Report Volume II paragraphs 10.204-10.206.
¶86.12 In the lobby, Nadia Jafari and her father knocked on the doors of neighbours. She spoke to Natasha Elcock in Flat 82 and even tried to go back into Flat 86. She was not able to lock the door of the flat, which was left partly open. The smoke emerging from Flat 86 did not immediately fill the lobby of floor 11 and the lights were still visible. Nadia suggested to her father that they use the lift to leave the tower.142 Phase 1 Report Volume II paragraphs 10.206-10.209. By that time, Ali Yawar Jafari had been exposed to only a limited amount of smoke.
¶86.13 Mohamednur Tuccu and Rhea Rojo were already in the north lift when it stopped at floor 11. Khadija Khalloufi, who had made her way down from her own flat on floor 17, entered the lobby of floor 11 and got into the lift at the same time as the Jafaris.143 Phase 1 Report Volume II paragraphs 10.208 and 10.221-225. There appears to have been no smoke in the lift when it reached floor 11.
¶86.14 The lift started to descend but suddenly stopped at floor 10. Smoke began to seep in through the closed doors. When they opened, the inward rush of smoke filled the lift obscuring the lights. The occupants were left coughing and shouting. In the panic Ali Yawar Jafari, Mohamednur Tuccu and Khadija Khalloufi went into the lobby, which by then was filled with dense black smoke.144 Phase 1 Report Volume II paragraph 10.225. Unable to find a way out, Ali Yawar Jafari became trapped in the lobby on floor 10.
¶86.15 The lift probably stopped on floor 10 shortly before 01.26 (the time when Nadia Jafari and Rhea Rojo are seen leaving the lift on the ground floor).145 Phase 1 Report Volume II paragraph 10.216. Initially, Nadia Jafari thought her father had left the lift on the ground floor ahead of her.146 Phase 1 Report Volume II paragraph 10.217.
¶86.16 When they had left the tower and realised that their father had not escaped the building, Nadia and Maria Jafari tried to re-enter it but were stopped by a police officer, possibly PC Kiran Sangha, who recalled being told by a family he had prevented from entering the tower that their grandfather was stuck in the lift. The officer told a fireman outside the tower that there were people stuck in a lift but was told that the fire brigade had control of the lifts in the tower.147 Sangha {MET00007837/3} page 3. There is no evidence of what, if any, further steps were taken in response to what the officer had said.
Recovery and identification
¶86.17 CM Martin Hoare and FF Matthew Tanner tallied out at 02.55.148 Phase 1 Report Volume II paragraph 10.225. Having originally been sent to search Flat 74 on floor 10, they were reassigned with other firefighters to search for a missing firefighter on floor 12. Once that emergency had been resolved, they returned to their original task. When they reached floor 10 and opened the door to the lobby, they were confronted by intense heat with smoke extending down to a foot above the floor. Crawling into the lobby, they found Ali Yawar Jafari's body near the lift and brought him out into the stairwell. CM Hoare accepted that he had originally wrongly identified the casualty as Mohamednur Tuccu.149 Hoare {MET00008027/15-25} pages 15-16 and 25; Phase 1 Report Volume II paragraphs 10.224-10.225; Phase 1 Report Volume III paragraphs 17.13 (e) and 20 (c).
24¶86.18 As he and FF Tanner were carrying Ali Yawar Jafari down the stairs, CM Hoare realised that he was running out of air.150 Standard duration breathing apparatus provides a working time of about 30 minutes depending on a range of factors, including workload and environmental conditions: Phase 1 Report Volume I paragraph 7.63. Concluding that Ali Yawar Jafari had already died, the firefighters laid his body on the stairs.151 Phase 1 Report Volume III paragraph 17.20 (c). Returning to the bridgehead, they reported where they had left him. FFs Charlie Rawlings, Andrew Brooks and James Morcos were sent to recover his body.152 Rawlings {MET00005588/2} page 2; Brooks {MET00005262}; Morcos {MET00005585/1} page 1. It was carried out of the tower at 03.34.153 Phase 1 Report Volume II paragraph 10.225. At 03.35, paramedic Mark Hodson confirmed that he was dead.154 Hodson {MET00017061/5} page 5.
¶86.19 The coroner, Professor Wilcox, was satisfied that the casualty recovered by CM Hoare and FF Tanner was Ali Yawar Jafari and therefore issued an interim certificate of the fact of death.155 Interim certificate of the fact of death for Ali Yawar Jafari {MET00065589}.
Cause and time of death
¶86.20 The post-mortem on Ali Yawar Jafari found that his body was intact. There were soot deposits around his nose and mouth and some superficial burns and heat damage to the skin. The post-mortem also confirmed that he had suffered from severe heart disease which affected the blood supply to his heart and made him more vulnerable to the conditions produced during a fire, so contributing to his death.156 Jafari post-mortem report {COR00000088/11}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/122} Table 17.
¶86.21 The level of carboxyhaemoglobin in a blood sample taken from Ali Yawar Jafari was found to be 47%.157 Jafari toxicology report {COR00000092/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/124} paragraph 493. That is within the toxic range for someone whose pre-existing heart disease made him more vulnerable to conditions in the lobby.158 Jafari post-mortem report {COR00000088/11}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/125} paragraph 493. No cyanide was detected in the sample when it was later tested. As cyanide was found in samples taken from Mohamednur Tuccu and Khadija Khalloufi, its absence in the case of Ali Yawar Jafari was probably due to degradation of the sample over time.159 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. It is likely therefore that Ali Yawar Jafari inhaled hydrogen cyanide, although we cannot say how much.
¶86.22 The medical cause of death was recorded as: Ia. Inhalation of fire fumes. II. Coronary and hypertensive heart disease.
¶86.23 In the light of Professor Purser's evidence we find that a more accurate description of the primary cause of death is "inhalation of asphyxiant gases".
¶86.24 Given his poor health, the manner in which he came to leave the lift on floor 10, the conditions in the lobby on that floor and the fact that his body was recovered near the lift, we find that Ali Yawar Jafari probably collapsed due to the inhalation of asphyxiant gases within a minute or so of stepping out of the lift. While unconscious, he continued to inhale those gases until his respiration and circulation ceased some minutes later and he died at about 01.37,160 Purser, Phase 2 Report, Section 6 {DAPR0000006/167-170} paragraphs 925-935; Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 943 and Figure 46. mainly from the effects of carbon monoxide poisoning.161 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/136} paragraph 568; Purser, Phase 2 Report, Section 6 {DAPR0000006/171-172} paragraphs 942 and 946. He would have had to be rescued before about 01.35 to have had a reasonable prospect of survival.162 Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 945.
25Mohamednur Tuccu
¶Date of birth: 24 May 1973 (44 years). Place of birth: Eritrea. Gender: Male. Occupation: Security Officer. Usual address: Arne House, Tyers Street, London Place of death: Lobby of floor 10, Grenfell Tower, London Time of death: By 01.46 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶86.25 Born in Eritrea, Mohamednur Tuccu had lived in the United Kingdom since 1991. Aged 44 years (born 24 May 1973), he was working as a security guard at the time of the fire. Mohamednur Tuccu is not listed as a resident in the spreadsheet163 Noble {Day119/75:19-22}. produced on the night of the fire by David Noble.164 Noble {TMO00000884/1} page 1, paragraph 3. His wife, Amal Ahmedin, and daughter, Amaya Tuccu- Ahmedin, lived in Flat 166 on floor 19. On the evening of 13 June 2017, Amna Idris, Amal Ahmedin's cousin, was visiting the family.165 Phase 1 Report Volume IV paragraphs 32.154-32.163.
Events of 14 June 2017
¶86.26 Mohamednur Tuccu was seen on CCTV entering Grenfell Tower at 00.36.166 O'Riordan {MET00013136/4} page 4. His movements thereafter are unknown, but it is very likely that he visited his family. By 01.25, the fire had reached the top of floor 19 and was outside Flat 166.167 Phase 1 Report Volume II paragraph 10.118. Shortly after 01.25, Meron Mekonnen, who lived in Flat 163, left her home having been alerted to the fire. She saw Amal Ahmedin and Amna Idris in the lobby of floor 19. They told each other that there was a fire in the building.168 Phase 1 Report Volume II paragraphs 10.255-10.257. Meron Mekonnen left the tower at 01.32. Amal Ahmedin, with her daughter, and Amna Idris subsequently made their way up to shelter in Flat 201 on floor 23. It is likely that they reached it by about 01.30.169 Phase 1 Report Volume II paragraphs 10.260 and 10.287-10.289. They died on floor 23 and we deal with the circumstances of their deaths in Chapter 97.
26¶86.27 There is no evidence that Mohamednur Tuccu was in Flat 166 when Meron Mekonnen saw Amal Ahmedin or that he was among those who made their way up the tower. He was, however, in the north lift when Rhea Rojo entered it on floor 12.170 Phase 1 Report Volume II paragraphs 10.219 and 10.224-10.225. It is not known where Mohamednur Tuccu entered the lift, but it would have been somewhere above floor 12. Since the lift stopped at floors 11 and 10 and reached the ground floor at 01.26,171 Phase 1 Report Volume II paragraphs 10.216-10.217. it is reasonable to conclude that he left Flat 166 before the fire had reached floor 19.
¶86.28 When the lift stopped at floor 11, Khadija Khalloufi, who had made her way down the stairs from her home on floor 17 and had entered the lobby on floor 11, got into the lift together with Nadia Jafari and her father, Ali Yawar Jafari.172 Phase 1 Report Volume II paragraphs 10.208 and 10.221-10.224.
¶86.29 The lift probably stopped on floor 10 shortly before 01.26, when Nadia Jafari and Rhea Rojo can be seen leaving the lift on the ground floor.173 Phase 1 Report Volume II paragraph 10.216.
¶86.30 It is unlikely that Mohamednur Tuccu had been exposed to any smoke before the lift reached floor 10. When the doors opened, the inward rush of smoke filled the lift obscuring the lights. Those in the lift were left coughing and shouting. In the panic Mohamednur Tuccu, together with Ali Yawar Jafari and Khadija Khalloufi, entered the lobby on floor 10, by then filled with dense black smoke.174 Phase 1 Report Volume II paragraph 10.225. Unable to find a way out, he was trapped there.
Recovery and identification
¶86.31 At 02.04,175 BA Telemetry Data {LFB00023326/1} page 1. FFs Oliver Desforges and Robert Mitchell were deployed with other firefighters to rescue Mariko Toyoshima-Lewis and her family from Flat 9 on floor 3. They were then deployed to floor 24. Climbing the stairs, the two firefighters realised that they did not have enough air to get there. They decided to search a floor they could reach,176 Phase 1 Report Volume II paragraphs 14.225-14.227; Mitchell {MET000086063/4-5} pages 4-5; Desforges {MET00008013/4-5} pages 4-5. which turned out to be floor 10.
¶86.32 FF Desforges said that the heat they encountered on opening the door from the stairwell into the lobby was the most intense he had ever experienced. The lobby was filled with hot black smoke and it was impossible to see anything. Keeping low to the ground, the two firefighters found and were able to recover two casualties, Mohamednur Tuccu and Khadija Khalloufi.177 Mitchell {MET000086063/5} page 5; Desforges {MET00008013/5-6} pages 5-6.
¶86.33 With the assistance of other firefighters, Mohamednur Tuccu was carried down the stairs and out of the tower at 02:28.178 Phase 1 Report Volume II paragraph 10.224. At 02.37, paramedic Stuart Matthews formally confirmed that he was dead.179 Matthews {MET00013948/4} page 4.
¶86.34 The coroner, Professor Wilcox, was satisfied that the casualty recovered by FFs Desforges and Mitchell was Mohamednur Tuccu and therefore issued an interim certificate of the fact of death.180 Interim certificate of the fact of death for Mohamednur Tuccu {MET00065634}.
27Cause and time of death
¶86.35 The post-mortem on Mohamednur Tuccu recorded that his body was intact without any burns and that there were significant soot deposits on his face, in his nostrils and in his respiratory system.181 Tuccu post-mortem report {COR00001106/10}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/136} paragraph 570. There was bruising on the back of the head consistent with minor blows sustained during an attempt to escape.182 Tuccu post-mortem report {COR00001106/10}.
¶86.36 The level of carboxyhaemoglobin in a blood sample taken from him was found to be 73%,183 Tuccu first toxicology report {COR00001119/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/137} paragraph 571. which indicates that he had inhaled a considerable amount of carbon monoxide before he died. Later analysis of the blood sample measured a cyanide concentration of 0.18 milligrams/litre.184 Tuccu second toxicology report {INQ00011095/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/141} paragraph 604. That is not in the toxic range but is elevated by comparison with the level naturally occurring in the blood.185 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. It is likely that it was affected by degradation of the sample and did not reflect the level of cyanide in the blood at the time of death.186 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. Its presence shows that Mohamednur Tuccu had inhaled some hydrogen cyanide at the time of his death but it is not possible to say how much.
¶86.37 The post-mortem recorded the medical cause of death as "inhalation of fire fumes" but in the light of more recent evidence we find that a more accurate description is "inhalation of asphyxiant gases".
¶86.38 Given the circumstances in which Mohamednur Tuccu left the lift on floor 10, the conditions in the lobby on that floor and the level of carboxyhaemoglobin subsequently found in his blood, we are satisfied that he probably collapsed due to the inhalation of asphyxiant gases within a few minutes of stepping out of the lift. While unconscious, he continued to inhale those gases until his respiration and circulation ceased some minutes later and he died. The level of carboxyhaemoglobin in his blood indicates that the exposure to carbon monoxide alone would have been fatal, although he also inhaled some hydrogen cyanide.187 Purser, Phase 2 Report, Section 6 {DAPR0000006/173-174} paragraphs 948-949. He would have had to be rescued before about 01.35 at the latest to have had a reasonable prospect of survival.188 Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 945.
¶86.39 Having considered the evidence, we find that Mohamednur Tuccu had died by 01.46 before being exposed to the direct effect of the flames.
Khadija Khalloufi
¶Date of birth: 6 September 1964 (52 years). Place of birth: Mohammedia, Morocco. Gender: Female. Occupation: Homemaker. Usual address: Flat 143, floor 17, Grenfell Tower, London.
28¶Place of death: Lobby of floor 10, Grenfell Tower, London. Time of death: By 01.44 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶86.40 Born in Mohammedia, Morocco on 6 September 1964 as the eldest of seven siblings, Khadija Khalloufi was 52 years old at the time of her death. A graduate, she had managed a pharmacy in Morocco before moving to Holland to live and work and ultimately settling in London. At the time of the fire, Khadija Khalloufi lived in Flat 143 on floor 17 with her husband Sabah Abdullah. They had married in 1990.189 Phase 1 Report Volume IV paragraphs 32.234-32.239; Presentation relating to Khadija Khalloufi {Day306/24:22}-{Day306/26:19}.
Events of 14 June 2017
¶86.41 Khadija Khalloufi returned to Grenfell Tower on 13 June 2017 at 16.02190 O'Riordan {MET00013136/3} page 3. and remained in her home. Mesrob Kassemdjian, who lived in Flat 146 with his aunt, Rita Tankarian, alerted Khadija Khalloufi to the fire before leaving floor 17. She then turned back into her flat to speak to her husband, Sabah Abdullah. Mesrob Kassemdjian left the tower at 01.25 just ahead of Rita Tankarian. She recalled Sabah Abdullah telling her outside the tower that he had lost his wife on the stairs at some point between floors 14 and 17.191 Phase 1 Report Volume II paragraph 10.222.
¶86.42 Khadija Khalloufi was next seen by Nadia Jafari. She entered the lobby of floor 11, called the lift and waited for it with Nadia Jafari and her father, Ali Yawar Jafari.192 Phase 1 Report Volume II paragraph 10.208. We do not know why Khadija Khalloufi chose to enter floor 11. It is unlikely that at that stage she had been exposed to any smoke.
¶86.43 Mohamednur Tuccu and Rhea Rojo were already in the lift when it reached floor 11 and Khadija Khalloufi, Nadia Jafari and her father all entered it. When the lift suddenly stopped at floor 10, smoke began to seep in through the closed doors. When they opened, the inward rush of smoke filled the lift obscuring the lights. Those in the lift were left coughing and shouting. In the panic Khadija Khalloufi, together with Ali Yawar Jafari and Mohamednur Tuccu, came out into the lobby of floor 10, by then filled with thick black smoke.193 Phase 1 Report Volume II paragraph 10.215. Unable to find her way out, Khadija Khalloufi became trapped.
Recovery and identification
¶86.44 At 02.04,194 BA Telemetry Data {LFB00023326/1} page 1. FFs Oliver Desforges and Robert Mitchell were deployed with other firefighters to rescue Mariko Toyoshima-Lewis and her family from Flat 9 on floor 3. They were then deployed to floor 23. Climbing the stairs, the two firefighters realised that they did not have enough air to reach that floor. They decided to search a floor that they could reach.195 Phase 1 Report Volume II paragraphs 14.222-14.227; Mitchell {MET000086063/4-5} pages 4-5; Desforges {MET00008013/4-5} pages 4-5. That turned out to be floor 10.
29¶86.45 FF Desforges described the heat they encountered on opening the door from the stairwell into the lobby was the most intense he had ever experienced. The lobby was filled with hot black smoke and it was impossible to see anything. Keeping low to the ground, he and FF Mitchell found and were able to recover two casualties, Mohamednur Tuccu and Khadija Khalloufi.196 Mitchell {MET000086063/5} page 5; Desforges {MET00008013/5-6} pages 5-6.
¶86.46 Khadija Khalloufi was carried out of the tower at 02.28.197 Phase 1 Report Volume II paragraph 10.224. At 02.41, paramedic Stuart Matthews formally confirmed that she was dead.198 Matthews {MET00013948/4} page 4.
¶86.47 The coroner, Professor Wilcox, was satisfied that the casualty recovered by FFs Desforges and Mitchell was Khadija Khalloufi and therefore issued an interim certificate of the fact of death.199 Interim certificate of the fact of death for Khadija Khalloufi {MET00065597}.
Cause and time of death
¶86.48 The post-mortem on Khadija Khalloufi recorded that her body was intact without any burns and that there was dense soot staining around the nostrils and ears and extensive soot contamination in the respiratory system. There were some minor abrasions and bruising which she probably sustained during attempts to find her way out of the lobby on floor 10.200 Khalloufi post-mortem report {COR00000840/14}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/122} Table 17.
¶86.49 The carboxyhaemoglobin level in a sample of blood taken from Khadija Khalloufi was 66%,201 Khalloufi first toxicology report {COR00000842/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/136} paragraph 569. which indicated the inhalation of a significant amount of carbon monoxide. Later analysis of the sample showed a cyanide concentration of 0.59 milligrams/litre.202 Khalloufi second toxicology report {INQ00011089/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/141} paragraph 604. That is significantly higher than the background level of cyanide found naturally in the blood.203 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. That it was detected shows that Khadija Khalloufi had inhaled hydrogen cyanide, but since the sample is likely to have degraded over time,204 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. we do not know how much cyanide was in her blood at the time of her death.
¶86.50 The post-mortem recorded the medical cause of death as "inhalation of fire fumes" but in the light of more recent evidence we find that a more accurate description is "inhalation of asphyxiant gases".
¶86.51 Given the circumstances in which Khadija Khalloufi left the lift when it reached floor 10, the conditions in the lobby and the level of carboxyhaemoglobin in her blood, we find that she probably collapsed due to the inhalation of asphyxiant gases within a few minutes of exiting the lift. While unconscious, she continued to inhale those gases until her respiration and circulation ceased some minutes later and she died. The level of carboxyhaemoglobin subsequently found in her blood indicates that the degree of exposure to carbon monoxide alone would have been fatal, but she must have also inhaled some hydrogen cyanide.205 Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 947.
30¶86.52 Having considered the evidence, we are satisfied that Khadija Khalloufi had died by 01.44. She would have had to be rescued no later than 01.35 to have had a reasonable prospect of survival. We are satisfied that she died before being exposed to the direct effect of the flames.
31Chapter 87: Floor 11
¶87.1 By 01.22 on 14 June 2017 the fire on the outside of the building had reached the top of floor 11 outside Flat 86.206 Phase 1 Report Volume II paragraph 10.116. All six flats on floor 11 were still occupied. Except for Ali Yawar Jafari, whose body was recovered from the lobby of floor 10, and Abdeslam Sebbar, who remained in Flat 81, all the occupants of floor 11 survived the fire.
¶87.2 The Jafari family, in Flat 86, were the first to leave. Of that family, Nadia Jafari and her father, Ali Yawar Jafari, left last. By that time, flames and smoke had begun to penetrate Flat 86.207 Phase 1 Report Volume II paragraphs 10.204-10.206.
¶87.3 The front door of Flat 86 did not have an effective self-closing device and when she left Nadia Jafari left the door partly open.208 Phase 1 Report Volume II paragraph 10.207. She did not see or smell smoke while she was in the lobby. She and her father then entered the lift when it stopped on that floor.209 Phase 1 Report Volume II paragraph 10.208. Since Nadia Jafari left the lift at 01.26 when it reached the ground floor,210 Phase 1 Report Volume II paragraph 10.216. it is likely that they entered the lift shortly before that time. As we have explained, Ali Yawar Jafari died after leaving the lift on floor 10.211 See Chapter 86.
¶87.4 The occupants of Flat 85 (Youssef Khalloud, Mouna El-Ogbani and their three children) were the next to leave floor 11, followed by the occupants of Flat 84 (Miran Lovsin and Branislav Lukic). They all left the building between 01.27 and 01.49.212 Phase 1 Report Volume III Annex A. That left Abdeslam Sebbar in Flat 81, Natasha Elcock and her family in Flat 82 and Elpidio Bonifacio in Flat 83.
¶87.5 Between 01.28 and 04.41, those on floor 11 or their relatives outside the tower made 22 calls to the emergency services. Abdeslam Sebbar and his grandson made four calls between them.213 Phase 1 Report Volume II paragraphs 10.91 and 11.106; Phase 1 Report Volume III paragraphs 15.119 and 19.72. Elpidio Bonifacio's daughter-in-law made four calls about him between 02.58 and 05.31.214 Phase 1 Report Volume III paragraphs 16.73, 16.90, 18.73, 19.74 and 20.49. Natasha Elcock made 14 calls between 01.28 and 04.33.215 Phase 1 Report Volume II paragraphs 10.209-10.210, 10.316, 11.103, 11.105, 11.146, 12.54-12.55, 14.207-14.209, 14.237, 14.257; Phase 1 Report Volume III paragraphs 15.113-15.116, 15.154, 15.182, 17.105-17.108, 17.123, 18.48- 18.50, 18.68, 19.42-19.44 and 19.71. The first two calls from Natasha Elcock showed how quickly conditions worsened in the lobby of floor 11. She described a rapid change in the density of the smoke between her first call at 01.28 (when there was only a small amount of smoke) and her second call at 01.33 (at which time she described the lobby as pitch black).216 Phase 1 Report Volume II paragraphs 10.209-10.210 and 11.103-105. When at some time before 01.40, Miran Lovsin and Branislav Lukic made an unsuccessful attempt to leave Flat 84, they found the lobby full of thick black smoke.217 Phase 1 Report Volume II paragraphs 11.108-11.112.
32¶87.6 No firefighters were deployed to floor 11 before 04.00. Between then and 04.50, firefighters were sent to search Flats 81 to 84. They had difficulty searching floor 11 because of the intense heat in the lobby.218 Phase 1 Report Volume III paragraphs 19.18(b), 19.19(c), 19.19(d), 19.19(f), 19.22(b) and 19.29(b). Another team that had been sent to floor 9 miscalculated and arrived on floor 11, where they helped Natasha Elcock, her partner and child, to leave.219 Phase 1 Report Volume III paragraphs 19.19(g) and 19.44; Barritt {MET000083284/5-6} pages 5-6. The family left the tower at 04.47.220 Phase 1 Report Volume III paragraphs 19.42–19.44.
¶87.7 Elpidio Bonifacio was the last surviving resident of the tower to be rescued, reaching the base of the tower at 08.07.221 Phase 1 Report Volume III paragraph 20.37.
¶87.8 No resident of floor 11 had contact with Abdeslam Sebbar on the night of the fire and there is no evidence to suggest that he ventured from Flat 81.
Abdeslam Sebbar
¶Date of birth: 11 September 1939 (77 years old). Place of birth: Larache, Morocco. Gender: Male. Occupation: Retired. Usual address: Flat 81, floor 11, Grenfell Tower, London. Place of death: Flat 81, floor 11, Grenfell Tower, London. Time of death: Between 3.50 and 04.05 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶87.9 Born on 11 September 1939 in Larache, Morocco, Abdeslam Sebbar was a 77-year-old retired coffee shop owner and chef. He lived alone in Flat 81, a one-bedroom flat on the east side of floor 11 of Grenfell Tower.222 Phase 1 Report Volume IV paragraph 32.301; Presentation relating to Abdeslam Sebbar {Day301/1:23}-{Day301/2:6}. He had been the tenant of Flat 81 since 1978 and very involved in his local community.223 Sebbar {IWS00002375/1} page 1, paragraph 3; Presentation relating to Abdeslam Sebbar {Day301/2:3-18}.
Vulnerability
¶87.10 In a letter to RBKC dated 9 November 2016 the TMO stated that Abdeslam Sebbar was diabetic and frail, had difficulty using stairs and needed accommodation at ground level or with a lift.224 Letter from TMO to RBKC dated 9 November 2016 {BSR00000108}. He appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system,225 Noble {Day119/77:17}-{Day119/82:5}. but it contained no information about his physical limitations.226 Noble spreadsheet {TMO00862588}.
33Events of 14 June 2017
¶87.11 Abdeslam Sebbar returned home at approximately 00.23 on 14 June 2017 and did not leave again.227 O'Riordan {MET00013136/4} page 4. He called the emergency services at 01.25, shortly after the fire reached the top of floor 11 at about 01.22.228 Phase 1 Report Volume II paragraph 10.116. In that call, he reported a fire but did not say where he was.229 Phase 1 Report Volume II paragraph 10.91; Phase 1 Report Volume III paragraph 15.117.
¶87.12 Abdeslam Sebbar also called his son, Mohamed Sebbar, who, having learned of the fire, was driving to the tower with his own son, Youness Sebbar.230 Phase 1 Report Volume II paragraph 11.107. Mohamed Sebbar tried to reassure his father and told him to leave, although he believed his father would need help to do so. They were still speaking to each other when Mohamed Sebbar reached the tower at around 01.30.231 Phase 1 Report Volume II paragraph 11.107.
¶87.13 At 01.33, Abdeslam Sebbar made a second call to the emergency services which was the last direct contact he had with them. Before disconnecting the call, he reported that he was on floor 11 and that the fire was in his flat. He did not give the number of his flat.232 Phase 1 Report Volume III paragraph 15.117; 999 call transcript {LFB00000312}. By that time the fire had not penetrated Flat 81, but was established in the adjacent flat, Flat 86. As Natasha Elcock reported in the emergency call she made at the same time, smoke had by then reached the lobby of floor 11.233 Phase 1 Report Volume II paragraphs 10.116, 10.204-10.206 and 11.102-11.105.
¶87.14 Having reached the tower, Mohamed Sebbar spoke to his father twice more, the first time between 01.45 and 02.30.234 Sebbar {IWS00002375/2} page 2, paragraph 7. At 02.46, Youness Sebbar made a call to the emergency services which was connected to Merseyside Fire and Rescue Service. He said that his grandfather was stuck in Flat 81 and had stopped talking and that help was needed urgently. That information was passed on to the LFB in a call timed at 02.47.235 Phase 1 Report Volume III paragraph 15.119; 999 call transcript {INQ00000532}. The Phase 1 report concluded that Abdeslam Sebbar stopped responding to his family shortly before 02.46.236 Phase 1 Report Volume III paragraph 15.119. However, in a statement dated 20 May 2022, Mohammed Sebbar recalled that his last call with his father had taken place after Youness Sebbar had made an emergency call at about 02.46. In that last call, Abdeslam Sebbar was sheltering in the lavatory of Flat 81 and was struggling to breathe. The call continued until approximately 03.30 when Abdeslam Sebbar stopped responding.237 Sebbar {IWS00002375/2} page 2, paragraph 8.
¶87.15 Youness Sebbar made a second emergency call at 04.39 that was taken by CRO Pamela Jones, in which he asked if there was any information about his grandfather. Youness Sebbar gave the number of his grandfather's flat and asked if it could be checked. He also asked where casualties were being taken. CRO Jones was not able to provide any information.238 Phase 1 Report Volume III paragraph 19.72.
34Information to the incident ground
¶87.16 Two of the emergency calls made by or about Abdeslam Sebbar (his own call at 01.33 and that of his grandson at 02.46) included information about his location and the fact that he was still in his flat. However, information about Abdeslam Sebbar did not reach the incident ground until 03.00: a. Although Natasha Elcock's first two emergency calls at 01.28 and 01.33 prompted
service requests relating to Flat 82,239 LFB Short Incident Log Report {MET00013830/18}. none was generated in response to the calls relating to Abdeslam Sebbar.
¶b. Flat 81 was not listed on the whiteboards which SM Jason Oliff was using between about 02.33 and 06.41 to collate information to pass from the LFB control room to the command units, although information relating to Flats 82 and 83 was recorded.240 Phase 1 Report Volume III paragraphs 15.139-15.141 and 20.54 and Figures 15.8 and 15.9.
¶c. No information about Flat 81 appears on the white laminated sheet used in Command Unit 7 (CU7) to collate information about those needing to be rescued.241 Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3.
¶d. WM Glynn Williams began recording information about people needing to be rescued on a wall of the ground floor lobby from 02.15. Nothing was recorded in relation to Flat 81.242 Phase 1 Report, Volume II paragraphs 14.103-14.105 and Figure 14.5; Photographs of ground floor wall {MET00005774} and {MET00005776}.
¶e. After the bridgehead had been moved from floor 3 to the ground floor at about 03.10,243 Phase 1 Report Volume III paragraph 17.11; Phase 1 Report Volume IV paragraph 28.86. SM Gareth Cook photographed the wall on floor 3 where information about those needing to be rescued had been recorded. Although "11" had been written on the wall (denoting floor 11), nothing else had been recorded.244 Cook Exhibit GAC/2 - Grenfell Tower statement notes {MET00015779/16} page 16; Phase 1 Report Volume II Figure 15.7.
¶87.17 From about 03.00, CU7 moved to recording information on a whiteboard using a grid system.245 Phase 1 Report Volume III paragraphs 15.13 and 16.12. Photographs of that whiteboard,246 Phase 1 Report Volume III Figure 16.5; Photograph of whiteboard {MET00015924}. taken much later, show that the following had been entered on the grid: "81 1 1 P" with the first "1" in green indicating an adult, the second "1" in black indicating a child, and the "P" in red and circled, indicating a priority.247 Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. A red tick was used on the grid to indicate that a crew had been deployed. No red tick appeared in the entry. The mention of a child is an error but, in any event, we do not know when the entry was made or how the information reached CU7. It was probably sent after Youness Sebbar made his call at 02.46.
¶87.18 Once the bridgehead had been moved to the ground floor, information was recorded on a green wall at the bottom of the stairs.248 Phase 1 Report Volume IV paragraph 28.87. The inscription "BABY 81 82 83 84 – 11" appears in photographs of that wall taken by SM (now GM) Michael Mulholland at about 04.45.249 Mulholland Exhibit MBM/02 - Photograph of green wall {MET00018721}; Mulholland Exhibit MBM/02 -Photograph of green wall {MET00018731}. It is not clear when that information was put there. It may have been after 04.05 as one of the manuscripts notes delivered to WM Brien O'Keeffe by runners refers to "81 11" together with what appears to be a time stamp of "04.05".250 O'Keeffe {MET00013967/15} page 15; O'Keeffe notes {LFB00001929/1} page 1.
35Recovery and identification
¶87.19 The remains of Abdeslam Sebbar were recovered from the bathroom of Flat 81.251 Purser, Phase 2 Report, Section 6 {DAPR0000006/159} paragraph 877. The coroner, Professor Wilcox, was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.252 Interim certificate of the fact of death for Abdeslam Sebbar {MET00065630}.
Cause and time of death
¶87.20 The post-mortem on Abdeslam Sebbar found soot in his airways and no clear evidence of burns or trauma before death.253 Sebbar post-mortem report {COR00000009/10} page 10; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/119} Table 17. The level of carboxyhaemoglobin in his blood was 90%,254 Sebbar first toxicology report {COR00000020/1} page 1; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/116} Table 16. indicating that he must have inhaled a considerable amount of carbon monoxide before he died. Later analysis of the same blood sample detected cyanide at a level of 0.17 milligrams/litre.255 Sebbar second toxicology report {INQ00011094/1} page 1; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/116} Table 16. That is only slightly elevated compared to naturally occurring levels, probably as a consequence of degradation of the sample over time.256 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. While the level of cyanide in his blood at the time of death is therefore unknown, its presence shows that he had been exposed to hydrogen cyanide before he died.
¶87.21 The post-mortem recorded the medical cause of death as "inhalation of fire fumes" but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".
¶87.22 By 02.46, Abdeslam Sebbar had been sheltering in the bathroom for some time. Its location meant that it was one of the last parts of the flat to be affected by internal fires. While that afforded Abdeslam Sebbar some protection, he was still exposed to asphyxiant gases entering the flat from the lobby and the outside. By 02.53 the fire had reached the outside of Flat 81.257 Phase 1 Report Volume III paragraph 16.3. Flames could be seen inside the windows of Flat 81 from about 03.45.258 External Spread of Fire Report {MET00012593/78-79} Images 45-56 (applying a +58 minute correction to timestamps).
¶87.23 Mohamed Sebbar's evidence about the last time he spoke to his father was not available when Professor Purser was preparing his report. However, the evidence did not affect his conclusion that Abdeslam Sebbar died from the inhalation of asphyxiant gases. Professor Purser estimated that Abdeslam Sebbar died within 20 to 30 minutes of losing consciousness.259 Purser {Day297/145:10}-{Day297/148:6}.
¶87.24 In the light of Mohamed Sebbar's evidence, Professor Purser's evidence of the effect of asphyxiant gases and the post-mortem evidence, we find that Abdeslam Sebbar lost consciousness at about 03.30 due to the inhalation of asphyxiant gases. He continued to inhale those gases until his respiration and circulation ceased some minutes later and he died before any flames reached his body. Although he must have inhaled hydrogen cyanide, the level of carboxyhaemoglobin in his blood was such that his exposure to carbon monoxide alone would have been fatal. Abdeslam Sebbar died between 03.50 and 04.05.
37Chapter 88: Floor 14
¶88.1 When the fire began, all the flats on floor 14 were occupied apart from Flat 114. Nina Mangoba and her family in Flat 116 were the first residents to leave. As the fire progressed the remaining residents were gathered in Flat 113, the home of Oluwaseun Talabi and Rosemary Oyewole. They were Denis Murphy from Flat 111, brothers Omar Alhaj Ali and Mohammad Alhajali from Flat 112 and Zainab Deen and her son, Jeremiah Deen, from Flat 115. Firefighters subsequently rescued Oluwaseun Talabi, Rosemary Oyewole and their daughter as well as Omar Alhaj Ali. Following that rescue, Mohammad Alhajali, Denis Murphy, Zainab and Jeremiah Deen remained in Flat 113. They died during the fire.
¶88.2 In Phase 1, the chairman made findings about the events on floor 14 and in Flat 113 in particular.260 Phase 1 Report Volume II paragraphs 14.109-14.111; Phase 1 Report Volume II paragraphs 14.195-14.206; Phase 1 Report Volume III paragraphs 15.91-15.95. He said that the circumstances under which four people, one a child, had been left behind in Flat 113 required a more detailed examination than could conveniently be carried out in the context of the narrative description of the events of 14 June 2017 and proposed to undertake that examination at a later date after further submissions and possibly additional evidence had been received.261 Phase 1 Report Volume III paragraph 15.96.
¶88.3 In the end it was not necessary to hear any further evidence. We have, however, been assisted by representations made on behalf of the family of Mohammad Alhajali, the family of Denis Murphy and the LFB, as well as by a further statement from FF Peter Herrera, one of the firefighters involved in the partial evacuation of Flat 113.262 Herrera {LFB00032237}.
¶88.4 Since they are of particular importance to understanding the circumstances of the individual deaths on floor 14, we set out first not only our general findings about the events that took place on that floor but also our findings on how four people came to be left behind in Flat 113.
The arrival of the fire
¶88.5 By 01.23, the fire had spread up the eastern face of the tower and had reached the top of floor 15.263 Phase 1 Report Volume II paragraph 10.118. Flat 116 was the first flat on floor 14 to be affected by the fire. When Nida Mangoba and her family left it, there was thick black smoke in the hallway but only light smoke in the lobby.264 Phase 1 Report Volume II paragraphs 10.233-10.235. In Phase 1, the chairman was unable to decide whether Nida Mangoba's recollection that she had left the front door open was faulty or whether the door had closed sometime after she left; FFs Desmond Murphy and Charles Cornelius later found the front door closed.265 Phase 1 Report Volume II paragraph 14.206. In any event, the front door did not impede the rapid ingress of smoke into the lobby.
38¶88.6 According to Denis Murphy, who made an emergency call at 01.25 to report a fire in the tower, by then there was already significant smoke in the lobby.266 Phase 1 Report Volume II paragraph 10.236. Oluwaseun Talabi and Rosemary Oyewole found the lobby filled with smoke when they tried to leave shortly before their first call to the emergency services at 01.37.267 Phase 1 Report Volume II paragraphs 11.91-11.92. The conditions in the lobby were such that those who remained on floor 14 after 01.30 felt unable to cross the lobby and reach the stairs.268 Phase 1 Report Volume II paragraphs 11.90-11.96 and 14.195; Phase 1 Report Volume IV paragraphs 25.10 (b) and 25.11 (b).
The first deployments to floor 14
¶88.7 By 01.45, Denis Murphy,269 Phase 1 Report Volume II paragraphs 10.236 and 11.89. Zainab Deen,270 Phase 1 Report Volume II paragraphs 10.237, 11.93, 12.58 and 12.96. and Rosemary Oyewole,271 Phase 1 Report Volume II paragraphs 11.90-11.92. had made six emergency calls of which four were to the LFB control room.272 Phase 1 Report Volume II paragraph 14.195. At that stage Omar Alhaj Ali and Mohammad Alhajali in Flat 112 had not made any calls to the emergency services but had communicated to firefighters on the ground by shouting from the windows.273 Alhaj Ali {IWS00000781/6} page 6, paragraph 17.
¶88.8 As a result of emergency calls being made from floor 14, the incident ground was informed that there were occupants trapped on that floor, which probably prompted the following actions: a. At 01.35, having answered the call from Denis Murphy, OM Alexandra Norman in
the LFB control room asked WM Daniel Meyrick in CU8 to arrange for crews to check on people trapped on different floors, including a person trapped in Flat 111 on floor 14.274 Phase 1 Report Volume II paragraph 11.149. At 01.43, CRO Sharon Darby informed CU8 that smoke was coming into flats on floor 14, although she did not mention any particular flat.275 Phase 1 Report Volume II paragraph 12.73 (d).
¶b. WM Meyrick passed the information he received to WM Mark Kentfield who was near the tower. WM Kentfield wrote it down on pieces of paper which he passed to SM Brett Loft. That included an A4 sheet of paper, which came to be known as the "Sadler envelope" and on which was written, "111, 115 14th FLOOR". SM Loft passed the information he received to the bridgehead on floor 2, probably by radio.276 Phase 1 Report Volume II paragraphs 11.5-11.6, 12.18-12.19 and Figure 12.4.
¶c. At the bridgehead information was recorded on a wall and, from some time after 01.50, on a forward information board.277 Phase 1 Report Volume IV paragraph 28.84 (b); Phase 1 Report Volume II paragraphs 13.52-13.53 and Figures 14.4 and 13.2. Although no written record was made of Flats 111 or 115, it is likely that a message about Flat 111 was received from SM Loft, since two teams of firefighters were deployed to that flat, although none were sent to Flat 115.
¶88.9 FFs Desmond Murphy and Charles Cornelius were sent to Flat 111 on floor 14 to rescue a man. They tallied out at 01.51.278 Phase 1 Report Volume II paragraph 13.7. At about the same time, FFs Harvey Sanders and Nicke Merrion were also sent to floor 14. FF Sanders recalled that they had been sent specifically to Flat 111, but FF Merrion could not recall whether they had been sent to Flat 111 or Flat 112. FF Merrion recalled that he had been instructed to tell the occupants to remain in their flat.279 Phase 1 Report Volume II paragraphs 13.11-13.12.
39¶88.10 FFs Murphy and Cornelius arrived on floor 14 first. They found Denis Murphy in Flat 111 which was quite heavily smoke-logged.280 Phase 1 Report Volume II paragraph 13.8. FFs Sanders and Merrion arrived on floor 14 soon afterwards. FF Merrion went to Flat 112, where he spoke to Omar Alhaj Ali and his brother, while FF Sanders went to Flat 113, where he met Rosemary Oyewole and Oluwaseun Talabi with their daughter. Those two flats were relatively clear of smoke.281 Phase 1 Report Volume II paragraphs 14.197 and 14.200.
¶88.11 Denis Murphy was moved initially to Flat 112.282 Phase 1 Report Volume II paragraphs 13.9 and 14.198. The four firefighters met in the lobby and agreed to move all the occupants remaining on floor 14 to Flat 113, which was furthest from the fire.283 Phase 1 Report Volume II paragraphs 14.88-14.89 and 14.201-14.203. Rosemary Oyewole and Oluwaseun Talabi agreed to their request to bring their neighbours into their flat.284 Phase 1 Report Volume II paragraph 14.202.
¶88.12 Flat 113 was a two-bedroom flat in the southwest corner of the tower.285 External Spread of Fire Report {MET00012593/12}. FF Murphy was one of the firefighters who went into the flat. Before leaving it, he counted six adults and two children. He told them that the crew were low on air and were going to change their cylinders. Although the residents wanted to leave, FF Murphy told them to stay in the flat with the door shut and that another crew would come up to them.286 Phase 1 Report Volume II paragraphs 14.90 and 14.203.
¶88.13 The firefighters' decision to move all the occupants into one flat arose from their belief that conditions in the stairwell made it impossible for eight people to leave safely,287 Phase 1 Report Volume II paragraphs 13.9, 13.13, 13.64 and 14.90. their view that Flat 113 was the safest place for them to be288 Merrion {MET000086060/8} page 8; Merrion {Day38/16:4-15}. and their concerns about how much air was left to them.289 Desmond Murphy {Day38/46:2-7}. Although it was in the stairs that people escaping from floor 14 were most exposed to asphyxiant gases, those who had absorbed only a minimal amount of carbon monoxide in their flats and the lobbies before entering them could at all times survive the descent.290 Purser {Day296/217:19-22}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/7} paragraph 26. Since people were inhaling an increasing amount of asphyxiant gases while in their flats, the longer they remained in them, the greater the danger of their accumulating an amount sufficient to cause collapse and death.291 Purser {Day297/7:18}-{Day296/8:2}. We note that some of the occupants of Flat 113 were later able safely to evacuate floor 14 without the assistance of any specialist equipment at a time when conditions were described by Rosemary Oyewole as significantly worse.292 Oyewole {Day58/75:5-13}. Although we accept that it might have been possible for the occupants of floor 14 to have escaped safely at that time, we do not consider that the decision made by FFs Merrion, Sanders, Murphy and Cornelius can be criticised, given the circumstances confronting them.
¶88.14 Some time after the firefighters left floor 14, another crew of firefighters visited Flat 113 by chance. They were FFs Luke Cook and Brian Flanagan, who went to Flat 113 between 02.03 and 02.37, probably at around 02.20. They noted that the flat contained eight people, including two children. They left the residents in the flat and returned to the bridgehead. There is no evidence that they reported the location those still on floor 14 to the bridgehead.293 Phase 1 Report Volume II paragraph 14.111.
40The second deployments to floor 14
¶88.15 On returning from floor 14, FFs Merrion, Sanders, Murphy and Cornelius told the bridgehead that residents remained on that floor. a. FFs Merrion and Sanders probably reached the bridgehead first at around 02.15.
Information appearing on both the forward information board and on a wall on floor 2294 Phase 1 Report Volume II paragraphs 13.53, 14.73, and 14.110, Figures 13.2 and 14.4. supports the conclusion that they reported that eight people were in Flat 113 on floor 14.
¶b. FFs Murphy and Cornelius' end of wear times were 02.19 and 02.18 respectively. They told WM Brien O'Keeffe, who was commanding the bridgehead on floor 3 after 02.17, that there were six adults and two children in Flat 113 in safe air, but that crews needed to go back up with second BA sets as the air was not safe for those residents to be brought down. A photograph of a wall on floor 3 shows that the words "113 8 PEOPLE" were written to the left of a sketch plan drawn on the wall.295 Phase 1 Report Volume II paragraph 14.110; Photograph of wall on floor 3 {MET00016948}.
¶88.16 The LFB control room continued to pass information about floor 14 to the incident ground even after the first deployment of firefighters: a. At 01.48, it received a call from Surrey Police passing on information that
Denis Murphy was trapped in Flat 111 on floor 14 and struggling to breathe. The information had come from Denis Murphy's brother. CRO Christine Howson created a service request and CRO Darby passed the information to the incident ground at 01.53.296 Phase 1 Report Volume II paragraph 12.95.
¶b. At the same time, Zainab Deen, still in Flat 115, spoke to CRO Howson in the LFB control room. CRO Howson created a service request at 01.54 which led, a minute later, to CRO Darby passing on a message to CU8 about a woman with a baby in Flat 115, which was heavily smoke-logged.297 Phase 1 Report Volume II paragraphs 12.58 and 12.96-12.97.
¶c. A note on a control information form identified both Flats 111 and 115 as priorities.298 Control Information Form {LFB00001968/40}. It is difficult to track this through to the bridgehead but it may explain the deployment of FFs McAlonen and Juggins, at 02.31, to which we refer below.
¶d. At 02.09, CRO Angie Gotts took a call from the police reporting that a woman was trapped with her son in Flat 115. That call was the outcome of contact between the police and Zainab Deen which had begun with her first call to the emergency services at 01.29. That call had been put through to the police but had ended abruptly. The police called her back at 02.01.299 Phase 1 Report Volume II paragraphs 10.237 and 14.249; 999 call transcripts {LFB00000341}; {INQ00000270}. It is difficult to track that information through to the bridgehead.
41¶88.17 WM Glynn Williams began recording information on a ground floor wall of the tower at 02.15. He explained that he had written "FSG @2.15" on the wall and had then begun listing information immediately below that heading. (A second list was subsequently created on the wall to the left of the first.) The order in which he listed information initially matched that on the Sadler envelope and included Flats 111 and 115.300 Phase 1 Report Volume II paragraphs 14.100-14.103 and Figure 14.5; Williams {Day31/100:8}-{Day31/101:10}. That WM Williams was also receiving fresh information, however, is suggested by his having written "1xA 1xK" (for 1 adult and 1 kid) next to Flat 115.301 Williams {Day31/113:3-5}; Phase 1 Report Volume II Figure 14.5.
¶88.18 In any event, the information that had been received from returning fire fighters and from the control room prompted the deployment of two more crews to floor 14 within minutes of FFs Murphy and Cornelius reaching the bridgehead.
¶88.19 FFs Herrera and Teresa Orchard tallied out at 02.26 and 02.27 respectively with instructions from WM Louisa de Silvo to go to Flat 113. A sketch of what looks like a football in which is written "113, FL 14th" and "Lambeth PL" (for pump ladder) was made on the wall on floor 3. Although WM De Silvo said that it was not in her handwriting, it may have related to the deployment of FFs Herrera and Orchard, given that the former was based at Lambeth Fire Station.302 Phase 1 Report Volume III paragraph 15.91; Photograph of wall on floor 3{MET00015819}; De Silvo {Day30/45:15-25}; Herrera {Day38/97:20-22}.
¶88.20 FF Herrera recalled having been told that a man, woman and child needed to be rescued. On the other hand, FF Orchard recalled that they had been instructed to rescue six people in Flat 113. Although in the Phase 1 report the chairman noted that it was unlikely that WM De Silvo had given two members of the same crew inconsistent instructions relating to the same flat, he was not able to find which account was correct.303 Phase 1 Report Volume III paragraph 15.91.
¶88.21 FF Herrera's recollection of the briefing reflects the emergency call made by Rosemary Oyewole at 01.37. However, although she mentioned that she had a baby, she did not confirm how many people were in the flat.304 Phase 1 Report Volume II paragraph 11.92; 999 call transcript {LFB00000678}. No other emergency calls were made from Flat 113 until after FFs Herrera and Orchard had set off. Although FF Orchard did not refer to six people in her contemporaneous note, we think that her recollection was more reliable on this point. It is closer in time to the earlier, but still recent, reports to the bridgehead provided by FF Merrion, Sanders, Murphy and Cornelius, even though the information about two children was lost. We find that it was those reports, and in particular the explicit reference of FFs Murphy and Cornelius to the need for crews to return to floor 14, that prompted the deployment of FFs Herrera and Orchard. It is possible, however, that some reference was made during the briefing to a family of three which, amid all the noise and activity at the bridgehead, FF Herrera mistook as his instructions.
¶88.22 CM Benjamin McAlonen and FF Elliot Juggins tallied out at 02.31 shortly after FFs Herrera and Orchard. They had been instructed by WM Paul Watson to find a woman and child in Flat 111 on floor 14.305 Phase 1 Report Volume III paragraph 15.92. That is, we think, confirmed by the inscription on the wall of floor 3 which referred to Flat 111 and floor 14, together with the word "Lambeth". Since both CM McAlonen and FF Juggins were based at Lambeth Fire Station, the note probably refers to their deployment.306 Photograph of wall on floor 3{MET00015819}; McAlonen {Day38/160:8-10}; Juggins {Day40/62:16-18}. In our view, this briefing resulted from the information received from the calls to the emergency services made at 01.48. It was wrong in that Zainab and Jeremiah Deen had been in Flat 115 and, more importantly, were by then in Flat 113 together with others.
42¶88.23 The two crews were not aware that they were both being deployed to floor 14.307 Herrera {Day38/105:22-23}; Orchard {Day39/50:18-20}; McAlonen {Day38/167:11-14}; Juggins {Day40/65:18-21} The effect of the separate briefings was that only one crew (FFs Herrera and Orchard) was deployed to Flat 113 and without the spare BA sets that FF Cornelius had said were necessary. Neither member of that crew was aware that their task was to rescue eight people from Flat 113.308 Phase 1 Report Volume III paragraph 15.91.
The partial evacuation of Flat 113
¶88.24 CM McAlonen and FF Juggins reached floor 14 first. They searched Flat 111 before then searching Flat 112.309 Phase 1 Report Volume III paragraph 15.93. CM McAlonen tried to make radio contact with the bridgehead to gain more information but could not get through. FF Orchard and FF Herrera had reached floor 14 by then and went to Flat 113.310 Phase 1 Report Volume III paragraph 15.94. The two crews described the stairwell as being full of black smoke from the bridgehead up to floor 14 and the lobby on that floor to be smoke‑logged.311 Herrera {Day38/106:13-19}; McAlonen {Day38/168:1-8}; Orchard {Day39/51:13-19}; {Day39/52:6-22}; Juggins {Day40/68:20}-{Day40/69:23}. Rosemary Oyewole and Oluwaseun Talabi said that when they left Flat 113, the lobby was full of acrid black smoke which made it difficult to breathe. The stairs were full of the same smoke but felt much hotter than the lobby. They ran down the stairwell and did not see any light until about floor 3.312 Oyewole {Day58/76:3}-{Day58/79:13}; Talabi {IWS00000851/14-15} pages 14-15, paragraphs 57-62. Omar Alhaj Ali recalled the lobby and stairwell being filled with hot smoke and without any visibility. He did not see any light in the stairwell until he reached floor 2 or 3.313 Alhaj Ali {Day59/83:18}-{Day59/85:12}.
¶88.25 There was a conflict of evidence relating to much of what happened when the firefighters reached Flat 113, but the following is not disputed. First, the evidence from both firefighters and occupants shows that Rosemary Oyewole and Oluwaseun Talabi (with their daughter tied to his back) left Flat 113 first, followed by Omar Alhaj Ali.314 McAlonen {Day38/171:10}-{Day38/173:25}; Juggins {Day40/78:7}-{Day40/81:11}; Orchard {Day39/58:1-16}; Oyewole {Day58/73:24}-{Day58/74:11}; Talabi {Day59/148:6-18}; Alhaj Ali {Day 59/71:9-19}. Second, FF Herrera was the only firefighter to enter Flat 113.315 Orchard {Day39/57:9-11}; Herrera {Day38/110:9-12}; McAlonen {Day38/170:20-22}; Juggins {Day40/81:18-23}. Third, as the chairman found in the Phase 1 report, FF Herrera did not conduct a search or secondary sweep of Flat 113.316 Phase 1 Report Volume III paragraph 15.96. Fourth, as we have already observed, four people did not leave Flat 113.
¶88.26 That four people were left behind is, on the face of it, an extraordinary state of affairs and makes it necessary to consider how it could have come about. We answer that question by reference to the evidence given by the firefighters and those who were present in Flat 113 at the time and survived the ordeal. In doing so we have considered the representations that we have already mentioned.
¶88.27 Unfortunately, the evidence bearing on the question is rather confusing. Rosemary Oyewole, Oluwaseun Talabi and Omar Alhaj Ali all gave evidence, as did FF Herrera and Orchard, but their accounts were difficult to reconcile with each other and in some cases were internally inconsistent.
43¶88.28 Rosemary Oyewole said that when her neighbours from Flats 111, 112 and 115 had been brought into her flat they had dispersed around the various rooms, as might be expected. However, after having been advised by one of the firefighters who had returned to Flat 113 that they should all go into her bedroom (the larger bedroom opposite the front door) they had congregated in that room. The two children had been sitting on the bed, Denis Murphy on the side of the bed nearer the door and Zainab Deen on the floor near the door into the hall.317 Oyewole {IWS00000852/9-11} pages 9-11, paragraphs 31-43; Oyewole {Day58/45:12}-{Day58/52:7}; {Day58/69:23}-{Day58/70:20}.
¶88.29 Rosemary Oyewole said that at the time there had been some smoke in the flat, but not enough to reduce visibility to a significant extent.318 Oyewole {Day58/48:4-8}; {Day58/59:4-22}. She said that after they had all gone into the bedroom she had kept the door closed in order to prevent smoke from coming into the room from the hall. Earlier, Oluwaseun Talabi had threatened to leave the flat by the bedroom window using an improvised rope made of bedsheets but had been dissuaded from doing so. As they waited to be rescued, however, they had become more desperate and, with the assistance of Omar Alhaj Ali and Mohammad Alhajali, Oluwaseun Talabi had begun to make a serious attempt to escape from the window with his daughter tied tightly to his back.319 Oyewole {Day58/55:15}-{Day58/56:11}; {Day58/57:13}-{Day58/58:23}; {Day58/60:9}-{Day58/65:1}. At that stage, according to Rosemary Oyewole, the bedroom door flew open and she saw a firefighter (who must have been FF Herrera) standing by the front door.320 Oyewole {Day58/67:3}-{Day58/69:22}; {Day58/85:23}-{Day58/86:20}. She rushed out of the room into the hall and out into the lobby, closely followed by Oluwaseun Talabi, who was still carrying their daughter on his back. She did not appear to have a clear recollection of having passed Denis Murphy or Zainab Deen, although she said that she must have done so; nor did she remember having said anything to the others in the room at that time.321 Oyewole {Day58/72:7-21}; {Day58/73:22}-{Day58/75:23}; {Day58/88:3}-{Day58/89:9}.
¶88.30 Oluwaseun Talabi recalled that when their neighbours had been brought into Flat 113 they had moved around quite a lot but had eventually all congregated in the larger bedroom.322 Talabi {Day59/127:9}-{Day59/128:19}. He said he remembered Mohammad Alhajali sitting on the side of the bed further from the door reading his Qur'an.323 Talabi {Day59/132:8-11}. As he was preparing to make a second attempt to leave from the window he had heard a knock at the front door. As he remembered it, the bedroom door had been open and he could see through to the front door. There was smoke in the flat, but visibility was reasonable.324 Talabi {Day59/137:6}-{Day59/138:21}. He was asked by counsel to confirm that everyone had been in the bedroom at that point. He was clear that Zainab and Jeremiah Deen had been there and also Denis Murphy, as well as himself and Rosemary Oyewole, but he was unsure whether Omar Alhaj Ali and Mohammad Alhajali had also been there or whether they had been elsewhere in the flat. He thought that if the bedroom door had been open it would have been possible to see Denis Murphy and Jeremiah Deen from the hallway.325 Talabi {Day59/139:2}-{Day59/140:23}.
¶88.31 Oluwaseun Talabi thought that the firefighter who had come to the door had not come far into the flat; indeed, he thought that he had scarcely crossed the threshold. Everything happened very quickly. He and Rosemary Oyewole had left the flat hand in hand with their daughter still tied to his back. He did not remember whether any of his neighbours had been ahead of him, or indeed what they had done. Again, he was not sure whether Omar Alhaj Ali and Mohammad Alhajali had been in the bedroom at that critical point.326 Talabi {Day59/141:2}- {Day59/143:25}.
44¶88.32 Omar Alhaj Ali recalled that when they had been moved into Flat 113, they had all initially gathered in the lounge.327 Alhaj Ali {Day59/42:8-14}. He remembered Oluwaseun Talabi's first attempt to leave by way of the window, but was not sure whether that had been the window in the bedroom or the window in the lounge.328 Alhaj Ali {Day59/47:6}-{Day59/49:6}. He remembered that they had all gathered in the bedroom, but that it had seemed quite small and that he and his brother had walked around at times.329 Alhaj Ali {Day59/60:18}-{Day59/62:19}. He described smoke coming under the front door and getting thicker in the hallway. Visibility, as he recalled, had reduced significantly.330 Alhaj Ali {Day59/58:17}-{Day59/59:17}; {Day59/67:15}-{Day59/68:22}. He was not sure whether he had been in the bedroom when the firefighters came to rescue them, because people had been moving around in the flat. He said that when the firefighter opened the front door he had seen Oluwaseun Talabi run towards it, so he had followed him. He initially said that he thought Mohammed might have been in the lounge at that time, but later said that he thought he had been with everyone else in the bedroom. When the door was opened, thick black smoke had come into the flat making it difficult to see. He was not very sure whether he himself had been in the bedroom or the living room when the firefighter had opened the door, but he had followed Oluwaseun Talabi; everyone else, including Mohammed, had been behind him. Just before that he had been talking to Mohammed, who had been standing close to him. He did not remember any firefighter going into the bedroom or the lounge and was adamant that he had not had any conversation with FF Herrera. He just remembered being bundled out of the flat and across the lobby.331 Alhaj Ali {Day59/69:18}-{Day59/80:17}; {Day59/81:2}-{Day59/83:10}.
¶88.33 When he had left the building, Omar Alhaj Ali looked for his brother and, realising that he might still be inside the tower, telephoned him. He told firefighters that Mohammed was still in Flat 113 with two other adults and a child332 Alhaj Ali {Day59/85:18}-{Day59/93:5}. but denied, as FF Herrera recalled, ever having used words to the effect that he had been mistaken.333 Alhaj Ali {Day59/93:21}-{Day59/95:17}.
¶88.34 FF Herrera said that, when he had been briefed by WM De Silvo, he had not been told to search the flat; simply that there were three people there waiting to be rescued, so he had expected them to be ready to leave as soon as he arrived.334 Herrera {Day38/102:22}-{Day38/103:11}; {Day38/120:16-20}; {Day38/128:21}-{Day38/129:7}. As explained above, we consider it more likely that WM De Silvo's briefing had reflected the information most recently received at the bridgehead.
¶88.35 FF Herrera said that he had banged on the door of Flat 113 and had shouted to those inside that they were the fire brigade and had come to take them down. He recalled that the occupants had at first appeared reluctant to open the door, perhaps because inside they were in clean, safe air, but that once they had opened the door a little he had been able to push his way in.335 Herrera {Day38/108:25}-{Day38/110:12}. Although he said that at first he had gone only into the hall, he said that he had then gone as far as the living room. That might suggest that he had gone into the main reception room (at no point did he suggest that he had gone into a bedroom), but when asked whether he had formed an impression of the number of people there he said that there had been four, two men, one woman and a child.336 Herrera {Day38/109:7}-{Day38/112:6}.
45¶88.36 In his first statement FF Herrera had said that he had seen the silhouette of a man standing in the living room. He said that he had asked him whether there was anyone else in the flat, to which the reply had been "No, I am the last one". FF Herrera said he had then taken him out into the lobby and towards the stairs. He said that he had not thought it necessary to search the flat because the man had been clear that there was no one else left in it.337 Herrera {MET00010876/5} page 5; Herrera {Day38/112:7}-{Day38/114:22}.
¶88.37 FF Herrera recalled that having told WM De Silvo and WM Williams that Flat 113 was empty, he and the other firefighters left the tower and were approached by Omar Alhaj Ali who told him that his brother was still inside the building. As FF Herrera recalled it, Omar Alhaj Ali had said words to the effect that he had been mistaken, possibly implying that he had been wrong to say that there was no one else in the flat. As a result of that conversation FF Herrera returned to the ground floor lobby and told WM Williams that there was another person in Flat 113. He then went to the bridgehead where he also told WM De Silvo, but he did not know what she had done with the information.338 Herrera {Day38/116:6-20}; {Day38/118:4}-{Day38/120:25}; {Day38/122:23}-{Day38/124:9}. Another witness, Ammar Alkabib, who described himself as a friend of Omar Alhaj Ali and Mohammad Alhajali, provided a statement to the police, in which he said that he had been at the tower when Omar was brought out. He described Omar as asking in desperation where Mohammad was and saying, "It's my mistake, it's my mistake."339 Alkabib {MET00021446/2} page 2. Omar Alhaj Ali denied, however, having said anything of the kind.340 Alhaj Ali {Day59/94:14-24}.
¶88.38 It is difficult to know what to make of this rather confused body of evidence. We are entirely confident that the man with whom FF Herrera said that he had had a brief conversation inside Flat 113 must have been Omar Alhaj Ali, since he was the only person taken out in addition to Oluwaseun Talabi, Rosemary Oyewole and their daughter, but Omar Alhaj Ali firmly denied that words of any kind had passed between himself and FF Herrera. Although the witnesses gave different descriptions of the amount of smoke in the flat, we think that by the time FFs Herrera and Orchard arrived it had probably become dense enough to restrict visibility to a significant extent. The fact that FF Herrera said that he had seen the silhouette of a man, tends to suggest that that was the case.
¶88.39 Despite the clear evidence of Rosemary Oyewole that everyone in the flat was together in her bedroom when the firefighters arrived, we think that is unlikely to have been the case. The evidence of Rosemary Oyewole and Oluwaseun Talabi suggests that as soon as the front door had been opened and the bedroom door was at least ajar, they rushed out of the room to be met by FF Herrera. In doing so they may have inadvertently obstructed his view into the room. At that point FF Herrera, who had walked further into the flat than Oluwaseun Talabi remembered and had reached the hall, saw the silhouette of a man in the lounge which caught his attention. That is not something about which he could reasonably have been mistaken and we do not think he was making it up. The man he saw was Omar Alhaj Ali, who had moved out of the bedroom into the lounge. FF Herrera said that he had reached the point at which he could see into the lounge and Omar Alhaj Ali accepted that he and his brother had moved around the flat from time to time, although the evidence suggests that the others had not done so once they had been advised to stay in the bedroom. We think it likely that, after FF Herrera had entered the flat (allowing a cloud of dense smoke to enter the hallway), the door to Rosemary Oyewole's bedroom remained partly closed, thereby obstructing his view of Denis Murphy and Jeremiah Deen, both of whom were sitting on the bed. It is difficult to know why he did not see Zainab Deen or Mohammad Alhajali; it may have been because she was sitting on the floor and he was sitting on the far side of the bed, or perhaps because of a combination of poor visibility and the speed at which events unfolded at that point. We say that because, if the door had been wide open and the room substantially free of smoke, it is difficult to see how FF Herrera could have failed to see them.
46¶88.40 We do not think FF Herrera's evidence that he had formed the impression that there were four people in the "sitting room" is reliable. His reference to two men, one woman and a child can in the circumstances only have been to Omar Alhaj Ali, Oluwaseun Talabi, Rosemary Oyewole and their daughter. He was plainly unaware, for whatever reason, of the presence of Mohammad Alhajali, Denis Murphy, Zainab Deen and Jeremiah Deen, but we think it is reasonably clear that they were all in the bedroom when he arrived. No one suggested that FF Herrera had gone into that room at any stage and, for the reasons we have given, we think it quite likely that his view of it was obstructed.
¶88.41 The sharpest conflict of evidence relates to the conversation which FF Herrera said he had had in Flat 113 with Omar Alhaj Ali. We think it very unlikely that Omar Alhaj Ali actually said that he was the last person in the flat, since, knowing that there were others, including his brother, in the bedroom, he had no reason at that stage to think that he was. On the other hand, we do not think that FF Herrera invented the conversation. One has to remember that things were happening very quickly in only moderate visibility and that FF Herrera had been expecting to find only three people. On finding a fourth, it would be natural to ask whether there was anyone else, but the question, spoken through the mask of a BA set, might have been misinterpreted as referring only to the lounge, in which there was indeed no one else.
¶88.42 Although the weight of the evidence suggests that when he had left the tower and realised that his brother had not escaped with him, Omar Alhaj Ali did say that it was his mistake, we do not think that much significance can be attached to that. When describing his escape from Flat 113 Omar Alhaj Ali said he had thought that his brother was behind him, but he did not remember what he had been doing. When saying that he had been mistaken, he may well have been referring to his assumption that Mohammed was following him out of the building and we think it likely that, having himself escaped, he felt responsible for the fact that Mohammad had not. We accept that FF Herrera was anxious to leave the flat as quickly as possible but, having discovered that it contained at least one more person than he had been led to expect, he should not have relied on what he understood to be an assurance that there was no one else there and should have looked in the other rooms.
¶88.43 We have reached these conclusions with varying degrees of confidence, but given the uncertainties inherent in the evidence, we think they provide the most likely explanation of what occurred.
The third deployment to floor 14
¶88.44 Omar Alhaj Ali left the tower at 02.45 followed a minute later by Rosemary Oyewole, Oluwaseun Talabi and their daughter.341 Phase 1 Report Volume III Annex A. CM McAlonen and FF Juggins followed them down.342 McAlonen {Day38/171:10}-{Day38/172:23}; Juggins {Day40/78:7}-{Day40/79:11}. At the bridgehead on floor 3 CM McAlonen told WM De Silvo which flats he and FF Juggins had visited and reported that three people had been brought down but that they could not confirm that Flat 113 was clear. By then the following had been written on the wall on floor 3: "14, 111, 115, 112, 113". WM Silvo put a tick through Flats 111, 112 (which CM McAlonen and FF Juggins had visited) and 113, against which she wrote "3 rescues".343 McAlonen {Day38/166:8-11}; {Day38/174:2-12}; De Silvo Exhibit LDS/3 - Photograph of wall on floor 3 {MET00015819}. CM McAlonen only mentioned "3 rescues" because, as he explained, he had not seen Rosemary Oyewole and Oluwaseun Talabi's daughter.344 McAlonen {Day38/173:9}.
47¶88.45 FF Herrera told WM De Silvo that Flat 113 had been searched and was empty. He said the same to WM Williams who put a tick next to the flat number on the ground floor wall, indicating that it had been cleared.345 Herrera {Day38/116:6-9}. That may explain why "113/14" (with 113 circled and ticked) appears next to "3 rescues" on the wall.346 De Silvo Exhibit LDS/3 - Photograph of wall on floor 3 {MET00015819}. As recorded in the Phase 1 report, a circle indicated that further information had been received and a cross through the number of the flat indicated that it had been searched and a rescue carried out.347 Phase 1 Report Volume IV paragraph 28.86. It may also explain why a tick and "BA" (to show a crew had been deployed to and reached a flat) appears next to "113 14th" towards the bottom of the first list that WM Williams had made.348 Williams {Day31/106:17}-{Day31/107:21}; Phase 1 Report Volume II Figure 14.5.
¶88.46 We have mentioned that, on reaching the ground floor of the tower, Omar Alhaj Ali spoke to firefighters. The first of those conversations occurred even before FF Herrera spoke to WM Williams. Omar Alhaj Ali explained, by reference to a set of CCTV stills timed at 02.44, that he had been telling firefighters that other people remained in Flat 113, including his brother.349 Alhaj Ali {Day59/85:24}-{Day59/90:17}. One of those firefighters was WM Williams.350 CCTV Stills {INQ00000449}, {INQ00000450}, {INQ00000253}, Williams {Day31/140:18}. In each still, WM Williams is the firefighter without a helmet. That occupants still remained in Flat 113 was reinforced by FF Herrera's return at 02.57351 LFB Operational Response Report {LFB00119333/248}. following his conversation with Omar Alhaj Ali outside the tower.
¶88.47 The information now available at the bridgehead probably prompted the deployment of FFs Jon Wharnsby and Terence Lowe, a crew based at Shoreditch, who tallied out at 03.04 to go to Flat 113 on floor 14.352 BA Telemetry data {LFB00023326}; Wharnsby {Day38/186:16}-{Day38/187:13}. The word "Shoreditch" appears just above "14 113" on the wall on floor 3, where the bridgehead was located up to about 03.10, which supports the conclusion that the entry relates to the deployment of that crew. However, the two firefighters did not reach floor 14. They encountered people in the stairwell whom they assisted down. FF Wharnsby recalled that by the time he and his colleague returned to the bridgehead it had moved to the ground floor. He said that he had made sure that others were aware that they had not completed their original task.353 Wharnsby {Day38/188:19}-{Day38/189:3}; {Day38/191:18}-{Day38/197:4}.
Information to the incident ground after 03.00
¶88.48 Zainab Deen made two further emergency calls at 03.06 and 03.17, both of which were answered in the LFB control room.354 Phase 1 Report Volume III paragraphs 17.93 and 17.94. In the first, CRO Sarah Russell took care to confirm her location, which she gave as Flat 113 on floor 14. The call ended abruptly.355 999 call transcript {LFB00000405}. In the first call Zainab Deen did not say how many people were in Flat 113, but in the second she said that she was there with her baby. She did not mention anyone else.356 999 call transcript {LFB00000418}. That this information reached the incident ground is apparent from the following:
48¶a. A reference to Flat 113 appears on the second of two whiteboards used by SM Jason Oliff to collate information to pass from the control room to the command units. The entry includes the following: "Inside can't leave phone went dead.".357 Phase 1 Report Volume III paragraphs 15.139-15.141 and Figures 15.8 and 15.9.
¶b. A control information form on which is written "Flat 113, line gone dead" and "call from CU". The form is marked priority and timed at 3.21.358 Control Information Form {LFB00001968/44}.
¶c. The first entry in the second list created by WM Williams on the ground floor wall concerns Flat 113 and has "line dead" written next to it.359 Phase 1 Report Volume II Figure 14.5; Williams {Day31/137:13}-{Day31/139:21}. WM Williams said that the note "BA" which appears next to"113" was not intended to be linked by an arrow to that flat but to Flat 123 which appears immediately next in the list.
¶88.49 From about that time, friends of Zainab Deen and Mohammed Alhajali, who were in contact with them by telephone, approached police officers and firefighters with information as follows: a. Mahmoud Al-Karad, a friend of Omar Alhaj Ali and his brother who also lived in
Flat 112, spoke to Mohammad Alhajali by telephone several times during the fire. Their last call was at 03.19 during which Mohammad Alhajali said that there had been eight people in Flat 113 and now there were only four. Mahmoud Al-Karad passed that information on to the police at the scene and was told that the control room would be informed.360 Al-Karad {IWS00000821/8-9} pages 8-9, paragraph 35; Al-Karad Exhibit MAK2 – telephone log {IWS00000791}. Whether it was passed on is uncertain but we observe that among the material found in CU7 was a note from the police recording that four people were in Flat 112 and four in Flat 113.361 Metropolitan Police Memo {LFB00001968/26}. That was wrong in part, because there were never four people trapped in Flat 112, but it is possible that the information provided by Mahmoud Al-Karad became confused at some point in transmission. It may also explain a note on the ground floor wall used by WM Williams to record information later in the night that eight people were trapped in Flat 112.362 Phase 1 Report Volume II Figure 14.5.
¶b. Francis Dean, a friend of Zainab Deen, began his last call with her at 03.34.363 Zainab Deen call records. These records were not available to the Inquiry at the time of publication of the Phase 1 Report. During that call, Francis Dean passed the telephone to CM Christopher Batcheldor, who then continued to speak to Zainab Deen for over an hour. He gave her location to WM Thomas Furnell who was organising FSG information. WM Furnell confirmed that he was already aware of Zainab Deen.364 Phase 1 Report Volume III paragraphs 17.95-17.97; Furnell {Day40/5:8-14}; {Day40/6:7-20}; {Day40/8:20}. CM Batcheldor subsequently took a note on which Francis Dean had written his name and telephone number and the names and ages of Zainab and Jeremiah Deen to CU7.365 Batcheldor {Day34/172:5}-{Day34/173:10}; Notebook entry {LFB00001968/17}.
¶88.50 In the Phase 1 report the chairman found that CM Mayne and FF Lundquist, a crew wearing extended duration breathing apparatus, were deployed as a result of FF Herrera's report to the bridgehead that he had apparently not rescued all the occupants of Flat 113.366 Phase 1 Report Volume IV paragraph 28.114. However, having reviewed the evidence further, we now think it more likely that they were in fact deployed in response to the two emergency calls made by Zainab Deen after 03.00. They were instructed to go to Flat 113 on floor 14 and tallied out at 03.29.367 Phase 1 Report Volume III paragraph 17.20 (d). FF Lundquist recalled that the briefing was to rescue a mother and baby or small child. That must have been Zainab Deen and Jeremiah. When the crew reached the front of the queue of BA wearers at the bridgehead, however, their instructions were changed and they were redeployed to floors 3 and 4.368 Phase 1 Report Volume III paragraph 17.20 (d). As we have explained above, it is likely that the information FF Herrera gave to the bridgehead prompted the earlier deployment of FFs Wharnsby and Lowe at 03.04. The time of the deployment and the nature of the briefing approximate more closely to the contents of Zainab Deen's calls than the information FF Herrera had given to the bridgehead.
49¶88.51 Even without the additional information, the bridgehead was aware shortly after the partial evacuation of Flat 113 that people were still trapped there. The fire did not reach the exterior of the bedroom, where the occupants had sheltered, before 03.35.369 Purser, Phase 2 Report, Section 6 {DAPR0000006/143} paragraph 769; External Fire Spread Report {MET00012593/78} image 42 (applying a +58 minute correction to timestamp). Even though conditions in the flat began to deteriorate rapidly thereafter,370 Purser, Phase 2 Report, Section 6 {DAPR0000006/146-147} paragraph 793. Zainab Deen and Mohammad Alhajali were still in contact with friends outside the tower. However, no more firefighter crews were able to reach Flat 113.
Denis Murphy
¶Date of birth: 10 October 1960 (56 years). Place of birth: Hammersmith, London. Gender: Male. Occupation: Painter and Decorator. Usual address: Flat 111, floor 14, Grenfell Tower, London, W11. Place of death: Flat 113, floor 14, Grenfell Tower, London, W11. Time of death: Between 04.05 and 04.35 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶88.52 Born on 10 October 1960, Denis Murphy was 56 years old in June 2017. He was the eldest of four children in a close-knit family and had two brothers and a sister. Denis Murphy had first moved into Grenfell Tower in 1984 with his wife and was still living there when his son was born in 1989. He returned to the tower in 1997 after he and his wife separated amicably. Denis Murphy continued to live at Grenfell Tower for the next 20 years and lived alone in Flat 111. A painter and decorator by trade, he was not working at the time of the fire. His passion for sport was something he maintained throughout his life.371 Phase 1 Report Volume IV paragraphs 32.285-32.291.
50Vulnerability
¶88.53 Denis Murphy had emphysema.372 Murphy {IWS00001049/2} page 2, paragraph 4. The spreadsheet produced on the night of the fire by David Noble based on information held on the TMO's Capita Insight system373 Noble {Day119/77:17}-{Day119/82:5}. identified Denis Murphy as a resident but not as having any particular vulnerability.
Events of 14 June 2017
¶88.54 We have set out our general findings about the events on floor 14 above. We focus here on factual matters of specific relevance to the death of Denis Murphy.
¶88.55 Denis Murphy returned to Grenfell Tower during the afternoon of 13 June 2017.374 O'Riordan {MET00013136/2} page 2. He did not leave after that.
¶88.56 As we have already observed, Flat 116 was the first flat on floor 14 to be affected by the spread of the fire up the tower. Flat 111 was on the east side of Grenfell Tower located between Flats 116 and 112375 External Fire Spread Report {MET00012593/7}. and was close to the exterior fire once it reached Flat 116. When he made his first 999 call from floor 14 at 01.25, Denis Murphy told OM Norman that the fire was outside his window. There was no smoke in the flat although he could smell it. Later in the call Denis Murphy reported that smoke was entering the flat from the lobby. The amount of smoke in the lobby was sufficient to deter him from leaving.376 Phase 1 Report Volume II paragraphs 10.236 and 10.312.
¶88.57 Denis Murphy then called his brother Timothy Murphy and left a message. Timothy returned the call at about 01.36. During the call he could hear a smoke alarm in the background. Denis Murphy was coughing and sounded distressed and in a state of panic. He opened the front door when his brother told him to leave but then told Timothy Murphy that it was pitch black in the lobby and that smoke was coming into the flat. Timothy told Denis that he would call the emergency services and to shelter in the bathroom.377 Murphy {IWS00001049/2} page 2, paragraph 4.
¶88.58 The conditions in Flat 111 deteriorated rapidly. When at 01.40, Denis Murphy spoke to CRO Howson in his second 999 call, he told her that his flat was full of smoke coming in from the windows and front door and that he was sheltering in the bathroom. CRO Howson advised him to block the bathroom door with towels and reassured him that firefighters were on their way.378 Phase 1 Report Volume II paragraphs 11.89 and 12.70.
¶88.59 Having spoken to Surrey Police, Timothy Murphy rang Denis Murphy again and reassured him that help was on its way.379 Murphy {IWS00001049/2} page 2, paragraph 6. Surrey Police spoke to the LFB control room at 01.48. They gave Denis Murphy's name and location and said that he was trapped in the bathroom and struggling to breathe.380 Phase 1 Report Volume II paragraph 12.95.
¶88.60 As we have explained earlier in this part of the report, these calls to the emergency services (together with calls from other occupants trapped on floor 14) led to the deployment of firefighter crews to that floor.
51¶88.61 FFs Murphy and Cornelius were the first crew to arrive on floor 14. They found Flat 111 to be heavily smoke logged. Denis Murphy was conscious but bent over and coughing with soot on his face. The firefighters immediately brought him into the lobby where the air was clearer. They decided not to escort him down the stairs, given the smoke conditions that they had encountered in the stairwell.381 Phase 1 Report Volume II paragraphs 13.8-13.9. Following the arrival of FFs Sanders and Merrion on floor 14, Denis Murphy was moved to Flat 112 where the air was clear. Omar Alhaj Ali recalled that he had been coughing and having difficulty breathing when he came into Flat 112.382 Phase 1 Report Volume II paragraphs 14.198-14.199. Subsequently, Denis Murphy was moved into Flat 113.383 Phase 1 Report Volume II paragraphs 14.90 and 14.202.
¶88.62 Rosemary Oyewole did not recognise Denis Murphy when he first came into Flat 113; his face was covered in thick, black soot.384 Oyewole {IWS00000852/9} page 9, paragraph 34. While he was able to move without help, Denis Murphy was quiet and appeared to be in shock.385 Oyewole {Day58/47:8-13}. Rosemary Oyewole helped him to wash his face and removed some of the soot from his eyes.386 Oyewole {IWS00000852/10} page 10, paragraph 37; Talabi {Day59/127:17}–{Day59/128:8}. She left him in the living room, but when another set of firefighters (FFs Cook and Flanagan) visited the flat and told them to stay in the bedroom, she and Oluwasean Talabi encouraged Denis Murphy to move there. When he did do so, Denis Murphy sat on the edge of the bed.387 Oyewole {IWS00000852/11} page 11, paragraph 42; Alhaj Ali {Day59/62:2-5}.
¶88.63 Denis Murphy remained in contact with his family. Timothy Murphy and his partner, Angela, spoke to him several times during the fire, but he could not remember the precise times of those calls or what they had said. The last contact Denis Murphy had with his family was at about 02.30 when he spoke to his sister Anne Murphy and his son Peter Murphy. He told them that he was in a neighbour's flat and that he was struggling with his breathing.388 Phase 1 Report Volume III paragraph 19.40. Anne Murphy continued to call Denis Murphy's telephone until 06.00 but received no answer.389 Phase 1 Report Volume III paragraph 19.40.
¶88.64 Although all those in Flat 113 were initially sheltering in different parts of it, most of them began to congregate in the bedroom facing the front door.390 Phase 1 Report Volume II paragraph 14.206. We have set out above our analysis of their movements and how Denis Murphy came to be left behind during the partial evacuation which followed the deployment of CM McAlonen and FFs Juggins, Herrera and Orchard to floor 14. We conclude that the bridgehead was aware shortly after that partial evacuation that people remained trapped on floor 14. No other firefighters were able to reach that floor.
¶88.65 There was no direct contact with Denis Murphy after the partial evacuation. There is nothing in the 999 calls made by Zainab Deen at 03.06 and 03.17391 999 call transcript {LFB00000405}; 999 call transcript {LFB00000418}; Phase 1 Report Volume III paragraphs 17.93-17.94. or from the longer call that she had with CM Batcheldor392 Phase 1 Report Volume III paragraphs 17.95-17.97. which offers any information about Denis Murphy. That call ended at 04.48.393 Zainab Deen call records. These records were not available to the Inquiry at the time of completion of the Phase 1 Report.
52¶88.66 Mohammad Alhajali's friends and family gathered outside the tower and were able to reach him by telephone. His last conversation was with his brothers Omar and Hashem, during which Mohammad said that others in the flat were no longer responding to him. The precise time at which the call ended is uncertain. Hashem Alhajali thought that it had ended between 04.00 and 05.00, but Omar Alhaj Ali was taken to hospital at 04.26.394 Hashem Alhajali {MET00007745/4} page 4; Phase 1 Report Volume III paragraphs 19.32-19.33 A friend and flatmate, Mahmoud Al-Karad, was with Omar when he was speaking to Mohammad. Mahmoud Al-Karad was unable to reach Mohammad Alhajali after 04.26.395 Phase 1 Report Volume III paragraph 19.34. A cousin, Aesem Alhajali, said that there came a time between 04.00 and 05.00 when no one was able to reach Mohammad Alhajali. It was as if his phone had been switched off.396 Aesem Alhajali {MET00039851/6} page 6. In a 999 call at 05.05, Ammar Al Kabir, a cousin, said that he had last spoken to Mohammad Alhajali an hour earlier (evidence which we think is more reliable than his later recollection that the call had taken place at 04.30). In the circumstances, we conclude that the last contact with Mohammad Alhajali probably occurred at about 04.05. Following that contact, Mohammad Alhajali fell to his death from the tower.
¶88.67 The fire first reached the outside of the bedroom where those in Flat 113 had sheltered at about 03.33.397 Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} Images 41-42 (applying a +58 minute correction to timestamps). If they had not already done so, it would have caused them to move into the living room, which, being the most south-westerly part of the flat, would have been furthest away from the approaching fire. The fire reached the south side of the living room at about 03.52 but the west side of the flat remained unaffected.398 Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} page 78, Image 47 (applying a +58 minute correction to timestamps). The fire did not begin to affect the west side of the flat until sometime between 04.23 and 04.28.399 External Spread of Fire Report {MET00012593/85} Images 44-47 (applying a +58 minute correction to timestamps). In calls with friends and family outside the tower, Mohammed Alhajali asked that firefighters continue directing water at the part of the tower where Flat 113 was located.400 Phase 1 Report Volume III paragraphs 17.88 and 19.35. From 03.28 a ground monitor was used to apply a jet of water to the south side of the tower although its reach varied.401 Stoianov, Chapter 5 {ISTRP00000006/141}, {ISTRP00000006/142}; {ISTRP00000006/148-153}.
Recovery and identification
¶88.68 Denis Murphy's remains were recovered from the kitchen area of Flat 113.402 Purser, Phase 2 Report, Section 6 {DAPR0000006/151} paragraph 826. The coroner was satisfied about the identification of those remains and so issued an interim certificate of the fact of death.
Cause and time of death
¶88.69 The post-mortem report on Denis Murphy recorded the medical cause of death as "consistent with the effects of fire", but in the light of more recent evidence we find that a more accurate description is "inhalation of asphyxiant gases". Toxicological testing was not possible.
¶88.70 We accept Professor Purser's conclusion that Denis Murphy had suffered significant exposure to smoke by the time he was moved to Flat 113.403 Purser, Phase 2 Report, Section 6 {DAPR0000006/139} paragraph 748. In the time that he sheltered in Flat 113 he continued to be exposed to asphyxiant gases in the smoke coming into the flat, particularly from the lobby. That exposure increased significantly with the arrival of the fire outside the bedroom where he was sheltering. Conditions in Flat 113 continued to worsen as the fire spread to the south side of the living room.
53¶88.71 The location of Denis Murphy's remains is consistent with his having moved from the bedroom once the fire had reached that point. Although we do not have a record of the level of carboxyhaemoglobin in his blood, we note that in a sample taken from Mohammad Alhajali it had reached the threshold lethal level of 50%.404 Purser, Phase 2 Report, Section 6 {DAPR0000006/154} paragraph 845. That supports our conclusion that the level of asphyxiant gases in Flat 113 after 03.33 was sufficient to cause Denis Murphy to lose consciousness. He continued to inhale those gases until his respiration and circulation ceased and he died at some time between 04.05 and 04.35. We are satisfied that Denis Murphy died before suffering any direct effects of fire.
Zainab Deen
¶Date of birth: 25 May 1985 (32 years). Place of birth: Freetown, Sierra Leone. Gender: Female. Occupation: Unemployed. Usual address: Flat 115, floor 14, Grenfell Tower, London, W11. Place of death: Flat 113, floor 14, Grenfell Tower, London, W11. Time of death: 04.35 to 04.50 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Jeremiah Deen
¶Date of birth: 4 December 2014 (2 years). Place of birth: London, UK. Gender: Male. Occupation: N/A. Usual address: Flat 115, floor 14, Grenfell Tower, London, W11. Place of death: Flat 113, floor 14, Grenfell Tower, London, W11. Time of death: Between 03.30 and 04.00 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶88.72 Zainab Deen lived in Flat 115 with her son Jeremiah Deen. She was born on 25 May 1985 in Freetown, Sierra Leone and was 32 years old. She had moved to the UK at the age of 16. Jeremiah was born on 4 December 2014 in London. He was two and a half years old at the time of the fire and attending a local nursery.405 Phase 1 Report Volume IV paragraphs 32.266-32.273.
54Vulnerability
¶88.73 Zainab and Jeremiah Deen moved into Flat 115 in February 2015. When signing her tenancy agreement with RBKC Zainab Deen confirmed that she did not have a disability.406 Tenancy Agreement for Zainab Deen {TMOH00013271}. The spreadsheet produced on the night of the fire by David Noble based on information held on the TMO's Capita Insight system407 Noble {Day119/77:17}-{Day119/82:5}. identified Zainab and Jeremiah Deen as residents. Jeremiah was identified as being under 18.
Events of 14 June 2017
¶88.74 We have set out our general findings about the events on floor 14 above. We focus here on factual matters of specific relevance to the deaths of Zainab and Jeremiah Deen.
¶88.75 On 13 June 2017, Zainab Deen had had a successful job interview.408 Dean {IWS00001048/2} page 2, paragraph 10. She returned to the tower with Jeremiah and her friend, Francis Dean, between 21.30 and 22.00.409 Dean {IWS00001048/3} page 3, paragraph 11. Zainab and Jeremiah Deen were seen on CCTV in the lift lobby at 23.20 having come down with Francis Dean when he left the tower.410 O'Riordan {MET00013136/4} page 4; Dean {IWS00001048/3} page 3, paragraph 14.
¶88.76 Zainab Deen made her first call to the emergency services a few minutes after the fire had reached floor 14.411 Phase 1 Report Volume II paragraph 10.118. Having been connected to the police control centre at 01.29, she reported that she was on floor 14 and had a baby with her. The call then disconnected.412 Phase 1 Report Volume II paragraph 10.237; 999 call transcript {INQ00000270/3-4}.
¶88.77 At 01.38, Zainab Deen spoke to CRO Yvonne Adams in the LFB control room. She sounded distressed. She was able to tell CRO Adams that smoke was coming into her flat through the door and windows. CRO Adams advised Zainab Deen to block up the doors and shut the windows, which she did. She was not able to confirm Zainab Deen's location before the call ended abruptly.413 999 call transcript {LFB00000321/7}.
¶88.78 At 01.48, Zainab Deen spoke to CRO Christine Howson in the LFB control room and was able to say that she was in Flat 115 on floor 14 with her baby. There was now smoke throughout the flat. CRO Howson advised her that the flat was "the safest place" and to keep trying to stop smoke coming in. She told Zainab Deen that the fire was not on floor 14 and said that she would alert the firefighters who would come to her.414 Phase 1 Report Volume II paragraphs 12.58 and 12.96.
¶88.79 As we have explained earlier in this part of the report, Zainab Deen's calls to the emergency services (together with those from others trapped on floor 14) led to the deployment of firefighter crews to that floor, albeit none were sent specifically to Flat 115.
¶88.80 At 02.01 and before any firefighters had visited Flat 115 the police operator who had spoken to Zainab Deen at 01.29 called her back. Zainab Deen was very distressed. The operator advised her that the fire brigade was trying to evacuate everyone and asked whether she could go downstairs.415 999 call transcript {INQ00000270/3-4}. At 02.12 the operator told the LFB control room that Zainab Deen and her son were trapped in Flat 115.416 999 call transcript {LFB00000341}.
55¶88.81 FF Murphy recalled that, when they found Zainab Deen in Flat 115, she was very frightened and asked the firefighters not to leave her and her son alone.417 Phase 1 Report Volume II paragraph 14.203. Others sheltering in Flat 113 describe her as panicking for much of the time she was there.418 Oyewole {Day58/46:16}; Omar Alhaj Ali {Day59/46:17-18}. Rosemary Oyewole carried Jeremiah Deen to the bedroom opposite the front door and put him on the bed with her own daughter.419 Oyewole {Day58/46:19-23}. Once in Flat 113, Zainab Deen spent much of her time on the telephone.420 Oyewole {Day58/46:24}-{Day56/Day47:4}. After she had moved to the bedroom opposite the front door she got up three or four times to open the door believing she could hear that help had arrived. Zainab Deen was very frightened and so Rosemary Oyewole had to be forceful when shouting at her to close the door. At that time, there was already smoke in the hallway of Flat 113.421 Oyewole {Day58/59:4-15}. After that Zainab Deen remained sitting on the floor by the door to the bedroom.422 Oyewole {Day58/61:19-20}; {Day58/69:23}-{Day58/70:20}; {Day58/87:15}.
¶88.82 At 02.12, Zainab Deen made another 999 call. It could not be put through to the LFB control room and the operator was in the course of transferring it to North West Fire Control when it was abandoned.423 Phase 1 Report Volume II paragraph 14.255. When that fire service called Zainab Deen back at 02.21, she gave her address as Flat 115 on floor 14, although she had by now been moved to Flat 113.424 999 call transcript {MET00017520}. Francis Dean also spoke to North West Fire Control at 02.17 and told them that a woman and her son (he described them as his sister and her son) were trapped in Flat 115 on floor 14.425 999 call transcript {LFB00000694}. It does not appear that North West Fire Control passed the information from those calls to the LFB, but by then Zainab and Jeremiah Deen had already been moved to Flat 113.
¶88.83 Francis Dean had returned to the tower when Zainab Deen called him at 01.38 to tell him of the fire. They remained in contact, speaking again at 02.00 and 02.03, when she said she was now in Flat 113.426 Phase 1 Report Volume III paragraph 17.91. As well as making calls to the emergency services, Francis Dean spoke to firefighters and police officers telling them that Zainab Deen and her son were still in the tower.427 Phase 1 Report Volume III paragraph 17.92.
¶88.84 While initially all those now sheltering in Flat 113 were in different parts of the flat, they began to congregate in the bedroom facing the front door.428 Phase 1 Report Volume II paragraph 14.206. We have set out above our analysis of their various movements and how Zainab and Jeremiah Deen came to be left behind during the partial evacuation of Flat 113 which followed the deployment of CM McAlonen and FFs Juggins, Herrera and Orchard to floor 14.
¶88.85 Following that partial evacuation, Zainab Deen made two further 999 calls, both of which reached the LFB control room. At 03.06, Zainab Deen spoke to CRO Sarah Russell who was able to confirm that she was in Flat 113 on floor 14. It appears that Zainab Deen was still in the bedroom (she is heard to tell someone not to open the door). She also said that they were covered with smoke and that her baby was unconscious. When CRO Russell asked if they could leave, Zainab Deen replied: "No, we can't leave. Nobody is coming for us."429 Phase 1 Report Volume III paragraph 17.93. At 03.17, Zainab Deen made her last 999 call. She told CRO Howson that she was in Flat 113. CRO Howson advised her to cover herself with a towel and make her way down the stairwell. She told Zainab Deen to expect smoke in the stairwell. Zainab Deen appeared to agree to leave with Jeremiah.430 Phase 1 Report Volume III paragraph 17.94.
56¶88.86 Those 999 calls led to the deployment of CM Mayne and FF Lundquist. However, no firefighter was able to reach floor 14 after the partial evacuation of Flat 113.
¶88.87 Zainab Deen's final call to Francis Dean was the last contact with her. The call began at 03.34 and ended at 04.48.431 Zainab Deen call records. These records were not available to the Inquiry at the time of completion of the Phase 1 Report. She told Francis Dean that Jeremiah had collapsed. Francis Dean tried to tell Zainab Deen to cover herself and her son in wet blankets and leave but she refused to do so because of the smoke.432 Phase 1 Report Volume III paragraphs 17.94-17.95.
¶88.88 As the call continued, Francis Dean encountered CM Batcheldor and passed his telephone to him. CM Batcheldor remained on the call with Zainab Deen for what he estimated to be over an hour. Shortly after beginning to speak to her, CM Batcheldor gave her location to WM Furnell who confirmed he was already aware of a call from her. He did not know that firefighters had already been sent to Flat 113 but had then had their instructions changed before they set out.433 Phase 1 Report Volume III paragraphs 17.96-17.97.
¶88.89 Zainab Deen told CM Batcheldor that she could not get out and that she had been told to stay in the flat, which he took to mean that the stay put policy was still in place. His view was that Zainab Deen was trapped in the flat. CM Batcheldor sought to reassure her and concentrated on keeping her safe by advising her to move to the least smoky room, to lie down on the floor and to cover Jeremiah's face with a cloth. When their conversation began, Zainab Deen said there was smoke in the flat but made no mention of fire.434 Batcheldor {Day34/162:3}-{Day34/164:20}.
¶88.90 When he first began speaking to Zainab Deen, CM Batcheldor was able to hear Jeremiah Deen in the background. About 35 minutes into the call, she told him that her son had died. At this point CM Batcheldor passed the phone to Francis Dean for a few seconds, asking him to encourage Zainab Deen not to give up.435 Batcheldor {Day34/164:23}-{Day34/168:24}. He returned to WM Furnell to ask what the position was and was told that firefighters could not get past floor 12.436 Batcheldor {Day34/168:24}-{Day34/169:22}.
¶88.91 CM Batcheldor remained on the line speaking to Zainab Deen for about another 35 minutes. She was coughing and spluttering but became increasingly quiet. He could not hear anyone else in the background. There was silence for about five or 10 minutes before CM Batcheldor then heard her screaming before becoming silent again. After about another 10 minutes he believed Zainab Deen had died. He waited a few more minutes before disconnecting the call.437 Batcheldor {Day34/170:3}-{Day34/171:9}; Batcheldor {MET00007511/7} page 7.
¶88.92 CM Batcheldor did not tell Francis Dean that the line had gone silent, just that the battery had died. Francis Dean tried to call Zainab Deen again, but she did not answer.438 Phase 1 Report Volume III paragraph 17.99.
57¶88.93 The fire first reached the outside of the bedroom where those in Flat 113 had sheltered at about 03.33.439 Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} page 78, Images 41-42 (applying a +58 minute correction to timestamps). If they had not already done so, that would have caused them to move into the living room, which, being the most south-westerly part of Flat 113, was farthest from the approaching flames. The fire reached the south side of the living room at about 03.52 but the west side of the flat was not affected.440 Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} Image 47 (applying a +58 minute correction to timestamps). It did not begin to affect the west side of the flat until sometime between 04.23 and 04.28.441 External Spread of Fire Report {MET00012593/85} Images 44-47 (applying a +58 minute correction to timestamps). In calls with friends and family outside the tower, Mohammed Alhajali asked that firefighters continue to direct water at the part of the tower where Flat 113 was situated.442 Phase 1 Report Volume III paragraphs 17.88 and 19.35. From 03.28 a ground monitor was used to apply a jet of water to the south side of the tower although its reach varied.443 Stoianov, Chapter 5 {ISTRP00000006/141}, {ISTRP00000006/142}; {ISTRP00000006/148-153}.
Recovery and identification
¶88.94 The remains of Zainab and Jeremiah Deen were recovered from the living room of Flat 113.444 Purser, Phase 2 Report, Section 6 {DAPR0000006/152} paragraph 827. The coroner was satisfied about the identification of those remains and so issued interim certificates of the fact of death for both Zainab Deen and her son.445 Interim certificate of the fact of death for Zainab Deen {MET00065637}; Interim certificate of the fact of death for Jeremiah Deen {MET00065619};
Cause and time of death
¶88.95 The post-mortem for Zainab Deen found evidence of soot inhalation. Analysis of a blood sample detected carboxyhaemoglobin but it was not possible to measure its concentration.446 Zainab Deen post-mortem report {COR00001553}; Zainab Deen toxicology report {MET00039590}; Purser Phase 2 Report, Section 6 {DAPR0000006/152} paragraph 827. The post-mortem for Jeremiah Deen found soot stained mucus in the respiratory system. Carboxyhaemoglobin was detected in a blood sample at a high concentration albeit the level could not be measured.447 Jeremiah Deen post-mortem report {COR00000735}; Jeremiah Deen toxicology report {MET00039530}; Purser Phase 2 Report, Section 6 {DAPR0000006/152} paragraph 828.
¶88.96 In both cases, the examining pathologist was able to give the medical cause of death as "inhalation of fire fumes". In light of more recent evidence, we find that a more precise description is "inhalation of asphyxiant gases".
¶88.97 The exposure of Zainab and Jeremiah Deen to asphyxiant gases increased once the fire reached the west side of Flat 113 with the consequent deterioration of conditions inside. They and the other occupants were able, at least initially, to move to those parts of the flat which the fire had yet to reach. However, conditions worsened once the fire reached the south side of the flat.
¶88.98 During the call with CM Batcheldor, Zainab Deen was increasingly affected by the significant levels of toxic smoke permeating Flat 113 and as a result she struggled to respond to him. At a relatively late stage of the call Zainab Deen screamed out. We think that is more likely to have been because she realised that the fire was very close (and may even have begun to penetrate the flat) rather than because she was being directly affected by the fire itself. A significant period of time then elapsed (we think it could have been as much as 10 to 15 minutes) before CM Batcheldor disconnected the call, during which Zainab Deen made no response at all. We think that she died during that period, probably between 04.35 and 04.50. We are satisfied that Zainab Deen died before suffering the direct effects of fire.
58¶88.99 The rate at which a child absorbs asphyxiant gases is roughly twice that of an adult,448 Purser, Phase 2 Report, Section 6 {DAPR0000006/153} paragraph 834. which supports our conclusion that Jeremiah died before his mother. He was already beginning to be unresponsive by 03.06 when she spoke to CRO Russell. In the light of CM Batcheldor's evidence we conclude that Jeremiah Deen died at some time between 03.35 and 04.10. Like his mother he would have lost consciousness but continued to inhale asphyxiant gases until his respiration and circulation ceased and he died. Jeremiah Deen died before suffering the direct effects of fire.
Mohammad Alhajali
¶Date of birth: 27 November 1993 (23 years). Place of birth: Damascus, Syria. Gender: Male. Occupation: Student. Usual address: Flat 112, floor 14, Grenfell Tower, London, W11. Place of death: Grenfell Tower, Grenfell Road, London, W11. Time of death: Between 04.30 and 04.56 on 14 June 2017. Cause of death: Multiple injuries consistent with a fall from height.
Background and composition of household
¶88.100 Mohammad Alhajali was born on 27 November 1993 in Damascus, Syria. He grew up in Darra, a small city in the south of Syria, with his parents and four siblings. In 2014, he left Syria with his brother Omar and came to the United Kingdom. He remained in close contact with his family in Syria, speaking to them every day.449 Phase 1 Report Volume IV paragraph 32.279.
¶88.101 In June 2017, Mohammad Alhajali was 23 years old. He was studying engineering at university and working part-time. He was engaged to be married and was looking forward to building a life for his family in the United Kingdom.450 Phase 1 Report Volume IV paragraph 32.281.
¶88.102 Mohammad Alhajali lived in Flat 112 with his brother, Omar Alhaj Ali, and their childhood friend, Mahmoud Al-Karad.451 Phase 1 Report Volume IV paragraph 32.274.
Vulnerability
¶88.103 Mohammad Alhajali did not have any known vulnerabilities. He was not recorded in the spreadsheet produced on the night of the fire by David Noble based on information held on the TMO's Capita Insight system452 Noble {Day119/77:17}-{Day119/82:5}. because he was a tenant of a private landlord.
59Events of 14 June 2017
¶88.104 We have set out our general findings about the events on floor 14 above. We concentrate here on factual matters of specific relevance to the death of Mohammad Alhajali.
¶88.105 On the evening of 13 June 2017, Omar Alhaj Ali and Mohammad Alhajali went to their cousins' house to break the Ramadan fast together.453 Alhaj Ali {IWS00000781/4} page 4, paragraph 12. They returned to the tower at around midnight.454 Mohammad Alhajali appears on CCTV returning to the tower at 00.07. O'Riordan {MET00013136/4}. Mohammad Al-Karad was still at work.455 Phase 1 Report Volume II paragraph 11.94. He returned after the fire had started.
¶88.106 The two brothers were alerted to the fire when they heard shouting outside and smelt smoke. The sight of flames at the level of floors 4 and 5 prompted them to leave. When they approached the front door of Flat 112, they saw smoke coming into the flat under the door. Finding the lobby dark and full of smoke, they decided not to leave. That was at about 01.30. The brothers then began to call for help from a window until a firefighter shouted back telling them to stay where they were.456 Phase 1 Report Volume II paragraphs 11.94 - 11.96. They continued calling for help and firefighters next to the main entrance told them to stop shouting and that they were coming up to help them.457 Alhaj Ali {IWS00000781/7} page 7, paragraph 20. Given the absence at that time of information indicating that the occupants of Flat 112 needed to be rescued, it appears that the brothers' calls for help did not result in a message being sent to the bridgehead.
¶88.107 The brothers opened their front door again at around 02.00 to see if it was now easier to leave. There was still smoke in the lobby with limited visibility. Flat 112 was still clear of smoke and they remained in the flat.458 Phase 1 Report Volume II paragraphs 14.196 - 14.197.
¶88.108 We have described how calls to the emergency services made by those trapped on floor 14 led to the deployment of FFs Merrion and Sanders and FFs Cornelius and Murphy to that floor. When FF Merrion entered Flat 112, the brothers pleaded with him to take them out but he told them to remain in the flat.459 Phase 1 Report Volume II paragraphs 13.12 and 14.197. Subsequently, they agreed to a request from FF Murphy to be allowed to move Denis Murphy into Flat 112, which had clean air.460 Phase 1 Report Volume II paragraphs 13.9-13.10 and 14.198. At that time the visibility in the lobby had improved to the point at which Omar Alhaj Ali was able to make out firefighters there.461 Phase 1 Report Volume II paragraph 14.199. The firefighters then returned and moved Omar Alhaj Ali, Mohammad Alhajali and Denis Murphy from Flat 112 and Zainab Deen and Jeremiah Deen from Flat 115 to Flat 113.462 Phase 1 Report Volume II paragraph 14.88. Omar Alhaj Ali recalled that at that time the smoke in the lobby was not as thick as before.463 Phase 1 Report Volume II paragraph 14.202. For the reasons we have already given we conclude that no criticism can be made of the decision not to evacuate those on floor 14 at that time.
¶88.109 Although all those sheltering in Flat 113 were initially in different parts of the flat, most of them eventually congregated in the bedroom facing the front door.464 Phase 1 Report Volume II paragraph 14.206. We have set out above our analysis of their various movements and how Mohammed Alhajali came to be left behind during the partial evacuation of Flat 113, following the deployment of CM McAlonen and FFs Juggins, Herrera and Orchard to floor 14. We have also concluded that the bridgehead was aware shortly after the partial evacuation that people remained trapped on floor 14. However, no other firefighters were able to reach that floor.
60¶88.110 Gathered outside the tower, Mohammad Alhajali's friends and relations were in contact with him by telephone. Mahmoud Al Karad's last conversation with Mohammad Alhajali was at 03.19. He told Mahmoud Al-Karad that he could not leave because he was with a mother and child. (He did not mention Denis Murphy.)465 Phase 1 Report Volume III paragraph 17.88. His last conversation was with his brothers Omar and Hashem. In that call Mohammad said that the others in the flat were no longer responding to him. The evidence of the precise time at which the call ended is uncertain. Hashem Alhajali estimated that it ended between 04.00 and 05.00, but Omar Alhaj Ali was taken to hospital at 04.26.466 Hashem Alhajali {MET00007745/4} page 4; Phase 1 Report Volume III paragraphs 19.32-19.33. Mahmoud Al-Karad was with Omar when he was speaking to Mohammad. He was unable to reach Mohammad Alhajali after 04.26.467 Phase 1 Report Volume III paragraph 19.34. A cousin, Aesem Alhajali, said that no one was able to reach Mohammad Alhajali after some time between 04.00 and 05.00.468 Aesem Alhajali {MET00039851/6} page 6. In a call to the emergency services at 05.05, Ammar Al Kabir, a cousin, said that he had last spoken to Mohammad Alhajali an hour earlier (evidence which we think is more reliable than his later recollection that the call had taken place at 04.30). In the circumstances, we conclude that the last contact with Mohammad Alhajali probably occurred at about 04.05.
¶88.111 Following that contact, Mohammad Alhajali fell to his death from the tower. His body was found by WM Steven Collins469 Collins {MET00010086/5} page 5. by the gate on the elevated walkway leading to Grenfell Tower from Grenfell Walk and at the base of a 13.5 metre ladder. The ladder was not in use at the time but was leaning against the south face of the tower. The body of Mohammad Alhajali was covered in debris suggesting that he had fallen some time before his body was found. Together with CM Jamal Stern and FF William Murphy, WM Collins moved the body to a protected area inside the lobby of one of the walkways. No sign of life was found, and WM Collins then assigned another firefighter to locate a paramedic.470 Collins {MET00010086/10-13} pages 10-13; Collins Exhibit SMC/5 - Photographs of Grenfell Tower {MET00015914/24}. That paramedic pronounced life extinct at 04.56.471 Sibthorpe {MET00015658/5} page 5.
¶88.112 The coroner, Professor Wilcox, subsequently issued an interim certificate of the fact of death for Mohammad Alhajali.472 Interim certificate of the fact of death for Mohammad Alhajali {MET00065645}.
Cause and time of death
¶88.113 The post-mortem for Mohammad Alhajali recorded injuries consistent with a fall from a height. The injuries were such that there would have been a near-instantaneous collapse and loss of consciousness with no protracted suffering. There were no signs of burns to the skin or airways were recorded. Soot deposits were found in the respiratory system, consistent with the inhalation of fire fumes. The level of carboxyhaemoglobin in a blood sample was found to be 50%, which confirms that Mohammad Alhajali had inhaled sufficient carbon monoxide to bring him within the fatal range.473 Alhajali post-mortem report {COR00001135}; Purser, Phase 2 Report, Section 6 {DAPR0000006/152} paragraphs 829-831. Later analysis in
61¶April 2019 did not detect the presence of cyanide but that may simply have been due to the degradation of the sample over time.474 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447.
¶88.114 The reporting pathologist concluded that the inhalation of a potentially lethal dose of carbon monoxide was not inconsistent with an attempt by a fit young man to jump from the building.475 Alhajali post-mortem report {COR00001135}; Purser, Phase 2 Report, Section 6 {DAPR0000006/152} paragraphs 830. The medical cause of death was recorded as "Multiple injuries consistent with fall from height". We accept that conclusion.
¶88.115 The absence of any burns to Mohammad Alhajali's skin suggests that he jumped before the exterior fire had enveloped the south side of Flat 113 and before a fire had developed in the interior of the flat. The time it took for WM Collins and his colleagues to move the body of Mohammad Alhajali, check for signs of life and then find a paramedic means that some minutes elapsed between finding the body and pronouncing life extinct. Taking these factors into consideration, we are satisfied that Mohammad Alhajali fell from the tower at some time between 04.05 and 04.30.
63Chapter 89: Floor 15
¶89.1 All six flats on floor 15 were occupied at 00.54 when the fire started.476 Phase 1 Report Volume II paragraph 10.15. Between 01.21 and 01.36, the occupants of Flats 121, 123, 125 and 126 left the tower. Only Steve Power, his daughter Rebecca Ross (both in Flat 122) and Christos Fairbairn (in Flat 124) then remained. Steve Power did not survive the fire.
¶89.2 Aziza El-Ouahabi Raihani from Flat 126 had left the tower477 Phase 1 Report Volume III Annex A. by the time the fire reached the outside of her flat at 01.23.478 Bisby, Supplemental Phase 1 Expert Report {LBYS0000001/159}. A few minutes earlier, Rashida Ali, who lived in Flat 125, had ventured into the lobby on floor 15 to find that it was still clear of smoke.479 Ali {Day67/47:8-17}. She left the tower at 01.23.480 Phase 1 Report Volume III Annex A.
¶89.3 Conditions quickly changed as the fire on the outside of the building entered Flat 126. At 01.27, FF David Badillo entered the tower on his way to floor 20 in search of Jessica Urbano Ramirez.481 Phase 1 Report Volume II paragraph 10.79 (b). When the lift stopped at floor 15 and the doors opened it filled with black smoke. Struggling to breathe and see, FF Badillo left the lift, found his way to the stairwell door and went down the stairs.482 Phase 1 Report Volume II paragraph 10.101 (a). He had no contact with any of the residents on floor 15.483 Badillo {Day13/119:6}-{Day13/123:7}. By 01.31, FF Badillo had left the tower.484 Phase 1 Report Volume II paragraph 11.10. Reem Dedrich (Flat 123) and Sid Ali Atmani (Flat 125) left the tower at 01.33 and 01.36 respectively. The lobby on floor 15 was full of thick dark smoke when each of them escaped.485 Phase 1 Report Volume II paragraphs 11.86 and 11.87.
¶89.4 FF Steven Mills and Geoffrey Campbell tallied out at 01.51 to go to Flat 175 on floor 20. When they reached floor 15, they realised that they could not reach floor 20 without extended duration breathing apparatus.486 Phase 1 Report Volume II paragraph 13.14. FF Mills recalled that before descending the stairs he and FF Campbell had banged on the doors of all the flats on floors 15 and 14.487 Mills {MET000080584/6} page 6. FF Campbell was less certain whether they had stopped on floor 14 or floor 15 before descending and thought that they may have searched floor 9.488 Campbell {MET00010788/8-10} pages 8-10. Christos Fairbairn heard banging on his front door,489 Phase 1 Report Volume II paragraph 14.194. but he did not become aware of the fire until much later, probably not before 02.20.490 Phase 1 Report Volume II paragraph 14.194. Since the firefighters had logged off the system by 02.11,491 BA Telemetry Data {LFB00023326/1} page 1. it is unlikely that what Christos Fairbairn heard had anything to do with them.
¶89.5 Neither Rebecca Ross, her father nor any relatives or friends made an emergency call reporting that persons were in Flat 122, although the LFB received that information by other means. Christos Fairbairn made six emergency calls, the first at 03.00 and the last at 03.31, four of which were to the fire and rescue service.492 Phase 1 Report Volume III paragraphs 17.85, 17.138, 18.43 and 18.44. He was advised to leave the building and when he did do so he encountered firefighters who helped him out. Christos Fairbairn left the tower at 03.54.493 Phase 1 Report Volume III paragraphs 18.46 and 18.47. His calls did not result in the deployment of any firefighters to floor 15.
64Steven Power
¶Date of birth: 18 August 1953 (63 years). Place of birth: London, UK. Gender: Male. Occupation: Retired. Usual address: Flat 122, floor 15, Grenfell Tower, London. Place of death: Flat 122, floor 15, Grenfell Tower, London. Time of death: Between 03.15 and 04.00 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
¶Coronary artery atheroma.
Background and composition of household
¶89.6 Steven (Steve) Power lived in Flat 122 with his daughter Rebecca Ross, his son Bobby Ross and his three dogs Stevie, Diva and Jess. A retired driver, he was a keen fisherman and disc jockey who had lived in the tower since 1985.494 Phase 1 Report Volume IV paragraphs 32.259-32.263.
Vulnerability
¶89.7 Steve Power suffered from emphysema, which made walking difficult.495 Ross {IWS00001036/6} page 6, paragraph 15. He had also been diagnosed with bowel cancer.496 Bobby Ross Exhibit BR/4 – Letters from North Kensington Law Centre to KCTMO {IWS00002360}. Rydon's resident survey of November 2014 notes that they had yet to speak to him.497 Rydon Residents Survey {RYD00024466/24}. He did not appear in the spreadsheet listing vulnerable residents produced on the night of the fire by David Noble of the TMO based on information from the TMO's Capita Insight system.498 Noble {TMO00000884}.
Events of 14 June 2017
¶89.8 Both Steve Power and Rebecca Ross were home in Flat 122 on the evening of the fire. Steve Power woke his daughter at about 01.30 to tell her that there was a fire in the building. She wanted to leave, but he thought they should remain in the flat.499 Phase 1 Report Volume II paragraph 14.191.
65¶89.9 Rebecca Ross was able to see something of the fire from the flat, but it was only on seeing an image on Twitter that she realised its extent. By that time friends and family members were calling and urging Steve and Rebecca to leave and she tried to persuade her father to do so. At about 02.00, she opened the front door to see a cloud of thick grey smoke in the lobby although the lighting was still visible.500 Phase 1 Report Volume II paragraphs 14.192-14.193.
¶89.10 At about 02.22, while Rebecca Ross was on the telephone to her brother Wayne Power‑Davis, black smoke began to fill the flat. She and her father agreed to leave. While he put on his shoes, she soaked towels for them both. As she was moving to the front door, Rebecca Ross noticed that flames appeared to be about to come through the kitchen window. She found the lobby so full of black smoke that it was impossible to see. Her father was still in the flat when she left. Leaving the front door open, she managed to find her way to the stairwell and began to make her way down the stairs.501 Phase 1 Report Volume III paragraphs 16.64-16.66; Ross {IWS00001036/15} page 15, paragraph 35.
¶89.11 At 02.47, FF Robert Dwyer and Christopher Perez encountered Rebecca Ross on the stairs between floors 10 and 11. She was struggling to breathe, so they decided to carry her down the stairs.502 Dwyer {MET00012781/5-6} pages 5-6; Perez {MET00017426/6} page 6; LFB Operational Response Report dated July 2020 {LFB00119333/231}. Rebecca Ross was able to tell them that her father was trapped in Flat 122 on floor 15. As well as sending that information to the bridgehead, the firefighters briefed the bridgehead directly when they reached it.503 Perez {MET00017426/6} page 6.
¶89.12 Rebecca Ross left the tower at 02.54.504 Phase 1 Report Volume III Annex A. She subsequently learned that a friend of her father had spoken to him on the telephone after she had left Flat 122.505 Ross {IWS00001036/21} page 21, paragraph 55. There is no further evidence of when the call was made or what was said, but it appears to have been the last contact with Steve Power.
Information to the incident ground
¶89.13 Between 02.10 and 02.22 CU7 was given the task of managing information about people who needed to be rescued from the tower.506 Phase 1 Report Volume IV paragraph 28.84 (d). The crew used a laminated sheet to record information obtained from pieces of paper created in CU8.507 Phase 1 Report Volume II paragraphs 12.8-12.9. It included the following information: "122 15 2 Persons".508 Phase 1 Report Volume II Figure 12.3. The same information appears on the whiteboard used by CU7 after 03.00 to record information.509 Phase 1 Report Volume III paragraph 15.13; Phase 1 Report Volume III paragraph 16.12 and Figure 16.5; Photograph of whiteboard {MET00015924}. There the number "2" was written in green indicating two adults.510 Goodall {MET000083296/11} page 11.
¶89.14 FF Mandeep Singh acted as a runner taking messages from the command units to the bridgehead and to WM Glynn Williams in the ground floor lobby of the tower.511 Singh {MET000083327/12} page 12. From 02.15 WM Williams began using the wall of the lobby to record information that was then passed to the bridgehead.512 Phase 1 Report Volume II paragraphs 14.103-14.105 and Figure 14.5; Photographs of ground floor wall {MET00005774} and {MET00005776}. One note in FF Singh's handwriting read: "Glen Williams" at the top and then "15th Floor 122 x 2 people x 2 dogs."513 Singh Exhibit MSI/1 – pages from notebook {MET00013089/1}. WM Williams did not see FF Singh's note and the information was not added to the wall.514 Phase 1 Report Volume IV paragraph 28.85 (a).
66¶89.15 The information in FF Singh's note must be linked to his recollection of having been approached by a man to say that his father was on floor 15 in Flat 122. The man had told him that there were two people and two dogs in the flat and that his father was refusing to leave. FF Singh said he had recorded the information in a note and had taken it to the bridgehead.515 Singh {MET000083327/16} page 16.
¶89.16 In any event, at some point, information about Flat 122 was recorded on the lobby wall. Photographs of that wall show the following had been written on it: a. "BA 122 15th" and "Smoke log" on the right-hand side. WM Williams said that the
entry was in his handwriting and that the information had come from the command unit. The notation of "BA" was to show that a crew had been deployed to that flat.516 Williams {Day31/113:23}-{Day31/114:1}; {Day31/162:9-22}.
¶b. "122 15?" on the left-hand side. WM Williams said that that entry was also in his handwriting but he could not remember what the question mark meant.517 Williams {Day31/164:18-21}.
¶c. "122 15 1P" also on the left-hand side. WM Williams said that that entry was not in his handwriting.518 Williams {Day31/164:9-17}.
¶89.17 At the time that FF Dwyer relayed the information from Rebecca Ross, the bridgehead was still on floor 3. WM Louisa De Silvo recorded information about people needing to be rescued on a wall on that floor. It included: "122 FIRE IN THE KITCHEN 122". The first "122" was circled and marked with two ticks and the second underlined and circled.519 Phase 1 Report Volume II Figure 15.7; The photograph was taken at 03.08 when the bridgehead was about to be relocated to the ground floor: Cook Exhibit GAC/2 - Grenfell Tower statement notes {MET00015779/16} page 16. A tick against a particular flat indicated that a crew had been deployed there and a circle indicated that WM de Silvo had received further information, either by runner or radio or from a returning crew. A cross through the flat indicated that it had been searched. She thought that "122" had probably been written and circled again, and underlined, for emphasis because she had received further information about it or because firefighters had been unable to reach it.520 De Silvo {Day30/24:16}-{Day30/25:6}; {Day30/31:6}-{Day30/32:17}. It is likely that some of the information came from FFs Dwyer and Perez, since it appears on a control information form together with the time 2.47.521 Control information form {LFB00001955/1}. The forms were used at the incident ground to record information about people needing to be rescued.
¶89.18 Although WM De Silvo could not recall having deployed a crew to Flat 122,522 De Silvo {Day30/32:8-17}. FF Leon Whitley and Ricky Nuttall tallied out at 02.44 and 02.45 respectively with instructions to go to Flat 122. They took a hose with them. On reaching floor 15, they charged the hose and located Flat 122 but then realised they were low on air. Being concerned that they would not be able to carry out an effective rescue, they decided to return to the bridgehead. FF Nuttall described the visibility on floor 15 as zero with thick black smoke. By the time they reached the bridgehead, it had been moved to the ground floor. FF Nuttall tried to tell WM Williams about Flat 122, but he was too busy to take the information in. Outside the tower, FF Nuttall gave the information to a watch manager who said he would deal with it.523 Phase 1 Report Volume III paragraphs 15.59-15.60; Nuttall {MET00012561/11-14} pages 11 and 13-14.
67¶89.19 The reference to two adults makes it likely that the information recorded in CU7 and by FF Singh was received before Rebecca Ross had left Flat 122. One source was probably a friend of Rebecca Ross outside the tower.524 Ross {IWS00001036/11} page 11, paragraph 29. The proximity in timing between FFs Dwyer and Perez finding Rebecca Ross and FFs Nuttall and Whitley being deployed suggests that it was the information from FFs Dwyer and Perez that prompted their deployment. WM De Silvo may have added the detail about a fire in the kitchen of Flat 122 after that deployment. Of the notes made on the ground floor lobby, the reference to "BA" and "smoke log" are likely to refer to that deployment.
¶89.20 The information received from FFs Dwyer, Perez, Nuttall and Whitley did not prompt a further deployment to Flat 122.
Recovery and identification
¶89.21 The remains of Steve Power were recovered from the bedroom of Flat 122.525 Purser, Phase 2 Report, Section 6 {DAPR0000006/134} paragraph 723. The coroner, Professor Wilcox, was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.526 Interim certificate of the fact of death for Steven Power {MET00065616}. Steve Power was found with his dogs, Stevie, Diva and Jess.527 Presentation relating to Steven Power {Day307/92:10-15}.
Cause and time of death
¶89.22 The post-mortem and toxicological investigations on Steve Power found soot in, and mild heat damage to, the respiratory system. Carboxyhaemoglobin was present in the blood but it was not possible to quantify the concentration. There was significant evidence of coronary artery atheroma, which, although not a direct cause of death, rendered Steve Power more vulnerable to the effects of carbon monoxide. A lower concentration would therefore have resulted in drowsiness, unconsciousness, and death.528 Power post-mortem report {COR00001432}; Power toxicology report {COR00001444}; Purser, Phase 2 Report, Section 6 {DAPR0000006/134} paragraph 723.
¶89.23 In the post-mortem report on Steve Power the medical cause of death was recorded as: Ia. Inhalation of products of combustion II. Coronary artery atheroma.
¶89.24 In the light of Professor Purser's evidence, we find that a more accurate description of the primary cause of death is "inhalation of asphyxiant gases".
¶89.25 The fire on the outside of the building reached Flat 122 between 02.23 to 02.29. By 02.49, it had spread from the east face of the living room to the south face. Between about 03.02 and 03.12 it spread to and across the external walls of the bedrooms.529 Purser, Phase 2 Report, Section 6 {DAPR0000006/133} paragraph 715.
68¶89.26 Steve Power's pre-existing health conditions made it difficult for him to leave the tower with his daughter. Having regard to the extent to which Rebecca Ross was exposed to asphyxiant gases, the time at which the fire spread to his flat and his underlying health condition, we are satisfied that Steve Power lost consciousness soon after his daughter left Flat 122. The mild heat damage to his respiratory system probably occurred after he had lost consciousness. Steve Power died between 03.15 and 04.00.530 Purser {Day297/114:14-25}.
69Chapter 90: Floor 16
¶90.1 All the flats on floor 16 were occupied on 14 June 2017. Two residents of this floor, Sheila in Flat 132 and Joseph Daniels in Flat 135, died in the fire.
¶90.2 The fire reached floor 16 outside Flat 136 by 01.24.531 Bisby, Supplemental Phase 1 Expert Report {LBYR00000001/149} Figure 96. Thereafter, conditions on that floor deteriorated rapidly.
¶90.3 Hamid Wahbi, the sole occupant of Flat 136 on the night of the fire, left his home on seeing smoke and flames enter through the kitchen window. The smoke had already reached the living room and hallway by the time he left. When he did so, Hamid Wahbi found the lobby on floor 16 clear of smoke.532 Phase 1 Report Volume II paragraph 10.238. He left his front door open533 Phase 1 Report Volume II paragraph 10.238. and, since it did not have an effective self-closing device, smoke entered the lobby.534 Wahbi {IWS00001157/6-10} pages 6 and 10, paragraphs 26 and 55; Wahbi {Day62/36:18}-{Day62/37:1}.
¶90.4 In Flat 135, Samuel Daniels, who lived there with his father Joseph Daniels, became aware of a burning smell. That was before Hamid Wahbi had left his flat. Samuel Daniels went into the lobby on three occasions to investigate. Initially, it was clear of smoke. When he next entered the lobby, he saw smoke from the ceiling down to waist level. On the third occasion there was still smoke in the lobby, but it remained possible to breathe. On all three occasions, he found the stairwell clear of smoke.535 Phase 1 Report Volume II paragraphs 11.68 and 11.70.
¶90.5 When, having failed to persuade his father to leave, Samuel Daniels finally left Flat 135, thick black smoke came into the flat when he opened the front door. The lobby was filled with smoke and visibility was limited. The stairs at that time remained free from smoke.536 Phase 1 Report Volume II paragraphs 11.77 and 11.78.
¶90.6 The occupants of Flat 131, Richard Fletcher, his wife, Hime Gashaw and their daughter left their flat at about the same time. There was thick black smoke in the lobby when they opened their front door. The family crossed the lobby and left the tower at 01.31.537 Phase 1 Report Volume II paragraphs 1171-11.73.
¶90.7 Samuel Daniels met FF Justin O'Beirne on the stairs and told him about his father.538 Phase 1 Report Volume II paragraph 11.79. FF O'Beirne called for assistance for a bedbound man on floor 16.539 Phase 1 Report Volume II paragraphs 11.79, 10.101 (b) and 10.101 (c). CM Jamal Stern and FF Richard Hippel responded to that call and went to floor 16.540 Phase 1 Report Volume II paragraphs 10.101 (b) and (c). CM Stern found the lobby of floor 16 to be smoke-logged when he first opened the stairwell door.541 Stern {MET00012483/10} page 10. FF Hippel recalled black smoke coming out from the open stairwell door.542 Hippel {Day26/63:7}-{Day26/68:21}. On floor 16 they found a man by the lobby door (Hamid Wahbi) and another man in the lobby (Edward Daffarn).543 Phase 1 Report Volume II paragraphs 10.101 (c), 11.81 and 11.82.
70¶90.8 When Edward Daffarn left Flat 134, the smoke in the lobby was so thick it was difficult for him to see. He struggled to find his way out until he was found by CM Stern and FF Hippel. Edward Daffarn left the tower at 01.34.544 Phase 1 Report Volume II paragraphs 10.101 (c) and 11.81.
¶90.9 Having assisted Edward Daffarn, CM Stern and FF Hippel then entered the first flat they found on floor 16, which is likely to have been Flat 136. They found it empty, extremely hot and heavily smoke-logged.545 Phase 1 Report Volume II paragraph 10.101 (c); Hippel {Day26/93:7}-{Day26/94:14}. As they were low on air, they left before searching any other flats.546 Phase 1 Report Volume II paragraph 10.101 (c). CM Stern said that they had knocked on the doors of two other flats, which he thought had been Flats 134 and 135.547 Stern {MET00012483/12-13} pages 12-13; Stern Exhibit JAS/3 – Floorplan of Floor 16 {MET00016893}. FF Hippel said that when searching floor 16, he and CM Stern had kicked the front door of each flat and shouted out.548 Hippel {Day26/93:7}-{Day26/96:13}. He could not explain why the occupants of Flat 133 had not heard them but suggested that they might have been asleep.549 Hippel {Day26/95:19-25}. Sener Macit, in Flat 133, said that he had not heard any knocking on his door or any noises coming from the lobby.550 Macit {Day65/130:14-19}.
¶90.10 CM Stern and FF Hippel returned to the bridgehead on floor 2 at about 01.38. CM Stern told WM O'Keeffe that they had rescued one person (Edward Daffarn) but had been unsuccessful in rescuing another (Joseph Daniels). CM Stern was not sure if he had mentioned that the person they had been unable to rescue had been bedbound.551 Phase 1 Report Volume II paragraph 11.15; Stern {Day26/190:3}-{Day26/193:20}. FF O'Beirne said that when he had left the tower, he told SM Brett Loft that there was a bedbound man on floor 16 whom crews had not been able to reach. SM Loft did not recall that exchange.552 Phase 1 Report Volume II paragraph 11.15.
¶90.11 After leaving the tower, Hamid Wahbi spoke to two firefighters, SM Loft and WM Watson.553 CCTV Stills {INQ00000478}; {INQ00000477}; {INQ00000479}. He told them that there was a man and a woman on floor 16. Although he did not give a flat number, he was referring to Joseph Daniels in Flat 135 and Sheila in Flat 132.554 Wahbi {Day62/62:12}-{Day62/64:20}. SM Loft did not recall that conversation.555 Loft {Day29/37:17}-{Day28/39:9}.
¶90.12 By 01.45, only Sheila in Flat 132, Joseph Daniels in Flat 135 and Sener and Hanife Macit in Flat 133 remained on floor 16. Sener Macit was the only one to call the emergency services. His first call was at 01.37 and was put through to the police. He told them that he was on floor 16 but was not asked for, and did not give, the number of his flat.556 999 call transcript {INQ00000280}. The police passed the information that people were trapped on floor 16 to the LFB in a call taken by CRO Heidi Fox at 01.43.557 Phase 1 Report Volume II paragraph 12.79; 999 call transcript {LFB00000497}. The information was passed to CU8 at 01.46.558 Phase 1 Report Volume II paragraph 12.88; Short Incident Log Report {MET00013830/19-20}; LFB Radio Messages {LFB00002952}.
71¶90.13 Sener Macit's first emergency call led to a conference call at 01.46 between the police operator, Sener Macit and CRO Adams in the LFB control room. Sener Macit told CRO Adams that he was in Flat 133 and that smoke was coming under his front door. He could not escape as it was pitch black.559 Phase 1 Report Volume II paragraph 12.89. CRO Adams passed on the details of that call to the incident ground at 01.50.560 Phase 1 Report Volume II paragraph 12.90.
¶90.14 Between 02.10 and 03.33, Sener Macit made a further six emergency calls. At 02.10, he was connected to North West Fire Control to whom he spoke for almost half an hour. At a late stage in that call, he was told that firefighters were on their way to floor 16 but was advised to leave his flat.561 Phase 1 Report Volume II paragraph 14.188; Phase 1 Report Volume III paragraphs 15.86-15.87. Following a failed attempt to leave, Sener Macit spoke to the LFB again at 02.41,562 Phase 1 Report Volume III paragraph 15.89. 02.49,563 Phase 1 Report Volume III paragraph 15.89. 03.02,564 Phase 1 Report Volume III paragraph 17.80. and 03.12.565 Phase 1 Report Volume III paragraphs 17.80-17.82. His daughter also called the LFB at 03.01566 999 call transcript {LFB00000560}. and 03.45.567 999 call transcript {LFB00000529}. Sener and Hanife Macit eventually managed to escape without assistance, leaving the tower at 03.47.568 Phase 1 Report Volume III paragraphs 18.39-18.42.
¶90.15 After CM Stern and FF Hippel had left floor 16, there were two further deployments, both after 03.00. CM Aldo Diana and FF Dean Nelson tallied out at 03:24.569 BA Telemetry Data {LFB00023326/2} page 2. They were sent to Flat 133 but failed to reach floor 16 as they stopped to help other residents escape.570 Diana {MET00018800/8-12} pages 8-12; Nelson {MET00010926/4-9} pages 4-9; Phase 1 Report Volume III paragraph 18.20 (b). The last crew deployed to floor 16 were SM Gareth Cook and CM Ben Gallagher who tallied out at 04.04.571 BA Telemetry Data {LFB00023326/3} page 3. They were sent to investigate reports of ten people trapped in a flat on floor 16 and 11 people trapped on floor 18. However, SM Cook's alarm sounded between floors 6 and 12 and CM Gallagher's air was low, so they returned to the bridgehead without reaching floor 16.572 Phase 1 Report Volume III paragraph 19.9; Cook {MET00007882/14-15} pages 14-15. It is unclear what prompted that deployment, given the absence of information to support the suggestion that so many people were trapped on floor 16.
Joseph Daniels
¶Date of birth: 10 February 1948 (69 years). Place of birth: Lucknow, India. Gender: Male. Occupation: Retired. Usual address: Flat 135, floor 16, Grenfell Tower, London. Place of death: Flat 135, floor 16, Grenfell Tower, London. Time of death: Between 02.55 and 03.15 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
72Background and composition of household
¶90.16 Joseph Daniels was born on 10 February 1948 in Lucknow, India. He was 69 years old at the time of the fire.573 Phase 1 Report Volume IV paragraph 32.255. He came to the United Kingdom from India in 1982 after marrying Lucy Smyth. They moved into Flat 135 in 1983 and had one son, Samuel Daniels. The couple subsequently divorced and Joseph Daniels continued to live in Flat 135. He also had a daughter, Stephanie Hillier, from another relationship.574 Presentation relating to Joseph Daniels {Day307/46:19}-{Day307/47:22}; Tenancy Agreement {TMOH00024682}.
¶90.17 By June 2017, Joseph Daniels was retired and in poor health. He shared Flat 135 with his son, Samuel Daniels, who was registered as his father's full-time carer.575 Presentation relating to Joseph Daniels {Day307/47:24}-{Day307/48:3}.
Vulnerability
¶90.18 By June 2017, Joseph Daniels was suffering from dementia and diabetes and had limited mobility.576 Phase 1 Report Volume II paragraph 11.67. He was not, however, bedbound. He needed the lift to leave the tower.577 Daniels {IWS00000608/2} page 2, paragraph 8. Samuel Daniels said his father had not been able to walk up and down the stairs for about a year and a half before the fire and had not left the flat at all for the last two months of his life.578 Daniels {Day56/5:8-22}; Phase 1 Report Volume II paragraph 11.67.
¶90.19 Rydon's resident survey of November 2014 did not identify Joseph Daniels as having any known physical or mental health vulnerabilities, although it was noted that he had some vulnerabilities associated with his self-care.579 Rydon Residents Survey {RYD00024466/20}.
¶90.20 The TMO was aware of Joseph Daniels' vulnerability. In 2015, it had referred him to an occupational therapist as he was having difficulty getting in and out of the bath. The referral recorded that he had mobility problems but did not want to use a walking stick or glasses for his poor vision.580 TMO Referral Form {TMOH00024715}; Daniels {IWS00002065/9} page 9, paragraph 55. An assessment in May 2015 carried out by RBKC's social services department noted that he suffered from dementia, brain damage, type 2 diabetes, breathlessness and tremors.581 Daniels {IWS00002065/8} page 8, paragraph 52; Email from RBKC regarding adult social care {RBK00038674}; Care and Support Plan Review of Samuel Daniels {RBK00059536/4}.
¶90.21 The spreadsheet produced on the night of the fire by David Noble582 Noble {TMO00000884/1} page 1, paragraph 3. based on information held on the TMO's Capita Insight system583 Noble {Day119/77:17}-{Day119/82:5}. did not identify Joseph Daniels as having any vulnerability.
Events of 14 June 2017
¶90.22 Joseph Daniels was at home with his son, Samuel Daniels, on the evening of 13 June 2017.584 Daniels {IWS00000608/8} page 8, paragraph 47.
¶90.23 Samuel Daniels first became aware of the fire when he noticed a faint burning smell. He checked the flat, lobby and stairs but could not find its source. Nonetheless, he was sufficiently concerned to decide that he and his father should leave. Between efforts to persuade his father to leave, Samuel Daniels went into the lobby twice more, noticing an increasing amount of smoke there on each occasion.585 Phase 1 Report Volume II paragraphs 11.68 and 11.70. The smoke entering the lobby at that stage was coming from Flat 136, the door to which had not closed after Hamid Wahbi left.586 Phase 1 Report Volume IV paragraph 24.31; Wahbi {IWS00001157/10-11} pages 10-11, paragraph 55.
73¶90.24 Samuel Daniels could not persuade his father to leave. He left on his own, leaving the door open for his father to follow. Samuel Daniels had told the TMO on 4 April 2017 that the front door of Flat 135 did not close itself. A recommendation for a complete overhaul was made on the following day but the job was later recorded as "fully abandoned".587 Daniels {IWS00000608/6} page 6, paragraph 40; Daniels {Day56/18:18}-{Day56/20:4}; Daniels Exhibit SD/02 -TMO repairs log for Flat 135 regarding front door not closing {IWS00002067}; Daniels Exhibit SD/03 - TMO dashboard snapshot of front door repair at Flat 135 {IWS00002068}; Daniels Exhibit SD/04 - TMO dashboard snapshot of the repairs log for Fat 135 {IWS00002069}. However, it is likely that Joseph Daniels shut the door after his son had left because CM Stern and FF Hippel found it closed when they searched floor 16.
¶90.25 Samuel Daniels met FF O'Beirne in the stairwell at around floor 11 at some time between 01.28 and 01.38.588 Phase 1 Report Volume II paragraph 11.79. He told FF O'Beirne that his father was trapped in his flat on floor 16. FF O'Beirne told the bridgehead by radio that a man was bedbound on floor 16 and asked for assistance.589 Phase 1 Report Volume II paragraph 10.101 (b). CM Stern and FF Hippel responded to that request.
¶90.26 On arriving at floor 16, CM Stern and FF Hippel found the lobby full of thick smoke and visibility very limited.590 Stern {MET00012483/10} page 10; Hippel {Day26/63:7}-{Day26/68:21}. Having first helped Edward Daffarn, they searched the first flat they came to, probably Flat 136.591 Phase 1 Report Volume II paragraphs 11.81 and 10.101 (c). They could not search other flats, because they were running low on air,592 Phase 1 Report Volume II paragraph 10.101 (c). but they did knock on other doors. There was a difference in recollection between them about how many doors they knocked on, but there is no evidence that Joseph Daniels was aware of the presence of the firefighters on floor 16.593 Stern {MET00012483/12-13} pages 12-13; Stern Exhibit JAS/3 - Floorplan of Floor 16 {MET00016893}; Hippel {Day26/69:19}-{Day26/73:7}.
¶90.27 Samuel Daniels was waiting on the stairs when he saw the firefighters return from floor 16. He tried to ask them about his father but was told to leave the tower. He did so at 01.38.594 Phase 1 Report Volume II paragraph 11.82.
Information to the incident ground
¶90.28 CM Stern and FF Hippel returned to the bridgehead on floor 2 at around 01.38. CM Stern told WM O'Keeffe that he and FF Hippel had rescued one person (Edward Daffarn) but had not been able to rescue another (Joseph Daniels). He was not sure if he had said that that person was bedbound.595 Phase 1 Report Volume II paragraph 11.15; Stern {Day26/190:3}-{Day26/193:20}. FF O'Beirne said that he told SM Brett Loft that there was a bedbound man on floor 16 who the crews had been unable to reach. SM Loft did not recall this exchange with FF O'Beirne.596 Phase 1 Report Volume II paragraph 11.15.
74¶90.29 Shortly after 02.17, CM Charles Batterbee made a note of the information on a forward information board that had been used while the bridgehead was located on floor 2.597 Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c). His note did not include any reference to floor 16, which may explain why the information provided by the firefighters on their return from floor 16 did not lead to a further deployment before the bridgehead moved from floor 2 at about 02.17.598 Phase 1 Report Volume IV paragraph 28.84 (b).
¶90.30 The bridgehead was located on floor 3 between 02.17 and 03.10.599 Phase 1 Report Volume IV paragraphs 28.86 and 28.87. During that time information about people needing to be rescued was recorded on a wall in the lobby of floor 3. The only information about floor 16 on the wall was a note relating to Flat 133.600 Phase 1 Report Volume II Figure 15.7; The photograph was taken at 03.08 when the bridgehead was about to be relocated to the ground floor: Cook Exhibit GAC/2 - Grenfell Tower statement notes {MET00015779/16} page 16.
¶90.31 The bridgehead was moved to the ground floor lobby at about 03.10. Once it was there, a green wall by the stairs was used to record information about those needing to be rescued.601 Phase 1 Report Volume IV paragraph 28.87. A photograph of that wall taken at about 04.45 shows the numbers "134" and "135" on the wall.602 Mulholland Exhibit MBM/02 - Photograph of green wall {MET00018739}. We do not know who put that information on the wall but its limited detail reflects that recorded on a control information form provided to the Inquiry. The forms were used at the incident ground to record messages about people needing to be rescued. The relevant form recorded just the following, "133+134+135 16".603 LFB Control Information Forms {LFB00001955/10} page 10. On the form, "133" is scrubbed out and marked "left", indicating that those in Flat 133 had got out but that Flats 134 and 135 remained occupied. It is not possible to say with any confidence who wrote on the form. (WM Sadler used a pad of such forms604 Phase 1 Report Volume IV paragraph 28.84 (e). but they were also used, for example, by those in CU7.)605 Phase 1 Report Volume IV paragraph 28.84 (g).
¶90.32 We cannot say when the information was put on the green wall (save that it must have been after 03.10) or indeed when the control information form was completed. If the information on the wall is associated with the control information form, it may have been recorded after Sener and Hanife Macit left the tower at 03.47. The information recorded in the control information form and the green wall may have come from more than one source. It is unlikely that Hamid Wahbi was the source of the information relating to Flat 135, as he did not provide the firefighters he spoke to outside the tower with the numbers of any flats.606 Wahbi {Day62/63:5}-{Day62/65:18}; CCTV Stills {INQ00000476}; {INQ00000477}; {INQ00000478}; Loft {Day28/37:17}-{Day28/39:9}. It is more likely that the source, at least in relation to Flat 135, was Samuel Daniels. Once outside the tower, and having found his mother, he told someone, who may have been either a firefighter or a police officer, that his father was still in Flat 135. That was at about 02.00.607 Daniels {IWS00000608/14} page 14, paragraph 85; Daniels {Day56/71:13-23}. His mother gave the officer the number of the floor and the flat.608 Daniels {Day56/71:20}-{Day56/72:3}.
¶90.33 The information that someone might still be in Flat 135 did not prompt any further deployments. The two deployments which took place after 03.24 were not sent to Flat 135 and neither of them reached floor 16. CM Diana and FF Nelson tallied out at 03.24609 BA Telemetry Data {LFB00023326/2} page 2. to go to Flat 133 but stopped to help other occupants escape. They reported that to the bridgehead.610 Diana {MET00018800/8-12} pages 8-12; Nelson {MET00010926/4-9} pages 4-9; Phase 1 Report Volume III paragraph 18.20 (b). SM Gareth Cook and CM Ben Gallagher set off at 04.04 to investigate reports of 10 people trapped in a flat on floor 16, but a shortage of air prevented them from reaching that floor.611 Phase 1 Report Volume III paragraph 19.9; Cook {MET00007882/14-15} pages 14-15.
75¶90.34 There was no further contact from Joseph Daniels after his son left Flat 135.
Recovery and identification
¶90.35 The remains of Joseph Daniels were recovered from the living room of Flat 135.612 Purser, Phase 2 Report, Section 6 {DAPR0000006/126} paragraph 678; Presentation relating to Joseph Daniels {Day307/71:3-6}. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.613 Interim certificate of the fact of death for Joseph Daniels {MET00065647}.
Cause and time of death
¶90.36 The post-mortem on Joseph Daniels found soot deposits in his respiratory system. Analysis of a sample of his blood confirmed the presence of carbon monoxide, but the condition of the sample meant that its concentration could not be measured.614 Daniels post-mortem report {COR00000793/10}; Daniels supplementary post-mortem report {COR00000791/2}; Daniels toxicology report {MET00039529}; Purser, Phase 2 Report, Section 6 {DAPR0000006/127} paragraph 688. The medical cause of death was recorded as "consistent with the effects of fire", but in the light of more recent evidence we find that a more accurate description is "inhalation of asphyxiant gases".
¶90.37 If, as we think likely, the front door of Flat 135 was closed after Samuel Daniels left, it would have slowed the passage of smoke from the lobby into the flat. Exposure to asphyxiant gases was limited until the fire reached the outside walls of the bedrooms at between 02.32 and 02.34. Conditions in the living room deteriorated rapidly when the fire on the outside of the building reached the north side of the living room between 02.49 and 02.55.615 Purser, Phase 2 Report, Section 6 {DAPR0000006/127} paragraph 686.
¶90.38 It is likely that Joseph Daniels lost consciousness and died from the inhalation of asphyxiant gases at some time between 02.55 and 03.15.616 Purser, Phase 2 Report, Section 6 {DAPR0000006/127} paragraph 686; Purser {Day297/111:4-5}. Accordingly, the last chance to rescue him was some time before 03.00. That was well before the deployments of CM Diana and FF Nelson at 03.24 and of SM Cook and CM Gallagher at 04.04.
Sheila
¶Date of birth: 17 September 1932 (84 years). Place of birth: Market Harborough, Leicestershire. Gender: Female. Occupation: Retired. Usual address: Flat 132, floor 16, Grenfell Tower, London. Place of death: Flat 132, floor 16, Grenfell Tower, London.
76¶Time of death: Between 03.09 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶90.39 Sheila was born on 17 September 1932 and was 84 years old.617 Phase 1 Report Volume IV paragraph 32.257. In life, she made the decision to use only her first name, a decision that we have respected during the Inquiry. Retired, Sheila was a mother and grandmother, living alone in Flat 132. She had lived there since 23 April 1984.618 Tenancy Agreement {TMOH00018942}. Sheila led an independent life with a longstanding interest in meditation, yoga and alternative therapies.619 Presentation relating to Sheila {Day304/58:24}-{Day304/59:18}.
Vulnerability
¶90.40 Sheila was physically fairly mobile but her health had deteriorated before the fire.620 Smith {COR00001396/4} page 4. Like some other residents, she struggled when the lifts in the tower were not working,621 Video footage of the meeting with residents on 17 July 2015 {MET00078076}. but she did not appear in the TMO's records as being vulnerable. Rydon's resident survey of November 2014 recorded that she was over 80, had slight deafness and a poor memory.622 Rydon Residents Survey {RYD00024466/21}.
¶90.41 The spreadsheet produced on the night of the fire by David Noble623 Noble {TMO00000884/1} page 1, paragraph 3. based on information held on the TMO's Capita Insight system624 Noble {Day119/77:17}-{Day119/82:5}. did not identify Sheila as having any vulnerability.
Events of 14 June 2017
¶90.42 Sheila returned to the tower at 14.22 on 13 June 2017. She does not appear to have left her flat again.625 O'Riordan {MET00013136/2} page 2. She usually went to bed between 20.00 and 21.00 and wore an eye mask and ear plugs.626 Smith {COR00001396/4} page 4.
¶90.43 It is possible that Sheila never became aware of the fire. CM Stern and FF Hippel reached floor 16 sometime before 01.38,627 Phase 1 Report Volume II paragraph 10.101 (c). but there is no evidence that she was aware of their presence. Sheila is not known to have made any telephone calls to friends or family. Nor did she make any calls to the emergency services.
¶90.44 Despite the repeated emergency calls made by Sener Macit in Flat 133 and the information reaching the incident ground about a man (Joseph Daniels) and a woman (Sheila) still on floor 16, only two crews were deployed there after CM Stern and FF Hippel. CM Diana and FF Nelson tallied out at 03.24628 BA Telemetry Data {LFB00023326/2} page 2. but stopped before reaching floor 16 to assist other occupants to escape. They reported back to the bridgehead.629 Diana {MET00018800/8-12} pages 8-12; Nelson {MET00010926/4-9} pages 4-9; Phase 1 Report Volume III paragraph 18.20 (b). SM Gareth Cook and CM Ben Gallagher tallied out at 04.04. They were sent to investigate reports of 10 people trapped in a flat on floor 16, but a shortage of air prevented them from reaching it.630 Phase 1 Report Volume III paragraph 19.9; Cook {MET00007882/14-15} pages 14-15.
77¶90.45 Neither crew was briefed to find Sheila and neither crew reached floor 16. Even if they had done so and had been able to search it, it is likely that Sheila would already have been dead.
Recovery and identification
¶90.46 Sheila's remains were recovered from the bedroom of Flat 132. She was lying on her back with her head towards the window and near the remains of the mattress, indicating that she had probably been in bed when she died.631 Purser, Phase 2 Report, Section 6 {DAPR0000006/130} paragraph 702; Presentation relating to Sheila {Day304/68:14-19}. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.632 Interim certificate of the fact of death for Shiela {MET00065609}.
Cause and time of death
¶90.47 The post-mortem examination on Sheila found that it was not possible to obtain samples suitable for toxicology analysis.633 Sheila post-mortem report {COR00001397}. Although the examination concluded that it was not possible to give a definite cause of death, the medical cause of death was recorded as "consistent with the effects of fire", but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".
¶90.48 Sheila was in her bedroom throughout the fire. By 02.22, the fire was outside the living room and by 02.29 it had spread across the outside wall of that room. Between 03.09 and 03.17 it had begun to spread across the outside of the bedroom.634 Purser, Phase 2 Report, Section 6 {DAPR0000006/129} paragraphs 696-698. From the time the fire reached floor 16, Sheila was exposed to an increasing level of asphyxiant gases infiltrating her home, initially from the lobby. That exposure and the rate of absorption of asphyxiant gases increased rapidly once the fire reached the outside of her bedroom.635 Purser, Phase 2 Report, Section 6 {DAPR0000006/129} paragraphs 699-701. Given her prolonged exposure to asphyxiant gases, Sheila may have been unconscious before the fire reached her bedroom. If not, she became unconscious shortly after. She then continued to inhale asphyxiant gases until she died sometime between 03.09 and 03.30.636 Purser, Phase 2 Report, Section 6 {DAPR0000006/130} paragraphs 704-705.
¶90.49 We are satisfied that Sheila died through the inhalation of asphyxiant gases before suffering any direct effects of flames entering her bedroom.
79Chapter 91: Floor 17
¶91.1 All six flats on floor 17 were occupied at the time of Behailu Kebede's telephone call to the emergency services.637 Phase 1 Report Volume II paragraph 10.15. By 01.30, the occupants of Flats 141, 143, 145 and 146 had left the building safely,638 Phase 1 Report Volume III Annex A. apart from Khadija Khalloufi, who died on floor 10.639 See Chapter 86. Those residents who remained on floor 17, Kamru Miah, his wife, Rabeya Begum, and their adult children Mohammed Hamid, Mohammed Hanif and Husna Begum, all of whom lived in Flat 142, and Vincent Chiejina, who lived in Flat 144, all died in the fire.
¶91.2 Rita Tankarian, her nephew, Mesrob Kassemdijan, and his girlfriend, Fung Hee-Cheung, were in Flat 141 and were the first to leave floor 17. Although Rita Tankarian and Mesrob Kassemdijan could smell smoke in the lobby on floor 17, none was visible.640 Phase 1 Report Volume II paragraphs 10.239-10.240. They left the tower between 01.25 and 01.26.641 Phase 1 Report Volume III Annex A.
¶91.3 The fire reached the outside of Flat 146 at about 01.24.642 Phase 1 Report Volume II paragraph 10.118. Virgilio (Larry) Castro lived there with his friend, Genaro Batoan. His girlfriend was also staying that night. Shortly before he and his girlfriend followed Genaro Batoan out of the flat, Larry Castro saw flames coming through the extractor fan in the kitchen window. The door to Flat 146 needed to be pulled shut as the self-closing device did not work effectively. Larry Castro thought that he had not pulled it shut. The black smoke that then came into the lobby made him cough.643 Phase 1 Report Volume II paragraphs 10.242-10.243; Phase 1 Report Volume VI paragraph 24.31 (e).
¶91.4 On leaving Flat 145, Corinne Jones saw Larry Castro outside his front door. Thick black smoke was coming from the top of the door and moving along the ceiling. She briefly went back into her flat and on returning to the lobby found that the amount of smoke had increased significantly.644 Phase 1 Report Volume II paragraphs 10.244-10.245. She and Larry Castro both left the tower at 01.30.645 Phase 1 Report Volume II paragraphs 10.239-10.240.
¶91.5 At 01.29, Husna Begum made an emergency call which was connected to the police. She reported that there was smoke coming into the flat, that flames could be seen outside, and that the fire was "in the house right next to us".646 Phase 1 Report Volume II paragraph 10.247. Like Flat 146, Flat 142 was on the east side of the tower.
¶91.6 It is likely that the lobby of floor 17 rapidly filled with smoke within a few minutes after the fire reached the outside of Flat 146 and then entered it. The contents of Flat 146 were alight between 02.19 and 02.25.647 Lane, Supplemental Phase 1 Report, Section 12 {BLAS0000012/19} paragraph 12.3.17.
¶91.7 The kitchen window of Flat 142 faced east; its living room windows faced south and east. The bedroom windows faced south.648 External Spread of Fire Report {MET00012593/12} page 12. By about 02.23, the fire was outside the kitchen of Flat 142. By about 02.31, having spread south, it covered the entire east side of the flat. By 02.48, the fire had reached the south-facing windows of the living room. By 03.20 the fire was well established on the south face of Flat 142, affecting both the living room and bedroom windows. By 03.33, it had almost ceased outside the east and south faces of the flat and had spread west to Flat 143.649 Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 640. The evidence does not suggest that the contents of Flat 142 were alight at 03.33.650 Purser, Phase 2 Report, Section 6 {DAPR0000006/118-119} paragraphs 640 and 648.
80¶91.8 Flat 144 was a one-bedroomed flat situated on the west side of the tower.651 External Spread of Fire Report {MET00012593/12} page 12. By 03.39 the fire was approaching the bedroom of Flat 144 and by 03.44 it was established outside it. By 03.58, the fire was outside the kitchen and was beginning to affect the living room. Flames continued to burn outside the living room but by about 04.30 they had ceased.652 Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraph 667.
¶91.9 Following Husna Begum's emergency call at 01.29, the occupants of Flat 142 made three more emergency calls in the period up to 03.18. Those were the only emergency calls made from floor 17. None resulted in the deployment of firefighters.
The Miah / Begum family
Kamru Miah
¶Date of birth: 12 August 1937 (79 years of age). Place of birth: Sylhet, Bangladesh. Gender: Male. Occupation: Retired. Usual address: Flat 142, floor 17, Grenfell Tower, London. Place of death: Flat 142, floor 17, Grenfell Tower, London. Time of death: Between 03.20 and 03.33 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
¶Ischaemic heart disease.
Rabeya Begum
¶Date of birth: 15 November 1952 (64 years of age). Place of birth: Bangladesh. Gender: Female. Occupation: Homemaker. Usual address: Flat 142, floor 17, Grenfell Tower, London Place of death: Flat 142, floor 17, Grenfell Tower, London. Time of death: Between 03.20 and 03.33 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
81Mohammed Hamid
¶Date of birth: 19 January 1989 (28 years of age). Place of birth: London. Gender: Male. Occupation: Sales Assistant. Usual address: Flat 142, floor 17, Grenfell Tower, London. Place of death: Flat 142, floor 17, Grenfell Tower, London. Time of death: Between 03.20 and 03.33 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Mohammed Hanif
¶Date of birth: 20 February 1991 (26 years of age). Place of birth: London. Gender: Male. Occupation: Sales Assistant. Usual address: Flat 142, floor 17, Grenfell Tower, London Place of death: Flat 142, floor 17, Grenfell Tower, London. Time of death: Between 03.20 and 03.33 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Husna Begum
¶Date of birth: 4 February 1995 (22 years of age). Place of birth: London. Gender: Female. Occupation: Sales Assistant. Usual address: Flat 142, floor 17, Grenfell Tower, London. Place of death: Floor 17, Grenfell Tower, London. Time of death: Between 03.20 and 03.33 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
82Background and composition of household
¶91.10 Kamru Miah, his wife Rabeya Begum and three of their adult children, Mohammed Hamid, Mohammed Hanif and Husna Begum lived in Flat 142. The family had moved to Grenfell Tower in August 2016.653 Hakim {IWS00000019/2} page 2, paragraph 4. Their eldest son, Mohammed Hakim, lived nearby but his wife, Farhana, was staying with his family in Flat 142. She was not there on the night of the fire.654 Phase 1 Report Volume IV paragraph 32.240.
¶91.11 Kamru Miah was born on 12 August 1937 and was 79 years old. Respected within his community, he had moved to the United Kingdom in 1963 and was a retired baker and tandoori chef.655 Phase 1 Report Volume IV paragraph 32.241. Rabeya Begum was born on 15 November 1952 and was 64 years old. She came to London after marrying Kamru Miah. Committed to her family, she had devoted herself to raising the couple's four children.
¶91.12 Mohammed Hamid was born on 19 January 1989 and was 28 years old. He spent much time caring for his father, who had suffered two strokes.656 Phase 1 Report Volume IV paragraphs 32.242 and 32.248-32.249. Mohammed Hanif was born on 20 February 1991 and was 26 years of age. He was particularly creative with a talent for drawing and animation.657 Phase 1 Report Volume IV paragraphs 32.242 and 32.251. Husna Begum was born on 4 February 1995 and was 22 years old. Like her mother she was an excellent cook and enjoyed creative writing.658 Phase 1 Report Volume IV paragraphs 32.242 and 32.252-32.253. She was the youngest member of the family and the only daughter and was due to marry on 29 July 2017.659 Hakim {IWS00000019/7} page 7, paragraph 21. All three siblings worked full-time in the retail sector.660 Hakim {IWS00000019/1} page 1, paragraph 3.
Vulnerability
¶91.13 Kamru Miah had previously suffered a heart attack and two strokes. He used a walking stick and easily got out of breath when walking.661 Khanom {COR00001147/7-8} pages 7-8; Hakim {IWS00000019/2} page 2, paragraph 6. Before the family moved to Grenfell Tower, Rohema Khanom, the niece of Rabeya Begum, had helped her complete an assessment form on which they had recorded that Kamru Miah had suffered a heart attack and a stroke and could not manage stairs. Rohema Khanom had also attended a meeting in August 2016 with RBKC to interpret for her aunt and uncle. She recalled that her uncle's health had been discussed at that meeting.662 Khanom {COR00001147/2} page 2.
¶91.14 The spreadsheet produced on the night of the fire by David Noble663 Noble {TMO00000884/1} page 1, paragraph 3. based on information held on the TMO's Capita Insight system664 Noble {Day119/77:17}-{Day119/82:5}. did not identify Kamru Miah as a vulnerable person.
Events of 14 June 2017
¶91.15 The family were all at home on the night of the fire. Mohammed Hakim had visited them so they could break the Ramadan fast together. He left at about 22.00. On arriving at his home, he telephoned his mother at about 23.00.665 Hakim {IWS00000019/3} page 3, paragraphs 9-10.
83¶91.16 At 01.29, Husna Begum made an emergency call that was connected to the police. She reported that smoke was entering the flat, that the family could see flames from a window and that the fire was in a nearby flat. She asked for help. The police operator told her that the LFB had been informed and that someone would be coming to help them. The sound of a smoke alarm could be heard in the background.666 999 call transcript {INQ00000264}; Phase 1 Report Volume II paragraph 10.247; Phase 1 Report Volume IV paragraph 28.102 (a). The mention of the fire being in a nearby flat must be a reference to Flat 146 and it is clear that smoke had started to infiltrate Flat 142 from the lobby by the time of the call.
¶91.17 At 01.38, the police notified the LFB that a family of five were in Flat 142 on floor 17 and that smoke was coming into the flat. OM Alexandra Norman passed the information to CU8 at 01.43.667 Phase 1 Report Volume IV paragraphs 28.102 (b) and 28.102 (c).
¶91.18 How it then reached the bridgehead, then on floor 2, is unclear, but a note recording "17th Fl, 142 FSC" was written on a wall, probably on the second-floor mezzanine.668 Photograph of notes made by LFB on walls inside Grenfell Tower {MET00005789}. While the bridgehead was on floor 2 WM Louisa De Silvo used a forward information board to record information about those awaiting rescue.669 Phase 1 Report Volume II paragraphs 13.52-13.53. Shortly before the bridgehead moved to floor 3 (at around 02.17), CM Charles Batterbee went to the bridgehead and copied the information on a forward information board into his own notebook.670 Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c). There was no reference to floor 17 and no deployment was made to that floor before the bridgehead moved to floor 3. Following that move, no information relating to Flat 142 was recorded on the wall on floor 3 used to record information about people needing to be rescued.671 Phase 1 Report Volume IV paragraph 28.102 (c); Phase 1 Report Volume II Figure 15.7.
¶91.19 At 02.27, Husna Begum made a second emergency call, speaking to CRO Heidi Fox in the LFB control room. She told CRO Fox that the family had been waiting for help for an hour and included two elderly adults. Husna Begum told her that the fire was right next to their window and that they were afraid they were going to die. CRO Fox told her that they were not going to die and that she would pass the information to the command unit.672 999 call transcript {LFB00000354}; Phase 1 Report Volume III paragraph 15.85; Phase 1 Report Volume IV paragraph 28.102 (d). By that time the fire was outside the kitchen window of Flat 142.673 Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 640.
¶91.20 At 02.29, CRO Fox created a service request in relation to Flat 142 and CRO Sharon Darby then sent a radio message at 02.30 which referred to five adults, including two elderly persons, being trapped inside Flat 142.674 Phase 1 Report Volume III paragraph 15.149; LFB radio message {LFB00002784}. Although Husna Begum's call at 02.27 probably explains the reference to Flat 142 which appears on the white laminated sheet used in CU7,675 Phase 1 Report Volume II paragraphs 12.8-12.9; Phase 1 Report Volume IV paragraphs 28.86 and 28.102 (f). there is no evidence about what happened to that information once it had been received by CU7,676 Phase 1 Report Volume IV paragraph 28.102 (e). apart from the fact that it was recorded on a control information form.677 LFB Control Information Forms {LFB00001955/12} page 12. The forms were used at the incident ground to record messages about people needing to be rescued.
¶91.21 Having spoken to Husna Begum, who told her that there was a fire in the tower, Rohema Khanom made her way there. On the way she telephoned Husna Begum between 02.20 and 02.50 and then spoke to Rabeya Begum, who told her that the fire was now in the flat. Her aunt said that the family were all in the bedroom used by Mohammed Hanif and Mohammed Hamid. She then returned the phone to Husna Begum, who said it was pitch black in the flat, before ending the call.678 Phase 1 Report Volume III paragraph 15.84. By that time the fire covered the entire east side of Flat 142.679 External Spread of Fire Report {MET00012593/77} Image 25 (applying a +58 minutes time correction); Lane, Supplemental Phase 1 Report, Section 12 {BLAS0000012/10} Figure 12.3; Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 640.
84¶91.22 At about 03.00, Rohema Khanom spoke to Mohammed Hanif, who told her that the family were all together.680 Phase 1 Report Volume III paragraph 17.76.
¶91.23 Husna Begum called her brother Mohammed Hakim at 03.08. She told him about the fire and said that the family were trapped in the flat. She said she did not think she would survive. She then ended the call.681 Phase 1 Report Volume III paragraph 17.76. Mohammed Hakim then tried to call all five members of his family, but the calls all went to voicemail.682 Hakim {IWS00000019/1} page 5, paragraph 15.
¶91.24 At 03.09, CRO Adams answered an emergency call from Husna Begum and one of her brothers. That was the third such call from Flat 142. Husna Begum told CRO Adams that there were five people in the flat and that there was fire in the kitchen and the hallway. There is no record of the call being passed to CU7. CRO Adams advised them to leave but was told that it was not possible to do so as the smoke in the stairs was too thick.683 Phase 1 Report Volume III paragraph 17.77; Phase 1 Report Volume IV paragraph 28.102 (h). That suggests that the family must have tried at some point to leave Flat 142.
¶91.25 Husna Begum also spoke to Rohema Khanom again, but we do not know when. She told Rohema Khanom that it was smoky and dark and that she could not see anything. She was having difficulty breathing and was coughing continuously.684 Phase 1 Report Volume III paragraph 17.76.
¶91.26 The fourth and last emergency call from Flat 142 was made at 03.18. Husna Begum spoke again to CRO Fox, who advised the family to leave. Husna Begum said that they were unable to do so because it was too hot outside the door, probably meaning in the lobby. She said that there were five adults in the flat, including two elderly people, and that they were near the front door. Husna Begum asked for someone to come to the flat. CRO Fox said that she would pass the information on by radio. However, there is no entry on the LFB Short Incident Log of any service request to that effect and no other record of any radio call.685 999 call transcript {LFB00000419}; Phase 1 Report Volume IV paragraph 28.102 (i). After that, no one in Flat 142 contacted the emergency services or anybody else outside the tower.686 Phase 1 Report Volume III paragraph 17.79.
¶91.27 The second of the two whiteboards used by SM Jason Oliff to collate information in the LFB control room to pass to the command units contained a reference to Flat 142.687 Phase 1 Report Volume III paragraphs 15.139-15.141 and Figures 15.8 and 15.9. It is likely, in view of its low position on the second whiteboard, that that reflected one of the later calls made by Husna Begum at 03.09 and 03.18. Flat 142 also appeared on the whiteboard grid on CU7, showing five persons and a "P" for priority, which might have indicated the presence of elderly persons. The photograph of the whiteboard grid was taken between about 03.15 and 04.00. It is therefore at least possible that it recorded the information given in Husna Begum's call at 03.18.688 Phase 1 Report Volume IV paragraph 28.102 (j).
85¶91.28 By the time Husna Begum made her last call at 03.18 the bridgehead had been moved to the ground floor (at around 03.10). After that, a green wall by the stairs was used to record information about those needing to be rescued.689 Phase 1 Report Volume IV paragraph 28.87. A photograph of that wall taken at about 04.45 shows the number "142".690 Mulholland Exhibit MBM/02 - Photograph of green wall {MET00018739}; Phase 1 Report Volume IV paragraph 28.102.(l). It is not clear when it was put there.
¶91.29 The last crew that would have been able to reach floor 17 or above consisted of FFs Michael Pole, Niki Mitchell and Chris Cheesman, who were deployed to floor 23 between 02.51 and 02.53. However, having stopped at floor 18 to help evacuate the occupants of Flat 153, they realised that they did not have enough air to reach floor 23.691 See Chapter 92. The last opportunity of rescue for the family in Flat 142 lay in the timely communication to the bridgehead of the information provided in Husna Begum's second call at 02.27 and its being acted upon swiftly. The information did eventually arrive, but there is no evidence that it was acted on.692 Phase 1 Report Volume IV paragraph 28.103.
Recovery and identification
¶91.30 The body of Husna Begum was recovered from the lobby of floor 17. Those of the other members of the family were recovered from the bedroom nearest the front door of Flat 142, which was the last area to be affected by the westward spread of the fire.693 Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 638. The coroner, Professor Wilcox, was satisfied about the identification of the remains recovered, and therefore issued interim certificates of the fact of death for all five members of the family.694 Interim certificates of the fact of death for Kamru Miah, Rabeya Begum, Mohammed Hamid, Mohammed Hanif and Husna Begum {MET0006560}; {MET00065588}; {MET00065642}; {MET00065628}, {MET00065594}.
¶91.31 Husna Begum probably tried to leave after making her call to the emergency services at 03.18. We do not know whether other members of the family also tried to leave at the same time but were forced to return to Flat 142 by the conditions they encountered.
Cause and time of death
¶91.32 It is possible that until the time of the last emergency call, the family in Flat 142 were able to reduce their exposure to asphyxiant gases by keeping a bedroom window open.695 Purser, Phase 2 Report, Section 6 {DAPR0000006/118-119} paragraphs 645 and 646. However, once the fire had reached the window of the bedroom where they were sheltering, conditions in the room deteriorated rapidly within a few minutes.696 Purser, Phase 2 Report, Section 6 {DAPR0000006/119} paragraph 646. The fire had reached the bedrooms of Flat 142 by 03.20 and had passed them by 03.33.697 Bisby, Phase 1 Expert Report {LBYR00000001/175} Figure 116; Lane, Supplemental Phase 1 Report, Section 12 {BLAS0000012/11} Figure 12.4; Purser, Phase 2 Report, Section 6 {DAPR0000006/118} paragraph 640. In the circumstances, we are satisfied that Kamru Miah, Rabeya Begum, Mohammed Hamid and Mohammed Hanif all died at some time between 03.20 and 03.33.
¶91.33 Husna Begum's last emergency call to CRO Fox lasted one minute and 20 seconds.698 LFB Operational Response Report dated July 2020 {LFB00119333/289} page 289. By then the fire was affecting both the living room and bedroom windows on the south side of Flat 142.699 Purser, Phase 2 Report, Section 6 {DAPR0000006/118} paragraph 640. It is likely that from about 01.29 to 03.20, Husna Begum (and indeed the other members of her family) was increasingly exposed to asphyxiant gases. Husna Begum had therefore already been exposed to a significant level of asphyxiant gases while she remained in Flat 142. On leaving the bedroom where she had been sheltering with her family, she encountered a high concentration of smoke and gases in the hallway of Flat 142 and then in the lobby.700 Purser, Phase 2 Report, Section 6 {DAPR0000006/119-122} paragraphs 647 and 662-663.
86¶91.34 We find that Husna Begum sought to leave Flat 142 shortly after she had made her last emergency call and while the fire was still outside the bedroom where the family was sheltering. We are satisfied that she also died between 03.20 and 03.33.
¶91.35 The remains of the members of the family found in Flat 142 were extensively charred.701 Miah post-mortem report {COR00000814/4}; Rabeya Begum post-mortem report {COR00001322/5-6}; Hamid post- mortem report {COR00001153/4}; Hanif post-mortem report {COR00000812/4}; Purser, Phase 2 Report, Section 6 {DAPR0000006/119-121} paragraphs 649-652 and 657. Heavy soot deposits were found in Kamru Miah's airways. There was evidence of mild heat-related damage to the lining of the trachea which would have occurred while he was alive.702 Miah post-mortem report {COR00000814/6-8}; Purser, Phase 2 Report, Section 6 {DAPR0000006/119} paragraph 650. Soot deposits were also found in the airways of Rabeya Begum703 Rabeya Begum post-mortem report {COR000001322/8-9}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 652. and Mohammed Hamid.704 Hamid post-mortem report {COR00001153/4-5}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 653.
¶91.36 The level of carboxyhaemoglobin in a blood sample taken from Kamru Miah was 47%;705 Miah toxicology report {COR00000822/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 651. that in a sample taken from Mohammed Hanif was 69%.706 Hanif toxicology report {MET00039589/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 651. Both are within the range associated with death from carbon monoxide poisoning. Toxicological analysis confirmed that Mohammed Hamid's blood contained carboxyhaemoglobin but the concentration could not be measured.707 Hamid post-mortem report {COR00001153/8}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 653. It was not possible to conduct a toxicological examination of Rabeya Begum.708 Rabeya Begum post-mortem report {COR00001322/9}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 652.
¶91.37 Given the high levels of carboxyhaemoglobin in Kamru Miah and Mohammed Hanif's blood and the fact that the four members of the family were together in the bedroom, we find that they were all exposed to a level of asphyxiant gases which was so high that it caused loss of consciousness and death before their bodies suffered any serious effects of direct heat or fire.709 Phase 2 Report, Section 6 {DAPR0000006/119-121} paragraphs 650-653 and 658. In Kamru Miah's case, significant heart disease made him more vulnerable to collapse and death from the effects of asphyxiant gases.710 Miah post-mortem report {COR00000814/8}; Purser, Phase 2 Report, Section 6 {DAPR0000006/119} paragraph 650.
¶91.38 The body of Husna Begum was recovered intact. There was no obvious soot staining to her airways. Carboxyhaemoglobin appeared to be present in the blood, but it was not possible to measure the concentration due to the condition of the sample. There was significant heat damage to the body that is unlikely to have occurred while Husna Begum was still in Flat 142.711 Husna Begum post-mortem report {COR00000636/4}; Husna Begum toxicology report {COR00000642}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120-122} paragraphs 654, 659 and 664.
87¶91.39 Although the examining pathologist could not completely exclude the possibility that some heat damage had occurred before death, we think it more likely that it occurred after Husna Begum had died. We think that the extent of her exposure to asphyxiant gases (carbon monoxide with some hydrogen cyanide) and the physical exertion involved in leaving Flat 142 caused her to collapse and lose consciousness soon after entering the lobby. She continued inhaling those gases while unconscious and died shortly after.712 Purser, Phase 2 Report, Section 6 {DAPR0000006/119-122} paragraphs 647 and 662-663.
¶91.40 The medical cause of death in the case of Kamru Miah was recorded as: Ia. Inhalation of products of combustion. II. Ischaemic heart disease. In the light of Professor Purser's evidence, we find that a more accurate description of the primary cause of death is "inhalation of asphyxiant gases".
¶91.41 The post-mortems on Rabeya Begum, Mohammed Hamid, Mohammed Hanif and Husna Begum recorded the medical cause of death in each case as "consistent with effects of fire". A more accurate description would be "inhalation of asphyxiant gases".
Vincent Chiejina
¶Date of birth: 1 June 1957 (60 years old). Place of birth: Nigeria. Gender: Male. Occupation: Retired. Usual address: Flat 144, floor 17, Grenfell Tower, London Place of death: Flat 144, floor 17, Grenfell Tower, London Time of death: Between 04.00 and 04.15 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶91.42 Vincent Chiejina was born on 1 June 1957 and was 60 years old at the time of the fire. He spent his early years in Nigeria before travelling to the United Kingdom with his mother, Magdalene, and his sister, Jindu Maria. The eldest of four siblings, Vincent Chiejina and his family had lived on the Lancaster West estate between 1974 and 1981. He studied Electrical and Electronic Engineering at Sheffield University.713 Phase 1 Report Volume IV paragraphs 32.228-32.230; Chiejina {IWS00002348/2} page 2, paragraphs 6 and 10. Vincent Chiejina had lived alone in Flat 144 on floor 17 of Grenfell Tower since February 2001.714 Tenancy Agreement for Vincent Chiejina {TMOH00025056}. He was an active member of the Roman Catholic Church715 Presentation relating to Vincent Chiejina {Day307/27:17-18}. and a men's group.716 Phase 1 Report Volume IV paragraph 32.232.
88Vulnerability
¶91.43 Vincent Chiejina had a history of mental health difficulties. He had been diagnosed with schizophrenia, for which he received medication.717 Chiejina {IWS00002348/2} page 2, paragraphs 11-13. Rydon's survey of Grenfell Tower residents carried in November 2014 and provided to the TMO recorded that he suffered from learning disabilities and schizophrenia.718 Rydon Residents Survey {RYD00024466/18}.
¶91.44 The spreadsheet produced on the night of the fire by David Noble719 Noble {TMO00000884/1} page 1, paragraph 3. based on information held on the TMO's Capita Insight system identified Vincent Chiejina as a vulnerable person but contained no information about his mental health or learning difficulty.720 Noble spreadsheet {TMO00862588}.
Events of 14 June 2017
¶91.45 Vincent Chiejina remained in his home throughout the course of the fire. He did not contact the emergency services and there is no evidence of his having contact with anyone else, either inside or outside the tower.721 Phase 1 Report Volume II paragraph 11.64.
¶91.46 There is no direct evidence of what Vincent Chiejina did during the course of the fire but it is possible that he may have been awake for part of the time, since his remains were recovered from the living room rather than the bedroom. The living room was affected by the fire later than the bedroom and kitchen.722 Purser, Phase 2 Report, Section 6 {DAPR0000006/122} paragraph 666.
Recovery and identification
¶91.47 The remains of Vincent Chiejina were recovered from the living room of Flat 144 close to the window.723 Purser, Phase 2 Report, Section 6 {DAPR0000006/122} paragraph 665. The coroner, Professor Wilcox, was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.724 Interim certificate of the fact of death for Vincent Chiejina {MET00065620}.
Cause and time of death
¶91.48 The post-mortem on Vincent Chiejina recorded that he had mild coronary heart atheroma (heart disease). His remains were extensively charred. Soot was found in his respiratory system, including the lungs. There was evidence of damage to the lungs which could have been caused by the inhalation of hot smoke.725 Chiejina post-mortem report {COR00001473/10}; Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraphs 669-670. Toxicological analysis of a sample of his blood showed a carboxyhaemoglobin level of about 39%, but that must be regarded as little more than an estimate because of the condition of the sample.726 Chiejina toxicology report {COR00001483/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraphs 669-670.
¶91.49 Over the course of the fire, the quantity of smoke in Flat 144 increased, with smoke initially penetrating the flat from the lobby from about 01.30. The rate at which smoke entered the flat increased from about 03.44, when the fire became established outside the bedroom before spreading to the outside of the kitchen.727 Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraph 672.
89¶91.50 Vincent Chiejina was therefore exposed to a rising level of asphyxiant gases that increased even more when the fire reached the outside of his living room at about 03.58, resulting in a rapid deterioration of conditions in that room. The level of carboxyhaemoglobin in his blood indicates that he inhaled a considerable amount of asphyxiant gases before his death, probably sufficient to cause a loss of consciousness within minutes. The exposure to asphyxiant gases could of itself have been sufficient to cause death. The inhalation of hot gases before death may have contributed by causing breathing difficulties, again leading to rapid collapse followed shortly thereafter by death due to asphyxia.728 Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraphs 670 and 673-674; Purser {Day297/102:13} -{Day297/103:18}. It is possible that Vincent Chiejina's mild heart disease increased his susceptibility to carbon monoxide.729 Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraph 670; Purser {Day297/103:19}-{Day297/104:11}.
¶91.51 The post-mortem report recorded the medical cause of death as "inhalation of products of combustion" but in the light of more recent evidence we consider that a more accurate description is "inhalation of asphyxiant gases".
¶91.52 We are satisfied that Vincent Chiejina died between 04.00 and 04.15 before suffering the direct effects of heat or fire.730 Purser {Day297/99:3}-{Day297/103:18}.
91Chapter 92: Floor 18
¶92.1 All six flats on floor 18 were occupied when Behailu Kebede made an emergency call to report a fire in his flat.731 Phase 1 Report Volume II paragraph 10.15. By 01.26, the fire had reached the outside of Flat 156 on floor 18,732 Phase 1 Report Volume II paragraph 10.118. the home of Shah Ahmed and his wife, Sayeda Ahmed. Woken by smoke alarms, Shah Ahmed saw fire outside his kitchen window, which then appeared to explode inward. He called the emergency services at 01.27 and was connected to the police. He was not able to speak to the operator before leaving with his wife. Together they knocked on their neighbours' doors. Shah Ahmed left the door of his home shut. He and his wife then left floor 18, leaving the tower by 01.31.733 Phase 1 Report Volume II paragraphs 10.249-10.250; Phase 1 Report Volume III Annex A.
¶92.2 Rabia Yahya, who was in Flat 152 with her children, heard a knocking at her door. When she opened it she saw Shah and Sayeda Ahmed by the door to the stairwell. Sayeda Ahmed warned her of the fire and told her to leave.734 Phase 1 Report Volume II paragraph 10.251. Shortly after Shah and Sayeda Ahmed had raised the alarm, Hamid Kani, who lived alone in Flat 154, Sakina Afrasehabi and her sister, Fatemeh Afrasiabi, who was staying with her in Flat 151, left their homes. Berkti and Biruk Haftom, who lived in Flat 155, may have decided to leave even before the Ahmeds alerted their neighbours.735 Phase 1 Report Volume II paragraphs 10.254, 10.289 and 14.125. They all died, having sought refuge on floor 23. We return to the circumstances of their deaths in Chapter 97.
¶92.3 At 01.33, Rabia Yahya made a call to the emergency services which was put through to the LFB. She told CRO Angela Gotts that she was pregnant and trapped on floor 18 with her three children. Rabia Yahya was not asked for the number of her flat. She reported that she had been unable to leave because of thick black smoke which, she later recalled, had been in the stairwell. Rabia Yahya was advised to stay in her flat.736 Phase 1 Report Volume II paragraph 11.59; 999 call transcript {LFB00000662/1-2} pages 1-2. At 01.36, CRO Gotts created a service request in response to that call, recording that the caller was on floor 18.737 Short Incident Log Report {MET00013830/19} page 19. OM Alexandra Norman and CRO Sharon Darby then told WM Daniel Meyrick in CU8 and the crew in appliance G261 that there was a person trapped on floor 18.738 Phase 1 Report Volume II paragraphs 11.148-11.154. At 01.43, during the course of a radio exchange with CU8, CRO Darby again passed on information about a caller on floor 18 with thick smoke outside her flat.739 Phase 1 Report Volume II paragraphs 12.72-12.73. At 01.45, CRO Darby recorded the service request as complete.740 Short Incident Log Report {MET00013830/19} page 19.
¶92.4 WM Mark Kentfield recorded the information reaching CU8 on pieces of paper, which were then passed to SM Brett Loft positioned outside the tower.741 Phase 1 Report Volume II paragraph 11.6; Phase 1 Report Volume IV paragraph 28.84 (a). They included the A4 sheet of paper that later became known as the "Sadler envelope". The last entry in that document reads "152 – 18th pregnant".742 Phase 1 Report Volume II paragraphs 12.18-12.19 and 14.71 and Figure 12.4. How the information passed from SM Loft to the bridgehead is unclear.743 Phase 1 Report Volume IV paragraph 28.84 (b). A photograph taken by FF Justin O'Beirne shows that after the bridgehead had moved to floor 3 there was written on the wall "18 MOTHER +CHLD NO FLAT NUMBER" followed by the number 152 circled. The number 18 was ticked.744 O'Bierne {MET000083321/19} page 19; Phase 1 Report Volume III Figure 16.6.
92¶92.5 In any event, as a result FFs Katie Foster and Gregory Lawson were deployed at 01.53 to floor 18 in general rather than to a specific flat or to find a pregnant resident.745 Phase 1 Report Volume II paragraph 13.47. The crew probably reached floor 18 at or shortly after 02.00. By then, just two flats, adjacent to each other on the south side of floor 18, remained occupied. Rabia Yahya and her children were still in Flat 152. Yehualashet Enyew, Berkti Haftom's lodger, had moved from Flat 155 to Flat 153 to join Paulos Tekle, Genet Shawo and their two sons.746 Phase 1 Report Volume II paragraphs 11.60-11.62 and 14.180-14.181.
¶92.6 When they arrived at floor 18, FFs Foster and Lawson found the visibility in the lobby to be restricted by thick black smoke. They conducted a sweep of the floor. The door of the first flat they reached (Flat 151) was locked. When they reached Flat 152, they spoke to Rabia Yahya inside her home, which was still clear of smoke. They told her that they would check on neighbouring flats and get everyone out together. She was advised to put damp blankets against her front door.747 Phase 1 Report Volume II paragraphs 13.51, 13.67, 14.181 and 14.182. FFs Foster and Lawson then moved to Flat 153. When Yehualashet Enyew opened the front door, Paulos Tekle was sitting on the ledge of a sitting room window. He moved back into the flat to speak to the firefighters. Their advice was again to block up the front door. Those in Flat 153 then covered the letterbox and front door and sat down to wait.748 Phase 1 Report Volume II paragraphs 13.49 and 14.184-14.186.
¶92.7 FFs Foster and Lawson then searched Flat 154 followed by Flat 155. They found the doors to both flats open and their interiors to be pitch black and full of smoke. The door of Flat 156 was closed and they decided not to force an entry, given the indication that there was now fire inside.749 Phase 1 Report Volume II paragraph 13.50. The crew concluded that conditions were too difficult to enable them to rescue the nine remaining occupants on floor 18 at that time. They both tried to contact the bridgehead by radio but without success. As they were running low on air, they made their way down the stairs without returning to Flat 152 or 153.750 Phase 1 Report Volume II paragraphs 13.51 and 14.182.
¶92.8 The fire reached Flat 152 by about 02.22.751 Phase 1 Report Volume III paragraph 15.3. Rabia Yahya thought that the fire had broken into her kitchen at about 02.30. She immediately left with her children and went to Flat 153. She found conditions in the lobby worse than when she had answered the door to FFs Foster and Lawson. The lobby felt hot and visibility was so poor that she had to use the wall as a guide. There was no smoke in Flat 153 when she arrived there.752 Phase 1 Report Volume III paragraphs 15.79-15.81.
¶92.9 By about 02.30, all those remaining on floor 18 were sheltering in Flat 153. The fire brigade was aware that there were people there, both from information provided by FF Lawson when he returned to the bridgehead and from calls to, and between, the emergency services. However, no more firefighters were sent to floor 18 until shortly after 03.00 and those then deployed had to abandon their task. At about the same time, those in Flat 153 left the building. During the descent from floor 18, Isaac Paulos became separated from the group and died shortly afterwards.
93Isaac Paulos
¶Date of birth: 22 September 2011 (5 years old). Place of birth: London. Gender: Male. Occupation: N/A. Usual address: Flat 153, floor 18, Grenfell Tower, London. Place of death: Lobby of floor 13, Grenfell Tower, London Time of death: Between 03.09 and 03.15 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶92.10 Isaac Paulos lived in Flat 153 with his mother, Genet Shawo, and his younger brother. His father, Paulos Tekle, did not live in Grenfell Tower but visited almost every day.753 Tekle {IWS00001051/1-2} pages 1-2, paragraph 5. Isaac loved Taekwondo, swimming, and football. His teachers described him as especially gifted at maths and reading.754 Phase 1 Report Volume IV paragraphs 32.214-32.217.
Vulnerability
¶92.11 Apart from his age, Isaac Paulos was not known to have any vulnerabilities. He was recorded as a child in the spreadsheet produced on the night of the fire by David Noble.755 Noble {TMO00000884/1} page 1, paragraph 3; Noble {Day119/75:19-21}; Noble spreadsheet {TMO00862588}.
Events of 14 June 2017
¶92.12 Isaac Paulos returned home from a Taekwondo session at about 18.30 on 13 June 2017.756 O'Riordan {MET00013136/3} page 3. The family spent the evening together.757 Tekle {IWS00001051/3-4} pages 3-4, paragraphs 11-14. At some time after the fire had started, his parents were woken by sounds from the lobby. Opening the front door, they saw Rabia Yahya, who told them about the fire.758 Phase 1 Report Volume II paragraph 10.252. That conversation must have occurred just after Rabia Yahya had spoken to Sayeda Ahmed and before 01.32 when Paulos Tekle telephoned his friend Abraham Abebe who lived in Flat 44.759 Phase 1 Report Volume II paragraph 10.252. The call was not answered. At 01.43, Genet Shawo spoke to Hashim Kedir, who lived in Flat 192. He told her that he had been advised by the emergency services to remain in his flat. He advised her to do the same.760 Phase 1 Report Volume II paragraph 11.61.
Information to the incident ground after 02.30
¶92.13 After leaving floor 18, FFs Foster and Lawson returned to the bridgehead, which by that time was on floor 3.761 Phase 1 Report Volume III paragraph 17.11; Phase 1 Report Volume IV paragraph 28.86. Their end of wear time was 02.27.762 Phase 1 Report Volume III paragraph 15.31. FF Lawson gave a debrief, drawing a plan on a wall to indicate which flats on floor 18 the crew had visited and which they had found empty. He also explained why they had not brought anyone down and that it was necessary to send more crews to floor 18 immediately.763 Phase 1 Report Volume III paragraph 15.31. A photograph taken by SM Gareth Cook at 03.08764 Cook Exhibit GAC/2 - Grenfell Tower statement notes {MET00015779/16} page 16. shows that the information recorded on a wall of floor 3 while the bridgehead was located there included the following: "18 MOTHER + CHILD, NO FLAT NO 152" with a tick next to the number 18 and with "152" circled.765 Phase 1 Report Volume III Figure 15.7. A tick against a particular flat indicated that a crew had been sent there and a circle indicated that the bridgehead had received further information by runner or radio or from a returning crew.766 De Silvo {Day30/31:13}-{Day30/32:17}. That information related to the deployment of FFs Foster and Lawson.
94¶92.14 Leaving the bridgehead, FF Lawson went out through the ground floor lobby. There he spoke to CM Charles Batterbee, drawing another plan of floor 18 and repeating the information that he had given at the bridgehead. He did not see what CM Batterbee did with the information.767 Phase 1 Report Volume III paragraph 15.32. CM Batterbee recalled that FF Lawson had given him the numbers of two flats. CM Batterbee's recollection was that those flats were on floor 18. He wrote the information on a piece of paper and WM Glynn Williams then wrote it on the wall of the ground floor lobby. The information was then passed to WM Paul Watson who took it to the bridgehead.768 Batterbee {Day12/156:4}-{Day 12/158:25}.
¶92.15 Three control information forms contain information that relates to floor 18. The first refers to about four people being in Flat 153. The second, timed at 03.01, refers to Flat 153 but also records "People in Flat C+B waiting by window. CAME FROM BA CREW." (The form then names FF Lawson as the source of information. A note in a different hand referring to four adults and 5 children appears on the blue copy of the form). The third (a yellow copy) is timed at 03.02 and refers (wrongly) to a family waiting in Flat 154. Again, FF Lawson is given as the source of the information.769 Control Information Forms {LFB00001955/21-26} pages 21-22 and 26. The forms were used at the incident ground to record messages about people needing rescue. The references to Flats 153 and 154 may explain why those flats were recorded by CM Batterbee.770 Phase 1 Report Volume II paragraph 14.73.
¶92.16 WM Williams had begun putting information on the ground floor wall at about 02.15.771 Phase 1 Report Volume II paragraph 14.103. Photographs of that wall772 Wolfenden Exhibit PFW/2 - Photograph of ground floor wall {MET00017597}; De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}. taken at a later stage show that it included references to Flats 154, 153 and 152. The letters "BA" appear against each flat number with ticks next to 153 and 152. All three flats are linked by a bracket to Floor 18 (written as "18th"). A reference to four people is written by Flat 152 (i.e. Rabia Yahya and her three children). These details reflect information provided by FF Lawson.
¶92.17 FF Lawson's debrief did not prompt any further deployment to floor 18.
¶92.18 Rabia Yayha and her children had reached Flat 153 by 02.32, when Paulos Tekle made an emergency call reporting that there were four adults and five children in his flat. He told CRO Yvonne Adams that the fire was coming nearer and that they could not leave. CRO Adams told him that everyone should move to the room with the least smoke, that the fire service would get to them as soon as possible and that he should ring back if conditions got worse. Paulos Tekle later recalled that there had been no smoke or fire in Flat 153 at the time but that he had been able to see flames outside coming from the direction of Flat 152.773 Phase 1 Report Volume III paragraph 15.82; 999 call transcript {LFB00000361/5-6} pages 5-6.
95¶92.19 Paulos Tekle's call to the emergency services overlapped with a similar call made by Rabia Yahya at 02.34. She told CRO Heidi Fox that she was in Flat 153 and that the fire had reached Flat 152. CRO Fox told her that they should all try to leave. Rabia Yahya said they could not do so because of the thick black smoke and added that the firefighters had said they would return but had not done so. When asked who was there, Rabia Yahya told CRO Fox that there were four adults and five children sheltering in Flat 153 and that she was pregnant. CRO Fox said that she would alert the command unit to go to them.774 Phase 1 Report Volume III paragraph 15.81; 999 call transcript {LFB00000365}.
¶92.20 Although no service request was created following Paulos Tekle's call at 02.32,775 Phase 1 Report Volume III paragraph 15.152. CRO Fox did create one at 02.40 following the call from Rabia Yahya and repeated it a minute later. However, neither call led to a radio message being sent to the incident ground.776 Phase 1 Report Volume III paragraphs 15.152 and 15.173; Short Incident Log Report {MET00013830/23} page 23. References to both calls appear on the whiteboards used from about 02.33 by SM Jason Oliff to collate information coming into the LFB control room. It is likely therefore that he passed information about Flat 153 to the incident ground by mobile telephone.777 Phase 1 Report Volume III paragraphs 15.139-15.141, 15.152 and 15.173 and Figure 15.8.
¶92.21 Paulos Tekle made another call to the emergency services at 02.35 which was taken by CRO Peter Duddy. He did not respond to CRO Duddy's requests for information and the line then dropped out.778 999 call transcript {LFB00000362}. Shortly after, at 02.42, a further call from someone in Flat 153 was connected to the control room. The caller was probably Yehualashet Enyew. He told CRO Gotts that there were about nine people in the flat, that smoke was coming in and that the fire had reached Flat 152. Her advice was to block out the smoke if they could not leave and that the fire service would be informed to come and find them.779 999 call transcript {LFB00000371}. The call did not result in a service request.
¶92.22 At 02.45, CRO Christine Howson took a call from the police passing on information that three children and a pregnant woman were still in Flat 152 on floor 18.780 999 call transcript {LFB00000541}. That information, which plainly referred to Rabia Yahya and her children, had come from calls to the police made from outside the tower.781 999 call transcripts {INQ00000265}; {INQ00000266}. Shortly afterwards, at 02.47, CRO Gotts took a call from a relative of Rabia Yahya who was concerned that her sister-in-law was trapped on floor 18. The caller did not give the number of the flat. CRO Gotts replied that the control room had just received a message about floor 18 and told the caller that, if she spoke to Rabia Yahya, she should tell her to leave.782 999 call transcript {LFB00000542}.
¶92.23 That information from these calls reached the incident ground is apparent from the white laminated sheet used in CU7 to collate information.783 Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3. It contained the following notations:
96"152 18 3 kids, 1 PREGNANT adult". There is a red asterisk next to the entry. And a little lower: "151 18 3 kids, 1 adult"
¶And as the last entry: "153 18 4 adults 5 children can't escape".784 It is not clear what that was intended to indicate, but it may have been priority.
¶92.24 At 02.48, CRO Howson answered a call in which Rabia Yahya said that they were trapped in Flat 153 on floor 18. When told that the fire had reached Flat 152, CRO Howson told her that the fire service would not be able to reach the flat and that its occupants should leave.785 Phase 1 Report Volume III paragraphs 15.83 and 15.192. They spoke over each other at the relevant point in the call, so Rabia Yahya can only be heard saying that there were four people in Flat 153.786 999 call transcript {LFB00000384/3} page 3.
¶92.25 At about that time, radio messages were being exchanged between CRO Sharon Darby and CU7, during which she said that about four people were trapped in Flat 153.787 LFB Radio messages {LFB00002340}; {LFB00002128}; {LFB00002031}; LFB Operational Response Report dated July 2020 {LFB00119333/234-235} pages 234-235. The calls from Yehualashet Enyew at 02.42 and Rabia Yahya at 02.48 were probably the source of the information.
¶92.26 At 02.51, Essex Fire and Rescue Service received a call from Paulos Tekle, who reported that smoke was entering Flat 153. CRO Russ White told him to block out the smoke, to try to get some fresh air, or to leave if it was safe to do so.788 999 call transcript {LFB00000691}; Phase 1 Report Volume III paragraph 16.79. Having been advised by the LFB control room that callers from the tower should be told to leave, CRO White telephoned Paulos Tekle at 02.54 and left a message telling him that he and his family should cover themselves with wet towels and try to leave. He repeated that advice when he spoke to Paulos Tekle at 02.56.789 Phase 1 Report Volume III paragraphs 17.57-17.58; White {MET00012847/5} page 5. Those in Flat 153 began to collect wet towels.
¶92.27 At 03.02, as the occupants of Flat 153 were preparing to leave, CRO Duddy telephoned Paulos Tekle to tell him that everyone in the flat had to leave.790 Phase 1 Report Volume III paragraphs 17.58 and 17.122; LFB callback transcript {INQ00000193}. CRO Duddy's call was prompted by a conversation with Essex FRS {LFB00000557}. At the same time, FF Joe Worley set out791 BA Telemetry data {LFB00023326/2} page 2. together with three other firefighters to rescue a family of four from Flat 153 on floor 18.792 Worley {MET00007891/5} page 5; LFB Operational Response Report dated July 2020 {LFB00119333/286} page 286. However, the crew had to be stood down shortly after as they did not have extended duration breathing apparatus.793 Grant {MET00007883/4-5} pages 4-5. That deployment was probably prompted by the radio message sent by CRO Darby at 02.48.
¶92.28 From about 03.00, the crew of CU7 began recording information on a whiteboard using a grid system.794 Phase 1 Report Volume III paragraphs 15.13 and 16.12. At some point they became aware that there were nine people in Flat 153, which was marked as a priority.795 Phase 1 Report Volume III Figure 16.5; Photographs of whiteboard {MET00008663}; {MET00015924}.
The evacuation of Flat 153
¶92.29 Yehualashet Enyew was the first to leave Flat 153 holding Isaac Paulos by the hand. Rabia Yahya and her children followed. Paulos Tekle, carrying his youngest son, and Genet Shawo were at the rear of the group as they all left.796 Phase 1 Report Volume III paragraph 17.58.
¶92.30 Coincidentally, a group of firefighters arrived on floor 18 at that time. FFs Michael Pole, Niki Mitchell and Chris Cheesman had tallied out at 02.53, to go to floor 23. As they went up the stairs, the crew realised that they would not have enough air to get to floor 23 and back. They therefore decided to rescue anyone they could from the floor they had reached (floor 18) rather than continue going up. When they entered the lobby of floor 18, the crew came across the people leaving Flat 153. The group then formed a chain descending the stairs.797 Phase 1 Report Volume III paragraphs 16.15-16.20 and 17.66-17.69.
97¶92.31 By that time conditions were hazardous and disorientating. The lobby of floor 18 was dark and full of smoke. Dense smoke in the stairwell made it hot and difficult to breathe. Both Paulos Tekle and Yehualashet Enyew felt themselves beginning to lose consciousness. Rabia Yahya's asthmatic son collapsed on the stairs and was carried down by firefighters.798 Phase 1 Report Volume III paragraphs 16.19 and 17.58-17.71.
¶92.32 At some point during the descent from Flat 153, Isaac Paulos became separated from Yehualashet Enyew.799 Phase 1 Report Volume III paragraph 17.61. In the Phase 1 report the chairman found that the body of Isaac Paulos had been recovered from floor 13.800 Phase 1 Report Volume III paragraph 17.72. Further evidence suggests that he collapsed and died in the stairwell at the level of floor 13 and that his body was later moved into the lobby on that floor.801 Tyldesley {MET000083333/7} page 7; Stevenson {MET00012860/2} page 2; Gray {MET00010806/14} page 14; Hiscock {MET00010877/4} page 4; Simpson {MET00008040/10} page 10; Purser, Phase 2 Report, Section 6 {DAPR0000006/112} paragraph 616.
¶92.33 In the Phase 1 report the chairman found that it was not possible on the evidence to reach a clear conclusion about how and when Yehualashet Enyew lost his grip on Isaac Paulos' hand.802 Phase 1 Report Volume III paragraphs 17.56-17.74. We have not received any further evidence that allows us to reach a more positive conclusion.
¶92.34 Paulos Tekle, Genet Shawo and their youngest son, Rabia Yahya and her three children and Yehualashet Enyew all left the tower between 03.13 and 03.18.803 Phase 1 Report Volume III paragraph 17.72.
Recovery and identification
¶92.35 Isaac Paulos probably collapsed on the stairs. His body was recovered from the lobby of floor 13.804 Phase 1 Report Volume III paragraph 17.72. The coroner, Professor Wilcox, was satisfied about the identification of his remains and therefore issued an interim certificate of the fact of death for Isaac Paulos.805 Interim certificate of the fact of death for Isaac Paulos {MET00065641}.
Cause and time of death
¶92.36 The post-mortem report on Isaac Paulos noted soot deposits over much of his body. Soot was also present in his airways and lungs. The signs of heat damage to his body were consistent with its having occurred after death. There was no sign that he had sustained any recent injuries before he died.806 Paulos post-mortem report {COR00000675/9} page 9; Purser, Phase 2 Report, section 6 {DAPR0000006/111} paragraphs 607 and 609.
¶92.37 The level of carboxyhaemoglobin in a blood sample taken from Isaac Paulos was found to be 67%, which is within the toxic range. Cyanide was detected at a level of 0.060 milligrams/litre.807 Paulos toxicology report {MET00053154}; Purser, Phase 2 Report, Section 1-4 {DAPR0000005/121} Table 17. That is below what is normally considered to be a toxic level but, since the sample is likely to have degraded over time,808 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112-113} paragraph 447. it is not a reliable indication of the level of cyanide in the blood at the time of death. However, the presence of cyanide shows that Isaac Paulos was exposed to hydrogen cyanide before he died.
98¶92.38 The post-mortem recorded the medical cause of death as "inhalation of fire fumes" but in the light of more recent evidence we find that a more accurate description is "inhalation of asphyxiant gases".
¶92.39 Professor Purser observed that, if those in Flat 153 had left by about 01.40, the concentration of asphyxiant gases in the stairwell would have been considerably lower. However, if they had waited until FFs Foster and Lawson reached floor 18, conditions in the stairwell might have been similar to those they encountered when leaving about an hour later.809 Purser, Phase 2 Report, Section 6 {DAPR0000006/108} paragraphs 601–602. The occupants had had minimal exposure to asphyxiant gases before they left the flat.810 Purser, Phase 2 Report, Section 6 {DAPR0000006/108-109} paragraphs 588 and 593.
¶92.40 If the occupants of Flat 153 began to leave at about 03.04, as Professor Purser estimated,811 Purser, Phase 2 Report, Section 6 {DAPR0000006/109} paragraph 593. it must have taken them at most 15 minutes to leave the tower. He thought that the group had been exposed to a significant dose of asphyxiant gases as they crossed the lobby on floor 18 and descended the stairs, but not enough to incapacitate them.812 Purser, Phase 2 Report, Section 6 {DAPR0000006/111-112} paragraphs 609 and 614-615.
¶92.41 However, the rate of uptake of toxic gases is more rapid in children than in adults.813 Purser, Phase 2 Report, Section 6 {DAPR0000006/112} paragraph 611. Taking into account his size and the physical activity involved in descending the stairs, we are satisfied that Isaac Paulos is likely to have absorbed asphyxiant gases at almost twice the rate of an adult,814 Purser, Phase 2 Report, Section 6 {DAPR0000006/112-113} paragraph 618-623. leading to rapid incapacitation and collapse.815 Purser, Phase 2 Report, Section 6 {DAPR0000006/112} paragraph 611. We are therefore satisfied that he collapsed and lost consciousness within a few minutes of entering the stairs. Having lost consciousness, he continued to inhale asphyxiant gases until his respiration and circulation ceased shortly afterwards and he died.816 Purser, Phase 2 Report, Section 6 {DAPR0000006/111-112} paragraphs 607 and 617; Purser, Phase 2 Report, Section 6 {DAPR0000006/114} paragraphs 627-628. Death was rapid and occurred between 03.09 and 03.15.
99Chapter 93: Floor 19
¶93.1 All the flats on floor 19 were occupied on the night of the fire. By 01.25, the fire had reached the top of floor 19 and was outside Flat 166.817 Phase 1 Report Volume II paragraphs 10.118 and 10.122. Within a short time, nearly everyone had left their flats. By 01.30, only Flat 165, the home of Nicholas and Pily Burton, was still occupied.
¶93.2 Meron Mekonnen in Flat 163 had been alerted to the fire at 01.25 and told to leave. Although there was light smoke in the lobby when she left with her children, it did not affect her visibility or have any physical effect on her or her children. Meron Mekonnen and her children left the tower at 01.32.818 Phase 1 Report Volume III Annex A.
¶93.3 Amal Ahmedin and her daughter Amaya Tuccu Ahmedin lived in Flat 166. On 14 June 2017, her cousin, Amna Idris, was visiting them. All three took shelter on floor 23, where they died. Marjorie and Ernie Vital from Flat 162 were also among those who moved to floor 23. By 01.34, they were already in Flat 202, where they also eventually died. We return to the circumstances of the deaths of these individuals in Chapter 97.
¶93.4 Fadumo Ahmed lived alone in Flat 164. At around 01.20, she received a call alerting her to the fire. When she left her flat, she found the lobby full of dark grey smoke;819 Phase 1 Report Volume II paragraph 10.259. it is likely that it had come from Flat 166.
¶93.5 Fadumo Ahmed saw her neighbour Deborah (Debbie) Lamprell, who lived in Flat 161, near the lifts. They both took shelter in Flat 201 on floor 23. Amal Ahmedin, her daughter and Amna Idris were already in Flat 201 when Fadumo Ahmed reached it.820 Phase 1 Report Volume II paragraphs 10.259-10.260. Later, Fadumo Ahmed left Flat 201. She was rescued by firefighters and carried out of the tower at 02.25.821 Phase 1 Report Volume II paragraphs 14.128–14.131. Debbie Lamprell died in the fire, as did a friend, Gary Maunders, who had been visiting her that night and who took shelter in Flat 203. We return to the circumstances of their deaths in Chapter 97.
¶93.6 Shortly after 01.30, Nicholas Burton was woken by the sound of banging on his front door. We do not know who banged on the door; it is possible that he was woken by the sounds of neighbours leaving. In any event, when he opened the front door, there was so much black smoke outside that he could see little.822 Phase 1 Report Volume II paragraphs 11.56-11.57.
¶93.7 At 01.41, a BT operator informed North West Fire Control that a caller from the tower had hung up. CRO Aisha Jabin called the number back and spoke to Debbie Lamprell. She said that she was one of a group of 10 people sheltering in a flat on floor 23; she later gave her flat number as 161.823 Phase 1 Report Volume II paragraphs 12.64-12.67 and 12.86; 999 call transcripts {MET00014977}; {LFB00055500}. Flat 161 was Debbie Lamprell's home on floor 19. The information that there were people trapped in Flat 161 on floor 23 was passed to the LFB's control room at 01.46 and to the incident ground at 01.47.824 Phase 1 Report Volume II paragraph 12.86. As a result, FFs Adam Johnson and Terence Roots were sent to Flat 161. They found it empty but found Nicholas and Pily Burton still in Flat 165 and helped them leave the tower.825 Phase 1 Report Volume II paragraphs 12.86 and 14.116.
100Maria del Pilar ("Pily") Burton
¶Date of birth: 10 August 1946 (70 years of age). Place of birth: Ferrol, Galicia, Spain. Gender: Female. Occupation: Retired. Usual Address: Flat 165, floor 19, Grenfell Tower, London. Date of death: 29 January 2018.
Background and composition of household
¶93.8 Maria del Pilar (Pily) Burton lived with her husband Nicholas Burton and their beagle, Lewis Hamilton II, in Flat 165 on floor 19.826 Burton {IWS00000064/2} page 2, paragraph 9. Pily had moved to Grenfell Tower in the 1970s. She worked for the National Health Service as a contract manager until she had to leave work in 2015 due to ill-health.827 Phase 1 Report Volume IV paragraph 32.174.
Vulnerability
¶93.9 The spreadsheet produced on the night of the fire by David Noble828 Noble {TMO00000884/1} page 1, paragraph 3. based on information held on the TMO's Capita Insight system829 Noble {Day119/75:19-21}. identified Pily Burton as a vulnerable person but contained no information about her condition.830 Noble spreadsheet {TMO00862588}.
Events of 14 June 2017
¶93.10 Having opened the front door of Flat 165 to find black smoke in the lobby, Nicholas Burton decided that he and Pily should remained where they were. He was aware of the stay put advice displayed in the tower. He placed wet towels across the bottom of the front door, woke Pily and helped her dress. They waited in their living room. A friend called him urging him to leave, but he felt it was too dangerous to do so as Pily was so frail.831 Phase 1 Report Volume II paragraph 11.57.
¶93.11 At 01.56, Nicholas Burton made a call to the emergency services which was answered by CRO Christine Howson. He told her that he was in Flat 165 on floor 19 with his wife and dog and that there was a lot of smoke in the lobby, some of which had come into the hallway of his flat when he opened the front door. CRO Howson told him that firefighters would visit them and advised him to remain in his flat.832 Phase 1 Report Volume II paragraphs 13.75-13.77; 999 call transcript {LFB00000334}.
101¶93.12 Prompted by another call from his friend, Nicholas Burton decided that the bathroom would be the safest place in which to wait. He moved Pily there and closed all the internal doors. Seeing the glow of the fire, he made his second and final emergency call at 02.13. He told CRO Yvonne Adams that he was trapped on floor 19, that no one had come, and that the flames were getting very close to their windows. CRO Adams told him that firefighters were trying to get to people and said that he should call back if conditions in the flat deteriorated. At the time of the call, the only smoke in the flat was that which had entered from the lobby when he had opened the front door just after 01.30.833 Phase 1 Report Volume II paragraphs 14.173-14.175; 999 call transcript {LFB00000344}.
¶93.13 The bathroom was near the front door. Waiting there, Nicholas Burton heard a noise at the front door. FFs Johnson and Roots who were outside the door told him to get wet towels and to be ready to come out.834 Phase 1 Report Volume II paragraph 14.176. Having confirmed the number of people present and that the flat was not on fire, FF Johnson told the occupants to cover their heads with wet towels. He and FF Roots then searched Flat 161 before returning to Flat 165 to rescue Nicholas and Pily Burton.835 Johnson {MET00010082/7} page 7; Johnson {Day45/14:1}-{Day45/15:20}.
¶93.14 By that time, the lobby of floor 19 was full of thick black smoke and visibility was limited. The firefighters helped the couple across the lobby, into the stairwell and down the stairs. The stairwell was also full of thick black smoke and felt very hot. Both firefighters were concerned that they were low on air and tried to descend as quickly as they could. Pily Burton fell more than once and FF Johnson had to carry her down.
¶93.15 At some point the two firefighters became separated. FF Roots and Nicholas Burton reached the ground floor first, but Nicholas Burton refused to leave the building until he knew where his wife was. At about floor 10, two other firefighters appeared and helped FF Johnson to carry Pily Burton. They reached the ground floor a few minutes after Nicholas Burton. He followed as Pily Burton was carried out of the tower.836 Johnson {MET00010082/9-10} pages 9-10; Roots {MET00012876/6-7} pages 6-7; Burton {IWS00000064/12-13} pages 12-13, paragraphs 54-56. The couple left the tower at 02.32.837 Phase 1 Report Volume II paragraph 14.179.
¶93.16 FFs Johnson and Roots returned to the bridgehead and told WM O'Keeffe that they had brought two casualties down from Flat 165. They gave the same information to a firefighter who was recording information about people needing to be rescued and saw him write something on a wall.838 Johnson {MET00010082/10} page 10.
Information to the incident ground
¶93.17 No service requests were generated in response to either of Nicholas Burton's 999 calls839 Short Incident Log Report {MET00013830/21-22}. and no firefighters were deployed to Flat 165.
The circumstances of Pily Burton's death
¶93.18 Pily Burton's condition deteriorated in the months that followed her escape from Grenfell Tower. She suffered a severe stroke in early January 2018 and died in hospital on 29 January 2018 with Nicholas Burton by her side.840 Phase 1 Report Volume IV paragraph 32.174.
103Chapter 94: Floor 20
¶94.1 On 14 June 2017, all the flats on floor 20 were occupied. Victoria (Vicky) King and her daughter Alexandra Atala, who lived in Flat 172, Mary Mendy and her daughter Khadija Saye, who lived in Flat 173, and four of the five members of the Belkadi family, who lived in Flat 175, died in the fire. Jessica Urbano Ramirez, whose family home was Flat 176, was among those who died in Flat 201 on floor 23. We describe the circumstances of Jessica Urbano Ramirez's death in Chapter 97.
¶94.2 Emma O'Connor and Luke Towner from Flat 171 were the first of those who lived on floor 20 to leave the tower, doing so shortly before 01.20. When they left, smoke was coming through the vents on floor 20, but the lobby was otherwise clear.841 Phase 1 Report Volume II paragraph 10.261.
¶94.3 By 01.26, the fire had reached the outside of Flat 176.842 Phase 1 Report Volume II paragraph 10.118. At that time, the only person there was Jessica Urbano Ramirez. She must have left by or before 01.26, since she spoke to CRO Sarah Russell from Flat 201 at 01.29.
¶94.4 The lobby on floor 20 became full of smoke within minutes after the fire reached the outside of Flat 176.843 Phase 1 Report Volume IV paragraph 25.10 (b). Farah Hamdan spoke to CRO Alexandra Norman at 01.30 and reported that there was smoke coming into the flat from the lobby.844 Phase 1 Report Volume II paragraph 11.47. Petra Doulova and her husband, who lived in Flat 174, left the tower at 01.41. She described the lobby on floor 20 as being pitch black and full of smoke, making it difficult to breathe. The couple had to feel their way across the lobby to the stairwell door.845 Phase 1 Report Volume II paragraphs 11.48-11.51.
¶94.5 FF David Badillo was one of the first firefighters to arrive at the tower.846 Phase 1 Report Volume II paragraph 10.19. He met Melanie Urbano Ramirez, Jessica Urbano Ramirez's sister, outside the tower and agreed to go to Flat 176 to find her.847 Phase 1 Report Volume II paragraph 10.79. After a failed attempt to reach floor 20 alone, FF Badillo returned with CM Christopher Secrett and FF Christopher Dorgu. They tallied out at 01.33848 Phase 1 Report Volume II paragraphs 11.10-11.11 and 12.6. and were the first firefighters to reach that floor.
¶94.6 The lobby on floor 20 was so full of smoke that CM Secrett could not see equipment he had put on the floor.849 Phase 1 Report Volume II paragraph 12.30. The firefighters moved around the lobby using touch and torches.850 Badillo {Day13/154:15}. When they found Flat 176, FF Badillo found the front door slightly ajar. The flat was full of smoke but the contents were not alight, although fire could be seen outside a window which was about to fail. CM Secrett's warning whistle on his breathing apparatus began to sound shortly after they returned to the lobby having searched the flat and found it empty. The crew decided to make their way back to the stairwell and down. They did not knock on the doors of any other flats.851 Phase 1 Report Volume II paragraphs 12.6, 12.31 and 13.6.
104Firefighter deployments to floor 20
¶94.7 Between 01.30 and 03.33 several emergency calls were made to the control room from inside and outside the tower reporting that Flats 173 and 175 were still occupied.852 Phase 1 Report Volume II paragraphs 11.47, 12.60, 14.167, 16.59 and 16.60.
¶94.8 Three crews were deployed to floor 20 between 01.50 and 02.00.
¶94.9 FFs Geoffrey Campbell and Steven Mills tallied out at 01.51 to go to Flat 175, the home of the Belkadi family, but were unable to reach floor 20.853 Phase 1 Report Volume II paragraphs 13.14-13.15 and 14.85. On their descent they met a Paddington crew led by CM Philip Wigley that had been sent to the roof of the tower.854 Phase 1 Report Volume II paragraphs 11.12-11.13. FFs Campbell and Mills told them that they had been unable to rescue a woman on floor 20. Having continued upward but realising that they would not be able to reach the roof, the Paddington crew made their way to floor 20 intending to rescue the woman they had been told about. FF Duane Harris opened the door to the lobby which was full of smoke. Members of the crew shouted but did not go into the lobby to knock on the doors to the flats. At about that time FF Roberts found Fadumo Ahmed on the stairs between floors 20 and 21. The crew assisted her down the stairs and out of the tower.855 Phase 1 Report Volume II paragraphs 13.14-13.15, 14.85-14.87 and 14.131-132; Gillam {Day27/71:20}-{Day27/73:16}.
¶94.10 CM Craig Eden and FF Tom Welch were instructed by WM O'Keeffe to go to floor 20 to assess the situation and report to the bridgehead. CM Eden said they had been told that there were persons trapped on floor 20. FF Welch said that they had not been told that there were people who needed rescuing and that he had assumed that the building had been evacuated.856 Eden {MET00008019/5} page 5; Welch {MET000080606/7} page 7. The crew tallied out at 01.59. A minute later, FFs Vincent Williams and Agnel Fernandes tallied out with instructions to go to Flat 175 on floor 20.857 Phase 1 Report Volume II paragraph 14.80.
¶94.11 CM Eden and FF Welch reached floor 20. By that time, they were running low on air, so they decided to connect a fire hose to the dry riser.858 Phase 1 Report Volume II paragraph 14.81. Both firefighters described the lobby as so full of hot smoke that they could not see anything. CM Eden banged loudly on three doors but received no response. FF Welch said that, as they followed a wall left past two flat doors to find the dry riser, CM Eden had banged on those doors and announced that they were firefighters. Given the location of the dry riser, they are likely to have been the doors of Flats 172 and 173.859 Eden {MET00008019/10} page 10; Welch {MET000080606/7} page 7.
¶94.12 FFs Williams and Fernandes reached floor 20 shortly after CM Eden and FF Welch and met them there. They too recalled thick smoke and no visibility. They tried to find their way to Flat 175, kicking and banging on doors and shouting through letterboxes as they went.860 Williams {MET00010829/6-7} pages 6-7; Fernandes {Day39/176:19}-{Day39/177:4}.
¶94.13 There were no further deployments to floor 20 after 02.00. FFs Luke Cook and Brian Flanagan were sent to floor 20 at some time after about 02.03 but we think it likely that they went to a different floor.861 Cook {MMET00012855/3} page 3; Flanagan {MET00012855/7} page 7.
105Victoria (Vicky) King
¶Date of birth: 12 June 1946 (71 years old). Place of birth: Highgate, London, England. Gender: Female. Occupation: Retired. Usual address: Flat 172, floor 20, Grenfell Tower, London. Place of death: Flat 172, floor 20, Grenfell Tower, London. Time of death: By 3.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Alexandra Catherine Atala
¶Date of birth: 24 April 1977 (40 years old). Place of birth: Reading, England. Gender: Female. Occupation: NA. Usual address: Flat 172, floor 20, Grenfell Tower, London. Place of death: Flat 172, floor 20, Grenfell Tower, London. Time of death: By 3.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶94.14 Born on 12 June 1946, Victoria (Vicky) King was 71 years old in 2017. She had been the registered tenant of Flat 172 since 26 January 1998862 Lancaster West EMB New Letting form {IWS00001930/2}. and lived there with her daughter, Alexandra Atala. Born on 4 April 1977, Alexandra Atala was 40 years old.863 Phase 1 Report Volume IV paragraph 32.150. Vicky King and Alexandra Atala had a very close relationship and lived together throughout their lives.864 Phase 1 Report Volume IV paragraph 32.153.
Vulnerabilities
¶94.15 Both Vicky King and Alexandra Atala had mental health difficulties.865 Bennett {IWS00001882/2} page 2, paragraphs 7-8. Alexandra Atala suffered from panic disorder associated with agoraphobia.866 Letter from Dr Meena Nathan to Stella Fitzgerald dated 12 December 2017 {BSR00000141}. RBKC and the TMO were aware of their vulnerabilities.
106¶94.16 On 9 July 2006, Janice Jones recorded that both Vicky King and Alexandra Atala had mental health difficulties.867 Floating Support Service Referral Form {IWS00001908}. In a survey of tower residents carried out by Rydon in 2014 during the refurbishment both women were recorded as having problems with their mental health.868 Rydon Residents Survey {RYD00024466}.
¶94.17 In the spreadsheet produced on the night of the fire by David Noble869 Noble {TMO00000884/1} page 1, paragraph 3. based on information held on the TMO's Capita Insight system870 Noble {Day119/77:17}-{Day119/82:5}. Vicky King was listed as a resident but there was no reference to any vulnerability. Alexandra Atala was recorded as being vulnerable on the grounds of mental health.
Events of 14 June 2017
¶94.18 Both Vicky King and Alexandra Atala were in Flat 172 when the fire started. Vicky King had returned to the tower in the afternoon of 13 June 2017.871 O'Riordan {MET00013136/2} page 2. Alexandra Atala had not left her home for some time. Neither mother or daughter had any contact, whether by telephone or otherwise, with anyone either in or outside the tower during the fire.
¶94.19 Although firefighters did manage to reach floor 20, none were sent specifically to Flat 172. There is no evidence that Vicky King or Alexandra Atala ever became aware of the fire or that they heard other residents leaving floor 20 or firefighters arriving on that floor.
¶94.20 The fire reached the east side of the kitchen and living room of Flat 172 between about 02.02 and 02.08.872 Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 478. At some time after 02.55 it had spread to the south face of the living room and the two bedrooms of Flat 172.873 Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 478.
Recovery and identification
¶94.21 The remains of Vicky King and Alexandra Atala were recovered from the second bedroom in Flat 172 (the most southerly room in the flat and so farthest away from the fire).874 Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 482; Presentations relating to Victoria King and Alexandra Atala {Day305/15:10}. The coroner, Professor Wilcox, was satisfied about the identification of the remains recovered and therefore issued interim certificates of the fact of death for Vicky King and Alexandra Atala.875 Interim certificates of the fact of death for Victoria King and Alexandra Atala {MET00065648}; {MET00065622}.
Cause and time of death
¶94.22 The post mortem examination on Vicky King noted that there was soot in the oesophagus. The carboxyhaemoglobin content of a blood sample taken from her was 58%, which is within the fatal range and indicated that she had inhaled carbon monoxide before her death. It was not possible to test the remains of Alexandra Atala.876 King post-mortem report {COR00001454/5} page 5; Atala post-mortem report {COR00000066/6} page 6; Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 481.
¶94.23 Drawing on the evidence of other occupants of floor 20, the evidence of the occupants of flats in a similar location on other floors and the evidence of Professor Purser, we are satisfied that from about 01.30 smoke probably began to enter Flat 172 from the lobby. When the fire reached the east side of Flat 172 shortly after 02.00, smoke began to enter the flat from outside. Until about 02.45 Vicky King and Alexandra Atala could probably have escaped from the building if they had been able to cross the lobby and descend the stairs.877 Purser, Phase 2 Report, Section 6 {DAPR0000006/87-88} paragraphs 482 and 484.
107¶94.24 Conditions in the second bedroom began to deteriorate once the fire started to spread across the southern face of Flat 172.878 Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 482. Since their remains were found in a bedroom, it is possible that Vicky King and Alexandra Atala were asleep by the time the fire started and slept through it.879 Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 480.
¶94.25 Taking into account the presence of soot in Vicky King's respiratory system, the level of carboxyhaemoglobin in her blood and that her remains and those of Alexandra Atala were recovered from a bedroom, we are satisfied that inhalation of asphyxiant gases caused both of them to lose consciousness and die before the contents of Flat 172 caught fire.
¶94.26 The post mortem reports on Vicky King and Alexandra Atala recorded the medical cause of death in each case as "consistent with the effects of fire",880 Atala post-mortem report {COR00000066}; King post-mortem report {COR00001454}. but in the light of more recent evidence we find that a more accurate description is "inhalation of asphyxiant gases".
¶94.27 There is not enough evidence to allow us to determine the time of death with any precision but we think that Vicky King and Alexandra Atala had probably both died by about 03.30.
Mary Mendy
¶Date of birth: 11 June 1963 (54 years). Place of birth: Banjul, The Gambia. Gender: Female. Occupation: Carer. Usual address: Flat 173, floor 20, Grenfell Tower, London. Place of death: Stairwell, Grenfell Tower, London. Time of death: Between 03.50 and 04.10 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Khadija Saye
¶Date of birth: 30 July 1992 (24 years). Place of birth: Hammersmith, London. Gender: Female. Occupation: Artist. Usual address: Flat 173, floor 20, Grenfell Tower, London. Place of death: Stairwell, Grenfell Tower, London.
108¶Time of death: Between 03.50 and 04.10 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶94.28 Mary Mendy had been the sole tenant of Flat 173 since 17 January 1994.881 Tenancy Agreement {TMOH00011129}. She lived there with her daughter, Khadija Saye.
¶94.29 Mary Mendy was born on 11 June 1963 in The Gambia and was 54 years old.882 Phase 1 Report Volume IV paragraph 32.142. She had moved to the United Kingdom in the 1980s.883 Phase 1 Report Volume IV paragraph 32.144. Khadija Saye was born on 30 July 1992 in London.884 Phase 1 Report Volume IV paragraph 32.142. She was 24 years old. At the time of the fire Mary Mendy was working as a care assistant. Khadija Saye had attended Rugby School on a scholarship and studied photography at the University of the Creative Arts in London. In May 2017, her work was exhibited at the Venice Biennale.885 Phase 1 Report Volume IV paragraphs 32.147-32.148.
Vulnerabilities
¶94.30 There is no evidence that Mary Mendy or her daughter suffered from any vulnerability that would have impeded their escape.
Events of 14 June 2017
¶94.31 Khadija Saye and Mary Mendy returned home during the evening of 13 June 2017. Khadija was seen on CCTV entering the lift lobby on the ground floor of the tower at 21.08. Her mother was seen on CCTV in the lift lobby at 23.06.886 O'Riordan {MET00013136/3} page 3. They remained in Flat 173 thereafter.
¶94.32 We do not know when they first became aware of the fire but at 01.49 Khadija Saye posted a message on Facebook saying that there was a fire in the tower and that she and her mother could not leave their flat.887 Phase 1 Report Volume II paragraph 12.61. The contents of that post suggest that neither Khadija Saye nor her mother had become aware of the presence on floor 20 of FFs Badillo, Dorgu and CM Secrett, who searched Flat 176 for Jessica Urbano Ramirez at some time between 01.33 and 01.57.888 Phase 1 Report Volume II paragraph 11.10 and 13.16. That may be because Flat 176 was in the northeast corner of the tower and Flat 173 in its southwest corner. It appears that Khadija Saye became aware of the presence of one or both of the other crews which later reached floor 20, since she told a friend in a telephone call at 02.50 that she had heard firemen "arguing" outside her door and then nothing else.889 Email from Adele Evelyn to Marion Tefler dated 19 June 2017 {BSR00000102}. As Khadija Saye was able to say that those outside were firefighters, she must have heard them announce themselves as such. However, there is no evidence that Khadija Saye or her mother tried to call out to them.
Information to the incident ground
¶94.33 At 02.26, Khadija Saye made an emergency call, in the course of which she told CRO Sarah Russell that a lot of smoke was coming into the flat. She and her mother were in the living room and had shut all but one of the windows. CRO Russell said that they could stay or to try to leave but Khadija Saye told her that they were too high up to leave and that there was too much smoke outside the front door. CRO Russell then advised her to try to prevent the smoke coming in by blocking doors and shutting windows. CRO Russell said she would notify the firefighter crews and explained that they were trying to make their way up but that it would take them some time.890 Phase 1 Report Volume IV paragraph 16.59; 999 call transcript {LFB00000355/2}.
109¶94.34 That was the only emergency call Khadija Saye made. She communicated with friends on Facebook who then made emergency calls to the LFB on her behalf reporting that she and her mother were trapped in Flat 173 on floor 20. There were five such calls between 02.50 and 03.33. On each occasion, the caller was advised to tell Khadija Saye to leave her flat.891 Phase 1 Report Volume III paragraph 16.60. No service requests appear to have been generated in response to any of those calls or to Khadija Saye's earlier call. However, an entry reading "173 20th – 2 adults" appears on the second of the two whiteboards which SM Jason Oliff was using in the LFB control room from 02.33 to collate information to pass to the command units.892 Phase 1 Report Volume III paragraphs 15.139-15.140 and Figure 15.9. The position of that entry suggests that it had been prompted by one of the later calls about Flat 173.
¶94.35 Information about Flat 173 did reach the incident ground. Although no mention of Flat 173 appears on the white laminated sheet used in CU7 to collate information,893 Phase 1 Report Volume II paragraphs 12.8-12.9; Phase 1 Report Volume IV paragraph 28.86. a reference to it was made on a whiteboard used in CU7 from about 03.00.894 Phase 1 Report Volume III paragraphs 15.13 and 16.12; Phase 1 Report Volume III Figure 16.5; Photograph of whiteboard {MET00015924}. That whiteboard used a grid system. The figure "2" appears against Flat 173 indicating two adults. Next to it is a "P" in red, circled, indicating a priority.895 Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. A red tick was used on the grid to indicate that a crew had been deployed. No red tick appears on the grid.
¶94.36 The bridgehead was located on floor 3 between 02.17 and 03.10.896 Phase 1 Report Volume IV paragraphs 28.86 and 28.87. No note about Flat 173 appears on the wall of floor 3 where WM Louisa De Silvo recorded information while the bridgehead was located there. That may be because information about Flat 173 did not reach CU7 before 03.00.
¶94.37 WM Glynn Williams began recording information on the wall of the ground floor lobby at about 02.15. Someone had written "173 20 2P".897 Phase 1 Report Volume II paragraphs 14.103-14.105 and Figure 14.5. The note was probably made by SM Peter Wolfenden, who entered the ground floor after the bridgehead had been moved there and started recording information on the wall from about 03.21.898 Wolfenden {Day40/168:3}-{Day40/172:16}; {Day40/182:14}-{Day40/186:9}. He said that a tick had been used to indicate that a crew had been sent to a particular flat.899 Wolfenden {Day40/188:5}-{Day40/190:4}. No tick appears next to the entry for Flat 173.
¶94.38 We are satisfied, therefore, that no crews were deployed specifically to Flat 173 in response to the calls made from or about it.
110The last movements of Khadija Saye and Mary Mendy
¶94.39 The advice for people to remain in their flats was changed at 02.35900 Phase 1 Report Volume II paragraph 15.161. after Khadija Saye's call to the LFB. After her first post on Facebook, Khadija Saye next posted at 02.41.901 Telfer Exhibit MT/1 – Facebook timeline {IWS00001188/18}. At 02.55 she learned that the LFB's advice was now to leave the building when a friend, who had called the control room, sent her a message. The same friend, having spoken to the control room again, repeated the advice to leave at 02.57.902 Phase 1 Report Volume III paragraph 17.51; Telfer Exhibit MT/1 – Facebook timeline {IWS00001188/18}.
¶94.40 Khadija Saye replied that she was afraid to leave. At 03.05, as the exchange continued, she said that there was a lot of smoke in the flat. Having been reassured that there was only smoke in the stairwell, Khadija Saye sent another message at 03.14 saying that she had tried to leave but that the smoke had been too strong. Asked if she had found the way to the stairs, Khadija Saye replied that it was too dark and that she had begun to choke after a few steps. At 03.27, she described another attempt to leave, adding that it was impossible and that she had felt as though she was going to faint. At 03.30, in what was her last message, she said "It's in my rooms". We do not know if that was a reference to the fire or smoke. Her friend continued to send her messages, but we do not know if Khadija Saye saw them.903 Phase 1 Report Volume III paragraphs 17.51-17.55; Telfer Exhibit MT/1 – Facebook timeline {IWS00001188/18-20}.
¶94.41 Between 03.20 and 03.29, the fire reached the outside of the two bedrooms of Flat 173 on the south side of the tower. Between 03.37 and 03.53, it had reached the south side of the living room and moved round to the west side of the living room and to the kitchen of the flat.904 Purser, Phase 2 Report, Section 6 {DAPR0000006/102} paragraph 557.
¶94.42 The arrival of the fire outside Flat 173 did not immediately cause Mary Mendy and Khadija Saye to try for a third time to leave their home, but they did so shortly after 03.30. This time they were able to cross the lobby and enter the stairwell.
Recovery and identification
¶94.43 FFs Methusael Sonson and James Cuthbert tallied out at 03.46 with instructions to search floor 5. Their end of wear time was 04.12. After they had been deployed, they were instructed to go to Flat 84 on floor 11. Making their way up the stairs, they found the body of Khadija Saye in the stairwell near floor 10. FF Sonson confirmed that she had no pulse.905 Sonson {MET00010824/8} page 8; Cuthbert {MET00012878/11-12} pages 11-12; BA Telemetry Data {LFB00023326/3}. Given where these firefighters found Khadija Saye, that must have been shortly before 04.12.
¶94.44 Khadija Saye's body was subsequently moved to the lobby on floor 9 from which it was later carried out of the tower.906 Phase 1 Report Volume III paragraph 17.55. The coroner, Professor Wilcox, was satisfied about the identification of the casualty found by FFs Sonson and Cuthbert and therefore issued an interim certificate of death for Khadija Saye.907 Interim certificate of the fact of death for Khadija Saye {MET00065605}.
¶94.45 CM Timothy Cutbill and FF Steven Bolton tallied out at 05.28 as part of a crew of four sent to floor 11 to search for casualties and, if possible, to go further up the tower. Their end of wear time was 05.59. As they ascended the stairs, they came across the body of Mary Mendy between floors 12 and 13.908 Cutbill {MET00010872/5} page 5; Boulton {MET000080564/8} page 8. Her body was later moved into the lobby on floor 13 and then taken out of the tower.909 Phase 1 Report Volume III paragraph 17.55. The coroner, Professor Wilcox was satisfied about the identity of the casualty found by FFs Cutbill and Bolton and issued an interim certificate of the fact of death for Mary Mendy.910 Interim certificate of the fact of death for Mary Mendy {MET00065585}.
111Cause and time of death
¶94.46 The post-mortems on Mary Mendy and Khadija Saye noted that, although it was not possible to obtain a blood sample from either of them, the presence of soot in their upper airways together with the discolouration of soft tissues showed that they had both inhaled carbon monoxide and hydrogen cyanide.911 Mendy post-mortem report {COR00001031}; Saye post-mortem report {COR00000855}; Purser, Phase 2 Report, Section 6 {DAPR0000006/103} paragraphs 565 and 567.
¶94.47 Professor Purser calculated that, if Mary Mendy and Khadija Saye had entered the stairs at 03.36, the latest time at which they could have safely left the building without collapsing was about 03.16.912 Purser {Day297/91:22}–{Day297/94:1}. We accept his conclusion that, taking account of the conditions on floor 20 and in Flat 173 and the experience of survivors from flats in similar locations, Mary Mendy and Khadija Saye died from the inhalation of asphyxiant gases, mainly carbon monoxide but some hydrogen cyanide. They were exposed to a substantial amount of such gases while still in Flat 173, though not enough to incapacitate them. Conditions in the flat deteriorated by 03.30, when the fire had reached the bedrooms on the south side of the flat. Once they had left their home, their exposure to asphyxiant gases increased as they ventured into the smoke-filled lobby and then, albeit to a lesser degree, the stairwell. That exposure, coupled with the physical exertion required to descend from floor 20, caused them to collapse in the stairwell.913 Purser, Phase 2 Report, Section 6 {DAPR0000006/104} paragraphs 568-574.
¶94.48 Mary Mendy probably collapsed and lost consciousness between floors 12 and 13. Khadija Saye was able to continue for a short distance before she lost consciousness near floor 10. Thereafter, they both continued inhaling asphyxiant gases for a short time until their respiration and circulation ceased some minutes later and they died.
¶94.49 The post-mortem report on Khadija Saye recorded the medical cause of death as "inhalation of fire fumes and burns".
¶94.50 The post-mortem report on Mary Mendy recorded the medical cause of death as "consistent with the inhalation of fire fumes".
¶94.51 In the light of Professor Purser's evidence we find that in each case a more accurate description is "inhalation of asphyxiant gases".
¶94.52 Although Professor Purser estimated that Mary Mendy and Khadija Saye died between 04.00 and 04.20,914 Purser {Day297/91:22}–{Day297/94:1}. having regard to the evidence as a whole, including the time at which Khadija Saye made her last post on Facebook, we find that Mary Mendy had collapsed before FFs Sonson and Cuthbert found Khadija Saye. We therefore conclude that Mary Mendy and Khadija Saye both died between 03.50 and 04.10.
112The Belkadi Family
Farah Hamdan
¶Date of birth: 23 February 1986 (31 years). Place of birth: London, UK. Gender: Female. Occupation: Nursery Assistant. Usual address: Flat 175, floor 20, Grenfell Tower, London. Place of death: Stairwell between floors 19 and 20, Grenfell Tower, London. Time of death: Between 02.45 and 03.10 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Omar Belkadi
¶Date of birth: 1 August 1984 (32 years). Place of birth: Morocco. Gender: Male. Occupation: Courier. Usual address: Flat 175, floor 20, Grenfell Tower, London. Place of death: Stairwell between floors 19 and 20, Grenfell Tower, London. Time of death: Between 02.45 and 03.10 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Malak Belkadi
¶Date of birth: 26 September 2008 (8 years). Place of birth: London. Gender: Female. Occupation: Student. Usual address: Flat 175, floor 20, Grenfell Tower, London. Place of death: St Mary's Hospital, Paddington, London. Time of death: 15:01 on 15 June 2017. Cause of death: Inhalation of asphyxiant gases.
113Leena Belkadi
¶Date of birth: 12 December 2016 (6 months). Place of birth: London. Gender: Female. Occupation: N/A Usual address: Flat 175, floor 20, Grenfell Tower, London. Place of death: Stairwell between floors 19 and 20, Grenfell Tower, London. Time of death: Between 02.45 and 03.10 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶94.53 Farah Hamdan and Omar Belkadi had lived in Flat 175 on floor 20 since 18 November 2013.915 Tenancy Agreement {TMOH00011495}. They lived there with their three daughters, Malak Belkadi, Leena Belkadi and their middle daughter who survived the fire.
¶94.54 Farah Hamdan was born on 23 February 1986 in London.916 Phase 1 Report Volume IV paragraph 32.134. She was 31 years old and a teacher. Omar Belkadi was born on 1 August 1984 in Morocco. He was 32 years old and was working for a restaurant in June 2017 while training to be a taxi driver.917 Phase 1 Report Volume IV paragraph 32.139; Presentation relating to the Belkadi family {Day305/44:12-13}. Malak, their eldest daughter, was born on 25 September 2008 at St Mary's Hospital, London. She was eight years old when she died. Leena was born on 14 December 2016 at St Mary's Hospital, London. She was six months old when she died.918 Phase 1 Report Volume IV paragraph 32.134.
Vulnerability
¶94.55 Farah Hamdan and Omar Belkadi did not have any known impairments. Their three children were under 18 years of age. The two elder daughters were recorded as living in the tower in the spreadsheet produced on the night of the fire by David Noble919 Noble {TMO00000884/1} page 1, paragraph 3. and were known to be under 18. Leena was not listed.
Events of 14 June 2017
¶94.56 The family were at home on the night of the fire. Farah Hamdan was seen on CCTV entering the lift lobby of the tower at 18.31 with her daughters.920 O'Riordan {MET00013136/3} page 3. Omar Belkadi returned home later and was seen on CCTV in the lift lobby at 00.12.921 O'Riordan {MET00013136/4} page 4. They became aware of the fire at an early stage, since Farah Hamdan called her sister, Samira Hamdan, at about 01.00 to tell her of a fire at the tower.922 Phase 1 Report Volume II paragraph 14.168.
¶94.57 At 01.30, OM Alexandra Norman answered an emergency call from Farah Hamdan, who told her that the family were in the living room, that smoke was coming into the flat and that the fire was in a neighbour's flat. That must have been a reference to Flat 176; the smoke was probably coming from the lobby. OM Norman's advice was to stay in the flat unless it was safe to leave. She added that she did not know what conditions were like in the stairs.923 Phase 1 Report Volume II paragraph 11.47.
114¶94.58 At 01.31, CRO Peter Duddy created a service request telling the incident ground that there was a fire on floor 20 and that people were trapped there.924 Phase 1 Report Volume II paragraph 11.144. A little later, following a call from Natasha Elcock at 01.33, he created another service request containing the same information and including a reference to Flat 82.925 Phase 1 Report Volume II paragraphs 11.145 and 11.146.
¶94.59 At 01.35, OM Norman spoke to WM Daniel Meyrick in CU8, which had just arrived at the incident ground. She told him that five people were in Flat 175 on floor 20 with a lot of smoke entering the premises.926 Phase 1 Report Volume II paragraph 11.149. WM Meyrick was passing the information he received to WM Mark Kentfield at the incident ground by radio. He was also recording the information on a piece of paper.927 Phase 1 Report Volume II paragraph 11.5. It is likely that WM Meyrick recorded the information he received from OM Norman on such a piece of paper, which was subsequently used to populate a white laminated sheet in CU7. That sheet included the following notation: "175 20 5 PERSON".928 Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3.
¶94.60 While OM Norman was speaking to WM Meyrick, CRO Sharon Darby contacted appliance G261 with the information that there were persons on floor 20 reporting that smoke was coming into their flat. CRO Darby was not able to give the numbers of the flats affected.929 Phase 1 Report Volume II paragraphs 11.147-148 and 11.152. At 01.35, she noted that the service requests relating to floor 20 were being acted upon and at 01.41 she marked them as completed.930 Short Incident Log Report {MET00013830/19}.
¶94.61 The calls made by OM Norman and CRO Darby were the first messages to reach the incident ground. At around 01.40, SM Brett Loft, who was positioned at the front of the tower to handle incoming information, received a piece of A4 paper from WM Kentfield containing a list of flats from which people needed to be rescued. It included a reference to Flat 175 on floor 20. SM Loft passed the information he received to the bridgehead.931 Phase 1 Report Volume II paragraphs 11.6 and 12.8-12.9 and Figure 12.4.
¶94.62 At that time the bridgehead was on floor 2, where it remained until 02.17. While it was there, WM Louisa De Silvo recorded information on a forward information board.932 Phase 1 Report Volume II paragraphs 13.52-13.53. At about 02.13, CM Charles Batterbee went to the bridgehead and copied the information on a forward information board into his own notebook. It included Flat 175 on floor 20, against which a tick appeared. CM Batterbee explained that this indicated a flat to which crews had been deployed, as reported by WM De Silvo.933 Phase 1 Report Volume II paragraphs 14.73-74 and Figure 14.4. We find that the tick related to the deployment of FFs Mills and Campbell who had been sent to Flat 175 but did not reach floor 20.934 See Chapter 89.
¶94.63 At 01.43, Farah Hamdan's second emergency call was connected to North West Fire Control. She gave the number of her flat and the floor and reported that the fire had reached the floor below. She said that the family had tried to leave but that black smoke in the lobby had prevented them from doing so. Farah Hamdan also said that there was now smoke inside her own flat. She was advised to block the smoke from coming in and was told that her location had been passed to the crews.935 Phase 1 Report Volume II paragraph 12.60.
115¶94.64 At about the same time, OM Norman in the LFB control room took a call from Team Leader Paula Craig at North West Fire Control, who told her that five people were in Flat 175 on floor 20.936 Phase 1 Report Volume II paragraphs 12.75-12.76. It is unclear how that information was passed to the incident ground. No service request was created and when CRO Yvonne Adams called CU8 by telephone at 01.50 and 02.00 she did not refer to Flat 175.937 Phase 1 Report Volume II paragraphs 13.86 and 14.230. However, an entry at 02.01.43 in the LFB's short incident log notes that CU8 was told at about 01.50 that five people were trapped in Flat 175 on floor 20.938 Short Incident Log Report {MET00013830/21} page 21. It may be that SM Jason Oliff, who was in contact with CU8 throughout on his personal mobile, passed the information on.939 Phase 1 Report Volume II paragraph 14.243.
¶94.65 At around 02.00 CM Eden and FF Welch left the bridgehead to investigate the situation on floor 20 while FFs Williams and Fernandes were sent to Flat 175 on floor 20.940 Phase 1 Report Volume II paragraphs 14.80-14.81. That may have been the result of the emergency call made by Farah Hamdan at 01.43 or of information received from FFs Campbell and Mills on their return to the bridgehead.941 Campbell {MET00010788/12} page 12; Mills {MET000080584/7} page 7.
¶94.66 At 02.11, CRO Heidi Fox answered a third emergency call from Farah Hamdan. She told CRO Fox that, despite having put sheets under the front door, there was now a lot of smoke in the flat. Farah Hamdan gave her the number of the flat and the floor on which it was situated and said that the five people sheltering there included three children. CRO Fox confirmed that she was passing the information on. She advised Farah Hamdan to keep trying to stop smoke coming in with damp towels and sheets and to call back if the situation worsened.942 Phase 1 Report Volume II paragraph 14.167; 999 call transcript {LFB00000342}.
¶94.67 The notation "175 20th Flr – 2 adults 2 children" appears on a whiteboard in the LFB control room used by SM Oliff to record information about people needing to be rescued. Despite the error about the number of children, that note was probably made in response to Farah Hamdan's call at 02.11, since that was the last call in which she provided her location.943 Phase 1 Report Volume III paragraphs 15.138-15.140.
¶94.68 The final emergency call from Flat 175 at 02.17 was incomplete. The BT operator heard the caller say, "No Malak, it's not safe" and then ask for the fire brigade. The call was then put through to the LFB but there was no further response from the caller.944 Phase 1 Report Volume II paragraph 14.169. It was at about that time that CM Eden and Welch and, shortly after them, FFs Williams and Fernandes reached floor 20.945 Phase 1 Report Volume II paragraph 14.170. Although the visibility there was extremely limited the two crews were aware of each other.946 Williams {MET00010829/3-8} pages 3 and 8; Fernandes (Day39/171:14-22}; Eden {MET00008019/11} page 11.
116¶94.69 When FF Williams and Fernandes reached Flat 175, FF Williams went in and spoke to Omar Belkadi and Farah Hamdan. He told them they needed to leave but they made no move to do so. FF Williams called the bridgehead to ask for assistance but could not hear the response. He then took the couple's second daughter by the hand to encourage the rest of the family to follow him.947 Phase 1 Report Volume II paragraph 14.82; Williams {MET00010829/7-9} pages 7-9.
¶94.70 FF Fernandes had also tried to use his radio to report that they had located a casualty but discovered that it was not working. CM Eden and FF Welch were still on floor 20. Both FF Williams and Fernandes shouted out to them for assistance. CM Eden positioned himself at the stairwell door while FF Welch moved closer towards Flat 175. In conditions of near zero visibility, FF Fernandes made his way to the stairwell door to hold it open. There was a similar lack of visibility in the stairwell.948 Fernandes {MET000083292/4-5} pages 4-5; Williams {MET00010829/10} page 10; Eden {MET00008019/11} page 11.
¶94.71 CM Eden's recollection was that, while on floor 20, he had become aware that there were five people needing to be rescued from Flat 175.949 Eden {MET00008019/11} page 11; Welch {MET000080606/9} page 9. He heard a man (Omar Belkadi) shouting for help and a woman (Farah Hamdan) calling out for her baby. FF Fernandes heard something similar. He first saw the family when they arrived at the stairwell door but was not aware how many of them there were. When FF Williams reached the stairwell, they began their descent. FF Fernandes went down first backwards, so that he could guide FF Williams, who was carrying the Belkadis' second daughter.950 Phase 1 Report Volume II paragraph 14.83; Fernandes {Day39/181:5-20}. He could not recall any conversation with CM Eden and FF Welch about evacuating the family.951 Fernandes {Day39/183:2-14}.
¶94.72 CM Eden and FF Welch tried to help Omar Belkadi. In response to CM Eden, Omar Belkadi said that apart from himself, the group was made up of his wife, two children and a baby. Omar Belkadi was, understandably, panicking and finding it difficult to breathe. CM Eden and FF Welch helped him down the stairs. CM Eden described the stairwell as full of smoke and hot. FF Welch thought that without breathing apparatus one would struggle to breath there.952 Eden {MET00008019/11} page 11; Welch {MET000080606/9} page 9.
¶94.73 Although we are satisfied that FF Fernandes and Williams, carrying the Belkadi's second daughter, entered the stairwell first, the evidence does not enable us to make a finding about the order in which the Belkadi family, supported by the firefighters, left floor 20. They did so in conditions that were particularly difficult and the firefighters were conscious that they were low on air.953 Eden {MET00008019/11} page 11; Williams {MET00010829/7} page 7. FF Welch recalled that Omar Belkadi had collapsed as soon as they began descending. On CM Eden's account they had got no further than the half landing between floors 20 and 19. At about that time, the low-pressure warning on the firefighters' breathing apparatus began to sound.954 Phase 1 Report Volume II paragraph 14.83; Eden {MET00008019/11} page 11; Welch {MET000080606/9} page 9.
¶94.74 CM Eden and FF Welch decided that CM Eden would return to the bridgehead to seek help while FF Welch stayed with Omar Belkadi. In the event, FF Welch was able to leave Omar Belkadi with another crew as he had to return to the bridgehead because his air was running low.955 Phase 1 Report Volume II paragraph 14.83.
117¶94.75 FF Williams carried the second daughter of Farah Hamdan and Omar Belkadi out of the tower at 02.26.956 Phase 1 Report Volume III Annex A. FF Fernandes provided a debrief on reaching the bridgehead but could not remember what he had said.957 Fernandes {Day39/184:22-24}. The end of wear time for CM Eden and FF Welch was between 02.27 and 02.29.958 BA Telemetry Data {LFB00023326/1} page 1. Neither of them said that he had provided any kind of debrief to the bridgehead on his return.959 Phase 1 Report Volume II paragraph 14.83.
¶94.76 When the bridgehead moved to floor 3 after 02.17, WM De Silvo started recording information about people needing to be rescued on a wall. There was a list of floors from 3 to 23 against which the numbers of specific flats were written as information came in. WM De Silvo put a tick against a flat number to show that a BA crew had visited it, a circle to indicate when further information was received and a cross to show that it had been searched and a rescue carried out. There was a tick to show that that Flat 175 had been visited. Given that there were no deployments to that flat after 02.00, it is likely that the information recorded on floor 3 was brought across from floor 2.960 Phase 1 Report Volume IV paragraph 28.86; Phase 1 Report Volume II paragraphs 15.23 and 15.25, Figure 15.7.
¶94.77 No firefighters were deployed to look for Omar Belkadi, Farah Hamdan or their two children after CM Eden and FF Welch returned. At 02.44, FFs Tom Reddington and Nikki Upton tallied out to go to floor 21. They had reached what they believed was floor 18, when they came upon Farah Hamdan. She was unresponsive and the firefighters were unable to move her body as her leg was trapped in the banister railings. FF Upton found Malak Belkadi near her mother. They were able to move her and made the difficult decision to take her down since they could not free her mother.961 Phase 1 Report Volume III paragraph 15.57.
¶94.78 It is likely that FFs Upton and Reddington found Farah Hamdan and her daughter on the stairs higher than floor 18. As they were descending with Malak Belkadi, they encountered a four-person crew who were ascending to go to floor 23. They told them that they had left a female casualty who needed assistance. One of that crew, FF Jessamine Bate, then assisted FFs Upton and Reddington to carry Malak Belkadi down the stairs. The remaining three firefighters, FFs Michael Pole, Niki Mitchell and Chris Cheesman, continued upwards. When they realised that they had insufficient air to reach floor 23, they stopped at floor 18 and helped evacuate occupants in Flat 153. None of these firefighters describe seeing a female casualty on the stairs.962 Phase 1 Report Volume III paragraph 15.58; LFB Operational Response Report dated July 2020 {LFB00119333/263} page 263.
¶94.79 Malak Belkadi was carried out of the tower at 03.07.963 Phase 1 Report Volume II paragraph 14.172.
Recovery and identification
¶94.80 After the fire the bodies of Farah Hamdan, Omar Belkadi and their daughter, Leena, were found on the stairs between floors 20 and 19.964 Phase 1 Report Volume II paragraph 14.172. The coroner was satisfied about their identification and therefore issued an interim certificate of the fact of death for each of them.965 Interim certificates of the fact of death for Omar Belkadi, Farah Hamdan and Leena Belkadi {MET00065583}; {MET00065592}; {MET00065638}.
118Cause and time of death
¶94.81 The post-mortem on Omar Belkadi noted significant soot staining of the body and minor heat damage, both of which had occurred after death. Similarly, there was heavy soot staining and minor heat damage to Farah Hamdan's body. Leena Belkadi had soot staining to her face and again some minor heat damage. In all three cases, there was soot staining of the respiratory airways, indicating inhalation of smoke-filled air. Toxicological analysis of blood samples taken from Farah Hamdan, Omar Belkadi and Leena Belkadi found the levels of carboxyhaemoglobin in their blood to be 85%, 87%, and 84% respectively,966 Omar Belkadi post-mortem report {COR00001303/11}; Hamdan post-mortem report {COR00000397/9}; Leena Belkadi post-mortem report {COR00000876/9}; Leena Belkadi toxicology report {COR00000885}; Purser, Phase 2 Report, Section 6 {DAPR0000006/94} paragraph 522-524. in each case significantly higher than the lethal threshold.
¶94.82 Malak Belkadi was unconscious and in cardiac arrest when carried from the tower. Resuscitation efforts began at the scene and continued at St Mary's Hospital where, at 03.41, a return of circulation was recorded. With treatment, the concentration of carboxyhaemoglobin in her blood dropped from 45% on arrival at hospital to 26%. Toxicological analysis of a sample taken five hours after the start of the fire recorded the level of carboxyhaemoglobin in her blood to be approximately 10%. As the post-mortem report for Malak Belkadi observes, that followed treatment in an oxygen-enriched environment. The level of cyanide in her blood, when first measured some hours after she had been brought out of the tower, was 0.19 milligrams/litre. That reflected the elimination half-life of cyanide being one to two hours. A CT scan showed general cerebral oedema with possible superimposed hypoxic ischaemic brain injury. No brain activity could be found. At 15.01 on 15 June 2017, Malak Belkadi was declared dead.967 Report of paediatric intensive care consultant concerning Malak Belkadi {COR00001720/3-9} pages 3-9; Malak Belkadi toxicology report {COR00000966/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/95} paragraphs 525-527. The coroner, Professor Wilcox, also issued an interim certificate of the fact of death for Malak Belkadi.968 Interim certificate of the fact of death for Malak Belkadi {COR00001713}.
¶94.83 The reports of the post-mortems carried out on Omar Belkadi, Farah Hamdan, Malak Belkadi and Leena Belkadi gave the medical cause of death as "inhalation of fire fumes" but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".
¶94.84 In the light of the evidence as a whole, including that given by Professor Purser, we are satisfied that the family entered the stairwell at about 02.19. They all collapsed soon after doing so because they had already had a significant exposure to asphyxiant gases entering from the lobby rather than from the outside. Their departure from Flat 175 was made in difficult circumstances into a lobby which was heavily smoke logged. As the family crossed the lobby, they inhaled hot smoke and asphyxiant gases and continued to do so on entering the stairwell. The result was that they quickly accumulated an incapacitating dose of asphyxiant gases. The inhalation of hot gases contributed by causing breathing difficulties. The family continued to inhale asphyxiant gases (mainly carbon dioxide but also hydrogen cyanide) until their breathing ceased and they died. In the case of Malak Belkadi, she continued to breathe until she suffered cardiac arrest and fatal brain damage.
119¶94.85 A blood carboxyhaemoglobin level of 30–40% is enough to cause a person to lose consciousness.969 Purser, Phase 2 Report, Section 6 {DAPR0000006/97} paragraph 535. The lethal threshold is around 50%.970 Purser, Phase 2 Report, Section 6 {DAPR0000006/99} paragraph 543. In children, because of their smaller body size, the rate of absorption of asphyxiant gases is more rapid than in adults.971 Purser, Phase 2 Report, Section 6 {DAPR0000006/99} paragraph 543. It is likely that the blood carboxyhaemoglobin level of the Belkadi family reached the lethal threshold by about 02.49; it is unlikely that anyone would have survived if rescued after that time.972 Purser, Phase 2 Report, Section 6 {DAPR0000006/98} paragraphs 541-543.
¶94.86 All the times mentioned above are to some degree conjectural. All we can say with any confidence is that Omar Belkadi, Farah Hamdan and Leena Belkadi died between 02.45 and 03.10, probably closer to 02.45, and that both Farah Hamdan and Leena Belkadi were already dead by the time FFs Upton and Reddington found them. By that time Malak Belkadi was close to the point of death. Having been carried from the tower and despite the treatment provided at hospital, she died at 15.01 on 15 June 2017.
121Chapter 95: Floor 21
¶95.1 Except for Flat 185, all remaining five flats on floor 21 were occupied when the fire started. Ligaya Moore, who lived in Flat 181, and all five members of the El Wahabi family who lived in Flat 182, died in the fire.
¶95.2 By 01.26 on 14 June 2017 the fire on the outside of the building had already spread to floor 21.973 Phase 1 Report Volume II paragraph 10.118. Mustapha Abdu in Flat 184 was the first occupant of the floor to leave. He left the tower at 01.28 and had no contact with anyone else on floor 21.974 Phase 1 Report Volume II paragraph 10.271.
¶95.3 Helen Gebremeskel lived in Flat 186 with her daughter. Woken by her kitchen smoke alarm, she went into her kitchen to see black smoke and flames coming through the window. She and her daughter quickly left the flat closing the front door behind them975 Phase 1 Report Volume II paragraph 10.265. because it did not have an effective self-closing device.976 Gebremeskel {Day68/133:1-2}; {Day68/143:15}.
¶95.4 At 01.26, when she was in the lobby, Helen Gebremeskel called the emergency services to report a fire in her flat. She and her daughter tried to leave together with the El Wahabi family, but they abandoned the attempt and by 01.30 had taken shelter in Flat 183, the home of Marcio Gomes and Andreia Perestrelo.977 Phase 1 Report Volume II paragraphs 10.269. By that time there was a layer of black smoke close to the ceiling of the lobby.978 Phase 1 Report Volume II paragraph 10.270. The El Wahabi family returned to Flat 182.
¶95.5 From about 01.25 the lobby of floor 21 rapidly filled with smoke to an extent that it deterred those who remained on that floor from trying to leave. a. At about 01.30 Abdulaziz El Wahabi told his sister Hanan Wahabi, who had already
escaped, that the amount of smoke in the lobby had prevented him and his family from leaving.979 Phase 1 Report Volume III paragraph 11.42. At about 01.41 in the course of an emergency call to the LFB control room he told CRO Pam Jones that it was very smoky in the lobby.980 999 call transcript {LFB00055498/6}.
¶b. At 02.32, Marcio Gomes used his mobile phone to make a video recording of black smoke coming through the sides of his closed front door. When he opened the door, the lobby was pitch black with no indication that the lighting was working.981 Phase 1 Report Volume II paragraphs 15.74-15.76.
¶95.6 Further emergency calls alerted the control room to the fact that occupants were trapped on floor 21. Those still on floor 21 spoke to the control room on no fewer than 11 occasions. In Flat 182, the El Wahabi family were in contact with the control room in a call which lasted from 01.38 to 02.37.982 Phase 1 Report Volume II paragraph 13.103. They spoke to the control room again at 02.43, 02.46, 02.51, 02.53 and 02.57.983 Phase 1 Report Volume III paragraphs 15.180 and 15.186-15.187. A call made at 02.39 was connected to the London Ambulance Service.984 Phase 1 Report Volume III paragraph 16.53. Marcio Gomes in Flat 183 spoke to the LFB control room at 02.21, 02.46, 02.55, 03.09 and 03.25.985 Phase 1 Report Volume III paragraphs 15.130, 16.56, 16.84, 17.48, 17.50, 17.132, 17.139 and 18.29.
122¶95.7 Only one firefighter crew, FFs Nikki Upton and Tom Reddington, was sent to floor 21. They set out at 02.44 but failed to reach floor 21 because they stopped to assist casualties they found on the stairs.986 Phase 1 Report Volume III paragraph 15.57.
¶95.8 However, one firefighter did reach floor 21. FF Dean Roberts was part of a five-member crew sent to the roof of the tower987 Phase 1 Report Volume II paragraphs 11.12-11.13. that set out between 01.56 and 01.57.988 BA Telemetry Data {LFB00023326}. Somewhere between floors 20 and 21, they found Fadumo Ahmed collapsed in the stairwell. While his colleagues helped her, FF Roberts continued up to floor 21 and opened the door to the lobby. He found it to be pitch black with smoke from floor to ceiling. He shouted and kicked the stairwell door but he did not see or hear any reaction before he left that floor.989 Phase 1 Report Volume II paragraphs 14.85-14.87; Roberts {Day27/125:5}-{Day27/127:17}. There is no evidence that the occupants on floor 21 heard FF Roberts shout into the lobby.
Ligaya Moore
¶Date of birth: 28 October 1938 (78 years). Place of birth: San Luis, Philippines. Gender: Female. Occupation: Retired. Usual address: Flat 181, floor 21, Grenfell Tower, London. Place of death: Flat 181, floor 21, Grenfell Tower, London. Time of death: Between 01.40 and 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶95.9 Ligaya Moore was retired and was 78 years old in June 2017. Born in the Philippines, she had moved to London in 1972 and worked as a nanny. She met her husband, James Moore, in London and they moved into Grenfell Tower in 1981. Ligaya Moore continued to live in Flat 181 after the death of her husband.990 Phase 1 Report Volume IV paragraphs 32.119 -32.124.
Vulnerability
¶95.10 In 2013 the TMO became aware that Ligaya Moore was prone to hoarding and advised her that it could affect her tenancy.991 RBKC Core Assessment for Ligaya Moore {RBK00059526/2}. The situation did not improve. In October 2014, following their survey of residents, Rydon informed the TMO that the accumulation of items in Flat 181 made it impossible for it to carry out works.992 Report dated 31 October 2014 from Rydon RLO {RYD00022561}. Janice Jones, TMO neighbourhood officer, referred Ligaya Moore to RBKC's social services department for assistance. They tried to carry out an assessment in May 2015, but she was not willing to co-operate. Hoarding was noted to be a possible fire safety risk, the consequences of which would be catastrophic. Ligaya Moore was recorded as being independently mobile and able to call out if in danger. She did agree to a referral to a de-cluttering service but would not consent to social services contacting her doctor or to being contacted by the LFB for a fire safety check.993 RBKC Core Assessment for Ligaya Moore {RBK00059526/9-13}.
123¶95.11 A care and support plan completed in September 2015 noted that Ligaya Moore had had three sessions with the de-cluttering service and had agreed to be referred to Age UK's de-cluttering service but had refused further involvement with social services. The housing department were to continue to monitor the situation.994 RBKC Care and Support Plan Review for Ligaya Moore {RBK00059524/3}. Nerita Bunggay, a friend of Ligaya Moore who saw her every day, described her as so embarrassed by the state of her home that she did not want others to see it. Hoarding was still a problem for her in June 2017.995 Bunggay {IWS00002374/2} page 2, paragraphs 7-13.
¶95.12 Ligaya Moore appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system.996 Phase 1 Report Volume III paragraphs 20.65-20.66; Noble Spreadsheet {TMO00862588}. It recorded that she was over 65 years of age but did not mention any other vulnerability.
Events of 14 June 2017
¶95.13 Ligaya Moore returned to Grenfell Tower shortly after 22.20 on 13 June 2017.997 O'Riordan {MET00013136/4} page 4. She did not leave her home after that.
¶95.14 It is likely that she never became aware of the fire. No other occupant of floor 21 had any communication with her during its course and there is no evidence to suggest that she became aware of the movements of the other occupants trapped on that floor or that she had contact with the emergency services, family or friends by telephone or otherwise.
Recovery and identification
¶95.15 All the combustible contents of Flat 181 were destroyed in the fire.998 Purser, Phase 2 Report, Section 6 {DAPR0000006/65} paragraph 315. Ligaya Moore's remains were recovered from the bedroom area. They were associated with the remains of a bed which suggests that she was in bed at the time of the fire. The coroner was satisfied about the identification of the remains recovered and therefore issued an interim certificate of the fact of death.999 Interim certificate of the fact of death for Ligaya Moore {MET00065603}; Purser, Phase 2 Report, Section 6 {DAPR0000006/65} paragraph 319.
Cause and time of death
¶95.16 The post-mortem report for Ligaya Moore recorded the medical cause of death as "consistent with the effects of fire", but in the light of more recent evidence we find that a more accurate description is "inhalation of asphyxiant gases".
124¶95.17 Flat 181 was a one-bedroom flat situated on the east side of the tower between Flats 186 and 182.1000 External Spread of Fire at Grenfell Tower {MET00012593/7}. The fire had reached floor 21 before 01.30.1001 Phase 1 Report Vol II paragraph 10.118. It was outside the living room of Flat 181 by about 01.32 and from then on smoke began to leak into Flat 181 both from the outside and the lobby. By about 01.52 the fire was outside the bedroom window.1002 Purser, Phase 2 Report, Section 6 {DAPR0000006/64} paragraph 314.
¶95.18 It is very difficult to make a finding with any confidence about the time at which Ligaya Moore died. However, in the light of all the evidence including that of Professor Purser1003 Purser, Phase 2 Report, Section 6 {DAPR0000006/65} paragraph 319 and {DAPR0000006/66} paragraphs 320-321., we think it likely that she became incapacitated as a result of inhaling asphyxiant gases, including carbon monoxide and hydrogen cyanide, by about 01.40 and that she had died in her sleep by about 02.00, well before fire took hold in her bedroom.
The El Wahabi family
Abdulaziz El Wahabi
¶Date of birth: 01 December 1964 (52 years old). Place of birth: Larache, Morocco. Gender: Male. Occupation: Hospital Porter. Usual address: Flat 182, floor 21, Grenfell Tower, London. Place of death: Flat 182, floor 21, Grenfell Tower, London. Time of death: Between 03.00 and 03.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Faouzia El Wahabi
¶Date of birth: 01 June 1975 (42 years old). Place of birth: Larache, Morocco. Gender: Female. Occupation: Homemaker. Usual address: Flat 182, floor 21, Grenfell Tower, London. Place of death: Flat 182, floor 21, Grenfell Tower, London. Time of death: Between 03.00 and 03.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
125Yasin El Wahabi
¶Date of birth: 09 August 1996 (20 years old). Place of birth: Paddington, London. Gender: Male. Occupation: Student. Usual address: Flat 182, floor 21, Grenfell Tower, London. Place of death: Flat 182, floor 21, Grenfell Tower, London. Time of death: Between 03.00 and 03.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Nur Huda El Wahabi
¶Date of birth: 27 June 2001 (15 years old). Place of birth: Paddington, London. Gender: Female. Occupation: Student. Usual address: Flat 182, floor 21, Grenfell Tower, London. Place of death: Flat 182, floor 21, Grenfell Tower, London. Time of death: Between 03.00 and 03.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Mehdi El Wahabi
¶Date of birth: 22 February 2009 (8 years). Place of Birth: Chelsea, London. Gender: Male. Occupation: Student. Usual address: Flat 182, floor 21, Grenfell Tower, London Place of death: Flat 182, floor 21, Grenfell Tower, London. Time of death: Between 03.00 and 03.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
126Background and composition of household
¶95.19 Abdulaziz El Wahabi and Faouzia El Wahabi lived in Flat 182 on floor 21 of Grenfell Tower with their three children, Yasin, Nur Huda and Mehdi. Abdulaziz El Wahabi was born on 1 December 1964 in Larache, in northern Morocco. He was 52 years old and had worked as a hospital porter at University College Hospital for 22 years.1004 Phase 1 Report Volume IV paragraphs 32.106 and 32.109. His wife Faouzia was born on 1 June 1975, also in Larache. She was 42 years old and was a homemaker.1005 Phase 1 Report Volume IV paragraphs 32.106 and 32.110.
¶95.20 The couple's three children were all born in London. Yasin was 20 years old, having been born on 9 August 1996. A trained football referee, he was studying accountancy at Greenwich University.1006 Phase 1 Report Volume IV paragraphs 32.106 and 32.113. Nur Huda was 15 years old, having been born on 27 June 2001. She was studying for her GCSEs at Holland Park Secondary School.1007 Phase 1 Report Volume IV paragraphs 32.106 and 32.115. Mehdi was eight years old, having been born on 22 February 2009. He was a pupil at Oxford Gardens Primary School.1008 Phase 1 Report Volume IV paragraphs 32.106 and 32.118.
Vulnerability
¶95.21 None of the family had a disability that affected their ability to respond to an emergency. Nur Huda and Mehdi El Wahabi were both under 18 years of age at the time of the fire. In the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system Nur Huda was recorded as being under 18 but Mehdi did not appear.1009 Noble Spreadsheet {TMO00862588}.
Events of 14 June 2017
¶95.22 Nur Huda El Wahabi was the first member of the family to return home on the evening of 13 June 2017, coming into the tower at 18.16. Abdulaziz, Faouzia and Mehdi El Wahabi returned at 21.17. Yasin El Wahabi was the last of the family to return to the tower, at 00.47 on 14 June 2017.1010 O'Riordan {MET00013136/3} page 3.
The first evacuation attempt
¶95.23 Hanan Cherbika, a friend of the El Wahabi family, called Nur Huda El Wahabi soon after 01.10. She told her that there was a fire in the tower and that the family needed to leave. Nur Huda El Wahabi reassured her that the fire was downstairs. Hanan Cherbika encouraged her to wake her mother and to let her decide what to do.1011 Hanan Cherbika {IWS00000016/5} page 5, paragraph 18. Yousra Cherbika, Hanan Cherbika's daughter, also spoke to Nur Huda El Wahabi, who told her that she was going to come down.1012 Yousra Cherbika {IWS00001032/6} page 6, paragraph 21.
¶95.24 Hanan Wahabi, Abdulaziz El Wahabi's sister, who lived in Flat 66 on floor 9, left the tower at 01.21. She called her brother just after 01.25 to warn him of the fire. She advised the family to leave the tower.1013 Phase 1 Report Volume II paragraph 10.266. Shortly afterwards, Helen Gebremeskel saw the El Wahabi family in the lobby on floor 21 and warned them there was a fire in her flat, Flat 186. They told her the whole building was affected. Together with Helen Gebremeskel and her daughter, the El Wahabi family then tried to leave the tower. They reached the stairs but could not go down as a group of people were coming up. Those coming up told them that they should all go back to their flats.1014 Phase 1 Report Volume II paragraphs 10.267 and 10.268. The El Wahabi family returned to Flat 182. Helen Gebremeskel and her daughter went to Flat 183, the home of Marcio Gomes, Andreia Perestrelo and their two daughters.1015 Phase 1 Report Volume II paragraph 10.270.
127¶95.25 Hanan Wahabi spoke to her brother again at about 01.30. He said the family had tried to leave but there had been too much smoke and they had been unable to see or breathe.1016 Phase 1 Report Volume II paragraph 11.42.
The first emergency call from Flat 182
¶95.26 Flat 182 was in the south-east corner of the tower. The windows of the living room faced east and south.1017 External Spread of Fire at Grenfell Tower {MET00012593/7}. The El Wahabi family had converted it into a three-bedroom flat, with the bedroom of Abdulaziz and Faouzia El Wahabi being opposite the front door with a window facing south.1018 Wahabi {IWS00000074/3} page 3, paragraph 9 and {IWS00000074/22} page 22, Appendix I.
¶95.27 The first emergency call from Flat 182 was made at 01.38 and lasted for just over 59 minutes. It was answered by CRO Pam Jones in the LFB control room. While various members of the family spoke to CRO Jones at different times, Abdulaziz El Wahabi spoke to her for most of the call.1019 Phase 1 Report Volume II paragraphs 13.103 and 14.157; 999 call transcript {LFB00055498/7}; {LFB00055498/16}; Wahabi {IWS00001146/9} page 9, paragraph 29. He told CRO Jones that he was with his wife and three children in Flat 182.1020 999 call transcript {LFB00055498/8}.
¶95.28 During the call, the family told CRO Jones that they had tried to go down the stairs but had been forced to return as it was too smoky.1021 999 call transcript {LFB00055498/3}; {LFB00055498/9-10}. CRO Jones advised them to stay in the flat if it was too smoky to leave, to block up any places where smoke was coming in and to get fresh air from a window.1022 999 call transcript {LFB00055498/4-6}; {LFB00055498/10}. She said that she would let the firefighters know which flat the family were in and that they would try to reach them as soon as possible.1023 999 call transcript {LFB00055498/11-12}; {LFB00055498/14-15}. At 01.47, the family reported that, despite the use of blankets, smoke was still coming into the flat through the front door. At this time they were sheltering in the living room.1024 999 call transcript {LFB00055498/16-17}; {LFB00055498/20}.
¶95.29 At about 01.55, Abdulaziz El Wahabi told CRO Jones that someone outside had told the family that the fire had reached the flat next door (i.e. Flat 181).1025 999 call transcript {LFB00055498/31-32}. Over the next few minutes the family were able to see the fire next door and smoke began to come into the living room. CRO Jones advised them to move to another room and they then moved to the bedroom of Abdulaziz and Faouzia. By then the fire had reached the kitchen of Flat 182.1026 999 call transcript {LFB00055498/35-50}; Phase 1 Report Volume II paragraphs 14.159-14.160.
¶95.30 Hanan Wahabi called her brother for the last time at 02.15. Faouzia El Wahabi answered the telephone and Hanan Wahabi urged her to leave. Faouzia said they were trying to do so. She said that the fire was in the kitchen of Flat 182 and that the family had been told to go to the bedroom.1027 Wahabi {IWS00000074/16} page 16, paragraph 55. Meanwhile, the call with CRO Jones was continuing. She ascertained that the bedroom was smoke-free and advised the family to remain there with the door shut and a window open for air. She assured them that firefighters would come to them.1028 999 call transcript {LFB00055498/57-67}; {LFB00055498/73-76}.
128¶95.31 Throughout the call with CRO Jones, members of the El Wahabi family were in contact with friends and family outside the tower who were telling them to leave. The family responded that they had been advised to remain in their flat.1029 Phase 1 Report Volume II paragraph 14.162. However, at about 02.24 smoke began to enter the bedroom through the open window and CRO Jones advised them to close the window.1030 999 call transcript {LFB00055498/80}. At about 02.34, having been told by OM Alexandra Norman that those in the tower should now be advised to leave, CRO Jones told the El Wahabi family to cover themselves with wet clothes and towels and to leave the flat.1031 Phase 1 Report Volume III paragraph 15.156; Jones {LFB00032090/6} page 6, paragraph 30. She continued to encourage the family to leave until the call was disconnected at 02.37.1032 999 call transcript {LFB00055498/95-101}.
Information to the incident ground
¶95.32 The LFB control room passed messages about Flat 182 to the incident ground while CRO Jones was speaking to the El Wahabi family.
¶95.33 At about 01.47, CRO Jones told them that a message had been passed to firefighters about Flat 182 but she did not create a service request.1033 999 call transcript {LFB00055498/15}; LFB Short Incident Log {MET00013830}. At about 01.50, CRO Jones told them that the control room was calling the firefighters again.1034 999 call transcript {LFB00055498/23}. At that time, CRO Yvonne Adams, who was sitting next to CRO Jones, spoke to command unit CU8 and passed on information about two flats, one of which was Flat 182. CRO Adams told CU8 that those in Flat 182 had not been able to stop smoke coming under the front door, were in the living room and sounded "panicked".1035 Phase 1 Report Volume II paragraphs 13.85-13.86; Transcript of call between LFB control room and CU8 {INQ00000203}.
¶95.34 WM Mark Kentfield recorded the information reaching CU8 on pieces of paper which were then passed to SM Brett Loft who at that time was positioned outside the tower. He had taken charge of managing information about people needing to be rescued and was passing it to the bridgehead, probably by radio.1036 Phase 1 Report Volume II paragraph 11.6 and Phase 1 Report Volume IV paragraphs 28.84 (a) and 28.84(b). The information provided to SM Loft included an A4 sheet of paper at the top of which was written "BRETT LOFT IC". The seventh entry down on that document read: "182 – 21st FLOOR".1037 Phase 1 Report Volume II paragraphs 12.18-12.19 and figure 12.4. Given that SM Loft recalled receiving information on paper from WM Kentfield at around 01.40,1038 Phase 1 Report Volume II paragraphs 11.7 and 12.19. it is likely that the mention of Flat 182 was the result of CRO Adams's call to CU8.
¶95.35 At 02.00, CRO Adams made a second call to CU8, during which she passed on information about several flats, including Flat 182. She reported that there were two adults and three children trapped in the flat, that the fire was next door to them and that smoke was pouring in. An officer in CU8 replied that they had the impression that floors 21 to 23 were the most severely affected.1039 Phase 1 Report Volume II paragraphs 14.230 and 14.231; Transcript of call between LFB control room and CU8 {INQ00000195}.
129¶95.36 Between 02.10 and 02.22 CU7 was designated as the command unit responsible for handling information about people needing to be rescued.1040 Phase 1 Report Volume IV paragraph 28.84d. Initially the crew used a laminated white sheet to record information previously recorded in CU8 on pieces of paper.1041 Phase 1 Report Volume II paragraphs 12.8-12.9. The entries on that sheet included a reference to Flat 182 where two adults and three children were trapped (although the flat was incorrectly recorded as being on floor 18). The reference to the composition of the family makes it likely that the call made by CRO Adams to CU8 at 02.00 was the source of that information. Indeed, the information on the laminated sheet appeared on a control information form on which was also written "From CU list".1042 Control Information Form {LFB00001922/6}.
¶95.37 Shortly after 02.17, CM Charles Batterbee made a note of the contents of a forward information board used while the bridgehead had been located on floor 2 of the tower to record information about people needing to be rescued. There was no reference to Flat 182 but there was a reference to Flat 204 on floor 21.1043 Phase 1 Report Volume II paragraph 14.73 and Figure 14.4; Phase 1 Report Volume IV paragraphs 28.84(b) and 28.84(c). That suggests either that the message about Flat 182 that had been passed to CU8 at 01.50 and then again at 02.00 did not reach the bridgehead on floor 2, or that the information was passed on incorrectly. In any event, there was no deployment of firefighters to floor 21 while the bridgehead was located on floor 2.
¶95.38 At about 02.33, SM Jason Oliff began recording information about people needing to be rescued on two whiteboards in the LFB control room. The first entry, and the first information he passed to the command unit, was recorded as "182 21st Flr – 3 children 2 adults. Leave."1044 Phase 1 Report Volume III paragraphs 15.139-15.141 and Figure 15.8. That follows the change of advice communicated to the El Wahabi family by CRO Jones.
¶95.39 That information did reach the bridgehead on floor 3, as is confirmed by a reference to Flat 182 on the wall used by WM Louisa De Silvo at the bridgehead to record information about those needing to be rescued.1045 O'Beirne {MET000083321/19} page 19; Phase 1 Report Volume III Figure 16.6. Flat 182 was circled and ticked to indicate that a crew had been deployed. (A circle indicated that she had received further information, including information from a returning crew.)1046 Phase 1 Report Volume IV paragraph 15.25. In this case, the tick referred to the deployment at 02.44 of FFs Nikki Upton and Tom Reddington wearing EDBA to floor 21.1047 Phase 1 Report Volume III paragraph 15.57. FF Upton recalled that she and her colleague had been briefed by WM de Silvo and WM O'Keeffe but she could not remember whether they were to go to Flats 182 and 183 or to Flats 183 and 184.1048 Upton {MET00007524/5} page 5; Upton {Day38/144:22}-{Day38/147:21}. We think it was probably the former, because her contemporaneous note1049 Upton {MET00005625/1} page 1. records that the crew were deployed to Flats 182 and 183. Moreover, no call for help had been received from Flat 184, whose occupant, Mustapha Abdu, had already escaped.
¶95.40 The two firefighters did not reach floor 21 because as they were going up the stairs they found Farah Hamdan and Malak Belkadi and brought Malak Belkadi down. On returning to the bridgehead, FF Upton told a crew manager that she and her colleague had not been able to reach floor 21. She could not recall to whom she had spoken.1050 Upton {Day38/150:24}- {Day38/151:11}.
130Further emergency calls from Flat 182
¶95.41 After the call with CRO Jones had been disconnected at 02.37, the El Wahabi family made a series of short emergency calls. At 02.39, they were put through to the control room of the London Ambulance Service,1051 Phase 1 Report Volume III paragraph 16.53. which at that time was not aware that the LFB had revoked the stay put advice.1052 Phase 1 Report Volume III paragraph 15.172. The caller said that five people were trapped in Flat 182 and was told that help was on the way. The call handler then put the call on hold to ask a manager what instructions to give the caller, but at that point the connection was lost. The call handler did not call back as the protocols of the London Ambulance Service required.1053 999 call transcript {INQ00000383}; Woodrow {LAS00000009/12} page 12; Woodrow {Day72/129:10}-{Day72/131:22}.
¶95.42 At 02.43, Nur Huda El Wahabi spoke to CRO Heidi Fox in the LFB control room. She reported that there were two adults and three children in Flat 182 and, when asked, said that they could not leave. CRO Fox was in the course of advising her to cover herself in wet blankets when the call was disconnected.1054 Phase 1 Report Volume III paragraph 16.53; 999 call transcript {LFB00000374}.
¶95.43 Nur Huda El Wahabi made another emergency call that was answered by CRO Adams at 02.46. She confirmed that there were five people in Flat 182 and said there was too much smoke for them to get out. CRO Adams said they should try to cover themselves in wet towels and leave, as the fire brigade could not reach them. Nur Huda replied: "… too much smoke, I can't breathe."1055 Phase 1 Report Volume III paragraphs 15.186 and 16.54; 999 call transcript {COR00000376/6}.
¶95.44 When the call was disconnected, the line remained open to the BT operator who reconnected the call to the LFB on three further occasions at 02.51, 02.53 and 02.57.1056 Phase 1 Report Volume III paragraph 16.54. The transcripts of those calls,1057 999 call transcript {COR00000376/8} and {COR00000376/10}. including the family's exchanges with the BT operator,1058 999 call transcript {COR00000376/1-5}. show that they were coughing, having difficulty breathing and saying that they were feeling faint. We conclude from that that by that time there was a significant amount of smoke in the bedroom.
¶95.45 The first two calls were answered by CRO Adams and CRO Christine Howson respectively. Both advised the El Wahabi family that they had to leave. During the calls the CROs were told that the family could not breathe and that they had tried to leave but had been unable to see because of the smoke. In the second of those calls, the family said that they were again trying to leave.1059 999 call transcript {COR00000376/8} and {COR00000376/10}.
¶95.46 At 02.57, the El Wahabi family was connected to the LFB control room for the third and last time. The call ended at 02.58, the line going silent before CRO Howson could speak to any member of the family.1060 Phase 1 Report Volume III paragraph 16.54 (c). That was the last contact anyone had with the El Wahabi family.
¶95.47 The whiteboard used in CU7 from about 03.00 to record information about people needing to be rescued shows that those later emergency calls may have resulted in information reaching that command centre.1061 Phase 1 Report Volume III paragraphs 15.13 and 16.12. Photographs taken later show that Flat 182 appeared on the grid with "5" in green and "2" in black next to it.1062 Phase 1 Report, Volume III Figure 16.5; Photograph of whiteboard {MET00015924}. There was no red tick, which would have indicated a deployment.1063 Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. We conclude that those later emergency calls did not prompt a deployment to Flat 182.
131Recovery and identification
¶95.48 The remains of the five members of the El Wahabi family were recovered from the bedroom of Abdulaziz and Faouzia El Wahabi.1064 Purser, Phase 2 Report, Section 6 {DAPR0000006/68} paragraph 369. The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for all members of the family.1065 Interim certificate of the fact of death for Abdulaziz El Wahabi, Faouzia El Wahabi, Yasin El Wahabi, Nur Huda El Wahabi and Mehdi El Wahabi {MET00065595}; {MET00065626}; {MET00065631}; {MET00065627}; {MET00065652}.
Cause and time of death
¶95.49 The post-mortem reports for all five members of the El Wahabi family recorded the medical cause of death as "consistent with the effects of fire", but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".
¶95.50 Toxicological analysis was not possible.
¶95.51 We are satisfied that the members of the El Wahabi family probably lost consciousness shortly after the last emergency call from Flat 182 ended at 02.58 and perhaps rather earlier in the case of the younger members of the family. Death due to inhalation of asphyxiant gases, particularly carbon monoxide and hydrogen cyanide, occurred a few minutes later and before any internal fires had become established in the bedroom. Death probably occurred within 20 minutes of loss of consciousness, that is, by 03.20, and before suffering the direct effects of fire.1066 Purser, Phase 2 Report, Section 6 {DAPR0000006/69} paragraphs 371 and 373 and {DAPR0000006/70} paragraph 378; Purser {Day297/69:11}-{Day297/72:6}.
Logan Gomes
¶Date of birth: 14 June 2017. Place of birth: London, UK. Gender: Male.
Background and composition of household
¶95.52 Andreia Perestrelo and Marcio Gomes lived in Flat 183 on floor 21 with their two daughters. At the time of the fire, Andreia Perestrelo was pregnant with the couple's son Logan whose birth was expected on 21 August 2017.1067 Phase 1 report Volume IV paragraphs 32.101-32.102. It had been a healthy pregnancy and Andreia was intending to begin her maternity leave on 14 August 2017.1068 Perestrelo {IWS00000349/1} page 1, paragraph 5. The whole family was eagerly awaiting the new arrival.1069 Phase 1 report Volume IV paragraphs 32.102-32.103.
¶95.53 Logan Gomes was delivered stillborn on 14 June 2017 following his mother's evacuation from the tower.
132Events of 14 June 2017
¶95.54 The family returned home on the evening of 13 June 2017 after dinner with friends.1070 Perestrelo {IWS00000349/8} page 8, paragraph 46. They became aware of the fire shortly before 01.30, when Helen Gebremeskel knocked on their door following her attempt to leave floor 21 with the El Wahabi family. Helen Gebremeskel and her daughter were invited to shelter in Flat 183.1071 Phase 1 Report Volume II paragraphs 10.267-10.269.
¶95.55 Some 20 minutes later, Marcio Gomes began to use wet towels to block out smoke which was by then seeping around the sides of the front door to Flat 183.1072 Phase 1 Report Volume II paragraph 14.163. He was in contact with Miguel Alves, another resident of the tower, who had already left. Miguel Alves passed on the advice of a policeman that Marcio Gomes should stay in the flat.1073 Phase 1 Report Volume II paragraph 14.164.
¶95.56 The two families then in Flat 183 decided to try to leave but were deterred by the amount of smoke in the lobby.1074 Phase 1 Report Volume II paragraph 14.165. Marcio Gomes then made his first emergency call at 02.21 and spoke to CRO Heidi Fox in the LFB control room. She explained that firefighters were going to the flats and that she would tell them about Flat 183. At 02.24, CRO Fox created a service request recording that three adults, including one pregnant lady and three children, were trapped. CRO Sharon Darby passed the message by radio to CU7 at 02.24.1075 Phase 1 Report Volume II paragraph 14.165; Phase 1 Report Volume II paragraph 15.130; LFB Short Incident Log {MET00013830/22}.
¶95.57 Between 02.10 and 02.22 CU7 began handling information relating to people needing to be rescued.1076 Phase 1 Report Volume IV paragraph 28.84d. Initially, a white laminated sheet was used to record information. The entries on that sheet included "183 21 6 adults, 1 pregnant" (the number 6 was written in red pen and appeared to replace an erased 3).1077 Phase 1 Report Volume II Figure 12.3 and paragraphs 12.8-12.9; Phase 1 Report Volume III Figure 15.6 and paragraphs 15.11-15.13. At about the same time, WM Paul Sadler was instructed to collate information about people needing to be rescued for onward transmission to the bridgehead which, from 02.17, was located on the third floor of the tower. He communicated with the bridgehead either by radio or through paper control information forms.1078 Phase 1 Report Volume I1 paragraph 14.65-14.72; Phase 1 Report Volume IV paragraph 28.84e.
¶95.58 No note relating to Flat 183 appears on the wall on floor 3 used to record information about people needed to be rescued during the period when the bridgehead was located on that floor.1079 Phase 1 Report Volume II Figure 15.7. However the existence of a control information form which contains information consistent with the service request created by CRO Fox (in particular the reference to a "pregnant lady") suggests that the message did reach the bridgehead.1080 Control Information Form {LFB00001922/10}. The consequence was the deployment at 02.44 of FFs Nikki Upton and Tom Reddington to Flats 182 and 183 on floor 21, which was prompted not only by information about those needing to be rescued from Flat 182, but also, we find, by similar information relating to Flat 183.
133¶95.59 However, FFs Upton and Reddington did not reach floor 21. They found Farah Hamdan and Malak Belkadi in the stairwell and brought Malak Belkadi down. On returning to the bridgehead, FF Upton told a crew manager that she and her colleague had not been able to reach floor 21. She could not recall to whom she had spoken.1081 Upton {Day38/150:24}-{Day38/151:11}.
¶95.60 Marcio Gomes made a second emergency call from Flat 183 at 02.46. He reported that the fire had reached the flat next door and was coming through the windows. CRO Christine Howson advised him to leave if he no longer considered it safe to remain. When he replied that there was too much smoke to leave, she advised him to use wet clothes as protection against the smoke and to get to the stairwell. It was not clear whether CRO Howson had been told of the change in the "stay put" advice at that time, as she gave the impression during the call that firefighters were still on their way up the building.1082 Phase 1 Report Volume III paragraphs 15.78, 15.189 and 15.191.
¶95.61 The two families made a further attempt to leave Flat 183 but could not cross the lobby. Marcio Gomes then made a third emergency call at 02.55 and spoke to CRO Angela Gotts. He told her that they were unable to leave and that smoke was coming into the flat despite towels being used to block it out. During that call, Marcio Gomes said that there were "...three kids and three adults and one heavily pregnant wife" in the flat. CRO Gotts said she would let the firemen know to come up to them. She did not create a service request but passed a message to CRO Sharon Darby, who then sent it by radio to CU7 at 02.58. The message stated that there were six persons in the flat, one of whom was pregnant. The information was also entered on a whiteboard in the LFB control room by SM Jason Oliff.1083 Phase 1 Report Volume III paragraphs 15.139-15.141, 16.56 -16.57, 16.84, Figures 15.8 and 15.9; 999 call transcript {LFB00000392}; Radio transcript {LFB00002017}.
¶95.62 At 03.09, Marcio Gomes made a fourth emergency call and spoke to CRO Howson again. He was advised to leave but said it was not possible to do so. He said that there were six people in the flat, including someone who was pregnant. CRO Howson said she would inform the crews and make reaching him a priority. She asked him again to try to leave.1084 Phase 1 Report Volume III paragraph 17.48; 999 call transcript {LFB00000412}. By that time conditions in Flat 183 had deteriorated, with more smoke entering the flat.1085 Phase 1 Report Volume III paragraphs 17.50 and 17.132.
¶95.63 Although we cannot trace the passage of the information given in the three emergency calls made by Marcio Gomes between 02.46 and 03.09 individually to the bridgehead, the fact that information about Flat 183 was reaching it is indicated by the following: a. Entries for Flat 183 appeared on the whiteboard used in CU7 after 03.00 to record
information about people needing to be rescued. The number of entries for Flat 183 suggests that more than one message was received and that the information on the whiteboard was revised accordingly.1086 Phase 1 Report Volume III paragraphs 15.13 and 16.12 and Figure 16.5; Photograph of whiteboard {MET00015924}.
¶b. The completion of control information forms that refer to six people, one pregnant, in Flat 183.1087 Control Information Forms {LFB00001922/12-15}. One of the forms contains a reference to floor 23 and a list of other flats in the tower identified as priorities.1088 Control information form {LFB00001922/14}. WM Sadler may have amended the form to include floor 23 following the receipt of fresh information. The list of priorities was added after the form left him,1089 Sadler {Day29/95:5}-{Day29/100:20}. but we cannot say with any confidence when that was done or whether Flat 183 was one of the flats designated as a priority.
134¶c. A reference to Flat 183 on the wall on the ground floor where, from 02.15, WM Glynn Williams had started recording information about people needing to be rescued.1090 Phase 1 Report Volume II paragraphs 14.103-14.105 and Figure 14.5; Photographs of ground floor wall {MET00005774} and {MET00005776}. The notation "183 21" appeared in a list created on the left hand side of the wall. It is likely that that list was begun after the bridgehead had been moved down to the ground floor and that the first entry on it was made some time after 03.21.1091 Williams {Day31/137:13}-{Day31/139:21}.
¶95.64 In any event, there was no further deployment of firefighters to Flat 183 or even to floor 21.
¶95.65 At 03.25, Marcio Gomes spoke to CRO Fox in what was his fifth emergency call. It lasted for 33 minutes and 53 seconds.1092 Phase 1 Report Volume III paragraph 17.50; 999 call transcript {LFB00055501}. By the time the call began conditions in Flat 183 had worsened, with smoke continuing to come through the front door. Initially, Marcio Gomes told CRO Fox that it was not possible to leave and that they had tried three times to do so. CRO Fox told him that she would try to make them a priority. After the call had continued for about a minute and a half, Marcio Gomes told CRO Fox that the fire had entered the flat. The two families then covered themselves with wet towels and made their way to the stairwell.1093 Phase 1 Report Volume III paragraphs 18.29-18.31.
¶95.66 They found the lobby and the stairwell to be hot and full of smoke; there was no visibility or breathable air. CRO Fox continued talking to Marcio Gomes and encouraged him to continue through the lobby and down the stairs. While doing so she spoke to a colleague in the control room, passing on information and telling her that he was struggling to breathe. CRO Fox told him that firefighters were aware of their location and making their way up to them.1094 Phase 1 Report Volume III paragraphs 18.30-18.34; 999 call transcript {LFB00055501/17}; {LFB00055501/6-21}. Although CRO Fox said that a message was being sent to the incident ground by radio, we have not been able to confirm that that was done or whether any information reached the incident ground either by radio or telephone.
¶95.67 As he went down the stairs Marcio Gomes lost contact with his wife and daughters. He tried to make his way back up but encountered firefighters who said they would find them. He also spoke to a firefighter who asked which flat and which floor his family had started from.1095 Phase 1 Report Volume III paragraph 18.35; 999 call transcript {LFB00055501/30}. That contact may explain how WM Louisa De Silvo came to write "183 – Daughter" (underlined), with "21 or 22" written underneath on the green wall used on the ground floor to record information about people needing to be rescued after the bridgehead had moved there.1096 De Silvo {Day30/63:1}; De Silvo Exhibit LDS/7 - photo of green wall {MET00015820}. CM Aldo Diana and FF Dean Nelson were the firefighters who told Marcio Gomes that they would find his family. Originally sent to Flat 133 on floor 16, they found Andrea Perestrelo, her younger daughter and Helen Gebremeskel, who were all close to collapse. The two firefighters then went up again to find Helen Gebremeskel's daughter and Andrea Perestrelo's elder daughter, both of whom had collapsed on the stairs. They carried them down.1097 Phase 1 Report Volume III paragraph 18.20; Nelson {MET00010926/6} page 6; Diana {MET00018800/10} page 10.
135¶95.68 The group left the tower between 03.37 and 03.55.1098 Phase 1 Report Volume III paragraph 18.37. Andreia Perestrelo, her daughters and Marcio Gomes were taken by ambulance to King's College Hospital.1099 Perestrelo {IWS00000349/14} page 14, paragraph 83. Andreia Perestrelo and her daughters were put into induced comas. An emergency caesarean section was performed on Andreia Perestrelo at 23.03 on 14 June 2017. Sadly, Logan Gomes was stillborn.1100 Perestrelo {IWS00000349/14} page 14, paragraphs 84-87.
Cause of death
¶95.69 The post-mortem on Logan Gomes found features of terminal pathophysiological stress and nothing to suggest developmental abnormality, malformation or any other underlying pathology. There was less than 5% carboxyhaemoglobin in his blood.1101 Purser, Phase 2 Report, Section 6 {DAPR0000006/80} paragraph 433.
¶95.70 When admitted to hospital, Andreia Perestrelo had significant carbon monoxide poisoning and possible hydrogen cyanide poisoning. The resulting severe acidosis is likely to have been the cause of Logan's death at some time during the day on 14 June 2017.1102 Letter from Dr Leonie Penna to Andreia Perestrelo dated 28 July 2017 {BSR00000140}; Purser, Phase 2 Report, Section 6 {DAPR0000006/84} paragraph 462. An extract from Dr Penna's letter was read out during the presentation concerning Logan Gomes {Day306/19:8}.
¶95.71 It is likely that those who were sheltering in Flat 183 absorbed a relatively small amount of asphyxiant gases before they left the flat.1103 Purser, Phase 2 Report, Section 6 {DAPR0000006/77-84} paragraph 416 and 460. However, their exposure to the conditions in the lobby and the stairs, coupled with the physical effort involved in making their way down, resulted in their accumulating a quantity of asphyxiant gases by the time they reached the ground floor that was nearly sufficient to incapacitate them.1104 Purser, Phase 2 Report, Section 6 {DAPR0000006/76-79} paragraphs 426-431.
137Chapter 96: Floor 22
¶96.1 On the night of 14 June 2017 all six flats on floor 22 were occupied. Only Chia-Yuan (Naomi) Li and her cousin, Chin-Hsuan (Lydia) Liao from Flat 195 survived. Those who died were Nura Jemal, her husband, Hashim Kedir, and their three children who lived in Flat 192, Nadia Choucair, her husband, Bassem Choukair, and their three children, who lived in Flat 193, Sirria Choucair, the mother of Nadia Choucair, who lived in Flat 191, and Anthony (Tony) Disson, who lived in Flat 194. Mariem and Eslah Elgwahry, who lived in Flat 196, died in Flat 205 where they had taken shelter. We deal with the circumstances of their deaths in Chapter 97.
¶96.2 Naomi Li was alerted to the fire at about 01.15 when she became aware of a smell like burning plastic. Having spoken to Lydia Liao, she checked the lobby. Although she could smell smoke, she saw very little sign of it in the lobby. Returning to her flat, she telephoned her husband, Lee Chapman, who was abroad. At 01.21 she made an emergency call and spoke to CRO Yvonne Adams in the LFB control room, who told her that the fire brigade was attending a fire on the fourth floor of the tower and that she should stay in her flat. During that call Naomi Li gave CRO Adams the number of her flat.1105 Phase 1 Report Volume II paragraphs 10.272, 10.276 and 10.308.
¶96.3 Naomi Li decided to tell her neighbours. In the lobby she met and spoke to Nura Jemal, who then returned to Flat 192. She then saw Mariem and Eslah Elgwahry leaving Flat 196. When she told them that there was a fire on floor 4, Mariem Elgwahry replied that the fire was in their kitchen. At that time the door to Flat 196 was closed and Naomi Li could not see any smoke coming from it.1106 Phase 1 Report Volume II paragraph 10.277. She saw Mariem and Eslah Elgwahry enter the stairwell. Naomi Li next spoke to Tony Disson, who then returned to his own flat.1107 Phase 1 Report Volume II paragraph 10.277.
¶96.4 Naomi Li and Lydia Liao tried to leave but could not go down the stairs because a group of people were coming up. Returning to the lobby, they met Nadia Choucair, who invited them into Flat 193.1108 Phase 1 Report Volume II paragraph 10.279. Sirria Choucair was probably already there.
¶96.5 By 01.26, the fire on the outside of the building had reached floor 23. It is likely that from that time Flat 196, like other 'Flat 6s' in the tower, rapidly filled with smoke. The front door of Flat 196, although closed, failed to prevent smoke coming from the flat into the lobby of floor 22. In separate calls made at 01.30, both Naomi Li and Tony Disson reported that there was a lot of smoke on floor 22.1109 Phase 1 Report Volume II paragraphs 11.37-11.40.
¶96.6 In subsequent calls to the emergency services, those trapped on floor 22 referred to the presence of a significant amount of smoke in the lobby.1110 Phase 1 Report Volume II paragraph 12.62; Phase 1 Report Volume III paragraphs 16.33-16.39. That was a significant factor in preventing them from leaving the building, despite their efforts to do so. Nura Jemal, Hashim Kedir and their children were able to move from Flat 192 to Flat 193, arriving there shortly before 03.00.1111 Phase 1 Report Volume III paragraph 16.42. Tony Disson was able to reach the stairwell but collapsed and died on the stairs.1112 Phase 1 Report Volume III paragraphs 18.27-18.28. Only Naomi Li and Lydia Liao managed to escape from the building.1113 Phase 1 Report Volume III paragraphs 17.35-17.36 and 17.104.
138Deployments to floor 22
¶96.7 There were numerous emergency calls to the LFB, to North West Fire Control and to Kent, Essex and Surrey Fire and Rescue Services by and about those trapped on floor 22 during the fire. a. Having made her first call from Flat 195 at 01.21, Naomi Li spoke to the LFB on three more occasions from Flat 193 at 01.30, 02.51 and at 03.07.1114 Phase 1 Report Volume II paragraph 10.280; Phase 1 Report Volume III paragraphs 16.39 and 17.32-17.37.
¶b. Nadia Choucair and Bassem Choukair made six calls from Flat 193 at 01.48, 02.37, 02.43, 02.55, 03.02 and 03.05.1115 Phase 1 Report Volume II paragraphs 12.62, 14.155 and 14.269; Phase 1 Report Volume III paragraphs 16.34-16.35, 16.41, 17.38-39 and 17.126; 999 call transcript {LFB00000396}. At 03.15, Nadia Choucair spoke to a BT operator, but the line cleared before she could be put through to a fire and rescue service.1116 Phase 1 Report Volume III paragraph 17.38. At 03.21, the Metropolitan Police called Nadia Choucair in response to her earlier call to the emergency services, when the line had been disconnected before contact had been established.1117 Phase 1 Report Volume III paragraph 17.39.
¶c. At 01.34,1118 Phase 1 Report Volume II paragraph 11.41. while they were in Flat 192, Hashim Kedir and Nura Jemal spoke to the emergency services and called them again a further seven times at 02.03,1119 Phase 1 Report Volume II paragraph 14.153. 02.10, 02.18, 02.31, 02.34, 02.45 and 02.53.1120 Phase 1 Report Volume II paragraphs 14.153-14.154; Phase 1 Report Volume III paragraphs 16.47-16.50. Shortly after they and their children had moved to Flat 193 a call from Hashim Kedir was put through to Kent Fire and Rescue Service but he did not respond to the call handler.1121 999 call transcript {LFB00000658}. Hashim Kedir and Nura Jemal made another call at 03.08 when they spoke to CRO Gotts in the LFB control room.1122 Phase 1 Report Volume III paragraphs 16.51 and 17.130. The final contact with those in Flat 193 occurred at 03.24 when Hashim Kedir spoke to CRO Peter Duddy.1123 Phase 1 Report Volume III paragraph 18.23.
¶d. Tony Disson in Flat 194 spoke to the emergency services six times between 01.30 and 03.01.1124 Phase 1 Report Volume II paragraphs 11.37, 12.63 and 14.152; Phase 1 Report Volume III paragraphs 16.43-16.46, 16.45-16.46 and 17.41. In five calls made between 02.28 and 03.22, family members and a friend reported that Tony Disson was trapped in the tower.1125 Phase 1 Report Volume III paragraphs 15.148, 15.183, 15.195, 17.44-17.46, 17.127 and 17.131; 999 call transcript {LFB00000549}. A CRO in the LFB control room and one from Surrey Fire and Rescue Service called him back at 02.51 and 03.27 respectively.1126 999 call transcript {LFB00000469}; Phase 1 Report Volume III paragraph 18.27. The latter call was the last contact the emergency services had with Tony Disson.
¶96.8 Despite the information provided in those calls, the only deployment of firefighters to floor 22 was made in response to the call made by Naomi Li at 01.21.
139¶a. At 01.32, a service request was created referring to persons on floor 22 who reported smoke coming into Flat 195. At 01.35, CRO Sharon Darby passed a message to the incident ground that there were persons trapped on floor 22 with "smoke coming into their flat".1127 Phase 1 Report Volume II paragraphs 11.152-11.153. That message reflected the information provided by Naomi Li and Tony Disson in their calls at 01.21 and 01.30.
¶b. WM Mark Kentfield recorded the information reaching command unit CU8 about people needing to be rescued on pieces of paper, which were then passed to SM Brett Loft who was positioned outside the tower.1128 Phase 1 Report Volume II paragraph 11.6; Phase 1 Report Volume IV paragraph 28.84 (a). SM Loft passed the information he received to the bridgehead, probably by radio.1129 Phase 1 Report Volume II paragraph 12.18. He was receiving information of that kind from about 01.40. Some was written on the A4 sheet of paper that later became known as the "Sadler envelope", at the top of which was written "BRETT LOFT IC". The third entry on that document reads "Flat 195 22nd FLOOR".1130 Phase 1 Report Volume II paragraphs 12.18-12.19, 14.71 and Figure 12.4.
¶c. The bridgehead was located on floor 2 until 02.17.1131 Phase 1 Report Volume IV paragraph 28.84 (b). Shortly after that time, CM Charles Batterbee made a note of the contents of a forward information board used at the bridgehead to record information while it was located on floor 2. It contained no reference to floor 22.1132 Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c).
¶d. At 02.17 the bridgehead was moved to floor 3, where it remained until 3.10, when it was moved down to the ground floor.1133 Phase 1 Report Volume IV paragraphs 28.86-28.87. While the bridgehead was located on floor 3, a wall was used to record information about people needing to be rescued. The second entry at the top of this wall read "22 195", next to which was written "CODD + JOSEPH".1134 O'Beirne {MET000083321/19} page 19; Phase 1 Report Volume III Figure 16.6.
¶e. CM Raoul Codd and FF John Joseph were sent to floor 22 by WM Louisa De Silvo but not to a specific flat. They set out between 03.03 and 03.05. CM Codd and FF Joseph did not reach floor 22 because when they came across casualties in the stairs they decided instead to help them escape.1135 Phase 1 Report Volume III paragraph 17.13 (g); LFB Telemetry data {LFB00023326}; Codd {MET00012539}.
¶96.9 Although information about those in Flats 192, 193 and 194 did reach the incident ground, none of it reached the bridgehead, with the result that there were no deployments to those flats. We do not know why information about Flat 195 given in a call made at 01.21 reached the bridgehead only after it had been moved to floor 3 (i.e. after 02.17), but we are satisfied that when it was received it prompted the deployment of CM Codd and FF Joseph.
¶96.10 One firefighter did reach floor 22. FF Dean Roberts was one of the five-member Paddington crew from appliance A216, which included CM Philip Wigley and FFs Martin Gillam, Russell Gonzalez and Andrew Harris. The crew was sent to the roof of the tower to carry out firefighting operations.1136 Phase 1 Report Volume II paragraphs 11.13 and 13.5. They tallied out between 01.56 and 01.57. The crew did not reach the roof because they found Fadumo Ahmed on the stairs between floors 20 and 21 and helped her down. FF Roberts appears to have been able to make his way up to floor 22. He opened the stairwell door and shouted but received no response and re‑joined his crew.1137 Phase 1 Report Volume II paragraphs 14.85-14.87; Roberts {MET00007890/6} page 6.
140The Kedir and Jemal family
Hashim Kedir
¶Date of birth: 7 March 1973 (44 years). Place of birth: Addis Ababa, Ethiopia. Gender: Male. Occupation: Black Cab Driver. Usual address: Flat 192, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Nura Jemal
¶Date of birth: 1 August 1981 (35 years). Place of birth: Silte, Ethiopia. Gender: Female. Occupation: Homemaker. Usual address: Flat 192, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Yahya Hashim
¶Date of birth: 5 August 2003 (13 years). Place of birth: London, UK. Gender: Male. Occupation: Student. Usual address: Flat 192, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
141Firdaws Hashim
¶Date of birth: 13 January 2005 (12 years). Place of birth: London, UK. Gender: Female. Occupation: Student. Usual address: Flat 192, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Yaqub Hashim
¶Date of birth: 18 May 2011 (6 years). Place of birth: London, UK. Gender: Male. Occupation: Student. Usual address: Flat 192, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶96.11 Hashim Kedir, Nura Jemal and their three children lived in Flat 192 on floor 22 of the tower.1138 Phase 1 Report Volume IV paragraph 32.89.
¶96.12 Nura Jemal was born on 1 August 1981 in Silte, Ethiopia. She was 35 years old. Her husband, Hashim Kedir, was born on 7 March 1973 in Addis Ababa, Ethiopia. He was 44 years old. Their three children were all born in London. The eldest, Yahya Hashim was born on 5 August 2003 and was 13 years old. Firdaws Hashim was born on 13 January 2005 and was 12. Their youngest child, Yaqub Hashim, was born on 18 May 2011 and was 6 years old.1139 Phase 1 Report Volume IV paragraph 32.90.
¶96.13 Hashim Kedir had moved to the UK in 2000. He took various jobs before successfully passing the test to become a black cab driver. He and Nura Jemal met in the UK where they married. Their children were thriving at local schools.1140 Phase 1 Report Volume IV paragraphs 32.93-32.98.
Vulnerability
¶96.14 No member of Nura Jemal and Hashim Kedir's family had a known vulnerability.
142Events of 14 June 2017
¶96.15 The family came home at various times on 13 June 2017, Hashim Kedir being the last to return at 23.21.1141 O'Riordan {MET00013136/3-4} pages 3-4. They became aware of the fire at an early stage. Naomi Li spoke to Nura Jemal in the lobby of floor 22 between her two emergency calls at 01.21 and 01.30.1142 Phase 1 Report Volume II paragraph 10.277. At 01.34, Hashim Kedir made his first call to the emergency services. During it he told CRO Duddy that smoke on the stairs had prevented the family from leaving and was now coming into their flat from the lobby. CRO Duddy's advice was to close all doors and windows and to block any smoke coming through the door. He concluded by explaining that firefighters were on their way.1143 Phase 1 Report Volume II paragraph 11.41; 999 call transcript {LFB00000315/3}. When he gave that reassurance, CRO Duddy did not have confirmation that firefighters would attend but assumed that they would do so if they were told that a flat needed to be checked.1144 Duddy {Day42/215:7}-{Day42/216:5}; Phase 1 Report Volume II paragraph 11.157.
¶96.16 CRO Duddy did not create a service request in response to that call but one had already been created following calls from other occupants of floor 22. It recorded "PERSONS ON THE 22ND FLOOR SMOKE COMING INTO FLAT."1145 LFB Short Incident Log {MET00013830}. CRO Darby passed the information to appliance G261 at 01.35, stating that she could not provide flat numbers.1146 Phase 1 Report Volume II paragraph 11.152. The service request was marked as completed at 01.41.1147 LFB Short Incident Log {MET00013830}.
¶96.17 No information relating to floor 22, including that passed on by CRO Darby, reached the bridgehead while it was located on floor 2.1148 Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraphs 28.84b and 28.84c
¶96.18 At 01.43, Hashim Kedir spoke to Genet Shawo, who lived in Flat 153 on floor 18. He told her that the emergency services had told him to remain in his flat and he advised her to do the same.1149 Phase 1 Report Volume II paragraph 11.61.
¶96.19 Hashim Kedir and Nura Jemal continued to make calls to the emergency services. a. At 02.03, Hashim Kedir told CRO Angie Gotts that there was smoke in the corridor
(probably meaning the lobby) and that the fire could be seen approaching the flat. He gave the number of his flat and floor. CRO Gotts did not confirm the number of people in the flat.1150 Phase 1 Report Volume II paragraph 14.153; 999 call transcript {LFB00000339}.
¶b. By 02.10 the fire on the outside of the building had begun to affect Flat 192.1151 Phase 1 Report Volume II paragraph 14.3. During a call which began at 02.10, Hashim Kedir told CRO Christine Howson that the fire had reached the kitchen of Flat 192 and that the smoke was making everyone in the flat cough. CRO Howson initially said that firefighters were dealing with a fire on the fourth floor but then said that, although the advice was for people to stay in their flats, the family would have to decide whether they should leave because there was a fire in the flat. Hashim Kedir told CRO Howson that the family was trapped. The line was disconnected before he could clarify what CRO Howson thought she had heard, namely that there were two adults and five children in the flat.1152 Phase 1 Report Volume II paragraphs 14.153 and 14.251; 999 call transcript {LFB00000345}.
143¶c. At 02.18, CRO Howson spoke to Hashim Kedir again. He told her that the kitchen was on fire and that a considerable amount of smoke was entering the living room. Having been told that there were two adults and three children in the flat, CRO Howson told him that the family could either make their way to the stairwell or move to somewhere in the flat with less smoke. Asked when the firefighters were coming, CRO Howson told him that they were on their way but making slow progress. She appeared to mistake Hashim Kedir for a woman, and asked if the caller's husband was present.1153 Phase 1 Report Volume II paragraphs 14.154 and 14.266; 999 call transcript {LFB00000351}.
¶d. At 02.30, the Metropolitan Police contacted the LFB control room to pass on the information that a woman, her husband and their three children were trapped in Flat 192.1154 999 call transcript {LFB00000671}. That information had come from a friend of Nura Jemal who had called on her behalf from outside the tower.1155 999 call transcript {INQ00000289}.
¶e. At 02.34, CRO Howson answered another call from Flat 192. She was told that there were two adults and three children in the flat. The fire had reached the living room and the family were being affected by the conditions. CRO Howson advised them to leave. She said she would alert the firefighters, who would try to meet them.1156 Phase 1 Report Volume III paragraph 16.48.
¶f. At 02.35, a police operator spoke to Nura Jemal who confirmed her location. She said that there were two adults and three children in the flat and that the fire had reached a bedroom.1157 999 call transcript {INQ00000276/3} page 3. There is no record of the police passing on that further message to the LFB.
¶g. At 02.45, Hashim Kedir spoke to CRO Heidi Fox. He told her again that the lobby was full of smoke. The family had tried unsuccessfully to leave and were now trapped in a bedroom. Hashim Kedir asked why a helicopter could not be sent to rescue them. CRO Fox again encouraged him to leave, saying that the firefighters were on different floors.1158 Phase 1 Report Volume III paragraph 16.49; 999 call transcript {INQ00000378}.
¶h. At 02.53, Hashim Kedir spoke to CRO Pam Jones and reported that the family were still in Flat 192. CRO Jones advised them to leave.1159 Phase 1 Report Volume II paragraph 16.50.
Information to the incident ground
¶96.20 Although the calls set out above cannot be traced individually to the incident ground, in light of the following facts we have concluded that information about Flat 192 did get through. a. Although the first three calls did not generate a service request, in a radio message
timed at 02.09, CRO Sharon Darby told CU8 that there was a caller in Flat 192 on floor 22 who was unable to leave.1160 Phase 1 Report Volume II paragraphs 14.247-14.248. That information must have come from the call made by Hashim Kedir at 02.03.
¶b. Between 02.10 and 02.22 CU7 was the command unit designated to receive information about people needing to be rescued.1161 Phase 1 Report Volume IV paragraph 28.84 (d). Initially a laminated white sheet
144was used to record information that had previously been recorded on pieces of paper in CU8.1162 Phase 1 Report Volume II paragraphs 12.8-12.9. The following was noted on that sheet: "192 22 1 woman 3 children unable to leave". That reflects in part the entry on a control information form that records "192 22 1 woman 3 kids".1163 LFB Control Information Forms {LFB00001955/10} page 10. It cannot, however, be linked to any of the three calls made by Hashim Kedir between 02.03 and 02.18, although it is possible that SM Jason Oliff, in the LFB control room, may have passed on information about Flat 192 when he called WM Daniel Meyrick in CU8 on his mobile phone.1164 Phase 1 Report Volume II paragraphs 14.243 and 14.261.
¶c. The information recorded on the whiteboards used by SM Oliff from about 02.33 to collate information coming into the control room included the following: "192 22nd flr – fire entering flat* (left flat) Bedroom Living room 2 women 3 children."1165 Phase 1 Report Volume III paragraph 15.140 and Figure 15.8. It is likely that the calls made by Hashim Kedir at 02.10 and 02.18 were the source of that information.
¶d. From about 03.00, CU7 changed to recording information on a whiteboard using a grid system.1166 Phase 1 Report Volume III paragraphs 15.13 and 16.12. In relation to Flat 192, there was recorded the number "2" in green, the number "5" in black and the letter P in red and circled.1167 Phase 1 Report Volume III Figure 16.5; Photograph of whiteboard {MET00015924}. That indicated that two adults and five children were in the flat and that it was a priority rescue.1168 Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. The source of that information must have been the call made by Hashim Kedir at 02.10, given the reference to five children.
¶96.21 Information relating to floor 22 did not reach the bridgehead while it was on floor 2. Between 02.17 and 03.10 it was located on floor 3.1169 Phase 1 Report Volume IV paragraphs 28.86 and 28.87. No note relating to Flat 192 appears on the wall used by WM De Silvo to record FSG information while the bridgehead was located on floor 3.1170 Phase 1 Report Volume III Figure 15.7.
The family's move to Flat 193
¶96.22 Having been unsuccessful in their efforts to leave their home, Hashim Kedir, Nura Jemal and their children were able to make their way to Flat 193, reaching it shortly before 03.00. Naomi Li recalled Nura Jemal and her daughter coming into Flat 193 shortly after the Choucair family had tried unsuccessfully to leave. At that time the amount of smoke in Flat 193 made it difficult to see anyone.1171 Phase 1 Report Volume III paragraphs 16.41-42 and 16.50-51. At 03.02 a BT operator put an emergency call from Hashim Kedir through to Kent Fire and Rescue Service explaining that they could not get the caller's attention but could hear coughing and commotion in the background. The call‑handler at the Kent Fire and Rescue Service was also unable to obtain a response.1172 999 call transcript {LFB00000658}.
¶96.23 Naomi Li made an emergency call at 03.07 during which she told CRO Howson that there were 12 people in Flat 193. She said that the smoke was very bad and that they could not leave. CRO Howson's advice was to make their way to the stairwell.1173 Phase 1 Report Volume III paragraphs 16.51 and 17.33; 999 call transcript {LFB00000404}. At that time everyone was in the living room of Flat 193. Naomi Li told them they had to leave. She was unable to see any reaction because of the amount of smoke in the flat. She and Lydia Liao were able to reach the stairwell.1174 Phase 1 Report Volume III paragraphs 17.34-36. Making their way down the stairs, they were found by WM Peter Clarke, WM Alexander Cardy and FF Enrico Beltrami who helped them and Karen Aboud and her two children from Flat 92 to leave the tower.1175 Phase 1 Report Volume III paragraph 17.20 (a).
145¶96.24 Naomi Li said that she had told the firefighters that there were more than ten people still in Flat 193 on floor 22, but that she did not know what the firefighters had done with that information.1176 Phase 1 Report Volume III paragraph 17.104. WM Cardy said that he had made a report to WM De Silvo at the bridgehead but it is not clear whether he gave her any information about Flat 193.1177 Cardy {MET00010085/10} page 10. By that time the bridgehead had been moved to the ground floor where information was being recorded on a green painted wall at the rear of the lobby.1178 Phase 1 Report Volume IV paragraph 28.87. There was no reference to Flat 193 on that wall.
¶96.25 That the information may have been passed on is suggested by an entry on the ground floor wall where, from 02.15, WM Glynn Williams had begun recording information about people needing to be rescued. SM Peter Wolfenden started recording information on the same wall from about 03.21.1179 Wolfenden {Day40/168:3}-{Day40/172:16}; {Day40/182:14}-{Day40/186:9}. He said that a tick had been used to indicate that a crew had been sent to a particular flat.1180 Wolfenden {Day40/188:5}-{Day40/190:4}. SM Wolfenden may well have been responsible for an entry on that wall which recorded "192 22 10 3K",1181 De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}. meaning ten people, including 3 children. No tick appears next to the entry. Although it is possible that that information may have been the result of emergency calls from those in Flat 193, and although the flat number is wrong, the reference to ten people reflects Naomi Li's explanation. In any event, however that information came to reach the ground floor, it did not lead to the deployment of a crew to floor 22.
The final calls from Flat 193
¶96.26 At 03.08, CRO Angie Gotts answered a call during which she spoke to both Hashim Kedir and Nura Jemal. They said they were in Flat 193 on floor 22 and that they could see a helicopter; they asked if it could help them to escape. CRO Gotts advised them to try and get out using wet towels to cover their heads.1182 Phase 1 Report Volume III paragraph 17.130; 999 call transcript {LFB00000406}.
¶96.27 At 03.14 Nadia Choucair told a BT operator that her baby was unconscious. The BT operator said the advice was to get out of the tower. As the call was being put through to the LFB, Nadia Choucair could be heard telling everyone that they needed to get to the stairs. The call ended before a call-handler could speak to her.1183 Phase 1 Report Volume III paragraphs 17.37-17.38; 999 call transcript {COR00001081}; 999 call transcript {LFB00000414}. At 03.21, a police operator telephoned Nadia Choucair and told her that she needed to leave. She said that there was too much smoke, but as the call ended she could be heard telling those in Flat 193 that they needed to leave.1184 999 call transcript {LFB00000337} page 3.
¶96.28 The last contact with those still in Flat 193 was a call made by Hashim Kedir at 03.24 that was answered by CRO Duddy. He told CRO Duddy that there were 12 adults and seven children in the flat (in fact there were five adults and six children) and that they were trapped. As the call continued, CRO Duddy repeatedly told him that the only chance of survival was to leave by the stairs; a rescue by helicopter was not possible. Hashim Kedir said that it was not possible to leave; they had tried but had been unable to do so because of the smoke. Towards the end of the call, he could be heard calling out "I love you". He was speaking to his children.1185 Phase 1 Report Volume III paragraphs 18.24-18.26.
146Recovery and identification
¶96.29 The remains of the five members of the Kedir and Jemal family were recovered from the living room of Flat 193.1186 Purser, Phase 2 Report, Section 6 {DAPR0000006/46} paragraph 219. The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for Hashim Kedir, Nura Jemal and their children, Yahya, Firdaws and Yaqub.1187 Interim certificates of the fact of death for Hashim Kedir, Nura Jemal, Yahya Hashim, Firdaws Hashim and Yaqub Hashim {MET00065640}; {MET00065629}; {MET00065633}; {MET00065587}; {MET00065644}.
Cause and time of death
¶96.30 The medical causes of death in the cases of Hashim Kedir, Nura Jemal, Yahya Hashim and Yaqub Hashim were recorded as "consistent with the effects of fire". The medical cause of death in the case of Firdaws Hashim was recorded as "inhalation of products of combustion". In light of Professor Purser's evidence, we find that a more accurate description of the cause of death in the case of all five members of the family is "inhalation of asphyxiant gases".
¶96.31 It was possible to detect carboxyhaemoglobin in tissue recovered from Yahya Hashim and Firdaws Hashim, although the concentration could not be measured.1188 Purser, Phase 2 Report, Section 6 {DAPR0000006/47} paragraph 220. The fact that two of those sheltering in Flat 193 inhaled smoke containing carbon monoxide indicates that it is likely that all those in the flat also did so.1189 Purser, Phase 2 Report, Section 6 {DAPR0000006/55} paragraph 263. They would all have been exposed to asphyxiant gases entering Flat 193, particularly from the lobby.
¶96.32 Given that Naomi Li and Lydia Liao were able to escape, it is likely that until about 03.11, despite increasing amounts of smoke, those in Flat 193 had accumulated a relatively limited dose of asphyxiant gases.1190 Purser, Phase 2 Report, Section 6 {DAPR0000006/47-51} paragraphs 224 and 240. From about 03.11, however, they accumulated increasing amounts of asphyxiant gases as the fire on the outside of the building reached Flat 193, in particular, when it reached the living room at about 03.37.1191 Purser, Phase 2 Report, Section 6 {DAPR0000006/51-54} paragraphs 238 and 251. From that time, conditions deteriorated rapidly, causing the occupants to lose consciousness by about 04.13 and within a few more minutes they had inhaled a lethal dose of asphyxiant gases. Since children take up asphyxiant gases at twice the rate of adults, they are likely to have lost consciousness soon after 03.50.1192 Purser, Phase 2 Report, Section 6 {DAPR0000006/54} paragraph 253.
¶96.33 We are satisfied that Hashim Kedir, Nura Jemal and their children Yahya, Firdaws and Yaqub all lost consciousness and died from the inhalation of asphyxiant gases between 03.37 and 04.20, before the fire reached their bodies. It is likely that the three children died before their parents.
147The Choucair / Choukair family
Sirria Choucair
¶Date of birth: 25 October 1956 (60 years). Place of birth: Nahle Village, Lebanon. Gender: Female. Occupation: Retired. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Bassem Choukair
¶Date of birth: 1 December 1976 (40 years). Place of birth: Nahle Village, Lebanon. Gender: Male. Occupation: Supermarket Section Co-Ordinator. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Nadia Choucair
¶Date of birth: 14 January 1984 (33 years). Place of birth: London, UK. Gender: Female. Occupation: Nursery School Teacher Assistant. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
148Mierna Choucair
¶Date of birth: 22 November 2003 (13 years). Place of birth: London, UK. Gender: Female. Occupation: Student. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Fatima Choucair
¶Date of birth: 1 March 2006 (11 years). Place of birth: London, UK. Gender: Female. Occupation: Student. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Zainab Choucair
¶Date of birth: 17 May 2014 (3 years). Place of birth: London, UK. Gender: Female. Occupation: N/A. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶96.34 Sirria Choucair was born on 25 October 1956 in Lebanon. She was 60 years old. Her daughter, Nadia, was born on 14 January 1984 in London. She was 33 years old. Bassem Choukair, Nadia's husband, was born on 1 December 1976 in Lebanon and was 40 years old. Their three daughters were born in London. Mierna Choucair, born on 22 November 2003, was 13 years old, Fatima Choucair, born on 1 March 2006, was 11 years old and Zainab Choucair, born on 17 May 2014, was three years old.
149¶96.35 At the age of 17 Sirria Choucair moved to the UK, where she married and brought up her family. She worked at the Royal Marsden Hospital until her retirement.1193 Phase 1 Report Volume IV paragraphs 32.76–32.81. Bassem Choukair and Nadia Choucair met when Nadia was visiting members of her family in Lebanon. He moved to the UK following their marriage and was Section Co-ordinator in a supermarket. Nadia Choucair worked at Avondale Park Primary School as a nursery officer. Mierna and Fatima were at school; the couple's youngest daughter, Zainab, attended nursery.1194 Phase 1 Report Volume IV paragraphs 32.82-32.84.
¶96.36 Nadia Choucair, Bassem Choukair and their three children lived in Flat 193. Sirria Choucair lived in Flat 191 on the same floor.
Vulnerability
¶96.37 Sirria Choucair had severe arthritis and back pain that affected her mobility.1195 Sawson Choucair {IWS00001799/9} page 9, paragraph 9; Hisam Choucair {IWS00001851/2} page 2, paragraph 8; Nabil Choucair {IWS00002365/2} page 2, paragraph 8. The survey of residents prepared by Rydon in November 2014 recorded that she had high blood pressure, back pain and difficulty in walking.1196 Rydon Residents Survey {RYD00024466/17}. She was recorded as a resident of Flat 191 in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system,1197 Phase 1 Report Volume III paragraphs 20.65-20.66; Noble Spreadsheet {TMO00862588}. but not as having any vulnerabilities. Nadia Choucair, Bassem Choukair and their eldest daughter, Mierna, were recorded as residents of Flat 193. Their younger daughters did not appear in the spreadsheet.
Events of 14 June 2017
¶96.38 On the evening of 13 June 2017, the Choucair family were at home. CCTV shows Bassem Choukair returning to the tower at 15.02, shortly before his three children came back with Sirria Choucair at about 15.38. Nadia Choucair returned to the tower at 16.13.1198 O'Riordan {MET00013136/2-3} pages 2-3.
¶96.39 It is unclear when the family became aware of the fire. Shortly before 01.30 Nadia Choucair opened her front door and saw Naomi Li from Flat 195 in the lobby. Naomi Li told her that the fire brigade had said that there was a fire on floor 4 but their neighbour said it was in her kitchen. (Naomi Li was referring to Mariem Elgwahry from Flat 196.)1199 Phase 1 Report Volume II paragraphs 10.279-10.281. Nadia Choucair invited Naomi Li and her cousin, Lydia Liao, into her home, which was still free of smoke.1200 Phase 1 Report Volume II paragraph 10.279.
¶96.40 Naomi Li made her second emergency call from Flat 193 at 01.30. She told CRO Gotts in the LFB control room that she was in a neighbour's flat on floor 22.1201 Phase 1 Report Volume II paragraph 10.281.
¶96.41 Between 02.17 and 03.00, the LFB control room received further emergency calls relating to eight people trapped in Flat 193.
150¶96.42 Nadia Choucair made her first emergency call at 01.40. After seven minutes trying to connect her to the LFB, the BT operator redirected the call to Essex Fire and Rescue Service at 01.48.1202 999 call transcript {MET00015407}. Nadia Choucair spoke to CRO Sharon Lancaster and gave her address as Flat 193 Grenfell Tower. She said that she was on floor 22 and that it was smoky in the flat.1203 999 call transcript {LFB00000325}. CRO Lancaster told her that the fire service was at the scene and that she would report to London for her.1204 Phase 1 Report Volume II paragraph 12.62.
¶96.43 CRO Lancaster and her colleague CRO Katrina Marshall tried to contact the LFB to pass on the information from Nadia Choucair but were unable to get through until 02.18.1205 Phase 1 Report Volume II paragraph 12.94. CRO Marshall spoke to CRO Adams in the LFB control room and told her that they had received a call from a person on floor 22 who said that it was starting to get smoky. Although she said that they had not obtained a flat number from the caller, that was incorrect as Nadia Choucair had told CRO Lancaster that she was in Flat 193. It appears that the information had not been entered on the incident log.1206 Phase 1 Report Volume II paragraph 14.269. CRO Adams told CRO Marshall that they had given the correct advice when telling Nadia Choucair to stay put.1207 Phase 1 Report Volume II paragraph 12.94; 999 call transcript {LFB00000347}.
¶96.44 Nadia Choucair and Bassem Choukair made two separate emergency calls at 02.37 and 02.43. On each occasion they were connected to the LFB control room and each spoke to CRO Adams. In both calls, CRO Adams was told that there were eight people in the flat (i.e. the six members of the Choucair family and Naomi Li and Lydia Liao).1208 Phase 1 Report Volume III paragraph 16.36.
¶96.45 When she called at 02.37, Nadia Choucair was advised to block any smoke coming in to the flat and to close the windows.1209 Phase 1 Report Volume III paragraph 16.34. CRO Adams reassured her that the firefighters were on their way and would get to her.1210 Phase 1 Report Volume III paragraph 16.34. When Bassem Choukair called at 02.43, CRO Adams encouraged him to try to find the stairs and get out.1211 Phase 1 Report Volume III paragraph 16.35. He said that it was not possible to leave because of the smoke. CRO Adams said that he should make the decision whether to leave or not.1212 Phase 1 Report Volume III paragraph 16.35.
¶96.46 At about 02.35, DAC Adrian Fenton in the LFB control room decided to revoke the stay put advice and tell people to try to leave the building. He was aware that at the time crews could not get above floor 15.1213 Phase 1 Report Volume III paragraphs 15.161–15.163. It took some time for the change in advice to be disseminated to, and implemented by, the CROs.1214 Phase 1 Report Volume III paragraph 15.168. That might explain why at 02.37 CRO Adams advised Nadia Choucair to stay put, but at 02.43 she told Bassem Choukair to try to leave.
¶96.47 The information from the calls was passed to the incident ground. a. From 02.33 SM Jason Oliff began recording information about those in the tower
151needing rescue on two whiteboards in the LFB control room.1215 Phase 1 Report Volume II paragraphs 15.140-15.141 and Figure 15.8. The following was recorded on one of the boards: "193 22 fl – 8 adults 3 children get out advice." The number of people recorded as being in Flat 193 was incorrect, since until 03.00 there were only eight people in the flat, including three children. That may have led to command unit CU7 being told that more people were present in Flat 193.
¶b. Until about 03.00 officers in CU7 were using a white laminated sheet to record information about people needing to be rescued. On it was the notation "193 22 10 people."1216 Phase 1 Report Volume II Figure 12.3. The number of persons recorded must have been a mistake, as only eight people were in Flat 193 before 03.00.
¶96.48 In any event, that information did not reach the bridgehead, which from 02.17 was on floor 3.
Attempts at evacuation
¶96.49 After Bassem Choukair had spoken to CRO Adams at 02.43 the family tried to leave the flat covering their heads with wet towels.1217 Phase 1 Report Volume III paragraphs 16.36-16.37. They reached Flat 194 and spoke to Tony Disson but then returned to Flat 193.1218 Phase 1 Report Volume III paragraph 16.45.
¶96.50 Soon after they had returned, Hashim Kedir, Nura Jemal and their children came into Flat 193.1219 Phase 1 Report Volume III paragraph 16.42. There were now 13 people in the flat. Those sheltering there spoke to the LFB control room on a number of occasions. They were encouraged to try to get out. a. At 02.55, Nadia Choucair and Lydia Liao spoke to CRO Duddy who told them to leave
and get to the stairwell. Lydia Liao told us that by then the smoke in the flat had become so dense that they could not see each other. She was now aware of the fire approaching Flat 193.1220 Phase 1 Report Volume III paragraph 16.41; Liao second witness statement {IWS00001191/2} page 2, paragraphs 7, 8 and 9.
¶b. At 03.02, Bassem Choukair spoke to CRO Howson, telling her that there were 20 people in Flat 193 on floor 22. He asked for a helicopter. CRO Howson told him they should leave the building.1221 999 call transcript {LFB00000396}.
¶c. At 03.05, Bassem Choukair told CRO Duddy that they had been unable to reach the stairwell as there was too much smoke and they could not see. CRO Duddy told him to cover himself in wet towels and feel his way along the wall. He was told that their only chance of survival was to get to the stairwell.1222 Phase 1 Report Volume III paragraph 17.126.
¶d. At 03.06, CRO Darby sent a radio message to CU7 passing on information from the NPAS helicopter, which had identified the presence of people on floors 17, 21 and 22.1223 Phase 1 Report Volume III paragraph 17.128. e. At 03.07, Naomi Li spoke to CRO Howson who told her to leave.1224 Phase 1 Report Volume III paragraph 17.33.
¶f. At 03.08, CRO Gotts answered another call from Flat 193, which overlapped with Naomi Li's call to CRO Howson.1225 Phase 1 Report Volume III paragraph 17.37. The callers asked for a helicopter to rescue them. They said the fire had reached the flat. CRO Gotts told them to use wet towels and leave. She said she would pass the information on to the firefighters.
152¶96.51 Following her call at 03.07, Naomi Li told everyone in the flat that they had to leave. She was not able to see their reactions because there was too much smoke in the room. Naomi Li and Lydia Liao did then leave. On the stairs they encountered WM Peter Clarke, WM Alexander Cardy and FF Enrico Beltrami, who helped them, and also Karen Aboud and her two children from Flat 92 to leave the building.1226 Phase 1 Report Volume III paragraph 17.20 (a).
¶96.52 Naomi Li said that she told the firefighters that there were more than ten people in Flat 193 on floor 22. She did not know what the firefighters did with that information.1227 Phase 1 Report Volume III paragraph 17.104. WM Cardy said that he had reported to WM De Silvo at the bridgehead but it is not clear if he passed on any information about Flat 193.1228 Cardy {MET00010085/10} page 10. From 03.10, the bridgehead was on the ground floor and a green painted wall at the rear of the lobby was being used to record information about those still trapped in flats.1229 Phase 1 Report Volume IV paragraph 28.87. No reference to Flat 193 appeared on that wall.
¶96.53 Separately, from 02.15, WM Glynn Williams had begun recording information about those needing rescue on a different wall on the ground floor. SM Peter Wolfenden began recording information on the same wall from about 03.21.1230 Wolfenden {Day40/168:3}-{Day40/172:16}; {Day40/182:14}-{Day40/186:9}. He may well have been responsible for an entry on that wall that recorded "192 22 10 3K",1231 De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}. meaning ten people including three children. SM Wolfenden explained that a tick had been used to show that a crew had been sent to a flat1232 Wolfenden {Day40/188:5}-{Day40/190:4}. but no tick appears next to that entry. Although the entry refers to Flat 192, the reference to ten people indicates that the source may have been Naomi Li, but it is also possible that the information came from calls made by others on floor 22. In any event, however the information recorded on the wall came to reach the ground floor, it did not lead to a deployment to floor 22.
The final calls from Flat 193
¶96.54 At 03.08, CRO Gotts answered a call during which she spoke to both Hashim Kedir and Nura Jemal. They said they were in Flat 193 on floor 22. They said they could see a helicopter and asked for it to help them escape. CRO Gotts told them to try to get out using wet towels to cover their heads.1233 Phase 1 Report Volume III paragraph 17.130; 999 call transcript {LFB00000406}.
¶96.55 At 03.14 Nadia Choucair told a BT operator that her baby was unconscious. She was speaking of her youngest daughter, Zainab. The operator said the advice was to get out of the tower. As the call was being put through to the LFB, Nadia Choucair could be heard telling everyone in the room that they needed to get to the stairs. The call ended before someone in the control room could speak to her.1234 Phase 1 Report Volume III paragraphs 17.37-17.38; 999 call transcript {COR00001081}; 999 call transcript {LFB00000414}. At 03.21, a police operator telephoned Nadia Choucair and told her that she needed to leave. She said that there was too much smoke, but as the call ended she could be heard telling those in Flat 193 that they needed to leave.1235 999 call transcript {LFB00000337/3} page 3.
¶96.56 Hashim Kedir's call at 03.24 was the last contact with those still in Flat 193. He told CRO Duddy that there were 12 adults and seven children trapped in Flat 193 (in fact there were five adults and six children). As the call continued, CRO Duddy repeatedly told him that the only chance of survival was to leave by the stairs and that it was not possible to rescue them by helicopter. Hashim Kedir told CRO Duddy that it was not possible for them to leave; they had tried but had been unable to do so because of the smoke.1236 Phase 1 Report Volume III paragraphs 18.24-18.26.
153¶96.57 Information received by the LFB control room after 03.00 was passed on to the incident ground but did not result in any deployments. It was recorded in the following places: a. SM Oliff in the control room recorded on the second whiteboard in green "193 22th
10 people" followed by "Told to leave flat" in black ink. The floor number had been rubbed out making it possible that it had been written as 23. A note in grey ink had been added just above "10 people" stating "12 adults 3 children". That additional information may have come from a further call.1237 Phase 1 Report Volume III Figure 15.9.
¶b. After 03.00, a whiteboard with a grid system was used in CU7 to record information about people needing to be rescued. Next to Flat 193 there was a notation reading "12 3 P", indicating that 12 people and 3 children were trapped in Flat 193. The letter 'P' written in red and circled indicated that it was a priority destination.1238 Phase 1 Report Volume III Figure 16.5.
¶c. WM Williams wrote "193 22 10P" at the bottom of the central column of notes he made on the wall of the ground floor lobby. He accepted that that information may have come from a control information form that records that ten people were in Flat 193 on floor 22 and gives the source as "unknown via CU".1239 De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}; Williams {Day31/155:18}-{Day31/157:8}; Control information form {LFB00001922/20}. Later entries were made to the left of that central column,1240 Williams {Day31/99:13-16}; Wolfenden {Day40/183:24}-{Day40/184:25}. including one which read "Flat 222" on floor 22.1241 Phase 1 Report Volume II Figure 14.5. (This note seems to have been made before that relating to Flat 192).
¶d. At some time before 03.47 WM Tom Furnell had made a note in his notebook that there were 11 people in Flat 193 on floor 22.1242 Furnell Exhibit TGF/2 - original notes {MET00017035}; Furnell {Day40/37:2-25}. He was not sure how he had obtained that information but suspected that it had come from CU7.1243 Furnell {Day40/24:15-24}. He said he had sent the information to the bridgehead but did not know who would then have been responsible for sending a crew to Flat 193.1244 Furnell {Day40/38:9-19}.
Recovery and identification
¶96.58 The remains of the six members of the Choucair / Choukair family were recovered from the living room of Flat 193.1245 Purser, Phase 2 Report, Section 6 {DAPR0000006/46} paragraph 219. The coroner was satisfied about the identification of the remains and issued interim certificates of the fact of death for Sirria Choucair, Bassem Choukair, Nadia Choucair and their three daughters, Fatima, Mierna and Zainab.1246 Interim certificates of the fact of death for Sirria Choucair, Bassem Choukair, Nadia Choucair, Mierna Choucair, Fatima Choucair and Zainab Choucair {MET00065600}; {MET00065610}; {MET00065613}; {MET00065651}; {MET00065599}; {MET00065618}.
154Cause and time of death
¶96.59 The medical cause of death in the case of the members of the Choucair / Choukair family was recorded as consistent with the effects of fire. In light of Professor Purser's evidence we find that a more accurate description of the cause of the deaths of all six members of the family is "inhalation of asphyxiant gases".
¶96.60 Although there is no toxicological analysis available for any member of the family, the fact that carboxyhaemoglobin was found in tissue recovered from the remains of Yahya Hashim and Firdaws Hashim (who also died in Flat 193) makes it likely that all those in Flat 193 had inhaled carbon monoxide,1247 Purser, Phase 2 Report, Section 6 {DAPR0000006/55} paragraph 263. particularly as a result of gases entering the flat from the lobby of floor 22.
¶96.61 The fact that Naomi Li and Lydia Liao were able to escape from the tower makes it likely that until about 03.11 those in Flat 193 had accumulated a relatively low dose of asphyxiant gases, despite the increasing amounts of smoke in the flat.1248 Purser, Phase 2 Report, Section 6 {DAPR0000006/47-50} paragraphs 224 and 235. Their accumulation of such gases increased as the fire on the outside of the building reached Flat 193 and particularly when it reached the living room at about 03.37.1249 Purser, Phase 2 Report, Section 6 {DAPR0000006/51-54} paragraphs 238 and 251. From that time onwards conditions deteriorated rapidly, with the result that the inhalation of asphyxiant gases caused them to become unconscious by about 04.13. Within a few more minutes they had acquired a lethal dose. Since children absorb asphyxiant gases at twice the rate of adults, they are likely to have lost consciousness sooner, at about 03.50 or shortly after.1250 Purser, Phase 2 Report, Section 6 {DAPR0000006/54} paragraph 253.
¶96.62 We find that Sirria Choucair, Bassem Choukair and Nadia Choucair and their three children, Mierna, Fatima and Zainab had all lost consciousness and died from the inhalation of asphyxiant gases between 03.37 and 04.20 before the fire reached their bodies. It is likely that the three children died before their parents.
Anthony (Tony) Disson
¶Date of birth: 27 November 1951 (65 years). Place of birth: Hammersmith, London, UK. Gender: Male. Occupation: Retired. Usual address: Flat 194, floor 22, Grenfell Tower, London. Place of death: Stairwell, Grenfell Tower, London. Time of death: By 04.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
155Background and composition of household
¶96.63 Anthony (Tony) Disson was born on 27 November 1951. In June 2017 he was 65 years old and had retired. He and his wife, Cordelia, had three sons, Harriboy, Alfie and Charlie.1251 Phase 1 Report Volume IV paragraphs 32.68- 32.69. Tony Disson had lived in Flat 194 since June 2010.1252 Tenancy Agreement {TMOH00000779}. His son, Charlie, lived with him but was not at home on the night of the fire.1253 Charles Disson {IWS00000239/1} page 1, paragraph 2.
Vulnerability
¶96.64 A priority needs assessment for RBKC completed in June 2009 in support of Tony Disson's application for emergency housing recorded that he had problems with his legs, which were getting worse, and that he needed access to a lift or a ground floor flat.1254 Priority Needs Assessment {TMOH00000849}. Tony Disson's tenancy agreement for Flat 194 recorded that he did not suffer from any disability.1255 Tenancy Agreement {TMOH00000779}.
¶96.65 In April 2016, a doctor at his local surgery wrote to the TMO in support of Tony Disson's request for repairs to be carried out in his flat. The letter indicated that the current condition of the flat was having a detrimental effect on his health and well-being but did not refer to his having any difficulties with mobility.1256 GP Liaison letter to KCTMO dated 26 April 2016 {TMOH00000861}.
¶96.66 Tony Disson was not identified as having any vulnerabilities in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system.1257 Noble Spreadsheet {TMO00862588}.
Events of 14 June 2017
¶96.67 Tony Disson returned to the tower shortly before the fire began on 14 June 2017,1258 O' Riordan {MET00013136/4} page 4. having spent the day with his son, Alfie, and his wife, Cordelia.1259 Alfie Disson {IWS00000241/4} page 4, paragraph 60; Cordelia Disson {IWS00000242/9} page 9, paragraphs 113-114. He became aware of the fire at an early stage, having spoken briefly to Naomi Li in the lobby on floor 22 at about 01.25.1260 Phase 1 Report Volume II paragraph 10.277. Conditions on floor 22 had deteriorated by 01.30 when he made his first call to the emergency services. He described conditions in the lobby as terrible and told CRO Heidi Fox in the LFB control room that he could not see anything. Although he said that he was on floor 22, he did not give her the number of his flat. She told him to use towels to block any smoke coming into his flat and said that firefighters were on their way.1261 Phase 1 Report Volume II paragraphs 11.37-11.39; 999 call transcript {LFB00000459}.
¶96.68 At 01.32 a service request was created which recorded "PERSONS ON THE 22ND FLOOR SMOKE COMING INTO FLAT."1262 LFB Short Incident Log {MET00013830}. That was probably the result not only of Tony Disson's first call but also of a call at 01.30 from Naomi Li, in which she reported that she was trapped on floor 22.1263 999 call transcript {INQ00000472}. CRO Darby passed that information to appliance G261 at 01.35, confirming that she could not provide the number of the affected flats.1264 Phase 1 Report Volume IV paragraph 28.84 (b). The service request was marked as completed at 01.41.1265 LFB Short Incident Log {MET00013830}. The information was not passed to the bridgehead, which at that time was on floor 2, where it remained until 02.17.1266 Phase 1 Report Volume IV paragraph 28.84 (b). The forward information board used on floor 2 to record information about people needing to be rescued contained no reference to floor 22.1267 Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c).
156¶96.69 Tony Disson next spoke to the LFB control room at 01.50. He told CRO Peter Duddy that smoke was coming into his flat. CRO Duddy told him to close all the windows and said that firefighters were making their way to floor 22.1268 Phase 1 Report Volume II paragraph 12.63. That call did not prompt a message to the incident ground.
¶96.70 At 02.00, Tony Disson made his third emergency call. He told CRO Howson that conditions were deteriorating in his flat. He gave the numbers of his floor and his flat and was reassured that firefighters were coming to him.1269 Phase 1 Report Volume II paragraph 14.152; 999 call transcript {LFB00000337/3}. CRO Adams, who was speaking to command unit CU8 at the time, passed on the information that a pensioner was trapped in Flat 194 on floor 22.1270 Phase 1 Report Volume II paragraphs 14.230-14.231; 999 call transcript {INQ00000195/5}. However, that information did not reach the bridgehead.
¶96.71 Tony Disson made further calls to the emergency services. a. In a call at 02.24 he told CRO Adams that he was frightened and that he had been
waiting for 45 minutes; he threatened to jump out of the window. The line was disconnected before he could be given any advice.1271 999 call transcript {LFB00000352}.
¶b. A call made at 02.40 cleared before the operator could put it through to North West Fire Control. Nonetheless, the operator was able to pass on the message that the caller was in Flat 194 and had said that he could not breathe.1272 999 call transcript {LFB00000695}. It appears that that information was not passed to the LFB control room.
¶c. At 02.49, Tony Disson spoke again to CRO Adams. He asked for someone to come and get him. For the first time he was told to leave the tower.1273 Phase 1 Report Volume III paragraphs 16.43 and 17.41.
¶96.72 It was probably after the last of those calls that Bassem Choukair knocked on Tony Disson's door, having left Flat 193 with his family. At the time Tony Disson was on the telephone to his wife, Cordelia. She heard Bassem Choukair ask him for help and Tony Disson reply that he could not help himself. She described Tony Disson as becoming more desperate from that point.1274 Phase 1 Report Volume III paragraphs 16.44-16.45. The Choucair / Choukair family were back in Flat 193 by 02.55 when Nadia Choucair made another emergency call.1275 Phase 1 Report Volume III paragraph 16.41.
¶96.73 Tony Disson was also in contact with his son, Alfie, and his partner, Chanade Prentice. She made two emergency calls at 02.28 and 02.45 which were connected to Surrey Fire and Rescue Service.1276 Phase 1 Report Volume II paragraph 17.44. Surrey in turn contacted the LFB control room saying that a man was trapped in Flat 194 on floor 22.1277 999 call transcript {LFB00000357}; 999 call transcript {LFB00000544}. At 02.54, Sharon Haley, a friend and resident of the tower who had already left the building, also spoke to the LFB control room and gave it the same information.1278 999 call transcript {LFB00000549}; Haley {IWS00001219/11} page 11, paragraph 123.
157¶96.74 Surrey gave the LFB control room Tony Disson's mobile number. CRO Gotts called him at 02.51 and told him to leave.1279 999 call transcript {LFB00000469}. When Tony Disson called the LFB control room again at 03.01, CRO Fox gave him the same advice. He told CRO Fox that it was too dark and hot for him to leave.1280 999 call transcript {LFB00000395}; Phase 1 Report Volume II paragraph 17.41. In calls to his family, Tony Disson described the conditions in his flat as worsening and said that it was filling with smoke.1281 Phase 1 Report Volume II paragraph 17.43
Information to the bridgehead
¶96.75 The bridgehead was located on floor 3 between 02.17 and 03.10, when it was moved to the ground floor.1282 Phase 1 Report Volume IV paragraphs 28.86-28.87. Notwithstanding the significant number of calls to the emergency services from and about Tony Disson, information about him did not reach the bridgehead while it was on floor 3. a. From about 02.33, SM Jason Oliff began using two whiteboards to collate information
received by the LFB control room about people needing to be rescued to enable him to pass it to the incident ground. One of the earliest entries read "194 22 flr – Heavy smoke 1 adult."1283 Phase 1 Report Volume III paragraphs 15.139-15.141 and Figures 15.8 and 15.9. However, we do not know whether that information reached the incident ground before 03.00.
¶b. The white laminated sheet initially used in CU7 to record information about people needing to be rescued contained a reference to Flat 193 but no reference to Flat 194.1284 Phase 1 Report Volume II paragraphs 12.8-12.11 and Figure 12.3.
¶c. From 03.00, CU7 began to record information on a whiteboard using a grid system.1285 Phase 1 Report Volume III paragraphs 15.13 and 16.12. Against Flat 194, the number "1" had been written on the grid in green (indicating an adult) with next to it the letter "P" in red and circled,1286 Phase 1 Report, Volume III Figure 16.5; Photograph of whiteboard {MET00015924}. indicating a priority.1287 Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. A red tick was used in CU7 to indicate that a crew had been despatched. No red tick appears against Flat 194. It is possible that information about a person trapped in Flat 194 had been passed to CU7 by SM Oliff.
¶d. WM Glynn Williams began recording information about people needing to be rescued on a wall of the ground floor lobby from 02.15. Nothing was recorded in relation to Flat 194.1288 Phase 1 Report, Volume II paragraphs 14.103-14.105 and Figure 14.5; Photographs of ground floor wall {MET00005774} and {MET00005776}.
¶e. During the period that the bridgehead was located on floor 3, similar information was recorded on a wall there. Flat 194 is not listed on that wall.1289 Phase 1 Report Volume III paragraphs 15.23-15.24; Phase 1 Report Volume II Figure 15.7.
¶96.76 It follows that the emergency calls concerning Flat 194 did not prompt the decision to send CM Raoul Codd and FF John Joseph to floor 22 shortly after 03.00.1290 Phase 1 Report Volume III paragraph 17.13 (g).
158Final contact with Tony Disson
¶96.77 At about 03.00, Tony Disson told his son Alfie that the firefighters were not coming for him and that he was going to try to leave.1291 Phase 1 Report Volume III paragraph 17.43. Chanade Prentice spoke to Surrey Fire and Rescue Service again at 03.05 telling CRO Caili Beckham that the fire had now reached Tony Disson's flat and that he was struggling to breathe.1292 Phase 1 Report Volume III paragraph 17.44.
¶96.78 When Surrey Fire and Rescue Service passed the information on to the LFB control room, they were told that the occupants of the tower were now being advised to leave. At 03.09, CRO Beckham called Alfie Disson to tell him of the change of advice. He said that his father would not leave because he could not see well enough to reach the stairs. CRO Beckham said that she would let the LFB know, as Tony Disson should be treated as a priority. She spoke to CRO Jones in the LFB control room at 03.10. CRO Jones could not offer any more advice but did call Tony Disson at 03.15. The call was not answered.1293 Phase 1 Report Volume III paragraphs 17.45 and 17.131.
¶96.79 By about 03.20, Flat 194 was being affected by the fire on the outside of the building.1294 Phase 1 Report Volume III paragraph 17.7. Cordelia Disson spoke to Kent Fire and Rescue Service at 03.22. She said that she had just spoken to Tony Disson, that the fire had reached his front door and that he was having difficulty breathing. CRO Zoe Martin said that she would call him.1295 Phase 1 Report Volume III paragraph 17.46.
¶96.80 CRO Martin's call to Tony Disson was the last contact anyone had with him. By that time, he had left his flat and had reached the stairs. The call ended abruptly.1296 Phase 1 Report Volume III paragraph 18.27; 999 call transcript {LFB00000660}. In the Phase 1 report the call is said to have been made at 03.31 but evidence received since shows that it was in fact made at 03.27.
Recovery and identification
¶96.81 Tony Disson's body was found in the stairwell at the level of floor 18.1297 Phase 1 Report Volume III paragraph 18.28. The coroner was satisfied about his identity and issued an interim certificate of the fact of death.1298 Interim certificate of the fact of death for Anthony Disson {MET00065649}.
Cause and time of death
¶96.82 The medical cause of death was recorded as "inhalation of fire fumes" but in the light of more recent evidence we find that a more accurate description is "inhalation of asphyxiant gases".
¶96.83 The post-mortem on Tony Disson noted that there were heavy soot deposits on his head, face and arms. Soot was also found in the airways consistent with the inhalation of smoke‑filled air. There was some heat damage to the skin. Toxicological analysis found the level of carboxyhaemoglobin in Tony Disson's blood to be 71%. The post-mortem noted that such a level would be associated with death in any individual, even without the pre‑existing widespread coronary artery disease from which he suffered.1299 Disson post-mortem report {COR00000181/12}; Purser, Phase 2 Report, Section 6 {DAPR0000006/57} paragraphs 278-279.
159¶96.84 The carboxyhaemoglobin level in his blood shows that Tony Disson had inhaled a significant quantity of carbon monoxide before he died. Later analysis in April 2019 of the blood sample did not detect any cyanide.1300 Disson toxicology report {INQ00011096/1} page 1; Purser, Phase 2 Report, Section 6 {DAPR0000006/61} paragraph 296. However, it is likely that the sample had degraded over time, so the finding does not necessarily reflect the level of cyanide in his blood at the time of death.1301 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447.
¶96.85 Tony Disson was still in Flat 194 when he spoke to Cordelia Disson shortly before 03.22 and had not got very far down the stairs when CRO Martin spoke to him at 03.27. That suggests that he did not spend long in the lobby after leaving his flat. We conclude that by the time he left his flat Tony Disson had inhaled close to an incapacitating dose of asphyxiant gases.1302 Purser, Phase 2 Report, Section 6 {DAPR0000006/61} paragraphs 296-304. He lost consciousness and collapsed shortly after the call with CRO Martin. Tony Disson had probably suffered a lethal exposure to asphyxiant gases by about 03.56 and died before 04.30.1303 Purser, Phase 2 Report, Section 6 {DAPR0000006/60} paragraph 295; Purser {Day297/43:3-7}. In our view, the heat damage to the skin noted at the time of the post-mortem very probably occurred after death.
161Chapter 97: Floor 23
¶97.1 On the night of the fire the six flats on floor 23 were occupied as follows:
Flat 201 by Raymond (Moses) Bernard. Flat 202 by Gloria Trevisan and her partner, Marco Gottardi. Flat 203 by Rania Ibrahim and her two daughters, Fethia Hassan and Hania Hassan. Flat 204 by Hesham Rahman. Flat 205 by Mohammed (Saber) Neda, his wife, Flora (Shakila) Neda, and their son, Shekeb (Farhad) Neda. Flat 206 by Fathia Ahmed Elsanousi and her daughter, Isra Ibrahim. Fathia Ahmed Elsanousi's son, Abufras Mohamed Ibrahim, was visiting.
Conditions and the upward migration from lower floors
¶97.2 The fire reached floor 23 by 01.26. The exterior of Flat 206, in the north-east corner of the tower, was enveloped by flames by 01.30.1304 Phase 1 Report Volume II paragraphs 10.118 and 10.122; External Fire Spread Report {MET00012593/14}.
¶97.3 Farhad Neda in Flat 205, which had two bedrooms in the north-west corner of the tower, saw smoke entering the lobby from the smoke extraction vents at some time before 01.30. The smoke gradually filled the lobby. The Neda family tried to walk down the stairs but were unable to do so due to a group of people coming up from lower floors who told them that there was a fire. Altogether, 16 people moved up from lower floors to floor 23, only one of whom survived the fire. In the Phase 1 report the chairman set out the possible reasons why that upward movement occurred.1305 Phase 1 Report Volume II paragraphs 10.284-10.286 and 10.290-10.292. It has not proved possible for us to reach any more confident conclusion.
¶97.4 There is evidence that by 01.39 the lobby on floor 23 was dark, probably due to smoke.1306 Phase 1 Report Volume II paragraphs 11.29-11.34; External Fire Spread Report {MET00012593/14}.
¶97.5 Between 01.50 and 02.20, Fadumo Ahmed ran to the stairwell from Flat 201. At that time the lobby was full of black smoke with no visibility. There was dark smoke in the stairwell which made her cough and feel dizzy. She had difficulty breathing.
¶97.6 Farhad Neda and Shakila Neda encountered similarly difficult conditions when leaving Flat 205 at some time after 02.15. The temperature in the lobby was higher than in the flat and the smoke caused a burning sensation that made Shakila Neda vomit and choke. The stairs were thick with black smoke and the handrail was not visible. Farhad Neda and Shakila Neda were rescued by firefighters and left the tower by 02.43.1307 Phase 1 Report Volume III paragraphs 15.64-15.67 and Annex A. They were the last occupants of floor 23 to escape the tower.
162Deployments to Floor 23
¶97.7 There were numerous emergency calls reporting people trapped on floor 23. Some identified specific occupants and flats; others were made by members of the public who could see people signalling and waving from the top floor of the building.1308 Phase 1 Report Volume II paragraph 14.235. The information received at the incident ground resulted in deployments of firefighters to floor 23 but no firefighters succeeded in reaching it.
¶97.8 One crew was briefed to go to the roof.1309 Phase 1 Report Volume II paragraphs 11.12-11.13, 13.5, 13.15 and 14.85-14.87; Phase 1 Report Volume III paragraph 15.30. Three other crews were sent to floor 23.1310 Phase 1 Report Volume II paragraph 14.117; BA Telemetry Schedule {LFB00023326}; Phase 1 Report Volume III paragraphs 15.54-15.56 and 15.66; Phase 1 Report Volume III paragraphs 16.15-16.20 and Figure 16.6. A fourth deployment to floor 23 was changed to a search and rescue operation just before the firefighters set off.1311 Phase 1 Report Volume III paragraph 18.15 (b). The deployment of FFs Terence Roots and Adam Johnson to Flat 161 on floor 19 at about 02.05 had been to rescue Debbie Lamprell, but by then she had already moved to floor 23.1312 Phase 1 Report Volume II paragraph 12.86.
¶97.9 Having arrived at the incident ground at about 01.35, the Paddington crew (CM Philip Wigley, FFs Martin Gillam, Russell Gonzalez, Andrew Harris and Dean Roberts) equipped with extended duration breathing apparatus were sent by WM Michael Dowden to the roof of the tower to run a jet of water down from the top of the building.1313 Phase 1 Report Volume II paragraphs 11.12-11.13, 13.5, 13.15 and 14.85-14.87; Phase 1 Report Volume III paragraph 15.30. They tallied out between 01.56 and 01.57. They met FFs Steven Mills and Geoffrey Campbell coming down, who told them that they had been sent to rescue a woman in Flat 175 or a woman on floor 20. At about floor 15 or 16, the Paddington crew realised that they could not reach the roof. They went to floor 20 instead to try to rescue the woman FFs Mills and Campbell had told them about. They found Fadumo Ahmed between floors 20 and 21 and helped her. Fadumo Ahmed had come from Flat 201, where others were also sheltering. FF Gillam told us that she had told him that there was no one left on her floor but that none of the crew had asked her from which floor she had come. The crew's end of wear times were between 02.21 and 02.23.1314 Phase 1 Report Volume II paragraphs 11.12-11.13, 13.5, 13.15 and 14.85-14.87; Phase 1 Report Volume III paragraph 15.30.
¶97.10 FFs John Wright, Zade Alassad and Scott Bell were sent to two flats on floor 23, which are likely to have been Flats 201 and 205. It is not clear exactly which emergency call or calls had prompted their deployment, but the call by Jessica Urbano Ramirez from Flat 201 at 01.29 may have prompted it, as messages were passed to the incident ground relating to it. The crew tallied out between 02.08 and 02.10. They stopped at floor 10 and helped other firefighters to carry the bodies of Mohamednur Tuccu and Khadija Khalloufi out of the tower. FF Bell recalled telling someone they had not reached floor 23, but he could not remember to whom he had spoken or what that person had done with the information. Their end of wear times were between 02.28 and 02.29.1315 Phase 1 Report Volume II paragraph 14.117; BA Telemetry Data {LFB00023326}.
¶97.11 CM Richard Evans and FF Gemma Bloxham were sent to Flat 205 on floor 23. They tallied out at 02.24. Between floor 18 and floor 20, they came across two occupants, probably Farhad Neda and Shakila Neda, and helped them to escape. Shakila Neda had been on the telephone to members of her family on floor 23. On overhearing the conversation, CM Evans tried to make radio contact with the bridgehead but did not obtain a response. Farhad Neda told the firefighters that his father and four other people were trapped in Flat 205. One of the firefighters wrote that in his notebook. Once CM Evans had got back down, he told the officer in charge at the bridgehead that he and FF Bloxham had not reached Flat 205. The crew's end of wear time was 02.42.1316 Phase 1 Report Volume III paragraphs 15.54-15.56 and 15.66.
163¶97.12 FFs Michael Pole, Niki Mitchell, Chris Cheesman and Jessamine Bate from Euston Fire Station were deployed to floor 23, probably to Flats 204 (a west-facing flat) and 205. The crew had tallied out by 02.53. On the stairs, they met FFs Upton and Reddington carrying Malak Belkadi. FF Bates helped them to carry her. FFs Mitchell, Pole and Cheesman continued upwards and reached floor 18. There they realised that they did not have enough air to reach floor 23 and get back down again. Instead they helped to rescue those who had sheltered in Flat 153. FF Mitchell recalled telling WM Louisa De Silvo that they had not reached floor 23. The crew's end of wear times were 03.15 to 03.17.1317 External Fire Spread Report {MET00012593/14}; Phase 1 Report Volume III paragraphs 16.15-16.20 and Figure 16.6.
¶97.13 FFs Matthew Harold, David Friend and Richard Peacock tallied out between 03.31 and 03.32. They had originally been sent to Flat 203 on floor 23 in the south-west corner of the tower but their instructions were changed just before they set off. Instead, they were told to carry out search and rescue operations from the ground floor upwards. They searched floors 4 and 5 and found no casualties.1318 Phase 1 Report Volume III paragraph 18.15(b); External Fire Spread Report {MET00012593/14}.
Events surrounding Flat 201
¶97.14 Flat 201, the home of Raymond (Moses) Bernard, was a one-bedroom flat facing east.1319 Phase 1 Report Volume IV paragraph 32.55; External Fire Spread Report {MET00012593/14}. Those who took refuge there included Fadumo Ahmed (Flat 164, floor 19), Debbie Lamprell and Gary Maunders (Flat 161, floor 19), Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris (Flat 166, floor 19), Berkti Haftom and Biruk Haftom (Flat 155, floor 18), Hamid Kani (Flat 154, floor 18) and Jessica Urbano Ramirez (Flat 176, floor 20). Most of those who moved up to floor 23 probably reached it by around 01.30.1320 Phase 1 Report Volume II paragraphs 10.257, 10.258, 10.260, 10.289 and 14.125.
¶97.15 Amna Idris and Gary Maunders did not live in Grenfell Tower. Amna Idris was visiting her cousin, Amal Ahmedin, and her family. Gary Maunders was visiting Debbie Lamprell.1321 Phase 1 Report Volume II paragraphs 10.223 and 14.136. He moved from Flat 201 to Flat 203 at around 01.39.1322 Phase 1 Report Volume II paragraphs 11.30-11.31.
¶97.16 There were three children in the group sheltering in Flat 201: Jessica Urbano Ramirez (12 years old), Biruk Haftom (12 years old) and Amaya Tuccu Ahmedin (3 years old).1323 Phase 1 Report Volume IV paragraphs 32.126, 32.154 and 32.198.
¶97.17 Of the 11 people who were in Flat 201 at some point, only Fadumo Ahmed survived. She left the tower at 02.25 with the assistance of firefighters.1324 Phase 1 Report Volume II paragraph 14.131; Phase 1 Report Volume III Annex A.
¶97.18 The remains of Moses Bernard, Debbie Lamprell, Amna Idris, Berkti Haftom, Biruk Haftom, Hamid Kani and Jessica Urbano Ramirez were all recovered from Flat 201.
164¶97.19 The remains of Gary Maunders were recovered from Flat 203. Those of Amal Ahmedin and her daughter, Amaya Tuccu Ahmedin, were recovered from the lobby of floor 23. We do not know when or under what circumstances Amal Ahmedin and Amaya Tuccu Ahmedin left Flat 201.1325 Phase 1 Report Volume II paragraph 14.132.
Conditions in Flat 201
¶97.20 By 01.29 the fire had spread to the eastern and northern sides of floor 23, affecting first Flat 206 in the north-east corner.1326 Phase 1 Report Volume II paragraph 10.107. The fire moved across Flat 206 in a southerly direction along the east face and towards Flat 201, which was next door.1327 Lane, Phase 1 Supplemental Report, Section 12 {BLAS0000012/8-9}; External Fire Spread Report {MET00012593/18-19}.
¶97.21 Smoke had been entering the lobby on floor 23 since before 01.30.1328 Phase 1 Report Volume II paragraphs 10.285-10.286. From about 01.30, Flat 201 filled with smoke from the lobby and from the fire outside the living room windows.1329 Purser, Phase 2 Report, Section 6 {DAPR0000006/9} paragraph 18.
¶97.22 By 01.34, the occupants of Flat 201 were struggling to breathe. There were about ten people sheltering in the hallway of the flat. Fadumo Ahmed and Amal Ahmedin tried unsuccessfully to put out a fire which was burning at the top of the living room window.1330 Phase 1 Report Volume II paragraphs 11.25-11.26; 999 call transcript {LFB00055504/5-10}.
¶97.23 The fire entered the living room and set things alight. The conditions in the flat prompted the group to move from the hallway to the bedroom.1331 Phase 1 Report Volume II paragraph 11.25. While in the bedroom, both Debbie Lamprell and Jessica Urbano Ramirez had long telephone calls with the emergency services.
¶97.24 By the time Fadumo Ahmed decided to leave thick smoke was coming into the flat from the lobby. At some time between 01.50 and 02.20 she left the flat and ran straight to the stairwell. Both the lobby and the stairs were filled with thick, dark smoke. Due to the smoke, there was no visibility in the lobby and the stairs could not be seen.1332 Phase 1 Report Volume II paragraphs 14.128-14.130.
¶97.25 By about 01.56, the fire on the outside of the building had spread across the exterior of the living room and kitchen. It then spread outside the bedroom window where the occupants were sheltering.1333 Purser, Phase 2 Report, Section 6 {DAPR0000006/9} paragraph 19.
¶97.26 By 02.01 the windows of the bedroom of Flat 201 were cracking. By 02.06, flames were entering the bedroom window and the interior of the flat was on fire.1334 Phase 1 Report Volume II paragraphs 14.134 and 14.138.
¶97.27 By 02.20, towards the end of their respective emergency calls, Jessica Urbano Ramirez and Debbie Lamprell had stopped responding; they both probably lost consciousness at about that time.1335 Phase 1 Report Volume II paragraphs 14.135 and 14.140; 999 call transcript {LFB00055500/42-43}; 999 call transcript {LFB00055504/78-82}; Purser, Phase 2 Report, Section 6 {DAPR0000006/12} paragraph 36.
¶97.28 It is likely that all those in Flat 201 lost consciousness from about 02.15 and had been exposed to a lethal dose of asphyxiant gases by about 02.23.1336 Purser, Phase 2 Note on Toxicity Endpoints {DAPR0000013}.
165¶97.29 The firefighting crews deployed to floor 23 all tallied out after 02.08. Conditions in the stairwell between 02.00 and 02.20 had deteriorated to the point at which they posed a risk to anyone who attempted to escape.1337 Phase 1 Report Volume IV paragraph 25.28. It is therefore doubtful that firefighters would have been able to rescue the occupants of Flat 201, even if they had succeeded in reaching floor 23.
Emergency services calls, information at the incident ground and deployment to Flat 201
¶97.30 Jessica Urbano Ramirez and Debbie Lamprell each made a long emergency call while they were in Flat 201. Although the calls overlapped in time, there does not appear to have been any direct communication between the two callers. Biruk Haftom also made an emergency call from Flat 201.1338 Phase 1 Report Volume II paragraphs 10.289 (d) and 14.127.
¶97.31 Although messages from Flat 201 were passed to the incident ground and recorded in various places, there was only one deployment of firefighters specifically to Flat 201.1339 Phase 1 Report Volume II paragraph 14.117.
Jessica Urbano Ramirez's long emergency call
¶97.32 Jessica Urbano Ramirez used Berkti Haftom's telephone to make an emergency call at 01.27, but it was disconnected before the BT operator could transfer it to the LFB control room.1340 999 call transcript {MET00015554}. The BT operator contacted the LFB control room at 01.29 and spoke to CRO Sarah Russell, telling her that the caller was a child who had asked for the fire brigade. CRO Russell called back using Berkti Haftom's number and was connected to Jessica Urbano Ramirez at 01.29. The call lasted until 02.24. Jessica stopped responding towards the end of the call. Early in the conversation she reported her location as floor 23 and said that there were about ten other people in the flat.1341 Phase 1 Report Volume II paragraph 10.317. She said that smoke was coming from the floor and that people were having difficulty breathing. She later said that fire had entered the living room and that the group had moved from the hallway to the bedroom. She said she was in Flat 201. She also described the group as containing about 11 people, including a two-year-old child, who must have been Amaya Tuccu Ahmedin.1342 Phase 1 Report Volume II paragraphs 11.25, 12.66 (b) and 12.67.
¶97.33 At 01.45, CRO Russell created a service request which sought assistance for 11 people trapped in the bedroom of a flat on floor 23.1343 Phase 1 Report Volume II paragraph 12.84. That was the first service request created as a result of information received from Jessica Urbano Ramirez.1344 Phase 1 Report Volume II paragraph 12.84. CRO Sharon Darby contacted CU8 at 01.46 and passed on a message about 11 people in a bedroom of a flat on floor 23.1345 Phase 1 Report Volume II paragraph 12.88. The service request was then marked as completed at 01.47.1346 LFB Short Incident Log {MET00013830/20}.
¶97.34 The call continued. A further service request referring to 11 persons and a baby in Flat 201 was created at 01.58 (once CRO Russell had become aware of the flat number and the presence of a baby) and messages were passed to CU8 about Flat 201.1347 Phase 1 Report Volume II paragraph 13.104. The service request relating to 11 persons and a baby in Flat 201 was marked as completed at 02.00.1348 LFB Short Incident Log {MET00013830/21}. Also at 02.00, CRO Adams rang CU8 to pass on a number of messages to WM Meyrick. One of those messages related to Flat 201 on floor 23 containing 11 adults and one child.1349 Phase 1 Report Volume II paragraphs 14.230-14.232; LFB Short Incident Log {MET00013830/19-21}.
166¶97.35 While Jessica Urbano Ramirez's call to CRO Russell was going on, there was an unrelated attempt to rescue her. Her sister, Melanie, thought that Jessica was still in Flat 176. At 01.26 she told FF David Badillo that her sister was in Flat 176 on floor 20 and gave him the keys. FF Badillo first tried to reach the flat alone, then recruited CM Christopher Secrett and FF Christopher Dorgu to go with him. They set out by 01.35. Having reached Flat 176 and found it empty, they returned to the ground floor. Their end of wear time was 01.57. No information about the emergency call from Jessica Urbano Ramirez reached the crew during their deployment.1350 Phase 1 Report Volume II paragraphs 10.79 (b), 10.101 (a), 11.10 and 13.17.
¶97.36 The messages about Flat 201 sent by the control room to the incident ground at 01.46 and 02.00 were passed on to the bridgehead, which was located on floor 2 until 02.17.1351 Phase 1 Report Volume IV paragraphs 28.11, 28.84 (b) and 28.86. Shortly after 02.17, CM Charles Batterbee recorded in his notebook the information written on a forward information board that had been used while the bridgehead was located on floor 2.1352 Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c). Flat 205 appears in that entry, but not Flat 201. A circled note written on the wall on floor 2 refers to Flats 201 and 205 and the names Alassad, Bell and Wright.1353 Phase 1 Report Volume II Figure 13.2 and paragraph 13.53. That is likely to have related to the unsuccessful deployment of firefighters John Wright, Zade Alassad and Scott Bell to floor 23 before 02.10. There were no further deployments to Flat 201 after that.
¶97.37 From about 02.33 SM Jason Oliff recorded information coming into the LFB control room on two whiteboards. In a photograph taken at the end of the incident the first whiteboard can be seen to include the notation "Flat 201 23rd flr – 2 yr old 11 people – now unconscious".1354 Phase 1 Report Volume III paragraphs 15.139-15.140 and Figure 15.8. That probably reflected the call from Jessica Urbano Ramirez.
¶97.38 Between about 02.00 and 03.00, a white laminate sheet was being used by firefighters in command unit CU7 at the incident ground to record information about people needing to be rescued. The laminate sheet recorded "Flat 201 Floor 23 1 person lost call".1355 Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3; Phase 1 Report Volume IV paragraph 28.85 (d). That message must have related to Jessica Urbano Ramirez's call, during which she had stopped responding towards the end. Firefighters at the incident ground were therefore informed that contact with her had been lost.1356 As there had been no further update passed on from NWFC to the LFB control room in relation to Debbie Lamprell's call (see below), this must have related to Jessica Urbano Ramirez's call.
Debbie Lamprell's long emergency call
¶97.39 At 01.41, a BT operator connected to North West Fire Control said that a caller for the LFB had hung up after waiting for about five minutes.1357 999 call transcript {MET00014977}. That caller was Debbie Lamprell. At 01.41 CRO Aisha Jabin's call back to Debbie Lamprell was connected. The call lasted for over 40 minutes, until 02.21. The group in Flat 201 had by then moved from the hallway to the bedroom. During the call, Debbie Lamprell confirmed her location as Flat 161 on floor 23.1358 Phase 1 Report Volume II paragraph 12.86. Flat 161 was her home address and was not on floor 23.
167¶97.40 At 01.46, Team Leader Paula Craig at North West Fire Control contacted the LFB control room and spoke to AOM Debbie Real. Based on inaccurate information from Debbie Lamprell's continuing emergency call she reported a call from "Flat 161 on Floor 23" with ten people trapped in the bedroom. AOM Real did not record the information contemporaneously in the incident log, but she appears to have passed it on to OM Alexandra Norman. OM Norman passed the information to the incident ground at 01.47 and at 02.01 recorded having done so in the incident log.1359 Phase 1 Report Volume II paragraph 12.85.
¶97.41 However, at around 01.52 Debbie Lamprell explained to CRO Jabin that she was in fact in Flat 201 on floor 23. As a result, CRO Jabin made further entries in the incident log, first to record that she was unsure of the flat number and then at 01.53 to record "10 PEOPLE IN FLAT 201 23rd FLOOR".1360 Phase 1 Report Volume II paragraph 12.86.
¶97.42 The correct location of Flat 201 was not communicated to the LFB control room, nor was it recorded in the incident log or in radio messages, even after CRO Jabin had become quite sure that it was on floor 23. The forward information board at the bridgehead included an entry for Flat 161 on floor 19, which probably reflected the message passed by North West Fire Control to the LFB following Debbie Lamprell's call.1361 Phase 1 Report Volume II paragraphs 12.86 and 14.73.
¶97.43 As a result of that message, at about 02.05 FFs Terence Roots and Adam Johnson were deployed to Flat 161 on floor 19, which was empty. Having swept Flat 161, FFs Roots and Johnson helped Nicholas and Pily Burton from Flat 165 to leave the building.1362 Phase 1 Report Volume II paragraphs 12.85-12.86 and 14.116.
Other emergency calls and information recorded at the incident ground
¶97.44 At 01.32 CRO Christine Howson answered an emergency call from Biruk Haftom, who was in Flat 201 at the time. He said, "My actual door number is 155 but I'm at someone else's house". Biruk Haftom reported that eight children and a lot of adults were in a flat on the top floor and that the window was already "burning up". He said they could not get out. He also reported a lot of smoke in the flat and in the building. CRO Howson told him and an adult who also spoke to her to try to stop smoke coming into the flat.1363 Phase 1 Report Volume II paragraphs 10.289 (d) and 11.28.
¶97.45 No service request appears to have been created in response to Biruk Haftom's call, but OM Norman rang CU8 at 01.35 and reported that there were eight children and a number of adults on the top floor and that smoke was entering their flat.1364 LFB Short Incident Log {MET00013830}; Phase 1 Report Volume II paragraphs 11.148-11.149. At 01.36, CRO Darby contacted appliance G261 and passed on that information.1365 Phase 1 Report Volume II paragraph 11.155.
¶97.46 FF Mandeep Singh arrived at the tower at 01.35 and was instructed to pass information about people needing to be rescued from the command unit to the bridgehead. He recalled having been handed telephones and speaking to residents inside the tower. During one such call, FF Singh spoke to a woman who gave her location as "the 23rd floor, doors 205 and 201". She said that she had brought all the occupants of floor 23 into her flat. FF Singh advised her to stay put.1366 Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17; A page from his notebook contains the following entry "23rd FLOOR ALL OCCUPANTS 205/201 [illegible] WM BRIAN O'KEITH WM (Illegible)".1367 Singh Exhibit MS/1 - pages from notebook {MET00013089/2}. In his witness statement FF Singh said that he thought the woman he had spoken to was the person who can be heard in a video recording saying that she will let people in. That was probably Rania Ibrahim, who was in fact in Flat 203, not Flat 201 or Flat 205.1368 Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17.
168¶97.47 WM Glynn Williams started to record information on the wall of the lobby on the ground floor at 02.15. He said the information had come from CU7. A photograph of the wall taken much later on in the incident includes the notation "201 23 11".1369 Phase 1 Report Volume II paragraphs 14.103-14.104 and Figure 14.5.
¶97.48 The bridgehead was moved from floor 2 to floor 3 at about 02.17, where it remained until 03.10.1370 Phase 1 Report Volume IV paragraphs 28.86-28.87. Messages were recorded on the wall of that floor. There is no reference to Flat 201 on the wall during that time.1371 Phase 1 Report Volume III Figure 15.7. Accordingly, it is likely that no further messages about Flat 201 were passed from CU7 to the bridgehead after 02.17.
¶97.49 After 03.00, the laminated sheet in CU7 was replaced by a whiteboard with a grid. A photograph of the whiteboard taken much later in the morning shows Flat 201 annotated with "11 1" and a red mark, which is difficult to read. The "11" is in green indicating 11 people and the "1" is in black indicating a child.1372 Phase 1 Report Volume III Figure 16.5; Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. The red mark may signify a "P" for priority.
People who died in or near Flat 201 Raymond (Moses) Bernard
¶Date of birth: 22 May 1954 (63 years old). Place of birth: Penal, Republic of Trinidad and Tobago. Gender: Male. Occupation: Retired electrical engineer. Usual address: Flat 201, floor 23, Grenfell Tower, London. Place of death: Flat 201, floor 23, Grenfell Tower, London. Time of death: About 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶97.50 Born in Trinidad on 22 May 1954, Raymond (Moses) Bernard was 63 years old at the time of the fire. He came to the UK in 1969 to join his parents and completed his schooling here. At the age of 16, he began an electrical engineering apprenticeship working, once qualified, at the House of Lords and Buckingham Palace. A father of four, Moses Bernard had lived in Flat 201 for over 30 years. He lived there with his dog, Marley.1373 Tenancy Agreement {TMOH00001235}; Phase 1 Report Volume IV paragraphs 32.55 -32.58.
169Vulnerability
¶97.51 Moses Bernard had been diagnosed with arthritis ten years before his death in the fire. As a result, his mobility had deteriorated and he walked with the assistance of a cane. He had difficulty climbing stairs.1374 Bernard {IWS00002337/3} page 3, paragraphs 21-23.
¶97.52 Moses Bernard's sister, Sheramin Bernard, wrote to RBKC several years before the fire informing them of her brother's medical and mobility problems in an attempt to have him re-housed on medical grounds. Sheramin Bernard received no reply. No assessment or review was carried out in light of the information provided.1375 Bernard {IWS00002337/3-4} pages 3-4, paragraphs 21-24.
¶97.53 Rydon carried out surveys of residents during the refurbishment and compiled a list of their vulnerabilities in November 2014. They carried out a survey on Moses Bernard's home on 14 October 2014 and recorded that he had no problems with his health and no pets.1376 Rydon Residents Survey {RYD00024466/5}.
¶97.54 Moses Bernard was not identified as a vulnerable resident in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system.1377 Phase 1 Report Volume III paragraphs 20.65-20.66; David Noble Spreadsheet {TMO00862588}.
Events of 14 June 2017
¶97.55 Moses Bernard returned to Grenfell Tower in the early evening of 13 June 2017.1378 O'Riordan {MET00013136/3} page 3. It is uncertain when he first became aware of the fire but by about 01.30 he had offered refuge in his home to ten people.1379 Phase 1 Report Volume II paragraphs 10.257, 10.258, 10.260, 10.289 and 14.125.
¶97.56 Moses Bernard did not make any calls to the emergency services himself, but during the course of Biruk Haftom's call to the LFB control room at 01.32 he took over and spoke briefly to CRO Howson, when towards the end of the call she asked to speak to an adult. Moses Bernard told her that the fire was approaching and that smoke was coming through the window.1380 Phase 1 Report Volume II paragraph 11.28; Presentation relating to Raymond (Moses) Bernard {Day300/77:17}-{Day300/78:14}.
¶97.57 Jessica Urbano Ramirez was sheltering in the bedroom of Flat 201 during her extended call with CRO Russell. About 17 minutes into the call she referred to a man who may have been Moses Bernard. She said he could not talk to CRO Russell because he was struggling to breathe.1381 999 call transcript {LFB00055504/32-33}.
Recovery and identification
¶97.58 The remains of Moses Bernard were recovered from the bedroom of Flat 2011382 Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14.. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.1383 Interim certificate of the fact of death for Raymond Bernard {MET00065646}.
170Cause and time of death
¶97.59 The post-mortem report on Moses Bernard recorded a cause of death as "consistent with the effects of fire."1384 Bernard post-mortem report {COR00000150/5}. In the light of Professor Purser's evidence, we find that a more accurate description is inhalation of asphyxiant gases.
¶97.60 We are satisfied that Moses Bernard died at about 02.45 before suffering the direct effects of fire.1385 Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20.
Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris
Amal Ahmedin
¶Date of birth: 1 January 1982 (35 years old). Place of birth: Sudan. Gender: Female. Occupation: Retail assistant. Usual address: Flat 166, floor 18, Grenfell Tower, London. Place of death: Floor 23 lobby, Grenfell Tower, London. Time of death: Between about 02.20 and 02.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Amaya Tuccu Ahmedin
¶Date of birth: 25 February 2014 (3 years old). Place of birth: London, UK. Gender: Female. Occupation: N/A. Usual address: Flat 166, floor 18, Grenfell Tower, London. Place of death: Floor 23 lobby, Grenfell Tower, London. Time of death: Between about 02.20 and 02.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Amna Mahmud Idris
¶Date of birth: 1 January 1990 (27 years old). Place of birth: Eritrea Gender: Female. Occupation: Student.
171¶Usual address: Grafton Road, London W3. Place of death: Flat 201, floor 23 Grenfell Tower, London. Time of death: About 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶97.61 Amal Ahmedin was born in Sudan on 1 January 1982 and was 35 years old in 2017. She lived in Flat 166 on floor 19 of Grenfell Tower with her daughter, Amaya Tuccu Ahmedin, who had been born in London on 25 February 2014 and was 3 years old when she died.1386 Phase 1 Report Volume IV paragraph 32.154. Mohamednur Tuccu, the husband of Amal Ahmedin and the father of Amaya Tuccu Ahmedin, was also in Grenfell Tower on the night of the fire, probably visiting his family. We have dealt with the circumstances of his death in Chapter 86.
¶97.62 On the evening of 13 June 2017, Amna Idris, Amal Ahmedin's cousin, was also visiting the family. Amna Idris had been born in Eritrea on 1 January 1990 and was 27 years old. She had joined her husband Ibrahim in London in March 2016.1387 Phase 1 Report Volume IV paragraphs 32.163-32.165.
Vulnerability
¶97.63 Amal Ahmedin had no known vulnerabilities. She and Amaya Tuccu Ahmedin both appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system.1388 Noble {TMO00000884/1} page 1, paragraph 3. Amaya Tuccu Ahmedin's age (3 years) was recorded in the spreadsheet.1389 David Noble's list {TMO00862588}.
Events of 14 June 2017
¶97.64 Amal Ahmedin, Amna Idris and Amaya Tuccu Ahmedin all entered the tower on 13 June 2017. Mohamednur Tuccu entered the tower at 00.36 on 14 June 2017.1390 O'Riordan {MET00013136/2-4} pages 2-4.
¶97.65 Meron Mekonnen was a neighbour of Amal Ahmedin and Amaya Tuccu Ahmedin. She lived at Flat 163 on floor 19 and was alerted to the fire at 01.25 by telephone. When she left her flat, she saw Amal Ahmedin and Amna Idris in the lobby of floor 19. She did not see Mohamednur Tuccu. The door to Flat 166 (the home of Amal Ahmedin and Amaya Tuccu Ahmedin) was wide open. It had a door closer but it was not working. Amal Ahmedin and Meron Mekonnen told each other about the fire before Amal Ahmedin ran back into Flat 166.
¶97.66 That was the last time Meron Mekonnen saw Amal Ahmedin. Amna Idris followed Meron Mekonnen and her daughters into the stairwell, probably before 01.30. It is likely that Flat 166 was affected by the fire at an early stage and that Amal Ahmedin and Amaya Tuccu Ahmedin left soon after.1391 Phase 1 Report Volume II paragraphs 10.223, 10.255-10.257 and 10.289(e); Mekonnen {Day55/23:25}-{Day55/24:6}; BRE Investigation Report {MET00039807/77}.
172¶97.67 There is no evidence that Mohamednur Tuccu was in Flat 166 when Meron Mekonnen saw Amal Ahmedin or that he was among those who made their way up the tower. He was, however, in the north lift when Rhea Rojo entered it on floor 12.1392 Phase 1 Report Volume II paragraphs 10.219 and 10.224-10.225.
¶97.68 Amna Idris initially went down the stairs with a group of people including Meron Mekonnen and her children. At around floor 15 or floor 16, she heard a man shouting at them to go back and the group (including Amna Idris) began to run back upstairs. When she reached floor 19, Meron Mekonnen stopped and decided to go back downstairs again. She could not recall what Amna Idris had done at that time, but she must have gone upstairs to floor 23, as she was later seen in Flat 201 by Fadumo Ahmed.1393 Phase 1 Report Volume II paragraph 10.258; Mekonnen {IWS00000912/3-4} pages 3-4, paragraphs 17-20; Phase 1 Report Volume III Annex A.
¶97.69 Fadumo Ahmed, who lived in Flat 164 on floor 19, was made aware of the fire at around 01.20. When she left her flat, the lobby was full of thick, dark grey, steamy smoke which was hard to see through. She went up to floor 23 where she found that the smoke in the lobby was worse than it had been on floor 19. She recalled that Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris had been part of the group sheltering in Flat 201 by 01.30.1394 Phase 1 Report Volume II paragraphs 10.259-10.260 and 10.289; Phase 1 Report Volume III Annex A; External Fire Spread Report {MET00012593/12}.
¶97.70 In her call to CRO Russell that had started at 01.29, Jessica Urbano Ramirez said that the group in the bedroom of Flat 201 included a two-year-old child, whom she also referred to as a baby. Debbie Lamprell also referred to a baby in her call to CRO Jabin that had started at 01.41. It is likely that they were both referring to Amaya Tuccu Ahmedin.1395 Phase 1 Report Volume II paragraphs 12.66-12.67, 12.86, 14.127 and 14.132; 999 call transcript {LFB00055504/36-37}.
¶97.71 Between 01.50 and 02.20, Fadumo Ahmed left Flat 201. The remains of Amal Ahmedin and Amaya Tuccu Ahmedin were later found in the lobby of floor 23. It is not possible to determine at exactly what time Fadumo Ahmed left Flat 201 or whether Amal Ahmedin and Amaya Tuccu Ahmedin followed her out at the same time or left Flat 201 later.1396 Phase 1 Report Volume II paragraphs 14.128 and 14.132.
¶97.72 At around 02.00, Jessica Urbano Ramirez was still talking to CRO Russell, and was heard to ask someone in the room not to leave. CRO Russell asked if someone was leaving, and Jessica Urbano Ramirez replied to say she had been mistaken. It is possible though, that she had been referring to Amal Ahmedin and Amaya Tuccu Ahmedin. At about 02.06, Jessica Urbano Ramirez said that the fire was in the flat and later confirmed that flames were coming through the bedroom window. CRO Russell tried to persuade her to move to another room. She told CRO Russell that people had tried to leave but had been unable to do so because of the smoke.1397 Phase 1 Report Volume II paragraphs 14.132-14.134.
¶97.73 Meanwhile, Debbie Lamprell had told CRO Jabin at 02.01 that the windows were cracking and at 02.06 that the flat was on fire. CRO Jabin spoke to her team leader and told Debbie Lamprell to leave. Debbie Lamprell said she was unable to leave because people on the other side of the room were trying to get out. She confirmed that she was still in the bedroom.1398 Phase 1 Report Volume II paragraphs 12.86, 14.127 and 14.138-14.140. We do not know whether Debbie Lamprell was referring to Amal Ahmedin.
¶97.74 At some point Amal Ahmedin left Flat 201 with Amaya Tuccu Ahmedin. She was unable to cross the lobby on floor 23 and collapsed there. Amna Idris remained in Flat 201.
173Recovery and identification
¶97.75 The remains of Amal Ahmedin and Amaya Tuccu Ahmedin were recovered from the communal lobby on floor 23.1399 Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 16. The remains of Amna Idris were recovered from the bedroom of Flat 201.1400 Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14. The coroner was satisfied about the identification of the remains recovered and therefore issued interim certificates of the fact of death in respect of Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris.1401 Interim certificates of the fact of death for Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris {MET00065590}; {MET00065639} and {MET00065591}.
Cause and time of death
¶97.76 Conditions in Flat 201 were deteriorating quite seriously at and after the time that Fadumo Ahmed left. If Amal Ahmedin and Amaya Tuccu Ahmedin left Flat 201 at any time after about 02.00, they would already have accumulated a significant proportion of the amount of asphyxiating gases needed to incapacitate them. We think it likely that they left Flat 201 between about 02.00 and 02.10, when the fire reached the bedroom window and conditions further deteriorated. By that time even the effort involved in getting up and walking from the flat into the lobby could have been sufficient to result in immediate collapse. Their remains were recovered from the lobby just outside Flat 201.1402 Purser, Phase 2 Report, Section 6 {DAPR0000006/10} paragraphs 21 and 24; {DAPR0000006/11} paragraphs 26-28.
¶97.77 The post-mortems on Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris recorded the cause of death in each case as "consistent with the effects of fire" but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases". Toxicological testing was only possible for Amna Idris. That showed a level of blood carboxyhaemoglobin in her blood of 68%.1403 Amal Ahmedin post-mortem report {COR00000111/5-7}; Amal Ahmedin post-mortem report {COR00000111/5-7}; Amna Idris post-mortem report {COR00000155/3-8}.
¶97.78 We are satisfied that Amal Ahmedin and Amaya Tuccu Ahmedin died between about 02.20 and 02.30 and that Amna Idris died at about 02.45.1404 Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser {Day296/28:15}-{Day296/29:8}.
Berkti Haftom and Biruk Haftom
Berkti Haftom
¶Date of birth: 2 November 1987 (29 years old). Place of birth: Asmara, Eritrea. Gender: Female. Occupation: Cleaner / Catering. Usual address: Flat 155, floor 18, Grenfell Tower, London. Place of death: Flat 201, floor 23, Grenfell Tower, London. Time of death: About 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
174Biruk Haftom
¶Date of birth: 27 April 2005 (12 years old). Place of birth: London, UK. Gender: Male. Occupation: Student. Usual address: Flat 155, floor 18, Grenfell Tower, London. Place of death: Flat 201, floor 23 Grenfell Tower, London. Time of death: About 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶97.79 Berkti Haftom was born on 2 November 1987 in Eritrea and was 29 years old. Her son Biruk was born on 27 April in London and was 12 years old. They had lived in Flat 155 on floor 18 of Grenfell Tower since 2007. At the time of the fire, they were living in Flat 155 with Berkti's partner Michele Chiapetto and a lodger, Yehualashet Enyew. Berkti Haftom was pregnant at the time of the fire.1405 Phase 1 Report Volume IV paragraphs 32.197-32.198 and 32.203; Tenancy Agreement {TMOH00026234}.
Vulnerability
¶Both Berkti and her son appear on the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system.1406 Noble {Day119/77:17}-{Day119/82:5}. Biruk Haftom's age (12 years) was recorded.1407 Noble spreadsheet {TMO00866002}. Neither had any known vulnerabilities.
Events of 14 June 2017
¶97.80 Berkti Haftom and Biruk Haftom both returned to Grenfell Tower during the evening of 13 June 2017.1408 O'Riordan {MET00013136/3} page 3.
¶97.81 Yehualashet Enyew was awoken at about 01.15 on 14 June 2017 by the smell of smoke. He alerted Berkti Haftom to the fire at about 01.20. As he prepared to leave, he heard Berkti Haftom calling him from the hallway and then heard the door slam. When he left Flat 155, probably at about 01.30 or soon after, Berkti and Biruk Haftom were not in the lobby. At that point he found the stairwell filled with thick, choking smoke.1409 Phase 1 Report Volume II paragraphs 10.253 and 11.58-11.60.
¶97.82 At some point before 01.27, Berkti and Biruk Haftom met Jessica Urbano Ramirez. She used Berkti Haftom's phone to make an emergency call at 01.27,1410 999 call transcript {MET00015554}. but the call was disconnected before the operator could put it through to the LFB.1411 999 call transcript {LFB00000481}. When Jessica called her mother, Adriana Ramirez, shortly afterwards, she said that she was on floor 18. Adriana Ramirez could hear voices in the background, which were probably those of Berkti and Biruk Haftom.1412 Phase 1 Report Volume II paragraph 10.289 (f); Ramirez {IWS00001116/4-5} pages 4-5, paragraphs 21 and 22.
175¶97.83 Shah and Sayeda Ahmed, who lived in Flat 156 on floor 18, were woken by the smoke alarms in their flat. They left their flat at about 01.27 and knocked on their neighbours' doors. There was no answer from Flat 155, so Berkti and Biruk Haftom had probably already left Flat 155 to go upstairs.1413 Phase 1 Report Volume II paragraphs 10.249-10.250, 10.254 and 10.289 (b).
¶97.84 Berkti Haftom, Biruk Haftom and Jessica Urbano Ramirez probably all reached floor 23 before 01.30.1414 Phase 1 Report Volume II paragraph 10.289. CRO Russell's call to Jessica Urbano Ramirez at 01.29 was made on Berkti Haftom's telephone.1415 Phase 1 Report Volume II paragraph 10.289 (f). By that time, Jessica Urbano Ramirez was in Flat 201. When Fadumo Ahmed reached Flat 201 she joined a group in the hallway that included Berkti and Biruk Haftom.1416 Phase 1 Report Volume II paragraphs 10.259-10.260.
¶97.85 Biruk Haftom spoke to CRO Howson at 01.32 from Flat 201. He told her that he lived in Flat 155 but was calling from someone else's flat. He told her that there were eight children and a lot of adults in a flat on the top floor and that the window was already burning up. He said that there was a lot of smoke in the flat and in the building and that they could not get out. CRO Howson told him and the adult to whom she also spoke briefly to try to stop smoke coming into the flat.1417 Phase 1 Report Volume II paragraphs 10.289 (d) and 11.28. There is no evidence that Berkti Haftom contacted the emergency services.
¶97.86 Michele Chiapetto (Berkti Haftom's partner) and the family of Berkti and Biruk Haftom made several unsuccessful attempts to contact them by phone during the night. Berkti Haftom's phone stopped ringing at about 07.00.1418 Chiapetto {IWS00000679/2-4} pages 2-4, paragraphs 10-17; Semre {IWS00000954/4} page 4, paragraphs 24-25.
Recovery and identification
¶97.87 The remains of Berkti and Biruk Haftom were recovered from the bedroom of Flat 201.1419 Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14.
¶97.88 The coroner was satisfied about their identification and therefore issued interim certificates of the fact of death for Berkti and Biruk Haftom.1420 Interim certificates of the fact of death for Berkti and Biruk Haftom {MET00065608}; {MET00065623}.
Cause and time of death
¶97.89 We are satisfied that the occupants of Flat 201, including Berkti and Biruk Haftom, had died by about 02.45 as the result of the inhalation of asphyxiant gases before they suffered from the direct effect of the flames.1421 Purser, Phase 2 Report, Section 6 {DAPR0000006/13} paragraph 38; Purser {Day296/28:15}-{Day296/29:8}.
¶97.90 The post-mortem recorded causes of death for both Berkti and Biruk Haftom as "consistent with the effects of a fire",1422 Berkti Haftom post-mortem report {COR00000216/5}; Biruk Haftom post-mortem report {COR00000240/3}. but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".
176Hamid Kani
¶Date of birth: 24 January 1956 (61 years). Place of birth: Shahr-e-Ray, Iran. Gender: Male. Occupation: Retired. Usual address: Flat 154, floor 18, Grenfell Tower, London. Place of death: Flat 201, floor 23, Grenfell Tower, London. Time of death: About 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of the household
¶97.91 Hamid Kani had been the sole tenant of Flat 154 on floor 18 since 10 September 1990.1423 Tenancy agreement {TMOH00026143}. He lived alone. Having been born in Iran on 24 January 1956, he had come to London in the 1970s to study. In the 1980s he had been an actor and comedian but later changed careers, working in restaurants as a chef.1424 Phase 1 Report Volume IV paragraphs 32.204-23.209.
Vulnerability
¶97.92 Hamid Kani suffered from backache and hip pain, making it difficult for him to climb stairs.1425 GP Letter dated 23 July 1990 {TMOH00026128}. He included a reference to his disability in the tenancy information form he completed on 23 April 2015.1426 KCTMO Tenancy Information form {TMOH00026145/10}. He was not identified as vulnerable in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system.1427 Phase 1 Report Volume III paragraphs 20.65–20.66; David Noble Spreadsheet {TMO00866002}.
Events of 14 June 2017
¶97.93 Hamid Kani returned to Grenfell Tower for the last time in the early evening of 13 June 2017.1428 O'Riordan {MET00013136/3} page 3.
¶97.94 When Shah and Sayeda Ahmed left their flat and knocked on their neighbours' doors at about 01.27, Hamid Kani opened his door in response. He had therefore been alerted to the fire by 01.27.1429 This timing is derived from the fact that at 01.27 the MPS operator asked the BT operator for a playback of Shah Ahmed's 999 call, in which Shah Ahmed had not spoken to the BT operator. Phase 1 Report Volume II paragraphs 10.249-10.250 and 10.289 (b).
¶97.95 Hamid Kani went up to floor 23 to take shelter and was able to enter Flat 201. He probably got there by about 01.30 and did not leave.1430 Phase 1 Report Volume II paragraphs 14.125 and 10.287-10.289.
¶97.96 There is no evidence that he spoke to the emergency services or to relatives or friends during the fire.
177Recovery and identification
¶97.97 The remains of Hamid Kani were recovered from between the bedroom area and the entrance to the bathroom from the hall of Flat 201.1431 Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.1432 Interim certificate of the fact of death for Hamid Kani {MET00065623}.
Cause and time of death
¶97.98 Hamid Kani was in a protected location in the hallway and bathroom area of the flat and was therefore more shielded from exposure to the heat. We are satisfied that he died at about 02.45, before suffering the direct effects of fire.1433 Purser, Phase 2 Report, Section 6 {DAPR0000006/13} paragraph 38; Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20.
¶97.99 The post-mortem report on Hamid Kani recorded the cause of death as "consistent with the effects of fire"1434 Kani post-mortem report {COR00000566/7}. but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".
Debbie Lamprell
¶Date of birth: 3 August 1971 (45 years). Place of birth: Walthamstow, London. Gender: Female. Occupation: Personal Assistant / Safety Officer. Usual address: Flat 161, floor 19 Grenfell Tower, London. Place of death: Flat 201, floor 23 Grenfell Tower, London. Time of death: Between 02.20 and 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶97.100 Debbie Lamprell grew up as an only child in Highams Park. She worked as a safety officer at the Holland Park Opera. She had lived in Flat 161 on floor 19 of Grenfell Tower since 2005.1435 External Fire Spread Report {MET00012593/12}; Phase 1 Report Volume IV paragraphs 32.186-32.189; Presentation relating to Debbie Lamprell {Day300/1:21}-{Day300/2:20}.
Vulnerability
¶97.101 Debbie Lamprell had no known vulnerabilities.
178Events of 14 June 2017
¶97.102 Debbie Lamprell returned from work at 22.57 on 13 June 2017. Her friend Gary Maunders was visiting her that night. He also died in the fire.1436 O'Riordan {MET00013136/4} page 4; Presentation relating to Debbie Lamprell {Day300/2:21-25}; Phase 1 Report Volume II paragraph 14.136; Phase 1 Report Volume III Annex A.
¶97.103 Fadumo Ahmed was Debbie Lamprell's neighbour and lived in Flat 164 on floor 19. She first became aware of the fire at around 01.20. When she left her flat, the lobby was full of thick, dark grey, steamy smoke that was hard to see through. Fadumo Ahmed saw Debbie Lamprell, who said people were going upstairs. Fadumo Ahmed said that Debbie Lamprell was not panicking, but behaved as if she had received instructions to go upstairs. Fadumo Ahmed and Debbie Lamprell went upstairs together. There was only a little bit of smoke in the stairwell between floors 19 and 23. Fadumo Ahmed said that she saw nobody other than Debbie Lamprell on the stairs.1437 Phase 1 Report Volume II paragraphs 10.259-10.260. However, Debbie Lamprell later told CRO Jabin that she and her friend had gone up together, which suggests that Gary Maunders may have also climbed the stairs with Fadumo Ahmed and Debbie Lamprell.1438 999 call transcript {LFB00055500/29}.
¶97.104 Fadumo Ahmed and Debbie Lamprell joined a group of people sheltering in the hallway of Flat 201 on floor 23. Debbie Lamprell probably reached Flat 201 at about 01.30 or soon after.1439 Phase 1 Report Volume II paragraphs 10.259-10.260 and 10.289.
¶97.105 Gary Maunders moved to Flat 203 at around 01.39.1440 Phase 1 Report Volume II paragraphs 11.30-11.31. At about that time, Debbie Lamprell made an emergency call which lasted for under a minute. She was heard to shout for Gary, which indicates that she had lost contact with Gary Maunders by that time.1441 999 call transcript {COR00000269}.
¶97.106 At 01.41 a BT operator spoke to North West Fire Control and said that a caller asking to speak to the LFB had hung up after waiting for around five minutes.1442 Phase 1 Report Volume II paragraphs 12.66-12.67; 999 call transcript {MET00014977}. The number belonged to Debbie Lamprell. When CRO Aisha Jabin called the number back, Debbie Lamprell answered and they spoke for over 40 minutes. During that call there was a misunderstanding about Debbie Lamprell's location. She first gave her location as Flat 161 on floor 23, but later corrected that to Flat 201 on floor 23. Unfortunately, the correct location was not passed from North West Fire Control to the LFB control room. As a result, just before 02.10 FFs Roots and Johnson were sent to Flat 161 on floor 19 but there was no one there.1443 Phase 1 Report Volume II paragraphs 12.85-12.86 and 14.116.
¶97.107 At about 01.55, Debbie Lamprell told CRO Jabin that the smoke was making it difficult for everyone to breathe and that the fire was "burning through the windows".1444 Phase 1 Report Volume II paragraph 12.64.
¶97.108 At 02.01 Debbie Lamprell told CRO Jabin that the windows were cracking and at about 02.05 she said that she had lost her friend; he had disappeared and she did not know where he was. They had come up together, but he had gone.1445 Phase 1 Report Volume II paragraphs 14.127 and 14.138; 999 call transcript {LFB00055500/26-29}. She must have been referring to Gary Maunders, who by then had already moved to Flat 203.
179¶97.109 At 02.06 Debbie Lamprell told CRO Jabin that she could feel the heat and that the flat was on fire. CRO Jabin spoke to her team leader and then advised Debbie Lamprell to leave. She tried to leave the bedroom and could be heard telling someone to move out of the way of the door. Debbie Lamprell said that people on the other side of the room were trying to get out and that was why she could not get out. She confirmed that she was still on the floor in the bedroom. She stopped responding at about 02.20, just before the end of the call. That was the last known contact anybody had with Debbie Lamprell.1446 Phase 1 Report Volume II paragraphs 14.138-14.140; 999 call transcript {LFB00055500/42-43}.
Recovery and identification
¶97.110 The remains of Debbie Lamprell were recovered from the bedroom of Flat 201.1447 Archaeology Report Volume 2 {COR00001585/190}. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death for Debbie Lamprell.1448 Interim certificate of the fact of death for Debbie Lamprell {MET00065596}.
Cause and time of death
¶97.111 Toxicology analysis was not possible.1449 Coroner's report for Lamprell {COR00000254/7}. The post-mortem on Debbie Lamprell recorded the medical cause of death as "consistent with the effects of fire,"1450 Lamprell post-mortem report {COR00000263/6-7}. but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".
¶97.112 We find that Debbie Lamprell probably lost consciousness due to the effects of asphyxiant gases at about 02.20 when she stopped responding to CRO Jabin. We are satisfied that she died between 02.20 and 02.451451 Purser {Day297/12:14-25}. before suffering the direct effects of fire.1452 Purser, Phase 2 Report, Section 6 {DAPR0000006/13} paragraph 38; Purser {Day296/28:15}-{Day296/29:8}.
Jessica Urbano Ramirez
¶Date of birth: 4 July 2004 (12 years old).
¶Place of birth: London, UK.
¶Gender: Female.
¶Occupation: Student.
¶Usual address: Flat 176, floor 20, Grenfell Tower, London.
¶Place of death: Flat 201, floor 23, Grenfell Tower, London.
¶Time of death: Between 02.17 and 02.45 on 14 June 2017.
¶Cause of death: Inhalation of asphyxiant gases.
180Background and composition of household
¶97.113 Jessica Urbano Ramirez lived in Flat 176 on floor 20 with her family. She moved into Grenfell Tower in September 2013 with her mother, Adriana Ramirez, her father Ramiro Urbano and her sister Melanie.1453 Tenancy Agreement {IWS00002062/7}. At the time of the fire, she was looking forward to celebrating her 13th birthday with her friends.1454 Phase 1 Report Volume IV paragraph 32.132.
Vulnerability
¶97.114 Jessica Urbano Ramirez appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system as a child and was known to be under 18. She had no other known vulnerabilities.
Events of 14 June 2017
¶97.115 On 13 June 2017, Jessica Urbano Ramirez returned to Grenfell Tower at 18.20.1455 O'Riordan {MET00013136/3} page 3. Adriana Ramirez and Melanie Urbano Ramirez were at home at the time. Adriana Ramirez left at around 18.30 to go to work.1456 Ramirez {IWS00001116/4} page 4, paragraph 18; Ramirez {MET00007773/3} page 3. Melanie Urbano Ramirez stayed at the flat until about 22.00 when she also went out.1457 Ramirez {IWS00001116/4} page 4, paragraph 20; {MET00007773/3} page 3. Adriana Ramirez returned home at about midnight and checked on Jessica, who was asleep. She left the flat again at about 00.40 to take some medicine to the home of a friend who lived nearby.1458 Ramirez {IWS00001116/4} page 4, paragraph 19; {MET00007773/4} page 4. Jessica remained alone in the flat.
¶97.116 At some time before 01.27, Jessica Urbano Ramirez met Berkti and Biruk Haftom. At 01.27 she used Berkti Haftom's phone to make an emergency call1459 999 call transcript {MET00015554}. before calling her mother.1460 999 call transcript {COR00000774}. The call was disconnected before the BT operator could connect it to the LFB. The BT operator contacted the LFB control room at 01.29 and spoke to CRO Russell telling her that the caller was a child and had asked for the fire brigade. CRO Russell agreed to call the number back.1461 999 call transcript {LFB00000481}.
¶97.117 Jessica Urbano Ramirez then called her mother and told her that she was on the "landing" on floor 18.1462 Ramirez {IWS00001116/4-5} page 4-5, paragraph 21. They agreed that she should come down the stairs.1463 Ramirez {IWS00001116/4-5} page 4-5, paragraph 21; Phase 1 Report Volume II paragraph 10.289(f). However, instead of continuing down to the ground floor, Jessica went up to floor 23 with Berkti and Biruk Haftom and a group of other residents. She probably reached floor 23 by 01.30.1464 Phase 1 Report Volume II paragraph 10.289.
¶97.118 At 01.29, CRO Russell called Berkti Haftom; the call was answered by Jessica Urbano Ramirez.1465 Phase 1 Report Volume II paragraph 10.289(f). The call probably interrupted Jessica's call with her mother as she answered the call saying 'Mum' three times and CRO Russell's call overlapped in time with Jessica's call to Adriana Ramirez.
¶97.119 The call between CRO Russell and Jessica Urbano Ramirez lasted 55 minutes. During the first 10 minutes of the call (between 01.30 and 01.40), Jessica told CRO Russell that she was in the hallway of a flat on floor 23 with about 10 other people. She later identified it as Flat 201.1466 Phase 1 Report Volume II paragraphs 10.317 and 11.25. She said that smoke was coming "from the floor" and that people were having difficulty breathing. Jessica and the group of people in Flat 201 moved from the hallway to the bedroom.
181¶97.120 Adriana Ramirez said that she spoke to Jessica a second time about 10 minutes later.1467 Ramirez {IWS00001116/5} page 5, paragraph 22. The call records for Berkti Haftom's phone show that she called Jessica back and it is likely that they spoke while the call with CRO Russell was on hold for a short period of time.1468 999 call transcript {LFB00055504/19}.
¶97.121 While the call was in progress, FF David Badillo from North Kensington made an attempt to rescue Jessica, who was still believed to be in Flat 176. At 01.26, he met Melanie Urbano Ramirez, Jessica's sister, outside the tower. She gave him the keys to Flat 176 on floor 20 and told him that her sister was still there. At 01.27 FF Badillo went into the tower to rescue Jessica Urbano Ramirez.1469 Phase 1 Report Volume II paragraph 10.79 (b). He was not able to make it to floor 20 immediately. He tried to take the lift to floor 20 but it stopped on floor 15 and the lift filled with black smoke. He found his way to the lobby doors and went down the stairs and out of the tower to get BA equipment.1470 Phase 1 Report Volume II paragraph 10.101 (a). He returned to the tower with BA equipment and recruited CM Christopher Secrett and FF Christopher Dorgu to go to Flat 176 with him.1471 Phase 1 Report Volume II paragraph 11.10. They tallied out between 01.33 to 01.35.
¶97.122 When the crew reached floor 20 they found that the communal lobby and Flat 176 were smoke logged. They searched Flat 176 after finding the front door slightly ajar.1472 Phase 1 Report Volume II paragraphs 12.6, 12.30 and 13.16. They did not find anyone in Flat 176 and returned to the ground floor. Their end of wear time was 01.57.1473 Phase 1 Report Volume II paragraph 13.16. No information about the emergency call from Jessica Urbano Ramirez reached the crew during their deployment.1474 Phase 1 Report Volume II paragraph 13.17.
¶97.123 At 02.01, Jessica Urbano Ramirez was still talking to CRO Russell.1475 Phase 1 Report Volume II paragraph 14.133. She repeatedly said that she was having difficulty breathing.1476 Phase 1 Report Volume II paragraph 14.133.
¶97.124 At 02.06, Jessica Urbano Ramirez and Debbie Lamprell each reported separately that the flat was on fire.1477 Phase 1 Report Volume II paragraphs 14.134 and 14.138. Jessica said that people had tried to leave but could not do so because of the smoke.1478 Phase 1 Report Volume II paragraph 14.134. She stopped responding to CRO Russell at around 02.17 but could be heard breathing until 02.24.1479 999 call transcript {LFB00055504/76-82}.
Recovery and identification
¶97.125 The remains of Jessica Urbano Ramirez and others were recovered from the bedroom of Flat 201.1480 Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.1481 Interim certificate of the fact of death for Jessica Urbano Ramirez {MET00065625}.
182Cause and time of death
¶97.126 The post-mortem on Jessica Urbano Ramirez noted that it was not possible to be definite on the cause of death due to the condition of the remains, but that their appearance was consistent with the effects of fire.1482 Ramirez post-mortem report {COR00000770/3}. It was not possible to carry out toxicological analysis or DNA testing.
¶97.127 The post-mortem report recorded the medical cause of death as being consistent with the effects of a fire. However, in the light of Professor Purser's evidence we find that the cause of death is more accurately expressed as inhalation of asphyxiant gases.
¶97.128 Jessica probably lost consciousness due to the inhalation of asphyxiant gases at around 02.17 when she stopped responding to CRO Russell. She would have continued to inhale those gases while unconscious until she died.1483 Purser, Phase 2 Report, Section 6 {DAPR0000006/13-17} paragraphs 36–58.
¶97.129 Professor Purser estimated that the level of carboxyhaemoglobin in Jessica Urbano Ramirez's blood had exceeded the lethal threshold of 50% by about 02.23 and that she had died by 02.45.1484 Purser, Phase 2 Report, Section 6 {DAPR0000006/14} paragraph 48; Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser, Phase 2 Report, Section 6 {DAPR0000006/15} Figure 28; Purser {Day297/12:14-25}. While the time of death might be different for children, he observed that she had lost consciousness at about the same time as Debbie Lamprell and there may not have been much difference in the time of death.1485 Purser {Day297/13:4-18}.
¶97.130 In the light of Professor Purser's evidence we are satisfied that Jessica Urbano Ramirez died between 02.17 and 02.45 before suffering the direct effects of fire.
Flat 202
¶97.131 Flat 202 on floor 23 had two bedrooms and was situated in the south-east corner of the tower. It was the home of Gimja Tekie, who was not present during the night of the fire. Gloria Trevisan and Marco Gottardi had been living in Flat 202 since April 2017.1486 External Fire Spread Report {MET00012593/12}; Phase 1 Report Volume IV paragraph 32.50; Disaró {IWS00000543/3} page 3, paragraphs 8-9; External Fire Spread Report {MET00012593/12}; Tekie {IWS00000953/3} page 3, paragraph 16.
¶97.132 By 02.10, Flat 202 had become affected by the spread of the fire on the outside of the building.1487 Phase 1 Report Volume II paragraph 14.3. It spread across the east face of the kitchen and living room of Flat 202 from about 02.10. It moved across the south face of the living room between about 02.33 and 02.51 and had spread across the bedrooms by 02.55.1488 Purser, Phase 2 Report, Section 6 {DAPR0000006/18} paragraph 63.
Those who sheltered in Flat 202
¶97.133 On the night of the fire, Majorie and Ernie Vital took shelter with Gloria Trevisan and Marco Gottardi. They had moved upstairs from their own flat on floor 19.1489 Phase 1 Report Volume II paragraphs 10.287 and 10.289 (g).
183Conditions and events on 14 June 2017
¶97.134 By approximately 01.25 the fire had reached the top of floor 19, where Flat 162, Majorie Vital's home, was situated.1490 Phase 1 Report Volume II paragraph 10.118. There is no evidence that Majorie or Ernie Vital made contact with the emergency services, members of their family or friends on the night of the fire. At about 01.30, they went upstairs to floor 23.1491 Phase 1 Report Volume II paragraphs 14.125 and 10.287-10.289; External Fire Spread Report {MET00012593/12}. Fadumo Ahmed identified Ernie Vital as one of the people she had seen gathered inside or outside one of the flats on floor 23.1492 Ahmed post-mortem report {MWP00000034/3}; Ahmed {COR00000103/1} page 1; Foley {COR00000304/1} page 1.
¶97.135 Ernie and Majorie Vital had knocked at the door and sought shelter in Flat 202. When Gloria Trevisan and Marco Gottardi opened the door, they found the lobby filled with a thick, dense smoke.1493 Phase 1 Report Volume II paragraph 11.35.
¶97.136 Gloria Trevisan's parents were in Italy. Gloria called her mother, Emanuela Disaró, at 01.34 from Flat 202; the call lasted for just under 31 minutes. She told her mother that there were firefighters downstairs. She said they had been told to stay inside. It is not clear where that information came from. She said that they could not leave because of the smoke or go to the roof because the gate to the roof was locked. They made signs to attract attention.1494 Phase 1 Report Volume II paragraphs 10.287-10.289, 11.35, 14.125 and 14.141; Disaró {IWS00000543/6} page 6, paragraphs 20-21.
¶97.137 Rania Ibrahim lived in Flat 203, a neighbouring flat on floor 23. At 01.38, she started to live stream on Facebook. A little over one minute into the recording, she opened her front door and called out into the lobby "Hello" and "Come here". When Emanuela Disaró watched the video she thought that she could hear Marco Gottardi responding to Rania Ibrahim's shouts, saying "We are here, we are inside my apartment."1495 Phase 1 Report Volume II paragraphs 11.29-11.35; External Fire Spread Report {MET00012593/12}. They remained in Flat 202.
¶97.138 Gloria Trevisan made a video call to her parents at 02.13. She said the fire was large and had reached floor 23. Black smoke was entering the flat through the living room windows. Emanuela Disaró could hear her daughter coughing. Gloria Trevisan was having difficulty breathing. Emanuela Disaró could hear Marco Gottardi speaking to Ernie Vital in the background. She heard Marco Gottardi ask whether there was anyone in another apartment and then say that he would go out to ask. Then Emanuela Disaró heard Marco Gottardi say in English "I tried but there's too much smoke."1496 Phase 1 Report Volume II paragraphs 14.142-14.143.
¶97.139 At 02.45 Gloria Trevisan began her last call from Flat 202 to her parents. It lasted for almost 23 minutes, until 03.08. She told her mother that Majorie and Ernie Vital and Marco Gottardi were still with her. Marco was also speaking to his parents. Gloria said that smoke was coming from everywhere and that there was no way out. The flat was full of smoke. She could see the fire outside the window. They had shut the window because pieces of glass had been coming in. Gloria's eyes and throat were burning and hurting. She was having difficulty breathing. She said that the fire had come through the window. That was the last contact she had with either of her parents.1497 Phase 1 Report Volume III paragraphs 16.21 and 16.23.
184¶97.140 Marco Gottardi spoke to his father, Giannino Gottardi, at some point after 02.45. He told his father that they had not left the building because there was too much smoke and they had been told to stay put. He said he had filled the bath with water. The last call between Marco Gottardi and his father started at 03.15 and was brief.1498 Phase 1 Report Volume III paragraphs 16.25 and 17.30. That was the last known contact with anyone in Flat 202.
Information at the incident ground
¶97.141 Emanuela Disaró asked Gloria Trevisan during their last conversation whether they had made others aware that they were in the flat. Gloria Trevisan said that she had, and she asked the others in the flat the same question. Emanuela Disaró could not hear their responses. There is no record of any calls to the emergency services from any of those trapped in Flat 202.1499 Phase 1 Report Volume III paragraph 16.22. Calls to the emergency services were made by and on behalf of people trapped in Flats 201, 203, 204 and 205 on floor 23. Information about people trapped in all of these flats was recorded at the incident ground: Phase 1 Report Volume II Figure 12.3.
¶97.142 The LFB was aware of conditions on floor 23 in general. In response to information received from emergency calls about seven people unable to leave Flat 205 on floor 23 (among other flats on other floors), a message was sent by radio to command unit CU8 at 01.43. CU8 confirmed receipt of that message confirming "the 23rd floor" and "heavy smoke logging".1500 LFB Control Room Report {LFB00004790/43-46}.
¶97.143 Between 02.01 and 02.02, CROs Gotts and Howson received calls from members of the public saying that they could see people at the top of the tower waving and signalling for help. In one call people were said to be on top of the building. As a result, a service request was created at 02.05 saying "Reports of people on the roof of the building". CRO Darby passed that message to the incident ground at 02.05.1501 Phase 1 Report Volume II paragraphs 14.235-14.236. Further calls were received until 03.11 from members of the public reporting seeing people on the top floor.1502 LFB Control Room Report {LFB00004790/63-124}.
Gloria Trevisan and Marco Gottardi
Gloria Trevisan
¶Date of birth: 2 December 1990 (26 years old).
¶Place of birth: Camposampiero, Italy.
¶Gender: Female.
¶Occupation: Trainee Architect.
¶Usual address: Flat 202, floor 23, Grenfell Tower, London.
¶Place of death: Flat 202, floor 23, Grenfell Tower, London.
¶Time of death: Between 03.15 and 03.30 on 14 June 2017.
¶Cause of death: Inhalation of asphyxiant gases.
185Marco Gottardi
¶Date of birth: 26 June 1989 (27 years old). Place of birth: Motta di Livenza, Italy. Gender: Male. Occupation: Architect. Usual address: Flat 202, floor 23, Grenfell Tower, London. Place of death: Flat 202, floor 23, Grenfell Tower, London. Time of death: Between 03.15 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases; single vessel coronary artery atheroma.
Background and composition of household
¶97.144 Gloria Trevisan was 26 years old, having been born on 2 December 1990 in Italy. Marco Gottardi was 27 years old, having been born on 26 June 1989 also in Italy. They met at university and graduated with degrees in architecture in 2016. Wanting to improve their English and develop their professional skills, they came together to London in March 2017. Both found work with architectural practices in London. They moved into Flat 202 in April 2017.1503 Phase 1 Report Volume IV paragraphs 32.545-32.54.
Vulnerability
¶97.145 Gloria Trevisan and Marco Gottardi did not have known vulnerabilities.
Events of 14 June 2017
¶97.146 Gloria Trevisan and Marco Gottardi returned to Grenfell Tower at around 19.47 on 13 June 2017.1504 O'Riordan {MET00013136/3}. They remained in Flat 202 thereafter.
¶97.147 At around 01.30, Ernie and Majorie Vital knocked on their front door, alerting them to the fire and joining them in Flat 202.
¶97.148 There is no evidence that Gloria Trevisan or Marco Gottardi made contact with the emergency services on the night of the fire, however they did call their families, as described above.
Recovery and identification
¶97.149 The remains of Gloria Trevisan and Marco Gottardi were recovered from the hallway of Flat 202.1505 Purser, Phase 2 Report, Section 6 {DAPR0000006/19} paragraph 71. The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death.1506 Interim certificates of the fact of death for Gloria Trevisan and Marco Gottardi {MET00065586}; {MET00065617}.
186Cause and time of death
¶97.150 We are satisfied that Gloria Trevisan and Marco Gottardi both died between about 03.15 and 03.30 before suffering the direct effects of fire.1507 Purser, Phase 2 Report, Section 6 {DAPR0000006} Table 20; Purser {Day296/28:15}-{Day296/29;8}.
¶97.151 Gloria Trevisan was found to have a blood carboxyhaemoglobin saturation of 78%.1508 Trevisan post-mortem report {COR00000546/9}. The post-mortem recorded the cause of her death as "inhalation of products of combustion" but in the light of Professor Purser's evidence we find that a more accurate description of the primary cause of death is inhalation of asphyxiant gases.
¶97.152 The post-mortem report on Marco Gottardi recorded the cause of death as "inhalation of products of combustion" and "single vessel coronary artery atheroma".
¶97.153 Carboxyhaemoglobin was present in Marco Gottardi's blood, but it was not possible to measure the levels.1509 Gottardi post-mortem report {COR00000974/8}; Gottardi toxicology report {MET00007684/1}. The single vessel coronary atheroma put Marco Gottardi at risk of collapse and death at a lower carboxyhaemoglobin concentration than would otherwise have been the case.1510 Purser {Day297/33:4-20}.
¶97.154 Although we acknowledge the contribution of single vessel coronary atheroma, we consider that the primary cause of death was inhalation of asphyxiant gases.
Majorie and Ernie Vital
Majorie Vital
¶Date of birth: 14 November 1948 (68 years old). Place of birth: Soufrière, Dominica. Gender: Female. Occupation: Retired. Usual address: Flat 162, floor 19, Grenfell Tower, London. Place of death: Flat 202, floor 23, Grenfell Tower, London. Time of death: Between 03.15 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Ernie Vital
¶Date of birth: 11 January 1967 (50 years old). Place of birth: London, UK. Gender: Male. Occupation: Unemployed. Usual address: Amhurst Park, London N16.
187¶Place of death: Flat 202, floor 23, Grenfell Tower, London.
¶Time of death: Between 03.15 and 03.30 on 14 June 2017.
¶Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶97.155 Majorie Vital was a retired seamstress and had lived in Flat 162 on floor 19 of Grenfell Tower for nearly 40 years. It was there that she brought up her two sons. Ernie Vital was staying with her on the night of the fire.1511 Tenancy Information Questionnaire for Flat 162 {TMOH00025319/3}; Phase 1 Report Volume IV paragraphs 32.176-32.182.
Vulnerability
¶97.156 Majorie Vital's mental health vulnerability was recorded by RBKC in 1987 and by the TMO in a memorandum on 14 July 2004.1512 RBKC letter dated 24 August 1987 {TMOH00025230}; TMO Memorandum {TMO00865242}. Rydon sent an email to the TMO on 31 October 2014 saying that she had Parkinson's Disease and needed support.1513 Email from Rydon dated 31 October 2014 {TMOH00025320}. That information was also recorded in November 2014 during the survey of residents carried out by Rydon.1514 Rydon Residents Survey {RYD00024466/14}.
¶97.157 Majorie Vital had declared both a disability and mental health support needs in response to a TMO questionnaire on 17 March 2015.1515 Tenancy Information Questionnaire for Flat 162 {TMOH00025319/9}. She appeared in the TMO list of Grenfell Tower residents created by David Noble on 14 June 2017 from information held on the TMO's Capita Insight system which recorded that she was in the age group "65 plus" and had some mental health problems.1516 David Noble's list {TMO00862588}.
Events of 14 June 2017
¶97.158 Majorie Vital returned to Grenfell Tower at around 15.14 on 13 June 2017. Ernie Vital entered the tower at around 19.07 on 13 June 2017.1517 O'Riordan {MET00013136/2-3} pages 2-3.
¶97.159 Majorie and Ernie Vital had both moved from floor 19 up to floor 23 by around 01.30. They knocked on Flat 202 and sought shelter with the residents of that flat, Gloria Trevisan and Marco Gottardi. They remained in that flat thereafter.
¶97.160 There is no evidence that either Majorie or Ernie Vital contacted anybody outside the tower on the night of the fire.
Recovery and identification
¶97.161 The remains of Majorie and Ernie Vital were recovered from the bathroom of Flat 202.1518 Purser, Phase 2 Report, Section 6 {DAPR0000006/19} paragraph 71. The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death.1519 Interim certificate of the fact of death for Majorie and Ernie Vital {MET00065611}; {MET00065635};
188Cause and time of death
¶97.162 The post-mortem reports recorded the cause of death in the case of both Majorie Vital and Ernie Vital as "consistent with the effects of fire".1520 Majorie Vital post-mortem report {COR00000934/6}; Ernie Vital post-mortem Report {COR00000309/4}. In the light of more recent evidence we find that a more accurate description of the primary cause of death is inhalation of asphyxiant gases.
¶97.163 We are satisfied that Majorie Vital and Ernie Vital died between about 03.15 and 03.30 before suffering the direct effects of fire.1521 Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser {Day296/28:15}-{Day296/29;8}.
Flat 203
¶97.164 Flat 203 on floor 23 had two bedrooms and was situated in the south-west corner of the tower. It was the home of Rania Ibrahim, her husband, Hassan Awadh Hassan (who was abroad at the time of the fire), and their two daughters, Fethia Hassan and Hania Hassan.1522 External Fire Spread Report {MET00012593/12}; Phase 1 Report Volume IV paragraph 32.34. The south-west corner of the tower was farthest from where the fire had started.1523 Phase 1 Report Volume II paragraph 14.145.
¶97.165 Smoke began to enter Flat 203 by 02.05, although at that stage not through the windows.1524 Phase 1 Report Volume II paragraph 14.146. From about 02.40 smoke increasingly affected the south facing wall of the tower, spreading towards Flat 203.1525 Purser, Phase 2 Report, Section 6 {DAPR0000006/35} paragraph 159.
¶97.166 Flat 203 was the last of those on floor 23 to be affected by the spread of fire on the outside of the building. By about 03.11 the fire had reached the area between Flats 202 and 203 and continued to move in a westerly direction across Flat 203. By 03.43 Flat 203 was fully affected by the fire.1526 Lane, Phase 1 Supplemental Report, Section 12 {BLAS0000012/11}; Phase 1 Report Volume III paragraph 18.5; Purser, Phase 2 Report, Section 6 {DAPR0000006/35} paragraph 162.
¶97.167 The fire reached the south-west corner of the tower at the level of floor 23 by 03.58. From 04.07 onwards, there was a rapid deterioration of the conditions in the living room of Flat 203.1527 Phase 1 Report Volume III paragraph 18.4; Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 165.
¶97.168 The adult occupants of Flat 203 are likely to have become comatose from the inhalation of asphyxiant gases by about 04.13, and to have inhaled a lethal dose of asphyxiant gases by about 04.17.1528 Purser, Phase 2 Report, Section 6 {DAPR0000006/38} Figure 34. For the children, these events are likely to have happened sooner.1529 Purser, Phase 2 Report, Section 6 {DAPR0000006/54} paragraph 253; Purser {Day297/65:3-8}.
Those who sheltered in Flat 203
¶97.169 Rania Ibrahim gave shelter in her home to people who had fled from elsewhere in the tower. Those who went to Flat 203 seeking refuge were Fathia Ahmed Elsanousi, Isra Ibrahim, Abufras Ibrahim and Gary Maunders.1530 Phase 1 Report Volume II paragraph 14.125.
189¶97.170 Fathia Ahmed Elsanousi lived in Flat 206 on floor 23 with her daughter, Isra Ibrahim. Abufras Ibrahim, the son of Fathia Ahmed Elsanousi, had been visiting his mother and sister on 14 June 2017.1531 Phase 1 Report Volume IV paragraph 32.7.
¶97.171 Gary Maunders did not live in Grenfell Tower. He had been visiting Debbie Lamprell from Flat 161 on floor 19. They went up to floor 23 and initially took shelter in Flat 201 at about 01.30. Gary Maunders then moved to Flat 203 at about 01.39.1532 Phase 1 Report Volume II paragraphs 10.259-10.260, 10.287-10.289 and 11.30-11.31.
¶97.172 All those who were in Flat 203 died. Rania Ibrahim, Fethia Hassan, Hania Hassan, Isra Ibrahim, Fathia Ahmed Elsanousi and Gary Maunders all died there. Abufras Ibrahim fell from the tower and his body was recovered from outside the south side.1533 Phase 1 Report Volume III paragraph 18.22; Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraphs 166-167.
Events in Flat 203
¶97.173 By 01.30 the outside of Flat 206, in the north-east corner of the tower (home to Fathia Ahmed Elsanousi and Isra Ibrahim), had become enveloped by flames.1534 Phase 1 Report Volume II paragraphs 10.118 and 10.122; External Fire Spread Report {MET00012593/12}. Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim must have left it at an early stage. The precise time of their arrival at Flat 203 is not known but they must have reached it before 01.38 when Rania Ibrahim began to live-stream a video to Facebook. The female voice heard on the video telling Rania Ibrahim not to open the door was probably that of Isra Ibrahim. Abufras Ibrahim also appears in the video and can be heard telling Rania Ibrahim to close the door as she was letting smoke in.1535 Phase 1 Report Volume II paragraphs 11.30-11.31.
¶97.174 At about 01.39 Rania Ibrahim can be seen opening the front door. Gary Maunders can be seen entering the flat when invited to do so. The video shows that the lobby on floor 23 was dark with smoke at the time.1536 Phase 1 Report Volume II paragraph 11.32 and Figure 11.9. Shortly afterwards, Rania Ibrahim went out into the lobby where she was able to breathe, speak and stand, at least for a short period. She shouted "Hello" and "Come here". It was probably Marco Gottardi from Flat 202 who responded by saying "We are here. I am inside our apartment".1537 Phase 1 Report Volume II paragraphs 11.33 and 11.35.
¶97.175 At around 01.43, a voice can be heard coming from outside the building shouting, "This is the fire service. If you are able, exit the building". That was probably FF Patrick Murray.1538 Phase 1 Report Volume II paragraph 11.34.
¶97.176 FF Mandeep Singh arrived at the tower at 01.35 and was instructed to pass FSG information from the command unit to the bridgehead. He recalled being handed telephones and speaking to residents inside the tower. During one such call, FF Singh spoke to a female occupant of the tower who gave a location of the "23rd floor, doors 205 and 201". She said that she had brought all of the occupants of floor 23 into her flat. FF Singh advised her to stay put.1539 Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17; A page from his notebook contains the following entry "23rd FLOOR ALL OCCUPANTS 205/201 [illegible] WM BRIAN O'KEITH WM (Illegible)".1540 Singh Exhibit MS/1 - pages from notebook {MET00013089/2}. In his witness statement FF Singh said that he thought the woman he had spoken to was the same person who can be heard in a video recording, saying that she will let people in. This was probably Rania Ibrahim, who was in fact in Flat 203, and not in
190¶Flat 201 or Flat 205.1541 Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17.
¶97.177 At 01.57 CRO Heidi Fox answered an emergency call from a member of Rania Ibrahim's family.1542 LFB Control Room Report {LFB00004790/57}. That was the first call relating to Flat 203. As a result, she created a service request at 01.59 in relation to "a person with two children" trapped in Flat 203 on floor 23. CRO Darby passed the information to CU8 by radio a few seconds later.1543 Phase 1 Report Volume II paragraph 13.105. At 02.00, CRO Darby marked the service request as completed.1544 LFB Short Incident Log {MET00013830/21}. That was the only service request created in relation to Flat 203.1545 LFB Short Incident Log {MET00013830}.
¶97.178 The second emergency call about Flat 203 was made at 02.05 by Isra Ibrahim. She told CRO Howson that there were five adults and two children in Flat 203. They were in the living room and kitchen area. Smoke was coming into the flat, but they were keeping the doors closed. No smoke was coming through the windows. Isra Ibrahim had smoke around her nose. CRO Howson advised her to remain in the flat.1546 Phase 1 Report Volume II paragraph 14.146.
¶97.179 At 02.21, Isra Ibrahim spoke to CRO Gotts. She reported that the occupants of the flat were stuck and the flat next door (probably Flat 202) was on fire. She gave her location as Flat 203 on floor 23. CRO Gotts advised her to try to block the doors and to stay away from the side of the flat on fire. Isra Ibrahim asked for someone to come to the flat immediately and whether helicopters could assist. CRO Gotts explained that firefighters were on the lower floors but were on their way up to floor 23. She said that the helicopter was being sent up so that they could see the fire from the air. At the very end of the call, CRO Gotts said "22nd floor, Flat 192. All right?". That was not the location Isra Ibrahim had given, but the call ended before she could respond.1547 Phase 1 Report Volume II paragraph 14.147; 999 call transcript {LFB00000663/1-5}. The first image of the fire taken by the National Police Air Support ("NPAS") helicopter was taken at 01.43, therefore it had reached the tower sometime before or around this time: Phase 1 Report Volume II paragraph 12.104 and Figure 12.8.
¶97.180 CRO Gotts passed the information orally to CRO Darby who sent a message to command unit CU7 at 02.26 about persons in Flat 192 on floor 22 who had said that the fire was in the flat next door to them. No service request was created by CRO Gotts in relation to either Flat 203 or Flat 192.1548 Phase 1 Report Volume III paragraph 15.144.
¶97.181 At 02.35, the "stay put" advice was revoked in the control room, but it took some time for all the control room operators to be told and for them to begin giving fresh advice.1549 Phase 1 Report Volume III paragraph 15.168.
¶97.182 At 02.42, Isra Ibrahim spoke to CRO Howson from Flat 203 and reported five adults and two children in the flat. That was the fourth emergency call relating to Flat 203. She said that the amount of smoke in the flat was increasing and that the flat next door (again, probably Flat 202) was on fire. CRO Howson advised Isra Ibrahim to block out the smoke, told her that firefighters were making their way to her and said that, as long as there were no flames, the flat was the safest place to be "because you don't know what's going on outside".1550 Phase 1 Report Volume III paragraph 15.73.
191¶97.183 At 02.58, an unidentified male caller spoke to CRO Howson. That was the fifth and final call relating to Flat 203. He told her that the police would not let him into the tower and had told him to call the emergency services. The caller said that he had just spoken to someone in Flat 203 with two children. CRO Howson told him that they needed to try to get out of the building and that she would pass on the information that people were still in the flat. The caller must have been referring to Rania Ibrahim. It is not known if he was able to speak to her again to pass on CRO Howson's advice.1551 Phase 1 Report Volume III paragraphs 16.27-16.28. That was the first time those in Flat 203 were advised to leave the building.
¶97.184 Rania Ibrahim appears to have thought that the "stay put" policy was still in place at that time. Munira Mahmud, a close friend who had earlier left floor 5, called her at about 03.00. Rania Ibrahim was coughing a lot and Munira Mahmud could tell that she was finding it difficult to breathe. Munira Mahmud tried to persuade her to leave. Rania Ibrahim said she had called the emergency services and that whoever had answered the call had told her to stay inside and wait for help. She also said that the roof door was locked but that they were sending help, as she could see a helicopter. Munira Mahmud continued to tell Rania Ibrahim that she should try to leave. That was the last conversation she had with Rania Ibrahim; she was unable to reach her by telephone again.1552 Phase 1 Report Volume III paragraph 16.29.
¶97.185 Sayeda Ibrahim spoke to her sister Rania Ibrahim at 01.00, 02.50 and 03.00. The call at 03.00 was the last known contact with anyone in Flat 203.1553 Phase 1 Report Volume III paragraphs 16.30-16.31; Mahmud {MET00080727/18-19} pages 18-19. Attempts by a friend of Munira Mahmud to call Rania Ibrahim from about 03.15 were unsuccessful.
¶97.186 Information about those needing to be rescued from Flat 203 was recorded at various places at the incident ground.
¶97.187 The information from the first emergency call relating to Flat 203 at 01.57 was passed by radio to CU8 at 02.00.1554 LFB Control Room Report {LFB00004790/58}.
¶97.188 We have seen no evidence of messages passed to the incident ground in response to the second call made by Isra Ibrahim at 02.05.1555 LFB Control Room Report {LFB00004790}. However, from 02.06, SM Oliff in the LFB control room was passing information to WM Meyrick in CU8 using his personal mobile telephone. The calls were not recorded and there is no record of the information he passed on.1556 Phase 1 Report Volume II paragraph 14.243.
¶97.189 The bridgehead was maintained on floor 2 from the beginning of the incident until about 02.17.1557 Phase 1 Report Volume IV paragraphs 28.84(b) and 28.86. CM Charles Batterbee copied information from a forward information board at the bridgehead into his own notebook. There is no reference to Flat 203 in that notebook,1558 Phase 1 Report Volume II paragraph 14.73 and Figure 14.4. so it appears that the radio message about Flat 203 sent at 02.00 went astray and did not reach the bridgehead.
¶97.190 From 02.17 until about 03.08 the bridgehead was located on floor 3.1559 Phase 1 Report Volume III paragraph 17.11; Phase 1 Report Volume IV paragraph 28.86. During that period the third, fourth and fifth emergency calls were made in relation to Flat 203.
192¶97.191 At 02.21, when the third call made by Isra Ibrahim came to an end, CRO Gotts misunderstood the caller's location as being in Flat 192 on floor 22 and the radio message sent to command unit CU7 at 02.26 referred to persons in Flat 192 on floor 22. No other messages appear to have been passed to the incident ground in relation to Flat 203 as a result of that call.1560 LFB Control Room Report {LFB00004790/81}.
¶97.192 The fourth and fifth emergency calls relating to Flat 203 were made at 02.42 and 02.58.
¶97.193 SM Oliff recorded information in the control room on two whiteboards from around 02.33. In a photograph taken at the end of the incident the first whiteboard shows the notation "Flat 203 23rd fl – 5 adults 2 children – smoke logging".1561 Phase 1 Report Volume III paragraphs 15.139-15.140 and Figure 15.8. It is possible that SM Oliff passed information about Flat 203 to WM Meyrick in CU8 using his mobile phone.
¶97.194 Messages about Flat 203 did reach command unit CU7. Between about 02.00 and 03.00, a white laminated sheet was being used in CU7 to record information about people needing to be rescued. The laminated sheet recorded "Flat 203 Floor 23 5 adults 2 children" as can be seen in a photograph taken at 02.59.1562 Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3.
¶97.195 Messages about Flat 203 were also inscribed on a wall of the lobby on the ground floor. WM Glynn Williams started to record information on the wall of the lobby on the ground floor at 02.15. He said the information came from CU7. A photograph of the wall taken much later in the incident includes the notation "203 23 5A 2C".1563 Phase 1 Report Volume II paragraphs 14.103-14.104 and Figure 14.5.
¶97.196 After 03.00, the laminated sheet in CU7 was replaced by a whiteboard bearing a grid. A photograph taken of the whiteboard much later in the morning shows Flat 203 and the annotation "5 2 P". The "5" is in green indicating five adults, the "2" is in black indicating two children, and the "P" is in red and is circled, indicating a priority.1564 Phase 1 Report Volume III paragraph 16.12 and Figure 16.5; Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}
¶97.197 Given that no firefighters were sent to Flat 203 before 03.08, when the bridgehead was moved from floor 3 to the ground floor, it appears that messages relating to Flat 203 did not reach the bridgehead while it was on floor 3. However, after the bridgehead had moved to the ground floor firefighters were sent to Flat 203, which suggests that information from at least one of the emergency calls relating to Flat 203 was passed to the bridgehead after 03.08.
¶97.198 FFs Matthew Harold, David Friend and Richard Peacock were initially sent to Flat 203 but at the last minute their instructions were changed and they were sent to carry out search and rescue operations on floors 4 and 5. They tallied out between 03.31 and 03.32.1565 Phase 1 Report Volume III paragraph 18.15(b).
¶97.199 None of the other firefighting crews sent to floor 23 succeeded in reaching it.
193Rania Ibrahim, Fethia Hassan and Hania Hassan
Rania Ibrahim
¶Date of birth: 3 March 1986 (31 years old). Place of birth: Aswan, Egypt. Gender: Female. Occupation: Carer for children. Usual address: Flat 203, floor 23, Grenfell Tower, London. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Between 03.55 and 04.05 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Fethia Hassan
¶Date of birth: 5 October 2012 (4 years old). Place of birth: Chelsea, London. Gender: Female. Occupation: N/A. Usual address: Flat 203, floor 23, Grenfell Tower, London. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Between 03.55 and 04.05 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Hania Hassan
¶Date of birth: 4 June 2014 (3 years old). Place of birth: Chelsea, London. Gender: Female. Occupation: N/A. Usual address: Flat 203, floor 23, Grenfell Tower, London. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Between 03.55 and 04.05 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
194Background and composition of household
¶97.200 Rania Ibrahim lived in Flat 203 with her husband, Hassan Awadh Hassan, and their two daughters, Fethia and Hania. Hassan Awadh Hassan was away at the time of the fire. Rania Ibrahim and her family moved into Flat 203 in 2016.1566 Tenancy Agreement for Hassan Awadh Hassan {TMOH00010399}; Presentations relating to Rania Ibrahim, Fethia Hassan and Hania Hassan {Day299/52:1-22}.
¶97.201 Born in Aswan, Egypt on 3 March 1986, Rania Ibrahim was 31 years old when she died. She had a place to study law in Cairo but had come to London to help her sister, who was unwell. She had met Hassan in London in 2010 and they got married. Fethia was born on 5 October 2012 and Hania on 4 June 2014. They were four and three years old respectively when they died.1567 Phase 1 Report Volume IV paragraphs 32.34-32.43.
Vulnerability
¶97.202 The family appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system. The ages of Fethia and Hania were respectively recorded as "5" and "3". No other vulnerabilities were noted.1568 David Noble's list {TMO00862588}.
Events of 14 June 2017
¶97.203 Rania Ibrahim, Fethia Hassan and Hania Hassan had all returned to Grenfell Tower for the last time by 18.09 on 13 June 2017.1569 O'Riordan {MET00013136/3} page 3.
¶97.204 On the evening of 13 June 2017, Rania Ibrahim and her daughters spent time with a close friend, Munira Mahmud, who lived in Flat 25 on floor 5 of Grenfell Tower. Munira Mahmud's children played with Fethia and Hania and ate dinner. After Rania Ibrahim and her daughters had returned to Flat 203, at about 21.30 Munia Mahmud brought Rania Ibrahim food for the iftar meal ending the Ramadan fast.1570 Mahmud {IWS00000776/1-4} pages 1-4, paragraphs 3, 15, 16; Presentations relating to Rania Ibrahim, Fethia Hassan and Hania Hassan {Day299/54:10-15}.
¶97.205 Rania Ibrahim did not make any emergency calls herself. However, she appears to have given her mobile telephone to Isra Ibrahim, who made a number of emergency calls as described above.1571 Presentations relating to Rania Ibrahim, Fethia Hassan and Hania Hassan {Day299/58:15-19}. Calls were also made on behalf of Rania Ibrahim and her daughters by people outside the tower.
Recovery and identification
¶97.206 The remains of Rania Ibrahim, Fethia Hassan and Hania Hassan were all recovered from the bathroom of Flat 203.1572 Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167. The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death.1573 Interim certificate of the fact of death for Rania Ibrahim, Fethia Hassan and Hania Hassan {MET00065635}; {MET00065604}; {MET00065636}.
195Cause and time of death
¶97.207 Toxicology testing for Rania Ibrahim and her daughters was not possible.1574 Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167. The post-mortem reports on Rania Ibrahim, Fethia Hassan and Hania Hassan recorded their cause of death as "consistent with the effects of fire".1575 Rania Ibrahim post-mortem report {COR00000444/3}; Fethia Hassan post-mortem report {COR00001724/3}; Hania Hassan post-mortem report {COR00001723/3}. In the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".
¶97.208 Given the lack of response to calls made to Rania Ibrahim's telephone after 03.00, we consider it likely that Rania Ibrahim, Fethia Hassan and Hania Hassan had lost consciousness by that time. We are satisfied that they all died between 03.55 and 04.05 before suffering the direct effects of fire.1576 Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser {Day296/28:15}-{Day296/29:8}.
Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim
Fathia Ahmed Elsanousi
¶Date of birth: 1 January 1940 (77 years old). Place of birth: Al Nuhood, West Kordofan province, Sudan. Gender: Female. Occupation: Retired. Usual address: Flat 206, floor 23, Grenfell Tower, London. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Between 04.20 and 04.40 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Isra Ibrahim
¶Date of birth: 8 August 1983 (33 years old). Place of birth: Khartoum, Sudan. Gender: Female. Occupation: Care worker and sales assistant. Usual address: Flat 206, floor 23, Grenfell Tower, London. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Between 04.20 and 04.40 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
196Abufras Ibrahim
¶Date of birth: 8 January 1978 (39 years old) .
¶Place of birth: Khartoum, Sudan.
¶Gender: Male.
¶Occupation: Fishmonger and sales assistant.
¶Usual address: Queensgate, London SW7.
¶Place of death: Outside Grenfell Tower, London.
¶Time of death: Between 03.50 and 03.55 on 14 June 2017.
¶Cause of death: Multiple injuries (consistent with a fall from height).
Background and composition of household
¶97.209 Fathia Ahmed Elsanousi was born in 1940 in Al Nuhood, Sudan and was 77 years old in 2017. She had been a headteacher in Sudan and had moved to the UK to escape the civil war there.1577 Phase 1 Report Volume IV paragraphs 32.8-32.12. Her daughter, Isra Ibrahim, was born on 8 August 1983 and was 33 years old. She and her mother had been tenants of Flat 206 since 2008.1578 Presentations relating to Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim {Day307/96:7-10}. Abufras Ibrahim was born on 8 January 1978 and was 39 years old. He did not live in Grenfell Tower but was visiting his mother and sister on 14 June 2017.1579 Phase 1 Report Volume IV paragraph 32.7.
Vulnerability
¶97.210 Fathia Ahmed Elsanousi suffered from serious health problems that had been recorded in her housing file since 2000. She had breathing problems which required her to use a portable oxygen machine. Her mobility was impaired as a result of a stroke in 2006. She had been unable to manage stairs easily since January 2007.1580 Presentations relating to Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim {Day307/99:5-13}; Health Assessment Form {BSR00000110}. Isra Ibrahim did not have any known vulnerabilities. Neither she nor her mother were identified as vulnerable in the spreadsheet of vulnerable tower residents created by David Noble on 14 June 2017.1581 David Noble's list {TMO00862588}.
Events of 14 June 2017
¶97.211 Fathia Ahmed Elsanousi last entered Grenfell Tower on 9 June 2017. Isra Ibrahim and Abufras Ibrahim entered Grenfell Tower in the evening of 13 June 2017.1582 O'Riordan {MET00013136/2-4} pages 2-4.
¶97.212 The Neda family lived in Flat 205. At about 01.25, Farhad Neda and his mother, Flora Neda, looked out into the lobby of floor 23. Flora Neda saw Isra Ibrahim from Flat 206 start running down the stairs. Fathia Ahmed Elsanousi was behind her, walking slowly. That was at about the time that the fire reached the outside of floor 23.1583 Phase 1 Report Volume II paragraphs 10.283 and 10.118; Farhad Neda {Day61/37:1-25}; Neda {IWS00000887/7} page 7, paragraph 33; Flora Neda {Day61/130:12-18}. By 01.30 the flames had enveloped all the "Flat 6s", including Flat 206.1584 Phase 1 Report Volume II paragraph 10.122.
197¶97.213 By about 01.30, several occupants had reached floor 23, having come upstairs from lower floors. At about the same time, Fathia Ahmed Elsanousi and Isra Ibrahim returned to floor 23. By 01.38 they and Abufras Ibrahim were already sheltering with Rania Ibrahim and her children in Flat 203 when Rania Ibrahim began her live-stream video to Facebook.1585 Phase 1 Report Volume II paragraphs 10.289 and 11.29-11.30.
¶97.214 Isra Ibrahim made three emergency calls from Flat 203, at 02.05, 02.21 and 02.42 as described above.
¶97.215 At about 03.50 Abufras Ibrahim fell from the tower. He fell first onto the canopy over the door to the main entrance of the tower on the south side. His body then landed on the south side of the tower close to the walkway connecting it to Grenfell Walk. His body was subsequently moved to a sheltered area by firefighters.1586 Phase 1 Report Volume III paragraph 18.22; Moore {MET00010819/10} page 10; Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 166. He was pronounced dead at 06.05 on 14 June 2017 outside the tower.1587 Abufras Ibrahim post-mortem report {COR00000049/3}.
Recovery and identification
¶97.216 The remains of Fathia Ahmed Elsanousi and Isra Ibrahim were both recovered from the bathroom in Flat 203.1588 Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167. Abufras Ibrahim's body was recovered from outside the tower. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death for each member of the family.1589 Interim certificate of the fact of death for Fathia Ahmed Elsanousi; Isra Ibrahim and Abufras Ibrahim {MET00065632}; {MET00065593}; {MET00065614}.
Cause and time of death
¶97.217 Toxicological testing for Abufras Ibrahim showed that the level of carboxyhaemoglobin in his blood was 20%, which is significant but not incapacitating. His body showed slight soot stains to the skin and nostrils but no burns. Despite a long period of slow smoke infiltration from the lobby and 40 minutes of serious smoke penetration of the bedrooms, he had been able to limit his exposure until the fire spread to the outside of the room in which he had taken refuge.1590 Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 166.
¶97.218 The post-mortem report for Abufras Ibrahim recorded the cause of death as "Multiple injuries (consistent with fall from height)". We are satisfied that Abufras Ibrahim died between 03.50 and 03.55, either instantly when he landed outside the tower or very shortly afterwards.
¶97.219 The post-mortem reports on Fathia Ahmed Elsanousi and Isra Ibrahim recorded the cause of death as "consistent with the effects of a fire"1591 Elsanousi post-mortem report {COR00000443/3}; Isra Ibrahim post-mortem report {COR00000448/5-6}. but in the light of Professor Purser's evidence we consider that a more accurate description is "inhalation of asphyxiant gases".
¶97.220 We are satisfied that Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim all died before suffering the direct effects of fire.
¶97.221 Fathia Ahmed Elsanousi and Isra Ibrahim died from inhalation of asphyxiant gases between 04.20 and 04.40.1592 Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20.
198Gary Maunders
¶Date of birth: 4 January 1960 (57 years).
¶Place of birth: Hammersmith, London.
¶Gender: Male.
¶Occupation: Painter and decorator.
¶Usual address: Lancaster Road, London W11.
¶Place of death: Flat 203, floor 23, Grenfell Tower, London.
¶Time of death: Approximately 04.20 – 04.40 on 14 June 2017.
¶Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶97.222 Gary Maunders was born in London on 4 January 1960; in 2017 he was 57 years old. He was the father of two children. A talented footballer in his youth, Gary worked as a painter and decorator.1593 Phase 1 Report Volume IV paragraphs 32.191-32.196. On the night of the fire he was visiting Debbie Lamprell at her home in Flat 161 on floor 19 of the tower.
Events of 14 June 2017
¶97.223 Gary Maunders was one of those who went up to floor 23 to take shelter. He probably reached it by about 01.30.1594 Phase 1 Report Volume II paragraphs 14.125 and 10.287-10.289; External Fire Spread Report {MET00012593/12}. He initially went into Flat 201, the home of Raymond (Moses) Bernard.
¶97.224 Fadumo Ahmed, Debbie Lamprell's neighbour, left her flat at 01.20 and saw Debbie Lamprell near the lifts. She gained the impression that she had been told to go upstairs. They both walked up the stairs to floor 23. There was only a little bit of smoke in the stairwell at that time. Fadumo Ahmed said she did not see anyone else in the stairwell, but Debbie Lamprell later told CRO Jabin that she and her friend had come up together, which suggests that Gary Maunders may have also climbed the stairs with them.1595 999 call transcript {LFB00055500/29}. Fadumo Ahmed saw people at the door to Flat 201 and joined a group in the hallway that included Gary Maunders and Debbie Lamprell.1596 Phase 1 Report Volume II paragraphs 10.259-10.260.
¶97.225 The occupants of Flat 201 were soon having difficulty breathing. The fire was at the window and then entered the living room.1597 Phase 1 Report Volume II paragraphs 10.289 (d), 11.25 and 11.28.
¶97.226 We do not know how Gary Maunders and Debbie Lamprell became separated. Nor do we know at what time he left Flat 201. He entered Flat 203 at about 01.39,1598 Phase 1 Report Volume II paragraphs 11.29-11.30. which coincides with Debbie Lamprell's emergency call from Flat 201, during which she was shouting for "Gary". That suggests she may already have lost contact with him.1599 999 call transcript {COR00000269}. Debbie Lamprell remained in Flat 201 and at 02.05 during a 999 call she referred to having lost her friend, saying they had come up together, but he had gone: 999 call transcript {LFB00055500/26-29}.
199¶97.227 Gary Maunders made no calls to the emergency services on the night of the fire.
Recovery and identification
¶97.228 Gary Maunders' remains were recovered from the bathroom of Flat 203. Toxicological testing was not possible.1600 Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.1601 Interim certificate of the fact of death for Gary Maunders {MET00065624}.
Cause and time of death
¶97.229 The post-mortem report on Gary Maunders recorded the cause of death as "consistent with the effects of a fire"1602 Maunders post-mortem report {COR00000521/3}. but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".
¶97.230 We are satisfied that Gary Maunders died between 04.20 and 04.40.1603 Purser, Phase 2 Report, Section 6 {DAPR0000006/1} Table 20.
Flat 204 Hesham Rahman
¶Date of birth: 30 January 1960 (57 years old). Place of birth: Cairo, Egypt. Gender: Male. Occupation: Retired. Usual address: Flat 204, floor 23, Grenfell Tower, London. Place of death: Flat 204, floor 23, Grenfell Tower, London. Time of death: Between 03.45 and 04.00 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶97.231 Hesham Rahman was born on 30 January 1950 in Egypt and was 57 years old in 2017. He was a retired hairdresser.1604 Phase 1 Report Volume IV paragraphs 32.29-32.32. Flat 204 had been his home since August 2012. He lived there alone.1605 Tenancy Agreement {TMOH00013384/6-7}.
Vulnerability
¶97.232 Hesham Rahman had diabetes and associated serious mobility problems which pre-dated his move to Grenfell Tower. His cousin said that his health had deteriorated after 2012. He had difficulty using stairs and relied on the lifts at Grenfell Tower. He had a disability blue badge for his car and a parking space at the tower for drivers with disabilities.1606 El-Baghdady {IWS00001535/2-4} pages 2-4, paragraphs 7-14.
200¶97.233 RBKC was aware of Hesham Rahman's health conditions and mobility difficulties. RBKC's assessments of 19 December 2006, August 2009 and 7 December 2010 all recorded his difficulty in managing stairs.1607 {BSR00000133/3-5}; {BSR00000130/3-5}; {BSR00000131/3-4}. The assessment dated 7 December 2010 noted the contents of a letter from a consultant confirming his diagnoses and their interference with his ability to walk. He recommended an upper or lower ground floor property with no more than six steps to obtain access to the premises or a property up to fourth floor level with lift access.1608 {BSR00000131/2-3}.
¶97.234 A housing officer visited Hesham Rahman on 9 October 2012 and 28 June 2013 and on both occasions recorded that he had problems with mobility. A question whether any signs of a need for support had not been picked up when he was signed up for a tenancy was not completed in relation to the first visit and answered "No" in relation to the second.1609 {TMOH00013422/1}; {TMOH00013423/1-2}.
¶97.235 Hesham Rahman was not identified as vulnerable in the spreadsheet of tower residents created by David Noble on 14 June 2017.1610 David Noble's list {TMO00862588}.
Events of 14 June 2017
¶97.236 Hesham Rahman returned to Grenfell Tower at 20.54 on 13 June 2017.1611 O'Riordan {MET00013136/3} page 3.
¶97.237 At about 01.20, Anna Krivsoun, the daughter of Hesham Rahman's former partner, called to tell him that the tower was on fire and that he should leave. He agreed and said he would get dressed.1612 Krivsoun {MET00039926/1} page 1.
¶97.238 At some point before 01.30, Farhad Neda from Flat 205 saw smoke entering the lobby on floor 23 through the smoke extraction system vents. He also saw Hesham Rahman open and close the door to Flat 204.1613 Phase 1 Report Volume II paragraphs 10.149 and 10.283-10.286. That was the last contact anyone in the tower had with Hesham Rahman; no one else took shelter in Flat 204.
¶97.239 Hesham Rahman spoke to the emergency services on five occasions during the fire. He made his first call at 01.39 and spoke to OM Norman. He reported that a little smoke was coming into his flat and that he could smell it. He said that he could not see outside at all.1614 Phase 1 Report Volume II paragraph 11.36.
¶97.240 When Hesham Rahman received a call from OM Norman at 01.46, he said the fire had not reached his flat but was next door. The flats immediately next door to his were Flats 203 and 205. OM Norman said the fire was on floor 4 and he replied, "I think it's gone upstairs". OM Norman advised him to stay put, saying firefighter crews would get to him.1615 Phase 1 Report Volume II paragraph 12.68; External Fire Spread Report {MET00012593/12}. Of the two neighbouring flats, the exterior fire affected Flat 205 first, by 02.09-02.10: Lane, Phase 1 Supplemental Report, Section 12 {BLAS0000012/9-11}.
¶97.241 Although no service requests were created in response to Hesham Rahman's first two emergency calls, it appears that information about a person needing to be rescued from Flat 204 was passed by telephone to command vehicle CU8 by OM Norman at
201¶01.47. OM Norman recorded the message in the incident log afterwards at 02.01.1616 Phase 1 Report Volume II paragraph 12.76; LFB Short Incident Log {MET00013830/21}; LFB Control Room Report {LFB00004790/50}.
¶That is the first record of Hesham Rahman's situation and location being passed to the incident ground.
¶97.242 CRO Russell took Hesham Rahman's third emergency call at 02.36. He reported smoke coming into his flat and said that he was finding it difficult to breathe. CRO Russell advised him to try to make his way out of the building. He told her that he had a disability and needed assistance. No service request was created in response to his call, but a note of his disability was added to a whiteboard in the control room. By the time she took that call CRO Russell had received the instruction from SOM Smith to change the "stay put" advice. She recalled that the new advice had been for people to cover themselves, not to breathe in the smoke and to make their way down the stairs.1617 Phase 1 Report Volume III paragraph 15.169; LFB Short Incident Log Report {MET00013830}.
¶97.243 Hesham Rahman's fourth call to the emergency services was taken by CRO Russell at 03.10. He was then in the living room of his flat. He had blocked the front door but a lot of smoke was still coming in. He was advised to leave but said that he could not do so because he could not walk properly due to his disability. He told CRO Russell that he was lying on the floor with a wet cloth over his nose and that his windows were shut. CRO Russell told him that the crews were coming up to him. No service request appears to have been created in response to that call.1618 Phase 1 Report Volume III paragraph 17.26; LFB Short Incident Log Report {MET00013830}.
¶97.244 At 03.16, a person who identified herself as Hesham Rahman's daughter spoke to CRO Yvonne Adams. When told to call him back and tell him that he needed to leave, the caller explained that he could not leave because of his disabilities.1619 Phase 1 Report Volume III paragraph 17.28.
¶97.245 Hesham Rahman's fifth and final emergency call at 03.20 was also taken by CRO Adams. It lasted 2 minutes and 38 seconds. By that time the flat was full of black smoke and he could not see anything. The fire was coming into his flat. No service request was created in response to the call.1620 Phase 1 Report Volume III paragraphs 17.27 and 18.21; LFB Short Incident Log Report {MET00013830}.
¶97.246 Anna Krivsoun made emergency calls on Hesham Rahman's behalf from outside the tower, probably including calls made at 03.38 and 04.01. It was reported to CRO Gotts during the call at 03.38 that he had not been able to leave his flat and was struggling to breathe. At 04.01 the caller told CRO Russell that he was no longer responding and that it had been clear that he was struggling to breathe.1621 Phase 1 Report Volume III paragraph 18.21.
¶97.247 Anna Krivsoun had last spoken to Hesham Rahman by telephone at 03.43. She could hear him coughing and struggling to breathe.1622 Phase 1 Report Volume III paragraph 18.21. That appears to be the last contact Hesham Rahman had with anyone outside the tower.
¶97.248 At the incident ground, there were references to Hesham Rahman and Flat 204 in various places. WM Meyrick in command unit CU8 was receiving information by radio from the control room which he was passing to WM Kentfield.1623 Phase 1 Report Volume II paragraph 11.5. At some point between 01.40 and 01.49 SM Loft received a piece of paper from WM Kentfield on which messages had been recorded. That piece of paper later became known as "Sadler's Envelope". One of the notes recorded on the paper was "FLAT 204 23 FLOOR".1624 Phase 1 Report Volume II paragraphs 12.18-12.19 and Figure 12.4.
202¶97.249 Between about 02.00 and 03.00, a white laminated sheet was being used on CU7 to record emergency calls.1625 Phase 1 Report Volume IV paragraph 28.85(d). It contained the notation "FLAT 204 FLOOR 23 1 PERSON disabled light smoke".1626 Phase 1 Report Volume IV paragraph 28.102(f); {MET00015930}.
¶97.250 At about 02.17, CM Batterbee went to the bridgehead on floor 2. He made a note of the entries on a forward information board, which included the note "204 (tick) 21st".1627 Phase 1 Report Volume II paragraph 14.73 and Figure 14.4. (Flat 204 was in fact on floor 23.)
¶97.251 WM Glynn Williams started to record information on the wall of the lobby on the ground floor at 02.15. A photograph of the lobby wall taken much later on in the incident shows the notation "204 21" with "21" circled.1628 Phase 1 Report Volume II paragraphs 14.103-14.104 and Figure 14.5. That is another example of inaccurate recording of the location of Flat 204.
¶97.252 Between about 02.20 and 03.08, WM Louisa De Silvo recorded information about people needing to be rescued on the wall of the lobby of floor 3 when the bridgehead had been re-located on that floor. A photograph of that wall from later in the incident shows the notation "EUSTON – 23 205 204" with 204 circled and ticked. The writing also included the expression "21 (tick) 204".1629 Phase 1 Report Volume II paragraph 14.108; Phase 1 Report Volume III paragraph 15.23 and Figure 15.7 A tick against a particular flat indicated that a crew had been sent there and a circle indicated that further information had been received, by runner, by radio or from returning crews.1630 De Silvo {Day30/14:18}-{Day30/15:15}. The floor on which Hesham Rahman's flat was situated seems to appear both correctly and incorrectly on the wall.
¶97.253 WM Sadler described being given an "envelope" ("Sadler's Envelope"), which was in fact an A4-size piece of paper. He immediately photographed it, at 02.19.1631 Phase 1 Report Volume II paragraph 14.71. As noted above, that piece of paper had written on it "FLAT 204 23 FLOOR".
¶97.254 From about 02.33 SM Oliff recorded information in the control room on two whiteboards.1632 Phase 1 Report Volume III paragraph 15.139. Following Hesham Rahman's call to CRO Russell at 02.36, to the first whiteboard he added the details "1 disabled male" to the entry "204 23 flr".1633 Phase 1 Report Volume III paragraph 15.169.
¶97.255 After 03.00, the laminated sheet used on command unit CU7 was replaced by a whiteboard with a grid. Flat 204 was annotated with "1 disabled P" with "1 disabled" in green and "P" in red and circled.1634 Phase 1 Report Volume IV paragraph 28.85 (d); {MET00015924}.
¶97.256 FFs Pole, Mitchell, Cheesman and Bate from Euston Fire Station were sent to floor 23, probably to Flats 204 (where Hesham Rahman lived) and 205. A photograph of the wall on floor 3 where the bridgehead was by then positioned shows that the word "Euston" had been written against Flats 204 and 205 on floor 23. In the bottom right-hand corner of the photograph can be seen the words "23rd Euston 204 205".1635 Phase 1 Report Volume III paragraph 16.15 and Figure 16.6. We therefore conclude that the emergency calls by and on behalf of Hesham Rahman did lead to an attempt to reach his flat.
203¶97.257 The crew tallied out by 02.53. They came across another crew at about floor 12 and FF Bate was handed a child casualty, whom he decided to take out of the tower. FFs Mitchell, Pole and Cheesman continued upwards and reached what they thought was floor 18. There they realised that they did not have enough air to reach floor 23 and get back down again; they therefore helped to rescue seven residents from that floor. FF Mitchell recalled telling WM De Silvo that they had not reached floor 23. The crew's "end of wear times" were between 03.15 and 03.17.1636 Phase 1 Report Volume III paragraphs 16.15-16.20.
¶97.258 Flat 204 on floor 23 faced west and had one bedroom.1637 External Fire Spread Report {MET00012593/12}. The exterior fire spread to the outside of the bedroom of Flat 204 by 03.20 and to the outside of the living room by 03.34. By 03.42 it was spreading to the column between Flats 204 and 203 and affecting Flat 203 next door.1638 Purser, Phase 2 Report, Section 6 {DAPR0000006/24} paragraph 93 and {DAPR0000006/32} paragraph 139.
Recovery and identification
¶97.259 The remains of Hesham Rahman were recovered from a partitioned area, which may have been a cupboard, in the living room of Flat 204.1639 Purser, Phase 2 Report, Section 6 {DAPR0000006/33} paragraph 143. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.1640 Interim certificate of the fact of death for Hesham Rehman {MET00065606}.
Cause and time of death
¶97.260 Hesham Rahman was exposed to a slow increase in smoke and asphyxiant gases from about 01.29, followed by a more rapid increase after about 03.20 as the fire spread past his bedroom. The increase was even more rapid after the fire reached his living room.1641 Purser, Phase 2 Report, Section 6 {DAPR0000006/33} paragraph 145.
¶97.261 Hesham Rahman is likely to have lost consciousness at about 03.43, which was the time of the last reported communication with him. He died at some point between about 03.45 and 04.001642 Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20. from the inhalation of asphyxiant gases and before suffering the direct effects of fire.1643 Purser, Phase 2 Report, Section 6 {DAPR0000006/33-34} paragraphs 146-147 and 153.
¶97.262 The post-mortem report on Hesham Rahman recorded the cause of death as "consistent with the effects of fire,1644 Rahman post-mortem report {COR00001718/4}. but in light of Professor Purser's evidence we find a more accurate description to be "inhalation of asphyxiant gases". The latest time at which he could have been rescued successfully was 03.15.
204¶Flat 205
¶Mohammed Amied (Saber) Neda
¶Date of birth: 3 May 1960 (57 years).
¶Place of birth: Afghanistan.
¶Gender: Male.
¶Occupation: Chauffeur.
¶Usual address: Flat 205, floor 23, Grenfell Tower, London.
¶Place of death: West Side of Grenfell Tower, London.
¶Time of death: 02.41 on 14 June 2017.
¶Cause of death: Multiple injuries (consistent with a fall from height).
Background and composition of household
¶97.263 Mohammed Amied (Saber) Neda lived in Flat 205 with his wife, Shakila (Flora) Neda, and his son, Shekeb (Farhad) Neda. His family and friends knew him as Saber.1645 Phase 1 Report Volume IV paragraph 32.22.
¶97.264 Saber Neda was born on 3 May 1960 in Afghanistan. In 2017 he was 57 years old. One of 10 children, he grew up in Afghanistan where he met his wife, Flora, in 1989. They married in 1991 in Kabul. The family moved to the UK in 1998 with their young son, Farhad. The family moved into Flat 205 in 1999.1646 Phase 1 Report Volume IV paragraphs 32.22–32.27. Saber Neda established his own chauffeur business, which by 2017 he had operated for 10 years.1647 Phase 1 Report Volume IV paragraphs 32.22–32.27.
Vulnerability
¶97.265 Saber Neda did not have any known vulnerabilities.
Events of 14 June 2017
¶97.266 Saber Neda returned home with his wife and son at 00.52 on 14 June 2017. On reaching floor 23 they noticed that a noise was coming from the vents of the extractor fans located in the lobby. Farhad Neda called the TMO at 01.10 to report it and also reported that there was an electrical burning smell. The call responder told him that they had received a call about the fire alarms and that the fire brigade was on its way.1648 Phase 1 Report Volume II paragraph 10.148.
¶97.267 At the time the lobby was clear of smoke.1649 Phase 1 Report Volume II paragraph 10.150. About 15 minutes later the family decided to leave the tower. Saber Neda had looked out the window and thought there was a fire downstairs. A burning smell was still detectable in the lobby. Visibility in the lobby was still clear when the Neda family tried to leave but Farhad Neda saw black smoke coming into the lobby from the smoke extraction vents.1650 Phase 1 Report Volume II paragraph 10.283.
205¶97.268 The family reached the stairwell but were prevented from going down the stairs by people coming up from the lower floors.1651 Phase 1 Report Volume II paragraph 10.284. Among those coming up were Mariem and Eslah Elgwahry from floor 22 and Sakina Afrasehabi and Fatemeh Afrasiabi from floor 18. The Neda family returned to their flat and took in the Elgwahrys and Sakina Afrasehabi and Fatemeh Afrasiabi shortly before 01.30.1652 Phase 1 Report Volume II paragraph 10.284.
¶97.269 The Neda family took them into the living room. Black smoke slowly began to enter the flat underneath the front door. Within 10 to 15 minutes there were black marks around people's noses due to the smoke.1653 Phase 1 Report Volume II paragraph 13.79.
¶97.270 Saber Neda did not make any calls to the emergency services on 14 June 2017, but Mariem Elgwahry made a number of calls from Flat 205. Her first two calls were made at 01.301654 Phase 1 Report Volume II paragraph 10.289 (a). and 01.38.1655 Phase 1 Report Volume II paragraphs 11.27 and 11.163. As a result, a message about persons trapped in Flat 205 on floor 23 was passed to the incident ground.1656 LFB Short Incident Log Report {MET00013830/19}; Phase 1 Report Volume II paragraphs 12.72 and 12.73 (b). SM Loft was in front of the tower passing information he had received from WM Kentfield on command unit CU7 to the bridgehead, probably by radio.1657 Phase 1 Report Volume II paragraph 12.18. He said that the first message he had received related to Flat 205. He passed it to the bridgehead at about 01.40.1658 Phase 1 Report Volume II paragraph 12.19. Flat 205 and floor 23 were recorded on the forward information board used to record information about people needing to be rescued while the bridgehead was located on floor 2.1659 Phase 1 Report Volume II paragraph 14.73 and Figure 14.4.
¶97.271 Although information about Flat 205 reached the bridgehead soon after 01.40, firefighters were not sent to floor 23 until 02.08.1660 Phase 1 Report Volume IV paragraph 28.101. FFs Zade Alassad, Scott Bell and John Wright tallied out between 02.08 and 02.10 to go to Flats 201 and 205 on floor 23.1661 Phase 1 Report Volume II paragraph 14.117. Their names were written next to a circled note on a wall of floor 2 which read "Wandswor 23rd flts 201 205."1662 Phase 1 Report Volume II Figure 13.2 and paragraph 14.117; Phase 1 Report Volume IV paragraph 28.101. However, the crew did not reach floor 23 because they stopped to help other firefighters take down casualties found on floor 10.1663 Phase 1 Report Volume II paragraph 14.117. FF Bell said that he had told someone that they had not reached floor 23 but he could not remember to whom he had spoken or what that person did with the information.1664 Phase 1 Report Volume II paragraph 14.117.
Contact with others outside the tower
¶97.272 Farhad Neda was in contact with friends outside the tower who were able to speak to firefighters and pass advice back to him. He also spoke directly with a firefighter who gave him advice. The collective advice was for those in Flat 205 to cover their faces with wet towels, wet the carpets, put wet towels against the doors and remain in the flat until firefighters came.1665 Phase 1 Report Volume II paragraph 13.81. The Nedas filled buckets with water which they threw on the carpets and soaked towels to cover their mouths when they saw smoke coming into the flat.1666 Phase 1 Report Volume II paragraph 13.80.
206¶97.273 Mariem Elgwahry made a third emergency call from Flat 205 at 01.54 and spoke to CRO Gotts.1667 Phase 1 Report Volume II paragraphs 13.78 and 13.98. At 01.57 CRO Darby sent a message to the incident ground about a caller in Flat 205 on floor 23 who had reported the fire coming up to the flat.1668 Phase 1 Report Volume II paragraph 13.98.
¶97.274 When Saber Neda saw that the fire had reached the bedroom in Flat 205 he closed the door and told everyone not to enter it.1669 Phase 1 Report Volume III paragraph 15.64. At around 02.15 Farhad Neda decided that they needed to leave. He seized his mother and shouted for his father to follow.1670 Phase 1 Report Volume III paragraph 15.64. Saber Neda agreed and said he would be behind them. He handed out wet towels to Eslah and Mariem Elgwahry and sisters Sakina Afrasehabi and Fatemeh Afrasiabi in preparation for them all to leave.1671 Phase 1 Report Volume III paragraph 15.64. Farhad Neda and Flora Neda then left the flat thinking that the others would follow them.
¶97.275 However, Saber Neda did not follow his family out but remained in Flat 205 with Fatemeh Afrasiabi, Sakina Afrasehabi and Mariem and Eslah Elgwahry.1672 Phase 1 Report Volume III paragraph 15.65.
Further deployment to Floor 23
¶97.276 In a further emergency call at 02.25, Mariem Elgwahry described the conditions in the flat as having deteriorated significantly.1673 Phase 1 Report Volume III paragraph 15.143 She said that they were running out of air and the whole flat was black.1674 Phase 1 Report Volume III paragraph 15.61. The fire had reached the bedroom and the door to that room had been closed. Mariem Elgwahry said that they had tried to leave but it was totally black outside the front door.1675 Phase 1 Report Volume III paragraph 15.61.
¶97.277 CRO Adams called CU8 at 02.28 to pass on a message about that call. She was unaware of a request that all information about people needing to be rescued should now be sent to CU7. We do not know whether a message was sent to the bridgehead from CU7.1676 Phase 1 Report Volume III paragraph 15.147.
¶97.278 In any event, a message reached the bridgehead sometime after 02.17 when it had moved to floor 3, since Flat 205 was included in the information on the wall on that floor.1677 Phase 1 Report Volume III Figure 15.7. As a result CM Richard Evans and FF Gemma Bloxham were sent to Flat 205 on floor 23 after 02.24.1678 Phase 1 Report Volume III paragraph 15.54.
¶97.279 CM Evans and FF Bloxham had reached floor 20 when they came across Farhad and Flora Neda, whom they then helped to leave the tower.1679 Phase 1 Report Volume III paragraphs 15.54-15.56; Phase 1 Report Volume IV paragraph 28.101. Farhad Neda told the firefighters that his father and four others were trapped in Flat 205, which one of them recorded in a notebook. As they left the main entrance Farhad Neda told the firefighters again that there were still people in the flat. CCTV shows him and his mother leaving the tower between 02.42 and 02.43.1680 Phase 1 Report Volume III paragraphs 15.66-15.67.
207¶97.280 CM Evans returned to the bridgehead and told the officer in charge that they had not reached Flat 205 but that they had brought two people down.1681 Phase 1 Report Volume III paragraph 15.56. That report may have led to a further deployment of firefighters to the top floor. At 02.51, FFs Niki Mitchell, Jessamine Bate, Michael Pole and Chris Cheesman from Euston Fire Station were sent to floor 23.1682 Phase 1 Report Volume IV paragraph 28.101. On the wall of the bridgehead, then on floor 3, was written the word "Euston" against Flats 204 and 205 on floor 23.1683 Phase 1 Report Volume III paragraph 16.15 and Figure 16.6. The notation was repeated further down where the words "23rd Euston 204 205" can be seen. The firefighters did not reach floor 23 but helped casualties escape from Flat 153 on floor 18.1684 Phase 1 Report Volume III paragraphs 16.17-16.20; Phase 1 Report Volume IV paragraph 28.101. FF Mitchell recalled telling WM Louisa De Silvo that they had not reached floor 23 but had got fairly high up the tower and had rescued a family of seven. The crew's end of wear times were between 03.15 and 03.17.1685 Phase 1 Report Volume III paragraphs 16.17-16.20. Although they did not reach floor 23, their deployment was too late for them to have had any prospect of rescuing Saber Neda.
¶97.281 No firefighter successfully reached floor 23 on 14 June 2017.1686 Phase 1 Report Volume IV paragraph 28.101.
Last contact with Saber Neda
¶97.282 At 02.37, Saber Neda called his nephew Lotfrahman (Massi) Abdulrahman. He was still in Flat 205 at the time and asked why no one had come to help. Massi Abdulrahman could hear female voices in the background. After the call ended he tried to call his uncle back, but without success.
¶97.283 At 02.40, Saber Neda left a message for his brother-in-law, Habibirahman Abdulrahman. He said: "Goodbye. We are now leaving this world, goodbye. I hope I haven't disappointed you. Goodbye to all." There was no further contact with Saber Neda.
Recovery and identification
¶97.284 At 02.41, the body of Saber Neda was found in the children's playground on the west side of the tower. He had fallen from the tower.1687 Phase 1 Report Volume III paragraph 15.70. A paramedic formally pronounced him dead at 02.50.1688 Matthews {COR00001112/5} page 5. The coroner was satisfied about the identification of his remains and therefore issued an interim certificate of the fact of death.1689 Interim certificate of the fact of death for Saber Neda {MET00065621}.
Cause and time of death
¶97.285 The post-mortem on Saber Neda recorded the cause of death as multiple traumatic injuries consistent with a fall from a significant height. The injuries were unsurvivable and death, which occurred at or just before 02.41, was instantaneous.1690 Neda post-mortem report {COR00001210/15}. The level of carboxyhaemoglobin in his blood was 20%, significantly lower than the level associated with death from carbon monoxide poisoning.1691 Neda post-mortem report {COR00001210/14}.
208Eslah Elgwahry and Mariem Elgwahry
Eslah Elgwahry
¶Date of birth: 1 December 1952 (64 years). Place of birth: Alexandria, Egypt. Gender: Female. Occupation: Retired. Usual address: Flat 196, floor 22, Grenfell Tower, London. Place of death: Flat 205, floor 23, Grenfell Tower, London. Time of death: Between 02.50 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Mariem Elgwahry
¶Date of birth: 11 April 1990 (27 years). Place of birth: London, United Kingdom. Gender: Female. Occupation: Marketing Manager. Usual address: Flat 196, floor 22, Grenfell Tower, London. Place of death: Flat 205, floor 23, Grenfell Tower, London. Time of death: 02.50 to 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶97.286 Eslah Elgwahry lived in Flat 196 on floor 22 with her daughter Mariem. She was born on 1 December 1952 in Alexandria, Egypt and was 64 years old. Her daughter, Mariem was born on 11 April 1990 in London. She was 27 years old.1692 Phase 1 Report Volume IV paragraphs 32.61-32.63.
¶97.287 Eslah Elgwahry had lived in Grenfell Tower for 34 years. She raised her two children, Mariem and her older brother, Ahmed, alone after their father died when they were young. She instilled in them a strong bond.1693 Phase 1 Report Volume IV paragraphs 32.61-32.63. Eslah Elgwahry had retired by the time of the fire. Mariem Elgwahry graduated from Roehampton University and had established a successful career as a marketing manager.1694 Phase 1 Report Volume IV paragraphs 32.64-32.65.
209Vulnerability
¶97.288 Eslah Elgwahry had a complex range of health problems which resulted in her having difficulty walking.1695 Elgwahry {IWS00001757/7} page 7, paragraph 19. She was not able to climb many stairs without assistance. Mariem Elgwahry had no known vulnerabilities. She was Eslah Elgwahry's carer.1696 Elgwahry {IWS00001757/7} page 7, paragraph 19.
¶97.289 Rydon's survey of residents, prepared in November 2014 and provided to the TMO, recorded that Eslah Elgwahry had mental health problems and high blood pressure.1697 Rydon Residents Survey {RYD00024466/6}. On 24 June 2015, she completed a TMO Tenancy Information Form as part of a tenancy audit on Flat 196, in which she reported that she considered herself to have a physical disability and to need the support of a carer.1698 Tenancy Audit Form for Flat 196 {IWS00001778}.
¶97.290 Both Eslah and Mariem Elgwahry were recorded as residents in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system. Eslah Elgwahry was identified as being over 65 but there was no record of her vulnerabilities.1699 Noble spreadsheet {TMO00866002}.
Events of 14 June 2017
¶97.291 Eslah Elgwahry was alone in Flat 196 on 13 June 2017 until 22.14 when Mariem Elgwahry returned to the tower.1700 O'Riordan {MET00013136/3} page 3. Eslah Elgwahry was seen on CCTV in the lift lobby of the tower at 15.21. O'Riordan {MET00013136/2} page 2. It is not clear when they first became aware of the fire but its rapid spread up the "Flat 6s" prompted them to leave their home. (The fire on the outside of the building had passed Flat 196 by 01.26.)1701 Phase 1 Report Volume II paragraph 10.118.
Movement to Flat 205
¶97.292 Mariem Elgwahry and Eslah Elgwahry left Flat 196 at about 01.25.1702 Phase 1 Report Volume II paragraph 10.277. Naomi Li, who lived in Flat 195, met them in the lobby of floor 22. Mariem told Naomi that the fire was already in their kitchen. Naomi said that they had closed the door to Flat 196 and Mariem Elgwahry was locking it before they left through the stairwell door.1703 Phase 1 Report Volume II paragraphs 10.277 and 10.281.
¶97.293 Mariem Elgwahry and Eslah Elgwahry were prevented from going down the stairs by a group of other people going up.1704 Phase 1 Report Volume II paragraph 10.282. They went up to floor 23 instead.1705 Phase 1 Report Volume II paragraph 10.284. Together with Sakina Afrasehabi and Fatemeh Afrasiabi, who had come up from Flat 151 on floor 18, Eslah and Mariem Elgwahry were able to shelter in Flat 205, the home of the Neda family.1706 Phase 1 Report Volume II paragraphs 10.284 and 10.288-10.289.
210The first emergency messages from Flat 205
¶97.294 At 01.30, Mariem Elgwahry made her first call to the emergency services. She spoke to CRO Peter Duddy in the LFB control room1707 Phase 1 Report Volume II paragraph 10.289 (a). and told him that she was with others on floor 23. Mariem Elgwahry said that the fire had broken into her flat on floor 22 and that they had been forced to run to a neighbour's flat. She said there was smoke everywhere. The call was cut off before CRO Duddy could give her any advice.1708 Phase 1 Report Volume II paragraph 11.141.
¶97.295 Mariem Elgwahry's second emergency call followed shortly afterwards at 01.38, when she spoke to CRO Fox in the LFB control room.1709 Phase 1 Report Volume II paragraphs 11.27 and 11.163. She said that there was no smoke coming into Flat 205 and that there were seven people in the flat. CRO Fox told her to "put things on the door" and to keep the windows closed if smoke started to come in.1710 Phase 1 Report Volume II paragraphs 11.163-11.164.
¶97.296 CRO Fox then created a service request which read, "Seven people in flat 205 on 23rd floor; persons unable to leave property."1711 LFB Short Incident Log {MET00013830/19}. CRO Darby passed the information to WM Meyrick in CU8 at 01.43.1712 Phase 1 Report Volume II paragraphs 12.72 and 12.73 (b). She then marked the service request as completed.1713 LFB Short Incident Log {MET00013830/19}.
¶97.297 WM Kentfield was passing messages received by WM Meyrick in command unit CU8 to SM Loft, who was in front of the tower passing information to the bridgehead, probably by radio.1714 Phase 1 Report Volume II paragraph 12.18. He said that the first message he had received related to Flat 205.1715 Phase 1 Report Volume II paragraph 12.19.
¶97.298 Flat 205 and floor 23 appeared on the forward information board used to record information about people needing to be rescued while the bridgehead was located on floor 2.1716 Phase 1 Report Volume II paragraph 14.73 and Figure 14.4.
¶97.299 Although information about Flat 205 reached the bridgehead soon after 01.40, firefighters were not sent to floor 23 until 02.08.1717 Phase 1 Report Volume IV paragraph 28.101.
Further emergency messages from Flat 205
¶97.300 At 01.54, Mariem Elgwahry made a third call to the emergency services and spoke to CRO Gotts. She reported that she was one of seven people in Flat 205. She said that the flat was full of smoke and that the fire was approaching; they could see the flames outside the window. CRO Gotts told her that the firefighters were trying to send people up and that she would make them aware of their location and the urgency of the situation.1718 Phase 1 Report Volume II paragraphs 13.78 and 13.98.
¶97.301 After the call had ended, CRO Gotts went to check that the earlier message about Flat 205 had been sent to the incident ground. Although she did not create a service request, CRO Darby sent a radio message at 01.57 saying that the caller in Flat 205 on floor 23 had reported that the fire was coming right up to her flat.1719 Phase 1 Report Volume II paragraph 13.98. We cannot say whether that further message reached the bridgehead or, if it did, whether it added to the information about Flat 205 already held there.
211The first deployments to floor 23
¶97.302 FFs Zade Alassad, Scott Bell and John Wright were sent by WM Watson to two flats on floor 23.1720 Phase 1 Report Volume II paragraph 14.117. They tallied out at between 02.08 to 02.10. Their names were written next to a circled note on the wall of floor 2 which read "Wandswor 23rd flts 201 205."1721 Phase 1 Report Volume II Figure 13.2 and paragraph 14.117; Phase 1 Report Volume IV paragraph 28.101. It is likely that they were sent to Flats 201 and 205.1722 Phase 1 Report Volume II Figure 13.2 and paragraph 14.117, Phase 1 Report Volume IV paragraph 28.101.
¶97.303 FFs Alassad, Bell and Wright did not reach floor 23. They stopped at floor 10 and helped to carry down casualties found on that floor.1723 Phase 1 Report Volume II paragraph 14.117. FF Bell said that he told someone they had not reached floor 23 but he could not remember to whom he had spoken or what that person did with that information.1724 Phase 1 Report Volume II paragraph 14.117.
Contact with others outside the tower
¶97.304 Mariem Elgwahry spoke to her brother, Ahmed Elgwahry, at about 01.43. She told him that there was a fire in the kitchen and that she was with their mother. Ahmed Elgwahry told her to get out of the building. He then left his home and went to the tower.1725 Ahmed Elgwahry {IWS00000988/2} page 2, paragraphs 5 and 6.
¶97.305 Mariem Elgwahry called Ahmed Elgwahry again at 01.48 and then 01.49. She told him that they had tried to go down the stairs but could not do so as others had been coming up and telling her to go back. She explained that she was now in Flat 205 after a neighbour had let them into his flat.1726 Ahmed Elgwahry {IWS00000988/3} page 3, paragraph 9.
¶97.306 Mariem Elgwahry spoke to her sister-in-law, Ferzana Elgwahry, at 01.56. She was distressed and crying and coughed a lot during the call. She confirmed that they had already covered their mouths with damp towels.1727 Ferzana Elgwahry {IWS00000995/3} page 2, paragraph 10.
¶97.307 Mariem Elgwahry was also in contact with her close friend, Lucy Ho. At about 02.00, Lucy Ho called her and tried to persuade her to leave. She told Lucy Ho that the emergency services knew where they were and would come for them. Lucy Ho went to find a firefighter who told her to speak to a police officer. She told the police officer that her friend, her mother and four others were in Flat 205.1728 Phase 1 Report Volume II paragraph 14.149. It has not been possible to identify that police officer.
¶97.308 Ahmed Elgwahry arrived at the tower at about 02.13 and then called Mariem Elgwahry. A police officer took Ahmed Elgwahry to a command unit, where a firefighter told Mariem Elgwahry to lie low and breathe through the drain in the bathroom and block out smoke using wet towels. The firefighter then told her to call the emergency services. The firefighter has not been identified.1729 Phase 1 Report Volume II paragraph 14.150.
212Farhad and Flora Neda evacuate Flat 205
¶97.309 Saber Neda saw that the fire had reached the bedroom in Flat 205 and closed the door. He then told everyone not to enter it.1730 Phase 1 Report Volume III paragraph 15.64. Farhad Neda decided that they needed to leave at around 02.15 and grabbed his mother and shouted for his father to follow.1731 Phase 1 Report Volume III paragraph 15.64. Saber Neda agreed and said he would be behind them. Saber Neda handed out wet towels to Eslah and Mariem Elgwahry and sisters Sakina Afrasehabi and Fatemeh Afrasiabi in preparation to leave.1732 Phase 1 Report Volume III paragraph 15.64. Farhad and Flora Neda then left the flat at this time believing that the others would follow them.
¶97.310 Eslah Elgwahry and Mariem Elgwahry remained in the flat with Saber Neda, Sakina Afrasehabi and Fatemeh Afrasiabi.1733 Phase 1 Report Volume III paragraph 15.65.
Final FSG message from Flat 205
¶97.311 Mariem Elgwahry's last call to the LFB was connected to CRO Howson at 02.25.1734 Phase 1 Report Volume III paragraph 15.143 Mariem Elgwahry said she was one of seven adults who were sheltering in the kitchen. They were running out of air and the whole flat was black.1735 Phase 1 Report Volume III paragraph 15.61. She said that she was with her mother, who was diabetic and had asthma. The fire had reached the bedroom and the door to that room had been closed. CRO Howson advised her to leave, if necessary. Mariem Elgwahry told her that they had tried to leave but that it was totally black outside the front door.1736 Phase 1 Report Volume III paragraph 15.61. Ahmed Elgwahry tried to call her while she was still speaking to CRO Howson.1737 Phase 1 Report Volume III paragraph 15.62.
¶97.312 CRO Adams called CU8 at 02.28 to pass on the information she had received from Mariem Elgwahry. She was not aware that a message from CU7 recorded in the incident log a few minutes earlier had asked for all information about people needing to be rescued to be sent to CU7 instead of CU8.1738 Phase 1 Report Volume III paragraph 15.147.
¶97.313 Mariem Elgwahry called Ahmed Elgwahry again at 02.31. She told him that she was with six or seven people in the kitchen of the flat. She said they could not leave because the lobby was full of black smoke and it was impossible to see.1739 Phase 1 Report Volume III paragraph 15.62.
The second deployment to Flat 205
¶97.314 The next deployments to floor 23 were after 02.24. CM Richard Evans and FF Gemma Bloxham were sent to Flat 205 on floor 23. They had reached floor 20 when they came across Farhad and Flora Neda on their way down. CM Evans and FF Bloxham stopped to help them out of the tower, not knowing that they had left the flat that they had been sent to.1740 Phase 1 Report Volume III paragraphs 15.54-15.56; Phase 1 Report Volume IV paragraph 28.101. Farhad Neda told the firefighters that his father and four others were trapped in Flat 205, which was recorded by one of the firefighters in a notebook. As they left the main entrance, Farhad Neda told the firefighters again that there were still people in the flat. They are recorded on CCTV leaving the tower between 02.42 and 02.43.1741 Phase 1 Report Volume III paragraphs 15.66-15.67.
213¶97.315 The crew's end of wear time was 02.42, which must have been at about the time that CM Evans told the officer in charge at the bridgehead that they had not reached Flat 205.1742 Phase 1 Report Volume III paragraph 15.56.
¶97.316 CM Evan's message to the bridgehead may have led to a further deployment of firefighters to the top floor. At 02.51, FFs Niki Mitchell, Jessamine Bate, Michael Pole and Chris Cheesman from Euston Fire Station were sent to floor 23.1743 Phase 1 Report Volume IV paragraph 28.101. At the bridgehead, then on floor 3, the word "Euston" had been written on the wall against Flats 204 and 205 on floor 23.1744 Phase 1 Report Volume III paragraph 16.15 and Figure 16.6. The message was repeated further down. That crew did not reach floor 23 but helped casualties evacuate from Flat 153 on floor 18.1745 Phase 1 Report Volume III paragraphs 16.17-16.20; Phase 1 Report Volume IV paragraph 28.101. FF Mitchell recalled telling WM Louisa De Silvo that they had not reached floor 23 but had got fairly high up the tower and had rescued a family of seven. The crew's end of wear times were between 03.15 and 03.17.1746 Phase 1 Report Volume III paragraphs 16.17-16.20.
¶97.317 No firefighter reached floor 23 on 14 June 2017.1747 Phase 1 Report Volume IV paragraph 28.101.
Last contact with Mariem Elgwahry
¶97.318 The last telephone call between Ahmed Elgwahry and Mariem Elgwahry began at 02.33 and ended at 04.27. Ahmed Elgwahry said that there had been no background noise in the flat. He could hear coughing and his sister's coughing increased. He tried to encourage her to leave but she said she could not leave as the landing was filled with thick black smoke. Ahmed Elgwahry believed that his sister did not want to leave their mother behind.1748 Phase 1 Report Volume III paragraph 17.21.
¶97.319 Ahmed Elgwahry could see that the kitchen of Flat 205 was the last room to be affected by the fire on the outside of the building. He heard Mariem Elgwahry begin to panic. She started mumbling and making a deep humming sound. She was initially able to make banging sounds in response to requests from her brother but stopped responding soon after. Ahmed Elgwahry then heard his mother say in Arabic, "I can't breathe." He thought that that was at about 03.10. He did not hear from them again. Five to ten minutes later he could hear the sound of glass windows breaking and the fire entering the flat. He kept the line open until 04.27, long after he had ceased to hear from them.1749 Phase 1 Report Volume III paragraphs 17.23-17.24.
¶97.320 The fire reached the west face of Flat 205 by around 03.14.1750 Bisby, Supplemental Phase 1 Expert Report {LBYS0000001/221} paragraph 1043; Purser, Phase 2 Report, Section 6 {DAPR0000006/29} paragraph 119. By 03.33, there was evidence of a large fire throughout Flat 205.1751 Phase 1 Report Volume III paragraph 17.4 and Figures 17.3 and 17.4; Purser, Phase 2 Report, Section 6 {DAPR0000006/29} paragraph 120.
Recovery and identification
¶97.321 The remains of Eslah and Mariem Elgwahry were recovered from the kitchen area of Flat 205.1752 Purser, Phase 2 Report, Section 6 {DAPR0000006/24} paragraph 100 The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for Eslah and Mariem Elgwahry.1753 Interim certificate of the fact of death for Eslah and Mariem Elgwahry {MET00065607}; {MET00065615}.
214Cause and time of death
¶97.322 The pathologist who carried out the post-mortems on Eslah and Mariem Elgwahry attributed their deaths to the effects of fire but could not be more precise.1754 Eslah Elgwahry post-mortem {COR00001002/4}; Mariem Elgwahry post-mortem {COR00000337/3}. However, in the light of the evidence as a whole, including that of Professor Purser, we are satisfied that they died from the inhalation of asphyxiant gases.
¶97.323 It is likely that they had lost consciousness by 02.50 and that the concentration of asphyxiant gases in their blood had exceeded the lethal threshold a few minutes later.1755 Purser, Phase 2 Report, Section 6 {DAPR0000006/28} paragraph 117; Purser Summary table of toxicity endpoints in each 23rd floor flat {DAPR0000013}.
¶97.324 We are satisfied that Eslah and Mariem Elgwahry died between 02.50 and 03.30 before suffering the direct effects of fire.
Sakina Afrasehabi
¶Date of birth: 4 April 1952. Place of birth: Abadan, Iran. Gender: Female. Occupation: Homemaker. Usual address: Flat 151, floor 18, Grenfell Tower, London. Place of death: Flat 205, floor 23, Grenfell Tower, London. Time of death: Between 02.50 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Fatemeh Afrasiabi
¶Date of birth: 15 November 1957. Place of birth: Abadan, Iran. Gender: Female. Occupation: Homemaker. Usual address: Martin Close, Edmonton, London, N9. Place of death: Flat 205, floor 23, Grenfell Tower, London. Time of death: Between 02.50 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
215Background and composition of household
¶97.325 Sakina Afrasehabi was born on 4 April 1952 in Abadan, Iran. She was 65 years old in June 2017.1756 Phase 1 Report Volume IV paragraphs 32.218–32.227. She was the sole tenant of Flat 151 and had lived there since February 2016.1757 Aghlani {IWS00000774/1} page 1, paragraph 3. Her younger sister Fatemeh Afrasiabi was born on 15 November 1957 in Abadan, Iran. She was 59 years old in June 2017. Fatemeh Afrasiabi was staying with her sister on the night of 13 June 2017.1758 Phase 1 Report Volume IV paragraphs 32.218–32.227.
¶97.326 Sakina Afrasehabi and Fatemeh Afrasiabi grew up in Iran with four other siblings. They had a happy childhood before living through the revolution and the Iran-Iraq war. They moved to the UK from Iran and were very close.
Vulnerability
¶97.327 Sakina Afrasehabi suffered from diabetes, high blood pressure and arthritis. Due to an accident in Iran, she could walk only with the aid of a walker. It was difficult for her to walk a short distance without assistance.1759 Aghlani {IWS00000774/1-2} pages 1-2, paragraphs 5-6.
¶97.328 Sakina Afrasehabi was recorded as a resident in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system. She was identified as being over 65 and as vulnerable because of her mental and physical health.1760 Spreadsheet of residents {TMO00866002}.
Events of 14 June 2017
¶97.329 Fatemeh Afrasiabi and Sakina Afrasehabi spent the evening of 13 June 2017 in Flat 151 with family. Their other relatives left before 22.00 but Fatemeh Afrasiabi stayed the night with her sister.1761 Sattar {IWS00000769/2} page 2, paragraph 7; Afrasehabi {IWS00000767/2} page 2, paragraph 7.
¶97.330 Sakina Afrasehabi was first alerted to the fire by her neighbours from Flat 156, Shahid and Sayeda Ahmed. They had evacuated their flat after the fire broke into their kitchen at around 01.27 and had then knocked on the doors of all the other flats on that floor, including Flat 151.1762 Phase 1 Report Volume II paragraphs 10.249-10.250.
¶97.331 Sakina Afrasehabi and Fatemeh Afrasiabi left their flat and were told by others they met on the stairs to go up to floor 23.1763 Phase 1 Report Volume II paragraph 10.289 (c). There the Neda family invited them to shelter in their home, Flat 205. Mariem and Eslah Elgwahry, who had also come up to floor 23, joined them in Flat 205. By 01.30 there were seven people in Flat 205.1764 Phase 1 Report Volume II paragraphs 10.284 and 10.288-10.289.
¶97.332 Neither Sakina Afrasehabi nor Fatemeh Afrasiabi themselves called the emergency services on 14 June 2017, but nonetheless a message was passed by the LFB control room to the incident ground about persons trapped in Flat 205.1765 Phase 1 Report Volume II paragraphs 12.18-12.19, 12.72 and 12.73 (b); LFB Short Incident Log Report {MET00013830/19}. Phase 1 Report Volume II paragraphs 12.72 and 12.73 (b). Phase 1 Report Volume II paragraphs 12.18-12.19. That was in response to calls received from Mariem Elgwahry at 01.301766 Phase 1 Report Volume II paragraph 10.289 (a) . and 01.38.1767 Phase 1 Report Volume II paragraphs 11.27 and 11.163. The fact that there were people trapped in Flat 205 was communicated to the bridgehead on floor 2 and recorded there on a forward information board.1768 Phase 1 Report Volume II paragraph 14.73 and Figure 14.4.
216¶97.333 The first team of firefighters sent to floor 23 in response to those messages set out between 02.08 and 02.10. FFs Zade Alassad, Scott Bell and John Wright were sent to Flats 201 and 205 on floor 23.1769 Phase 1 Report Volume II paragraph 14.117; Phase 1 Report Volume II Figure 13.2 and paragraph 14.117; Phase 1 Report Volume IV paragraph 28.101. A photograph taken of the wall on floor 2 shows writing which reads "Wandswor 23rd flts 201 205." Next to this are the names of Alassad, Bell and Wright.1770 Phase 1 Report Volume II Figure 13.2. FFs Alassad, Bell and Wright did not reach floor 23. They stopped at floor 10 and helped to carry down casualties found on that floor.1771 Phase 1 Report Volume II paragraph 14.117. FF Bell said that he told someone they had not reached floor 23 but he could not remember to whom he had spoken or what that person did with the information.1772 Phase 1 Report Volume II paragraph 14.117.
Conditions in Flat 205
¶97.334 Farhad Neda said that conditions in Flat 205 had changed rapidly.1773 Phase 1 Report Volume IV paragraph 25.17. By 01.54, Mariem Elgwahry described Flat 205 as full of smoke in a 999 call. He saw black smoke beginning to enter the flat beneath the front door. Within 10 to 15 minutes of the sisters' coming into the flat there were black marks around people's noses from the smoke.1774 Phase 1 Report Volume II paragraph 13.79.
Contact with others outside the tower
¶97.335 Solmaz Sattar, the niece of Fatemeh Afrasiabi, had several telephone conversations with her aunt during the night. In a call which occurred after Solmaz Sattar had reached the tower, Fatemeh Afrasiabi said they were in Flat 205. Solmaz Sattar passed the information to a police officer and a firefighter standing nearby. The firefighter advised that they should remain in the flat and that they should make everything wet, including themselves. The Nedas had filled buckets with water which they threw on the carpets and soaked towels to cover their mouths when they saw smoke coming into the flat.1775 Phase 1 Report Volume II paragraph 13.80. Later, Fatemeh Afrasiabi told her niece that the water had stopped.1776 Phase 1 Report Volume II paragraph 13.82.
¶97.336 Fatemeh Afrasiabi and Sakina Afrasehabi were also in contact with Sharokh Aghlani, Sakina Afrasehabi's son. Fatemeh Afrasiabi first called him around 01.20 to tell him of the fire. He went to the tower and told police officers there that his mother and aunt were on floor 23.1777 Phase 1 Report Volume III paragraph 17.25. (It has not been possible to identify with any confidence which officer Sharokh Aghlani and Solmaz Sattar spoke to.) It is possible that his message was passed to the bridgehead. At the same time, Mariem Elgwahry in Flat 205 had made further calls to the LFB control room at 01.541778 Phase 1 Report Volume II paragraphs 13.78 and 13.98. and 02.25.1779 Phase 1 Report Volume III paragraph 15.143 The information from both calls was passed to the incident ground at 01.571780 Phase 1 Report Volume II paragraph 13.98. and 02.28 respectively.1781 Phase 1 Report Volume III paragraph 15.147.
217¶97.337 At least one of the messages about Flat 205 reached the bridgehead while it was still on floor 3 (between 02.17 and 03.10). That led to a further deployment of firefighters. At 02.24 CM Richard Evans and FF Gemma Bloxham set out to go to Flat 205.1782 Phase 1 Report Volume III paragraph 15.54.
¶97.338 Shortly before that, Saber Neda had seen that the fire had reached the bedroom of Flat 205. He closed the door and told everyone not to enter it.1783 Phase 1 Report Volume III paragraph 15.64. At about 02.15 Farhad Neda decided that it was time to leave. He seized his mother and shouted for his father to follow.1784 Phase 1 Report Volume III paragraph 15.64. Saber Neda agreed and said he would be behind them. He gave wet towels to Sakina Afrasehabi and Fatemeh Afrasiabi in preparation to leave.1785 Phase 1 Report Volume III paragraph 15.64. Farhad and Flora Neda then left the flat thinking that the others would follow them. Instead, Sakina Afrasehabi and Fatemeh Afrasiabi remained in the flat with Saber Neda and Mariem and Eslah Elgwahry.1786 Phase 1 Report Volume III paragraph 15.65.
¶97.339 CM Evans and FF Bloxham had reached floor 20 when they came across Farhad and Flora Neda. CM Evans and FF Bloxham stopped to help them out of the tower.1787 Phase 1 Report Volume III paragraphs 15.54-15.56; Phase 1 Report Volume IV paragraph 28.101. Farhad Neda told the firefighters that his father and four others were trapped in Flat 205, which was recorded by one of the firefighters in a notebook. As they left the main entrance between 02.42 and 02.43, Farhad Neda told the firefighters again that people were still in the flat.1788 Phase 1 Report Volume III paragraphs 15.66-15.67.
¶97.340 At about 02.42 CM Evans told the officer in charge at the bridgehead that they had not reached Flat 205 but that they had brought two people down.1789 Phase 1 Report Volume III paragraph 15.56. That may have led to a further deployment of firefighters to the top floor.
¶97.341 At 02.51, FFs Niki Mitchell, Jessamine Bate, Michael Pole and Chris Cheesman from Euston Fire Station were sent to floor 23.1790 Phase 1 Report Volume IV paragraph 28.101. The wall of the bridgehead, then on floor 3, shows that the word "Euston" had been written against Flats 204 and 205 on floor 23.1791 Phase 1 Report Volume III paragraph 16.15 and Figure 16.6. The message was repeated on the lower right hand corner of the photograph where the words "23rd Euston 204 205" can be seen. They did not reach floor 23 but helped casualties evacuate from Flat 153 on floor 18.1792 Phase 1 Report Volume III paragraph 16.17-16.20; Phase 1 Report Volume IV paragraph 28.101. FF Mitchell recalled telling WM De Silvo that they had not reached floor 23 but had got fairly high up the tower and they had rescued a family of seven. The crew's end of wear times were between 03.15 and 03.17.1793 Phase 1 Report Volume III paragraphs 16.17-16.20.
¶97.342 No firefighter successfully reached floor 23 on 14 June 2017.1794 Phase 1 Report Volume IV paragraph 28.101.
218Last contact with Fatemeh Afrasiabi and Sakina Afrasehabi
¶97.343 Shahrokh Aghlani spoke to his mother, Sakina Afrasehabi, and his aunt, Fatemeh Afrasiabi, several times in the early hours of 14 June 2017. During his last call he could hear them wheezing. He heard his aunt say "forgive us" before the line was disconnected. About 50 seconds before that he heard the sound of an explosion. It is difficult to determine when that conversation took place.1795 Phase 1 Report Volume III paragraph 17.25.
¶97.344 Ahmed Elgwahry was on the telephone to Mariem Elgwahry from 02.33 until 04.27. He said that he had last heard Mariem and Eslah Elgwahry respond to him at between 03.10 and 03.15. He also heard the sound of windows breaking about 5 to 10 minutes later.
¶97.345 Sakina Afrasehabi and Fatemeh Afrasiabi are likely to have become unconscious from the effects of asphyxiant gases at about the same time as Eslah and Mariem Elgwahry, given their close proximity to each other in the kitchen of Flat 205.
Recovery and identification
¶97.346 The remains of Sakina Afrasehabi and Fatemeh Afrasiabi were recovered from the kitchen area of Flat 205.1796 Purser, Phase 2 Report, Section 6 {DAPR0000006/24} paragraph 94. The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for Sakina Afrasehabi and Fatemeh Afrasiabi.1797 Interim certificate of the fact of death for Sakina Afrasehabi and Fatemeh Afrasiabi {MET00065598}; {MET00065612}.
Cause and time of death
¶97.347 The pathologist who carried out the post-mortems on Sakina Afrasehabi and Fatemeh Afrasiabi attributed their deaths to the effects of fire but could not be more precise.1798 Afrasehabi post-mortem report {COR00000425/5}; Afrasiabi post-mortem report {COR00001380/5}. However, in the light of the evidence as a whole, including that of Professor Purser, we are satisfied that they died from the inhalation of asphyxiant gases.
¶97.348 It is likely that Sakina Afrasehabi and Fatemeh Afrasiabi lost consciousness at about 02.50 and died at some time between 02.50 and 03.30 before suffering the direct effects of fire.
5Part 10: Response and recovery
7Chapter 98: Introduction to Part 10
¶98.1 The Grenfell Tower fire was one of the worst post-war civil disasters in the UK. As the emergency services fought the fire, hundreds of people were displaced from their homes in the tower and surrounding properties. Many of those affected felt that in the hours and days that followed the fire they were abandoned by the authorities at the time of their greatest need.
¶98.2 This Part of the report is concerned with the response of the local authority and the government in the days immediately following the fire.1 Paragraph 1(h) of the Terms of Reference. We have examined the legal and organisational framework for responding to emergencies with a view to finding out what plans were in place for responding to a major emergency of that kind, what the response was, in particular by way of emergency relief, when the emergency struck and whether that response was adequate.
¶98.3 We have examined those matters through the lens of the Civil Contingencies Act 2004 ("the Act") and its associated regulations and guidance which establish the duties and responsibilities of the government and local authorities to prepare for and respond to emergencies of all kinds. That includes consideration of the statutory duties to assess risk, develop and maintain emergency plans and ensure that those who have the task of responding to emergencies are adequately trained, practise putting their plans into action and have sufficient staff to meet their responsibilities. Some of the bodies identified in the List of Issues, including the government and the TMO, were not subject to duties under the Act, but in view of their importance we have included them in our investigation. As far as the Act itself is concerned, the overriding question is whether the Royal Borough of Kensington and Chelsea ("RBKC") complied with its duties and (if it did) whether it was sufficiently prepared for, and responded adequately to, the fire.
¶98.4 That is the context in which we have examined the provision of emergency relief in the days immediately following the fire. There is no statutory definition of "emergency relief" and we have therefore drawn on the guidance published by the government to accompany the Act entitled Emergency Response and Recovery, which defines "humanitarian assistance" as the provision of proper care for those involved in and affected by a major incident. We have concentrated on the following aspects of emergency relief: a. Shelter and accommodation. b. Basic provisions and financial assistance. c. Psychosocial support. d. Meeting the needs of specific groups. e. Public communication. f. The provision of information to the family and friends of those affected. g. Co-ordination of the activities of different responders.
8¶98.5 The most important question we have had to consider is whether those affected by the fire received adequate emergency relief and assistance from the authorities. We examine that through the evidence of those most directly affected, which is considered in relation to the various categories of emergency relief set out above.
¶98.6 In examining the adequacy of the response to the fire, we have concentrated on the actions of the government, the council and the TMO in the seven days following the fire. That is long enough to allow us to consider the key decisions made in those early hours and days that had significant consequences for the response and recovery effort. Those seven days cover both the initial period during which RBKC was in control of the response and the period that began in the afternoon of 16 June 2017 when London Local Authority Gold ("London Gold") took control as part of the London-wide resilience arrangements. However, although our investigations have concentrated on that relatively short period, we recognise that the appalling after-effects of the fire continue to this day.
¶98.7 An important and striking feature of the response to the Grenfell Tower fire was the substantial involvement of community, voluntary and faith groups in providing sanctuary and support to those most seriously affected. We describe the circumstances in which that took place and the extent to which it filled a vacuum left by the authorities.
9Chapter 99: The legislative framework
¶99.1 The framework for emergency planning and response arrangements in the United Kingdom is governed by the Civil Contingencies Act 2004 ("the Act")2 Civil Contingencies Act 2004 {CAB00004616}. and the Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 ("the Regulations").3 Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 {CAB00007003}.
¶99.2 Part I of the Act4 Civil Contingencies Act 2004, Sections 1-18 {CAB00004616/1}. deals with local arrangements for civil protection, defining an "emergency" and establishing a statutory framework of roles and responsibilities for responders. The Grenfell Tower fire was an emergency within the meaning of the Act.5 Civil Contingencies Act 2004, Sections 1(1)(a) and 1(2) {CAB00004616/1}.
¶99.3 The Act divides responders into Category 1 responders (which include the fire and rescue, police, and ambulance services and local authorities)6 Civil Contingencies Act 2004, Schedule 1, Part 1, paragraph 1(c) and paragraph 1A {CAB00004616/31}. and Category 2 responders (which include utility companies and transport providers).7 Civil Contingencies Act 2004, Schedule 1, Part 3{CAB00004616/34}. Category 1 responders are subject to legal duties relating to civil protection, which include assessing the risk of emergencies occurring, putting in place emergency plans, making arrangements to provide information to the public about civil protection matters, maintaining arrangements to warn, inform, and advise the public in the event of an emergency, sharing information with other local responders to enhance co-ordination, and co-operating with other local responders to enhance co-ordination and efficiency.8 Civil Contingencies Act 2004, Section 2{CAB00004616/2}; Explanatory Memorandum to Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005, paragraph 7.2 {HOM00000492/4}. Category 2 responders are required to co-operate with Category 1 responders in connection with the performance of their duties.9 Civil Contingencies Act 2004, Section 2(1) {CAB00004616/2}; Civil Contingencies Act 2004 (Contingency Planning) Regulations, Regulation 4(5) {CAB00007003/5}.
¶99.4 Government departments are not responders for the purposes of the Act. Bodies such as the TMO are also not subject to duties under the Act.
¶99.5 In London, Category 1 responders discharge their statutory obligations collectively through the London Resilience Forum ("the Forum") and work together within the Forum to assess the risk of an emergency of any particular kind occurring in London.10 Civil Contingencies Act 2004, Section 2(1)(a) and (b) {CAB00004616/2}. They are required to maintain plans for emergencies collectively within the Forum11 Civil Contingencies Act 2004, Section 2(1)(d) {CAB00004616/3}. and to maintain arrangements to warn the public and provide it with information and advice if an emergency is likely to, or has, occurred.12 Civil Contingencies Act 2004, Section 2(1)(g) {CAB00004616/3}.
10Ministerial intervention and emergency powers
¶99.6 Under Part 1 of the Act ministers have the power to make legally enforceable orders to reduce, control, or mitigate the effects of a local emergency, or take other action in connection with it, subject to an affirmative resolution of both houses of Parliament.13 Civil Contingencies Act 2004, Section 5(1) and 5(3); Civil Contingencies Act 2004, Section 17(2) {CAB00004616/7} and {CAB00004616/18}. Orders can require collaboration with a specified person or body or confer a power on a minister or some third party that would normally be exercised by a responder (Civil Contingencies Act 2004, Section 5(4) {CAB00004616/7}). They can also require or permit the disclosure of information, which would otherwise not be available (Civil Contingencies Act 2004, Section 6 {CAB00004616/8}). In cases of urgency, ministers can issue temporary written directions to responders, without any further formality, that remain binding for 21 days.14 Civil Contingencies Act 2004, Section 7 {CAB00004616/9}. Neither of those powers was used in connection with the Grenfell Tower fire. The Act also contains provision for making emergency regulations,15 Civil Contingencies Act 2004, Sections 19-31 {CAB00004616/20-28}. See also Responding to Emergencies: The UK Central Government Concept of Operations ("ConOps") {CAB00000026/66-67}. but those powers were not used either.
Subsidiarity
¶99.7 Part I of the Act and the Regulations are supplemented by statutory guidance entitled Emergency Preparedness, revised by the Cabinet Office in 2011. It deals with matters that must be considered before an emergency occurs (the so-called "pre-emergency phase") and describes the requirements of the Act and the Regulations.16 Emergency Preparedness: Chapter 1 {CAB00000079}; Chapter 2{CAB00007027}; Chapter 3 {CAB00004536}; Chapter 4 {CAB00004537}; Chapter 5 {CAB00004623}; Chapter 6 {CAB00007026}; Chapter 7 {CAB00004543}; Chapter 8 {CAB00004544}; Chapter 9 {CAB00004545}; Chapter 10 {CAB00004531}; Chapter 11 {CAB00004594}; Chapter 12 {CAB00004595}; Chapter 13 {CAB00004596}; Chapter 14 {CAB00004597}; Chapter 15 {CAB00004598}; Chapter 16 {CAB00004599}; Chapter 19 {CAB00004622}. The Act is further supplemented by non-statutory guidance entitled Emergency Response and Recovery, which gives guidance on how to respond to emergencies and what the recovery phase should entail.17 Emergency Response and Recovery {CAB00004519}.
¶99.8 The UK's approach to civil contingencies is based on the principle that decisions should be taken at the lowest appropriate level with co-ordination at the highest necessary level.18 Emergency Preparedness, Chapter 16 {CAB00004599/3} paragraph 16.1. In all cases, local agencies are considered to be the building blocks of response and recovery operations.19 Emergency Response and Recovery {CAB00004519/18} paragraph 2.4.1. The role of the government is to support and supplement the efforts of local responders through the provision of resources and co-ordination. The central and sub-national tiers of government only become involved in emergency response and recovery efforts where it is necessary or helpful to do so.20 Emergency Response and Recovery {CAB00004519/18} paragraph 2.4.2.
¶99.9 Emergency Response and Recovery states that humanitarian assistance is about ensuring that those involved in and affected by a major incident are properly cared for.21 Emergency Response and Recovery {CAB00004519/116} paragraph 7.1.1. That is likely to include the provision of basic shelter, information about what has happened, medical assistance and treatment, financial and legal support, psychosocial support, advice and direction on how to get further help and assistance, communication facilities to enable people to contact and meet each other, providing a link to a police investigation, where relevant, and providing a point of contact for longer-term support and advice.
11¶99.10 Emergency Response and Recovery also indicated that in this case RBKC (as the relevant local authority) should work with partners to provide immediate shelter and welfare for survivors who did not require medical support, their families and friends, through rest centres, humanitarian and other centres, in order to meet their immediate or short-term needs), to provide for the medium- to longer-term welfare of survivors (for example, by means of support from social services and financial assistance and also by providing helplines to answer questions from the public in one place), to facilitate the remediation and re-occupation of sites or areas affected by the emergency, to co-ordinate the activities of any voluntary sector agencies and spontaneous volunteers and to lead the recovery effort.22 Emergency Response and Recovery {CAB00004519/33-34} paragraph 3.2.34.
Guidance supporting the Act
¶99.11 In addition to the two core guidance documents, Emergency Preparedness and Emergency Response and Recovery, there are a large number of further guidance and policy documents which deal with various aspects of the civil protection regime and emergency response arrangements.23 {CAB00000010} sets out policies, procedures, plans and strategy documents of which the Civil Contingencies Secretariat considered as of potential relevance to the Grenfell Tower fire response. Hammond {CAB00014764/2} page 2, paragraph 8. They include Evacuation and shelter guidance,24 {CAB00004627}. Human Aspects in Emergency Management25 {CAB00000036}. and National Recovery Guidance.26 {INQ00015207}.
¶99.12 Katharine Hammond, then Director of the Civil Contingencies Secretariat (part of the Cabinet Office), told us that guidance and policy documents were made available to local responders through an online platform,27 Resilience Direct is the private web-based platform used by responders both in planning and in response and recovery. Hammond {CAB00014764/10} page 10, paragraph 33. but that many local responders also had hard copies.28 Hammond {Day280/139:18}-{Day280/140:4}. Although Ms Hammond could not recall any concern or complaint being raised about the complexity or quantity of guidance and policy documents or the general complexity of the civil contingencies framework,29 Hammond {Day280/140:11-25}. the guidance and policy documents are lengthy, numerous, and do not always define important concepts in the same way.
¶99.13 Emergency Preparedness states that emergency plans should have particular regard to the vulnerable (those with mobility difficulties, those with mental health difficulties or who are dependent on others, such as children) and to survivors and others affected (those directly affected by the emergency or the anxiety of not knowing what has happened).30 Emergency Preparedness, Chapter 5 {CAB00004623/39-40} paragraphs 5.97-5.103. Emergency Response and Recovery recognises that special consideration must be given to the needs of various of groups for care and support, with particular reference to four groups which can make challenging demands on responding agencies, namely, (i) children and young people, (ii) faith, religious, cultural and minority ethnic communities, (iii) elderly people and (iv) people with disabilities.31 Emergency Response and Recovery {CAB00004519/129-131} section 7.7.
12¶99.14 In addition, the Home Office issued guidance entitled The Needs of Faith Communities in Major Emergencies: Some Guidelines32 "Needs of Faith Communities in Major Emergencies" guidance {CAB00014865}. and the Cabinet Office issued guidance documents which specifically addressed the needs of vulnerable people,33 MacFarlane {CAB00014862/3-4} pages 3-4, paragraph 11; Emergency Preparedness, Chapter 5 {CAB00004623/39} paragraphs 5.98. including Identifying people who are vulnerable in a crisis,34 "Identifying People Who Are Vulnerable in a Crisis: Guidance for Emergency Planners and Responders", guidance, published in 2008, specifically refers to minority language speakers {CAB00014864/14} and the Disability Discrimination Act as "other legislation may interact with responsibilities under the Civil Contingencies Act" {CAB00014864/7} paragraph 11. Expectations and Indicators of Good Practice Set for Category 1 and 2 Responders35 "Expectations and Indicators of Good Practice Set for Category 1 and 2 Responders" guidance, revised in October 2013, lists giving special consideration to vulnerable people when producing plans as a "mandatory requirement" {CAB00004629/26} and reminds responders of the need to consider vulnerable groups when communicating with the public {CAB00004629/28}. and Preparation and planning for emergencies: responsibilities of responder agencies and others.36 "Preparation and planning for emergencies: responsibilities of responder agencies and others" guidance, published in February 2013 {CAB00014785}. We have not found it necessary to examine that further guidance in detail.
¶99.15 At the time of the Grenfell Tower fire, most of the Cabinet Office guidance did not refer to the Equality Act 2010 or to how responders should discharge their duties under it, including the public sector equality duty, when planning for emergencies.37 The Equality Act 2010 was identified in Annex C of Human Aspects in Emergency Management as a key piece of legislation that should be considered when planning for Humanitarian Assistance {CAB00000036/56}. In contrast and by way of example, at the London level the Act was referred to directly in the London Resilience Partnership's 2015 document "Identification of the Vulnerable: A Guidance Note for Local Implementation" {LFB00061174/6} paragraph 1.6 and the Humanitarian Assistance Framework, v.5 dated April 2017 {LFB00061172}. We observe that although the National Resilience Standards introduced in July 2018 now include one discrete reference to the Equality Act 2010,38 MacFarlane {CAB00014862/5} page 5, paragraph 14. the Act is not mentioned in either Emergency Preparedness or Emergency Response and Recovery. Nor is it listed in Chapter 19 of Emergency Preparedness, which addresses what is called "the fit with other legislation" but has not been revised since its publication in February 2011.39 Emergency Preparedness, Chapter 19 {CAB00004622}.
Risk assessment at national level
¶99.16 Since 2005 the Civil Contingencies Secretariat has produced a National Risk Assessment. Originally it was produced annually but since 2014 it has been produced biennially.40 McCloghrie {CAB00014798/2} page 2, paragraph 6. The assessment, which since 2019 has been incorporated into the National Security Risk Assessment, is a classified document which identifies what the government considers to be the most serious types of risks facing the United Kingdom over the coming five years. In order for a risk to be included, it must constitute a civil emergency within the meaning of the Civil Contingencies Act, be an event that could plausibly occur within the next five years and have an effect which exceeds a certain minimum level. There are usually between 70 and 100 risks identified in the NRA.41 McCloghrie {CAB00014798/3} page 3, paragraph 11.
¶99.17 The designated "owner" of each risk, normally a government department, is responsible for collecting evidence to inform the assessment and is required to work with experts from within and outside the organisation to gain a clear understanding of the risk and its consequences. The owner of the risk is required to use the information obtained in that way to identify a serious but plausible manifestation of the risk (known as "a reasonable worst-case scenario"),42 A reasonable worst case scenario (RWCS) is defined as a challenging yet plausible manifestation of the risk. Hammond {CAB00014799/5-6} pages 5-6, paragraph 17. the likelihood of its occurring and the potential effect if it were to do so.43 McCloghrie {CAB00014798/4} page 4, paragraph 13. The most recent edition of the National Risk Assessment before the Grenfell Tower fire had been completed in 2016 and released in February 2017.44 Hammond {CAB00014799/3} page 3, paragraph 8. At that time, the Home Office was the owner of the risk in relation to fire.45 Hammond {Day280/103ː1-17}; Hammond {CAB00014799/4} page 4, paragraph 10.
13¶99.18 The National Risk Assessment released in 2017 included in its risks a significant wildfire.46 McCloghrie {CAB00014798/10-11} pages 10-11, paragraph 36. It did not envisage a major fire in a high-rise building47 Edwards {HOM00050071/7-8} pages 7-8, paragraph 28. and no consideration appears to have been given to an event of that kind.48 Hammond {CAB00014868/2} page 2, paragraphs 7-8; Edwards {HOM00050071/8} page 8, paragraph 30. Luke Edwards, director of fire and resilience within the Crime, Policing and Fire Group at the Home Office,49 Edwards {HOM00050071/1} page 1, paragraph 3. was not aware that it had been considered50 Edwards {HOM00050071/8} page 8, paragraph 30. and Ms Hammond was unable to say whether a tower block fire had been considered and discounted or had not been considered at all.51 Hammond {Day280/107ː4-8}.
¶99.19 The National Risk Assessment was based in part on certain assumptions (the National Resilience Planning Assumptions), which establish the maximum expected scale, duration, and severity of the common consequences of the reasonable worst-case scenario described in the risk summaries.52 Hammond {CAB00014799/2} page 2, paragraph 4.3; Hammond {CAB00014799/10} page 10, paragraph 33. Examples include the number of casualties and the extent of disruption to certain essential services.53 Hammond {CAB00014799/16-17} pages 16-17, paragraph 55.
¶99.20 The National Risk Assessment and the National Resilience Planning Assumptions together form the basis of the National Risk Register, which is a public document54 Hammond {CAB00014764/6} page 6, paragraph 22. used by local responders and local resilience forums to inform their own risk assessments and planning assumptions. The National Risk Register current at the time of the Grenfell Tower fire, published in March 2015,55 National Risk Register 2015 {CAB00007009}. identified the risk of severe wildfires but did not identify the risk of a major fire in a high-rise building.56 National Risk Register 2015 {CAB00007009/27-28}.
¶99.21 Ms Hammond said that although the National Risk Assessment issued in 2016 did not identify a significant urban fire (including a fire in a tower block), a number of reasonable worst-case scenarios indicated the need to plan for outcomes very similar to those seen at Grenfell Tower. That in turn should have meant that the omission of an urban fire did not prejudice the ability of Category 1 and Category 2 responders to make a fully informed local risk assessment.57 Hammond {Day280/114ː8-15}.
¶99.22 Ms Hammond accepted, however, that the inclusion of an urban or tower block fire in the 2016 version of the National Risk Assessment would have provided a focus for responders58 Hammond {Day280/133ː2-7}. and we consider that it would have significantly increased the likelihood of its inclusion in documents such as the London Risk Register, to which we come later. We note that the version of the Local Risk Management Guidance produced by the Civil Contingencies Secretariat in 2016, which was intended to help Category 1 and 2 responders fulfil their local risk assessment duties and provide advice on how best to use information from the 2016 National Risk Assessment in a local context,59 Hammond {CAB00014799/13-15} pages 13-15, paragraphs 45-49. directed responders to consider which of the risks identified in the National Risk Assessment were relevant to their own areas.60 Hammond {CAB00014799/14} page 14, paragraph 48.1.
14¶99.23 The Civil Contingencies Secretariat is also responsible for the management of the online database which acts as a single repository of information obtained from a variety of sources which is thought to provide lessons for the future.61 MacFarlane {CAB00014794/10} page 10, paragraph 35. Known as the Joint Organisational Learning system, it is specifically intended to meet the need to capture, promulgate and implement lessons learnt from major incidents.62 MacFarlane {CAB00014794/10} page 10, paragraph 35. However, at the time of the Grenfell Tower fire the database did not include any lessons learnt from earlier incidents involving fires in high-rise buildings, such as the Lakanal House fire in July 2009, the Shirley Towers fire in Southampton in 2010 or the Adair Tower fire in October 2015.63 MacFarlane {CAB00014803/3} page 3, paragraph 7. Ms Hammond, who was not in post at the time of those incidents, did not know why lessons learnt from them had not been included.64 Hammond {Day280/120ː2-14}. It is not clear whether an urban or tower block fire would have merited inclusion as a separate risk in the 2016 version of the National Risk Assessment, but we are concerned that the omission from the database of lessons gained from any urban fires may have limited the material available to inform the assessment of risks.
¶99.24 Following the Grenfell Tower fire, the National Risk Register issued in September 2017 was revised to include the risk of fire in a residential building, with specific mention of the Grenfell Tower fire.65 National Risk Register 2017, "Industrial and Urban Accidents" {CAB00000069/46-49}. See also the National Risk Register 2020 "Major Fires" {INQ00015149/83-86}. In that edition the "Major Fires" chapter is separate to the chapter on "Industrial Accidents". A Home Office witness explained that the decision to include it was made in the light of the widespread use of combustible cladding and the new understanding that other buildings might be at risk. It was thought that using the publicly available National Risk Register was a sensible way of communicating those matters more widely.66 Edwards {HOM00050071/9} page 9, paragraph 32. The National Security Risk Assessment completed in 2019, the most recent version of the National Risk Assessment, includes the example of a fire in a high-rise residential building as the reasonable worst case scenario for a fire risk, with the risk of wildfire remaining as an alternative.67 McCloghrie {CAB00014798/12} page 12, paragraph 40. The inclusion of an urban fire has also resulted in some small changes to the National Resilience Planning Assumptions, for example, a major fire is now a risk to consider in the planning assumption for rubble, debris, and trapped people.68 McCloghrie {CAB00014798/12} page 12, paragraph 40. Ms Hammond told us that the Civil Contingencies Secretariat had a better understanding of the fire risk which had been improved by revised Home Office modelling following the Grenfell Tower fire. As a result, it was now recognised that the consequences of a major tower block fire were more significant than had previously been assessed.69 Hammond {CAB00014799/20} page 20, paragraph 65.
¶99.25 Local resilience forums are responsible for risk assessments in their areas. The London Resilience Forum discharges the statutory duties in relation to Greater London to assess risks across London and maintain plans for responding to them.70 Civil Contingencies Act 2004, Section 2(1)(d) {CAB00004616/2-3}.
15The London Risk Register
¶99.26 The London Risk Register is developed in a way that is consistent with the National Risk Register71 Hetherington {LFB00119130/14} page 14, paragraph 44. and provides an overview of the principal risks which may affect London as a whole.72 Hetherington {Day277/109:11-23}. The register completed in February 2017 and therefore current at the time of the Grenfell Tower fire did not refer to the risk of a major fire in a residential tower block, although it did refer to the risk of a severe wildfire.73 London Risk Register v.5.4, 2017 {LFB00061165/13}. That was because a residential tower block fire had not been included in the register since it had not been included in the National Risk Register and had not been identified by the London Risk Assessment Group as a risk that required a London-wide approach.74 Hetherington {Day277/110:14-24}.
¶99.27 When it revised the London Risk Register in February 2017, the London Risk Assessment Group did not consider whether the fires at Lakanal House in July 2009 and Adair Tower in 2015 had altered the level of risk presented by a tower block fire in London, it seems because it had not been alerted to the fact that it might need to take account of those fires.75 Hetherington {Day277/111:1-11}. The responsibility to feed that risk into the process for compiling the London Risk Register rested with the relevant Category 1 responders, the London Borough of Southwark in the case of the Lakanal House fire and RBKC in the case of the Adair Tower fire.76 Hetherington {Day277/116:17-25}. In addition, the LFB, which had primary responsibility for identifying risks relating to fire in London, had not alerted those responsible for the London Risk Register to the risk of a major tower block fire.77 Hetherington {Day277/128:5-25}. As of May 2022, the London Resilience Group had still not given any consideration to those omissions.78 Hetherington {Day277/117:1-3}.
¶99.28 When he gave evidence, John Hetherington, then deputy head of the London Resilience Group,79 Hetherington {LFB00061158/2} page 2, paragraph 5; Hetherington {Day277/7:1-10}. accepted that the risk of a high-rise or urban tower block fire should have been included as a separate entry on the London Risk Register before June 2017 and that its absence was a serious failing.80 Hetherington {Day277/121:12-19}. We agree. The fires at Lakanal House and Adair Tower, not to mention the fires that had occurred in high-rise buildings abroad, ought to have prompted consideration of that risk which should have been taken into account by those responsible for the London Risk Register as part of their assessment and incorporated into it.
16¶99.30 The Borough Risk Register issued in December 2016 described itself as a "living document" that was to be revised and updated as and when required.84 {RBK00036688/8} section 2.3. There appears to have been little or no consideration of the inclusion of the risk of fire in a high-rise building, despite the history of fires in buildings of that kind in London, including the Adair Tower fire in October 2015 (which happened within RBKC's resilience jurisdiction) and the Lakanal House fire in 2009.85 Kerry {Day268/23:11-17}. Although the regulatory framework requires Category 1 responders to consider risks specific to their locality, it is apparent from the evidence of David Kerry86 Kerry {Day268/22:17}-{Day268/23:10}. that significant reliance was placed on the London Risk Register instead of the Borough Risk Register.87 Also referred to as the Community Risk Register {RBK00036688/8} section 2.2.
¶99.31 In our view, tower block fires should have been included in both the London and Borough risk assessments. Government tools (such as the Joint Organisational Learning online database) were defective and Ms Hammond's expectation that the planning assumptions would act as a "safety net", catching any gaps in the reasonable worst-case scenarios, did not reflect the reality of local risk assessment. If there had been a reference to a tower block fire in the National Risk Register, as there now is, it is likely that local risk assessors would have been prompted to consider the risks in detail.
17Chapter 100: Personal experiences
Introduction
¶100.1 It is appropriate that we begin our description of the response to the Grenfell Tower fire by recounting in their own words the personal experiences of those who were most directly affected. RBKC, as a Category 1 responder, had a responsibility to ensure that the needs of those affected by the fire were properly met. For that reason, the quality and effectiveness of the response must be judged in a large part by their experience. We recognise that, although many people were affected in similar ways, the experience of each person was unique and that recollections may be affected in many different ways. Although we do not doubt the sincerity and honesty of those who gave evidence, it has not been possible for us to obtain specific responses from those who were seeking to provide help and who might wish to put forward a different perspective. This chapter should therefore be read with that in mind. It should be understood as an account of the experiences of people who had suddenly lost their homes and all their possessions and were entirely dependent on others to satisfy their basic needs.
¶100.2 We received 220 witness statements dealing with the response to the fire. We also heard oral evidence from Karim Mussilhy, Hisam Choucair, Mahmoud Al-Karad, Mohammed Rasoul, Mouna El Ogbani, Fatima Boujettif, Hanan Cherbika, Nabil Choucair and Hanan Wahabi. An extensive thematic summary of the evidence of all those who had provided statements was read during the hearings.88 {Day264/108:21}-{Day264/213:12}; {Day267/41:16}-{Day267/93:10}. That substantial body of evidence has enabled us to examine in detail the steps taken by RBKC, London Gold, the TMO and the government to provide humanitarian relief.
¶100.3 Although our investigations have concentrated on the seven days following the fire, we acknowledge that it continues to have a searing effect every day on many of those affected. We are extremely grateful to those who have shared their experiences with us and thank them for their courage and dignity in recounting them.
¶100.4 Taken as a whole, the evidence portrays a community whose lives have been changed forever by the fire. We learnt much of the immediate effects of the fire and of the long- lasting trauma that so many have experienced and still do. Those affected include, but are not limited to, survivors who escaped from the tower, residents of the tower who lost their homes, those who lost loved ones and those who were evacuated from nearby properties, some of whom also lost their homes. Such is the closeness of the local community that many survivors and residents are also bereaved, having lost loved ones, friends and neighbours. It is clear to us that they were, and, most importantly, felt themselves to have been, comprehensively failed by those to whom they looked for protection in the wake of a major disaster. Safety and security are as much to do with the perceptions of those affected as they are with the actions of those responsible for providing protection.
18The early hours
¶100.5 While the emergency services were fighting the fire, survivors, residents of the tower and those evacuated from surrounding properties89 Residents were evacuated from Grenfell Walk, Treadgold House, Hurstway Walk, Barandon Walk and Testerton Walk. Residents were also evacuated from Bramley House but not for an extended period and did not require accommodation. were abandoned without information about where to go or what to do.90 Levi {IWS00001753/8-9} pages 8-9, paragraphs 34 and 36; Dainton {IWS00000939/12} page 12, paragraph 80; John {IWS00001681/2-3} pages 2-3, paragraph 11; Adam {IWS00001301/10} page 10, paragraph 85; Khalloud {IWS00001754/5} page 5, paragraph 24. There was "absolute chaos and confusion everywhere".91 Sadafi {IWS00001806/3} page 3, paragraph 8. The scene was described as a "horror film"92 Mussilhy {Day264/17:7-8}. and a "war zone".93 Cherbika {Day266/89:5}. Mr Mussilhy told us that the area was "engulfed"94 Mussilhy {Day264/20:5}. with people and, given the chaos on the street, he expected to see people in authority with high-visibility jackets and clipboards, but there was nobody.95 Mussilhy {Day264/22:2-21}. Such was the confusion about what to do or where to go that some survivors96 Moghaddam {IWS00001266/4} page 4, paragraphs 14 and 15. and residents of the walkways slept in their cars.97 Ranito {IWS00001256/4-5} pages 4 - 5, paragraphs 22 and 23. Other residents waited for hours for buses that they had been told would be coming to take them to a rest centre,98 Ahmed {IWS00001335/129} page 129, paragraph 358. but instead they had to walk in the early hours to rest centres that had opened spontaneously nearby.99 Thompson {IWS00000158/10} page 10, paragraph 60.
¶100.6 In the absence of timely support from the authorities, members of the community took it upon themselves to open informal rest centres. They organised themselves quickly in an effort to meet a diverse range of needs.100 The response of the community, voluntary and faith sectors is examined in Chapter 106. Community centres were filled with people with nowhere to go trying to find shelter. Although community rest centres did their best to support those affected, some were forced through overcrowding to refuse entry to those who were not survivors.101 Moses {IWS00001276/14} page 14, paragraph 97; Cherbika {Day266/87:21-24}. Some survivors had to sleep in rest centres,102 Khoudair {IWS00001616/11} page 11, paragraph 33; Alfawaz {IWS00001274/7} page 7, paragraph 55; John {IWS00001685/8} page 8, paragraph 33. while some of those who lived in the walkways were left wandering the estate, displaced and unable to return home.103 Ranito {IWS00001256/4-5} pages 4 - 5, paragraphs 22 and 23.
¶100.7 In the absence of anyone apparently in authority104 Ramiro Urbano {IWS00000496/8} page 8, paragraph 45. or any information, survivors and residents were left to fend for themselves, having experienced the shock of the fire and in many cases searching frantically for loved ones. So far as they could see, the council and the TMO had "vanished" in the immediate aftermath of the fire105 Chiapetto {IWS00001780/4} page 4, paragraph 15. and were conspicuous by their absence.106 Abebe {IWS00000847/10} page 10, paragraph 31. Although RBKC began to assemble a presence in and around the tower from about 2.30am107 Nick Layton (LALO) Initial Log {RBK00014632/1}. and the TMO from 3.30am,108 Summary of Actions taken by the TMO Document {TMO00899668/1}. they were not clearly visible to those who might need them.
19Emergency accommodation
¶100.8 Many of those who had lost their homes experienced a number of problems with emergency accommodation. They included uncertainty about how long they might have to stay in hotels, unsuitable rooms, problems with the provision of suitable food, the distance of hotels from the community and failures to provide for particular needs.
¶100.9 The initial allocation of accommodation was confused and inconsistent. Some of those affected were allocated emergency accommodation in community rest centres, as RBKC sent representatives to the Rugby Portobello Trust and the Clement James Centre. Ms Wahabi told us about her experience of being allocated hotel accommodation at the Rugby Portobello Trust on 14 June 2017. She said that there had been no clear system for the allocation of emergency accommodation. She described feeling like "cattle just coming through".109 Wahabi {Day267/111:10}-{Day267/112:14}. The interviews lacked privacy, empathy and humanity and were described by some as being undertaken in a robotic and formulaic way.110 Wahabi {Day267/111:10}-{Day267/112:14}; Simms {Day275/193:15-17}. The lack of any system meant that individual needs could not be catered for.
¶100.10 RBKC housing teams were sent only to the Rugby Portobello Trust and the Clement James Centre.111 Laura Johnson {RBK00035592/8} page 8, paragraph 33. Although TMO staff were sent to more community rest centres, they did not visit some important places, such as the Al Manaar Muslim Cultural Heritage Centre or St Francis of Assisi church.112 TMO Staff Cover on 14 June 2017 {TMO00869981}; Brown {Day274/31:10-25}. That contributed to a lack of awareness amongst those affected of what support with accommodation was available and where.
¶100.11 Some survivors had to wait for days before being allocated accommodation.113 Yousuf {IWS00001626/3} page 3, paragraph 14; Alves {IWS00001596/10} page 10, paragraph 53; El-Guenuni {IWS00002034/8} page 8, paragraphs 31. Others were not contacted about their emergency accommodation until two weeks after the fire and in the meantime had to make their own arrangements.114 Patel {IWS00001610/10} page 10, paragraph 49.
¶100.12 A particular concern was the lack of information about accommodation for those who had been taken to hospital. Some survivors were discharged with no information about where to go.115 Alhaj Ali {IWS00001533/12-13} pages 12 - 13, paragraphs 62 and 63. One family attended the Town Hall to try and get some information but were told to come back the following day as there was nobody available.116 Abdulhamid {IWS00001919/3} page 3, paragraph 16.
¶100.13 For those who were allocated emergency accommodation there was often a lack of support in getting there. Some survivors were given oyster cards;117 Abdulhamid {IWS00001919/3} page 3, paragraph 16. others were just told by telephone that a room had been made available to them but were given no information about how to get there. Many had no money and only the clothes they stood up in.118 Moses {IWS00001281/9} page 9, paragraph 47. Some people arrived at the designated hotel only to find that it did not have a booking for them119 Ali {IWS00001617/12} page 12, paragraph 144. and that they had to go and stay with friends.120 Alves {IWS00001587/18} page 18, paragraph 93. Due to booking errors, one former resident of the tower went to three different hotels before arriving at the right one.121 Batoon {IWS00001687/11-12} pages 11 - 12, paragraph 47.
20¶100.14 The emergency accommodation arranged by RBKC was in many cases wholly inadequate. Many were distressed to find that they had been placed in rooms on high floors.122 Thompson {IWS00002110/33} page 33, paragraph 120; Burton {IWS00001661/24} page 24, paragraph 129; Yahya {IWS00000498/8} page 8, paragraph 32; Hamide {IWS00001651/4} page 4, paragraphs 17 and 18. Those affected described how the rooms allocated to them were small and unsuitable.123 Mohamed {IWS00001545/11} page 11, paragraph 47; Abdu {IWS00001956/10} page 10, paragraphs 52 and 53; Yousuf {IWS00001626/3} page 3, paragraph 14. Families of four124 Alves {IWS00001587/18} page 18, paragraph 91; Chebiouni {IWS00001979/5} page 5, paragraph 24. and five125 Yahya {IWS00000498/8} page 8, paragraph 32; Adam {IWS00001301/12} page 12, paragraph 100. were given one room126 Rasoul {Day265/156:1-7}. with a double bed. One couple was given a single room with a single bed and had to wait for a double room a month later.127 Kabouh {IWS00001613/6} page 6, paragraph 30. Insufficient space in rooms meant that on one occasion a member of a family had to sleep on the sofa in the hotel reception.128 Jamalvatan {IWS00001704/5} page 5, paragraph 21.
¶100.15 The council did not tell people who had been placed in hotels how long they would be able to stay there,129 Macit {IWS00001563/12} page 12, paragraph 52; Shaw {IWS00001752/8} page 8, paragraph 39; El-Sawy {IWS00001829/7} page 7, paragraph 31. which added significantly to the anxiety that people were experiencing at that difficult time.130 Ho {IWS00001551/20} page 20, paragraph 82. One family with three children were placed in a hotel on 17 June 2017, but were told the next day that they had to find alternative accommodation for themselves.131 El-Guenuni {IWS00002034/9} page 9, paragraph 34. Many were told that they were booked in for only one night and had the uncertainty of not knowing whether the booking was going to be extended.132 Quang {IWS00001821/12} page 12, paragraphs 58. Some received notes under their doors saying they were booked in for another week133 Daniels {IWS00002065/15} page 15, paragraph 99. but others had a note left on the door giving them just a few hours to leave.134 Sadafi {IWS00001806/23} page 23, paragraph 73. Ms El-Ogbani put it particularly vividly. She told us that the uncertainty was "really stressful and made us really angry, because you don't know how you're going to live the next day … our future was blank".135 El-Ogbani {Day266/22:14-16}.
¶100.16 Although hotel placements were intended to be emergency accommodation, for many their stay was not temporary or short-term. Some people lived in inadequate and unsuitable conditions for months,136 Pasztor {IWS00001682/4} page 4, paragraph 17 (7-8 months); El-Sawy {IWS00001829/8} page 8, paragraph 34 (9 months); Ollivierre {IWS00001758/6} page 6, paragraph 26 (9 months); Elbouti {IWS00001605/11} page 11, paragraph 50 (10 months). and in some cases longer,137 Lopez {IWS00001680/8} page 8, paragraph 48 (14 months); Rasoul {Day265/154:14} (19 months); Cherbika {Day266/102:5} (just over a year); Hanan Wahabi {Day267/113:25}-{Day267/114:3} (18 months); Chebiouni {IWS00001979/6} page 6, paragraph 34 (18 months). while trying to rebuild their lives.
¶100.17 Some survivors and residents of the area surrounding the tower were accommodated in places far from their former homes. That created a sense of loneliness and isolation.138 Al-Karad {Day265/111:17-19}; Chiapetto {IWS00001780/3} page 3, paragraph 10; Pahlavani {IWS00001244/14} page 14, paragraph 42. Some survivors were allocated accommodation as far away as Wandsworth and described an "acute sense of being completely isolated".139 Demissie {IWS00001540/6} page 6, paragraph 21. They felt they were being ignored and "moved further and further away".140 Lukic {IWS00001760/6} page 6, paragraph 25. No account appeared to have been taken of the need for people to be close to hospitals in order to visit their relatives141 El-Guenuni {IWS00002034/9} page 9, paragraph 35. some of whom were in a critical condition.142 Gomes {IWS00001078/39} page 39, paragraph 203. Some described having to use two or three taxis each day for hospital visits, which was expensive and inconvenient.143 Neda {IWS00001302/3} page 3, paragraph 15. As a result, many people struggled to visit rest centres and hospitals as well as taking their children to school.144 Hassani {IWS00001636/17-18} pages 17 - 18, paragraph 72; Khalloud {IWS00001754/6} page 6, paragraph 31. Those affected described how stressful it was having to return to the area in order to visit the rest centres to obtain support.145 Ignacio {IWS00001820/15} page 15, paragraph 78.
21¶100.18 When arranging emergency accommodation RBKC failed to give sufficient consideration to the needs of particular groups. In some cases cots were not available for those with babies or young children146 Mensah {IWS00001944/9} page 9, paragraph 43. nor any means of sterilising babies' bottles147 Ignacio {IWS00001820/14} page 14, paragraph 70. or making up bottles of milk.148 Cherbika {Day266/104:15}-{Day266/105:8}. No consideration appeared to have been given to the needs of children or to the importance of space for homework and play.149 Cherbika {Day266/102:15}-{Day266/103:9}; Cherbika {Day266/119:9-20}; Chebiouni {IWS00002043/6} page 6, paragraph 35; Chebiouni {IWS00002043/8} page 8, paragraph 52. Some pregnant women were not given sufficient consideration; one was forced to sleep on a sofa or the floor because the only bed in the room was too high for her to get into it.150 Adam {IWS00001296/4} page 4, paragraph 23. Some of those who had restricted mobility struggled with their accommodation because it was not adapted to their needs, for example, by having a walk-in shower151 Moses {IWS00001281/10} page 10, paragraph 54; Rasoul {Day265/157:13-25}. or a bed lever.152 Lokko {IWS00001516/4-5} pages 4-5, paragraph 34. At the time of the fire, many of those who lived in and around the tower were observing Ramadan, but halal food was not available at all hotels153 Moses {IWS00001281/10} page 10, paragraph 58. and it was not possible to observe the requirement to eat at set times.154 El Amine {IWS00001946/10-11} pages 10-11, paragraph 46; El-Ogbani {Day266/23:20}-{Day266/24:5}; Choucair {IWS00001799/15-16} pages 15-16, paragraph 20(c). People relied on the provision of food and support from the community.155 Chebiouni {IWS00002043/6} page 6, paragraph 39; Jones {IWS00001691/5} page 5, paragraph 24.
¶100.19 An illustration of these difficulties was provided by Mr Rasoul. He told us in graphic terms how the needs of his elderly father with disabilities and of his children were not adequately assessed by RBKC in the immediate aftermath of the fire and that the support they needed had not been provided, despite their "lives being turned upside down" and the fact that they were grieving.156 Rasoul {Day265/171:19-25}-{Day265/172:1-5}.
¶100.20 There was significant confusion about whether food was available for survivors and residents at hotels and if so of what kind. One survivor, who lost her son in the fire, told us that she did not know what she was entitled to and so restricted herself to just one meal a day.157 Shawo {IWS00001290/4} page 4, paragraph 25. Some heard that the council would only pay for drinks, so they only ordered drinks.158 Lewis {IWS00001629/6} page 6, paragraph 25. Others spent their own money on food159 Al-Assad {IWS00001789/11} page 11, paragraph 67. because they did not become aware until a month after the fire that food would be paid for.160 Araya {IWS00001648/4} page 4, paragraph 20. Mr Rasoul told us that he had not been aware for several weeks that food was available.161 Rasoul {Day265/159:13-23}. The arrangements for obtaining food at some hotels made some people feel like refugees.162 Ortiz {IWS00001283/7} page 7, paragraphs 51 and 53.
22¶100.21 Other basic facilities, such as the means of laundering clothes, were not available.163 El-Ogbani {Day266/25:1-5}; Khalloud {IWS00001754/6} page 6, paragraph 30. Families had to pack their laundry into black bags and suitcases and take it to the laundrette in a taxi, which they felt was demeaning and humiliating. The picture we saw was that of a vulnerable group of people facing not only the shock, grief and trauma of the fire itself but also, as an immediate priority, the need to satisfy the most basic of their daily needs. Survivors described it as living in limbo, with no space to heal.164 Rasoul {Day265/160:10}-{Day265/161:5}.
The Walkways: the forgotten residents
¶100.22 Adjoining Grenfell Tower were a number of low-rise residential buildings known locally as 'The Walkways'. The Walkways consisted of Hurstway Walk, Barandon Walk, Testerton Walk and Grenfell Walk. Treadgold House was not one of the Walkways but its residents were also evacuated and displaced.165 Brown {TMO00869990/4} page 4, paragraph 18; Brown {TMO00894124/17-18} pages 17 - 18, paragraphs 60 and 61; Exhibit TB/59 {TMO00894203/2}. While the council grappled with its response to the needs of those displaced from the tower, residents from the surrounding properties said they felt forgotten.166 Sang {IWS00001939/11} page 11, paragraph 55.
¶100.23 In the days after the fire, responsibility for the residents evacuated from the surrounding properties appears to have been informally delegated by the council to the TMO. However, the numbers were huge: about 845 people had been displaced and were in need.167 Exhibit TB/11 {TMO00869977/2}; Brown {TMO00894124/17} page 17, paragraph 60. The TMO was singularly ill-equipped to deal with so many people. Residents described how in the provision of emergency accommodation their needs took second place.168 Boujettif {Day266/75:1-14}. Although they had been displaced from their homes, their needs were considered to be less important.169 Archid {IWS00001618/15} page 15, paragraph 83. They were left in an invidious position, unable to return to their homes while the cordon remained in place but with insufficient hotel rooms available to accommodate them all. Many sought help from family and friends. Not all were so fortunate and some displaced residents were left sleeping on the grass by the Walkways close to the tower.170 Dowlut {IWS00001787/10-11} pages 10-11, paragraphs 37, 38 and 39; Wake {IWS00001642/5} page 5, paragraph 18.
¶100.24 Residents of the Walkways voiced their resentment at the way in which the council determined eligibility for the provision of support, including emergency accommodation, noting that "trauma does not work along strict geographical lines".171 Bedford {IWS00001652/8-9} pages 8 - 9, paragraph 32. However, allocation of emergency accommodation to this group of residents was haphazard. Exceptionally, some residents were allocated accommodation at the Westway Centre as early as 14 June 2017.172 Novell {IWS00001288/10} page 10, paragraph 57. Those who were allocated hotel accommodation were placed much later on.173 Rullo {IWS00001655/9} page 9, paragraph 36. One resident of the Walkways was advised to stay at the Westway Centre despite being pregnant and having three children, aged one, six and twelve.174 Raihani {IWS00001263/2} page 2, paragraph 10. She was not placed in a hotel for two weeks.175 Raihani {IWS00001263/5} page 5, paragraph 22. Residents had to take the initiative to approach the council to try to secure a place in a hotel. For some that took a few weeks176 Al-Assad {IWS00001789/9} page 9, paragraph 54. but others were not placed in emergency accommodation until (in some cases) as late as October 2017.177 Lara {IWS00001589/11} page 11, paragraph 41.
23¶100.25 Others were actively denied emergency accommodation. One resident was told she should sleep on a friend's sofa;178 Richer {IWS00001253/11} page 11, paragraph 51. another family who lived in Testerton Walk were refused emergency accommodation by a representative of the council at the Westway Centre, because they lived "too far" from the tower, even though their neighbours were offered a place in a hotel immediately.179 Lasharie {IWS00001546/5-6} pages 5-6, paragraph 24.
¶100.26 Some Walkway residents tried to ask for accommodation through the council's housing line, with unsatisfactory results.180 Stergiopoulou {IWS00001586/11} page 11, paragraph 43. One resident called the phone line three times because the council had failed to respond to her enquiries. She was told not to call again as she was not a priority and that she was taking up the line.181 Hessel {IWS00001645/8} page 8, paragraph 33. Others had similarly miserable experiences and were told a hotel would be organised for them, only for no one to follow up or call them back.182 Gil {IWS00001679/7} page 7, paragraph 56; McMahon {IWS00001966/10} page 10, paragraph 43. One resident was able to secure emergency accommodation only when he mentioned his partner's chronic health condition, and even then the hotel to which they were sent was available for only one night.183 Ranito {IWS00001249/8} page 8, paragraph 39. The residents of the Walkways understood very well that many people needed help but they too were in shock and despair and needed somewhere to stay.184 Hessel {IWS00001645/8-9} pages 8 - 9, paragraph 33. Several of them did not know that emergency accommodation was available185 John {IWS00001681/3} page 3, paragraph 15. and did not ask for it.186 Hartley {IWS00001257/11} page 11, paragraph 43. At least one booked his own hotel accommodation as the only alternative was to stay at a rest centre, which he thought would have an adverse effect on his mental health.187 Norbert {IWS00001252/8} page 8, paragraph 41. One walkway resident who used a wheelchair was never made aware of the availability of emergency accommodation. He stayed at his sister's home for three to four days and then returned home to Barandon Walk where there was no hot water or proper wheelchair access.188 John {IWS00001681/3-4} pages 3 - 4, paragraphs 17, 20 and 21.
The lifting of the cordon
¶100.27 Among the residents of the Walkways there was a general state of confusion and uncertainty about whether it was safe to return to their homes.189 Hartley {IWS00001257/11} page 11, paragraphs 41 and 42; Levi {IWS00001753/12-13} pages 12 - 13, paragraphs 52 and 53; El-Sawy {IWS00001829/5} page 5, paragraph 22; Yahya {IWS00001825/10} page 10, paragraph 50. On the day after the fire, TMO staff told some residents that they could return at their own risk, but did not explain what the risks were or suggest any alternatives.190 Serroukh {IWS00001747/5} page 5, paragraph 22. Some residents received a text message later in the week saying they could return home, but when they tried to do so were denied access by the police.191 Boujettif {Day266/67:7-14}.
24¶100.28 Having nowhere else to go, some residents returned to their flats to find that there was no hot water or heating,192 John {IWS00001681/4} page 4, paragraphs 20-22. which was particularly difficult for those with small children.193 Serroukh {IWS00001747/5-6} pages 5 - 6, paragraphs 23 and 24. They were left to use the showers at Virgin Active194 Serroukh {IWS00001747/6} page 6, paragraph 24. and the Westway Centre.195 Archid {IWS00001618/14} page 14, paragraph 79. Other residents returned home on 15 June 2017 and were allowed in, only to be told later in the afternoon that they had to leave again.196 O'Connell {IWS00001574/5} page 5, paragraph 17.
¶100.29 The residents of Grenfell Walk were in a different position from that of other residents evacuated from nearby properties, in that, like the residents of Grenfell Tower, they needed to be resettled in new accommodation.197 Procedure Note for Resettlement Packages {RBK00028643}. The council does not appear to have fully understood that fact when it came to the provision of humanitarian assistance.198 Cherbika {Day266/116:23}-{Day266/117:23}. Ms Cherbika told us that "we needed help desperately, and every door we kept going to was closed because we wasn't bereaved or wasn't a survivor … we was in between. We didn't come out of the tower, but we couldn't also go back to our properties, so we were homeless, but nobody was helping…".199 Cherbika {Day266/117:16-23}. Some residents said that the difference in treatment between residents of the tower and residents of the Walkways created "hierarchy and a division" within the community which, before the fire, had been one.200 Moses {IWS00001276/13} page 13, paragraph 92.
The Westway Centre
¶100.30 The Westway Centre initially opened spontaneously as a rest centre.201 Norman {CFV00000061/2} page 2, paragraphs 2a- 2d. Staff responsible for its management said that no official support had been offered in the initial hours of the first day.202 Norman {CFV00000061/4} page 4, paragraph 2l. Representatives from RBKC and the TMO attended later on 14 June 2017203 Norman {CFV00000061/4} page 4, paragraph 2m. when it became the official rest centre in an attempt to concentrate support in one place. However, there were serious shortcomings in the way the centre was set up and managed, which meant that those who needed it encountered significant difficulties in obtaining immediate humanitarian support. We examine those shortcomings in Chapter 104. They included displaced residents being denied entry, a lack of clarity about the services available, a need for people to provide the same information on several occasions to obtain support of different kinds and an absence of staff representing those in authority, such as RBKC and the TMO.
¶100.31 Those working in the Westway Centre did not know that residents had been evacuated from nearby properties and that some had lost their homes. Many of those who went to the centre were therefore initially refused help.204 Gomez {IWS00001264/8} page 8, paragraphs 53 and 54. Some were denied entry altogether.205 Moussaid {IWS00001282/5} page 5, paragraph 25; Moses {IWS00001276/14} page 14, paragraph 99. Cherbika {Day266/89:16}-{Day266/91:4}.
¶100.32 A number of residents and survivors had difficulty gaining entry to the Westway Centre after a registration system was introduced on 14 June 2017.206 Girma {IWS00001732/12} page 12, paragraph 23. Many displaced people were asked to provide evidence of identity in order to enter the centre, despite the fact that they had lost everything in the fire. Sometimes those running help desks insisted on the production of identification documents before they would provide help.207 Thompson {IWS00002110/34} page 34, paragraph 123. Gaining access to the centre was considered so difficult that some residents had to "sneak in" after they had been refused official entry.208 Hirsi {IWS00001776/4} page 4, paragraph 11.
25¶100.33 Community leaders who visited the Westway Centre, described a multiple-choice system where people were asked "Are you a survivor, are you bereaved, or are you a visitor?"209 Simms {Day275/211:15-20}. The process was described as astonishingly perfunctory and without compassion.210 Simms {Day275/211:22-25}.
¶100.34 As part of the verification process, the Red Cross gave people wristbands on entry.211 Ranito {IWS00001249/7-8} pages 7 - 8, paragraph 37. Some residents were concerned that that made them easily identifiable in the street, including by journalists, and did not like being "marked" and given a new wristband every day.212 Vieiro {IWS00001798/12} page 12, paragraph 50; Dainton {IWS00001974/31} page 31, paragraph 177.
¶100.35 The experiences of those who came to receive support at the Westway Centre were not happy. The physical layout of the space was confused and the centre lacked basic systems for processing the influx of donations and signs to direct people to services of different kinds.213 Alves {IWS00001587/16} page 16, paragraph 83. Some survivors who had lost loved ones arrived at the Westway Centre after being discharged from hospital but did not see anyone from the council and were not given any help.214 Alhaj Ali {IWS00001533/12-13} page 12 - 13, paragraphs 62 and 63; Jolly {IWS00001621/6-7} page 6-7, paragraphs 30 and 31. Although the council had a desk there, its staff appeared to be "powerless" as they could not offer any support to those affected other than emergency accommodation.215 Miller {IWS00001940/12} page 12, paragraph 52. The centre was described as lacking "warmth"216 Boujettif {Day266/71:12-14}. and its atmosphere as being "formal and bureaucratic".217 Dainton {IWS00001804/24} page 24, paragraph 152; Wahabi {Day267/131:9-18}. For example, one individual who was trying to find five loved ones was told to send an email.218 Patterson {CFV00000055/12} page 12, paragraph 44. For some, "it felt like a shelter for government representatives and the council staff rather than a refuge and support centre…".219 Girma {IWS00001732/12} page 12, paragraph 23. Consequently, residents and survivors preferred the rest centres run by the community, as they were more "community orientated".220 Wahabi {Day267/131:9-18}; Girma {IWS00001732/12} page 12, paragraph 23.
¶100.36 A particular problem with the way in which the Westway Centre was organised was that those in need of assistance had to go there and say what they needed in order to receive support. However, that meant that some of those who were injured, traumatised or isolated felt that they could not obtain what they needed when they should have been the priority.221 Jolly {IWS00001621/6-7} page 6 - 7, paragraphs 30 and 31; Richards {Day275/150:24}-{Day275/151:4}. We were told that "it felt as though rather than coming to us for support, we had to go to them."222 Girma {IWS00001732/12} page 12, paragraph 23. Some were thankful that they had been able to obtain some of the services available at the Westway Centre, such as replacement documents. Others, however, said that they felt very exposed. They complained of a lack of privacy and said that, because everything was happening in one place, it was overwhelming.223 Wahabi {Day267/130:18}-{Day267/131:5}.
26¶100.37 Some survivors slept at the Westway Centre in the first few days following the fire. It was described by one person as being like a "refugee camp",224 Ragab {IWS00001536/6-7} pages 6 - 7, paragraphs 29 and 30. with people sleeping on mats and donated mattresses on the tennis hall floor.225 Norman {CFV00000061/7} page 7, paragraph 4(g). One member of staff was concerned that no consideration had been given to the trauma people had experienced.226 Norman {CFV00000061/7} page 7, paragraph 4(g). It was described as a "very sad place to be" and "somewhere for people that did not have anywhere better to go."227 Lukic {IWS00001760/4-5} pages 4 - 5, paragraphs 18 and 19. The Jafari family remained at the Westway Centre for 10 days228 Jafari {IWS00001815/14} page 14, paragraph 64. and describe staying there as "horrific" due to the lack of privacy.229 Jafari {IWS00001815/13} page 13, paragraph 55.
¶100.38 Given their role in supporting those affected by the fire, many community leaders had the opportunity to observe the services being provided at the Westway Centre close at hand. Some were of the view that centralising support at that location failed to consider existing relationships that those affected had with organisations in the area,230 Richards {CFV00000012/24-25} pages 24 - 25, paragraph 155. and that the centre was "intimidating".231 Richards {CFV00000012/6} page 6, paragraph 46; Richards {CFV00000012/16} page 16, paragraph 107.
¶100.39 Some staff from community rest centres refused to go to the Westway Centre and withdrew because they felt that the system in operation there was inhumane and cruel.232 Simms {Day275/203:17}-{Day275/204:4}. Instead of making traumatised survivors and the displaced constantly justify the need for support233 Richards {Day275/152:16-17}. there should have been a system, according to one volunteer, where people had to explain their situation once and receive the information and support needed in an environment where they felt safe and knew the staff.234 Richards {Day275/152:2-15}.
Financial assistance
¶100.40 There were significant problems in providing financial assistance to those affected by the fire. The council did not have a policy in place for arranging and distributing financial assistance or communicating how it could be obtained. As a result, many of those who had been displaced or who had lost their belongings in the fire235 Raihani {IWS00001300/4} page 4, paragraph 25; El-Ogbani {Day266/36:21}-{Day266/37:8}. had no access to funds at a time of unprecedented need and were trying to support themselves and their children.236 El-Ogbani {Day266/36:21}-{Day266/37:9}. Some people did not receive any financial assistance at all and were entirely dependent upon support from charities.237 Bonifacio {IWS00001887/7} page 7, paragraph 47. Others were actively denied assistance by the council. One survivor was told that she was not entitled to any financial assistance because she and her partner were in employment.238 Jones {IWS00001548/12} page 12, paragraph 56. Other survivors were refused assistance,239 Nalukwago {IWS00001568/1} page 1, paragraph 6. or offered a significantly lower amount,240 Afeworki {IWS00001756/5} page 5, paragraph 26. because they were not formally tenants of flats in the tower. Some residents who had been evacuated were refused financial assistance because they were leaseholders.241 Rullo {IWS00001655/9} page 9, paragraph 38. Although they did not feel ready to do so, some felt they had to go back to work soon after the fire simply because they could not afford to do otherwise.242 Al-Sadi {IWS00001247/7} page 7, paragraph 39. Some residents were refused payments because, as they understood it, the money allocated to them had been wrongly given to someone else.243 Serroukh {IWS00001747/7} page 7, paragraph 30; Yahya {IWS00001827/8} page 8, paragraph 37; Ollivierre {IWS00001758/6} page 6, paragraph 25. For those who did receive financial assistance, the payments were often significantly delayed;244 Ortiz {IWS00001283/8} page 8, paragraph 60. some told us that they had had to wait for over four months for any financial assistance from the council.245 Raihani (IWS00001300/4} page 4, paragraph 25; Richer {IWS00001253/12} page 12, paragraph 58; Talabi {IWS00001731/7} page 7, paragraph 22.
27¶100.41 The general experience was of inconsistency of approach. As an illustration, one resident received £500 to be shared with her brother,246 Ross {IWS00001826/12} page 12, paragraph 58. but others received as little as £100 in the first week and nothing thereafter.247 Wahabi {Day267/117:20}-{Day267/118:7}; Hariri {IWS00001295/11} page 11, paragraph 86. Payments made were often insufficient given the variety of needs, such as travel, food and clothing.248 Al-Karad {Day265/124:2-6}. People understandably felt demeaned and humiliated249 El Amine {IWS00001946/10} page 10, paragraph 44; Cherbika {IWS00001305/12} page 12, paragraph 100; Gil {IWS00001679/11} page 11, paragraph 90. when having to go back to ask for more financial assistance.250 El Amine {IWS00001946/10} page 10, paragraph 44. A great many of them were proudly independent and self-reliant and the experience of having to ask the authorities for a handout was a humiliating one.
¶100.42 The process of obtaining assistance was an uphill battle251 Abdulhamid {IWS00001919/5} page 5, paragraph 22. and for many, embarrassing and intrusive.252 Rasoul {Day265/164:5-11}. One survivor was told by the council to write down everything she needed money for, despite the fact she had lost everything in the fire.253 Dainton {IWS00001804/19} page 19, paragraph 124. Mr Al-Karad told us that the difficulties in obtaining financial support added greatly to the stress he was under and it was not easy to get help. He said that in the first few months he had had to fight for what he needed and sometimes ask for it "20 times".254 Al-Karad {Day265/121:22}-{Day122:4}.
¶100.43 The source of the problem was that the council did not take active steps to tell people what they were entitled to and how they could obtain it.255 Abdulhamid {IWS00001919/5} page 5, paragraph 22; Li {IWS00001622/9}, page 9, paragraphs 62 and 63. Instead, it waited for them to ask.256 Rasoul {Day265/164:11-18}. During the week following the fire, and in some cases even later, people became aware by word of mouth that they were entitled to financial assistance.257 Jones {IWS00001548/12} page 12, paragraph 56; Ahmed {IWS00001335/132} page 132, paragraph 364. By the time some people found out about the various kinds of assistance to which they were entitled, the council told them it was too late to claim.258 Abdulhamid {IWS00001919/5} page 5, paragraph 22; Toyoshima-Lewis {IWS00001725/66} page 66, paragraph 265.
¶100.44 Adequate and timely financial assistance in the immediate aftermath of a major incident is an essential aspect of an effective humanitarian response. Those who did receive such assistance described how it made a huge difference to them to be able to choose what they needed for themselves.259 Moses {IWS00001281/11} page 11, paragraph 61. In the absence of such support, others described the humiliation of having to search through donations to find suitable clothes, in some cases without success.260 Al-Karad {Day265/106:22}-{Day265/107:21}.
28Psychosocial support
¶100.45 In the immediate aftermath of the fire there was limited psychological support available and a lack of information about the kind of support that people could obtain. Survivors described how they struggled with their mental health, desperately needing help but not knowing where to get it at a time when they were at their most vulnerable.261 Ross {IWS00002356/8} page 8, paragraphs 42 and 45; Diejomaoh {IWS00001303/5-6} pages 5 - 6, paragraphs 27 and 28; Cherbika {Day266/106:1-22}.
¶100.46 Many survivors and residents did not hear about the availability of counselling support until a considerable time after the fire.262 Pahlavani {IWS00001244/15} page 15, paragraph 46; Ramirez {IWS00002061/6} page 6, paragraph 35. Several survivors said that they had not received offers of counselling until two years later.263 Sobieszczak {IWS00001555/8} page 8, paragraphs 29 and 30; Jamalvatan {IWS00001704/7} page 7, paragraph 30. In the absence of support from other sources, people had to arrange their own.264 Miller {IWS00001940/19} page 19, paragraph 90; Ramirez {IWS00002061/6} page 6, paragraph 35; Kebede {IWS00001795/10} page 10, paragraph 38; Jones {IWS00001710/5} page 5, paragraphs 29 and 30. Although counselling services were available at the Westway Centre, some chose not to make use of them as they did not consider it to be sufficiently private.265 Laci {IWS00001831/6} page 16, paragraph 40.
¶100.47 Psychological support was available from 16 June 2017 in some of the hotels in which displaced people had been accommodated and some of them understood that counselling services were available if needed.266 Vieiro {IWS00001798/10} page 10, paragraph 42. Other hotels did not provide such support, however, which meant that survivors had to go elsewhere if they wanted to find it.267 Wahabi {Day267/125:16-25}. Some residents were unable to obtain counselling services due to language barriers;268 Al Assad {IWS00001267/5} page 5, paragraph 25. others found it too difficult to undertake counselling sessions through an interpreter and so stopped attending.269 Kabouh {IWS00001942/7} page 7, paragraph 34. There were particular concerns about the lack of emotional support and counselling for children, all of whom had witnessed a grave tragedy and some of whom had lost family and friends in the fire.270 Cherbika {Day266/118:23}-{Day266/119:8}.
Key workers
¶100.49 The use of key workers was an important means of ensuring that those affected received the support they needed, but the system did not operate efficiently in many cases for a variety of reasons, including uneven and late allocation of key workers, inconsistent quality of service and a high turnover of staff.
¶100.50 Survivors were assigned key workers at different times, some within 24 hours of the fire,274 Jones {IWS00001548/14} page 14, paragraph 64. others only after waiting three or four months.275 Jamalvatan {IWS00001724/7} page 7, paragraph 29; Ranito {IWS00001249/9} page 9, paragraph 44. Some were not allocated key workers until a year later because they had not been residents of the tower, and only then after asking for one.276 Benjamin {IWS00001764/12} page 12, paragraphs 83 and 84. Others were not assigned a key worker at all.277 Young {IWS00001261/10} page 10, paragraph 47. Some residents of the Walkways were told that key workers were available only to former residents of
29¶Grenfell Tower and Grenfell Walk.278 Murray {IWS00001639/8} page 8, paragraph 43.
¶100.51 There was a similarly inconsistent approach to the allocation of key workers to the bereaved. Some people were contacted about a month after the fire,279 Pumar {IWS00002346/5} page 5, paragraph 29. while others were assigned a key worker some months later and then only after asking their family liaison officers to approach the council.280 Jniah {IWS00001600/16} page 16, paragraph 61.
¶100.52 There were mixed experiences of the quality of key workers, some of whom appeared to be more engaged than others. We were told of key workers who were not properly prepared for the task and not fully informed, and thus unable to provide support and information.281 Gashaw {IWS00001738/24} page 24, paragraph 24; Raihani {IWS00001300/5} page 5, paragraph 28. Residents often picked up important information before their key workers.282 Ramirez {IWS00002061/6} page 6, paragraph 36. That led to increased stress and uncertainty for many.283 Kassemdjian {IWS00001784/15} page 15, paragraph 77. Some key workers failed to respond to residents' questions,284 Patel {IWS00001610/15} page 15, paragraph 70. which caused further difficulty if support had to be arranged through a key worker.285 Patel {IWS00001610/15-16} pages 15 - 16, paragraph 72. A number of witnesses spoke of contradictory information about the support available being given by different key workers.286 Dainton {IWS00001974/35} page 35, paragraphs 201, 202 and 207. Some regarded their key workers as merely a "support placebo" because they lacked the authority to make decisions.287 Haynes {IWS00001809/9} page 9, paragraph 30.
¶100.53 On the other hand, some had more positive experiences of their key workers288 Ibrahim {IWS00001751/7-8} pages 7 - 8, paragraph 29. and found them to be a useful single point of contact.289 Hessel {IWS00001645/13} page 13, paragraph 53; Benkhaoula {IWS00001269/7} page 7, paragraphs 60 and 61. They provided regular information about the support available.290 Laci {IWS00001831/8} page 8, paragraphs 51 and 52; Sobieszczak {IWS00001562/13} page 13, paragraph 58. The benefits of the system were thus available but were unevenly distributed.
¶100.54 A number of those affected experienced a high turnover of key workers.291 Kasote {IWS00001775/8} page 8, paragraph 28; Sobieszczak {IWS00001562/13} page 13, paragraph 58; Neda {IWS00001302/4} page 4, paragraph 19; Beadle {IWS00001872/15} page 15, paragraph 61. In some cases, key workers had to step down because they had been assigned too many people to look after.292 Patel {IWS00001610/15} page 15, paragraphs 70 - 72. Others could not continue in the role because they had been traumatised by their work.293 Hessel {IWS00001645/13} page 13, paragraph 53. Mr Rasoul told us that he had been allocated six different key workers in one month, with one lasting for just a weekend.294 Rasoul {Day265/167:18-21}. Some developed positive and supportive relationships with their key workers,295 Alfawaz {IWS00001274/11-12} pages 11-12, paragraphs 88-91. but in many cases there was a lack of continuity, with some leaving after a number of months.296 Alhaj Ali {IWS00001533/26} page 26, paragraphs 131 and 132. For some, that was very unsettling. Ms Cherbika described her own experience thus: "They kept changing all the time. I probably went through eight or nine key workers, support workers, whatever workers …
30¶I felt like when I clicked with somebody … the council would take that person away".297 Cherbika {Day266/108:16-25}-{Day266/109:1-2}.
¶Some survivors were left for a time with no key workers.
¶100.55 A particular problem which some faced as a result of having a frequent change of key worker was that they had to describe their experiences from the beginning over and over again.298 Alhaj Ali {IWS00001533/26} page 26, paragraphs 131 and 132; Neda {IWS00001302/4} page 4, paragraph 19; Rasoul {Day265/167:5-17}; Ollivierre {IWS00001758/5} page 5, paragraph 24. Some people found that traumatising.299 Cherbika {Day266/109:7-19}; Al-Karad {Day265/126:19-24}; Rasoul {Day265/169:17}-{Day265/170:5}; Ali {IWS00001617/15} page 15, paragraphs 183 - 185.
Public communication
¶100.56 One common experience in the immediate aftermath of the fire was an absence of information from official sources about the assistance available. In the week following the fire those who had been displaced did not receive any communication from the council telling them what services were available or where to go for help.300 Ho {IWS00001551/16} page 16, paragraph 62. There were no calls or text messages from either the council or the TMO.301 Ho {IWS00001551/16} page 16, paragraph 62. The council did not use its website to provide information for those evacuated from the area within the cordon302 Hartley {IWS00001257/13} page 13, paragraph 50. who were waiting to find out when they could return to their homes.303 Quang {IWS00001552/20} page 20, paragraph 83.
¶100.57 Despite what they had been through, survivors and residents were thus forced to seek information for themselves, which caused additional stress.304 Le-Blanc {IWS00001271/26} page 26, paragraphs 239 and 240; Vieiro {IWS00001798/12} page 12, paragraph 49; Murray {IWS00001639/8} page 8, paragraphs 45 and 46; Gil {IWS00001679/13} page 13, paragraphs 102-104; Gashaw {IWS00001738/18} page 18, paragraph 20. Ms El-Ogbani told us that there was: "No one from government, no one from the authority. We didn't know where to go, we didn't know how to seek help, we didn't know what will happen next. It was just question mark, question mark, question mark…"305 El-Ogbani {Day266/29:17-21}. We heard the same experience voiced by many witnesses.
¶100.58 Mark Simms from the Rugby Portobello Trust told us that although RBKC had been gathering information, there was not much of it.306 Simms {Day275/193:7-18}. RBKC councillors offered help, but they were not there in an organisational role. They too, were struggling to get hold of information.307 Simms {CFV00000005/10} page 10, paragraph 42. There was an "absolute sense that everyone was overwhelmed".308 Simms {CFV00000005/10} page 10, paragraph 42; Simms {Day275/195:17}-{Day275/196:21}.
¶100.59 The lack of information had a direct effect on the distribution of support. Those who obtained information about the support available were the first to receive assistance, while those who did not were left behind.309 Abdulhamid {IWS00001919/5-6} pages 5-6, paragraph 27. That particularly affected vulnerable people, such as those with mobility problems and those who could not speak English.310 Abdulhamid {IWS00001919/5-6} pages 5-6, paragraph 27; Vieiro {IWS00001798/12} page 12, paragraph 49.
¶100.60 When official communications were eventually released, they were in English.311 El-Sawy {IWS00001822/10} page 10, paragraph 42. That included communications sent to those who had been placed in hotels. People described feeling at a disadvantage because they could not read English well and had significant difficulty in gaining access to services, which they felt created unfairness.312 Jamalvatan {IWS00001724/6-8} pages 6-8, paragraphs 27 and 33; Lopez {IWS00001680/11} page 11, paragraphs 68 and 69; Belfassi {IWS00001802/11} page 11, paragraphs 70 and 71; Elbouti {IWS00001605/13-14} pages 13-14, paragraph 64.
31¶They had to rely on family and friends in order to help them understand the information provided and said that an interpreter would have provided greater support.313 Quang {IWS00001821/15} page 15, paragraphs 75 and 76; Kebede {IWS00001795/11} page 11, paragraph 45; El- Sawy {IWS00001829/9} page 9, paragraph 41. Some people did not want to rely on friends and neighbours to interpret confidential and personal information.314 Belfassi {IWS00001802/11} page 11, paragraphs 70 and 71. In some cases interpreters were provided, but not always in the right language.315 Jafari {IWS00001815/16} page 16, paragraph 71. Despite complaints to the council and, later, London Gold about the need for materials to be provided in different languages, it took some time for that to be done.
Information about those missing
¶100.61 Those that were looking for their loved ones immediately after the fire encountered numerous obstacles to their searches.316 John {IWS00001685/8} page 8, paragraph 32. Some families desperately went from hospital to hospital, rest centre to rest centre, in their search for information, but to no avail.317 Ibrahim {IWS00001751/5} page 5, paragraphs 17 and 21; Nabil Choucair {Day267/7:23}-{Day267/12:2}. The overwhelming thrust of their evidence was that they had experienced feelings of utter helplessness and despair as they navigated an environment in which there was a complete absence of information.318 Nowak {IWS00001559/10} page 10, paragraph 50; Mussilhy {Day264/62:1-8}.
¶100.62 Family members visited the numerous rest centres that had been set up in the community, repeatedly asking for information about their loved ones.319 El-Baghdady {IWS00001535/8} page 8, paragraphs 36 and 38; Jniah {IWS00001600/9} page 9, paragraph 32; Chiejina {IWS00002348/5} page 5, paragraphs 30 and 32; Hisam Choucair {Day265/19:7-12}. It rapidly became apparent to them that neither the representatives of the council nor the TMO320 Rasoul {Day265/146:14-19}. were able to provide even the most basic information. The council staff at the Rugby Portobello Trust did not have a list of those who had lived in the tower and were asking people who they were and which flat they lived in.321 Dainton {IWS00001804/19} page 19, paragraph 122. Mr Rasoul told us that after he had escaped from the tower he had visited the Latymer Community Church (known at the time of the fire as the Latymer Christian Centre)322 Blanchflower {CFV00000045/1} page 1, paragraph 2. in his search for missing friends. There he found a representative from the TMO with a list of flat numbers and names, but the list incorrectly included people who no longer lived there.323 Rasoul {Day265/146:14-19}. As a result of the lack of information, the community felt compelled to compile its own list of those who were missing324 John {IWS00001685/8} page 8, paragraph 32. and piece together its own picture of what had happened.325 Burton {IWS00001661/29} page 29, paragraph 153. Mr Mussilhy told us that that was the only way for people to know who was still missing and who had survived.326 Mussilhy {Day264/68:15-24}.
¶100.63 By the evening of 14 June 2017, the Westway Centre had been designated as the official rest centre. As we have already described, the site was hard to access without documentary identification or a wristband, but there was no clear information about how or where to obtain a wristband.327 Mussilhy {Day264/32:20-21}; Chellat {IWS00001284/1} page 1, paragraph 5. Even those who managed to get into the Westway Centre felt that they did not receive adequate information or assistance.
32¶Although there were information desks there, they did not have information about those who were missing in order to assist those looking for loved ones.328 Anderson {IWS00001561/4} page 4, paragraphs 11-12.
¶100.64 In the absence of any official assistance, family members visited hospitals across London desperately looking for their loved ones.329 Hisam Choucair {Day265/39:25}-{Day265/40:3}; Nabil Choucair {Day267/10:25}-{Day267/11:4}; Al-Karad {Day265/97:11-25}; Anderson {IWS00001561/3} page 3, paragraph 10. It was difficult obtaining information from hospitals,330 Ramiro Urbano {IWS00001984/7} page 7, paragraph 42; Chiejina {IWS00002348/4} page 4, paragraph 26. which were concerned about releasing personal information.331 Hisam Choucair {Day265/50:9-14}; Nabil Choucair {Day267/46:24}-{Day267/47:2}. Hisam and Nabil Choucair told us about their painstaking visits to about 12 hospitals332 Nabil Choucair {Day267/23:2-12}. in the search for members of their family. For them that merely compounded the trauma.333 Hisam Choucair {Day265/72:14-20}.
¶100.65 Nabil Choucair told us about the call he made to the emergency services on 14 June 2017 seeking information about his family. He told us that he had searched rest centres, hospitals and had called the casualty bureau.334 Nabil Choucair {Day267/17:9}-{Day267/26:6}. He said, "We were left to fend for ourselves, left to try and find help. … There was chaos. … Nobody knew what they were doing …".335 Nabil Choucair {Day267/32:12-22}. Those looking for their loved ones felt "lost with no direction of what to do or where to go next".336 Anderson {IWS00001561/4} page 4, paragraphs 11 and 12.
¶100.66 In the days that followed families continued their searches, desperately trying to find information.337 Spence {IWS00001657/3} page 3, paragraph 11. A particular challenge arose when news of a different rest centre or possible hospital emerged, as they felt compelled to flock there in a (usually futile) attempt to obtain information.338 Hisam Choucair {Day265/34:1-4}. Some families were not able to carry out extensive searches themselves and had to rely on help from relatives, without which they felt "completely forgotten or overlooked".339 Lamprell {IWS00001673/7} page 7, paragraph 45. Some people who had lost loved ones lived abroad and did not receive any information about their family members, which was itself distressing.340 Ibrahim {IWS00001650/3} page 3, paragraph 12; Jebari {IWS00001550/4} page 4, paragraphs 15 and 18.
¶100.67 One survivor who escaped the tower but became separated from his wife, who perished in the fire, was placed in emergency accommodation without any information about her or how he might find her.341 Abdullah {IWS00001279/5} page 5, paragraph 22. Mr Mussilhy shared his experiences of his search for his uncle and his realisation as the days passed that "We were completely alone … and abandoned in the worst way possible while we were looking for our relatives."342 Mussilhy {Day264/27:7-12}.
¶100.68 A casualty bureau was opened by the Metropolitan Police at 08.00 on 14 June 2017.343 Chalmers {MET00077804/6}, page 6, paragraph 30. Its existence was publicised as a point of contact at 08.02344 Chalmers {MET00077804/11}, page 11, paragraph 51. but it was designed to receive information about those who were missing and not to release information to callers.345 Mendy {IWS00002349/2} page 2, paragraph 6. In the hours after the fire, many who called the number found it to be engaged346 Bernard {IWS00002337/7} page 7, paragraph 53. or were greeted with a recorded message stating that there were no people to answer calls and that they were waiting for call-handlers.347 Murphy {IWS00001709/3} page 3, paragraph 9. Others told us that, when they eventually got through, they were told that someone would come round or would call, but they did not hear back. Others called on many occasions but were told to call back another time for more information.348 Lamprell {IWS00001673/3} page 3, paragraph 20; Lamprell {IWS00001673/8} page 8, paragraph 49. When callers were able to have a conversation with the operator, they found it to be entirely one-way, the operator simply asking for information about the caller and those who were missing.349 Jones {IWS00001691/4} page 4, paragraph 15; Nabil Choucair {Day267/12:20-25}. The casualty bureau, at least to those who encountered it, was a means of gathering information, not providing information to relatives.350 El-Gourja {IWS00001700/5} page 5, paragraph 24.
33¶100.69 The failure to contact bereaved families soon after the fire left many feeling that they did not matter.351 El-Wahabi {IWS00001697/5} page 5, paragraph 21. Some of those affected felt that information was released by police in a haphazard way and that there was no co-ordinated effort to relay information to families.352 Chellat {IWS00001306/2-3} pages 2-3, paragraph 14. Due to the scale of events, it took a number of days for family liaison officers to be appointed.
¶100.70 Families had mixed experiences of family liaison officers. Some people were assigned an officer about a week after the fire and found that support reassuring.353 Anderson {IWS00001561/5} page 5, paragraph 16. Others, however, found the officer allocated to them formal and difficult to talk to.354 Alhaj Ali {IWS00001533/10} page 10, paragraphs 50 and 51. Some family members felt marginalised and unimportant355 Elsanosi {IWS00001837/4} page 4, paragraphs 12 and 14. because they were not allocated their own officer356 Jniah {IWS00001600/15} page 15, paragraph 55. when an officer had been allocated to another family member in accordance with Metropolitan Police guidance.357 Kieran {MET00077793/5} page 5, paragraph 16; Exhibit KK/1 {MET00077792/37-38} Section 5.7.
¶100.71 The absence of a clear and centralised system for providing information about those who were safe and those who were missing led to the growth of false information. Some people were told that their loved ones had been seen alive when they had in fact died.358 Daniels {IWS00002065/11} page 11, paragraphs 73 and 74; Chiapetto {IWS00001780/1} page 1, paragraph 2; Murphy {IWS00001709/3} page 3, paragraph 12; Wahabi {Day267/102:8}-{Day267/103:17}. It was difficult for family members to verify rumours that were circulating in the community as there was no single source of reliable information.359 Jniah {IWS00001600/4} page 4, paragraph 13. Those desperate for information were left in the dark and felt alone.360 Shawo {IWS00001290/5} page 5, paragraph 35. The dreadful results of the failure to establish a method of communicating with the former residents of the tower are best exemplified by the experience of one family who learned of their son's death by hearing about it on the television news.361 Shawo {IWS00001290/5} page 5, paragraph 35.
35Chapter 101: Local government
Introduction
¶101.1 In later chapters we shall refer extensively to the part played by Mr John Barradell under the arrangements made by the London boroughs for responding to emergencies affecting the capital. John Barradell, chief executive of the City of London, led what was called the Grenfell Fire Response Team. In order to provide the context for that part of the report in this chapter we give a brief description of the way in which local government in London fulfils its obligations under the Civil Contingencies Act through the operation of London Resilience.
London Resilience
¶101.2 London Resilience is an overarching term used to denote a structure that encompasses three different bodies: the London Resilience Forum, the London Resilience Group and the London Resilience Partnership.362 Hetherington {LFB00061158/2} page 2, paragraph 6; Hetherington {Day277/10:8-20}.
¶101.3 The London Resilience Forum is the term used to describe the group of organisations that meets periodically to co-ordinate arrangements for responding to major emergencies. It is currently chaired by the Deputy Mayor for Fire and Resilience, Baroness Twycross. At the time of the Grenfell Tower fire the role of Deputy Mayor for Fire and Resilience had not been established and Dr Twycross chaired the forum in her capacity as the chair of the London Fire and Emergency Planning Authority (LFEPA).363 Hetherington {LFB00061158/3} page 3, paragraph 9. The deputy chair of the forum was the town clerk and chief executive of the City of London Corporation, John Barradell.364 Hetherington {Day277/25:13-16}, Minutes of London Resilience Forum meeting dated 6 February 2017 {LFB00119171/2}.
¶101.4 The London Resilience Group is a body which provides business and administrative support for the London Resilience Forum.365 Hetherington {Day277/16:9-13}. Its staff are provided and hosted by the London Fire Brigade (LFB).366 Hetherington {Day277/12:10-25}. At the time of the Grenfell Tower fire, the head of London Resilience was Steve Hamm; his deputies were John Hetherington, Toby Gould and Hamish Cameron.367 Hetherington {LFB00061158/2} page 2, paragraph 5; Hetherington {Day277/7:1-10}.
¶101.5 The London Resilience Partnership is the term used to describe the persons and organisations in Greater London that are designated under the Civil Contingencies Act as Category 1 and Category 2 responders,368 Hetherington {Day277/16:14-24}. together with organisations which are not formally designated as responders but have important roles to play in resilience, such as faith and voluntary organisations, and the government in the form of the Ministry of Housing, Communities and Local Government (formerly the Department for Communities and Local Government (DCLG)).369 Bellamy {MOL00000025/5} page 5, paragraph 18; McManus {Day283/19:15-21}. The partnership consists of about 170 organisations.
36¶101.6 The City of London and each of the London boroughs is an independent local authority. To co-ordinate their activities in relation to resilience they have established the Local Authorities' Panel which represents the interests of all London local authorities on the Forum.370 Hetherington {Day277/34:21-25}. At the time of the fire the Local Authorities' Panel was chaired by John Barradell.371 Hetherington {Day277/31:23}. In June 2014 the 33 local authorities were grouped into 6 sub-regional groups known as sub-regional resilience forums,372 Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005, Schedule {CAB00007003/27}. which acted as links between the borough resilience forums and the London Resilience Forum.373 Hetherington {LFB00119130/3} page 3, paragraph 9.
London Local Authority Gold
¶101.7 By 2011 each of the London boroughs and the City of London had confirmed a resolution, originally passed in 2004 and known as the Gold Resolution,374 Hetherington {LFB00061158/4} page 4, paragraph 12; the Gold Resolution {LFB00061166}. to provide each other with mutual aid and assistance in the event of an emergency requiring a co-ordinated response. Under that resolution each authority delegated to whichever borough had agreed to undertake the role in response to a particular incident its power under section 138 of the Local Government Act 1972 to incur expenditure to avert or alleviate the effects of an emergency calling for a co-ordinated response. The boroughs and the City of London also entered into a memorandum of understanding setting out the procedure for implementing those arrangements.375 London Local Authorities Mutual Aid {LFB00061169/3} paragraph 1.1.1-1.1.5. We shall refer to those arrangements as "the Gold arrangements" and the chief executive of the borough to which power has been delegated under those arrangements as "London Gold". The agreement for mutual aid and assistance is supported by the London Local Authority Co-ordination Centre, which co-ordinates requests for mutual aid between boroughs and across London as a whole.376 Hetherington {LFB00061158/5} page 5, paragraph 13; LLAG Operating Procedure v.8.0 July 2016 {LFB00061185}.
¶101.9 The Grenfell Tower fire was only the third occasion on which the Gold arrangements had been implemented, the last occasion having been in 2014.381 Hetherington {Day277/46:9-12}; There were instances when mutual aid was provided, for example, the Croydon flooding in 2014, but Croydon London Borough Council remained the lead responder {Day277/44:20-25} -{Day277/45:1-12}. The evidence indicated that there was some uncertainty about how they could be invoked, in what circumstances and by whom,382 Barradell {Day279/14:16}-{Day279/15:5}; {Day279/58:15-16}; Farrar {Day284/10:3}-{Day284/13:7}; Hetherington {Day277/60:6-23}. whether they were based on any power383 Hetherington {Day277/59:6}-{Day277/60:5}; Barradell {Day279/12:10-25}. and the degree to which the chief executive of the affected borough could delegate responsibility for decision-making in the aftermath of an emergency to London Gold, apart from the powers contained in section
37¶138.384 Barradell {Day279/116:9-19}; Farrar {Day284/138:7-14} and {Day284/139:7-9}; Hetherington {Day277/58:4-8}. We explore the extent to which that confusion affected the response to the fire further in Chapter 102.
Voluntary and faith sector panels
¶101.10 Category 1 responders have a legal duty to have regard to voluntary organisations in their area that are relevant to an emergency.385 Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005, reg. 23; Hetherington {Day277/68:18-21}. The Voluntary Sector Panel and the Faith Sector Panel are two of the panels that make up the forum.386 London Resilience, Terms of Reference, Appendix 01/C {LFB00061162/7}. A representative of each of those panels therefore attends meetings of the forum.387 Hetherington {LFB00119130/12} page 12, paragraph 36. Guidance on involving the voluntary sector was developed and agreed by the London Resilience Forum in a document entitled Voluntary Sector Capabilities Document.388 Voluntary Sector Capabilities Document v.6.0 April 2017 {GOL000000027}.
Borough resilience forums
¶101.12 We consider that having the same person (in the case of RBKC, Mr Kerry) sitting on many related bodies created a danger of over-reliance on one person's knowledge and experience. It also reduced the field of those within a borough able to acquire and share knowledge and experience of the London resilience arrangements in action. It appears that such a concentration of knowledge and experience was not unusual across London.393 Hetherington {Day277/80:19-23}-{Day277/81:3}.
The Greater London Authority
38¶The commissioner carries out that function through the London Resilience network and in particular the sector panels within the forum. The GLA together with the commissioner and the boroughs funds the London Resilience Group.
¶101.14 Notwithstanding the GLA's role in maintaining strategic oversight of resilience399 Protocol relating to the discharge of statutory resilience functions by London Fire and Emergency Planning Authority on behalf of the Greater London Authority {MOL00000042/29} Schedule 1. and the fact that it has the power to appoint the chair of the London Resilience Forum, at the time of the Grenfell Tower fire there was no mechanism by which the Mayor of London or the GLA could scrutinise the work of the forum,400 Bellamy {Day282/12:23}-{Day282/13:11}; {Day282/13:23}. thus preventing either of them from exercising any effective supervisory or monitoring role.
The Mayor of London
¶101.15 The guidance in Emergency Preparedness states that the Mayor of London "plays a full part in supporting the effective implementation of the Act and improving the preparedness of the capital".401 Emergency Preparedness, {CAB00004545/11} paragraph 9.22. Paragraph 9.23 of the guidance lists the ways in which the Mayor and the GLA should achieve that outcome. In summary, the Mayor and the GLA should be closely engaged in high-level discussions and decisions relating to the management of emergencies in London. The Mayor should inform Londoners about the content of emergency plans, warn and inform the public during an emergency and chair or appoint the chair of the forum.
¶101.16 The Mayor of London is not a Category 1 responder under the Civil Contingencies Act. However, because the Mayor forms part of the GLA,402 s.2(1)(a) of the Greater London Authority Act 1999. we understand that he regards himself by extension as a Category 1 responder.403 Bellamy {Day282/17:18-24}. Consistent with that view, the statutory guidance, Emergency Preparedness, explicitly refers to the role of the Mayor of London in the preparedness404 Process of preparing to deal with known risks and unforeseen events or situations that have the potential to result in an emergency. Emergency Preparedness, Glossary {CAB00000055/21}. of the capital.405 Emergency Preparedness, {CAB00004545/11} Chapter 9 London.
¶101.17 The responsibilities of the Mayor of London in the response phase are set out in the Strategic Co-ordination Protocol,406 Strategic Coordination Protocol {LFB00061180/25} at paragraphs 2.8.9-2.8.11, 2017 v.7.1. This Protocol is explained in Phase 1, Report Volume IV, paragraph 30.24-30.28. namely, that he will support the operational response to an emergency in London by providing a unified statement so as to act as the "voice of London" and will collaborate closely with the Strategic Co-ordinating Group and central government where appropriate.407 Strategic Coordination Protocol {LFB00061180/25} at paragraph 2.8.11. The term "voice of London" does not appear in the statutory guidance,408 Bellamy {Day282/21:8}. but David Bellamy, the Mayor's current chief of staff, told us that his understanding of the expression was that in an emergency the Mayor will speak on behalf of London to Londoners to explain what is happening, to give them the information they need to understand what has happened and to tell them what effect it is expected to have on them.409 Bellamy {Day282/21:10-20}. However, the Mayor of London has no responsibility for the operational response to a civil emergency.410 Khan {MOL00000189/16} page 16, paragraph 62. His is essentially a political and communications role.
39The Royal Borough of Kensington and Chelsea
¶101.19 Category 1 responders have a statutory duty to maintain and modify emergency plans as necessary.412 Section 2 (1)(c)-(e) Civil Contingencies Act 2004 {CAB00004616/3}. In addition, they have a statutory obligation to consider whether it would be appropriate to perform their duty by collaborating with another Category 1 responder in maintaining a multi-agency plan.413 Regulation 22(2) Civil Contingencies Act 2004 (Contingencies Planning) Regulations 2005 {CAB00007003/12}.
¶101.20 The aim of emergency plans is to increase multi-agency and community resilience by ensuring that all those charged with tackling an emergency on behalf of the community know their roles, are competent to carry out the tasks assigned to them, have access to available resources and facilities and have confidence that their partners in response are similarly prepared.414 Chapter 5 (Emergency Planning) of Emergency Preparedness {CAB00004623/19} paragraph 5.51.
¶101.21 There are three groups of plans covering London as a whole:
i. Multi-agency plans produced by the London Resilience Partnership, which set out the partnership's emergency response arrangements. They are also known as "frameworks".415 Hetherington {LFB00061158/7} page 7, paragraph 21. ii. Plans relating to arrangements made by local authorities for a regional response (e.g. the London Gold arrangements).416 Hetherington {LFB00061158/9-10} pages 9-10, paragraphs 23-27. iii. Plans relating to the internal arrangements made by the London Resilience Group for responding to an emergency.
¶101.22 Each of the frameworks is managed by a lead agency with a senior responsible "owner", a member of the forum who has responsibility for developing the framework and in doing so for considering all risk assessments, planning assumptions and lessons learnt from previous incidents and exercises.417 Hetherington {Day277/130:25}-{Day277/131:11}. At the time of the fire there were no fewer than 25 plans in place, ten of which were formally activated or described arrangements that were deployed in response to the Grenfell Tower fire.418 Hetherington {LFB00061158/8} page 8, paragraph 22. Two highly pertinent frameworks relevant to the response to the Grenfell Tower fire call for particular examination.
40The Humanitarian Assistance framework
¶101.23 The Humanitarian Assistance framework419 Humanitarian Assistance Framework, April 2017 {LFB00061172}. dated April 2017 was a draft framework due for approval by the London Resilience Forum on 28 June 2017.420 Hetherington {LFB00061158/8} page 8, paragraph 22. Its aim was to ensure that humanitarian care was delivered in an effective manner that met the needs of those affected by a major emergency.421 Humanitarian Assistance Framework, April 2017 {LFB00061172/4} paragraph 1.1.
¶101.24 The lead responder for humanitarian assistance is the local authority.422 Hetherington {LFB00061158/6} page 6, paragraph 18. The Humanitarian Assistance framework provided that in the first few hours following an incident in which a significant number of people had been displaced the local authority would take the lead in providing rest centres with secondary responsibility being given to voluntary agencies.423 Humanitarian Assistance Framework, April 2017 {LFB00061172/20} paragraphs 7.2 and 8.15.
¶101.25 The purpose of a rest centre, as described in paragraph 8.13 of the Humanitarian Assistance framework, is to provide immediate shelter for people who have been evacuated from an area or are otherwise in need of emergency accommodation following an incident, to provide initial light refreshment for evacuees, to enable details of evacuees to be maintained in the centre for reference, to provide for the well-being of the evacuees, to offer support and information on a wide range of welfare-related subjects and to provide evacuees and survivors with current information about the incident and its potential effects on them.424 Humanitarian Assistance Framework, April 2017 {LFB00061172/24} paragraph 8.13. We discuss the Humanitarian Assistance framework further in Chapter 104.
The Identification of the Vulnerable framework
¶101.26 The guidance entitled Identification of the Vulnerable, drafted by the London Resilience Partnership, was published in January 2015 for local implementation.425 The Identification of the Vulnerable v.1 {LFB00061174}. The guidance adopts the Cabinet Office's definition of vulnerability426 The Identification of the Vulnerable v.1 - The guiding principle of the framework is that; "While all people caught up in an emergency could be (and in some circumstances will be) defined as vulnerable due to their proximity to the event, planning and response arrangements should focus on those who are assessed as not being self-reliant and may need external assistance to become safe". {LFB00061174/5} paragraph 1.5. and is directed at emergencies contained within a single borough. Its aim is said to be to inform, complement and align the capability planning of the Borough Resilience Forum to encourage a proactive and coherent approach towards the identification of vulnerable persons.427 The Identification of the Vulnerable v.1 {LFB00061174/4} paragraph 1.2.
¶101.27 It is the responsibility of the Borough Resilience Forum to identify vulnerable people and undertake the six core steps set out in the guidance.428 The Identification of the Vulnerable v.1 (1) Assess, prioritise and accept risks; (2) Ascertain who holds what information: That included compiling a "list of lists" for contacts of organisations that hold data on vulnerable people; (3) Establish planning and procedural arrangements; (4) Document options for dynamic identification; (5) Understand information sharing principles; (6) Exercise and assure {LFB00061174/8} paragraph 2.1. They include compiling a "list of lists" for contacts of organisations that hold data on vulnerable people to enable them to obtain the information quickly in the event of an emergency. The guidance recognises that it would be impossible to maintain an accurate central list of vulnerable people.429 Identifying people who are vulnerable in a crisis {CAB00014864/3}; The Identification of the Vulnerable v.1 {LFB00061174/8} paragraph 2.3.
41¶Boroughs were supposed to have a systematic process in place for making the relevant information available quickly and to have run training exercises so that they were confident not only that their systems worked but that their staff knew how to operate them, not least because it would be difficult to obtain all the relevant information quickly at the time of an incident.430 Hetherington {Day277/151:7-24}. Mr Kerry's view, however, was that apart from compiling a list of lists, the guidance was too difficult to achieve in practice.431 Kerry {Day268/177:12–16}.
¶101.28 Mr Hetherington told us that that approach failed to meet the standards envisaged by the framework and provided examples from other boroughs of how it could have been done. He would have expected someone in Mr Kerry's position to have done better.432 Hetherington {Day277/152:3-19}. He did not accept Mr Kerry's view that the Cabinet Office guidance on the identification of the vulnerable was unachievable433 Kerry {Day268/175:15-16}; Hetherington {Day277:152:21}–{Day277/153:6}. and told us that although identifying vulnerable people was difficult, because the lists are subject to constant change, it was certainly achievable.434 Hetherington {Day277/153:12-18} e.g. London Borough of Brent, Identifying the Vulnerable Framework {LFB00061174/15}. We think that the Cabinet Office guidance was indeed achievable and that Mr Kerry's attitude to the identification of the vulnerable was defeatist and inappropriate.
Review of local authority emergency planning in London
¶101.29 In 2016 Mark Sawyer, then Deputy Head of Emergency Planning in the LFB Emergency Planning Team,435 Sawyer {GOL00001349/1} page 1. was instructed by the Local Authorities' Panel to undertake a review of local authority emergency planning in London.436 Sawyer {GOL00001349/2} page 2, paragraph 9. He was asked to undertake the task because the panel recognised the heightened pressure on councils and the increase in external and internal risks. Those risks included a "loss of corporate knowledge and capacity".437 Sawyer {GOL00001349/2} page 2, paragraph 9.
¶101.30 Mr Sawyer was supported in his review by Mr Kerry and their report, known as "EP2020", was issued on 3 October 2016.438 Recommendations for Local Government Emergency Planning and Resilience for the 2020's {GOL00001515}. Their overall assessment was that there was a developing trend towards a reduction in capacity and capability across London and that the ability of local authorities to provide leadership on resilience to the level communities would expect and deserve was under strain.439 Recommendations for Local Government Emergency Planning and Resilience for the 2020's {GOL00001515/3}.
¶101.31 The report provided a clear and prescient warning. It identified the problems for civil contingency planning that reduced staffing levels had created. It is worth quoting the following passage:
42"Emergency planning staffing levels are at the lowest point since 2009, with a downward trend established since the 2012 Olympics … This reduction combined with continuing demand for efficiencies across authorities has the potential to significantly affect our ability to satisfy the expectations of our communities and assure them that we possess the appropriate means to prepare and respond, where necessary, to the myriad of resilience challenges that need to be addressed".440 Recommendations for Local Government Emergency Planning and Resilience for the 2020's {GOL00001515/8} paragraph 3.1.1.
¶101.32 The report also reviewed the Minimum Standards for London, introduced in 2007, which contained 16 standards designed to ensure that all local authorities had the appropriate policies and procedures in place to support the London Gold arrangements.441 Recommendations for Local Government Emergency Planning and Resilience for the 2020's {GOL00001515/12}. Those standards were set by the Local Authorities' Panel with the aim of ensuring a basic standard of resilience planning by London's local authorities that met statutory requirements and the government's expectations and was commensurate with London's risk profile.442 Minimum Standards for London {LFB00119219/4-7}. At the time, compliance with the minimum standards was based on self-assessment in odd years (e.g. 2015) and a peer-review in even years (e.g. 2016).
RBKC plans
¶101.34 Issue 9 of RBKC's Contingency Management Plan446 Contingency Management Plan {RBK00004396} Issue 9 (dated 30 April 2015) was the relevant version at the time of the fire. dated 30 April 2015 had been drafted by Mr Kerry.447 Kerry {Day268/25:19}. It was the council's core plan for major emergencies. Part 1 was an overarching generic contingency management plan, which was accompanied by a suite of annexes numbered 1 to 42 which set out plans covering particular situations.
¶101.35 There were substantial shortcomings in the RBKC Contingency Management Plan. As Mr Kerry accepted, a number of the annexes had been left empty,448 Kerry {RBK00058091/2-5} pages 2-5, eleven of which were left empty: annexes 5-9, 18, 30, 34, 37-38, 40-41 or were wrongly labelled,449 Annex 14a ("Guidance for setting up a Community Assistance Centre") was incorrectly numbered; and Annex 15 ("Emergency Shelter and Rest Centre Directory") was the incorrect version of the document, with the correct version having been labelled as Annex 14a along with another document. Kerry {RBK00058091/3} page 3. or were still in draft form, or contained outdated plans.450 Kerry {Day268/29:9-13}. Significantly, they included Annex 16, a Humanitarian Assistance Centre plan dated 15 April 2008.451 Annex 16 of the RBKC Contingency Management Plan, Humanitarian Assistance Centre plan {RBK00051900}; {Day263/123:18-23}; RBKC Opening Submissions {RBK00068467/10} paragraph 37. Mr Kerry acknowledged that it was outdated, was no longer viable and should have been removed.452 Kerry {RBK00058091/3} page 3. A document entitled Framework for Identifying and Contacting Vulnerable Persons in an Emergency in Annex 21 was in draft form dated April
43¶2012. Mr Kerry conceded that in hindsight more could have been done to produce a finished version,453 Kerry {RBK00058091/4} page 4. but the real question is why there was insufficient foresight, given that the whole point of contingency planning is to look to the future.
¶101.36 There were different versions of Issue 9 of the Contingency Management Plan.454 {RBK00028631/5} exhibited by Nicholas Holgate, Town Clerk, RBKC; {RBK00004396/5} exhibited by David Kerry does not refer to CMP Part 2 at page 5. One version referred to a "Contingency Management Plan Part 2 - Tactics and Contacts" that was designed to provide information to assist those with designated roles in the response. Contingency Management Plan Part 2 (draft v2) was dated 21 June 2016.455 Contingency Management Plan {RBK00005194}. It included action cards for Council Silver and for specific emergency responses.456 Contingency Management Plan {RBK00005194/3}. Mr Kerry said that they were both draft documents,457 Kerry {Day268/47:11-18}-{Day268/52:10-11}. but he conceded that there had been a need in 2017 for a proper guide to tactics.458 Kerry {Day268/48:24}-{Day268/49:5}. In our view, there had been enough time to complete and incorporate Part 2 into the Contingency Management Plan in the year that followed. The action guides were likely to complement the plan and in an emergency direct the reader to the relevant plans contained in the Annexes and the London Resilience Partnership plans. That opportunity was not taken, as it should have been.
¶101.37 The Contingency Management Plan did not include a communications plan and Mr Kerry was not aware of any document that described how different parts of the council would co-ordinate their communications in an emergency.459 Kerry {Day268/43:18-21}. There was a difference between Mr Kerry and the head of the Media Communications Team, Martin Fitzpatrick, about why that was.460 Kerry {Day268/44:20}-{Day268/44:20}-{Day268/45:16}. However, it is not necessary for us to decide which of them was correct, given that the council has admitted that there was no up to date communications plan.461 Kerry {Day268/43:18-21}. It is clear that there was a draft communications plan dated 2010 but that it had not been completed or added as an annex to the Contingency Management Plan before the Grenfell Tower fire. The consequences of the absence of a communication plan, the lack of any co-ordination with the Media Communications Team and the failure to integrate that team into the planning process were seen in the hours and days that followed the fire.
¶101.38 In its opening statement for Module 4 of the Inquiry RBKC accepted that it had failed adequately to practise an emergency communication plan. It also recognised that its failure had adversely affected the council's response to the fire.462 RBKC {Day263/115:15-24}.
Training and practice
¶101.39 Regulation 25 of the Civil Contingencies Regulations provides that the plans maintained by Category 1 responders must include provision for the training of an appropriate number of staff and the carrying out of exercises for the purpose of ensuring that plans are effective.463 The Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 {CAB00007003/13}.
44¶101.40 At the time of the Grenfell Tower fire, LFEPA was responsible for providing training for London boroughs on plans affecting London as a whole.464 Service Level Agreement between LAP and LFEPA {LFB00061184/2}. In order to test those arrangements, LFEPA was obliged to design and deliver an annual programme of exercises.465 Emergency Preparedness paragraph 9.6 {LFB00061171/6} and {LFB00061184/3}.
¶101.41 The London Resilience Group delivered training to those involved in the London Resilience Partnership, and the London Gold arrangements, as well as those involved in its own emergency response arrangements.466 Hetherington {LFB00061158/14-15} page 14-15, paragraph 42.
¶101.42 The London Resilience Partnership's programme of training and exercises467 London Resilience Partnership and Training Programme 2017-2020 {LFB00061201}. was designed by a group chaired by Mr Gould and Mr Hetherington, then joint deputy heads of the London Resilience Group.468 LRP Training and Exercising Group Terms of Reference v.1.0 {LFB00061201/12} paragraph 6. It expected individual partners to make best use of the activities delivered through the programme but to retain full responsibility for their own preparedness, including training personnel, and the effectiveness of their response and recovery capabilities.469 LRP training and exercising programme, 2017 to 2020 {LFB00061201/1} paragraph 1.3. We were told that the London Resilience Partnership provided an overall addition to local training in the form of insight, information and an awareness of the role of the London Gold arrangements.470 Hetherington {Day277/166:16}; {LFB00061201/2-7} paragraphs 3.1-3.15.
¶101.43 The training to support the London Gold arrangements was delivered three times in 2016 to a number of local authorities but not to RBKC.471 Hetherington {Day277/204:18-25}. That was the last London Gold support team training delivered, after which it was decided there was no longer a requirement for local authorities to have a support team in place.472 Overview of Local Authority Training Delivered by LRG 2016/17 {LFB00061215/3}.
¶101.44 The London Resilience Group provided training on its own emergency response arrangements which involved a series of internal sessions delivered to staff. Its staff also participated in events held under the training and exercise programme and local authority training events provided by London Resilience Partnership, which are examined further in this chapter.473 Hetherington {LFB00061158/16} page 16, paragraphs 49-50.
¶101.45 There was no mechanism by which the London Resilience Group or the Local Authorities' Panel could assess the quality of training being given by an individual local authority, or its level of preparedness,474 Hetherington {Day277/167:6-14}. otherwise than through the Minimum Standards for London, which we have touched on above and which we examine further below.475 Hetherington {Day277/170:3}. The attendance of representatives from individual local authorities at training events provided by the London Resilience Partnership was voluntary.476 Hetherington {Day277/166:24}-{Day277/167:4}.
¶101.46 We consider the position in relation to training to have been unsatisfactory. It was piecemeal, unco-ordinated, not subject to any external assessment or validation and voluntary. Those shortcomings helped to create a situation in which individual local authorities lacked capability in some respects and the quality of preparedness could become inconsistent between different local authorities.
45¶101.47 The Minimum Standards for London published by the Local Authorities' Panel comprised a set of standards designed to ensure that all local authorities had appropriate procedures and policies in place to support the London Gold arrangements. It described the plans and capabilities that each borough should have in place to support arrangements for planning and response across London.477 Minimum Standards for London, Draft 2016.1 {LFB00119219/4} paragraph 3.1. At the time of the fire, the 2016 draft of the standards applied, having been approved by the implementation group in September 2016.478 Hetherington {LFB00119130/19} page 19, paragraph 61. It referred to publication of an annual programme of exercises to support the London Gold arrangements,479 Minimum Standards for London, Draft 2016.1 {LFB00119219/13} 1.14a. including an annual exercise involving all 33 boroughs, the Co-ordination Centre and London Gold.480 Minimum Standards for London, Draft 2016.1 {LFB00119219/14} 1.15a.
¶101.48 The exercise Unified Response in 2016 was the first substantial London-wide exercise held since exercise Safer City in 2013481 Hetherington {Day277/173:13}–{Day277/174:1}; Exercise Safer City 2017, Post Exercise Report, February 2017 v.1 {LFB00061212/4}. that involved London Gold and the London Local Authorities Co-ordination Centre.482 Kerry {RBK00033579/11} page 11, paragraph 39. It was also the first opportunity in three years to test London-wide local authority co-ordination arrangements.483 Hetherington {Day277/173:13}-{Day277/174:1}; Exercise Safer City 2017, Post Exercise Report, February 2017 v.1 {LFB00061212/4}. In November 2015, RBKC also participated in exercise Babel, organised by the London Borough of Hammersmith and Fulham, to explore and test the interoperability of the two boroughs' response arrangements.484 Exercise Babel Post Exercise Report {RBK00005188/1}.
¶101.49 Exercise Unified Response took place over four days between 29 February and 3 March 2016 and involved the simulation of a major building collapse at Waterloo station involving 70 fatalities.485 Exercise Unified Response {LFB00061214/141} paragraph 3.6; Hetherington {LFB00061158/15} page 15, paragraph 46. One of its objectives was to test London's multi-agency strategic co-ordination arrangements, including the Strategic Co-ordination Centre and plans, policies and procedures.486 Exercise Unified Response {LFB00061214/141}. The evaluation report prepared by Dany Cotton, then London Fire Commissioner, and published in April 2017 identified a number of vulnerabilities and lessons to be learnt.487 Exercise Unified Response {LFB00061214/144} paragraph 3.6.7; {LFB00061214/151} paragraph 3.6.25; {LFB00061214/153} paragraph 3.6.34; {LFB00061214/155} paragraphs 3.6.37-38; {LFB00061214/157} paragraph 3.6.41; {LFB00061214/157-158} paragraphs 3.6.43 and 44; {LFB00061214/159} paragraph 3.6.45; {LFB00061214/173-174} paragraph 3.7.8. Vulnerabilities included inadequate situational awareness and decision-making, difficulty in tracking the number and locations of casualties, delay in setting up a survivor reception centre and concentrating too much on process and not enough on the care of survivors, a failure to manage faith and disability concerns consistently and to make sufficient resources available to prioritise support to children and young people correctly. Among lessons learnt were that situational awareness and decision-making could be improved by having a single source of information at the scene of an incident reporting to strategic-level command. Those deficiencies, revealed by a major London practical exercise only 17 months before the Grenfell Tower fire, were in many respects repeated in the response to it.
¶101.50 The exercise also identified communicating with the public as an area in which improvement was needed. That applied particularly to groups which had been disrupted by the incident and those who knew or were related to people who might have been affected by it.488 Exercise Unified Response Evaluation Report April 2017 {GOL00001154/149} paragraph 3.6.18. That foreshadowed what we heard from a number of witnesses about their experiences following the Grenfell Tower fire. We also heard that arrangements for communicating with the public were not regularly practised before the fire.489 Hetherington {Day277/177:21-25}. Given that that problem had been identified in exercise Unified Response, more regular practice might have drawn attention to the importance of communicating effectively with the general public.
46¶101.51 We understand that the evaluation report on exercise Unified Response490 Exercise Unified Response Evaluation Report April 2017 {GOL00001154}. was shared quite widely across the Local Authorities' Panel and that there was a mechanism491 Hetherington {Day277/177:9-20}. through the learning and implementation group to record the lessons and review the relevant frameworks.492 Hetherington {Day277/176:18}-{Day277/177:20}. We note that, for some reason, the evaluation report was not produced until April 2017 and therefore left little opportunity before the fire for the lessons to have been learnt effectively or produce any tangible change.493 Exercise Unified Response Evaluation Report April 2017 {GOL00001154}.
¶101.52 We were told that it had been difficult to ensure that the right people attended the exercises and that there had been a tendency for the same people to attend regularly and others not at all. We agree with Mr Hetherington that responsibility for resilience must lie with the whole of an organisation, not just the contingency planning unit. Everyone in an organisation needs to be involved in resilience and consider it part of their personal responsibility. As far as possible, the arrangements underpinning it should be part of everyday processes to avoid putting new arrangements in place under pressure.494 Hetherington {Day277/178:1-22}.
RBKC training and practice
¶101.53 In recognition of its obligation under the regulations495 The Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005{CAB00007003/13} regulation 25. RBKC's Contingency Management Plan provided for training to be offered to staff with designated emergency response roles annually; it also provided for an exercise to be held at least once a year to test the plan's effectiveness.496 Contingency Management Plan, Section 1.8 {RBK00004396/11}. However, training for those with designated roles in any response was not provided as often as the plan required. The Council Gold group (the chief executive and the executive directors) was responsible for setting the strategy for responding to an incident.497 Kerry {RBK00033579/8} page 8, paragraph 26. Before June 2017, the most recent Council Gold group training had been held on 14 September 2015. That took the form of a two-hour seminar attended by (among others) Nicholas Holgate, Tony Redpath, Stuart Priestley and Laura Johnson.498 Kerry {RBK00058091/6-7} pages 6-7, paragraph 2.5. Mr Kerry had asked to have four hours available but was only allowed two. He conceded that the training was "insufficient".499 Kerry {Day268/78:2-6}. The failure to undertake Gold training regularly was of long standing. Before September 2015, the previous sessions had been on 29 March 2010 and 15 September 2008.500 Kerry {RBK00058091/8} page 8, paragraph 2.6-2.7.
¶101.54 There was no formal training programme in place for Council Silver, who held the crucial role of leading the operational response to an emergency.501 Priestley {Day270/6:16}-{Day270/7:20}. Such a programme was implemented only after the Grenfell Tower fire.
47¶101.55 An overarching feature of RBKC training was the absence of records.502 Kerry {RBK00058091/25} page 25, paragraphs 6.5 and 7.1. Without such records, it was unable to demonstrate (or to keep any internal track of) how frequently training took place or who received it. Training of those responsible for staffing the Borough Emergency Control Centre (BECC)503 The role of the Borough Emergency Control Centre (BECC) is to oversee and coordinate the Council's incident response, being a single point of contact and source of information for Council Gold, Council Silver, external agencies and other council services; Kerry {RBK00033579/8} page 8, paragraph 29. and Local Authority Liaison Officers (LALOs) was infrequent, irregular and basic in nature.504 Kerry {Day268/85:12}-{Day268/86:5}; Kerry {RBK00058091/27} page 27, paragraph 11.1; Blackburn {Day270/122:2-14}; {RBK00068318}. The preparation of a new training plan for BECC officers was deferred to await a London-wide standardisation programme following exercise Unified Response in March 2016. Rebecca Blackburn, who worked with and reported to Mr Kerry as a Contingency Planning Officer at RBKC, told us that she thought that the decision left a significant gap in training.505 Blackburn {Day270/106:19}-{Day270/107:13}. We agree.
¶101.56 Exercises to practise the operation of the Contingency Management Plan were held infrequently and were of a limited nature. That was another long-standing problem about which concern had been expressed within the Contingency Planning Unit since 2013. At that time Ms Blackburn had expressed her concern about the lack of large-scale exercises to senior management.506 Blackburn {Day270/115:20}-{Day270/116:25}. In late 2016, on her return from a secondment, she found that the situation had deteriorated,507 Blackburn {Day270/119:3-10}. and that exercises were limited to London-wide exercises conducted by the London Resilience Group.508 Blackburn {Day270/106:24}-{Day270/107:3}. She considered that other members of staff were not aware of the Contingency Planning Unit or its work in general.509 Blackburn {Day270/113:24-114:9}. We accept what she said about that also.
¶101.57 RBKC's participation in London-wide exercises was on occasion hampered by a lack of available staff. Four months before the Grenfell Tower fire, it was unable to participate in exercise Safer City because not enough people had volunteered to take part.510 Kerry {Day268/97:13}-{Day268/98:1}; {RBK00058054/1}. Ms Blackburn described the approach of RBKC to London Resilience Group exercises as being to do the least it could.511 Blackburn {Day270/112:4-21}. That was due to a combination of capacity, attitude and lack of commitment.512 Blackburn {Day270/112:25}-{Day270/113:20}.
¶101.58 The exercises that were carried out disclosed a number of problems.513 Exercise Responder, October 2015 {RBK00058067/2}; Exercise Babel, November 2015 {RBK00005188/4}. They included insufficient staff at the BECC in the early stages, problems with information technology when setting up the BECC, senior staff covering more than one role and difficulties in obtaining information about vulnerable people. Improvements identified in the subsequent reports included the need for greater understanding of the incident, better channels of communication to provide current information, structured handovers in the BECC and more training and more frequent borough exercises. However, those lessons were not implemented and the problems appeared again during the response to the Grenfell Tower fire.
48¶101.59 Mr Kerry recognised at the time that the training and exercises undertaken by RBKC were insufficient and did not accord with the Contingency Management Plan.514 Kerry {Day268/72:19}-{Day268/73:6}. He admitted that the shortcomings had been caused by a lack of available staff.515 Kerry {Day268/73:7-16}. Despite his pivotal role as the head of the Contingency Planning Unit, he did not consider that he was senior enough to press the chief executive, Mr Holgate, or senior management at RBKC over those matters.516 Kerry {Day268/78:14-15}. Although he considered that Mr Holgate was supportive of training, Mr Kerry found RBKC's senior management in general to be somewhat resistant to attending training.517 Kerry {Day268/78:22}-{Day268/80:17}.
¶101.60 The lack of support from senior management at RBKC may explain the sense of inertia that prevailed in the Contingency Planning Unit and throughout RBKC towards planning for an emergency and its capacity to mount an effective response.
¶101.61 Within RBKC there was a systemic shortage of staff trained to deal with emergencies and ensure that it complied with its duties as a Category 1 responder. In 2014 Mr Kerry raised concerns with the council's management board about what he saw as a significant lack of trained emergency staff.518 Kerry {Day268/61:19-23}; Report to the Management Board, paragraph 1.2 {RBK00058038/1}. He warned that the council did not have enough trained volunteers to carry out emergency management roles in the BECC in relation to a major incident.519 Kerry {Day268/62:6-11}. There were only three qualified "Council Silvers", far fewer than the ten he considered to be the minimum. In addition, there were only ten Incident Response Officers, half the number he considered necessary.520 Report to the Management Board, paragraph 2.1 {RBK00058038/1-2} explains that Borough (Council) Silver manages the council's tactical response to an incident and paragraph 3.1 gives the required number. Paragraph 2.2 sets out the role of Incident Response Officer and paragraph 3 gives the required number.
¶101.62 There was no improvement when the position was reviewed in early 2016. Mr Kerry candidly summarised the position at that time as "rock bottom" and did not believe it had substantially improved by the time of the fire.521 Kerry {Day268/70:10-11}.
¶101.64 The long-standing shortage in the number of trained emergency staff was partly the result of RBKC's practice of seeking volunteers among its existing staff to undertake those roles rather than paying staff to be on standby.525 Kerry {Day268/66:2-9}. The London Borough of Hammersmith and Fulham, which was a party to a tri-borough agreement with RBKC and Westminster City Council, did pay its staff to undertake emergency roles. Despite the concerns raised by Mr Kerry, RBKC had chosen not to change its policy by the time of the Grenfell Tower fire.
49¶In our view RBKC's policy of relying on volunteers undermined its ability to practise its emergency plans in accordance with its statutory duty.
¶101.65 RBKC was systemically ill-equipped to deal with a serious emergency. Over a number of years, the capability of its staff to respond to a major emergency had been allowed to decline. There were clear warnings to senior management that it did not have enough trained staff and that contingency plans were not practised enough. As a result, RBKC was wholly unprepared to provide an adequate response to the Grenfell Tower fire.
¶101.66 Under the Minimum Standards for London each borough was required to report to the London Resilience Group each year the state of its preparedness for responding to an emergency, rating plans and capabilities as green (operational), amber (operational but requiring development) or red (not operational). The 2016 report was the most recent to have been completed at the time of the Grenfell Tower fire.526 Minimum Standards for London Assessment Template RBKC 2016 {RBK00036770}. It was produced by Mr Kerry,527 Kerry {Day268/146:6-8}. who rated various aspects as amber.528 MSL Assessment Template 2017 {RBK00047524}. Training and borough level exercises fell into that category. RBKC recognised in the report that BECC exercises needed to be improved and that there was insufficient refresher training. The report also referred to a need to revise an analysis of training needs, but that was no more than an aspiration. The analysis had not been revised by the time of the Grenfell Tower fire.529 Blackburn {Day270/124:4}-{Day270/125:10}; Kerry {Day268/147:2-15}.
¶101.67 Significantly, the borough's capability for humanitarian assistance was also rated amber.530 Kerry {Day268/153:7}-{Day268/154:11}. That reflected the fact that its humanitarian assistance plan dating from April 2008 was out of date. Efforts to develop the plan stagnated because it was found too difficult.531 Kerry {Day268/153:7}-{Day268/155:7}.
¶101.68 The report indicated that RBKC had no Humanitarian Assistance Lead Officer (HALO).532 Kerry {Day268/164:18}-{Day268/168:4}; Humanitarian Assistance Framework {RBK00011313/2}. When a significant emergency has occurred, the HALO has an important part to play in bringing together various partners, including health agencies, the police, and voluntary and faith sectors to oversee the humanitarian assistance effort. The continued lack of a trained HALO created a significant gap in RBKC's ability to respond effectively to a serious emergency.533 Kerry {Day268/168:18-22}.
¶101.69 Minimum Standards for London required local authorities to have documented procedures in place allowing access at any time to information required to identify vulnerable persons known to them and to make that information available in a form in which it could be used by different responders.534 Identifying the Vulnerable Framework paragraph 1.7.1 {LFB00061174/6}; Minimum Standard tab 2.6 {LFB00119219/20}; Kerry {Day268/168:24}-{Day268/175:1}. That was another respect in which the report showed that RBKC required improvement. However, in reality the position fell far short of that, because in substance all that existed was a draft plan dated April 2012.535 Kerry {RBK00058091/3-4} pages 3-4. Annex 21: 'A framework for identifying and contacting vulnerable persons in an emergency.
¶101.70 The report showed that there had been no exercise to test the plan for identifying vulnerable persons and did not show that any lessons had been learnt from training or exercises. Despite requests to hold a multi-agency exercise in the wake of exercise Babel in November 2015 none had been carried out by June 2017, even though it had been intended to hold one by April 2016.536 Kerry {Day268/170:9}-{Day268/171:5}; {RBK00005188/4}. Mr Kerry accepted that the system in place at RBKC for identifying vulnerable people was materially inferior to those operated by its tri-borough partners.537 Kerry {Day268/179:22}-{Day268/181:8}. Indeed, in March 2017, he had told Tony Andrews,
50¶Emergency Planning Manager (Humanitarian Assistance) at Westminster City Council that it remained a considerable concern within RBKC.538 {RBK00058010}; Kerry {Day268/156:4}-{Day268/157:18}; {Day269/2:24}-{Day269/5:11}.
¶101.71 Although the information in the report was received by the London Resilience Group, there was no oversight of the process, which relied entirely on self-assessment. Mr Hetherington told us that if a quarter or more of the boroughs were not fully operational (i.e. were either amber or red) in relation to any particular function, the London Resilience Group would inform the Local Authorities' Panel to enable it to consider how it could improve them.539 Hetherington {Day277/155:15)–{Day277/156:1}. In relation to the identification of vulnerable persons, the reports for 2016 showed that nine of the 33 boroughs were amber.540 MSL Peer Review Results 2016 {LFB00119221}. For 2017, ten of the 33 boroughs were amber and one red.541 MSL Results for all Borough 2017 (final); MSL Self-Assessment Results 2017 {LFB00119222/10} excludes Hackney {LFB00119232}.
¶101.72 As part of its report RBKC also indicated that it did not have in place a documented strategy for community resilience which described a programme of multi-agency collaborative work with emergency responders, members of the public and voluntary and faith sectors.542 Kerry {Day268/156:4}-{Day268/159:12}. Notwithstanding some limited efforts, there was generally a failure to engage with local voluntary agencies and faith groups. In that respect RBKC failed to discharge its statutory duty as a Category 1 responder to maintain plans involving the voluntary sector.543 Section 2(1)(c)-(d) Civil Contingencies Act 2004 {CAB00004616/3}; Regulation 23 Civil Contingencies Act (Contingency Planning) Regulations 2005 {CAB00007003/13}. The fact is that RBKC did not have a strategy which actively considered and engaged the voluntary sector during the planning process or in training or exercises.544 The Role of the Voluntary Sector {CAB00004597/2} paragraph 14.6; Kerry {Day268/163:3-7}. It was not treated as a priority by David Kerry and the Contingencies Planning Unit, although with hindsight he accepted that it should have been, a sentiment with which we agree.545 Kerry {Day268/159:5-12}, {Day268/158:25}-{Day268/159:6}.
¶101.73 In our view, the report together with the wider evidence reveals a culture of neglect at RBKC over a number of years towards planning for humanitarian assistance. The existence of an effective plan for providing such assistance would probably have made a material difference to its response to the Grenfell Tower fire.546 RBKC Closing Submissions {RBK00068546/24} paragraph 84.
¶101.74 None of those matters were reported to the chief executive or senior executive board of RBKC.547 Kerry {Day268/151:2}-{Day268/153:5}. The council had no system in place to inform senior management that it was not meeting the standards expected by Minimum Standards for London. As a result, there was a lack of oversight in relation to those important matters. Ultimately, the defects identified in the report were the very areas in which its response to the fire failed.
51Chapter 102: The London-wide response
Introduction
¶102.1 In this chapter we examine the response of the London Resilience Group, the London Resilience Partnership, London Gold, the Mayor of London and the Greater London Authority, concentrating in particular on their reactions to the fire and the arrangements available to support RBKC in leading the humanitarian response.
Notification of the fire to the London Resilience Group
¶102.2 The duty manager of the London Resilience Group is the person to be notified of an emergency and the person responsible for putting any strategic co-ordination arrangements into action.548 London Resilience Group Duty Officers' Handbook v.1.3.1., March 2017 {LFB00061187/6} Figure 2.2; Hogan {LFB00119334/6} page 6, paragraph 21. On 14 June 2017 the duty manager was Matthew Hogan,549 Hogan {LFB00119334/1} page 1, paragraph 4; Hogan {LFB00119334/6} page 6, paragraph 20. overseen by Toby Gould, a deputy head of London Resilience, who acted as the strategic advisor.550 The London Resilience Strategic Advisor role is defined in the London Resilience Group Duty Officers' Handbook v.1.3.1, March 2017 {LFB00061187/6} paragraph 2.2, see also {LFB00061187/15-16}. John Hetherington, also a deputy head of London Resilience, took over at 08.30.551 Gould {LFB00061268/3} page 3, paragraph 8.
¶102.3 Although a major incident552 A major incident is defined as an event or situation with a range of serious consequences which requires special arrangements to be implemented by one or more emergency responder agency: 'Joint Doctrine: The Interoperability Framework', 2nd Edition, July 2016 {CAB00004642/8}. had been declared by the Metropolitan Police at 01.26,553 Phase 1 Report Volume IV paragraph 30.38. Mr Hogan first became aware of the Grenfell Tower fire from a BBC news flash on his mobile phone at 02.30.554 Hogan {LFB00119334/6} page 6, paragraph 22. The first official notification he received of the fire was in an email from Transport for London at 03.12.555 {LFB00119337}; Hogan {LFB00119334/7} page 7, paragraph 26. That was not how the London Resilience Group would normally expect to be notified.556 Hetherington {Day277/182:2-15}. Mr Hogan should have been notified by the police themselves that they had declared a major incident.557 Hetherington {Day277/182:2-15}. The London Resilience Partnership Strategic Co-ordination Protocol v.7.3, February 2017 (public facing) {GOL00001153/3} and Hogan {LFB00119334/7} page 7, paragraph 25 states, "any partner organisation experiencing or having knowledge of a potential disruptive, major incident or emergency should contact the LRG Duty Officer to jointly assess the situation to determine the level of strategic co-ordination required". At 03.18 Mr Hogan received a WhatsApp notification from Glenn Sebright, head of communications at the LFB, followed by an email at 03.20 stating that the LFB had also declared the fire a major incident.558 Hogan {LFB00119334/8} page 8, paragraph 28; "40 pump fire, major incident, north Kensington". Glenn Sebright then emailed LRT Alerts and other London Resilience Partners at 03.21 stating that LFB had declared the fire a 'major incident' {LFB00119338}.
52¶102.4 The London Resilience Partnership Strategic Co-ordination Protocol,559 The London Resilience Partnership Strategic Co-ordination Protocol v.7.3, February 2017 (public facing) {GOL00001153}, the protocol is introduced in the Phase 1 Report Volume IV paragraphs 30.24 - 30.28. which sets out the arrangements for London's response to a major incident,560 {CAB00004616/1}; {GOL00001153/10} paragraph 1.1.1. does not say when the London Resilience Group ought to be notified; Mr Hetherington said that he would expect it to be notified as soon as reasonably practicable.561 Hetherington {Day277/182:17-25}. It is clear that there was a delay on the part of the police and the LFB in informing it of the fire.562 MPS at 01.26 although CAD said "critical incident", LFB at 02.06 and LAS at 02.26, Phase 1 Report Volume IV paragraph 30.38. As the Phase 1 report concluded, the declaration of a major incident is all but useless if it is not communicated to other Category 1 or 2 responders as soon as possible and that applies equally to communication to the London Resilience Group.563 Phase 1 Report Volume IV paragraph 30.19.
The strategic co-ordinating group
¶102.5 In February 2017 the London Resilience Partnership published version 7.3 of its Strategic Co-ordination Protocol containing the procedures to be followed by its members in response to a major incident. The first step is to establish a strategic coordinating group,564 {MET00023288}. the purpose of which is to enable the agencies responding to the incident to formulate a joint strategy, to agree on joint actions and share information565 Emergency Response and Recovery {CAB00004519/20}, paragraph 2.6.1. in order to provide direction in the response.566 {MET00023288/15-16} paragraphs 2.2.2- 2.2.7; Hetherington {LFB00061158/5} page 5, paragraph 14. A full strategic co-ordinating group consists of both Category 1 and 2 responders, as well as others, such as the voluntary and faith sectors.567 {MET00023288/37} Appendix 2. Local authority attendance at the strategic co-ordinating group is at Gold Group level, which means that either the chief executive of the affected borough or its Gold Commander is expected to attend.568 Hetherington {Day277/187:16-19}; {MET00023288/17} paragraph 2.2.12. states "Representatives at the Strategic Coordinating Group must have the level of knowledge, expertise and authority to identify and to commit the resources of their respective agency." That may also include the duty London Gold, whether or not he or she is involved in the response at that stage.569 {MET00023288/37} Appendix 2. Mr Hetherington told us that if the duty Gold is available, he or she should attend meetings of the strategic co-ordinating group.570 Hetherington {Day277/189:5-7}.
¶102.6 The duty Gold had two functions when attending a strategic co-ordinating group meeting following the Grenfell Tower fire. The first was to ensure that RBKC had everything it needed; the second was to assess whether there were implications for other London boroughs.571 Hetherington {Day278/87:1-9}; Sawyer {Day278/89:23}-{Day278/90:1}. John Barradell told us that before the Gold Resolution had been formally activated the role of the duty London Gold was to attend the strategic co-ordinating group meetings to keep a watching brief.572 Barradell {Day 279/17:19}-{Day 279/19:9}. It was therefore a departure from the standard procedure that both the duty London Golds on the night of the fire, Andrew Blake-Herbert followed by Christopher Naylor, were absent from the initial strategic co-ordinating group meetings on the morning of 14 June 2017.573 Barradell {Day279/29:15-25}; {MET00023288/33}.
53¶102.7 Mr Sawyer, Chief Executive Liaison Officer (Resilience) for the City of London Corporation, said that it was not mandatory for London Gold to attend strategic coordinating group meetings,574 Sawyer {Day278/86:10-17}. particularly in relation to an incident confined to a single borough. That had changed, however, when it became clear that RBKC was unable to discharge its responsibilities.575 Sawyer {Day278/92:5-10}. Mr Barradell disagreed and admitted that he had been surprised that neither of the duty London Golds had attended a meeting of the strategic co-ordinating group.576 Barradell {Day279/29:25}. It is therefore unclear why, after Mr Sawyer's attendance at the first meeting that took place at 05.00, the duty London Gold did not attend any of the subsequent four meetings on 14 June 2017577 Strategic Coordinating Group meetings on 14 June 2017: 06.30 {LFB00028077}; 08.30 {LFB00003366}; 14.00 {LFB00003369}; 19.30 {LFB00119322}. or the meeting on 15 June 2017.578 Strategic Coordinating Group meeting on 15 June 2017 at 11.00 {MOL00000047}. The first strategic co-ordinating group meeting attended by the duty London Gold was at 11.00 on 16 June 2017.579 Minutes of the Strategic Coordinating Group Meeting on 16 June 2017 at 11.00 {MOL00000036}. Sawyer {Day278/87:11-20}; The LLAG also attended on 17 June 2017 at 14.00 and 22 June 2017 at 13.00. In our view, the prompt convening of a strategic co-ordinating group attended by people, including the duty London Gold, with the level of knowledge, expertise and authority to identify and commit the resources of their respective agencies, is essential to its proper functioning. Until the Gold resolution had been invoked, London Gold had no active part to play, but the presence of a duty London Gold could have provided a senior figure to assess and, if appropriate, challenge the information provided by RBKC.
Meetings of the strategic co-ordinating group
¶102.8 The first meeting of the strategic co-ordinating group was held at 05.00 on 14 June 2017.580 Minutes of the 05.00 Strategic Coordinating Group Meeting on 14 June 2017 {MOL00000026}; Hetherington {Day277/187:3-5}. The LFB had asked for the meeting to be convened at 04.30, but the request was not made until 04.09 and Mr Gould and Mr Hogan did not think that there was enough time to organise a meeting by 04.30.581 {LFB00119343}. The meeting therefore took place at 05.00.582 Hogan {LFB00119334/12} page 12, paragraph 43; Gould {LFB00061268/5} page 5, paragraph 12; {LFB00119343}. The lapse of time between the declaration of a major incident at 01.26 and the convening of a strategic co-ordinating group at 05.00 was caused in large part by a delay of almost two hours in telling the London Resilience Group of its occurrence. That in turn meant that the identification of potential difficulties and full coordination between the Category 1 and 2 responders did not formally begin until three and a half hours later.583 "A key feature of leadership decision-making in crises and emergencies is the need for decisions to be made quickly…" {MET00023288/22} paragraph 2.7.5.
¶102.9 One of the responsibilities of the London Resilience Group duty manager is to ensure that London Gold is aware of the declaration of a major incident.584 {MET00023288/14} paragraph 2.1.5; {LFB00061187/9}. Mr Hogan contacted the duty London Gold, Andrew Blake-Herbert, at 04.55.585 At 04.38 Mr Hogan sent an email to Mr Naylor, the chief executive of the London Borough of Barking and Dagenham, and Paul Martin, the chief executive of Richmond and Wandsworth Council, to give them the sign-in details for the 05.00 Strategic Coordinating Group meeting as he wrongly thought that Mr Naylor was the duty Gold and Mr Martin the secondary Gold. Mr Hogan then tried calling Mr Naylor at 04.38, 04.39 and 04.41. {LFB00119351/1}; Hogan {LFB00119334/13} page 13, paragraph 50; Hogan {LFB00119334/17} page 17, paragraph 74. There is no guidance on how soon after being informed of a major incident the duty manager should notify London Gold, although as a matter of common sense it should be as soon as possible.586 Hetherington {Day277/185:3}; {MET00023288/14} paragraph 2.1.5 states that the LRG manager will check that relevant organisations are aware including the duty LLAG. In this case, there was a delay of an hour and 43 minutes,587 The period between the LRG being notified of the fire at 03.12 and Mr Blake-Herbert, duty Gold being notified by Mr Hogan at 04.55. which on any view was far longer than was reasonable. Mark Sawyer, who was copied into the notification, told us that he thought that there had been insufficient time to notify the duty London Gold of the first strategic co-ordinating group meeting, so he attended himself.588 Sawyer {Day278/87:13}-{Day278/88:4}. Whether that affected the response of London Gold is difficult to tell, as, although Mr Sawyer did not take on the role of London Gold during the meeting, he was a representative of London Gold and had previous experience in dealing with major incidents.589 Sawyer {GOL00001349/10} page 10, paragraph 49; Sawyer {Day278/87:11-20}. Even so, if the duty London Gold had been present, he might have provided a wider perspective as chief executive of a
54¶London borough. That is all the more so given that RBKC's own chief executive did not attend until the group's third meeting at 08.30590 {MOL00000014}. and the first London Gold did not attend a meeting until 11.00 on 16 June 2017.591 {MOL00000036}.
Early consideration of the London Gold arrangements
¶102.11 At about 04.55 on 14 June 2017, Mr Hogan and Mr Blake-Herbert spoke to each other on the telephone.595 Hogan {LFB00119334/14} page 14, paragraph 58. At that stage Mr Blake-Herbert was happy for RBKC to continue to take the lead.596 {LFB00119359/1}; Gould {LFB00061268/7} page 7, paragraph 18. Mr Hetherington and Mr Gould discussed the activation of the Gold arrangements in a telephone call at 05.42.597 Hetherington Incident Log Book {LFB00061216/6}. Mr Gould told Mr Hetherington that RBKC was dealing with the incident and that it did not require the arrangements to be activated.598 Hetherington {LFB00061158/18} page 18, paragraph 54. In an email sent to Mr Hetherington at 05.58 Mr Hogan referred to his earlier telephone call to Mr Blake-Herbert and confirmed that he had been happy for RBKC to lead the response.599 {LFB00119359/1}; Gould {LFB00061268/7} page 7, paragraph 18.
¶102.12 The London Resilience Group contacted RBKC to ensure that it had enough support. At 07.44 Mr Gould asked Nicholas Holgate to indicate whether the position of RBKC had changed and whether it required London Gold's assistance on any matters affecting London as a whole. Mr Gould said that he was not aware of any such matters, given that the incident was entirely within the borough. At 07.50 Mr Holgate told Mr Gould that, apart from a need for housing that might spill over borough boundaries, he did not think London Gold needed to prepare for action.600 {LFB00061289/1}. That did not surprise Mr Hetherington.601 Hetherington {Day277/196:24} – {Day277/197:1}.
55¶102.13 It is clear to us that the London Resilience Group was working on the assumption that, as the incident was contained within one borough, the assistance of London Gold was unlikely to be required and that RBKC would take control unless other boroughs were affected.602 Mr Hetherington gave an example of 'overspill' in the case of a terror incident which, although confined to a single borough, may have ramifications as regards the monitoring of hate crime or preventing crime, in which case LLAG would oversee those aspects of the response, Hetherington {Day277/197:16}-{Day277/198:5}; Barradell {Day279/31:3-16}. Christopher Naylor, who became the duty Gold at 09.00 on 14 June 2017, said that the usual practice was that if the effect of an incident were confined to a single borough, that borough would retain control unless it invited outside support.603 Naylor {GOL00001603/2} page 2, paragraph 4. The Gold Resolution604 The Gold Resolution, July 2010 {GOL00001725}; Addendum to the Gold Resolution, July 2010 {GOL00001717}. did not provide for the duty Gold to intervene otherwise than in response to a request for assistance from the chief executive of the borough affected.605 Naylor {GOL00001603/2} page 2, paragraph 4. Likewise, once the Gold Resolution had been activated it was the task of London Gold to support the chief executive of the affected borough, not to take control of the response.606 Barradell {Day279/19:22}-{Day279/20:15}.
¶102.14 We were told that the primary purpose of the Gold Resolution was to provide a single command in response to an emergency affecting the whole or a wide area of London, such as "rising tide" incidents,607 For example, flood, pandemic or a civil disturbance which develops over time; Naylor {GOL00001603/2} page 2, paragraph 5. or a roaming terrorist attack.608 Naylor {GOL00001603/2} page 2, paragraphs 4-5. Before the Grenfell Tower fire, the London Resilience Group had expected that in the case of an incident confined to one location the relevant borough would take control of the response609 Hetherington {Day277/197:16}-{Day277/198:5}. and that London Gold would not be involved. If a disaster occurred of such a scale and complexity that no one local authority could be reasonably expected to respond to it on its own, it was expected that London Gold might become involved, but only if the borough asked for assistance.610 Hetherington {Day277/198:12}. That was based on the assumption that a borough knew its residents, resources and capacity best and could be expected to have an interest in leading the response to its residents.611 Hetherington {Day277/198:12-19}.
¶102.15 At the time of the fire, London Gold could not intervene unilaterally in a borough's response if it had not been asked for assistance.612 Barradell {Day279/14:6-21}. It was easier to invoke the Gold Resolution if an incident had occurred affecting a wide area than if the effect of an incident were confined to a single borough.613 Barradell {Day 279/14:16}-{Day 279/15:5}. Mr Barradell confirmed that he had no power to invoke the Gold Resolution and that Mr Holgate had to do that.614 Barradell {Day279/58:15-16}. The government also acknowledged that there was no readily available means for London Gold to take control or to require a borough to act in a particular way.615 Key points from the discussion between Peter Tallantire, a Deputy Director in the Civil Contingencies Secretariat, Cabinet Office, and No.10 {CAB00014827} paragraph 1; Tallantire {CAB00014830/9} page 9, paragraph 27.6.
Training
¶102.16 Chief executives received little training to prepare them for taking on the role of London Gold. When Mr Naylor took over as London Gold at 09.00 on 14 June 2017 it was the first time he had acted in that capacity.616 Gould {LFB00061268/9} page 9, paragraph 26. We were told that the only training a chief executive would receive from the London Resilience Group before being added to the
56¶London Gold rota was an hour-long briefing from someone at the London Resilience Group or Mr Sawyer and a tour of the special operations room at Lambeth.617 Hetherington {Day277/202:16}-{Day277/203:6}.
¶102.18 The Gold Resolution was not considered to be a matter of concern in 2016 and as such was not within the scope of the review of local authority emergency planning which in 2016 gave rise to the "EP2020" report.622 Sawyer {Day278/72:7-25}. Recommendations for Local Government Emergency Planning and Resilience for the 2020's ("EP2020"), report by Mark Sawyer, 3 October 2016 {GOL00001515/3} paragraph 2, 'The two elements excluded are; the London Local Authority Gold Resolution and the principle of all 33 chief executives participating in the London Local Authority Gold rota'. Mr Hetherington told us that it had been recognised before the Grenfell Tower fire that the training for chief executives needed to be improved. The process had begun before the fire, but the fire had caused the new training to be postponed.623 Hetherington {Day277/204:5-16}. Mr Sawyer also said that there had been a need to improve training for chief executives.624 Sawyer {Day278/187:1-3}. The second edition of the "EP2020" report published in 2019 recommended that all chief executives and their deputies attend training events and exercise programmes to prepare them to undertake the duties of London Gold.625 EP2020 Enhancement Programme, July 2019 {INQ00015129/15} Recommendation 20.
Early signs that RBKC was not coping
¶102.19 Jon-Paul Graham was duty officer at the GLA on the night of the fire.626 Graham {GLA00000004/4} page 4, paragraph 18. He was first made aware of it at 03.09 on 14 June 2017 by the Commissioner of the LFB, Dany Cotton.627 Graham {GLA00000004/4} page 4, paragraph 18. The Mayor of London, Sadiq Khan, was subsequently notified between 03.20 and 03.30 by the head of his private office, Ali Picton.628 Bellamy {MOL00000025/15} page 15, paragraph 68.
¶102.20 Mr Graham attended the first three strategic co-ordinating group meetings on 14 June 2017. Emma Strain, Assistant Director of External Relations at the GLA, attended all the other meetings of the group between 14 and 20 June 2017, except the meeting on 18 June 2017, which was attended by David Bellamy, the Mayor of London's chief of staff.629 Strain {GLA00000009/1} page 1, paragraph 3; Bellamy {MOL00000025/13} page 13, paragraphs 60 and 63; Minutes 14/06/17 at 05.00 {MOL00000026/3}, 06.30 {MOL00000015/3}, 08.30 {MOL00000014/5}, 14.00 {LFB00003369/6}, 19.30 {LFB00119322/7}, 15/06/17 at 11.00 {MOL00000047/6}, 16/06/17 at 11.00 {MOL00000036}, 17/06/17 at 14.00 {LFB00119508}, 18/06/17 at 13.30 {MOL00000004}, 19/07/17 at 11.30 {MOL00000045}, 20/07/17 at 13.00 {MOL00000043}. The GLA is a standing member of the Strategic Coordinating Group, see {LFB00123769/7}. The Mayor's Gold Cell group is called together when a major incident has been declared. Its purpose is to ensure that the Mayor is kept well informed in order to enable him to carry out his role as spokesman for the capital and provide civic leadership and reassurance.630 Mayor of London's Major Incident and Civil Contingencies Response Protocol - Gold Cell (November 2016) {MOL00000040/12} Section 4. It was convened by Mr Graham following the first strategic co-ordination group meeting at 05.00 on 14 June 2017.631 Graham {GLA00000004/6} page 6, paragraph 32. Its first meeting was held at 08.00.632 Graham {GLA00000004/6} page 6, paragraph 32.
57¶102.21 In his written evidence, Mr Graham said that, at the meeting of the strategic co-ordinating group at 06.30, he had been shocked to hear that RBKC had not yet held its own Gold Group meeting and was not intending to do so until 11.00, four and a half hours later.633 Graham {GLA00000004/7} page 7, paragraph 35. He was concerned even at that early stage that RBKC might not be coping with the demands of the incident.634 Graham {GLA00000004/7} page 7, paragraph 36, Mr Graham's kept a typed note which he used to brief colleagues in City Hall {GLA00000004/5} paragraph 26. That note {MOL00000039} did not refer to any concerns as set out in his statement. However, Mr Graham did not report his concerns to Mr Bellamy and Mr Bellamy did not recall their being raised at the first meeting of the Mayor's Gold Cell group.635 Graham {GLA00000004/8} page 8, paragraph 39; Bellamy {Day282/30:23}-{Day282/31:5}. An opportunity for the GLA and the Mayor to raise concerns about RBKC's handling of the response may therefore have been missed, although, as we have said, there was no machinery by which either of them could take control of events.
¶102.22 Regrettably, a log was not kept of the action taken by the Mayor's Gold Cell group, nor were any minutes kept of its meetings in the days following the fire.636 Bellamy {Day282/32:13-19}. That was contrary to the Mayor's own protocol, which expressly provided that maintaining a record of key events, actions and decisions together with their reasons was of paramount importance.637 {MOL00000040/15} paragraph 4.4. Mr Bellamy explained that the absence of logs and minutes was due to the relatively recent introduction of the protocol in November 2016, which had meant that the training required to establish it had not taken place. In addition, the resources of the London Resilience Group were stretched, as they were dealing with a number of other serious incidents at the time.638 Bellamy {Day282/33:7}-{Day282/35:13}. Be that as it may, the absence of records has made it difficult for us to tell when concerns were first raised by the Mayor's office about RBKC's handling of the response to the fire and when they were first communicated to others.
The London Resilience Group
¶102.23 Until the early afternoon of 14 June 2017, the London Resilience Group thought that RBKC was taking appropriate steps to ascertain the needs of those affected by the incident and provide accommodation and practical support. It is clear to us that by that stage the scale of the incident should have been clear to everyone, not least because it involved the mass displacement of residents.639 {LFB00061223}. However, because it had failed to appreciate the scale of the incident and had not activated fully its Contingency Management Plan, RBKC was unable to cope on its own with the demands imposed on it. Mr Holgate was determined to retain control of the response and the mistaken understanding of the London Resilience Group, Mr Barradell and the London Gold that RBKC was able to keep up with the demands made the problem worse by delaying the introduction of experience and resources from across London.640 Barradell {Day279/96:16-22}.
58¶102.24 During the afternoon of 14 June 2017, Mr Sawyer was asked to arrange a conference call between a group which included Nicholas Holgate, Christopher Naylor (then London Gold), John Barradell, John Hetherington, Eleanor Kelly (chief executive of Southwark Council) and John O'Brien, (chief executive of London Councils).641 Holgate {Day273/112:7-12}; Sawyer {GOL00001349/7} page 7, paragraph 34; Sawyer {GOL00001349/8-9} pages 8-9, paragraph 41. The purpose of the call was to understand the support that RBKC was likely to require and how it could best be provided by other boroughs. The intention was to provide strategic support to Mr Holgate.642 {GOL00000155}.
¶102.25 The call took place at 17.30 on 14 June 2017. Although RBKC insisted that it was keeping up with the demand for support from residents, it was agreed during the call that Mr Barradell and Ms Kelly would offer peer support to Mr Holgate the next day, 15 June 2017. In addition, it was agreed that two senior directors from Southwark Council would attend RBKC on 15 June 2017 to provide advice and assistance.643 Kelly {GOL00000439/9} page 9, paragraph 31; Sawyer {GOL00001349/9-10} pages 9-10, paragraph 46; Email from Mr Hetherington to Mr Holgate, Mr Naylor, Mr Barradell, Mr O'Brien and Mr Sawyer at 18.58 on 14 June 2017 {LFB00061225}.
¶102.26 In addition to the offer of peer support, it was decided that Mr Sawyer would go to RBKC the following day to provide initial support and the benefit of his experience of previous major incidents.644 {LFB00061225}; Barradell {Day279/68:14}-{Day279/69:11}. Mr Sawyer agreed that his aim should be to encourage and identify potential areas of improvement.645 Sawyer {Day278/136:4-23}. It was rare for him to be asked to assist a local authority so soon after an incident;646 Sawyer {Day278/108:7-23}; Sawyer {Day278/109:21-24}. his involvement reflected the size and complexity of the emergency.
¶102.27 There was no discussion during the call about invoking the Gold Resolution.647 Holgate {Day273/118:11-22}. Hetherington {LFB00119130/30} page 30, paragraph 95. "The activation of LLAG was not discussed during this call, which focused on what immediate support was required by RBKC from other boroughs". Mr Holgate was aware of the possibility of doing so, but formed the view that none of those taking part thought that it was necessary for there to be a wider response by local government.648 Holgate {RBK00035426/6} page 6, paragraph 32. No one told him that the incident was too big for one local authority to deal with. He therefore did not consider activating the Gold Resolution and gained the impression that the others taking part in the call thought that RBKC was coping adequately. Nevertheless, we are surprised that the Gold Resolution was not mentioned, particularly in view of the concern that Mr Naylor felt about RBKC's ability to respond to the needs of the wider community.649 Naylor {GOL00001603/6} page 6, paragraph 13.
¶102.28 One reason for Mr Barradell's failure to intervene at that stage was that he assumed, based on what he was being told by RBKC, that RBKC had a capable group of officers who understood what to do in such circumstances.650 Barradell {Day279/50:4-6}; Barradell {Day279/51:14-23}. Despite the fact that by the time of the call there was, as he put it, "rising concern" about RBKC's ability to manage the response,651 Barradell {Day279/50:20-24}. he admitted that he had not challenged Mr Holgate's own view of the situation. By the time he gave evidence he had come to regret that he had accepted what he was being told at face value, although it was obviously wrong.652 Barradell {Day279/49:7-15}.
59¶102.29 Among the matters discussed during the call were significant changes to the situation and the structures in place for co-ordinating support across London.653 {LFB00061224/2}. That involved describing the groups that were being set up under the auspices of the strategic co-ordinating group, including those dealing with mass fatalities and humanitarian assistance, and generally giving those involved an understanding of the breadth of the structures being set up.654 {LFB00061224/2}; Hetherington {Day277/218:6-23}. Mr Hetherington also told us that it was necessary to do that, even though the Gold Resolution had not been invoked, in order to give Mr Holgate an understanding of the wider response that could be made available if he wanted to make use of it.655 Hetherington {Day277/218:1-12}.
¶102.30 Apart from Mr Holgate's initial reluctance to ask for assistance from London Gold, there was also a reluctance on the part of the London Resilience Group to be drawn into long-term support. In an email sent after the conference call late on 14 June 2017 John Hetherington expressed the hope and expectation that, once RBKC had support from the right people, it could be left to get on with it.656 {LFB00061229}. Mr Sawyer told us that there was a general concern among the London Resilience Group at the time, unrelated to the Grenfell Tower fire, that individual boroughs needed to take more direct responsibility for responding to emergencies.657 Sawyer {Day278/111:17}-{Day278/112:6}.
¶102.31 The reluctance of the London Resilience Group to become engaged in long-term support was due to its involvement at that time in the response to other incidents, in particular, the London Bridge attack in Southwark.658 Hetherington {Day277/224:6-25}. That suggests a shortage of available resources across London at the time of the fire, but it was not the reason why more was not done sooner to assist RBKC.659 Hetherington {Day277/224:6-25}. If RBKC had asked for assistance, we are confident that it would have been provided with alacrity.
Offers of assistance
¶102.32 In addition to the offer of peer support made during the conference call, RBKC was inundated throughout 14 June 2017 with general660 {RBK00002651}; {RBK00009882}. and specific661 {GOL00000326}; {RBK00060182}; {RBK00064677}. offers of help from various local authorities. They were, in the main, refused by RBKC, which did not wish to appear incapable of managing the situation but did not have sufficient regard to an objective analysis of its needs.662 Barradell {Day279/84:16-25}; Barradell {Day279/97:7-22}. In particular, it feared that invoking the Gold Resolution would be seen as a sign that its response had failed.663 Barradell {Day279/85:11-17}.
¶102.33 In our view RBKC's decision to refuse external help was misguided and reflected a misplaced belief on the part of Mr Holgate that it could manage on its own. Mr Barradell was surprised that offers of support should have been turned down by any borough following an incident of that kind and would have expected a formal request for support.664 Barradell {Day279/43:10-24}. That view was shared by Mr Sawyer,665 Sawyer {Day278/115:5-16}. who thought that RBKC was overwhelmed and lacked strategic oversight.666 Sawyer {Day278/115:21}-{Day278/116:2}. When he gave evidence Mr Holgate accepted that his refusal to accept external assistance at an earlier stage of the response had been due to his misguided belief that the council was managing the response adequately.667 Holgate {Day273/130:17-23}. However, we also think that he was blind to the obvious and regarded accepting assistance as an admission of defeat.
60¶102.34 Mr Barradell said that at the meeting on 14 June 2017 he had not had concerns about the ability of RBKC to manage the response,668 Barradell {Day279/48:5-9}. which suggests that he was relying on his previous positive view of RBKC.669 Barradell {Day279/50:4-6}; Barradell {Day279/96:16-22}. As such, on 14 June 2017 he did not offer advice or express any concern to Mr Holgate about his leadership, despite perhaps having certain reservations.670 Barradell {Day279/69:5-11}.
The Mayor of London's conversation with the Secretary of State
¶102.35 At 18.15 on 14 June 2017, the Mayor of London spoke to the Secretary of State for Housing, Communities and Local Government, the Rt Hon Sajid Javid MP.671 Khan {MOL00000189/8} page 8, paragraph 32. A summary of the call records that the Mayor said that he had been impressed with the government's response thus far and that they had discussed matters such as the re-housing of displaced persons and the provision of counselling for firefighters.672 {CLG00003011}. In his witness statement, however, the Mayor said that he had expressed a deep concern for the situation faced by the local community and that, having seen the chaos on the ground, he had expressed the need for a single point of contact and advice for the local community and for visible support from the local authority and the government.673 Khan {MOL00000189/9} page 9, paragraph 33; {MOL00000182}.
¶102.36 Mr Bellamy told us that, although the Mayor himself had noticed certain things on his visit to the tower on 14 June 2017, he had not thought that he knew enough about RBKC's response to make a reliable assessment of it and could rely only on what he had been told after the strategic co-ordinating group meetings.674 Bellamy {Day282/53:1-10}. The difference between the note of the Mayor's conversation with the Secretary of State and his subsequent recollection is not of importance and we agree with Mr Bellamy that it would have been helpful for those who were present at the strategic co-ordinating group meetings to have questioned Mr Holgate more closely about what he said was happening.675 Bellamy {Day282/53:16-25}.
Questions from DCLG
¶102.37 By the morning of 15 June 2017, officials from the Department for Communities and Local Government (DCLG) were seeking information about how the response was going. Although the Resilience and Emergencies Division ("RED") was not responsible for supporting local authorities in an emergency and had no power to control their responses,676 Farrar {Day284/135:23-24}. it did have a responsibility to collect and share information about an incident.677 McManus {CLG10009725/23} page 23, paragraph 95; Farrar {Day284/8:2-4}.
¶102.38 On the morning of 15 June 2017, Lynne Dowdican, RED resilience advisor, spoke to the deputy head of the London Resilience Group,678 Dowdican {CLG00030419/6} page 6, paragraph 27. who confirmed that RBKC was reasonably confident that it had found accommodation for all those who needed it and could deal with any shortage that might emerge.679 {LFB00119653} Email forwarded to Hamish Cameron with Laura Johnson's (RBKC) response to the DCLG queries. At 09.24 she sent an email to the London Resilience
61¶Group asking how many people had been accommodated in rest centres overnight, whether families with vulnerable people or children had been housed and if so, in what kind of accommodation. She also enquired about the support available to families, the telephone numbers of the rest centres, family support services, the casualty bureau and the family and friends centre.680 {LFB00061311/1}. It appears that she was not prepared to take the assurances she had been given at face value. At 09.31 the London Resilience Group confirmed that answers were being sought from RBKC and the police. It provided a link to
¶RBKC's newsroom which gave out information about support lines, facilities, and telephone numbers that had been revised the evening before.681 {LFB00061311/1}.
¶102.39 At 10.01 on 15 June 2017, Philip James, a government liaison officer with RED, told Mr Gould about concerns that had been raised by Nicholas Hurd, the Minister of State for Policing and the Fire Service, some of which related to the adequacy of the sleeping facilities at the Westway Centre. He asked for confirmation that the Red Cross and the Samaritans were involved and that the sleeping conditions would be better that evening.682 {LFB00061313/1}. That message was passed on by Mr Gould to Mr Sawyer and Mr Holgate with a request for a positive response to the questions it contained. Mr Gould also asked whether Mr Holgate would like to appoint someone at RBKC to act as a point of contact for DCLG,683 {LFB00061313/1}. but Mr Holgate did not choose to do so.684 Hetherington {Day278/9:11}-{Day278/10:9}.
¶102.40 Mr Hetherington told us that he had not been made aware of the concerns that Mr Hurd had expressed about the sleeping facilities at the Westway Centre.685 Hetherington {Day278/9:21}-{Day278/10:23}. They were important matters of which Mr Hetherington should have been made aware. The fact that a government minister felt it necessary to raise such matters should have sounded a warning to Mr Holgate and Mr Gould that there were problems with the response.
¶102.41 At 10.20 Jenny Shellens of RED sent Mr James an email asking him to clarify a number of matters when he attended a meeting of the strategic co-ordinating group later that morning. They included the number of those displaced and what arrangements had been made for temporary accommodation. At the end of her message she asked him whether they could be satisfied that RBKC had a grip on the emergency.686 {CLG00003099/2}. Her question went unanswered.
¶102.42 A further sign that by the morning of 15 June 2017 DCLG was beginning to be concerned about the adequacy of RBKC's response was the suggestion that Mr James might be sent from the police special operations room to the RBKC Borough Emergency Control Centre.687 {CLG00018936/3} email at 09.52 and {CLG00018936/2} email at 10.09. Mr Gould advised against it.688 Email from Mr Gould to John Bentham 15 June 2017 at 10.09 {CLG00018936/2}. Mr Hetherington told us that there was no precedent for a government liaison officer to be deployed in a local authority's BECC.689 Hetherington {Day278/7:19}-{Day278/8:8}. We think that it was more efficient for an official to be a standing member of the strategic co-ordinating group, thereby giving access to the information from all the agencies involved, rather than being present at the BECC.
62The Mayor of London's concerns
¶102.43 The Mayor of London visited Grenfell Tower for the second time at 14.00 on 15 June 2017.690 Khan {MOL00000189/10} page 10, paragraph 41. He described how the full scale of the tragedy was starting to become clear. During that visit some members of the community had been very upset and angry and wanted answers from someone in authority, so his attendance at the scene drew a large crowd. Someone threw a bottle of water at him.691 Khan {MOL00000189/11} page 11, paragraph 46. He was advised by his security team to leave the Notting Hill Methodist Church by the back door but he felt strongly that it was his duty as Mayor to listen to the community's concerns, so he remained and spoke to those affected for another hour.692 Khan {MOL00000189/12} page 12, paragraph 48.
¶102.44 The news of what had happened during the Mayor's visit was relayed to Mr Hetherington by Commander Jerome, the police Gold, who told him that the Mayor had been mobbed during his visit. Consequently, and as a result of further concerns about civil unrest, Commander Jerome, as chairman of the strategic co-ordination group was no longer willing to move from the emergency response phase to the recovery phase on 16 June 2017,693 Emergency Response and Recovery {CAB00004519/83}. since that would entail handing over management of the response to RBKC alone.694 {LFB00061233}.
¶102.45 Mr Bellamy attended the second cross-government ministerial meeting at 15.30 on 15 June 2017,695 Minutes of the Ministerial Meeting at 15.30 on 15 June 2017, {CAB00002720} and Actions, {CAB00001255}. which he said was the first time he had become aware that there was unease about RBKC's handling of the response.696 Bellamy {Day282/58:17}-{Day282/59:10}. Following the meeting, he returned to City Hall, where he heard reports from a number of colleagues that RBKC was failing in its response.697 Bellamy {Day282/61:8}-{Day282/61:10}; {Day282/62:6}; {GLA00000854/26} "Is there a way we can get across that RBKC are totally out of their depth". He was sufficiently concerned at its lack of progress to telephone Mr Barradell at 17.39 to discuss what action could be taken to improve it.698 Bellamy {MOL00000025/16} page 16, paragraph 79; Bellamy {Day282/59:24} - {Day282/60:1}. It appears that that call took place shortly after the telephone conference between Mr Barradell and Mr Holgate at 17.00.
¶102.46 It was clear from Mr Bellamy's evidence that his intervention in contacting Mr Barradell on 15 June 2017 following the second ministerial meeting had been generated by his worries rather than a desire for the Gold arrangements to be set in motion. He said that at the time he had not known enough about those arrangements to consider that possibility.699 Bellamy {Day 282/67:11-15}.
¶102.47 By the evening of 15 June 2017, the London Resilience Group, DCLG and City Hall had all expressed significant concern about the response.700 {LFB00061238}. The performance of RBKC and London Resilience as a whole was under increasing scrutiny from both the government and the Mayor's office and the need for an improvement had become paramount. In that context it is difficult to understand why there was further delay between the decision to activate the Gold arrangements and the formal steps required to do so.
63The first request for mutual aid
¶102.48 The first formal request by RBKC for assistance from other local authorities was not made until 17.03 on 15 June 2017.701 Emergency Response and Recovery, non-statutory guidance accompanying the Civil Contingencies Act 2004, {CAB00004624/225}: Mutual aid is "An agreement between Category 1 and 2 responders and other organisations not covered by the Act, within the same sector or across sectors and across boundaries, to provide assistance with additional resource during an emergency". RBKC did receive assistance from Westminster City Council and the London Borough of Hammersmith and Fulham as part of the tri-borough agreement on 14 and 15 June 2017. It was prompted by an email sent by Gillian Maxwell on behalf of the London Local Authority Coordination Centre to RBKC at 16.34 asking it to give some serious thought to what assistance it was likely to need from other boroughs over the next 24 to 48 hours.702 {LFB00061234/2}. (Mr Hetherington confirmed that he considered that request for staff to have been the council's first request for mutual aid.)703 Hetherington {Day278/29:10-14}; {LFB00061234/2}. RBKC responded at 17.03 to say that it was likely to need liaison officers, rest centre managers, rest centre teams and emergency planning staff and asked the London Local Authority Coordination Centre to arrange that on its behalf.704 {LFB00061234/1}. The request for assistance was sent to other boroughs at 17.54 on 15 June 2017.705 Hetherington {LFB00061158/23} page 23, paragraph 73. That was almost 36 hours after the last surviving occupant had left the tower. We think that RBKC should have asked for assistance far sooner. The London Local Authority Coordination Centre had been open and ready to help since 08.15 on 15 June 2017 in the expectation that the Gold arrangements would be activated or that assistance would be requested and there is no reasonable explanation why its services could not have been used a good deal earlier.706 Hetherington {Day278/25:17}-{Day278/26:4}.
The operation of the Gold Resolution
¶102.49 Mr Barradell told us that communications with Mr Holgate on 14 and 15 June 2017 were designed gently to encourage him to operate the Gold Resolution, although he accepted that his approach had perhaps not been forceful enough.707 Barradell {Day279/58:6-11}. We are satisfied that Mr Barradell did not expressly raise with Mr Holgate the desirability of invoking the Gold arrangements at any time before the meeting at 17.00 on 15 June 2017. In fact, he did the opposite. When on 14 June 2017 Christopher Naylor, the duty Gold, asked Mr Barradell if there was more he could be doing to support RBKC, Mr Barradell told him that the operation of the Gold Resolution was a matter for Mr Holgate and that unless RBKC's position changed he should remain on standby.708 Naylor {GOL00001603/5} page 5, paragraph 11. John Barradell was right in his understanding that only Mr Holgate as chief executive of RBKC could operate the Gold Resolution, but that did not need to prevent senior figures in London Resilience from giving him clear and firm advice of the need to seek assistance from other boroughs. Mr Barradell accepted that he should have been more robust.709 Barradell {Day279/207:5-6}. As it was, an opportunity to persuade Mr Holgate that RBKC needed help immediately was lost.
¶102.50 At 17.00 on 15 June 2017 a conference call was held between Mr Holgate, Mr Barradell and Mr Sawyer to discuss Mr Sawyer's fear that Mr Holgate and his senior management team were not fully aware of the scale and complexity of the task facing RBKC.710 Sawyer {GOL00001349/11} page 11, paragraph 54.
64¶Dissatisfaction with the response of RBKC was growing among senior members of
¶London Resilience and was being expressed in the media.711 Kelly {GOL00000439/9} page 9, paragraph 32. It reflected the fact that the situation had not improved significantly during the day.712 Blackburn {Day270/181:6-8}.
¶102.51 The evidence about exactly when and how it was agreed that the Gold arrangements would be put into operation is unclear. No minutes of the meeting were kept. Mr Holgate recalled that he had made the decision during the conference call at 17.00.713 Holgate {RBK00035426/7} page 7, paragraph 38; Holgate {Day273/170:24}-{Day273/171:25}. Ms Kelly referred to a series of later calls, during which Mr Holgate had asked for Mr Barradell's support from the following day.714 Kelly {GOL00000439/9} page 9, paragraph 33. Mr Barradell said that at no point during the call at 17.00 had Mr Holgate asked for the Gold arrangements to be put into operation and that he had had further conversations with Mr Holgate later on to encourage him to do so.715 Barradell {Day279/86:2-12}; Barradell {Day279/87:18}-{Day279/88:9}.
¶102.52 Despite the differences of recollection, the documents show that very soon after the conference call at 17.00, Mr Holgate decided to operate the Gold Resolution. At 18.39 Mr Hetherington recorded in his log a call from Mr Sawyer in which the reasons for the decision were described as being the increasing complexity of the incident, the recent request from RBKC for mutual aid and a number of other factors.716 {LFB00061219/12}.
The delay in formal activation
¶102.53 Although the decision to put the Gold arrangements into operation had been made in the early evening of 15 June 2017, the formal steps required for that purpose were not taken until the afternoon of 16 June 2017.717 Hetherington {LFB00061158/26} page 26, paragraph 88; Hetherington {LFB00119130/32} page 32, paragraph 101. The delay has never been satisfactorily explained. Mr Hetherington told us that he was unsure what had caused it.
¶102.54 In an email sent at 22.04 on 15 June 2017, Mr Hetherington told his colleagues in the London Resilience Group that the Gold arrangements were not likely to be activated before 13.00 the next day and that Mr Barradell would go to RBKC to see what he was taking on before he activated the Gold arrangements.718 {LFB00061240/1}. Mr Hetherington suggested that that was necessary because it was possible that the situation had already moved beyond that which the Gold arrangements were designed for.719 Hetherington {Day278/36:7-15}. He and Mr Barradell both described the situation as a unique set of circumstances which were close to reaching the limits of what those arrangements could respond to.720 Barradell {Day279/22:7-21}; Hetherington {Day278/38:9-23}.
¶102.55 As the evidence progressed it became clear that there was (and may still be) some uncertainty in people's minds about the effect of operating the Gold arrangements. We described the Gold Resolution and the accompanying memorandum of understanding in Chapter 101. It did not provide for London Gold to take control of the management of the response, which remained in the hands of the chief executive of the borough affected by the emergency. It was no doubt possible for the chief executive to delegate to London Gold authority to act on behalf of the borough in certain respects, but that is another matter.
65¶102.56 Mr Barradell assumed the position of London Gold during the early afternoon of 16 June 2017. Both Mr Sawyer and Mr Hetherington maintained that he had not taken over the response; rather that he had supported Mr Holgate and RBKC in the provision of humanitarian assistance.721 Sawyer {Day278/149:20-24}; Hetherington {Day278/39:3-15}. We agree with Mr Sawyer that the Gold resolution did not give London Gold the power to take over the response to an incident.722 Sawyer {Day278/155:20}-{Day278/155:25}. Mr Hetherington said that before the fire, phrases such as "intervention" and "taking over" had not been part of the vocabulary of those who managed the London Gold arrangements; they had come to be used only after the fire.723 Hetherington {Day277/56:13-19}. Mr Barradell's evidence was to a similar effect. He told us that London Gold stood by the borough and not in its shoes,724 RBKC Module 4 Closing Submissions {RBK00068546/12} paragraph 34; Barradell {Day279/22:2-7}; Barradell {Day279/22:22}-{Day279/23:12}; Barradell {Day279/19:22}-{Day279/23:12}. and rejected the suggestion that he had taken over the response to the fire,725 Barradell {Day279/83:3-17}. because he had no authority to do so.726 Barradell {Day279/112:1-6}. He said that at that stage Mr Holgate had still been in charge.727 Barradell {Day279/112:12-15}.
¶102.57 It is important, in our view, that the individual boroughs and London Resilience as a whole understands clearly the effect of the arrangements for co-operation in mounting an effective response to an emergency, particularly one that affects two or more boroughs concurrently. Whatever the terminology and niceties of the arrangements, however, it is clear that the activation of the Gold Resolution led to significant additional resources and greater experience being made available to RBKC, but not to a handover of control. In the event, the government in the form of Dr Jo Farrar, director general for local government and public services at DCLG, intervened during the afternoon of 16 June 2017 to bring about an agreement under which Mr Holgate ceded control of the response to Mr Barradell.728 Holgate {RBK00035426/10} page 10, paragraph 51. From that moment Mr Holgate ceased to play any effective part in managing the response; he resigned as chief executive of RBKC on 21 June 2017.729 Farrar {CLG00030414/16-17} pages 16-17, paragraphs 78-79; Barradell {Day279/113:13-25}; Barradell {Day279/121:21}-{Day279/123:4}. It is important to note, however, that the substitution of Mr Barradell as leader of the response did not reflect the working out of these complex arrangements. It represented nothing more or less than a pragmatic response to a terrible emergency which required the co-operation, or at least the acquiescence, of RBKC. It throws into sharp relief the absence of any mechanism for vesting in one person control over the response to a major disaster affecting more than one borough.
¶102.58 The London Gold arrangements for the provision of mutual aid finally came into effect at 14.00 on 16 June 2017,730 Barradell {GOL00000244/10} page 10, paragraph 39. some 19 hours after the decision to operate them had been made. Mr Hetherington did not think at the time that the delay had had any adverse effect on the provision of emergency relief731 Hetherington {Day278/40:5 -20}. and had seen no benefit in involving another chief executive in the early stages of the incident, given that whoever had been appointed would not have been familiar with the resources or capability of the borough or with its residents.732 Hetherington {Day277/198:12-19}. However, we do not altogether agree with that assessment. Although it is impossible to say what precise effect on the response the earlier operation of the London Gold arrangements would have had, it seems likely that if RBKC had had the benefit of Mr Barradell's experience sooner, the response would have benefited from improved strategic oversight. The response was faltering and a greater sense of urgency would have reinforced it. Instead, time was lost over the weekend of 17 and 18 June 2017 setting up the structures and identifying the needs of those affected by the fire.
66¶102.59 Mr Sawyer thought that the London Gold arrangements should have been activated during the morning of 14 June 2017.733 Sawyer {Day278/153:4-7}. Mr Kerry thought that they should have been activated early in the morning of 14 June 2017.734 Kerry {Day273/222:19}-{Day273/223:1}. Mr Kerry may have been speaking with the benefit of hindsight, but on any view the scale of the incident was very substantial, involving the displacement of hundreds of people. As the day wore on it should have been increasingly obvious to RBKC that it did not have the capacity, skills or training required to lead the response on its own and should therefore have considered putting the London Gold arrangements into operation that day.
The response of London Gold
¶102.60 By the time the Gold resolution was activated on the afternoon 16 June 2017, RBKC had still not worked out what support it required.735 Sawyer {Day278/151:12-17}. It had been unable to obtain accurate information about the number of those affected by the tragedy or to assess their individual needs. As a result, the Gold team spent a considerable amount of time assessing the situation in order to determine what humanitarian assistance was required and organise it appropriately.736 Harpley {GOL00000441/4} page 4, paragraph 13.
¶102.61 During the afternoon of 18 June 2017 Mr Barradell asked DCLG to send a community expert to assist the response.737 LLAG log book (entry no.12) at 11.36 on 18 June 2017 {GOL00001675/3}. Hilary Patel was asked to act in that capacity and a community engagement meeting was held on 20 June 2017.738 Patel {CLG10009793/10} page 10, paragraphs 35-36; Gregory {HOM00046125/3} page 3, paragraph 7; Email from Rachael Wright-Turner on 21 June 2017 containing the notes of the Community Engagement meeting on 20 June 2017, {RBK00022888}. This is explored further at Chapter 106.
¶102.62 Later on 18 June 2017, a public statement was made by Ms Kelly, the deputy London Gold,739 Email including the statement of Eleanor Kelly {CLG00005448}. on behalf of the newly established Grenfell Fire response team740 Eleanor Kelly was also the Deputy Chair of the Local Authorities' Panel. Kelly {GOL00000439/3} page 3, paragraph 12. acknowledging that the initial response had simply not been good enough. Although many would regard that as self-evident, it was an important public recognition of the deficiencies in the response. The number of chief executives who by that time were assisting the response with the aim of bringing about positive change was an indication of the scale and complexity of the task. It also demonstrates why the Gold Resolution should have been activated at an earlier stage. Despite the considerable efforts across local government in London, it took a number of days for London Gold to steer the response in a more effective direction.
67Chapter 103: The government's response
Introduction
¶103.1 A description of the part played by the government in the response to the Grenfell Tower fire must begin with a brief summary of the relevant legal and administrative arrangements in place at the time.
¶103.2 The government is not a responder under the Civil Contingencies Act.741 Civil Contingencies Act 2004. It is, however, responsible for establishing the policy framework under which those who have a duty to respond to emergencies in England and Wales operate.742 Hammond {CAB00014764/3} page 3, paragraph 9. The formulation of that policy is the responsibility of the Cabinet Office, which, together with DCLG,743 Now called the Ministry of Housing, Communities and Local Government. plays a non-statutory oversight role.744 Hammond {CAB00014764/6} page 6, paragraph 21.
The Civil Contingencies Secretariat
¶103.3 Within the Cabinet Office, the Civil Contingencies Secretariat leads the work on emergency response and resilience. It is primarily a body that co-ordinates the work of others in the planning, response and recovery phases. It does not have a direct operational role in responding to emergencies.745 Hammond {CAB00014764/9} page 9, paragraph 29.
¶103.4 The Civil Contingencies Secretariat is part of the National Security Secretariat. It reports to Cabinet Office ministers and provides advice directly to the Prime Minister on matters relating to civil contingencies.746 Hammond {CAB00014764/10} page 10, paragraph 34. At the time of the fire, Katharine Hammond was Director of the Civil Contingencies Secretariat.
¶103.5 If an emergency occurs the Cabinet Office is responsible for notifying relevant government departments and agencies, ensuring a department has been identified to lead the response, providing staff to run the Cabinet Office Briefing Rooms ("COBR") and any associated crisis facilities as appropriate, initiating the supporting structures for a central response and devising solutions to problems when necessary.747 ConOps {CAB00000026/19-20} para 2.26(e)-(j).
¶103.6 If COBR has been activated, the Civil Contingencies Secretariat, in consultation with the lead government department, decides which elements of the supporting arrangements should be activated and how they may best be used. It also provides secretariat support and ensures that business is managed effectively748 ConOps {CAB00000026/22} paragraph 3.4. The COBR arrangements and the role of the lead government department role are explained below.
68The Prime Minister's office
¶103.7 In consultation with the Prime Minister's office ("No.10") and the lead government department, the Cabinet Office decides whether to set in motion the central response mechanism,749 ConOps {CAB00000026/19} paragraph 2.26(d). co-ordinating the activities of national, regional and local responders and deciding which departments need to be represented at COBR meetings and how often such meetings need to take place.750 ConOps {CAB00000026/37} paragraph 3.53.
The Home Office
¶103.8 Responsibility for fire policy was transferred to the Home Office from DCLG on 1 April 2016.751 {HOM00050060/5}. In the case of a sudden major incident,752 As opposed to a rising tide incident {HOM00050060/8}. such as the Grenfell Tower fire, the Office for Security and Counter Terrorism, which was part of the Home Office, provided support for the government in the first 24 to 48 hours in the form of managing communications, providing information, briefing ministers for COBR meetings, monitoring the situation and co-ordinating action across the Home Office.753 Edwards {HOM00050058/2} page 2, paragraph 6.1.
¶103.9 The Home Office did not have an operational role in responding to any major fire.754 Lamberti {HOM00046095/4} page 4, paragraph 14. Its main function was to support the independent fire services through the provision of resources and to provide advice and information to ministers and civil servants.755 Lamberti {HOM00046095/4} page 4, paragraph 14. However, it became the lead government department for the response in the period immediately following the Grenfell Tower fire because of the prominence of the emergency services and its responsibility for the fire and rescue services.756 Edwards {HOM00050071/2-3} pages 2- 3, paragraph 9.
The Department for Communities and Local Government
¶103.10 The Department for Communities and Local Government (DCLG) changed its name after the fire to the Ministry of Housing, Communities and Local Government.757 McManus {Day283/4:7-20}. At the time of the fire, Dame Melanie Dawes DCB was the Permanent Secretary.
¶103.11 The Resilience and Emergencies Division of DCLG (RED) was established in 2011.758 Dowdican {CLG00030419/1} page 1, paragraph 3. The director general for local government and public services at the time of the fire was Dr Jo Farrar OBE, whose directorate included RED.759 Farrar {Day284/5:13-17}. Jillian Kay, director of local government policy, was the director of RED; Katherine Richardson was the deputy director.760 McManus {CLG10009725/4} page 4, paragraph 11. There was a head of emergencies management,761 Mason {CLG00030435/2} page 2, paragraph 5. five heads of resilience762 McManus {CLG10009725/4} page 4, paragraph 11. and resilience advisors who had responsibility for particular geographic areas and particular types of risk.763 Richardson {CLG00030412/6} page 6, paragraph 18.
¶103.12 RED had two functions: one was to produce advice and plans in preparation for the occurrence of identified risks; the other was to ensure effective communication between Category 1 and Category 2 responders and the government if an emergency were to occur.764 Richardson {CLG00030412/2} paragraph 6. Part of its responsibility was to co-ordinate planning and ensure that Category
69¶1 responders had the support they needed.765 Emergency Preparedness, Chapter 2 {CAB00007027/59} paragraph 2.153. In addition, RED was a standing member of local resilience forums766 Emergency Preparedness, Chapter 2 {CAB00007027/59} paragraphs 2.153-2.154. and was required to have a comprehensive understanding of their work.767 Emergency Preparedness, Chapter 2 {CAB00007027/59} paragraph 2.154. That was a national responsibility. RED had offices in London, Leeds,
¶Birmingham and Bristol.768 Richardson {CLG00030412/6} page 6, paragraph 18.
¶103.13 As part of its planning and advisory function, RED participated in exercises in London arranged by the London Resilience Forum. There was a small resilience advisor team that worked with the London Resilience Forum, including a head of resilience.769 Richardson {CLG00030412/4} page 4, paragraph 12. The involvement of RED resilience advisors was intended to help the London Resilience Forum understand the role of central government in the emergency response and to assist it in revising and improving plans.
¶103.14 The London-wide plans, discussed earlier, were developed by working groups that included representatives of Category 1 responders, including the London boroughs. RED assisted the production of those plans primarily by sharing information.770 McManus {Day283/25:20}-{Day283/26:9}. It was not the function of RED resilience advisors to approve any particular plan.771 McManus {Day283/26:13-22}.
¶103.15 RED was not responsible for overseeing a local authority's response to an emergency.772 Farrar {Day284/135:23-24}. Its function during the response phase, as set out in Emergency Response and Recovery, was to take immediate steps to ensure that it could support the local response as necessary.773 Emergency Response and Recovery {CAB00004624/154-55} paragraph 9.1.2. The guidance provided some indication of the form that that support should take, such as the collection and sharing of information,774 Emergency Response and Recovery {CAB00004624/154-55} paragraph 9.1.2; McManus {CLG10009725/23} paragraph 95; Farrar {Day284/8:2-4} the DCLG RED was not responsible for supporting the local authority response. provision of strategic information and, if necessary, telling the responders where they could get wider help and support.775 Emergency Response and Recovery {CAB00004624/154-55} paragraph 9.1.2; McManus {CLG10009725/23} paragraph 95.
¶103.16 When an incident occurred RED duty officers were the initial point of contact between DCLG, other organisations and the government generally. During a duty period, the duty Head of Resilience and two officers were normally on call 24 hours a day.776 DCLG Emergency Response Plan, version 3.4, June 2017 {CLG00021013/6} paragraph 1.15. They were expected to join strategic co-ordinating group meetings as government liaison officers (GLO), to represent the government777 McManus {CLG10009725/3} page 3, paragraph 7(b) and (c); McManus {CLG10009725/23} page 23, paragraph 95, except for incidents, such as terrorism, or the release of chemical, biological, radioactive or nuclear material, for which the Home Office would deploy a GLO and the DCLG RED would form part of the Government Liaison Team {CLG00021013/5} paragraph 1.13; {CAB00000026/39} paragraph 3.56; {CAB00000026/51} paragraph 6.2(ii); {CAB00004624/154} paragraph 9.1.2. and obtain relevant information to enable them to provide briefings for ministers and senior officials.778 DCLG Emergency Response Plan, version 3.4, June 2017 {CLG00005657/44}. Any member of RED who undertook the role of duty officer would be regarded as suitable to take on the role of GLO.779 McManus {Day283/53:17-20}.
70¶103.17 In London, there were two heads of resilience. They worked with the London Resilience Forum and supported it with plans relating to London as a whole. They also took part in training events and themselves provided training to Category 1 responders.780 Dowdican {CLG00030419/2-3} pages 2-3, paragraphs 9-10.
¶103.18 If an incident occurred, the head of resilience would decide what degree of involvement from RED might be required.781 McManus {CLG10009725/23} page 23, paragraph 94. If the deputy director considered that the incident would place significant pressure on RED's resources, or if COBR had been activated, an emergency notice would be sent out.782 DCLG Emergency Response Plan, version 3.4, June 2017 {CLG00005657/11} paragraph 2.16; McManus {CLG10009725/23} page 23, paragraph 94. That would inform the department, as well as other departments and ministers across government, that an emergency response had been triggered and that their own arrangements might need to be put into operation783 For instance, if they are a Lead Government Department, they may be required to release staff members to support the RED Operations, McManus {CLG10009725/23} page 23, paragraph 94; DCLG Emergency Response Plan, version 3.4, June 2017 {CLG00005657/11} paragraph 2.17.
¶103.19 The role of the lead government department was to organise other government departments, to take the lead on any governmental group and to be the first point of contact for government as a whole. It did not normally have any operational role.784 Farrar {Day284/15:3-13}.
¶103.20 When the response reached the point at which the demands on the emergency services were reducing, a decision would be made locally to transfer responsibility for the incident from the strategic co-ordinating group to a recovery working group.785 DCLG's Emergency Response Plan {CLG00005657/41}.
Responding to emergencies: the concept of operations ("ConOps")
¶103.21 The government's guidance on responding to emergencies was contained in a document entitled Responding to Emergencies in the form of a concept of operations,786 {CAB00000026} First published by Civil Contingencies Secretariat in 2010 and revised in April 2013. known colloquially as "ConOps".787 Tallantire {CAB00014769/3} page 3, paragraph 10. ConOps restated the principle of subsidiarity and confirmed that local responders were the basic building blocks of the response to an emergency in the UK.788 ConOps {CAB00000026/7} paragraph 1.7. It identified three broad types of emergency likely to require the direct involvement of the government: level 1 significant emergencies, level 2 serious emergencies and level 3 catastrophic emergencies.789 ConOps {CAB00000026/8-9} paragraph 1.8 sets out examples of each level and the type of direct central government engagement typical for each {CAB00000026/68}.
¶103.22 ConOps directed that a level 2 or level 3 emergency required the initiation of the government's crisis management facilities (i.e. COBR)790 ConOps {CAB00000026/11} paragraph 2.2. in order to enable the rapid co-ordination of the government's response and effective decision-making.791 ConOps {CAB00000026/11} paragraph 2.2.
¶103.23 The Cabinet Office was responsible for deciding whether the central response mechanism should be activated,792 The terminology of "central government response mechanism" and "COBR" are used throughout ConOps in some cases as equivalent terms: see ConOps {CAB00000026/8-9} paragraph 1.8; ConOps {CAB00000026/11} paragraph 2.2; ConOps {CAB00000026/19} paragraph 2.26(d); ConOps {CAB00000026/68}] and in others as distinct alternatives: ConOps {CAB00000026/36} paragraphs 3.50-3.51, ConOps {CAB00000026/45} paragraph 4.2 iii. consulting colleagues, the lead government department and the Prime Minister's Office as necessary.793 ConOps {CAB00000026/19-20} para 2.26. Although ConOps identified different levels of emergency with the intention of helping users to determine the likely form of government engagement, the decision was not taken in that way.794 Hammond {Day280/163:2-3}. The important question was whether to activate the government response mechanism.795 Hammond {Day280/164:1-9}. See also Hammond {Day280/155:8-10}. The phrase "COBR meeting" appears to have been used in Whitehall at the time without distinguishing between meetings taking place in the Cabinet Office Briefing Rooms and meetings taking place elsewhere in accordance with the COBR procedure.
71¶103.24 "COBR" was sometimes used as shorthand for a decision-making body of senior politicians, civil servants and others convened in accordance with the COBR procedure. Such a body was supported by a number of separate groups called "cells"796 It is not obvious that this referred to people rather than places, but it is the former. Para 2.26 of ConOps refers to the Cabinet Office's role in initiating the supporting structures for the central response such as the situation cell, the secretariat, and policy support and provide staff for the activation of those support mechanisms. and was designed to be flexible.797 ConOps {CAB00000026/21} paragraph 3.2.
¶103.25 For all level 2 and level 3 emergencies, other than terrorist incidents, the senior decision-making body was the Civil Contingencies Committee.798 A Cabinet Office construct bringing together ministers and officials from the key departments and agencies involved in the response and wider impact management along with other organisations as appropriate, see ConOps {CAB00000026/23} paragraph 3.7. A situation cell was established to ensure that there was a single, immediate, authoritative overview of the situation available to decision-makers.799 ConOps {CAB00000026/23-24} paragraph 3.9. The situation cell developed and maintained a common recognised information picture ("CRIP") consisting of information relating both to the incident and its significant wider consequences and including the main developments and decisions.800 ConOps {CAB00000026/24} paragraph 3.10.
¶103.26 ConOps indicated that, if there were uncertainty over the direction of the government's response to an emergency or the effectiveness of the local response in England and Wales, the Cabinet Office would convene a meeting (if appropriate in COBR)801 The ConOps guidance did not make it clear whether the use of "COBR" here referred to activation of central government's crisis management facilities or a meeting held in the physical location of the Cabinet Office Briefing Rooms. to assess the situation and advise ministers as necessary.802 ConOps {CAB00000026/45} paragraph 4.2iii. It recommended that, in cases of doubt, it was generally better to activate the central response, even if it were subsequently stood down.803 ConOps {CAB00000026/37} paragraph 3.52. ConOps advised that in practice, the level of government engagement may change over time (both up and down) as the demands of the emergency changed.804 ConOps {CAB00000026/9} paragraph 1.10.
¶103.27 In the event of a catastrophic or serious emergency in England, the Prime Minister, the Home Secretary or other senior ministers nominated by the Prime Minister, would direct the central government response from COBR. In cases of doubt, the Home Secretary would at least initially, assume the chair in COBR.805 ConOps {CAB00000026/45} paragraph 4.2iv.
Lead government departments
¶103.28 If an emergency occurred, the Cabinet Office was responsible for notifying relevant departments and agencies and ensuring that a lead government department was appointed.806 ConOps {CAB00000026/19-20} paragraph 2.26(e)-(j); Hammond {CAB00014764/12} page 12, paragraph 38.
72¶103.29 The lead government department normally took responsibility for assessing the situation, ensuring that its ministers and other relevant ministers were briefed, and providing support as necessary to local responders. Individual departments remained responsible for their particular policy areas.807 ConOps {CAB00000026/13} paragraph 2.8; ConOps {CAB00000026/27} paragraph 3.24.
¶103.30 At the time of the Grenfell Tower fire the Cabinet Office maintained a list of departments' responsibilities for planning, response, and recovery from emergencies dated March 2009 which was intended to make clear in advance which department would lead on main potential challenges.808 {HOM00013085}. The document included a reference to an emergency involving a fire. As the Home Office was responsible for fire and rescue services, it was the logical lead government department in the case of the Grenfell Tower fire.809 Hammond {Day280/166:11-12}; Dawes {Day285/32:5}-{Day285/33:4}. DCLG was the department assigned for the recovery phase of an incident of that kind, which was likely to engage local authority responsibilities. DCLG was the lead government department for matters involving local authorities.810 Hammond {Day280/170:2-6}. Dame Melanie Dawes did not think that the appointment of a lead government department occurred automatically and therefore put her department forward to undertake that role on the morning of 14 June 2017.811 Dawes {Day285/20:5}-{Day285/21:2}. She did not recall the Home Office asking the DCLG to be the recovery partner.
¶103.31 In paragraphs 2.16 to 2.18, ConOps envisaged that different government departments might lead on the response and recovery phases, although it recognised that in such a case they would need to work together closely from the outset to ensure a smooth handover of responsibilities at the appropriate time and the integration of those two different activities.812 ConOps {CAB00000026/16} paragraph 2.17.
The response phase
¶103.32 The response phase encompasses the decisions and actions taken to deal with the immediate effects of an emergency, to protect life, contain and mitigate the effects of the emergency and create the conditions for a return to normality. It comprises two separate but closely related and often overlapping challenges: crisis management and consequence management.813 ConOps {CAB00000026/6-7} paragraph 1.5 and ConOps {CAB00000026/27} paragraphs 3.22-3.23. Typically this phase lasts for a matter of hours or days.814 Emergency Response and Recovery {CAB00004519/10} paragraph 1.3.2. It usually precedes the recovery phase.
¶103.33 In paragraph 2.16, ConOps set out the role of the lead government department for the response phase, which it undertook in consultation with other government departments and with support from the Cabinet Office as necessary, if COBR had been activated. The responsibilities were extensive, including producing a handling plan as soon as possible, acting as a focal point for communication between the government and strategic co-ordinating groups in the affected area, ensuring that responders and affected communities had access to the resources they needed to manage the emergency and ensuring that recovery is borne in mind throughout and that arrangements were in place to ensure a smooth transition to the recovery phase.815 ConOps {CAB00000026/15-16} paragraph 2.16. The guidance was silent on whether the lead government department for response was expected to fulfil the same role where COBR had not been activated.
73The recovery phase
¶103.34 The recovery phase is defined as the process of rebuilding, restoring and rehabilitating the community following an emergency.816 ConOps {CAB00000026/7} paragraph 1.6. It formally starts once the situation has been stabilised. However, preparation for the recovery phase should be considered alongside crisis and consequence management in the early stages of a response.817 ConOps {CAB00000026/7} paragraph 1.6.
¶103.35 According to ConOps, in order to ensure that all departments and agencies were aware of the arrangements for handover from the response to recovery phase and its implications, leadership should formally be handed over from the lead government department for response to the lead government department for recovery.818 ConOps {CAB00000026/43} paragraph 3.74. The timing of the formal handover from response to recovery was to be agreed between the two departments in consultation with the Cabinet Office. In some circumstances (e.g. flooding across a wide area), it is possible (and sometimes vital) for response and recovery activity to be undertaken at the same time.819 ConOps {CAB00000026/43} paragraph 3.76; Hammond {Day281/86:19}-{Day281/87:1}.
¶103.36 The role of lead government department for the recovery phase included acting as the focal point for communications between the government and the recovery co-ordinating group at local level, together with many of the responsibilities of the lead government department for the response phase.820 ConOps {CAB00000026/16-17} paragraph 2.18.
¶103.37 ConOps suggested that it was the activation of COBR that triggered responsibilities, particularly for the Cabinet Office and the lead government department for response. However, Ms Hammond told us that the Civil Contingencies Secretariat's responsibilities arose in relation to any ministerial meeting convened to deal with a civil emergency, whether or not it was treated as a COBR meeting, and that the formal activation of COBR did not make a difference in practice.821 Hammond {Day280/165:7-17}; {Day280/171:20}-{Day280/172:25}. Later in Ms Hammond's evidence, she told us that there would never be a formal activation of the COBR procedure {Day280/174:24}-(Day280/175:12}. The difference between what the guidance says and how things work in practice is unsatisfactory, given that the Civil Contingencies Secretariat is the author of ConOps, operates COBR and provides introductory training for civil servants in relation to COBR.822 MacFarlane {CAB00014794/7} page 7, paragraph 23, provided by Robert MacFarlane's team within the CCS.
Government training
¶103.38 The Civil Contingencies Secretariat provided training and support to local responders for a fee823 EPC 2017 Training Course Programme {CAB00014795}. For example, in 2017, the cost per attendee for a 2-day training on 'Planning for Mass Fatalities' was £835 plus VAT. through the Emergency Planning College, which was operated by SERCO on behalf of the Cabinet Office. The courses824 Titles included "Strategic emergency and crisis management", "Emergency Control Centre Operations", "Chief Executives: your role in civil protection", and "Webinar: planning for needs of vulnerable adults in emergencies" {CAB00014792} Cat 1 Responders, column C, rows 40, 52, 130 and 185. were not mandatory for government departments nor for Category 1 or 2 responders.825 MacFarlane {CAB00014794/4-5} pages 4-5, paragraphs 14, 19.
¶103.39 The number of Emergency Planning College training courses undertaken by a responder is at best a crude measure of their level of training and expertise. Apart from anything else, it does not take into account the existing qualifications of staff or training that has been undertaken with another supplier.826 {Day280/149:18}-{Day280/150:2}. However, in the three and a half years before the
74¶Grenfell Tower fire the difference in the number of courses purchased by Westminster City
¶Council (88)827 {CAB00014792} Cat 1 Responders, Row 51, columns F, G, H and I. and RBKC (3) is stark. Unlike Westminster, RBKC had taken no courses in civil protection.828 {CAB00014792} Cat 1 Responders, Row 317, columns F, G, H and I.
¶103.40 There was no system within the Civil Contingencies Secretariat for monitoring training or notifying responders that were not undertaking a minimum level of training that they should be doing more.829 Hammond {Day280/150:3-10}. As a result, central government was not aware of shortfalls in the training of local responders.
¶103.41 In the three and a half years before the Grenfell Tower fire, there were also significant differences between central government departments in the number of delegates attending Emergency Planning College training courses. Only four delegates from each of DCLG830 {CAB00014793} Row 119, columns E, F, G and H. and the Home Office attended,831 {CAB00014793} Row 202, columns E, F, G and H. as against 94 from the Cabinet Office.832 {CAB00014793} Row 7, columns E, F, G and H. The Civil Contingencies Secretariat had a relatively high turnover of staff,833 Hammond {Day280/146:1-2}. all of whom attended the Emergency Planning College as part of the normal induction process,834 Hammond {Day280/147:8-9}. but it was not part of its function to monitor training undertaken by other government departments and it did not know how many courses were expected to have been undertaken by the departments that would regularly be deputed to act as lead government department for response or recovery.835 Hammond {Day280/145:2-12}.
¶103.42 The Civil Contingencies Secretariat itself also provided introductory training for civil servants whose roles were likely to require them to work with COBR.836 MacFarlane {CAB00014794/7} page 7, paragraph 23. Ms Hammond did not think that training was mandatory for those with a direct role in COBR, but it was expected that they would undertake it.837 Hammond {Day280/151:5-7}. It is not clear whether there was an expectation that ministers would receive training or an equivalent briefing.
¶103.43 RED conducted its own training led by Gill McManus, its acting head of London Resilience838 Ms McManus had been temporarily promoted to head of resilience for the London area from within Robert Mason's team. Mason {CLG00030435/6} page 6, paragraph 16. She confirmed that she had not received any specific training before her appointment as a head of resilience {Day283/42:16-20}. and Lynne Dowdican. It included induction training, revision exercises and discussions following RED responses to reflect on what had been learnt.839 McManus {Day283/35:11-15}; Dowdican {CLG00030419/2} page 2, paragraph 9. The department also held RED training days, ran a mentoring programme and held training sessions in team meetings.840 Dowdican {CLG00030419/2} page 2, paragraph 9. Most RED team members took part in the Multi-Agency Gold Incident Command course led by the College of Policing.841 Richardson {CLG00030412/15} page 15, paragraph 48. However, no training was provided specifically for duty officers.842 Welch {CLG00030737/3} page 3, paragraph 14; McManus {Day283/46:9-10} and {Day283/47:3-6}. Ms McManus accepted that that was inadequate843 McManus {Day283/47:3-8} and RED has now introduced a specific training programme for duty officers.844 McManus {Day283/46:19-21}.
75¶103.44 RED reserves,845 There were 51 RED reserves at the time of the Grenfell Tower fire, Richardson {CLG00030412/7} page 7, paragraph 22. who can be called upon by the department in an emergency response, had access to some training, but it was not mandatory846 Richardson {CLG00030827/5} page 5, paragraph 9b. and apparently it was not unusual for a reserve to have received no training.847 Doug Taylor, resilience advisor, had not received any RED reserve training. McManus {Day283/124:20}-{Day283/125:3}. Given the role the reserves may be called upon to play in response to an emergency, we consider that to be unsatisfactory.
¶103.45 Resilience advisors in RED took part in training exercises arranged by the London Resilience Forum that acted out various situations to check emergency preparedness, to help the London Resilience Forum partners to understand the role of the government in an emergency response and to assist them with revising and improving their plans.848 Welch {CLG00030737/4} page 4, paragraph 15. They included the major exercise known as exercise Unified Response that took place from 29 February to 4 March 2016849 McManus {CLG00030739/2} page 2, paragraph 8. and has been referred to earlier. The most recent resilience exercise involving local responders and the government before the Grenfell Tower fire had taken place on 17 May 2017.850 Dowdican {CLG00030419/2} page 2, paragraph 7.
¶103.46 In October 2015, RED had issued a learning strategy851 Resilience and Emergencies Division Training, Exercising and Organisational Learning Strategy 2015 – 2018, version 0.3, 2015 {CLG00030780}. which drew attention to the lack of structured monitoring of the lessons learnt from exercises and emergencies it had been involved in and the failure to link those lessons to training requirements.852 Resilience and Emergencies Division Training, Exercising and Organisational Learning Strategy 2015 – 2018, version 0.3, 2015 {CLG00030780/4} paragraph 3.2. The strategy also identified a lack of focus on training in the rest of the department.853 Resilience and Emergencies Division Training, Exercising and Organisational Learning Strategy 2015 – 2018, version 0.3, 2015 {CLG00030780/4} paragraph 3.3. Ms McManus told us that since the Grenfell Tower fire DCLG has taken a much more professional and structured approach to training which is being developed further.854 McManus {Day283/38:3-7}.
The government's understanding of responders' capability
¶103.47 From time to time the Civil Contingencies Secretariat organised a survey of the capability of local responders to respond to emergencies of various kinds. The results were collated in a national Resilience Capability Survey. Before the Grenfell Tower fire the Civil Contingencies Secretariat used the Resilience Capabilities Survey to help identify potential gaps in capability.855 Hammond {CAB00014764/6} page 6, paragraph 21. A fresh survey had been carried out in the spring of 2017 but the results had not been analysed by the time of the Grenfell Tower fire and therefore the version currently in use was the 2014 survey.856 Hargreaves {CAB00014871/4} page 4, paragraph 13; 2014 Resilience Capabilities Survey: Highlight Report {CAB00000094}. Participation in the 2014 survey had not been compulsory and 29% of Category 1 and 2 responders had not taken part.857 2014 Resilience Capabilities Survey: Highlight Report {CAB00000094/3}. Moreover, it had been based entirely on self-assessment by responders with no external verification of the results.858 Workstream 3 of the National Security Capabilities Review {CAB00007083/4}. Responses to the survey were processed and aggregated by a third party; the Civil Contingencies Secretariat received only a high-level report based on aggregated data859 Hargreaves {CAB00014871/5} page 5, paragraph 14. and was therefore unable to examine the responses of individual Category 1 and Category 2 responders.860 Hargreaves {CAB00014871/5} page 5, paragraph 14. Before the Grenfell Tower fire the capability of RBKC to respond to an emergency had not caused concern, either as a result of the survey or as a result of any information reaching the government from other sources.861 Workstream 3 of the National Security Capabilities Review {CAB00007083/4}. Central government thus had no means of effectively predicting the effectiveness of a local responder.
76The days immediately following the fire
¶103.48 Over the course of the seven days following the Grenfell Tower fire the government itself was still in a state of flux following the general election held on 8 June 2017.862 Held on Thursday 8 June 2017 {CAB00014768/1} paragraph 1. It was already having to respond to a number of significant emergencies, including terrorist attacks at Manchester Arena and London Bridge, and on 19 June 2017 a further terrorist attack took place outside the Finsbury Park mosque.863 That attack occurred in Finsbury Park, London, England, on 19 June 2017. Email at 10.46, 19.06.17 {CAB00005309} and Kay {CLG00030430/15} page 15, paragraph 62.
¶103.49 The National Security Secretariat watchkeepers (a small team of officials within the Civil Contingencies Secretariat who continuously monitor events) became aware of the Grenfell Tower fire at about 01.30 on 14 June 2017. The duty officer then notified Katharine Hammond, the senior civil servant on duty, of the fire at just after 03.00.864 Hammond {CAB00014764/13} page 13, paragraph 42.
¶103.50 The Civil Contingencies Secretariat assumed that the fire was a major incident and that a meeting of a strategic co-ordinating group of local responders would be called.865 Hammond {Day280/176:19}-{Day280/177:14}. The duty officer contacted DCLG RED so that it could provide a GLO to attend the meeting on behalf of the government.866 Hammond {Day280/177:11-14}. We note that ConOps indicated that the GLO would normally be from the lead government department, ConOps {CAB00000026/39} paragraph 3.56. Denise Welch, resilience advisor and RED duty officer that night,867 Welch {CLG00030737/1} page 1, paragraph 1; Welch {CLG00030737/2-3} pages 2-3, paragraph 11. received the call at about 03.30.868 Welch {CLG00030737/4} page 4, paragraph 16; McManus {CLG10009725/5} page 5, paragraph 15. Ms Welch called Gill McManus,869 Welch {CLG00030737/4} page 4, paragraph 17. who was acting for the first time that night as duty head of resilience,870 McManus {CLG10009725/5} page 5, paragraph 15. and then called David Norris, Home Office fire duty officer,871 Welch {CLG00030737/4} page 4, paragraph 17. at about 03.45.872 McManus {CLG10009725/7} page 7, paragraph 23. Mr Norris became aware of the fire only at that point.873 Welch {CLG00030737/4} page 4, paragraph 17. Ms Welch followed up her call with an email at 04.13874 Email at 04.13 on 14 June 2017 {CLG00008000/4}; Welch {CLG00030737/4} page 4, paragraph 17. and at 04.29 Mr Norris sent the information to various members of the Home Office staff.875 Email at 04.29 on 14 June 2017 {CLG00008000/3-4}. Given the Home Office's role in fire and rescue services,876 Hurd {HOM00046080/1} page 1, paragraph 4. we are surprised that it was unaware of the Grenfell Tower fire until it had been notified by DCLG RED.877 McManus {CLG10009725/7} page 7, paragraph 23; McManus {Day283/49:14}-{Day283/50:3}. RED also contacted the London Resilience Group, which confirmed that a major incident had been declared and that a strategic co-ordinating group meeting would take place at about 05.00. Ms McManus told us that it was unusual for RED not to have heard about an incident of this magnitude directly from the London Resilience Group.878 McManus {Day283/51:10-18}. Meanwhile, at 03.49,
77¶Ms Hammond sent an email to Stuart Wainwright, head of the Readiness and Response team, to notify him that the duty team was taking action.879 Hammond {CAB00014764/13} page 13, paragraph 44.
¶103.51 At 04.44, on Ms Hammond's instructions, the duty officer sent a situation report to No.10,880 Emails at 06.17 and 08.14, 14.06.17 {CAB00005650}. the National Security Adviser, Mark Sedwill, and the Deputy National Security Adviser, Paddy McGuinness.881 Hammond {CAB00014764/13} page 13, paragraph 44; amongst those copied into the 04:44, 14.06.17 email were DCLG RED and OSCT Operational Support in the Home Office {CAB00000337/5-6}. At 06.17, Alastair Whitehead, private secretary at No.10 with responsibility for the Home Office, sent an email to the Prime Minister informing her of a major fire at Grenfell Tower. He described the entire block as ablaze, with some reports suggesting that residents were still trapped inside. The Prime Minister confirmed receipt of the email at 08.14.882 {CAB00005650}.
¶103.52 The Home Office assumed the role of lead government department for the response phase in view of its responsibility for the fire and rescue services.883 Hurd {Day282/115:14}-{Day282/116:2}; Hurd {HOM00046080/1} page 1, paragraph 4. As part of that role the Home Office prepared situation reports in the days following the fire until 19 June 2017.884 Known as Sit Reps and dated 14, 15, 16, 17 and 19 June 2017 {HOM00046089}; Hurd {HOM00046080/6} page 6, paragraph 21; ConOps {CAB00000026/15} paragraph 2.16(ii). Dame Melanie Dawes contacted Dr Jo Farrar on the morning of 14 June 2017, indicating that she thought that DCLG would be designated the lead government department for the recovery phase. However, she told us that it would not automatically be asked to do so in relation to an incident of that kind and that she had no recollection of the Home Office asking DCLG to take on that role or talking to DCLG as the recovery partner.885 Dawes {Day285/20:16}-{Day285/21:2}.
The government's role in the strategic co-ordinating group
¶103.53 In her capacity as GLO Ms Welch joined the first strategic co-ordinating group meeting, which took place at 05.00, by telephone.886 Hammond {CAB00014764/14} page 14, paragraph 45. The GLO was not expected to attend the scene of an emergency887 McManus {CLG10009725/23} page 23, paragraph 95. but was expected to attend the strategic command centre or special operations room at which the strategic co-ordinating group was based.888 Emergency plan {CLG00005657/40-41}; McManus {Day283/55:8-17}; {Day283/56:14}-{Day283/58:7}. However, Ms McManus thought that it would be more effective for Ms Welch to join the meeting remotely,889 McManus {Day283/55:21}-{Day 283/56:9}. so she did not ask her to go to the strategic command centre890 McManus {CLG10009725/7} page 7, paragraph 25; emails at 04.40 and 04.55 on 14 June 2017 {CLG00030443/1}. and she did not do so.891 McManus {Day283/61:24}-{Day283/62:18}. In fact, no GLO was sent to the strategic command centre on the morning of 14 June 2017.892 McManus {Day283/89:1-11}. The presence of a GLO at an early stage of the response would have helped RED understand what was going on and what was needed and would have reinforced its effectiveness as a link between the strategic co-ordinating group and the government.893 Richardson {CLG00030412/28} page 28, paragraph 105; McManus {Day283/61:9-23}; McManus {Day283/58:7-12}; Module 4 Closing statement on behalf of the Department for Levelling Up, Housing and Communities {CLG00036423/2} paragraph 4b.
78Dissemination of reports
¶103.54 On the morning of 14 June 2017, RED was not providing timely reports about the prevailing situation from the strategic co-ordinating group meetings.894 Readout of 05.00 SCG meeting {CAB00000157/2}; readout of 06.30 SCG meeting {CAB00010263/1-2}; readout of 08.30 SCG meeting {CAB00008475/2}. Ms Welch produced a summary of the meeting at 05.00,895 {CAB00000157/2-3}. which she sent to colleagues at RED and to the Civil Contingencies Secretariat Control email address at 06.16.896 Email at 06.16 on 14 June 2017 {CAB00000157/2}. The OSCT Operation Support within the Home Office circulated to the CCS Control and others a situation report at 05:56 on 14 June 2017, which included reference to, but not a summary of, the 05:00 SCG meeting {HOM00046089/1-3}. However, the Civil Contingencies Secretariat Control did not send it on to Mr Wainwright until 07.13,897 Email at 07.13 on 14 June 2017 {CAB00000157/2}; Hammond {Day280/181:23}-{Day280/182:1}. by which time the second meeting held at 06.30 had already started.898 Both the DCLG RED and the Home Office joined the 06:30 SCG by telephone: email at 07:27 on 14 June 2017 {CAB00000157/1}. At that stage, no decision had been made about the need for national support,899 Hammond {Day280/183:14-16}. as Mr Wainwright considered that the Civil Contingencies Secretariat would be better able to make that decision after the meeting.900 Email at 07.27 on 14 June 2017 {CAB00000157/1}.
¶103.55 Mr Wainwright did not receive a summary of the 06.30 meeting until 08.40.901 Email at 08.35 on 14 June 2017 {CAB00014771/3-4}. A summary of the next strategic co-ordinating group meeting held at 08.30 was not sent to RED until 10.41902 Email at 10.41 on 14 June 2017 {CAB00008475/2}. and was not sent on to the Civil Contingencies Secretariat until 11.10.903 Email at 11.10 on 14 June 2017 {CAB00008475/1}. DCLG considered it unusual904 McManus {Day283/85:7-23}; email at 13.24 on 14 June 2017{CLG00008026/1}. that the Civil Contingencies Secretariat asked it to join the next meeting of the strategic co-ordinating group at 14.00,905 Email at 11.43 on 14 June 2017{CLG00008024/2}. but, in view of the repeated delays in sharing information that morning, we find it unsurprising. In our view the failure to share information from the strategic co-ordinating group promptly undermined at a critical stage the government's understanding of what was going on.
Assessment that support was not needed
¶103.56 The focus of the emails sent by DCLG in the early hours of 14 June 2017 was on the department's responsibilities for building regulations and housing, not on the local authority's ability to deal with an incident the size of the fire.906 Emails at 04.08 and 04.33 {CLG00030443/1}; emails at 05.55 and 07.12 {CLG00002860}; email at 08.07 {CLG00030453}; email at 08.11 {CLG00002867/2}; email at 08.26 on 14 June 2017 {CLG00030455}; McManus {Day283/65:8-12}. Ms McManus told us that the information coming through at that time indicated that RBKC was coping well and that other boroughs were providing assistance.907 McManus {Day283/77:18}-{Day283/78:3}. She told us that, in the absence of a request for support, RED would not normally contact a local authority in the middle of an emergency response.908 McManus {Day283/78:5-15}.
79¶103.57 At 08.09 Mr Wainwright sent an email to Ms Hammond saying that the LFB was not seeking additional resources and that the NHS had reported that it had sufficient capacity.909 Email at 08.09 on 14 June 2017 {CAB00000159/1}; Hammond {CAB00014816/9} page 9, paragraph 20. RBKC's capacity was not mentioned. Ms Hammond told us that the national resources available to local responders included anything that the fire and rescue service needed, because at that stage they were in the response phase.910 Hammond {Day280/184:11-19}.
¶103.58 We heard that on 14 June 2017 the Civil Contingencies Secretariat had been consistently told that the responders did not need any resources or assistance from the government.911 {Day280/188:2-4}; Hammond {CAB00014764/14} page 14, paragraph 46. Ms Hammond said that she had regarded the absence of a request for help from RBKC as reassuring.912 {Day280/190:16-17}.
¶103.59 The response phase of the reaction to an emergency comprises crisis and consequence management, which for many emergencies is the biggest and most complex area of work.913 ConOps {CAB00000026/27} paragraphs 3.22-3.23. It includes managing community relationships and providing shelter to displaced persons.914 ConOps {CAB00000026/6-7} paragraph 1.5; ConOps {CAB00000026/27} paragraph 3.22-3.23. That overlapping, but integral, part of the response phase appears to have been overlooked in the initial stages of setting in motion the government's response.
Issuing an emergency notice
¶103.60 An emergency notice putting the rest of the department on notice that matters might escalate and that RED reserves might need to be brought in should be issued915 The DCLG RED Reserves are people who work in other parts of the Department who can be released to work on urgent RED projects: McManus {CLG10009725/11} page 11, paragraph 41. if the deputy director considers that an incident will place significant pressures on RED's resources or if COBR has been activated.916 DCLG's Emergency Response Plan {CLG00005657/11} paragraph 2.16. Katherine Richardson, deputy director of RED, decided to issue an emergency notice at 09.18917 Email at 09.18 on 14 June 2017 {CLG00002875/2}; DCLG's Emergency Response Plan {CLG00005657/11} paragraph 2.16. after receiving an email at 09.16 from Robert Mason, head of DCLG's Emergencies Management Team.918 Robert Mason {CLG00030435/2} page 2, paragraph 4. Page 7, paragraph 19; Email at 09.16 on 14 June 2017 {CLG00002874/1}. Ms McManus told us that the emergency notice had been sent then,919 Email at 09:37 on 14 June 2017 {CLG00002879/1-2}; email at 09.39 on 14 June 2017 {CLG00002876}; Emergency Notice {CLG00008012}. after three strategic co-ordinating group meetings had been held and some eight hours after the police had declared a major incident,920 Phase 1 Report II paragraph 10.332. because by that time staff had been available to set up the operations centre.921 McManus {Day283/94:6-10}. However, it seems clear to us that the delay was an oversight that was corrected by Mr Mason's intervention.
¶103.61 The emergency notice informed recipients that RED had set up an operations centre922 The three main cells are the situation cell, the policy cell and the briefing cell: DCLG's Emergency Response Plan {CLG00005657/12-13} paragraphs 3.7-3.17. at 08.00.923 DCLG RED Emergency Notice {CLG00008012}; McManus {CLG10009725/22} page 22, paragraph 93. (An operations centre is the name for a collection of "cells" working together on behalf of the department to respond to a severe emergency or one affecting a wide area.) However, by 09.37, at least two of the three main cells (the situation cell and the briefing cell) had not been formally activated.924 Email at 09.37 on 14 June 2017 from Lynne Dowdican to RED Control notifying them that she had appointed an Operations Centre Manager and was seeking a briefing cell and a situation cell {CLG00002879/1-2}. Ms Dowdican had taken over from Gill McManus minutes earlier, see email at 09.32 on 14 June 2017 {CLG00002875/1}; McManus {Day283/81:13}-{Day283/82:5}. Although a full operations centre is used only for the most serious emergencies, it was clear from the outset to Mr Mason that RED and the government generally were likely to be heavily involved in the case of the Grenfell Tower fire.925 Robert Mason {CLG00030435/6-7} pages 6-7, paragraph 17. The delay in formally setting up the situation and briefing cells may have affected
80¶RED's understanding of what was happening at the incident, although we recognise that
¶DCLG was not standing still until the emergency notice was issued.
¶103.62 Despite the fact that Mr Mason was not on duty on 14 June 2017,926 Robert Mason {CLG00030435/7} page 7, paragraph 19; Robert Mason {CLG10009810/2-3} pages 2-3, paragraph 7. he was still recorded as the response manager for the operations centre in the emergency notice.927 {CLG00008012}. Mr Mason explained that the roles of response director and response manager were "standing roles", which Ms Richardson, as deputy director of RED, and he, as head of emergencies management, would automatically fill.928 Robert Mason {CLG00030435/7} page 7, paragraph 19; Robert Mason {CLG10009810/2-3} pages 2-3, paragraph 7.
Decision to hold a cross-government meeting
¶103.63 By 10.04 on 14 June 2017, the Prime Minister had asked for929 Whitehead {CAB00014857/9} page 9, paragraph 27. a cross-government meeting930 Email at 10.04 on 14 June 2017 {CAB00000337/1}. to be arranged to understand better what was happening, to ensure that the different departments that might have a role were co-ordinating their operations and to establish whether any additional assistance could be provided.931 Whitehead {CAB00014857/9} page 9, paragraph 27. It was to be held at 10 Victoria Street.
¶103.64 It was decided that the meeting should be held at minister of state level, rather than cabinet-level, because the Home Secretary was unavailable.932 Email at 10.04 on 14 June 2017{CAB00000337/1-2}. It was chaired by the Minister for Policing and Fire, Mr Nicholas Hurd MP,933 Email at 10.04 on 14 June 2017 {CAB00000337/1}. who had been appointed to the post two days earlier.934 Appointed on 12 June 2017; Hurd {HOM00046080/1} paragraph 1. He told us that at the time he had not been aware of the Civil Contingencies Act or the Regulations, the Emergency Preparedness guidance, the Emergency Response and Recovery guidance or the ConOps guidance935 Hurd {Day282/114:15}-{Day282/115:4}. and had had no training in resilience.936 Hurd {Day282/115:5-13}.
¶103.65 Ms Hammond told us that she had not assumed that the minister would not have mastered his brief simply because he had been so recently appointed.937 Hammond {Day281/154:14-16}. In our view, however, that might have been a safer assumption to make. Indeed, when Mr Hurd was asked whether he was adequately briefed for the task, he frankly admitted that that was scarcely possible, given that it was only his second day in the post.938 Hurd {Day282/148:16-23}. The Civil Contingencies Secretariat later concluded that the first cross-government meeting should have been chaired by a more senior minister. A similar recommendation had been made by the cabinet in the aftermath of the flooding in 2014 and 2015.939 Grenfell Tower tragedy – Lessons for the Central Response {CAB00014768/4} paragraph 17. With the benefit of hindsight Dame Melanie Dawes expressed the view that, if the initial cross-government meeting had been chaired at cabinet level940 By a Secretary of State. or by the Prime Minister, more questions might have been asked about the local response.941 Dawes {CLG00030653/36} page 36, paragraph 119. It is not clear why earlier recommendations were not followed.
81¶In our view, the cross-government meetings would have benefited from being chaired by a more senior minister who had a better understanding of what was required to respond to an emergency.
¶103.66 The meeting was described as a cross-government co-ordination meeting942 Email at 10.09 on 14 June 2017 {CAB00000337/1}. and in the email correspondence relating to it was specifically stated not to have been a COBR meeting.943 Email at 10.14 on 14 June 2017 {CAB00014775}. Alastair Whitehead told us that on 14 June 2017 there had been no detailed discussion within No.10 about activating COBR because it had been understood that, although the incident was serious, it was one that was being handled by the local emergency services, who could rely on the assistance of other boroughs where necessary.944 Whitehead {CAB00014857/8} page 8, paragraph 26. It is interesting to note that none of the witnesses told us that they had referred to ConOps during the period following the fire.945 Hammond {Day280/159:18-22}.
¶103.67 A message from Ms Hammond to Camilla Marshall in the No.10 Press Office at 12.58 on 14 June 2017 shed more light on the Civil Contingencies Secretariat's understanding of the level of the emergency at the time. In it she sought to explain the difference between a formal crisis management response (the COBR process, technically a cabinet sub-committee) and a less formal co-ordination meeting.946 Email at 12.58 on 14 June 2017 {CAB00013996/1}. She said that what really determined the difference was whether the government had a leading role in the response, which in that case was clearly being managed extremely well by local responders. They were therefore checking on requirements for resources and looking ahead to what arrangements for support were going to be needed from across the system in the next few days.947 Email at 12.58 on 14 June 2017 {CAB00013996/1}. Although not identified as a factor, it is clear that the absence of a request from RBKC for support and the belief that the response was being handled well by local responders influenced the level of government engagement on 14 June 2017. Ms Hammond told us that if it had been clear to the Civil Contingencies Secretariat at the time that RBKC was struggling, it is possible that a COBR meeting would have been called.948 Hammond {Day280/212:20-25}.
¶103.68 In preparation for the cross-government meeting at 16.00 on 14 June 2017 the Civil Contingencies Secretariat provided the secretariat support and developed an information pack (CRIP), as it would have done for a COBR meeting.949 Hammond {CAB00014816/8} page 8, paragraph 17; ConOps {CAB00000026/24} paragraph 3.10. It is likely that some of the people working in the situation cell preparing the CRIP would also then have been part of the secretariat for the meeting.950 Hammond {Day281/192:5}-{Day281/193:5}. Ms Hammond said that in practical terms there was no significance in the fact that the meeting was not formally a COBR meeting and that the Civil Contingencies Secretariat had done all the same things.951 Hammond {Day280/200:15-22}; Hammond {Day280/213:1-8}. The implications of failing to activate COBR formally are discussed further at paragraphs 103.172 to 103.177.
82Checks on RBKC
¶103.69 At 09.00 on 14 June 2017, Dr Farrar received a briefing from Ms Richardson which included information about the leadership and co-ordination of the local response. At that stage, it had not become clear who was leading the response in relation to humanitarian assistance.952 Farrar {Day284/16:14-23}. At 09.07, Dame Melanie Dawes sent an email to Nicholas Holgate offering government support as and when it might be helpful.953 Email at 09.07 on 14 June 2017 {RBK00005766}. He responded by thanking her but did not ask for assistance, saying that there was plenty of "blue light resource".954 Email at 09.09 on 14 June 2017 {RBK00005766}. Mr Holgate told us that he had not thought of going back to Dame Melanie at a later stage because it was not obvious to him what assistance the government could provide.955 Holgate {Day273/98:3}-{Day273/99:3}.
¶103.70 At 09.27 Dr Farrar's secretary attempted to get hold of Mr Holgate to tell him that Dr Farrar was his primary contact in the government and to arrange a time for them to speak.956 Email at 09.27 on 14 June 2017 {CLG00030460}; Farrar {Day284/27:6}-{Day284/28:3}. Dr Farrar followed that up with a text message to Mr Holgate but did not receive any response and was unable to speak to him until the next day.957 Farrar {Day284/28:4-11}; Holgate {Day273/98:19-23}; Farrar {CLG00030414/6} page 6, paragraph 27; Farrar {CLG00030414/10} page 10, paragraph 44. DCLG continued to make efforts to contact RBKC and offer government support throughout 14 June 2017,958 Email at 11.22 on 14 June 2017 {RBK00048990}; email at 12.16 on 14 June 2017 {CLG00030466/1}; Randall {CLG00030427/13-14} pages 13-14, paragraph 54; email at 16.37 on 14 June 2017 {CLG00002995}. but its offers were couched in general terms.
¶103.71 At 13.42 on 14 June 2017 Dr Farrar's secretary contacted Alex Powell, deputy director for local government stewardship at DCLG, to ask for background information on RBKC.959 Farrar {CLG00030414/6} page 6, paragraph 30. Dr Farrar described it as standard procedure960 Farrar {Day284/29:1-11}. and no concerns were raised about the general performance of RBKC.961 Farrar {Day284/29:14}-{Day284/30:3}; email at 14.05 on 14 June 2017 {CLG00002954}. Dame Melanie sent some general information about the leader of RBKC, Nicholas Paget-Brown, and the chief executive, Nicholas Holgate, to the Rt Hon Alok Sharma MP, then Minister of State for Housing and Planning. She described Mr Paget-Brown as "a safe pair of hands" and said that Mr Holgate had previously worked in the Treasury and that the department had a very good relationship with him.962 Email at 14.19 on 14 June 2017 {CLG00002952}. Dr Farrar accepted that the information that had been gathered was quite basic and superficial.963 Farrar{Day284/33:5}-{Day284/34:4}. Crucially, no information was provided to Dr Farrar which was relevant to RBKC's ability to respond to an emergency. Dr Farrar told us that she did not believe that it had been RED's responsibility to make such an assessment and that it did not have the resources to do so.964 Farrar {Day284/34:10}-{Day284/35:4}. The fact that the leader and chief executive of RBKC were both known to those at DCLG and held in high regard by those who knew them appears to have contributed to a confidence in the ability of RBKC to respond to the fire that turned out to be misplaced.965 {CLG00002952}; Farrar {Day284/35:1-4}.
83Ministerial visit to Grenfell Tower
¶103.72 One of the first things Mr Hurd did was to visit Grenfell Tower at approximately 13.00 on 14 June 2017,966 Hurd {HOM00046080/2} page 2, paragraph 6; Hurd {Day282/145:23}-{Day282/146:1}. where he met Dany Cotton, LFB Commissioner, and others.967 Hurd {HOM00046080/2} page 2, paragraph 7. He was not accompanied by anyone from RBKC, having taken the initiative himself to go there,968 Hurd {Day282/147:19}-{Day282/148:15}. and did not visit any of the surrounding areas, including the rest centres.969 Hurd {Day282/146:2-12}. He told us that, in hindsight, he wished things had been done differently because he could then have gone into the cross-government meeting with some basic information which he fairly conceded the meeting did not have.970 Hurd {Day282/147:19}-{Day282/148:15}.
Cross-government meeting 14 June 2017
¶103.73 After consulting No.10 and the Home Office971 Emails at 10.44 {CAB00001126/2}, and 12.05 on 14 June 2017 {CAB00001126/1}; email at 13:51 on 14 June 2017 {CAB00002927}. the Civil Contingencies Secretariat produced a number of documents in preparation for the meeting on 14 June 2017, including an agenda, brief for the chairman and a list of those invited to attend.972 {CAB00001129}; {CAB00002715}; {CAB00002711}. Matters for discussion included immediate shelter and medium-term rehousing and support for those affected by the fire.973 {CAB00001129}; {CAB00002715/2-3} items 3(b)-3(c). The list of those invited to attend did not include a representative from RBKC.974 {CAB00002711}. Ms Hammond told us that she had expected information about the local authority to come from the Mayor of London, RED and the ministers to whom they had been reporting.975 Hammond {Day281/5:1-10}. She could not remember anyone deciding that RBKC should or should not be represented, but she accepted that it would have been normal for Mr Holgate, as the chief executive of RBKC, to attend a meeting of that kind.976 Hammond {Day281/7:23-24}.
¶103.74 At 13.55 on 14 June 2017, RED sent the Civil Contingencies Secretariat by email Mr Holgate's name and telephone number as the local government representative977 Email at 13.55 on 14 June 2017 {CAB00000365/1}. and at 16.30, 30 minutes after the meeting had begun, RED asked the Civil Contingencies Secretariat to arrange for him to join the meeting by telephone to provide a local contribution as soon as possible.978 Email at 16.30 on 14 June 2017 {CAB00007461/2}. Until that point the Civil Contingencies Secretariat had not appreciated that Mr Holgate's details had been sent to enable him to join the meeting.979 Emails at 17.40, 17.49 and 17.59 on 14 June 2017 {CAB00007461/1-2}. As a result, no one from RBKC attended the meeting. Apparently, no one at the meeting remarked on the absence of RBKC.980 Hammond {CAB00014764/16} page 16, paragraph 51.
¶103.75 Ms Hammond did not accept that the omission of Mr Holgate from the list of those invited was a significant error.981 Hammond {Day281/6:2-13}. The failure of the Civil Contingencies Secretariat to include someone from RBKC in the list or to mention RBKC in the chairman's brief made it less likely that anyone would notice Mr Holgate's absence.
84¶103.76 Ms Hammond did not think that the absence of RBKC had adversely affected the meeting's understanding of what was happening, given the other sources of information available to it.982 Hammond {Day281/8:19-24}. However, those sources of information were inevitably one step removed from the local authority. It is self-evident that many of the questions raised in the chairman's brief, such as those relating to arrangements for emergency shelter, the provision being made for those requiring alternative accommodation, for how long alternative housing might be required and how difficult that would be for the local authority to organise, would have been better answered by the chief executive of RBKC, particularly in the context of a fast-moving emergency.983 Chair's Brief {CAB00002715/2} paragraph 8.
¶103.77 Following the meeting, Mr Hurd told the media that he had left it feeling reassured that the resources and the capacity needed to support people were in place.984 Fourth SIT REP – 18:20hrs on 14 June 2017 (Home Office, OSCT Operational Support) {HOM00046089/16}. It appears to us that the government had fundamentally misunderstood the position.985 That is echoed in the CCS report 'Grenfell Tower tragedy - Lessons for the Central Response', which identified a "significant discrepancy between the situation as generally understood in Whitehall for the first 24-36 hours, and that facing the local community" but failed to identify Mr Holgate's absence from the 14 June cross-government co- ordination meeting as a contributing factor. That is because the review erroneously recorded RBKC's chief executive as having attended the meeting on 14 June 2017. That was a critical error in what was intended to be an exercise in identifying lessons learnt, {CAB00014768/1} paragraph 4 and {CAB00014768/2-3} paragraph 11.
¶103.78 The minutes of the meeting do not record any discussion of the need for financial assistance, information or humanitarian support for those affected by the fire.986 Minutes 14 June 2017 {CAB00002714}. Although it was agreed that trauma counselling should be offered to firefighters and ambulance workers,987 Minutes 14 June 2017 {CAB00002714/1} paragraph (c). we have seen nothing to suggest that there was any discussion about providing counselling of a similar nature to former residents of the tower.988 Hammond {Day281/10:10}. Moreover, although the minutes refer to providing temporary accommodation for residents of the tower they do not mention the need to provide accommodation for residents evacuated from the surrounding area.989 Minutes 14 June 2017 {CAB00002714/1} paragraph (b). See also Hurd {Day282/145:7-17}. It appears that, with the exception of shelter,990 To which there is a brief, general mention: "The local Council were presently identifying temporary accommodation for those residents of Grenfell Tower." {CAB00002714/1} paragraph (b). none of the initial needs of survivors without serious injuries described in Emergency Response and Recovery were considered at that first meeting.991 The guidance indicates that the initial needs of survivors without serious injuries are likely to include shelter and warmth, information on and assistance with contacting family and friends, support in their distress, food and drink, treatment of injuries and medicinal and mobility needs, changing, washing and toilet facilities and perhaps spare clothing. It also warns that the immediate and longer-term psychological needs of survivors without serious injuries (who may also be bereaved) should not be overlooked {CAB00004519/119-120} paragraphs 7.3.2-7.3.4.
¶103.79 Following the fire, Workstream 4 of the National Security Capability Review drafted by the Civil Contingencies Secretariat acknowledged that there can be a tendency for the strategic co-ordinating group to concentrate during the early stages of a crisis on the response of the emergency services to the detriment of those matters that fall to local government and other civilian-led support services.992 Workstream 4 of the National Security Capability Review, dated 28 September 2017 {CAB00007084/2} paragraph 6. In our view, reliance at the cross-government meeting on information derived from members of the strategic co-ordinating group, but not from RBKC directly, is likely to have exacerbated any tendency to focus on that aspect.
85¶103.80 Ms Hammond said that support from the government was more likely to be needed in the recovery phase. Be that as it may, it did not obviate the need for the first cross-government co-ordination meeting to consider the immediate needs of the survivors.993 Hammond {Day280/210:23}-{Day280/211:8}. Indeed, ConOps specifically contemplated that for most emergencies response and recovery would initially be undertaken in parallel.994 ConOps {CAB00000026/43} paragraph 3.76.
¶103.81 In our view, at the meeting on 14 June 2017 too few of the right questions were asked about the local authority's responsibilities to those affected. The questions that were asked were asked of the wrong people and the minister chairing the meeting did not have the experience needed to perform that task.
¶103.82 The Civil Contingencies Secretariat took the minutes of the meeting. Ms Hammond told us that minutes of such meetings are kept for the purposes of providing records995 Hammond {Day281/11:18-25}. but are not circulated to those present for approval or correction and that, if anyone wanted to refer to them, it would be necessary to ask the Civil Contingencies Secretariat for permission.996 Hammond {Day281/23:17-19}; emails at 12.22 {CAB00009842/2} page 2 and 17.55 {CAB00009842/1}. The only document circulated to those who had been present at the meeting was a list of "Actions".997 Actions 14 June 2017{CAB00001236}; Hammond {CAB00014868/8} page 8, paragraph 23(f).
¶103.83 A draft version of the minutes contained the following passage:
"The Minister for Local Government stated that the local Council were presently identifying temporary accommodation for those residents of Grenfell Tower. Longer term re-housing would also be the responsibility of the Council. The Mayor of London pressed for further reassurance and asked that contact was made with the local Council to ensure that affected individuals are not left without accommodation."998 Draft Minutes 14 June 2017 {CAB00013811/1}. That draft version was emailed internally within the CCS at 11.21 on 15 June 2017 {CAB00013810}.
¶However, in the final version999 Hammond {CAB00014868/7} page 7, paragraph 23(a). the final sentence of that passage was deleted and replaced by a sentence reading simply:
¶"The Council were not currently asking for additional support".1000 Minutes 14 June 2017 {CAB00002714/1} paragraph (b).
¶It is not clear how the draft came to be altered and Ms Hammond could not assist.1001 Hammond {Day281/21:10-25}.
¶In our view, it is indicative of the approach of the Civil Contingencies Secretariat, which involves equating the absence of a request for support with reassurance that support is not needed. The working assumption was that if people needed help, they asked for it.1002 Hurd {Day282/205:12-24}.
¶103.84 We accept that local authorities may not be predisposed to ask for support and may need both encouragement and a clear process for doing so.1003 Workstream 4 of the National Security Capability Review, dated 28 September 2017 {CAB00007084/3} paragraph 8. Mr Hurd said that the government should have realised earlier that the scale and complexity of the disaster were such that no one local authority could be expected to cope with it and that it should have been quicker to put in place the means of understanding what was happening in the locality.1004 Hurd {Day282/207:25}–{Day282/208:15}. We agree and endorse the recommendation of the Civil Contingencies Secretariat that in future the government probe further to establish whether the local tier is handling the response to an emergency adequately.1005 Workstream 3 of the National Security Capability Review, dated 28 September 2017 {CAB00007083/10}. In our view, the absence of a request for support is not a safe or sufficient basis for the government to assume that support is not required.
8615 June 2017: the picture becomes clearer
¶103.85 We have seen evidence to suggest that the strategic co-ordinating group was aware of the shortage of accommodation recorded in RED's summary of the meeting held at 19.30 on 14 June 2017.1006 Email at 21.28, 14.06.17 {CLG00008048/2}; Email at 20.49, 14.06.17 {CAB00007180/1-3}; Farrar {Day284/39:15}-{Day284/44:5}. Nonetheless, on the morning of 15 June 2017 Dr Farrar did not question the shortfall of accommodation.1007 Farrar {CLG00030414/8} paragraph 39; Farrar {Day284/53:14}-{Day284/54:4}. Instead, she passed the information she had received from RBKC by email to Dame Melanie's private secretary, noting that there had been a quick response in providing temporary accommodation on the evening of 14 June 2017 and that the task for 15 and 16 June 2017 was to find more permanent homes.1008 Email at 10.37 on 15 June 2017 {CLG00003102}. Dr Farrar told us that she had trusted RED to follow up concerns and report any problems and that her email to Dame Melanie was a note of what she had been told.1009 Farrar {Day284/52:1}-{Day284/54:4}.
¶103.86 At 08.34 on 15 June 2017, Alastair Whitehead sent an email to Stuart Wainwright observing that shelter still seemed to be a concern based on the situation report he had seen.1010 Email at 08.34 on 15 June 2017 {CAB00003270/1}. He then sent an email to Lorna Gratton, private secretary at No.10 with responsibility for DCLG, in which he described rehousing and co-ordination of support for the families affected as "a mess" and proposed the deployment of DCLG teams in the area.1011 Email at 09.15 on 15 June 2017 {CAB00005941}. At the same time, the Prime Minister was speaking directly to the Secretary of State, the Rt. Hon Sajid Javid MP, making the same point and asking what central government could do to support RBKC.1012 Email at 09.17 on 15 June 2017 {CAB00005941}. Sir Jeremy Heywood, head of the Civil Service, also sent an email to Dame Melanie Dawes expressing concern that the local authority did not have a grip on the aftermath of the fire and asking whether DCLG should send staff to help.1013 Email at 09.12 on 15 June 2017 {CLG10009750}. Dame Melanie told us that she had been concerned about what was being communicated at strategic co-ordinating group meetings because direct communication with the council was revealing problems that were not being raised at those meetings.1014 Dawes {Day285/99:8-20}.
¶103.87 At about midday on 15 June 2017 the Prime Minister visited Grenfell Tower. She was briefed by the emergency services but did not meet any residents.1015 Emails from 09.09 to 13.55 on 15 June 2017 {CLG00008159/2-6}; Jones {IWS00001723/5} page 5, paragraph 30; El- Gourja {IWS00001700/8} page 8, paragraph 34; Dainton {IWS00001974/38} page 38, paragraph 221.
¶103.88 During the course of 15 June 2017, the Civil Contingencies Secretariat became increasingly concerned in the light of discussions with DCLG about whether individuals affected by the fire were being properly looked after.1016 Wainwright {CAB00014776/8} page 8, paragraph 29. At 14.26, it received confirmation that DCLG had raised the provision of temporary accommodation with the local authority, but a full picture had yet to emerge and DCLG had not provided current information on the number of people displaced from the tower.1017 Action Tracker {CAB00001253/1-2} Items 2-3, circulated by email at 14.27 on 15 June 2017 {CAB00003286}. The Civil Contingencies Secretariat's increasing concern was also reflected in detailed questions about those matters in the chairman's brief produced for the cross-government meeting later that day.1018 Chair's Brief on 15 June 2017 {CAB00002721/2} paragraphs 8-9.
87Contact between DCLG and RBKC
¶103.89 On the morning of 15 June 2017, Dame Melanie's office tried unsuccessfully to arrange a call with Mr Holgate.1019 Email at 09.52 on 15 June 2017 {CLG00003084}; Dawes {CLG00030653/16} page 16, paragraph 50. At 12.30, Dr Farrar finally spoke to him.1020 Farrar {Day284/28:4-11}; Farrar {CLG00030414/10}, page 10, paragraph 44. She thought it unsatisfactory that that was the first time they had spoken, given that she was the person in DCLG designated as the point of contact with him.1021 Farrar {Day284/68:15}-{Day284/69:18}. Their conversation added to her concerns. Although Mr Holgate sounded very confident and reassuring, the information he gave her did not match that which she had received from other sources.1022 Farrar {Day284/73:3-5}. For example, he assured her that there was hotel accommodation for everybody who needed it, although in addition to those who had lived in the tower there were 845 people who did not have access to their homes.1023 Email at 16.26 on 15 June 2017 {CLG00008140}; Farrar {Day284/71:1}-{Day284/72:3}. During the call Dr Farrar twice offered government support to Mr Holgate, which he declined.1024 Farrar {Day284/74:6-7}. Dr Farrar specifically asked him about support from London Resilience, which he confirmed he had, notwithstanding that the Gold arrangements had not then been formally invoked.1025 {LFB00061240/1}; Farrar {Day284/84:15}-{Day284/85:25}; McManus {Day283/102:18}-{Day283/103:21}. We heard from Dame Melanie that she and Dr Farrar could have checked whether the Gold arrangements were in operation but did not do so.1026 Dawes {Day285/212:14-23}.
¶103.90 By 14.45 on 15 June 2017 DCLG had deployed an official to the police strategic command centre. It had also offered to make DCLG staff available to help out at RBKC offices, but that had been declined. RED reported to No.10 that the police and RBKC together were getting things under control.1027 The DCLG RED Note to No.10 at 14.45 on 15 June 2017 {CLG00003194}; Kay {CLG00030430/7} page 7, paragraph 29.
¶103.91 At about 15.00 on 15 June 2017, Ms McManus contacted Mr Priestley, chief community safety officer at RBKC and Council Silver responsible for the operational response.1028 Email at 15.10 on 15 June 2017 {CLG00020191}. She did not recall having asked him how the local authority was coping and told us that that was not the kind of information she would gather at that point. In our view, that was a missed opportunity for RED to improve its understanding of the situation and explain what assistance it could provide.1029 McManus {Day283/99:10-25}.
The second cross-government meeting
¶103.92 The second cross-government meeting took place at 15.30 on 15 June 2017. It was again chaired by Nicholas Hurd and was the first cross-government meeting attended by Mr Holgate.1030 Minutes of 15 June 2017 {CAB00002720/1}. That appears to have been the first contact between Mr Hurd and Mr Holgate: Hurd {Day282/154:17-21}.
88¶103.93 The minutes recorded that 77 people from Grenfell Tower and 25 people from the surrounding area had been placed in hotels for immediate shelter and, with only 30 people at the Westway Centre the previous night, a large number of people were assumed to have gone to stay with friends and family.1031 Minutes 15 June 2017 {CAB00002720/3} paragraph 2(a). At that stage, it appears that the Civil Contingencies Secretariat was not aware that about 845 people who had been evacuated from nearby properties were also likely to require short-term accommodation.1032 Hammond {Day281/47:14}-{Day281/48:5}. Dr Farrar had discussed that figure with Mr Holgate at 12.30, but the summary of their call was not circulated to those who attended the cross-government meeting until four hours later.1033 Email at 16.26 on 15 June 2017 {CLG00008140/1-2}. We consider that was an unreasonable delay in a fast-moving situation, which meant the opportunity to challenge the figures was missed.
¶103.94 During the meeting the Civil Contingencies Secretariat's concern about RBKC's handling of the response became firmer when it became clear that RBKC did not know how many people had been displaced from the tower.1034 Hammond {Day281/44:25}-{Day281/45:3}. Mr Holgate was defensive and tried to assure ministers that no additional help was required.1035 Richardson {CLG00030412/21} page 21, paragraph 77; Hurd {Day282/173:12-14}. However, he was unable to articulate a clear plan for housing those affected and was unable to say how many people would require accommodation, what services they needed, what resources RBKC had to deliver those services or what support it would need to do so.1036 Wainwright {CAB00014776/9} page 9, paragraph 30. We heard from Mr Hurd that his overriding impression was of the complete collapse of Mr Holgate's credibility under questioning.1037 Hurd {Day282/168:6-12}; See also email at 20.08 on 15 June 2017 {CAB00002899/1}.
¶103.95 By 17.30, No.10 had asked DCLG to look into further support for RBKC, suggesting that people could be sent to assist it.1038 Email at 17.32 on 15 June 2017 {CAB00006264/1}. However, DCLG still failed to recognise the seriousness of the problems with RBKC.1039 Email at 22.09 on 15 June 2017 in which Dame Melanie expressed her view about how well RBKC was "gripping this" {CLG10009757}. At 20.39, Ms Hammond contacted DCLG proposing it take stock of how RBKC was doing1040 Email at 20.11 on 15 June 2017 {CAB00002896/2}. and, later, suggested that Dr Farrar might call Mr Holgate as someone with experience of senior leadership in local government.1041 Email at 20.39 on 15 June 2017 {CAB00002896/1}. At 21.03 Ms Richardson responded, confirming that Dr Farrar had spoken to Mr Holgate, offering specific support on housing, and that DCLG's housing minister also intended to speak to RBKC the following morning in order to obtain the missing details.1042 Email at 21.03 on 15 June 2017 {CAB00002896/1}.
The morning of 16 June 2017
¶103.96 On the morning of 16 June 2017, there was growing concern within the Civil Contingencies Secretariat that the government did not have an accurate picture of the situation as it affected the survivors and other local residents.1043 Hammond {Day281/68:20-21}. Following the conclusion of the cross-government meeting on 15 June 2017, Mr Hurd had received a series of unofficial calls from individuals working as volunteers in the community, including the vicar of St Clement's church, impressing upon him the extent of the problems and the need for government support.1044 Hurd {Day282/174:13-22}.
89¶103.97 At 07.41 on 16 June 2017, Lorna Gratton told DCLG of her concern about the organisation of the response and suggested that more support from the DCLG, such as the secondment of a small team of people similar to the victim support unit, might be necessary.1045 Email at 07.41 on 16 June 2017 {CLG00008227/2}. Following that intervention and the concerns raised at the same time by Mr Hurd,1046 Email at 08.02 on 16 June 2017 {CLG00008227}. Helen MacNamara sent a message to a colleague in DCLG saying that the Prime Minister had expressed concern and wanted the government to get a grip on the situation.1047 Email at 08.23 on 16 June 2017 {CLG00008227}.
¶103.98 During the morning of 16 June 2017 Lorna Gratton asked DCLG to suggest ways in which RBKC could be supported,1048 Table of the DCLG calls and meetings on 16 June 2017 {CLG00018819/3}. offering further resources, if required, and seeking a date by which everyone displaced by the fire would be re-housed, ideally within two weeks. She also sought a commitment from DCLG to ensure that further support was accepted by RBKC. DCLG suggested that the victim support unit within the Home Office could be expanded to provide support to those affected by the Grenfell Tower fire.1049 Email at 11.19 on 16 June 2017 {CAB00006453/1}. A little later, Mr Hurd's private secretary expressed concern about the lack of co-ordination of the response and emphasised the need to use the coming cross-government meeting to find out what was really happening.1050 Email at 09.33 on 16 June 2017 {CAB00001152/1-2}. By that time the co-ordination of the government's response was being severely hampered by inadequate information.1051 Hurd {Day282/181:20}-{Day282/182:10}.
DCLG visit to the Westway Centre
¶103.99 Following her conversation with Mr Holgate at 12.30 on 15 June 2017, Dr Farrar decided to join the Secretary of State's visit to the Westway Centre on the morning of 16 June 2017.1052 Farrar {CLG00030414/10} page 10, paragraph 46; email at 19.21 on 15 June 2017 {CLG00003210/1}. That visit became pivotal to her understanding of RBKC's ability to manage the situation.1053 Farrar {Day284/121:11-13}. She formed the view that the relief effort was neither well-managed nor properly co-ordinated.1054 Farrar {CLG00030414/14} page 14, paragraph 62. Dr Farrar told us that, when she attended the Westway Centre on 16 June 2017, she had been surprised by a notable absence of senior RBKC officers and had not been reassured by her discussions with those officials from RBKC who were there.1055 Farrar {CLG00030414/14} page 14, paragraph 63; Farrar {Day284/113:18}-{Day284/115:9}. At about 09.40 on 16 June 2017, Dr Farrar was present at a meeting between the leader of the council, Mr Paget-Brown, and the Secretary of State.1056 Farrar {CLG00030414/14} page 14, paragraph 63. She told us that she had been worried that the offers of support had not been passed to Mr Paget-Brown, who did not seem to be aware of what was available.1057 Farrar {Day284/119:21-25}. When he had agreed that additional support for RBKC's rehousing effort would be helpful, Dr Farrar communicated that by text message to Katherine Richardson, who sent it on to Sally Randall to take forward without delay.1058 Farrar {CLG00030414/14-15} pages 14-15, paragraph 67; text message at 10.13 on 16 June 2017 {CLG00030628}; See also email at 14.11 on 16 June 2017 {CLG00003383} summarising the meeting between the Secretary of State and Mr Paget-Brown.
90¶103.100 The minutes of the meeting of the strategic co-ordinating group held at 11.00 following the Secretary of State's visit recorded the government's misgivings for the first time,1059 McManus {Day283/105:15}-{Day283/106:3}. in particular the Secretary of State's worries about access to cash, donations and information for the survivors.1060 Minutes of SCG meeting at 11.00 on 16 June 2017 under heading 'DCLG' {MOL00000036/3}.
The appointment of John Barradell
¶103.101 Following the meeting with Mr Paget-Brown on the morning of 16 June 2017, Dr Farrar contacted Ms Richardson1061 Text message {CLG00030627}. and Dame Melanie Dawes to discuss the appointment of a specialist emergency manager, proposing Mr Barradell1062 The Deputy Chair of the London Resilience Forum, Chair of the Local Authorities' Panel and the Town Clerk and Chief Executive of the City of London Corporation. as a potential candidate.1063 Farrar {CLG00030414/16} page 16, paragraph 75. Separately, by the evening of 15 June 2017 the decision had been taken to activate the London Gold arrangements and Mr Barradell had arranged to attend RBKC for a preliminary discussion.1064 {LFB00061240/1}; Sawyer {GOL00001349/11} page 11, paragraph 54. It appears that RED was unaware that the decision to activate the Gold arrangements had been made on the evening of 15 June 2017 and that their formal activation was expected to occur the next day.1065 {LFB00061236}; McManus {Day283/102:18}-{Day283/103:21}; {LFB00061250} The documents we have seen suggest that RED and DCLG generally did not have a good understanding of what was happening.1066 {CLG00030627}; Farrar {CLG00030414/16} page 16, paragraphs 76-77; {CLG00003297}; {CLG00030514}; Farrar {CLG00030414/16} page 16, paragraph 77.
¶103.102 When Dr Farrar went to see Mr Holgate he was in discussion with John Barradell, who said that he was there to support Mr Holgate and that there would be a chief executive rota as part of the London Resilience arrangements.1067 Farrar {CLG00030414/16} page 16, paragraph 78. She felt that an experienced person needed to be in the lead, rather than acting as support.1068 Farrar {Day284/132:21-23}. She intervened, asking Mr Barradell privately if he would take over the London Gold role on a permanent basis.1069 Farrar {CLG00030414/17} page 17, paragraph 79. He agreed in principle and she then sent a text message to Dame Melanie telling her that she was speaking to London Councils to obtain their agreement.1070 Farrar {CLG00030414/16} page 17, paragraph 79. Dr Farrar then spoke to John O'Brien, chief executive of London Councils,1071 Farrar {Day284/140:2-13}; Farrar {Day284/143:8}. who agreed to help in bringing that about.1072 Farrar {Day284/140:18-22}. Mr Holgate also agreed to that course.1073 Farrar {CLG00030414/16-17} pages 16-17, paragraph 78-79. Dr Farrar told Ms Richardson that Mr Barradell had taken over London Gold full time under the London Councils' arrangement.1074 {CLG00030626}. Mr Barradell said that Dr Farrar may have had a different understanding of the effect of activating the London Gold arrangements.1075 Barradell {Day279/113:1-25}. However, Mr Barradell told us that when taking on a role beyond that envisaged by the civil contingencies structure in London, he was not concerned about his authority as long as he had the support of the political leadership of RBKC and the support of the government.1076 Barradell {Day279/116:9}-{Day279/117:3}.
91¶103.103 At about the same time Ms Hammond learned from David Bellamy that John Barradell had been appointed to take over from RBKC as "Recovery Gold".1077 Hammond {CAB00014764/19} page 19, paragraph 68. She thought that the decision had been taken by the Mayor's office or Mr Bellamy and that there had been an existing arrangement under which that was possible.1078 Hammond {Day281/77:8-11}. Ms Hammond did not suggest that she had looked into the legal basis for his appointment; she said that no legal concerns had been raised.1079 Hammond {Day281/77:8-11}. The CRIP produced at 12.00 on 16 June 2017 stated that John Barradell had been appointed to co-ordinate logistical support to RBKC.1080 CRIP 3 {CAB00000148/1-2}.
Transition from response to recovery
¶103.104 The question when to move from response to recovery was raised repeatedly in correspondence in the days immediately following the fire but was never clearly answered.1081 Whitehouse {CAB00014782/8-9} pages 8-9, paragraphs 21-23; email at 13.05 on 14 June 2017 {CAB00004061}; email at 21.28 on 14 June 2017 containing notes from the 19.30 SCG meeting {CLG00008048/1-2}; Farrar {Day284/40:19}-{Day284/43:15}; email at 06.42 on 15 June 2017 {CAB00003269/1}; email at 08.32 on 15 June 2017 {CAB00003269/1}. Mr Hurd told us that he had not been aware of the particular moment at which the Home Office had relinquished the role of lead government department to DCLG; rather he sensed that during the course of 15 June 2017 there had been a growing recognition that DCLG was effectively evolving as the lead ministry for the recovery phase.1082 Hurd {Day282/116:16-24}.
¶103.105 At 08.14 on 16 June 2017 Dr Farrar received an email from Mr Mason, head of emergencies management at RED, indicating that the police had been pressing the previous day to transfer control of the local relief effort to RBKC but that RBKC felt it was too early.1083 Email at 08.14 on 16 June 2017 {CLG00003294/1}; Farrar {CLG00030414/12-13} pages 12-13, paragraph 57. Dr Farrar expressed her concern that RBKC might find it difficult to take overall leadership of the relief effort and asked Mr Mason to contact the Home Office to gauge its view.1084 Email at 09.02 on 16 June 2017 {CLG00003294/1}; Farrar {CLG00030414/12-13} pages 12-13, paragraph 57.
¶103.106 At 09.22 on 16 June 2017, Ms Hammond said that she thought it likely that there would be a transition to the recovery phase on 17 or 18 June 2017.1085 Email at 09.22 on 16 June 2017 {CAB00001150/1}. However, at 10.50, No.10 notified the Civil Contingencies Secretariat that the Prime Minister had decided to chair that afternoon's cross-government meeting and that it would be renamed "The Grenfell Tower Recovery Taskforce".1086 Email at 10.50 on 16 June 2017 {CAB00000473/3}; Tallantire {CAB00014769/3} page 3, paragraph 12; Gratton {CAB00014853/22} page 22, paragraph 64. The change of name had been proposed by Mr Whitehead1087 Whitehead {CAB00014857/20} page 20, paragraph 54. to shift the focus from the initial emergency response to supporting the recovery phase. It had been decided upon without consulting the Civil Contingencies Secretariat.1088 Hammond {CAB00014764/20} page 20, paragraph 69. ConOps provided that, although, following most emergencies, response and recovery activity will initially be undertaken in parallel,1089 ConOps {CAB00000026/43} paragraph 3.76. the timing of the formal handover from the response to the recovery phase should be agreed between the two lead government departments, in consultation with the Civil Contingencies Secretariat1090 ConOps {CAB00000026/43} paragraph 3.74-3.76. and should start once the situation has been stabilised.1091 ConOps {CAB00000026/7} paragraph 1.6.
92¶103.107 Ms Hammond described the creation of the Grenfell Tower Recovery Taskforce as marking a formal shift in emphasis which reflected the primary focus of the meeting, rather than the end of one thing and the start of another.1092 Hammond {Day281/88:25}-{Day281/89:11}. However, we do not think that the recovery phase began on 16 June 20171093 Hammond {Day280/210:23}-{Day280/211:8}. or that the first meeting of the Grenfell Tower Recovery Taskforce was concerned with recovery.1094 Hammond {Day281/91:6-10}.
¶103.108 The government's formal transition to the recovery phase took place on 25 July 20171095 The local transition appears to have taken place at 23.59 on Friday 23 June 2017 {GOL000000062/3}. with the first meeting of the Grenfell Ministerial Recovery Group.1096 Summary Grenfell Fire Response (CCS Internal Lessons) {CAB00000105/1} paragraph 1; Whitehouse {CAB00014782/13-14} pages 13-14, paragraph 34. In our view, the designation by No.10 of the cross-government meetings as meetings of a "Recovery Taskforce" was rightly seeking to shift their focus towards the immediate needs of the survivors, but it ignored the fact that they were an essential part of the response phase and risked creating confusion while the situation had yet to be stabilised.
The Grenfell Tower Recovery Taskforce
¶103.109 Meetings of the Grenfell Tower Recovery Taskforce ("the Taskforce") were held in the Cabinet Office Briefing Rooms at 70 Whitehall, the location from which COBR normally operated.1097 ConOps {CAB00000026/21} paragraph 3.1. Although Ms Hammond invited us not to attach any significance to that change of location, we think that in this case it indicated an increase in government engagement in line with, at least, a Level 2 serious emergency, as outlined in ConOps,1098 Hammond {Day281/91:11-16}; ConOps {CAB00000026/8-9} paragraph 1.8. and that a de facto COBR meeting had been initiated for the first time.1099 Hammond {Day281/202:16-22}.
¶103.110 Ms Hammond told us that there had been no reason to activate COBR on 16 June 2017 because the things that could be discussed at a COBR meeting could as easily be discussed at a meeting of the Taskforce.1100 Hammond {Day281/93:23}-{Day281/94:6}. It seems to us that the Civil Contingencies Secretariat should have formally activated a COBR response by that time,1101 ConOps {CAB00000026/19} paragraph 2.26(d). as envisaged by ConOps, taking forward elements of the recovery phase before formally handing over to a ministerial recovery group to take further action once the situation had been stabilised.1102 ConOps {CAB00000026/27} paragraph 3.22; See also ConOps {CAB00000026/22} paragraph 3.2 diagram which includes a "Recovery Group" as one of the potential COBR supporting structures to be activated. Neither the Prime Minister nor the officials in her office had expertise in responding to an emergency of the kind facing them and would have had to rely on the expertise and advice of the Civil Contingencies Secretariat, the relevant government departments and other public bodies.1103 Gratton {CAB00014853/22} page 22, paragraph 63. The evidence suggests that No.10 received no advice about the possibility of activating COBR at that stage, or the benefits of doing so, or about the distinction between the response and recovery phases.1104 Gratton {CAB00014853/5} page 5, paragraph 15.
93¶103.111 Following the Prime Minister's decision to chair the meeting of the Taskforce on 16 June 2017, the secretariat role of the Cabinet Office was largely taken over by No.10, which drafted the agenda, produced the CRIP1105 Email at 11.39 on 16 June 2017 {CAB00001158/1}; email at 10.50 on 16 June 2017 {CAB00012900}; email at 13.19 on 18 June 2017 {CAB00003178/1}. and decided who should attend.1106 Emails from 12.56 to 12.59 on 16 June 2017 {CAB00000462/1-2}; Attendees List for 16 June 2017 {CAB00002728}. It declined the Civil Contingencies Secretariat's offer of a "pre-brief".1107 Emails at 19.40 and 19.46 on 16 June 2017 {CAB00001286/2}.
Support for those affected
¶103.112 The first Taskforce meeting took place at 13.00 on 16 June 2017. It was chaired by the Prime Minister, the Rt Hon Theresa May MP, and was attended by, among others, the National Security Adviser, Mark Sedwill, Mr Barradell, described as "Local Authority Gold Commander",1108 Minutes 16 June 2017 {CAB00002726/2}. and Mr Holgate.1109 Minutes 16 June 2017 {CAB00002726/2}.
¶103.113 At the beginning of the meeting the Prime Minister said that she wanted to ensure that the government was providing the best package of support for the victims and doing everything possible to assist those on the ground.1110 Minutes 16 June 2017 {CAB00002726/2} paragraph 1. It is clear from the minutes that there were still significant problems over the provision of immediate support to those affected. The Secretary of State for Communities and Local Government could not provide an absolute assurance that there was complete co-ordination between the government and the local authority but told those present that DCLG had already undertaken to deploy more people.1111 Minutes 16 June 2017 {CAB00002726/3} paragraph 3. A list of Grenfell Tower residents remained outstanding,1112 Minutes 16 June 2017 {CAB00002726/6} paragraph 15. together with the number of residents that needed re-housing.1113 Minutes 16 June 2017 {CAB00002726/5} paragraph 8.
The Grenfell Victims Unit
¶103.114 The Prime Minister said that she wanted the government to support the affected families and in particular wanted to establish a single point of contact for families that could deal with all aspects of their recovery.1114 Draft Minutes 16.06.17 {CAB00012896/1}. It was agreed that DCLG would set up an integrated support service following the model of the Victims of Terrorism Unit to co-ordinate cross-government activity and provide those affected with a single point of access to government services,1115 Actions 16 June 2017 {CAB00002727/1} Action 4. such as immigration, benefits, transport, the coronial process, education, health and financial assistance.1116 Kay {CLG00030430/9} page 9, paragraph 38.
¶103.115 The gap in victim support had been raised by Isla Hurley Brunt, then head of community resilience and recovery at the Civil Contingencies Secretariat,1117 Hurley Brunt {CAB00014787/1} page 1, paragraph 1: Isla Hurley Brunt reported to Ian Whitehouse. on 14 June 2017 when she sent an email to Ian Whitehouse expressing doubts about the support that would be available when it was unclear whether those affected were victims of crime.1118 Email at 18:03 on 14 June 2017 {CAB00014358}; Isla Hurley Brunt {CAB00014801/4} page 4, paragraph 14. However, it was not until 16 June 2017 that a central victim support unit was proposed, notably by Ms Gratton, a No.10 official without the Civil Contingencies Secretariat's expertise in emergency response.1119 Email at 07.41 on 16 June 2017 {CAB00005546/1}. That stands in marked contrast to the automatic support that would have been available in response to a terrorist attack.1120 Email at 09.43 on 15 June 2017 {CLG00003087/2}; Grenfell Tower tragedy – Lessons for the Central Response {CAB00014768/3} paragraph 13. We agree with the
94¶Civil Contingencies Secretariat's own assessment that there were inconsistencies between the response to the Grenfell Tower fire and the response to recent terrorist attacks that require attention.1121 Grenfell Tower tragedy – Lessons for the Central Response {CAB00014768/3} paragraph 13.
¶103.116 Following the meeting of the Taskforce on 16 June 2017, Ms Hammond chaired a meeting of officials focusing on the establishment of a Grenfell Victims Unit.1122 Hammond {CAB00014764/20} page 20, paragraph 72; email at 16.14 on 16 June 2017 {CLG00030523/2-3}. During the meeting, representatives from the Victims of Terrorism Unit explained how it worked. It was agreed that every government department involved1123 Jillian Kay's 16 June 2017 Paper on Victims Unit: Grenfell Tower {CLG00030529}; Kay {CLG00030430/9} page 9, paragraph 39. would identify someone to work with the unit and that HM Revenue and Customs would provide 20 caseworkers to start work on the morning of 17 June 2017.1124 Email at 18.28 on 16 June 2017 {CLG00030523/2-3}; Kay {CLG00030430/9} page 9, paragraph 38. Her Majesty's Revenue and Customs' surge team was made up of operational staff who were trained to deploy into administrative roles in different parts of central government. Jillian Kay, director for local government policy at DCLG,1125 Kay {CLG00030430/2} page 2, paragraph 7. and Suzanne Kochanowski, also of DCLG, were given the responsibility for setting up the Grenfell Victims Unit.1126 Hammond {CAB00014816/17} page 17, paragraph 45; Kay {CLG00030430/9} page 9, paragraph 37.
¶103.117 On 17 June 2017, the 20 members of the HM Revenue and Customs surge team and two people from the Department for Transport were deployed by DCLG to Portland House, the centre of London Gold operations, to support the Gold Command under Mr Barradell, and the Westway Centre.1127 Kay {CLG00030430/10} page 10, paragraph 41. Over the weekend, Ms Kay's priorities were to understand the nature of the support being put in place by the new Gold Command structure and to enable the Grenfell Victims Unit to work alongside the support being provided locally. There was a danger that, if it were a separate channel of support, it could cause confusion and further frustration among those affected by the fire.1128 Kay {CLG00030430/9} page 9, paragraph 38. DCLG had been pursuing the idea of a direct public telephone line for the victims unit1129 Jillian Kay's 16 June 2017 Paper on Victims Unit: Grenfell Tower {CLG00030529/1} paragraph 5. until Ms Kay learned that Gold Command was intending to use a key worker model with a social worker or other named contact point for each of the affected families and was talking to the Red Cross about establishing a telephone line.1130 Kay {CLG00030430/10-11} pages 10-11, paragraph 44. In the light of that, DCLG developed a single telephone line and email address for family liaison officers and key workers to use to secure support from across the government,1131 Email at 18.10 on 17 June 2017 {CLG00030555}. repositioning the Grenfell Victims Unit as a second line of support.1132 Kay {CLG00030430/10-11} pages 10-11, paragraph 44. By 16.11 on 18 June 2017, the telephone number and email address of the Grenfell Victims Unit were in use. However, at that stage there were still families without a family liaison officer or support worker. Although DCLG was aware of that, the victims unit emphasised that the service was not an advice line for victims and that families should not call it directly.1133 Email at 16.11 on 18 June 2017 {CLG00008945}.
95¶103.118 On 19 June 2017 a pack was produced by DCLG setting out the purpose of the victims unit. It contained a telephone number and email address, made it clear that they were to be used by support and key workers and in addition provided the telephone number for the Red Cross for victims to contact.1134 Pack for Key Workers {CLG00005692/1}; email at 20.06 on 19 June 2017 {CLG00005691/1}; Kochanowski {CLG00030416/14} page 14, paragraph 50.
¶103.119 At 22.56 on 19 June 2017, Ms Kochanowski sent an email to Ms Kay telling her that the Westway Centre had been a bit chaotic1135 Email at 22.56 on 19 June 2017 {CLG00030588}. Ms Kay told us that that had prompted her to visit the Westway Centre on 20 June 2017, Kay {CLG00030430/15} page 15, paragraph 63. and that it was still unclear whether the key workers had been appointed. She said that the number of cases being handled by the victims unit was low (three in all) but that was because government staff were by then present at the Westway Centre. She also warned that the staff provided by HMRC would struggle to resolve the more difficult problems and navigate their way around government departments.1136 Email at 22.56 on 19 June 2017 {CLG00030588}.
¶103.120 Dame Melanie Dawes told us that DCLG's provision of support had been slowed down by confusion about what the Grenfell Victims Unit was, what ministers had asked for and what ultimately could be provided.1137 Dawes {Day285/214:15}-{Day285/215:8}. It seems to us that by 19 June 2017 the victims unit had become something quite different from what had been envisaged at the meeting of the Taskforce on 16 June 2017. The Prime Minister's intention had been to use the unit directly to support victims and fill any gaps in the support provided by others, whereas the model adopted by DCLG followed the approach of the Victims of Terrorism Unit. That depended on support already being in place for all who needed it, which, in the case of the Grenfell Tower fire, was lacking.1138 Not everyone had a key worker or social worker by that stage.
Events following the Taskforce meeting on 16 June 2017
¶103.121 Following the first Taskforce meeting, Mr Sedwill sent an email to Ms Hammond offering to contact DCLG about London-wide and government support for RBKC. He thought that RBKC was clearly out of its depth and that the Civil Contingencies Secretariat probably should have prompted DCLG to intervene earlier.1139 Email at 15.50 on 16 June 2017 {CAB00002898/1}. His offer was declined by Ms Hammond on the grounds that Mr Barradell and Dame Melanie had spoken to each other and everything was all right.1140 Email at 15.58 on 16 June 2017 {CAB00002898/1}.
¶103.122 During the afternoon of 16 June 2017, the Prime Minister attended a round table meeting at the Clement James Centre with residents and volunteers from Grenfell Tower and the surrounding area1141 List of attendees {CAB00005765/2} attached to email at 16.13 on 16 June 2017 {CAB00005764}; email at 17.26 on 18 June 2017 {CAB00006308/1-4}. and at 17.56 she sent an email to senior officials in No.10 expressing her frustration at what she described as the "utter uselessness" of RBKC.1142 Email at 17.56 on 16 June 2017 {CAB00005339}.
¶103.123 At 18.25, Mr Whitehead sent an email to Ms Hammond informing her that there would be another Taskforce meeting chaired by the Prime Minister the following day and possibly a conference call on Sunday.1143 Email at 18.25 on 16 June 2017 {CAB00011967/1}. That was contrary to Ms Hammond's assumption that the next Taskforce meeting would not be held until Monday afternoon.1144 Emails at 18.04 and 18.22, 16 June 2017 {CAB00011967/1-2}. At that stage, Ms Hammond was worried about the pressure being put on DCLG.1145 Email at 09.22 on 16 June 2017 {CAB00001150/1}; Hammond {Day281/166:7-10}. Again, it appears that the Civil Contingencies Secretariat was being pressed to increase the level of intervention and oversight.
96¶103.124 At 19.36, Ms Gratton sent an email to Dame Melanie and the Principal Private Secretary to the Secretary of State informing them that the Prime Minister was keen to make a further offer of assistance to RBKC and Gold Command, proposing that DCLG bring together whatever additional resources it could for the council and that it contact Gold Command to identify where the government could immediately and helpfully place people.1146 Email at 19.37 on 16 June 2017 {CAB00005727}.
¶103.125 That evening the Prime Minister also spoke to Mr Paget-Brown. He assured her that everyone made homeless would be in housing by the end of the day and that someone from RBKC would be in touch that evening with every one of the support centres.1147 Email at 19.54 on 16 June 2017 {CAB00006343}; However, Ms Gratton's note of 17 June 2017 indicates that Nicholas Paget-Brown did not make contact with all mosques, churches and temples by end of day Friday {RBK00038856/1-3}. In the event those assurances were not met.
Events of 17 June 2017
¶103.126 At 11.00 on Saturday, 17 June 2017, the Prime Minister chaired a further meeting of the Taskforce, again focusing on the provision of support for victims.1148 Minutes 17 June 2017 {CAB00002735}. Those attending the meeting were told that residents were unsure how to obtain support and needed help to do so.1149 Minutes 17 June 2017 {CAB00002735/3} paragraph 5. It was agreed that a number of steps should be taken directed at community engagement, obtaining detailed figures for the numbers of those who had been living in the tower, of those from the immediate vicinity who could not return to their homes and of those who could, keeping the Westway Centre open and providing financial support.1150 Actions, 17 June 2017 {CAB00001248/1-2} actions 2, 4, 5 and 11. A Taskforce meeting for officials was arranged for the following day to monitor progress.1151 Minutes 17 June 2017 {CAB00002735/7} paragraph 20.
¶103.127 On 17 June 2014 the Home Secretary, the Rt Hon Amber Rudd MP, and Mr Hurd visited the Westway Centre for the first time.1152 Email at 16.11 on 17 June 2017 {LFB00119799/1}; Hurd {HOM00046080/15-16} pages 15-16, paragraph 51. They discovered a number of problems,1153 Hurd {Day282/189:16}-{Day282/190:3}. which in turn prompted the Home Office to write to Mr Barradell, among others, with observations about the current response. They included drawing attention to the distribution of money, the provision of emergency accommodation and poor communication.1154 {HOM00046091}.
¶103.128 On the evening of 17 June 2017, Peter Tallantire, head of the crisis management team in the Civil Contingencies Secretariat,1155 Peter Tallantire had taken over from Stuart Wainwright as the Deputy Director leading on the response on the evening of 15 June 2017, following a short, informal handover meeting, Tallantire {CAB00014769/2} page 2, paragraph 7. confirmed that it was not fully aware of what DCLG was doing and was worried that DCLG was operating in a largely reactive manner with limited power to influence the direction of the response.1156 Email at 23.19 on 17 June 2017 {CAB00003152/1}. Mr Tallantire suggested that the Civil Contingencies Secretariat try to do more to control the outcome by deploying a liaison officer to DCLG to work alongside its team, thereby enabling the Civil Contingencies
97¶Secretariat to know what DCLG was thinking, shape events and help co-ordinate government support.1157 Email at 23.19 on 17 June 2017 {CAB00003152/1}.
¶103.129 Nearly four days after the fire, with Mr Barradell in post and the Prime Minister chairing the Taskforce meetings, the situation on the ground remained chaotic. That prompted Mr Sedwill to email Dame Melanie Dawes proposing the appointment of a "Gold for Whitehall on all the wider issues", or alternatively a "Gold plus Gold Minister", warning that it was necessary to drop everything else.1158 Email at 23.47 on 17 June 2017 {CAB00002980/1-2}. There was an acknowledgement, both within and outside the Civil Contingencies Secretariat, that it needed to deploy additional resources to help co-ordinate government support.
Events of 18 June 2017
¶103.130 On the morning of Sunday 18 June 2017, Ms Hammond supported Mr Sedwill's suggestion and offered to provide someone from the Civil Contingencies Secretariat to provide a link with whoever was chosen for the task.1159 Email at 07.11 on 18 June 2017 {CAB00002980/1}. Following that morning's meeting of Taskforce officials, she advised the Rt Hon Damian Green MP, First Secretary of State and Minister for the Cabinet Office, on how DCLG could be supported as the response to the emergency moved into recovery. Among other things she suggested that Ian Whitehouse be seconded to DCLG, which took place the next day.1160 Hammond {CAB00014764/22} page 22, paragraph 79.
Consideration of protected groups
¶103.131 Apart from one reference to a need to consider the religious dimension of burials,1161 Minutes 16 June 2017 {CAB00002726/6} paragraph 15. neither the briefs nor the minutes of the cross-government or Taskforce meetings indicate an understanding of the particular needs of people from protected groups1162 The relevant protected characteristics under the Equality Act 2010 are set out at section 149. Emergency Response and Recovery identifies four groups which require special consideration, see {CAB00004519/129-131} section 7.7. or any steps being taken to meet them. In our view, questions should have been asked and a greater effort should have been made about the different groups of people affected in order to understand better the effects of the fire on them and to find out whether steps were being taken to mitigate them.
Use of government staff
¶103.132 On the afternoon of 16 June 2017, Fiona Darby, deputy director for homelessness at DCLG, had contacted Laura Johnson, head of RBKC's housing department, to propose that Lizzie Clifford, a housing specialist at DCLG, join RBKC's BECC that afternoon as the link with DCLG to assist with the rehousing efforts.1163 Randall {CLG00030427/19} page 19, paragraph 74. Ms Johnson proposed in response that Ms Clifford join her three days later, on 19 June 2017.1164 Emails at 14.16 and 14.44 on 16 June 2017 {CLG00003398/1}. Following an intervention by Mr Barradell,1165 Emails at 16.14 and 16.24 on 16 June 2017 {CLG00003453/1-2}. Ms Clifford was subsequently deployed to Portland House, the seat of London Gold's operations,1166 McManus {CLG10009725/14} page 14, paragraphs 57-58; McManus {Day283/126:12}-{Day283/127:4}. from the morning of 17 June 2017. Ms McManus was also deployed to Portland House on 17 June 2017.1167 McManus {CLG10009725/14} page 14, paragraphs 57-58; McManus {Day283/126:12}-{Day283/127:4}.
98The Westway Centre
¶103.133 At the meeting of the Taskforce on 17 June 2017 it was suggested that a single centre should provide services and advice to those affected by the fire, which was to be appropriately and sufficiently staffed by government officials and others and kept open for as long as necessary.1168 Minutes 17 June 2017 {CAB00002735/4} paragraph 9(ii); Actions 17 June 2017 {CAB00001248/2} Action 5. The Home Office made arrangements for officials to go to the designated centre on 18 June 2017 to assist with immigration enquiries. The officials were instructed that no immigration enforcement action should be taken and that they should wear plain clothes rather than uniform and not carry their Home Office badges.1169 Owen {HOM00046114/3} page 3, paragraph 11. The officials met their counterparts from DCLG at 08.00 in Westminster, as DCLG had not yet confirmed the location of the support centre. They subsequently arrived at the Westway Centre at 11.00.1170 Owen {HOM00046114/4} page 4, paragraph 13. The officials stayed at the centre until 16.30, by which time they had not received any enquiries for some two hours.1171 Owen {HOM00046114/4} page 4, paragraph 16. That day the Home Office also began operating a 24-hour telephone line to assist with immigration and passport matters.1172 Hepple {HOM00046110/6-7} pages 6-7, paragraph 19.
¶103.134 On 18 June 2017, RED wanted to ensure it was providing support as requested by Gold Command.1173 Kay {CLG00030430/12} page 12, paragraph 51. It was concerned about using junior civil servants to carry out tasks that involved engaging with the local community, for which they had not been trained and with which staff from other London boroughs were much more familiar.1174 McManus {Day283/119:10} -{Day283/120:8}. At the Taskforce meeting held that morning,1175 That was a meeting, chaired by Paddy McGuinness and attended only by officials, rather than ministers: Attendees List for 18 June 2017 {CAB00002785}; Hammond {CAB00014764/21} page 21, paragraph 76. Mr Barradell asked the government1176 Kay {CLG00030430/13} page 13, paragraph 54; Kay {CLG00030430/14} page 14, paragraph 59; email at 20.01 on 18 June 2017 {CLG00009076}. for support in the form of staff experienced in community engagement. As a result, an official from the integration and faith team at DCLG1177 Suzanne Kochanowski was a senior team leader within the division and responsible for government policy and stakeholder engagement on race equality, racial and ethnic minorities, faith communities and community cohesion {CLG00030416/2} page 2, paragraph 5; See also Patel {CLG10009793/3} page 3, paragraph 6. was deployed to Gold Command that evening.1178 Kay {CLG00030430/13} page 13, paragraph 56. Mr Barradell also asked for and received professional help from DCLG and the Home Office to improve the signs and labelling at the Westway Centre.1179 Email at 18.04 on 18 June 2017 {CLG00008968/1}; Kay {CLG00030430/14} page 14, paragraph 59. He was very complimentary about the support provided by central government.1180 Barradell {Day279/215:18}-{Day279/216:3}.
¶103.135 On the evening of 18 June 2017, DCLG directed staff from six government departments to attend the Westway Centre for the next seven days, starting at 9.00 on Monday 19 June, as a "PM priority".1181 Email at 18.36, 18 June 2017 {CLG00020672/2-3}. Although HM Revenue and Customs operated a "surge" team of administrative officers who could be deployed to perform specific administrative functions, they were of limited use as they did not have experience in carrying out departmental roles.1182 Hammond {Day281/144:16-25}: for example, issuing a driving licence. Ms Hammond told us that it was uncommon for staff from government departments to be deployed as part of a local response to an emergency1183 Hammond {CAB00014816/18} page 18, paragraph 47. and there do not appear to have been any procedures in place for such an eventuality. The fact that government staff were deployed at the Westway Centre is an indication of the degree of concern felt about the effectiveness of the centre as the focal point for support for those affected by the fire.
99¶103.136 That same day, at the request of the Home Secretary, the Home Office produced leaflets in several languages containing government advice; they were delivered to the Westway Centre on 19 June 2017.1184 Lamberti {HOM00046095/6} page 6, paragraph 20. Mr Hurd accepted in evidence that they could and should have been sent out sooner.1185 Hurd {Day282/199:1-3}.
¶103.137 On 19 June 2017, Francesca Flessati from the Foreign and Commonwealth Office contacted DCLG and the Civil Contingencies Secretariat asking whether the latter would be offering advice on crisis management co-ordination and asking for any documents explaining how the centre was supposed to operate, its aims and objectives and its co-ordination and communication processes.1186 Email at 14.54 on 19 June 2017 {CAB00009996/3}. After receiving a response from the Civil Contingencies Secretariat expressing complete faith in Mr Barradell but declining to provide any substantive advice, Ms Flessati complained that just gathering civil servants in a sports hall with no proper communications did not seem the best way of providing an effective service.1187 Email at 15.49 on 19 June 2017 {CAB00012084/3}. Although by that stage the London Gold arrangements had been invoked and the Westway Centre was no longer being run by RBKC, there were still problems with the response on the ground.1188 London Local Authority Gold Incident Log Book {GOL00001690/7}; McManus {Day283/132:8}-{Day283/134:8}.
¶103.138 On the morning of 20 June 2017, Sebastian Bassett-James at the Department for Business, Energy and Industrial Strategy ("BEIS") sent an email to the Civil Contingencies Secretariat raising similar concerns. Mr Bassett-James identified a lack of leadership and command and control and suggested that government oversight was needed together with more co-ordination and more information about what services were already being provided.1189 Email at 11.46 on 20 June 2017 {CAB00009946/2}; Bassett-James {BEI00002844/3-5} pages 3-5, paragraphs 12-19. In light of Mr Bassett-James's email, Ms McManus notified London Gold that RED had received reports that the Westway Centre did not seem structured.1190 London Local Authority Gold Incident Log Book {GOL00001690/7} entry 73; McManus {Day283/132:8}-{Day283/134:8}. When Ms Kay visited it late on the morning of 20 June 2017, she observed that it was fairly makeshift, with handwritten signs at the government desks that were hard to read. However, she considered the situation to be calm and improving.1191 Kay {CLG00030430/15-16} pages 15-16, paragraphs 65-69.
¶103.139 We have seen no evidence that the Civil Contingencies Secretariat provided any documentation or other support to government staff deployed to the Westway Centre. Indeed, Ms Hammond told us that it had not formally co-ordinated their deployment and that any training of staff was a matter for individual departments.1192 Hammond {CAB00014816/18} page 18, paragraph 47; By comparison, Sebastian Bassett-James at BEIS produced a Utilities Co-ordination Cell staff guide, specifically designed to support staff in the Utilities Coordination Cell who were physically present at the Westway Centre because they were not crisis professionals and therefore needed specific guidance {BEI00002843}; Bassett-James {BEI00002844/2-3} pages 2-3, paragraphs 10-11; Bassett-James {BEI00002844/7-8} pages 7-8, paragraphs 30-32. Given its expertise in emergency response and recovery, we consider that the Civil Contingencies Secretariat should have given them some guidance on the objectives of the centre, and the role that they were expected to play.1193 Email at 15.49 on 19 June 2017 {CAB00012084/3}. The description of the Westway Centre as "organised chaos", with large numbers of officials, charities and community groups all trying to help,1194 Gill {HOM00046118/2} page 2, paragraph 8. is endorsed by the Civil Contingencies Secretariat's own report, which found that most departmental staff who answered the urgent request for help on 18 June 2017 felt that the arrangements there were disjointed and that there was a lack of clear leadership or concern for the welfare of staff.1195 Grenfell Tower tragedy - Lessons for the Central Response {CAB00014768/3-4} paragraph 16.
100Evacuated residents
¶103.140 The minutes of the Taskforce meeting on 16 June 2017 recorded, for the first time, that there had been 800 families living within the cordon in addition to those living in the tower.1196 Minutes 16 June 2017 {CAB00002726/4} paragraph g. Until that point, there does not appear to have been any consideration at the cross-government meetings of the needs of residents who had been forced to evacuate, most of whom could not return home. The minutes recorded a commitment to ensure that residents, including those with nearby homes within the cordon,1197 Minutes 16 June 2017 {CAB00002726/2} Item 2(1). were accommodated locally as quickly as possible, but government decision-making and monitoring continued to be hampered by inadequate and unreliable information.1198 Grenfell Tower tragedy - Lessons for the Central Response {CAB00014768/3} paragraph 12. Six days into the emergency response, the categorisation of residents was still changing, and the government remained unclear about the precise number of residents of Grenfell Tower and Grenfell Walk who were in emergency accommodation.
¶103.141 No concern was raised in the cross-government meetings about the effectiveness of the TMO until the Taskforce meeting on 19 June 2017.1199 Minutes 19 June 2017 {CAB00002741/3-4} paragraph 7. Ms Hammond told us that she had been aware of concern about its poor relationship with the tenants, the difficulties in getting precise information and a sense that it was not fulfilling its function.1200 Hammond {Day281/138:13}-{Day281/139:10}.
¶103.142 The minutes of that meeting also recorded problems with the provision of hot water and gas to about 400 households within the wider cordon and noted that all households affected in that way were entitled to hotel accommodation and access to the discretionary fund.1201 Minutes 19 June 2017 {CAB00002741/3-4} paragraph 7. The list of things to be done following the meeting included directing DCLG and "Recovery Gold" (Mr Barradell) to consider urgently how best to respond to worries about the effectiveness of the TMO and reaching an immediate decision on what steps to take next.1202 Actions 19 June 2017 {CAB00002739/1} Action 1. However, the list did not identify any specific action to be taken in response to the lack of hot water or gas in properties within the wider cordon.1203 Actions 19 June 2017 {CAB00002739}. Further, although those concerns were recorded at government level, Robert Black, the chief executive of the TMO, was not made aware of them1204 Black {Day275/104:12-16}. or of the decision to give affected residents access to hotel accommodation and financial assistance.1205 Black {Day275/78:20}-{Day275/79:1}. The lack of hot water remained a problem and was raised again at the meeting of Taskforce officials on 20 June 2017, when Mr Barradell suggested that an engineering solution was required.1206 Minutes 20 June 2017 {CAB00002792/3} paragraph 6.
101¶103.143 On 20 June 2017, it became apparent to Dame Melanie Dawes that there was concern about the leadership of the TMO1207 Dawes {Day285/184:11-22}; {CLG00005813/1}; Dawes {CLG00030653/32} page 32, paragraph 102. and thereafter DCLG began to think how it could orchestrate a change of leadership.1208 Dawes {Day285/185:18-22}. However, the government does not appear to have properly understood the role of, or the limitations placed upon, the TMO.
The commitment to re-house residents
¶103.144 On 16 June 2017, the Prime Minister announced that those who had lost their homes as a result of the fire must be re-housed at the earliest possible opportunity and that the aim was to achieve that within three weeks at the latest.1209 Randall {CLG00030427/8} page 8, paragraph 28. In recognition of the exceptional nature of the circumstances and of the fact that that commitment went further than a local authority's obligations to other homeless households, the government agreed to meet the costs of providing temporary accommodation.1210 Randall {CLG00030427/8} page 8, paragraph 28. From 16 June 2017 onwards DCLG inevitably played a major part in seeking to deliver what it later recognised was an unrealistic commitment.1211 Randall {CLG00030427/8} page 8, paragraphs 28-29. See also email at 12.52 on 16 June 2017 {CLG00003260}.
¶103.145 On 18 June 2017, Helen MacNamara, director general of housing and planning at DCLG, sent an email to Barbara Brownlee, who had taken over responsibility for finding accommodation for those rendered homeless, to clarify the government's commitment.1212 Email at 15.15 on 18 June 2017 {CLG00030574}. She said that residents of Grenfell Tower or Grenfell Walk (so-called "Category A" households) would be re-housed within three weeks in the local area with the costs of temporary accommodation met by the government.1213 Email at 15.15 on 18 June 2017 {CLG00030574}. Consideration was still being given to the situation of those who had lived in other buildings in the vicinity of the tower. The commitment was no doubt well meant but was always unrealistic and raised expectations in a way that was irresponsible. Some residents were still living in hotel accommodation two years after the fire.1214 Al-Assad {IWS00001789/9} page 9, paragraph 56.
Financial assistance
¶103.146 Providing financial assistance to those affected by the fire was hampered by a lack of reliable information. Records of financial support provided during previous emergencies were not readily available and information about the amount of money being distributed was often inconsistent or absent altogether.
¶103.147 At a meeting on 14 June 2017 Ms Richardson, Dr Farrar, Ms Kay and the Secretary of State discussed the local response and the support that the government could offer, including funding under the Bellwin scheme of emergency financial assistance to local authorities.1215 Farrar {Day284/18:25}-{Day284/20:1}. Bellwin is the name given to the statutory scheme established under s.155 of the Local Government and Housing Act 1989 to provide emergency financial assistance to local authorities, Baldwin {CLG00030437/3} page 3, paragraph 8; Kay {CLG00030430/4} page 4, paragraph 14. The next day, the Secretary of State announced the availability of funding under that scheme,1216 Baldwin {CLG00030437/4} page 4, paragraph 13. but did not indicate, otherwise than in general terms, which costs would be met. The details were still being clarified on 19 June 2017.1217 Baldwin {CLG00030437/5} page 5, paragraph 14; email at 01.01 on 19 June 2017 {CLG00009221/1-5}.
102¶103.148 On the morning of 16 June 2017, Lorna Gratton asked the Treasury what the government had done in the past in similar circumstances by way of giving residents immediate help with basic necessities.1218 Email at 08.50 on 16 June 2017 {CAB00005938/6-7}. It does not appear that any such request had been made previously.1219 Emails at 09.17 and 11.53 on 16 June 2017 {CAB00005938/5-6}. We are surprised that the Civil Contingencies Secretariat had not already obtained that information. It appears that DCLG had not spoken to the Treasury about the creation of a discretionary fund to support the residents of Grenfell Tower1220 Baldwin {CLG00030437/2} page 2, paragraphs 4-5; Baldwin {CLG00030437/5} page 5, paragraph 16. by the time of a discussion between the Secretary of State and No.10 that morning.1221 No.10 asked for a briefing on whether RBKC could set up a hardship fund, potentially funded by Bellwin, which would allow people to get SIM cards, mobile phones etc to reconnect, email at 11.37 on 16 June 2017 {CLG00008316/2}.
¶103.149 It appears that the creation of a substantial discretionary fund was discussed for the first time at a cross-government meeting on 16 June 2017,1222 Minutes 15 June 2017 meeting refer simply to DWP "working to provide access to emergency and hardship funds" {CAB00002720/3} paragraph 2(b). at which the Prime Minister said that a £5 million discretionary fund would be established to help support those affected.1223 Minutes 16 June 2017 {CAB00002726/4} paragraph 7. The size of the fund and what it would cover in general terms was announced by the Prime Minister later that day.1224 Baldwin {CLG00030437/5} page 5, paragraph 16. From that point onwards, there were considerable difficulties in getting a clear and consistent understanding of how many people had received money and how much money had been distributed.1225 Hammond {CAB00014816/28} page 28, paragraph 72. At a number of Taskforce meetings, different figures were quoted by DCLG and ministers from the Department of Work and Pensions (DWP), making it difficult to obtain a clear picture.1226 Summary Grenfell Fire Response (CCS Internal Lessons) {CAB00000105/1} paragraph 5.
¶103.150 At the meeting of the Taskforce on 17 June 2017 it was pointed out that after the winter floods in 2015 all affected households had been given a payment of £5,000.1227 Minutes 17 June 2017 {CAB00002735/5} paragraph 12(c); Khan {MOL00000189/14-15} pages 14-15, paragraph 60. The Mayor of London recalled that some of those present appeared to be reluctant to make lump sum payments of £5,000 rather than payments by way of instalments to those who needed support.1228 Khan {MOL00000189/14-15} pages 14-15, paragraph 60. It was agreed in principle that every family that had lived in the tower and those who had been forced out of their homes by the fire should be eligible to receive a sum of money to be paid out immediately through DWP staff on the ground.1229 Actions 17 June 2017 {CAB00001248/2} Actions 9 and 11. Following the meeting, DCLG was directed to produce a proposal for distributing the support fund.
¶103.151 It was subsequently ascertained that the government had provided each household affected by the floods in 2015 with an initial £500 in cash and a further £5,000 paid into bank accounts (i.e. £5,500 in total). Miss Gratton asked whether colleagues were happy to take the same approach to avoid unfavourable parallels being drawn with that emergency.1230 Email at 14.49 on 18 June 2017 {CAB00005286/1}. See also email at 14.29 on 18 June 2017 {CLG00005376/1}; email at 14.55 on 18 June 2017 {CAB00005286/1}; emails at 14.10, 14.33 and 17.50 on 18 June 2017 {CLG00005468/1-3}. That was two days after the Prime Minister had confirmed a £5 million discretionary fund and more than four days after the fire. We are surprised that the information about payments made to the victims of flooding was not already available to the Civil Contingencies Secretariat. In our view, the lack of easily accessible information about how victims of previous emergencies had been supported financially contributed to the delay in funds being provided.
103¶103.152 In the event, it was agreed that every household that had lost its home as a result of the fire should receive £5,500, made up of £500 in cash payment from the council and £5,000 paid into a bank account by DWP.1231 Baldwin {CLG00030437/8-9} pages 8-9, paragraph 28. Everyone over the age of 16 who had been displaced as a result of the fire was also able to claim a £500 cash payment. RBKC could increase the amount of the cash payment in individual circumstances,1232 Baldwin {CLG00030437/8-9} pages 8-9, paragraph 28. drawing on the further funding from the government's Grenfell Tower Residents Discretionary Fund.1233 Email at 01.01 on 19 June 2017 {CLG00009178/2}.
¶103.153 The Discretionary Fund scheme went into operation on 19 June 2017.1234 Baldwin {CLG00030437/9} page 9, paragraph 29. By lunchtime on 19 June, £202,000 of discretionary support had been provided, Baldwin {CLG00030437/10} page 10, paragraph 31. We heard that some of those who went to the Portobello Road Post Office1235 Email at 01.01 on 19 June 2017 {CLG00009178/2}. to receive payments had not had any previous contact with the emergency relief effort.1236 Baldwin {CLG00030437/10} page 10, paragraph 32. The lack of any previous contact five days after the fire reflects poorly on the wider emergency relief effort. Westminster City Council staff who became involved as part of a tri-borough agreement1237 See paragraph 91.64. reported that some of the people coming in for help were vulnerable and required counselling before any practical steps could be taken to make payments to them.1238 Baldwin {CLG00030437/10} page 10, paragraph 32.
¶103.154 Following the Taskforce meeting on 19 June 2017, Mr Barradell was asked to confirm by the end of the day how many people eligible to receive a £500 cash payment had not yet done so and to make those payments as soon as possible.1239 Actions 19 June 2017 {CAB00002739/1} Action 4. It was not until the CRIP produced for the meeting on 21 June 2017 that reasonably reliable information was available about the number of those who were eligible to receive payments and the number of those who had done so. Even at that stage the figures were not consistent with those contained in other documents of the same date.1240 CRIP 9 {CAB00002403/4} Minutes 20 June 2017 {CAB00002792/3} paragraph 9: "63 (out of approximately 125) payments of £5,000 had been paid to households". We agree with the Civil Contingencies Secretariat's own assessment that its understanding of the operational response was poor throughout that period and that inconsistent and missing data, particularly from DCLG, represented a constant challenge.1241 Grenfell Tower tragedy - Lessons for the Central Response {CAB00014768/3} paragraph 12; Summary Grenfell Fire Response (CCS Internal Lessons) {CAB00000105/1} paragraph 5.
Pressure on DCLG
¶103.155 DCLG was under considerable pressure during the seven days following the fire. Although RED was experienced in leading liaison with local responses in relation to other kinds of emergencies (such as flooding, or terrorist incidents), in the months before the Grenfell Tower fire it had been required to respond to emergencies more often than usual.1242 These included the Westminster terrorist attack on 22 March 2017, the Manchester Arena bombing on 22 May 2017, the London Bridge terrorist attack on 3 June 2017, and the General Election on 8 June 2017 (including the run- up to it), Mason {CLG00030435/4} page 4, paragraph 11. At the same time, it was short of staff1243 Email at 20.26 on 20 June 2017 {CAB00012068/2}. and was in the process of being reduced in size.1244 Email at 08.48 on 19 June 2017 {CAB00002960/1}; On 14 June 2017, Dame Melanie had told Sir Jeremy Heywood that "at some point we may need to reflect on the impact of cuts to the civil service (DCLG will be less than 50% of its 2010 size by 2020)", email at 20.00 on 15 June 2017 {CLG10009757/2}.
104¶103.156 Furthermore, the scale of the Grenfell Tower fire, involving a huge loss of life and mass displacement, was greater than anything it had previously encountered. The disaster generated immense public and political concern, made all the more intense by the fact that it fell within its own area of policy responsibility (local government and housing).1245 Whitehouse {CAB00014782/14} page 14, paragraph 35. Although the emergency was concentrated in a single location, it had national implications for the safety of tower blocks1246 Minutes 14 June 2017 {CAB00002714}; Dawes {CLG00030653/36} page 36, paragraph 118. and it appears that for that reason a significant part of the department's limited resources was taken up with reviewing its response to the earlier Lakanal House fire.1247 Dawes {Day285/98:13}-{Day285/100:9}. DCLG was, in effect, trying to manage two crises at the same time.1248 Dawes {Day285/98:13}-{Day285/100:9}.
¶103.157 Even after Mr Barradell's appointment as Recovery Gold, there were difficulties in obtaining clear, accurate information about who was responsible for what and the number of people needing support.1249 Tallantire {CAB00014769/5} page 5, paragraph 18. Nevertheless, we have seen no evidence to suggest that Ms Hammond raised concerns about DCLG with Mr McGuinness or Mr Sedwill.1250 Hammond {Day281/73:18-22}.
¶103.158 An Internal Lessons report produced by the Civil Contingencies Secretariat in August 2017 concluded that it should have pressed for a liaison officer from DCLG to be present within the COBR situation cell regardless of the pressures on resources at DCLG.1251 Summary Grenfell Fire Response (CCS Internal Lessons) {CAB00000105/1} paragraph 5; Hammond {Day281/201:1-18}. However, in the email he sent to Katharine Hammond on 17 June 2017 Peter Tallantire indicated that he felt it was too late to do that and that it was probably the wrong solution, as most of the worries related to DCLG, which was already considered to be struggling.1252 Email at 23.19 on 17 June 2017 {CAB00003152/1}. Mr Tallantire suggested instead that the Civil Contingencies Secretariat's ignorance of DCLG's thinking should be resolved by deploying a liaison officer from the Civil Contingencies Secretariat to DCLG.1253 Email at 23.19 on 17 June 2017 {CAB00003152/1}. Although Ian Whitehouse was transferred to DCLG on 19 June 2017, we think that the Civil Contingencies Secretariat should have taken action at least three days earlier,1254 Email at 15.50 on 16 June 2017 {CAB00002898/1}. once it realised that DCLG was overstretched and under-resourced.1255 Email at 09.22 on 16.06.17 {CAB00001150/1}; Hammond {Day281/166:7-10}.
¶Contact between the Prime Minister and the residents of
¶Grenfell Tower
¶103.159 On the afternoon of 17 June 2017, the Prime Minister hosted a further meeting with Grenfell residents and community members in which wide-ranging complaints were made about the co-ordination of the response, the distribution of money to those who needed it and the limited information available on where people should go for help of different kinds. Those who attended the meeting asked, among many other things, that the TMO be removed from the management of the buildings affected, that central co-ordinators ensure they had links with local leaders and that liaison officers be provided for those affected.1256 Email at 18.03 on 17 June 2017 {RBK00038856/1-3}. Feedback from that meeting was then filtered back by No.10 to DCLG.1257 Emails from 17.26 to 20.04 on 18 June 2017 {CAB00006308}.
105¶103.160 Thereafter, No.10 staff continued to be in direct contact with the residents and volunteers who had spoken to the Prime Minister and became involved in dealing with difficulties facing individual residents, such as re-housing1258 Emails from 16.11 to 19.24 on 17 June 2017 {CLG00005331}. and the distribution of cash.1259 Email at 17.24 on 18 June 2017 {CAB00005730}. The staff of No.10 were not usually involved in detailed matters of that kind during the response to an emergency but, given the lack of co-ordination between the government and the local authority, they clearly felt compelled to respond to the personal concerns of those affected.1260 Gratton {CAB00014853/29} page 29, paragraph 79. See also {CLG00005565/1-2}.
¶103.161 On 19 June 2017, Lorna Gratton and Jamie Cowling both raised the complaints of Walkway residents with DCLG. At 10.16 on 19 June 2017, Ms Gratton sent an email to DCLG relaying residents' complaints about the organisation and responsiveness of the TMO and asking for proposals for finding out whether they were justified.1261 Email at 10.16 on 19 June 2017 {CLG00009261}. By 13.27, Mr Cowling had informed DCLG that the TMO had sent texts to residents of the Walkways telling them to return to their homes, despite the fact that front doors were broken and there was significant dirt and debris from the fire both inside and out. Mr Cowling asked DCLG to let him know by 17.00 that day when repairs to residents' doors and cleaning would begin.1262 Email at 13.27 on 19 June 2017 {CAB00005619}. See also email at 15.28 on 19 June 2017 {CAB00005564/1}; emails at 09.29 and 09.37 on 21 June 2017 {CAB00005909/1}. Following receipt of that email, DCLG sought to investigate how widespread was the problem of residents being expected to return to properties that did not have functioning utilities.1263 Emails from 14.02 to 14.15 on 19 June 2017 {CLG00005583/1-2}. See also email at 17.05 on 19 June 2017 {CLG00005667/2-3}. At 16.00 on 19 June 2017, questions about the effectiveness of the TMO were raised at a cross-government meeting for the first time.1264 Minutes 19 June 2017 {CAB00002741/3-4} paragraph 7.
¶103.162 Although the meetings between the Prime Minister and a select group of residents and volunteers were seen as constructive and as providing a mechanism by which to identify problems that had yet to be resolved,1265 Email at 18.06 on 19 June 2017 {CAB00006017/1}; email at 22.57 on 18 June 2017 {CAB00006311/1}. we consider that they demonstrate the lack of co-ordination between the government and local responders and the extent to which the concept of resilience based on the principle of subsidiarity failed in the case of the Grenfell Tower fire.1266 The principle of subsidiarity, by which decisions should be taken at the lowest appropriate level with co-ordination at the highest necessary level, is outlined in Chapter 99.
¶Failures of communication between No. 10 and the Civil
¶Contingencies Secretariat
¶103.163 Mr Tallantire's note headed "Key Points of Discussion with No.10", produced in the course of preparing the Civil Contingencies Secretariat's report entitled Grenfell Tower tragedy – Lessons for the Central Response,1267 {CAB00014768}; Tallantire {CAB00014830/9} page 9, paragraph 27.6. drew attention to a lack of consistent, reliable data both centrally and locally, difficulties contacting DCLG staff and an assurance by Dame Melanie Dawes that all was well at DCLG which had all the staff it needed.1268 {CAB00014827}; Hammond {Day281/205:15-18}. Although the note contained a positive view of the Civil Contingencies Secretariat, it identified problems in relation to its communication with No.10. The Prime Minister's office had been working directly with DCLG on most policy matters as it sought to get the government's response under control and often did so without informing the
106¶Civil Contingencies Secretariat of the requests and decisions it had made.1269 {CAB00014827}.
¶103.164 At 15.47 on 20 June 2017, No.10 asked for a detailed brief from DCLG containing a description of the situation on the ground, the latest victim figures and a short background note on the wider Lancaster West estate.1270 Email at 15.47 on 20 June 2017 {CAB00001178/2}. In response, the private secretary to the Secretary of State suggested that No.10 talk to colleagues from the Civil Contingencies Secretariat about the latest numbers, given the pressures on DCLG. He later explained that that had been a plea to No.10 to use the latest version of the CRIP as a situation report for the Prime Minister.1271 Email at 19.31 on 20 June 2017 {CAB00001178/1}. No.10's requests for more information and briefings created additional reporting mechanisms in parallel with those undertaken by the Civil Contingencies Secretariat, which added to the pressure on an already struggling DCLG. It also suggests that No.10 was not getting what it wanted from the Civil Contingencies Secretariat.
¶103.165 Mr Tallantire's "Key Points of Discussion with No.10" proposed that the Civil Contingencies Secretariat think more about how it could support without getting in the way.1272 {CAB00014827}. In our view, it could have given No.10 better information about the emergency response and recovery arrangements and the options available to the government. At the same time, No.10 should have taken further steps to ensure that the Civil Contingencies Secretariat was aware of the requests and decisions it had made and was not kept in the dark.1273 {CAB00014827}.
¶103.166 During the days following the fire many of the suggestions for support that were implemented came from No.10 rather than the Civil Contingencies Secretariat. In a detailed and reflective analysis at the end of her evidence, Dame Melanie Dawes recognised that it would have helped the government, and the speed of ministerial decision-making, to have been clearer about the kind of support that it could provide in different situations and to consider in greater detail the kinds of action that the government might be asked to undertake.1274 Dawes {Day285/214:15}-{Day285/215:8}. We agree.
Ministerial intervention and emergency powers
¶103.167 Dr Farrar told us that government intervention in a local authority could range from a light-touch approach, under which individuals are deployed to a local authority to work within a specific department or within the existing leadership team, to the government's taking over the running of a local authority, putting in commissioners to run it directly. However, an intervention of the latter kind takes a number of weeks to implement. Consequently, although Dame Melanie and Dr Farrar did discuss sending in commissioners, it would have been hard to do that quickly,1275 Farrar {Day284/100:7}-{Day284/102:20}. not least because it generally involves taking over all the functions of the local authority concerned.1276 Farrar {Day284/107:21}-{Day284/109:17}.
107¶103.168 During the period immediately after the fire, the government appears to have thought that there were no powers readily available to it to intervene directly1277 Key points from the discussion between Peter Tallantire and No.10 {CAB00014827}. and that it was therefore forced to rely on the power of persuasion1278 Farrar {Day284/107:21}-{Day284/109:17}. and the subsequent appointment of Mr Barradell. Ms Hammond told us that she had no recollection of any consideration being given to the powers available to ministers to give directions to Category 1 and Category 2 responders under sections 5(1) and 7 of the Civil Contingencies Act1279 Hammond {Day280/94:2-18}. Dr Farrar accepted that an order under section 5 has to be made by a statutory instrument, subject to the affirmative resolution procedure and, as such, would have taken considerable time to implement, Farrar {Day284/146:7}-{Day284/148:12}. Sections 5(1) and 7 of the Act {CAB00004616/7-10}. Ministerial Intervention under Part 1 of the Act is outlined in Chapter 99. and we have seen no evidence to suggest that consideration was given to using the powers to make emergency regulations under part 2 of the Act.1280 Sections 19-31 of the Act {CAB00004616/20-28}. Emergency Powers are outlined in Chapter 99.
¶103.169 On the morning of Monday 19 June 2017, No.10 proposed developing a new strategy for national and local resilience in response to major disasters which could include a new "Civil Disaster Reaction Force".1281 Email at 08.25 on 19 June 2017 {CAB00002960/2-3}. That proposal was prompted by concerns, even at that stage, about the response to the fire, rather than by any considered programme of work. It indicates the extent of the reflection being undertaken at the highest level and No.10's realisation that the government had limited practical ability to intervene to control events. Mr McGuinness pointed out that local authorities provide assistance to each other (although not always quickly enough) and that they have the skills to reinforce each other. He expressed the view that RED was meant to provide the means by which the government could reinforce and support their action, but that it was underpowered.1282 Email at 08.40 on 19 June 2017 {CAB00002960/1-2}.
¶103.170 In response, Ms Hammond suggested that RED should be enhanced to enable the government to spot failing local authorities more quickly and ensure that support reached them and that better mutual aid arrangements should be put in place between local authorities with the addition of a national deployment mechanism.1283 Email at 08.47 on 19 June 2017 {CAB00002960/1}. She envisaged something similar to the National Police Co-ordination Centre,1284 Email at 18.42 on 19 June 2017 {CAB00002897/1}. with a centrally co-ordinated mechanism receiving a request from one authority for additional support, finding that support and deploying it.1285 Hammond {Day281/168:7-22}. Although a mechanism of that kind might have accelerated the process of providing mutual aid, it would not have solved the main difficulty, namely, that RBKC did not realise that it was unable to respond adequately to the situation that had been created. Reflecting on the Grenfell Tower fire a month later, Mr Sedwill re-emphasised his view that the government needed a mechanism to take over control in a crisis before a local authority realised that it could not cope.1286 Email at 07.37 on 17 July 2017 {CAB00002910/1}.
¶103.171 In September 2017 as part of a National Security Capability Review the Civil Contingencies Secretariat was asked in the light of events that had occurred in June 2017 to consider whether it was possible in law for the government to require a Category 1 responder to accept national support.1287 Workstream 4 of the National Security Capability Review dated 28 September 2017 {CAB00007084/10} paragraph 32.
108Failing to activate COBR
¶103.172 We heard from Ms Hammond that none of the meetings to which we have referred were held under the auspices of COBR1288 Hammond {CAB00014816/8} page 8, paragraph 17. When asked about the many contemporaneous references to COBR1289 On 16 June 2017 Action 11 on the Actions List starts "COBR agreed…" {CAB00002727/2}; at 07.08 on 20 June 2017 Lorna Gratton refers to "COBR" in an internal No.10 email {CAB00005733/1}. Further, the Civil Contingencies Secretariat's Summary "Grenfell Fire Response (Civil Contingencies Secretariat Internal Lessons) asserted that COBR was activated on 14 June 2017 and ran until 25 July, when the Ministerial Recovery Group met for the first time, {CAB00000105/1}. and whether they indicated a degree of confusion about whether the process had been activated or not, Ms Hammond told us that they were simply administrative errors.1290 Hammond {Day281/105:9-11}. Ms Hammond also sought to explain references to COBR on the basis that, from 16 June 2017, the Taskforce meetings were held in the rooms in which COBR meetings are often held.1291 Hammond {Day281/105:17-23}. When asked why emails from Dame Melanie Dawes and Mr Sedwill referred to a Taskforce meeting as a COBR meeting,1292 Email at 20.26 on 16 June 2017 {CAB00002932/1}; email at 23.47 on 17 June 2017 {CAB00002980/1-2}. she maintained that there had been no confusion and that it was just a shorthand for a meeting of that type.1293 Hammond {Day281/115:23}-{Day281/116:8}; Hammond {Day281/125:12-13}.
¶103.173 A considerable part of Ms Hammond's evidence was spent clarifying the meaning and relevance of the reference to COBR. She explained that a parallel version of COBR was not operating,1294 Hammond {Day281/202:16-22}. and her firm position throughout was that exactly the same things were done as would have been done if COBR had been formally activated.1295 Hammond {Day280/207:17-19}.
¶103.174 Formally activating COBR represents the government's highest level of response. Mr Hurd told us that it would have been appropriate to call a meeting at a more senior level from the start.1296 Hurd {Day282/126:4-10}. In this case, formally activating COBR would have emphasised the gravity of the incident and would have resulted in more senior ministers chairing the early cross-government meetings.1297 ConOps {CAB00000026/45} paragraph 4.2(iv). However, whether that would have made any material difference is debatable. The scale and urgency of the government's response increased significantly when the Prime Minister took over the meetings.
¶103.175 We heard from Dame Melanie that, if the initial cross-government co-ordination meeting had been chaired at cabinet-level1298 By a Secretary of State. or by the Prime Minister, it might have provided an additional layer of questioning and challenge about the local response to that being provided by the DCLG and the Home Office.1299 Dawes {CLG00030653/36} page 36, paragraph 119. In our view, that could have made a material difference to the way in which the meetings were approached and the actions arising from them.
¶103.176 For those outside central government, activating COBR would in itself have been an important indication to local responders of the likely form of central government engagement in the initial stages1300 Whitehead {CAB00014857/4} page 4, paragraph 15. and would have given them a signal that central government oversight was not with junior ministers but with senior cabinet ministers.
109¶103.177 On 16 June 2017, Dame Melanie told Sir Jeremy Heywood that the new Gold Command considered the situation to be more complex than that which had followed the London bombings in 2005. She thought that the Prime Minister should have chaired a COBR meeting on 14 June 2017.1301 Email at 19.49 on 16 June 2017 {CLG00008533}. Her message indicates that a reference to COBR resonated inside as well as outside government. We do not doubt that, but the emphasis, as we see it, was on the importance of involving the Prime Minister at an early stage.
111Chapter 104: The response of RBKC
Introduction
¶104.1 As the fire in Grenfell Tower continued to rage, hundreds of residents from the tower and surrounding properties were evacuated from their homes. As a Category 1 responder, RBKC was responsible for the provision of humanitarian assistance to those displaced. Its response was guided by its own Contingency Management Plan and the wider civil contingencies framework described in Chapter 99.
¶104.2 In this chapter we examine the provision of humanitarian assistance, which encompasses the provision of emergency shelter, food and drink, financial assistance, information about those who are missing, public communication and the provision of psychological support to those affected by the incident. RBKC led the response until support from London as a whole was enlisted through the operation of the Gold Resolution on 16 June 2017.1302 See above at Chapter 101. From that point on, John Barradell, as London Gold, led the response. The circumstances in which he became involved are described in Chapter 102.
Activation of the RBKC Contingency Management Plan
¶104.3 The RBKC Contingency Management Plan provided that if an incident occurred out of hours, the out of hours contact centre should contact the duty Silver,1303 RBKC Contingency Management Plan {RBK00004396/33}. who was responsible for determining the level of the initial council response and initiating the call‑out procedures.1304 RBKC Contingency Management Plan {RBK00004396/30} page 30, paragraph 4.1. Levels of response were graded from 1 to 3, level 3 being the most serious and requiring the setting up of a Borough Emergency Control Centre (BECC) at Kensington Town Hall.1305 RBKC Contingency Management Plan {RBK00004396/31-37}.
¶104.4 At 02.03 on 14 June 2017, the police informed RBKC of the Grenfell Tower fire using the out of hours service.1306 Phase 1 Report, Volume II, paragraph 14.272. Nickolas Layton, the duty officer, alerted David Kerry at 02.21.1307 Emergency Event Log Sheet for Grenfell {RBK00013296/1}. He told Mr Kerry that many had been able to leave the tower but that some people remained trapped and that casualties were expected.1308 Emergency Event Log Sheet for Grenfell {RBK00013296/1}. As the council did not have anyone on call to act as duty Silver due to staff shortages, Mr Kerry took on the responsibility of determining the level of response required.1309 Kerry {Day268/187:4-17}.
¶104.5 Mr Kerry realised that the incident was serious but he did not formally categorise it by reference to the Contingency Management Plan.1310 Kerry {Day268/189:19-24}. He remained at home and assumed the role of Borough Emergency Controller, whose task was to co-ordinate the council's response. (At the time, the term "Borough Emergency Controller" was being replaced by the term "Council Silver", and the two were used interchangeably.1311 Kerry {Day268/190:15-20}. We shall use the term "Council Silver".)
112¶104.6 Mr Kerry proceeded on the basis that the response should be at level 2 rather than level 3, the highest level.1312 Kerry {Day268/190:15}-{Day268/192:5}; RBKC Contingency Management Plan {RBK00004396/33}: A level 2 response requires the Duty Silver to become the controller, working from home. The Department and Service management are called out to respond. A level 3 response requires the Duty Silver to remain at home acting as controller until the Borough Emergency Control Centre (BECC) is opened and staffed. Later in the morning the severity of the incident became clearer to him and the response moved up to level 3.1313 Kerry {Day268/192:6-25}. The effect of his initial assessment, however, was that he did not open the Borough Emergency Control Centre (BECC) at the outset.1314 The role of the Borough Emergency Control Centre (BECC) is to oversee and co-ordinate the council's incident response Kerry {RBK00033579/8} page 8, paragraph 29. He accepted in hindsight that he initially underestimated the scale of the response required.1315 Kerry {Day268/195:10-24}.
¶104.7 Mr Kerry's first step was to contact Laura Johnson, RBKC's Director of Housing, at 02.34.1316 Emergency log sheet for Grenfell {RBK00013296/1}. Ms Johnson contacted Robert Black, the chief executive of the TMO,1317 Laura Johnson {RBK00035592/5} page 5, paragraph 15. and sent an email to her housing team at 02.53 telling them of the fire and alerting them to the likely need for a considerable amount of emergency accommodation the following day.1318 {RBK00001606}. Although Mr Kerry did not look at the TMO emergency plan,1319 Kerry {Day268/136:12-17}. he said that he had been aware that the TMO would attend the scene to assist RBKC.1320 Kerry {Day268/132:2-18}.
¶104.8 At 02.50 Mr Kerry contacted his line manager, Stuart Priestley, RBKC's Chief Community Safety Officer. They agreed that the situation should be monitored from home until further information was available.1321 Priestley {RBK00035672/4} page 4, paragraph 14. Shortly after that call, Mr Priestley became aware of the scale of the incident, having seen an email with images of the fire sent at 02.25 by a former LFB borough commander which said "You have a massive fire, Grenfell Tower".1322 Priestley {RBK00035672/4} page 4, paragraph 15. Mr Priestly tried to contact Mr Kerry and managed to speak to him at 03.31, over an hour after Mr Kerry had been told of the fire. They decided that the full contingency management plan should be put into action, that staff should be called in to the Town Hall and that work should be transferred from the BECC (in effect, Mr Kerry) to the Town Hall.1323 Priestley {Day270/15:19-25}. The effect was to raise the level of the response and to proceed on the basis of a level 3 response.
¶104.9 Nevertheless, some time elapsed before Mr Kerry set about calling staff, in particular those in the Contingency Planning Unit, into the Town Hall. At 04.09 he rang Keith Robins, the contingency management officer, but received no answer.1324 Emergency event log sheet {RBK00013296/4}. At 04.13 he rang Elaine Chumnery, a BECC officer, who returned his call at 04.49 and agreed to go to the Town Hall to support Mr Priestley in opening the BECC.1325 Emergency event log sheet {RBK00013296/5}. He rang Rebecca Blackburn at 05.23 and asked her to go in to the Town Hall at 08.00 to take over from him.1326 Emergency event log sheet {RBK00013296/7}.
113¶She arrived at the Town Hall at about 07.20. It is unclear whether the delay was due to
¶Mr Kerry's failing to grasp the urgency of the situation or whether he was struggling to deal with the number of demands on him at the time. It is likely that it was a combination of both, as Mr Kerry was seeking to stagger the attendance of staff to ensure that some were available to work later in the day.1327 Kerry {Day268/208:2-9}. However, in failing to obtain support from other staff at an earlier stage, he placed himself in an impossible position in seeking to discharge all his duties as Council Silver.
¶104.10 The delay in calling in staff and activating the BECC were compounded by problems in obtaining access to the facilities within the Town Hall. Although Stuart Priestley arrived at the Town Hall at 04.38, he was unable to find the key to the cupboard containing the telephones and computer equipment.1328 Priestley {Day270/16:18-21}. He sent an email to Mr Kerry at 05.25 with the subject "Can you come PDQ. We cannot get into the cupboards."1329 Priestley {Day270/19:7-11}; {RBK00035661}. There was a further delay of about an hour and a quarter until Mr Kerry arrived with the key at about 06.00.1330 Priestley {Day270/17:23}-{Day270/19:6}. RBKC have since installed a key box to prevent something similar happening in the future.1331 Kerry {Day269/14:5-10}.
¶104.11 Mr Kerry did not follow the protocol for the activation of the Contingency Management Plan. In particular, he should have contacted staff earlier, because there was too much for one person to do in the time available. Although it is easy to criticise with the benefit of hindsight, we think that Mr Kerry should have realised that as soon as he was warned about the risk of fatalities, and even more so as information began to come in about residents being evacuated from surrounding properties. At all events, the BECC was not operational at the Town Hall until about 06.00 on 14 June 2017; it should have been opened between about 03.00 and 04.00.1332 Blackburn {Day270/127:22}-{Day270/128:18}. That was a substantial delay that had significant consequences for RBKC's response, not least in identifying the number and location of the rest centres that had by then opened spontaneously. As hundreds of displaced people poured onto the streets of North Kensington in need of support, RBKC was already many hours behind in assessing and meeting those needs. We are reinforced in that view by the evidence of members of the Contingency Planning Unit whose own assessment of the initial response was that by the time the BECC opened RBKC had already lost control of the incident.1333 Blackburn {Day270/140:9-15}.
The involvement of Nicholas Holgate
¶104.12 Nicholas Holgate, town clerk and chief executive of RBKC, visited North Kensington early on the morning of 14 June 2017. He found the scale and ferocity of the fire deeply shocking.1334 Holgate {RBK00035426/4} page 4, paragraph 19. He visited the rest centres at the Harrow Club and Rugby Portobello Trust sometime between 04.30 and 06.00 and thought they were functioning properly.1335 Holgate {RBK00035426/4} page 4, paragraph 19; Holgate {Day273/48:10-11}. Still at the scene, he did not dial into the first meeting of the strategic co-ordinating group at 05.00,1336 Mr Kerry and Mr Priestley attended as RBKC's representatives. Minutes of the Strategic Coordinating Group Meeting at 05.00 on 14 June 2017 {MOL00000026/3}. since, as he told us, he had not been told about it.1337 Holgate {Day273/55:14}-{Day273/56:9}; Kerry {Day269/51:12}-{Day269/52:7}. John Hetherington, deputy head of planning, London Resilience, told us that the absence of the chief executive was not desirable, but in his experience not altogether unusual.1338 Hetherington {Day277/189:8-14}.
114¶104.13 Mr Holgate arrived at the Town Hall at about 06.00 and had a meeting with Mr Kerry, Ms Johnson, Mr Priestley and Robert Black. It is unclear at what time that meeting was held. Mr Priestley said that it had taken place at 06.30,1339 Priestley {Day270/22: 9}-{Day 270/24:20}. although Mr Kerry thought that it had taken place at 10.00.1340 Kerry Emergency Event Log 10.00 {RBK00013296/10}; Kerry {Day269/99:15}-{Day269/100:3}. Notwithstanding that difference of recollection, it is clear that there was a meeting that morning at which Mr Kerry provided significant advice to Mr Holgate. Mr Kerry's log records that he advised him that the incident was bigger than any one local authority in London could manage and that consideration should be given to asking for mutual aid for the BECC. The log further records that there were people who could support Mr Holgate and RBKC Gold, including John Barradell, Eleanor Kelly, Andrew Meek (head of organisational resilience at the London Borough of Haringey and London's expert on humanitarian assistance) and Alistair Ayres from Hammersmith and Fulham.1341 Kerry Emergency Event Log 10.00 {RBK00013296/10}; Kerry {Day269/99:15}-{Day269/100:3}.
¶104.14 Mr Kerry's advice was based on his concern that there were insufficient RBKC staff to keep the BECC running for an extended period.1342 Kerry {Day269/100:4-9}. He believed at the time, and maintained his view when giving evidence, that none of London's local authorities could have coped with the incident on their own, given its scale.1343 Kerry {Day269/100:10-24}. He told us that it was clear to him that it was massive and that it was for such incidents that there were mutual aid arrangements in place that he believed were well understood and practised. He told us that it was for the RBKC Gold strategic meeting to consider what resources were required. Once that assessment had been made, they would have been able to activate the London Gold arrangements, if necessary.1344 Kerry {Day269/104:24}-{Day269/105:4}. We accept his evidence about that.
¶104.15 Mr Priestley recorded in his log that in response to David Kerry's advice Mr Holgate had said "That looks like we can't cope".1345 Priestley Log {RBK00013318/2}. Mr Holgate did not recall making that comment, but he did not dispute the accuracy of Mr Priestley's note.1346 Holgate {Day273/69:7-12}. Mr Holgate did not agree with the view that the incident was bigger than any one local authority could manage.1347 Holgate {Day273/66:14-19}. Despite the advice of Mr Kerry, he thought that RBKC would be able to respond effectively, if everyone worked together as a team.1348 Holgate {Day273/67:6-9}. He denied being influenced by a need to preserve the council's reputation.1349 Holgate {Day273/72:9-18}. We are satisfied that the comment recorded by Mr Priestley accurately reflected Mr Holgate's state of mind. In our view his attitude was defensive and his confidence in RBKC's ability to manage the response was misplaced. It became more pronounced as it persisted into the following day, 15 June 2017.1350 RBKC Gold group meeting at 11.00 on 14 June 2017 {RBK00013271/4}; and 10.00 on 15 June 2017. {RBK00013270/3}.
115¶104.16 Following the meeting of the RBKC Gold group at 10.00 on 15 June 2017, Ms Blackburn told Mr Holgate and Tony Redpath that they needed to seek assistance from other London boroughs and activate the London Gold arrangements.1351 Blackburn {Day270/179:22}-{Day270/180:17}. Her view was that RBKC was not coping and that there were not enough members of staff to support the response.1352 Blackburn {Day270/181:6-8}. Mr Holgate and Mr Redpath both told her that the council could manage.1353 Blackburn {Day270/181:5}. Ms Blackburn's impression was that senior management at RBKC was reluctant to seek help.1354 Blackburn {Day270/180:7-11}. In her view, either they could not see what those on the ground were seeing or they could not cope and chose not to see it.1355 Blackburn {Day270/181:6-8}. Ms Blackburn told us that, having been in the BECC for two days, she ought to have been able to provide a clear picture of what was happening on the ground, but could not. That internal view was consistent with the concerns that were beginning to emerge on 15 June 2017 in the media, the London resilience agencies and the government.
The Borough Emergency Control Centre (BECC)
¶104.17 The BECC was the key element in the council's organisation in the days immediately following the fire. Despite the best efforts of those who volunteered to staff the BECC on the morning of 14 June 2017, it was overwhelmed by the incident.1356 Blackburn {Day270/138:4-20}; RBKC Module 4 Closing Submissions {RBK00068546/11} page 11, paragraph 30. It struggled throughout the period in which RBKC led the humanitarian response before handing over leadership to John Barradell during the afternoon of 16 June 2017. The circumstances in which that occurred are described in Chapter 102.
¶104.18 The computer equipment used by the BECC was outdated and slow. It was due for replacement but that had not taken place by the time of the fire.1357 Kerry {Day269/23:22}-{Day269/26:6}. Problems which had arisen in previous training exercises recurred. At the outset, it was not possible to obtain access to the system for logging information and technical assistance was needed to solve the problem.1358 Blackburn {RBK00058170/14} page 14, paragraph 9.10. That affected the ability of the BECC to function efficiently, not least because staff could not open a log to enter tasks and chart progress. Although he could have done so remotely, Mr Kerry had not created an electronic log at the outset. If he had done so, it would have been available to others within the BECC later.1359 Kerry {Day269/22:7-18}. Ms Blackburn eventually opened one at 13.18 on 14 June 2017, almost eleven hours after RBKC had been informed of the fire.1360 Blackburn {RBK00058170/14} page 14, paragraph 9.8; Blackburn {Day270/155:4-19}. As a result, important decisions taken in the previous hours had not been electronically logged.
¶104.19 Between 07.00 and 07.30 on 14 June 2017 David Kerry, as the first Council Silver and thus the person responsible for co-ordinating RBKC's overall response,1361 {RBK00004396/31}. transferred his duties as Council Silver to Stuart Priestley.1362 Priestley {Day270/34:20}-{Day270/35:1}; {Day270/35:22}-{Day270/36:10}; Kerry {Day269/62:2-13}. Mr Kerry did not provide him with a copy of his handwritten log (the electronic log was not yet open) and the handover was limited in detail.1363 Kerry {Day269/22:20}-{Day269/23:4}. That was partly a reflection of Mr Kerry's failure to appreciate the scale of the incident and partly the result of his being by that stage mentally and physically overcome by the incident.1364 Sawyer {GOL00001349/14} page 14, paragraph 70; Kerry {Day269/170:5-14}. He was uncertain about the number and locations of the rest centres that had opened during the morning and did not know how many displaced people were at them. At that stage RBKC had not sent any staff to the rest centres.1365 Laura Johnson {Day272/46:6-13}.
116¶104.20 A constant feature throughout the period in which RBKC led the humanitarian response was the shortage of trained staff to operate the BECC. Untrained volunteers from elsewhere in RBKC were drafted in to assist.1366 Kerry {Day269/63:21}-{Day269/64:16}; Priestley {Day270/40:13}-{Day270/41:4}. Mr Kerry, an experienced contingency planning manager, worked nights and was not available during the day when his advice was most needed. The burden of leading the operational response during the day fell on Mr Priestley. Although he was a trained Council Silver and Mr Kerry's manager, he had never previously held that role in an emergency.1367 Priestley {RBK00035672/3} page 3, paragraph 11; Priestley {Day270/7:11-20}; {Day270/11:11-13}; {Day270/12:8-14}. A further consequence of the staff shortages was that Mr Priestley had to manage the BECC in addition to acting as Council Silver.
¶104.21 By the evening of 14 June 2017 Mr Priestley thought that RBKC needed more help at every level of the response.1368 Priestley {Day270/71:4-14}. When he returned to the BECC on the morning of 15 June 2017 it was just as he had left it the previous evening. Both he and Rebecca Blackburn had expected more to have been done overnight by Mr Kerry, who had taken over as Council Silver, such as completing a rota for the rest centre, tidying up the BECC log and creating a strategy for the coming day.1369 Priestley {Day270/72:4}-{Day270/73:16}; Blackburn {Day270/173:6-14}. Mr Kerry confirmed that Council Silver was responsible for developing the tactical plan for responding to an emergency.1370 Kerry {Day268/59:2-5}. In our view the absence of coherent strategic and tactical plans hindered the response.
¶104.22 By 15 June 2017, it had become apparent that RBKC was unable to provide effective assistance. Mark Sawyer visited the Town Hall on the morning of 15 June 2017 to provide support.1371 The circumstances in which he attended RBKC are examined in Chapter 102 when considering the London- wide response. His observations provided an important external insight into how RBKC was coping with the challenge facing it. Mr Sawyer considered that the BECC was failing; it did not have a clear picture of the situation in North Kensington and no situation report had been produced.1372 Email from Mr Sawyer to himself on 1 July 2017 {GOL00001301} paragraph 6. (A situation report is vital to enable information to be shared with the Gold group internally and with the strategic co-ordinating group or London Local Authority Co-ordination Centre externally when needed.) The first situation report was not produced until 07.00 on 16 June 2017.1373 RBKC BECC Situation Report No.1, 16 June 2017 {RBK00015017}. Mr Sawyer's observations echoed Ms Blackburn's description of the BECC as lacking any organisation.1374 {RBK00029019/2} page 2, paragraph 3; Blackburn {Day270/138:1}-{Day270/139:19}. We consider that the inability of RBKC throughout that period to obtain, maintain and record in full information about the situation was a significant failing and delayed support being directed to those who were in need.
¶104.23 Mr Sawyer spent most of 15 June 2017 with Nicholas Holgate and attended the RBKC Gold group meetings.1375 RBKC Gold Group meeting on 15 June 2017 at 10.00 {RBK00013270} and at 15.30 {RBK00013262}; Sawyer {GOL00001349/14-15} pages 14-15, paragraphs 69-76. His immediate concern was that RBKC had not been galvanised into a proper response.1376 {GOL00001301} paragraph 2. He also advised Mr Holgate, following the meeting of the RBKC Gold group at 10.00 on 15 June 2017, to limit membership of the Gold group to his senior management team and tactical lead officer (Silver) to ensure that discussions were more strategic, as he thought that the meetings had concentrated too much on operational matters.1377 Sawyer {GOL00001349/14-15} pages 14-15, paragraph 73. Mr Sawyer thought that Mr Kerry had been traumatised and had ceased to be in a position to influence the strategic direction of the response.1378 {GOL00001301} paragraph 3.
117Emergency shelter and accommodation
¶104.24 The aim of the Humanitarian Assistance framework is to ensure that care is delivered in an effective way that meets the needs of those affected by a major emergency.1379 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/4} page 4, paragraph 1.1. It provides that a rest centre can be opened when a significant number of people have been displaced following an incident.1380 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/20} page 20, table 3. A rest centre is a building opened by a local authority for the temporary accommodation of people who have been displaced. It is a place where immediate practical and emotional support may be offered. It is a place of refuge and support for those affected or displaced by an emergency and is often the first point of contact that affected persons have with the authorities. The local authority is responsible for opening and running designated rest centres in the wake of an emergency.1381 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/24} page 24, paragraph 8.15: "The decision to set up a rest centre will be made by the Local Authority often at the request of the police or fire brigade."
¶104.25 RBKC failed to open suitable rest centres in the early morning of 14 June 2017 to meet the needs of the growing number of people displaced from Grenfell Tower and the surrounding properties. Mr Kerry did not refer to the Contingency Management Plan to identify an appropriate centre from the directory annexed to it.1382 Contingency Management Plan, Emergency Shelter and Rest Centre Directory, Annex 15 {RBK00048005}. Instead, he accepted an offer from a member of the public to use Belushi's Bar in Shepherd's Bush that could provide shelter for up to 100 people.1383 David Kerry's Emergency Log {RBK00028849/1}. However, he failed to assess its suitability. Belushi's Bar was not on RBKC's list of approved premises and was about a mile from the scene of the fire.1384 {CAB00003753}; {LFB00119615}. That alone made it an unusual choice for a rest centre in an urban area.1385 Spragg {Day280/23:10-18}.
¶104.26 At 03.16 David Kerry called the Red Cross into action at Belushi's Bar under the Memorandum of Understanding.1386 Memorandum of Understanding between the British Red Cross and RBKC, 27 November 2015 {BRC00000055}; It had lapsed at the time of the Grenfell Tower fire but the British Red Cross confirmed that that would have made no difference to their attendance, Spragg {Day280/13:24}-{Day280/14:2}. Its staff arrived at 03.45.1387 British Red Cross Emergency Log {BRC00000051/4}. By contrast, no RBKC staff were deployed to support them or to manage the rest centre. By 05.30, no one affected by the fire had gone to Belushi's Bar1388 British Red Cross Emergency Log {BRC00000051/4}. and Mr Kerry made the decision to close it as a rest centre.1389 Kerry {Day269/46:21}-{Day269/47:2}. It was unusual for a rest centre to be empty for almost two and a half hours after it had been opened and it is clear that it was the wrong place to choose.1390 Spragg {Day280/23:7-13}. That signalled a false start from which RBKC struggled to recover. Vital Red Cross resources were diverted from the immediate area and further time was lost in getting help to those most in need.
118¶104.27 Mr Kerry accepted that the Humanitarian Assistance framework set out the responsibilities of RBKC in relation to setting up rest centres, but he did not accept that its reliance on the Red Cross to do that was an abdication of its responsibility as a Category 1 responder.1391 Kerry {Day268/89:2-25}. We accept that local authorities are entitled to make use of others to discharge their functions and frequently do so, but, as Mr Kerry himself accepted,1392 Kerry {Day268/91:7-11}. RBKC should have had its own staff at the rest centres to monitor and supervise the Red Cross.
¶104.28 On the morning of 14 June 2017 information about the existence and location of rest centres spread by word of mouth alone. The result was that those affected by the fire had to endure the stressful experience of going to different rest centres to find information and support.1393 Wesley Ignacio {IWS00001820/15} page 15, paragraph 78. The Harrow Club spontaneously opened in the early hours of the morning and soon after that, at about 03.30, it was formally adopted by RBKC as the second rest centre.1394 Layton {RBK00029034/6} page 6, paragraph 17; Kerry {RBK00033579/15} page 15, paragraph 58. The Harrow Club was on RBKC's list of approved rest centres. It was a long-established youth club with a large sports hall, located approximately half a mile from Grenfell Tower. Additional Red Cross staff arrived at 04.55 and recorded that there were about 25 people there.1395 British Red Cross Emergency Log {BRC00000051/4}. TMO staff arrived at 05.30 but there was no one from RBKC there.1396 Warrier {TMO00887108/2} page 2, paragraph 6. From 05.30 the Red Cross asked RBKC several times over a period of some five hours for information about when its staff would come to the rest centres to provide support.1397 British Red Cross Emergency Log {BRC00000051/4-6}. See entries 05.30, 06.45, 07.40, 08.15, 09.15, 10.30. The absence of its staff from the various community rest centres in the hours that followed the fire was a prominent feature of the council's early response.
¶104.29 The Rugby Portobello Trust is a local charity group whose building is situated about 400 yards from Grenfell Tower.1398 Simms {CFV00000005/2} page 2, paragraphs 7 and 9. On 14 June 2017 it opened spontaneously as a rest centre. We heard how people who were shocked, bewildered and in distress started arriving in large numbers in the early hours of 14 June 2017.1399 Simms {CFV00000005/4-6} pages 4-6, paragraphs 19-20, 28; William Thompson {IWS00000158/10} page 10, paragraph 60; Toyoshima-Lewis {IWS00001725/46} page 46, paragraph 154. At 05.45 the Red Cross became aware of its existence as a rest centre and notified RBKC. As a result, Mr Kerry decided to move people from the Harrow Club to the Rugby Portobello Trust.1400 British Red Cross Emergency Log {BRC00000051/5}. However, RBKC did not send any senior managers or staff there and by 10.30 none of its staff had arrived at any of the other places of shelter which had opened during the morning to accommodate the growing number of evacuees.1401 British Red Cross Emergency Log {BRC00000051/6}; Spragg {Day280/31:22-24}; Stuart Priestley's Log 14 June 2017 {RBK00013318/3}. They included the Clement James Centre, the Latymer Community Church and St. Mark's Church.1402 The operation of spontaneous rest centres run by voluntary and community groups is examined in Chapter 106. Its absence was noted by many survivors and added to the sense that they had been abandoned by the council.1403 Benjamin {IWS00001764/10} page 10, paragraph 69; Senate Jones {IWS00001691/2} page 2, paragraphs 5-6; Wesley Ignacio {IWS00001820/14} page 14, paragraph 75.
¶104.30 RBKC had a responsibility to register those who went to rest centres seeking support,1404 Spragg {Day280/16:11-15}. but it failed to put in place an adequate registration process, which in turn made it difficult to identify, organise and deliver the support needed.1405 Adamson {BRC00000075/27} page 27, paragraph 124. The absence of RBKC staff at the rest centres in those crucial early stages directly affected the effectiveness of the registration process. It was left to the TMO,1406 The work of the TMO in compiling lists of the 'missing' and 'survivors', including the significant errors that occurred, is examined in Chapter 105. the Red Cross and various voluntary organisations to fill the gap and make whatever arrangements they could.
119¶104.31 In the absence of effective leadership there was no organised and integrated record of where people were and what they needed. The Red Cross tried using paper registration forms. At 04.55, its team arrived at the Harrow Club and found that the staff there had started to make a list of who was present and had given representatives of the TMO forms to register residents.1407 British Red Cross Emergency log, 04.55{BRC00000051/4}. However, the number of rest centres that had sprung into existence, some with no Red Cross presence, made the process haphazard.1408 Richards {CFV00000012/13} page 13, paragraph 89. There was no system for recording information electronically; instead, everyone relied on loose pieces of paper with handwritten notes that were circulated among responders and staff from the TMO.1409 Rupinder Hardy's Personal Briefing Document {LBE00000056/2} 17-18 June 2017: "All documentation was paper based in terms of residents/staff/volunteers on site". Even when the Westway Centre became the official rest centre later on the 14 June 2017,1410 Kerry {Day269/189:1-6}. the process of recording and handling information about residents remained rudimentary. People were just asked by the Red Cross to provide a note of their names and the numbers of their flats.1411 Omar Ali {IWS00001533/12} page 12, paragraph 59.
¶104.32 Significantly, in the early days of the response the registration that did take place did not appear to be collated and recorded centrally by RBKC. The starkest illustration of that was recalled by Mr Colin Brown, a senior Red Cross official, who said that the details of those who had registered were recorded using triple carbon paper, one copy being retained and the other two copies being provided to RBKC.1412 Colin Brown {BRC00000005/25} page 25, paragraph 100. RBKC did not ask them to put the information onto any electronic system or collate it in any other way. He recalled that, in the first few days while RBKC was still notionally in charge of the response, a Red Cross volunteer had found a box containing copies of several registration forms intended for RBKC unattended at the Westway Centre. He did not think that RBKC had made any effort to collate the data and arranged for his concerns to be reported to it.
¶104.33 Registration continued to present problems until 22 June 2017, even after London Gold had taken over management of the response.1413 Adamson {BRC00000075/21} page 21, paragraph 99. Without a coherent registration process, it was difficult to identify who had been affected, what their needs were and how best to respond to them. It was also sometimes unclear where those who had been affected actually were.1414 Adamson {BRC00000075/21} page 21, paragraph 98.
¶104.34 As the hours passed on the morning of 14 June 2017, no RBKC staff were sent to the rest centres. At the Town Hall, RBKC housing staff were being made ready for deployment as the BECC struggled to find out how many rest centres there were and how many of those who were at them had been affected by the fire.1415 Blackburn {RBK00035364/4} page 4, paragraph 19; Blackburn {Day270/139:11-24}. It was thanks to the initiative of Ms Blackburn1416 Blackburn {RBK00035364/5} page 5, paragraph 22. that at about 10.00 RBKC housing staff were sent to the Rugby Portobello Trust and the Clement James Centre.1417 Laura Johnson {RBK00035592/8} page 8, paragraph 33.
120¶104.35 Laura Johnson, Director of Housing at RBKC, said that the delay in sending people to North Kensington had been caused not only by a shortage of staff at the Town Hall but also by a lack of information about which rest centres were being used.1418 Laura Johnson {Day272/46:24}-{Day272/47:19}. A further hindrance to the deployment of staff was the fact that several of the rest centres had been opened spontaneously by the community.1419 RBKC Incident Situation Report {RBK00033583/2}. It was difficult to co-ordinate the emergency response in the absence of a single official rest centre whose existence and location could be widely communicated.1420 Laura Johnson {Day272/48:1-11}.
¶104.36 Ultimately, council staff did not reach any of the rest centres for some eight hours after RBKC had been notified of the fire. That was far too long. In our view, the strategic decisions taken at the outset by Mr Kerry as Council Silver failed to reflect the seriousness and scale of the emergency. There was a consequent lack of urgency, direction and, ultimately, co-ordination. Given that staff from the TMO were present at rest centres from an early stage, contact could and should have been made with them to find out how many displaced persons were there and how many staff were required. RBKC employees should have been called in to the Town Hall earlier to ensure there were sufficient staff available to be sent to the rest centres.1421 Kerry {RBK00033579/17} page 17, paragraph 78; Blackburn {RBK00035364/11} page 11, paragraph 52. Both Ms Blackburn1422 Blackburn {RBK00035364/5} page 5, paragraph 22; Blackburn {Day270/153:3-10}. and Mr Priestley1423 Priestley {Day270/47:10-20}. considered that they should have been despatched four hours earlier, at about 06.30.1424 Minutes of the SCG meeting at 06.30 on 14 June 2017 {MOL00000015/2} page 2, paragraph 3.5.
¶104.37 The delay in sending out RBKC staff left the Red Cross and members of the community who voluntarily opened their premises without support and without information about how the response was being led. That made it difficult for them to know who was in charge, what was needed or what was going to be brought to the rest centres to enable them to direct people to the right source of support.1425 Spragg {Day280/32:5-13}.
The Westway Centre
¶104.38 The Westway Centre is a large sports and fitness centre that opened spontaneously as a rest centre in the early hours of 14 June 2017.1426 Alison Norman {CFV00000061/1-2} pages 1-2, paragraphs 2a-2b. It was not until later in the afternoon on 14 June 2017 that RBKC decided to consolidate the rest centres and designate the Westway Centre as the one official location.1427 Norman {CFV00000061/5} page 5, paragraphs 3a-3c; Priestley {RBK00035672/8-9} pages 8-9, paragraph 39. At a meeting of the RBKC Gold group at 15.001428 RBKC Gold Meeting Minutes, 14 June 2017 at 15.00 {RBK00013272/2}. that day it was confirmed that it would remain open overnight. At that stage RBKC was trying to determine how many people needed to be accommodated. By then, 30 households had been identified in the Clement James Centre, but no information was available from the other rest centres, despite the presence of TMO staff.1429 RBKC Gold Meeting Minutes, 14 June 2017 at 15.00 {RBK00013272/2}.
¶104.39 The decision to concentrate the provision of humanitarian assistance in one place was standard practice and viewed in isolation was a reasonable decision.1430 Priestley {RBK00035672/9} page 9, paragraph 39: "It was a challenge to communicate with the many number [sic] of rest centres which had established themselves that residents who required Council support and overnight accommodation should be encouraged to attend the Sports Centre." Spragg {BRC00000050/14} page 14, paragraph 61; Spragg {Day280/81:8-17}. However, the failure of communications led to a situation in which many who needed support did not know they should go to Westway Centre or what support was available there.
121¶104.40 Unfortunately, the Westway Centre was not very readily accessible to many of those who were in need of support.1431 Daffarn {IWS00002109/124} page 124, paragraph 384. Some survivors told us that they had been asked to provide identification and of having to sneak into the building if they could not provide it.1432 Hirsi {IWS00001776/4} page 4, paragraph 11. Wristbands were introduced as a method of verifying the identity of those who had been displaced.1433 Blanchflower {CFV00000045/9} page 9, paragraph 36; Hardy {Day276/8:22-24}; Cesar Ranito {IWS00001249/7-8} pages 7-8, paragraph 37. As we have said in Chapter 100, the Westway Centre was described, both by those who went there and by the professionals who were there to support them, as unwelcoming. There was a visible police cordon at the entrance which in the words of one witness made it look like a "crime scene".1434 Girma {IWS00001732/12} page 12, paragraph 23; Eleanor Kelly {GOL00001730/8} page 8, paragraph 19; Hardy {LBE00000025/6} page 6, paragraph 35; {LBE00000025/9} page 9, paragraph 42: "The initial appearance of the Rest Centre was like that of a cordoned off crime scene rather than a welcoming place where bereaved, survivors and residents would want to come for help". Although the police needed to maintain a presence in the light of the significant media interest, its effect, albeit unintentional, was to deter people who needed support from attending it or visiting it as often as they needed to.
¶104.41 The interior of the Westway Centre was described as chaotic and confusing, with a lack of signs to assist visitors.1435 Al-Karad {IWS00001541/23} page 23, paragraph 113. Survivors described it as uncomfortable1436 Antonio Roncolato {IWS00001774/19} page 19, paragraph 109. and impersonal1437 Jenny Dainton {IWS00001804/24} page 24, paragraph 152. and there were concerns about inadequate sleeping arrangements. Some of those who had been displaced were sleeping on mats or mattresses donated to the relief effort.1438 Alison Norman {CFV00000061/7} page 7, paragraph 4g; Belfassi {IWS00001802/6} page 6, paragraph 36; Hoang Khanh Quang {IWS00001821/11} page 11, paragraph 51; Maria Jafari {IWS00001815/14} page 14, paragraph 64; Email from Maureen Mandirahwe (WCC) to RBKC BECC at 21.08 on 17 June 2017 {RBK00005386/1}. Coupled with a lack of privacy,1439 Spragg {BRC00000050/18} page 18, paragraph 78 (b). cleanliness and facilities for disposing of rubbish,1440 Hardy {LBE00000025/18} page 18, paragraph 96. that demonstrated an inability on the part of those responsible for its management to create an environment that was appropriate and welcoming.
¶104.42 The problems at the Westway Centre were due in a large part to the lack of leadership and organisation.1441 Mussilhy {IWS00001783/8} page 8, paragraph 31; Kuchar {RBK00035291/5} page 5, paragraph 19: "I remember being advised on the walk there to put our ID badges away.". RBKC had no visible presence and the absence of senior RBKC staff and qualified rest centre managers was a constant theme among those who gave evidence. RBKC was reliant on volunteers from within its own staff and on staff from neighbouring boroughs to act as rest centre managers. The point was raised at the RBKC Gold group meeting on 15 June 2017.1442 Nicholas Austin {RBK00035340/5} page 5, paragraphs 17-18: "I volunteered to go down there [Rugby Portobello Trust] as a senior manager… I arrived there around 6.30pm. I was there until it closed. I had received no formal training in setting up or managing rest centres." RBKC Gold Group meeting on 15 June 2017 at 15.30 {RBK00013262/3}: "NA said the WSC needs a Senior Manager and a Rest Centre Manager. BECC working on a rota for Rest Centre Manager. Senior officers thin on ground but will think about this". The absence of leadership at the Westway Centre left the Red Cross and the many volunteers at the centre without the support they needed.
¶104.43 The perception that RBKC staff were not present at the Westway Centre endured. On 17 June 2017, volunteers were complaining that RBKC was not helping and that they were doing everything.1443 {LBE00000014/1}. The perception was not entirely justified, but it was exacerbated by the lack of identifying tabards for staff to wear.1444 Kerry {RBK00033579/19} page 19, paragraph 84. Minutes of the SCG meeting at 19.30 on 14 June 2017 {LFB00119322/3}: "David Kerry confirmed that identification tabards were being delivered to Rest Centres for their staff". The result was that it was difficult to distinguish RBKC staff among the many volunteers and others who were there. We were told that senior managers of RBKC had told staff not to wear tabards or lanyards out of a concern for their safety.1445 Health Response Group Meeting, 18 June 2017 at 14.00, {RBK00035310/3}. Email from Ann Ramage, Head of Environmental Health for commercial services of RBKC and LBHF, updating on the Westway Centre on 17 June 2017 {RBK00005539}.
122Change of leadership
¶104.44 Shortly after leadership of the humanitarian response had passed to London Gold,1446 Hardy {Day276/3:14}-{Day276/4:4}; Hardy {LBE00000025/7} page 7, paragraph 39; Email from Rupinder Hardy at 09.36 on 17 June 2017 {LBE00000004}. Rupinder Hardy, a local authority liaison officer (LALO) from the London Borough of Ealing, attended the Westway Centre which at that point was still being managed by RBKC. Although Ms Hardy recognised that there would inevitably be an element of chaos, given the number of people involved,1447 Hardy {Day276/114:22}-{Day276/115:5}. she did not find the Westway Centre a welcoming space where responders and services could easily be identified.1448 Hardy {Day276/14:2}-{Day276/16:15}. She described it as a "shambles" and not what she was used to seeing from a local authority.1449 Hardy {LBE00000025/11} page 11, paragraph 57. She told us that the help desks were a jumble and that it was difficult to know what was going on and what support was being offered. She raised her concerns with Mr Barradell and Ms Kelly,1450 Hardy {LBE00000025/10} page 10, paragraphs 45-46; Email from Eleanor Kelly {GOL00000372} attaching notes of the meeting between John Barradell, Eleanor Kelly and Rupinder Hardy on 17 June 2017 {LBE00000055}. who by that time were leading the response. As a result, they decided to transfer the management of the Westway Centre to the London Borough of Ealing. That took effect on 17 June 2017, when Ms Hardy assumed the role of manager and brought in a team from her borough.1451 Hardy {LBE00000025/10} page 10, paragraph 48; Paul Najsarek was the Chief Executive of the London Borough of Ealing. Hardy {Day276/53:12-21}: 40 members of staff deployed from Ealing. Hardy {LBE00000025/14} page 14, paragraph 73: "The number of staff deployed by Ealing, in the region of 197 officers from the 17-22 June 2017".
¶104.45 Ms Hardy sought to improve the process for providing support at the Westway Centre.1452 Hardy {LBE00000025/19} page 19, paragraph 98. The new process included placing the service stalls in a U-shape, allowing people to come in from one side and work their way round the services that were being offered in order to receive the support, advice and help they required.1453 Hardy {Day276/77:3}-{Day276/78:3}; Rupinder Hardy's photographs taken during her deployment as LALO at the Rest Centre {LBE00000051}. Community workers reported that families were not going to the Westway Centre because they found the process of obtaining support difficult due to long queues, much paperwork and an unwelcoming atmosphere.1454 Email at 15.19 on 20 June 2017 from Sarah Mail (WCC) to RBKC, {RBK00012356/1} page 1, paragraph 1; {CLG00021227}. Clare Richards, chief executive officer of the Clement James Centre, told us that although she could understand why the space had been set up as it was (i.e. to allow people to go from table to table), the reality was that people in a state of distress had to keep explaining why they were there and why they needed support.1455 Richards {Day275/151:9-21}. She considered that to be inappropriate and very upsetting for those affected.1456 Richards {Day275/151:2-8}. Ms Hardy accepted that the process was harrowing. She told us that one thing she had learned was that a process in which personal information was collected at a single point and then distributed to those providing the emergency response would have been better.1457 Hardy {Day276/83:19}-{Day276/84:15}.
123¶104.46 Despite the efforts and generosity of those who ran the Westway Centre and the many volunteers who attended to assist, as the official rest centre it fell far short of the service that those affected were entitled to expect and should have received following a major emergency.
Community rest centres
¶104.47 Despite RBKC's decision on 15 June 2017 to designate the Westway Centre as the official rest centre, displaced people were still making use of four or five other rest centres,1458 Community Impact Assessment {RBK00005288/14}. which led to confusion within the community about which one was the official rest centre.1459 Spragg {Day280/33:9-14}. As RBKC began to concentrate its efforts on the Westway Centre from 15 June 2017 onwards, it decided that other rest centres run by the community, such as the Rugby Portobello Trust which remained open, would not receive council services,1460 Minutes of the HASG meeting at 14.00 on 15 June 2017 {RBK00020525/1} unnumbered paragraph 7: "The Council's efforts are at Westway as a council-run rest centre. Other informal rest centre's (sic) may continue but they will not be resourced with Council services". despite the fact that people were relying on them.1461 Email from Nicholas Holgate to RBKC colleagues at 11.01 on 16 June 2017 {RBK00009876}. The resulting confusion was made worse by a failure to tell the community and religious centres about the services available at the Westway Centre. Volunteers from some of the centres reported that they did not know what services were being offered there.1462 Email from Lady Borwick, former MP for Kensington, at 17.39 on 18 June 2017 {CLG00009154/2}.
¶104.48 The Reverend Mark O'Donoghue of Christ Church, Kensington contacted RBKC councillors, pointing out areas that needed rapid improvement. He emphasised the need for a single point of contact at RBKC to assist with the needs of those at the rest centres (mentioning, in particular, the Clement James Centre, the Rugby Portobello Trust and Latymer Community Church). He found it difficult to believe that it was beyond the wit of RBKC to appoint one person to talk to people like him, who could then talk to their own networks to provide help.1463 Email from Mark O'Donoghue to RBKC {RBK00003251}.
¶104.49 Community leaders said that what was needed was the visible presence of RBKC staff wearing identifying insignia, such as high-visibility jackets, and in possession of up-to-date information.1464 Long {CFV00000010/6-7} pages 6-7, paragraph 32. In the absence of such a presence, information or support, community organisations felt abandoned.1465 Long {CFV00000010/7} page 7, paragraph 32.
Emergency accommodation
¶104.50 In addition to its obligation to open a rest centre, RBKC had an statutory obligation to provide displaced persons with emergency accommodation.1466 Local authorities have an initial duty to provide accommodation for all persons who are homeless and eligible for assistance, (Housing Act 1996, sections 188 and 189(1) Part 7); RBKC Housing Contingency Plan, {RBK00035406/7-8} pages 7-8, paragraphs 2.1.2 and 2.2. {RBK00002747}. The council's Housing Contingency Plan, dating from 2012, had not been the subject of an annual exercise in accordance with its own guidance and was not referred to during the response to the fire.1467 Laura Johnson {Day272/7:6}-{Day272/9:25; {Day272/10:13}-{Day272/11:3}. The aim of the plan was, among other things, to support and extend the Contingency Management Plan and to provide the information and describe the procedures and action to be taken to ensure an effective, flexible and timely response by the housing department to any emergency that might arise.1468 {RBK00035406/5} paragraph 1.2. Furthermore, the
124¶RBKC's own Housing Risk Register1469 RBKC Housing Risk Register, November 2016 {RBK00036587}. dated November 2016 recognised that it did not have sufficient capacity to arrange temporary accommodation in an emergency.1470 Laura Johnson {Day272/18:21}-{Day272/19:17}.
¶However, there were no processes in place to address that deficiency. Although there were arrangements to make use of local premises as rest centres, there were no standing arrangements with local hotels of a kind that would facilitate the provision of accommodation for displaced residents.1471 Laura Johnson {Day272/21:25}- {Day272/22:4}; {Day272/60:6-23}.
¶104.51 From about 07.30 on 14 June 2017, RBKC housing officers began telephoning hotels in central and west London to reserve rooms in anticipation of a need to house people that evening.1472 Stuart Priestley, RBKC Chief Community Safety Officer, Log – Wednesday 14 June 2017 {RBK00013318}. Laura Johnson told us that at that early stage they were looking for hotels within the borough or in adjacent boroughs because people needed to be close to their support networks.1473 Laura Johnson {Day272/55:7-19}.
¶104.52 Ms Johnson also told us that they had received a huge number of offers of accommodation from different organisations and members of the public.1474 Laura Johnson {Day272/63:17-24}. The accommodation ranged from spare bedrooms offered by members of the public to unfurnished accommodation in existing social housing blocks.1475 Laura Johnson {Day272/113:3-25}. Ms Johnson explained that she did not consider those offers to be appropriate because, she felt, people needed the privacy of a self-contained room and their own bathroom,1476 Laura Johnson {Day272/113:6-9}. as well as being close to their neighbourhood.1477 Laura Johnson {Day272/113:22-25}. Her team's view was that hotel accommodation was the most appropriate solution.1478 Laura Johnson {Day272/112:11-21}.
¶104.53 In the days that followed the fire RBKC struggled to keep up with the demand for accommodation to house a growing number of displaced people. Over 800 people had been forced to leave their homes and although most went to stay with families or friends, many depended on the council to find them somewhere to live.1479 Project Athena Report {RBK00028618/74-82} pages 74-82, paragraphs 18.8 and 20.8.
Allocation of accommodation
¶104.54 At the outset RBKC drew a distinction between those who had been displaced from the tower itself and those who had been displaced from the surrounding blocks within the wider cordon (i.e. the Walkways).1480 This included approximately 845 residents from Hurstway Walk, Barandon Walk, Testerton Walk, Grenfell Walk and Treadgold House {TMO00869977}; Teresa Brown {TMO00894124/17} page 17, paragraph 60; Police Cordon Slideshow {MET00080826}. In the first instance, those living in the Walkways were advised to try to stay with families or friends and were provided with accommodation only if they had nowhere to go.1481 Laura Johnson {RBK00035592/13} page 13, paragraph 49 However, the criteria applied to those living in the Walkways were changed during the course of 14 June. At 13.46, Ms Johnson told Emma Strugnell, a media and communications officer at RBKC, that the council was providing emergency hotel or bed and breakfast accommodation for people who had lived in the tower;1482 {RBK00018898/1}. those who had been evacuated from the Walkways were to go to the emergency rest centres and would be provided with accommodation only if they were old or vulnerable in some way.1483 {RBK00018898/1}. In the case of those who were not old or vulnerable, RBKC waited to find out whether they could return to their homes or whether emergency accommodation at a rest centre would be needed. Later that day families with children were included among those eligible for accommodation.1484 {RBK00031298/2}.
125¶104.55 The more restrictive criteria applying to residents of the Walkways created confusion within the housing department. They were not adequately communicated to staff and were not widely communicated to the public.1485 Laura Johnson {Day272/76:8-16}; {Day272/82:6}-{Day272/83:15}; Shawo {IWS00001290/3} page 3, paragraph 20. They resulted in some Walkway residents who qualified for emergency accommodation not being offered it.1486 {RBK00012043/5}: George Edwards was evacuated from a nearby building and was suitable for temporary accommodation but was turned away by the housing officer and told that "if it was determined that nearby evacuees were to be considered for housing he could return". At 16.21 on 14 June 2017, Ryan Bird, one of RBKC's housing officers, pointed out to the housing team that the instructions were that those who did not live in the tower were not to be accommodated.1487 {RBK00031298/2}. Mr Bird noted in a later email that there were "Many helpful but confused folk here. Lots of information but little of it entirely accurate".1488 {RBK00031298/1}.
¶104.56 By the night of 14 June 2017 and into 15 June 2017, 77 households had been placed in 102 hotel rooms and it was expected that more people would approach the council for accommodation.1489 {RBK00027735}; Laura Johnson {RBK00035592/12} page 12, paragraph 47. Ms Johnson told us that anyone who asked for a place was offered one immediately and without question.1490 Laura Johnson {RBK00035592/12} page 12, paragraph 47. However, she was of the view that it was not her department's responsibility to speak to everyone and make sure they had somewhere to stay; it was for those who needed accommodation to approach the housing team. She may or may not have been entitled to take that view, but the result was that some residents were sleeping rough simply because they were unaware that they could ask for emergency accommodation.1491 {TMO10036665} Column J, row 114, row 123 and row 390; {RBK00029413}, row 228. RBKC accepted that they did not receive the level of care to which they were entitled under the Housing Contingency Plan and acknowledged that a number of Grenfell Tower residents were not told about the availability of emergency accommodation.1492 Laura Johnson {Day272/94:6-13}; RBKC Opening Statement, {Day263/120:5-13}.
¶104.57 Part of the reason for the housing department's failure to accommodate all residents on the first day of the fire is that Ms Johnson and the emergency planning team failed to recognise the scale of the incident in the early hours and failed to grasp what it required of them.1493 Laura Johnson {Day272/43:12-23}.
¶104.58 Most of those accommodated by RBKC in hotels were residents of the tower.1494 RBKC Opening Statement, {Day263/120:9}. Residents of the Walkways continued to be a secondary priority,1495 Laura Johnson {Day272/74:22}-{Day272/75:16}; {RBK00031298}. despite their obvious need for alternative accommodation as a result of their homes lacking gas or water and containing debris from the fire.1496 Email from Judith Blakeman to Laura Johnson on 18 June 2017 {RBK00027966}, paragraphs 1 and 3; Email from TMO to RBKC regarding 11 households in need of accommodation as "there's debris from the fire on elevations" at 16.27 on 16 June 2017 {RBK00049529}; Email from Councillor Lasharie at 00.42 on 15 June 2017 {RBK00003049}; Email from Councillor Lasharie at 16.15 on 15 June 2017 {RBK00003071}. RBKC thought that residents of the Walkways should return to their flats, despite being told by the TMO that they were not yet suitable for reoccupation.
126¶Teresa Brown, the TMO's Director of Housing, recommended that residents should not be rushed into returning until the TMO could ensure proper provision of services.1497 Teresa Brown {TMO00869990/9} page 9, paragraph 45; TMO staff also notified RBKC's Allocation Team about the need to re-house those with balconies overlooking Grenfell Tower, to avoid further trauma. Teresa Brown {TMO00869990/11} page 11, paragraph 57.
¶Her advice was not accepted by RBKC, which stuck to its decision that those who lived in the Walkways should return to their flats. Ms Johnson told a Gold group meeting on
¶16 June 2017 that she would house the vulnerable or those with children and without hot water but that others would have to manage.1498 RBKC Gold Group Meeting Minutes at 10.00 on 16 June 2017 {RBK00001862/2}.
¶104.59 The lack of any existing plans or agreements with local hotels (for example, in relation to methods of payment) led to significant disruption and distress to those seeking accommodation. In some cases transport was a problem. Ms Johnson told us that on the first day her team had attempted to hire taxis to take people from the Westway Centre to their hotels, but she accepted that in some cases people had not been provided with transport and had been forced to make their own way to the hotels in which they had been placed.1499 Laura Johnson {Day272/120:19}-{Day272/121:24}; Abdulhamid {IWS00001919/3} page 3, paragraph 16; Alison Moses {IWS00001281/9} page 9, paragraph 47. This was a requirement identified in the RBKC Housing Contingency Plan at Annex 2 {RBK00035406/19}.
¶104.60 Residents placed in hotels often had to be moved to alternative accommodation, sometimes without much notice.1500 {RBK00002735/2}; Sadafi {IWS00001806/23} page 23, paragraph 73; Lukic {IWS00001760/6} page 6, paragraph 24. Despite informing the RBKC Gold group at 11.00 on 14 June 2017 that block bookings of hotels had been made until Monday 19 June 2017 as a short term solution,1501 {RBK00013271/2}. the group was told the following morning that officers were in the process of rebooking hotel rooms for all those that needed them.1502 Gold Group Meeting Minutes at 10.00 on 15 June 2017 {RBK00013270}. It was noted that four households had to be moved to another hotel on 15 June 2017 and, because some bookings could not be carried over the weekend (17 and 18 June 2017), RBKC needed to find alternative accommodation for 24 households.1503 'Grenfell Residents Action Plan 15 June 2017: Short Term' {RBK00027735}. The first time that some residents who had been accommodated in hotels learned they needed to check out was when the hotel told them.1504 Laura Johnson {Day272/68:2-8}; {Day272/69:25}-{Day272/70:4}; El-Guenuni {IWS00002034/9} page 9, paragraph 34; Sadafi {IWS00001806/23} page 23, paragraph 73. See Chapter 2.3.4 Length of Hotel Placements in Chapter 2.
¶104.61 In some cases delays in bookings were caused by the lack of sufficient credit on RBKC's credit cards.1505 Laura Johnson {RBK00035592/23} page 23, paragraph 84; Laura Johnson {Day272/56:5-11}. The problem persisted for a number of days following the fire, resulting in some employees using their own cards to secure rooms.1506 Laura Johnson {Day272/58:10-22}; Laura Johnson {RBK00035592/24} page 24, paragraph 87. The problem with credit limits had led to some payments being declined and to some hotels informing residents that their bookings would end.1507 Email from Chris Scott (RBKC Housing) at 08.19 on 21 June 2017 {RBK00012306}. As part of the tri-borough arrangements for providing humanitarian assistance RBKC had agreed that duty officers and some senior Housing and Adult Social Care managers should be given greater spending limits for use in emergencies, but it appears that it had either failed to implement that agreement or had set inadequate credit limits.1508 {RBK00036274/2}; The agreement had been reached in early 2016 in the wake of the Adair Tower fire the previous October.
127¶104.62 With no list of approved local hotels, RBKC was unable to ensure that the hotels booked provided for residents with particular needs, which were often not met.1509 Redmond {Day271/89:19}-{Day271/90:20}. That included, but was not limited to, people with disabilities1510 David Lewis {IWS00001629/5} page 5, paragraph 21-23; Rasoul {IWS00001768/22} page 22, paragraph 107; Oyewole {IWS00001730/10} page 10, paragraph 17-19; Alison Moses {IWS00001281/10} page 10, paragraph 54. and families with babies and young children.1511 Khoudair {IWS00001616/11-12} pages 11-12, paragraph 81-88; Jason Miller {IWS00001940/9} page 9, paragraph 37; Zakariya Chebiouni {IWS00001979/5} page 5, paragraph 24; Mensah {IWS00001944/9} page 9, paragraph 43; Ryan Ignacio {IWS00001820/14} page 14, paragraph 70. In many cases survivors found being housed on upper floors of hotels traumatic following their recent experiences.1512 RBKC email at 17.53 on 18 June 2017, "1 gentleman put on 14th floor of hotel – needs moving" {RBK00039300}; Email from Maureen Mandirahwe (WCC) to RBKC BECC at 21.08 on 17 June 2017, "Complaints of traumatised persons being housed in a second floor hotel/tower, when they had vocalised from the onset that they cannot cope with living in a tower. They were moved to other towers 3 times. He came to us very angry and traumatised." {RBK00005386/2}; Emma O'Connor {IWS00001699/6} page 6, paragraph 33.
¶104.63 Ms Johnson told us that RBKC had tried to meet the specific needs of those affected but conceded that they had not got it right in all cases.1513 Laura Johnson {Day272/118:25}-{Day272/119:15}; {Day272/132:5-20}. We have seen little to suggest that the allocation process involved much more than simply matching the numbers of people seeking accommodation to the rooms available. We consider that specific plans and standing agreements with hotel providers, coupled with periodic training exercises, would have equipped the housing department to respond better to the challenges it faced in finding accommodation for a large number of displaced residents.1514 Laura Johnson {Day272/22:14}-{Day272/23:1}.
¶104.64 After it had found them accommodation the housing department did not communicate adequately with its residents.1515 Laura Johnson {Day272/170:4-25}. They lacked clear guidance about when their bookings would end,1516 Sener Macit {IWS00001563/12} page 12, paragraph 52; Bernard Shaw {IWS00001752/8} page 8, paragraph 39; Karema El-Sawy {IWS00001829/7} page 7, paragraph 31. about the food and services that they were entitled to receive at their hotels1517 Shawo {IWS00001290/4} page 4, paragraph 25; David Lewis {IWS00001629/6} page 6, paragraph 25; Ahmed Al-Assad {IWS00001789/11} page 11, paragraph 67; Araya {IWS00001648/4} page 4, paragraph 20; Rasoul {Day265/159:13-23}. and about whom to contact for information and assistance.1518 Samuel Daniels {IWS00002065/15} page 15, paragraph 99. As a result, in many cases they did not receive the full extent of the support available to them and lived in a constant state of uncertainty. We have set out in detail in Chapter 100 the difficulties felt by some of those who had been displaced by the fire.
¶104.65 As a Category 1 responder RBKC should have been ready to meet the immediate personal needs of those affected by the emergency.1519 Emergency Response and Recovery non-statutory guidance, {CAB00004519/119} page 119, paragraph 7.3.2.; LRP. Humanitarian Assistance Plan v3, {GOL00001151/27} page 27, paragraph 7.12-7.14; RBKC Contingency Management Plan {RBK00004396/17}. They included food and drink of a suitable kind, access to places of worship and other personal, cultural or religious needs, but it does not appear to have given any consideration to matters of that kind and had no plan to provide for them. Those who attended the Westway Centre relied on the generosity of volunteers who brought them culturally appropriate food to meet their needs.1520 Belfassi {IWS00001802/7} page 7, paragraph 40. Moussaid {IWS00001282/14} page 14, paragraphs 68-69.
128¶104.66 The problems of obtaining access to the Westway Centre led to many of those affected seeking support through unofficial rest centres, such as the Clement James Centre and the Rugby Portobello Trust, which became the main source of food for many in the days immediately following the fire.1521 Richards {CFV00000012/2-6} pages 2-6, paragraphs 7, 11, 20, 22 and 41; Ahmed Chellat {IWS00001306/1} page 1, paragraph 6; Ghamhi {IWS00001706/4} page 4, paragraph 23; Simms {CFV00000005/17} page 17, paragraph 78; Hariri {IWS00001295/14} page 14, paragraph 106.
¶104.67 Difficulties in providing for basic needs, such as food and drink, continued in some cases even after people had been placed in hotels. In some cases they did not know what food or drink they were entitled to receive.1522 Richards {Day275/147:11-16}. With hotel rooms in short supply, RBKC took rooms in a number of hotels that provided only limited services, which in some cases did not include food or drink.1523 Laura Johnson {Day272/132:1-4}. That prompted those in the community, voluntary and faith sector to obtain, distribute and serve food to some of those at hotels.1524 Richards {CFV00000012/3} page 3, paragraph 14.
¶104.68 In some cases, hotels did not provide food suitable for those with particular religious needs, such as halal food, particularly during Ramadan. Although Ms Johnson was aware of the cultural and religious diversity of the residents of Kensington and Chelsea, she did not recall having made any specific request to hotels to accommodate religious dietary requirements.1525 Laura Johnson {Day272/132:5-15}. That was reflected in the evidence of Brahim El Amine, Mouna El-Ogbani and Sawson Choucair, all of whom were placed in hotels that did not serve food at times that respected their observation of Ramadan.1526 El Amine {IWS00001946/10-11} pages 10-11, paragraph 46; El-Ogbani {Day266/23:20}-{Day266/24:5}; Sawson Choucair {IWS00001799/15-16} pages 15-16, paragraph 20(c). As a result, they and others in their position had to rely on food being provided by the community.1527 Senate Jones {IWS00001691/5} page 5, paragraph 24. Similarly, Nadia Jafari, who was on a diet following surgery, had to rely on food she received from the mosque and charities.1528 Maria Jafari {IWS00001815/13} page 13, paragraph 56.
¶104.69 RBKC accepted that it should have done more in the days following the fire to cater for those from diverse backgrounds, in particular those many residents of the Muslim faith who were observing Ramadan at the time. Their experience contributed to the widespread feeling among them that the council had no regard for their cultural and religious needs.
¶104.70 We do not believe that those were isolated incidents limited to a few individuals and families. The evidence suggests that the experiences of those, particularly from Muslim and minority ethnic communities, whose basic needs were not met were symptomatic of a more general, systemic failure on the part of RBKC to think about and plan for those needs in advance.
¶104.71 The outcomes and experiences of those affected which bore on their faith and ethnicity lead us to conclude that RBKC failed to take any or any adequate steps to follow the guidance contained in those parts of Emergency Preparedness (2013) and Emergency Response and Recovery (2005) to which we referred in the introduction. In particular, we conclude that RBKC failed to give any, or any adequate, consideration to the needs of the members of the various faith, religious, cultural and minority ethnic communities who were affected by the fire. That lack of consideration was marked by the absence from RBKC's preparations of any plan for catering for their particular needs and a lack of any training to ensure that they were met. Nor did RBKC put in place any arrangements for addressing them in the days immediately following the fire. Such efforts as were made were piecemeal and unevenly distributed.
129¶104.72 The guidance to which we have referred seems to us to reflect in a large measure the legislative aim of section 149(1) of the Equality Act 2010 in the context of civil contingencies. Whether RBKC failed to have due regard to the matters identified in section 149(1) of the Act in making its civil contingency arrangements is a question we are not in a position to answer. What matters more is how people were treated in practice. It is enough to say that in our view many of those affected by the fire who had particular religious or cultural or social needs suffered a significant degree of discrimination in ways that could and would have been prevented if the guidance had been properly followed.
Financial assistance
¶104.73 The Humanitarian Assistance framework indicated that local authorities might provide financial assistance for food, clothing, toiletries and other essential requirements as part of their responsibility for providing humanitarian assistance.1529 London Resilience Partnership Humanitarian Assistance Framework, {RBK00011313/42}. "Local Authorities: May provide financial assistance". On 14 June 2017, arrangements were made by RBKC to provide those affected by the fire with such assistance. At the start, the housing team attended the rest centres with sufficient cash to give people a small sum of money, about £50 a person.1530 Laura Johnson {Day272/143:16-19}. At 12.33, Francis Austin, RBKC's interim group finance manager, provided Kevin Bartle, then director of finance, with a note saying that £10,000 had been drawn in cash to be used to pay for immediate expenses.1531 {RBK00012261}. That included everything from toothbrushes to hotel accommodation. That evening, Robert Shaw, a RBKC housing officer, sent a message to his colleagues telling them that three rest centres were to remain open throughout the night and that TMO staff would be present with enough money to hand out to residents.1532 {RBK00006091}; {TMO10031177/3}.
¶104.74 How those affected should be supported financially had not been planned in advance, which caused delay in implementing a process for the distribution of funds. On 15 June 2017 RBKC agreed that households should be given cash to cover immediate living expenses and a further allocation of up to £1,000 a household, leaving over for later consideration what procedure should be adopted for managing it.1533 {RBK00027735}. A further £36,000 was made available for residents, together with a draft form intended to be completed for each payment.1534 {RBK00020131}. That was the first time any formal plan for the distribution of cash had been put in place. It appears that following a further meeting on 16 June 2017, the arrangements were changed. Instead of payments of up to £1,000 being made available, £500 in cash was to be distributed to each household and the remaining £500 held available.1535 Amanda Gill {RBK00044877/8} page 8, paragraph 46; {RBK00047576}; Laura Johnson {Day272/143:14}– {Day272/145:5}. That was considered the easiest way to provide emergency funds for people who did not have a bank account or did not have any of their cards or other documents of the kind needed to obtain access to funds in the bank.1536 Laura Johnson {Day272/143:22}-{Day272/144:1}
130¶104.75 Following the activation of the Gold resolution, RBKC remained responsible for the provision of financial assistance.1537 {CAB00014720}. Despite efforts to establish a procedure for providing households with access to funds,1538 {RBK00020131}. the facility does not appear to have been fully used. On 17 June 2017, Ms Hardy told us that she was given money in an envelope and a list of names, possibly those who had been given money, written on the back of the envelope.1539 Hardy {Day276/87:4}-{Day276/88:15}. She was given no other information or explanation of how to organise the distribution. Perhaps because of changes in the amount of payments being made or the lack of rigour in the process, different amounts varying from £200 to £1,000 were distributed to the residents of the tower.1540 {RBK00026735}. According to Michael Adamson of the Red Cross, cash was distributed in a haphazard way by a number of different officials, which made it impossible to track who had received what.1541 Adamson {BRC00000075/15} page 15, paragraph 68.
¶104.76 Financial assistance was initially provided only to those displaced from the tower and not to those displaced from the Walkways.1542 Augustine {RBK00035411/6} page 6, paragraph 29. Some members of RBKC's staff resorted to their own personal funds to provide financial support to those in need.1543 Augustine {RBK00035411/6} page 6, paragraph 30.
¶104.77 The housing department did not take steps to inform those affected by the fire that they were entitled to financial assistance,1544 Laura Johnson {Day272/149:2-9}. which resulted in delays in their receiving the assistance to which they were entitled and in some cases to their not receiving it at all.1545 Laura Johnson {Day272/150:2-12}; Hanan Cherbika {IWS00001286/11} page 11, paragraph 85; Jevon Moses {IWS00001276/16} page 16, paragraph 113; Toyoshima-Lewis {IWS00001725/66} page 66, paragraph 265. It was reported that people were either unaware of the opportunity to obtain financial assistance at the Westway Centre or were reluctant to go there.1546 {RBK00004144}.
¶104.78 Financial support provided to families staying in hotels was inconsistent; some families were left to support themselves. The problem was compounded by residents being placed in hotels at some distance from the Town Hall and the Westway Centre. On 18 June 2017, the London Borough of Ealing, which at the time was managing the Westway Centre, did not have the resources to visit displaced residents to distribute funds.1547 {RBK00004144}. A stark illustration of how certain families lacked support was provided to Gerry Crowley, property and place manager of the London Borough of Hammersmith and Fulham, who visited three hotels on 19 June 2017. He reported inconsistent levels of service being provided by the hotels and found that RBKC had not been in contact with residents at the Premier Inn, Hammersmith since placing them there almost six days earlier. The families had each been given only £50 to help with immediate expenses.1548 {RBK00021897/3}. Many people said they had encountered significant difficulty in obtaining financial support and as a result had been forced to rely on the generosity of charities and voluntary groups.1549 Talabi {IWS00001731/7} page 7, paragraph 22; Rosita Bonifacio {IWS00001887/7} page 7, paragraph 47; Aziza Raihani {IWS00001300/4} page 4, paragraph 25.
131Information about those who were missing
¶104.79 One of the recurring themes of the evidence given by those who had been displaced was that of the profound feeling of helplessness and despair they experienced as they desperately went from hospital to hospital, rest centre to rest centre, trying to obtain information about missing relatives, but to no avail.1550 Abu Baker Mohamed Ibrahim {IWS00001751/5} page 5, paragraphs 17 and 21. We have therefore tried to find out what led to that lack of information.
Family and friends reception centre
¶104.80 The guidance in Emergency Recovery and Response provides that steps should be put in place to ensure that information provided to those making enquiries is accurate, consistent and not contradictory.1551 Emergency Response and Recovery, non-statutory guidance accompanying the Civil Contingencies Act 2004 {CAB00004519/122} page 122, paragraph 7.4.2. The Humanitarian Assistance framework described the purpose of family and friends reception centres as being to help reunite family and friends with survivors, to provide a place for the police to record enquiries about missing persons and collect information which may aid their investigation and to provide access to practical and emotional support.1552 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/24-25} pages 24-25, paragraph 8.17. It is the responsibility of the police in consultation with local authorities to decide whether there is a need to set up a family and friends reception centre as part of a wider process of identifying victims of a disaster. Such centres are likely to be set up within the first 24 hours of the incident1553 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/25}, page 25, paragraphs 8.20-8.21. and are usually staffed by police, local authorities and voluntary organisations.1554 Emergency Response and Recovery, non-statutory guidance accompanying the Civil Contingencies Act 2004 {CAB00004519/122-123} pages 122-123, paragraph 7.4.4.
¶104.81 On 14 June 2017, RBKC told the police that a family and friends reception centre would be set up at the Salvation Army building at 12.30. Mr Adrian Clee, who had been appointed the Salvation Army's strategic lead for the Grenfell Tower emergency response that morning,1555 Clee {CFV00000059/1} page 1, paragraph 1. confirmed that it had opened its building on Portobello Road as a family and friends reception centre to provide a safe haven for those directly affected by the fire and relatives of those who were awaiting news.1556 Clee {CFV00000059/3-4} pages 3-4, paragraph 2. A member of staff from RBKC was sent to the centre and several police liaison officers attended to speak to witnesses and take statements.1557 Clee {CFV00000059/4} page 4, paragraph 2. The police reported that at 22.05 on 14 June 2017 the centre had been closed down because no staff from RBKC were available to manage it.1558 Stokoe {MET00079356/30} page 30, paragraph 4; Clee {CFV00000059/4} page 4, paragraph 2 believed it was closed on 15 June 2017. Its functions were transferred to the Westway Centre on 15 June 2017.
¶104.82 Unfortunately, those who were running the Westway Centre were not told that the friends and family reception centre had been moved there and as a result some people looking for information about friends or relations were wrongly turned away1559 Spragg {Day280/54:5-12}. and sent to the wrong place.1560 Spragg {Day280/55:16-22}. How that happened we do not know. On 16 June 2017 at 18.19, Emma Spragg sent an email to senior figures in RBKC voicing her concern about the way in which the Westway Centre was being described to ensure that friends and family could also have access to support.1561 Email from Emma Spragg at 18.19 {RBK00038595/1}: "Friends and family are not always being allowed in as people at Westway believe it to be a rest centre for displaced residents (CAC) and that F and F are to go to the Salvation Army." She pointed out that they were not always being allowed into the Westway Centre as some people understood it to be a rest centre for displaced residents only and that family and friends were to go to the Salvation Army. She wanted communications to be better co-ordinated.1562 {RBK00038595}.
132¶104.83 Many of those seeking information about family and friends did not know where the reception centre was or where they should go to obtain information.1563 Nabil Choucair {Day267/10:3-8}; Alison Moses {IWS00001281/11} page 11, paragraph 65; Gashaw {IWS00001738/24} page 24, paragraph 24.
The casualty bureau
¶104.84 The Metropolitan Police Service was responsible for setting up a casualty bureau,1564 Granville {MET00077845/1-2} pages 1-2, paragraph 4. the primary purpose of which was to provide an initial point of contact for receiving and assessing information relating to persons who had been, or were thought to have been, involved in the incident.1565 Emergency Response and Recovery: non-statutory guidance {CAB00004519/124} page 124, paragraph 7.5.6. The guidance in Emergency Response and Recovery provided that part of its function was to provide accurate information to relatives and friends.1566 Emergency Response and Recovery: non-statutory guidance {CAB00004519/124} page 124, paragraph 7.5.7. It is clear, however, that there was widespread confusion about the function of a casualty bureau and about whether, and if so how, it was expected to provide information to the public.
¶104.85 Detective Inspector Gail Granville told us that the purpose of a casualty bureau is to gather information, not to provide detailed information about those believed to be missing or dead.1567 Granville {MET00077845/8-9} pages 8-9, paragraph 29. She said that information of that kind is provided only after the identification process involving the coroner has been completed and must be conveyed in a sensitive and appropriate manner by a trained family liaison officer.1568 Granville {MET00077845/8} page 8, paragraph 29. D I Granville explained that limited information is given to call-handlers to prevent them from inadvertently providing information to callers.1569 Granville {MET00077845/9} page 9, paragraph 30. It was unfortunate, therefore, that the telephone number of the casualty bureau was given to those seeking information about family and friends. The result was that they were unable to obtain any help from the casualty bureau without understanding why, which caused considerable frustration and anger.
¶104.86 The police Gold Commander, Commander Jerome, asked for a casualty bureau to be established at 02.30 on 14 June 2017.1570 Chalmers {MET00077804/3} page 3, paragraph 11. At 07.34 on 14 June 2017 RBKC advertised its number as an emergency contact number for anyone concerned about their loved ones.1571 {RBK00060585}. The telephone number was provided by the police in a statement to the media at 08.02. It was also publicised on social media and the Metropolitan Police website.1572 Chalmers {MET00077804/11} page 11, paragraph 51. The delay in setting up the casualty bureau resulted from the need to ensure that there were enough operators available who were appropriately trained to take the calls.1573 Chalmers {MET00077804/6} page 6, paragraph 31. The first calls were answered at 08.04; 4,446 calls were received on 14 June 2017.1574 Chalmers {MET00077804/8-9} pages 8-9, paragraph 40. The number fell as the days passed and the lines were closed on 24 June 2017.1575 Chalmers {MET00077804/9-10} pages 9-10, paragraph 43.
133¶104.87 Some of those who called the casualty bureau reported that they had been unable to speak to anyone directly and received only an automated message.1576 Rajaa Chellat {IWS00001284/2} page 2, paragraph 11. Those who were able to speak to someone were not provided with information; after giving details of their family members, they waited for further news but did not receive a call back.1577 Nabil Choucair {Day267/14:11-25}.
¶104.88 The problems surrounding the family and friends reception centre and the limitations of the casualty bureau were compounded by the circulation of inaccurate information about those who were safe and those who were missing. The lists of those who were safe and missing provided to various agencies on 14 June 2017 had included errors, with some who had died in the fire shown as safe.1578 Spreadsheet: the resident list circulated at 12.21 on 14 June 2017 {TMO00869931}. The difficulties of obtaining accurate information about the fate of friends and relations demonstrates the fundamental importance of accurate registration and record-keeping at rest centres, coupled with clear and accessible sources of information for those enquiring in person or by telephone.
RBKC's public communications
¶104.89 As a Category 1 responder RBKC had a duty under the Civil Contingencies Act 2004 to communicate with the public and provide them with information and advice as necessary in an emergency.1579 Section 2(1)(g) of the Civil Contingencies Act 2004 {CAB00004616/3}; Emergency Preparedness Guidance, Chapter 7 {CAB00004543/3} page 3, paragraph 7.1. RBKC's media and communications team was small and its main functions were similar to those of a press office, responding to media enquiries and issuing press releases.1580 RBKC Opening Statement {Day263/115:12-15}. At the time of the Grenfell Tower fire the Contingency Management Plan did not include any provision for emergency communications,1581 Kerry {Day268/43:7-21}. although a plan may have been available within the communications team.1582 Fitzgerald {RBK00059598/2} page 2, paragraph 8. RBKC conceded that those who worked in the media and communications team had failed adequately to rehearse the emergency communication plan with practical exercises and were insufficiently familiar with the plans that existed.1583 RBKC Module 4 Opening Statement {RBK00068467/25-26} paragraphs 99-100. RBKC also conceded that the arrangements that were in place were not capable of providing the level of service needed by the public after the fire and were not as clear or as well understood within the organisation as they should have been.1584 RBKC Opening Statement {Day263/115:4-6}.
¶104.90 Martin Fitzgerald, RBKC's head of media and communications, described the pressure as great, with unprecedented demands from various directions.1585 Fitzpatrick {RBK00059598/3} page 3, paragraph 16. Email from Mark Sawyer to himself on 1 July 2017 {GOL00001301} paragraph 6, "Comms team in denial and overwhelmed. Asked why missed 08.30 comms call - missed amongst two hundred emails". We can well understand that, but, for whatever reason, there was a delay in providing clear, accessible information to the survivors, including information about where to go for help,1586 Spragg {Day280/68:2-10}; Spragg {BRC00000050/18} page 18, paragraph 78(a). which made it more difficult for them to obtain the emotional and practical support they needed.1587 Spragg {Day280/68:12-17}; Spragg {BRC00000050/18} page 18, paragraph 78(a). The stark truth is that RBKC's communications systems were quickly overwhelmed. As a result, it failed to provide the public with clear, consistent information in the days immediately following the fire.1588 RBKC Opening Statement {Day263/115:17-24}.
134¶104.91 No dedicated helpline was set up at the outset to enable displaced residents to obtain information or advice.1589 Emergency Preparedness, Chapter 7, paragraph 7.58 provides that "immediately when an emergency occurs, and during the first hours, the public would want amongst other things a helpline number" {CAB00004543/28} page 28, paragraph 7.58. It also says that "responders should plan how to make best use of helplines and public inquiry points... in any emergency. ...Helplines may already be in place for other purposes. Plans can be developed to take them over and provide their staff with a relevant briefing or suitable recorded messages" ({CAB00004543/42} page 42, paragraph 7.90-7.91). At 07.24 on 14 June 2017 RBKC published the telephone number of the casualty bureau as an emergency number to be used by anyone concerned about friends or relatives.1590 {RBK00060585}. At 10.13 RBKC's housing department put its telephone number on the council's website for use by residents who had been displaced.1591 {RBK00060669}. By the early afternoon it had published the same number as the point of contact for those wishing to volunteer to help the support effort.1592 {RBK00060676}. As a result, the line was inundated with calls and quickly became overwhelmed.1593 Spragg {Day280/72:5-13}.
¶104.92 RBKC did not accept offers of assistance that could have strengthened and expanded its communications resources. At the meeting of the strategic co-ordinating group at 08.30 on 14 June 2017, Ms Spragg recommended making use of the Red Cross telephone helpline that was already in place following the Manchester Arena attack as a helpline for those affected.1594 Spragg {Day280/69:8-20}; SCG Meeting on 14 June 2017 at 08.30 {LFB00003366/4}. Her offer was not immediately accepted. She repeated her suggestion at the meeting of the humanitarian assistance steering group at 14.00 on 15 June 2017.1595 Spragg {Day280/69:21-25}; HASG Meeting Minutes from 15 June 2017 at 14.00 {RBK00001920/4}.
¶104.93 Later on 15 June 2017, RBKC accepted the offer of the Red Cross helpline but the line did not become operational until the next day, 16 June 2017.1596 Spragg {Day280/70:10}-{Day280/71:15}; British Red Cross Operational update 9 {BRC00000087/25}. Sue Redmond, the interim executive director for adult social care and public health who was appointed as humanitarian assistance lead officer (HALO) on 15 June 2017, told us that the delay was caused by an attempt to link the RBKC housing line with the Red Cross line.1597 Email from Sue Redmond on 15 June 2017 {RBK00011415}; Humanitarian Assistance Steering Group Actions and Decisions sheet, 16 June 2017 at 12.00 {RBK00002040/1}; Redmond {Day271/109:10-11}. It had not been possible to co-ordinate the two helplines by the time London Gold took over the response on 16 June 2017.1598 Redmond {Day271/111:15-25}; {Day271/112:9-16}; Spragg {Day280/70:10}-{Day280/71:15}.
¶104.94 The delay in setting up a dedicated helpline was compounded by difficulties in publicising its number. Despite efforts by the Red Cross,1599 Gemma Hamilton {BRC00000012/5} page 5, paragraph 20. Leaflets advertising the number were delivered to the Westway Centre. as late as the evening of 17 June 2017 it was apparent from complaints made by those at the Westway Centre1600 Email from Tony Andrews to Andrew Meek and RBKC BECC sent on 17 June 2017 at 17.44 {GOL00000982}. that the helpline number needed to be published immediately.1601 Email from Tony Andrews on 17 June 2017 at 17.28, circulating key points and actions from the Community Assistance Centre Group meeting {RBK00021073}. In addition, concerns were expressed about the quality of the information being provided to those using the helpline. On 20 June 2017 checks by RBKC revealed that the helpline staff, although warm and friendly, were vague in their responses and merely advised callers to go to the Westway Centre.1602 {RBK00041515/3}.
135¶Further checks on 22 June 2017 indicated that the problems persisted. The call-handlers were directing callers to the Westway Centre or advising them to contact Victim Support but were not able to say what help either of them could offer,1603 {RBK00041515/1}. despite the fact that they had been given a guidance pack the previous day containing full details of how to deal with questions.1604 {RBK00023810/1}.
Language barriers
¶104.95 Inadequate provision was made for those whose first language was not English. The guidance in Emergency Response and Recovery was that, if it could reasonably be expected that an emergency would be likely to involve members of cultural or ethnic minorities, suitable arrangements should be built into plans.1605 {CAB00004519/130} page 130, paragraph 7.7.6. The Lancaster West estate was such a community, but despite that clear guidance, it was not until 24 June 2017, some seven days after London Gold had taken over the response, that the helplines made provision for those who did not speak English fluently or for whom English was not their first language.1606 Spragg {Day280/74:2}-{Day280/75:19}. It was difficult for the operators of the helpline to know in advance which languages needed to be spoken, as no proper assessment of the likely requirements had been made, but the result was that some of those who did not speak English were unable to use the helpline for a number of days.1607 Spragg {Day280/75:20}-{Day280/76:8}.
¶104.96 The lack of translation services was not limited to the helpline. Official communications, such as letters from the council, were available only in English.1608 Zakaria El-Sawy {IWS00001822/10} page 10, paragraph 42; Khanh Quang {IWS00001821/15} page 15, paragraph 75-76. As a result, those who did not speak or read English found it difficult to obtain information and assistance. Others relied on their children and friends to translate for them.1609 Belfassi {IWS00001815/16} page 16, paragraph 71.
Leaflets
¶104.97 RBKC failed to produce other forms of communication, such as flyers or information leaflets, with sufficient urgency, despite recognising the need to do so. At 05.01 on 15 June 2017, Councillor Mary Weale told Tony Redpath that she had raised the matter with Mr Holgate the previous day.1610 {RBK00004117/1}. A leaflet was then produced by some of the councillors, which was shared with Mr Holgate and Mr Redpath at 18.46 on 15 June 2017 for distribution.1611 {RBK00038615}. However, it took until the evening of 16 June 2017 for a final version of the leaflet to be produced1612 {RBK00020873/1}. and it was not distributed until 17 June 2017.1613 {RBK00003124/2}. The leaflets were produced in English and were not translated into other languages until 24 June 2017.1614 Spragg {Day280/75:3-8}; {BRC00000087/39}. Mr Redpath recognised at the time that it was extraordinary for the council to have taken so long to carry out such a simple task.1615 {RBK00003124/2}. He said that it had been faced with an avalanche of demands and had been unable to attend to anything other than the most immediate and pressing tasks.1616 {RBK00003124/2}.
136¶104.98 In our view insufficient consideration was given to those important matters. The guidance quite properly emphasised the need for rapid and effective communication but RBKC failed to give it the priority it deserved. As the Grenfell Tower fire revealed, it had failed to grasp that accurate and timely information from an authoritative source is one of the most valuable forms of support that can be given to those seeking help, in whatever form.
Social media
¶104.99 Although RBKC used social media and maintained a website, information was not published promptly or consistently across the different media platforms and some of those dealing with the response were concerned that not enough information was being given out.1617 Email sent at 10.13 for a website update with details of the rest centre at Rugby Portobello Trust {RBK00060669}; Twitter update at 11.39 with details of rest centre at Rugby Portobello Trust {RBK00060621}; Twitter update at 11.40 with details of rest centre at St Clement Church {RBK00060622}; Twitter update at 11.41 with details of rest centre at the Westway Centre {RBK00060623}; {RBK00060669}. At 16.15 on 14 June 2017, Desmond Zephyr, a LALO, told Mr Priestley, Ms Blackburn and Mr Kerry that information was not being released and that although he had directed people to the website, it was inadequate. He suggested greater use of social media.1618 {RBK00008513}; Also see email from Ann Ramage to Martin Fitzpatrick on 17 June 2017 at 02.29 {RBK00010918/2} That view was echoed by the Mayor of London's office.1619 {GOL00000147}.
¶104.100 The problems affecting communication with the public do not appear to have been resolved by the activation of London Gold. On 18 June 2017, the new Grenfell Fire response team issued a press statement giving details of the Red Cross helpline.1620 {RBK00012573}. A leaflet was also produced and circulated that day for distribution through DCLG which contained information about the Red Cross helpline, the contact number of the casualty bureau, details of bereavement services and NHS mental health support.1621 {CLG00009134}. As late as 20 June 2017 there was still concern about the absence of a central point of contact and the lack of effective communication with those affected.1622 Email from Hilary Patel (the DCLG) to Doug Patterson (London Borough of Bromley) on 20 June 2017 {GOL00000289/1}. RBKC's media and communications team was required to obtain London Gold's approval before it published anything on the council's website or communicated with the media, which caused significant delay in the publication of information.1623 Brady {RBK00059591/2} page 2, paragraph 10. One member of the team, Bernard Brady, said that a response would often not be received from London Gold for hours or even until the following day (and sometimes not at all).1624 Brady {RBK00059591/2} page 2, paragraph 10.
137The humanitarian assistance steering group
¶104.101 A key feature of the Humanitarian Assistance framework is the appointment of a humanitarian assistance lead officer (HALO) to co-ordinate the humanitarian response.1625 London Resilience Partnership Humanitarian Assistance Framework, {RBK00011313/4} paragraph 1.1 and {RBK00019712/9}, paragraph 3.7: Local authorities will prepare to respond to the humanitarian need by: Identifying a senior officer to lead the Humanitarian Response (usually a director with responsibility for adult social care) – hereafter described as the Humanitarian Assistance Lead Officer (HALO). The HALO brings together various partners, including health, the police, and voluntary and faith sectors, to oversee that aspect of the response. At the time of the fire RBKC had no one suitably trained to undertake that task and no relevant plan in place.1626 Kerry {Day268/164:18}-{Day268/168:4}; London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/2}. The lack of a trained HALO significantly affected its ability to deal with the consequences of the fire.1627 Kerry {Day268/168:18-23}.
¶104.102 Sue Redmond was an experienced director of adult social care who had worked at a senior level for a number of local authorities. She had returned to Hammersmith and Fulham in April 2017 and held a tri-borough role which also covered Westminster City Council and RBKC. She had not received any training or guidance from Hammersmith and Fulham or RBKC on the Contingency Management Plan.1628 Redmond {RBK00058120/2} page 2, paragraphs 2.1-2.2. In her previous positions she had received some training in responding to emergencies, but she did not think that it had prepared her adequately for the Grenfell Tower fire.1629 Redmond {RBK00035676/3} page 3, paragraph 13; Project Athena interview, {RBK00029014/2}, unnumbered ninth paragraph. Her training had not given her any grounding in the function of the BECC, the role of a HALO,1630 Redmond {Day271/24:2}-{Day271/25:5}; {Day271/31:9-16}; Redmond {RBK00035676/8} page 8, paragraph 36. or what running the humanitarian assistance steering group entailed.1631 Redmond {RBK00058120/3} page 3, paragraph 3.3; Redmond {Day271/29:3-5}. She was wholly unprepared for the role she was thrust into.
¶104.103 The Humanitarian Assistance framework provided that if a major incident occurred with substantial consequences for the welfare of a community, the local authority would appoint a HALO,1632 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/9} page 9, paragraph 3.9. whose identity would be confirmed by the strategic co-ordinating group.1633 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/9} page 9, paragraph 3.10. The HALO was to call and chair the first meeting of the humanitarian assistance steering group,1634 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/9} page 9, paragraphs 3.1, 3.7 and 3.11. whose purpose was to determine the direction of the humanitarian response and ensure co-ordination of the activities of the responders. Its officers were to be senior officials who were able to make decisions about resources while having an overview of the needs of the people affected and ensuring there was appropriate support.1635 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/12} page 12, paragraph 4.14. {RBK00019712/48}.
¶104.104 Although the framework did not say when the group was to meet for the first time, it did indicate that the humanitarian assistance effort should begin very soon after the incident.1636 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/11} paragraph 4.2. That was recognised by members of the London Resilience Group early on 14 June 2017. As a result, Andrew Meek, head of organisational resilience at the London Borough of Haringey, sent an email to David Kerry at 10.23 recommending that he appoint a HALO and plan a first meeting of the humanitarian assistance support group that afternoon.1637 {GOL00001052}. However, Mr Kerry had finished his shift that morning and had gone off duty and the message does not appear to have been passed to Stuart Priestley, then
138¶Council Silver, or the BECC.1638 Andrew Meek {GOL00001166/2} page 2, paragraph 6 at 10.23; Kerry {Day269/120:5}-{Day269/121:16}.
¶104.105 That was only one of a number of reasons for the delay in setting up the group. The Humanitarian Assistance framework was in the process of being revised at the time and although a draft of the new version existed, it had not been published.1639 Meek {GOL00001166/5} page 5, paragraph 6 and {GOL00001166/9} page 9, paragraph 12; {GOL00001166/5} page 5, paragraph 6, entry 'evening': Andrew Meek drafted a revised Humanitarian Assistance Centre (HAC) Plan during the evening of 17 June 2017 as the Humanitarian Assistance Framework did not contain an HAC plan {RBK00021646}. Tony Andrews, Emergency Planning Manager (Humanitarian Assistance) at Westminster City Council, sent a copy of the revised version to RBKC at 13.16.1640 {RBK00011312}. Ms Redmond then had to spend time familiarising herself with the material in the expectation that she might become the HALO.1641 Redmond {RBK00058120/5} page 5, paragraphs 7.2-7.3. Formal confirmation of her appointment was not made until the morning of 15 June 2017 at the RBKC Gold meeting.1642 Redmond {RBK00058120/2-3} pages 2-3, paragraphs 3.1-3.4. It is unclear why that was. At all events, the first meeting of the group chaired by Ms Redmond was not held until 14.00 on 15 June 2017.1643 Redmond {Day271/70:22}-{Day271/71:9}; Gold Group Meeting Minutes at 10.00 on 15 June 2017 {RBK00013270/3}; Humanitarian Assistance Steering Group Minutes {RBK00001920}. We consider that, in light of the seriousness of the incident and the advice received on the morning of 14 June 2017, a meeting should have taken place that afternoon.1644 Redmond {Day271/52:23}-{Day271/53:4}. The delay of 24 hours had an adverse effect on the identification and assessment of the needs of those affected.
¶104.106 By the afternoon of 15 June 2017, the humanitarian assistance support group had developed an agenda which Ms Redmond considered to be massive and overwhelming.1645 Redmond {Day271/73:19-25}; {Day271/76:7-8}. The operation of the group was subsequently criticised by some of those who attended the meeting. In an email to a colleague Toby Gould described it as disorganised. Some representatives were not present and the telephone conference facilities did not work well. He was not convinced that the group was giving enough attention to urgent business.1646 {LFB00061320/1} page 1, paragraph 4. Although national voluntary organisations, such as Victim Support and the Red Cross, had been represented, he thought there was a lack of understanding at RBKC about other relevant local voluntary organisations.1647 {RBK00019929/3}. Many community organisations involved in the response to the fire were frustrated by the lack of information being shared by London Gold and its failure to gather information from organisations on the ground.1648 Richards {Day275/166:2-6}.
Psychological support
¶104.107 Due to the delays in setting up the humanitarian assistance support group, it was unclear to those affected by the disaster what psychological support was available at the official rest centre. That in turn led to differences in the level of support received. Some survivors discovered that counselling was available from the NHS at the Westway Centre,1649 Dedrich {IWS00001275/7} page 7, paragraph 49; Sener Macit {IWS00001563/14} page 14, paragraph 65; Gashaw {IWS00001738/18} page 18, paragraph 20; Wesley Ignacio {IWS00001820/16} page 16, paragraph 85; but some people did not think that there was sufficient privacy to enable them to take advantage of it.1650 Laci {IWS00001831/6} page 6, paragraph 40. Maureen Mandirahwe, a member of the tri-borough social care team, drew attention to the inadequacy of the mental health support at the Westway Centre and the lack of privacy for those grieving.1651 {RBK00011468}; Log of issues, {RBK00014781}.
139¶104.108 Psychological support was provided by the NHS West London Clinical Commissioning Group. The NHS is a Category 1 (and for some purposes a Category 2) responder with an established response plan.1652 Proctor {NHS00000002/4} page 4, paragraph 13. Although its staff were in the rest centres on 14 and 15 June 2017,1653 Minutes of the Health Response Group teleconference on 15 June 2017 at 17.00 {RBK00026985/2} page 2, paragraph 2.1. by 16 June 2017 they were advising those in need to call a 24-hour telephone number to obtain mental health support services and information instead of offering to meet them.1654 {RBK00038406}. On 18 June 2017 the Prime Minister had asked for additional NHS staff to attend the next day.1655 {RBK00011424}. Those concerns were not isolated. Later that day it became clear that doctors did not know where to refer people needing care, who was in charge or whom to contact in connection with a need for acute care. There was a sense that no one was in charge.1656 {RBK00011798}.
¶104.109 Survivors described how they struggled with their mental health after the fire, desperately needing help but not knowing where to get it at a time when they were at their most vulnerable.1657 Bobby Ross {IWS00002356/8} page 8, paragraphs 42 and 45; Diejomaoh {IWS00001303/5-6} pages 5-6, paragraphs 27-28; Hanan Cherbika {Day266/106:1-22}. Most of those who had been affected indicated that psychological support had not been offered to them within the seven days following the fire.1658 Towner {IWS00001705/8} page 8, paragraph 42; Shawo {IWS00001290/4} page 4, paragraph 29.
¶104.110 Some of those in need of mental health support received prompt assistance from the Red Cross,1659 Deen {IWS00002301/5} page 5, paragraph 35. which provided psychosocial support at the Westway Centre.1660 Spragg {Day280/47:8-23}; Spragg {BRC00000050/16} page 16, paragraph 71. The Red Cross also worked with the NHS teams to increase their capacity to reach people in hotels and other places, although there was some delay in finding out where they were.1661 Spragg {Day280/48:1-12}. There were variations in how that support was delivered. The most common form of mental health support required was counselling. It was provided by "Time to Talk" at the St Charles Centre1662 Pahlavani {IWS00001244/15} page 15, paragraph 46. and later by the Grenfell Health and Wellbeing service.1663 Rullo {IWS00001655/10} page 10, paragraph 43. A few people mentioned other sources of help, but they had often become available some time after the fire. Others asked their doctors to refer them for psychological support,1664 Alfawaz {IWS00001274/11} page 11, paragraph 85. or received counselling by other routes, such as through their employers.1665 Christopher Roncolato {IWS00001786/13} page 13, paragraph 78; Hamza Jones {IWS00001710/5} page 5, paragraph 30. Yet others paid privately for their own counselling.1666 Norbert {IWS00001252/10} page 10, paragraph 55. Some survivors reported a delay in receiving psychological support, in some cases for as much as six months.1667 Alison Moses {IWS00001281/11} page 11, paragraph 64; Farhad Neda {IWS00001302/4} page 4, paragraph 20; Wahabi {IWS00001714/15} page 15, paragraph 68.
140Identification of specific needs
¶104.111 When London Gold assumed control on 16 June 2017, there was insufficient understanding of the needs of those affected and the humanitarian response was disorganised. Mary Harpley, chief executive of the London Borough of Hounslow, took over as HALO from 16 June.1668 Harpley {GOL00000441/1} page 1, paragraph 4. She described RBKC as exhausted and not in a position to provide any meaningful handover.1669 Harpley {GOL00000441/4} page 4, paragraph 13. As a result, London Gold had to spend time assessing the situation, obtaining contact information for families and finding out who the community leaders were.1670 See Chapter 102. Adamson {BRC00000075/17} page 17, paragraph 77. Ms Harpley identified a number of things that were needed, such as a single, definitive list of the hotels into which people had been placed, regular communication with survivors, a clear understanding of residents with the greatest needs and a list of the community, faith and other leaders with whom RBKC should have engaged.1671 Harpley {GOL00001114/2} page 2, paragraph 3. She thought that RBKC had tried to cover all the important strands of humanitarian assistance, but had not managed to demonstrate enough progress on any of them to give survivors and observers confidence that the right work was being done.1672 Harpley {GOL00001114/2} page 2, paragraph 3. Based on the other evidence we have seen, we agree with her assessment.
Key workers
¶104.112 The use of key workers played an increasingly important part in enabling people to obtain the support that was available. On the afternoon of 16 June 2017, as concern about the provision of humanitarian assistance mounted, the Prime Minister declared that everyone affected by the fire, including those from the area surrounding the tower, should be allocated a key worker and that all the key workers should be social workers. That meant finding over 200 social workers from the London boroughs and defining their responsibilities.1673 Redmond {RBK00035676/13} page 13, paragraph 64. The role of a key worker was to provide practical support,1674 Chamberlain {RBK00035302/14-15} pages 14-15, paragraph 57. not to provide psychological support, and differed from that of family liaison officers, who were police officers trained to support the next of kin of those who had died or were missing.1675 Humanitarian Assistance Guidance Pack {BRC00000008/2}. In the days following the announcement, social workers from other boroughs who were being deployed as key workers arrived at the rest centre without notice and without any idea of what was expected of them,1676 {RBK00012323}. reflecting an initial lack of co-ordination and a failure to explain what they were expected to do.
¶104.113 Meeting the commitment to provide all those affected with a key worker proved difficult in the short term. On 19 June 2017, Mr Gould told the BECC that 43 social workers from 11 boroughs were available.1677 {RBK00009467}. By 21 June 2017, some people were still waiting to be given a key worker. However, even when a key worker had been provided, there was no guarantee that residents would be visited. By 21 June 2017, only two-thirds of the 106 residents who had been given key workers had been contacted. The number of residents actually visited was still unknown.1678 {RBK00022845}.
141¶104.114 That remained a problem one month after the fire. On 13 July 2017 it was reported that all residents of the tower and Grenfell Walk had key workers, but a number of families from the Walkways housed in temporary accommodation had not been allocated a key worker because there were not enough available.1679 {RBK00044499} email from Martin Hinckley WCC to RBKC 13 July 2017 attaching residents without key workers and addressed to Natasha Bishop at the Key Workers Hub {RBK00044500/1}. The report recognised that even at that stage the problem could not be resolved quickly and it was uncertain when the government's objective for every household in temporary accommodation to have a key worker was likely to be achieved.1680 {RBK00044500/1}.
¶104.115 The level of support provided to residents by key workers varied. Some said that their social workers and key workers had been helpful1681 Novell {IWS00001288/11} page 11, paragraph 67. and that key workers had provided advice on counselling.1682 Alan Ali {IWS00001745/8-9} pages 8-9, paragraph 38. Others reported that the high turnover of key workers was unhelpful1683 Le-Blanc {IWS00001271/30} page 30, paragraph 284; Khoudair {IWS00001616/14} page 14, paragraph 111; Yousuf {IWS00001626/4} page 4, paragraph 21. and one complained that they had no experience of dealing with people facing trauma.1684 Rashida Ali {IWS00001617/15} page 15, paragraph 185.
¶104.116 It does not appear that there was any urgent attempt to establish a system for responding to the needs of those whose mental health had been affected. It is not clear whether that was due to a lack of organisation on the part of RBKC or to the guidance in the Humanitarian Assistance framework, which indicated that formal help, such as counselling, should not be offered in the first few weeks after an incident.1685 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/6-7} pages 6-7, paragraphs 2.7-2.8.
¶104.117 Before ending this chapter it is important that we recognise that many of RBKC's staff, not least those whose roles involved contact with the public, worked extremely hard for long hours, day after day. They too were seriously affected by the tragedy and were expected to carry on under circumstances that placed them under great deal of scrutiny and often challenge. In common with the residents of North Kensington they were let down by the leadership of the council, the inadequacy of its standing systems and the provision it made for staff.1686 In an email sent on 17 June 2017 at 16.00 to Ray Brown (RBKC), Rebecca Hennessy (also RBKC) said that she was angry at the lack of leadership and how the situation had been handled by [RBKC]. She felt let down by the council. Those in authority refused to listen to those on the ground and there were no clear communications {RBK00049712}.
143Chapter 105: The response of the Tenant Management Organisation
Introduction
¶105.1 The principal purpose of the Tenant Management Organisation was to manage and maintain RBKC's housing stock. Unlike RBKC, it was not a responder for the purposes of the Civil Contingencies Act 2004. Nonetheless, from the first hours it was directly involved in several aspects of the humanitarian response to the disaster, including through attendance at rest centres, RBKC Gold group meetings, creating and managing a list of safe and missing residents and facilitating the return of residents evacuated from properties within the police cordon.
¶105.2 We heard evidence from Robert Black, the chief executive, and Teresa Brown, the Director of Housing, about the steps taken by the TMO in response to the situation created by the fire. We also received 47 witness statements from members of the TMO's staff.
Emergency planning
¶105.3 The TMO had its own emergency plan which identified various responsibilities in the event of a major emergency.1687 TMO Emergency Plan {RBK00057991}. It was created in August 2004 and had subsequently been revised in 2009 and 2016. For present purposes we are concerned with the 2016 version, which was in effect at the date of the fire.
¶105.4 Part 1 of the plan described the TMO's role in emergency planning and response. In their evidence, Mr Black and Ms Brown initially suggested that the plan had been designed for localised incidents1688 Brown {Day274/6:16-22}; Black {TMO10048970/2} page 2, paragraph 11. and had never been intended to apply to a major incident,1689 Black {TMO10048970/2} page 2, paragraph 11; Brown {TMO00869990/2} page 2, paragraphs 6-7. as the TMO did not have sufficient resources to deal with an emergency on that scale.1690 Black {TMO10048970/3} page 3, paragraph 12. In such an event, the RBKC Contingency Management Plan would come into operation rather than the TMO's emergency plan.1691 Black {TMO10048970/1} page 1, paragraph 4; Brown {TMO00869990/2-3} pages 2-3, paragraph 9. In those circumstances the TMO would have no formal role other than to provide resources and support RBKC when requested.1692 Black {TMO10048970/3} page 3, paragraph 15. However, the introduction to the emergency plan suggests that it did envisage a role for the TMO in response to a major incident that exceeded its own capabilities and resources.1693 TMO Emergency Plan {RBK00057991/13}. In such a situation, the TMO would be expected to work with the council. Both Mr Black1694 Black {Day275/8:6-22}; {Day275/14:11-25}. and Ms Brown1695 Brown {Day274/8:20}-{Day274/9:1}. accepted that the plan could, in theory, have applied to the Grenfell Tower fire, reflecting a degree of uncertainty about the part that the TMO was expected to play in response to a major emergency.
144Relationship with the council
¶105.5 There was no effective arrangement or shared understanding between the TMO and RBKC about the part that the TMO would play in the event of a major emergency affecting one or more of its properties1696 Black {Day275/15:1-6}. and RBKC's Contingency Management Plan did not refer to the TMO.1697 RBKC Contingency Management Plan {RBK00004396}; Brown {TMO10048970/3} page 3, paragraph 14. Following the fire at Adair Tower in October 2015, there was a discussion at the TMO executive team meeting on 11 November 2015 in which those present recognised the need for the TMO to be more involved with RBKC in emergency planning in order to ensure that all were aware of their responsibilities.1698 {TMO00840414/2} item 3. It was agreed that in response to an incident involving more than a few dwellings the TMO would provide details of residents' known vulnerabilities.1699 Summary of meeting on 11 April 2016 with Contingency Planning, Housing and TMO to follow-up on the Adair Tower fire {RBK00057975/3}. However, Mr Black did not seek to clarify with RBKC the formal role of the TMO in the event of an emergency;1700 Black {Day275/15:7-10}. he expected that Laura Johnson and her team would tell the TMO how it fitted into RBKC's plan.1701 Black {Day275/15:11-14}. At the time of the Grenfell Tower fire, therefore, the TMO did not have a formal and clearly defined role in RBKC's contingency planning arrangements.1702 Black {Day275/17:21}-{Day275/18:1}. Given that the need for such a role had been identified as a result of the Adair Tower fire, that gap should have been filled.
Training
¶105.6 The emergency plan required staff to undertake a number of tasks in the event of an emergency, including ensuring that the primary needs of residents were met, opening and managing rest centres to care for those affected and identifying residents' special needs or vulnerabilities.1703 TMO Emergency Plan {RBK00057991/28}. However, TMO staff were not properly trained to carry out those tasks. Notably, neither Mr Black nor Ms Brown undertook any training in responding to emergencies during the course of their employment by the TMO,1704 Brown {TMO00894124/1} page 1, paragraph 3; Black {Day275/10:23}-{Day275/11:2}. despite their senior roles and the fact that Ms Brown was identified in the emergency plan as a contact and key decision-maker.1705 TMO Emergency Plan {RBK00057991/17}; Brown {Day274/15:8-12}. Mr Black told us that, although no training had been provided to staff about their own responsibilities, staff on call and out-of-hours contractors did receive training on their responsibilities when on duty.1706 Black {Day275/17:14-20}. Although some staff received more general briefings from the TMO's Health and Safety team,1707 Chamchoun {TMO10048972/2} page 2, paragraph 5; Singh {TMO00840373/2} page 2, paragraph 5; Hutchison {TMO10048971/3} page 3, paragraph 17. several people who were identified in the emergency plan as key contacts had not received training on the plan itself,1708 Singh {TMO00840373/2} page 2, paragraph 5; Chamchoun {TMO10048972/2} page 2, paragraph 5. let alone in any detail.1709 Sharples {TMO10048975/2} page 2, paragraph 17. Mr Black could not recall whether any specific training on the emergency plan had been given to the executive team so that they could help staff understand their roles and responsibilities in co-operation with RBKC.1710 Black {Day275/17:6-12}. TMO staff had not received training in managing rest centres or collating information in an emergency situation.1711 Brown {Day274/60:16}-{Day274/61:14}; {Day274/63:21-25}. Mr Black accepted that TMO staff should have received more training in how to respond to an emergency.1712 Black {Day275/14:5-7}.
145The night of the fire
¶105.7 The TMO's emergency plan was not activated in response to the fire. Mr Black accepted that it could have been but that, in reality, the incident was overwhelming for the TMO. In any event, RBKC's Contingency Management Plan was in operation by the time he arrived at the scene.1713 Black {Day275/8:6-24}. RBKC did not actively ask for the TMO's assistance but welcomed the support it offered.1714 Black {TMO00887150/1-2} pages 1-2, paragraph 4. The TMO's involvement was essentially voluntary1715 Black {Day275/19:3}-{Day275/20:20}. and it co-operated with RBKC to respond to the situation as it evolved.1716 Black {Day275/19:3}-{Day275/20:20}. TMO staff brought particular insights into the tower, the local area and the residents that others did not share.1717 Black {Day275/30:3-7}. Ms Brown's understanding was that the council had been in charge of the response to the emergency and that the TMO had had a supporting role, providing assistance when RBKC asked it to do so.1718 Brown {Day274/11:2-16}. She told us that TMO staff had wanted to do what they could to help and so had stepped in.1719 Brown {Day274/11:2-16}.
¶105.8 Although RBKC asked the TMO for information on certain housing matters, it did not ask for its assistance in responding to the effects of the fire. However, despite the absence of any existing arrangements or any request to help in providing humanitarian assistance, TMO employees voluntarily made themselves an integral part of the response, both on the night of the fire and in the week that followed. Although Ms Brown had some practical experience in providing such assistance as a result of her involvement in the Adair Tower fire and dealing with smaller emergencies,1720 Brown {Day274/16:7}-{Day274/17:25}. that was not sufficient to prepare her or her team to respond to a major emergency of the kind then facing them.
Rest centres
¶105.9 The TMO was not involved in setting up any of the rest centres1721 Brown {Day274/26:13-16}. and RBKC did not initially tell Ms Brown what she and her staff were expected to do when they went there.1722 Brown {TMO00894124/4} page 4, paragraph 13; Brown {Day274/26:25}-{Day274/27:1-2}. Ms Brown told us that they had been left to decide for themselves what to do1723 Brown {Day274/26:25}-{Day274/27:1-2}. and that they thought that the most useful thing would be to go to rest centres and start supporting residents and collecting information for the LFB about who was safe and who was missing.1724 Brown {Day274/27:3}-{Day274/28:5}.
¶105.10 In the early hours of 14 June 2017, TMO staff attended the Rugby Portobello Trust, St Clement's Church, the Methodist Church, the Westway Centre, and the Latymer Community Church.1725 TMO Staff Presence at Rest Centres {TMO00869981}. Ms Brown did not allocate any staff to other community rest centres, such as the Al Manaar Cultural Heritage Centre, St Francis of Assisi Church or the Salvation Army, because she did not know about them.1726 Brown {Day274/31:10-14}; {Day274/36:20-22}. TMO staff did not, therefore, collect information about residents that attended those centres.1727 Brown {Day274/31:16-25}. However, when he attended the second RBKC Gold group meeting at 15.00 on 14 June 2017,1728 RBKC Gold Group Meeting {RBK00023239}.
146¶Mr Black incorrectly told the meeting that the TMO had staff in every rest centre.1729 RBKC Gold Group Meeting {RBK00023239/2}. His error was the result of his not having been given the latest information about rest centres.
¶That contributed to RBKC's lack of accurate information about the number of people who had been displaced by the fire.
¶105.11 Between them RBKC and the TMO failed to take effective measures to tell survivors and displaced residents about the support available at the rest centres. Ms Brown told us that she had expected the Local Authority Liaison Officer (LALO) to tell the emergency services, who in turn would direct residents to the rest centres as they were evacuated,1730 Brown {TMO00869990/4} page 4, paragraph 18. since she was not allowed within the cordon.1731 Brown {Day274/39:9-23}. However, TMO staff did not take any steps to communicate with the LALO to ensure that residents were told where they could go.1732 Brown {Day274/39:20}-{Day274/40:3}. Similarly, no consideration was given to deploying TMO staff in the streets outside the police cordon in order to direct residents to rest centres.1733 Brown {Day274/40:24}-{Day274/41:7}. A significant number of residents who had been displaced did not know where to go after they had left the tower or their homes nearby.
The Westway Centre
¶105.12 During the course of 14 June 2017, the TMO was advised by Amanda Johnson and Robert Shaw of RBKC that they should tell people to go to the Westway Centre as the designated rest centre and stay there overnight.1734 Brown {Day274/42:3-25}. There was difficulty in persuading people to leave the existing rest centres because some wanted to stay in rest centres run by the community.1735 Brown {TMO00869990/7} page 7, paragraph 36; Brown {Day274/43:10-13}.
¶105.13 Although the Westway Centre had become the centralised place of support during the course of the day on 14 June 2017,1736 Priestley {RBK00035672/8-9} pages 8-9, paragraph 39. Ms Brown did not visit it, either on 14 June 2017 or subsequently,1737 Brown {TMO00894124/13} page 13, paragraph 46. because she considered that there were capable staff in place.1738 Brown {Day274/51:23}-{Day274/52:4}. There was a TMO desk at the Westway Centre but there were no TMO staff there on Saturday 17 June or Sunday 18 June 2017 because of worries about their safety.1739 Brown {TMO00894124/13} page 13, paragraph 47. Given the TMO's position as the body with whom most residents had had regular contact before the fire, it is not surprising that they expected to see people from the TMO offering support in the days following it. Some residents complained that the TMO was not sufficiently active in its response to the fire and had failed to provide support for people at the Westway Centre,1740 Razza {IWS00001607/9} page 9, paragraph 42. but it was not responsible for setting up the Westway Centre as a rest centre or for running it. That was the responsibility of RBKC.
147¶105.14 Until 19 June 2017 no mechanism was introduced at the Westway Centre to deal with questions from residents of the tower and surrounding blocks.1741 Internal TMO email sent on 19 June 2017 at 11.52 {TMO00870375}. On 23 June 2017 a log was created to help staff in providing responses to questions.1742 Internal TMO email sent on 23 June 2017 at 10.22 {TMO10035572}. TMO staff working at the Westway Centre were provided with daily briefings to enable them to assist people,1743 Brown {Day274/52:6-20}. but no written briefings were provided until 26 June 2017.1744 Briefing - Staff Expectations for covering TMO Westway Helpdesk {TMO10036663}.
List of those safe and missing
¶105.15 Ms Brown initially collated information about those missing to assist the LFB with rescue efforts.1745 Brown {TMO00869990/5} page 5, paragraph 23. That evolved into creating and maintaining a spreadsheet containing lists of safe and missing people to provide to RBKC to assist with providing emergency accommodation.1746 Brown {Day274/27:20-24}; Brown {Day274/58:17}-{Day274/59:2}; Email from Kiran Singh (TMO) on 14 June 2017 at 12.21 {TMO00869930} attaching list of safe and missing residents {TMO00869931}. The spreadsheet was also circulated to a number of agencies, including the casualty bureau and the BECC.1747 Brown {TMO00894124/6} page 6, paragraph 20; Brown {Day274/58:9-21}.
¶105.16 Ms Brown had not been asked by RBKC to undertake that task;1748 Brown {Day274/57:1-20}. she had done so voluntarily because it was a practical way in which she could help and she knew it was important.1749 Brown {Day274/57:1-9}. She directed her initial efforts only to residents of Grenfell Tower and not to those who had been evacuated from the Walkways or Treadgold House.1750 Brown {Day274/123:8-10}.
¶105.17 There were two fundamental problems with the creation and maintenance of the safe and missing lists. First, the spreadsheet was based on the tenancy information held by the TMO in its electronic records,1751 Tenancy List {TMO00866006}. which was incomplete and inaccurate. Secondly, the method by which TMO staff were collecting information at rest centres was haphazard. A combination of these two problems led to errors in the list and to people being misinformed about the safety of their loved ones.
Inaccurate information
¶105.18 The TMO relied for the accuracy of its records primarily on information provided by its tenants.1752 Singh {TMO00894410/2} page 2, paragraph 3c. Although good practice required it to carry out an audit of each property every year, it did not do so because it had more pressing matters to attend to.1753 Williams {TMO00879804/9} page 9, paragraph 62.
¶105.19 Ms Brown told us that the tenancy list contained a mixture of tenants and other household members.1754 Brown {Day274/68:6-19}. In some cases only the tenant appeared; in others the tenant and other members of the household were included. In some cases residents did not appear in the list at all. The information held by the TMO about disabilities or particular needs, such as preferred language and mental and physical health, was incomplete. The list was amended by staff whenever they were provided with fresh information. Ms Brown accepted the shortcomings of the tenancy list as the basis for identifying who was in the tower on the night of the fire.1755 Brown {Day274/71:12-19}. Kiran Singh, who produced the list, was unable to say when it had last been revised.1756 Singh {TMO00894410/2} page 2, paragraph 3c.
148¶105.20 The inaccuracies in the tenancy information provided by the TMO in turn created problems for other agencies using the information. The police had difficulty establishing a clear picture of who had been in the tower and realised by the end of the first day that the TMO's list was not accurate.1757 Email from the Metropolitan Police Service to various agencies regarding updated briefing on the number of fatalities and/or missing people {RBK00018233/2}.
¶105.21 The inaccuracies also hampered residents' searches for their loved ones. Mohammed Rasoul told us that, when he attended the Latymer Community Church, somebody whom he believed to be from the TMO was present with a list of flat numbers and names. Virginia Duffy was listed as the occupier of Flat 153, even though she had died the previous year. In June 2017 it was the home of Isaac Paulos, aged 5, who died in the fire.1758 Rasoul {Day265/146:4-19}.
¶105.22 After the fire, RBKC was aware that the tenancy information was inaccurate. As late as 17 June 2017, Mr Robert Shaw of RBKC sent an email to TMO staff asking how many residents, not just lead tenants, lived in the tower. Mr Singh qualified his reply with a warning that the information was not likely to be completely accurate as households had changed over the years and the TMO had not always been told.1759 Email correspondence between Robert Shaw (RBKC Housing) and Kiran Singh (TMO) on 17 June 2017 {TMO10035581/4}. Ms Brown accepted that meant that there were people who were not accounted for and therefore not contacted.1760 Brown {Day274/72:4-9}.
¶105.23 On 14 June 2017, the safe and missing lists were initially revised on the basis of information collected at rest centres. TMO staff later called all known residents of the tower who had not made contact through the rest centres, although that effort was hampered by the fact that contact information was not always correct.1761 Brown {TMO00869990/5} page 5, paragraph 23. Ms Brown and another colleague continued calling residents of the tower until about 21.00 on 14 June 2017, but in many cases without success.1762 Brown {TMO00894124/8} page 8, paragraph 28.
¶105.24 The minutes of the second RBKC Gold group meeting at 15.30 on 14 June 2017 recorded that the TMO had made contact with 81 households from the tower but that they did not know where some residents were staying.1763 RBKC Gold Group Meeting {RBK00023236/1}.
¶105.25 It is not clear whether residents to whom the TMO was able to speak were asked about any vulnerabilities or specific needs or whether they were offered any particular support.1764 Luke Towner stated that his partner was contacted by the TMO on 14 June only to confirm that if they escaped, they were not offered any support or a call back at a later date, Towner {IWS00001705/8} page 8, paragraph 41. Ms Brown told us that the focus at that stage had been on finding out whether people were safe.1765 Brown {Day274/95:19-25}.
149¶105.26 By 16 June 2017, 129 Grenfell Tower residents on the TMO's list had been accounted for but 102 had not been found.1766 {TMO00869959}. There was no clear plan for contacting those residents who had not been reached. That is consistent with the evidence we heard from survivors1767 Moghaddam {IWS00000392/8} page 8, paragraph 42; Patel {IWS00001610/10} page 10, paragraph 49; Ho {IWS00001551/16} page 16, paragraph 62; Gomes {IWS00001734/28} page 28, paragraph 44; Ross {IWS00001826/14-15} pages 14-15, paragraph 69. and residents of the tower who said they had not been contacted by the TMO in the first few days following the fire. Ms Brown did not know whether RBKC was also trying to account for the residents of the tower.1768 Brown {Day274/97:7-15}. By 19 June 2017 RBKC and the TMO had still not established an accurate list of those who had been living in the tower.1769 RBKC Log {RBK00028712/1}.
Haphazard recording of information
¶105.27 Before sending her staff to the rest centres, Ms Brown told them to collect the names and addresses of those who were safe and those who were missing and information on particular needs, including in relation to accommodation.1770 Brown {Day274/29:17-23}. They were not asked to record that information in a particular way1771 Brown {TMO00894124/7} page 7, paragraph 24. and did not use the template in the emergency plan.1772 {RBK00057991/31}. Ms Brown did not receive any instructions from RBKC on the kind of information that should be collected or how to collate and organise it.1773 Brown {Day274/57:1-20}.
¶105.28 Ms Brown thought that her staff were clear about what they needed to do,1774 Brown {Day274/60:16}-{Day274/61:14}. but one member of the team who had been sent to the Harrow Club did not think that she was the right person to be running a rest centre, having received no training. However, she felt she had no choice but to carry on.1775 Warrier {TMO10048986/4} page 4, paragraph 18, Ms Warrier was a Neighbourhood Team Leader.
¶105.29 Clare Richards, the chief executive of the Clement James Centre, was concerned by the way in which TMO staff were recording information. She said that they had been recording information on scraps of paper, had not been making an accurate record of who was there and had not known who they were looking for.1776 Richards {CFV00000012/13} page 13, paragraph 89. She offered them the use of laptops to capture information on a spreadsheet, but the offer was declined.1777 Richards {CFV00000012/13} page 13, paragraph 89. Ms Brown told us that she had not wanted staff to record information on different laptops because it would have taken time to amalgamate the different lists. She wanted a single spreadsheet1778 Safe and Missing List circulated at 12.21pm {TMO00869931}. to minimise confusion1779 Brown {Day274/80:10-16}. and the risk of error.1780 Brown {Day274/79:1-7}.
¶105.30 The pieces of paper containing handwritten notes1781 Examples of handwritten notes taken by the TMO staff at rest centres {TMO10035210}; {TMO10035236}; {TMO10035242}; {TMO10035218}; Brown {Day274/75:3-10}. from the various rest centres were passed to Mr Singh,1782 Brown {Day274/81:23}-{Day274/82:6}. who brought a laptop to the Clement James Centre on the morning of 14 June 2017.1783 Brown {TMO00894124/6} page 6, paragraph 20. He amended the original spreadsheet1784 Safe and Missing List circulated at 12.21pm {TMO00869931}. using the information on the loose sheets of paper and recorded whether residents were safe. He also recorded any other relevant information, such as whether they were staying with friends and relatives or in a hotel.1785 Brown {Day274/81:23}-{Day274/82:6}; Singh {TMO00894410/1-2} pages 1-2, paragraph 3a. Ms Brown accepted that there was a degree of error in recording information at the rest centres in that way,1786 Brown {Day274/76:8-15}. but said the system was as efficient as it could be.1787 Brown {Day274/79:11-25}.
150¶Unfortunately, although her efforts to create a centralised system were intended to reduce error, their outcome was the opposite.
Errors in the lists
¶105.31 As a consequence of the errors and omissions in the tenancy records and the defects in the further information gathered at the rest centres, there were a number of significant errors in the safe and missing lists.
¶105.32 In the spreadsheet circulated on 14 June 2017 at 12.211788 Safe and Missing List circulated at 12.21pm {TMO00869930}. a number of people who had died in the fire were marked as safe, including Denis Murphy,1789 {TMO10017313} Row 11: Denis Murphy was marked safe as seen by the yellow highlight. Khadija Khalloufi,1790 {TMO10017313} Row 51: Khadija Khalloufi was marked safe as seen by the yellow highlight. Faouzia El-Wahabi, Yasin El-Wahabi, Abdulaziz El-Wahabi and Nur Huda El-Wahabi1791 {TMO10017313} Rows 104-107: Faouzia El-Wahabi, Yasin El-Wahabi, Abdulaziz El-Wahabi and Nur Huda El-Wahabi were marked safe as seen by the yellow highlight. and Saber Neda.1792 {TMO10017313} Row 136: Saber Neda was marked safe as seen by the yellow highlight. Some of those marked safe were also marked as missing, such as Denis Murphy and Khadija Khalloufi.1793 {TMO10017313} Rows 11 and 51: Denis Murphy and Khadjia Khalloufi were also marked under the 'missing' tab as seen by the pink highlights. The same inaccuracies remained throughout the day. Revised lists were circulated by Mr Singh at 13.08 and 13.44; recipients included RBKC for forwarding to teams on the ground.1794 Brown {TMO00869990/5} page 5, paragraph 26. However, those lists still recorded as safe some who had died.1795 {TMO10017359} Safe and Missing list sent from Kiran Singh to Rob Shaw at RBKC at 13.44 on 14 June 2017. The same inaccurate information is recorded in the 'SAFE' tab at Row 11: Denis Murphy, Row 51: Khadija Khalloufi, Row 102: Jessica Urbano Ramirez, Rows 104-107: Faouzia El-Wahabi, Yasin El-Wahabi, Abdulaziz El-Wahabi and Nur Huda El-Wahabi, Row 136: Saber Neda, as seen by the yellow highlights.
¶105.33 Another spreadsheet circulated at 17.27 contained revisions made after the neighbourhood team had telephoned every resident from whom they had not heard, but it still listed Denis Murphy and Khadija Khalloufi as safe. The El-Wahabi family were still listed as safe, save for a note stating that one member might be missing.1796 {TMO00869982} Kiran Singh circulated Resident List at 17.27 confirming that the Neighbourhood team had rang every resident they had not heard from. Row 11: Denis Murphy, Row 51: Khadija Khalloufi, Rows 104-107: Faouzia El-Wahabi, Yasin El-Wahabi, Abdulaziz El-Wahabi and Nur Huda El-Wahabi, Row 136: Saber Neda, Row 102; Jessica Urbano Ramirez were marked 'safe' on that list as seen by the yellow highlights {TMO10017480}; Brown {TMO00869990/6} page 6, paragraph 27; Brown {Day274/89:15}-{Day274/91:5}. Ms Brown could not explain why people had been listed as safe and missing on the same spreadsheet; she told us that they had tried to check the information as they went along.1797 Brown {Day274/84:3-14}. She accepted that the safe and missing tabs on the spreadsheet should have been cross-checked to make sure that those recorded as safe were not also recorded as missing and vice versa.1798 Brown {Day274/85:18-23}.
¶105.34 Errors were clearly made in the reporting and recording of information at the rest centres,1799 Brown {Day 274/83:12-18}. but there were also significant errors in transferring the information from the handwritten notes into the spreadsheet. That was demonstrated by the fact that one handwritten note recorded Jessica Urbano Ramirez as missing,1800 Handwritten note marking residents as safe or missing in the rest centre {TMO10035210}. whereas in the lists circulated at 13.44,1801 {TMO10017359} Row 102: Jessica Urbano Ramirez marked 'safe' as seen by the yellow highlight. 14.461802 {TMO00869935} Row 102: Jessica Urbano Ramirez marked 'safe' as seen by the yellow highlight. and 17.261803 {TMO10017480} Row 102: Jessica Urbano Ramirez marked 'safe' as seen by the yellow highlight. she was marked as safe. That is likely to have been due more to human error than the method used to record the information.
151¶105.35 Ms Brown told us that she had understood that other organisations, including the council, the casualty bureau and the BECC, would be relying on the information in the list as a base and using it in delivering their emergency response.1804 Brown {Day274/59:15-24}. In particular, both she and Mr Black1805 Black {Day275/105:24}-{Day275/106:5}. had known that it would be relied on by RBKC's housing department.1806 Brown {Day274/85:3-7}. Mr Black told us that at the time he had thought it was the TMO's responsibility to provide the information, but in hindsight he thought it had been the responsibility of RBKC as Category 1 responder.1807 Black {Day275/107:12-18}. He said that although people had done their best, it was not as good as it should have been and he apologised for the heartbreak that that must have caused people.1808 Black {Day275/119:13}-{Day275/120:10}.
¶105.36 Given the significance of the safe and missing lists and the fact that several organisations were known to be relying on the information they contained, TMO staff should not have been left to do the best they could.1809 Brown {Day274/61:4-7}. The problems stemmed from poor record-keeping before the fire, resulting in tenancy information that was unreliable. If reliable information had been readily available to the TMO, it would have allowed more residents to be accounted for more quickly and their particular needs to be identified. it would also have reduced the risk of inaccurate and inconsistent information being circulated.
¶105.37 As a Category 1 responder, RBKC should have had a plan in place to account for safe and missing residents in the event of an emergency affecting any of its properties. Instead, the burden of devising a means of achieving that objective fell on a handful of staff at the TMO. However, the TMO should have made it clear to RBKC that it needed support to put in place a robust and effective system. Difficulties in establishing an accurate list of those who had been living in the tower continued throughout the following week.1810 RBKC Log 9 dated 19 June 2017 {RBK00028712/1}. Unfortunately, the system implemented by the TMO led to systemic errors, with people being wrongly told that their loved ones were safe, when they were in fact missing.1811 Daniels {IWS00002065/11} page 11, paragraphs 73-74; Chiapetto {IWS00001780/1} page 1, paragraph 2; Murphy {IWS00001709/3} page 3, paragraph 12; Wahabi {Day267/102:8-25}-{Day267/103:1-17}. A resident was informed by the TMO that his missing wife was reported as safe at the St Clements Centre. His son received a conflicting report from another TMO officer {RBK00012043}.
152Residents evacuated from the surrounding area
¶105.38 About 8451812 {TMO00869977}; Brown {TMO00894124/17} page 17, paragraph 60. residents of Hurstway Walk, Barandon Walk, Testerton Walk, Grenfell Walk and Treadgold House were evacuated on the night of the fire1813 Brown {Day274/97:21}-{Day274/99:3} residents from Bramley house were also evacuated but not for an extended period and so did not require accommodation. and were prevented by the police cordon from returning to their homes.1814 Brown {TMO00894124/19} page 19, paragraph 66; Police Cordon Slideshow {MET00080826}. The residents of Grenfell Walk have never been able to return to their properties.1815 Cherbika {Day266/117:1-3}; {Day266/177:19-21}; Moses {IWS00001276/13} page 13, paragraphs 88, 91 and 92; Lopez {IWS00001680/8} page 8, paragraphs 43, 47-48; Procedure Note for Resettlement Packages {RBK00028643}. As a result, there were significant numbers of people requiring emergency accommodation and other support.
¶105.39 Ms Brown told us that although RBKC had been responsible for managing the response to the emergency, the TMO had some operational capability which it used to help displaced residents.1816 Brown {Day274/172:1-25}.
Prioritising the needs for emergency accommodation
¶105.40 It does not appear that RBKC was fully aware of the number of people displaced or their particular needs. In part, that seems to have been due to a widely held expectation that residents evacuated from surrounding buildings would be able to return home without much delay.1817 Brown {Day274/102:9-18}. As a result, on 14 June 2017, RBKC's strategy was to prioritise residents of the tower for emergency accommodation.1818 Brown {Day274/48:25}-{Day274/49:5}; Brown {TMO00869990/6} page 6, paragraph 28. However, residents evacuated from the Walkways were not allowed to return home immediately and in many cases were not able to return for days, weeks and in some cases for a number of months.1819 Pasztor {IWS00001682/4} page 4, paragraph 17 (7-8 months); El-Sawy {IWS00001829/8} page 8, paragraph 34 (9 months); Ollivierre {IWS00001758/6} page 6, paragraph 26 (9 months); Elbouti {IWS00001605/11} page 11, paragraph 50 (10 months); As reflected in the minutes of the Gold Group meeting on 16 June 2017, at which Laura Johnson of RBKC said that she would house the vulnerable or those with children and without hot water but that others would have to manage, RBKC treated the problem as one for the TMO.1820 Black {Day275/64:20}-{Day275/65:4}; RBKC Gold Group Meeting Minutes at 10.00 on 16 June 2017 {TMO10033491/2} paragraph 7. However, RBKC did attempt to consider the needs of residents evacuated from surrounding properties who were vulnerable, elderly or had families.1821 Brown {Day274/46:2-6}.
¶105.41 On 14 June 2017 at 17.05, Robert Shaw, Housing Options and Allocations Manager at RBKC, asked for information from the TMO about the number of tenants living in the cordoned area, and in particular the number of those who were vulnerable, elderly or had families with children, in order to determine how many people required emergency accommodation.1822 {TMO00869925}. David Noble gave him a total number of residents across the evacuated properties, which included 25 disabled people.1823 {TMO00869977}. That response was incomplete and did not provide information about other vulnerabilities, the elderly or families with children. Furthermore, the figure of 25 people was based on information received from residents;1824 Brown {Day274/104:14-19}. the true number is likely to have been higher.1825 Brown {Day274/104:24}-{Day274/105:3}.
153¶105.42 Ms Brown told us that RBKC had been identifying vulnerable residents and those with children through social services and family and children's services.1826 Brown {Day274/105:17-21}. However it is clear that RBKC was relying on information provided by the TMO to decide whom to place in emergency accommodation.1827 Brown {Day274/107:10}-Day274/108:2}. As a result, at 17.48 on 14 June 2017 Mr Shaw sent an email to various colleagues at RBKC attaching the list of residents from the cordoned area. He told them that there were 845 residents (tenants and families), including 25 recognised as disabled by the TMO.1828 {TMO10033708}.
¶105.43 Although he went on to say that families with children, vulnerable people and older people would be housed if they did not have an alternative place to stay, he did not draw attention to the fact that information relating to the latter categories had not been provided by the TMO and that numbers were therefore still unknown.1829 {TMO00869945}. It was clear that even by the time of the RBKC Gold group meeting at 10.00 on 16 June 2017 not all families and those with vulnerabilities had been given hotel accommodation.1830 Black {Day274/64:10-15}.
The Westway Centre
¶105.44 During the afternoon of 14 June 2017 RBKC told the TMO that, if the police cordon remained in place, the remaining residents evacuated from buildings within the cordon would have to be accommodated at the Westway Centre unless they were vulnerable, elderly, disabled or had children.1831 Brown {TMO00894124/11} page 11, paragraph 38; Brown {TMO00894124/9} page 9, paragraph 31. TMO staff relayed that advice to the rest centres,1832 Brown {TMO00894124/9} page 9, paragraph 31. although residents at rest centres where there was no one from the TMO present may not have received it1833 Brown {Day274/112:3-19}. and indeed Ms Brown accepted that some people had not received it.1834 Brown {Day274/112:13-25}-{Day274/113:1-16}.
¶105.45 That method of communicating with those who had been evacuated from properties surrounding the tower was defective, not least because some were not aware of the existence of the rest centres1835 Belfassi {IWS00001802/6} page 6, paragraph 35. and others had even been refused entry.1836 Moses {IWS00001276/14} page 14, paragraph 97; Cherbika {Day 266/87:12-25}. No attempts were made that day to communicate with evacuated residents by other means as TMO staff were concentrating on going through the tenancy list for Grenfell Tower and trying to establish contact with those who had lived there.1837 Brown {Day274/113:17}-{Day274/114:3}. Although the TMO had the ability to send a single text message to a large group of people at the same time, it was not used.1838 Brown {Day274/114:4-9} it was not used until 16 June 2017.
¶105.46 Mr Black attended the RBKC Gold group meeting at 10.00 on 15 June 2017 at which it was reported that only a limited number of people were at the Westway Centre.1839 RBKC Gold Group Meeting {RBK00023234/1}. Although questions were asked about the whereabouts of the rest of the residents, it was assumed that they were staying with family and friends.1840 Black {Day275/49:24}-{Day275/50:8}. Mr Black could not recall any discussion about the possibility that residents had not received the message to go to the Westway Centre or that some residents might be missing.1841 Black {Day275/50:10-16}.
154¶105.47 Although TMO staff were taking the lead operationally in respect of residents evacuated from properties within the police cordon, Mr Black accepted that he could have had a better understanding of how information was being collected and shared with RBKC. He did not have a clear picture of what the TMO was doing.1842 Black {Day275/42:15}-{Day275/43:23}. Although he tried to stay on top of matters, he found it difficult to do so.1843 Black {Day275/89:16-25}.
Initial contact with evacuated residents
¶105.48 The first time efforts were made by the TMO to contact residents evacuated from buildings within the cordon was on 15 June 2017, when the neighbourhood team called residents to confirm their whereabouts.1844 Brown {TMO00869990/9} page 9, paragraph 46; Brown {Day274/123:1-15}; {Day274/133:1-10}. However, the process suffered from the same limitations as that used to compile the safe and missing lists, in that it was based on information taken from the housing management system.1845 Brown {Day274/133:10-25}-{Day274/134:1-25}. There was incomplete information relating to vulnerabilities,1846 {TMO10017528} Kiran Singh provided information on vulnerable residents to the National Grid on 15 June 2017 and confirmed "this will definitely be an underreported figure". information about leaseholders rather than occupiers was recorded1847 Brown {Day274/68:18-19}. and contact details were out of date.1848 See column L and the rows highlighted in red {TMO00894411}; Brown {Day274/135:19}-{Day274/136:5}. That was particularly serious given that on the evening of 14 June 2017 RBKC had asked the TMO to provide information about residents who had been evacuated and were elderly, disabled, vulnerable or had children in order to place them in emergency accommodation. By the evening of 15 June 2017, TMO staff could not account for the whereabouts of residents of 216 of the 367 properties in Hurstway Walk, Testerton Walk and Barandon Walk.1849 Email 15 June 2017 at 18.26 {TMO10036651}; Brown {Day274/129:23}-{Day274/132:22}.
¶105.49 A script was prepared to assist TMO staff making calls to residents of the Walkways and Grenfell Tower1850 {TMO10036636}. but there were significant differences in the information provided. Residents of Grenfell Tower were told that they could go to the Westway Centre for support and were provided with contact details for the casualty bureau and the temporary accommodation team.1851 {TMO10036636/2-3}. Those evacuated from the Walkways were not given that information.1852 {TMO10036636/1-2} detailed written briefings for staff knocking on doors and making telephone calls to the residents of Barandon, Hurstway and Testerton Walks were provided only on 20 June 2017 {TMO00894205}; 22 June 2017 Neighbourhoods Team Briefing {TMO10033766} and 23 June 2017 Support Briefing Note {TMO10035544}. Given that RBKC had specifically told the TMO to tell residents of the Walkways that they should seek accommodation at the Westway Centre, that was a significant omission.1853 Brown {TMO00894124/9} page 9, paragraph 31.
Decision to return residents
¶105.50 Stuart Priestley, RBKC's Council Silver,1854 For Council Silver's role see Chapter 101 and {RBK00035662/1} paragraph 2.1. told Ms Brown early in the morning of 15 June 2017 that consideration was being given to allowing residents of buildings within the police cordon to return to their properties.1855 Brown {Day274/142:24}-{Day274/143:1}. Ms Brown explained her concerns about people returning to their homes with no gas and no hot water or cooking facilities. In addition, doors damaged when the police had forced entry needed to be repaired and the door entry system needed to be re-routed.1856 Brown {TMO00869990/9} page 9, paragraph 45; Brown {Day274/142:3-23}. She suggested that the return of residents should not be rushed and should wait until the provision of services could be ensured. The decision that people should return to their properties was taken by RBKC; the
155¶TMO was in effect left to work out how to enable them to do so.1857 Brown {Day274/141:5-9}.
¶105.51 Although Ms Brown thought that her objections were being passed to the BECC,1858 Brown {Day274/143:2-12}. she was contacted later that evening and asked to meet Inspector Bean to inspect the area to identify what needed to be boarded up before residents returned.1859 Brown {TMO00869990/9} page 9, paragraph 48; Brown {Day274/142:24}-{Day274/144:14}. During the inspection she was told that it was the intention of RBKC Gold group that residents should return as soon as possible.1860 Brown {TMO00869990/9} page 9, paragraph 48. Ms Brown told us that she had continued to be unhappy about that. She called her manager, Sacha Jevans, to pass on her views and spoke in turn to RBKC's Director of Housing, Laura Johnson.1861 Brown {Day274/146:2}-{Day274/147:2}. Ms Brown subsequently learned that Laura Johnson had told Ms Jevans that the Gold group decision1862 RBKC Gold Group Meeting {RBK00023236/3}. had to be followed.1863 Brown {TMO00869990/9-10} pages 9-10, paragraph 48.
¶105.52 The RBKC Gold group decided at its meeting at 15.30 on 15 June 2017 that the Walkway properties would be reoccupied that night.1864 RBKC Gold Group Meeting {RBK00023236/3}. However, although the decision to allow residents to go home had been made in principle that day, it was not formally implemented until 16 June 2017.1865 Brown {TMO00894124/17} page 17, paragraph 59. At the RBKC Gold group meeting at 10.00 on 16 June 2017 the position in relation to displaced residents was still not clear. The action sheet from the meeting records that the police were not providing clear information about re-occupation and were turning people away from Treadgold House.1866 RBKC Gold Group Meeting {RBK00023238/2}. The formal decision to allow residents to return to Treadgold House was taken at 12.30 on 16 June 2017.1867 Brown {TMO00869990/11} page 11, paragraph 54. Shortly after, a decision was made that residents of Barandon Walk, Testerton Walk and Hurstway Walk (except Flats 501-562) could also return home.1868 Brown {TMO00894124/19} page 19, paragraph 67; Brown {TMO00869990/11} page 11, paragraph 55; {TMO00894201/1-2}. Ms Brown1869 Brown {Day274/151:1-25}-{Day274/152:1-5}. and Mr Black told us that there had been confusion between the police, the BECC and RBKC Gold group in communicating the decision on when residents could return home.1870 Black {Day275/61:15-25}; {Day275/63:14-17}.
¶105.53 The decision by RBKC to send residents home so quickly was driven by the shortage of emergency accommodation for the significant number of displaced people.1871 Brown {Day274/147:12}-{Day274/148:19}. That is evident from the notes of the first humanitarian assistance steering group meeting at 14.00 on 15 June 2017 which recorded that "Those disbanded [sic] in the cordoned off areas are not priorities as there is [sic] not resources to support this" and "AG [RBKC] explained that there is a shortage of hotels locally and those from Grenfell are the priority".1872 Humanitarian Assistance Board Meeting Minutes {RBK00020410/2}. Similarly, the action sheet from the RBKC Gold group meeting at 15.30 on 15 June 2017 stated, "If cordon is not lifted, then [we] have over 800 people to find places. Will need to seek help from Government."1873 RBKC Gold Group Meeting {RBK00023236/1}; Black {Day275/57:23}-{Day275/58:9}.
156¶105.54 The concerns expressed at an operational level by Ms Brown do not appear to have been voiced at a strategic level by Mr Black. Despite knowing of them,1874 Black {Day275/55:19}-{Day275/56:1}. he could not remember whether he had raised them at any of the RBKC Gold meetings.1875 Black {Day275/56:2-7}. There is no suggestion in the action sheets from those meetings that he raised any specific objections to returning residents to their homes, even though that was something his staff would have to organise. He accepted that the TMO was being required to send people back to their homes, despite their condition, because there were too many displaced people for RBKC to provide all of them with emergency accommodation.1876 Black {Day275/57:3-8}. He accepted that that created difficulties for the TMO, which had to make sure the properties were habitable and safe.1877 Black {Day275/58:4-9}.
Attempts to communicate with residents
¶105.55 Once Ms Brown had received confirmation on 16 June 2017 that residents could return to buildings within the cordon, she arranged for 11 TMO officers to telephone them to tell them that they could go home, at the same time warning them about the lack of heating and hot water and telling them about the washing facilities at the Westway Centre.1878 Brown {TMO00869990/11} page 11, paragraph 56. She also arranged for 15 members of the TMO's staff to visit the Walkways and Treadgold House to check on residents, refer people to support services, see whether any repairs or cleaning were required and check the electricity supply.1879 Brown {Day274/156:10}-{Day274/157:6}. TMO staff kept notes of those visits with the intention of keeping a record of vulnerabilities and of any need for assistance that could be added to the central electronic list of residents.1880 Singh {TMO00894410/5} page 5, paragraph 4d. However, the records were often haphazard,1881 {TMO00894169}. inconsistent and incomplete.1882 {TMO10017543} spreadsheet on 15 June 2017 which features residents from Grenfell Walk with no pre-populated columns relating to vulnerabilities; {TMO10034288} spreadsheet on 19 June 2017 features residents from Walkway properties and Bramley House, but not Grenfell Walk which does include pre-populated columns relating to vulnerabilities; {TMO10036665} spreadsheet on 15 June 2017 relating to all Walkways with pre-populated columns relating to vulnerabilities, but not Bramley House or Grenfell Walk residents.
¶105.56 The TMO used the "text burst" facility for the first time on 16 June 2017 to let residents from Barandon Walk, Treadgold House and Hurstway Walk know that they could go home and to warn them that they might not have hot water or gas.1883 It is not clear whether that was also sent to residents of Testerton Walk, or what was sent, if anything, to Grenfell Walk residents. Residents were told that they could continue to stay with family or friends or in what was described as "the resource centre".1884 Brown {TMO00869990/12} page 12, paragraph 58; {TMO00869949}. That was intended to be a reference to the Westway Centre, but it is not clear whether people realised that. The message did not provide any information about the Westway Centre, what support was available there or how to get there. Although it was unlikely to reach everyone, the "text burst" facility was a useful means of communication and should have been used earlier and more often to provide information to displaced residents.
¶105.57 On 19 June 2017, further attempts to call residents were made.1885 Brown {TMO00894124/25} page 25, paragraph 93. TMO staff also visited homes again to find out whether more residents had returned, to give advice and to see whether repairs were needed.1886 Brown {Day274/176:25}-{Day274/177:11}; Brown {TMO00869990/13} page 13, paragraph 69. A number of residents had still not returned home.1887 Brown {Day274/177:4-20}.
157¶The TMO repeated the exercise the next day to conduct welfare checks and identify the need for any further support,1888 Brown {TMO00869990/15} page 15, paragraph 78. although some residents had still not returned home seven days after the fire.1889 Brown {Day274/179:22-25}. Despite the TMO's efforts to communicate with the residents, some still complained that no one had contacted them,1890 Internal TMO email regarding a log of queries arising at the Westway Centre {TMO10035599/55}. indicating that not all residents were being reached.
¶105.58 On 20 June 2017, Ms Brown asked RBKC for a list of those who had been provided with emergency accommodation in order to identify any residents that had not been given accommodation and had not yet returned to their properties.1891 Brown {Day274/184:19}-{Day274/185:1}. However, Mr Shaw told her that RBKC was still in the process of reconciling the list.1892 {TMO10035589/17}.
¶105.59 Detailed written briefings for staff trying to contact residents of Barandon Walk, Hurstway Walk and Testerton Walk were not provided until 20 June 20171893 {TMO00894205}. and were issued again on 22 June 20171894 Neighbourhoods Team Briefing {TMO10033766}. and 23 June 2017.1895 Support Briefing Note {TMO10035544}. They included guidance on the message to be given to residents of surrounding blocks, information about the support available at the Westway Centre, tasks to be carried out, staff rotas and useful contact information. They were much more detailed than the aide memoire provided earlier to assist staff making telephone calls.1896 Script for calls to residents {TMO10036636}.
Continuing confusion
¶105.60 It is clear that even after the Gold resolution had been activated and John Barradell had taken over the response, there was no clear strategy for dealing with displaced residents. On 19 June 2017 RBKC and the TMO were looking for guidance to the Westminster City Council housing team, which had been brought in as part of the wider London response.1897 RBKC Gold Group Meeting Action Sheet {RBK00005507/2} "people in finger blocks constantly approaching for housing. Need a steer from the WCC Team…what do we do with the 91 families not from Grenfell Tower and Walk".
¶105.61 As a result, in the days and weeks following the fire there were conflicting messages about when residents could return home. Although some residents had returned early at the instigation of RBKC Gold group,1898 Brown {TMO00894124/17} page 17, paragraphs 58-59. others were turned away by the police when they tried to return1899 Brown {Day274/117:17-19}; {Day274/152:11-17}; Internal TMO email 19 June 2017 {TMO10035566/1}; Dowlut {IWS00001787/10} page 10, paragraph 37; Boujettiff {Day266/67:7-14}; McMahon {IWS00001966/9} page 9, paragraph 41; Pasztor {IWS00001682/3} page 3, paragraph 15. or were told that they could return at their own risk.1900 {TMO00869927}; Serroukh {IWS00001747/5} page 5, paragraph 22; RBKC Gold Group Meeting 20 June 2017 Action Sheet {TMO10033447/3}; Khadija Yahya {IWS00001825/10} page 10, paragraph 50; Mohamed Yahya {IWS00001827/8} page 8, paragraph 33. Some were not told whether it was safe to return1901 Hartley {IWS00001257/11} page 11, paragraphs 41-42; Levi {IWS00001753/12-13} pages 12-13, paragraphs 52 and 53; El-Sawy {IWS00001829/5} page 5, paragraph 22; Yahya {IWS00001825/10} page 10, paragraph 50. and at least one other had been told by RBKC representatives at the Westway Centre that he could not return.1902 Levi {IWS00001753/12} page 12, paragraph 52. On 20 June 2017, Ms Brown sent an email to the BECC to clarify which residents could return home and which could not, so that a clear position could then be communicated to the police.1903 Brown {TMO00869990/15-16} pages 15-16, paragraph 79; {TMO00894213}.
158¶105.62 Overall, the evidence shows that the various bodies involved failed to co-operate properly to ensure that the information they gave about returning residents to their homes was the same.1904 Brown {Day274/182:18}-{Day274/183:22}. That left people without clear information for longer than was necessary, causing further inconvenience and distress.1905 Brown {Day274/182:18}-{Day274/183:22}.
Problems on return
¶105.63 Once residents had returned, Ms Brown's worries about the condition of the properties were borne out. They mainly related to the lack of gas and hot water, which left residents without washing or cooking facilities for a long time. Permanent repairs to locks and doors did not begin until 29 June 2017.1906 Exhibit TB/64 {TMO00894218/3} page 3. The gas supply was restored to all properties except Grenfell Walk by 29 June 2017 and hot water was restored to most, though not all, properties on 4 July 2017.1907 Brown {TMO00894124/26} page 26, paragraphs 95 and 96.
¶105.65 Although RBKC was aware of the steps being taken by the TMO to help the residents, it did not offer any tangible support or resources to meet their needs or assist their return home,1911 Brown {Day274/172:22}-{Day274/173:2}. leaving the TMO to manage the needs of significant numbers of residents. The burden weighed heavily on Ms Brown, despite her not being a member of the TMO's executive team. Mr Black told us that in retrospect it would have been better for RBKC or London Gold to have organised the return of displaced residents after 16 June 2017.1912 Black {Day275/108:4-11}.
¶105.66 In our view, accounting for the significant number of displaced people and enabling them to return to their homes, where that was possible, was too great a task for the TMO, despite Ms Brown's best efforts. Although RBKC was the responder which should have assumed that responsibility, it concentrated its efforts on the needs of the survivors from the tower largely to the exclusion of those who had been evacuated from the surrounding buildings. It is understandable that it should have done so in the initial stages of the disaster, but it should not have taken it long to realise that those who had been hastily evacuated from neighbouring buildings had also been seriously affected and had many of the same needs. As a Category 1 responder, RBKC should in our view have provided more support to the TMO in its efforts to enable the residents of those buildings to return to their homes. The roles and responsibilities of RBKC and the TMO in relation to the residents of the surrounding buildings were never clearly defined. As a result, RBKC did not make additional resources available to the TMO to provide the help they needed, nor did the TMO ask for them.
159The TMO and London Gold
¶105.67 When the London Gold arrangements were put into operation during the afternoon of 16 June 2017 John Barradell took charge of the humanitarian response. Mr Black did not have a working knowledge of the London resilience arrangements or of London Gold's powers and capabilities.1913 Black {Day275/75:4-15}. He did not suggest that a senior member of the TMO's staff should be attached to the London Gold group to help with providing support to residents of the Lancaster West estate,1914 Black {Day275/86:6-12}. nor did he have a personal meeting with Mr Barradell.1915 Black {Day275/79:4-6}. It was his impression that Mr Barradell had taken over the situation and wanted to bring fresh people in.1916 Black {Day275/86:15-20}. Although the TMO had a detailed knowledge of the Lancaster West estate, he thought that it had been regarded as more of a hindrance than a help.1917 Black {Day275/86:21}-{Day275/87:3}.
¶105.68 Mr Barradell accepted that the care of the residents evacuated from properties surrounding the tower fell within the scope of his responsibility and recognised that considerable support was being provided by the TMO.1918 Barradell {Day279/175:12}-{Day279/176:6}. Nevertheless, he did not want it to be part of the arrangements because he did not believe that it had the confidence of the local community. He thought that the necessary functions could be better performed and directed by other people.1919 Barradell {Day279/181:1-9}. He told us that demonstrating that those providing help were independent of the TMO was as much about building confidence as making sure that help was actually delivered.1920 Barradell {Day279/183:8-16}.
¶105.69 The strategic decision by London Gold to keep the TMO at a distance was reflected in the day-to-day contact between them. Ms Brown's contact with London Gold was limited to arranging for one person to carry out an inspection of the fire exits on the Walkways.1921 Brown {Day274/215:19}-{Day274/216:12}. She told us that she did not have any contact with Ms Brownlee1922 At the relevant time, Ms Brownlee was the Director of Housing and Regeneration for Westminster City Council {GOL00000859/2} page 2, paragraph 6; and was leading on the housing response for London Gold; Brownlee {GOL00000859/4} page 4, paragraph 17. or anyone from Westminster Council.1923 Brown {Day274/215:19-22}. We would have expected far greater communication between Ms Brown and London Gold, given that her team was helping to arrange the return of large numbers of residents to the surrounding properties. Everyone was seeking to tackle the problems created by the numbers involved and the difficulties of communication. Ms Brown acknowledged that London Gold had provided assistance to the TMO when it was asked for, particularly in relation to matters such as rebuilding the fire exits at the Walkways,1924 Brown {Day274/202:19}-{Day274/203:4}. but otherwise its involvement was limited to identifying vacant properties which it reported to Graham Webb, the managing director of Repairs Direct.1925 Brown {Day274/174:3-21}.
¶105.70 Mr Black told us that his impression was that London Gold would not help the TMO,1926 Black {Day275/74:14-19}. and although it understood local authorities, he was not confident that it understood how the TMO was structured and how it operated.1927 Black {Day275/74:20-25}. Although Mr Black had initially regarded London Gold's involvement as a positive development,1928 Black {TMO00887150/12} page 12, paragraph 44. he did not think that the TMO had been adequately supported by it. It could have offered more help but decided not to do so and largely left the TMO to get on with it.1929 Black {Day275/110:3-16}; {Day275/112:6-23}.
160¶105.71 Given the central role played by the TMO in supporting the return of residents to properties within the cordon, we think that London Gold should have done more to establish direct contact with it, co-operate with it and provide it with support.
The TMO and the government
¶105.72 On 19 June 2017, officials from several central government departments were deployed to the Westway Centre. Later that day, reservations about the effectiveness of the TMO were voiced for the first time at the ministerial meeting chaired by the Prime Minister.1930 Grenfell Tower Recovery Taskforce Ministerial Meeting Minutes {CAB00002741/3-4} pages 3-4, paragraph 7; Email from Jamie Cowling to Katherine Richardson on 19 June 2017 at 13.27 {CLG00005618/3} page 3.
¶105.73 From 19 June 2017, officials from BEIS were present at the Westway Centre, answering some questions posed by residents and community representatives and relaying others to the government's utilities co-ordination cell.1931 Bassett-James {BEI00002844/3} page 3, paragraph 11. Sebastian Bassett-James, who had been seconded from BEIS to take charge of the team responsible for restoring utilities, found it difficult to contact both RBKC and the TMO, which he understood to be providing the primary response to the fire.1932 Bassett-James {BEI00002844/12} page 12, paragraph 49. He said that the TMO had not provided the help needed to restore the utilities, leaving the residents frustrated for longer than necessary.1933 Bassett-James {BEI00002849/6} page 6, paragraph 21.
¶105.74 Mr Bassett-James said that, although the TMO had had people at the Westway Centre, they had not had authority to make decisions, take action or respond to his team's questions,1934 Bassett-James {BEI00002849/4} page 4, paragraph 15. but Ms Brown told us that her staff at the Westway Centre were able to contact her and Mr Webb to get any necessary authority.1935 Brown {Day274/205:17}-{Day274/206:15}. According to Mr Bassett-James, when members of the BEIS team at the Westway Centre attempted to telephone the TMO their calls went unanswered and voicemails were not returned.1936 Bassett-James {BEI00002849/4} page 4, paragraph 16. By 21 June, BEIS was working with the Department for the Environment, Food and Rural Affairs (DEFRA) and DCLG to identify a point of contact within the TMO. Eventually they were successful.1937 Bassett-James {BEI00002849/6} page 6, paragraph 20.
¶105.75 In the opinion of Mr Black, the government did not understand the nature or role of the TMO or its limitations.1938 Black {Day275/97:4}. For example, emails sent within No.10 on 21 June 2017 commented adversely on the TMO's handling of communications with the residents,1939 Email from Jamie Cowling from No.10 on 21 June 2017 at 09.29 {CAB00005909/1}. but Mr Black told us that during the days immediately following the fire the TMO had not been allowed to communicate with them without the approval of RBKC, which itself had had to be channelled through the Gold group.1940 Black {TMO10048970/2} page 2, paragraph 8; Black {TMO00887150/2} page 2, paragraph 7; Black {Day275/96:19-21}. It seems that No.10 laboured under the misapprehension that the TMO had an extensive formal role which made it necessary or desirable that DCLG intervene to remove it from the situation.1941 Email from Chris Gray on 21 June 2017 at 09.38 {CAB00005909/1}. That was not correct and failed to take proper account of the fact that the TMO was not itself a responder.
161¶105.76 DCLG gained its understanding of the position and effectiveness of the TMO from second-hand reports. On 19 June 2017 Dame Melanie Dawes became aware that concerns were being expressed in some quarters about the performance of the TMO, particularly in relation to restoring heating and hot water to the Lancaster West estate, when they were raised by John Barradell at the Grenfell Recovery Taskforce meeting that day.1942 Dawes {CLG00030653/32} page 32, paragraph 102. However, although those concerns were recorded at governmental level, Mr Black was not made aware of them.1943 Black {Day275/104:12-16}. Mr Barradell told us that he had not raised them with the TMO because they had to be raised at the Grenfell Recovery Taskforce meeting in order for them to be addressed.1944 Barradell {Day279/181:22}-{Day279/182:25}.
¶105.77 At the same meeting a decision was taken that residents who were affected by the lack of hot water and gas should be given hotel accommodation and financial assistance.1945 Ministerial Meeting Minutes on Grenfell Tower fire {CAB00002741/3-4} paragraph 7. However, that decision was not communicated to the TMO, which was responsible for arranging the return of the residents and dealing with matters relating to properties in the blocks that had been evacuated.1946 Black {Day275/78:20}-{Day275/79:1}.
¶105.78 On 20 June 2017, internal DCLG correspondence recounted Ms Brownlee's impression from a "TMO meeting" that the TMO had no leadership, that staff were "drifting around", traumatised and without reliable information on important matters, such as the state of the flats in the Walkways.1947 Email from Sally Randall at 10.50 {CLG00021055/3}. Ms Brown acknowledged that TMO staff were very traumatised by what had happened but maintained that they were concentrating on getting on with the job and doing what they could to support people.1948 Brown {Day274/214:20-24}. She denied that they lacked leadership.1949 Brown {Day274/215:13-18}. Ms Brownlee's impression, as expressed in the DCLG correspondence, had not been informed by any discussion with Mr Black or Ms Brown.1950 {CLG00005723} Teresa Brown did not speak to Ms Brownlee or anyone at Westminster, Brown {Day274/215:1-22}; {Day274/216:9-10}.
¶105.79 Although internal DCLG correspondence recorded that the TMO needed "a new strong Chief Exec, who can provide a single point of liaison, clear information, and strong leadership", neither DCLG nor Ms Brownlee sought to contact Mr Black or the TMO board.1951 {CLG00005723}; Black {Day275/100:15-23}. Mr Black told us that those negative impressions of the TMO had been formed without speaking to it and that, in his view, it had suited the government to blame the TMO.1952 Black {Day275/104:23}-{Day275/105:8}. The decision to remove the TMO had been taken without a clear understanding of its structure or mode of operation or of the legal framework under which it operated.1953 Black {Day275/101:1-17}. His view seems to us to be borne out by the documents we have seen.
¶105.80 Ms Brown did not recall having received any support from central government in the week following the fire.1954 Brown {Day274/203:7-10}. Mr Black told us that, although the structure worked on paper, the scale of the emergency was such that more resources were needed from the government, rather than simply instructions on what should be achieved.1955 Black {Day275/80:8-16}. In our view, there was a tendency for other organisations and departments involved in the response and recovery phases to talk about the TMO rather than to it, and in doing so they left the TMO isolated and unsupported.1956 Black {Day275/112:6-20}. We think that in the days after the fire the TMO was to some extent seen by the government as a useful scapegoat, perhaps to deflect criticism from its own shortcomings in what had evolved into a full-blown humanitarian crisis in the heart of West London.
162Resources and support
¶105.81 Ms Brown told us that she felt she had been adequately supported by the TMO's executive team to enable her to fulfil the various roles that her team had undertaken in the immediate aftermath of the fire. She told us that her manager, Sacha Jevans, had been contactable by telephone to discuss any problems.1957 Brown {Day274/173:3-25}. She also said that, with the benefit of the additional staff arranged by Mr Black by 18 June,1958 Brown {Day274/196:2-23}; {Day274/202:16-18}; Brown {TMO00894124/24} page 24, paragraph 87. she did not feel that the TMO had been under-resourced.1959 Brown {Day274/202:3-12}.
¶105.82 However, we do not think that the senior leadership of the TMO provided sufficient oversight or support to staff who were dealing with the problems in the days immediately following the fire. Although Ms Brown may have felt at the time that she was adequately supported,1960 Brown {Day274/196:21-25}-{Day274/197:1}. she was not aware of the limits of her capacity. Although she could always contact her line manager for support if she felt she needed it, those in positions of greater seniority ought to have taken positive steps to ensure that she and her team had all the support and resources they needed, not least because she had assumed a role for which there was no standing guidance or training and was, in essence, improvising.
¶105.83 Mr Black told us that he had found the scale of the incident personally overwhelming.1961 Black {Day275/27:25}-{Day275/28:7}. As a result, he could not effectively manage the TMO's role in the response. He told us that he had not asked RBKC for more resources,1962 Black {Day275/47:6-13}. because everyone was in a difficult position.1963 Black {Day275/46:22}-{Day275/47:5}. Clearly, however, he should have done so, as he accepted.1964 Black {Day275/45:15}-{Day275/46:4}. He should have also made it known to RBKC that the expectations and demands on the TMO were beyond its capacity.
¶105.84 We accept that one reason for the TMO's failure to seek help for itself was that its senior executives were overwhelmed by the scale, uncertainty and ever-shifting nature of the incident. However, for reasons explored elsewhere in this report, Mr Black's style of management was to rely on his trusted team rather than share problems with those charged with oversight of the TMO, such as its board and RBKC.
¶105.85 Although Mr Black and Ms Brown fell short of what was expected of them in the period following the fire, we recognise that they were seeking to discharge a role that the TMO had assumed voluntarily. The root of the problem was the absence of an emergency plan clearly setting out the relationship between RBKC and the TMO and their respective responsibilities in the event of a major incident.
163Communications with the public
¶105.86 Olivia Hutchison was the head of customer services at the TMO.1965 Hutchison {TMO10048971/1} page 1, paragraph 3. She provided daily email briefings1966 On 14 June 2017 {TMO00869621/2-10}; 16 June 2017 {TMO00869621/16-19}; 20 June 2017 {TMO00869621/30-33} briefings were sent more than once a day; A briefing for the weekend of 17 and 18 June 2017 was sent in advance, on 16 June 2017 {TMO00869621/18-19}. The briefings contained a staff briefing, information about respite centres, contact numbers to redirect residents in need, information on hot water and gas, information on helplines, such as the casualty bureau and housing team, and information regarding donations and volunteering. for the Customer Services Centre team and Pinnacle (the TMO's out of hours contact centre) to assist them in dealing with incoming calls from residents affected by the fire.1967 TMO's out of hours provider {TMO00869621}; Brown {TMO00894124/20} page 20, paragraph 71.
¶105.87 Early in the afternoon of 14 June 2017, Amanda McDuff of Pinnacle asked for advice on dealing with calls in the evening. At 14.15 Ms Hutchison replied that the TMO's main concern was dealing with displaced residents.1968 Email from Olivia Hutchison to Amanda McDuff {TMO00869621/6-7}. She said that customers in need of re-housing should attend the "Westfield Community Sports Centre".1969 Email from Olivia Hutchison to Amanda McDuff on 14 June 2017 at 14.15 {TMO00869621/6}. There is no Westfield Community Sports Centre, but the Westfield retail site was very close to Grenfell Tower. No specific advice was provided for the residents of the surrounding blocks.1970 Email from Olivia Hutchison to Amanda McDuff {TMO00869621/6-7}.
¶105.88 At 17.09 on 14 June 2017, Ms Hutchison told the Pinnacle Team that anyone requiring assistance with temporary accommodation should contact the council's switchboard or go to the rest centres at the Westway Centre, Rugby Portobello Trust or St Clements Church.1971 Email from Olivia Hutchison to Pinnacle team {TMO00869621/8}.
¶105.89 At 17.37 on 15 June 2017, Ms Hutchison told Pinnacle that most residents of the tower had been placed in temporary accommodation but that residents from the surrounding buildings had still not been able to return to their homes due to fears for their safety.1972 Email from Olivia Hutchison to Pinnacle team {TMO00869621/11-12}. She said that the police had started letting some residents return, but that Hurstway Walk, Barandon Walk, Grenfell Walk, Testerton Walk and Treadgold House were all without hot water and would be without gas for cooking.1973 Email from Olivia Hutchison to Pinnacle team {TMO00869621/11-12}. In messages sent on 16 and 17 June 2017 Ms Hutchison identified which flats in each block could be re-occupied.1974 Emails from Olivia Hutchison to Pinnacle team, TMO staff and other London Boroughs {TMO00869621/18-24}.
¶105.90 On 19 June 2017, there were further briefings referring to the lack of hot water and cooking facilities. A briefing released at 10.22 on 19 June 2017 directed residents who required emotional support to the NHS's Single Point Access for Mental Health.1975 Email from Olivia Hutchison to the Customer Services Centre team and TMO staff {TMO00869621/26-27}. None of the briefings provided to Pinnacle referred to financial support.1976 Various emails from Olivia Hutchison providing updates to Customer Services Centre team, Pinnacle team, TMO staff and London Boroughs {TMO00869621/2-34}. In our view, the TMO should have told Pinnacle about the financial support available far earlier.
¶105.91 In the first few days after the fire the TMO tried to contact residents by knocking on doors and telephoning them, but no written communication was circulated until 22 June 2017.1977 Brown {TMO00894124/28} page 28, paragraph 103; {TMO00869984}. That letter was sent without London Gold's approval,1978 Brown {TMO00894124/28-29} pages 28-29, paragraph 105. even though formal communications with residents required his permission.1979 Brown {Day274/190:12-17}. A number of residents had asked for written communication and TMO staff drafted information briefings for approval,1980 Email thread {TMO10035589/58-59} email from Kiran Singh on 21 June 2017 at 10.45 entitled 'Comms to residents.' but nothing further in writing was sent out until 27 July 2017.1981 {TMO00869985} it should also be noted that the TMO sent their second briefing to London Gold for approval on 12 July, 20 days after the first briefing {TMO00894179/1-2}. The delay was caused by the need to obtain the approval of London Gold.1982 Brown {Day274/190:17-23}. Written communications were originally intended to describe what was planned, but eventually became a record of what had been done,1983 Brown {TMO00869990/18} page 18, paragraph 93. which was of little practical assistance to residents.1984 Brown {TMO00869990/18} page 18, paragraph 93.
164 165Chapter 106: Voluntary, community and faith sectors
Introduction
¶106.1 The evidence provided by local community leaders and representatives of the British Red Cross gave us a valuable insight into the assistance that they provided in the immediate aftermath of the fire. It is apparent that that assistance was required in order to fill a space which should have been occupied by RBKC.
¶106.2 We received 24 witness statements from individuals representing a range of local community organisations, charities and places of worship. Clare Richards, chief executive of the Clement James Centre, and Mark Simms, chief executive of the P3 Charity Group (of which the Rugby Portobello Trust is a part) gave evidence in person. Other organisations involved in the humanitarian response included the Al Manaar Muslim Cultural Heritage Centre, the Latymer Community Church, St Francis of Assisi Catholic Church, Notting Hill Methodist Church and the Harrow Club.
¶106.3 The evidence of witnesses from the local community painted a picture that portrays the very best of humanity. People from different backgrounds, faiths and communities came together in the face of grievous tragedy. They offered compassion, dignity and hope to the bereaved, survivors and the wider community. Their spontaneous response is a testament to the strength and resilience that characterises the North Kensington community. We pay special tribute to it.
A spontaneous community response
¶106.4 As a Category 1 responder RBKC was required to have regard to the voluntary sector organisations carrying out activities in the geographical area for which it was responsible.1985 The Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 {CAB00007003/13} Regulation 23; See also Emergency Preparedness, Chapter 14 – The Role of the Voluntary Sector {CAB00004534/3-5} paragraphs 14.3 - 14.17. The Emergency Preparedness guidance provides that:
"Category 1 responders must consider and discuss with relevant organisations the capabilities that those organisations within their area have to offer, and whether those capabilities should be built into response and recovery plans. Agreements reached should be captured in plans and signed off by all affected parties."1986 Emergency Preparedness, Chapter 14 – The Role of the Voluntary Sector {CAB00004534/4} paragraph 14.6.
¶106.5 Although the British Red Cross is neither a Category 1 nor Category 2 responder,1987 Adamson {BRC00000075/28-29} pages 28 - 29, paragraph 129. Michael Adamson, its chief executive, told us that it is recognised by the government as a voluntary society with a function auxiliary to that of the public authorities.1988 Adamson {BRC00000075/5} page 5, paragraph 24. That recognition establishes a relationship between the Red Cross and the government, such that, without being dependent on it, the Red Cross is required to have regard to the needs of the government when carrying out its primary responsibility to alleviate suffering in emergencies.1989 Adamson {BRC00000075/5} page 5, paragraph 24.
166¶106.6 RBKC had an established arrangement with the Red Cross but it failed to involve important community organisations in its contingency planning arrangements.1990 Simms {Day275/182:4-19}. It had no plans for the participation of community organisations in North Kensington and had not identified a function for any of them if an emergency occurred.1991 The Clement James Centre was on a list of centres in RBKC's Contingency Management Plan that would be opened in the event of an emergency to offer space but RBKC did not ask for it to be opened in response to the Grenfell Tower fire: Richards {CFV00000012/2} page 2, paragraph 5. Although RBKC had some limited engagement with larger voluntary organisations, it had not asked community leaders to become involved in a community resilience strategy, despite the willingness of many of them to take part.1992 Simms {Day275/182:10-14}; Richards {Day275/125:10-21}. This failure is particularly significant, given that local community organisations came to play a central part in the response to the fire.
¶106.7 RBKC also failed to engage with and make full use of those organisations after the fire had occurred.1993 Simms {Day275/182:20-23}. There was little or no consideration given to the value that local community organisations could provide in responding to the fire. They had an understanding of the history, character and diversity of the North Kensington community that larger voluntary organisations, such as the Red Cross, lacked.1994 Richards {Day275/169:1-8}. It was the existing relationships and trusted networks that enabled local community organisations to cater for the particular needs of those affected, and to do so in sensitive, informed and specific ways. Not only was RBKC unable to do that itself; it lacked the willingness and the skill to recruit the local community networks to help it.
¶106.8 As a result, the community response was entirely voluntary and self-generated.1995 Simms {Day275/182:20}-{Day275/183:2}; Richards {Day275/127:25}-{Day275/128:2}. In the early hours of 14 June 2017, community organisations opened their doors to provide shelter and sanctuary for those affected by the fire,1996 Sayed {CFV00000043/2} page 2, paragraph 7. despite the absence of any request from RBKC or the police. Community organisations were not aware of any co-ordinated response by the council;1997 Richards {CFV00000012/15} page 15, paragraph 104. nor were they asked to be part of one.1998 Richards {Day275/165:8-11}.
¶106.9 In the absence of any plan or official co-ordination, community organisations faced significant challenges in providing support to those affected. Community leaders were faced with hundreds of distressed people, not knowing whether emergency accommodation would be available for the coming night.1999 Richards {Day275/141:16-23}. Ms Richards from the Clement James Centre told us that she thought that, given the scale of the emergency, a team of people from the council would come to co-ordinate arrangements, but unfortunately that did not happen.2000 Richards {Day275/127:18-24}.
¶106.10 In the early hours of 14 June 2017 and throughout that day, community rest centres were packed with crowds of survivors, people searching for loved ones and shocked local residents evacuated from their homes.2001 Blanchflower {CFV00000045/3} page 3, paragraph 12. People could not obtain information about who had escaped from the tower, who was in hospital and who was still missing, which was particularly distressing.2002 Blanchflower {CFV00000045/3} page 3, paragraph 12. It was very difficult to know where to look for the missing or obtain reliable information to provide support to those in need.2003 Hisam Choucair {Day265/45:22}-{Day265/52:8}; Nabil Choucair {Day267/10:15}-{Day267/26:12}. Information was available only by word of mouth, but the situation was constantly changing.2004 Blanchflower {CFV00000045/3} page 3, paragraph 13. Despite expecting to be told what to do and to be a part of a co-ordinated plan, community leaders were left to support people with whatever resources they could muster.2005 Blanchflower {CFV00000045/7-8} pages 7 - 8, paragraph 28.
167¶106.11 Community organisations struggled to obtain information from official sources about what services were available.2006 Skinner {CFV00000002/7} page 7, paragraph 21. Organisations like the Clement James Centre, the Harrow Club and the Al Manaar Muslim Cultural Heritage Centre were trying to find out what was going on, without success.2007 Simms {Day275/210:2-6}. Mark Simms of the P3 charity told us that there had been no plan and that he had had no idea what the next day would bring, given that there was no communication from any official body about what to do.2008 Simms {CFV00000005/11} page 11, paragraph 48. He tried to contact the council BECC on 14 June 2017 but could not get hold of anyone by telephone or email.2009 Simms {Day275/185:18-20}. By the end of the day he still had not received any information from the council about the official response.2010 Simms {Day275/198:9-12}. Indeed, he said that even at the time he was giving evidence he was still waiting to find out what the longer term plan was.2011 Simms {Day275/198:25}-{Day275/199:1}. Day 275 was 10 May 2022.
¶106.12 Community leaders described the involvement of RBKC in the first few days as a "chaotic fog, in which little information was available".2012 Long {CFV00000010/6} page 6, paragraph 31. The absence of any overall co-ordination of the relief effort was regarded as astonishing.2013 Long {CFV00000010/6} page 6, paragraph 31. They said that the lack of information had compounded the distress for people in rest centres, with community leaders unable to provide any information or reassurance. The consequence was that people already facing so much stress were left to feel that nobody cared for them.2014 Richards {Day275/141:22-23}; Richards {Day275/164:4-14}. These are, of course, general impressions conveyed to us long after the event rather than recollections of particular circumstances, but they are consistent with other, more specific, evidence.
¶106.13 Community leaders told us that in the days following the fire local organisations providing a humanitarian response had received little support from RBKC, the government or the TMO. Three days after the fire, Abdurahman Sayed from the Al Manaar Muslim Cultural Heritage Centre told councillors that they were struggling to cope with the logistical demands of dispensing large volumes of donations, organising volunteers and providing support to those relying on their services. Despite a request for assistance, the Al Manaar Muslim Cultural Heritage Centre received no support from RBKC.2015 Sayed {CFV00000043/4} page 4, paragraph 17. Community leaders shared the frustration of those who felt that the council and the government were absent at a time where they were needed most. Any support that did come was often too little, too late.2016 Sayed {CFV00000043/8} page 8, paragraph 35; Sayed {CFV00000043/5} page 5, paragraph 22.
¶106.14 The experience of the community, voluntary and faith groups was that the authorities kept their distance and were slow to respond to the immediate needs of those affected by the fire. There was a clear need for an overall plan but instead, people were left to fend for themselves and not surprisingly they turned to the voluntary and faith sector and other organisations they trusted to fill the gap.2017 Blanchflower {CFV00000045/10} page 10, paragraph 41; Blanchflower {CFV00000045/3} page 3, paragraph 13.
168¶106.15 The following provides an indication of the support provided by some of the leading community organisations in what has been aptly described as a spontaneous outpouring of compassion.2018 Skinner {CFV00000002/1} page 1, paragraph 2.
Rugby Portobello Trust
¶106.16 The Rugby Portobello Trust provides support for young people in North Kensington and is located 400 yards from Grenfell Tower.2019 Simms {CFV00000005/1-2} pages 1 - 2, paragraphs 5 and 6. It suspended its normal services in order to assist survivors from June until October 2017. It supported about 210 people representing 165 households from Grenfell Tower and Grenfell Walk.2020 Simms {Day275/200:6-10}; {Day275/204:6-11}. It offered assistance of various kinds to survivors, including the provision of clothing, food, money, accommodation and medical assistance, as well as a pop-up pharmacy and temporary doctor's surgery.2021 Simms {Day275/199:7-16}. It also provided help with obtaining identification documents, access to bank accounts and technology.2022 Simms {Day275/185:21}-{Day275/186:6}; Simms {CFV00000005/18} page 18, paragraph 84. Subsequently, the Rugby Portobello Trust organised a scheme providing survivors with smartphones, laptops, televisions, kettles and microwaves.2023 Simms {Day275/199:21}-{Day275/200:4}. During the first week, it obtained about £80,000 in cash which it distributed to those in need.2024 Simms {Day275/186:11-16}. Later, at the request of the Charity Commission, it distributed payments in partnership with the National Zakat Foundation, a Muslim charity involved in the humanitarian response.2025 Simms {CFV00000005/14} page 14, paragraph 64. The Rugby Portobello Trust issued over 3,200 separate grants totalling more than £16.8 million from funds generated by public donations.2026 Simms {Day275/200:24}-{Day275/201:3}.
¶106.17 In its response to the disaster the Rugby Portobello Trust focused on the importance of dignity in providing humanitarian support.2027 Simms {Day275/188:1-16}. That entailed ensuring that survivors had access to money, rather than just donated goods, in order to give them the ability to regain an element of control over their own lives.2028 Simms {CFV00000005/8} page 8, paragraph 36; Simms {Day275/187:15}-{Day275/188:16}.
The Clement James Centre
¶106.18 The Clement James Centre is a local charity situated adjacent to the Lancaster West estate that supports the community through education, employment and wellbeing programmes.2029 Richards {CFV00000012/1} page 1, paragraph 3. In the immediate aftermath of the Grenfell Tower fire, it provided food, distributed donations, provided access to information, collected prescriptions, obtained offers of accommodation which it allocated to those in need and created a list of those who were safe and missing.2030 Richards {Day275/129:3-15}; Richards {CFV00000012/2} page 2, paragraph 7. On 14 June 2017 the Clement James Centre was also involved in arranging emergency accommodation for people who had been displaced from the tower or surrounding blocks and had still not been told that they would be provided with accommodation.2031 Richards {Day275/145:1-9}.
169Al Manaar Muslim Cultural Heritage Centre
¶106.19 The Al Manaar Muslim Cultural Heritage Centre is a place of worship that also provides cultural education and outreach.2032 Sayed {CFV00000043/1} page 1, paragraph 2. Its response included the provision of food and water and the distribution of donations.2033 Sayed {CFV00000043/4} page 4, paragraph 13. As the fire occurred during Ramadan, the mosque was already catering for about 300 people every evening. That increased to about 600 people a day after the fire.2034 Sayed {CFV00000043/4} page 4, paragraph 12. It later helped to provide services such as counselling, art therapy and survivors' groups.2035 Sayed {CFV00000043/6} page 6, paragraph 27.
Other voluntary organisations
¶106.20 A number of other local community, voluntary and faith organisations also provided direct and immediate support. They included the Notting Hill Methodist Church, which provided a base for emergency relief in the first few days following the fire. It was particularly involved in the provision of clothes and toiletries to those from the Walkways and Grenfell Walk.2036 Long {CFV00000010/7} page 7, paragraph 34. The church helped those looking for missing loved ones to make posters appealing for information. The St Francis of Assisi catholic church offered a variety of support to those affected, including food and drink, spiritual and emotional support, practical assistance, such as mobile phone chargers, and the distribution of financial and other donations.2037 Skinner {CFV00000002/2-3} pages 2 - 3, paragraph 5. Local organisations sought to ensure that dignity, compassion2038 Richards {Day275/128:9-23}. and sensitivity to specific needs was at the centre of their response.
¶106.21 The Al Manaar Muslim Cultural Heritage Centre was well known and respected within the local Muslim community and provided support for those with specific needs in relation to prayer, clothes, food and observing Ramadan.2039 Sayed {CFV00000043/3} page 3, paragraph 9. That was particularly important, given that many of those affected were of the Muslim faith. Similarly, the Latymer Community Church provided a safe space, refreshments, and someone for people to talk to. A Muslim prayer room was set up within the church for those observing Ramadan. It started a memorial wall where people left messages and flowers and which became a focal point for the community.2040 Blanchflower {CFV00000045/4-5} pages 4 - 5, paragraph 17. Their actions acknowledged the importance of a humanitarian response that was sensitive to faith and culture and put that into action.
Official meetings
¶106.22 In the days and weeks that followed the fire, community leaders were involved in meetings with officials at various levels of government. An examination of those official meetings provide an insight into how the government was engaging with the community and a strong indication of the fundamental and pervasive problems that persisted in the humanitarian response, at least in the days after the fire.
¶106.23 The then Prime Minister, the Rt Hon Theresa May MP, attended the Clement James Centre on 16 June 2017 for an impromptu meeting.2041 Richards {Day275/152:21-25}. The purpose of the meeting was unclear, and the staff at the centre were given only 15 minutes' notice.2042 Richards {Day275/153:4-5}. The perception was that the Prime Minister was listening to what people had to say and gave everyone a chance to speak.2043 Richards {Day275/154:10-11}. However, not a great deal was achieved, not least because the meeting was cut short by the Prime Minister's security team due to crowds forming outside the church.2044 Richards {Day275/154:10-17}.
170¶106.24 A further meeting was arranged at 10 Downing Street on 17 June 2017 with the same people.2045 Richards {Day275/154:17-24}. Among the matters raised was the need for highly visible hubs2046 Notes from the meeting with Theresa May on 17 June 2017 {CFV00000041}. to be set up in the local area providing housing, legal support, counselling, police family liaison officers, financial support,2047 Richards {Day275/155:6-14}. psychological support and translators to ensure accessibility of information.2048 Richards {Day275/159:10}-{Day275/160:7}.
¶106.25 A particular complaint was that the people making the decisions were not communicating with those who were affected.2049 Richards {Day275/157:6-9}. London Gold, who had by then taken over leading the response, had not reached out to the community rest centres.2050 Richards {Day275/157:12-14}. There was a view amongst residents that people's experiences needed to be captured, which they suggested could be done through consulting a representative group of residents about their needs.2051 Richards {Day275/156:25}-{Day275/157:2}; Notes from the meeting with Theresa May on 17 June 2017 {CFV00000041}. However, nothing came of that suggestion.
¶106.26 A further meeting took place on 20 June 2017 with Hilary Patel from the London Gold team at which various people from the voluntary sector and council officers were present.2052 Richards {CFV00000012/23} page 23, paragraph 153. There was widespread dissatisfaction about the absence of further information or a commitment to resolve any of the problems that those affected were facing.2053 Richards {Day275/163:7-9}; Simms {Day275/202:16}-{Day275/203:3}; Simms {CFV00000005/13} page 13, paragraph 60. Mr Sayed of the Al Manaar Muslim Cultural Heritage Centre, who continued to be involved with official meetings in the days and weeks following the fire, felt that representatives were not properly prepared2054 Sayed {CFV00000043/5-6} pages 5 - 6, paragraph 23. to address the wishes of residents. Those affected were left with the sense that the council and the government simply did not care.2055 Sayed {CFV00000043/6} page 6, paragraphs 24 and 25.
¶106.27 Despite the fact that the community organisations were not designed to respond to an emergency, they played a central role in meeting the immediate needs of those affected by the fire.2056 Sayed {CFV00000043/8} page 8, paragraph 34. However, because of the failure of RBKC and the apparatus of London Resilience to act with the necessary speed, the Rugby Portobello Trust and other community organisations found themselves leading actors in the response to the fire.2057 Simms {Day275/214:4-8}.
¶106.28 Those directly affected spoke positively of the community's response.2058 Yousuf {IWS00001626/4} page 4, paragraph 25; Razza {IWS00001607/8-9} pages 8 - 9, paragraph 41; Sobieszczak {IWS00001562/12} page 12, paragraph 54. Mohammed Rasoul said, "The public's response in the tragedy was something I'll never forget for the rest of my life. To me, that represented what humanity should strive for… there were no barriers…everyone was proud of their identity, of their diversity…it wasn't a barrier…in that moment you had something that we could all strive for in this society [that] we should be proud of."2059 Rasoul {Day265/165:3-22}.
171Chapter 107: Conclusions
The human factor
¶107.1 No response to an emergency can be considered effective if it leaves those whom it is supposed to serve feeling abandoned and bereft. Yet that was the experience of very many of the people who had lost their homes in the Grenfell Tower fire or whose loved ones had lost their lives in it. Their experiences, described in their own words in Chapter 100, attest vividly to the failure of the system, but within the community in North Kensington the official response to the fire also served to confirm a deep distrust of those in authority, the existence of which long predated the fire. The community's perception was that in the days that followed the fire there was an absence of leadership,2060 Ramirez {IWS00002061/7} page 7, paragraph 46. no central structure and nobody effectively in charge.2061 Murphy {IWS00001722/5} page 5, paragraph 25. Those who had been displaced suffered at first hand from the lack of co-ordination between the various organs of central and local government which should have been able to meet their needs but instead demonstrated an inability to deal adequately with a tragedy on the scale that confronted them.2062 Ali {IWS00001617/13} page 13, paragraph 165.
Subsidiarity
¶107.2 The Grenfell Tower disaster shows that the principle of subsidiarity, which lies at the heart of the arrangements for responding to civil emergencies, is both its strength and its weakness. In general, the local authority, in conjunction with the emergency services, is usually best placed as a result of existing structures, familiarity with local conditions and knowledge of the communities affected, to respond effectively to an emergency, particularly one that is confined to a relatively small area. Even in cases where a larger area is involved, such as widespread flooding, the local authority is likely to be best placed to organise both the immediate response and the subsequent recovery. However, its effectiveness depends on four things: (i) the existence of an emergency plan that has been well thought out, is well understood by those who have to implement it and has been practised with sufficient frequency and rigour to ensure that it can be put into operation without undue delay; (ii) sufficient human and financial resources to enable the plan to be implemented; (iii) a chief executive with the necessary skills and strength of character to take control of the situation with the support of senior officers who are capable of taking responsibility for different aspects of the plan's implementation; and (iv) an understanding within the organisation of the importance of resilience and a commitment to achieving it.
¶107.3 Unfortunately, in the present case all four of those requirements were lacking. RBKC did not have an effective emergency plan that was directed to the displacement of a large number of people from their homes and such plan as it had did not make effective use of the TMO. In our view that is a serious criticism of a local authority responsible for resilience in a densely populated urban area containing many large residential buildings, in some cases in close proximity to each other. Fire is only one of a number of hazards that might necessitate the evacuation of a large number of people who would then require temporary accommodation. RBKC's plans did not include a system for obtaining a large amount of emergency accommodation at short notice. Nor, significantly, did it make any provision for identifying those who had been evacuated or for communicating with them. Arrangements for obtaining reliable information and disseminating it was also lacking.
172¶107.4 The absence of a good plan was compounded by the failure of RBKC to train its staff adequately. The necessary understanding of the importance of resilience and commitment to it were missing. Exercises were not held regularly and staff were not required to attend the training sessions run by the London Resilience group. Deficiencies which were well known to the senior management were not corrected. As a result, when disaster struck there was no semblance of a well-oiled machine that could move into action with the minimum of delay.
¶107.5 Financial resources do not appear to have been unduly constrained, but in this case RBKC lacked the personnel needed to administer the response effectively, both for the purposes of staffing the BECC and to deal with those who needed help.
¶107.6 Finally, RBKC did not have the benefit of a chief executive capable of taking control of the situation, understanding the magnitude of the task facing it and mobilising support of the right kind without delay. Mr Holgate was suddenly confronted with an enormously difficult situation without the benefit of a clear plan and with imperfect information at his disposal. However, the fact remains that he was not well-suited to dealing with the crisis that was unfolding in front of him. Nor did he have the benefit of a strong group of officers to whom he could delegate responsibilities for some aspects of the response. He was reluctant to take advice from those with greater experience and was unduly concerned for RBKC's reputation. His mishandling of the situation demonstrates a dangerous weakness in the arrangements for responding to civil emergencies generally.
¶107.7 Some of those weaknesses could and should have been avoided by better preparation, but in many cases the mettle of the chief executive will not have been tested before a crisis erupts. As this incident demonstrated, it is difficult to force the hand of a chief executive who does not recognise his own or his authority's limitations. Whatever may be the effect of the London Gold arrangements, everyone accepted that they could not be activated otherwise than at the request of the local authority concerned. That was obviously frustrating for many, including the government, but was the consequence of their being a voluntary arrangement.
¶107.8 The government has wide powers under the Civil Contingencies Act to give specific directions to a Category 1 responder to perform its functions for the purpose of reducing, controlling or mitigating the effects of an emergency and such orders may require that person to collaborate with another or to delegate functions to another (section 5); and in a case of urgency the minister can give similar directions in writing. Although the government does, therefore, have the power to override the principle of subsidiarity, the use of those powers does not appear to have been considered in this case, perhaps because once John Barradell had taken control it was thought that no more could usefully be done to manage the response.
London Resilience
¶107.9 The structures of London Resilience, through which individual London boroughs perform their duties as Category 1 responders, are complex and, at least to the outsider, difficult to understand, being bedevilled by jargon and acronyms. That of itself does not matter, of course, if they are understood by those who must use them and operate effectively. There is reason to think, however, that there is a misunderstanding, both among some in local authorities and in government, about the effect of the Gold resolution. On its face, the Gold resolution is limited to authorising expenditure under section 138 of the Local Government Act 1972. Mr Barradell, who has considerable experience in matters relating to London Gold, was well aware that invoking the Gold resolution did not give London Gold power to take control of the response, which remained in the hands of Mr Holgate while he chose to exercise it. Indeed, Mr Barradell was not the chief executive designated to act as London Gold on 16 June 2017 and was therefore not the person who would have taken charge under those arrangements in any event.
173¶107.10 The introduction of Mr Barradell to take control of the response owed little to the machinery of London Resilience or the operations of the Gold arrangements and much to the personal intervention of Dr Farrar and the influence of Mr Barradell himself in persuading Mr Holgate to step aside in his favour. That was not something envisaged by the standing arrangements and could not have been imposed on RBKC otherwise than by ministerial order. It points to a defect in the arrangements governing resilience, not only in London but potentially more widely. There was, and as far as we know still is, no derogation from the principle of subsidiarity within London, and the same presumably applies in the case of other large conurbations. Whether that should remain the case is a matter for the boroughs and the government to consider.
Communications
¶107.11 One thing that the disaster emphasised above all others was the need following a major emergency for rapid and reliable communication between those responsible for the response and those needing assistance. That requires planning, but with the aid of modern methods of communication should be capable of being achieved without too much difficulty unless there has been significant disruption to the internet and mobile telephone system. One of the most common complaints we heard from those that had been displaced was that they felt cut off or abandoned. It is clear to us that more thought and preparation needs to be put into establishing and operating communication points accessible to those affected by the incident, enabling them to be kept informed of developments and those attempting to provide support to gather vital information. Given the enormous importance of effective communications, emergency plans need to take into account the range of languages spoken in the locality.
The role of government
¶107.12 Although from the outset the government was keen to assist the response, its effectiveness was undermined by a shortage of reliable information and by its limited powers to intervene. The machinery as we have described it was in place to enable information to be obtained from those directly involved in the response but it did not work as well as intended. The government can, of course, provide a local authority dealing with an emergency with resources of all kinds, if it is minded to do so, but the statutory structure does not give it the power to play an active role in the response, short of invoking the powers under sections 5 and 7 of the Civil Contingencies Act. The powers are far-reaching, but cumbersome in operation and not well suited to taking control of the response when the local authority is failing or just not managing the response in what the government considers to be the best way. The government, particularly senior ministers, can bring a great deal of influence to bear but that is not the same as being able to take decisions.
174The TMO
¶107.13 The TMO was not formally a responder and had not been integrated into RBKC's emergency plan. That represented a significant failing on the part of RBKC because it held, or should have held, a lot of important information about the occupants of the tower and the surrounding buildings. The fact that the information it held was not as complete or reliable as it could or should have been detracted from its ability to assist those seeking to provide support to displaced residents, but RBKC should have realised that the TMO's close knowledge of the buildings and their occupants had an important part to play in any response to a disaster affecting any part of its housing stock.
¶107.14 Although it was not formally part of the response, either as a responder under the Act or under RBKC's emergency plan, the TMO threw itself into the response and helped to provide support, insofar as it was equipped to do so. It attracted a great deal of criticism from various quarters for its actions and omissions in the days following the fire, not all of it fair. We can understand why the hostile attitude of the residents towards it led Mr Barradell to keep it at arm's length, but we think that some of those within government who criticised it did not properly understand its position or the scope of its powers. There was a tendency to view it simply as a part of RBKC, which was seen quite quickly as a failing authority. Many of the difficulties encountered in returning residents to flats in the Walkways were not of its making. We think that to some extent it was convenient for London Gold and RBKC to leave solving the problems associated with restoring the Walkways to a habitable condition to the TMO. In our view Teresa Brown and her team, who went to some of the rest centres on 14 June 2017 to give what help they could, are to be commended for their willingness to become directly involved and the efforts they made at what was a very difficult time.
The local community
¶107.15 The people who emerge from the events with the greatest credit are the members of the local community, who, with the support of local voluntary organisations, provided support in the hours immediately following the fire when the authorities were conspicuous by their absence. Although their willingness and ability to organise themselves effectively at short notice may have been exceptional, and is deserving of the highest praise, we think it likely that many local communities would rise to the challenge if the opportunity presented itself. The ability to harness the energy, skills and goodwill of the community should not be overlooked when planning an emergency response.
175Part 11: Matters outstanding from Phase 1
177Chapter 108: Introduction to Part 11
¶108.1 In the Phase 1 report the Chairman concluded that, although there were many different factors, the main reason why the flames spread so rapidly up Grenfell Tower was the presence of ACM panels with polyethylene cores which melted and acted as a source of fuel for the growing fire. He also concluded that it was more likely than not that the presence of polyisocyanurate (PIR) and phenolic foam insulation contributed to the rate and extent of the vertical spread of flame, but that it was not possible at that stage to quantify their respective contributions.2063 Phase 1 Report, Volume IV, paragraph 23.52. He indicated that further work would be done during Phase 2 to gain a better understanding of how the materials behaved in conjunction with each other when exposed to fire. Further work also needed to be done to understand the extent to which exposed edges of the ACM panels and insulation boards may have contributed to the spread of flame.2064 Phase 1 Report, Volume IV, paragraphs 23.52 and 32.62.
¶108.2 In order to reach a better understanding of those matters, at our request a series of experiments was devised by Professors Bisby and Torero which were carried out by Professor Bisby and his colleagues at Edinburgh University. They included testing each material or product in isolation in order to understand its particular burning characteristics, followed by the testing of a series of models designed to shed light on the behaviour in fire of a ventilated rainscreen external wall system containing materials of the kind used on Grenfell Tower. The experiments were designed to enable them to identify the properties of both the individual constituents and the system as a whole that were most relevant to the growth and spread of fire at Grenfell Tower.
¶108.3 The work carried out by Professors Bisby and Torero is described in detail in their reports.2065 Bisby, Phase 2 Materials Testing Report {LBYMT00000002}; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002}; Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001}; Torero, Phase 2 Report {JTOR00000006/66-78} paragraphs 9.0.1- 9.3.16. Professor Bisby also gave oral evidence about it.2066 Bisby {Day289/105:10}-{Day289/186:20}; {290/9:11}-{Day290/84:2}. In the space available to us we cannot describe their work in detail, but we have sought to draw out the important conclusions that emerge from their experiments. We are extremely grateful to Professor Bisby and Professor Torero and to all the others who were involved in helping with the experiments. The work they have produced is immensely valuable and helps to explain what caused the rapid spread of flame over the external wall of Grenfell Tower. We hope that the information derived from their experiments will assist others who may be designing ventilated rainscreen walls in the future.
¶108.4 At the end of Phase 1 there remained a degree of uncertainty about the mechanism by which the fire escaped from the kitchen of Flat 16 into the external wall as a result of a reconstruction carried out by BRE. The chairman indicated that when the full information had become available he would ask Professor Bisby and Professor Torero to prepare supplementary reports. That they have since done, as described in Chapter 110.
179Chapter 109: Testing the materials
¶109.1 In his Materials Testing Report2067 Bisby, Phase 2 Materials Testing Report {LBYMT00000002}. Professor Bisby described the tests carried out under his supervision on a number of the important materials and products used in the external cladding system at Grenfell Tower. They included: a. Reynobond 55 PE ACM rainscreen panels (ACM PE); b. Celotex RS5000 foil-faced polyisocyanurate polymer foam insulation; c. Kingspan K15 foil-faced phenolic polymer foam insulation; d. Aluglaze extruded polystyrene polymer foam window infill panels.2068 Bisby, Phase 2 Materials Testing Report {LBYMT00000002/2} paragraph 4; Bisby, Phase 2 Materials Testing Report {LBYMT00000002/14} paragraph 79 and Table 1.
Aims and objectives
¶109.2 The purpose of the tests was to record fundamental physical information about the materials and products and to assess their key characteristics and properties in fire.2069 Bisby, Phase 2 Materials Testing Report {LBYMT00000002/2} paragraphs 6-8. In particular, the testing aimed to quantify the thermal responses of the materials and thereby to provide information that would be relevant to understanding the contribution of each material to ignition, fire growth and fire spread during the fire at Grenfell Tower.2070 Bisby, Phase 2 Materials Testing Report {LBYMT00000002/30} paragraph 135. The tests were undertaken both at the University of Edinburgh by Professor Bisby and, to a more limited extent, by BRE.2071 Bisby, Phase 2 Materials Testing Report {LBYMT00000002/2} paragraph 2; Bisby, Phase 2 Materials Testing Report {LBYMT00000002/7} paragraph 29; Bisby, Phase 2 Materials Testing Report {LBYMT00000002/30} paragraphs 138-142.
Methods
¶109.3 Four methods of thermal analysis testing were used.2072 Bisby, Phase 2 Materials Testing Report {LBYMT00000002/30} paragraphs 138-142. Each of them subjected a material or product to heat in a controlled environment and measured the changes that took place in various properties of the material during the heating process.2073 Bisby, Phase 2 Materials Testing Report {LBYMT00000002/30} paragraph 137. We explain briefly below the information provided by each of the four methods. a. Bomb calorimetry
This method measures the gross heat of combustion of a material, i.e. the total heat released.2074 Bisby, Phase 2 Materials Testing Report {LBYMT00000002/31} paragraphs 152-156.
¶b. Thermogravimetric analysis This analysis, undertaken in both reactive (air) and inert (with no oxygen) environments, measures the mass of a material and the rate at which mass is lost.
180¶c. Cone calorimetry This test calculates the heat release rate of a material. It can also measure the critical heat flux required for ignition, that is, the amount of heat that must be applied to the material in order to make it burn.2075 Bisby, Phase 2 Materials Testing Report {LBYMT00000002/35} paragraphs 176-179.
¶d. Dynamic Mechanical analysis This test measures the mechanical response of a material when subjected simultaneously to heat and mechanical stress. Data about changes in various mechanical properties of the material, such as stiffness, can be used to infer physical or chemical changes which have occurred in response to an increase in temperature.2076 Bisby, Phase 2 Materials Testing Report {LBYMT00000002/35-36} paragraphs 182-185.
The results
¶109.4 The tests disclosed no unexpected results, given the properties of the materials tested and the information available on similar materials.2077 Bisby, Phase 2 Materials Testing Report {LBYMT00000002/38} paragraph 191; Bisby, Phase 2 Materials Testing Report {LBYMT00000002/57} paragraph 276; Bisby, Phase 2 Materials Testing Report {LBYMT00000002/61} paragraph 288; Bisby, Phase 2 Materials Testing Report {LBYMT00000002/67} paragraphs 320-321; Bisby, Phase 2 Materials Testing Report {LBYMT00000002/68} paragraphs 326-331. Nothing in Professor Bisby's work was challenged and we accept the validity of his conclusions.
Regimes of Burning
¶109.5 In his report Work Package 1 – Regimes of Burning2078 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002}. Professor Bisby assessed how each of the four products used in Grenfell Tower's external wall responded to fire when tested in isolation. Over 150 separate experiments were carried out as part of that exercise.2079 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/4} paragraph 16. They were directed to demonstrating and understanding the complexity of the products' response to heating (both thermal and mechanical) under a range of heating and fixing conditions. The work was also intended to develop an understanding of the various thermal and mechanical factors that were relevant to the subsequent system experiments, to provide an understanding of how the different products burned under different conditions and to provide additional background information.2080 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/2-3} paragraphs 8-12; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/12} paragraphs 72-74. The tests were designed to answer questions relevant to quantifying the contributions of different products to the spread of fire at Grenfell Tower.2081 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/12} paragraph 75.
¶109.6 The report contains a detailed description of the responses of the four products to heating that we do not repeat here. (Those who are interested can read Professor Bisby's report on the Inquiry's website.) Instead, we list the important conclusions to be drawn from that work, taking each of the four products in turn. Again, nothing in Professor Bisby's work was challenged and we accept the validity of his conclusions.
181Reynobond ACM PE
¶109.7 Although Reynobond ACM PE was the most difficult of the products to ignite,2082 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/72-76} Tables 7, 8 and 9, Figures 28-29 and paragraph 391. once ignited it released energy more rapidly than any of the others and released more energy per unit area than any of the other products.2083 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/66-67} paragraphs 361-362, Table 4 and Figure 26. It had the highest heat of combustion2084 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/4} paragraph 18; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/63} Table 3, Figure 24 and paragraph 357. and was the largest potential contributor to energy release in the external wall system at Grenfell Tower.2085 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/4} paragraph 19; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/67} Figure 26. Of the four products, it had the greatest potential to contribute to fire growth and spread by a substantial margin, contributing up to 59% of the total energy available on any given floor of the tower, calculated by reference to the density of the different materials used, the energy they contained per square metre and their approximate area on each floor.2086 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/4} paragraph 19; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/65} Table 4.
¶109.8 In most of the experiments the bulk of the core of the product melted during heating and dripped downwards, flaming as it did so, collecting in burning pools on any available horizontal surfaces.2087 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/5} paragraph 26; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/58} paragraphs 331-332; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/50} paragraph 278.
¶109.9 The colour of the core did not affect the heat of combustion, with no material difference being observed between the products with clear and black cores.2088 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/63} Table 3 and Figure 24. Although the method of fixing in the tests did not materially influence the time it took for the panels to ignite,2089 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/73} Table 8; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/107} paragraph 627. it did significantly influence the rate of burning and the rate at which heat was released by the product.2090 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/108-109} Figure 36 and paragraphs 630-633 and 637; Bisby {Day289/144:20}-{Day289/145:4}. The method of fixing also had a substantial influence on the extent to which the core of the product burned in place within the panels or dripped and flowed downwards.2091 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/109} paragraphs 634-639; Bisby {Day289/145:4-9}.
¶109.10 Overall, Professor Bisby's tests confirmed that Reynobond ACM PE was the most influential product for promoting external fire spread across the system, in that the amount of energy released and the speed at which it was released were directly related to the rate and extent of external fire spread.2092 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/80} paragraph 453.
182Celotex RS5000
¶109.11 This product was tested both with and without foil facers and the presence of the facer made a major difference to the way in which the product burned.2093 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/93} paragraph 496; Bisby {Day289/146:20-24}; {Day289/148:16-21}. The foil facers provided protection to the core of the product,2094 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/100} paragraph 569; Bisby {Day289/133:18}-{Day289/134:3}. which was comparatively difficult to ignite when tested in that form. When tested without a foil facer, however, it displayed a very low time to ignition and was comparatively easy to ignite.2095 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/6} paragraphs 44-45; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/72-76}, Tables 7, 8 and 9, Figures 28 and 29 and paragraph 393. The foam core of the product itself displayed a substantially lower heat of combustion than either Reynobond ACM PE or the Aluglaze infill panels.2096 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/6} paragraph 41; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/63-64} Table 3 and Figure 24 and paragraph 357.
¶109.12 Once ignited, RS5000 had a much lower heat release rate per unit area than Reynobond ACM PE,2097 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/7} paragraph 47; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/89} paragraph 453; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/79} Figure 30; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/84}, Figure 33; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/86}, Figure 35. both with and without foil facers in place.2098 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/82} paragraph 427; Bisby, Phase 2 Experiments Work Package 1 Regimes of Burning {LBYWP100000002/88}, paragraph 445. That was due to the fact that thermosetting polymer foams, including polyisocyanurate foam, form a layer of char2099 Phase 2, Experiments Work Package 1, Regimes of Burning {LBYWP100000002/88} paragraph 448; Bisby {Day289/146:12-19}; {Day289/148:4-15}. and do not drip or melt.2100 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/58} paragraph 330; Bisby, Phase 2 Experiments Work Package 2, Systems Interactions {LBYWP200000001/22} paragraph 143; Bisby {Day289/149:9-11}. When tested, RS5000 showed a gradual thermal decomposition in response to sustained heat, with a layer of char forming that cracked2101 Bisby {Day289/148:6-15}; {Day289/149:23}-{Day289/150:5}. and a low heat release rate.2102 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/89} paragraph 454; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/94}, paragraph 497; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/100} paragraph 564. The periods over which that occurred were longer than those of external fire spread.2103 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/7} paragraph 46; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/89} paragraph 454. Nonetheless, of the four products tested, RS5000 was the second highest contributor (38%) to the available energy per floor at Grenfell Tower.2104 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/65-67} Table 4, Figures 25 and 26; Bisby {Day289/153:3-9}; Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/22} paragraph 141.
183Kingspan K15 289/150
¶109.13 When K15 was tested without its foil facers, it was relatively easy to ignite. With the foil facers in place, the time to ignition was significantly extended2105 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/8} paragraphs 58-59; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/72-76} Tables 7, 8 and 9, Figures 28 and 29 and paragraphs 394-395; Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/80} paragraph 460. but was still shorter than that of RS5000 with foil facers.2106 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/75} paragraph 394. That was due to the presence of tiny perforations in the foil facers of K152107 Bisby {Day289/120:1-7}; {Day289/134:13-18}; {Day289/153:10-16}; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/75} paragraph 394; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/102}, paragraphs 588-589. that were not present in the facers of RS5000 and increased its reaction to fire2108 Bisby {Day289/134:19-23}. by allowing the release of flammable products.2109 Bisby {Day289/169:23}-{Day/170:3}.
¶109.14 The heat of combustion of the phenolic foam core of K15 was comparable to that of RS5000,2110 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/7} paragraph 54. and was substantially lower than that of both the Reynobond rainscreen panels and the Aluglaze infill panels.2111 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/63-64} Table 3, Figure 24 and paragraph 357. As in the case of RS5000, once ignited, K15 exhibited a far lower heat release rate than Reynobond, both with and without foil facers.2112 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/89} paragraph 455; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/79} Figure 30; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/84} Figure 33; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/86}, Figure 35. It also exhibited a sustained, gradual thermal decomposition,2113 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/80} paragraph 458; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/95} paragraphs 515-516; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/102} paragraph 584. with a layer of char forming2114 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/89} paragraph 456; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/119} paragraph 713; Bisby {Day289/151:2-9}. at a rate slower than external fire spread.2115 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/80}, paragraph 453. Unlike RS5000, K15 showed some glowing2116 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/89} paragraph 456; Bisby {Day289/151:10-13}; {Day289/152:5-10}. and spalling, the latter resulting in hot fragments of phenolic foam being ejected.2117 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/23} paragraph 150. If it had been installed on Grenfell Tower in place of RS5000, it would have been the second largest potential contributor to the available energy per floor (39%).2118 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/119} paragraph 709; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/65-67} Table 4, Figures 25 and 26. It is worth bearing in mind that K15 accounted for only some 5% of the insulation used in the external wall of Grenfell Tower. It is not known exactly where on the tower it was placed.
184Aluglaze window infill panels
¶109.15 Although the extruded polystyrene core of the Aluglaze panels was comparatively easy to ignite2119 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/75} paragraph 392. and had both a higher heat of combustion2120 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/63-64} Table 3, Figure 24 and paragraph 357. and a higher heat release rate2121 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/79-80} Figures 30 and 31; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/82} paragraph 426; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/84-85} Figures 33 and 34; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/89} paragraph 452. than either RS5000 or Kingspan K15, the maximum potential energy contribution from the Aluglaze panels was very small (2-3%).2122 Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/64-67} paragraphs 360 and 362, Table 4 and Figures 25 and 26; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/116-117} paragraphs 686, 689 and 693. For that reason, they were not used in the experiments2123 Bisby, Phase 2 Experiments Work Package 2, Regimes of Burning {LBYWP200000001/21} paragraph 138. to which we refer below.
The system experiments
¶109.16 The configuration of the equipment used for the system experiments was intended to represent, in broad terms, a ventilated cladding system such as that installed at Grenfell Tower.2124 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/3} paragraph 11. It is described in detail by Professor Bisby in his report entitled Work Package 2 – System Interactions.2125 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/38-57} paragraphs 244-345; Bisby {Day289/159:3}-{Day289/163:22}. It consisted of an open-sided ventilated cavity created by placing a Reynobond ACM PE panel opposite various different materials, mostly insulation products. The overall size of the panel was 50cm wide by 100cm tall, being the maximum size which could be safely accommodated in the laboratory at Edinburgh.2126 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/42} paragraph 261. A propane line burner, (essentially a metal pipe with small holes in it which allowed the size of the initial flames to be controlled)2127 Bisby {Day289/159:14-20}. was used to heat and ignite the polyethylene core of the panel before being removed. The fire was then allowed to grow or extinguish itself without further intervention and a range of data was collected from each experiment.2128 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/2} paragraph 4.
185¶109.17 The following figure taken from Professor Bisby's report shows the experimental equipment ready for testing.2129 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/39} Figure 5.
¶Figure 109.1 – Annotated photo showing experimental setup ready for commencing an experiment
Aims and objectives
¶109.18 The apparatus used in the experiments was designed to deliver consistent and repeatable results and to allow a systematic exploration of the relative contributions of the different products to the fire.2130 Bisby {Day289/158:15-21}. The main point of interest was how a fire involving the Reynobond developed and the factors that influenced it. There were two particular physical processes that it was thought would be of importance:
¶a. The melting of the polyethylene and its consequent escape from the aluminium skins; and
¶b. The detaching of the aluminium skins exposing the polyethylene to the flames.2131 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/24} paragraphs 162-164.
186¶109.19 Once the polyethylene begins to melt, flow and ignite a complex heat transfer process occurs within the system. Energy is conducted away from the localised source of heat due to the high thermal conductivity of the aluminium skins,2132 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/24-25} paragraph 167. leading to the melting and involvement of ever greater quantities of polyethylene that then becomes available to burn. The process continues to release more energy than is required to melt and mobilise the polyethylene, leading to the growth of the fire.2133 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/25} paragraph 168. However, energy is also lost from the system and it is possible that losses due to conduction, radiation and convection can mean that the temperature of the panels cannot rise rapidly or may decrease, leading to the extinction of the fire.2134 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/25} paragraphs 168-169. Understanding the factors that affect the release of energy is fundamental to understanding whether an ACM product will burn in any given situation.2135 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/25} paragraph 171.
¶109.20 The release of energy is also affected by two other important factors: (1) the size and shape of the rainscreen cavity and (2) other materials and products (whether combustible or not) in the system, including the insulation.2136 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/25} paragraph 171. In the case of a rainscreen cavity, the reduction in the area available for the entrainment of air typically results in longer flames than would be observed in a similar fire in the open air, which leads to the heating of a larger area with the potential for additional heat release and fire growth.2137 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/25-26} paragraphs 173-174. In addition, the particular properties of the material forming the internal face of the cavity opposite the rainscreen panel determines the amount of thermal energy transferred back to the panels, either by reflection (e.g. from a foil facer)2138 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/26} paragraph 182. or as a result of ignition and burning which contributes additional energy to the system.2139 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/26-27} paragraph 183.
¶109.21 The experiments were intended to answer a number of important questions, including:
¶a. Did the presence of the cavity itself cause the panels to burn so vigorously?
¶b. Did they burn so vigorously because they were very well insulated by the other products? and
¶c. Did the burning of the combustible insulation products cause the panels to burn so vigorously?2140 Bisby {Day289/158:1-11}.
¶109.22 It is important to emphasise that the purpose of the experiments was to study the physical processes that might be relevant to the spread of fire at the tower, not to reproduce the tower on a small scale or to rate the products.2141 Bisby {Day289/158:22}-{Day289/159:2}. The experiments were directed to the spread of flames in a vertical direction only and no attempt was made to assess the spread of fire horizontally or downward.2142 Bisby {Day290/62:4-5}. All the tests carried out by Professor Bisby were designed specifically for the purpose because none of the standard tests was capable of providing the information he needed.2143 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/28} paragraph 196; Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/77} paragraph 9.3.7.
187The products and the conditions under which they were tested
¶109.23 The experiments focused on testing the following four products: a. Reynobond ACM PE; b. Celotex RS5000 foil-faced PIR polymer foam insulation; c. Kingspan K15 foil-faced phenolic polymer foam insulation; d. Foil-faced mineral wool insulation. Mineral wool insulation was used both for comparative purposes and to establish the fundamental thermal and physical processes leading to the upward spread of fire over the external wall.2144 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/28} paragraphs 197-201.
¶109.24 Experiments were also performed with a water-cooled steel plate replacing the insulation (referred to in the report as a "heat sink cavity") and without any cavity at all.2145 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/28} paragraphs 202-204. Experiments were also carried out with different fixing arrangements for the panels. They included one with edge-routing to simulate cassette fixing and one with edge-routing and face riveting to simulate riveted fixing. Rivets passing through the panel were expected to hold the aluminium skins in place in the early stages of a fire.2146 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/28-29} paragraphs 205-209; Bisby {Day289/162:20}-{Day289/163:17}.
¶109.25 Professor Bisby did not include the Aluglaze window infill panels in his experiments because they were not part of any continuous ventilated cavity at Grenfell Tower and were not thought to have played an important role in the spread of fire.2147 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/21} paragraphs 137-138.
Important aspects of system behaviour
¶109.26 Initial experiments carried out at Edinburgh demonstrated the importance of five important matters that affect the development of fires in cladding systems and that Professor Bisby and his team subsequently set out to control and vary in order to understand the behaviour of the system as a whole. They were: a. The burning and dripping of the polyethylene core of the ACM panels, b. The mechanical response of the panels, c. Thermal feedback from the insulation, d. Burning of the insulation, and e. Heat losses from the cavity.
¶109.27 The important factors influencing the growth and speed of fire within a cladding system were found to be (i) the amount of downwardly mobile polyethylene, (ii) the locations where it could pool and burn and (iii) the surface area of the resulting pool fire and hence its heat release rate.2148 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/29} paragraph 212. In addition, a number of important forms of mechanical behaviour were observed when the panels were heated, including warping of the aluminium skins and partial or full separation of the aluminium skins leading to exposure of the polyethylene core.2149 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/30} paragraphs 213-214.
188¶109.28 The extent to which the insulation provided thermal feedback to the panels was another important factor leading to the growth and spread of fire within the cladding system.2150 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/30} paragraphs 215-216. When heated to above their pyrolysis temperatures both Celotex RS5000 and Kingspan K15 produced combustible products which would burn within the cladding cavity, increasing the overall heat release rate and also potentially contributing to surface flaming of the insulation. That, in turn, influenced the thermal feedback to the panels and the growth and spread of fire within the system. To understand that better, experiments were performed with insulation products both with and without their foil facers.2151 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/30} paragraphs 217-218.
¶109.29 The extent to which heat was lost from the cavity by convection, radiation or conduction heat transfer mechanisms was likely to influence the growth and spread of the fire and therefore some experiments were performed without a cavity.2152 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/30} paragraphs 219-220.
The results of the system tests
¶109.30 Over 50 separate experiments were conducted in total, producing a large volume of data.2153 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/58} paragraph 346. Each test was run twice to check the repeatability of the results – Bisby {Day289/181:9-11}. In his report Professor Bisby described one of the experiments (Experiment 21) in detail because it exemplified a number of important processes that had been observed in some of the experiments and were of critical importance for Grenfell Tower. He also summarised what the data showed, both generally and with reference to the thermal and physical behaviour associated with each product and constituent material and the interactions between them.2154 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/58} paragraphs 348-350. We have adopted the same structure in this part of our report, although readers should refer to the detailed information set out in Professor Bisby's report and in the accompanying videos for a full explanation of the results of the experiments.
Experiment 21
¶109.31 Experiment 21 was performed on a cladding arrangement using an ACM PE panel with a routed (i.e. cassette-type) fixing and foil-faced Kingspan K15 insulation.2155 Bisby {Day289/164:3-7}. A number of key observations were made during the experiments,2156 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/59-65} paragraphs 356-381; Bisby {Day289/164:3}-{Day289/172:13}. For a more detailed examination of the physical processes examined during the tests see Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/68-76} paragraphs 9.1.1-9.2.21. of which the following were the most important:
¶a. After 1½–2 minutes of flame impingement on the panels from the line burner, a small pool fire of burning polyethylene began to form in the drip tray (which simulated something similar to a window ledge).
¶b. After 2¼ minutes, lateral movement of the aluminium facing on the lower return part of the aluminium cassette occurred and at about 3¼ minutes the facing slid off the return ledge and fell into the drip tray. That exposed the polyethylene on the top of the return ledge, leading to surface burning of the polyethylene in that area.
189¶c. Between 2¼ minutes and 4 minutes the pool fire within the drip tray grew in size. The mass of polyethylene increased during this period and corresponding increases occurred in the total heat release rate, temperature and flame height in the cavity during that time. d. By 4 minutes the flames had extended to about three quarters of the height of the cavity.
¶e. At about 5¼ minutes the first flames were visible above the experimental rig and by 6 minutes there was consistent flaming above the rig.
¶f. From about 6½ minutes the inside main vertical face of the panel began to separate from the outside face and a void began to form between the two aluminium skins.
¶g. From about 9 minutes visible flaming was evident on the inside of the ACM panel and flaming was also observed on the surface of the insulation. The following figure from Professor Bisby's report was taken at 9.44 minutes:2157 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/64} Figure 20.
¶Figure 109.2 – Experiment 21 (time 9.44 minutes)
¶h. Just before 10 minutes into the experiment the aluminium foil was lost from the face of the Kingspan K15 insulation and there was considerable surface flaming. The heat release rate was more than 50kW.
¶i. At about 10 minutes flames could be seen coming out of the top of the panel between the two aluminium skins.
¶j. At 10½ minutes the inside aluminium skin detached itself, exposing the remaining polyethylene in the core. At that point the heat release rate rose from about 150kW at 10½ minutes to a peak of 496kW at 10 minutes 50 seconds. In other words, in just 20 seconds the heat release rate more than trebled. Professor Bisby described that as the full involvement of the panel.2158 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/67} paragraph 394. The following figure from his report shows the system at that time:2159 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/65} Figure 23.
190¶Figure 109.3 – Experiment 21 (time 10.50 minutes)
¶k. Beyond that point the panel rapidly lost mass as burning and the involvement of the polyethylene increased.
¶l. Fully involved burning of the system continued for 2-3 minutes before the heat release rate rapidly declined to about 50kW by 13½ minutes. At that point the fire was running out of the fuel from the polyethylene needed to be able to maintain high heat release rates. m. After 13½ minutes the insulation continued to burn locally and slowly to lose mass. n. Flaming from the combustion of polyethylene was last observed at 18.04 minutes.
¶o. The insulation continued to burn locally in what appeared to be a self-sustaining reaction until the end of the experiment, which was terminated after 20 minutes. The smouldering eventually consumed the full thickness of the insulation in some places. Continued smouldering was not observed in similar experiments using PIR insulation; in those cases, the foam stopped burning when the polyethylene had been consumed.2160 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/62} paragraph 381; Bisby {Day290/65:10}-{Day290/66:8}; {Day290/66:19}-{Day290/67:9}.
System test results – general
¶109.32 When considering the data from all 50 experiments, it became apparent that not all of the tests had resulted in the full involvement of the panels. For example, the experiments carried out without a cavity, those carried out with a heat sink cavity and those in which the panel was riveted at its base did not progress to full involvement. In those cases, the peak heat release rate, the insulation mass loss and the total heat released were much lower than in all those cases in which full involvement of the panel had occurred.2161 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/79} paragraph 449.
191¶109.33 In those cases in which the panel did become fully involved in the fire some differences were observed in the magnitude of the peak heat release rate, the times taken to reach peak heat release rate, the mass of insulation lost and the total heat released.2162 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/79} paragraph 450. Those differences are discussed further below.
ACM tested in isolation
¶109.34 In the absence of a cavity, the polyethylene core of the ACM panel melted, dripped and ignited locally while the line burner was in place. However, the resulting pool fire failed to release enough energy to ensure that the energy retained within the system was sufficient for the temperature of the panel to increase at a distance from its base. As a result, insufficient polyethylene was mobilised to sustain continued burning and the growth of the fire and the fire extinguished itself when the line burner was removed.2163 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/124-125} paragraph 665; {LBYWP200000001/81-85} paragraphs 467-479. That demonstrated that a source of energy additional to that provided by the ignition of the polyethylene was required before localised burning of the polyethylene would lead to the delamination of the panels and full involvement of the core.2164 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/83} paragraphs 471-472.
ACM tested in a heat sink cavity
¶109.35 The introduction of a cavity in which a heat sink formed the internal face of the system resulted in minor increases in the feedback of heat to the panel and only a slight increase in the melting and mobilisation of the polyethylene core. That was caused by a slight increase in the height of the flames when they were small due to changes in air movements as well as the reflection of radiant heat.2165 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/125} paragraph 666; {LBYWP200000001/85-88} paragraphs 480-486. However, in none of those experiments did the panel become fully involved in the fire. That showed that the presence of a cavity was not by itself sufficient to cause the fire to develop.2166 Bisby {Day289/175:14-16}. Insulation also needed to be present, either to retain energy in the system or to burn and contribute additional energy.2167 Bisby {Day289/175:21-24}.
ACM with mineral wool insulation
¶109.36 The incorporation into the system of non-combustible insulation in the form of mineral wool resulted in the growth of the fire to full involvement of the panel because the insulation retained sufficient energy within the system to raise the temperature of the panel to the necessary level. Once the panel became fully involved there was a rapid increase in the heat release rate and in the total heat released. That demonstrated that it is not necessary for the insulation to burn in order for a fire to grow to the point at which the panels are fully involved.2168 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/125} paragraph 667; {LBYWP200000001/88-91} paragraphs 487-494. It also suggests that the critical factor in the development of a fire is the extent to which energy is retained in the system. Energy transmitted back to the panels supports continued heating, melting and the involvement of the polyethylene core and the deformation of the aluminium skins, which in turn increases the surface area of the burning polyethylene.
192ACM with combustible insulation without foil facers
¶109.37 The experiments showed that, by comparison with mineral wool, combustible foam insulation, whether PIR or phenolic, did not significantly increase the heat release rate or peak heat release rate of the system or the total heat released. However, the time taken to reach full involvement of the panels was shorter in the case of foam insulation (between 5 and 7 minutes) than in the case of mineral wool (between 10 and 12 minutes),2169 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/78} Figure 32; {LBYWP200000001/92} paragraph 506. primarily due to the ignition and surface flaming of the foam insulation, which both released additional heat and caused more uniform heating of the panel. As a result, the inner skin of the panel failed earlier, exposing a larger surface of polyethylene to burning.2170 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/125} paragraph 668; {LBYWP200000001/91-103} paragraphs 495-547. The combustibility of PIR and phenolic foams can therefore be seen to play a role in influencing the growth and spread of fire, but its contribution is secondary both to the burning of the polyethylene and to the insulating properties of the insulation.2171 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/96} paragraph 517; {LBYWP200000001/100} paragraph 535; Bisby {Day289/178:2-17}.
¶109.38 In the experiments carried out using Celotex RS5000 the behaviour of the system did not appear to be affected by the thickness of the material, which varied between 80mm and 100mm.2172 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/125} paragraph 669. The behaviour of systems incorporating Celotex RS5000 (a PIR foam) was broadly similar to that of systems incorporating Kingspan K15 (a phenolic foam), although there were subtle differences in the amounts of spalling observed and Kingspan K15 continued to smoulder after the ACM had burned itself out.2173 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/125} paragraph 670. That propensity to continue smouldering differentiated the phenolic foam from the PIR foam2174 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/97} paragraph 528. and both the total loss of mass and the total heat release of the system were higher when it incorporated phenolic insulation.2175 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/100} paragraph 534.
The addition of foil facers
¶109.39 Adding a foil facer to the mineral wool insulation resulted in a significant reduction in the time required for the fire to grow to the full involvement of the panel, a slight reduction in the amount of mass lost by the insulation up to that point, an increase in the temperatures within the panel and a very slight reduction in the total heat released. The introduction of the foil facer increased the reflective properties of the insulation, resulting in more rapid heating of the panel at a distance from the burning polyethylene at its base. The introduction of the foil facer also changed the surface properties of the insulation, including by promoting heat transfer by convection into the cavity.2176 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/126} paragraph 671; {LBYWP200000001/108} paragraphs 559-567.
¶109.40 Adding foil facers to RS5000 and K15 resulted in a clear increase in the time required to reach full involvement of the ACM, a reduction in the peak heat release rate (but without a major reduction in the total heat released), a clear reduction in the rate at which the insulation lost mass and a reduction in the temperatures measured at the midpoint of the panel.2177 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/126} paragraph 673. Professor Bisby concluded that the addition of the foil facers prevented early surface flaming of the insulation, thus reducing the early heating of the panel at a distance from the polyethylene pool fire at its base. The absence of surface flaming also resulted in less uniform heating of the inside face of the panel, a less symmetrical fire plume within the cavity and a more gradual compromising of the panel's inside face. That tended to prevent the sudden exposure of a large area of polyethylene and promoted a more gradual release of energy as it burned.2178 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/126} paragraph 674; {LBYWP200000001/109} paragraphs 569-573.
193¶109.41 In the case of Celotex RS5000, the addition of a foil facer resulted in a small reduction in the total mass lost. However, contrary to what might have been expected, the foil facer on Kingspan K15 promoted smouldering after the panel had burnt out,2179 Local burnout means that the polyethylene is not burning any more whether inside the panel or the drip tray – Bisby {Day290/62:24}-{Day290/63:7}. which explains a slightly greater loss of mass than when no foil facer was present.2180 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/126} paragraph 675; {LBYWP200000001/109} paragraph 574; Bisby {Day290/66:19}-{Day290/67:19}.
¶109.42 Those experiments again demonstrate the complexity of the process of heat transfer in a rainscreen cladding cavity. They also suggest that an intuitive view of the factors that govern the initiation, growth and spread of fire in such situations may lead to incorrect conclusions.2181 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/109} paragraph 575.
Varying the method of fixing the panels
¶109.43 Professor Bisby's experiments showed that the method of fixing ACM panels is capable of fundamentally altering their response to fire.
¶109.44 The inclusion of aluminium rivets passing through both faces over the lower third of the panel prevented the fire reaching the point at which the panel became fully involved. The rivets held the aluminium skins together and prevented the panel opening up. That reduced the area of polyethylene exposed to the fire and also discouraged its mobilisation into the drip tray, slowing and reducing the supply of fuel to the pool fire burning at the base of the panel.2182 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/127} paragraph 679. However, if the rivets were placed higher up the panel they did not prevent the separation of the panels lower down, which led to a very sudden loss of integrity, exposure of the polyethylene and a high peak heat release rate.2183 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/112} paragraph 585. All this indicates that riveting ACM panels would be likely to improve their performance in fire under most (but not all) circumstances,2184 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/127} paragraph 680; {LBYWP200000001/112} paragraphs 583-585. but that the number and location of the rivets are important in enabling them to slow or prevent the growth of fire.2185 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/127} paragraph 680. The behaviour of the panel in riveted form is to be contrasted with that of the panel in simulated cassette form as demonstrated in Experiment 21, described above.
¶109.45 In the case of the panels in simulated cassette form, the creation of additional routing lines on the inside faces resulted in a reduction in the time taken to reach full involvement in the fire and higher peak heat release rates. Professor Bisby attributed that to the fact that the increased amount of routing provided additional opportunities for the polyethylene to become involved in the fire and increased the propensity of the skins to separate, thereby exposing a larger area of polyethylene to the flames. That resulted in an increase in the rate of fire growth and made its development to the point of the full involvement of the panel more likely and more rapid.2186 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/126-127} paragraph 677. Accordingly, the routing of ACM panels for the purpose of cassette fixing made their fire performance worse.2187 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/127} paragraph 678; {LBYWP200000001/111-112} paragraphs 581-582.
194¶109.46 The evidence obtained from Professor Bisby's experiments provides further support for our understanding of why systems incorporating cassette-fixed ACM panels performed far worse when subjected to the European single burning item test (BS EN 13823) than those incorporating rivet-fixed panels.2188 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/112-113} paragraph 586. As discussed in Chapter 20. The differences in fire performance between the two fixing types again emphasises the complex way in which even simple systems respond to fire and the potential significance of what appear to be minor changes in methods of mounting and fixing.2189 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/113} paragraph 587.
Revisiting the Phase 1 conclusions
¶109.47 The results of Professor Bisby's experiments support the main conclusion reached by the chairman in the Phase 1 report, namely, that the principal reason why the flames spread so rapidly up Grenfell Tower was the presence of ACM panels with polyethylene cores which had a high calorific value, melted and acted as a source of fuel for the growing fire.2190 Phase 1 Report, Volume IV, paragraph 23.52. It is clear from the experiments that the principal factor which led to rapid growth of fire was the presence of unmodified polyethylene in the cores of the ACM panels, with its propensity to melt, drip and act as the primary source of fuel for the fire.2191 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/114-117} paragraphs 597-604 and 620; Bisby {Day289/184:7-10}. It was the burning of the polyethylene, rather than the burning of the insulation, which by a considerable margin determined how the external wall of the tower performed.2192 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/128-129} paragraph 695. In the words of Professor Bisby, ACM panels represent an extreme fire hazard, given their intense burning properties. We were struck by his evidence that every time he ran an experiment which led to the full involvement of the ACM he was surprised and alarmed.2193 Bisby {Day289/185:15-22}.
¶109.48 The experiments also support the conclusion in the Phase 1 report2194 Phase 1 Report, Volume IV, paragraph 23.52. that it was more likely than not that the presence of PIR and phenolic foam insulation contributed to the rate and extent to which the flames spread vertically.2195 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/115-117} paragraphs 605-620. However, it is now possible to be more specific about the precise contribution made by the insulation. In particular, the results of the experiments suggest that, although the contribution made by the insulation (with foil facers) to the total heat released during the period before the full involvement of the ACM is comparatively minor, representing less than 15% of the total energy released,2196 Even if all of the mass lost from the burning of the insulation products is assumed to be converted into energy, the Celotex RS5000 insulation is unlikely to have contributed more than 20% of the total energy released, the mineral wool about 0.1% of the total energy released and the Kingspan K15 about 53% of the total energy released. The figure for K15 reflects its propensity to smoulder after the ACM has substantively burned out – Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/128-129} paragraphs 692-695. it is the ability of the insulation to retain energy within the system and promote more rapid heating of the ACM that is the decisive factor in promoting the growth of fire.2197 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/127-128} paragraphs 682-686. PIR and phenolic foam products are exceptionally good insulators, a property that made matters much worse once fire had entered the rainscreen cladding.2198 Bisby {Day289/184:14-17}. That is why the experiments involving mineral wool also led to the full involvement of the ACM, because it too retains heat within the system and promotes rapid and extensive heating of the panels. It is not necessary for the insulation to be combustible for it to be capable of promoting the rapid and extensive growth of fire.2199 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/128} paragraph 690; Bisby {Day289/184:21-24}.
195¶109.49 It should be noted that when they did not have foil facers, the contribution of the insulation products to heat release rates was much higher and was comparable to that of the panels. It follows that, in the absence of foil facers, the contribution to a fire of the energy released through the burning of the insulation may be significant.2200 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/128} paragraphs 688-689.
¶109.50 The answers to the questions posed by Professor Bisby, therefore, are that it was not the presence of the cavity that caused the panels to burn with such vigour2201 Bisby {Day289/178:21-25}. nor the burning of the combustible insulation products,2202 Bisby {Day289:179:5}-{Day289/182:20}. but the fact that the cavity was very well insulated.2203 Bisby {Day289/179:1-4}.
Conclusions
¶109.51 The information obtained from the experiments support the following conclusions about the fire performance of rainscreen cladding systems incorporating ACM panels with unmodified polyethylene cores of the kind used on Grenfell Tower:
¶a. The most important influence on the growth of fire through such systems is the extent to which the particular materials and products of which they are composed cause energy to be retained within the system. Insulating or reflective materials within the cavity play an important part in performing that function.2204 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/129} paragraph 696.
¶b. The transfer of heat within a ventilated rainscreen system is extremely complex, even in the case of relatively small and simple arrangements. Particular modes of heat transfer may work in different ways for different materials and products in different situations.2205 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/129} paragraph 698; {LBYWP200000001/24} paragraphs 158-159; {LBYWP200000001/4} paragraph 17; Bisby {Day289/157:7-16}; {Day289/183:23}-{Day289/184:6}.
¶c. Intuitive assessments of the way in which fire is likely to spread are dangerous. They may lead to false assumptions that can be contradicted by empirical evidence, if sufficient time, care, instrumentation and technical insight is applied to understand the performance of the system.2206 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/129} paragraphs 701-703; {LBYWP200000001/4} paragraph 17; Bisby {Day290/73:11}-{Day290/74:14}.
¶d. The conditions required for ignition and the self-sustaining spread of flame are much less onerous than those typically encountered in ordinary compartment fires.2207 Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/67} paragraph 9.0.11; {JTOR00000006/76} paragraph 9.3.3.
196¶e. Even small changes in the configuration of the system, its geometry, the nature of the ventilation and the early development of the fire can have a significant effect on the speed at which the fire develops and the eventual outcome.2208 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/130} paragraph 704. For example, the experiments have drawn attention to the effect of mechanical fixings.2209 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/129} paragraph 699.
¶109.52 Nothing we have said in this chapter affects the chairman's previous conclusions about how the fire escaped from Flat 16 or the particular materials or physical processes that may have enabled that to occur.2210 Phase 1 Report Volume IV paragraphs 22.36-22.40. Professors Bisby and Torero were not asked to investigate the nature, amount or toxicity of the smoke emitted by any of the materials they examined under any conditions of burning.2211 Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/5} paragraph 34.
197Chapter 110: The escape of fire from Flat 16
¶110.1 In Chapter 22 of the Phase 1 Report the Chairman considered the process by which the fire escaped from the kitchen of Flat 16 at Grenfell Tower and entered the external wall. Based on the evidence available at the time, he concluded that it had escaped in one or other of two ways: either by flames passing through the cavity around the column following the collapse of the uPVC window jambs, or by flames passing through the open window and impinging on the rainscreen panels directly above.2212 Phase 1 Report Volume IV paragraphs 22.36-22.39. Although the video evidence was more consistent with the former mechanism, the latter might also have played a significant role.2213 It should be noted that the reference to Professor Bisby's Hypothesis B2 in paragraph 22.39 of the Phase 1 Report Volume IV on page 538 is a typographical error which should actually refer to Professor Bisby's Hypothesis B1. Ultimately, however, that was of little significance, because in both cases it was the proximity of combustible materials to the interior of the compartment that allowed the fire to spread.2214 Phase 1 Report Volume IV paragraph 22.39.
¶110.2 In June 2019 the Metropolitan Police Service provided the chairman with a copy of a report dated 24 May 2019 by BRE of a large-scale reconstruction of the fire in Flat 16 that it had carried out and the conclusions it had drawn from it.2215 BRE Global Grenfell Tower Fire Investigation Reconstruction {MET00040237}. The reconstruction sought to reproduce as accurately as possible the configuration and contents of the flat immediately before the fire and two storeys of the external wall above. Based solely on the results of that reconstruction, BRE concluded that the fire had probably spread to the external wall through the extractor fan and the window infill panel in which it had been mounted, igniting the exposed edge of the polyethylene core of the panel above the window. The second most likely route was through the construction around the window.2216 BRE Global Grenfell Tower Fire Investigation Reconstruction {MET00040237/4} penultimate paragraph.
¶110.3 The chairman indicated in the Phase 1 report that once full information had become available from the reconstruction he would ask Professor Torero and Professor Bisby to prepare short supplemental reports explaining whether it caused them to alter or refine the views they had expressed during Phase 1. He also indicated that he was willing to receive submissions from core participants on the relevance of the reconstruction during Phase 2. In those circumstances, the findings made in Chapter 22 of the Phase 1 report remained provisional and subject to revision in this report.2217 Phase 1 Report Volume IV paragraph 22.42.
¶110.4 Professor Torero and Professor Bisby both considered the reconstruction report for the purposes of Phase 22218 Torero, Phase 2 Report {JTOR00000006/163-169} paragraphs 13.1.10-13.1.43; Bisby, Phase 2 BRE Reconstruction Report {LBYP20000003}. and Professor Torero also dealt with it in the course of his oral evidence.2219 Torero {Day292/107:18}-{Day292/108:16}. He explained that even a large-scale test which attempted to reproduce the original construction and contents of Flat 16 as faithfully as possible could not accurately reproduce the evolution of the fire, since very minor changes in variable factors, including ventilation and fuel content, can result in very different outcomes.2220 Torero, Phase 2 Report {JTOR00000006/164} paragraph 13.1.16. He also analysed the fire created in the test and compared it with what is known about the evolution of the fire at Grenfell Tower, including the significant stages of its development. He concluded that the fire in the reconstruction was completely different from the fire that occurred in Flat 16 and that it was not possible to establish why its behaviour was so different.2221 Torero, Phase 2 Report {JTOR00000006/166} paragraph 13.1.31. In particular, the fire in the reconstruction had developed more quickly and had become hotter, with key events occurring at different times,2222 Torero, Phase 2 Report {JTOR00000006/167} paragraphs 13.1.33-13.1.34; Torero {Day292/107:18}-{Day292/108:16}. and had eventually reached flashover.2223 "Flashover" is a term used to describe the near simultaneous ignition of all combustible material within an enclosed area. As a result the materials around the window affected by the fire behaved differently during the reconstruction. That included the uPVC window surrounds, which are likely to have charred rather than deformed due to the sudden increase in temperature seen during the reconstruction. In those circumstances, the reconstruction represented a fire of a very different kind and did not cause him to change the opinions he had expressed in his previous evidence.2224 Torero, Phase 2 Report {JTOR00000006/167-169} paragraphs 13.1.35-13.1.43.
198¶110.5 Professor Bisby was of the same view. He also emphasised that large-scale reconstructions are extraordinarily complex and that their outcomes are influenced by a range of factors that are difficult, if not impossible, to control. They include small differences in the type, amount and distribution of fuel within the compartment, the initial ventilation conditions, the creation of additional ventilation as a consequence of the fire (for example, through windows breaking) and the effects of wind. All those, and other, factors could alter drastically the progress of a fire.2225 Bisby, Phase 2 BRE Reconstruction Report {LBYP20000003/10} paragraph 58. As a result, a reconstruction could only demonstrate what could happen, not what did happen.2226 Bisby, Phase 2 BRE Reconstruction Report {LBYP20000003/11} paragraph 60.
¶110.6 Professor Bisby agreed with Professor Torero that BRE's large-scale reconstruction created a fire that was inconsistent with the available evidence of what had occurred in Flat 16.2227 Bisby, Phase 2 BRE Reconstruction Report {LBYP20000003/11} paragraphs 62-64. He also made it clear that only by conducting a detailed analysis of the sensitivity of the reconstruction to various different factors (which was not possible given the limited data available from the reconstruction) could any conclusions be drawn about the relevance of what had been observed in the reconstruction.2228 Bisby, Phase 2 BRE Reconstruction Report {LBYP20000003/11} paragraph 65. In those circumstances he concluded that the reconstruction did not provide any information that contradicted the evidence he had given during Phase 1 or cause him to alter his views.2229 Bisby, Phase 2 BRE Reconstruction Report {LBYP20000003/12} paragraph 75.
¶110.7 We accept the unchallenged evidence of Professor Torero and Professor Bisby that the fire created in the BRE reconstruction differed significantly from the fire that occurred in the kitchen of Flat 16. Since the reconstruction did not lead either of them to revise his original opinion, there is no reason for us to depart from the provisional conclusions reached by the chairman in Chapter 22 of the Phase 1 report. Accordingly, they now represent our final conclusions on the means by which the fire escaped from Flat 16.
199Part 12: The fire testing regime
201Chapter 111: Assessing the fire performance of external walls
Introduction
¶111.1 For many years a variety of tests has existed for measuring the performance of materials in response to fire, ranging from small-scale laboratory tests up to full-scale tests of the kind described in the BS 8414 series. We have referred in earlier chapters of our report to some of those that are most widely used. No tests were carried out specifically on the combination of materials used in the refurbishment of Grenfell Tower or on the proposed external wall system, but those responsible for the choice of materials and the design of the external wall relied indirectly on results of some of the standard tests because they were referred to in the BBA certificate relating to Reynobond. They also relied on a widespread misunderstanding, not helped by poor guidance in Approved Document B, that any material with a Class 0 surface was suitable for use in the external wall of a high-rise building.
¶111.2 In those circumstances we think it is appropriate to consider whether the established tests, in particular BS 476 Parts 6 and 7, the results of which support the Class 0 classification, the European classification system or BS 8414 Parts 1 and 2, which contain the test methods for full-scale testing of external wall systems, are capable of providing the information that is required to enable designers to assess compliance with functional requirement B4(1). Any discussion of that question calls for an understanding of technical matters of a kind that is possessed only by those who are experts in the field. We have had the benefit of receiving reports and hearing evidence from three leading experts, Professor José Torero,2230 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006}. Professor Luke Bisby,2231 Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001}; Bisby, Phase 2 Report: BR 135 Desktop Assessment Report {LBYP20000004}. and Dr Barbara Lane,2232 Lane, Phase 2 Module 2 presentation: An explanation of the relevant Reaction to Fire tests and Classification methods to restrict the combustibility of external walls of high buildings {BLARP20000022}. all of whose evidence is available on our website. None of their evidence in relation to testing was challenged and we therefore feel justified in accepting it in full. It is lengthy and complex, but we would urge the government and any others who have an interest in or responsibility for testing the performance in fire of materials and products used in the construction industry to read it in full. For the purpose of this report, however, we have attempted to summarise in our own words those parts that are of particular relevance to the refurbishment of Grenfell Tower.
The testing regime in context
¶111.3 Every new building of any complexity, and certainly every high-rise building, should have a fire safety strategy created at the time of its original construction or as soon as possible thereafter. It is important to recognise that testing of materials for their performance in fire has to be related to the fire safety strategy for the particular building. It is the responsibility of those who design the building, including the external wall, to ensure that the information obtained from that testing is correctly used in the development of the fire safety strategy.2233 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/29} paragraph 4.2.7. In England and Wales the contents of the fire safety strategy are ultimately dictated by the functional requirements in Schedule 1 to the Building Regulations, which must be reflected in performance requirements appropriate to the building in question.2234 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/33} paragraph 6.0.1. It follows that the performance of the materials intended to be used will need to be assessed with the particular fire safety strategy in mind. Thus, in a building with a "stay put" strategy for responding to fire, no significant spread of fire beyond the compartment of origin can be tolerated,2235 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/38-39} paragraphs 6.2.7-6.2.8 and 6.2.11-6.2.16. whereas in a building with a controlled evacuation strategy some spread of fire can be tolerated, provided it is compatible with the ability of the occupants to escape.2236 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/34-37} paragraphs 6.1.3-6.1.23.
202Assessing the performance of an external wall system
¶111.4 The processes affecting the spread of flame vertically are complex and depend on a number of factors, including the properties of the materials exposed to the flame, the rate at which combustible gases are produced and their propensity to transfer sufficient heat to perpetuate the flame and ignite adjacent material.2237 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/49} paragraph 7.2.23. Two approaches to making such an assessment may be taken: one is to assess the likely velocity of flame spread; the other is to assess whether the flame is likely to be extinguished.
¶111.5 Fire engineers have tools at their disposal for assessing the speed at which flames are likely to spread over a building's external wall system. Simple methods can be used for the assessment of very simple systems and can be applied in a very conservative manner, although they may be better suited to ranking materials rather than to obtaining an understanding of how a system is likely to perform.2238 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/54} paragraph 7.3.27. Complex computational models can also be used.2239 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/54-55} paragraphs 7.3.30-7.3.33. In all cases some simplification is required and certain assumptions must be made and a high degree of skill and experience is required to use the tools effectively.2240 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/55} paragraph 7.3.35.
¶111.6 Although some external wall systems continue to support burning and the spread of flame after an external source of heat has been removed, others that exhibit only small differences do not, with the result that the fire goes out.2241 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/56} paragraph 7.4.1.
¶111.7 A good example is provided by small differences in the degree of exposure to flame of the polyethylene core of an ACM PE panel in an insulated rainscreen system. As demonstrated by the experiments conducted by Professor Bisby and his colleagues at Edinburgh University, the extent to which the core is exposed to flame, which in turn depends on the fixing arrangements, has a significant effect on whether the panels sustain continuous flaming or the flames die out.2242 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/56} paragraph 7.4.2; Bisby, Phase 2 Experiments Work Package 2: System Interactions {LBYWP200000001/79} paragraph 449; Bisby {Day291/9:18}-{Day291/12:19}.
203¶111.8 A material that is non-combustible will not catch fire, regardless of the temperature to which the surface is raised.2243 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/56} paragraph 7.4.7. It will not support ignition and therefore there will be no flames. A fire within a compartment can impose a heat flux in the order of 100kW/m² on the external walls. If the materials do not support ignition when exposed to a heat flux of that magnitude, they can be regarded as non-combustible.2244 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/57} paragraph 7.4.10.
¶111.9 It is very difficult to judge whether a combustible material will continue to burn when the source of heat is removed because it is necessary to assess whether sufficient heat is likely to be transferred ahead of the flame to sustain burning.2245 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/56} paragraphs 7.4.3-7.4.4. However, there are currently no models that will accurately predict that and therefore it is necessary to test individual samples. Precision is essential because small changes in materials or the system as a whole can have a significant effect on the outcome. That makes any assessment of whether, and if so when, extinction will occur much more difficult.2246 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/59} paragraph 7.5.6.
Encapsulation
¶111.10 Innovative techniques in the construction industry have added to the difficulty of assessing the fire performance of an external wall. One such technique is "encapsulation" in which a combustible material is enclosed in a non-combustible outer skin in a way that is intended to ensure that ignition cannot occur. It may involve full encapsulation, in which the combustible material is protected on all sides or partial encapsulation, in which the combustible material is exposed at the edges.2247 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/60-61} paragraphs 8.1.3-8.1.4 and Figure 6. Certain materials used for encapsulation, such as aluminium, have very high thermal conductivity and therefore will dissipate heat from an external source. If the heat is dissipated quickly, the combustible material may not reach the point of ignition and the exposed edges may not give rise to flaming.2248 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/61} paragraph 8.1.5 and Figure 6.
¶111.11 A number of factors influence whether encapsulation will prevent ignition and the consequent risk of flames spreading. They include:
¶a. the way in which the combustible material reacts to heat, including degradation, thermal expansion, deformation, melting and dripping;
¶b. the performance of the ensemble of which it forms part, including its relative deformation (splitting, cracking and peeling); c. the performance of any adhesive; and
¶d. temperature gradients, as they affect relative deformation, localised stress and similar behaviour.2249 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/61-62} paragraph 8.1.8.
¶111.12 Assessing the performance of an external wall incorporating materials of that kind is more complicated than just modelling the spread of flame because it must take into account all the factors affecting the spread of flame, as well as factors affecting the physical behaviour of the system. As a result, it is necessary to carry out detailed and comprehensive testing of the system to identify the different kinds of mechanical failure that may occur and the conditions which induce them.2250 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/62} paragraph 8.1.11.
204The role of the cavity
¶111.13 Although tools and models exist that can enable an assessment to be made of the spread of flames vertically over a flat surface, less attention has been given to the spread of flames within cavities. The width of the cavity plays an important part in determining the rate at which flames spread through it and increased rates at which flames have spread can be explained by the presence of open vertical channels which create chimney effects leading to increased burning of combustible material.2251 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/63} paragraph 8.2.2 and 8.2.4.
¶111.14 If the width of the cavity exceeds a certain size, however, the transfer of heat from one side to the other and an increase in the rate at which heat is transferred upwards both disappear. Flames then spread at a rate similar to that at which they spread over a flat surface. Conversely, if the width of the cavity falls below a certain size, thermal expansion of the gases interrupts the general flow of air and the flames cease to spread internally.2252 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/63} paragraph 8.2.3.
¶111.15 As Professor Bisby's experiments demonstrated,2253 See Chapter 109. an external wall system incorporating ACM PE panels contains many features that add to the difficulty of assessing its fire performance. They include:
¶a. the low melting temperature and high thermal conductivity of the aluminium skins, which result in a complex mechanism affecting the transfer of heat from the external flames into the combustible cores of the panels;
¶b. the melting of the aluminium leading to the loss of protection for the core;
¶c. the polyethylene core of the panels melting at low temperatures;
¶d. the temperature gradients between the inside and the outside of the panels resulting in differential deformations of the aluminium plates, the splitting of the plates and the involvement of the polyethylene core in the fire;
¶e. inside the cavity, the pyrolysing, charring and burning of the insulation and possible burn-out. There may also be a rapid spread of flame because of the low thermal inertia of the insulation,2254 The surface temperature of a material with a low thermal inertia will increase rapidly when heated and it will ingite more quickly – see Bisby Phase 1 Report {LBYS0000001/19} paragraph 121; Grenfell Tower Inquiry Phase 1 Report, Volume IV, page 522 paragraph 22.13. although its tendency to char reduces fuel production and flame lengths; and
¶f. the interaction during a fire of the panels and the insulation, each of which affects the way in which the other behaves.
¶111.16 Modern cladding systems include many other complexities, including cavity barriers, complex geometries and intumescent sealants, and very careful analysis is necessary to establish their probable fire performance.2255 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/64-65} paragraphs 8.2.6-8.2.9. It is misguided to think that the only way to assess their performance accurately is to conduct a large-scale test that is representative of the worst circumstances likely to be encountered in practice. Although there may be some value in tests of that kind, the results are extremely difficult to interpret and it is therefore important that those who are responsible for carrying them out have a detailed understanding of the processes involved and the means by which failure can occur before they are undertaken.
205¶111.17 The complexity of the processes involved in assessing the performance of an external wall was demonstrated by the simplified tests carried out by Professor Bisby and his team on aspects of the external wall system of Grenfell Tower.2256 Bisby Phase 2 Experiments Work Package 2: System Interactions {LBYWP200000001/4} page 4, paragraph 17. He was able to identify some of the features of the system that significantly affected its performance in fire, including the significant differences between the performance of riveted panels and that of cassette-fixed panels and between foil-faced and non-foil-faced insulation.2257 Chapter 109. We refer to the information obtained from those tests in a separate chapter,2258 Chapter 109. but for present purposes it is clear that it is possible for small- and medium-scale tests to yield useful results, provided their limits are properly understood.2259 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/65} paragraphs 8.2.12; {JTOR00000006/66-78} paragraphs 9.01-9.3.16; Torero {Day289/77:16}-{Day289/78:1}.
The Class 0 tests
¶111.18 Fire science and fire engineering are relatively new disciplines2260 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/81-83} paragraphs 10.1.10-10.1.20. and the development of the science of fire testing has been somewhat sporadic. Tests have often been developed in response to external events or the advent of new technologies,2261 Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/75} paragraph 356. rather than being driven by the desire for knowledge in its own right.2262 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/83-84} paragraphs 10.1.20-10.1.27. For example, World War II led to the development of a test method to measure the effectiveness of certain products at resisting fires caused by incendiary bombs. That led to a series of full-scale tests in corridors lined with different types of wall-board which evolved to become the BS 476-7 method for testing the surface spread of flame.2263 Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/58} paragraphs 259-261.
¶111.19 At the time of the Grenfell Tower fire, Approved Document B recommended that the external surfaces of the walls of high-rise buildings should meet the provisions of Diagram 40. In the case of Grenfell Tower Diagram 40e provided that, above 18 metres from the ground, the external surfaces of the walls should satisfy national Class 0 or European Class B. The main tests supporting the national Class 0 classification are BS 476-6 (fire propagation) and BS 476-7 (surface spread of flame). Despite our investigations, no one was able to explain how tests designed to determine the fire performance of wall linings were adopted in Approved Document B (and the antecedent versions of that statutory guidance) to assess the performance of the external walls of high-rise buildings.
¶111.20 We have explained in Chapter 5 how those tests are carried out and what information and data is obtained from them. As is clear from those descriptions, neither test is apt to provide relevant information about the performance of a material or product in a fire in the external wall of a building.
Test method BS 476-6
¶111.21 Fire propagation testing to BS 476-6 was developed as a method of testing the reaction to fire of internal wall linings2264 Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/32-33} paragraph 156. and is directed primarily to assessing the performance of the surface of the product being tested. The sample to be tested is board-shaped and mounted in the test apparatus so that the edges are not exposed. Consequently, if materials within the product are encapsulated in or simply covered by a flame-retardant coating, direct ignition of the underlying layer or core is prevented.2265 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/127} paragraphs 12.3.54-12.3.55. Unless the outer surface or coating of the product burns through, so that the underlying layer is exposed, the test will not detect the presence of any combustible material in the core or lower layers.2266 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/129} paragraphs 12.3.64.
206¶111.22 The test was designed to represent the development of a fire within a room and its transition to flashover.2267 Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/35} paragraph 162; Bisby {Day290/100:19}-{Day290/101:10}. It does not correspond to the development of a fire on the outside of a building2268 Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/35} paragraph 163; Bisby {Day290/109:24}-{Day290/110:8}; {Day290/118:3-23}. and does not provide information about the heating length or the speed at which flames will spread.2269 Torero {Day289/91:6-16}. The derivation of the fire propagation index is convoluted and it is not possible to relate the values obtained from the test to practical experience.2270 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/127} paragraph 12.3.57. The test standard itself makes clear that the test has been designed to give comparative information on the performance of products in the early stages of a fire and that it should not be used for assessing the fire hazard under actual fire conditions.2271 See Chapter 5; {CTAR00000016/11} paragraph 11(i); Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/129} paragraphs 12.3.58-12.3.60. It is not possible to calculate the heat flux to which the sample is exposed during the test, so its performance cannot be related to any particular design conditions, e.g. where assumptions are being made about the level of exposure to heat that can be accommodated in the external wall.2272 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/129} paragraph 12.3.62; Torero {Day292/28:7-16}. The small size of the sample also precludes any assessment of the thermo-mechanical behaviour of the product.2273 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/129} paragraph 12.3.65.
Test method BS 476-7
¶111.23 Testing in accordance with BS 476-7 for surface spread of flame was developed as a way of measuring the spread of fires within corridors, not the spread of fire over an external wall.2274 Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/30} paragraph 145; Bisby {Day290/109:24}-{Day290/110:8}. It was first published in 1971 and was revised in 1987 and 1997,2275 Lane {BLARP20000022/61}. There was also a change to the foreword in 2014. but its origins lie in World War II and the risks posed by incendiary bombs.2276 Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/58} paragraphs 259-261. The test measures the spread of flame horizontally rather than vertically. In a fire in the external wall of a building the spread of flame vertically is likely to be the primary mechanism of development and a material which may not easily support the spread of flame laterally could well be capable of enabling it to spread vertically, even in the absence of an external source of heat.2277 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/133} paragraph 12.3.80. That phenomenon was seen at Grenfell Tower. Fire spread rapidly up the east face of the building; the much slower spread of fire horizontally was driven primarily by a very particular feature of the building, namely the crown, which allowed molten polyethylene to drip down the walls.2278 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/133} paragraph 12.3.81; Grenfell Tower Inquiry Phase 1 Report, Chapter 23, page 558, paragraph 23.55.
207¶111.24 Heat fluxes of up to 120 kW/m² can occur in fires involving the external walls of buildings, which is very much higher than that imposed by the test (5-32.5 kW/m²).2279 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/133} paragraph 12.3.82; Torero {Day292/33:11-23}. The sample holder used for the test obscures the edges of the product, thereby ensuring that only the surface is exposed to the heat and that any materials below the surface are protected.2280 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/133} paragraph 12.3.84. In those circumstances, the results achieved in the test do not enable one to assess how an external wall incorporating the product would perform in response to a fire.2281 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/133} paragraph 12.3.83. Professor Torero also explains in his report how Professor Drysdale and others have concluded that the results of the test are strongly dependent on the particular apparatus used and therefore the test ought not to be used to assess the material properties of the product in a real-world situation, see Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/132-133} paragraphs 12.3.77-12.3.79 and see also Torero {Day292/30:20}-{Day292/32:11}.
¶111.25 Accordingly, neither the BS 476-6 test method nor the BS 476-7 test method provides any of the information needed to make an assessment of the suitability of a product for use in the external wall of a high-rise building and it is therefore inappropriate to use them as a measure of the performance of an external wall in a fire.2282 Torero {Day 292/32:12}-{Day292/33:9}, see also Bisby {Day290/114:3-5}. The tests are too simplistic for that purpose, particularly in relation to composite products, because they primarily assess the properties of the surface rather than what lies beneath it. For that reason they do not provide any information about the likely performance of ACM panels on external walls.2283 Torero {Day292/34:16-20}. As Dr Connolly of BRE concluded in 1994,2284 See Chapter 7. the tests do not accurately reflect the fire hazards associated with cladding systems.2285 {RCO00000001/46} 4th paragraph. It is unfortunate that the government did not take steps to remedy the situation in the years before the Grenfell Tower fire, in view of the fact that there were numerous opportunities to abandon reliance on national Class 0 as a standard by which the fire performance of materials proposed for use in external walls of high-rise buildings could be judged.2286 See Chapter 7.
The European classification system
¶111.26 The tests supporting the European system for classifying the reaction to fire of construction products were intended to enable designers to identify construction products that prevented or slowed the development of a fire in a compartment so that flashover and a fully developed fire did not occur.2287 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/136-137} paragraphs 12.4.17-12.4.19. The classification system was based on a test known as the "room corner test", which involved lining a full-scale compartment with a product, igniting it and monitoring the development of the fire.2288 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/137} paragraph 12.4.20; Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/35} paragraph 165. A smaller and less costly version of that test, known as the "Single Burning Item" test,2289 Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/35} paragraphs 165-166 and {LBYP20000001/114} paragraphs 595-596. was subsequently developed and now underpins classifications A2 to D of the European classification system.
208The Single Burning Item test
¶111.27 The single burning item test is a scenario test, that is, a test which seeks to reproduce a set of circumstances that are considered reasonably likely to be encountered in practice, in this case a fire in the corner of a compartment formed by the meeting of two walls.2290 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/150} paragraph 12.4.68. Unlike the national tests referred to above, the temperature and heat release measurements obtained during the test are potentially of some value to a fire engineer seeking information to assess the fire performance of the product when used on an external wall because they allow some assessment to be made of the way in which the speed of flame spread develops over time, together with the heat release rate.2291 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/151-152} paragraphs 12.4.79 and 12.4.85.
¶111.28 An important difference, however, between a fire in a room and a fire in the external wall of a building is the magnitude of the heat flux. The burner which is used in the single burning item test delivers a maximum heat flux of less than 40kW/m², which is much less than could be expected in the case of a fire in an external wall of a building, which can generate a heat flux of up to 120 kW/m². Consequently, although poor performance of a product in the single burning item test can indicate poor performance in a fire in an external wall, the converse does not always hold true. A material which has performed well in the test may perform badly in an external wall fire.2292 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/152} paragraph 12.4.81.
¶111.29 Moreover, the way in which heat develops in the structure created for the purposes of the test will inevitably differ significantly from that in which it develops in an external fire. As the test progresses the speed at which the flames spread will accelerate due to the increase of the heat flux operating on the sample. In practice, that means that the flame on the sample will usually spread over its full height. The remaining flame spread, which may be influenced by the increased heat flux, is likely to occur in a horizontal direction where burning is still to occur. That again is different from what would occur in a fire in the external wall of a tall building, in which flames spreading vertically will normally provide the dominant mechanism by which the fire spreads.2293 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/152} paragraphs 12.4.82-12.4.84.
¶111.30 For the purpose of the test the bottom and top edges of the product are clamped in place and therefore shielded from exposure to the heat. The junction between the panels is also held in place by a metal section. The only edges of the sample that are exposed are those which occur at any joints within the test specimen itself or at the sides (although they too may be shielded if that reflects the end-use application). Consequently, the test does not reproduce conditions encountered in practice2294 Torero Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/153} paragraphs 12.4.91-12.4.93; Torero {Day292/44:4}-{Day292/45:11}. and material enclosing a combustible core might survive the test but not a fire. In a real fire the product might burn vigorously, allowing a large amount of heat to be released instantaneously, thereby becoming a significant hazard.2295 Torero {Day292/44:25}-{Day292/45:11}. Moreover, the test is not intended to, and does not, produce any data that reflects the way in which the physical structure of the product responds to heat.2296 Torero Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/153} paragraph 12.4.93.
209¶111.31 It follows that the European classifications which emerge from the single burning item test (i.e. classifications A2 to D) are of little assistance when assessing the performance of external wall systems.2297 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/153} paragraph 12.4.90; Torero {Day292/41:2}-{Day292/42:17}; Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/116} paragraph 604.
¶111.32 We note that there was some disquiet within the fire community when the European classification system was introduced. Concern was expressed about whether the single burning item test could credibly classify some types of construction products. In particular, a steel-clad polystyrene sandwich panel was found to lead to flashover in the room corner test, but more than half the laboratories that carried out such tests reported a very low heat release rate in the single burning item test.2298 B Messerschmidt, The Capabilities and Limitations of the Single Burning Item (SBI) Test, Fire & Building Safety in the Single European Market, FireSeat, 2008 {INQ00014960} and see Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/153-154} paragraphs 12.4.94-12.4.96 and Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/37-38} paragraphs 175-177. That led to some adverse comments on the test2299 "FireSeat 08 - Presentation by Birgitte Messerschmidt. Part 3 of 4" (https://www.youtube.com/watch?v=wsQHKDUomSA) 00:03:02 – 00:03:14; Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/116} paragraph 608. Also Lane {Day68/61:22-62:}. and a warning that, when considering its use in the context of national regulatory systems, it was important that the link to the development of a fire in a compartment be maintained so that the test and the results obtained from it were used appropriately.2300 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/148} paragraph 12.4.67, with reference to B Messerschmidt, The Capabilities and Limitations of the Single Burning Item (SBI) Test, Fire & Building Safety in the Single European Market, FireSeat, 2008 {INQ00014960}. However, in the years before the Grenfell Tower fire the construction industry and those with responsibility for the regulations lost sight of that link.
Large-scale testing
¶111.33 From 2000 onwards the statutory guidance in England and Wales on the construction of the external walls of high-rise buildings referred to large-scale testing as a way of demonstrating compliance with functional requirement B4(1) of the Building Regulations and readers were told that advice on the use of insulation in external walls could be found in BR 135. Later, in 2006, Approved Document B referred to BR 135 (second edition) and stated that external walls should either meet the guidance or comply with the performance criteria in BR 135 using full-scale test data from BS 8414.2301 {CLG10000007/95} section 12.5. That guidance remained in place up to the Grenfell Tower fire.2302 A further version of BR 135 was published in 2013 {CLG00000224}.
The development of BS 8414 and BR 135
¶111.34 The first edition of BR 135, published in 1988, described the development of a research programme incorporating large-scale testing. That programme is best understood as a series of large-scale experiments rather than the methodical development of a means of assessing the performance of external wall systems in fire.2303 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/103} paragraphs 12.2.26 and 12.2.28 and see the evidence of Dr Connolly summarised in Chapter 7. The objective was to "identify the design principles on which constructional recommendations might confidently be based"2304 {BRE00001077/4}. and the primary focus was on the use of combustible insulation in a cladding system.2305 See the title to the document at {BRE00001077} and see e.g. pages 3, 5, 7. The problem addressed by the study was the risk of flames spreading over the surface of a wall and within cavities2306 {BRE00001077/4-5} under the heading "Regulatory Aspects". but that risk was wholly unquantified and was not related to any particular evacuation strategy. It was therefore necessary to assess the results of the test in each case and determine the extent to which the risk of flame spread was acceptable given the fire safety strategy for the building under consideration.2307 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/103} paragraph 12.2.29-12.2.30.
210¶111.35 Three particular cladding systems were assessed for the purposes of the first edition of BR 135, a system containing insulation between an external layer of render and a masonry wall, a system incorporating expanded polystyrene insulation fixed to a masonry wall with an external facing of aluminium sheets, and a system of timber cladding of the kind traditionally used for low-rise buildings,2308 {BRE00001077/4-6} see in particular pages 5-6 under the heading "Experimental Fires". and the recommendations reflected the structures and physical characteristics of those systems.2309 {BRE00001077/9}; Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/104} paragraph 12.2.33-12.2.34. Importantly, the exterior materials used in the first two systems were non-combustible (cementitious render and aluminium) and therefore no question of the spread of flame over the external surface of the wall arose.2310 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/105} paragraph 12.2.39.
¶111.36 The principal danger identified in the experiments was the elongation of flames within cavities and therefore many of the recommendations were directed to the provision of fire barriers within cavities.2311 {BRE00001077/9}. However, subsequent studies carried out by BRE showed that fire barriers were not completely effective.2312 Connolly's 10 Large-Scale Tests in 1994 {RCO00000001/46} section 4.2.3 second paragraph and see Chapter 7. In this country attention appears to have been concentrated on cavity barriers, although little effort has been made to understand their effectiveness.2313 Bisby {Day290/162:4-14}; Torero {Day292/68:5}-{Day292/69:20}. Despite that, later editions of BR 135 continued to focus almost exclusively on the threat posed by the propagation of fire through cavities.2314 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/105-106} paragraph 12.2.43; BR 135 2nd Edition {BRE00005554}; BR 135 3rd edition {BRE00005555}. The only direct reference to the risk of flames spreading over the external panels of external wall systems is to be found in one paragraph in the third edition of BR 135, published in 2013.2315 {CEL00000584/22} section 6.4.1 which states: "Combustible panels are typically based on vinyl or glass-reinforced plastic, although various new products are being developed in this area, some of which also contain insulation materials. These products generally have good surface spread of flame characteristics to prevent rapid fire spread across the surface of the system, but once the panels become involved in the fire, they have the potential to generate falling debris, add to the overall fire load, and provide a route for fire to propagate up the outside of the building." It seems clear, therefore, that the concentration on cavity barriers as a means of limiting the spread of fire over external walls had its origin in BR 135 but was not based on a proper understanding of their benefits and limitations.
¶111.37 BR 135 sets out the criteria by which an external wall system is to be judged acceptable. However, it contains no explanation of those criteria nor any indication of what they are deemed to represent2316 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/106} paragraph 12.2.48. and it is a striking fact that none of the witnesses was able to explain their basis.2317 See for example the examination of Dr Colwell (who was involved in Fire Note 3 and Fire Note 9 and co-authored both the second and third editions of BR 135) at {Day231/167:23}-{Day231/176:25}; Debbie Smith {Day236/107:20} -{Day236/113:18}; Martin {Day251/119:4}-{Day251/120:24}. See also Chapter 7. Moreover, BR 135 itself does not attempt to relate the criteria to the requirements of the Building Regulations or the guidance contained in Approved Document B2318 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/108} paragraph 12.2.58. and the relevance of the criteria to practical experience has never been clearly articulated.2319 Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/42} paragraph 207. As a result, it has been left up to those seeking to make use of the data derived from tests in accordance with BS 8414 to satisfy themselves that the system under consideration is suitable for the intended use.2320 Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/42} paragraph 209. That is made clear in the third edition of BR 135, which states that the classification applies only to the system as tested and described in the classification report.2321 {CEL00000584/27} left column.
211¶111.38 The BS 8414 test itself is unsatisfactory in other respects. Some materials, such as high-pressure laminate, do not reach their maximum temperatures until about 30 minutes after the start of the test; for such products the initial 15-minute assessment period is therefore too short to identify the risk they pose.2322 Lane, Phase 2 Module 2 presentation: An explanation of the relevant Reaction to Fire tests and Classification methods to restrict the combustibility of external walls of high buildings {BLARP20000022/257} where Dr Lane highlighted temperature readings taken in BS 8414 tests conducted by MHCLG of HPL panels over A1 insulation. See also Lane {Day68/115:15}-{Day68/117:21}. A system incorporating panels of that kind might satisfy the performance criteria in BR 135 but still not comply with the functional requirements of the Building Regulations.
¶111.39 BR 135 also has its defects. For example, it contains no criteria relating to mechanical performance. Although it says that mechanical performance of the system should be taken into account as part of an overall assessment,2323 {BRE00005555/29} section A2.4 and {BRE00005555/33} section B2.4. it offers no guidance on how to evaluate it, although it is possible to formulate effective criteria.2324 See e.g. the Loss Prevention Standard 1582 approved by the Loss Prevention Council which has performance criteria for mechanical performance - {INQ00013964/12} paragraph 4.1.5.
Relevance to high-rise residential buildings
¶111.40 Making use of BS 8414 and BR 135 to assess the performance of an external wall system involves the application of performance criteria based on the temperature reached at a level of two storeys above the fire compartment within 15 minutes of the start of the test. The main difficulty with that approach is that it is possible for a fire that has become established in the external wall of a building to spread in a way that poses a significant danger although the criteria are still met. A fire may therefore spread beyond the compartment of origin in a way that is incompatible with a "stay put" evacuation strategy even if the external wall system has satisfied the performance criteria in BR 135.2325 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/109} paragraphs 12.2.63-12.2.64.
¶111.41 That difficulty does not appear to have been recognised by any of the lay witnesses, including those from DCLG or BRE.2326 Colwell {Day231/175:11-24}; Smith {Day236/114:4}-{Day236/115:4}; Martin {Day251/96:19}-{Day251/98:19}; Burd {Day238/214:10}-{Day238/215:6}. We obtained the clear impression that many in the industry thought that if, following a test in accordance with BS 8414, a system satisfied the criteria in BR 135, the building when completed would inevitably satisfy functional requirement B4(1) of the Building Regulations. Indeed, many failed to appreciate that the BS 8414 test applies only to the system as a whole and does not tell one anything about its individual components. It is a matter of concern that no one appears to have considered whether the extent of flame spread that could occur while still satisfying the performance criteria in BR 135 was consistent with the adoption of a stay put evacuation strategy.
212¶111.42 Only a limited amount of information can be obtained from a BS 8414 test. In particular, it produces very little information that is relevant to important questions relating to external wall systems, such as the speed at which flames are likely to spread and whether they can be expected to die out naturally.2327 Torero {Day289/67:8-18}. In particular, the thermocouples forming part of the test equipment does not provide information about:
¶a. the likelihood that the fire will extinguish itself once the crib has been extinguished;
¶b. whether the ignition temperatures of any of the materials are so high that they can be considered non-combustible;
¶c. the rate of internal or external flame spread over the façade; or
¶d. other properties of the system, such as ignition temperature, thermal inertia and heat of combustion.2328 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/109} paragraphs 12.2.65-66.
¶111.43 At best the BS 8414 test can indicate only whether it would be wholly inappropriate to make use of a particular system when constructing the external wall of a building.2329 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/110} paragraph 12.2.68; Torero {Day292/77:8-17}; Bisby {Day290/143:1-8}; Torero {Day292/76:25}-{Day292/77:6}. It was not designed to and does not provide technical information which, taken in isolation, can enable the designer to be confident that a particular system will adequately resist the spread of fire over the walls of the building. Put another way, failure to meet the performance criteria in BR 135 will demonstrate that a given system is unlikely to comply with functional requirement B4(1) of the Building Regulations, but the converse is not necessarily true: a given system might meet the performance criteria of BR 135 and yet fail to comply with the functional requirement.
¶111.44 We think it important to recognise that only a limited amount of information can be obtained from a BS 8414 test. It can never accurately reflect the conditions the building will encounter in use because there will inevitably be differences between the large-scale test and the building itself.2330 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/110} paragraphs 12.2.69-12.2.73; Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/42-43} paragraphs 210-211; Bisby {Day290/138:22}-{Day290/141:13}. A significant responsibility therefore rests on the shoulders of the person charged with assessing the significance of the results.2331 Bisby {Day290/140:3}-{Day290/141:13}.
¶111.45 Until recently it has not been recognised as widely as should have been the case that the functional requirements of the Building Regulations alone determine the standards that have to be met. That may be due in part to the fact that the statutory guidance is framed in prescriptive terms and is therefore easier and more attractive to follow. One aspect of that was a widespread assumption that if a system met the criteria in BR 135, the building would comply with functional requirement B4(1) without any need to analyse the information obtained from the test itself or consider the conditions likely to be encountered in use. In our view the way in which the guidance in Approved Document B is expressed helped to perpetuate that assumption. However, there was and always has been an obligation on construction professionals to assess the results of BS 8414 tests and BR 135 classifications.
¶111.46 The deceptively simple terms of Approved Document B diverted attention from the fact that the information derived from large-scale tests needed to be analysed in conjunction with other relevant information in order to understand the likely behaviour of the external wall when exposed to flames and heat generated by a fully developed compartment fire.
213¶In our view an analysis of that kind calls for a level of skill greater than that possessed by many of the construction professionals who routinely relied on such tests.
The future of large-scale testing
¶111.47 It is possible to criticise the BS 8414 test as not representing conditions likely to be encountered in practice and as being liable to deliver differing results based on random variations in the systems tested.2332 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/111} paragraph 12.2.78 and see for example the paper by Schultz J, Kent, Crimi, Glocking, Hull, "A Critical Appraisal of the UK's Regulatory Regime for Combustible Facades," Fire Technology, 57, 261-290, 2021 {INQ00014943}. Moreover, it is essential to recognise that even if it can be made more realistic it will never provide all the information necessary to make a reliable assessment of the performance of an external wall. That will have to be derived from a range of tests, including small- and medium-scale tests, to determine the physical properties of the external wall that are likely to influence the spread of fire. The proper role of the BS 8414 test is to check the accuracy of assessments based on other methods.2333 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/111-112} paragraph 12.2.79; Torero {Day292/84:12}-{Day292/86:25}. It should never be the only basis upon which the performance of an external wall system is assessed.
¶111.48 The reaction to fire of the external wall of Grenfell Tower amply illustrates the point. Any competent designer should have appreciated that the presence of polyethylene in the ACM panels presented a very significant danger, given the amount of energy that could be released if it became involved in fire. It should also have been clear that the aluminium sheeting enclosing that polyethylene was likely to deform and delaminate in response to heating and that the exposed polyethylene was likely to melt and drip. The experiments carried out at the University of Edinburgh demonstrated that it was possible to design small- and medium-scale tests capable of identifying the thermo-mechanical processes that led to the deformation of the panels and the involvement of the polyethylene in the fire.2334 Chapter 109. It follows that any assessment of the likely performance of an external wall system calls for a methodical analysis of a range of data and cannot be based on a single test that may not adequately reflect conditions liable to be encountered in practice.
¶111.49 Finally, it is important to recognise that if large-scale tests are to be of any value, it is important to ensure that those who carry them out make the data derived from them fully available to the manufacturer and designer. That degree of co-operation was lacking on the part of many of those who were involved in large-scale testing before the Grenfell Tower fire.2335 See in particular Chapter 22 and Chapter 24.
Desktop assessments
¶111.50 In relation to external wall systems, so-called "desktop assessments" or "desktop studies" involve the use of data derived from (usually) large-scale tests of one or more systems to establish by extrapolation how the system being assessed would respond if subjected to the same or a similar test. In practical terms, it is a method of demonstrating by reference to data derived from a BS 8414 test carried out on another system that the system under consideration would, if it were to be subjected to the same test, satisfy the criteria in BR 135.2336 Bisby, Phase 2 Report: BR 135 Desktop Assessment Report {LBYP20000004/8} paragraph 41. Although no desktop study was undertaken in relation to the external wall of Grenfell Tower, by the time of the fire they had become commonplace,2337 See for example Lewis {NHB00003433/38} page 28, paragraph 148; Lewis {NHB00003433/53} page 53, paragraph 194; Evans {NHB00003020/70} page 70, paragraph 190(d); Evans {NHB00003020/77} page 77, paragraph 200(a). particularly after they had been recognised by the Building Control Alliance in its Technical Guidance Note 18 as a means of demonstrating compliance with paragraph 12.7 of Approved Document B.2338 {NHB00000760}.
214¶111.51 Although a desktop assessment can, in principle, constitute a valid means of providing some of the information needed to assess the behaviour of an external wall system in response to fire,2339 Bisby, Phase 2 Report: BR 135 Desktop Assessment Report {LBYP20000004/8} paragraphs 41 and 44; Torero Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/114} paragraph 12.2.93; Torero {Day292/91:17}-{Day292/92:3}. its value depends to a very substantial extent on the quality of the data available for that purpose and the competence of the person carrying it out. To carry conviction such an assessment will need to be the subject of peer review or other competent oversight.2340 Bisby, Phase 2 Report: BR 135 Desktop Assessment Report {LBYP20000004/2} paragraph 7; {LBYP20000004/39} paragraphs 288 and 289; Bisby {Day291/66:6-13}; {Day291/89:4-11}.
¶111.52 The value of any desktop assessment of that kind also depends on both the author's and the reader's understanding of the limitations of the BS 8414 test and the criteria in BR 135. Just as a BS 8414 test should be regarded as no more than one source of information, so a desktop assessment should be treated as only part of what is a complex exercise that requires information from various sources.2341 Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/115} paragraphs 12.2.96 and 12.2.97; Bisby {Day290/92:8}-{Day290/93:3}; {Day291/66:22}-{Day291/67:10}; {Day291/74:19}-{Day291/75:10}.
¶111.53 Moreover, whether a system has itself been subjected to a test or has only been the subject of a desktop study, it is still necessary to assess how it is likely to perform as part of a building.2342 Bisby, Phase 2 Report: BR 135 Desktop Assessment Report {LBYP20000004/8} paragraphs 45 and 46; {LBYP20000004/24} paragraph 170; {LBYP20000004/42} paragraph 305; Bisby {Day290/123:10}-{Day290/124:7}; {Day290/140:17}-{Day290/141:9}; {Day291/73:4-24}. For the reasons we have given, meeting the criteria in BR 135 does not of itself demonstrate compliance with the functional requirements of the Building Regulations2343 Bisby {Day291/69:2-6}. and was not intended to do so.
¶111.54 There was ample evidence that those matters were not properly understood by construction and building control professionals in the years preceding the Grenfell Tower fire. For example, desktop assessments were often accepted by NHBC as "proving compliance" not only with Approved Document B but with the requirements of the Building Regulations themselves.2344 Evans {NHB00003020/10} page 10, paragraph 28(a); Evans {NHB00003020/15} page 15, paragraph 42, second sentence; Evans {NHB00003020/22} page 22, paragraph 68; Evans {NHB00003020/24} page 24, paragraph 74(b); Evans {NHB00003020/38} page 38, paragraph 107, final sentence; Evans {NHB00003020/63} page 63, paragraph 173, final sentence; Evans {NHB00003020/66}, page 66 paragraph 183; Evans {Day220/15:11-18}; {Day220/64:20-23}; {Day221/163:15-21}; {Day221/170:7-13}; {BLM00000211/3} second paragraph in blue text; Lewis {Day224/45:19-24}; {Day224/74:3-14}; {Day224/128:15}-{Day224/129:11}. See also {NHB00001408/4} paragraph 1.1.1.
¶111.55 The need for a methodical and scientifically rigorous approach to assessing how a system that has met the criteria in BR 135 will perform in practice2345 Bisby, Phase 2 Report: BR 135 Desktop Assessment Report {LBYP20000004/24} paragraph 170. is of greater importance when the data that provides the basis for the assessment has been derived from one or more tests carried out on different systems.2346 Bisby {Day291/68:6-14}. That exercise necessarily introduces additional layers of complexity, because the person making the assessment must take into account the potentially complex variations between the different systems. Accordingly, the level of expertise and experience required to make the assessment are higher.2347 Torero {JTOR00000006/114}, Phase 2 Report: Adequacy of the Current Testing Regime paragraph 12.2.95.1 and {JTOR00000006/115} paragraphs 12.2.97 and 12.2.98. See also Bisby {Day291/67:16}-{Day291/68:5}.
215BS 9414:2019
¶111.56 BS 9414,2348 {BSI00001934}. which was published in 2019, offers guidance on the interpretation of BS 8414 test data and provides procedures and rules for the way in which such data can be extended to systems other than those tested.2349 {BSI00001934/9} first paragraph. It proceeds on the assumption that the BS 8414 test series is in itself a sufficient mechanism for establishing the fire performance of a system; the limitations of the information that can be derived from BS 8414 test data are not acknowledged. It does not explain how the effect of any differences between the system as tested and the system as built are to be assessed without a desktop assessment at each stage of the process identified as requiring an application evaluation. Instead, it attempts to simplify the process of assessment using a set of prescriptive rules instead of calling for an examination by a qualified fire engineer.2350 Torero {Day292/95:19-21}; {Day292/99:20}-{Day292/100:19}; {Day292/103:25}-{Day292/104:13}. It aims to standardise what is intended to be an individual assessment.2351 Torero {Day292/100:9-19}. In our view it should be used with great caution and with the considerations we have mentioned in mind.
Conclusions
¶111.57 It seems clear to us that the regime that existed before the Grenfell Tower for assessing the performance of external walls in fire was inadequate. It relied heavily on small-scale tests which did not provide the information needed to make a reliable assessment of how materials were likely to perform in a significantly different context. It also relied on a large-scale test which lacked coherent performance criteria and provided limited useful information. The assessment method in BR 135 was too simplistic, allowing for a simple pass or fail result, when the results of the test required a degree of interpretation that was beyond the competence of most in the industry. Moreover, guidance on how to carry out effective desktop assessments was lacking.
¶111.58 Although we recognise that some changes have been made to the regulatory system since that time, including a ban on the use of certain combustible materials on some tall buildings, we remain troubled by the fact that there is still no fire testing regime that delivers relevant information and by the failure to recognise the need for the application of competent professional judgement. We think that a comprehensive overhaul of the fire testing regime needs to be undertaken together with initiatives that will improve the number of fire engineers capable of carrying out complex assessments.
217Part 13: International responses
219Chapter 112: The response of other countries
Introduction
¶112.1 In the years before the Grenfell Tower fire there were a number of similar fires in other countries that in some cases led to the introduction of new measures designed to prevent any recurrence. We have not attempted to carry out a comprehensive investigation into the measures adopted elsewhere but we consider that the information we have been able to obtain provides a strong foundation for the recommendations made in Part 14.
¶112.2 We have had the benefit of a report from Professor José Torero, whose experience in this field is unrivalled. Professor Torero has spent considerable periods of his career working in other countries, including Queensland, Australia (2012–2017)2352 Torero, Phase 2 Report {JTOR00000006/4} paragraph 1.2.1. Between 2012 and 2017 Professor Torero was Professor of Civil Engineering and Head of the School of Civil Engineering at the University of Queensland, Australia. and more recently at the University of Maryland in the United States (2017–2019).2353 Torero, Phase 2 Report {JTOR00000006/4} paragraph 1.2.1. Between 2017 and 2019 Professor Torero held the John L. Bryan Chair at the Department of Fire Protection Engineering and was the Director of the Center for Disaster Resilience at the Department of Civil Engineering at the University of Maryland, USA. He included as an appendix to his report on the current testing regime2354 Torero, Phase 2 Report {JTOR00000006}. a review of international responses to the Grenfell Tower fire, on which he also gave oral evidence.2355 Torero {Day291/106:10}-{Day291/193:18}; {Day292/1:20}-{Day292/3:18}. We draw particular attention to that part of his report, which, in the absence of any challenge to his evidence, we have generally accepted. We recommend that it be read carefully by all those responsible for ensuring safety from fire. His report, together with the other documents and reports to which we have referred, all of which are available on the Inquiry's website, provides the basis of much of what follows.
¶112.3 We are grateful to a number of foreign governments and other overseas bodies that have taken the trouble to tell us about their regulatory regimes relating to fire safety and the measures they have taken in response to cladding fires both in their own countries and elsewhere. We acknowledge in particular the contributions received from the National Fire Protection Association (NFPA) in the United States2356 {USA0000001}., the Dubai Civil Defence Office2357 Johnson {DCD00000001/1} page 1, paragraphs 3-3.1.2., the government of New South Wales,2358 {NSW0000001}. the government of Queensland2359 {QLD00000002}. and the government of Victoria.2360 {VIC00000001}. Although construction work in each state is governed by its own legislative provisions, the approach to regulation adopted throughout Australia is broadly similar to that adopted in England, which renders the response of the authorities there of particular interest.
220Prohibition
¶112.4 In some countries the use of combustible materials in external walls had already been prohibited by the time fires in high-rise buildings began to be encountered. In those cases it was not thought necessary to introduce new measures in response to the threat beyond strengthening the existing provisions.2361 Torero, Phase 2 Report {JTOR00000006/210} paragraph A3.1. That was the case, for example, in France and Germany and in Hong Kong and China.2362 Torero, Phase 2 Report {JTOR00000006/210} paragraph A3.1. A similar approach has been taken in this country since the Grenfell Tower fire by prohibiting the use on the external walls of buildings over 18 metres in height of materials with a European classification lower than A2-s1,d0,2363 The Building etc. (Amendment) (England) Regulations 2022, regulation 2(4)(b). but it is potentially disadvantageous because the development of new materials and methods of construction is liable to require frequent legislative intervention.2364 Torero {Day292/129:1-10}.
Prescriptive regulation
¶112.5 Since 1984, the legislation governing building work in England and Wales has been based on functional requirements. In the United States, by contrast, there is a preference for a much more prescriptive approach. A commercial body, the National Fire Protection Association (NFPA),2365 {USA0000001/4} fifth paragraph; Torero, Phase 2 Report {JTOR00000006/211} paragraph A3.9; Torero {Day291/109:19}-{Day291/110:9}; {Day291/121:23}-{Day291/122:2}. publishes building and safety codes that, although voluntary, are widely adopted by clients and contractors. As a result, although each state is a separate legal jurisdiction with its own laws, most buildings are constructed in accordance with the requirements of the NFPA codes which require the provision of an extensive range of fire safety systems, such as sprinklers,2366 {USA0000001/5} third paragraph. voice alarm communication systems2367 {USA0000001/5} fourth paragraph. and two staircases2368 Torero {Day291/120:7-8}. and allow little scope for independent design choices.2369 Torero {Day291/113:13}-{Day291/114:2}; {Day291/120:2-19}; {Day291/115:20}-{Day291/116:7}. The codes are constantly revised by NFPA committees which meet regularly to ensure that they keep pace with the introduction of new technologies.2370 Torero {Day291/120:25}-{Day291/121:9}. A wide range of interested persons and organisations are included in the process and the effectiveness of the work is judged by reference to fire safety statistics.2371 Torero {Day291/121:10}-{Day291/122:24}. The prescriptive approach embodied in the NFPA codes reflects a conservative approach to fire safety which is embedded in North American culture.2372 Torero {Day291/122:25}-{Day291/123:24}. Professor Torero contrasted this approach with that which has prevailed in Europe where the existing building stock and the need for post-war regeneration meant that less prescriptive, conservative solutions had to be adopted. Torero {Day291/123:25}-{Day291/124:23}. Under the codes, large-scale testing using a test method broadly similar to BS 8414, known as NFPA 285,2373 NFPA test standard 285: Standard Fire Test Method for Evaluation of Fire Propagation Characteristics of Exterior Non-Load-Bearing Wall Assemblies Containing Combustible Components {USA0000001/6} first paragraph. is mandatory.2374 {USA0000001/6} section 3, first paragraph.
¶112.6 The fundamental differences of approach between the United States and the United Kingdom to regulating building work means that it is not possible to transpose individual elements from one system to another. One marked point of difference, however, from which we might learn, is that in the United States those involved in the design, construction and inspection of buildings are typically required by law to hold some form of certification, licence or similar qualification to demonstrate that they have achieved a minimum level of competence in the area in which they practise.2375 {USA0000001/6} section 3, third paragraph. However, the prescriptive nature of the codes means that construction professionals do not have to understand and interpret functional requirements, as is the case in England and Wales and Australia2376 Torero {Day291/128:12-19}. and to that extent the demands imposed on them are less onerous.
221¶112.7 The NFPA codes and standards rely on independent testing laboratories to confirm that materials and products used in construction comply with their requirements.2377 {USA0000001/7-9} section 4. The requirement for accreditation and certification of professionals also extends to those involved in the testing, certification, design and approval process.
New legislation: United Arab Emirates (including Dubai)
¶112.8 The UAE has one of the highest concentrations of high-rise buildings in the world.2378 Johnson {DCD00000001/2} page 2, paragraph 4. It has also experienced a large number of cladding fires. Before 2013, cladding forming part of the external wall of a building in the UAE often incorporated ACM rainscreen panels with unmodified polyethylene cores.2379 Johnson {DCD00000001/2} page 2, paragraph 4.1.1. The UAE Fire and Life Safety Code of Practice 20112380 {INQ00014966}. did not contain any provisions relating to the spread of fire over external walls or any requirements for the reaction to fire of the external walls of buildings more than three metres apart.2381 Torero, Phase 2 Report {JTOR00000006/211} paragraph A3.10. Following a serious fire in a high-rise building in 2012, the legislation was amended to introduce minimum requirements for cladding systems and for fire-stopping.2382 Johnson {DCD00000001/2} page 2, paragraphs 4.1.2 and 6.2. Subsequently, a unified document was prepared in the form of the 2018 edition of the UAE Fire and Life Safety Code.2383 Johnson {DCD00000001/3} page 3, paragraphs 6.5-6.5.1; https://www.dcd.gov.ae/portal/eng/UAEFIRECODE_ENG_ SEPTEMBER_2018.pdf.
¶112.9 The UAE Fire and Life Safety Code 2018 adopts many elements of a prescriptive approach to building regulation. It prohibits the use of cladding assemblies for mid-rise and high-rise buildings that are not fire-rated2384 Torero, Phase 2 Report {JTOR00000006/211-212} paragraph A3.10; see the 2018 UAE Fire and Life Safety Code, Chapter 1 {INQ00014966} section 2.6. and requires the incorporation of a fire resistant spandrel in buildings over 15 metres in height.2385 Torero, Phase 2 Report {JTOR00000006/212} paragraph A3.10; Johnson {DCD00000001/4} page 4, paragraph 6.6.1; see the 2018 UAE Fire and Life Safety Code, Chapter 1 {INQ00014966} section 2.8.10. It also requires materials used in external walls (including the cores of panels) to be tested in accordance with prescribed tests similar to those used in the UK and the USA2386 Torero, Phase 2 Report {JTOR00000006/212} paragraph A3.11; see the 2018 UAE Fire and Life Safety Code, Chapter 1, at e.g. 1.1.35 to 1.1.40 and section 2.6. and the system as a whole to be tested using a large-scale test method similar to NFPA 285 and BS 8414.2387 Torero {Day291/145:8-13}. All facade contractors have to be licensed by the Civil Defence Office.2388 Johnson {DCD00000001/5} page 5, paragraph 6.9.
¶112.10 A novel step taken by the UAE was the creation in 2012 of a "House of Expertise", a group of fire and life-safety consultants chosen for their expertise in designing external walls and supervising facade contractors,2389 Johnson {DCD00000001/5} page 5, paragraph 6.9. whose role is to advise the Civil Defence Authority on proposals for the construction of new buildings.2390 Johnson {DCD00000001/3} page 3, paragraph 6.3. In practice all the most complex buildings are reviewed by the group.2391 Torero {Day291/135:4-17}. The role played by the House of Expertise, therefore, is akin to that played in this country by building control. In practice, the regulation of building work in the UAE now relies heavily on the expertise of that group.2392 Torero {Day291/136:10-14}.
222¶112.11 The Fire and Life Safety Code recognises that a "stay put" strategy in response to a fire needs to be carefully evaluated and provides in terms that partial evacuation would be a suitable strategy for a high-rise building.2393 Table 19.1 of the Code on page 1236 at https://www.dcd.gov.ae/portal/eng/UAEFIRECODE_ENG_ SEPTEMBER_2018.pdf. That reflects a change of approach from that previously adopted,2394 Torero {Day291/138:5}-{Day291/139:24}. but it is not clear to what extent it applies to existing buildings designed to operate a "stay put" strategy.
¶112.12 The inspection and enforcement regime relating to the construction of new buildings in the UAE has also been strengthened in recent years.2395 Torero, Phase 2 Report {JTOR00000006/213} paragraph A3.12; Johnson {DCD00000001/6-7} pages 6-7, paragraphs 8-8.5. The construction of external walls is inspected and approved by a consultant or a member of the House of Expertise.2396 Johnson {DCD00000001/5} page 5, paragraph 6.9. All commercial buildings must contain equipment that actively monitors the fire safety systems (including fire alarm, water and lift systems) and reports any fault or fire in the building to a control centre.2397 Johnson {DCD00000001/2} page 5, paragraph 5.1.
Australia
¶112.13 Like the United States, the Commonwealth of Australia is a federation of states and territories. The National Construction Code, which applies to the country as a whole, prescribes certain standards that must be met by all new buildings. It obtains the force of law by being incorporated into the law of the different states and territories, sometimes with minor amendments. Like the Building Act 1984, those requirements are couched in functional terms. For example, it provides that "a building must have elements which will, to the degree necessary, avoid the spread of fire between buildings."2398 National Construction Code, CIP2(1)(c). The fact that regulations are expressed in terms of functional (or performance) requirements means that the basic approach taken in Australia is the same as that taken in the UK.
¶112.14 The fire that affected the external wall of the Lacrosse building in Melbourne, Victoria on 25 November 2014 was a significant national event. Together with other building failures,2399 Including structural failures and moisture ingress failures. Torero {Day291/150:25}-{Day291/151:3}. it led to a series of investigations into the state of the construction industry in Australia. As a result, three important reports were published, the Lambert report in 2015 commissioned by the government of New South Wales,2400 Lambert M. Independent Review of the Building Professionals Act 2005 – Final Report, October 2015 {INQ00014958}. the Shergold & Weir report in 2018 commissioned by the federal government,2401 Shergold, P. and Weir, B., Building Confidence – Improving the effectiveness of compliance and enforcement systems for the building and construction industry across Australia, February 2018 {INQ00014963}. and the Warren Centre reports produced by the University of Sydney.2402 The Warren Centre Project – professionalising fire safety engineering, The Warren Centre, University of Sydney, https://www.sydney.edu.au/engineering/industry-and-community/the-warren-centre/fire-safety-engineering.html, study launched in July 2018 and final report dated 2020. Taken together, they represented a careful and detailed investigation of professional practices in the construction sector in Australia that is of global significance.2403 Torero, Phase 2 Report {JTOR00000006/213} paragraph A3.15.
223¶112.15 The first report of the Warren Centre (The Warren Centre Education Report, 2019) drew attention to the fact that in 2017 only two state governments, those of Queensland and Tasmania, operated licensing schemes for fire engineers.2404 https://www.sydney.edu.au/content/dam/corporate/documents/faculty-of-engineering-and-information- technologies/industry-and-government/the-warren-centre/the-education-report-fire-safety-engineering-the- warren-centre.pdf Some other states had formulated requirements for practitioners wishing to be registered, but they were not enforceable and there were no penalties for practising as a fire engineer without being registered.2405 Lane, Phase 2, Recommendations Report {BLAR200000001/127} paragraph 5.10.4. The licensing of fire engineering professionals was also emphasised as an important recommendation in the Shergold & Weir report.2406 Lane, Phase 2, Recommendations Report {BLAR200000001/127} paragraphs 5.10.5-5.10.6. We think that similar considerations apply in this country.
¶112.16 The competence of building professionals and its importance in ensuring fire safety in the built environment received particular attention in the Warren Centre reports, in particular, in a report specifically devoted to that subject.2407 This was report 5 of the series {INQ00014933}. It identified the skills that fire engineers need to possess and can be obtained through an accredited degree programme followed by a period of supervised practice, continuing professional development and effective monitoring, all supported by disciplinary procedures when standards are not met. The report identified a need to raise standards among those seeking to become fire engineers and a requirement for consistency of approach to their education, training, supervision and regulation.2408 {INQ00014933/29-30}. Engineers Australia, the body that governs admission to the status of Chartered Engineer in Australia, subsequently adopted the Warren Centre report for the purposes of assessing applicants for membership.2409 Lane, Phase 2, Recommendations Report {BLAR200000001/129} paragraph 5.10.15.
¶112.17 In its final report the Warren Centre made a wide range of recommendations relating to fire engineering, including recommendations for the professional education, training, development and accreditation of fire engineers.2410 {INQ00014933/21-23}. It also made a number of recommendations for changes to the national building code and guidance, and for the introduction of a scheme for registering professional engineers, including the establishment of "assessment bodies" and a monitoring framework with sanctions for sub-standard work.2411 {INQ00014933/24-25}.
¶112.18 The Warren Centre reports provide a good example of collaboration between government, industry and the academic world in the delivery of a programme for the improvement of professional standards. It offers an interesting example of the kind of thing that might be done in the UK.2412 Torero, Phase 2 Report {JTOR00000006/193} paragraph A2.29.
224¶112.19 Following the Lacrosse fire in November 2014, Australia introduced a large-scale system test method known as AS 5113 to complement AS 1530.1, its existing combustibility test for materials,2413 This test is very similar to the BS 476-4 test. Torero {Day292/5:23}-{Day292/6:1}. and AS 1530.3, which tests the reaction of the surface of a material to heat. AS 5113 is virtually identical to BS 8414.2414 Torero {Day292/5:15-25}.
The State of Victoria, Australia
¶112.20 We received a very full and helpful submission from the Government of Victoria describing the steps it has taken in response to the problem posed by combustible cladding following the fire at the Lacrosse building in November 2014. The fire led to an audit of buildings constructed between 2005 and April 2015 which disclosed that the external walls of half of them had been constructed using non-compliant materials and required remedial work. To assist with the audit the government developed a risk assessment tool to assess the danger to life and property posed by combustible cladding. It contained two sections, one relating to the risk of ignition and the spread of fire and one relating to the ability of the occupants to escape.
¶112.21 It is not surprising that in the face of a serious problem of that kind the government resorted to legislation, giving the relevant minister the power to prohibit the use of products considered to pose a high risk. However, although the legislation came into effect in 2018, as far as we know, the power has not yet been exercised.2415 {VIC00000001/8} section 3.3. In that respect the government here has already gone further by prohibiting the use of rainscreen panels that are not classed A2-s1,d0 or better.2416 The Building etc. (Amendment) (England) Regulations 2022, regulation 2(4)(b).
¶112.22 In its submission the government of Victoria helpfully described a number of other measures it has taken to promote remedial work on buildings with dangerous cladding. However, they were tailored to the particular circumstances existing in that state and we do not think that similar measures would be suitable to the UK. One step that we think the UK government could usefully take note of, however, was to take legal action against building professionals involved in the installation of non-compliant cladding. Under Victoria's Building Act it is an indictable offence knowingly to carry out building work that is not in accordance with the Act or the regulations made under it, with a maximum penalty of five years' imprisonment.2417 {VIC00000001/8} section 3.6. That appears to be much stronger than section 35 of the Building Act 1984. Moreover, regulation of construction professionals by the Victorian Building Authority enables it to take disciplinary action against them when appropriate and at the time of the submission (September 2020) two practitioners had been suspended and a further nine faced disciplinary proceedings relating to the installation of non-compliant cladding.2418 {VIC00000001/8} section 3.6. Currently, certain engineers, including fire engineers, must be registered to provide professional engineering services in Victoria.2419 https://www.engineersaustralia.org.au/credentials/registration/state-registration#accordion-1506.
The State of New South Wales, Australia
¶112.23 The government of New South Wales was generous in providing us with a copy of its submission to the Public Accountability Committee describing its response to the emerging problem of combustible cladding. In July 2017 in response to the Grenfell Tower fire it devised a ten-point plan and established the New South Wales Fire Safety and External Wall Cladding Taskforce to develop new policies and operational proposals. The Taskforce meets regularly to plan and co-ordinate the government's response to the risks posed by combustible cladding.
225¶112.24 New South Wales also resorted to legislation. In December 2017 parliament passed legislation in the form of the Building Products (Safety) Act 2017, designed to ensure the safety of building products. The Act gives the Commissioner of Fair Trading power to prohibit the use of products if he has reasonable grounds to consider their use unsafe and to identify buildings on which products have been used in a way that is prohibited (including buildings on which products were used before the prohibition took effect). In August 2018 the Fair Trade Commissioner prohibited the use of ACM panels with cores of more than 30% polyethylene on certain buildings.2420 {NSW0000001/42}.
¶112.25 Other measures of note are the passing of legislation to strengthen the independence of building certifiers (broadly the equivalent of our building control officers) and the introduction of a requirement that certain functions affecting the fire safety of buildings be performed only by accredited fire safety practitioners.2421 {NSW0000001/46}. In New South Wales certain engineers need to be registered, including any professional engineer working on certain buildings, including apartment buildings.2422 https://www.engineersaustralia.org.au/credentials/registration/state-registration#accordion-1506
The State of Queensland, Australia
¶112.26 The government of Queensland also responded generously to an invitation from the chairman to make a submission to the Inquiry describing its response to the problem of combustible cladding. A number of important points emerge from that submission, all of which we found most helpful when considering how the matter could best be taken forward in this country.
¶112.27 Like the government of NSW, the government of Queensland established a task force consisting of a dedicated team of experts representing the government, the construction industry and fire service professionals working across government to guide construction industry, professionals and building owners in responding to the dangers of combustible cladding.2423 {QLD00000002/4}; {QLD00000002/21}.
¶112.28 Long before the Grenfell Tower fire the University of Queensland had developed a strong relationship with the fire service that included the provision of training.2424 Torero {Day291/181:2-11}. That approach was reinforced after the Grenfell Tower fire and a number of important initiatives were then undertaken.2425 Torero {Day291/182:4-19}. They included an audit of all publicly and privately-owned buildings to assess the extent of the risk and the amount of remediation required.2426 {QLD00000002/8}.
¶112.29 In Queensland the government took steps to ensure that building products were safe for their intended use. The Queensland Building and Construction Commission Act 1991 was amended to impose obligations on those involved in specifying or supplying products (including designers, architects, engineers, manufacturers, importers, suppliers and installers) to ensure that they are safe and fit for their intended purpose.2427 {QLD00000002/16}.
226¶The amendments also increased the powers of the Commission to investigate the use of inappropriate building products and to take action in respect of them, including by issuing warnings and recalling products.2428 {QLD00000002/8}.
¶112.30 In Queensland "Fire Engineer" is a protected title awarded by the Board of Professional Engineers of Queensland that certifies the professional competence of all engineers. The functions and duties of engineers are set out in the Professional Engineers Act 2002.2429 {QLD00000002/20} first paragraph.
¶112.31 In collaboration with various international institutions the government of Queensland established a five-day continuing professional development course for fire engineers to provide the specialist knowledge that would enable them to understand the implications of using certain products and produce effective fire safety strategies.2430 {QLD00000002/28}. However, in 2019 Queensland also decided to resort to legislation, prohibiting the use of ACM panels with polyethylene cores of more than 30% by mass.2431 {QLD00000002/24}.
¶112.32 Nonetheless, recognising that there was a need to improve the knowledge of building surveyors and the industry more generally, it introduced a series of courses designed to be taken by building surveyors,2432 Building surveyors in Queensland must be licensed as building certifiers and are decision-makers for building approval compliance {QLD00000002/19}. building inspectors and other industry professionals as part of continuing professional development to enable them to acquire the knowledge needed to carry out fire risk assessments of buildings with complex combustible cladding systems.2433 {QLD00000002/29}.
¶112.33 One of the most innovative responses to the threat posed by combustible cladding was the creation by the University of Queensland, with funding from the government, of a library of cladding materials to provide a catalogue and point of reference for materials that designers might be thinking of using in the future. The Cladding Materials Library is a substantial database containing information about a large range of products, including their performance in fire.2434 https://claddingmaterialslibrary.com. The intention behind it was to provide a source of publicly available information to assist fire engineers in assessing the hazards posed by particular materials. A series of tests was carried out on each product, including small-scale flammability tests, with the aim of identifying its properties.2435 Torero {Day292/12:1-9}.
¶112.34 It was originally intended to develop the Cladding Materials Library to incorporate the results of intermediate and large-scale tests, including tests similar to those carried out by Professor Bisby on the cladding materials used at Grenfell Tower.2436 Torero {Day292/14:10-19}. However, the programme was discontinued when the government decided to prohibit the use of certain cladding materials.2437 Torero {Day292/14:22}-{Day292/15:10}. Nonetheless, the Library remains publicly available and its development could be revived.
¶112.35 Although Queensland actively supported the introduction of the large-scale test, AS 5113, it recognised that the time and cost associated with such testing could cause difficulties for some building owners.2438 {QLD00000002/17}. It therefore developed testing protocols based on first principles2439 {QLD00000002/30}; Torero {Day292/4:7-19}. Small-scale tests were conducted which extracted the key information which is relevant to the spread of fire, including thermal inertia, ignition temperatures and mechanisms for mechanical failure. that enabled the reliable identification of cladding systems that needed to be replaced.2440 Torero {Day292/3:14}-{Day292/4:19}. They included a testing protocol that enables the fire performance of individual materials to be tested2441 {QLD00000002/30}. and is directed to quantifying the speed at which fire is likely to spread over an external wall.2442 Torero {Day292/4:20}-{Day292/5:4}; {Day292/20:2-16}. As such, it allows a quick and conservative assessment of the behaviour of individual cladding products to be made.2443 {QLD00000002/30}. That reflects the requirement throughout Australia for a phased evacuation rather than a stay put strategy in response to a fire in a high-rise building.
227Conclusions
¶112.36 We think that the following conclusions may fairly be drawn from this review:
¶a. In most countries the use of ACM panels with unmodified polyethylene cores is prohibited on high-rise buildings, either by pre-existing legislation or under legislation introduced specifically in response to the dangers created by combustible cladding.
¶b. In many countries construction professionals are subject to some form of licensing or accreditation and in many cases their titles and functions are protected by law.
¶c. Countries whose building regulations are based on performance or functional requirements have recognised the need for a body of highly skilled fire engineers capable of assessing the performance of external wall systems and producing fire safety strategies that will ensure that buildings are safe for those who live and work in them.
¶d. Many countries have also recognised that the knowledge and skills of other construction professionals, including those inspecting and approving buildings, also need to be improved through a combination of initial education, formal qualifications and continuing professional development.
¶e. Many countries have recognised the need for the testing and regulation of construction products to prevent the use of dangerous or unsuitable materials.
229Part 14: Recommendations
231Chapter 113: Recommendations
¶113.1 We are invited by our Terms of Reference to recommend measures to be taken in response to any deficiencies we found to exist in the matters under investigation. We have grouped our recommendations by reference to the subject matter to which they relate.
The construction industry
¶113.2 As appears from the findings in our report, we are satisfied that the system of regulating the construction and refurbishment of high-rise residential buildings that existed at the time of the Grenfell Tower fire was seriously defective in a number of respects. The statutory guidance in Approved Document B was poorly worded and liable to mislead designers into thinking that complying with its terms would inevitably ensure that the building would comply with the legal requirements of the Building Regulations. The government department responsible for the Building Regulations failed actively to monitor the performance of the system and failed to ensure that dangers of which it became aware were communicated to industry. It was not sensitive to the need to make urgent changes to the statutory guidance if conditions required it.
¶113.3 The remarks that follow are directed to the system for ensuring safety from fire, but we have no reason to think that other aspects of building safety are not subject to similar considerations. Safety of people in the built environment depends principally on a combination of three primary elements, good design, the choice of suitable materials and sound methods of construction, each of which depends in turn in a large measure on a fourth, the skill, knowledge and experience of those engaged in the construction industry. Unfortunately, as our investigations have shown, at the time of the Grenfell Tower fire there were serious deficiencies in all four of those areas.
The regulatory arrangements
¶113.4 We think that over the course of time the arrangements under which the construction industry was regulated had become too complex and fragmented. At the time of the fire the Department for Communities and Local Government (now the Ministry of Housing, Communities and Local Government) was responsible for the Building Regulations and the statutory guidance, the Department for Business, Energy and Industrial Strategy (now the Department for Business and Trade) was responsible for regulating products and the Home Office was responsible for the fire and rescue services. Building control was partly in the hands of local authorities and partly in the hands of approved inspectors operating as commercial organisations, enforcement of the law relating to the sale of construction products was carried out by Trading Standards and commercial organisations provided testing and certification services to manufacturers of products. UKAS accredited organisations operating as conformity assessment bodies. In our view, this degree of fragmentation was a recipe for inefficiency and an obstacle to effective regulation.
232Regulation
¶113.5 In our view all the functions to which we have referred, as well as some others to which we refer below, should be exercised by a single independent body headed by a person whom, for the sake of convenience, we shall call a construction regulator, reporting to a single Secretary of State. The establishment of such a regulator would bring a number of benefits, not least a focal point in driving a much-needed change in the culture of the construction industry. It would enable information to be shared effectively between those responsible for different aspects of the industry and promote the exchange of ideas. Information on developments in the industry, both in this country and abroad, could be shared more easily between all those interested in it. We envisage that such a construction regulator would have sufficient resources to take on the following functions, most of which are currently discharged by one or other of a variety of bodies: a. the regulation of construction products; b. the development of suitable methods for testing the reaction to fire of materials and products intended for use in construction; c. the testing and certification of such products;
¶d. the issue of certificates of compliance of construction products with the requirements of legislation, statutory guidance and industry standards; e. the regulation and oversight of building control; f. the licensing of contractors to work on higher-risk buildings;
¶g. monitoring the operation of the Building Regulations and the statutory guidance and advising the Secretary of State on the need for change; h. carrying out research on matters affecting fire safety in the built environment; i. collecting information, both in this country and abroad, on matters affecting fire safety; j. exchanging information with the fire and rescue services on matters affecting fire safety; k. accrediting fire risk assessors; l. maintaining a publicly available library of test data and publications.
¶113.6 We are aware that in the period since the Grenfell Tower fire Parliament has passed the Building Safety Act 2022 to regulate work on higher-risk buildings, to impose particular duties on those involved in the construction and refurbishment of such buildings and to establish a Building Safety Regulator responsible for building control and for overseeing standards of competence. However, responsibility for the range of functions identified above remains dispersed. We therefore recommend that the government draw together under a single regulator all the functions relating to the construction industry to which we have referred.
¶113.7 For the purpose of this and our other recommendations we have used the expression "higher-risk building" in the sense in which it is used in the Building Safety Act, that is, a building that is at least 18 metres in height (or has at least seven storeys) and contains at least two residential units.2444 Building Safety Act 2022, sections 31 and 65. However, we do not think that to define a building as "higher-risk" by reference only to its height is satisfactory, being essentially arbitrary in nature. More relevant is the nature of its use and, in particular, the likely presence of vulnerable people, for whom evacuation in the event of a fire or other emergency would be likely to present difficulty. We therefore recommend that the definition of a higher-risk building for the purposes of the Building Safety Act be reviewed urgently.
233Government
¶113.8 The fragmentation of responsibility for regulating the construction industry is currently mirrored in the range of government departments responsible for matters affecting fire safety. If a single body were responsible for all aspects of regulating matters affecting fire safety in the construction industry, that body should report to a single Secretary of State answerable to Parliament for all aspects of fire safety. That should improve the quality of government by providing an administrative environment in which information can be shared more quickly and more effectively between teams responsible for different aspects of the work and facilitate communication between the regulator and the department. It should also ensure that greater emphasis is placed on ensuring the safety of the built environment and that policy is developed in an holistic and coherent way. We therefore recommend that the government bring responsibility for the functions relating to fire safety currently exercised by MHCLG, the Home Office and the Department for Business and Trade into one department under a single Secretary of State.
Chief Construction Adviser
¶113.9 The minister will need to be able to turn for advice to someone who has a good working knowledge and practical experience of the construction industry. We therefore recommend that the Secretary of State appoint a Chief Construction Adviser with a sufficient budget and staff to provide advice on all matters affecting the construction industry, including: a. monitoring all aspects of the department's work relating to the Building Regulations and statutory guidance; b. providing advice to the Secretary of State on request; and
¶c. bringing to the attention of the Secretary of State any matters affecting the Building Regulations and statutory guidance or matters affecting the construction industry more generally of which the government should be aware.
Legislation and guidance
¶113.10 Nothing we have discovered in the course of our investigations has led us to think that expressing the legal requirements of the Building Regulations in terms of functional requirements is in itself unsatisfactory, but we do think that the way in which the statutory guidance in Approved Document B was expressed was unsatisfactory in a number of respects. We have drawn attention in Chapter 6 to the retention of Class 0 as a standard governing the fire performance of external wall panels and in Chapter 48 to the consequences of expressing in an apparently prescriptive form what is in reality no more than guidance. Most importantly we do not think that Approved Document B provides the information needed to design buildings that are safe in fire.
¶113.11 Approved Document B needs to be reviewed as a matter of urgency, taking into account the expert evidence of Professor Bisby, Professor Torero and Dr Lane, all of which is publicly available and none of which was significantly challenged in the course of our proceedings. It must then be kept under continuous review, together with the other Approved Documents, and amended annually or promptly whenever developments in materials or building methods make that desirable. It should be drafted conservatively to ensure, as far as possible, that compliance with it will provide a high degree of confidence that on completion of the work the building will comply with the Building Regulations.
234¶We therefore recommend that the statutory guidance generally, and Approved Document
¶B in particular, be reviewed accordingly and a revised version published as soon as possible.
¶113.12 Our investigations have shown that levels of competence in the construction industry are generally low and that by the time of the Grenfell Tower fire many contractors, designers and building control officers treated the statutory guidance as containing a definitive statement of the legal requirements. It is understandable that those who turn to the guidance for advice about how to comply with the Building Regulations should be tempted to treat it as if it were definitive, but that is a danger that the Secretary of State needs to recognise and guard against. We therefore recommend that a revised version of the guidance contain a clear warning in each section that the legal requirements are contained in the Building Regulations and that compliance with the guidance will not necessarily result in compliance with them.
¶113.13 We do not think it appropriate for us to recommend specific changes to Approved Document B, save in one respect. As we have pointed out in Chapter 48, the guidance proceeds on the assumption that effective compartmentation renders a stay put strategy an appropriate response to a fire in a flat in a high-rise residential building. New materials and methods of construction and the practice of overcladding existing buildings make the existence of effective compartmentation a questionable assumption and we recommend that it be reconsidered when Approved Document B is revised. One thing that has emerged clearly from our investigations is that in order to ensure the safety of occupants, including any with physical or mental impairments, those who design high-rise buildings need to be aware of the relationship between the rate at which fire is likely to spread through the external walls and the time required to evacuate the building or the relevant parts of it. A stay put strategy in response to a compartment fire will be acceptable only if there is negligible risk of fire escaping into and spreading through the external wall. Calculating the likely rate of fire spread and the time required for evacuation, including the evacuation of those with physical or mental impairments, are matters for a qualified fire engineer. We do not think that it would be helpful to attempt to include in Approved Document B an indication of what would be acceptable because each building is different, but we recommend that the guidance draw attention to the need to make a calculation of that kind. It is one that ought to form an essential part of any fire safety strategy.
¶113.14 We think that a fresh approach needs to be taken to reviewing and revising the Building Regulations and statutory guidance that is driven primarily by considerations of safety. Fresh minds are needed. We therefore recommend that, as far as possible, membership of bodies advising on changes to the statutory guidance should include representatives of the academic community as well as those with practical experience of the industry (including fire engineers) chosen for their experience and skill and should extend beyond those who have served on similar bodies in the past.
Fire safety strategy
¶113.15 A fire safety strategy for a building should describe its structure and the various fire protection systems it contains and set out how they work together to ensure the safety of the occupants in the event of a fire. Those involved in the design and execution of the Grenfell Tower refurbishment failed to understand properly the need for a fire safety strategy and therefore failed to ensure that a final version of the Outline Fire Safety Strategy begun by Exova was completed. That allowed the building to be in a dangerous condition on completion. In order to avoid a repeat of that error, we consider that there is a compelling case for requiring a fire safety strategy to be produced as a condition of obtaining building control approval for the construction or refurbishment of any higher-risk building and for it to be reviewed and approved on completion. We therefore recommend that it be made a statutory requirement that a fire safety strategy produced by a registered fire engineer (see below) to be submitted with building control applications (at Gateway 2) for the construction or refurbishment of any higher-risk building and for it to be reviewed and re-submitted at the stage of completion (Gateway 3). Such a strategy must take into account the needs of vulnerable people, including the additional time they may require to leave the building or reach a place of safety within it and any additional facilities necessary to ensure their safety.
235Fire Performance Tests
¶113.16 Assessing the fire performance of an external wall requires reliable information about the products and materials proposed for use in its construction, which in turn requires the availability of suitable methods for testing reaction to fire. As we have explained in Chapter 111, the small-scale test methods that have traditionally been relied on do not provide the information needed for that purpose and the large-scale test method (BS 8414) and classification in accordance with BR 135 lacks relevant performance criteria and provides a limited amount of useful information.
¶113.17 As is apparent from the experiments conducted by Professor Bisby and Professor Torero for Phase 2 of our investigations, the factors that affect the way in which fire spreads over ventilated rainscreen external wall systems are complex and understanding them is an evolving science. Intuitive judgements are often wrong because a small change in the system can have a significant effect on the outcome. It follows that assessing whether an external wall system can support a particular evacuation strategy is difficult because the necessary information is not always available. We therefore recommend that steps be taken in conjunction with the professional and academic community to develop new test methods that will provide the information needed for such assessments to be carried out reliably.
¶113.18 In the light of Professor Torero's evidence we think that BS 9414 will encourage people who are not trained fire engineers to think that they can safely assess the performance of a proposed external wall system by extrapolation from information obtained from tests on one or more different systems. For the reasons given by Professor Torero we think that BS 9414 should be approached with caution and we recommend that the government make it clear that it should not be used as a substitute for an assessment by a suitably qualified fire engineer.
Certification of products and publication of test data
¶113.19 It is essential that those responsible for designing buildings have access to reliable information about the materials and products they wish to use. In their product literature manufacturers make many claims for their products, some of which are not of an overtly technical nature but are calculated to give the impression that a particular product has passed a particular test or has been shown to be suitable for a particular use. That was one of the marketing devices employed by those who manufactured and sold the rainscreen cladding panels and the insulation used in the refurbishment of Grenfell Tower.
236¶113.20 Manufacturers were able to use misleading marketing material in part because the certification bodies that provided assurance to the market of the quality and characteristics of the products failed to ensure that the statements in the certificates they issued were accurate and based on appropriate and relevant test evidence. The United Kingdom Assessment Service (UKAS), the organisation charged with accrediting them, failed to apply proper standards of monitoring and supervision. The fact that three separate manufacturers were able to obtain misleading certificates relating to their products is evidence of a serious failure of the system and points to a need for a different approach to the certification of construction products.
¶113.21 We do not think that the appointment of a National Regulator of Construction Products will solve the problem because the system will still depend on the effectiveness of the conformity assessment bodies and the limited oversight of UKAS. Conformity assessment bodies provide a commercial service combined with an element of regulation, but the two functions do not sit easily together. Pressure to acquire and retain customers can all too easily lead such bodies to be less rigorous in their examination of products and materials and enforcing their terms of contracts than could reasonably be expected of bodies acting in the public interest.
¶113.22 We therefore recommend that the construction regulator should be responsible for assessing the conformity of construction products with the requirements of legislation, statutory guidance and industry standards and issuing certificates as appropriate. We should expect such certificates to become pre-eminent in the market.
¶113.23 In our view clarity is required to avoid those who rely on certificates of conformity being misled. We therefore recommend
¶a. that copies of all test results supporting any certificate issued by the construction regulator be included in the certificate;
¶b. that manufacturers be required to provide the construction regulator with the full testing history of the product or material to which the certificate relates and inform the regulator of any material circumstances that may affect its performance; and
¶c. manufacturers be required by law to provide on request copies of all test results that support claims about fire performance made for their products.
Fire engineers
¶113.24 Designing buildings that are safe in the event of a fire requires particular skill. It is a skill that can be acquired only by specialised education and experience worthy of formal recognition. Unfortunately, the term "fire engineer" does not at present denote any formal qualification and as a result it is possible for a person to practise as a fire engineer without any formal qualification. The evidence we have heard suggests that not all those who profess to be fire engineers are capable of performing that role competently and that the complexity of the subject matter is not well understood.
¶113.25 In those circumstances, and particularly given the importance of fire engineers in ensuring the safety of life, we think that the profession of fire engineer should be formally recognised and that both the title and the function should be protected by statute. Over time that would create a body of registered fire engineers who are capable of contributing to the design and delivery of safe buildings and of educating those construction professionals with whom they work in effective fire safety strategies. We therefore recommend that the profession of fire engineer be recognised and protected by law and that an independent body be established to regulate the profession, define the standards required for membership, maintain a register of members and regulate their conduct. In order to speed up the creation of a body of professional fire engineers we also recommend that the government take urgent steps to increase the number of places on high-quality masters level courses in fire engineering accredited by the professional regulator.
237¶113.26 Other construction professionals and more senior members of the fire and rescue services need to have a basic understanding of the principles of fire engineering as they apply to the built environment. The circumstances surrounding the Grenfell Tower fire show that an effective contribution from a fire engineer could have prevented the disaster by alerting the client and the principal contractor to the dangers of using aluminium composite panels with unmodified polyethylene cores and combustible insulation in the external wall of the building. They also show that the failure of Rydon and the TMO to understand the nature and importance of the analysis and advice that Exova should have provided contributed to their failure to obtain it. An authoritative statement of the skills that a fire engineer can be expected to bring to bear might assist the regulatory body and would improve the competence of other construction professionals and the fire and rescue services by enabling them to understand better the contribution that fire engineers can make to the construction of a safe building. It would also promote effective communication between them. Such a statement would need to draw on and reflect the experience of both practising fire engineers and those in the academic world to ensure that it was objective and properly reflected the scientific and intellectual demands of the role.
¶113.27 The development and maintenance of a statement of professional skills should ultimately be the responsibility of the body that regulates the profession, but pending the establishment of such a body we recommend that the government convene a group of practitioner and academic fire engineers and such other professionals as it thinks fit to produce an authoritative statement of the knowledge and skills to be expected of a competent fire engineer. Such a statement would also enable others in the construction industry to understand better the nature and importance of a fire engineer's work. We think it would be of benefit to those carrying out this work to have regard to the reports of the Warren Centre, to which we refer in Chapter 112.
¶113.28 We also recommend that the government, working in collaboration with industry and professional bodies, encourage the development of courses in the principles of fire engineering for construction professionals and members of the fire and rescue services as part of their continuing professional development.
Architects
¶113.29 Traditionally, the role of the architect has been fundamental to any construction project of significant size. Regrettably, the work of Studio E on the Grenfell Tower refurbishment fell significantly below the standard reasonably to be expected of it in a number of significant ways, in particular, in failing to exercise proper care in relation to the choice of insulation and rainscreen panels. The evidence, not least the fact that similar materials have since been found on hundreds of other high-rise buildings, suggests that there may be a widespread failure among the profession to investigate properly or understand the nature of the materials being chosen for that purpose.
238¶113.30 We recognise that both the Architects Registration Board and the Royal Institute of British Architects have taken steps since the Grenfell Tower fire to improve the education and training of architects. We recommend that they should review the changes already made to ensure they are sufficient in the light of our findings.
¶113.31 We also recommend that it be made a statutory requirement that an application for building control approval in relation to the construction or refurbishment of a higher-risk building (Gateway 2) be supported by a statement from a senior manager of the principal designer under the Building Safety Act 2022 that all reasonable steps have been taken to ensure that on completion the building as designed will be as safe as is required by the Building Regulations.
Contractors
¶113.32 The design and build form of contract, which is now very widely used, makes the principal contractor responsible for the whole range of activities relating to the work, even though it invariably engages sub-contractors to carry out different aspects of it. We have criticised Rydon for various failings in its organisation of the Grenfell Tower refurbishment. They include a failure to make it clear which contractor was responsible for particular aspects of the design and a failure to take an active interest in fire safety. We are not the first to conclude that the construction industry as a whole needs to become technically more competent and less willing to sacrifice quality to speed and cost.
¶113.33 We think that one way in which to eliminate shortcomings of the kind we have identified and to improve the efficiency of contractors would be to introduce a licensing system for those wishing to undertake work on higher-risk buildings. That would ensure that those working on the most sensitive buildings are qualified by experience and organisation to do so and such a system should lead to a general increase in competence among contractors. We also think that, in order to ensure that fire safety is given the importance it deserves, a senior member of the contractor's organisation should be personally responsible for taking all reasonable steps to ensure that on completion of the work the building is as safe as it should be. We therefore recommend that a licensing scheme operated by the construction regulator be introduced for principal contractors wishing to undertake the construction or refurbishment of higher-risk buildings and that it be a legal requirement that any application for building control approval for the construction or refurbishment of a higher-risk building (Gateway 2) be supported by a personal undertaking from a director or senior manager of the principal contractor to take all reasonable care to ensure that on completion and handover the building is as safe as is required by the Building Regulations.
Clients
¶113.34 The events surrounding the refurbishment of Grenfell Tower suggest that at that time those who commissioned building work may not have been fully aware of their responsibility for compliance with the provisions of the Building Regulations, particularly if an application for building control approval was made by a consultant on their behalf. We therefore welcome the introduction by regulations made under the Building Safety Act 2022 of a requirement for a Building Regulations compliance statement, made or approved by the client, to be provided at the time of an application for building control approval (Gateway 2). In the light of that requirement we do not think that any further action in relation to clients is currently required.
239Building control
¶113.35 The evidence shows that in the period leading up to the Grenfell Tower fire many of those involved in major construction projects, including clients, contractors and even architects, regarded building control primarily as a source of advice and assistance. It was even described as an extension of the design team. In many cases that was how building control itself saw its role. That was a serious misunderstanding, but it was fostered by building control bodies themselves, who preferred to co-operate with applicants to enable proposals to be approved rather than enforce the Building Regulations rigorously. In our view, that has to change.
¶113.36 The government has taken steps to improve the regulation of building control and the competence of those who consider applications for approval. We expect the construction regulator to continue these new arrangements, which are intended to introduce a wholly new climate in which both applicants for approval and building control officers understand that the function of building control is regulatory in nature.
¶113.37 One of the causes of the inappropriate relationship to which we have referred was the introduction into the system of commercial interests. Approved inspectors had a commercial interest in acquiring and retaining customers that conflicted with the performance of their role as guardians of the public interest. Competition for work between approved inspectors and local authority building control departments introduced a similar conflict of interest affecting them. As things stand that underlying conflict of interest will continue to exist and will continue to threaten the integrity of the system. We therefore recommend that the government appoint an independent panel to consider whether it is in the public interest for building control functions to be performed by those who have a commercial interest in the process.
¶113.38 The shortcomings we have identified in local authority building control suggest that in the interests of professionalism and consistency of service all building control functions, including those currently performed by local authorities, should be exercised nationally. Accordingly, we recommend that the same panel consider whether all building control functions should be performed by a national authority.
A construction library
¶113.39 Those who design buildings, particularly higher-risk and complex buildings, would benefit from having access to a body of information, such as data from tests on products and materials, reports on serious fires and academic papers. In Chapter 112 we have referred to the Cladding Materials Library set up by the University of Queensland, which could form the basis of a valuable source of information for designers of buildings in general. We recommend that the construction regulator sponsor the development of a similar library, perhaps as part of a joint project with the University of Queensland, to provide a continuing resource for designers.
240Response to recommendations
¶113.40 Our investigations have revealed that some important recommendations affecting fire safety were ignored by the government in the years leading up to the Grenfell Tower fire. Recommendations made by the Select Committee in 1999 were not implemented and the department's response to the recommendations made by the Lakanal House coroner was inadequate. The department had no system for recording recommendations made by public bodies or keeping track of its response to them. That was obviously unsatisfactory. We recommend that it be made a legal requirement for the government to maintain a publicly accessible record of recommendations made by select committees, coroners and public inquiries together with a description of the steps taken in response. If the government decides not to accept a recommendation, it should record its reasons for doing so. Scrutiny of its actions should be a matter for Parliament, to which it should be required to report annually.
Fire risk assessors
¶113.41 As we have pointed out in Chapter 12, concern has been expressed for many years about the competence of some of those offering their services as commercial fire risk assessors and the absence of any scheme of regulation to ensure that responsible persons under the Fire Safety Order can have confidence in the skill and experience of those whom they instruct to carry out fire risk assessments on their behalf. We therefore recommend that the government establish a system of mandatory accreditation to certify the competence of fire risk assessors by setting standards for qualification and continuing professional development and such other measures as may be considered necessary or desirable. We think it necessary for an accreditation system to be mandatory in order to ensure the competence of all those who offer their services as fire risk assessors.
Fire control switches in lifts
¶113.42 All modern lifts are fitted with fire control switches designed to be operated by drop keys to enable the fire and rescue services to take control of them in the event of a fire. We were surprised to learn that at the time of the Grenfell Tower fire there was a significant variation in the dimensions of drop keys available from commercial suppliers, not all of which were compatible with all fire control switches. We were also surprised to learn that, although drop keys for the use of firefighters are provided by fire and rescue services, firefighters commonly obtain their own from a variety of sources. As a result, it appears to have been largely a matter of chance whether the key carried by the first firefighter who tried to take control of a lift was capable of operating the switch. That is clearly unacceptable and may result in unnecessary casualties, as it did at Grenfell Tower.
¶113.43 We understand that since the problem came to light the LFB has taken steps to ensure that only drop keys of an approved pattern are carried by its firefighters. The evidence does not enable us to assess with any confidence whether similar problems have been encountered by other fire and rescue services and, if so, what steps they have taken in response. Accordingly, we are not in a position to determine whether greater standardisation of fire control switches and keys is required. We therefore recommend that the government seeks urgent advice from the Building Safety Regulator and the National Fire Chiefs Council on the nature and scale of the problem and the appropriate response to it.
241Pipeline isolation valves
¶113.44 Pipeline isolation valves are a critical part of the gas distribution network because they are intended to enable the supply of gas to be shut off quickly in an emergency. At the time of the fire at Grenfell Tower the valves could not be operated because they had been covered over in the course of hard landscaping. There was evidence that it was a common problem in the industry for pipeline isolation valves to be lost in that way. In our view that poses an unacceptable risk to health and safety and could have significant consequences. We therefore recommend that every gas transporter be required by law to check the accessibility of each such valve on its system at least once every three years and to report the results of that inspection to the Health and Safety Executive as part of its gas safety case review.
Ageing pipework
¶113.45 One of our expert witnesses, Mr Rodney Hancox, drew our attention to the danger posed by the fact that the internal gas pipework in some older buildings is not sleeved where it passes through walls and floors, as is now required by the Gas Safety Regulations 1972. He considers that a more active approach to replacement should be taken to avoid a serious leak with potentially catastrophic consequences.2445 See his reports at {RHX00000012/220} paragraphs 468-469, {RHX00000020/2-17} paragraphs 1-45 and his oral evidence at Hancox {Day161/181-204}. Although we are not in a position to make a formal recommendation to that effect, we think that the Health and Safety Executive and other relevant bodies should give careful consideration to his evidence.
Social housing providers
¶113.46 In Parts 4 and 5 of the report we have discussed the TMO, its relationship with its residents and its management of fire safety at Grenfell Tower. We make a number of criticisms of the way in which it carried out its responsibilities, including in relation to handling complaints, remedying defects identified in fire risk assessments, installing and maintaining fire protection systems and routine inspection and maintenance of fire doors. Others responsible for the management of social housing should give them careful consideration and take appropriate action accordingly.
¶113.47 In other circumstances shortcomings of those kinds would probably have led us to make a number of recommendations directed to ensuring that they were rectified and not repeated. However, since the fire Parliament has enacted the Social Housing (Regulation) Act 2023, which enables the Regulator of Social Housing to play a more active role in setting appropriate standards and ensuring that they are met. The regulator also has the power to set standards on the competence and conduct of those involved in the provision of services relating to the management of social housing and to require providers of social housing to make information available both to tenants and the regulator. The Act also makes safety a priority and imposes a duty on landlords to investigate and remedy within a specified time of being reported defects that may adversely affect health.
¶113.48 In those circumstances, we do not consider it necessary to make any additional recommendations in relation to the matters that we have uncovered.
242The London Fire Brigade
¶113.49 Our criticisms of the London Fire Brigade have been directed mainly to its failure to integrate the control room into the organisation effectively, its failure to ensure that adequate training was provided to control room staff in handling fire survival guidance calls and its failure to implement lessons learnt from previous incidents. In one way or another those are all criticisms of the organisation and management of the brigade, which in our view needs to become more streamlined and less bureaucratic.
¶113.50 Although the LFB is the country's largest fire and rescue service and is subject to a range of demands not imposed on similar services, it has tended to adopt an insular approach and to be reluctant to learn from others. No doubt some of the criticisms we have made of the LFB could be made of other fire and rescue services, but in any event we think that there is scope for all fire and rescue services to learn from each other's experience and thereby to promote best practice across the board, whether in relation to recruitment, training, organisation or management.
A College of Fire and Rescue
¶113.51 Although the National Fire Chiefs Council provides a forum for discussions and the formulation of policy, there is currently no central body that is equipped to provide education and training across the board to nationally approved standards. We welcome the government's ambition to create an independent College of Fire and Rescue expressed in the white paper Reforming our Fire and Rescue Service2446 CP 670 and we therefore recommend that the government establish such a college immediately with sufficient resources to provide the following services nationally:
a. practical training at all levels supplementary to that provided by individual fire and rescue services; b. education in the form of lectures and seminars on different aspects of the work of the fire and rescue services in order to share experience and promote good practice; c. research into matters that may affect the work of the fire and rescue services, including major fires; d. the development of equipment, policies and procedures suitable for ensuring the effectiveness of fire and rescue services nationally and the safety of firefighters and the public; e. setting and maintaining national standards of managerial competence for senior managers, including control room managers, and providing management training for, and regular assessment of, senior ranks by reference to such standards.
¶113.52 The constitution of the College of Fire and Rescue is a matter for the government in consultation with the National Fire Chiefs Council and other interested bodies, but it could be established as a not-for-profit company, independent of the government, with a board of directors drawn from a range of backgrounds, a significant proportion of whom are currently serving Chief Fire Officers or senior officers with significant firefighting experience. The board would be responsible for the overall management and operations of the college.
243¶113.53 Although it is for the government to decide how the college should be constituted, we recommend that it should have a permanent staff of sufficient size to manage its operations and develop its functions in response to the demands of fire and rescue services nationally and the requirements of the board. The college will need access to permanent facilities, including facilities for practical training and education. We envisage that much of the training and education will be delivered and led by firefighters of suitable experience drawn as the occasion requires from fire and rescue services around the country.
The control room
¶113.54 The control room should be at the heart of any fire and rescue service and should, therefore, be recognised as a key part of the organisation and fully integrated into it. Its staff must be trained to handle whatever demands are reasonably foreseeable.
¶113.55 The demands imposed on the LFB's control room by the Grenfell Tower fire were very great, but even so, its performance did not meet reasonable expectations. That was principally the result of inadequate training and a failure to carry out regular exercises, itself the result of poor management. The establishment of a College of Fire and Rescue could be expected to create improvements in all those areas by setting standards for training, by training more senior ranks to perform management roles effectively and by sharing best practice. In the meantime, we recommend that His Majesty's Inspectorate of Constabulary and Fire and Rescue Services ("the Inspectorate") inspect the LFB as soon as reasonably possible to assess and report on:
¶a. the extent to which the control room is now integrated into the organisation;
¶b. the effectiveness of the arrangements for identifying the training needs of control room staff, delivering effective training and recording its outcomes;
¶c. the effectiveness of the control room generally;
¶d. the ability of the control room to handle a large number of concurrent requests for advice and assistance from people directly affected by fires or other emergencies; and
¶e. the quality and effectiveness of the arrangements for communication between the control room and the incident commander.
Incident commanders
¶113.56 In Chapter 72 we are critical of the LFB's arrangements immediately before the Grenfell Tower fire for assessing the competence of those expected to act as incident commanders, particularly in the early stages of the response to a fire in a high-rise residential building. Steps have already been taken to respond to the criticisms made by the chairman in his Phase 1 report, but in order to reassure those who live in London we recommend that as soon as reasonably possible the Inspectorate inspect the LFB to examine and report on the arrangements it has in place for assessing the training of incident commanders at all levels and their continuing competence, whether by a process of revalidation or otherwise.
Operational planning
¶113.57 In the years before the Grenfell Tower fire the LFB consistently failed to implement an effective system for the collection, storage and distribution of operational risk information, in particular in relation to high-risk, high-rise residential buildings. We therefore recommend that as soon as reasonably practicable the Inspectorate inspect the LFB to examine and report on its arrangements for collecting, storing and distributing information in accordance with section 7(2)(d) of the Fire and Rescue Services Act 2004, and in particular its arrangements for identifying high-risk residential buildings and collecting, storing and distributing information relating to them.
244Implementing change
¶113.58 The LFB took steps to examine incidents, collect relevant information, establish boards and committees to digest it and produce appropriate changes to working practices. In most cases, however, the process was excessively bureaucratic and undermined the purpose for which it had been established. As a result, too little of the available information was translated into practical outcomes. We therefore recommend that the LFB establish effective standing arrangements for collecting, considering and effectively implementing lessons learned from previous incidents, inquests and investigations. Those arrangements should be as simple as possible, flexible and of a kind that will ensure that any appropriate changes in practice or procedure are implemented speedily.
Communications
¶113.59 We have explained in Chapter 80 why communication by radio is inherently likely to be adversely affected in certain environments, including tall buildings constructed mainly of dense or reflective materials such as stone, concrete, brick and steel. It is apparent, however, that the use of low-power intrinsically safe radio equipment exacerbates the problem because of its more limited transmission range. In many firefighting situations the danger of a spark from a radio igniting flammable gases is very low. The fire at Grenfell Tower is one example. We understand that intrinsically safe radios capable of operating at higher power are now available. We therefore recommend that fire and rescue services that continue to use low power intrinsically safe radios as part of breathing apparatus consider reserving them only for situations in which there is a real risk of igniting flammable gases and generally using radios of higher power, particularly in high-rise buildings.
¶113.60 There is strong evidence that in general digital radios are more effective than analogue radios. We therefore recommend that all fire and rescue services give consideration to providing all firefighters with digital radios.
¶113.61 Since radio communications are inherently unreliable in certain environments, we recommend that firefighters be trained to respond appropriately to the loss of communications and to understand how to restore them.
Water
¶113.62 On the night of the Grenfell Tower fire firefighters were unable to distinguish between different types of hydrant. That is a clear indication of a need for better training and we therefore recommend that basic training on the structure and operation of the water supply system, including the different types of hydrants in use and their functions, be given to all firefighters. Training should also be given on effective measures to increase water flow and pressure when necessary.
¶113.63 The Grenfell Tower fire made unusual demands on the supply of water, but other major fires may make similar demands in future. If it becomes necessary to seek the assistance of the statutory water undertaker to increase the volume or pressure of the supply, the fire and rescue service should be able to communicate with it quickly and clearly. We therefore recommend that all fire and rescue services establish and periodically review an agreed protocol with the statutory water undertakers in their areas to enable effective communication between them in relation to the supply of water for firefighting purposes.
245¶113.64 In paragraph 81.23 of Chapter 81 we considered British Standard 750:2002 relating to the flow coefficient of fire hydrants and noted that the standard does not state whether the figure stated in paragraph 10.2 relates to a simple hydrant tested under factory conditions or to a hydrant installed in the pipework necessary to connect it to the water network. Any confusion could easily be dispelled by a small amendment to the standard. We therefore recommend that the British Standards Institution amend BS 750 to include a description of the circumstances under which the flow coefficient to which it refers in paragraph 10.2 is to be measured.
Deployment of firefighters
¶113.65 How to deploy the available firefighters must remain the responsibility of the incident commander, who alone can judge how best to make use of the available resources. We also recognise that firefighters must be allowed to exercise discretion in how best to carry out their instructions. However, anyone reading Part 9 of the report will be struck by the number of times crews despatched to the highest floors of the tower in response to calls for assistance failed to reach their destinations because they decided to help people they encountered on the stairs on their way up. We cannot tell whether in any of those cases they would have been able to rescue people higher up the building if they had not done so, but we recommend that National Fire Chiefs Council consider whether, and if so in what circumstances, firefighters should be discouraged from departing from their instructions on their own initiative and provide appropriate training in how to respond to a situation of that kind.
Response and recovery
¶113.66 The Grenfell Tower fire created an emergency on an unprecedented scale as a result of the loss of life, the destruction of so many homes and the displacement of over 800 people who were rendered homeless and, in many cases, for all practical purposes destitute. The arrangements for responding to civil emergencies were severely tested and in many respects did not perform as well as expected. In December 2022 the government published a new Resilience Framework and put in place what is described as a new strategic approach to resilience. We welcome those steps. Nevertheless, there remain areas in which we think further improvements need to be made.
The Civil Contingencies Act 2004
¶113.67 The government's powers in sections 5 and 7 of the Act to intervene in response to an emergency are far-reaching but they do not enable it to intervene promptly or decisively when a Category 1 responder is failing to rise to the challenge. We therefore recommend that the Act be reviewed and consideration be given to granting a designated Secretary of State the power to carry out the functions of a Category 1 responder in its place for a limited period of time.
¶113.68 The response of local voluntary organisations to the disaster demonstrated their capacity to act as valuable partners in responding to an emergency. Regulation 23 of the Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 requires a Category 1 responder to have regard when making its plans to the activities of relevant voluntary organisations. We therefore recommend that the regulation be amended to require Category 1 responders to establish and maintain partnerships with the voluntary, community and faith organisations in the areas in which they are responsible for preparing for and responding to emergencies.
246Guidance
¶113.69 The current guidance on preparing for emergencies is contained in several documents, all of which are unduly long and in some respects out of date. We recommend that the guidance be revised, reduced in length and consolidated in one document which lays greater emphasis on the need for those leading the response to consider the requirements for recovery, the need to identify vulnerable people, the importance of identifying and ensuring co-operation with voluntary, community and faith groups and is consistent with the Equality Act 2010. We also recommend that regard for humanitarian considerations be expressly recognised by making it the ninth principle of effective response and recovery.
London Local Authority Gold arrangements
¶113.70 Although each London borough is a separate Category 1 responder, there are arrangements for promoting resilience across the capital as a whole, in particular through the London Local Authority Gold arrangements. Events demonstrated, however, that there is a need for a clearer understanding of the nature of the London Gold arrangements, in particular in situations in which a single borough is affected. We therefore recommend that the guidance on the operation of those arrangements be revised and that existing and newly appointed chief executives be given regular training to ensure they are familiar with its principles.
Local resilience forums
¶113.71 Our investigations revealed the inability of the London Resilience Forum to monitor the quality of its members' planning, training and preparation for responding to emergencies. Neither Minimum Standards for London, which applied at the time, nor its replacement, Resilience Standards for London, gave the local resilience forum any means of securing compliance with the standards they prescribed. We note that in the Resilience Framework the government has recognised the need to strengthen local resilience forums. We therefore recommend that local resilience forums adopt national standards to ensure effective training, preparation and planning for emergencies and adopt independent auditing schemes to identify deficiencies and secure compliance. We also recommend that a mechanism be introduced for independently verifying the frequency and quality of training provided by local authorities and other Category 1 responders.
Local authorities
¶113.72 The failure of The Royal Borough of Kensington and Chelsea (RBKC) to meet the basic needs of those displaced in the days immediately following the fire demonstrated the need for local authorities to have effective plans in place for providing humanitarian assistance. It also emphasised the need for those plans to be supported by a qualified humanitarian assistance liaison officer (HALO) and for there to be regular practice in putting them into effect. There is scope for all those required to respond to emergencies to learn from each other's experience and promote best practice.
247¶113.73 RBKC was not able to provide an effective response to the emergency because it had not made adequate arrangements for staffing the emergency communication centre, had not made adequate provision for humanitarian assistance, including the provision of accommodation and financial support, did not have the ability to keep accurate records of those who needed help and had no effective system for communicating with the public. All those shortcomings could and should be avoided in future by a combination of measures, but underpinning them all is a need for the staff of local authorities to treat resilience and preparedness for emergencies as an essential part of their responsibilities. We therefore recommend that local authorities train all their employees, including chief executives, to regard resilience as an integral part of their responsibilities.
¶113.74 RBKC had no effective means of collecting and recording information about those who had been displaced from the tower and surrounding buildings, including those who were missing. Compiling reliable information of that kind is difficult and the challenges likely to be faced by local authority Category 1 responders will vary according to the nature of the emergency. We recommend that all local authorities devise methods of obtaining and recording information of that kind, if possible in electronic form, and practise putting them into operation under a variety of different circumstances.
¶113.76 Effective humanitarian assistance is vital in ensuring that those who are most affected by an emergency are treated with dignity and respect and do not suffer additional trauma as a result of an inability to take control of their situation. In the case of the response to the Grenfell Tower fire three matters caused particular resentment: the circumstances surrounding some of the temporary accommodation, the difficulty in obtaining financial support in the days immediately following the fire and breakdowns in the support provided by key workers. Problems arising from the provision of suitable temporary accommodation may be difficult to resolve but other complaints should be easier to avoid by careful planning. We recommend that all local authorities include in their contingency plans arrangements for providing immediate financial assistance to people affected by an emergency. We also recommend that as part of their planning for emergencies local authorities give detailed consideration to the availability of key workers and the role they are expected to play so that suitable contingency arrangements can be made to ensure, as far as possible, continuity of support.
¶113.77 One important aspect of humanitarian assistance that was absent following the Grenfell Tower fire was regular communication between those providing assistance and those in need of it. For example, too many people who had been found temporary accommodation felt that they had then been left on their own, not knowing for how long they were expected to remain or on what terms and without anyone to turn to to provide that information. That gave rise to a sense of isolation and powerlessness. We recommend that as part of their emergency planning local authorities make effective arrangements for continuing communication with those who need assistance using the most suitable technology and a range of languages appropriate to the area.
248¶113.78 It is also important not to lose sight of those who, although not physically affected by an emergency, may be worried about the safety of friends or relations caught up in it. Again, effective communication is essential. We recommend that all local authorities include in their plans for responding to emergencies arrangements for providing information to the public by whatever combination of modern methods of communication are likely to be most effective for the areas for which they are responsible. In future, to avoid confusion, wasted effort and frustration we also recommend that what in the past has been called by the police a "casualty bureau" be described in a way that makes it clear that it does not provide information to the public about people affected by the emergency.
Vulnerable people
¶113.79 We conclude our recommendations by looking back to Phase 1. In the Phase 1 report the chairman recommended that the owner and manager of every high-rise residential building be required by law to prepare personal emergency evacuation plans (PEEPs) for all residents whose ability to evacuate the building without assistance may be compromised (such as persons with reduced mobility or impaired cognition)2447 Phase 1 report Volume IV paragraph 33.22(e). and to include current information about them and their associated PEEPs in a premises information box.2448 Phase 1 report Volume IV paragraph 33.22(f).
¶113.80 The considerations that led him to make those recommendations led us to investigate in Phase 2 why the LGA Guide advised landlords and responsible persons that it was usually unrealistic to plan for the evacuation and assistance in the event of a fire of disabled and vulnerable residents living in general needs blocks of flats, such as Grenfell Tower.2449 See Part 2, Chapter 14, paragraph 14.2. That led in turn to our making a number of criticisms of the government and to recommend that the advice in the LGA Guide be reconsidered.2450 See Part 2, Chapter 14, and especially paragraph 14.17.
¶113.81 Moreover, the further evidence that we have received in the course of Phase 2 has confirmed us in the view that the responsible person for a general needs residential building should collect sufficient information about vulnerable occupants to enable appropriate measures to be taken to assist their escape in the event of a fire.2451 Part 5, Chapter 46, paragraph 46.90. Much of the evidence relating to the individual deaths set out in Part 9 emphasises the importance of being able to provide the fire and rescue service with reliable information about the vulnerability of those needing to be rescued.
¶113.82 We therefore recommend that further consideration be given to the recommendations made in the Phase 1 report in the light of our findings in this report.
¶113.83 We also recommend that the advice contained in paragraph 79.11 of the LGA Guide be reconsidered.