THE GRENFELL TOWER INQUIRY

OPENING STATEMENT ON BEHALF OF THE KENSINGTON AND CHELSEA

TENANT MANAGEMENT ORGANISATION ("TMO")

Introduction

1. Topic 1 of Module 3 is primarily concerned with the TMO's systems for

communication with residents; consultation concerning the refurbishment of Grenfell

Tower; residents' complaints regarding fire safety risks; doors and the quality of

workmanship during the refurbishment; and the response and "degree of engagement"

of the TMO and RBKC to those complaints. The Inquiry will hear first from former

residents of Grente 11 Tower and then from witnesses from the TMO and RBKC,

regarding the systems, policies and procedures each body had implemented to deal with

residents' complaints and their response to those complaints, as well as management of

the building.

2. The Inquiry will also consider the governance arrangements between RBKC and the

TMO and in particular how they worked during the course of the refurbishment of the

building. To that end, senior representatives from the TMO and RBKC (among others)

will be called to give evidence.

3. When considering the issue of complaints and concerns, the TMO acknowledges that

the Inquiry's primary focus will be on matters causally connected with the fire, but the

Inquiry will also consider the way in which complaints more broadly were managed.

This being the case, the TMO intends to briefly address some of the wider issues here.

4. At the outset, the TMO acknowledges that the relationship with some residents was

strained and often difficult before and during the refurbishment period and the reasons

for this should be scrutinised by the Inquiry.

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TMO00900047/1 TMO00900047 0001 5. However, certainly not all residents were at odds with the TMO, and the Inquiry may consider whether views expressed by some more vociferous residents were

representative of the views of a majority of residents1.

6. When examining the nature of the relationship between the TMO and residents during the relevant period, the TMO submits that the Inquiry should have particular regard to the following three factors.

7. First, there had been vehement opposition from some residents at Grenfell Tower to the Kensington Academy and Leisure Centre (KALC) project from its very inception, and strong criticism of RBKC, in particular. Much of this criticism was voiced in the Grenfell Action Group Blog. The Inquiry may consider whether this soured the relationship between some tenants and the TMO/RBKC and also whether the strong opposition was representative of the Lancaster West community as a whol e, given that the project was to build a much-needed school and leisure facilities for children in the Borough.

8. Second, the TMO finally took over in 2014 from the Estate Management Board (EMB) for the Lancaster West Estate, which was a tenant-led organisation separate to and pre­ dating the TMO. It had first been registered in 1993.

9. By around 2010, the EMB was not functioning well and there was a strongly held view that members of the EMB were unaware of what was expected of thenr. Although residents voted at one point to retain the EMB, concerns remained about its performance and RBKC worked on an improvement plan, a step prescribed by the MM A. This failed to result in progress, and RBKC eventually terminated the

1 See for example RBK00003386- email from Councillor Blakeman dated 11 December 2013 " I can confirm that Mr. Daffarn does not represent the general opinion on the Estate...Unfortunately Mr. Daffarn continues to claim that he and his colleagues represent the Estate. They speak very loudly indeed and their views do influence people.. .My personal view is that continuing to give these people so much access to put their views is unhelpful as it gives them greater legitimacy, which they then use in discussions with residents. Mr. Daffam keeps shouting that this is "democracy" and any attempt to silence him is "undemocratic" -1 would call it more bullying than "democracy". At the moment Mr. Daffam ^^^^^^^^^^^^I^^B. but he has been so disruptive during the Grenfell Tower consultations that Peter Maddison has suggested and I have agreed that wc do not hold any more open meetings... At his last very aggressive face- to-facc confrontation with me (after the last Grenfell Tower consultation) Mr. Daffam said "we will re-form the Grenfell Action Group and we will fight" — but when I asked him what they were going to fight, he became completely confused and moved away!" The TMO makes no judgment on whether these words are correct but this is how it was reported by the Councillor at the time. 2 See for example RBK00003386 email from Cllr Blakeman in 10 December 2013: "While none of the members of the Estate Management Board appear to have the faintest idea, what is required of them as Board members and there is clearly complete confusion between the role of the EMB and the Residents' Association, I do not doubt the goodwill and commitment of those who were present... they are genuinely committed to trying to increase EMB membership and to work for the benefit of the Estate and its residents. They reported that the EME has over 400 members, which is a higher membership percentage than the TMO itself. I think one challenge is how to address the deficiencies of the EMB - and probably dissolve it - while retaining the goodwill of the Estate residents - and I think this will be very difficult. There has been a recent meeting with the Leader and Cllr. Fielding-Mellen, from which the Estate's representatives seem to have taken away the belief that the Council is going to demolish the finger blocks and get rid of all the tenants - and also that there is no intention to honour the undertaking to carry out the improvements to GT. I have no doubt that some of this ill will derives from the activities and pronouncements of the Grenfell Action Group, which I am afraid are given far more credence than the Council, or the TMO or indeed the ward councillors. Kind regards. Cllr. Judith Blakeman"

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TMO00900047/2 TMO00900047 0002 contractual relationship in 2014. Despite a widespread perception of mismanagement,

some residents thought it had been shut down in an 'underhand and duplicitous

manner '3 by RBKC. This undoubtedly created a breakdown in trust between the

TMO/RBKC and some residents; and impaired TMO achieving a good relationship

with tenants going forward.

10. Third, when considering the nature and volume of complaints made by residents during

the refurbishment project, it must be kept in mind thai for residents, continuing to live

in situ during a major refurbishment, with internal and external works, both in the

common parts and within individual flats, must have been extremely difficult. The

construction work to refurbish Grenfell Tower was intrusive and noisy and one lift was

often unavailable to residents because it was being used by builders.

11. Building work on one's home is always challenging and it would be unusual if such a

large refurbishment project, conducted with residents in situ, had not given rise to an

increased number of complaints and expressions of dissatisfaction from residents.

12. Consideration was given to the re-housing of residents during the refurbishment, but

this was not thought practicable or desirable. Some residents also had concerns that if

they left the area, they would be rehoused in an unfamiliar location and not be able to

return.4 While such concerns were baseless, they are indicative of the level of mistrust

that existed between some residents and the TMO/RBKC.

13. The Inquiry will also consider whether there was a strained relationship between the

contractors and the tenants; and whether this created dissatisfaction around the

refurbishment project.

14. As the Inquiry will be focussing on fire related complaints, the TMO will address the

contents of the Grenfell Action Group (GAG) blog dated 20 November 2016. In fact,

the language used there was indicative of the levels of mistrust that had built up in the

minds of some residents about the TMO. Having said this, the Inquiry may be cautious

about the contents of GAG blog, in part because it is a highly personal account and

contains a number of ad hominem attacks on employees; but also, because its authors

never identified themselves. The blog uses the word 'we' in connection with the

residents of Grenfell Tower when, so far as the TMO is concerned, it appeared to be

the work of at most a handful of authors.

3 rWS0OOO2203, GAG 23.11.15 'Is it time to resurrect the EMB? 4 RBK0O0O3663

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TMO00900047/3 TMO00900047 0003 15. In summary the blog said5 ... We believe that the KCTMO are an evil, unprincipled,

mini-mafia ....and that their sordid collusion with the RBKC Council is a recipe for a

future major disaster ....only an incident that results in serious loss of life of KCTMO

residents will allow the external scrutiny to occur that will shine a light on the practices

that characterise the malign governance of this non-functioning organisation...It is our

conviction that a serious fire in a tower block or similar high density residential

property is the most likely reason that those who wield power at the KCTMO will be

found out and brought to justice!

16. Despite the appearance of prophecy, the writers were certainly not predicting a cladding

fire of the type that occurred on 14 June 2017. In fact, during the refurbishment the fact

that the l ower was being clad and insulated was generally seen by residents as a good

thing, as it was to improve the thermal efficiency of the building.

17. No resident or TMO employee foresaw this type of fast-spreading fire; and no-one had

predicted the causes of it. As the evidence in previous modules has borne out, it was

certainly not caused by 'the malign governance of this non-functioning organisation'.

Rather, it arose from widespread and deep-rooted blindness, within the private and

public sector, to the inherent dangers of materials regularly used in the building

industry; or even worse by deception for commercial gain on the part of those

companies that marketed and supplied cladding and insulation. The evidence the

Inquiry has heard in Module 2 thus far was truly shocking and shows that even those

with responsibility for safety certification did not uncover the combustible nature of the

products used in the refurbishment.

18. A measure of the extent of the misconception is the evidence of the widespread use of

similar materials that has emerged after the fire. It was discovered that some 2000

buildings around the UK had been clad in and insulated with similarly dangerous

materials.

19. The debate about how to solve this systemic problem continues to this day between

government, the construction industry and private building managers and their tenants.

20. The TMO was an organisation staffed by non-construction professionals with a

background in social housing, who had relied upon various specialists and industry

professionals throughout the refurbishment project by virtue of the design and build

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TMO00900047/4 contract. The TMO's reliance on professional advisers represented the norm for

contract procurement and capital works within the public sector.

21. While the TMO was, as the Chairman has put it. an 'educated client', it operated only

with the reasonable foresight of a social housing manager in the public sector; and in

not foreseeing the terrible events of 14 June 2017. it was no different to hundreds of

different organisations across the UK and beyond.

22. In this context, Dr Lane's criticism - that the TMO should have treated the external

wall as a relevant fire hazard when carrying out a fire risk assessment - is not an opinion

shared by other fire risk experts6.

23. Dr Lane also criticises the TMO for not uncovering the risk the refurbishment posed

following warnings arising from two fires - the Lakanal House fire in 2009 and the

Shepherds Court fire in 2016. Her suggestion that the TMO could have by itself

uncovered the deception from manufacturers of the combustible cladding and other

combustible materials used on Grenfell Tower is not credible and ignores the

international and UK wide nature of this problem. It is difficult to see how this view

could be fairly reached when governing bodies approved and/or provided misleading

certificates which inspired trust in both the cladding and materials used on the Tower

as they did across the UK and the world.7

24. In reality, even if the TMO - one of many social housing managers and COM clients in

the same position across the country - had specifically sought to investigate the

properties of the cladding and insulation materials used at Grenfell more deeply, it is

highly unlikely they would have laid bare the corporate subterfuge or deeply entrenched

misconceptions about the suitability and classification of the cladding. The mere fact

that so many buildings across the UK are clad in similarly dangerous materials

illustrates the point. Hundreds of other building owners or managing organisations were

also unable to untangle this subterfuge - even when, like the TMO. advised by teams

of professionals, formally appointed with roles under the construction legislative

regime8.

6 Reports of Colin Todd, MET00012981 & CTAOOOOOOll 7 As the Inquiry has heard during the oral evidence from the British Board of Agrement and Herefordshire Building Control 8 Construction Design and Management Regulations 2007 and 2015

TMO00900047/5 Resident Engagement

25. The TMO put considerable effort and resource into 'Resident Engagement' across the

whole of the RBKC Borough housing stock. This was the drive to ensure that residents

were properly involved in decisions surrounding the management of their homes -

especially as the TMO was managing a housing stock of over c. 10,000 dwellings.

26. TMO was - and was designed to be - a resident-led organisation. By its constitution,

there was a requirement that the Board consisted of a majority of residents, including

the Chair.

27. Across the Borough, following the appointment of Robert Black as the Chief Executive

in 2009. fresh efforts were made to stimulate resident engagement. Initially, a door-

knocking exercise was organised across all the properties managed by the TMO in an

effort to understand what residents' main issues and concerns were.

28. From 2009, the TMO enhanced and developed resident engagement and increased

representation through greater TMO membership. It did this in a number of different

ways including holding events such as Roadshows, promoting resident associations and

resident conferences.9

29. This work was done by a dedicated Resident Engagement Team, which included a

Resident Engagement Manager - Janet Edwards - who was tasked with increasing and

enhancing resident engagement. The TMO reported to RBKC on Annual Resident

Engagement.10

30. In the report to the Directors for year ending 31 March 2012, a number of resident

engagement topics were addressed and it was noted that resident engagement continued

to develop, with over 2000 residents being involved in decision making or consultation;

this built on the 'TMO in Touch' campaign of 201 1. which resulted in 2200 residents

contributing their views and an overall satisfaction rate of 79%; the TMO developed

the 'Get on Board' Campaign, which focused on delivering 16 local estate Roadshows;

this attracted almost 600 residents. 90% of whom were new to involv ement with the

TMO.

31. The TMO also organised events designed to include and engage residents including

the Senior Citizens Annual Party"; Youth Engagement Project; TMO Live; "Up Your

9TMO10010079 10RBK00057511 " TMO10016531

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TMO00900047/6 TMO00900047 0006 Game" Projects12; participation in the Test of Opinion and various Residents

Conferences.1' There was also a lunch for vulnerable residents in 201314 and the TMO

also conducted borough-wide consultations and satisfaction surveys with residents.15

32. Following the demise of EMB in 2014, resident engagement in the Lancaster West area

was very low and the TMO prioritised increasing it. This was to allow the TMO to use

residents' experiences and knowledge to develop its action on key areas of

performance, such as tenant involvement and empowerment, homes and tenancies,

neighbourhoods and communities and value for money16.

33. The number of Resident Associations or Compacts17 had increased to 53 across the

borough and 10 had been either setup or re-established during the year 2015/2016.18

The Resident Engagement Panel's Chairs' 'Get Together', which had started in 2010,

and was designed to promote unity and consistency, took place in 2016-2017 at

Kensington Close Hotel and was attended by 26 R A Chairs.

34. Efforts made to improve resident engagement were successful - for example in 2015/16

there were 7000 resident engagement contacts made through 13 involvement methods19

- and there was an increase in turnout for TMO Board Member election20 as well as

increased participation in the AGM. The TMO elections were managed by an

independent company.

35. The level of resident engagement was monitored in many different ways, including

through KPIs21. These show that the level of resident engagement was increasing

progressively over time22 and KPIs were reported to the TMO Board regarding Resident

Engagement and Complaints '.

36. As with complaints. TMO resident engagement activity was monitored by the RBKC

as part of the annual performance review and Housing Revenue Account (HRA)

12TMO10016531 13 TMO 10010079 14 TMO10003046 15 TMO 10010079 16 TMO annual report 2014/2015 - http://ww.kctmo.org.uk/files/reports/164100_aiinual_report_2014-15.pdf 17 A resident compact is a group of residents living in or at the same locality who are recognised by the housing management department. They are less formal than residents' associations but still provide access to the most important benefits 18RBK00057511 " See the Board meeting minutes of 26 October 2016. 20 TMO10010079 - showed an increase in turnout for board elections of 65% in 2010, 7% m 2011 23% in 2012 and 47% in 2013. The annual general meeting for 2013 had 65 members attending and 616 voting either electronically or by post) 21 See the Resident Engagement report for the period of 1 April 2015 to 31 March 2016. 22 The Resident Engagement report for the period of 1 April 2015 to 31 March 2016 sets out an analysis of resident engagement KPIs including the number of membership applications per month, the number of residents engaging in TMO events, activities and involvement opportunities; the number of new members joining the Children's and Youth TMO; the number of new residents' associations and compacts; the number of residents attending the Training and Employment roadshows,th e number of residents signing up for training under the Personal Development Academy and the number of residents engaged in the Community Outreach project. 23 This included repairs and maintenance, neighbourhood maintenance and cleaning, customer service centre

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TMO00900047/7 TMO00900047 0007 meetings. Resident engagement received a substantial assurance result in the minutes

of the HRA Performance Meeting cm 6 February 2017.24

37. Possibly the most telling measure of resident engagement, and of resident approval,

was the survey of TMO members in which they were asked if they wanted the TMO to

continue to manage their homes. This was the so-called 'Test of Opinion' which was

carried out every five years.25 In 2013 the highest turnout for the Test of Opinion

occurred (122% higher than in 2006) with an increasing number of members and non-

members voting overwhelmingly in favour of TMO continuing in its management role.

If it had been the residents' wish, the TMO could have been voted out of existence or

other management arrangements put in place.

38. In addition to this, at every AGM, members were asked to consider a resolution that the

TMO continues to manage the properties. In 2016, 1193 members voted in favour of

the TMO, with 24 voting against and 27 spoiled papers.26

39. The efforts the TMO made in connection with resident engagement, and the success of

such efforts, can be evidenced through the continued support for the TMO's

management.

Resident Consultation for the Refurbishment

40. The TMO sought actively to consult with residents concerning the refurbishment from

the earliest stage. This included engaging with residents about how they would like to

be consulted, which was always an issue. For example, residents were asked27 in a

questionnaire in December 2013 how they wanted the TMO to consult with them: i.e.by

letter, by newsletter; by email; or by notice etc.28

41. Consultation on design proposals for Grenfell Tower's refurbishment took place

between February 2012 and August 2012.29 Residents were contacted in many different

ways, including through newsletters which invited them to consultations between 2012

and 2016, and a Roadshow on 22 March 20 1 230. In addition, there was contact with

24 The Home Ownership Team also received a substantial assurance rating for 2015-2016 - TMO10013928 25 See for example RBK00000480, the 2013 Test of Opinion showed that 85% of those surveyed wanted TMO to continue managing their homes. 26 AGM 2016 Poll Results. The 2011 Result was 95.74% in favour of TMO continuing to manage (180 votes in favour), the 2012 AGM Result was 97.49% in favour (427 votes in favour), the 2014 AGM Result was 96.87% in favour (1,022 votes in favour), the 2015 AGM Result was 98.3% in favour (712 votes in favour). 27 TMO10043698 28 TMO10043698 29TMO000837671 30 List of consultations set out in newsletters TMO between 2012-2016

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TMO00900047/8 residents electronically and by paper; and residents were invited to view a show flat.

The textburst system was also used to remind residents of drop-in sessions that they

could attend regarding proposals for the refurbishment.

42. A resident consultation was sent out in the form of a questionnaire to be returned by

17 February 2012.

43. As of 22 March 2012, 61 questionnaires had been completed out of a total of 120

residences, giving a return rate of just over 50%31. Residents were asked about: inter

alia, their priorities for windows; whether Grenfell Tower would benefit from thermal

insulation cladding (high yes vote); whether homes would benefit from new individual

boilers for heating and hot water, which can be controlled by each flat individually

(high yes vote).

44. A second stage consultation took place in an estate meeting on 15 May 2012 with

Lancaster West EMB and Resident Association representatives.

45. There was a further Roadshow on 29 May 2012, where a presentation was followed by

the issue of a second questionnaire, seeking further comments and observations on the

proposals for Grenfell Tower and the needs of the Lancaster West Estate. Residents

were consulted on a variety of issues: whether they wished to be involved; what money

should be spent on; their views on the I ower's appearance; their views on proposals

for regeneration and refurbishment: what the exterior cladding should look like: the

nursery/play area; how residents would like to be involved/contacted in plans for the

refurbishment; and form of the windows.

46. Further meetings to consult with residents about the proposals took place on 12 July

2012, 19 July 2012, 26 July 2012, 2 August 2012 and 9 August 2012.32 The meetings

took place in both evening and daytime to accommodate a larger pool of residents, as

concerns had been expressed about residents' ability to attend at particular times. There

were meetings with the nursery staff and boxing club staff in August 2012.33

47. Further consultation meetings and drop-in sessions took place in August 2012, where

residents were invited to meet with the TMO to put forward suggestions and obtain a

better understanding of proposals for the project.34

31 TMO0001007 32 11 August 2012 meeting was cancelled. 33 GT Newsletter dated 9 August 2012 34TMO00837648

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TMO00900047/9 TMO00900047 0009 48. Feedback from residents was reported in a Grenfell Tower Newsletter dated 15 July

201235: residents expressed no clear opinion about the colour or type of external

cladding but did say they wished to have communal gas-fired heating and hot water

with individual controls in each flat, and windows they could open.

49. The Grenfell Tower Newsletter of 22 July 20123,1 reported residents' preference on

windows (whether they should be self-cleaning and options for operation such as pivot,

reversible, sliding or tilt and turn); residents preferred a heating system which was

upgraded and located on the roof and serving all flats; out of the two options for hot

water - one with a hot water cylinder on the roof, the other with new hot water cylinders

within flats - the residents preferred a roof option; three cladding options were set out

including aluminium sheet, composite metal sheet and profiled zinc sheet, with a

preference expressed by residents for a metal cladding3".

50. The Grenfell Tower newsletter of 22 October 20 1 238 indicated that 'Due to a review of

the fire strategy within the plans submitted to RBKC there has been some alteration to

the floor layout which now takes consideration of an improved fire safety strategy'.

This led to revised plans being submitted to RBKC which caused some concern to

residents due to the delay that this would cause.

51. The Grenfell I ower Newsletters of 25 June 201339 and 3 July 2013 reported the issues

discussed at the 17 June 2013 residents' meeting at the EMB rooms, summarising

discussions regarding the 'Planning Application', 'Removal of Canopy'. 'Window

Design'. 'Meter for New Heating System'. 'Pipe Routes (water and heating)' and

'Programme'.

52. The November 2013 Newsletter to residents4'outlined the surveys the TMO had

conducted on the following areas of the building: structure, services, communal lobbies

and occupied spaces42.

53. In addition to the above. Rydons hosted coffee mornings, one-to-one resident

consultations and home visits from Rydons Resident I iaison Officer.43

54. Through its consultation process, the TMO sought to involve as many residents as

possible to obtain their views on the refurbishment. There were extensive consultation

35 TMO00837522 36 TMO00838538 37 TMO00838538 38 TMO00838206 39 TMO00838217 40 TMO00838240 41 TMO00831368 42TMO00831368 43 TMO00842301

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TMO00900047/10 TMO00900047 0010 processes in place and residents were afforded the opportunity to express their views,

should they so wish.

55. Moreover, the TMO adapted the project after listening to residents: for example, the

TMO changed the design of the windows when it became apparent that the initial

proposals would result in more intrusive work being done internally; it recognised and

engaged with a new residents' compact when it was suggested that residents' concerns

were not being heard; and it moved the HIU after residents challenged TMO about its

revised position.

Complaints vs Service Enquiries

56. The TMO had systems in place for dealing with concerns and complaints, including

those connected with the refurbishment. However, the TMO acknowledges the content

of many of the statements from residents and recognises that it may be difficult to

reconcile the picture painted by some resident witnesses and TMO witnesses.44

57. Complaints' handling was always a priority for the TMO. and complaints performance

was monitored both internally and externally: internally by Operational Teams, the

Operations Committee, the Senior Management Team, the Executive Team and the

Board; externally, by RBKC.

58. TMO operated a Complaints Policy which required the TMO to apply the Housing

Ombudsman (HO) principles for effective complaint handling45.

59. The portfolio was overseen on a day-to-day basis by the TMO's Policy and

Improvement Manager46; and there was a dedicated Complaints Manager47 and two

Complaints Officers48. The Complaints Team had monthly meetings where all issues

were discussed and a quarterly report on complaints was prepared containing

complaints KPIs and statistics.

60. The Complaints Policy distinguished between a complaint and an enquiry. An enquiry

was defined as:

"A first-time request for information, advice or for an action to be undertaken e.g.

estate cleaning not undertaken, estate lighting not working or a repair request. "

44 In the Phase 1 report the Chairman said "From the outset members of the local community have said that they warned the TMO on many occasions about fire hazards, both those arising from the refurbishment and more generally. There is a strong feeling among them that their voices were ignored and that if attention had been paid to them the disaster could have been avoided" 45 The Policy was revised by Catherine Dackin July 2015 and approved by the TMO Board on 10 September 2015. The TMO's Policy was to review the Policy every three years and it was therefore due to be reviewed again in July 2018 (YB.l, 'KCTMO Complaints Policy Final 2015') 46 Janet Seward 47 initially Joanne Burke and then Catherine Dack 48 Dulce de Oliviera Watts and Eva Sobtzak

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TMO00900047/11 61. An enquiry would be passed on by the staff member who received it to either the

Customer Service Centre, or directly to the relevant team for action. The intention was

always to resolve inquiries as soon as possible without them escalating into formal

complaints.

62. By contrast, a complaint, or 'service failure', was defined as:

"An expression of dissatisfaction about a KCTMO service (or a service provided by a

KCTMO contractor) not resolved immediately to the customer's satisfaction about the

level, quality or nature of a service which the customer feels should have been

provided."

63. The TMO publicised the Complaints Procedure widely to residents on the TMO's

website, at Roadshows, in the Link Magazine for residents and through leaflets and

posters in the Housing Offices.

64. Residents with concerns or complaints could contact the TMO by a number of means,

including emailing a dedicated complaints email address; calling the Customer Service

Centre, or visiting their local Housing Office.

65. Complaint's handling had originally been managed using the W2 System but. as a result

of concerns expressed in an external audit conducted in 201349, a new system

Customer Relationship Manager (CRM) - was developed, and complaints and

enquiries were logged and progressed through this.50

66. Upon receipt of a call or enquiry, a Customer Service Assistant or Housing Officer

would log the information on the CRM System which recorded all customer enquiries

and correspondence. CRM had a drop-down menu that allowed the user to select

complaint or enquiry, and depending on the entry, this then assigned a specific

complaint ID number to that entry.

67. A general enquiry would be raised as a case and would, if possible, be resolved then

and there by the officer taking the call, or it would be assigned to the relevant team for

action.

68. If escalated to the Complaints Team, a letter of acknowledgement would then be sent

to the resident informing them of the complaint, identification number and the name of

the Complaints Officer dealing with the complaint; and confirming that the

investigation would be completed w ith a written response sent within ten working days

of receipt.

49TMO10003283 50TMO10045537

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TMO00900047/12 TMO00900047 0012 69. The complaint would be assigned to the Complaints Team in the first instance and then

reassigned to the relevant TMO team; for example, the Repairs Team. However, as the

Complaints Team oversaw the resolution of complaints, it would monitor outstanding

complaints and their status to ensure a response was sent out on time. There was a

specified period within which complaints were to be dealt with and CRM had a feature

which would alert the user to how many days remained to respond to a complaint in

time. The user could liaise with the allocated Service Manager to ascertain whether they

needed more time to investigate and respond.

70. CRM also had a 'dashboard' which gave the Complaints Officer visibility of the

complaints in real time and they could see whether and to what extent a complaint was

being progressed. This allowed the Complaints Officer to monitor response and action

times in accordance with the Complaints' Policy.

71. The Complaints Policy set out a three-stage process. Stage One involved an

investigation by the manager of the relevant service area. If a resident was not happy

with the outcome of the investigation, they could escalate their complaint to Stage Two.

72. Stage Two involved an investigation by the Head of Service; residents who remained

dissatisfied at Stage Two could request a Stage Three Review. The Stage Three Review

was the final stage of the procedure and involved a formal panel meeting, comprising

of an independent Board Member or a Co unci 1-appo i nted Board Member, a resident

Board Member and an Executive Director. A Board Member chaired the panel51. In

later years, the complainant was invited to attend the Rev iew to address the panel about

his or her complaint. If dissatisfied with the outcome of the Stage Three Review, the

resident could appeal to the Housing Ombudsman, who would hear appeals according

to a defined process.

73. Statistical evidence was kept for complaints and complaint handling. The figures

represented complaints across the whole of the housing stock managed by the TMO.

The figures regarding complaints were published in the Link Magazine, which was sent

to residents every quarter.

74. The TMO also sought to develop its complaints procedures through resident

consultation and trialled a 'quick resolution stage' which occurred before the formal

complaints stage; the idea being that if the matter could be resolved quickly to the

resident's satisfaction, the formal procedure would not be invoked. Although this

51 TMO Complaints policy IWS00002131 says panel has a resident board member for Stage 3 and says a board member will be the chair. (Dated 30.7.15 agreed on 10.09.15)

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TMO00900047/13 measure was never implemented, it is indicative of a progressive and collaborative

approach to complaints handling.

Monitoring of Complaints Performance

75. Complaint performance was monitored using a set of KPIs52, which included the

number of new complaints, the number of Stage One responses and the percentage

answered in target; the number of Stage Two responses and the percentage answered in

target; and the number of Stage Three appeals.

76. Yvonne Birch reported KPI complaints to the TMO Executive Team on a monthly basis

and to the Operations Committee in quarterly meetings. A summary of complaints

performance was also provided to the Board as part of an Annual Report on

performance.

77. Complaints were also subject to an internal audit by an independent RBKC team and

RBKC maintained independent oversight of complaints at all times. Siobhan Bowman

would send high level KPI information directly to Celia Caliskan at RBKC on a

monthly basis.

78. RBKC hosted quarterly Housing Revenue Account Performance meetings in which the

TMO's performance was monitored by reference to KPIs and other reports. These

meetings were chaired by Amanda Johnson and attended by TMO and RBKC officers,

including Yvonne Birch.

79. RBKC also monitored the performance of the TMO through an annual performance

review required by the Modular Management Agreement. There was also a mid-year

performance review. The annual performance review considered the results of the

TMO's annual internal audits, which, depending on the year, could include complaints,

fire safety, repairs and asset management.

Complaints Arising from the Refurbishment of Grenfell Tower

80. There were seven formal complaints to the TMO. received from four separate residents

of Grenfell Tower during the period of the refurbishment. Of these seven, four were

submitted by the same resident.5' Four were not upheld, two were upheld and one was

partially upheld.

"Complaints" was one of five key performance indicators which were agreed with RBKC annually. TMO00842301

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TMO00900047/14 TMO00900047 0014 81. TMO recognises that this does not fully capture the level of concern expressed by

residents about the refurbishment, which was often conveyed in different ways, and

which will be discussed further below. However, this demonstrates that a proper

process was being followed to seek to resolve complaints made by residents to the

TMO.

82. It is important to understand that the primary mechanism for raising concerns during

the refurbishment was to Rydon. Because of this, the TMO would not know of every

concern raised, as issues resolved by Rydon would often not be reported back to the

TMO. Rydon had a site office based in the building and there was a permanent Resident

Liaison Officer (RLO) located there to deal with any day-to-day issues relating to the

refurbishment works. There was also a Rydon's email address via which residents could

express their written concerns direct to Rydon54. The RLO details, including when

they were available, were communicated in each newsletter 55. If residents remained

unhappy with the response from Rydon. they were able to go through the TMO's

complaints process. The TMO also had its own RLO.

83. The TMO and Rydon held Liaison Meetings involving the RLOs to discuss concerns.

These Liaison Meetings were held regularly during the refurbishment period and w ere

very much an opportunity for the TMO and Rydon to formally discuss housing

management issues impacting upon residents.

84. Dealing with the formal complaints raised to the TMO. First, a partieular complaint

encompassing several issues was made in early December 2015 by Edward Daffam

relating to the refurbishment works56. His complaint was heard at Stage One by Peter

Maddison; it was not upheld.

85. Mr Daffarn escalated his complaint to Stage Two where it was considered by Sacha

Jevans. Director of Operations and the Line Manager of Peter Maddison. After giving

54 yourcommunityfajrydon.co.uk 55 See for example Newsletter of September 2016 and October 2016 and February 2016TMO10031158, TMO00860882, TMO00834144 advertising how residents could complain naming Lynda Prentice, Christina Stephanou and Claire Williams along with a complaints phone number, email address and the TMO website address. 56 For background see YB24 'Peter noted that Edward Daffarn has a Stage 3 Complaint and explained the background to it. We wrote to Edward Daffam and made an appointment to have his work carried out. Edward was away ^^^^^^^^^^^^^^^^|. so his appointment was moved back. Then he couldn't do that appointment, so it was pushed back again. With the next appointment we knocked on his door, but he wouldn't allow us to do the work. He had lots of extra demands about what he wanted done. Then unfortunately for the next appointment Rydons didn't turn up on the correct day. Then we had to cancel the next appointment as Lady Borwick VIP was visiting. Edward is saying that he is happy to have the work done but we haven't answered all his questions yet. Edward has already been through Stages 1 & 2 and before we write to him about Stage 3 Peter will review the previous two stages. In the meantime, the Complaints Team will acknowledge receipt of it.

15

TMO00900047/15 reasons, the conclusion was that the handling of the matters that Mr Daffam was

appealing against had been appropriate and so the complaint was not upheld57.

86. Mr Daffam escalated his complaint to Stage Three, and it was heard by the Stage Three

panel on 11 February 201658. There was a unanimous decision of the panel not to

uphold Mr Daffarn's complaint. The panel consisted of a number of individuals chosen

to represent a broad range of experience and ensure independence; and was chaired by

an independent member of the Board.

87. Mr Daffarn took his complaint to the independent Housing Ombudsman (HO) and the

HO also concluded that there had been no maladministration and no service failure. In

the Ombudsman's report, the conclusion was that the TMO had acted reasonably,

rearranging commencement date for works; and there was no maladministration by the

TMO in the handling of Mr Daffarn's complaint. 59

88. While it will be for the Inquiry to discern whether complaints were properly speaking

connected with fire safety, the TMO notes that the only complaint outstanding at the

time of the fire made in relation to fire safety at Grenfell Tower, was regarding gas

pipework being installed at the Tower. The complaint was escalated to Sacha Jevans at

Director level.

89. The TMO notes that there had previously been some concerns raised about accessibility

to Grenfell Tower by the London Fire Brigade after the KALC redevelopment but the

LFB bi-monthly meetings with the TMO both during the works and afterwards

indicated that these concerns did not amount to a fire safety risk.

Consideration of Complaints that did not go through the Complaints Procedure

90. There was an existing Residents' Association for Grenfell Tower and the Lancaster

West Estate, which had been established in 201560. Some residents were unhappy about

the way in which it operated and wished to start a separate organisation. It was as a

result of this that a Residents' Compact came into existence in 201561. This operated

alongside c.53 other Residents' Associations that TMO engaged with.

57 See TMO10011679 58 YB.27, '11 Febraary 2016 Stage 3 notes summary' 59Report of the Housing Ombudsman dated 31.3.17 re compliant number 201518122. The Ombudsman did note that it would have been courteous to Mr Daffam to have communicated with him its decision to not arrange such a meeting in this intervening time and could have reduced his stress and alarm at receiving the first Solicitors' letter. 6%tps://staticl.squarespace.com/static/596cda2ca803bb43a3ba317c/t/59bla80180bd5e49f805ad8a/1504815304879/Lanc+West+RA+Const itution+2015.pdf 61 IWS0O0O2334

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TMO00900047/16 91. At a Residents' Compact meeting in June 2015, it was suggested by members that the

TMO had 'harassed, lied and intimated' residents over the duration of the works. At the

meeting, the TMO gave a commitment that any specific allegations would be

investigated in accordance with the Complaints Procedure and appropriate action taken

to resolve the matter.

92. A petition signed by 51 residents62 was presented to the TMO/RBKC meeting on 2nd

December 2015 asking the Chairman of the Housing and Property Scrutiny Committee

to undertake '...urgent scrutiny of the TMO and Rydon's management of the

refurbishment project currently underway at GT...our day-to-day concerns are

belittled and side-lined. While we recognise that, once completed, the Tower will at

long last be fit for the 21st Century, during this process we have had to endure living

conditions that at times have been intolerable...'. '63

93. Following receipt of the petition the TMO undertook a door knocking exercise,

speaking to 77 of 120 households in Grenfell Tower64. By contrast to the petition, the-

feedback received was that 90% of residents interviewed confirmed the improvements

to the heating and hot water were working effectively; 85% of residents confirmed they

understood how to operate the new heating system. 83%) of residents were happy with

the new windows and 97% understood how to operate them. The survey found that no

resident had raised any issues relating to bullying or harassment.

94. Mr Daffarn referred to this petition in a speech he gave to the Housing and Property

Scrutiny committee on 6 January 2016 where he said that a 'quantitative survey' had

shown that 90% of Grenfell Tower residents had reported they are dissatisfied with the

way in which the TMO has conducted the improvement works and that his survey found

that 68% of residents said that they had been lied to. threatened, pressurised or harassed

by the TMO. The survey also revealed, he said, that 58% of residents who have had the

Heating Interface Unit (HIU) fitted in their hallways would like it to be moved to a

more practical and safe location. Mr Daffarn also referred in the speech to the '/"//

treatment, incompetence and plain abuse that we have experienced at the hands of the

TMO during the GT Improvement Works' and he called for scrutiny of the

refurbishment project.65

62 TMO00842301 63 See RBK00000109 64 Door knocking by the TMO took place on 18 and 21 December 2015 whereby the TMO asked residents about their concerns and it dealt with some of these before Christmas. 65 RBK0OOOO338

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TMO00900047/17 TMO00900047 0017 95. The results of the survey and petition are plainly at odds with each other and the Inquiry

will consider why; and whether residents felt truly able to express themselves to either

group asking them questions.

96. The main concerns expressed in Mr Daffarn's speech were that there had been a lack

of consultation and resident engagement during the refurbishment works; that the TMO

and Rydon had "harassed and bullied" residents over the works; and about complaints

regarding the location of the Heating Interface Units ("HIUs") being moved to the

hallway outside flats.

97. In the light of the concerns in the speech, the TMO convened a formal review to

examine the Grenfell Project ('the Group') which took place after the works had been

largely completed. It was agreed that there should be a full inquiry into the concerns

and the presentation of a formal report to the Scrutiny Committee and the Board. Paula

Fance. a Council nominee on the TMO Board, was appointed as the Chair of the Panel

and agreed to lead the discussions and report back. Additionally, the panel comprised

of other Board Members including some Resident Board Members: Kush Kanodia.

Mary Benjamin. Deborah Price. Anne Duru and Councillor Condon-Simmonds. It was

agreed that a timeline of events would be prepared to show what had been done and

how complaints were dealt with.

98. At a meeting on 24 February 2016. it was agreed that the review would cover the

following areas: resident consultation and engagement; the posit ion of the HIU in the

hallways; allegations of threats, lies and intimidation; response to complaints; quality

of work and site management; and compensation

99. For the review on 12 March 2016. there was a presentation covering background

information to the project and each area of the review as set out above. The Group was

taken on a tour of Grenfell Tower: the construction works, the show flat, the boxing

club and the hidden homes. Each member was provided with a full pack for the day

which included the detailed information covering each area of the review's scope.

100. The Group concluded that: (inter alia) the residents were consulted and engaged

through a number of different methods, and this had been comprehensive; at the

beginning of the project. Rydon's RLO collected profile information on each resident,

w hich was used to identify specific additional needs or requirements of residents. The

Group reviewed all of the complaints and enquiries and was satisfied that the TMO had

responded adequately. It concluded that controls were sufficient to manage a

construction project of this size and nature. It found that the example of poor

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TMO00900047/18 workmanship cited in the speech presented to the Housing and Property Scrutiny

Committee was in relation to work in progress, and so was misleading as a description.

101. Overall, the Group concluded that the work had been carried out in line with

TMO objectives and it reported this to the RBKC Scrutiny Committee.' '' It reviewed

all of the complaints and enquiries and was satisfied that the TMO had responded

adequately. Neither the Group (nor the TMO Board) could find evidence that

substantiated the allegations of 'threats, lies and intimidation ' by either Rydon or the

TMO's staff.

102. The Group recognised that there were significant challenges with the project

and acknowledged that residents would have experienced inconvenience due to the

nature of this type of construction work and the constraints of the particular design of

Grenfell Tower.

103. The Group gave specific consideration to the issue of the HIUs. Some residents

objected to the new HIU being located in the hallway of their flats. 67 It was originally

proposed that the HIU would be located in the kitchen, however, when Rydon raised

technical restrictions about the original kitchen location, which presented practical

difficulties, it was decided to move it to the hallway.68 At a Board meeting on 31 March

2016, the technical complications were discussed in detail and the Board concluded it

was the right decision to encourage residents to locate the HIU in their hallway; it was

concluded there was sufficient communication and consultation with residents over the

positioning of the HIU; that due consideration was given to the requests of some

residents to locate the H1U in the kitchen; and that the TMO responded positively in

accommodating these requests.

104. The report produced by the Group was shared with the RBKC's Housing and

Property Scrutiny Committee on 11 May 2016.

Other Complaints and Concerns

105. There is considerable evidence of complaints being made by and on behalf of

the Grenfell Tower Leaseholders' Association. ('GTLA'). Some of these complaints

were taken up and promoted by Councillor Blakeman. a TMO Board Member. She also

took up and promoted complaints by other residents.

66 YB.l 5, '25 May 2017 Chief Executive's Report 67 TMO00853367 68 In a Board Report dated 31 March 2016, it was noted that the group concluded the residents were consulted and engaged through a number of different methods, and this had been comprehensive.

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TMO00900047/19 106. It is worth noting that her involvement in complaints alongside her board

membership gave rise to concerns in certain quarters, including among other

Councillors, about her independence.

107. An example of a complaint raised by Councillor Blakeman with the Board is

from Tunde Awoderu, when on 21 April 2017 he sent an email to individuals at the

TMO and RBKC69 requesting an independent expert investigate the gas works at

Grenfell Tower. This was forwarded to the TMO Board Members and Mr Awoderu

was informed in response that the matter had been addressed by the Board, who were

informed that advice had been sought from the Fire Risk Assessor, who provided

reassurance regarding risks to residents thereby. He was told that National Grid is a

utility company and statutory body, which is not required to enter into contractual

relationships with the TMO or RBKC. which therefore restricted the control the TMO

had over the work.

108. The uncovered gas pipes in the stairwell caused considerable concern to a

number of residents. The history of the matter is complex, but in essence when one of

the four historic risers supplying certain flats ruptured, it had to be replaced. The

replacement had to be carried out by the statutory gas utility company, then tRIIO.

pursuant to their statutory powers. While consulted, neither TMO nor RBKC had final

say over how. when and where the work was done. Residents started to express

concerns about the work and the manner in which it was being done; particularly the

fact that a gas pipe was left exposed in the stairway. Dr Lane seeks to suggest that the

TMO had duties as a Client in respect of this work. This is not correct and is a

misunderstanding of the statutory powers of utility companies.

109. In response to these concerns. TMO instructed Carl Stokes to visit the Tower

and inspect the newly installed gas riser and laterals, and it also corresponded further

with tRIIO. Carl Stokes visited the site on 26 January 2017 and published a report with

eight eonchisions/recommendations relating to fire-stopping and gas safety. This report

was provided to tRIIO for comment70. tRIIO provided assurance to TMO that the newly

installed lateral pipework would be boxed-in for ventilation purposes and holes sealed

where they were not needed for such ventilation/1 This work was ongoing at the time

of the fire.

69 To Sacha Jevans and Laura Johnson 70 TRI000000693 71 TRIOOO0OO757

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TMO00900047/20 TMO00900047 0020 110. The Inquiry may also consider other complaints and concerns raised by the

Grenfell Tower Leaseholders Association over the course of the refurbishment project,

and how these were dealt with by TMO. These included complaints relating to fire

safety, solicitors" letters to allow access by Rydon so works could be carried out; faulty

windows; emergency lighting; fire safety drills; signage and complaints arising from

the safety of the gas riser.

111. The Inquiry will also be hearing from the resident. David Collins, who rented

from the leaseholder, Mr Awoderu. It is recognised that Mr Collins also raised a number

of concerns and complaints with TMO at different times during the refurbishment

pro ject on behalf of himself and other residents.

112. One of his complaints was regarding the location of the HIU. which was

escalated by Councillor Blakeman to the Housing Ombudsman72.

113. Among other matters. Mr Collins stated that "a lack of engagement with the

TMO and their agents meant that residents never learnt in detail about the cladding

materials or other aspects of the project which were a risk to resident safety and

wellbeing"73 He also predicted a 'bad outcome' for the TMO if resident engagement

was not more effective and monitored externally.

114. The TMO accepts the Inquiry will give careful consideration to the complaints

made by Mr Collins and examine whether they were dealt with appropriately. In

relation to any complaint raised by him regarding consultation over the cladding, the

TMO will say that residents were consulted on which type of cladding they preferred;

but the issue of the fire-retardant cladding was never raised with them as it was

legitimately assumed by the TMO that its professional advisors gave due consideration

to compliance with safety standards.

115. Engagement with residents regarding their concerns during the refurbishment

were largely dealt with by Rydon's Resident Liaison Officers and Claire Williams.

Claire Williams liaised closely with Lynda Prentice, both during and after the works,

and always sought to ensure that residents' concerns and requests for repairs were dealt

with.

72 rWS00002328 73 rWS0O0O2334

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TMO00900047/21 116. Following the works, residents were spoken to directly to ascertain what defects

remained outstanding74. Lynda Prentice also saw and spoke to residents who reported

to her outstanding issues and concerns: so far as Ms Williams was aware, the only

outstanding concerns were regarding windows and kitchen fans.75

117. Lynda Prentice's evidence is closely reflected in the defects' lists compiled by

Rydon.76 The defects period expired on 4 July 2017; after the fire.

118. Complaints regarding fire hazards arising from blocked exits due to waste were

monitored and responded to by the neighbourhood office nearby Grenfell Tower .where

Siobhan Rumble and later Nicky Bartholomew and her team were located". The

Inquiry will hear from Siobhan Rumble, who dealt with matters directed to her in a

robust and practical manner.

119. The TMO submits that complaints and concerns were dealt with and responded

to in an appropriate and generally timely manner and in addition to the complaints

process, there was also scrutiny by a panel of Board members and oversight by RBKC.

The fact that some complaints which were formally escalated were eventually upheld

illustrates that there was a process and system in place which was transparent and

effective.

Topics 2 and 3

120. Topic 2 will consider the obligations of the TMO and RBKC under the

Regulatory Reform (Fire Safety) Order 2005 and their compliance with those

obligations. Topic 3 will consider the active and passive fire safety measures inside

Grenfell Tower and management of maintenance of the building, with the following

partieular issues to be considered: the TMO's maintenance regime; lifts; fire doors (flat

and stair doors); smoke control system, including Building Control approval of that

system; and gas works, including riser replacement works.

121. As Dr Lane's Report is prepared with Phase 2 Module 3 in mind, and she

addresses issues relevant to Topic 2 and 3 jointly, the TMO will deal with Topics 2 and

3 together and focus on a selection of her key findings, while giving due regard to the

74 Newsletter of September 2016 and October 2016, May 2016 referencing Rydon's defects period TMO10031158, TMO00860882 and TMO 1005 0006 75 RYD00094366 76 RYD00085825, RYD0OO51992

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TMO00900047/22 reports prepared by other experts commissioned by the Inquiry, such as Colin Todd and

Roger Howkins.

122. We make the following general observations about Dr Lane's Phase 2 Report.

It has only recently been served and is long, dense and complex. Dr Lane - along with

numerous assistants - has carried out a full forensic audit of the Fire Risk Assessments

('FRAs') and resultant action plans: and TMO's overall performance, referencing her

findings with the full range of legislation, statutory instruments and sector guidance.

123. Separately. Dr Lane's Report has been served piecemeal within the last month,

without its conclusion chapter, leaving the TMO with limited time to address it fully in

this Opening Statement. To the extent necessary, the TMO may address further issues

in its closing submissions for Modules 1. 2 and 3.

124. Dr Lane's Report has been produced with extensive time, resources and.

importantly, with the benefit of hindsight. It is submitted the Inquiry should be cautious

when assessing the conduct of the TMO and its employees and not judge using

hindsight. Nor should the TMO or their actions be judged on the premise that the nature

or scale of the terrible events of 14 June 2017 was reasonably foreseeable; or that it was

a scenario of this type the TMO should have been seeking to avert when establishing

and maintaining active and passive fire measures. As the Chairman points out. the

nature of the fire was such as to completely overwhelm all active and passive fire

measures, and even if (and the extent of this is to be decided) they had all performed

precisely as expected, they would still ultimately have been overwhelmed.

125. The TMO also considers that Dr Lane is frequently misguided in her criticisms

of Janice Wray. in particular. This may be connected with the fact that Dr Lane

overstates the nature and extent of Janice W ray's role at the TMO and at times appears

to fundamentally misunderstand it. Janice Wray was employed as the Health and Safety

Facilities Manager, which was an occupational health and safety role. She was not

health and safety manager for Grenfell Tower alone, but as an advisor for the whole

organisation covering a property portfolio, which included nineteen tower blocks and

over 10.000 properties. An example of over-statement is where Dr Lane says Janice

Wray had unique responsibility for ensuring active and passive fire measures were

properly maintained; when a large part of this fell to the Contracts Management Team,

headed up by Alex Bosnian. The TMO considers the Inquiry should hear evidence from

an individual within the Contract Management Team if such matters are to be

examined.

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TMO00900047/23 TMO00900047 0023 126. Dr Lane also suggests that Janice Wray should check the Estate Service

Assistants' (ESA) weekly and monthly reports for Grenfell. This expectation is wholly

unreasonable when considering that there were ESA reports for all 10.000 properties in

the housing stock.

127. It is submitted that Janice Wray was a hard-working and dedicated health and

safety professional who acted in a diligent, organised and efficient manner; always

seeking to gain full visibility of the health, safety and fire issues occurring within the

TMO and then to address them expeditiously with all resources available to her.

Further, she was not and never purported to be a specialist in fire safety or fire risk

assessment. For these reasons it was both necessary and reasonable for the TMO and

Janice Wray to rely substantially on specialist advice from independent contractors,

such as Salvus Consulting Ltd and Carl Stokes Associates Ltd. Indeed, the Fire Risk

Policy required that this be done, and this arrangement was fully with the knowledge

of others like RBKC and LFB.

128. It is for the Inquiry to decide whether Dr Lane's criticisms of Carl Stokes are

justified, although it is to be observed that Colin Todd, a well-known and respected

expert in fire risk assessment, also commissioned by the Inquiry, disagrees with Dr

Lane in many respects.

129. Again, many of the criticisms made by Dr Lane do not reflect the practical

reality of social housing with budgetary constraints and it is submitted that Dr 1 ane

often measures the TMO's performance against unreasonably high standards and based

on misunderstandings of the organisational structure. She makes no attempt to compare

the practice of the TMO and other equivalent social housing managers or understand

what would be expected of those in a similar position. The TMO invites the Inquiry to

bear in mind that thousands of other properties have become trapped in the 'cladding

crisis' and those managing them would, according to Dr Lane, also be in breach of duty

as Responsible Person management organisations.

TMO's System for Fire Risk Management: Carl Stokes' Competence

130. TMO accepts it was the Responsible Person for the purposes of the RRO(FS)

2005 and for identifying the general fire precautions for premises under its control.

There may have been other persons who also had the role of Responsible Person, which

is a matter for the Inquiry, but the TMO accepts its own primary responsibility.

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TMO00900047/24 TMO00900047 0024 131. The TMO operated a structured fire risk management system appropriate to the

nature and size of its undertaking. The system was primarily contained and articulated

in the TMO Fire Safety Strategy78. The system was intended to deliver and implement

the statutory fire risk assessment programme, which mainly comprised of arrangements

to have FRAs produced by a competent Fire Risk Assessor and the process for raising

actions and then closing them out as part of an action plan79.

132. The TMO always sought to develop its Fire Risk Strategy in consultation with

LFB as can be seen in the meeting of 16th September 200980. There was also

consultation with RBKC. Dr Lane considers that the arrangements set out in the TMO

Fire Safety Strategy Document were compliant with article 9 of the RR(FS)0 2005 if

implemented; including the provisions for review.

133. TMO's wider system for fire risk management, including FRAs. was a regular

point of discussion in periodic Health and Safety Committee meetings; a standing item

in the KCTMO Annual Health and Safety Reports between 2009 and 2017; and a point

of discussion within the bi-monthly meetings between LFB and the TMO. It was also

the sub ject of scrutiny at the RBKC Scrutiny Committee.

134. KPIs relating to FRAs began to be used formally in 2016 but before that time,

the Health and Safety Committee was kept abreast of progress with actions identified

by the FRA.

135. The TMO's Fire Safety Strategy was reviewed on a regular basis following

significant events, such as the introduction of W2; Adair and Grenfell Tower Notice of

Deficiency (NOD); and in response to concerns raised by RBKC. The TMO made

appropriate changes when problems were identified/1

136. Also, fresh FRAs were carried out when construction work commenced and

towards the end of the refurbishment. The door-replacement programme, which is

addressed in further detail below, was also instigated as a result of recommendations in

the 2009 FRA by Salvus.

137. The TMO also received a large amount of ad hoc advice from their appointed

Fire Risk Assessor at different times; this being part of the scope of the Assessor's

undertaking.

78 TMO00830598 79 See 79:2012 80 SAL00OOO039 81 See for example in 2013, RBK00000685

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TMO00900047/25 138. Dealing first with the wider question of Carl Stokes' competence to carry out

FRAs on behalf of TMO. In general terms, the TMO considered him to be a competent

fire risk assessor and fire consultant; and despite Dr Lane's findings, there is strong

evidence to confirm this, for example Colin Todd's Expert Reports Although there were

some anomalies in Carl Stokes' FRAs, these did not invalidate their overall quality; nor

should they have led the TMO to conclude that the assessments were unacceptable.

139. Dealing first with how Carl Stokes came to be TMO's lire risk assessor for

Grenfell Tower. The Regulatory Reform (Fire Safety) Order 2005 brought with it a

change of approach towards fire safety; the previous regime (which relied on the

production of fire certificates by fire authorities) being replaced by a system that

mandated a risk-based approach to fire safety by the "Responsible Person ". Pursuant

to the Order, and its management function, the TMO was required to ensure FRAs were

undertaken and documented for all communal areas across its stock.

140. In late 2008 to early 2009 the TMO, RBKC and LFEPA entered into discussions

about the suitability and sufficiency of the TMO's FRA Programme82. These

discussions resulted in a joint decision to procure specialist consultants to undertake

FRAs across the stock and adopt a risk-based approach. Properties were designated into

different potential risk categories: high, medium and low.

141. It was determined that priority should be given to high-risk buildings, and a

specification for companies tendering to offer fire risk assessment services was drawn

up. The specification was typical of those in use in comparable situations.

142. Four tenders were received by TMO for the FRAs and each of the four tenderers

was interviewed by the TMO and their bids assessed in accordance with a recognised

scoring system. The final decision was taken on suitability and the interview process

resulted in the shortlisting of two tenderers.

143. Of these two. Salvus Consulting Ltd was appointed to carry out the high-risk

Premises Assessment Programme. The representatives from Salv us were introduced to

the LFB. and the LFB approved its approach and proposed pro form a. TMO gave a

commitment to LFB to evaluate the performance of its Fire Risk Consultant.83

82 TMO: Health and Safety Annual Report 2011/12': TMO10031072 83 CTAOOOOOOll, Colin Todd says as follows: In 2009, it was found by LFB that these FRAs were not suitable and sufficient. From then onwards, there is significant evidence that LFB cooperated closely with the TMO over a considerable period of time to assist the TMO in achieving compliance with the Fire Safety Order and to progress towards a situation in which the FRAs were suitable and sufficient to the satisfaction of LFB.

26

TMO00900047/26 TMO00900047 0026 144. Further, it was agreed that the LFB would accompany Salvus' assessors on

selected FRA visits, and this occurred. TMO understands that LFB officers attended a

number of the initial regular progress meetings with Salvus to monitor progress,

identify issues, make recommendations for actions and ensure that agreed standards

were being applied consistently. TMO valued LFB's cooperation and assistance,

described as 'commendable' by Colin Todd.

145. The TMO began to receive finished FRAs by late 2009 and immediately started

to complete outstanding actions from the high-risk FRA programme.

146. The TMO put the contract for medium and low risk properties out to tender and

Salvus and a number of other companies submitted tenders, with all interviews

conducted jointly with RBKC, who had requested to be inv olved in the appointment

process.

147. TMO interviewed around six organisations and in August 2010 Carl Stokes &

Associates ("Carl Stokes") was identified by TMO and RBKC as the preferred

consultant and appointed. As the Inquiry is aware. Carl Stokes was engaged by Salvus

as a consultant and did the FRA for Grenfell Tower.

148. He carried out his first FRA for Grenfell Tower as a sole trader in December

2010. Thereafter, he carried out further 1 RAs for Grenfell Tower in 2012, 2014, April

2016 and June 2016.

149. In terms of experience, Carl Stokes was employed by several fire and rescue

services between 1986 and 2009; between 1994 and 2009. he was employed by

Oxfordshire Fire and Rescue Service as a Fire Safety Officer, during which time he had

experience of enforcing the RR(FS)0. He also consulted with licencing authorities and

building control bodies; acted as a liaison officer for Oxford University; and was lead

Fire Service Officer for four major hospital construction projects.

150. When assessing Carl Stokes' competence. Colin Todd notes there are (and

importantly were not) any express or statutory requirements for the education, training,

skills and qualifications of fire risk assessors. Colin Todd points out that a competent

FRA will have training and experience in the practice of fire safety; and this is

commonly found in fire safety officers from the Fire and Rescue Services, which is the

most typical background for fire risk assessors.

151. Overall, Colin Todd considers Carl Stokes' work experience, academic and

practical training and experience as a fire risk assessor - which included undertaking

audits of the common parts of high-rise residential tower blocks, and being part of a

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TMO00900047/27 TMO00900047 0027 working group that drafted very well-known and established guidance on fire safety in

certain types of housing - was more than adequate to equip him for the role of fire risk

assessor carrying out FRAs of Grenfell Tower, and other buildings within the TMO-

managed estate.

152. Of the assessments themselves Colin Todd says:

"The level of detail is, in my experience, well in excess of that normally included in fire

risk assessors' FRAs (though some of the text is standard wording incorporated in all

Mr Stokes' FRAs). The documented FRAs are amongst the most detailed of the many

thousands of FRAs I have studied; in my opinion, the level of detail goes well beyond

that necessary for the FRA to be regarded as suitable and sufficient. "

153. On the basis of the fire risk assessments. Colin Todd said 'were Mr Stokes to

apply for registration by the IFF on their Register of Fire Risk Assessors, I would have

no hesitation, on the basis of his training, experience and examination of his FRAs, in

recommending him for registration, subject only to formal interview, which is a normal

part of the registration process'.

154. Colin Todd's assessment of Carl Stokes' competence and risk assessments is

substantially at variance with Dr Lane's assessment. Whatever judgement the Inquiry

makes on their widely varying opinions, the TMO submits that on the basis of Colin

Todd's v iew alone, the TMO was fully entitled to engage and retain Carl Stokes to carry

out risk assessments of its high-risk blocks, including Grenfell Tower.

155. It is unreasonable to think that TMO should have continuously second-guessed

or appraised Mr Stokes' approach in the way Dr Lane has suggested84. First, for a non-

specialist organisation such as the TMO to disregard specialist advice is a dangerous

course for which it might rightly be criticised. Second, while there may have been

times when it was right for TMO to question his approach - such as when LFEPA

expressed their concerns in January 2016 - it is submitted that TMO did follow up on

these: and took appropriate steps to satisfy itself that Carl Stokes was approaching the

task of tire risk assessment in a suitable manner.

156. The TMO is aware that the Inquiry will examine the TMO's response to the

queries raised by LFEPA in connection with the fire performance of the cladding; and

what Dr Lane describes as TMO's 'shallow response'. She characterises this as based

on a quick email exchange absent of technical fact.

' Sec for example Phase 2 report; chapter 8; 8.43 et seq.

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TMO00900047/28 TMO00900047 0028 157. The TMO submits the view Dr Lane takes is unreasonable and simply not

credible when an impartial examination is made of the systemic issues that have seen

been identified worldwide. Even if the TMO had embarked upon a far deeper

examination of the situation (and it is not accepted that the way in which it acted was

unreasonably 'shallow') it could never reasonably have been expected to unpick

systemic longstanding industry-wide misconceptions about the suitability of cladding

with PE cores for multi-storey residential buildings; misconceptions that were fuelled -

if not caused - by cynical misrepresentations by companies such as Arconic. Celotex

and others.

158. If this were a TMO specific failing then it w ould be a failing for every client

across the UK and beyond, as well as a failing by every single engineer in the fire

engineering sector advising on such matters. It is not known if the 2000 or so other

buildings had a Client Design Advisor but either, like the TMO. did not or if they did

the CD A did not manage to untangle the subterfuge that Module 2 has so graphically

exposed. This is perhaps not unsurprising given the efforts of those companies involved

to present a misleading picture of compliance and certification. Against those

widespread systemic issues. Dr Lane's position on these matters simply is not credible.

159. Carl Stokes did investigate the fire performance of the cladding. He states that

he noted on the previous risk assessment "Cladding external Non-Combustible Metal

Fixings signed off by B/C. "85 He says he understood that "the system, and component

parts would have been compliant with the requirements of the Building Regulations and

ADB ".

160. Thus, when Dr Lane says in her Phase 3 Chapter 10 report that the LFPEA

concerns should have been addressed with the FRA process, it is submitted this was

done.

Closing Out Fire Risk Assessment Actions

161. The TMO had a system for dealing with actions identified by its fire risk

assessments and notices of deficiency; and fire safety was never a matter it disregarded

or ignored.

162. After a fire risk assessment, action points identified were initially put onto the

W2 system by Janice Wray or Cyril Morris. Janice Wray was then able to assign FRA

CST00003063

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TMO00900047/29 TMO00900047 0029 actions to departments, and individuals within departments for completion. Staff

assigned actions would be expected to update the entry on the W2 platform; but only

Janice Wray could mark the actions complete or partially complete. She and Ms

Matthews regularly emphasised to other staff the need to close out actions identified by

FRAs.

163. If. when actions were identified and targets for closing them out set. those

targets were sometimes missed, this is partly a function of the number of historical

actions that existed and limitations on resources and should not be taken to imply a lack

of urgency or disregard for safety by the TMO or its staff.

164. The picture surrounding the closing out of actions arising from FRAs is

statistically complex and the rate at which they were closed out varied between 2013

and 2017. For example. Dr Lane notes "KCTMO had difficulty in closing out actions

up until September 2015. After that point, a significant increase in completion rate

occurred".86

165. In light of the complex picture, it is not proposed to embark upon a detailed

analysis of all the available data in this opening; but the breadth and number of actions

being generated across the whole TMO estate is worthy of note. From December 2013

to June 2017, the total number of actions that had been assigned was. according to Dr

Lane. 3300. and the total number completed was 299387.

166. The TMO's FRA programme and the programme for identifying and closing

out actions arising were given proper consideration at appropriate levels of seniority.

Fire safety was always a standing item in the TMO's Annual Health and Safety Report

between 2009 and 201788.

167. The TMO's annual Health and Safety Report 2015/201689 described how the

TMO had comprehensively reviewed 299 FRA in 2015/2016 and that, as of 1 April

2016. 2132 FRA Actions had been fully completed. 140 partially completed, with 243

outstanding. This out of a total of 2515 actions, which covered the whole TMO estate,

including low. medium and high-risk properties, such as Grenfell Tower.

168. The number of actions outstanding was regularly reported to the Health and

Safety Committee, and in 2016 this resulted in Robert Black pressing for actions older

86 BLARP20OOOO27 87 BLARP20OOOO27 Chapter 8 page 8-43 88 BLARP20OOOO27 - Chapter 8 8.1.4. 89 TMO00843882

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TMO00900047/30 than 6 months to be completed urgently. At the Health and Safety meeting on 19

January 20 1 7,90 Barbara Matthews also raised a concern over the large number of

actions which had been outstanding for over 12 months, emphasising the importance of

clearing them as a matter of urgency. In fact, she requested that each team with

outstanding actions prepare a written report setting out the detail of each action

assigned, the steps taken and when the action would be fully completed. The Health

and Safety Committee meeting on 16 March 201791 minutes show that this was done.

169. Ms Matthews also emphasised in the 16 March 201792 Health and Safety

Committee meeting the need to continue prioritising and completing actions to prevent

them falling into the 12+ months category. Similarly, at the 13 June 2017 Committee

meeting93, she expressed concern at the volume of actions that teams had not yet

completed, emphasising the importance of completing them in a timely manner.

170. The TMO always sought to make data collection and processing a priority and

the TMO's move to a Customer Relationship Management system (CRM) was

indicative of an organisation driv en to improv ing its systems to provide a better service

to residents. Managers would be required to check any outstanding issues for their team

on at least a weekly basis under the CRM system.

171. Focussing on the most recent fire risk assessments for (Jrenfell l ower by Carl

Stokes, in April 20 1 694 and June 201695 and the actions arising before the tire.

172. The significant findings and action plan provided by Carl Stokes on 20 June

2016 indicated there were 47 items requiring action for Grenfell Tower, and all were

included on the tracker.96 In his letter of 19 October 201697, just before an inspection

by the LFB. he said 22 actions were outstanding. These were largely attended to by the

TMO.

173. At the 13 June 2017 Health and Safety Committee meeting, Janice Wray

advised 'that she had collated all the responsive repair items that were currently not

complete and had provided Derrick Singleton with a spreadsheet identifying the details

90 TMO10016032 91 TM010016739 92 TMO10016739 93TMO10017155 94CST00000451 95 CST00000101 96 Albeit 9b and 12a were combined. 97 CST0OOO1303. The outstanding matters were itemised as la, lb, 4, 9b, 12f, 12g, 12h, 12i, 12j, 15a, 17a, 17b, 17c, 11 f, 17h, 23a, 23b, 23d, 23e, 23f, 23g, and 23h.

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TMO00900047/31 of each and the repair stage (it had stopped at) Derrick had agreed to investigate,

advise and progress th ese works.

174. Dr Lane states that by the night of the fire, seven items remained open on the

tracker. This means 40 had been closed out98. Of the seven items open on the tracker,

five were marked as not fully completed and two completed.99 The 5 items not

completed were:

i) The occupier of fiat 1 12 (a leaseholder) to confirm that the new fiat door is

certified FD30 door, and that a self-closing device has been fitted to this door.

ii) There are 2 areas of this building covered by BS 5839 Part 1 manual and

automatic fire detection systems, the roof level area and the basement boiler

room. Identify where the fire alarm panel(s) is for those two fire detection

systems and that the two fire alarm systems are in full working order?

iii) Cheek that the gas supply system in this building is not interfaced with the AOV

system. Confirm that no other system is interfaced with the AOV system.

iv) At the roof level there is a fire alarm cable not connected at one end to anything.

What is the coil for? Can (Paul Steadman) remove the coil.

v) In the roof level lift motor and plant rooms and in the basement boiler room

there is BS 5839 Part 1 fire detection systems fitted. Where is the control

panel(s) for these BS5839 Part 1 systems and who is undertaking the servicing

etc of this system? Confirm that testing and servicing of the installed BS 5839

Part 1 fire alarm systems installed in this building are being undertaken.

Dealing with Notices of Deficiency (NODs)

175. Following the LFB visit on 27 October 2016. the LFEPA issued a NOD on the

17 November 2016 for Grenfell Tower100. The NOD listed recommended actions

which "should be taken by 18 May 2017". It related to seven issues, which Dr Lane

summarises in five issues. All of the issues were identified as 'minor deficiencies' by

the LFEPA101 and were concerned with fire safety arrangements; maintenance;

98 However, in her view out of the 40 that were closed by TMO only 23 should have been.

99 The seven active on the tracker were: 12h, 17a, 17c, 17d, 17f, 19d, 23a. However out of those 17c and 19d were marked as completed. 100 The NOD did not in fact list the larger number of items Dr Lane says were not closed out or should not have been closed out by TMO. It did not identify the 17 items that Dr Lane suggests had been wrongly closed out; and it only identified two of the 22 items which Carl Stokes had highlighted as outstanding in his letter of 19 October 2016. 101 LFB00105489

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TMO00900047/32 emergency routes and exits; general fire precautions and procedures for serious and

imminent danger; and for danger areas.

176. While it is correct that by the time of the fire, TMO had not resolved all of the

issues raised, but all had been given substantial attention.

177. In relation to the first issue raised. Dr Lane acknowledges that the TMO had

difficulties keeping common areas clear from obstructions. Janice Wray annotated the

NOD102 with "Neighbourhood Team instructed to treat as 'zero tolerance' items

removed and regular inspections ongoing.' ESAs undertook weekly inspections which

were recorded and were required to highlight any storage in the communal areas.

178. Janice Wray and Carl Stokes also undertook training with the ESAs which

covered the TMO's zero tolerance policy to storage in communal areas. The TMO does

not understand why. despite seeing the training agenda.I

presentation105 and Janice Wray's annotations, Dr Lane is 'unable to determine'

whether the ESAs were clearly given the 'treat as zero tolerance' instruction.

179. Members of the Executive Team, Health and Safety Team and the

Neighbourhood team would also report obstructions in communal areas on visits.

180. Dr Lane is critical of the fact that mobility scooters were still being charged in

the common parts and that this had been known for some time. Janice Wray annotated

the NOD with "OT asked to assess. Tenant visited by ESA + instructed not to charge

in communal areas. Suggested storage in clubroom being investigated it. "

181. Janice Wray also cross-referenced this with the 'zero tolerance' annotation and

she further raised the issue of mobility scooters with the LFB in a TMO and LFB liaison

meeting on 29 March 2017106.

182. This was not a straightforward topic capable of simple or rapid resolution, as Dr

Lane suggests. Some residents needed their scooters to reach their flat and some could

not park the scooter in the flat, because the scooter was too large. Janice Wray was in

the process of discussing matters and commenting on a draft guidance on Mobility

Scooters, which had been produced by the Chief Fire Officers Association by the time

of the fire. Furthermore. Barbara Matthews and Janice Wray had applied for funding

for an alternative storage facility, which had been refused.

102 JW/35 - TMO00873834 103 TMO00873860 104 TMO00847329 105 TMO00873836 m TMO10046970

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TMO00900047/33 TMO00900047 0033 183. The second issue raised by LFEPA was in relation to self-closers and flat

entrance doors. Dr Lane acknowledges that by the time of the fire, the TMO had

instigated a programme for the inspection of fire doors and their self-closing devices.

RBKC had approved a 5-year programme, despite TMO's recommendation for a 3-year

107 program.

184. Dr Lane concludes that she had seen "no substantial evidence of this program

having been started by the 14 June 2017". However, the NOD did not require the

installation programme to be completed by 18 May 2017 and it would realistically take

some time to complete. The notice required action to be taken and this was set out as

"This can be achieved by regularly checking the fire doors and their self-closers on

your escape stairs to ensure they close fully into their frame and if they do not take

appropriate action" and "Ensure adequate emergency routes and exits, for use by

relevant persons in the premises, are available and can be safely and effectively used

at all relevant times. This can be achieved by ensuring that all fire doors on the means

of escape route self-close"108. The Health and Safety team was discussing the cost of

the programme with Repairs Direct so as to agree additional funding from RBKC by

the time of the fire, but RBKC had approved a program for installation and retrofitting

of self-closers on doors.

185. The NOD also raised two necessary repairs required to two flat doors - flats 44

and 153. Checks made since show a responsive repair was completed in respect of one

flat and Janice Wray noted that the other flat door was actioned.109

186. The third issue raised by the NOD was in relation to the poor fitting of fire doors

on the staircases, which did not fully fit into their frames. The action specified by the

LFEPA was " Arrange initial and on-going maintenance to ensure fire safety measures

are kept in an efficient state, working order and good repair...110". Janice Wray

annotated the NOD with "Responsive order has been raised on 7/11/16 to attend

communal doors on floors 18,10,7 +5- completed 23/11/16. Door regularly inspection

by ESA + repairs reported" and the TMO have identified that the job relating to floors

5. 7, 10 and 18 were completed by Repairs Direct."1

107 TMO00873934 - paragraph 44. JW also refers to Flat 44 and Flat 153 and the fact that a responsive repair was supposed to have been raised for both flats, but one was only carried out for Flat 44. 108 TM0O0832135 109 BLARP20000027 - Chapter 8 - page 19-34 110TMO00873934 111 FORT04780053

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TMO00900047/34 187. The fourth issue related to damage observed to the top corner of one of the

panels protecting a services duct on the 8th floor, creating a breach in the service duct

void. The recommended action was to "take the general fire precautions required to

prevent fire and smoke spread by repairing or replacing the broken panel". Janice

Wray annotated the NOD with "responsive repair requested, ESA to monitor + report

any issues". Janice Wray also amended the TMO Fire Safety Strategy112 on 13

December 2016 to read "The services of a third-party accredited specialist fire contract

have been procured and this contractor can be instructed to competently undertake

work on any breaches of compartmentation". llj

188. The fifth issue raised in the NOD was in relation to Fire Action Notices. This

had been completed by 15 December 2016 in Grenfell l ower, which Dr Lane confirms.

189. This analysis shows that of the matters raised in the NOD. there were two

responsive repairs'14 and the programme of self-closers inspection and fitting,

outstanding. This does not tally with Dr Lane's opinion 'that only one matter had been

fully completed before the fire'. It is clear that the TMO took a number of proactive and

prompt steps to action the issues raised in the NOD and not one of the five issues was

overlooked or ignored.

190. Out of the actions raised by Carl Stokes in his last risk assessment, only 5

remained outstanding by the time of the fire."5 and none was causative of the cladding

fire.

Systems for Inspection and Monitoring

191. The Keystone Asset Management System went live in 2010 and was used to

monitor, for example, inspections for boilers, lifts, water, electrics and lighting and gas.

It was accessible to Carl Stokes and he was able to ascertain what certificates had been

issued and what cheeks and maintenance had been done by PPM contractors. The

Keystone System, which was managed by Alex Bosnian, showed on its dashboard what

was outstanding, and assets would only be listed as compliant once works had been

completed and a 'satisfactory' certificate could be uploaded.

112 TMOl 0046099 113 BLARP20000027 Chapter 8 page 19-35

"5 Dr Lane states that there were seven outstanding alongside 17 that were closed out which should not have been = 24.

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TMO00900047/35 192. Keystone also sent out exception reports to the team and relevant contractors

outlining which certification had expired and which were coming up for testing. 116 The

TMO re-procured many service contracts and Mr Bosnian was responsible for ensuring

that there was a robust system in place for logging and reporting compliance

information and certificates following re-procurement. There were fixed formats for the

documents that went onto Keystone, and as part of the procurement process, the TMO

put in place third party audit functions to check a percentage of actual works carried

out and compliance of the certification.

193. An RBKC Internal Audit Report"" in 2015/2016 gave a 'substantial assurance'

rating in respect of improved compliance for Health and Safety systems including

water, electric, central plant and lift maintenance. Real time compliance levels for those

systems were noted in the report for 21 January 2016 as 82.30% for water; 100% for

gas safety; 95.64% for domestic electric; 100% for communal electric; 100% for central

plant; and 100% for lifts. The report stated. "Significant improvements have been made

in terms of functionality of the system and its ability to generate appropriate

management reports and data to enable health and safety compliance to be closely

monitored." The report went on to say "all data captured within the system is now

accurate and reflects the current position with regard to safety inspection certification

and the ability of the system to generate real time data statistics has enabled

management to focus resources on specific areas where compliance is below

acceptable standards. Approximately 5,500 electrical and 6,500 gas safety certificates

have been reviewed and rechecked by staff since 2014 to ensure all data held on

Keystone is accurate and correct".

194. This is an example of material improvement by the TMO of their systems

following a previous external audit in 2013. which recommended that the Keystone

system should be developed to provide the TMO with the systems necessary to host

health and safety compliance reports and associated data, as well as a process to track

progress.118

195. The TMO also procured a specialist consultant to carry out an audit role in

respect of the contracts. This audit work was primarily desktop cheeking of the

certification provided, as well as the qualifications of the engineers used, but also

116 Alex Bosman's witness statement, TMO00880562 117RBK00OOO531 118 TMO10003283

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TMO00900047/36 included some onsite auditing to check the quality of work carried out. For example,

'GAS' acted as the audit function for the gas contracts.

Provisions for Vulnerable Residents

196. TMO accepts it was necessary to make provisions for the protection of vulnerable

persons (i.e. 'those especially at risk'119) in a fire scenario through its fire risk management

system. The provisions it made were determined to a high degree by its fire strategy - Stay

Put and its adherence to the LGA Guide. It is against the background of the TMO's

adherence to the LGA Guide and its Stay Put strategy that its approach towards vulnerable

persons should be viewed, including its approach towards PEEPs.

197. As Dr Lane acknowledges, the TMO did hav e records of residents with vulnerabilities

relevant to a fire and a list was produced on the night of the fire120; although it is noted that

Dr Lane criticises the extent of these lists121.

198. Dr Lane assesses and compares the wider guidance documents regarding vulnerable

persons and fire risk. Dr Lane opines that the TMO and/or Carl Stokes should, as a

minimum, have been required to consider the 'body of guidance' available, and not focus

solely on the LGA Guide, which Dr Lane concludes was the ease at Grenfell Tower.

199. Dr Lane also acknowledges that the LGA Guide provides substantially different advice

to the other guidance and by applying it a dutyholder would take a different approach

towards safeguarding of vulnerable persons.

200. The Inquiry will note that the guidance was produced by the LGA following the fire at

Lakanal House in July 2009. having been commissioned by the DCLG and published after

wide consultation, including among the DCLG itself and the Chief Fire Officers'

Association.

201. The TMO was a statutory body whose lawful obligation would be to follow guidance

produced by DCLG and LGA. Further, the LGA guidance postdates122 all of the other

sector specific guidance, having been produced in 2011, i.e. at the time the TMO was

embarking on its process of fire risk assessments. It was also specific to purpose-built fiats

and therefore there was a presumption the TMO should follow it, even when it was

119 Article 9 RR(FS))0 2005; the phrase 'vulnerable persons' is not defined in RR(FS)(0) 120 TMO0086002 121 Allocation decisions - i.e. who should be allocated accommodation in a particular building -- were taken by RBKC. 122 IIM Government fire safety risk assessment - sleeping accommodation (IIM "Sleeping accommodation" guide), 2006; IIM "Means of Escape for Disabled People" guide published March 2007; LA Co RS Housing - fire safety - Guidance on fire safety provisions for certain types of existing housing guide (2008) {CST00002516} (LACoRS Guide)

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TMO00900047/37 inconsistent with other guidance and adherence to the LGA Guide was reasonable for the

TMO.

202. The LGA guide states that while there may be vulnerable persons in blocks of flats.

'It is usually unrealistic to expect landlords and other responsible persons to plan

for this or to have in place special arrangements, such as 'personal emergency

evacuation plans'. Such plans rely on the presence of staff or others available to

assist the person to escape in a fire'

203. Paragraph 19 of the LGA Guidance points out that the alternative to a stay put strategy

is one that involves simultaneous evacuation, and notes that this requires a means of alerting

residents to the need to leave the building. It observes that purpose-built blocks of flats

(such as Grenfell Tower) are not normally prov ided with general fire detection and alarm

systems because experience has shown that most residents do not need to leave their flats

when there is a fire elsewhere in the building. Indeed, in some circumstances they might

place themselves at greater risk if they were to do so.

204. The LGA Guidance also suggests that the risk inherent in the absence of a fire-detection

and alarm system in high-rise blocks is acceptable because it is very rare for there to be an

extensive failure of compartmentation. This is consistent with the absence from Approved

Document B of any suggestion that high-rise residential buildings should be fitted with a

means of communicating with all occupants simultaneously in order to facilitate a total

evacuation.

205. Dr Lane has set out at length why it was not 'unrealistic' for the TMO to have in place

special arrangements, such as 'personal emergency evacuation plans'. Although it is a

matter for the Inquiry whether it was unrealistic or not. the TMO's approach to them was

affected by adherence to the LGA Guide and Stay Put strategy in a fire scenario.

206. Furthermore, the stay put policy had been in place for many years at Grenfell Tower

and was extensively communicated to the residents of Grenfell Tower. It was well known

to LFB and LFEPA and it was never suggested that the TMO should implement a full

evacuation policy, either in place of or in addition to a Stay Put Policy. This policy remains

to date one approved for similar high-rise blocks by the National Fire Chiefs' Council.1''

207. In her Module 3 Part 6 Report. Dr Lane sets out 3 scenarios in which vulnerable

residents may be affected in the event of a fire scenario in a block with a stay put strategy:

i. A fire within a flat (the flat of fire origin)

! https://www.nationalfirechiefs.org.uk/Stay-Put-position

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TMO00900047/38 TMO00900047 0038 ii. A fire within a neighbouring flat or flats;

iii. A fire which has spread to the common parts.

208. Dr Lane says that in the context of a residential building with a Stay Put Strategy the

relevant persons would as a minimum be:

iv. Occupants of the flat of fire origin who make their escape and;

v. Occupants in any adjacent flats who initially remain in place unless their flat

becomes affected from heat and/or smoke; and

vi. All other occupants in the building should a simultaneous evacuation strategy

become necessary.

209. Although scenarios i and iv are in reasonable contemplation of the LGA Guide,

scenarios ii. iii. v and vi are not; and were not therefore scenarios TMO had in mind when

devising a fire strategy for vulnerable people. Certainly, the TMO never contemplated a

full-scale evacuation of the building.

210. Even if more information about vulnerable residents could have been obtained, TMO

does not accept its policy ought to have been developed and/or reviewed in the extensive

ways Dr Lane describes in Chapter 6 of her Report. If there had been a policy to evacuate

all residents in a fire scenario it may have been appropriate to go to the lengths she suggests,

but with a Stay Put Policy in place, it was not.

211. It is ultimately a matter for the Inquiry, but it is to be noted that while Dr Lane assesses

the TMO's approach in the light of the guidance and legislation, and by reference to its

own policies and procedures, she does not make any assessment of whether the approach

adopted was consistent or inconsistent with that which was adopted by other providers of

high-rise buildings in social housing across the UK. It is submitted that this is something

the Inquiry should have regard to before reaching any final conclusions about the TMO's

conduct.

212. Also. Dr Lane is a fire expert, not a statistician and the TMO invites the Inquiry to be

cautious when considering her statistical analysis of the mortality rates of v ulnerable

residents at Grenfell Tower124. This is particularly so in the light of evidence given in Phase

One that LFB did not always act sufficiently forcefully when giving advice to abandon the

Stay Put Policy and that some requests for help from vulnerable persons were not passed

125 on .

124 See for example Dr Lane Phase 2 Chapter 6; 1.41 125 Such as those elderly persons living in Flat 142, the late Kamni Mi ah and Rabeya Begum.

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TMO00900047/39 TMO00900047 0039 213. Further, a PEEP also often relies on help from others being available if there is a need

to evacuate. The Inquiry may consider the fact that the LFB were unable to reach the

number of vulnerable people asking for help, demonstrating that PEEPs were not designed

to assist the vulnerable in such a catastrophic fire.

Lifts; Inability of LFB to Take Control of the Lifts

214. In his Phase One report the Chairman said: ' When the firefighters attended the

fire at Grenfell Tower, they were unable to operate the mechanism that should have

allowed them to take control of the lifts. Why that was so is not yet known, but it meant

that they were unable to make use of the lifts in carrying out jirefighting and search

and rescue operations. It also meant that the occupants of the tower were able to make

use of the lifts in trying to escape, in some cases with fatal consequences. The ability of

fire and rescue services to take control offirefighting or fire lifts in a high-rise building

is often key to successful operations'.

215. Following the Phase One Report, the Inquiry has obtained evidence from

various parties associated with the replacement of the lift in 2002-2005 and the

maintenance of it following the refurbishment, including the fire control switch.

216. As the Inquiry is aware, between 2003 and 2006 the lifts at Grenfell l ower were

replaced. The work was done by Apex Lift and Escalator Engineers Ltd pursuant to a

specification by Butler & Young Consultants Ltd. Butler & Young did not specify that

the replacement lifts should be firefighting lifts, something the Inquiry's lift expert.

Roger Howkins. criticises. In the event, fully compliant firefighting lifts were not

installed.

217. At a later stage, Carl Stokes represented in his FRAs that the lifts were

firefighting lifts, which was not correct. In fact, Janice Wray and Robin Cahalarn were

both aware that they were not firefighting lifts, despite Carl Stokes' representations and

so were not misled. Janice Wray always understood that the lifts would not be used to

evacuate residents in the event of a fire, as the fire scenario policy for Grenfell Tower

was stay put defend in place126.

218. While it is a matter for the Inquiry, the TMO is not aware of any evidence to

suggest that the failure of the lifts to have all the safety features of a firefighting lift

caused or contributed to the loss of life on the night of the fire127. In fact. Colin Todd

126 See for example TMO00000890 127 This is not intended to refer to the fire control switch, which has been addressed separately.

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TMO00900047/40 goes so far as to say, "/ do not consider that the design of the lift significantly affected

the risk to relevant persons from fire. "

219. Turning to the maintenance of the lifts, Roger Howkins states that although

there were 'some failures', overall, the lifts appeared to have been maintained to an

appropriate standard and were generally in compliance with the relevant standards and

industry practice. He did not think that it likely that a maintenance failure caused the

problems with the fire control switch.

220. Michael Arnold from Bureau Veritas also reached the same conclusion about

maintenance when he inspected them on 10th April 2017128.

221. Following their installation, the lifts at Grenfell Tower fell under a maintenance

and service contract overseen by a specific contract manager within the Building

Services team. The lift maintenance contractor was Apex Lifts Ltd. and the contract

included monthly inspections.

222. Michael Fallis-Taylor of PDERS129 will say that planned maintenance visits

were carried out on a monthly basis in accordance w ith the maintenance schedule. He

says engineers would follow a standard checklist when conducting a service. As well

as ensuring that the items listed on the schedule were in good working order, the

engineers would ensure that the fire control switch was in good and proper working

order by inserting the correct key. which at Grenfell Tower was an 'Express Drop Key'.

He says that they would insert the key into the switch, activate the system and cheek

the lifts would immediately move to the ground floor before opening the doors; they

would then check that the lift operated in the desired manner, i.e.. move to the chosen

floor before the doors would open when the correct buttons were pressed.

223. Certainly. Roger Hovvkins is of the view that the fire control switch was tested

by PDERS on a monthly basis130.

224. Against this background it is not understood why Dr Lane says in her reports:

7 have post-fire information hy means of witness statements from a small number of

lift maintenance contractors, that this was done (i.e. inserting and rotating the fire-

brigade switch) - but just that they never once documented it over a seven year period';

and then 'As there are years of records demonstrating concern about the various lift

contractors employed by KCTMO, it is not appropriate for me to rely on such weak

128 BVL00000017 129 From 2014 130 BLARP20000033 paragraph 12.5.21

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TMO00900047/41 TMO00900047 0041 evidence and so I have taken the decision not to rely on it.' The utility of such an

approach is questionable.

225. While the TMO accepts that records of checks would be desirable; and that

checking of the fire switch could have been a specific item on the ESA 's checklist, the

absence of such records is not to be equated with the checks not occurring.

Replacement of Flat Fire Doors131

226. Regarding the issue of self-closers on fire doors, it is accepted that the Inquiry

will subject this to a high degree of scrutiny in the light of the Chairman's conclusions

in his Phase One Report.

227. In March 2011, TMO entered into a contract13" with Manse Masterdor for the

renewal of flat entrance doors across 313 individual site addresses133 for multiple

properties at each address, including Grenfell Tower.

228. Between 201 1 and 2013. Manse Masterdor replaced 106 flat entrance doors to

tenanted flats at Grenfell Tower. It was part of the tender and conditions of contract that

the replacement doors would be 'FD 30S'; that is capable of resisting fire under test

conditions for a minimum of 30 minutes and limiting the leakage of smoke to a

prescribed extent. Carl Stokes was involved in the programme to fit new front doors,

including being asked to attend a trial fitting of one of the doors134 and reviewing the

Clerk of Works report on them. He later confirmed to the TMO that so far as he was

concerned the new fire doors met the requirements of the building regulations in terms

of fire protection.

229. Tests conducted after the fire showed there were serious discrepancies between

the relevant test ev idence provided to support the fire performance of the doors, and

how they were actually constructed. They did not have the 30 minutes tire resistance

represented by Manse Masterdor. It is difficult to overstate the seriousness of this

misrepresentation by Manse Masterdor.

230. With this in mind, the TMO queries the Inquiry's recent decision to dispense

with oral evidence from witnesses from Manse Masterdor. There is a strong argument

for saying these witnesses should be called to explain why their doors were non-

compliant, just as witnesses from Celotex. A iconic and Kingspan have been asked to

131 The TMO will deal with the communal doors to the emergency 132 MAS0OOOO0861 133 As listed in Appendix A of the Tender document MAS00OOOO37 134CST00001708

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TMO00900047/42 explain their own products. Particularly as after the fire, evidence has emerged of more

widespread failures in the performance of fire doors which led the then Communities

Secretary. James Brokenshire to conclude that there is evidence of "a broader issue

across the fire door marker132.

231. As the Inquiry is aware the earliest example of an issue with fire doors was in

the 2009 Salvus FRA. The TMO engaged RAND to expand its ongoing stock survey,

to include a survey of a sample of flat entrance fire doors across numerous properties136.

The data obtained confirmed that existing doors did not meet required standards and

needed to be replaced. Consequently, a programme of replacing flat entrance fire doors

was started, which led to over 1000 doors being replaced between 2011 and 2013.

232. The TMO Fire Safety Strategy also said that there was an expectation that

(existing) fire doors were fire rated for 30 minutes137.

233. TMO notes the evidence suggesting that almost immediately after the doors

were installed, it was noticed that some of the self-closing devices were insecure. Carl

Stokes was aware of this; and there is ev idence the issue was brought to the attention

of Manse Masterdor who returned to remediate the problem138. There does not appear

to be any definitive evidence to say what steps Manse Masterdor took, and how many

door closers were inoperative.

234. Seamus Dunlea (now deceased) states he disconnected a number of door closers

at residents' request. The issue was raised in correspondence between Janice Wray and

Siobhan Rumble139 and it is understood that Seamus Dunlea was told to desist.

235. Janice Wray was also aware of a problem some elderly residents had with door

closers, whereby the closers fitted were too stiff to be operable. She concluded that the

issue had been resolved140. Manse Masterdor actually recommended that the door closer

could be removed if the resident consented, but TMO would not countenance this.

236. In the years after the doors were replaced by Manse Masterdor and the

renovation Carl Stokes was tasked with doing a percentage-based inspection of all flat

fire doors at Grenfell Tower, including making a check on the functionality of the door

135 https://w^^\insidehousmgxo.uk/news/news/fire-doors-from-five-suppliers-fail-to-meet-standards-57418 136 TMO00847305 137 See for example TMO00830598 138 Mr Webster (Manse Masterdor) stated on 26th July 2011 to Ms Acosta "We are aware there was a problem and we started last Thursday going through the block changing the fixings if necessary". 139 TMO00859693 140 See TMO H&S Committee meeting IT"' November 2011

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TMO00900047/43 closer where access was possible. He refers to having made inspections in his FRA of

April 2016141. Dr Lane's suggestion that no such checks occurred is not correct.

237. Janice Wray was of the view that all inspection and maintenance of flat fire

doors would occur as part of the Contracts department's routine asset inspections and

scheduled PPMs. It is not a question of as Dr Lane suggests, the TMO not

understanding or accepting that inspection or PPM needed to occur.

238. As Dr Lane acknowledges there is a high degree of variation within the available

and applicable guidance on the frequency with which inspections should take place.

HM 'sleeping accommodation guide' states that daily checks should be made on

whether doors are closing fully, with monthly checks on the self-closing devices; while

the LGA guide only specifies checks on whether there are ineffective or missing self-

closing devices on a six-monthly basis. Some other guidance, including the LACoRS

Guide and BS 9991:2015 provides no recommendations about frequency.

239. The issue of the fire performance of fiat front doors was prominent for the TMO

in the years 2012-2015 because of the problems that arose with doors to leaseholder

flats. As the Inquiry is aware, there was intense and protracted consideration over who

should enforce compliance of leaseholder flat doors. This was discussed on many

occasions in different forums, including with LFB, LFEPA and RBKC.

240. When in late 2015 the TMO received a NOD in respect of Adair Tower, which

included recommendations in relation to fire doors, it sought to introduce a borough

wide replacement programme. There was also a NOD issued by LFEPA for Grenfell

Tower on 17th November 2016 where it was noted that the doors to flats 44 & 153 did

not self-close.

241. A paper was prepared for the Joint Management Team on 1st March 2017 where

the installation of self-closing devices, in response to inter alia the NODs, on flat

entrance doors was discussed142. It was also raised at the H&S meeting of 16 March

2017, where Janice Wray confirmed that Cynthia Vachino had been asked to rev iew

the access procedure to facilitate the fire safety works required by the LFPEA at Adair

and Hazlewood; and it was suggested that this be referenced in a fire safety strategy.

Barbara Matthews stated that RBKC had been consulted and confirmed their view that

a 5 year not a 3-year programme was appropriate.

141 CST0OOOOO92 142TMO10016138

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TMO00900047/44 TMO00900047 0044 242. There was no financial provision for this project within the TMO budget, and

therefore it was necessary for it to revert to RBKC to obtain funding for it. There was

also a policy reason why RBKC was consulted. TMO had intended for the door

replacement project, including the initial surveys to be completed within 3 years, but

RBKC thought a 5-year policy was more appropriate. TMO also applied for funding to

instigate a programme of periodic inspection and repair after the replacement

programme but this was not acceded to by RBKC.

243. Instigating the policy for inspection and replacement/repair was not easy and

relatively slow, partly because there were difficulties arranging the means of obtaining

access to residents' flats.

Concluding Remarks

244. The TMO acknowledges the immense tragedy of the Grenfell Tower fire and

nothing in these submissions is intended to diminish or detract from that tragedy. All

those who give evidence on behalf of the TMO continue to express their profound

sympathies and condolences to the bereaved, survivors and residents.

245. These submissions have been drafted in order to set out the general position of

the TMO in advance of the important evidence that will be heard in Module 3 of Phase

2. Of course, they hav e been prepared without hearing that evidence and anything said

here is subject to review once the evidence has been heard.

246. Finally, the TMO, and all the witnesses to give evidence in Module 3, continue

to offer their full support to the Inquiry in fulfilling its important statutory functions.

Messrs Kennedys

23 March 2021

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TMO00900047/45