LIVE: Statement from Grenfell Inquiry Chair Sir Martin Moor-Bick

that to have significant consequences because Studio e failed to recognize as a reasonably competent architect should have done that the insulation and Rain screen chosen for the refurbishment were combustible and unsuitable for that purpose ACM panels were chosen as the rain screen to keep down the cost neither Ryden the principal contractor nor Harley it's a cladding sub ractor was aware of the properties of the materials specified for use in the refurbishment although Harley as a specialist subcontractor dealing with cladding should have been and Ryden as principal contractor had its own responsibility to ensure the materials were suitable one of the problems that Afflicted the refurbishment was a failure on the part of all concerned to understand where responsibility for any particular decision lay that was especially the case in relation to the choice of the rain screen the generally prevailing view was that since aluminium composite material panels had been used on other buildings without apparent problems they were suitable for use on the tower but no one was prepared to accept responsibility for having chosen them and when questioned everyone who was asked said that someone else had been responsible for ensuring that they were suitable we find that studio e Ryden and Harley all took an unacceptably casual approach to contractual relations none of their employees engaged on the project understood the relevant provisions of the building regulations the stash guidance or such guidance from industry sources as was then available that might not have mattered quite so much if proper advice had been taken from a competent and experienced fire engineer or if building control had performed its task properly in fact the tenant management organization did instruct xover Warrington fire to produce a fire safety strategy for the refurbishment which should have included advice on the effect of the overcladding and the compliance of the external walls with the functional requirements of the building regulations exov produced three versions of a fire safety strategy but each version was stated to be a draft and was incomplete because it did not deal with that particular question which it said would be covered in a future issue of the report it was clear therefore that the fire safety strategy was incomplete but no one asked exov to finish its work nor did anyone provide it with details of the proposed cladding to enable it to do so xover itself failed to ask for the missing information or to complete the work it had been instructed to carry out the failure to obtain a final report was probably critical because if xover had considered the proposed cladding it should and probably would have identified the fact that the insulation and the rain scream did not comply with the statutary guidance or more importantly the building regulations in part eight we set out our findings on the management and training of the London fire brigade in the Years leading up to the fire that part of our investigations represented a continuation of the work started in Phase One In which I described the response of the lfb on the night I was critical of certain aspects of that response in particular the way in which the control room handled calls from people trapped in the building and the actions of some of the incident commanders who had not been properly trained to deal with a fire of that nature that made it necessary for us to examine the uh London Fire brigade's management and training in the period leading up to the fire as well as the way in which it made use of the information available to it in our report we find that there were deficiencies in the organization and management of the control room the training of control room officers and in the commissioning and delivery of training to operational crews in particular in relation to incident command there were also deficiencies in the collection of information needed to enable Crews to prepare effectively to respond to fires in individual buildings the primary cause of those problems was a chronic lack of effective leadership combined with an undue emphasis on process and an attitude of complacency we have also returned to investigate some aspects of the firefighting operations on the night of the fire on which I was unable to make findings in phase one in particular problems with Communications and the supply of water I shall return to part nine of the report in a moment but for now I move to Part 10 in which We examined the authorities response to the fire once again we have found that those who lost their homes as a result of the fire were badly let down by the organizations that should have provided the support they desperately needed the primary responsibility for that lay with the council which as a category one responder under the Civil contingencies act should have had plans in place to enable it to respond effectively to the emergency in the event however it had failed to put in place suitable plans or to provide the training to its staff that was required to enable it to respond effectively to the situation it faced in addition its chief executive was Ill suited to taking control of what was undoubtedly a very serious challenge the council did not have the capacity to identify those who needed accommodation and other important forms of assistance nor did it have Arrangements in place for communicating with those affected by the disaster or The Wider public as result it was not capable of meeting the immediate needs of those who had been displaced and from their homes for food and shelter in the end it was local voluntary and Community organizations that filled the Gap by providing rest centers and temporary shelter uh the London wide resilience structures that were intended to enable the capital to respond to an emergency affecting more than one bar did not operate effectively partly because they were not designed to provide Central direction to the response and partly because the Royal barough of Kensington and Chelsea did not seek assistance promptly in the event the government in the form of a senior official in the department for communities and local government brokered an arrangement under which the experienced town clerk of the city of London took control of the operation an important chapter of this part records the evidence given by those who were personally affected by the fire we are acutely aware that giving evidence particularly giving evidence in public was a difficult and daunting experience we should therefore like to thank all of those who contributed to our investigations by giving evidence but both in the form of witness statements and by being willing to speak about their experiences in public by doing so they ensured that we received the fullest possible account of the events that unfolded in the days following the fire in Parts 11 12 and 13 of the report we deal with a number of different matters including the experiments carried out by Professor Bisby and Professor Terrero on the materials used in the refurbishment they confirmed that the renob bond aluminium composite material panels were the primary reason for the fire's devastating progress part 14 contains our recommendations although some steps have already been taken to respond to the many failures that we have identified we think that more can and should be done to bring about a fundamental change in the attitudes and practices of the construction industry only such a change can ensure that in future buildings in general and higher risk buildings in particular are safe for those who live and work in them we think that in different ways implementation of our recommendations will improve fire safety particularly in high-rise buildings and ensure that dangerous materi materials cannot be used in construction in the future they will also improve the efficiency of Fire and Rescue Services nationally our recommendations include but are not limited to the following the appointment of a construction regulator to oversee all aspects of the construction industry bringing responsibility for all aspects of fire safety under one government Department the establishment of of a body of professional fire Engineers properly regulated and with protected status and the introduction of mandatory fire safety strategies for higher risk buildings a licensing scheme for contractors wishing to undertake the construction or refurbishment of higher risk buildings the regulation and mandatory accreditation of fire risk assessors the establishment of a college of fire and res to provide practical educational and managerial training to Fire and Rescue Services and the introduction of a requirement for the government to maintain a publicly accessible record of recommendations made by select committees coroners and public inquiries describing the steps taken in response to them or its reasons for declining to implement them I now return to part nine of the report which is the most personal part and contains the most difficult reading it contains a detailed account of the circumstances surrounding the deaths of those who perished in the fire I did not refer to it earlier because it seemed to me fitting to end these proceedings as they began in May 2018 with a reminder that the fire at grenal Tower was above all a human tragedy in which many lives were lost families were torn aunder homes were destroyed and a community was shattered the detailed reconstruction we have provided will be for many one of the most important parts of our report although it may make painful reading those who lost relatives and Friends naturally feel a need to know as much as possible about their loved ones last moments I said on many occasions that I hoped we could find sufficient facts to satisfy the coroner of the circumstances surrounding their deaths and avoid the need for any further proceedings I'm now able to say that we've been able to make detailed findings about the circumstances in which people died including calls made to the emergency services the transfer of information from the control room to the incident ground the recording of that information on its way to and at the bridge head and the steps taken to rescue those who were trapped we are satisfied that all those who died in the building were overcome by toxic gases produced by the fire and with expert assistance we've been able to establish a reasonably accurate time of death in each case we're satisfied that all those whose bodies were damaged by the fire were already dead by the time it reached them in a moment my fellow panel members M istan and Mr abbor wish to add some comments of their own before they do so however I should like to thank the inquiry Team without whom it would not have been possible to carry out an investigation of this kind it would be invidious to single out individual names for mention on this occasion because everyone involved whatever their particular task has played an essential part in enabling us to do our work with their help we have followed up many lines of inquiry some of which led to surprising Revelations and have collected and digested a huge number of documents and statements not to mention hearing many days of oral evidence all those who worked for the inquiry over the years are named in an appendix to the report and we owe them a deep debt of gratitude I now invite M esant to say a few words thank you sir Martin good morning before I joined the inquiry panel I spent nearly 30 years as an architect in that role I developed a particular interest in health and safety fire and accessibility matters returning home from a holiday in June 2017 I flew over West London and saw the burning Tower in the early hours from the air as for so many others this was a profound Shock first of course as a human response but also as a professional who had spent their career working to make building safe throughout this inquiry we have been determined to find out how such a disaster was possible and what needs to be done to save lives in the future as s Martin has just summarized we have found many failings across a wide range of Institutions organizations and individuals that Spann many years which together have led to the terrible fire at grenal Tower they include many failures of the construction industry my own sector which is where I will focus my comments on today since the fire the government has passed the building safety act the ACT is welcome but we need to go further our report identifies what we think is needed to make sure the legacy of grel is real and brings about lasting and Progressive change our recommendations Place new burdens and responsibilities on people and organizations I make no apologies for that but simply if you work in the construction industry and you do not feel the weight of responsibility you have for PE for keeping people safe you are in the wrong job the change we need to bring about is partly about structures and regulations so Martin has set out the key points in what we have proposed and the report explains our recommendations in detail but the necessary change is also one of culture and behaviors change on this scale needs to be owned and led by those of us working in the sector it is not enough to pass an act of Parliament and to sit back and think the work is done without change in behavior and a recognition that the needs of the people who use our buildings must be placed at the center of our work the lessons of grel will not truly be learned in full one of the core themes of our report is technical incompetence of many of those involved in the refurbishment project as hundreds of other buildings are now known to have similar cladding systems it is clear that the problem of incompetence is widespread it follows that part of the change that is needed to the culture of the industry is an ongoing commitment to the development of professional skills if we are not professionally curious we will not become technically competent again this change needs everyone in the construction industry to play their part in the implementation of the inquiries recommendations we must also keep at the very Forefront of our Minds our responsibilities towards those who are most vulnerable as GRL a significant number sorry at grenal a significant number of those who died were children had disabilities or were vulnerable in other ways the risks posed by a particular building and the right response to those risks are always as diverse as the people who live or work in it that is why we recommend that the government thinks again about defining higher risk buildings solely by reference to their height it is why the fire safety strategies must be provided for safety of all occupants and it is why a stay put strategy will never be appropriate where there's a risk of fire spreading over the building's external walls it is why we recommend that the government guidance should be reviewed so that the safety and re resilience of a building is prioritized and it is why we stand by the inquiry's phase one recommendation that the need for peeps personal emergency evacuation plans for residents with mobility issues or other impairments as a inquiry panel we have acted throughout with fairness Independence and impartiality that is what the law requires at the same time the losses so many people have suffered and my involvement in this process has left a mark on me as a person and as as a professional which will last far beyond this inquiry and although this inquiry is now ending we know that for many people they're Journey continues we wish them strength for the future I will now pass sorry I will now hand over to my colleague Ali thank you Thia good morning everyone my role as a panel member has been to listen to the evidence to consider what I have heard and work with sir Martin and sah to agree findings and recommendations firstly I would like to express my own heartfelt sympathy to all those whose lives have been affected by this tragic fire we know that an inquiry can feel like a very slow process but what I can say is that we have been painstakingly thorough and that we present our our report to you with confidence in its veracity secondly I would like to say that I grew up in Council housing I was involved in creating social housing organizations I was chief executive of a Housing Association for over 20 years what I can say is that working on the inquiry has had a profound impact on me personally and as a social housing professional in social housing we often say that we put our talant at the heart of what we do but it is not enough just to pay lip service to that ideal in our report we look at the Rel relationship between Kensington and Chelsea tenant management organization and its residents before the fire we find that it was one of distrust dislike personal antagonism and anger residents deserve to be treated with understanding and respect the TMO failed to do that we saw a similar failure to treat residents as people and as individuals in the aftermath of the fire including in the way that those with religious cultural or social needs suffered discrimination as a result of rbk's failure to prepare properly for emergencies it was obvious to me from watching and listening to evidence being given at the hearing that there were two different groups of people those who lived at Grantville and those who worked for the TMO rbkc and their agents in our report we set out how the government's focus on deregulation dominated the Department's thinking such that even matters affecting the safety of Life were ignored delayed or disregarded the deregulation agenda had a parallel impact on social housing on the social housing sector particularly in terms of consumer standards and protection for tenants the effects of that can be seen in the many failings of the TMO which we set out in our report and which were not prevent and which were not prevented or addressed by the regulatory system then in place Parliament has now passed the social housing regulation act which will enhance the powers of the regulator in support of stronger consumer standards and which stresses the need for involvement and empowerment of tenants and the reintroduction of inspection of landlords in my view this was not a moment too soon our report underlines why its full implementation is so important and so urgent I have focused so far on the tmo's role as a social housing provider the TMO played an important part in the refurbishment of Grenville Tower in its role as the Project's client we have found that the TMO paid insufficient care in its choice of architect and failed to pay enough attention to fire safety I hope that our report acts as a reminder to the clients of future building projects including social housing providers that they have a responsibility to the users of the their buildings to ensure that safety is not sacrific to the demands of speed and cost regulations should not be treated as boxes to be ticked but as a way of giving residents confidence that their homes are safe finally I would like to Echo something that thorah has said we cannot in a few words here today do full Justice to the totality of our report what is needed is for those with responsibility for building safety in my sector as in thoras to read the report to reflect on it and to treat grenfell as a touchstone in all that they do in the future and that is to act with professionalism with competence and to put people first I will now pass you back to Sir Martin thank you very much thank we should all remember that the grenal tower file was an remains an intensely personal tragedy for all those who lived in and around the tower and above all for those who died their families and friends we invite you therefore to join us in remembering them while I read out their names FAA Ahmed elsi Abu fras Muhammad ibraim isra Ibrahim Muhammad amid Sabah NADA hasham rakman Ria Ibrahim FIA Hassan Hana Hassan Marco gotard Gloria trevisan Raymond Herbert Moses Bernard Esla El Guri Mariam El guachi Anthony Keith dson basm shuk Nadia shuk Mira shuk Fatima share zanab share Syria share Hashim Kadir nura Jamal Yak Hashim fedos Hashim yakub Hashim abdulaziz Al wahabi faia El wahabi Yasin El wahabi n Huda El wahabi Mei El wahabi leaya Moore Jessica Orana Ramirez Omar badii Farah hamdan malac belardi Lena belardi Mary meni kadia Victoria King Alexandra atala Muhammad NKU Amal ahmedin Amaya tuku ahmedin Amna Mahmud Idris Maj vital Ernie vital Debbie lamel Gary MERS beti haftom ber haom Hamid khi Isaac paros Sakina Afra Habi fatim Arabi Vincent China Kadija koufi Camu Mia Raba beum Muhammad [Music] Hamid Muhammad hanif husna beum Joseph Daniels Sheila Steve P zanab Dean Jeremiah Dean Muhammad Al hajali Dennis Murphy Ali yahwa Jafari abdeslam Sabah Logan Gomez py Burton thank you all very much e e e e e e e e e e