港澳台_香港大埔宏福苑-特别重大火灾事故调查报告(委员会代表结案陈词627页)

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8 1

Independent Committee in relation to the fire

at Wang Fuk Court in Tai Po

WRITTEN CLOSING SUBMISSIONS OF

COUNSEL FOR THE INDEPENDENT COMMITTEE

Hearing bundle references are in the format [Bundle/page]

Transcript references are to the transcripts in the language as spoken at the Evidential

Hearings (Chinese for Days 1 to 26 and English for Day 27) and are in the format

[T[day]/page:line]

TABLE OF CONTENTS

Chapter 1: Introduction .......................................................................................................... 3

A. Preamble .................................................................................................................... 3

B. The Evidential Hearings ............................................................................................ 4

C. Structure of these Closing Submissions ................................................................... 10

Chapter 2: The Building Maintenance and Renovation Works at Wang Fuk Court ..... 17

A. Overview .................................................................................................................. 17

B. Parties and their Roles ............................................................................................. 19

C. Tender Process for the BMR Works ........................................................................ 29

D. Progress of the BMR Works up to the Day of the Fire ............................................ 53

Chapter 3: The Day of the Fire ........................................................................................... 127

A. Origin and Discovery of the Fire ........................................................................... 127

B. Rapid Spread of the Fire at Wang Cheong House (Block F) ................................. 133

C. Spread of the Fire to Other Blocks ........................................................................ 137

D. Conditions Inside the Blocks and Means of Escape .............................................. 149

E. Attempts to Activate Fire Service Installations During the Incident ..................... 176

F. Fatalities and Casualties ......................................................................................... 182

G. Property Damage ................................................................................................... 189

Chapter 4: Causes of the Fire, Fire Spread and Heavy Casualties ................................. 194

A. Overview ................................................................................................................ 194

B. Origin of the Fire ................................................................................................... 196

C. Cause of the Fire .................................................................................................... 201

D. Analysis of the Spread of the Fire .......................................................................... 207

E. Causes of Heavy Casualties ................................................................................... 217

Chapter 5: Emergency Response on the Day of the Fire ................................................. 228

A. Firefighting Operations .......................................................................................... 228

B. Involvement of the Police ...................................................................................... 243

C. Receipt and Handling of Assistance Requests ....................................................... 245

D. Fireman Ho Wai Ho ............................................................................................... 251

E. Evaluation of Firefighting, Evacuation and Emergency Call Operations .............. 259

F. Conclusion ............................................................................................................. 294

Chapter 6: Responsibility of Contractors and Private Parties to the Works ................. 295

A. Overview ................................................................................................................ 295

B. Overall Failures of PC&E and Will Power ............................................................ 296

C. Temporary Building Materials and Protective Measures ...................................... 311

D. Staircase Access Openings (生口) ......................................................................... 331

E. Shutdown of FAS and FH/HR Systems ................................................................. 336

F. ISS .......................................................................................................................... 361

Chapter 7: Responsibility and Accountability of Government Bodies ........................... 364

A. Overview ................................................................................................................ 364

B. The Independent Checking Unit (ICU) .................................................................. 366

C. The Buildings Department (BD) ............................................................................ 421

D. The Fire Services Department (FSD) .................................................................... 428

E. The Labour Department (LD) ................................................................................ 459

F. The Police .............................................................................................................. 474

G. Other Government Departments Referred to in the Evidence ............................... 475

Chapter 8: Recommendations on Fire Safety Matters ..................................................... 477

A. Introduction ............................................................................................................ 477

B. Recommendations for Immediate Implementation ................................................ 479

C. Recommendations for Long-Term and Systemic Policy Reforms ........................ 483

Chapter 9: Bid-rigging and Associated Misconduct ......................................................... 521

A. Introduction ............................................................................................................ 521

B. Bid-Rigging and Anti-Competitive Conduct is Prevalent in the Market ............... 522

C. Suspected Bid-Rigging and Other Irregularities at Wang Fuk Court .................... 531

D. Preventing Manipulation of the Voting Process .................................................... 576

E. Limitations with the URA’s Smart Tender Scheme .............................................. 586

Chapter 10: Recommendations on Bid-rigging and Associated Misconduct ................. 598

A. Introduction ............................................................................................................ 598

B. Market Integrity and Gatekeeping ......................................................................... 599

C. Enhanced Legal Deterrence & Professional Discipline ......................................... 612

D. Proxy and Voting Issues ........................................................................................ 615

Chapter 11: Conclusion ....................................................................................................... 622

CHAPTER 1: INTRODUCTION

A. Preamble

The fire at Wang Fuk Court in Tai Po on 26 November 2025 was one of the gravest tragedies to have ever occurred in Hong Kong. Even today, seven months later, the scale of the disaster – the loss of 168 lives, and the abrupt destruction of a neighbourhood which thousands called home, where they built families and created memories – remains difficult to comprehend.

Scenes of the fire will forever be seared into our collective memory. A small fire filmed from a distance by a passerby. An elderly man wailing in desperation in front of apartment blocks engulfed in smoke. Hundreds of flats fiercely burning against a dark night. Finally, blackened, empty towers with their half-destroyed scaffolding looming over a sea of fire appliances and swarms of exhausted firefighters.

The testimony which the Committee has heard – of loss, heroism and sacrifice – will reverberate long after the work of this Committee comes to a close. We will remember the family members who helplessly watched as their loved ones succumbed to the fire, the firefighters who braved dangerous conditions to rescue those trapped inside, and the residents who provided refuge for their neighbours at their time of greatest need.

We continue to grieve for each person who perished in the fire. Our thoughts will always be with their families and loved ones, and all others who continue to carry physical and psychological wounds from this tragic event.

The heartbreaking evidence which the Committee has heard serves as a stark reminder of the solemnity and significance of its work. A disaster of this scale should never have occurred and should never occur again. Society rightly expects clarity on what happened and accountability by those who were responsible. Lessons need to be urgently learned and

measures implemented to abate the extreme fire risks of building renovation works which are now readily apparent to all. The work of this Committee cannot undo the loss and suffering experienced by those who have been affected by the fire, but we hope that its findings and recommendations will bring some measure of solace and closure.

B. The Evidential Hearings

Given the nine-month timeframe set by the Chief Executive for the Committee to deliver its report, the task of gathering, organising and presenting all relevant evidence for use at the Evidential Hearings has not been an easy one. At the time of our oral opening address, the legal team had already received nearly one million individual files in excess of one terabyte. With further requests for information and disclosure continuing throughout the Evidential Hearings, the universe of evidence obtained by the Committee well exceeds one million files and two terabytes.

As was mentioned in our oral opening address, the evidence available to the Committee included, among other things, (i) images and video footage taken before, during and after the fire, (ii) witness statements and questionnaires taken by the Police from residents and other persons present on the day of the fire, (iii) records of complaints by residents to contractors, property management and the Government, and (iv) seized chat messages between contractors.

The Committee has now received oral evidence from over 70 witnesses of fact over 22 days. They included residents who lived through the renovation works and the fire, contractors, property management staff, frontline firefighters, and public servants from relevant Government and statutory bodies.

The Committee also received substantial expert evidence on the cause and spread of fire.

1. A comprehensive report (“IFITF Final Report”) was prepared by the Inter-Departmental Fire Investigation Task Force (“IFITF”) established by the Government on 28 November 2025.1

2. The IFITF comprises representatives from the Fire Services Department (“FSD”), the Hong Kong Police Force (“Police”), the Buildings Department (“BD”), the Electrical and Mechanical Services Department (“EMSD”), the Independent Checking Unit of the Office of the Permanent Secretary for Housing (“ICU”), the Labour Department (“LD”) and the Government Laboratory. They were also assisted on scientific matters by Ir Professor Yuen Kwok Kit, Richard, who prepared a report based on bench-scale tests, a full-scale fire test at the Sichuan University of Science and Engineering and computational fluid dynamics simulations (“Professor Yuen’s Final Expert Report”).

3. The Committee’s experts, Professors Asif Sohail Usmani and Jiang Liming, also conducted a separate analysis based on photographic and videographic evidence of the fire, combustion tests and computational fluid dynamics simulations and prepared a separate report (“IC Expert Report”).

The breadth and depth of the evidence received by the Committee provide it with a solid foundation for making findings regarding the causes of the fire and its rapid spread, the responsibilities of persons involved in the building renovation works at Wang Fuk Court, as well as the prevalence of bid-rigging and other irregularities in building renovation works in Hong Kong more generally.

In this regard, we would respectfully echo the Chairman’s expression of gratitude to all those who have assisted the Committee in its investigation.2 We note in particular those entities and individuals (including witnesses

[ER1/1-239]

[T25/3:8-27]

tendered by the Government) who made frank admissions of shortcomings or provided evidence against their personal interests. We are also particularly indebted to those residents of Wang Fuk Court, construction workers on site and property management staff who courageously accepted our invitations to give evidence regarding the day of the fire. It could not have been easy for them to relive one of the most traumatic events of their lives in an open, public hearing.

Only a few individuals and entities declined to cooperate with the Committee’s work. It is regrettable that they have set their face against an investigation which is so demonstrably in the public interest. But their noncooperation has not affected the Committee’s work. Their respective roles and responsibilities in the building renovation works are well evidenced by documentary evidence and not capable of dispute in any serious manner. To the extent necessary, it would also be open to the Committee to draw adverse inferences against them.

With all this evidence, it is clear that the fire at Wang Fuk Court on 26 November 2025 was preventable but not prevented, and foreseeable but not foreseen. The evidence demonstrates with startling clarity that there were numerous failings across the entire regime for building renovation works, each of which had a distinct causal contribution to the rapid spread of the fire and the unprecedented number of fatalities and casualties:

1. The contractors, led by Prestige Construction & Engineering Co., Ltd (“PC&E”), knowingly created a massive fire risk in breach of applicable regulations by using non-fire-retardant materials on the façade of Wang Fuk Court. They were driven at least in part by financial motives and sought to evade detection by way of repeated deliberate deception.

2. They failed to remedy issues of workers smoking on site and disposing of combustible construction waste on the scaffolding. Worse still, they compromised the integrity of the protected

staircases, being residents’ primary means of escape, for the sake of workers’ convenience.

3. When it came time to handle fire service installations, PC&E engaged a registered fire service installation contractor (“RFSIC”), China Status Development and Engineering Co. Ltd (中華發展工

程有限公司) (“China Status”), purely to submit forms to the FSD

without conducting any on-site inspection. PC&E then sought assistance from ISS EastPoint Properties Ltd (置邦興業有限公司)

(“ISS”), the property manager of Wang Fuk Court, to handle the actual task of draining the FS water tanks (“FS Tanks”), a task its staff were unqualified to perform. In so doing, an ISS works technician disabled the fire alarm systems without realising the gravity of his error.

4. The inactivation of the fire alarm systems was in fact spotted by Victory Fire Engineering Ltd (宏泰消防工程有限公司 )

(“Victory Fire”), another RFSIC which had been working at Wang Fuk Court shortly before the fire. However, it did not adequately investigate the reasons for the inactivation or inform the FSD of the situation. The result was that the fire alarm systems remained disabled on the day of the fire.

5. All these matters should have been confronted by Will Power Architects Co. Ltd (鴻毅建築師有限公司 ) (“Will Power”),

which was engaged by the Incorporated Owners (“IO”) to independently supervise PC&E and manage the renovation works on its behalf. Regrettably, Will Power did nothing. Even more egregiously, the Registered Inspector (“RI”) engaged by Will Power, Mr Ng Yeuk Wilson (吳躍), who was statutorily obliged

to supervise the works, only existed on paper: he was specifically paid only to sign forms and never attempted to perform his role as a matter of substance.

6. The failings of these contractors and consultants expose the existence of actors who displayed a shocking lack of integrity and a callous disregard for fire safety. The residents of Wang Fuk Court paid them for their professional expertise, but were failed by them.

The result of this litany of failures is that every single fire safety measure designed to protect life at Wang Fuk Court – internal compartmentation, protected staircases, the fire alarm systems, and the fire hydrant and hose reel systems – failed to operate as designed during the fire.

As for the Government, it created an “honour system” dependent on “selfregulation” by contractors, effectively leaving them without oversight. Forms and certificates were accepted without verification, representations by contractors were relied on without any scepticism, and inspections were in some cases pre-announced. In uncritically relying on the good faith of those it regulated, the bodies charged with regulation left obvious fire hazards uninvestigated and unaddressed.

Even where residents attempted to raise concerns, Government bodies did not take effective ownership of the fire risks at Wang Fuk Court. There were ample opportunities for the Government to detect and rectify the fire risks at Wang Fuk Court, but none was taken. Those complainants, some of whom lost family members during the fire, were failed by the system.

In the face of the evidence, the Government has acknowledged the existence of “systemic and operational weaknesses in its own supervisory framework”3 including, among other things, “over-reliance on the self regulation of professionals whose compliance was assumed rather than verified, the limited scope and frequency of audit checks and site inspections; inadequacies in prescriptive standards for certain construction materials; areas requiring improvements in interdepartmental communication; and a supervisory architecture that was not

Government’s Closing §1118

designed to address collaborative and coordinated concealment”.4 As the body which designed and operated the entire regulatory framework, the Government bears a share of the responsibility for allowing the Wang Fuk Court fire to happen.

The conclusions above are particularly sobering when one recalls Professors Usmani and Jiang’s oral evidence that the Wang Fuk Court fire was not strictly the first of its kind; what was unprecedented was its magnitude.5 The dangers inherent in the use of combustible materials on the façade of high-rise buildings and the risks of fire spread up chimneylike structures have been well understood since the King’s Cross fire in 1987, the Garley Building fire in 1996 and the Grenfell Tower fire in 2017.

There was, however, a failure to heed the wake-up call of those tragedies. As a result:

1. The façades of all eight blocks in Wang Fuk Court, including in the re-entrants of each block, were completely covered with combustible materials. The re-entrants, often colloquially referred to as light wells (天井), are the trapezoidal semi-enclosed spaces

at the corners of each block adjacent to the kitchens of individual flats. The combustible materials enabled pillars of fire to race up the re-entrants at unprecedented speeds and intensities. These rapid vertical re-entrant fires took hold in 12 of the 32 re-entrants at Wang Fuk Court, resulting in the uncontrollable spread of the blaze.

2. Staircases directly connected to those re-entrants were compromised by access openings created for the convenience of workers. When fire rapidly spread up the building, smoke filled

Government’s Closing §77

[T27/9:22-12:9]

the staircases through these access openings and denied residents the ability to escape.

3. Unbeknownst to residents, the fire alarm systems were improperly and unnecessarily disabled, delaying their awareness of the fire and reducing their available escape window.

Because of this combination of unacceptable failures, 168 lives were lost.

C. Structure of these Closing Submissions

The body of these Closing Submissions is divided into the following nine Chapters.

In Chapter 2, we set out key facts regarding the building maintenance and renovation works carried out at Wang Fuk Court prior to the fire.

We begin by introducing the contractors involved, the suppliers for various kinds of construction materials, and the key individuals involved. The tender process for the renovation works is then described. Finally, we detail the progress of the construction works from their commencement in July 2024 up until November 2025: the use and replacement of scaffolding nets, the covering of windows with polystyrene foam boards, the creation of access openings in the staircases, and the disabling of the fire alarm system.

Most of these facts are directly evidenced by available documentary evidence and not disputed by any party. Where conflicts exist in the evidence, they are specifically identified for the Committee’s attention.

In Chapter 3, we set out a detailed chronology regarding the spread of the fire on 26 November 2025. We summarise the evidence from residents and eyewitnesses regarding the development of the fire, the infiltration of smoke into the interiors of the buildings, and the status of the fire service installations in the buildings. The fatalities, injuries and property damage caused by the fire are then described and analysed.

The evidence summarised in this Chapter makes for painful reading. The fire spread with remarkable speed up individual blocks and onto other blocks. Common corridors and staircases filled with dense smoke in a matter of minutes. Those who were able to escape testified to leaving the buildings with only moments to spare. Those who survived inside the buildings long enough to be rescued described smoke-logged conditions which became increasingly inhospitable as the fire burnt on.

In Chapter 4, we set out the expert evidence regarding the likely cause and origin of the fire and the factors which led to the large number of fatalities.

With all other common causes of fire ruled out, the evidence suggests that the fire was caused by a single glowing source, likely a cigarette, which had been improperly disposed of on the flat roof between Flats 104 and 105 of Wang Cheong House (Block F). As for the spread of fire, the experts’ experiments and computational simulations show that the fire was significantly fuelled and promoted by the choice of non-fire-retardant temporary materials for the renovation works. In particular, the choice between non-fire-retardant safety nets and plastic sheeting on one hand, and their fire-retardant equivalents on the other, may have meant the difference between a catastrophic fire that engulfed seven blocks of the estate, and a fire which would have self-extinguished.

Finally, the number of fatalities resulted from the extremely limited escape window which was available to residents, in particular, those of Wang Cheong House (Block F) and Wang Tai House (Block E). The fire spread extremely quickly up the re-entrants and across the seven blocks, smoke was allowed to enter means of escape through the modified windows, and burning debris blocked building exits. Residents’ awareness of the fire was impeded by the inactivation of the fire alarm systems and polystyrene foam boards covering the windows in each block. In the case of Wang Cheong House, residents had only around seven minutes to escape: from the FSD’s receipt of the initial report of the fire at 14:51 until 14:58 when the staircases became filled with smoke. Even if they managed to escape to the

ground floor, safe evacuation only remained possible until around 15:05 when both entrances of Wang Cheong House became blocked.

In Chapter 5, we describe the FSD and the Police’s emergency response on the day of the fire and the evidence relating to the death of Fireman Ho Wai Ho (何偉豪) (“Fn Ho”).6 In full recognition of the unprecedented

challenges faced by our emergency responders on the day, we identify lessons which need to be learnt for the future and reviews which will have to be undertaken to strengthen their capabilities.

Most of our analysis in this Chapter, which is based on the candid evidence of FSD witnesses, aligns with the Government’s own evaluations in their Closing Submissions. We are also heartened by the FSD’s commitment to reviewing and improving its protocols to address the operational challenges faced during the Wang Fuk Court fire.7

In Chapter 6, we assess the responsibility of the various contractors and other relevant parties which participated in the renovation works at Wang Fuk Court.

The facts set out in Chapter 2 render this a straightforward exercise. PC&E and Will Power are to blame for the use of non-fire-retardant materials on the scaffolding of Wang Fuk Court, the covering of windows with polystyrene foam boards, and the creation of access openings in the staircases, each of which directly contravened applicable regulations. As for the disabled fire alarm systems, it was wrong for ISS to assist PC&E in handling the draining of the FS Tanks when its staff lacked the knowledge and qualifications to operate fire service installations. For its part, Victory Fire knew that the fire alarm systems were switched off, but failed to reinstate them or notify the FSD about the shutdown.

Posthumously promoted to the rank of Senior Fireman. For sake of consistency, we will refer to Fn Ho using his rank at the time of the fire in these Closing Submissions.

Government’s Closing §§781, 883

Mr Ng Yeuk Wilson and China Status did not even begin to perform their duties. They acted as mere rubber stamps, signing paperwork when required of them. They failed to discharge the professional responsibilities required of them as registered inspector and registered fire service installation contractor respectively.

In Chapter 7, we turn to the roles and responsibilities of the various Government bodies which had oversight over the renovation works. The Government has described its conclusions “in general terms as areas for improvement in the framework’s design or execution rather than as judgments on individual bureaux or departments”. 8 However, the Committee is required by its Terms of Reference to assess the respective roles and responsibilities of personnel with supervisory roles across all stages (including government officers, authorised professionals, contractors and others). The analysis in this Chapter is therefore structured by reference to each individual Government body, as well as government officers with supervisory roles where appropriate.

The systemic failures of the Government bodies were pervasive. There were common threads in their deficiencies: over-reliance on “selfregulation” by contractors and consultants, a lack of proper sampling or verification, a lack of effective inter-departmental communication and rigid adherence to bureaucracy in handling residents’ complaints. There were, however, particularly notable failings on the part of the ICU and the FSD which warrant special mention:

1. The former Head of the ICU accepted that, on matters of statutory building control, the ICU blindly followed the BD’s practices without independent review. 9 Yet, the ICU was unaware that, since 2023, the BD’s own practice had been to conduct site inspections in the course of minor works. The ICU itself conducted no site inspections during the works unless a complaint was

Government’s Closing §970

[T24/30:36-31:26]

received. It relied solely on residents’ complaints, trusting the contractor and RI to regulate themselves.

2. Contrary to the BD’s practices of making surprise checks in response to complaints (and indeed the practices of the FSD and LD in equivalent scenarios), the ICU gave advance notice of its inspections to contractors. In the case of Wang Fuk Court, this gave contractors sufficient time to procure fire-retardant scaffolding nets to stage compliance during the ICU’s inspections.

3. Even when complaints came, the response was inadequate. The ICU did not take adequate steps to verify the compliance of the scaffolding nets at Wang Fuk Court with safety standards. It accepted the certificates provided without conducting a basic desktop check of the name of the issuing institution. It conducted quick tests which were of little evidential value, and failed to take any follow-up steps even where a sample clearly failed the test.

4. The ICU did not take any meaningful steps to address residents’ concerns regarding the use of foam boards. The ICU saw and photographed workers using foam boards to cover windows during their inspections. Yet, the ICU did not pursue the matter beyond perfunctory enquiries with the contractors.

5. Finally, the ICU reviewed submissions with photos of staircases showing the modified access openings which were demonstrably contrary to applicable regulations. Despite examining these photographs, the ICU confirmed that the submissions were in order.

6. As for the FSD, it enjoyed jurisdiction over all fire risks and possessed broad powers to abate such risks. Yet, it operated on the basis that all passive fire safety provisions and building materials, including access openings and foam boards, fell outside its jurisdiction.

7. The FSD also adopted an overly lax approach towards handling shutdown notices issued by registered fire service installation contractors. It did not adequately monitor the length of shutdowns or the need for such shutdowns. While it visited Wang Fuk Court following each shutdown notice, it did not conduct any inspection of the FS pump room or the FS Tanks to verify the accuracy of the information reported in the shutdown notices. For these reasons, the FSD failed to notice that the fire alarm systems at Wang Fuk Court were disabled.

We conclude our analysis on the issues raised by paragraph 1 of the Terms of Reference in Chapter 8, by setting out recommendations which the Committee may wish to make based on the evidence. It is noted that in recent months, the Government has announced a series of measures to address obvious loopholes and deficiencies in the existing regulatory system which have been exposed by the fire. The analysis in this Chapter builds on these latest measures and invites the Committee to consider whether further measures would be necessary or appropriate.

In Chapter 9, we turn to the issues mandated by paragraph 2 of the Terms of Reference, namely the examination of the prevalence of bid-rigging, corruption and other irregularities in the tendering process of large-scale building maintenance and renovation works.

The evidence supplied by law enforcement agencies shows that bid-rigging and other anti-competitive conduct occur on a wide scale in building maintenance and renovation works, often with triad influence. While the Committee is not required by the Terms of Reference to make findings on the existence of such issues in the case of Wang Fuk Court, there are nonetheless indicia of suspected improper conduct, such as the unreasonable bid prices put forward by Will Power, PC&E’s connections with other bidders in its tender, and the concealment of PC&E’s litigation record by Will Power. The procurement process was also the subject of numerous complaints of proxy irregularities, a lack of proper information and strife amongst rival camps of residents.

Residents were left exposed to these risks by the regulatory framework. ISS had no system in place for verifying the authenticity of proxy votes. The Smart Tender scheme (招標妥 ) operated by the Urban Renewal

Authority (“URA”), which was implemented to reduce the risks of bidrigging, was simply ineffectual in achieving that purpose. Instead, it gave residents a false sense of security in the belief that the procurement process had been conducted under the supervision of independent professionals, when in fact no real scrutiny was exercised.

Our suggested recommendations on the issues under paragraph 2 of the Terms of Reference are set out in Chapter 10.

CHAPTER 2: THE BUILDING MAINTENANCE AND RENOVATION WORKS AT WANG FUK COURT

A. Overview

This Chapter sets out the key facts relating to the building maintenance and renovation works carried out at Wang Fuk Court (“BMR Works”) prior to the fire.

The structure of this Chapter is as follows:

1. Section B: Identification of relevant parties and their respective roles in relation to the BMR Works;

2. Section C: The tender process for the BMR Works;

3. Section D: The state of the BMR Works prior to the fire, including the condition of materials on the scaffolding, the creation of access openings in the staircases and the operational status of the fire service installations.

In 2014, Wang Fuk Court was selected as a target building under the Mandatory Building Inspection Scheme (“MBIS”). Statutory notices under section 30B of the Buildings Ordinance (Cap. 123) were subsequently issued on 10 June 2016, mandating that the IO of Wang Fuk Court arrange for the inspection and repair of the common areas and external walls of all eight blocks of Wang Fuk Court.10

Inspections were undertaken and completed in 2019, whereby necessary repairs were identified.11 A consultant was subsequently appointed in 2021 to design and supervise the BMR Works.12 In 2024, the main contractor

10 E.g. MBIS Statutory Notices for Wang Yan House [I1-2/1863-1866] 11 [T2/21:30-32]

12 [T2/22:12-14]

was appointed to carry out the BMR Works. 13 The BMR Works commenced in mid-2024, and remained in progress until the day of the fire on 26 November 2025. 14 A comprehensive timeline of events related to the BMR Works is set out in Sections B and C of this Chapter.

The BMR Works do not constitute mere background to the fire. The tender process described in Section C was controversial and gave rise to concerns of bid-rigging and collusion. Section D concerns the status of the BMR Works, which is central to understanding how a localised fire on the façade of one block came to engulf seven of the eight residential blocks of Wang Fuk Court at unprecedented speed and scale. By the time of the fire, the BMR Works had enclosed all eight blocks in a combustible envelope: bamboo scaffolding was sheathed in safety nets and combustible foam boards were placed over windows. Section D of this Chapter examines how these materials were selected, and why a substantial portion of them failed to comply with fire retardancy requirements.

The BMR Works bear on the tragedy in another respect. In the course of the works, worker access openings were created approximately every five floors in the staircases. The fire service installations at Wang Fuk Court, in particular the fire alarm systems serving the blocks, were disabled. Section D examines the circumstances surrounding these critical fire safety deficiencies.

This Chapter is concerned with establishing facts, not with resolving questions of causation or responsibility. The contribution of the combustible envelope to the fire spread, and the contribution of the worker access openings and disabled fire alarms to the loss of life, are addressed in Chapters 3 and 4. The responsibilities of various stakeholders are examined in Chapters 6 and 7.

B. Parties and their Roles

The key companies involved in the BMR Works and fire service installation (“FSI”) works at Wang Fuk Court were:

1. Will Power Architects Co. Ltd (鴻毅建築師有限公司) (Will Power): the consultant for the BMR Works;

2. Prestige Construction & Engineering Co., Ltd (宏業建築工程有

限公司) (PC&E): the main contractor for the BMR Works;

3. ISS EastPoint Properties Ltd (置邦興業有限公司) (ISS): Wang Fuk Court’s property management company; and

4. Victory Fire Engineering Ltd (宏泰消防工程有限公司) (Victory Fire) and China Status Development and Engineering Co. Ltd (中

華發展工程有限公司) (China Status): registered fire service installation contractors (RFSIC) engaged for FSI inspection and related works.

Under the statutory regime, a prescribed inspection under the MBIS must be carried out by an RI, an individual, not a firm, whose name appears on the register of inspectors kept by the Building Authority under section 3 of the Buildings Ordinance (Cap. 123). Further, under section 30D, any prescribed repair must be carried out by a registered contractor (“RC”) under the supervision of a registered inspector (RI). The RI on record in relation to the BMR Works at Wang Fuk Court differed at each stage:15

1. During the prescribed inspection: Mr Shum Kui Chung (沈鉅忠), who was a shareholder and director of Will Power until he passed away on 15 July 2022.

15 Table of shareholders and directors of Will Power [WS2/1298]

2. During the prescribed repair works: Mr Ng Yeuk Wilson (吳躍), who became a shareholder and director of Will Power on 12 December 2023.

Key personnel associated with the abovementioned companies are set out in the table below:

Table 2-1: Key personnel at Wang Fuk Court and their respective roles

Will Power - Consultant
Wong Hap Yin Jason 黃俠然	Director and shareholder of Will Power
Ng Yeuk Wilson 吳曜	Director and RI since 12 Dec 2023 and 10 Oct 2024 respectively, responsible for the supervision of prescribed repair works at Wang Fuk Court
Hung Sai Kit 孔世傑	Assistant Project Manager (助理項目經理) who prepared tender analysis
Choi Kwok Hing Steven 蔡國興 (“Steven Choi”)	Engineering Manager (工程經理) who attended inspections of scaffolding nets
Yeung Tsz Man 楊子文	Engineering Manager (工程經理) / Work Supervisor (工程監督), subordinate of Choi Kwok Hing, who attended inspections of scaffolding nets
Shum Kui Chung 沈鉅忠	Former director and RI until his death on 15 Jul 2022, responsible for the prescribed inspections at Wang Fuk Court
Hung Kwok Wai 洪國偉	Middleman who introduced Ng Yeuk Wilson to Wong Hap Yin Jason and offered Ng Yeuk Wilson remuneration for acting nominally as an RI
PC&E - Main Contractor
Hau Wa Kin 侯華建	Director and principal shareholder of PC&E
Cheung Yin Kam 張燕琴	Wife of Hau Wa Kin and clerical officer
Ho Kin Yip Gordon 何建業 (“Gordon Ho”)	Project Manager (經理) since 2008 and director of PC&E until 13 Jan 2026
Wong Chung Kee Steve 黃忠基	Authorised Signatory of PC&E, albeit employed by the Housing Department as a contract Building Maintenance Surveyor in Ngau Chi Wan

Tam Chun Son Sam譚雋生(“Sam Tam”)	Foreman for Wang Fuk Court
Cheung Yiu Wing Jason張耀榮	Foreman for Wang Fuk Court
Chong Po ChungMansfield張寶忠	Foreman for Wang Fuk Court, responsible for client complaints and handled FSI forms
Leung Lai Sze梁麗斯	Site clerical staff (地盤文員) at Wang Fuk Court
Wong Siu Tai Arthur黃兆泰	Site safety supervisor for Wang Fuk Court since Sep 2024, employed by Excel Target International Limited (卓迪國際有限公司)
Wong Pik Yi Karen黃碧儀	Clerical staff responsible for tenders
Yip Kwan Nga Sophie葉均雅	Clerical staff for preparing reports
ISS – Property Management Company
Lai Wing Lee黎永利	ISS Property Manager (駐苑經理)
Cheng Tsz Ying鄭芷盈	ISS Property Officer (物業主任) since Aug 2014
Lam Sai Man林世文	Assistant Property Manager (副物業主管) since Aug 2025
Lam Man Yan林文欣	ISS Engineering Officer (工程主任) (save for Apr 2025 to Aug 2025)
Law Kwok Shui羅國瑞	Works technician, licensed electrician
Lee Shing Foo李承富	Works technician, carpenter
Chung Sui Ha鍾瑞霞	Day shift building attendant at Wang Cheong House (Block F)
Wong Pak Shing黃百盛	Senior building attendant (高級管理員)
Lok Sin Ying駱倩盈	Clerk (文員) working under Lai Wing Lee and Cheng Tsz Ying
Victory Fire – RFSIC	Victory Fire – RFSIC
Chung Kit Man鍾傑文	Director and Engineer of Victory Fire

Wong Kin Wa 黃健華	Electrician who carried out annual inspection of FSIs at Wang Fuk Court in Mar 2025, and conducted repair works to FSIs on 19 Nov 2025
Li Chun Yin 李俊賢	Electrician who carried out annual inspection of FSIs at Wang Fuk Court in Mar 2025, and conducted repair works to FSIs on 19 and 21 Nov 2025
Tong Hing Lun 唐慶麟	Plumber who conducted repair works to FSIs at Wang Fuk Court on 16 and 17 Oct 2025
China Status – $RFSIC^{16}$
Leung Ping Kay Ivan 梁秉基	Director of China Status, contact person in relation to Wang Fuk Court who signed shutdown notices
Yim Choi Wah Alex 嚴財華	Director of China Status who signed FS251 certificates and some shutdown notices for Wang Fuk Court

PC&E engaged a chain of subcontractors and sub-subcontractors. Their roles and representatives are set out in the table below:

Table 2-2: Subcontractors and Sub-subcontractors in the BMR Works

Subcontractors (二判) - Companies
Gain Profit Shed Industry Ltd 盈利豐棚業有限公司 (“Gain Profit”)	Subcontractor of PC&E responsible for erecting the scaffolding
New Nam Fong Construction Ltd 新南方建築有限公司 (“New Nam Fong”)	Subcontractor responsible for works on external walls for Wang Sun House (Block C), Wang Shing House (Block G) and Wang Chi House (Block H)
Hoi Tak Construction Engineering Ltd 海德營造工程有限公司 (“Hoi Tak”)	Subcontractor responsible for works on external walls for Wang Kin House (Block D), Wang Tai House (Block E), and Wang Cheong House (Block F) Controlled by Jacky Yin (who also controls Hang Fung (恒豐), see Table 2-3 below)
Shing Construction Co., Ltd 承造工程有限公司 (“Shing Construction”)	Subcontractor responsible for works on external walls for Wang Yan House (Block A) and Wang Tao House (Block B)

Fred & Willie Bros Const & Eng Co 發利建設工程公司 ("Fred & Willie")	Subcontractor responsible for the removal of existing cladding of external walls and clearance of construction debris
Tin Hung Engineering Co. 天雄工程公司 ("Tin Hung")	Subcontractor responsible for renovation works for plastering works, paint work and water tanks on Wang Yan House (Block A), Wang Cheong House (Block F), Wang Shing House (Block G), and Wang Chi House (Block H)
Red Sun Construct (Asia) Engineering Ltd 太陽建設(亞洲)工程有限公司 ("Red Sun")	Subcontractor responsible for internal structural works and paint works of Wang Tao House (Block B), Wang Sun House (Block C), Wang Kin House (Block D), and Wang Tai House (Block E)
Wealth Pinnacle Ltd 滿昌工程有限公司 ("Wealth Pinnacle")	Subcontractor responsible for the replacement of windows, including the replacement of staircase windows with fire-rated windows
Subcontractors (二判) – Individuals/representatives
Gain Profit	Gain Profit
Chan Yiu Fai 陳耀輝	Operator of Gain Profit
Zhong Fengping 鍾鳳平	Nominal director and shareholder of Gain Profit, wife of Chan Yiu Fai
Yeung Chi Tim Andy 楊志添	Independent sub-subcontractor of Gain Profit for the scaffolding works
New Nam Fong	New Nam Fong
Lo Ka Ming 盧家明	Director, son of Lo Ping Nam
Lo Ping Nam 盧炳南	Director, father of Lo Ka Ming
Hoi Tak	Hoi Tak
Cheung Wai Hung 張葦鴻	Director, relative of Jacky Yin
Yin Chor Ki Jacky ("Jacky Yin") 嚴楚基	Controller and operator of Hoi Tak and Hang Fung
Shing Construction	Shing Construction
Yiu Kam Fai 姚錦輝	Operator
Fred & Willie	Fred & Willie
Tsang Wai Kit	Director / Architect

曾偉傑
Red Sun	Red Sun
Wu Rizhao吳日照	Operator
Sub-subcontractors (三判) – Individuals
Wong Luen Kuen王聯權(Operating under “權誠工程有限公司”)	Sub-subcontractor engaged by Shing Construction to work on Wang Yan House (Block A)
Zhang Minghai張明海(Operating under “明旺維修工程公司”)	Sub-subcontractor engaged by Shing Construction to work on Wang Tao House (Block B)
Wang Wa Tim王華添(Operating under “王華添工程公司”)	Sub-subcontractor engaged by New Nam Fong to work on Wang Sun House (Block C), and Wang Shing House (Block G)
Wong Chi Yam王志鑫(Operating under “On Cheong Engineering Ltd 安創工程有限公司”)	Sub-subcontractor engaged by New Nam Fong to work on Wang Sun House (Block C) and Wang Chi House (Block H)
Ng Pui Kwan吳培坤(Operating under “港鵬工程公司”)	Sub-subcontractor engaged by Hoi Tak to work on Wang Kin House (Block D), Wang Tai House (Block E), and Wang Cheong House (Block F)
Sub-subcontractors (三判) – Companies engaged in staircase minor works
Allied Architects Engineers & Associates Ltd聯基建築工程師有限公司(“Allied Architects”)	Sub-subcontractor engaged by Wealth Pinnacle (滿昌) to provide services in relation to the staircase window replacement works
Motive Design Limited動感室內設計有限公司(“Motive Design”)	Registered minor works contractor engaged by Lai Ka Wing to submit minor works submissions and site supervision plans for the staircase window replacement minor works in Blocks A and B (Wang Yan and Wang Tao)
Chi Fu Construction Co.志富建築公司(“Chi Fu Construction”)	Registered general building contractor engaged by Wealth Pinnacle (滿昌) to submit minor works submissions and site supervision plans for the staircase window replacement minor works in

	Blocks C to H (Wang Sun, Wang Kin, Wang Tai, Wang Cheong, Wang Shing and Wang Chi)
Building professionals engaged in the staircase minor works
Lai Ka Wing, Eric黎家榮	Authorised Person engaged by Allied Architects to supervise the staircase window replacement minor works in all eight blocks
Chi Wuh Jian Joseph Duncan戚務堅 (“Joseph Chi”)	Registered Structural Engineer engaged by Allied Architects to supervise and provide structural calculations for the staircase window replacement minor works in all eight blocks

The subcontractors acquired scaffolding nets, foam boards and other construction materials from various suppliers, including the following:

Table 2-3: Suppliers of materials in the BMR Works

Suppliers - Companies
Lam Kee Construction Materials 林記建築材料 (“Lam Kee”)	Supplier of scaffolding nets to Gain Profit
Shandong Chenxu New Materials Co., Ltd. 山東宸旭化纖繩網有限公司 (“Shandong Chenxu”)	Supplier of scaffolding nets to Gain Profit
Binzhou Yuanjin Chemical Fiber Rope Net Co., Ltd. 濱州市源進化纖繩網有限公司 (“Binzhou Yuanjin”)	Supplier of scaffolding nets to Gain Profit
Hang Fung Building Engineering Ltd 恒豐營造工程有限公司 (“Hang Fung”)	Company controlled by Jacky Yin (嚴楚基), on- sold foam boards to New Nam Fong
Wuhan Hansu New Materials Co., Ltd. 武漢漢塑新材料有限公司 (“Wuhan Hansu”)	Supplier of foam boards to Shing Construction
Hubei Yubo Energy-Saving New Materials Co., Ltd. 湖北宇博節能新材料有限公司 (“Hubei Yubo”)	Supplier of foam boards to Hoi Tak

Suppliers - Individuals
Wong Chi Ming王志明	Nephew of Yiu Kam Fai (姚錦輝) who introduced him to Wuhan Hansu (武漢漢塑)(see above) as foam board supplier
Yang Yao Fei楊耀飛	Owner of Hubei Yubo
Zhang Jieling張結玲	Contact person of Hubei Yubo

During the tender and construction stages of the BMR Works, the following members of the IO played a key role:

1. The former Chairman of the IO was Mr Tang Kwok Kuen (鄧國權), who had been a member of the IO since 1997 and held office as Chairman from 2012 before vacating both roles in September 2024.

2. Mr Tsui Moon Come Tony (徐滿柑) succeeded Mr Tang Kwok Kuen and acted as the new Chairman of the IO from September 2024 to 6 January 2026.

3. Mr Kong Cheung Fat (江祥發) served on the IO between 25 May 2024 and 6 January 2026. He was a member of the IO under the chairmanship of both Mr Tang Kwok Kuen and Mr Tsui Moon Come Tony, and was present at most of the key IO meetings.

The Management Committee of the IO has since been dissolved and an administrator (Hop On Management Company Ltd (合安管理有限公司)) was appointed by the Lands Tribunal on 6 January 2026.

Finally, various Government and statutory bodies were involved in the tender and renovation stages of the BMR Works, several of which received numerous complaints from residents of the estate. Chapter 7 examines the responsibilities of these bodies in greater detail. For present purposes, it suffices to note the following:

1. The URA facilitated the IO's selection of the consultant and main contractor under the “Smart Tender” scheme. The URA engaged RS Surveyors (富邦測量師行) (“RS Surveyors”) to act as an independent advisor to the IO in relation to the registered contractor tender process.

2. The ICU $^{17}$ issued the Statutory Notices for the inspection and repairs under the MBIS, received the submissions for minor works (including the alterations to staircase windows) and attended the site in response to complaints.

3. The LD and FSD likewise attended the site to follow up on complaints regarding the BMR Works.

4. The Home Affairs Department (“HAD”) assisted the IO on matters relating to building management, attended owners’ meetings and received complaints from residents.

The staff and officials from the Government and statutory bodies with direct involvement in Wang Fuk Court prior to the fire were as follows:

Table 2-4: Staff and officials from Government and statutory bodies involved in the BMR Works and associated complaints

URA	URA
Chan Yat Ho, Matthew 陳日豪 ("Matthew Chan")	Case Manager (Building Rehabilitation) assigned to handle the Wang Fuk Court file under the Smart Tender scheme and prepared tender price summaries
Yam Lap Yin, Brian 任立賢 ("Brian Yam")	Assistant Manager who attended IO meetings and dealt with the owners' enquiries
ICU	ICU

Ku Siu Ping, Andy 古小平 ("Andy Ku")	Senior Maintenance Surveyor and Head of the MBIS Team, conducted site inspections in response to complaints by Wang Fuk Court residents
Yung Siu Lun, Nick 容兆倫 ("Nick Yung")	Senior Maintenance Surveyor and Head of the Minor Works Team, reviewed minor works submissions for staircase window alterations in Wang Fuk Court
Tse Kam Ming, Franco 謝錦明 ("Franco Tse")	Former Senior Building Surveyor / Building Control seconded from the BD, was allegedly consulted by Ku Siu Ping on the use of foam boards to cover windows in Wang Fuk Court
Lau Ka Man, Amanda 劉嘉敏 ("Amanda Lau")	Maintenance Surveyor, responded to complaints by residents under Andy Ku's supervision, attended site inspections alongside Andy Ku and Lee Ka Ho
LD	LD
Lam Sau Ching 林秀青	Divisional Occupational Safety Officer (Minor Renovation and Maintenance Works) responsible for Wang Fuk Court throughout the BMR Works, supervised Occupational Safety Officers who inspected the site, and handled complaints to the LD
FSD	FSD
DO Hor Herman 賀俊維	Former Station Commander of Tai Po Fire Station, supervised the handling of enquiries concerning fire safety at Wang Fuk Court
SStnO Ng Wing Kwong 伍永光	Senior Station Officer of Tai Po Fire Station, handled an enquiry about the flammability of foam boards used at Wang Fuk Court
SStnO Hui Kin On 許健安	Senior Station Officer of Tai Po Fire Station, handled a complaint about workers smoking in Wang Fuk Court, subsequently assumed the role of the initial Incident Commander of the fire at Wang Fuk Court
HAD	HAD
Or Wai Yin 柯煒妍	Liaison Officer (5A) of Tai Po District Office of the HAD, attended owners' meetings at Wang Fuk Court and received complaints

C. Tender Process for the BMR Works

C1. Overview of tender process and roles of the URA and RS Surveyors

Following the ICU's issuance of the Statutory Notices under the MBIS on 10 June 2016,$^{18}$ the IO applied to join the "Smart Tender" scheme operated by the URA on 2 February 2018.

The Smart Tender scheme is an electronic platform and support service that is designed to reduce the exposure of building owners to bid-rigging.$^{19}$

Pursuant to a contract dated 16 June 2018 entered into between the IO and the URA, the URA agreed, inter alia, to provide the following services:20

1. Provide self-help tools to the IO, assist the IO in appointing an RI and designate an Independent Consultant to advise the IO.

2. Liaise with the Independent Consultant to advise the IO, review the RI's survey report, tender documents and cost estimates and attend IO meetings where necessary.

3. Provide an electronic tendering platform for the issuance of tender documents and the receipt of tenders for the main contractor and appoint an independent professional to open and record the tenders.

The URA designated RS Surveyors as the Independent Consultant to advise the IO.$^{21}$ RS Surveyors confirmed to the URA that it had no conflict of interest in acting for Wang Fuk Court.$^{22}$

By a tripartite agreement dated 16 June 2018, executed by the IO, RS Surveyors and the URA:23

1. RS Surveyors agreed to conduct a site survey and prepare an Initial Assessment Report identifying the MBIS works that were required, alongside a cost estimate for the same.

2. Based on the draft tender documents produced by the RI, RS Surveyors agreed to prepare a Pre-tender Assessment Report and an independent cost estimate, which would remain sealed until the tenders were opened.

3. After the opening of the tenders, RS Surveyors agreed to comment on the tender analysis report produced by the RI.

On 9 August 2018, RS Surveyors produced its Initial Assessment Report of the MBIS repair works that were required. The basic repair costs were estimated at HK$102,077,704.$^{24}$

However, the URA and RS Surveyors had limited involvement in the tender processes for the selection of the RI and consultant for Wang Fuk Court.$^{25}$ For example, while the URA prepared tender price summaries for

the tenders submitted by tenderers for the roles of RI and consultant,$^{26}$ the URA did not comment on the reasonableness of the tender prices.$^{27}$ The URA explained that, at the material time, the Smart Tender scheme only covered tendering exercises for the selection of contractors, and did not extend to the selection of RIs and consultants.$^{28}$

Therefore, in the RI and consultant tenders for Wang Fuk Court, no opinion was ever given by RS Surveyors or the URA on the reasonableness of the consultant's price.$^{29}$

Mr Wong Se King Peter (“Peter Wong”) (the URA’s Director, Building Rehabilitation) accepted that the existing system had, for many years, no effective means of addressing the known problem$^{30}$ of RIs securing appointments by submitting unreasonably low bids and subsequently helping contractors in inflating project prices. He acknowledged that the Smart Tender scheme provided no effective solution in this regard.$^{31}$

C2. Appointment of RI for the purpose of the MBIS inspection

On 3 September 2018, the IO put out an open tender for the appointment of the RI for the purposes of carrying out the inspection of buildings under the MBIS. The URA posted the tender notice on the URA's Building Rehabilitation Platform website.$^{32}$ The tender period was from 3 to 26 September 2018.$^{33}$

According to Madam Cheng Tsz Ying of ISS, an employee from the engineering department of ISS's headquarters, Mr Cheng Yat Kai (鄭日佳), assisted the IO with the preparation of standard form tender documents for the selection of the RI.$^{34}$ Madam Cheng Tsz Ying and the employees whom she supervised at ISS were responsible for administrative work, including preparing documents (other than the tender documents), attending to registration at meetings, collecting and processing proxy forms, and writing meeting minutes.$^{35}$

There were 24 bids received, ranging from HK$88,000 to HK$1,080,000. The average bid was around HK$500,000.$^{36}$

As part of the tender submission requirements, on 22 September 2018, Will Power and its RI, Mr Shum Kui Chung (沈鉅忠), signed a Declaration of Ethical Commitment Requirements (遵守道德承擔要求的聲明)$^{37}$ and an Integrity and Anti-Collusion Clauses Confirmation (誠信及反圍標條款確認書).$^{38}$ Will Power further signed an Anti-Collusive Tender Confirmation (不合謀投標確認書) on the same date.$^{39}$

On 25 January 2019, Wang Fuk Court's owners voted to appoint Will Power to carry out the prescribed inspections under the MBIS. Will Power received 67.5% of the votes, with the next-most-voted company (遠東建築師樓有限公司) only receiving 7.7%.$^{40}$

The final bid price of Will Power was HK$222,000, discounted from the original bid price of HK$240,000. Will Power gave its discount by a letter dated 22 September 2018, without any request by the IO. The discount was described as a measure implemented after taking into account Will Power's operational situation and in discharge of its social responsibility to reduce the residents' expenditure.$^{41}$

Will Power proceeded with the inspection at Wang Fuk Court. Following the inspection, Will Power issued the Inspection Reports. Some Inspection Reports were dated 3 April 2019, others were dated 30 July 2019, and one Inspection Report was undated.$^{42}$ Each of the Inspection Reports was signed by Mr Shum Kui Chung as the RI.$^{43}$

On 9 December 2019, Mr Shum Kui Chung (as the appointed RI) submitted the Inspection Reports and Forms MBI 3 to the ICU, officially reporting that the buildings required repair.$^{44}$

C3. Appointment of RI for the purpose of supervision of works

On 2 January 2020, the IO advertised a tender notice for the appointment of a consultant to design, plan and supervise the works. The URA provided limited assistance by posting the tender notice on its website.$^{45}$

The IO received 35 bids, ranging from HK$45,000 to HK$2,080,000. Will Power's bid was the eleventh lowest, at HK$308,000. The average bid was around HK$550,000.$^{46}$

The breakdown for Will Power's tender price was as follows:$^{47}$

1. Of the total tender price of HK$308,000, HK$60,000 was allocated for the works other than mandatory repairs under the MBIS.

2. The remaining amount of HK$248,000 allocated for mandatory repair works comprised: (i) HK$28,000 for 15 days of work in initial planning; (ii) HK$40,000 for 23 days in drafting the tender document for the tender for the main contractor; (iii) HK$32,000 for 19 days in tender analysis and advice; (iv) HK$20,000 for 9 days in drafting the repair works contract; (v) HK$100,000 for 68 days in inspecting and supervising the works; and (vi) HK$28,000 for 15 days of follow-up work.

Will Power therefore proposed fees in the sum of HK$248,000 for a total of 149 days of mandatory repair works under MBIS, or HK$1,664 a day. Will Power stated in its tender that the RI would personally carry out a total of 46 days of work relating to the MBIS repairs.$^{48}$

As part of the tender process for the consultancy appointment, on 15 January 2020, Will Power signed a further Declaration of Ethical Commitment Requirements and Anti-Collusive Tender Confirmation.$^{49}$

By a letter dated 28 February 2020 to the IO, Will Power explained that, since it had been involved in the MBIS inspection, it was familiar with the site of Wang Fuk Court and was therefore able to charge a relatively low fee.$^{50}$

Between 11 and 13 May 2020, the IO interviewed 14 of the tendering consultants. The URA did not participate in any of the interviews.51

At an Extraordinary General Meeting (“EGM”) held on 11 December 2021, the owners voted to appoint Will Power as the consultant to carry out the repair works by a majority of 56.69% of votes.52 The consultancy contract was signed by Will Power and the IO on 22 December 2021.53

C4. Appointment of the main contractor

The tendering process for the appointment of the main contractor then followed. Unlike the process of selecting the RI and consultant, the tendering process for the main contractor was conducted under the URA’s Smart Tender scheme. During this process:

1. As the project’s consultant, Will Power was responsible for drafting the tender document and rules of tender and evaluating the bids of the tendering contractors. Residents relied on Will Power for its professional advice.

2. As mentioned above, under the Smart Tender scheme, the URA agreed to provide, inter alia, an electronic tendering platform for the issuance of tender documents and the receipt of tenders. RS Surveyors also agreed to advise the IO on the draft tender documents and to comment on Will Power’s tender analysis after the tenders were opened.

Will Power submitted the first draft of the tender document to the URA on 23 August 2022.54 On 29 September 2022, the URA received from Will

51 [T21/6:7-10]

52 [G1-2/1478-1481]

53 [E1-4/8352-8411]

54 Chan Yat Ho Matthew WS §41 [WS1/438]

Power a Works Cost Estimate Report, which bore the signature of Mr Shum Kui Chung.$^{55}$ These documents were passed to RS Surveyors.

Will Power's RI representative, Mr Shum Kui Chung, passed away on 15 July 2022.$^{56}$ Nevertheless, the URA and RS Surveyors were not aware of Mr Shum's death when they received the Works Cost Estimate Report purportedly signed by him.$^{57}$

On 15 November 2022, RS Surveyors submitted its Pre-tender Assessment Report (Part 1) to the URA. The report served two functions: (i) to review Will Power's draft tender document for discrepancies, omissions, or technical deficiencies, in particular, whether repair works that were mandatory under the MBIS had been omitted from the scope of works in the tender document; and (ii) to compare RS Surveyors' own independent cost estimate against Will Power's cost estimate, flagging items with a variance of 30% or more.$^{58}$ The following points about the report are noted:

1. The URA's evidence is that RS Surveyors did not assess whether the draft tender document included in its scope any work that was superfluous.$^{59}$ It follows that RS Surveyors did not advise the IO whether Will Power might have deliberately expanded the scope of works for the purpose of inflating the contract price.

2. RS Surveyors' assessment was based on visual inspection only("目視"勘察), without any testing or laboratory analysis, and did not cover concealed or inaccessible locations.$^{60}$

55 [E1-4/8578-8579] 56 [O2/831] 57 [T21/17:17-26] 58 [T21/17:30-18:3] 59 [T21/19:27-20:12] 60 Pre-tender Assessment Report (Part 1) §§3.3-3.4 [E1-4/8599]

3. Paragraph 4 of the Pre-tender Assessment Report provided RS Surveyors' cost assessment of HK$224,916,383.$^{61}$ This was more than double its initial estimate of HK$102,077,704.$^{62}$ RS Surveyors explained this increase on the basis that Will Power's tender documents proposed different and additional repair items to those assumed in RS Surveyors' Initial Assessment Report.$^{63}$

On 25 November 2022, the Pre-tender Assessment Report (Part 1) was provided to the IO, except for paragraph 4 of the report which contained RS Surveyors' independent cost estimate. This paragraph was withheld from the IO, Will Power, and all potential contractors to prevent bid-rigging.$^{64}$

On 30 December 2022, after considering the Pre-tender Assessment Report (Part 1), Will Power submitted a revised draft tender document to the IO and the URA.$^{65}$

According to Wang Fuk Court's former Management Committee, from 19 January 2023, hard copies of the tender documents and the URA's assessment report (which is understood to be the Pre-tender Assessment Report (Part 1)) were placed in the lobby of each of the eight blocks.$^{66}$

At the EGM on 4 March 2023, the tender documents were confirmed by the owners of Wang Fuk Court, subject to a final review by the URA and RS Surveyors.$^{67}$

In the meantime, Will Power proposed to the IO and URA its tender scoring criteria for the purpose of the subsequent tender analysis stage:

1. The proposed scoring criteria for the "company background" of tendering contractors included but were not limited to scores relating to: (i) availability of licences, ISO certification, financial statements and fund proof; (ii) experience in large contract works; (iii) solicitor's confirmation of no litigation in the past 2 years; and (iv) litigation record in the past 8 years.$^{68}$

2. By an email on 15 March 2023, Mr Brian Yam of the URA provided his comments on the wording of the scoring criteria proposed by Will Power.$^{69}$ Mr Matthew Chan, also of the URA, testified that these comments were the product of his discussions with Mr Yam, and were based on the wording (措詞) and timeframes of the scoring criteria only.$^{70}$ He confirmed that the URA would not comment on whether scoring criteria were effective, reasonable or consistent with usual practice. In fact, the URA would not comment even if a scoring criterion was wholly unreasonable.$^{71}$

On 17 March 2023, the IO's Management Committee convened to discuss and approve the tender scoring criteria as proposed by Will Power. The meeting minutes recorded that the URA had been consulted and had no comments on the overall scoring framework.$^{72}$

The final tender document73 and the endorsed tender scoring criteria were submitted to the URA on 27 March 2023.74

1. In the tender document, one of the most significant aspects of the works involved “External wall mosaic tile redecoration works” (外

牆紙皮石位置粉飾工程). The tender was offered on the basis of three alternative options for this part of the works:75

(a) Option 1: Repair of mosaic tiles and application of transparent protective coating (紙皮石修補+透明面油保護方案).

(b) Option 2: Repair of mosaic tiles and application of coloured coating (紙皮石修補+顏色面油保護方案).

2. Tenderers were further put to a choice between use of “AKA” or “SKK” brand materials for the carrying out of each option.76

On 19 April 2023, RS Surveyors issued Pre-tender Assessment Report (Part 2), confirming that the tender documents conformed with the URA’s requirements under the Integrated Building Rehabilitation Assistance

73 [E1-4/8778-8939]

74 Chan Yat Ho Matthew WS §52 [WS1/440] 75 [E1-4/8878-8883].

76 [E1-4/8878-8883]

Scheme,$^{77}$ and enclosed an Independent Cost Estimate based on the finalised tender document. In the Independent Cost Estimate:$^{78}$

1. RS Surveyors assessed the costs of the BMR Works depending on which of the three options was chosen for the external wall works. If Option 1 were adopted, the total project cost was estimated at approximately HK$144 million. If Option 3, the total project cost was estimated at approximately HK$360 million.$^{79}$

2. The Independent Cost Estimate contained caveats, including that RS Surveyors' cost estimates could not be fully relied upon and were for general reference only (不能完全作準, 亦只可用作一般性參考).$^{80}$

The Independent Cost Estimate was placed in a sealed envelope and deposited into the URA's tender box on 4 July 2023, to be unsealed after the opening of the tenders.$^{81}$

On 16 May 2023, the URA advertised the tender notice on the electronic Smart Tender platform and sent a tender notice to all registered contractors. Ultimately, 99 contractors downloaded the tender document.$^{82}$

The bids (together with RS Surveyors' Independent Cost Estimate) were opened on 5 July 2023, overseen by URA officers and an independent Certified Public Accountant.$^{83}$ A total of 57 contractors submitted bids for the project. The bids were handed over to Will Power for its tender analysis.

77 [E1-4/8941]

78 [E1-4/8943-8951]

79 [E1-4/8947-8948]; [T21/25:29-35]

80 Independent Cost Estimate §§3.3-3.5 [E1-4/8944]

81 Chan Yat Ho Matthew WS §53&§56 [WS1/440]

82 Chan Yat Ho Matthew WS §54 [WS1/440]

83 Chan Yat Ho Matthew WS §57 [WS1/440]

On 18 September 2023, Will Power submitted its first draft Tender Analysis Report (承建商投標分析報告). It was purportedly signed by Mr Ng Yeuk Wilson, who later became the only RI with Will Power.$^{84}$ Companies Registry records however show that Mr Ng only joined Will Power as a shareholder and director on 12 December 2023.$^{85}$ Will Power applied the tender scoring criteria approved by the IO on 17 March 2023.

According to the URA's evidence, the URA did not check whether the tenderers were inter-related, and it did not investigate whether the Tender Analysis Report contained misleading information, including in relation to the litigation records. It relied on Will Power to deal with these matters.$^{86}$

On 14 and 16 October 2023, the Management Committee and Will Power conducted interviews with 14 shortlisted contractors.$^{87}$ The URA did not attend any of these interviews, but accepted that the interviews were an important part of the tendering process.$^{88}$

On 27 November 2023, RS Surveyors prepared an assessment report regarding the contents of Will Power's draft Tender Analysis Report,$^{89}$ and the same was sent to the IO on 4 December 2023 for its reference.$^{90}$

1. The assessment report prepared by RS Surveyors was only a few pages in length and, apart from identifying items in one of the tenders that deviated significantly from the Independent Cost

84     [E3/9557]; [T21/26:10-16]
85     [WS2/1298]; cf. Mr Ng Yeuk Wilson's WhatsApp message suggesting that he became a shareholder and director of Will Power since 9 March 2023 [A2/170].
86     [T21/26:19-36, 33:5-34:15]
87     [G1-2/1506]
88     [T21/27:27-28:14]
89     [E1-4/9139-9153]
90     Chan Yat Ho Matthew WS §61 [WS1/441]

Estimate,$^{91}$ it focused on calculation errors and typographical errors in Will Power's draft Tender Analysis Report.$^{92}$

2. The assessment report did not address issues that may assist owners in preventing bid-rigging.$^{93}$

On 11 December 2023, Will Power submitted a revised Tender Analysis Report, taking into account the observations in RS Surveyors' assessment report.$^{94}$

1. Publicly available Companies Registry records indicate that PC&E's Mr Hau Wa Kin (侯華建) was associated with at least five other tendering companies.$^{95}$ The Tender Analysis Report did not disclose any of these relationships, despite Will Power purporting to disclose that other tenderers were suspected of bid-rigging or collusion.$^{96}$

2. In the “Company Background” (背景分析) section, PC&E was the highest-scoring bidder and the only tenderer to be awarded a Grade B rating.$^{97}$ The Grade B rating reflected PC&E’s score of a total of 20 marks, which included the maximum 6 marks allocated for the scoring criteria of “no litigation record” (無法律訴訟) and “litigation record in the past 8 years” (過往 8 年訴訟記錄).$^{98}$

3. According to the criterion of “no litigation record”, 3 marks were awarded if a tenderer submitted a certificate from a practising

91 Assessment Report on Tender Analysis Report §§2.1.6-2.1.8 [E1-4/9140].
92 Assessment Report on Tender Analysis Report §§2.1.2, 2.1.10 [E1-4/9140-9141].
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lawyer stating it had no litigation in the past 2 years.$^{99}$ PC&E submitted a letter from a firm of solicitors, Messrs Pansy Leung Tang & Chua, which confirmed that PC&E had “no record of having been sued by owners’ corporation and management company in the past seven years.”$^{100}$ This confirmation was narrowly framed. It plainly did not cover criminal prosecutions, disciplinary actions or litigation brought by other types of plaintiffs.

4. The Tender Analysis Report failed to disclose that, in August 2023, PC&E was disciplined by the Registered Contractors Disciplinary Board as published on the website of the BD and in the Government Gazette.$^{101}$ It also failed to disclose that PC&E had been prosecuted 112 times and convicted 98 times for offences under occupational safety and health legislation from 2001 to 2023.$^{102}$

According to a chronology of the tender process prepared by the former Management Committee of Wang Fuk Court (流程記錄), a series of steps was taken by the IO to inform owners of the tenders:$^{103}$

1. Will Power held consultation sessions (業主諮詢會) on 2 and 6 October 2023, at which the Tender Analysis Report and the BMR Works were explained. Madam Or Wai Yin of the HAD confirmed her understanding from the HAD's records that consultation sessions had been held before the EGM.$^{104}$

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2. On 19 December 2023, a summary of the contractor tender prices (承建商投標價格總額一覽表) was distributed to the mailbox of each household (“Contractor Tender Pricing Summary”).$^{105}$ It recorded that, according to Will Power’s scoring, PC&E was the highest-ranking bidder for the background criteria.$^{106}$

3. A further owners' briefing was held on 6 January 2024. The tender information of all 57 contractors was displayed in the meeting room of the IO from 15 to 17 January 2024. On 18 January 2024, Will Power representatives answered owners' queries.

Despite these apparent measures, the evidence of residents suggests that owners were not fully aware of material information about the tenders. Mr Yip Ka Kui Sdanni (葉家駒) testified that, before the EGM, he did not know the tender prices and did not recall receiving the Contractor Tender Pricing Summary, although he accepted that the tender information of all 57 contractors may have been displayed in the IO's meeting room from 15 to 17 January 2024.$^{107}$

C5. EGM on 28 January 2024

On 28 January 2024, the IO held an EGM to officially vote on the three external wall repair options and the main contractor for the BMR Works.

According to the HAD's report of the EGM:$^{108}$

1. The EGM took place at the estate's basketball court. At 2:00 pm, the master of ceremonies announced the commencement of the EGM, noting that 293 owners were in attendance and the quorum was met. He stated that due to tight time constraints, there would

be no question-and-answer session, in respect of which some owners in attendance expressed their dissatisfaction.

2. On that day, the Police Community Relations Officer (警民關係

主任) and Tai Po District Councillors Madam Peggy Wong Pik

Kiu (黃碧嬌) (“Madam Wong Pik Kiu”), Mr Mui Siu Fung (梅

少峰), Mr Lo Hiu Fung (羅曉楓) and Mr Yu Chi Wing (余智榮)

attended the EGM as observers upon the invitation of the IO. The District Councillors supervised the vote-counting process (監票).

3. Will Power explained the Smart Tender process and the scoring mechanism to the owners, including the assessment of company background, tender pricing and interview scores. Notice boards inside the venue also displayed the Contractor Tender Pricing Summary (承建商投標價格總額一覽表).109

The licensing status and disciplinary record of PC&E were matters of controversy prior to and during the EGM:

1. On 23 January 2024, being five days before the EGM, Mr Lai Wing Lee of ISS emailed the URA noting that Mr Tang Kwok Kuen (鄧國權) (Chairman of the Management Committee at the

time) discovered an online article which alleged that: (i) PC&E had been formally disciplined by the Registered Contractors’ Disciplinary Board in August 2023; (ii) PC&E’s registered contractor licence was due to expire on 8 March 2024; and (iii) URA representative Mr Brian Yam had stated that if the contractor lost its licence before the contract was executed, the residents would need to recommence the tender process.110

109 [G1-1/1026-1028] 110 [E1-4/9446–9447]

2. On the same day, Mr Yam replied on behalf of the URA, suggesting Will Power should inform owners of the latest information pertaining to all of the contractors, including their licence details and shortcomings.$^{111}$

3. The minutes of the EGM recorded Will Power's explanation at the meeting. Will Power noted that the licence-expiry information for each tenderer had been set out in the Tender Analysis Report, the cut-off date of which was 4 July 2023. Upon a further review as at 23 January 2024, the licences of two bidders, Unitacs Engineering Company Ltd (全達建築有限公司) and Polyfair Construction & Engineering Ltd (寶發建築工程有限公司) no longer subsisted, while nine had been renewed. Will Power advised that owners could freely vote for any company, except the two tenderers whose licences had lapsed.$^{112}$

4. According to the testimony of Mr Matthew Chan of the URA, during the EGM, Mr Wong Hap Yin Jason (黃俠然) raised the matter of PC&E's licence status and provided an explanation. However, Mr Chan did not recall PC&E's litigation or disciplinary record being discussed. As the EGM permitted no questions, some dissatisfied residents were advised by security to leave.$^{113}$ Mr Kong Cheung Fat also had no impression of PC&E's adverse litigation or disciplinary record being discussed at the EGM.$^{114}$

After the EGM, the complaints about PC&E continued:

1. In one complaint by a resident, reference was made to PC&E's licensing status and disciplinary and litigation record, and it was

further alleged that PC&E was involved in the bid-rigging case of Garden Vista (翠湖花園) in Shatin.$^{115}$

2. In another complaint, a member of the public noted from publicly available information that PC&E was prosecuted or disciplined more than 140 times. He alleged that Will Power and the IO failed to keep residents fully informed in the tender analysis process.$^{116}$

Another matter of controversy concerning the EGM was the manner in which proxies were obtained.

1. After the EGM, several complaints were made to the HAD by residents alleging that the EGM commenced with around 293 persons in attendance in person or by proxy, but around 570 votes were later counted without explanation.$^{117}$

2. Madam Cheng Tsz Ying of ISS responded to this allegation, explaining that when an owner arrived to collect their ballot, it came with an attendance slip. Staff would accumulate a batch of slips before passing them to the counting company to conduct computerised counting, which may have given owners the mistaken impression that the recorded vote total had suddenly $surged.^{118}$

3. According to a complaint by a member of the public, residents who did not appoint any proxies reportedly saw their units listed as having appointed proxies.$^{119}$ Mr Kong Cheung Fat also recalled an incident where an owner’s voting ballot had been taken by another

person, but it subsequently transpired that the owner's mother had signed the proxy form in question.$^{120}$

4. No owner has given first-hand evidence to the Committee that his or her signature on a proxy form had been forged, or that a proxy had been used without authority. Mr Kong Cheung Fat accepted that, although allegations of fake proxy votes had been made, no substantive evidence was found to prove them.$^{121}$

5. The practice for collecting proxies was described by Mr Tsui Moon Come Tony, Chairman of the second term of the $12^{th}$ Management Committee. In brief, proxy forms were deposited by owners into a collection box on an anonymous basis around 14 days before a meeting. Proxies were not signed in the presence of the IO or ISS, and no one verified the authenticity of the proxies or the signatures on them. ISS would issue a receipt to the mailbox of units which submitted proxy forms.$^{122}$ At the meeting, owners and proxies produced identity cards and were checked against unit records before ballots were issued. A summary list of units that had lodged proxies (授權一覽表) was posted at the venue, showing the units that lodged proxies but not the identity of the proxy-holders.$^{123}$

6. Mr Tsui confirmed that the practice for collecting proxies remained unchanged before and after his Committee took office on 6 September 2024.$^{124}$ Notably, despite the misgivings which Mr Kong Cheung Fat and other members of the new Committee have

120

[T15/3:14-29]

[T15/7:18-36]

[T14/15:12-34]

[T14/16:1-14]

[T14/15:12-14]

expressed about the collection of proxies at previous meetings, they maintained the same mechanism after taking charge of the IO.

7. There were also allegations of District Councillors approaching and gathering proxies from residents under the guise of helping them apply for subsidies, as recorded in a complaint sent by Mr Tsui Moon Come Tony to the HAD.$^{125}$ The involvement of Madam Wong Pik Kiu in gathering proxies for the meetings on 11 December 2021 and 6 September 2024 is not disputed, as she accepted in her written answers to the Committee.$^{126}$ This leaves open the question as to whether any proxy form was obtained by deception or other improper means. While this question will be examined in Chapter 9, it is noted at this juncture that no owner has given first-hand evidence to that effect.

Against that context, the following resolutions were recorded in the minutes of the EGM:127

1. By a majority of 80.5% votes, the owners approved Option 3, i.e. the complete re-rendering of the external wall and re-tiling of mosaic tiles (重鋪外牆批盪及紙皮石方案).$^{128}$

2. By a majority of 76.82% votes, the owners resolved to replace existing windows of emergency stairs with fire-rated windows (更换為防火窗).$^{129}$

3. By a majority of 54.79%, the owners resolved to appoint PC&E as the main contractor of the renovation works,$^{130}$ at a contract sum of approximately HK$330 million.$^{131}$

C6. Replacement of the Management Committee

Following the EGM, there were several attempts by residents to call for meetings to nullify the resolution to appoint PC&E as the main contractor.$^{132}$

Between February and May 2024, residents requisitioned the then Chairman of the Management Committee, Mr Tang Kwok Kuen, to convene an EGM. When Mr Tang failed to accede to their request, the residents made complaints to the HAD, which issued four advisory letters to Mr Tang advising him to convene the EGM within 14 days, as required by the Building Management Ordinance (Cap. 344).$^{133}$ The residents' requisition was withdrawn some time before 3 May 2024.$^{134}$

The Contract for the Prescribed Repair Works (“Works Contract”) was executed on 16 April 2024 at a final contract sum of HK$336,616,277.$^{135}$ The Works Contract was signed by Mr Tang Kwok Kuen on behalf of the IO, Mr Hau Wa Kin on behalf of PC&E and Mr Wong Hap Yin Jason on behalf of Will Power.$^{136}$

In June 2024, solicitors acting for the IO issued a letter to the owners, demanding payment for the BMR Works in the sums of HK$156,602 (Flats

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3 and 7), HK$169,654 (Flats 2, 4, 6 and 8) and HK$182,702 (Flats 1 and 5) in six instalments due within a period of seven months.$^{137}$

The tight payment schedule gave rise to significant concerns. On 18 June 2024, the former Management Committee extended the payment deadline from 15 February 2025 to 31 May 2025. Residents nonetheless pressed on, hoping to further extend the payment schedule. After television coverage of the dispute in an episode of “Scoop” (東張西望) on 7 July 2024, residents gathered at a nearby school park, formed a residents’ monitoring group and began collecting the 5% of signatures required to requisition an EGM.$^{138}$

Mr Tang once again failed to accede to the requisition within the 14-day period required by law. Complaints were made to the HAD, which issued four advisory letters to Mr Tang.$^{139}$ One of the letters noted that some residents planned to issue proceedings in the Lands Tribunal.$^{140}$

Eventually, an EGM took place on 6 September 2024. The owners resolved to remove the former Management Committee, and a new Management Committee chaired by Mr Tsui Moon Come Tony was elected. Mr Kong Cheung Fat was the only member of the former Management Committee who remained on the Committee.$^{141}$ The meeting turned contentious. At about 9:35 pm, the outgoing chairman Mr Tang announced that the venue hire had expired and the meeting had to be adjourned, prompting protest from the owners present. With the assistance of the HAD, the venue agreed to extend the hire and the meeting eventually completed at 10:55 pm.$^{142}$

Mr Tsui's evidence was that there was no handover of any kind from the former Management Committee. No documents had been passed over, and relations between the two committees remained poor. Nevertheless, the new Management Committee moved quickly to establish a works subgroup to monitor the BMR Works. On 7 September 2024, they opened a WhatsApp group (宏福苑大維修 Group) with Will Power, PC&E and ISS. The new Management Committee sought to improve transparency with residents, holding forty-four sessions, including works meetings every Saturday that were open to residents to attend.$^{143}$

The new Management Committee inherited the Works Contract, which had already been executed. For this reason, Mr Tsui believed it was impossible to remove PC&E and Will Power. While the new Management Committee was dissatisfied with PC&E and Will Power, they had to rely on them to complete the BMR Works.$^{144}$

Within those constraints, the new Management Committee negotiated the reduction of certain items of works. On 13 November 2024, they discussed with PC&E and Will Power the reduction of individual items from the scope of the BMR Works.$^{145}$ The reduction of work items was ultimately put to the owners at an EGM on 21 March 2025.$^{146}$

Subject to these reductions, the Works Contract continued to provide the basis for the conduct of the BMR Works, which the following Section addresses.

D. Progress of the BMR Works up to the Day of the Fire

D1. Contracted works and duties of PC&E and Will Power

The Works Contract provides the starting point for understanding the scope of the BMR Works and the duties of PC&E and Will Power.

The scope of the BMR Works was extensive, covering virtually all parts of the estate. The scope of works is summarised in broad terms in Part 2 of the Works Contract to include the following nine main items:147

1. Setting up of the construction site and other preparatory works;

2. Hacking-off of existing external wall plastering and renovation;148

3. Repair and renovation of indoor common areas;

4. Improvement works to FSIs (including the staircase windows and smoke doors on each floor);

5. Drainage pipes works;

6. Miscellaneous works (including repairs to the water tanks);149

7. Air conditioning drainage pipes works;

8. Repair of concrete window hoods on the external walls; and

9. Repair of concrete slabs on the external walls that support air conditioners.

147 [F1/4]

148 The scope of this work includes the common external and internal walls, corridors, external and internal staircases and decks, the CLP substation, all common facilities rooms (including pump rooms and lift machine rooms), the exterior of the concrete water tanks, and the walls, ceilings, beams, joists, boundary walls, columns and structural elements of common facilities, etc; but excludes the main rooftop, all concrete window hoods on the external walls, and the tops and interiors of the concrete water tanks.

149 The bill of quantities specifies that repairs to water tanks fall under item 6 [F1/101].

Crucially, PC&E owed an express duty to coordinate and strengthen fire prevention measures to protect the life and property of building owners (承判人須於施工期間適當地配合及加強大廈安全及防火措施，以保障大廈業主之生命及財產), pursuant to the standard form of contract.$^{150}$

Relevant to the combustible materials found on the scaffolding is PC&E's duty under the conditions of tender in Part 4 of the Works Contract to clear away any rubbish and debris in a timely manner:

1. It was agreed that no materials, waste or debris should be stored on the scaffolding (except for temporary use) and should be cleared before the end of each working day (棚架上不得存放材料、廢料或泥頭垃圾，除非只作暫時用途，承建商必需於每日收工前立刻清走所有材料、廢料或泥頭垃圾).$^{151}$

2. This duty is repeated in other terms of the Works Contract.$^{152}$

The particular specifications of the repair works and construction materials were set out in Part 6 of the Works Contract,$^{153}$ with Part 7 containing the bill of quantities, a breakdown of the price with reference to each item of work.$^{154}$ The following clauses are relevant to various aspects of the state of the BMR Works on the day of the fire:

1. The specifications required PC&E to source and supply a double-layered scaffolding net.$^{155}$ In the event of a typhoon, PC&E was required to remove the nets and canvases from the scaffolding and to re-install them once the typhoon had passed. PC&E was

responsible for all damage to scaffolding caused by typhoons, and associated repair costs were included in the tender price.$^{156}$ The relevance of this will become clear later on, as the scaffolding nets at Wang Fuk Court had been damaged by multiple typhoons.

2. The specifications also required PC&E to install temporary steel covered pedestrian walkways (臨時鋼鐵有蓋行人通道頂蓋).$^{157}$ These steel covered walkways had not been constructed by the time of the fire.$^{158}$

3. In relation to the renovation of the external walls, PC&E was under a duty to implement adequate measures to protect the buildings and to supply sufficient protective boards.$^{159}$

4. In relation to the renovation of water tanks, the specifications in Clause 13 of Part 6 of the Works Contract provide that, unless otherwise specified, the renovation of water tanks shall include the FS Tank, fresh-water tank and the flush water tank. Where necessary, PC&E was required to provide a temporary water tank of equivalent capacity to maintain supply of water while the relevant water tanks were being water-proofed and re-�iled, and on completion to re-connect the pipework to the renovated water tank and remove the temporary tank.$^{160}$

Will Power, as the consultant, was under a duty to review and supervise the repair works.161 The following provisions suggest that Will Power’s role under the Works Contract was one of constant, close supervision:

1. PC&E was to provide a written report of the progress of the works to Will Power every week to facilitate supervision of the works. Upon completion of a particular item of work, PC&E must obtain Will Power’s approval of those works before proceeding to the next item of work. Further, the materials used for the repair works must be first approved by Will Power (任何工程中所採用之材

料，必須經工程顧問代表認同及批准方可使用).162

2. Will Power had the power to request PC&E to cease employing any construction worker whose performance or conduct is unsatisfactory.163

D2. The phasing of the works

Before its appointment as main contractor, PC&E issued a document dated 10 November 2023 answering questions raised by Will Power about the proposed works. PC&E proposed that the works would be conducted in two stages, with the completion of scaffolding in four blocks before erecting scaffolding in the remaining blocks.164

Subsequently, the Works Contract set out a provisional plan, subject to the final decision by the IO, for the works to be carried out in three phases. Phase I would begin with the renovation of one block, Phase II with the renovation of a further three blocks, and Phase III with the renovation of

161 Clause 3 (COT/08) of Part 4, Works Contract [F1/32]

162 Clauses 4.4-4.6 (COT/03-04) of Part 4, Works Contract [F1/27-28] 163 Clause 24 of Part 5, Works Contract [F1/48]

164 [O1/701]

the remaining four blocks. The works for each block would be completed within 360 working days.$^{165}$

The staged approach was discussed at a works meeting (工程曾議) on 9 May 2024, attended by representatives of the former IO, ISS, Will Power and PC&E. The works were proposed to be conducted in three rolling phases (流水式分期作業方式) with a “3-3-2” split, with Phase I involving Wang Cheong, Wang Shing and Wang Chi House (Blocks F, G and H), Phase II involving Wang Sun, Wang Kin and Wang Tai House (Blocks C, D and E), and Phase III involving Wang Yan and Wang Tao House (Blocks A and B).$^{166}$

The 3-3-2 rolling phased approach was approved at a subsequent works meeting on 30 May 2024. It was also unanimously agreed that the works would officially commence on 16 July 2024, with the preliminary works (such as the installation of a temporary office and toilet) commencing in mid-June 2024.$^{167}$

The progress reports prepared by PC&E from 15 August 2024 to 22 November 2025 provide a periodic record of how the three rolling phases of the works were carried out in practice. The progress reports were presented and discussed at the works progress meetings attended by PC&E, Will Power, ISS, the IO and residents.$^{168}$

As to the progress of the Phase I works, namely, in Wang Cheong, Wang Shing and Wang Chi House (Blocks F, G and H):

1. The scaffolding for Phase I began to be erected on 16 July 2024.$^{169}$

2. According to PC&E's progress report dated 17 September 2024,170 by that date the scaffolding had already been fully erected on the Phase I blocks, with scaffolding nets fully installed.171

3. The covering of windows with polystyrene foam boards was regarded as protection works under item 1.8 of the bill of quantities.$^{172}$ By a notice issued by PC&E on 23 August 2024, residents of Wang Cheong House (Block F) were informed that, from 30 August 2024 to 31 October 2024, works would be conducted to cover windows with protective foam boards and to saw-cut the window-side concrete.$^{173}$

4. The protection works, including the covering of windows with foam boards, were completed for 100% of the Phase I units by the week of 9 November 2024.$^{174}$

As to the progress of the Phase II works, namely, in Wang Sun, Wang Kin and Wang Tai House (Blocks C, D and E):

1. The scaffolding under Phase II began to be erected on 25 September 2024 after completion of the erection of scaffolding in Phase I.$^{175}$ The erection of scaffolding for Phase II was completed in the week of 2 November 2024, with scaffolding nets fully installed.$^{176}$

170     [M1/932]
171     [M1/935-937]
172     [F1/189]; Item 1.8 of Part 7, Works Contract [F1/86]
173     [F1/212-213]
174     [M1/1010]
175     [M1/956]
176     [M1/1002, 1006]

2. The protection works in Phase II, including the covering of windows with foam boards, were 100% completed by the week of 11 January 2025.$^{177}$

As to the progress of the Phase III works, namely, in Wang Yan and Wang Tao House (Blocks A and B):

1. The erection of the scaffolding commenced on 3 December 2024,$^{178}$ and was completed in the week of 4 January 2025, with scaffolding nets fully installed.$^{179}$

2. The protection works, including the covering of windows with foam boards, were planned to be commenced from the week of 20 December 2024.$^{180}$ The percentage completion of the protection works, as stated in subsequent progress reports, was unreliable.$^{181}$ The clear inference is that the Phase III protection works had been completed by 8 March 2025, as they were no longer listed as works required to be conducted.$^{182}$ Further, the windows would have to be covered by foam boards before the hacking-off works, which were well underway by 8 March 2025.$^{183}$

Therefore, the progress reports indicated that the scaffolding was erected in three sequential phases. However, the substantive works did not proceed one phase after another. Instead, the substantive works across the three phases overlapped and were carried out concurrently for almost a year until the day of the fire:

177 [M1/1096]

178 [M1/1048]

179 [M1/1085, 1090]

180 [M1/1076]

$^{181}$ The progress of protection works remained at 30% as late as May 2025 [M1/1228], which is contrary to the evidence and likely to be erroneous.

[M1/1144]; compare [M1/1133].

183 [M1/1141]

1. The progress reports and the situation on site made clear that the substantive works in Phases II and III commenced well before the substantive works in Phase I had been completed. When the Phase III scaffolding works commenced on 3 December 2024, the Phase I hacking-off works were 95% complete and the Phase II hacking-off works were 25% complete, with most of the remaining work items yet to be commenced across all eight blocks.$^{184}$

2. Moreover, the final progress report dated 22 November 2025 indicated that Phase I had yet to complete its rendering, tiling, and air-conditioning concrete hood works.$^{185}$

This meant that, for nearly a year until the day of the fire, Wang Fuk Court's residents had been living their day-to-day lives within the confines of the scaffolding and behind windows covered by opaque foam boards that blocked light and the view outside. A resident, Madam Tse Yuk Wa, testified that she rarely opened her window once the foam boards had been installed, because looking out revealed only rubbish and debris, leaving the environment outside too poor (太惡劣) to open the window at all.$^{186}$

Importantly, the concurrent enclosure of all eight blocks with combustible materials for a substantial period gave rise to obvious fire hazards.

Mr Tsui Moon Come Tony's evidence was that, shortly after the appointment of the new Management Committee in September 2024, it asked PC&E whether each phase could be completed before the next phase commenced. A reason for this request was a safety concern arising from the works being carried out concurrently across all eight blocks. PC&E declined on the basis of the resulting delay and additional bond and insurance costs, and the risk of losing its experienced scaffolding crew who might not be available in later phases. PC&E asserted that the previous

Management Committee had already given approval to the works proceeding together.$^{187}$

A related question is whether the foam boards could have been removed from the windows once the hacking-off works on the external walls were completed:

1. The evidence is that the hacking-off works were completed in the week of 14 December 2024 for Phase I, the week of 29 March 2025 for Phase II and the week of 26 April 2025 for Phase III.$^{188}$

2. Mr Zhang Minghai, a sub-subcontractor responsible for the hacking-off works in Wang Tao House (Block B), testified that he was instructed by Mr Yiu Kam Fai of Shing Construction not to remove the foam boards from the windows after the hacking-off works were completed.$^{189}$

3. Mr Tsui Moon Come Tony testified that the foam boards were not removed after the hacking-off because they served to protect the windows from stone and debris dislodged by the remaining works (such as works on the air-conditioning platforms). He accepted, with hindsight, that the new Management Committee had not explored carrying out the hacking-off one elevation (i.e. one face of the building) at a time and removing the foam boards when each elevation was completed.$^{190}$

D3. The works on the external wall

The works on the external wall were one of the most significant aspects of the renovation: the costs for these works amounted to HK$224,354,360,

187	[T14/21:7-22:18]
188	[M1/1061, 1162, 1217]
189	[T13/47:7-14]
190	[T14/29:14-35]

around two-thirds of the total contract price. These works were conducted by subcontractors engaged by PC&E.

The sequence of external wall works to be performed involved twelve steps that can be broadly categorised into three stages:191

1. The hacking-off and removal of original external wall tiling and removal of air conditioning units;

2. The repair of underlying concrete and rendering (including waterproofing); and

3. The retiling of external wall with new tiles, reinstallation of air conditioning, and washing of the finished wall surface.

The external wall works were intended to be carried out in rolling phases. Phase I (Wang Cheong, Wang Shing and Wang Chi House) was scheduled to begin on 8 October 2024,192 Phase II (Wang Sun, Wang Kin and Wang Tai House) on 18 December 2024,193 and Phase III (Wang Yan and Wang Tao House) on 15 February 2025.194

According to PC&E’s progress reports, the works did not strictly adhere to this schedule. The actual progress of the external wall works was as follows.

As to the first stage, the hacking-off works:

1. By 27 September 2024, Phase I hacking-off of the old tiles was 11% completed.195

191 Progress report dated 15 August 2024 [M1/903]; Works Contract, Part 7 [F1/87-92] 192 [F1/189]

193 [F1/190]

194 [F1/191]

195 [M1/958]

2. By 7 December 2024, Phase I hacking-off was 95% completed, with Phase II hacking-off 25% completed.$^{196}$

3. By 21 February 2025 Phase I hacking-off was 100% completed, with Phase II 83% completed, and Phase III 19% completed.$^{197}$

4. By 26 April 2025, the hacking-off works in all blocks had been 100% completed.$^{198}$

As to the next stage of external works, namely, the repair of underlying concrete, rendering and waterproofing:

1. The underlying concrete would first be repaired (described by the progress reports initially as “Hammer Tap & Concrete Repair”), before waterproof rendering works were carried out.

2. By 7 December 2024, the hammer tap and concrete repair works in Phase I were 40% completed.$^{199}$

3. By 4 January 2025, the hammer tap and concrete repair works for Phase I were 100% completed, with waterproof rendering 22% completed. Hammer tap and concrete repair works for Phase II were 20% completed.$^{200}$

4. The description of works changed in the work progress report on 21 February 2025.$^{201}$ The item “Hammer Tap & Concrete Repair” was renamed as “Ext Wall”. The completion percentage for this item remained at 100% for Phase I and 20% for Phase II. The “Ext

196	[M1/1050]
197	[M1/1130]
198	[M1/1217]
199	[M1/1050]
200	[M1/1085]
201	[M1/1130]

Wall” work item included two sub-items, “Ext Wall Concrete Repair” and “AC Hood Concrete Repair”. For the Phase I blocks, the completion percentages were 70% for the former sub-item and 30% for the latter sub-item.

5. Will Power subsequently reported that, following the hacking-off works, the window hoods (窗眉) were found to suffer from serious spalling and a shortage of steel reinforcement. An EGM was convened on 21 March 2025, at which the owners resolved to repair the hoods according to their existing condition (92.26%) and separately resolved to fund the rebuilding of severely dilapidated hoods by a capped lump sum of HK$16.5 million (89.45%).$^{202}$

6. During the works meeting on 29 March 2025, PC&E applied for an extension of the works period, so as to implement the owners' resolution to repair the hoods.$^{203}$

7. The progress report of the same date (29 March 2025) recorded the waterproof rendering item as “-” across all Phases.$^{204}$ This reflected the need to complete the hood repairs before rendering could continue.

8. By 12 April 2025, waterproof rendering was described at 3% for Phase I, indicating that the rendering works had resumed. Waterproof rendering remained at 3% for Phase I and “-” for Phases II and III up to and including 9 May 2025.$^{205}$

9. The format of the progress reports changed from the progress report dated 24 May 2025 onwards. Under the new format, the percentage completion of works was no longer listed, and the items

202	[G1-2/1527-1528]
203	[H1-3/6079]
204	[M1/1162]
205	[M1/1228]

were described differently.$^{206}$ The progress of the works could still be ascertained from the table entitled “Works to be Conducted in Upcoming 2-Weeks Period”.$^{207}$

10. By 5 July 2025, concrete repair was no longer listed as a work item under “Works to be Conducted in Upcoming 2-Weeks Period” for any of the Phases. It is to be inferred that the concrete repair process had been completed across all blocks.$^{208}$ Meanwhile, rendering works continued for all three Phases.

11. The final progress report on 22 November 2025 continued to list “Rendering” (批盪) as works to be conducted in all 3 Phases in the upcoming two-week period.$^{209}$ The report also included charts which listed the remaining rendering and tiling works on a unit-by-unit basis.$^{210}$

As to the final stage of the external works, namely, the re-tiling of mosaic tiles and stone-washing:

1. By 9 May 2025, “Tiling” was listed under “Works to be Conducted in Upcoming 2-Weeks Period” for the first time for Phase I.$^{211}$ By 24 May 2025, tiling was also listed for Phase II.$^{212}$

2. By 13 September 2025, the unit-by-unit progress charts recorded that tiling works had begun in the Phase III blocks, whereas tiling works for Phases I and II were continuing.$^{213}$

3. The final progress report recorded that tiling works were ongoing as at 21 November 2025.$^{214}$ It is to be inferred that such works were continuing until the day of the fire.

4. Since tiling had been completed on the Flat 2-3 sides of the external wall of Wang Cheong House (Block F), stone-washing was underway on those sides until the day of the fire.$^{215}$ However, only a part of the external walls of Block F had reached that final stage, and the tiling of the remaining external walls of other blocks had not been completed.

In summary, as at the date of the fire, the hacking-off works had been completed across all blocks, but the majority of blocks were undergoing rendering and tiling processes.

The following sub-sections will focus in greater detail on specific aspects of the works which concern fire safety.

D4. Use of scaffolding nets, plastic sheeting and toe boards

The scaffolding nets, plastic sheeting and toe boards were used in Wang Fuk Court to prevent tools, materials and debris from falling off the scaffolding.

(i) Scaffolding nets: the documentary and witness evidence

The requirement that scaffolding nets be fire-retardant was discussed before the scaffolding was erected. In this context, fire retardancy refers to the property of a material that enables it to resist ignition and selfextinguish once the external heat source is removed, rather than sustaining and propagating the flame.216

1. At the 30 May 2024 works meeting, PC&E informed the attendees that the scaffolding nets would be of fire-retardant quality (外牆

棚網具有阻燃性).217

2. In a works meeting on 17 June 2024, Will Power reminded PC&E to strictly adhere to the requirements of the BD’s Practice Note APP-70 and submit the fire-retardancy certificate for the scaffolding nets. PC&E was also asked to conduct an on-site testing of the fire-retardancy of the scaffolding nets (“工程顧問提

醒承建商必須嚴格按照屋宇署作業守則 APP-70 方面的規定

並提交遮布棚網耐燃証書，如合適最好於現場進行測試”).218

3. Practice Note APP-70 issued by the BD in May 1995 stipulates that plastic sheeting covering scaffolding must be flame-retardant, and that obstruction to natural ventilation and lighting of occupied buildings should be avoided as far as practicable.219

Three days later, on 20 June 2024, PC&E entered into a sub-contract with Gain Profit (盈利豐棚業有限公司) by which scaffolding works at Wang

Fuk Court were sub-contracted to Gain Profit for a contract price of

216 IC Expert Report §3.6.7 [ER3/2181] 217 [H1-3/6134-6135]

218 [H1-3/6131]

219 [J1-1/688]

HK$3.15 million per block.220

1. The sub-contract required Gain Profit to comply with applicable laws and regulations regarding scaffolding nets.221

2. The sub-contract enclosed Gain Profit’s quotation dated 29 May 2024, which provided that Gain Profit was to install a dual-layered fire-retardant scaffolding net (鋪雙砧阻燃網).222

3. Clause 12 of the terms and conditions further stipulates that Gain Profit is responsible for maintaining and repairing the scaffolding. It was agreed that, during typhoon seasons, Gain Profit must immediately adopt appropriate measures and follow-up on the state of the scaffolding and scaffolding nets. Such extra maintenance and repair costs were to be borne by Gain Profit who could not seek compensation from PC&E.223

The person-in-charge at Gain Profit was Mr Chan Yiu Fai (陳耀輝), who

has provided a witness statement. Mr Chan accepted that the scaffolding nets used must be of a fire-retardant quality. His evidence is consistent with the quotation issued by Gain Profit on 29 May 2024, as mentioned above.224

In July 2024, Gain Profit purchased the first batch of scaffolding nets for the Phase I blocks from Shandong Chenxu (山東宸旭化纖繩網有限公司).

Mr Chan’s evidence was that Gain Profit acquired 1,500 units of fireretardant nets from Shandong Chenxu for the purposes of Phase I of the

220 [Q1/8]

221 [Q1/8]

222 [Q1/11]; also [M1/167]

223 [Q1/9]

224 Chan Yiu Fai WS §§6 & 8 [WS2/1432-1434]

works.225 Delivery of the scaffolding nets was recorded in a delivery note dated 17 July 2024. 226

According to a fire-retardancy certificate dated 8 January 2024, Shandong Chenxu submitted scaffolding nets for testing by the National Quality Supervision and Inspection Centre for Labour Protection Products (Beijing) (國家勞動保護用品質量監督檢驗中心（北京）). 227 The certificate

stated that: (i) the fire-retardancy was tested according to the criteria in the national standard GB5725-2009; (ii) the test result was that the scaffolding net was ignited for 0 seconds in the after-flame test (i.e. it passed the test, which required flames to self-extinguish within four seconds of removal of the source of ignition).

The authenticity of the fire-retardancy certificate dated 8 January 2024 has been put in issue:

1. The certificate was issued in the name of “國家勞動保護用品質

量監督檢驗中心（北京）” (National Quality Supervision and

Inspection Centre for Labour Protection Products (Beijing)). That, however, was the institution’s former name. Prior to the date of issuance of the certificate, the centre had adopted the new name “國家勞動保護用品質量檢驗檢測中心（北京）”, omitting the

two characters “監督” (supervision) from its title.228 It is unlikely

that a genuine certificate would bear an obsolete name of the issuer.

2. Mr Andy Ku of the ICU accepted in evidence that, although no one at the ICU noticed the discrepancy when the certificate was received, after the fire, the ICU checked the accreditation number

225 Chan Yiu Fai WS §8 [WS2/1433-1434] See [D1/1604]

226 [D1/1604]

227 [D1/1599-1601]

228 [T1/35:17-18] The change of title was directed by the State Administration for Market Regulation, in accordance with the《市場監管總局關於進一步加強國家質檢中心管理的意見》

(

2021

)

16 號, dated 31 March 2021.

on the certificate and noted the two-character difference in the name of the issuing institution. The ICU’s post-fire checks therefore establish that the certificate was not genuine.229

3. Further, the ICU conducted an on-site burning testing of the scaffolding nets on 28 October 2024. One test showed that a scaffolding net continued to burn for over 10 seconds after the lighter was removed from the net and had to be blown out.230 Dr Lee Wing Man of the Government Laboratory testified that, based on the video of the tests on that day,231 she was of the opinion that there was cause for follow-up tests to be conducted in a laboratory setting.232

Mr Chan Yiu Fai claimed that, in September 2024, Gain Profit acquired additional fire-retardant nets from a new supplier, Binzhou Yuanjin (濱州

市源進化纖繩網有限公司 ), which were used in Phase II of the

scaffolding works. He suggested that the nets acquired from Binzhou Yuanjin were of a superior quality.233

In 2025, Hong Kong was struck by two No.10 typhoons – Typhoon Wipha (韋帕) on 20 July 2025 and Super Typhoon Ragasa (樺加沙) on 24

September 2025. Both typhoons inflicted severe damage to the scaffolding nets. After each typhoon, Gain Profit carried out repair works to replace the damaged nets.

In particular, after Typhoon Wipha struck on 20 July 2025:

229 [T22/51:26-29, 52:11-20]

230 [A2/94]

231 Including the re-tests of the same piece of scaffolding net after the first failed attempt, which Dr Lee observed were conducted at an angle and distance from the fire which made it more difficult to ignite compared to a laboratory setting [T25/46:17-23].

232 [T25/46:6-8]

233 Chan Yiu Fai WS §10 [WS2/1434-1435]

1. According to Mr Chan Yiu Fai’s account,234 he was asked by Mr Gordon Ho of PC&E to purchase non-fire-retardant scaffolding nets to replace the damaged nets. Mr Chan recalls a specific conversation where he explained to Mr Ho that it was not appropriate to use non-fire-retardant nets, to which Mr Ho instructed him to order as he was told, noting that Gain Profit would not be reimbursed if it ordered fire-retardant scaffolding nets (叫你訂就訂，唔使講咁多，你訂阻燃網都唔會找數俾

你).

2. The Committee does not have a contemporaneous record of the conversation between Mr Chan Yiu Fai and Mr Gordon Ho. Nevertheless, the conversation was mentioned during the opening statement of Counsel for the Committee, and Mr Ho has had an opportunity to respond to Mr Chan’s evidence.

3. Mr Gordon Ho’s two witness statements did not contradict Mr Chan’s account. In his latest witness statement submitted on 2 July 2026, Mr Ho admitted that scaffolding nets were replaced after the typhoon in July and that another replacement took place after the typhoon in September. He was unable to state what percentage of the nets came from which batch but believed that the first batch constituted the largest portion. As such, he claimed that “the majority of the scaffolding nets were of a high quality and were priced above the level of standard products”.235 This statement is notable because Mr Ho did not deny the fact that the scaffolding nets which replaced the damaged nets were not fire retardant.

4. Gain Profit placed orders on 22 and 24 July, 16 August and 3 September 2025 for a total of 900 units of 1.8m x 18m scaffolding nets from Lam Kee (林記建築材料) at a price of HK$54 per unit,

234 Chan Yiu Fai WS §14 [WS2/1437]

235 Gordon Ho 2nd WS §§32-33 [WS24/2634]

a different supplier from Shandong Chenxu, the initial supplier for the scaffolding nets.$^{236}$

5. In its letter in response to questions from the Committee, Lam Kee explained that all scaffolding nets were sold according to client specification, and that aside from a subsequent order on 27 October 2025, all of the orders placed by Gain Profit were expressly for non-fire-retardant nets (其他宏福苑的訂單客戶均指明不需要阻燃效能的防護網).$^{237}$ Mr Chan Yiu Fai also admitted that he had arranged for his wife, Madam Zhong Fengping (鍾鳳平), to purchase non-fire-retardant nets from Lam Kee.$^{238}$

160. After Super Typhoon Ragasa struck on 24 September 2025:

1. Mr Chan Yiu Fai's evidence was that Super Typhoon Ragasa caused more serious damage to the scaffolding nets than Typhoon Wipha. Mr Chan admitted that, pursuant to Mr Gordon Ho's instructions, the scaffolding nets ordered to replace the damaged nets following Super Typhoon Ragasa were not fire-retardant.$^{239}$

2. On 25, 26 and 30 September and 2 October 2025, Gain Profit placed further orders with Lam Kee for a total of 1,400 units of 1.8m x 18m non-fire-retardant scaffolding nets at a unit price of HK$54.$^{240}$

3. Gain Profit purchased further replacement nets from Binzhou Yuanjin (濱州市源進化纖繩網有限公司). WeChat discussions between Mr Chan and a representative of Binzhou Yuanjin on 25

236 [S1/1-5]

$^{237}$ Letter from Lam Kee to the Committee §3.1 [WS2/1557]

238 Chan Yiu Fai WS §14 [WS2/1437-1438]

239 Chan Yiu Fai WS §16 [WS2/1438-1439]

240 [S1/6-9]

and 28 September 2025 recorded that Mr Chan ordered 2,500 units of green non-fire-retardant scaffolding nets (綠色不阻燃) of 1.8m

x 17m per unit at a price of RMB 24 per unit.241

4. On 27 September 2025, a works progress meeting was held between the IO, PC&E, Will Power and ISS. In the meeting, PC&E confirmed that they would only replace nets that had been damaged and those that had lost their protective function, and would not replace all nets across the estate. 242 There was no disclosure of the fact that non-fire-retardant nets were used.

On 13 October 2025, Mr Chan Yiu Fai sent a voice message to Binzhou Yuanjin’s representative through WeChat, asking whether he could buy fire-retardant agents (阻燃劑) to change the nets to fire-retardant ones.

Binzhou Yuanjin replied that it was not possible.243

Mr Chan’s enquiry proved timely:

1. On 18 October 2025, a fire broke out at the scaffolding of the Chinachem Tower in Connaught Road Central.

2. This prompted the BD to issue a Circular Letter on 21 October 2025, calling on registered building professionals and registered contractors to take immediate action to inspect and ascertain that the protective net, screen, tarpaulin and plastic sheeting installed at the façade of buildings possess fire retardant properties in compliance with recognised standards, and reminding them of potential disciplinary action should materials with inadequate fireretardant properties be discovered to have been used.244

241 [A2/111]

242 [H1-3/6116-6117] 243 [A2/111]

244 [J1-2/6192-6193]

3. The ICU sent an email on 27 October 2025 to remind Will Power to comply with the BD's Circular Letter.$^{245}$

The Chinachem Tower fire prompted serious unease among residents. In a Facebook group for Wang Fuk Court's residents, one user mentioned (in a remark that now feels unsettlingly prescient) that if a similar fire occurred in Wang Fuk Court, it could send several hundred people to their deaths in a sea of fire (看见中環大火焼棚架，如果大維修的大廈同樣大火，可以做成數百人一同葬身火海).$^{246}$

On 23 October 2025, Mr Kong Cheung Fat sent an email to Ms Amanda Lau of the ICU to follow up on a complaint he had sent earlier (which the ICU received through 1823 on 3 October 2025$^{247}$) concerning scaffolding nets that were damaged after the typhoons. He noted the concerns from residents about the deteriorating state of the scaffolding nets following the Chinachem Tower fire and urged the ICU to carry out inspections.$^{248}$

On 25 October 2025, PC&E reported at a work progress meeting attended by the IO, PC&E, Will Power and ISS that the damaged scaffolding nets (except the rain canopies and catch-fans) had been replaced completely. No disclosure was made to the IO that the replacement nets were non-fire-retardant.$^{249}$

In response to Mr Kong's enquiry, the ICU arranged for an inspection. The following events occurred on 27 October 2025:

1. At 8:50 am, Ms Amanda Lau of the ICU sent a WhatsApp message to Mr Yeung Tsz Man (楊子文) of Will Power to arrange for an inspection in the afternoon of 28 October 2025. At 10:10 am, Ms

245     [I1-4/8913]
246     [O1/54]
247     [O1/52-53][I1-4/8689-8700]
248     [O1/52]; for a similar enquiry/complaint sent via 1823, see [O1/48].
249     [H1-3/6124]

Lau asked Mr Yeung to arrange for Mr Sam Tam (譚雋生) of PC&E to attend the inspection, and noted that the ICU wished to understand the specifications and fire retardancy of the old nets and the new nets installed after the typhoon (了解舊棚網與新棚網的規格與阻燃能力), further stating that Mr Andy Ku wished to sample-test at every block (古 sir 想安排每一座抽查試驗).$^{250}$

2. By 9:54 am, Mr Sam Tam messaged Mr Hau Wa Kin, expressly marked “not to be disclosed” (不公開), that the ICU would attend the site the next afternoon to burn-test the nets (明天下午預 ICU 到地盤預要燒棚網 check 定邊啲 ok).$^{251}$

3. Mr Chan Yiu Fai's evidence was that, on the same day (i.e. 27 October 2025), he received instructions from Mr Gordon Ho of PC&E to urgently replace the non-fire-retardant nets at the bottom of the scaffolding (棚腳) to fire-retardant ones, in anticipation of an inspection by the $LD.^{252}$

4. Accordingly, Gain Profit purchased 115 units of 1.8m x 18m fire-retardant nets from Lam Kee at a price of HK$100 per unit on 27 October 2025.$^{253}$ Lam Kee confirmed that this was the only fire-retardant batch it ever sold to Gain Profit, the price difference (HK$100 as against HK$54 per unit) reflecting the incorporation of fire-retardant agent in fire-retardant nets.$^{254}$

According to Mr Andy Ku's evidence about the ICU's inspection on 28 October 2025:

250
[I1-4/8766-8767]
251
[A2/95]
252
Chan Yiu Fai WS §17 [WS2/1439-1440]
253
[S1/12]
254
[WS2/1557]

1. The inspection followed the ICU's quick test method of burning nets with a lighter. The nets were sampled from readily accessible locations on the rooftop and ground levels.$^{255}$

2. The ICU considered that the quick tests did not give rise to specific concerns.$^{256}$

3. Mr Ku testified that had the ground-level nets (棚腳) not been switched, the deception by PC&E might have been discovered.$^{257}$

4. Mr Ku also confirmed that the ICU asked for but was not provided fire-retardancy certificates for the new nets. He explained that this was because Will Power represented to the ICU that the old and new nets were provided by the same supplier and that the same certificate was used.$^{258}$

On 20 November 2025, the LD inspected the site and asked for fire-retardancy certificates for the replacement nets. PC&E produced the same certificate dated 8 January 2024 purportedly issued by the National Quality Supervision and Inspection Centre for Labour Protection Products (Beijing),$^{259}$ which certificate PC&E had already produced to the LD some 16 months earlier. Madam Lam Sau Ching accepted that no one at the LD compared this certificate against the copy on file.$^{260}$

The representation to the ICU and the LD that the same fire-retardancy certificate applied to both the old and new nets was false. The replacements

255    [T22/55:7-12]
256    Ku Siu Ping 3rd WS §41 [WS14/2142]
257    [T22/60:19-20]
258    [T22/56:19-35]
259    [D1/1685-1687]
260    [T16/21:8-36]

were acquired from different suppliers261 expressly to a non-fire-retardant specification, at a lower price that reflected the lack of fire-retardant treatment. Had the replacement nets in fact been fire-retardant, PC&E could simply have produced a certificate for the new batch.

Taking into account the evidence above, the Committee is invited to find that a substantial proportion of the scaffolding nets enclosing the eight blocks at Wang Fuk Court at the time of the fire were non-fire-retardant nets acquired to replace those damaged in the typhoons:

1. Mr Chan Yiu Fai’s evidence was that Typhoon Wipha caused severe damage to the scaffolding nets (棚網嚴重損毁) and Super

Typhoon Ragasa caused even more severe damage (棚網損毁程

度比七月份的時候更為嚴重).262 As Mr Chan admitted, none of

the new nets used to replace the damaged nets was fire-retardant, save for the order of 115 units from Lam Kee on 27 October 2025 that was procured for the ICU’s inspection the following day.263

2. The purchase records alone demonstrate that at least 4,800 units of non-fire-retardant nets, each measuring 1.8m x 17m or 18m, were acquired between July and October 2025. The total surface area of these nets was approximately 150,000 m², an exceptionally large surface area by any measure.

3. By way of comparison, Mr Chan Yiu Fai’s evidence indicates that the initial batch of allegedly fire-retardant nets for Phase I of the works comprised only 1,500 units.264

261 Save that Mr Chan Yiu Fai claims that Binzhou Yuanjin had also supplied fire-retardant nets for the Phase II works.

262 Chan Yiu Fai WS §§14, 16 [WS2/1437, 1438-1439]

263 [S1/12]

264 Chan Yiu Fai WS §8 [WS2/1433-1434]

4. Had only a small or negligible proportion of the scaffolding nets been replaced, it would have been unnecessary for PC&E and Gain Profit to urgently replace scaffolding nets at accessible locations with fire-retardant nets upon being informed of the ICU's intended inspection on 28 October 2025. The very fact and timing of the urgent replacement shows their own understanding that the nets then enclosing the estate would fail inspection.

Further corroborating the extensive use of non-fire-retardant replacement nets is the photographic evidence. Scaffolding nets of a visibly lighter colour and greater translucency (characteristics which, on the evidence, distinguished the replacement nets installed after the typhoons$^{265}$) were seen in the area close to the seat of the fire at Wang Cheong House (Block F).

〔图〕插图

Figure 2-1: Photograph of the scaffolding nets during the initial stage of the fire at Wang Cheong House (taken by a worker on site)$^{266}$

The following photograph, taken on 8 October 2025 (i.e. two weeks after Super Typhoon Ragasa), shows significant areas of lighter-coloured nets alongside large sections still torn away or stripped, exposing the bamboo scaffolding beneath. The photograph demonstrates the scale of the netting replacement required at the time.

〔图〕插图

Figure 2-2: Photograph taken on 8 October 2025 showing the condition of scaffolding nets after Super Typhoon Ragasa $^{267}$

(ii) Scaffolding nets: the expert evidence

After the fire, tests were conducted by Dr Lee Wing Man of the Government Laboratory on the fire-retardancy of samples of scaffolding nets obtained from the scene.

Dr Lee explained that the national standard stipulated in GB5725-2009 required the after-flame time of both horizontal and longitudinal burning tests to be no more than 4 seconds after the source of flame was removed.

However, the standard required a sufficient number of specimens: 10 specimens for condition A and 5 specimens for condition B.$^{268}$

According to Dr Lee, there were limitations in her tests in terms of both sample size (as a substantial portion of scaffolding nets were destroyed by the fire) and the quality of the nets (as the quality of the remaining scaffolding nets could have been affected by the fire).$^{269}$ For example:

1. For Wang Cheong House (Block F), Dr Lee obtained 5 samples of scaffolding nets, out of which 4 failed the after-flame test.$^{270}$ However, Dr Lee pointed out that, as a result of the limitations identified above, this did not necessarily mean that 80% of the scaffolding nets in Block F were non-fire-retardant.$^{271}$

2. Dr Lee gave the same explanation for the tests conducted on samples taken from Wang Tai House (Block E), where both samples failed the after-flame tests.$^{272}$

3. As for Wang Sun House (Block C), there were not enough samples to conduct both a horizontal and longitudinal test.$^{273}$

4. On the other hand, for the remaining blocks, while it appeared that about 80% of the samples had an after-flame time of no more than 4 seconds, that does not establish that the majority of scaffolding nets on those blocks were fire-retardant. When it was put to her that the results might have reflected a “survivorship bias”, Dr Lee preferred to characterise the same point as a limitation in site

268     [ER2-1/487]
269     [T25/43:13-22]
270     [ER2-1/516-517]
271     [T25/46:28-47:15]
272     [ER2-1/476]; [T25/47:35-36; 48:1-5]
273     [ER2-1/476]

conditions.$^{274}$ Either way, it is submitted that the consequence is the same: the nets most completely consumed by the fire are under- represented in the samples, so the test results cannot be read as representative of the scaffolding nets installed before the fire.

176. As to Professor Richard Yuen's evidence:

1. Tests conducted in Sichuan to compare the characteristics of (i) fire-retardant scaffolding nets, (ii) non-fire-retardant nets,$^{275}$ and (iii) nets sampled from Wang Chi House (Block H) demonstrated that the nets sampled from Wang Chi House exhibited the fastest rate of fire spread and were eventually consumed by the fire.$^{276}$

〔图〕1086Z:91 270/97072026/04/2515:29:02\n

Figure 2-3: Photographs showing fire spread on fire-retardant nets (left) and Wang Chi House nets (right)$^{277}$

2. Full-size fire tests conducted in Sichuan (specifically, Tests 11 and 13) showed that the rapid development of the fire at Wang Fuk Court was “likely due to the use of non-FR safety nets and non-FR canvases. If FR materials had been used, the fire would have self-extinguished”.$^{278}$ Multiple videos and witnesses also confirmed that significant flaming droplets were observed from the nets at Wang Fuk Court,$^{279}$ which was consistent with non-fire-retardant behaviour. The combined effect of the safety nets collected from Wang Chi House and non-fire-retardant canvas was to transform a small fire into a rapidly spreading fire along the re-entrant.$^{280}$

3. Based on his scientific analysis, Professor Yuen agreed with Counsel for the Committee that, assuming all other variables at Wang Fuk Court remained exactly as they were – the only difference being that the scaffolding nets and canvases used on site possessed fire-retardant properties – the rapid vertical fire along the Wang Cheong House re-entrant would not have developed.$^{281}$ Professor Yuen also agreed with the learned Chairman that the non-fire-retardant netting was itself a very major factor in the rapid vertical fire spread within Wang Cheong House.$^{282}$

177. Professor Usmani and Professor Jiang reached similar conclusions:

1. In experiments conducted on scaffolding net samples collected from Wang Chi House (Block H), they observed that the nets generated dripping flames and propagated ignition very rapidly after the source of the fire had been extinguished, which was the behaviour of non-fire-retardant materials.$^{283}$ On the other hand,

samples collected from Wang Kin House (Block D) did not exhibit this behaviour and appeared to be fire-retardant.$^{284}$

2. According to their simulations, the non-fire-retardant nets acted as a continuous vertical wick that enabled the flames to propagate across the 31 levels.$^{285}$

3. Professors Usmani and Jiang agreed with Professor Yuen that, if the safety nets and canvases at Wang Fuk Court were fire retardant, the initial fire “may” have self-extinguished.$^{286}$ They agreed that the behaviour of non-fire-retardant nets played an important role in initiating the fire to unlock the energy inside the bamboo sticks. However, Professor Usmani emphasised that the operative word here is “may”,$^{287}$ and that there is an element of uncertainty.$^{288}$

The scientific evidence does not establish the exact proportions of fire-retardant and non-fire-retardant scaffolding nets on the day of the fire. In particular, Dr Lee Wing Man was unable to express a conclusive opinion on the fire-retardancy of scaffolding net samples obtained from the scene, owing to limitations arising from the site conditions. Even so, the evidence set out in Section (i) above – including the admissions from Lam Kee and Mr Chan Yiu Fai, the repeated deployment of the 8 January 2024 certificate that appears not to be genuine, and the photographs showing the scale of netting replacement after the two typhoons – provides a sufficient foundation for the Committee to make the relevant findings without laboratory precision.

Drawing all the threads together, the Committee is invited to conclude that a substantial proportion of the scaffolding nets enclosing the eight blocks

at Wang Fuk Court at the time of the fire were non-fire-retardant, even if fire-retardant nets may have been installed during the earlier stages of the works.

The use of a substantial amount of non-fire-retardant nets on the scaffolding was unacceptable. As the expert evidence suggests, it contributed significantly to the rapid spread of the fire at Wang Fuk Court.

(iii) Plastic sheeting and canvas

In addition to scaffolding nets, various types of plastic sheeting, also referred to as canvas (帆布), were also used around the scaffolding.

〔图〕8\n

(1) Green Safety Net

〔图〕C\n

(2) Blue white plastic sheeting

〔图〕8\n

(3) Green plastic sheeting

Figure 2-4: Photographs of plastic sheeting and canvas at Wang Fuk Court (extracted from Dr Lee Wing Man's presentation) $^{289}$

Dr To Chi Wing (Divisional Commander (Airport) of the FSD) testified that plastic sheeting and canvases were found on the flat-roof on the first

floor of each block (used as coverings to cover building materials stored in those locations) and were installed on the catch fans.$^{290}$

In the BD's Circular Letter dated 21 March 2023,$^{291}$ it was stated that protective net, screen, tarpaulin / plastic sheeting installed to cover the façade of buildings under repair or minor works should have appropriate fire-retardant properties in compliance with a recognised standard, including GB 5725-2009, BS 5867-2:2008 (Type B) and NFPA 701:2019 as examples.

Dr Lee Wing Man testified that the national standard GB 5725-2009 might not apply to materials other than safety nets, and that the British standard BS 5867-2:2008 (Type B) would apply to plastic sheeting and canvas.$^{292}$

Dr Lee Wing Man submitted a further statement dated 25 June 2026:

1. Dr Lee explained that, in accordance with the requirements of BS 5867-2:2008 (Type B), when a flame is applied to the specimen for 15 seconds under controlled conditions, no part of any hole nor the lowest boundary of any flame may reach the top edge or either vertical edge of the sample, and there must be no separation of flaming debris droplets.$^{293}$

2. Dr Lee tested four samples of plastic sheeting obtained from Wang Chi House.$^{294}$ The test results from these samples showed that, with the exception of one specimen, the flames or holes reached the upper or vertical edge of the specimens,$^{295}$ thereby failing the requirements in BS 5867-2:2008 (Type B). Most of the test

specimens were fully consumed in the tests (at §3.8). Dr Lee concluded that these samples were easily ignited by a small flame with remarkable spread, as well as generation of burning droplets which could aid the spread of fire (at §4.2).$^{296}$

Dr Lee Wing Man's evidence was that the tests conducted on the plastic sheeting found at the scene burned more severely than the safety nets,$^{297}$ and that all of these samples failed the applicable fire-retardancy standards (whichever standard was adopted).$^{298}$

Further, according to Professor Yuen, the large-scale fire tests in Sichuan demonstrated that it was the combination of non-fire-retardant safety nets with non-fire-retardant canvas that produced sufficiently excessive heat to ignite bamboo sticks. This showed that non-fire-retardant canvas played a critical role in accelerating fire growth, transforming limited and localised fires into a widespread and intense blaze across 31 levels along the re-entrant.$^{299}$

In light of the expert evidence, the Committee is invited to find that the plastic sheeting and canvas on the scaffolding at Wang Fuk Court on the day of the fire were not fire-retardant and contributed to the rapid spread of the fire.

(iv) Toe boards

Toe boards (踢腳板) were low, vertical barriers installed along the edges of the horizontal platforms of the scaffolding at Wang Fuk Court. Dr Lee Wing Man tested samples of toe boards obtained from various blocks at

Wang Fuk Court,$^{300}$ and observed that these were all orange-coloured corrugated polypropylene boards with 2mm thickness (at §3.6).$^{301}$

According to laboratory tests conducted by Dr Lee Wing Man, all of the toe board samples readily ignited after removing the direct source of the flame, sustained burning and generated burning droplets (at §§3.7 and 4.2-5.2).$^{302}$ The samples exhibited no sign of self-extinguishing.$^{303}$ The Committee is therefore invited to find that the toe boards used in Wang Fuk Court were non-fire-retardant.

D5. Foam boards and related window protection materials

Following the erection of the scaffolding, the external wall repair works were to commence. The first step of the process required the protection of windows from being damaged during the process of hacking-off the existing external wall.

Concerns regarding the flammability of foam boards proposed to be used as window protection were raised as early as the works meeting on 17 June 2024.$^{304}$

1. Will Power noted a concern that foam boards were readily ignited (易燃) and would generate a large amount of smoke when burned. It suggested using plywood (甲板) as an alternative material. PC&E replied that the protective functions of such alternative materials were poor compared to foam boards.

2. In the end, Will Power observed that each product had its pros and cons, but maintained the view that the use of foam boards carried

300 [ER2-1/467-468] 301 [ER2-1/469] 302 [ER2-1/470-471] 303 [ER4/2481] 304 [H1-3/6131]

a greater risk (發泡膠存在較大風險). Will Power stated that if PC&E insisted on using foam boards, it must consider the relevant risks and implement appropriate measures.

On 17 July 2024, PC&E issued a letter to Will Power (copying the IO and ISS) noting that approval had been given for the use of foam boards as window coverings at a works meeting on 16 July 2024. While there is no record of approval at any meeting on 16 July 2024, Will Power approved the contents of the letter with its chop and signature on 18 July 2024.$^{305}$ The letter did not record that PC&E proposed any measures to address the fire safety risks of using foam boards.

Thereafter, the first batch of orders began to be placed for foam boards from late August 2024:

1. Hoi Tak (海德營造工程有限公司), the subcontractor responsible for plastering works on the external walls of Wang Kin, Wang Tai and Wang Cheong House (Blocks D to F), placed three orders for foam boards (擠塑板) from Hubei Yubo (湖北宇博節能新材料有限公司) on 26 August, 3 September and 19 September 2024.$^{306}$

2. It was stated on the 19 September 2024 order that the foam boards were not fire-retardant (擠塑板(非阻燃)).$^{307}$ While the other two orders did not state whether the foam boards ordered were fire-retardant, the unit price for the foam boards was the same as that of the order of 19 September 2024 (RMB 350-360 per m$^{3}$).$^{308}$

By four invoices dated 27 August, 3 September, 9 September, and 17 September 2024, Hang Fung(恒豐營造工程有限公司), an associated

305 [F1/297] 306 [C1-2/1099-1127] 307 [C1-2/1099] 308 [C1-2/1113, 1121]

〔图〕Photo 2: Close up view of 25C2827/14 showingPhoto 1: Close up view of 25C2826/15, showingview of foam board with pattern

Figure 2-5: Examples of the two types of foam boards found at Wang Fuk Court (extracted from a statement of Dr Lee Wing Man)$^{313}$

2. Dr Lee observed that most of the foam boards found at Wang Fuk Court after the fire were embossed with the square-within-square pattern (回), and found that these were more readily ignitable than the foam boards with a rhombus pattern ( ◆ ).$^{314}$ The foam boards with a square-within-square pattern readily ignited, with flame spread exceeding 150mm within 16 to 19 seconds of flame application, and burned throughout the specified test period, generating flaming droplets.$^{315}$

3. The evidence from residents also shows that the foam boards supplied before February 2025 had a different pattern from the subsequent foam boards with a rhombus pattern. The earlier foam boards had a square-within-square pattern and “CO2” markings.$^{316}$

〔图〕2QOO271座\n

Figure 2-6: Photograph of a foam board taken on 28 September 2024$^{317}$

On 11 September 2024, Mr Tsui Moon Come Tony raised concerns about the flammability of the foam boards in the WhatsApp group with PC&E and Will Power (宏福苑大維修 Group). A member of the Management Committee mentioned that residents were concerned that if the window covers were made of foam instead of aluminium composite material (鋁塑板), it would be readily ignited by cigarette butts.$^{318}$ According to Mr Tsui, PC&E then explained that it would not use aluminium composite boards because it was difficult to cut the material on site.$^{319}$

On 12 September 2024, a works meeting was held (attended by ISS, PC&E, Will Power, the IO and URA), during which concerns were raised regarding the flammability of the foam boards. PC&E explained that the foam boards would not be ignited through contact with cigarette ends (不會因煙頭接觸而燃焼); however, the result would be different if they were ignited by a persistent naked flame (明火持續燃焼則另作別論). PC&E also noted that the law does not prohibit the use of such material.$^{320}$

317     [O2/1445]
318     [F4/1029]
319     [T14/30:19-24]
320     [H1-3/6019]

On 13 September 2024, PC&E and IO representatives continued to discuss the use of foam boards in their WhatsApp group:

1. Mr Sam Tam of PC&E sent videos to the WhatsApp group at 12:38, purporting to demonstrate that the foam boards would not be ignited by cigarette butts. He qualified the demonstration, noting that if a naked flame were used, many materials could be ignited, including bamboo scaffolding and safety nets.321

2. The IO remained concerned that these videos would not pacify the residents. At 12:44 pm, a member of the Management Committee referred PC&E to a Facebook video which showed that the foam boards were flammable. Mr Tsui also requested that enquiries be made to the FSD and BD to confirm that the foam board material was acceptable.322

3. Mr Gordon Ho made PC&E’s position clear at 1:28 pm. If the IO wished to replace the material for the protective window covers, it would have to wait until Phase II because the foam boards for Phase I had already arrived on site and the protection works were underway.323

4. At 10:31 pm that evening, Mr Wong Hap Yin Jason circulated Will Power’s written opinion. 324 Will Power asserted that no law required protective material used during external wall renovation works (other than scaffolding nets) to be fire-retardant; that external repair works on existing buildings would not ordinarily pose a serious fire risk; and that foam boards were less likely than scaffolding nets to spread fire. Hence, it reasoned, only scaffolding

321 [F4/1033-1034]; videos [F1/24.2-25.7]

322 For other videos of flammable foam boards captured by residents in September 2024, see [O1/A11.1, A11.2].

323 [F4/1034-1045]

324 [O2/1154]; note that the same message does not appear in the copy of the WhatsApp group messages supplied by Mr Tsui Moon Come Tony [F4/1039].

nets were regulated by the BD's Practice Note APP-70. Will Power concluded that effective prevention of fire spread would require all temporary materials on the façade to be fire retardant, and that requiring foam boards alone to be fire retardant was an unrealistic idea (不切實際的想法).$^{325}$

PC&E's progress reports indicated that, by 17 September 2024, foam boards had already been installed on some windows,$^{326}$ and the protection works for Phase I had been 15% completed.$^{327}$

On 17 September 2024, Mr Steven Choi of Will Power reported in the WhatsApp group that he made a telephone call to the FSD to enquire as to the use of foam boards and was informed by the FSD that there was no law specifying whether foam boards could be used.$^{328}$

Will Power's explanation did not allay the IO's concerns. On 19 September 2024, Mr Tsui requested Will Power to explain in writing to the residents why it had accepted the use of foam boards – which were not fire-retardant (不能阻燃) – as protective material.$^{329}$

Will Power never issued a written explanation to the residents. Instead, the residents received a verbal explanation during the briefing sessions held on 28 and 29 September 2024,$^{330}$ during which PC&E accepted that the foam boards could be ignited with naked flames.$^{331}$

The IO eventually enquired with the FSD (through its Vice Chairman, Mr Benny Mak) by email on 4 October 2024, highlighting the fact that "most

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[O2/1403]
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[M1/937]
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[M1/932]
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[F4/1057]
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[F4/1063]
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[T14/34:29-35:2]; Tsui Moon Come WS §51 [WS12/2085]
331
[F4/1108]

of the windows” were covered by foam boards, and that residents were “at high risks as the Foamboard is found to be highly flammable”.332 The FSD’s response was to tell Mr Mak to seek advice from the BD and LD.333

Meanwhile, alternative solutions for window protection were considered.

1. Mr Tsui’s evidence is that the IO considered switching from foam boards to corrugated plastic boards (中空板 ). The IO tested

samples of this material with a lighter and found it to be relatively flame retardant. Yet, PC&E refused to replace foam boards with corrugated plastic boards on the basis that corrugated boards were rigid and therefore difficult to cut on site.334

2. On 2 October 2024, Mr Gordon Ho privately messaged Mr Tsui to ask whether the IO would consider replacing foam boards with

5mm corrugated plastic boards for Phases II and III. Mr Tsui responded by asking whether PC&E could source foam boards that were less easily ignitable, and requested Mr Ho to film a burn test to demonstrate that the foam boards would self-extinguish (影段

片，燒完會自己熄就可以), in which case no certificate would be

needed (不用 cert).335

3. When asked about these messages, Mr Tsui testified that PC&E and Will Power had repeatedly told him that there was no certification system for foam boards, which was why he framed his request in that way. The messages show that he sent Mr Ho a link to a supplier’s video to demonstrate that foam boards with fire-retardant properties were commercially available. He told Mr Ho that PC&E’s own test video should not be as unconvincing as

332 [B6/4507]

333 Ng Wing Kwong WS §7 [WS2/1056] 334 [T14/31:9-28]

335 [A2/119]

that of the supplier (影响障碍好咁流). What he meant was that the foam board should be burned for a longer period to show that it could self-extinguish.$^{336}$

Eventually, PC&E used corrugated plastic boards alongside foam boards (but not in place of them) for window protection. According to a document issued by PC&E on 2 October 2024 describing the workflow of the external wall repair works:$^{337}$

1. Foam boards would first be placed over all glass windows of the units to protect them against damage.

2. Windows located on the floors undergoing external hacking-off works would receive an additional layer of temporary protection by way of an additional thin wooden board or corrugated plastic board (中空板).

3. The additional wooden board or corrugated plastic board would be immediately removed after works were completed on that particular floor.

4. In contrast, the foam boards would remain on the windows even when the hacking works were completed: see §140 above.

Around this time (i.e. early October 2024), the IO and PC&E agreed that new batches of foam boards with improved fire-retardancy would be ordered for Phases II and III.$^{338}$

1. PC&E stated at a works meeting on 19 October 2024 that a new batch of foam boards would arrive the following week, and it would conduct a burning test on those boards.$^{339}$

2. On 26 October 2024, PC&E stated in a further works meeting that the second batch of foam boards had arrived and PC&E tested them with a lighter, which showed that they were fire retardant (物料已到，宏業亦即場用火機測試，是不能點燃的).$^{340}$

3. This coincides with the evidence that, in early October 2024, Mr Yiu Kam Fai of Shing Construction (承造工程有限公司) obtained a sample foam board from its supplier Wuhan Hansu (武漢漢塑新材料有限公司). This batch was supported by a purported fire-retardancy certificate issued by Hubei Provincial Building Material Energy Conservation Testing Center Co., Ltd (湖北省建築材料節能檢測中心).$^{341}$

4. Further foam boards were acquired on 20 November 2024, when Hoi Tak placed an order of foam boards with Wuhan Hansu.$^{342}$ This order was expressly for fire-retardant foam boards at a unit price of RMB 16.5 per 0.02m $^{3}$, more than double the unit price of the non-fire-retardant foam boards ordered from Hubei Yubo for

339     [F1/299]
340     [F1/301]
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342     [C1-2/1087-1098]

Phase I.$^{343}$ Subsequently, Hoi Tak on-sold some of these new foam boards to New Nam Fong.$^{344}$

5. Mr Yiu Kam Fai of Shing Construction ordered additional foam boards from Wuhan Hansu on 16 December 2024.$^{345}$ These foam boards were accompanied by a purported fire-retardancy certificate.$^{346}$

While the new batches of foam boards were intended to be used in Phases II and III, the evidence suggests that the subcontractors did not pay particular attention to which batch of foam boards collected at the site was used for installation at which blocks.$^{347}$

The subsequent batches of foam boards were embossed with a rhombus pattern. As noted above, Dr Lee Wing Man observed that the more flammable type of foam board, i.e. the initial batches embossed with the pattern of a square within a square (回), was more extensively found at the

scene, whereas the foam boards with rhombus pattern ( ◆ ) were rarely found.$^{348}$

Dr Lee also opined that the subsequent batches of foam boards (with the rhombus pattern) exhibited fire-retardant properties.$^{349}$ This appears to be consistent with the purported fire-retardancy certificates that accompanied some of the new batches.$^{350}$ Nevertheless, it is important to observe that in Dr Lee's opinion, if a continuous source of flame was applied to the foam boards (of whichever type), the foam boards would continue to combust.$^{351}$ Professor Yuen also opined that, once ignited, polystyrene foam boards would produce burning droplets and dangerous toxic smoke.$^{352}$

The evidence suggests that foam boards remained substantially affixed to the windows of various units of the blocks on the day of the fire, save that:

1. According to the evidence of subcontractors hired for the stone-washing of external walls, the foam boards affixed to the windows of Flats 2 and 3 of Wang Cheong House (Block F) had been removed prior to the day of the fire, as works on those parts of the external wall had essentially been completed and cleansing works were being carried out.$^{353}$

2. Madam Chung Sui Ha of ISS (a building attendant at Block F) heard from residents that only a small portion of the foam boards had been removed (好少部分...佢嗰度拆咗，大部分都話未拆).$^{354}$

As mentioned above, corrugated plastic boards were used to provide a temporary second layer of protection to the windows, which were removed after the hacking-off works were completed on a particular floor. In addition, Dr Lee's evidence was that some windows at Wang Fuk Court were also found covered by semi-translucent corrugated plastic boards.

〔图〕插图

Wang Chi House, Room 106 living room

Figure 2-7: Photograph showing mixed use of foam board and corrugated plastic boards at Wang Chi House (extracted from Dr Lee Wing Man's presentation) $^{355}$

According to Dr Lee Wing Man's laboratory tests, some types of corrugated plastic boards obtained from the scene lacked fire-retardant properties. She observed sustained burning on all corrugated plastic boards, with the 2mm and 5mm corrugated boards further generating flaming droplets with no signs of self-extinguishing, whereas the 9mm corrugated boards were less susceptible to ignition.$^{356}$

D6. Combustible rubbish and debris on the scaffolding

The accumulation of combustible rubbish and debris on the scaffolding platforms and light wells was a persistent issue prior to the fire:

1. Madam Ng Oi See Elsie, a resident of Flat 305 of Wang Cheong House (Block F) (which was located directly above the seat of the fire), testified that she would hear construction material falling from height almost every day during the works and that the scaffolding outside her flat was littered with construction waste, including foam boards, nylon strips, and paper sheets.$^{357}$

2. Mr Chau Chi Wai, a resident of Flat 207 of Wang Cheong House, likewise described the accumulation of rubbish on the scaffolding platforms outside his windows. He testified that workers often stripped the backing paper from the mosaic tiles and threw it down from the scaffolding, but never swept it. The rubbish piled up in the lower floors and flat roof like a rubbish dump (垃圾崗).$^{358}$

3. A lower-floor resident of Wang Tai House (Block E), Mr Cheng King Hei, also observed a large amount of rubbish outside his bedroom windows, including left-over materials. He complained to PC&E about its failure to clear the rubbish, and on two occasions PC&E did clear the rubbish and left-over foam boards.$^{359}$

4. The accumulation of rubbish on the scaffolding was the source of persistent complaints. The WhatsApp group between the IO and PC&E recorded many of these complaints, including on 3 October 2024 (left-over foam boards outside a window $^{360}$), 5 October 2024

357	[T4/4:1-4, 24-33]
358	[T5/30:15-30]
359	[T4/29:18-33]
360	[F4/1119]

(accumulation of rubbish on a flat roof of Wang Chi House (Block H)$^{361}$), 12 November 2024 (rubbish and cigarette butts found on Wang Chi House lower $floor^{362}$), 24 July 2025 (rubbish on the scaffolding$^{363}$), 18 August 2025 (rubbish left-over from tiling$^{364}$), 20 August 2025 (rubbish in Wang Shing House (Block G)$^{365}$), 20 September 2025 (rubbish on scaffolding$^{366}$), and 8 October 2025 (workers found urinating and leaving rubbish on the scaffolding$^{367}$).

5. On 7 October 2024, PC&E's agreement to clear the rubbish on the flat roofs once a week was noted by ISS.$^{368}$ Subsequently, in the works meeting on 27 September 2025, the IO requested PC&E to clear the rubbish on the scaffolding on a daily basis.$^{369}$

6. Mr Tsui Moon Come Tony accepted that, despite these measures, the accumulation of rubbish persisted (持續發生), was a constantly recurring problem and was never completely resolved.$^{370}$

The witness evidence is corroborated by photographs taken before the fire, which showed a large amount of combustible waste on the scaffolding.$^{371}$

〔图〕插图

Figure 2-8: Photograph taken on 20 August 2025 (showing the accumulation of carton paper, backing paper and foam boards on a scaffolding platform)$^{372}$

After the fire, burnt remnants of combustible waste were also found upon the excavation of debris from the flat roof platform outside Flats 4 and 5 of Wang Cheong House (Block F), including large amounts of carton paper believed to be used in the packaging of the mosaic tiles.$^{373}$

〔图〕插图〔图〕插图

Photo 26: View of seat of fire toward the metal gate (substantial amount of burnt remnants of carton paper boxes, found in the area next to the metal fence near Flat 105). Foam board fragments and a corrugated plastic board (A) and a woven plastic bag of backing papers (B) were recovered in the middle area as marked in the blue rectangle

103

Figure 2-9: Photograph taken from excavated seat of the fire (extracted

from Dr Lee Wing Man’s presentation)374

D7. Worker access openings in the staircases (生口)

When the scaffolding was erected, PC&E replaced the windows in the staircases of Wang Fuk Court with openings to provide temporary access points for workers to access and exit the scaffolding.

The evidence shows that worker access openings were created at approximately every five floors in the fire escape staircases of the buildings. These openings were colloquially referred to as “saang hau” (生口), and

were made by removing the staircase windows and fitting an aluminium composite or wooden board as a door to cover the openings. The door was opened during the day for worker access and locked at night.375

On 1 August 2024, PC&E wrote to Will Power to seek its approval for the creation of worker access openings at the fifteenth floor of each block, for the convenience of workers to enter and exit the building through the scaffolding (為方便工程人員於搭棚後出入大廈). Will Power marked its

approval of the submission on the same day.376

Three weeks later, on 22 August 2024, PC&E wrote to Will Power seeking its approval to create worker access openings on the fifth, tenth, twentieth and twenty-fifth floors of each block. Again, Will Power marked its approval on the same day.377

374 [ER4/2479]

375 Police statement of Wong Luen Kuen [C1-1/843-844] 376 [O2/944]

377 [O2/1081]

The subcontractors' evidence was that they were asked by PC&E to make an access opening every five floors, except for the access openings that were already created on the fifteenth floor. For example:

1. Mr Ng Pui Kwan testified that he was instructed by PC&E to open a worker access opening in the rear staircase every five floors, except for the opening on the fifteenth floor which had already been created. When he asked whether it was permissible to create these openings, he was told to do it (佢嗌我做).$^{378}$ In a statement provided to the Police, Mr Ng Pui Kwan suggested that the access openings he created at Wang Cheong House (Block F) were created before October 2024.$^{379}$

2. Mr Wong Luen Kuen's evidence was that he began to create worker access openings in the staircase of Wang Yan House (Block A) on 3 January 2025. He was instructed by one of the site managers to create access openings on the fifth, tenth, twentieth and twenty-fifth floors, and that if he was unsure how to make the openings, he should refer to the pre-existing opening on the fifteenth floor.$^{380}$

Therefore, the worker access openings were created shortly after the scaffolding was erected for each block and remained in place for a substantial period of time up to the day of the fire.

〔图〕4宏建5.1F1259\n

Figure 2-10: Photographs of worker access openings (extracted from the IFITF Final Report) $^{381}$

Despite instructions to create worker access openings every fifth floor, some subcontractors may have mistakenly created openings on different floors. This is evident from the IFITF's summary of the worker access openings (see, for example, the access openings in Wang Yan House (Block A)).

361

Building	Staircase	Floor
Wang Yan House	Rear staircase	between 3/F & 4/F
Wang Yan House	Front staircase	between 8/F & 9/F
Wang Yan House	Rear staircase	between 15/F & 16/F
Wang Yan House	Rear staircase	between 19/F & 20/F
Wang Yan House	Front staircase	between 24/F & 25/F
Wang Yan House	Front staircase	between 28/F & 29/F
Wang Tao House	Front staircase	between 4/F & 5/F
Wang Tao House	Front staircase	between 10/F & 11/F

	Rear staircase	between 15/F & 16/F
	Front staircase	between 20/F & 21/F
	Front staircase	between 26/F & 27/F
Wang Sun House	Rear staircase	between 5/F & 6/F
Wang Sun House	Front staircase	between 10/F & 11/F
Wang Sun House	Rear staircase	between 15/F & 16/F
Wang Sun House	Rear staircase	between 19/F & 20/F
Wang Sun House	Front staircase	between 24/F & 25/F
Wang Kin House	Front staircase	between 4/F & 5/F
Wang Kin House	Rear staircase	between 9/F & 10/F
Wang Kin House	Rear staircase	between 15/F & 16/F
Wang Kin House	Rear staircase	between 19/F & 20/F
Wang Kin House	Front staircase	between 24/F & 25/F
Wang Tai House and Wang Cheong House	Rear staircase	between 5/F & 6/F
Wang Tai House and Wang Cheong House	Front staircase	between 10/F & 11/F
Wang Tai House and Wang Cheong House	Rear staircase	between 15/F & 16/F
Wang Tai House and Wang Cheong House	Front staircase	between 20/F & 21/F
Wang Tai House and Wang Cheong House	Rear staircase	between 25/F & 26/F
Wang Shing House	Rear staircase	between 3/F & 4/F
Wang Shing House	Rear staircase	between 9/F & 10/F
Wang Shing House	Front staircase	between 14/F & 15/F
Wang Shing House	Rear staircase	between 19/F & 20/F
Wang Shing House	Front staircase	between 24/F & 25/F
Wang Chi House	Front staircase	between 4/F & 5/F
Wang Chi House	Rear staircase	between 9/F & 10/F
Wang Chi House	Front staircase	between 14/F & 15/F
Wang Chi House	Rear staircase	between 19/F & 20/F
Wang Chi House	Front staircase	between 24/F & 25/F

Figure 2-11: Table summarising the locations of worker access openings (extracted from the IFITF Final Report)$^{382}$

In any event, the evidence establishes that the worker access openings were not necessary for the works on the external wall:

1. While Mr Ng Pui Kwan suggested that the creation of access openings was a common practice, he agreed that it was only a

measure of convenience to the workers and was not essential for the hacking-off works to be carried out.$^{383}$

2. Likewise, Mr Zhang Minghai agreed that access openings were unnecessary for his work on the external walls, and that it was purely a convenience for workers. He added that many external renovations did not have access openings.$^{384}$

No complaint or enquiry about the fire risks of the worker access openings was made to the FSD or ICU before the fire.$^{385}$ The former head of the ICU, Mr Lau Fu Kwok Rudolf ("Rudolf Lau"), accepted that the system at the time relied on self-supervision by the contractors and professionals, together with complaints from residents, yet residents without building expertise would not have recognised that a staircase opening was a fire hazard or that it was something to complain about.$^{386}$

This is borne out by the evidence. With a single exception, the evidence suggests that those involved failed to appreciate the fire hazards at the time. For example:

1. Mr Ng Pui Kwan testified that he did not appreciate or understand the effect of worker access openings on the staircases as a safe means of escape (呢啷我唔識).$^{387}$

2. Mr Tsui Moon Come Tony also stated that, while residents did raise queries on whether access openings were necessary,$^{388}$ it did

383     [T13/33:1-9]
384     [T13/41:19-27]
385     [T17/29:23-27]; [T22/24:35-25:1]
386     [T24/35:29-36]
387     [T13/31:24-28]
388     [F4/1178]

not occur to the new Management Committee that the access openings gave rise to fire hazards.$^{389}$

3. Similarly, Madam Cheng Tsz Ying accepted that ISS knew that the staircase windows at every fifth floor were converted to access openings, but that it was not aware of the fire hazards arising from this practice.$^{390}$

The single instance where a fire safety concern was raised about the worker access openings came from a layman – but his query was not taken up by the contractor or the consultant:

1. According to the WhatsApp group messages between PC&E and the former Management Committee, on 7 August 2024, Mr Tang Kwok Kuen, who described himself as a layman (外行人), enquired whether the window position should use fire-retardant or fire-resistant material (該窗位應否選用防火或耐火物料).$^{391}$

2. Mr Kong Cheung Fat (a member of the Management Committee at the time) accepted that, apart from that single remark, the materials disclosed show no further discussion of the fire risk of worker access openings.$^{392}$

D8. Fire-rated windows

Related to the worker access openings were the minor works to replace the existing staircase windows with fire-rated windows.

In Will Power's inspection reports submitted in December 2019, issues with the buildings' fire safety facilities were noted. In particular, Will

389	[T14/48:5-32]
390	[T8/26:3-16]
391	[O2/840]
392	[T15/36:8-24]

Power noted that the staircase windows were not fire-rated, and recommended replacing them with windows that met current requirements for fire resistance (see, for example, inspection report for Block C).$^{393}$

In the finalised tender document produced by Will Power on 27 March 2023, renovation of all 1/F to 31/F escape staircase windows was listed as part of the renovation works (Item 7.4A).$^{394}$

The replacement of staircase windows was not mandated under the MBIS. The issue of whether the staircase windows should be replaced with fire-rated ones was therefore put to a vote amongst the residents.

At the EGM on 28 January 2024, Will Power explained that there was no mandatory requirement to replace the windows, as Wang Fuk Court had yet to receive a fire safety direction under the Fire Safety (Buildings) Ordinance (Cap. 572). Nevertheless, the owners resolved by a majority of 76.82% votes to replace existing windows of emergency stairs with fire-rated windows.$^{395}$

Replacement of staircase windows with fire-rated windows (with no less than 30 minutes of fire-resistance) was duly incorporated into the Works Contract (Item 4.1).$^{396}$

Forms MW01 (Notice of Commencement of Class I Minor Works) were then submitted to the ICU to notify it of the proposed alteration of windows in the staircases from 1/F to 31/F (see for example, the Form MW01 for Block H).$^{397}$ The new windows were proposed to have a 60-minute fire-resistance rating.$^{398}$ Each Form MW01 included a site supervision plan,

requiring building professionals and contractors to conduct site inspections at the specified frequency levels.$^{399}$

The Forms MW01 listed the following contractors and building professionals responsible for the window replacement works:

1. Motive Design Limited (動感室內設計有限公司): subcontractor responsible for Wang Yan and Wang Tao House (Blocks A - B);$^{400}$

2. Chi Fu Construction Co. (志富建築公司): subcontractor responsible for the remaining blocks (Blocks C to H);

3. Mr Lai Ka Wing: Authorised Person for all eight blocks; and

4. Mr Chi Wuh Jian Joseph Duncan: Registered Structural Engineer for all eight blocks.$^{401}$

In answer to the Committee's requests for information, these contractors and building professionals all confirmed that they had no direct contractual relationship with PC&E. The relevant chain of contracts was as follows:

1. PC&E sub-contracted the window replacement works (including the replacement of staircase windows with fire-rated windows) to Wealth Pinnacle (满昌工程有限公司), for a total contract price of HK$2,503,200.$^{402}$

2. Wealth Pinnacle in turn engaged Chi Fu Construction by way of an oral contract. According to Chi Fu Construction, its only role was to submit minor works submissions and site supervision plans

for the staircase window replacement minor works in Blocks C to H. The actual works were conducted by Wealth Pinnacle.$^{403}$

3. On the other hand, Motive Design was engaged by Mr Lai Ka Wing. Again, according to Motive Design, the actual window replacement works were conducted by Wealth Pinnacle.$^{404}$

4. According to Mr Lai Ka Wing, Wealth Pinnacle engaged Allied Architects to provide services in relation to the staircase window works. He was in turn engaged by Allied Architects for his services. He claimed to have reviewed the submissions to the ICU and to have personally conducted weekly site inspections to verify that the window replacement works generally conformed to the submission requirements.$^{405}$

5. Mr Joseph Chi confirmed that he was engaged by Allied Architects pursuant to a verbal agreement. He claimed to have verified the drawing and structural calculations before submission to the ICU, and to have personally carried out site inspections.$^{406}$

Each of Motive Design, Chi Fu Construction, Mr Lai Ka Wing and Mr Joseph Chi confirmed awareness of the worker access openings:

1. The minor works submissions to the ICU contained photographs of the worker access openings.$^{407}$ According to Mr Lai Ka Wing, he observed from these submissions that some of the original windows had already been removed and covered by wooden boards before his involvement. However, he claimed not to be aware that these access openings potentially involved illegality,

403     [WS21/2367]
404     [WS21/2375]
405     [WS21/2386-2387]
406     [WS21/2403-2405]
407     E.g. [I1-3/7971]

noting that the original windows were openable and non-fire-rated and were not resistant to smoke and fire in any $event.^{408}$

2. In Mr Joseph Chi’s response to the Committee, he confirmed that he noticed the removal of staircase windows every five storeys. However, he did not regard the openings to be different compared to the openable windows before the replacement works.$^{409}$

3. Motive Design replied to state that the worker access openings existed when Wealth Pinnacle entered the site. Motive Design was aware of the access openings but did not consider it to be an issue.$^{410}$ Chi Fu Construction was also aware that access openings were created, noting that it was a common procedure.$^{411}$

Replacement works for the staircase windows were initially scheduled in Phases. Phase I (Blocks F-H) was scheduled to commence on 20 January 2025, Phase II (Blocks C-E) was scheduled to commence on 24 February 2025, and Phase III (Blocks A-B) was scheduled to commence on 2 May 2025.$^{412}$

The first record of the commencement of staircase windows works is the progress report on 21 February 2025, under which “Replace Staircase Windows” was listed under “FS Installations Improvement Works”, and was stated to have been 25% completed for Phase I.$^{413}$

408	[WS21/2387]
409	[WS21/2406-2407].
410	[WS21/2378]
411	[WS21/2367]
412	[F1/189-191]
413	[M1/1131]

By 29 March 2025, a progress report recorded that the staircase window replacement works were largely completed save for floors with worker access openings for Phase I (大致完成 (除咗生口樓層)).$^{414}$

The staircase window replacement works for Phase II were first listed as “Works to be Conducted in Upcoming 2 Weeks Period” in the progress report dated 12 April 2025.$^{415}$ Phase II staircase replacement works were largely completed save for floors with worker access openings by the time of the progress report dated 7 June 2025 (大致完成 (除咗生口樓層)).$^{416}$

As for Phase III, the staircase window replacement works were first listed as “Works to be Conducted in Upcoming 2 Weeks Period” in the progress report dated 24 May 2025.$^{417}$ They were largely completed save for floors with worker access openings by the time of the progress report dated 16 August 2025 (大致完成 (除咗生口樓層)).$^{418}$

Therefore, on the day of the fire, all of the windows in the staircases were replaced with fire-rated windows, except the worker access openings which remained on approximately every fifth floor. This state of affairs was confirmed by the FSD's witness, Mr Lam Kin Kwan (Deputy Chief Fire Officer, New Territories South).$^{419}$

D9. Water tank works

A point of controversy was the renovation works to the various roof-top water tanks, including the FS Tanks, of each block.

114

The evidence establishes that various FSIs were not functional on the day of the fire. The sections below examine how the renovation of the FS Tanks led to the shutdown of the FSIs.

(i) Initial planning of water tank works

In Wang Fuk Court, the rooftop of each block contained three public water tanks, being the FS Tank (消防缸), a fresh water tank (食水缸), and a saltwater tank or flush water tank (鹹水缸).

In Will Power’s inspection reports submitted in December 2019, defects were found in the rooftop water tanks, including severe rust staining and cracks in the internal walls of the tanks and rusting of the mercury float switch in the FS Tanks. 420 Repairs to the water tanks were therefore recommended.

Renovation works to “all public concrete water tanks” (所有公用石屎水

缸) were subsequently included as part of the listed works (Item 7.3A) in

the finalised tender document,421 and were retained as part of the listed works in the Works Contract (Item 6.2A).422

The particular specifications in the Works Contract provided that, unless otherwise specified, the scope of the waterproofing and retiling works for the water tanks included all rooftop public water tanks, including the fresh water tank, flush water tank and FS Tank (所有天台公眾水缸，包括食

水缸、沖廁缸及消防缸).423

The key steps of the water tank repairs involved the following:424

420 [I1-2/1891, 2567, 3255, 3987]; [I1-3/4748, 5585, 6446, 7286] 421 [E1-4/8895]

422 Item 6.2A of Part 7, Works Contract [F1/101-102]

423 Clause 13 of Part 6, Works Contract [F1/79]

424 Item 6.2A of Part 7, Works Contract [F1/101]

1. The hacking-off of existing finishes, rendering and waterproofing layer down to the concrete surface (鑿除飾面, 批盪及舊防水層至混凝土面);

2. Application of a water-proof layer (作防水膜) with a water test after completion of this step (試水); and

3. Tiling of all tank surfaces with white glazed tiles (所有水缸飾面均使用白階磚).

In this regard, the Committee may note the suggestion by Dr Chung Kit Man (鍾傑文) that it was unnecessary for FS Tanks to be retiled with white glazed tiles, which are normally required for freshwater tanks for sanitary purposes.$^{425}$ It is unnecessary at this juncture to reach a conclusion on the point. It suffices to note that tiling and water-proofing of the FS Tanks were part of the agreed works under the Works Contract.

Repair works for the tanks were initially planned to commence on 2 December 2024.$^{426}$

PC&E noted at a works meeting on 13 November 2024 attended by the IO, ISS and Will Power, that renovation works for the FS Tanks should be undertaken first, followed by the salt water and fresh water tanks. This was to allow for the FS Tanks (once renovated) to serve as temporary fresh water tanks while the original fresh water tanks were being repaired (宏業指可先做消防缸，再整咸水及淡水缸(屆時要借用消防缸)).$^{427}$

It was therefore contemplated that the FS Tanks' function of storing water for firefighting purposes would remain suspended beyond the period of the

116

renovation of the FS Tanks themselves. But what was not addressed was how long that suspension would last.428

Mr Kong Cheung Fat agreed that, at the time, there was no discussion of whether the conversion of the FS Tanks into temporary fresh-water tanks was necessary, nor of the alternative of providing a separate temporary water tank.429 Mr Tsui Moon Come Tony also accepted that these matters were not considered.430 This was despite PC&E’s contractual obligation, where necessary, to supply a temporary water tank,431 and Will Power’s earlier indication that a fibre temporary water tank may be provided.432

At a works meeting on 15 March 2025, PC&E stated that they would go ahead with the FS Tank renovation works (estimated to last 1.5 months).433

(ii) Commencement and progress of the water tank works

The FS Tank repairs were carried out by two of PC&E’s subcontractors, each handling four blocks: Red Sun (太陽建設(亞洲)工程有限公司)

(Blocks B, C, D and E) and Tin Hung (天雄工程公司) (Blocks A, F, G

and H).

At a works meeting on 29 March 2025 attended by the IO, Will Power, PC&E, ISS and some residents, PC&E reported that FS Tank renovation works would begin at Wang Tai House and Wang Chi House (Blocks E and H) starting from 7 April 2025. It was reported that the FS Tanks would

428 [T15/39:36-40:13]

429 [T15/39:29-35]

430 [T14/44:3-10]

431 Clause 13 of Part 6, Works Contract [F1/79] 432 [T15/18:12-23, 39:22-25]

433 [H1-3/6077]

be temporarily out of operation and that shutdown notices would be submitted to the FSD.$^{434}$

From the PC&E progress reports available, it can be seen that “Water Tank Waterproofing” was first listed as a “Works to be Conducted in Upcoming 2-Weeks Period” on 26 April 2025 for Phases I and II.$^{435}$

By 19 July 2025, the renovation works for FS Tanks in Wang Kin, Wang Tai, Wang Shing and Wang Chi House (Blocks D, E, G and H) had reached the stage of water-testing (消防水缸試水). The progress report indicated that renovation works for the FS Tanks at Wang Tao and Wang Sun House (Blocks B and C) had commenced.$^{436}$

At a works meeting held on 30 August 2025, which was attended by the IO, Will Power, PC&E, ISS and some residents, PC&E and Will Power reported that the FS Tank renovations in Wang Shing and Wang Chi House (Blocks G and H) were completed, and they would discuss with ISS to arrange for the conversion of the FS Tanks into temporary fresh water tanks. They reported that the FS Tank renovation works for Wang Kin, Wang Tai and Wang Cheong House (Blocks D to F) remained in progress.$^{437}$

This report was consistent with the progress report dated 13 September 2025.$^{438}$ The progress report on 27 September 2025 was the last time the FS Tank renovation progress was reported by PC&E in a formal progress report.$^{439}$

434     [H1-3/6080]
435     [M1/1220]
436     [M1/1271]
437     [H1-3/6113]
438     [M1/1305]
439     [M1/1315]; the progress report recorded that the renovation works in the FS Tanks of Wang Shing and Wang Chi House (Blocks G and H) had fully completed (with the tiling of white glazed tiles) and that the water tests (試水) had completed in the FS Tanks of Wang Kin and Wang Tai House (Blocks D and E).

118

Among the documents seized by the Police from PC&E’s temporary office was an internal works progress report dated 19 November 2025.440 The report recorded further progress in the FS Tank works:441

1. The renovation works for the FS Tanks in Wang Tao, Wang Sun, Wang Kin, Wang Tai and Wang Shing House (Blocks B, C, D, E and G) had been fully completed.

2. There were outstanding works in Wang Yan, Wang Cheong and Wang Chi House (Blocks A, F and H), including the finishing coat of render (盪面層) and retiling with white glazed tiles.442

3. Despite the remaining works, all of the FS Tanks had gone through a water test (試水測試) at some point in time.

According to the evidence from workers employed by Red Sun and Tin Hung, their works on refurbishing the walls of the FS Tanks at Blocks A, B, C, D, E and G had been completed by early November 2025. Those FS Tanks were waiting for a plumbing subcontractor to carry out follow-up works (such as installing buoys and a water gate and re-configuring the pipes for the purposes of converting the FS Tank into a freshwater tank). As to Blocks F and H, the works remained outstanding due to water leakage.443

The evidence therefore establishes that, on the day of the fire, the FS Tanks of the majority of blocks had been completed as required under the Works Contract, but the tanks were inoperative pending follow-up plumbing work, including works required to convert the FS Tanks into fresh-water tanks.

440 [C4/2357-2359]

441 [C4/2359]

442 It is notable that the renovation works of the FS Tank in Wang Chi House (Block H) were recorded as fully completed as of 27 September 2025, while outstanding works were noted for the same block on 19 November 2025. As explained below, it appears that water leakage was subsequently found in the FS Tank at Wang Chi House.

443 Police statements of Lui Sze Lung [C1-2/1179] and Wu Rizhao [C1-2/1191]

119

The renovation works for the FS Tanks in Wang Cheong and Wang Chi House (Blocks F and H) were likely to be incomplete.

A related issue concerns the conflicting evidence on whether the FS Tanks remained empty at the time of the fire:

1. According to Victory Fire’s plumber, Mr Tong Hing Lun (唐慶麟),

in the course of carrying out plumbing works related to the FS Tanks on 16 October 2025, he opened the tanks of Blocks A, B and C and found them completely empty. He was told that the FS Tanks were undergoing renovation, so there was no water.444 On 17 October 2025, when he continued with plumbing works related to the FS Tanks on the other five blocks, he did not check whether those FS Tanks had water.445

2. On the other hand, photographs taken around August to early November 2025 show that various FS Tanks had been filled with water (養水).446

3. Those photographs do not necessarily indicate that the renovation works for the FS Tanks had finished. The FS Tanks may have been filled with water solely for the purposes of water testing (i.e. to check the integrity of the water-proofing layer). If an FS Tank passed the water test, the water would be drained and tiling works would begin.

4. As noted earlier, all of the FS Tanks had gone through a water test (試水測試) at some point prior to 19 November 2025.447 The

photographs may well have been taken during those tests.

444 [T9/3:31-5:15]; Tong Hing Lun WS §5 [WS2/1542] 445 Tong Hing Lun WS §6 [WS2/1542]

446 [H6/6820-6834]

447 [C4/2359]

5. For completeness, according to the FSD's inspection between 28 November and 1 December 2025, it was observed that the FS Tanks were all empty except those in Wang Tao and Wang Shing House (Blocks B and G).$^{448}$

D10. Shutdown of FSI

One of the central issues in these hearings concerns the shutdown of FSIs on the day of the fire, in particular the fire alarm system (火警警報系統) ("FAS") and the fire hydrant / hose reel (消防栓/喉轆系統) ("FH/HR") system. Each block was equipped with one FAS and FH/HR system.

The mechanism of the FSI systems was described in the FSD's Report on FSI of Wang Fuk Court.$^{449}$ That account aligns with the following summary provided by Mr Wong Kin Wa (黃健華), an electrician employed by Victory Fire:

1. On each floor the corridor carries a fire alarm bell (火警鐘) and a break-glass call point (扲手). Breaking the glass initiates the fire booster pump to run and the alarm bell to sound (令到個消防泵行, 同埋個警鐘會響). The corridor on each floor has a hose reel (喉轆). There is also a fire hydrant outlet (消防栓) in the rear staircase on each floor, used by firefighters to draw water in the staircases in the event of a fire.$^{450}$

2. On the ground floor there are two pump rooms: (i) a pump room (泵房) housing the freshwater and salt-water upfeed pump together with the FS upfeed pump (上水泵), which refills the FS Tank on the roof-top drawing water from the ground floor FS

transfer tank in the pump room; and (ii) an FS pump room (消防加壓泵房) housing the two FS booster pumps (加壓泵) that serve to boost the water pressure in the FH/HR system for firefighting purposes.$^{451}$

In the FS pump room, there is a main control panel and an adjacent box containing the master power switch (消防泵總掣/刀掣).

〔图〕宏仁周ABE212\n

Figure 2-12: Photograph of the main control panel (left) and master power switch (right) in the FS pump room of Wang Yan $House^{452}$

1. According to Mr Wong Kin Wa, the master switch supplies power to the alarm bells and break-glass call points as well as the FS

booster pump. In other words, switching off the master power switch disables both the FAS and the FS booster pump.$^{453}$

2. Victory Fire's director, Dr Chung Kit Man, broadly agreed with Mr Wong's evidence but added that the master switch in the FS pump room controls only the FS booster pump and the FAS, but not the upfeed pumps (which were in the other pump room).$^{454}$

3. The FSD's evidence (via Assistant Director (Licensing & Certification) Keung Sai Ming (姜世明)) was also that the same master switch powers both the FAS and FH/HR systems.$^{455}$

To carry out the FS Tank repair works, the FS Tanks had to be drained. The preponderance of evidence indicates that switching off the master power switch – and with it the FAS – was not required for that purpose:

1. Dr Chung Kit Man's evidence was that the upfeed pump must be switched off but it was not strictly necessary to switch off the FS booster pump. In practice, however, the FS booster pump would usually be switched off as well, because running the FS booster pump dry would damage it (行空泵都會損壞).$^{456}$

2. To switch off the FS booster pumps, it was not necessary to turn off the master power switch. Mr Wong Kin Wa explained that the main control panel in the FS pump room had a Pump 1 Isolator switch and a Pump 2 Isolator switch, which enabled each of the two FS booster pumps to be switched off independently.$^{457}$

〔图〕804 73NVd 708INO9dWnd 83LSO08 38I4联818338不2新乙.\n

Figure 2-13: Close up photograph of the main control panel in the FS pump room of Wang Chi House (with annotations in green)$^{458}$

3. Assistant Director Keung Sai Ming also testified that draining the FS Tank only required turning off the pump isolator switches for the FS booster pumps (消防水泵嗰個獨立開關) and did not require switching off the master power switch. Mr Keung agreed that this was basic knowledge (基本嘅知識) for an RFSIC.$^{459}$

On the other hand, ISS's electrician, Mr Law Kwok Shui (羅國瑞) held a different understanding:

1. Mr Law understood that draining the FS Tank involved three steps: switching off the upfeed pump in the pump room, draining the FS

458	[C1-2/1641]
459	[T10/9:25-28, 10:2-4]; also Keung Sai Ming WS §10.3 [WS1/138]

124

Tank by loosening the handwheel of the drain valve and switching off the master power switch (刀掣) in the FS pump room.460

2. Mr Law believed that the master power switch in the FS pump room had to be switched off in order to prevent the FS booster pumps from running dry. Importantly, he was not aware that turning off the master power switch would also disable the FAS, nor did he know that the FS booster pumps could be switched off by the pump isolator switches on the main control panel.461

Since Mr Law is unqualified to operate FSIs, the evidence of the FSD and Victory Fire as to the correct means of powering off the FS booster pumps is to be preferred.

Mr Law Kwok Shui admitted that, acting on his understanding of the steps required to drain the FS Tank (an understanding which, on the evidence of the FSD and Victory Fire, was erroneous), he switched off the master power switches in the FS pump rooms of all eight blocks.462

Mr Law carried out the draining of the FS Tanks because he received a “job order” (工作單) from ISS requiring him to assist PC&E in draining

the FS Tanks:

1. According to Mr Lee Shing Foo (ISS’s carpenter), between May and August 2025, the management office issued eight job orders directing ISS works-department colleagues to assist PC&E in draining the FS Tanks.463

460 Law Kwok Shui WS §21 [WS2/1234]

461 [T7/46:16-34]

462 [T7/50:8-17]; Law Kwok Shui WS §22 [WS2/1234] 463 [T7/36:32-35]; [C1-2/1265-1267]

2. One of the job orders was issued by Madam Lok Sin Ying (駱倩盈), which instructed ISS works-department staff to drain the FS Tank at Wang Tao House (Block B) on 14 July 2025.$^{464}$

3. Given that the FS Tank formed part of the FH/HR system, the drainage of the FS Tank should have been handled by an RFSIC, not unqualified personnel. Mr Law Kwok Shui accepted that Mr Lee Shing Foo told him that only RFSICs could operate the FS Tanks, and that this accorded with his own understanding. He claimed that he asked Madam Lok Sin Ying of the management office whether it was appropriate for him to operate the FS Tanks without a licence, and was simply instructed to assist PC&E.$^{465}$

4. Madam Lok gave a different account.$^{466}$ Their competing accounts, roles and responsibilities will be addressed in Chapter 6.

After the master power switches were turned off in the FS pump rooms and the FS Tanks were drained, renovation works were carried out in respect of the FS Tanks as described in Section D9(ii) above. As mentioned above, the FS Tanks remained out of service on the day of the fire, as most of the FS Tanks were pending conversion into temporary freshwater tanks. Had the fire not occurred, the FH/HR would likely have remained inoperative for a substantial period until the fresh-water tanks were fully renovated.

There was no need for the master power switches (and with them the FAS) to remain off while the FS Tank renovations continued. Restoring the FAS required nothing more than switching on the master power switches in the FS pump rooms.

Although Mr Law Kwok Shui and Mr Lee Shing Foo knew that the master power switches were turned off, they did not appreciate that this also turned

126

off the FAS. Victory Fire, by contrast, discovered the position weeks before the fire and obviously understood the consequence.467 What Victory Fire and ISS knew – and what they did or failed to do – is the subject of a factual dispute addressed in Chapter 6.

The unfortunate fact remains that no one turned the master power switches back on until the day of the fire on 26 November 2025.

467 [T5/66:4-67:24]

CHAPTER 3: THE DAY OF THE FIRE

A. Origin and Discovery of the Fire

It was 26 November 2025. The weather was dry, with the relative humidity between 40% and 50%. A brisk east to south-easterly wind blew across Wang Fuk Court at 14 kilometres per hour.$^{468}$ A red fire danger warning had been issued.

The fire broke out between 14:30 and 14:40 that afternoon. The earliest indication of the fire was captured by a CCTV camera above the bicycle shed at the rear of Wang Cheong House (Block F). From 14:33 onwards,$^{469}$ the footage recorded faint traces of smoke drifting from the external scaffolding into the shed. The general direction of movement is illustrated by the red arrow in the image below.

〔图〕2025-11-26 14:33:00 星期三通道4\n

Figure 3-1: Still image from CCTV footage captured by the camera above the bicycle shed at the rear of Wang Cheong House (14:33:00)$^{470}$

The location of the surveillance camera is shown in the map below (CCTV camera #4).

〔图〕宏志1遊樂場2遊樂場18CH 6宏福苑CH 4(3821,大墙公路CH 3元洲仔段)宏盛閣-RCPCH 12CH 5宏新1元洲仔里122宏昌宏泰閣3\n

Figure 3-2: Map showing location of the CCTV camera $^{471}$

At 14:42:18, the CCTV camera captured the first glints of light. These were burning embers dripping from the scaffolding near the flat roof outside Flats 104 and 105 of Wang Cheong House. From 14:43:38, further embers dropped with increasing frequency. By 14:44:48, a small, self-sustaining fire had taken hold on the ground. The embers continued to fall until the surveillance footage cut out at 14:47:20.

〔图〕2025-11-26 14:43:00 星期三通道4\n 〔图〕2025-11-26 14:45:30 星期三通道4\n

Figure 3-3: Still images from CCTV footage captured by the camera above the bicycle shed at the rear of Wang Cheong House (14:43:00, 14:45:30)$^{472}$

Another CCTV camera corroborated the timing of the fire. It was located outside the worker access opening at the rear staircase between 5/F and 6/F of Wang Cheong House – directly above the seat of the fire.

At 14:42:55,$^{473}$ the CCTV footage recorded a male voice shouting “Hey, who is it who has been smoking and set these things alight?” (喂邊個食煙焫着左啲嘢呀？). The warning was ignored by others on the scaffolding. Another worker said, “Is it you smoking?” (你食煙咋嘛). Moments later, voices asked “Where is it?” (邊個位置啫？) and “Who’s responsible for that area?” (邊個做嗰個位？).

Meanwhile, workers continued working and conversing. It was not until 14:46:45 that they finally realised the gravity of the situation. Screams were heard. By 14:48, dust, smoke and flames overwhelmed the area. The video feed terminated at 14:48:03.

〔图〕2025-11-26 14:47:56-9\n 〔图〕2025-11-26 14:47:59-9\n

Figure 3-4: Still images from CCTV footage captured by the camera outside the rear staircase between 5/F and 6/F of Wang Cheong House at 14:47:56 and 14:47:$59^{474}$

At around 14:50, Mr Yip Fai, a passerby standing at Island House Lane, discovered the fire and called 999 to report the fire. The FSD received the call by 14:51. At 14:50:43, he captured the first clear view of the fire, on the flat roof outside Flats 104 and 105 of Wang Cheong House (Block F).$^{475}$

The footage showed a developed, yet localised, fire on the flat roof. In the right-hand corner of the frame, burning material could be seen dripping from the flat roof to the area outside the bicycle shed.

At 14:53, Mr Yip Fai shot a second video with a wider angle of Wang Cheong House and Island House Lane. On the audio track, an observer exclaimed in disbelief, asking why no fire alarm had sounded.

〔图〕插图

Figure 3-5: Still images from videos captured by Mr Yip Fai at around 14:50, 14:53$^{476}$

The Committee received no other videos or photographs indicating an alternative origin of the fire at Wang Cheong House (Block F). As confirmed by Dr Lee Wing Man, an IFITF witness, no other possible seat of fire has been identified (see Chapter 4 below).$^{477}$ The conclusion is clear: the fire began on the flat roof outside Flats 104 and 105 of Wang Cheong House.

The FSD responded promptly. The first fire appliances arrived at the scene at 14:56:22, 5 minutes and 5 seconds after the call was first received by the

FSD at 14:51:17.$^{478}$ The firefighting operations will be detailed in Chapter 5 below.

B. Rapid Spread of the Fire at Wang Cheong House (Block F)

Within minutes, the localised fire erupted into a vertical conflagration. A towering pillar of flame ascended the re-entrant between Flats 4 and 5 of Wang Cheong House (Block F) with immense speed and ferocity.

Two further videos captured by Mr Yip Fai showed this rapid ascent.$^{479}$ The Committee's experts analysed these videos. They determined that the vertical fire spread reached its full development by 14:59. By 15:02, it had already begun to decay.$^{480}$

1st Vertical Spreading Fire at Lightwell (Room 4-5) of Block F

〔图〕F114:5014:5514:5915:0015:0214:58Fast Development StageOrigin of fireDecay Stage\n

Figure 3-6: Still images from videos captured by Mr Yip Fai and other passersby, reproduced in the IC Expert Report $^{481}$

The scaffolding in the re-entrant quickly began to disintegrate. Bamboo members and other debris started to fall to the ground at around 14:57. This can be seen from the footage taken by Mr Yip Fai.

478     [B13/5734-5735]
479     [A2/11, 12]
480     IC Expert Report §3.3.2 [ER3/2168]
481     IC Expert Report Figure 3-4 [ER3/2169]

〔图〕插图

Figure 3-7: Still images from videos captured by Mr Yip Fai (14:56:58, 14:57:38 and 14:57:57)$^{482}$

The evidence of Senior Station Officer Hui Kin On (許健安) (“SStnO Hui”) is that these burning articles piled up and blocked the rear exit of Wang Cheong House facing Island House $Lane.^{483}$

At around 15:02, the fire consumed a second re-entrant on Wang Cheong House between Flats 6 and $7^{484}$.

〔图〕F2F2F215:0315:0415:0415:0815:0215:06InitiationDecay StageFast developmentGround Fire\n

Figure 3-8: Still images from videos captured between 15:02 and 15:08,$^{485}$ reproduced in the IC Expert Report$^{486}$

By 15:04, the fire ignited the shrubbery on the open ground outside Flats 7 and 8. Mr Yip Ka Kui Sdanni, a resident of Wang Tai House (Block E), testified that the area quickly deteriorated into a sea of flames advancing from Wang Cheong House to Wang Tai House.$^{487}$

〔图〕插图

Figure 3-9: Still image from a video taken by Mr Yip Fai (15:04:35) $^{488}$

The conflagration continued to spread. By 15:09, a third re-entrant fire erupted between Flats 1 and 8 of Wang Cheong House $^{489}$. As illustrated below, these pillars of flame developed sequentially in a clockwise direction, marked chronologically F1, F2 and F3 respectively.

〔图〕-wO-F1F3F2F3F3F2-e.w1ST FLOOR PLAN(FOR BLOCK F)15:0915:0915:10CE罐\n

Figure 3-10: Still images from videos of the third re-entrant fire at Wang Cheong House, reproduced in the IC Expert Report $^{490}$

By about 15:05, collapsed burning bamboo obstructed the front entrance of Wang Cheong House, according to the IFITF's findings.$^{491}$ Still images from 15:09 confirm that the area outside the entrance had quickly become a massive inferno (see Figure 3-8 above).$^{492}$

The front entrance and rear exit were the only means of escape from Wang Cheong House. By 15:05, both routes were obstructed by burning debris

on the ground. Escaping residents faced an impossible barrier less than 15 minutes after the first emergency call to report the fire.

These rapid towering pillars of flames were no isolated incident. They occurred a total of 12 times along the re-entrants at Wang Fuk Court. The Committee's expert, Professor Usmani, characterised the velocity of the spread as unprecedented in the history of major building fires. One of the re-entrant fires reached a maximum velocity of 10 metres per second. By contrast, the Grenfell Tower fire spread at a rate of just 8 metres per minute.$^{493}$

C. Spread of the Fire to Other Blocks

C1. Wang Tai House (Block E)

Within minutes of the first emergency call, the fire spread westward to Wang Tai House (Block E), the closest neighbouring block to the west. A CCTV camera captured smoking debris falling on the roof of Wang Tai House as early as 14:58.

〔图〕2025-1126、1468:395-11\n

Figure 3-11: Still image from CCTV footage on the roof of Wang Tai House (14:58:39) $^{494}$

SStnO Hui also observed specks of flame on the scaffolding on the east façade of Wang Tai House at around 15:00.$^{495}$

The open ground between the front entrance of Wang Tai House and Wang Cheong House was soon well alight. By 15:11, a CCTV camera positioned at the entrance captured bright flames reflecting off the metal gate. Between 15:11 and 15:18, haze and smoke gradually filled the open area.$^{496}$

〔图〕02*02善----密密Lq10\n

Figure 3-12: Still image from CCTV footage outside the front entrance of Wang Tai House (15:09:11, 15:16:03) $^{497}$

Fire pillars rapidly ascended Wang Tai House's re-entrants in a clockwise direction. At 15:16, the first pillar of flame engulfed the re-entrant between Flats 1 and 8. Just a minute later, a second erupted between Flats 2 and 3. By 15:30, a third column of flames took hold between Flats 4 and 5.

〔图〕E3E1E1BLOCK EBLOCK FBLOCK FBLOCK E15:3015:1715:1615:16Fast development of E2 & Decay of E1Fast development of E3Fast dev

Figure 3-13: Still images from videos of the re-entrant fires at Wang Tai House, reproduced in the IC Expert Report$^{498}$

By 15:18,$^{499}$ bamboo scaffolding collapsed near the front entrance of Wang Tai House, as observed from a CCTV camera at the bicycle shed.

〔图〕2025-11-26 15:17:02通道2\n

Figure 3-14: Still image from CCTV footage inside the bicycle shed of Wang Tai House (15:17:02)$^{500}$

Flames continued to consume the area outside the front entrance of Wang Tai House. The front entrance was completely blocked by flames at around 15:21, at which time the CCTV footage terminated.

〔图〕2025-11-26 15:19:17Block5 Lobby\n

Figure 3-15: Still image from CCTV footage outside the front entrance of Wang Tai House (15:19:17) $^{501}$

According to the IFITF, the front entrance and rear exit of Wang Tai House were obstructed by burning debris at 15:20 and 15:30 respectively.$^{502}$ This severely compromised the evacuation of residents.

C2. Wang Shing House (Block G)

The fire soon impacted a third building. By approximately 15:09, a video captured by a passerby provided the first photographic evidence of fire at Wang Shing House (Block G). The footage showed parts of the scaffolding ablaze along the south façade of the building.

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Figure 3-16: Still image from video footage of Wang Shing House and

Wang Cheong House captured outside Wang Kin House at around 15:09503

Witness testimony indicates that the fire may have reached Wang Shing House earlier than the photographic evidence suggests. As early as 15:00, Mr Wong Wai Sum observed burning fragments of scaffolding nets drifting from Wang Cheong House (Block F) and igniting flames on Wang Shing House (Block G). This is corroborated by Ms Tse Yuk Wa and Mr Yip Ka Kui Sdanni who both testified to seeing flaming debris and scaffolding nets flying from Wang Cheong House and landing on Wang Shing House by 15:05.504

Frontline observations from the FSD confirmed that the fire had spread to Wang Shing House no later than 15:20.505 Testifying for the IFITF, Mr Lam Kin Kwan (Deputy Chief Fire Officer, New Territories South)

503 [IE4/1510]

504 [T3/40:24-29]; [T5/3:26-36]

505 IFITF Final Report §5.2.4.1 [ER1/60]

142

verified that this observation represented the latest time by which the fire had spread.506

At Wang Shing House, rapid vertical spread of the fire only occurred much later, at around 16:22.

C3. Other blocks

The first fragments of flaming debris began to fall on the roof of Wang Sun House (Block C) at 15:12. At around 15:25, specks of flame were seen on the scaffolding of Wang Sun House.

506 [T25/28:13-15]

143

Figure 3-17: Still images taken from CCTV footage on the roof of Wang Sun House (15:12:21) and video footage captured at Kwong Fuk Estate looking towards Wang Sun House at around 15:25507

Consistently, frontline observations from the FSD confirmed that the fire had spread to Wang Sun House no later than 15:25.508

The first rapid re-entrant fire at Wang Sun House occurred around half an hour later between Flats 2 and 3. Video footage captured by eyewitnesses at 16:00 showed that the flame climbed the entire 31-storey height of the building within the span of approximately 1.5 minutes.

Further pillars of flame went up Wang Sun House re-entrants at 16:36 (between Flats 1 and 8) and 16:43 (between Flats 4 and 5).

507 [A2/21, 23]

508 IFITF Final Report §5.2.4.1 [ER1/60]

144

Figure 3-18: Still images taken from video footage captured outside Wang Sun House, reproduced in the IC Expert Report509

At around 16:45, bamboo scaffolding from Wang Sun House collapsed onto the ground below.510

As to the spread of fire to Wang Kin House (Block D):

1. Mr Wong Shing Kin, a resident of Flat 2108, testified that the scaffolding of Wang Kin House first caught fire at around 15:15. He saw flames on multiple parts of the scaffolding nets outside the kitchen window of his neighbour’s flat, each measuring approximately 10 cm by 10 cm.511

2. A resident of Kwong Lai House at the neighbouring Kwong Fuk Estate captured the first photographic evidence of the spread of fire to Wang Kin House at around 15:20. In the footage, specks of flame appeared on the scaffolding of the west façade of Wang Kin House.

509 IC Expert Report Figure 3-8 [ER3/2171] 510 [C11/2603]

511 [T5/32:11-30]

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Figure 3-19: Still image taken from video footage captured at Kwong Fuk Estate looking towards Wang Kin House (Block D)512

3. Frontline observations from the FSD confirmed that the fire had spread to Wang Kin House no later than 15:25.513

No vertical fire spread occurred at Wang Kin House despite multiple points of ignition on the scaffolding.514 Based on the results of a computational fluid dynamics simulation of the effect of wind on the fire spread, the IFITF observed that a recirculation zone515 may have formed around the building which extended the travel distance of embers, allowing them to cool before reaching Wang Kin House and reducing the risk of ignition. 516 This

512 [A2/22]

513 IFITF Final Report §5.2.4.1 [ER1/60]

514 [ER2-1/635]

515 A recirculation zone is a region where the fluid velocity locally reverses direction and forms a circulating loop. Instead of moving downstream, the flow rolls back upstream and creates a vortex-like structure.

516 IFITF Final Report §7.3.2.6 [ER1/117]

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accounts for why Wang Kin House was largely spared from fire damage, as detailed further below.

As to Wang Tao House (Block B) and Wang Yan House (Block A):

1. Frontline personnel from the FSD observed that the fire first spread to these buildings no later than 15:39 and 16:04 respectively.517

2. A rapid vertical fire engulfed the re-entrant between Flats 2 and 3 of Wang Tao House at 16:11. This re-entrant was immediately opposite the re-entrant between Flats 2 and 3 of Wang Sun House (Block C) which experienced a vertical fire at 16:01, just 10 minutes earlier.

3. The final re-entrant fire took place much later at 18:32, in the reentrant between Flats 2 and 3 of Wang Yan House.

Figure 3-20: Still images taken from video footage of fire at Wang Tao

House and Wang Yan House, reproduced in IC Expert Report518

The fire burned overnight. It spread into and completely consumed many flats, common corridors and staircases across the 7 blocks affected by the

517 IFITF Final Report §5.2.4.1 [ER1/60] 518 IC Expert Report Figure 3-9 [ER3/2171]

147

fire. The image below, taken from livestream coverage of the fire, showed many flats ablaze from their interior as at 19:00 on 26 November 2025.

Figure 3-21: Still image taken from i-Cable news footage at 19:00:00519

Firefighting operations were declared over at 10:18 on 28 November 2025, over 43 hours after the initial attendance. The firefighting response will be addressed in Chapter 5 below.

C4. Observations About the External Spread of the Fire

A few overarching observations can be made about the spread of the fire.

First, the fire spread most rapidly through vertical pillars of flame that ascended the re-entrants at an unprecedented speed. There were 12 such occurrences across the seven blocks affected by the fire. Among these, 11 fully-fledged re-entrant fires occurred within a two-hour period from 14:58 to 16:43.

519 [A2/26]

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Figure 3-22: Diagram illustrating vertical fires in Wang Fuk Court, taken from IC Experts’ Presentation on 25 June 2026520

Second, the fire spread from block to block primarily through flying embers and airborne burning debris (such as fragments of scaffolding nets, bamboo and other construction materials). Carried by the wind, these embers travelled significant distances and ignited combustible materials, including safety nets, on the exteriors of other blocks. This mechanism is amply supported by CCTV footage, video footage taken by residents and witness testimony.

Third, the wind conditions that day – east to south-easterly winds at around 14 km/h – played a role in the development of the fire. Wang Chi

520 [ER6/2685]; for minor corrections to the flat numbers at Wang Tao House (Block B), see [ER8/2750]

149

House (Block H), which was far to the north of Wang Cheong House (Block F), remained entirely unaffected by the fire. The IFITF’s simulation based on a CFD model demonstrated that the wind did not carry embers towards Wang Chi House that day.521 Wang Kin House (Block D), which found itself within a recirculation zone between Wang Sun House (Block C) and Wang Tai House (Block E),522 also suffered relatively minimal damage.

D. Conditions Inside the Blocks and Means of Escape

D1. Internal conditions within Wang Cheong House (Block F)

There is a significant correlation between the rapid re-entrant fires and the extent of interior damage. Among the 562 units in Wang Fuk Court that sustained severe or extremely severe fire damage, 518 units (92%) were located adjacent to re-entrants where rapid fire spread was observed.523

Conditions in the lift lobby corridors were also closely associated with rapid fire spread along re-entrants connected to the corridors. 524 It is therefore reasonable to infer that staircases connected to re-entrants engulfed by pillars of flames would also have been swiftly penetrated by smoke and heat. This inference is corroborated by the testimony of occupants who managed to escape the fire.

Occupants of Wang Cheong House (Block F) testified to the very limited window available to escape. Smoke filled individual flats, common corridors and staircases within minutes of the discovery of the fire:

1. By 14:59, the rapid vertical fire within the east re-entrant outside Flats 4 and 5 had become fully developed. Crucially, this re521 IFITF Final Report §7.3.2.4 [ER1/117] 522 IFITF Final Report §7.3.2.6 [ER1/117] 523 IFITF Final Report §8.3.1.2 [ER1/132] 524 Yiu Men Yeung 4th WS §32 [WS6/1853]

150

entrant was directly connected to the staircases of Wang Cheong House.525

2. Furthermore, the escape routes on the ground floor were blocked by falling debris by 15:05.526

Madam Chung Sui Ha, the building attendant on duty at Wang Cheong House, stated that she was first alerted to the fire by an individual who was neither a resident of Wang Cheong House nor a construction worker wearing a PC&E uniform. When she arrived at the rear of the block, she saw small flames on the flat roof outside Flats 104 and 105. She then notified the management office of the fire via walkie-talkie.527

By cross-referencing Madam Chung’s testimony with the footage captured by Mr Yip Fai528 and the evidence of Madam Lok Sin Ying, who called 999 at 14:52 shortly after receiving Madam Chung’s report,529 it can be inferred that Madam Chung was first informed of the fire at around 14:50.

Upon discovering the fire, Madam Chung then returned to Wang Cheong House to activate the fire alarms. She went up to 1/F as there was no break glass panel at the lobby, but could not activate the alarm. She then went up to 3/F to access the break glass panel there, but was similarly unsuccessful. On her way up, the staircases were still relatively smoke-free, but she could hear crackling noises and see flames outside the window. By the time she reached 3/F, smoke had begun to fill the staircases from higher floors, presumably from the worker access openings on the 5/F staircase. She therefore returned to the lobby where she reported the situation to Madam Cheng Tsz Ying. She continued to evacuate residents until the lobby

525 Figure 4-2, IFITF Final Report [ER1/21]; also fn 184 [ER1/231] 526 Hui Kin On WS §§14-15 [WS2/990]

527 [T7/31:4-32:8]

528 [A2/10]

529 [WS2/1227]

151

became uninhabitable due to the fire having already spread to the area outside the front entrance.530 This would have been around 15:05.

Ms Tse Yuk Wa, a resident of Flat 204 (directly above the seat of the fire), testified that smoke began penetrating through her kitchen window during the initial stages of the fire. Based on the photographs she took at the time, this occurred at around 14:53. When Ms Tse opened her front door to clear the smoke in her flat, she observed that the common corridor was becoming hazy. When she evacuated her flat at around 15:00, the staircase was already smoke-logged, large flames were visible through the window and the walls were radiating heat. By the time she left the building, smoke was billowing from the lobby into the surrounding area.531

Figure 3-23: Still images from footage taken by Ms Tse Yuk Wa in Flat 204 at 14:53532

530 [T7/32:11-33:4] 531 [T3/38:26-40:29] 532 [IE3/1362]

152

Mr Chan Chuen, Joe, a resident of Flat 605, explained that he first became aware of the fire through the smell of smoke at around 14:51. He immediately called the management office to inform them of the situation. At around 14:56, he observed his kitchen filling with smoke within a span of one to two minutes, transitioning from white smoke to dark smoke. There was some smoke in the corridor but noticeably less than in his flat. He evacuated via the staircase.533

Ms Wong Ka Yuen, a resident of Flat 1005, testified that, at around 14:50, she heard workers yelling outside her flat. When she looked out her window, she saw smoke but no flames outside. Looking into the corridor, she could smell smoke but the corridor was still clear. She left the flat and reached the lower floors by staircase at around 14:55. Inside the staircase, she saw that the window was already glowing red.534

Ms Ko Yee Lui, a resident of Flat 2405, stated that the television signal in her flat was abruptly lost at around 14:53. She noticed the smell of smoke when she opened the window in her living room at around 14:55 but could not see any smoke or flames outside. Concurrently, smoke began seeping into her flat through the exhaust vent. Smoke had begun to fill the common corridor. Upon attempting to use the staircases, she found them heavily logged with white smoke, leaving her no alternative but to escape via the lift. She reached the ground floor by 14:57, observing a plume of smoke rising above Wang Cheong House.535

533 [T4/18:2-19:11] 534 [T4/6:25-8:3] 535 [T3/42:32-44:11]

153

Figure 3-24: Photo taken by Ms Ko Yee Lui outside Wang Cheong House at 15:03536

The rapid infiltration of smoke into the staircases is further supported by the written statement of Mr Li Ka Ching, a tiling worker who was working in the water tanks on the rooftop of Wang Cheong House. He noticed that the temporary lighting inside the water tanks short-circuited at around 14:50. Roughly a minute later, he detected the smell of burning material and saw white smoke drifting above the water tanks, prompting him to evacuate. By then, the staircases were already heavily smoke-logged, with visibility reduced to 30% to 40%. Conditions within the stairwell were so poor that, when he reached the 14th floor at around 14:57, he was forced to exit the staircase briefly to catch his breath.537

According to Mr Li, during the approximately 30 seconds he spent on the 14th floor, the staircase became engulfed in black smoke and thus

536 [IE3/1167]

537 [IE2-2/1094-1095]

154

inaccessible. Observing that the lifts were still operational, he decided to use the lift instead and exited Wang Cheong House at 15:01. 538

Ultimately, few occupants were able to evacuate successfully from Wang Cheong House. Ms Tse Yuk Wa testified that, apart from an elderly woman whom she met at the staircase landing of 1/F, she did not encounter anyone else in the staircase or the G/F lobby.539 Ms Ko Yee Lui also testified that she did not encounter anyone when taking the lift to the ground floor.540 Mr Chan Chuen, Joe met another resident escaping by stairs on his way down, but stated that there were few people around when he arrived at the G/F lobby and he only counted fewer than 10 people escaping from Wang Cheong House.541 The overwhelming majority were trapped inside the block by the rapid spread of smoke and fire.

Mr Chau Chi Wai, a resident of Flat 207, testified that he first noticed the fire shortly before 15:00 when a window in his unit began glowing red and loud crackling noises emanated from outside his flat. This was explicable as his flat was adjacent to the second re-entrant engulfed in a pillar of flames. After a while, the polystyrene foam boards covering the window in his master bedroom caught fire and the glass window shattered. He attempted to extinguish the fire with a showerhead, but ultimately had to flee. By the time he and his wife left their flat, the common corridor was smoke-logged to the point of being unbearable. The staircase closest to their flat was also impassable. They were rescued by their neighbour, Mr Li Cheuk Lim, who sheltered them in his flat until they were finally rescued by firefighters (at around 17:00).542

Ms Huang Zulian and Mr Yiu Shun Yau, tiling workers who were working outside Flat 2703 of Wang Cheong House at the time, testified that they

538 [IE2-2/1094-1095] 539 [T3/40:3-5]

540 [T3/44:12-19]

541 [T4/19:15-17, 20:3-23] 542 [T5/28:11-30:1]

155

heard workers shouting “Fire!” and went over to the source of the noise near Flat 4 to investigate. They detected the smell of smoke and saw thick smoke rising up the re-entrant. They decided to escape by climbing up the scaffolding to the rooftop. When they reached the rooftop, they saw thick flames and smoke at the re-entrant between Flats 4 and 5. They tried opening the door to the staircase but it had been consumed by black smoke and was inaccessible. They therefore stayed on the roof to await rescue, which took place the next day.543

The Committee has heard tragic evidence from family members of deceased residents. Some testified as to the deteriorating conditions within Wang Cheong House in the early stages of the fire. It is apparent that individual units began to be infiltrated by smoke as early as 15:00.

Ms Lo Hiu Kei Phyllis’s late mother, Madam Lo Ying who lived at Flat 808, messaged the family’s WhatsApp group at 15:02 to inform them of the fire. Upon seeing the message one minute later, Ms Lo called her mother, who stated that the common corridor was filled with smoke. Her mother added that smoke continued to infiltrate the flat despite her attempts to seal the door with towels. Ms Lo spoke with her mother for around five minutes. Towards the end of the call, her mother told her and her brother to live a good life, after which the line abruptly disconnected.544

Mr So Hiu Fung’s late parents, Mr So Yan Yip and Madam Tsang Yuk May, resided in Flat 2701. He testified that his mother called him at around 15:07. She stated that their flat was filled with smoke, that she would try to head downstairs, and that she was about to die. Those were the last words Mr So heard from his mother, though the call lasted for another 1 hour and 49 minutes until around 17:00, when the line disconnected. Mr So immediately rushed to Wang Fuk Court from work and repeatedly sought assistance from FSD personnel to no avail.545 Call records provided by the

543 [IE2-2/96/1086-1087]; [T4/47:24-49:13, 53:15-30] 544 [T4/55:6-26]

545 [T5/25:18-26]

156

Police indicated the late Madam Tsang had called 999 at 15:00 to report that the scaffolding outside her flat was on fire and that her flat was filled with smoke.546

Mr Lee Kwok Hung gave evidence regarding the last moments of his late mother (Madam Tam) and her domestic helpers, Ms Dini-Martiana and Ms Darwati, who resided at Flat 2603. His family was first alerted to the fire when Mr Lee’s sister received a call from Madam Tam’s domestic helpers. Mr Lee’s sister had in fact just visited Madam Tam and had only left the flat at around 14:45. At around 15:00, Mr Lee himself learnt of the fire through a residents’ WhatsApp group. Upon learning of the fire, he checked footage from the surveillance camera installed in Madam Tam’s flat and saw that it was already smoke-logged and that his mother and the two domestic helpers were nowhere to be seen. He then repeatedly called Ms Dini-Martiana but was only able to get through at 15:15, when he heard Ms Dini-Martiana frantically screaming but was unable to communicate with her. The call disconnected after 48 seconds.547

Mr Lee subsequently retrieved footage from the surveillance camera within Flat 2603. The footage from the day of the fire showed that Ms DiniMartiana and Ms Darwati first discovered the fire at around 14:57. They hurriedly dressed Madam Tam and moved her from the flat at 14:59 into a visibly smoke-logged corridor. They subsequently sought refuge in Flat 2608 where they were discovered the next morning.

The surveillance camera inside Flat 2603 captured the flat becoming enveloped in smoke within less than one minute after 14:59, which only cleared at approximately 23:00.

546 [A2/45]

547 Lee Kwok Hung WS §§6-8 [WS2/1377]; [T13/48:13-52:33]

157

158

Figure 3-25: Still images from CCTV footage inside Flat 2603548

The internal conditions within Wang Cheong House were also evidenced by 999 call recordings and other video footage received by the Committee.

1. One of the 999 calls heard by the Committee was placed by a domestic helper trapped in Flat 502 at 15:00. She stated that her flat had been filled with and completely darkened by the smoke (而家嗰啲煙呢全入晒屋㗎喇喎 … 嗰啲煙已經屋企黑曬㗎

啦).549

2. Another call was placed by a resident of Flat 1706 at 15:04. The caller mentioned that smoke had blocked out the staircase lighting entirely and was entering her flat through the gaps in her front door (有好大煙由我門口走入去… 我門口嗰度太多煙，黑曬睇唔

到呀).550

548 [O1/259]; [O2/1727-1728] 549 [C6/2456-2459]

550 [C6/2463-2465]

159

3. Finally, footage captured by a door camera on 15/F showed the corridor filling completely with smoke within a span of six minutes between 14:54 and 15:00.

Figure 3-26: Still images taken from CCTV footage on 15/F of Wang Cheong House at 14:54:15 and 15:00:23, reproduced by The Collective551

Given the rapid spread of fire and smoke within Wang Cheong House, few were able to escape. Many of those who were trapped inside perished in the smoke and fire. Only a few were rescued by firefighters. Based on questionnaires distributed by the Police to residents shortly after the fire, approximately 20 individuals were able to evacuate from Wang Cheong House unassisted, with no resident from above the 10th floor able to

551 [A2/46]

160

evacuate via the staircases. Only 32 occupants were rescued from Wang Cheong House by the FSD.

D2. Internal conditions within Wang Tai House (Block E)

Wang Tai House (Block E) similarly experienced a rapid deterioration in tenable conditions once the fire spread. Nevertheless, compared to Wang Cheong House (Block F), residents had relatively more time to escape.

Mr Yip Ka Kui Sdanni, a resident of Flat 1701, testified that he was first alerted to the fire by his late wife, Madam Pak Shui Lin, who had detected a strong burning smell. They then opened their window facing Wang Cheong House, where they observed large volumes of smoke. He went downstairs to assess the situation at around 15:05 and exited the building around 15:07.552 CCTV footage capturing his departure confirms that the 17th floor corridor was still clear at that time.

Figure 3-27: Still image taken from CCTV footage inside lift of Wang Tai House showing conditions of 17/F corridor (15:03:49)553

Ms Lam Yin Ming, a resident of Flat 1703, testified that she first heard a commotion outside her flat at around 14:55. When she opened the door, she encountered Madam Pak Shui Lin who informed her of the fire at

552 [T5/1:32-2:27] 553 [A2/49]

161

Wang Cheong House and advised her to close the windows. Upon returning to her flat, she detected a faint odour of smoke through her window. However, her view was obstructed by the scaffolding, prompting her to go downstairs to investigate. Shortly thereafter, hearing Madam Pak’s voice in the corridor again, she reopened the door and was advised to pack her belongings. She subsequently escaped via the staircase, leaving the building at 15:12.554

Madam Pak remained in the building to continue alerting residents to the fire. Although she tragically perished, her heroic actions ultimately saved several lives.

Ms Lam also testified that, as she headed downstairs, she did not fully believe there was a fire, as she saw few others evacuating alongside her. There was virtually no smell of smoke inside the building, and the fire alarm had not activated. It was only when she saw the flames at Wang Cheong House that she realised the severity of the fire.555

The situation deteriorated very rapidly after Ms Lam left the building at 15:12. Smoke began to infiltrate the lift lobby corridors at Wang Tai House just four minutes later, at approximately 15:16.

1. As mentioned above, the first pillar of fire at Wang Tai House developed in the re-entrant between Flats 1 and 8 at 15:16. This re-entrant was connected to the lift lobby corridors of each floor, which had openable windows.556

2. Smoke entered the corridors through these openable windows, with immediate and devastating consequences for those who remained inside Wang Tai House.

554 [T5/14:1-15:24]

555 [T5/14:19-25]

556 Yiu Men Yeung 4th WS §§27-29 [WS6/1849-1850]

162

Footage taken in the lift lobby on the 31st floor shortly before 15:17557 showed black smoke infiltrating the common corridor through an open window opposite the lifts.

Figure 3-28: Video footage of the lift lobby window at 31/F Wang Tai House, uploaded by Orange News558

Surveillance footage from CCTV cameras installed inside the lifts of Wang Tai House also showed that the corridors across many floors became smoke-logged by around 15:19. The following photographs are side-byside comparisons of the conditions in the corridors of various floors between 15:13 and 15:20:

1. Lift lobby on the ground floor (15:17 and 15:20):559

557 The time of the footage can be identified by cross-referencing the individuals shown in the footage with surveillance footage from the CCTV cameras in the lifts.

558 [A2/41]

559 The timestamps recorded by the CCTV camera were 2 minutes behind reference time: IFITF Final Report fn 123 [ER1/178]

163

Figure 3-29: Still images taken from CCTV footage inside lift of Wang Tai House showing conditions of G/F lobby (15:14:50, 15:18:19, 15:18:49)560

2. Lift lobby corridor on the 18th floor (15:16 and 15:19):

Figure 3-30: Still images taken from CCTV footage inside lift of Wang Tai House showing conditions of 18/F corridor (15:14:02, 15:17:24)561

3. Lift lobby corridor on the 27th floor (15:17 and 15:20)

560 [A2/49-50] 561 [A2/50]

164

Figure 3-31: Still images taken from CCTV footage inside lift of Wang Tai House showing conditions of 27/F corridor (15:15:31, 15:18:04)562

By 15:21, the common corridors on multiple floors were clearly untenable, as the corridors and the lifts themselves became smoke-logged.

1. Lift lobby corridor on the 23rd floor (15:21):

Figure 3-32: Still image taken from CCTV footage inside lift of Wang Tai House showing conditions of 23/F corridor (15:19:25)563

2. Lift lobby corridor on the 24th floor (15:21):

562 [A2/50] 563 [A2/49]

165

Figure 3-33: Still image taken from CCTV footage inside lift of Wang Tai House showing conditions of 24/F corridor (15:19:29)564

This is consistent with footage from surveillance cameras installed by residents. The door camera installed at Flat 2407 showed the corridor smoke-logged at 15:13 and thick smoke infiltrating the flat at 15:18.

Figure 3-34: Still images taken from CCTV footage in Flat 2407 of Wang Tai House at 15:13:45 and 15:18:30565

Another camera inside Flat 2906 showed the smoke infiltrating the flat through the front door at 15:16. By 15:30, the flat had been completely enveloped in smoke.

564 [A2/50]

565 [C19/2847-2854]

166

Figure 3-35: Still image taken from CCTV footage in Flat 2906 of Wang Tai House at 15:16:23566

Following the infiltration of smoke into the lift lobby corridors, the staircases and ground exits at Wang Tai House became untenable by no later than 15:30. According to the IFITF:

1. The front entrance and rear exit at Wang Tai House were obstructed by burning debris by around 15:20 and 15:30 respectively.567

2. By 15:30, the third pillar of flames engulfed the west re-entrant between Flats 4 and 5. This re-entrant was directly connected to the staircases of Wang Tai House.568

Nevertheless, there were various flats and other areas which remained tenable for extended periods, though not in all cases long enough for firefighters to effect rescues.

1. Mr Cheung Chi Lim George, a resident of Flat 1006, testified that he and his wife were resting at home when they learned of the fire

566 [C20/2871]

567 IFITF Final Report §10.3.3 [ER1/208] 568 IFITF Final Report §9.3.2.4 [ER1/197]

167

via a WhatsApp message. When he looked out from his flat, he saw the garbage collection point in the roundabout on fire, and observed fire engines with their lights flashing but without sirens. Shortly thereafter, the scaffolding outside his flat and the neighbouring flats, which he attempted to extinguish. He and his wife decided to leave their flat at around 15:16 and proceeded to the staircases. The doorbell camera shows the corridor was clear as at 15:16 when Mr Cheung exited the flat. They then opened the fire doors to find both stairwells filled with smoke and inaccessible. They retreated into their flat together with their neighbour at 15:17. By that time, the common corridor had filled with smoke, presumably infiltrating from the window opposite the lift lobby.569

Figure 3-36: Still images taken from CCTV footage in Flat 1006 of Wang Tai House at 15:16:10 and 15:17:12570

2. While they awaited rescue within their flat, smoke infiltrated the living room and kitchen, forcing them to retreat into the toilet and bedroom. They were finally rescued at around 20:00. When firefighters breached the door, a wave of radiant heat swept into the room. While they were carried down the stairs by the

569 [T4/21:12-26:26] 570 [A2/48]

168

firefighters, hot water rushed down the stairwells and the railings were scalding hot.571

3. Madam Sin Sin Hing, a resident of Flat 1406, testified that when she was preparing to leave her flat at around 3 pm, she saw wisps of black smoke in the common corridor. She therefore decided to stay in her flat and await rescue. Smoke continued to infiltrate her flat through the gaps in the door frame. She turned on the fan to direct the smoke out of a window. During this period, she noticed that the paint on her wall had begun to crack due to the intense heat from the adjacent flat. When she was finally rescued by firefighters, the corridor was entirely dark and very hot. She observed a neighbouring flat had been completely burnt out, with a sizeable hole in the front door.572

4. Mr Lee Chun Ho, a resident of Flat 1907, gave evidence regarding the ordeal faced by his mother Madam Yip Pik Yi, his elder brother Mr Lee Chun Man, his niece Ms Li Yan Wing and their domestic helper Ms Erawati – all of whom tragically perished in the fire. He first called his mother at approximately 16:00, at which time she informed him that their flat had filled with dense smoke. Mr Lee and other family members subsequently called Madam Yip once every 15 minutes, during which calls she noted that there was no electricity and water supply to her unit. In one video call, Mr Lee saw his brother patting their mother to keep her awake in a dark flat. In his final call with his mother at approximately 21:30, he heard their cries for assistance and witnessed his brother collapse on screen. Throughout this period, Mr Lee had repeatedly requested assistance from firefighters and police on-site, but was

571 [T4/21:12-26:26] 572 [T4/12:11-15:14]

169

informed that firefighters were unable to go beyond the 14th floor.573

5. The Committee also received written evidence from Ms Hon Yuen Ling Florence, who attended a gathering of friends at Flat 3008 with Mr Cheng Hoi Yeung, Ms Yam Ting and Ms Yam Kuen on the day of the fire. The four individuals discovered the fire when they observed large volumes of smoke rising along the exterior of the building. They called the management office to enquire about the smoke, and were informed that there was no cause for concern as the fire was at Wang Cheong House and that it was safe to remain in their flat. Around 5 minutes later, flames appeared outside their unit and smoke began to infiltrate the flat through the kitchen window. They therefore decided to leave the premises.574

6. Upon reaching the staircase, they observed dense smoke and sparks ascending from lower floors, prompting them to switch to the other staircase, which was dark but tenable. Ms Hon and Mr Cheng reached the rooftop and were eventually rescued at around 2:00 am the following morning. In this process, they became separated from Ms Yam Ting and Ms Yam Kuen, who tragically succumbed to the fire.575

D3. Internal conditions within Wang Kin House (Block D)

Wang Kin House (Block D) remained relatively smoke-free and was tenable for a significantly longer period of time. As mentioned above, Wang Kin House did not experience any vertical fire spread and sustained minimal internal fire damage.

573 [T13/1:29-3:34] 574 [IE2-1/617-619] 575 [IE2-1/617-619]

170

Mr Wong Wai Sum, a resident of Flat 1807, was first alerted to the fire by his wife, who heard loud noises and smelled smoke at around 15:00. When they opened their living room window to investigate, they saw flames on Wang Shing House (Block G) and large amounts of smoke at Wang Cheong House (Block F). They both went downstairs by lift and left the building at around 15:10. 576 He stated that Wang Kin House was unaffected by the fire at the time.577

Other residents only became aware of the severity of the situation significantly later, when flames reached Wang Kin House.

Mr Man Ka Chun, a resident of Flat 3003, testified that he first detected the smell of smoke between around 15:05 and 15:10, after which he then heard sirens from fire appliances and noticed the scaffolding nets burning outside his flat. When he first opened his front door, he did not observe any smoke, and the stairwell was still free of smoke when he entered it. Upon reaching lower floors, however, he detected wisps of white smoke and saw visible flames outside the staircase windows. As he descended the building, he stopped at each floor to alert other residents to the fire. During this period, the common corridors remained free of smoke and flame. He reached the ground floor lift lobby at around 15:40.578

Mr Wong Shing Kin, a resident of Flat 2108, testified that he first noticed loud noises followed by smoke at around 15:14. He attempted to look out of his window to investigate the source of the disturbance but was unable to see any signs of the fire. A minute or two later, his neighbour, Madam Wong (transliteration) of Flat 2107, informed him that there were flames that were approximately 10 cm wide by 10 cm high outside her kitchen. They then attempted to extinguish the flames but were unsuccessful in operating the FH/HR system. They also exhausted the portable fire extinguishers on their floor. Upon observing that the flames had spread to

576 [T5/34:19-35:21]

577 [IE1/462]

578 [IE1/13.1/142-1-142-3]; [T4/37:9-39:24]

171

adjacent units, he decided to evacuate via the staircase. He left his flat at around 16:10. According to his evidence, the stairwell was generally clear at that time, though by the time he left the scene, he realised that his face mask had been blackened by soot.579

D4. Internal conditions within Wang Sun House (Block C)

The evidence indicates that the staircases in Wang Sun House (Block C) remained accessible until at least 15:22, at which point the video feeds from the CCTV cameras terminated.

Figure 3-37: Still image taken from CCTV footage inside staircase of Wang Sun House (15:22:32)580

Madam Tsang Wai Tai, a resident of Flat 104, gave evidence to the Police that she learnt of the fire and went down to the lobby to investigate at around 15:11. She then went back up to collect her valuables at around 15:23, and heard the fire alarms activate while she was packing her belongings. She safely exited the building before 15:35.581

Similarly, Mr Lee Kai Man, a resident of Flat 306, gave evidence to the Police that he evacuated the building upon learning of the fire from

579 [T5/32:11-33:22] 580 [A2/51]

581 [IE2-2/887-889]

172

television. The fire alarms activated as he left his flat. He did not notice any smoke in the corridors or staircases during his escape.582

Finally, Madam Ngai Nai-kim, a resident of Flat 701, gave evidence to the Police that she was observing the fire outside the lobby when she saw flames approaching from Wang Cheong House (Block F). She attempted to call her husband at 15:23 but was unable to reach him. She therefore returned to her flat via the staircases to alert her husband, and safely left the building with him.583

These accounts suggest that common corridors on multiple floors and the staircases continued to remain smoke-free for some period after 15:22.

By 15:45, however, the common corridors on multiple floors had already become smoke-logged.

According to the evidence from the FSD, at approximately 15:45, Station Officer Ma Man Ho, Fn Fung Ka Wing and Fn Ko Tsz Chun Felix took the lift up to 10/F with a view to deploying water jets towards the fire on the façade of the adjacent building, Wang Kin House (Block D). When the lift doors opened on that floor, they encountered severe conditions, with smoke accumulating in the upper half of the common corridor. They then took the lift down to 8/F, but upon the doors opening, smoke surged into the lift. They evacuated the building at approximately 15:50.584

Madam Chong Sio Pek, who lived with her late mother Madam Ieong Vun Ieng at Flat 1405, submitted evidence to the Committee explaining that her family first learned of the fire at Wang Cheong House at 14:59, but only realised the severity of the situation at around 15:20, when the fire spread rapidly up Wang Cheong House (Block F) and Wang Tai House (Block E). They attempted to contact Madam Ieong but when they finally reached her

582 [IE2-2/900-902]

583 [IE2-2/903-904]

584 [C19/2836-2837]; [C20/2855-2861]

173

at 15:48, Madam Ieong informed them that the corridors were already smoke-logged and the lifts were inoperable. Madam Ieong was still able to take a video call from Madam Chong’s elder brother at 16:27, but by that time she had already retreated to her bedroom and had sealed the gaps in her door frame with damp towels, as her living room had already become smoke-logged. That was the last time Madam Chong and her family were able to speak with Madam Ieong.585

D5. Internal conditions within Wang Tao House (Block B)

Wang Tao House (Block B) remained relatively smoke-free until approximately 16:00. CCTV footage showed multiple residents evacuating via the lifts while the corridors remained clear. However, by 16:09 (shortly before the video feed terminated, coinciding with the time when the first rapid vertical fire spread up Wang Tao House), residents could be seen covering their faces, suggesting that smoke had begun infiltrating the building.

Figure 3-38: Still image taken from CCTV footage inside lift of Wang Tao House (16:08:46)586

585 [IE1/4] 586 [C20/2863]

174

The common corridors of Wang Tao House rapidly became smoke-logged at around that time. Residents from Flats 1304 and 1704 testified as to the dense smoke in the corridors which also infiltrated their flats, preventing their escape.587

D6. Internal conditions within Wang Yan House (Block A)

Wang Yan House (Block A) remained accessible until 18:32, when a rapid vertical fire spread engulfed the re-entrant between Flats 2 and 3. Footage from surveillance cameras showed individuals evacuating, and police officers and firefighters entering the building, until around 18:07. The common corridor on 8/F also remained smoke-free until at least 18:21.

Figure 3-39: Still image taken from CCTV footage inside lift of Wang Yan House (18:21:02)588

D7. Internal conditions within Wang Shing House (Block G)

Finally, the evidence indicates that the conditions inside Wang Shing House (Block G) remained tenable up to around 16:20. This is consistent

587 [IE2-2/846, 849] 588 [C20/2862]

175

with the photographic evidence of a fully developed vertical fire in the reentrant between Flats 6 and 7 at around 16:22.589

CCTV footage from Wang Shing House showed that the lifts remained free of smoke at around 16:16. Residents were able to evacuate via the main entrance as late as around 16:20.

Figure 3-40: Still images taken from CCTV footage inside lift and outside entrance of Wang Shing House (16:16:40, 16:20:28)590

Mr Leung Ho Hin, a resident of Flat 303, gave evidence that he first learned of the fire via WhatsApp messages from his family at around 15:10. While he heard noises outside, the first sign that anything was wrong in his block occurred at around 15:30, when he tried to turn on the television but was

589 IC Expert Report Figure 3-9 [ER3/2171] 590 [C20/2864]

176

unable to do so. He first detected the smell of smoke when he opened his front door at around 16:00. When he left his flat around 16:21, there was already dense white smoke in the common corridor on his floor and in the staircases.591

Figure 3-41: Still image taken from CCTV footage outside Flat 303 of Wang Shing House (16:21:54)592

E. Attempts to Activate Fire Service Installations During the Incident

The status of the fire service installations at Wang Fuk Court prior to the fire, particularly the progress of the repair works on the FS Tanks, is detailed in Chapter 2 above.

In brief, the main power switch for the fire alarm and FH/HR systems had been switched off by ISS employees for the renovation works. Consequently, the fire alarm systems in all eight blocks were inoperative when the fire broke out at Wang Cheong House.

591 [T3/32:20-34:21] 592 [IE6/1522]

177

Nevertheless, the evidence indicates that successful attempts were made to activate the fire alarms at Wang Yan House (Block A) and Wang Sun House (Block C), albeit only briefly.

1. Mr Lam Man Yan, a Technical Officer employed by ISS at Wang Fuk Court, testified that, shortly after the discovery of the fire, Madam Cheng Tsz Ying called him and asked him to ascertain why the fire alarm systems were not operational.

2. Unable to reach Wang Cheong House (Block F), Mr Lam ran instead to Wang Yan House (Block A) and attempted to activate the break-glass alarm, which failed to function. He then went to the FS Pump Room and found the main power switch sitting in the “OFF” position. Upon moving it to the “ON” position, the fire alarm sounded in Wang Yan House. 593

3. Mr Lam then proceeded to Wang Tao House (Block B) and Wang Sun House (Block C), where he repeated the process. He was unable to activate the fire alarms in Wang Tao House, but successfully activated the fire alarms in Wang Sun House. He then proceeded to Wang Kin House (Block D) but was stopped by police officers, who instructed him to leave the area.594

4. Cross-referencing Mr Lam’s evidence against other witness testimonies and contemporaneous evidence obtained by the Committee, the evidence indicates that the fire alarms were first activated in Wang Yan House between around 15:20 and 15:27.595 As for Wang Sun House, the fire alarm would have been activated sometime between 15:23 (when Madam Tsang Wai Tai returned

593 Lam Man Yan WS §§19-20 [WS2/1217]

594 Lam Man Yan WS §§21-23 [WS2/1217-1218] 595 [A2/59]

178

to her residence in Flat 104 to pack her belongings) and 15:35 (when she left the building).596

5. Contrary to Mr Lam’s evidence, the FSD’s evidence is that StnO Shek Ngai Chun found the main power switch in the FS Pump Room of Wang Yan House (Block A) to be in the “OFF” position at approximately 16:00 on 26 November 2025.597 Since the door to the FS Pump Room was found unlocked, however, the possibility that someone had entered the FS Pump Room and deactivated the main power switch cannot be ruled out. Further, Mr Lam’s evidence is corroborated by evidence from 55 residents of Wang Yan House present at the scene, who submitted questionnaires to the Police stating that the fire alarms had indeed been activated.

As for the other blocks, the evidence clearly indicates that the FAS and FH/HR systems were not activated on the day of the fire. Indeed, attempts by some residents to utilise these fire service installations had unfortunately delayed their evacuation.

1. Madam Chung Sui Ha of ISS testified that she was unable to activate the fire alarms on 1/F and 3/F of Wang Cheong House (Block F). 598 A resident was also observed attempting unsuccessfully to activate the fire alarm on 15/F.

596 [IE2-2/888]

597 Keung Sai Ming 3rd WS §5.1 [WS4/1801-1802] 598 [T7/32:15-29]

179

Figure 3-42: Still image taken from CCTV footage on 15/F of Wang Cheong House at 14:54:12, reproduced by The Collective599

2. Ms Tse Yuk Wa, Ms Ko Yee Lui, Mr Chan Chuen, Joe and Mr Chau Chi Wai all testified that they did not hear any fire alarms while evacuating from Wang Cheong House (Block F).600 Ms Lo Hiu Kei Phyllis also confirmed that she did not hear any fire alarms during her final telephone conversation with her mother who lived at Flat 808 of Wang Cheong House.601

3. Mr Law Tak Pui, who evacuated from Wang Tai House (Block E) at around 14:55, and Ms Lam Yin Ming who escaped from Wang Tai House at 15:12, testified that they did not hear any fire alarms.602

4. Mr Man Ka Chun testified that, as he descended the staircase from 30/F of Wang Kin House (Block D), he proceeded to each floor to activate the fire alarms. These attempts were unsuccessful on each occasion. He also observed two individuals on the 21/F (whom we now know to be Mr Wong Shing Kin of Flat 2108 and Madam Wong of Flat 2107) attempting unsuccessfully to use the FH/HR

599 [A2/46]

600 [T3/39:20-21, 45:5-6]; [T4/19:12-13]; [T5/28:16-17] 601 [T4/55:27-28]

602 [T5/15:8-9, 18:12-13]

180

system to extinguish a fire outside their flat.603 This incident was captured by a door camera on 21/F.

Figure 3-43: Still image taken from CCTV footage on 21/F of Wang Kin House at around 15:24, reproduced by Tagline HK604

5. Mr Leung Ho Hin gave evidence that he did not hear any fire alarms throughout his evacuation from Wang Shing House (Block G). He observed a couple attempting unsuccessfully to use the FH/HR system at around 15:28.605

In fact, of the approximately 450 residents of Wang Fuk Court who were present at the scene of the fire and who completed questionnaires administered by the Police, none heard any fire alarms within Wang Tao House (Block B), Wang Kin House (Block D), Wang Tai House (Block E), Wang Cheong House (Block F), Wang Shing House (Block G) and Wang Chi House (Block H). Only residents of Wang Yan House (Block A) and Wang Sun House (Block C) heard the fire alarms. Again, this corroborates the evidence of Mr Lam Man Yan of ISS.

The Fire Protection Facilities Supervision Division of the FSD inspected the FAS and FH/HR systems at Wang Fuk Court on 26 and 27 November

603 [IE1/13.1/142-3]; [T5/33:8-9, 11] 604 [A2/57]

605 [T3/33:11, 20-24]

181

They observed that the main power switches of all blocks (save for Wang Sun House (Block C)) were in the “OFF” position and that the control fuses of all blocks (save for Wang Cheong House (Block F)) were blown.

Attempts were made by the FSD to reactivate the fire service installations at Wang Yan House (Block A), Wang Tao House (Block B), Wang Sun House (Block C), Wang Kin House (Block D), Wang Shing House (Block G) and Wang Chi House (Block H) by replacing the fuses and moving the switches to the “ON” position, but they were only able to successfully activate the fire alarm at Wang Chi House.606 A summary table of the FSD’s findings is below.

Table 3-1: Status of fire service installations at Wang Fuk Court following the fire

FS Pump / Intermediate Booster Pump

Control Fuse

Main Power Switch

Wang Yan House Could not be actuated despite fuse replacement

Blown

Off

Wang Tao House Could not be actuated

Blown

Off

Wang Sun House Could not be actuated

Blown

Wang Kin House Could not be actuated

Blown

Off

Wang Tai House Not tested due to waterlogged pump room

Blown

Off

Wang Cheong House

Not tested due to waterlogged pump room

Normal

Off

Wang Shing House Could not be actuated

Blown and mouldy

Off

Wang Chi House Could not be actuated during

fire, could be actuated during investigation by replacement of fuses

Blown

Off

606 [B11/5643]

182

F. Fatalities and Casualties

The evidence from the Police and the FSD is that 168 individuals perished and 79 individuals were injured in the fire.607

1. The fatalities were 58 men and 110 women ranging from 7 months to 98 years old. 114 victims were aged 65 or above, and 7 were under the age of 18.

2. There were 149 residents of Wang Fuk Court, 10 domestic helpers, 7 renovation and construction workers, 1 visitor, and 1 fireman, namely Fireman Ho Wai Ho (Fn Ho). 37 households lost 2 or more members.

3. The bulk of the fatalities were concentrated in Wang Cheong House (Block F) (81 fatalities) and Wang Tai House (Block E) (82 fatalities). There were no fatalities in Wang Kin House (Block D), whereas there were 2 fatalities each in Wang Tao House (Block B) and Wang Sun House (Block C) and 1 fatality in Wang Shing House (Block G).

4. The injured were 45 men and 34 women ranging from 3 months to 87 years old. They included 56 residents, 13 FSD personnel, 1 news reporter, 3 visitors, 3 construction and renovation workers, and 3 residents of the neighbouring Kwong Fuk Estate.

5. The injuries were similarly concentrated in Wang Cheong House (Block F) (33 injuries) and Wang Tai House (Block E) (14 injuries). There were 2 injuries in Wang Shing House (Block G), 9 injuries in Wang Tao House (Block B), 1 injury in Wang Yan House (Block A), and no injuries in Wang Sun House (Block C) and Wang Kin House (Block D).

607 [B13/5721-5733]

183

Graphical illustrations prepared by the FSD showing the location where the fatalities and injured persons were found are as follows:

184

185

Figure 3-44: Diagrams illustrating location of fatalities and injuries608

608 [B13/5728-5733]

186

It is notable that for Wang Cheong House (Block F), 57 of the 81 fatalities (70%) were found within flats with the remaining 24 found in staircases and corridors.

For Wang Tai House (Block E), 41 of the 82 fatalities (50%) were found within flats, whereas the remaining 41 were found in common spaces.

This illustrates that for Wang Cheong House (Block F), the fire took hold so rapidly that occupants had no opportunity to escape before being overwhelmed with smoke. In contrast, a larger number of occupants of Wang Tai House (Block E) had discovered the fire and had begun evacuating from their flats, but were then overwhelmed by smoke in the staircases.609

Based on post-mortem reports and autopsies conducted by the Public Mortuary,610 91 deaths were caused by the inhalation of fire fumes. They had raised levels of carboxyhaemoglobin in blood ranging from 15% to 80% saturation (with 50% saturation typically considered life threatening and associated with deep coma, cramps, cardiovascular failure and cardiac arrest).

Professors Usmani and Jiang have analysed how five individuals perished in flats in Wang Cheong House (Block F) which were completely undamaged, namely four individuals in Flat 1202 of Wang Cheong House and one individual in Flat 2602 of the same block. These fatalities were caused by two different modes of smoke spread:

1. In respect of Flat 1202 of Wang Cheong House, smoke infiltrated the unit through the door gaps, as heavy soot deposition is observed on the ceiling of the entrance foyer of the unit. The smoke most likely came from Flat 1201, which sustained serious

609 [ER5/2648]

610 25 autopsies were conducted and 143 waivers were granted: see [C14/2804]

187

fire damage, and the front door of the unit was completely burnt through.611

2. In contrast, for Flat 2602 of Wang Cheong House, the front door showed little soot deposition in the area facing the corridor. Since windows were found open, it is believed that smoke entered the unit from the exterior through the open windows.612

These examples demonstrated the fatal effects of smoke in units which were not damaged by the fire. There were numerous other examples of fatalities in units or common areas undamaged by fire. Illustrating the extent to which smoke spread within the blocks:

1. There were two fatalities in Flats 2206 and 2207 of Wang Tao House (Block B), which were completely undamaged by the fire.613 The cause of death of these occupants was the inhalation of fire fumes.614

2. There was one fatality each in Flats 306 and 2107 of Wang Tai House (Block E) and Flat 2802 of Wang Shing House (Block G). Their causes of death were similarly inhalation of fire fumes.

3. Professors Usmani and Jiang also observed that a significant proportion of fatalities occurred in the staircases and common corridors which did not contain any combustible fuel to generate flames or heat. This meant that smoke inhalation was the likely cause of death in these locations.615

611 IC Expert Report §§4.3.12-4.3.13 [ER3/2227-2229] 612 IC Expert Report §§4.3.14-4.3.16 [ER3/2230]

613 [ER2-1/626]

614 [B13/5721-5722]

615 IC Expert Report §4.2.4 [ER3/2217-2218]

188

Another 65 deaths were caused by “adverse effects of fire”, denoting persons whose remains were seriously burnt resulting in significant charring or disintegration, such that it was not possible to determine the specific cause of death. 616 Given the circumstantial evidence of fire, however, their deaths were likely caused by one or more of the typical causes of death, namely burn injuries, heat, inhalation of carbon monoxide or other noxious substances, trauma and/or pre-existing conditions such as natural disease or other injuries.

A further 12 deaths were determined to have been caused by a combination of inhalation of fire fumes and burns and/or multiple medical causes (such as heart disease).617

As for the injuries sustained in the fire, 50 of the 79 injured persons (63%) were admitted to hospital for inhalation injuries, shortness of breath, hypothermia or hyperventilation, 3 were admitted for burns, and 26 were admitted for a variety of conditions including heat exhaustion, physical injuries or minor conditions. 618

Finally, it would be right to pay tribute to the work of the FSD and the Disaster Victim Identification Unit (“DVIU”) of the Police in locating and recovering the remains of the deceased from the scene of the fire. FSD personnel recovered 106 bodies from the scene as part of their search and rescue operations, and the DVIU recovered body parts identified as belonging to 61 fatalities during their operation between 29 November and 9 December 2025. The final fatality was located by a forensic pathologist on 19 December 2025.619 For those involved in the exercise, this was a traumatic and thankless task.

616 [T26/43:13-16]

617 IFITF Final Report §9.3.1.3 [ER1/195] 618 IFITF Final Report §9.4.2 [ER1/201]

619 Cheng Ka Chun 2nd WS [WS10/1951-1953]

189

G. Property Damage

In terms of property damage, the evidence from the FSD is that:620

1. Wang Cheong House (Block F) experienced substantial damage across all floors. 158 flats (approximately 63%), common corridors of 27 floors (87%) and 34 flights of staircases (55%) were assessed as extremely severely damaged 621 or severely damaged.622

2. However, most of Flats 2 and 3 of Wang Cheong House (being the north-facing flats and the only flats adjacent to an unaffected reentrant) only suffered minor damage or were undamaged.

Figure 3-45: Diagram illustrating damage to flats and common spaces in Wang Cheong House623

3. Wang Tai House (Block E) suffered similar amounts of damage. 145 flats (58%), common corridors on 29 floors (94%) and 34

620 [ER2-1/606-638]

621 Denoting a completely burnt-out condition, with all combustible materials fully consumed or converted to ash, with extensive charring and deformation [ER2-1/619].

622 Denoting significant burnout, with majority of combustible materials destroyed, extensive charring and deformation [ER2-1/619].

623 [ER2-1/621]

190

flights of staircases (55%) were assessed as extremely severely damaged or severely damaged.

4. As with Wang Cheong House, it is notable that the north-facing Flats 6 and 7 of Wang Tai House were largely undamaged.

Figure 3-46: Diagram illustrating damage to flats and common spaces in Wang Tai House624

5. Wang Kin House (Block D) was largely undamaged. Only one flat on the sixteenth floor was extremely severely damaged and 7 other flats (2.8%) suffered minor damage, 4 of which were on the same floor. Only the common corridor on 16/F experienced fire damage, with all other corridors and staircases unaffected.

624 [ER2-1/622]

191

Figure 3-47: Diagram illustrating damage to flats and common spaces in Wang Kin House625

6. Wang Sun House (Block C), in contrast, was severely damaged, with every flat suffering some degree of damage. In total, 146 flats (58%), common corridors on all 31 floors (100%) and 50 flights of staircases (81%) were assessed as extremely severely damaged or severely damaged.

Figure 3-48: Diagram illustrating damage to flats and common spaces in Wang Sun House626

7. As to Wang Tao House (Block B), only 40 flats (16%), common corridors on 14 floors (45%) and 1 flight of staircases (1.6%) were assessed as extremely severely damaged or severely damaged. Damage was concentrated on the south-facing Flats 2 and 3, which were the flats adjacent to the re-entrant which experienced rapid vertical fire spread at around 16:11.

625 [ER2-1/623] 626 [ER2-1/624]

192

Figure 3-49: Diagram illustrating damage to flats and common spaces in Wang Tao House627

8. The position in Wang Yan House (Block A) was similar. 52 flats (21%), common corridors on 21 floors (68%) and 2 flights of staircases (3.2%) were assessed as extremely severely damaged or severely damaged. Most of the damaged flats were Flats 2 and 3, i.e. south-facing flats adjacent to the re-entrant which experienced rapid vertical spread.

Figure 3-50: Diagram illustrating damage to flats and common spaces in Wang Yan House628

9. Finally, Wang Shing House (Block G) was relatively unaffected. 21 flats (8.5%), common corridors on 10 floors (32%) and 2 flights of staircases (3.2%) were extremely severely damaged or severely

627 [ER2-1/626] 628 [ER2-1/627]

193

damaged. The damage was concentrated on the south-facing Flats 6 and 7, flats which were adjacent to the re-entrant which experienced rapid vertical spread.

Figure 3-51: Diagram illustrating damage to flats and common spaces in Wang Shing House629

629 [ER2-1/625]

194

CHAPTER 4: CAUSES OF THE FIRE, FIRE SPREAD AND HEAVY CASUALTIES

A. Overview

The evidence given by the IFITF and the Committee’s experts presents a clear scientific picture of the causes of the fire, its rapid spread and the heavy casualties. Their opinions supply the Committee with a scientific foundation to assess the responsibility of the various parties and to make recommendations on how to prevent such tragedies in the future.

As the Committee has seen from the Evidential Hearings, the conclusions in the expert reports are the product of detailed reviews of photographic and videographic evidence of the fire and its aftermath, experimental data from full-scale fire tests and combustion tests, and computational fluid dynamics simulations. The IFITF and the Committee’s experts have worked independently but nonetheless reached substantially similar conclusions.630 This lends substantial weight to their conclusions.

This Chapter seeks to summarise the main aspects of the expert evidence. The Committee is invited to consider the expert reports, which are comprehensive. The experts’ opinions, hypotheses and methodologies were not materially challenged in their oral evidence.

For the Committee’s easy reference, the key expert reports are as follows:

1. The IFITF Final Report [ER1/1-239], including as appendices:

(a)

The Final Expert Report of Ir Professor Yuen Kwok Kit, Richard [ER2-2/1174-1502].

(b)

The statements of Dr Lee Wing Man, Chief Chemist, Drugs, Toxicology and Documents Group of the Forensic

630 [T27/84:3-9]

195

Science Division of the Government Laboratory [ER2-1/460-549].631

2. The IC Expert Report of Professors Asif Sohail Usmani and Jiang Liming [ER3/2154-2282].

Chapter 2 establishes that the eight blocks were enclosed in combustible materials for over a year. Flammable rubbish and debris accumulated on the scaffolding platforms and in the light wells. Materials required to be fire-retardant – principally the scaffolding nets and plastic sheeting – were substantially not. This is a conclusion which rests on the contractors’ own admissions, purchase records and other documentary and circumstantial evidence. The expert evidence on the fire-retardancy of materials seized from the scene, analysed in Chapter 2, is consistent with that conclusion.632

The experts’ analysis of the contribution of combustible and non-fireretardant materials to the rapid spread of the fire is of particular importance to the Committee’s mandate to examine the adequacy of the standards and supervision for BMR Works and the effectiveness of testing and verification systems. Professors Usmani and Jiang demonstrated that:

1. The rapid vertical fires in the re-entrants were mainly governed by the availability of continuous combustible materials within the reentrants, including large quantities of bamboo, non-fire-resistant nets, canvases, toe boards and foam boards.633

2. The non-fire-retardant scaffolding nets acted as continuous vertical wicks enabling flame propagation across 31 storeys within

631 Dr Lee Wing Man has produced supplementary statements at [C14/2801-2802]; [C16/2812-2814], as well as a statement on the testing methodology of plastic sheeting at [C19/2826-2835].

632 The experimental tests conducted by Professors Yuen, Usmani and Jiang positively support this conclusion, whereas Dr Lee Wing Man’s tests on scaffolding nets are inconclusive in light of sampling limitations.

633 IC Expert Report §§3.7.16, 6.3.1 [ER3/2191, 2245]

196

minutes. Experiments demonstrated that non-fire-retardant nets seized by the Police from Wang Chi House (Block H) generated dripping flames and propagated ignition very rapidly even after the source of fire had been extinguished. When burned by a small, localised source of fire (0.09 MW), non-fire-retardant nets dripped and distributed flames to cardboard and wooden panels, allowing the fire to grow sufficiently large to ignite the bamboo sticks. In contrast, fire-retardant nets did not exhibit these characteristics.634

3. Polystyrene foam boards quickly melted off and dropped from glass panels when subjected to intense heating. Once fallen off, the foam boards propagated sustained flames onto other combustibles.635

4. As for bamboo, tests showed that it could not be ignited by low amounts of heat, but when subjected to high heating conditions, fast pyrolysis and burning could occur.636

The experts’ evidence as to the origin of the fire and the heavy casualties likewise highlights the danger of lax construction practices which escaped regulatory scrutiny, including workers smoking on site, unauthorised removal of windows in protected staircases and disabling of fire alarm systems. Together with the combustible envelope described above, these turned a small, localised fire into a tragedy of unprecedented proportions.

B. Origin of the Fire

The evidence shows that the fire was most likely caused by a glowing source, likely a cigarette, which ignited paper materials on the flat roof

634 IC Expert Report §§3.6.7-3.6.9, 3.6.19-3.6.23 [ER3/2181-2182, 2185-2187]; also §6.3.1 [ER3/2245]; [T27/59:17-60:3]

635 IC Expert Report §§3.6.2-3.6.3 [ER3/2179-2180]

636 IC Expert Report §3.6.12 [ER3/2183]

197

between Flats 104 and 105 of Wang Cheong House (Block F) and caused them to smoulder.

Dr Lee Wing Man explained that the damage in the light well between Flats 104 and 105 was substantially more severe than that in the other light wells of that block. Since the severity of fire damage reflects the length of time the area was affected by fire, 637 this suggests that the light well between Flats 104 and 105 burned for longer and more intensely than other light wells.

The concrete spalling patterns in Flats 104 and 105 also showed that the fire spread from the light well into the flats, as opposed to from the flats into the light wells. Specifically, concrete spalling was more severe in areas closer to the kitchen window (being the closest window to the light well) and decreased in severity as one moved away from the area. Parts of the concrete ceiling in the area above the kitchen window had burnt through and detached, whereas the ceiling of the entryway only displayed cracks.

Figure 4-1: Photos of Flat 105 of Wang Cheong House, reproduced in Dr Lee Wing Man’s presentation on 22 June 2026638

637 [T25/40:13-26] 638 [ER4/2455]

198

Likewise, the damage to the corridor of Wang Cheong House showed that the fire spread out of Flats 104 and 105 into the corridor, not vice versa.

Figure 4-2: Photos of 1/F corridor of Wang Cheong House, reproduced in Dr Lee Wing Man’s presentation on 22 June 2026639

Dr Lee Wing Man’s analysis is consistent with the contemporaneous evidence, including CCTV footage, Mr Yip Fai’s video footage of the fire on the flat roof and the timing by which residents discovered the fire. These have been addressed in Chapter 3.

The photographic and videographic evidence has also been analysed for the purpose of eliminating additional sources of fire. For example, a resident has submitted video footage of flames on the west face of Wang Kin House (Block D) at around 15:15.

639 [ER4/2458]

199

Figure 4-3: Still image taken from video footage captured outside Wang Kin House at around 15:15640

Since the west elevation of Wang Kin House does not face Wang Cheong House, there have been suggestions (such as in the online video from which the still image above was captured) that a separate fire broke out at Wang Kin House. However, the totality of the evidence before the Committee suggests that the flames captured on Wang Kin House spread from the original fire at Wang Cheong House (Block F).

1. By 15:15, there had already been fires in three re-entrants at Wang Cheong House. These fires produced substantial amounts of flaming debris, some of which had been ejected high up in the air. Large pieces of flaming debris had also begun to fall on the rooftop of Wang Sun House (the adjacent block, Block C).

640 [IE6/1523]

200

2. The fire on the exterior of Wang Kin House was relatively small and confined to the façade. None of the flats in the vicinity of the flames shown in the figure above suffered any interior fire damage. This supports the conclusion that this was the product of external fire spread as opposed to a separate source of fire.

3. According to the computational fluid dynamics simulations carried out by the IFITF, flying embers could have reached the west face of Wang Kin House from the re-entrant fires at Wang Cheong House based on the wind conditions at the time.

Figure 4-4: Computational fluid dynamics simulation of wind conditions at Wang Fuk Court on 26 November 2025641

As mentioned in Chapter 3, the Committee received no other videos or photographs indicating an alternative origin of the fire at Wang Cheong House. Dr Lee Wing Man also confirmed that she had not identified any other possible seat of fire.642 The preponderance of evidence therefore supports the conclusion that the fire began as a single fire on the flat roof outside Flats 104 and 105 of Wang Cheong House.

641 Figure 8 of Appendix D to Professor Yuen’s Final Expert Report [ER2-2/1492] 642 [T25/41:20-24]

201

C. Cause of the Fire

C1. The likely cause – smoking on site

There are several categories of evidence which point to a lighted cigarette being the cause of the fire.

First, there is substantial evidence of construction workers smoking on site, including on the scaffoldings, in the months leading up to the fire.

1. The Committee heard numerous accounts from residents who testified in the Evidential Hearings of workers smoking outside designated areas or improperly disposing of cigarettes. For example, Ms Tse Yuk Wa testified that she saw workers smoking on the scaffolding. 643 Similarly, Mr Cheung Chi Lim George mentioned finding cigarette packs on the scaffolding and on top of his air conditioning unit during the scaffolding works. His wife also routinely encountered plastic bottles filled with cigarettes in the staircases.644 Other residents, such as Ms Wong Ka Yuen and Ms Ko Yee Lui also mentioned routinely smelling cigarette smoke wafting into their flats from outside the building.645

2. The Complaints Logbook maintained by the management office recorded persistent complaints about workers smoking on the scaffolding. For example, see complaints on 29 July 2024 (smoking during erection of scaffolding 646 ), 9 October 2024 (worker disposed of lit cigarette end on scaffolding 647 ), 24 December 2024 (workers frequently smoking in corridors and on

643 [T3/37:19-22]

644 [T4/27:11-23]

645 [T3/45:31-46:5]; [T4/6:15-18] 646 [C1-1/749]

647 [C1-1/749]

202

scaffolding 648 ), 24 February 2025 (worker smoking on scaffolding649).

3. More than a dozen complaints about workers smoking were made to Government departments. Indeed, just two weeks before the day of the fire, the LD and FSD received a complaint about workers smoking on the scaffolding, which raised concerns about the risk of a scaffolding fire.650

4. Mr Tsui Moon Come Tony (Chairman of the new Management Committee) testified that despite the Management Committee having repeatedly raised the issue with PC&E, the problem about on-site smoking had not been satisfactorily resolved, and the complaints continued throughout.651

The situation persisted until the day of the fire:

1. The audio track from the CCTV footage taken above the seat of the fire recorded that, when the fire started, workers on the scaffolding assumed that the smoke was caused by a worker having improperly disposed of a cigarette: see Section A of Chapter 3.652

2. At 14:45 on 26 November 2025, a video was sent in a WhatsApp group between PC&E and Will Power showing numerous cigarettes in the staircases of Wang Shing House (Block G).

648 [C1-1/758]

649 [C1-1/766]

650 [D1/1411]; [B6/4512-4513] 651 [T14/48:33-51:4]

652 [A2/7]

203

Figure 4-5: Still image taken from video footage captured from 11-12/F of Wang Shing House circulated in WhatsApp group between PC&E and Will Power at 14:45 on 26 November 2025653

3. During the oral opening address, the Committee was also shown CCTV footage of a worker wearing a PC&E uniform who was smoking on the rooftop of Wang Cheong House (Block F). This footage was captured shortly before the fire was discovered.

653 [A2/73]

204

Figure 4-6: Still image taken from CCTV footage captured from the

rooftop of Wang Cheong House at 14:44 (around 14:45 reference time)654

Second, the excavation of debris on the flat roof outside Flats 104 and 105 of Wang Cheong House (Block F) uncovered (i) two cigarette ends, (ii) a burnt remnant of a cigarette end, and (iii) a substantial amount of partially burnt material (including cardboard boxes and backing papers for the mosaic tiles, and fragments of toe boards and plastic boards). If the cardboard came into contact with a cigarette butt that had not been extinguished, it could smoulder (i.e. burn unnoticed and without any flame) for a period of time before igniting and turning into a flaming combustion.655

Dr Lee Wing Man explained that these combustible materials were likely to be in close proximity to the initial source of the fire, and were preserved in their partially burnt state when other combustible material fell from height, suffocating the fire at the initial site of ignition.656

The littering of scaffolding platforms and flat roofs with combustible debris and materials was pervasive, as noted in Section D6 of Chapter 2. Post-fire inspections of the scaffolding and Wang Chi House (Block H) also revealed work platforms littered with, inter alia, cigarette butts.657

The low humidity level at the time of the fire (between 40% and 50%) reduced the moisture content in materials, rendering them more prone to combustion, and facilitated the development of smouldering fires.658

654 [A2/30]; IFITF Final Report fn 66 [ER1/78] 655 [ER4/2465-2467]; [T25/34:17-35:36]

656 [T25/41:3-13]

657 [ER2-1/608]

658 IFITF Final Report §6.1.9 [ER1/74]

205

C2. Reasons for eliminating other potential causes

Third, several other typical causes of fire have been ruled out in the case of Wang Fuk Court by the IFITF:

1. Sparks from hot works: It is unlikely that the fire was caused by sparks from hot works such as welding. The only works being conducted near the seat of the fire were the re-tiling of mosaic tiles on the external walls, which did not involve any welding.659 This is consistent with the progress of works examined in Section D3 of Chapter 2, where it was concluded that the hacking-off works had been completed across all blocks, and the majority of blocks were undergoing rendering and tiling processes.

2. Spontaneous combustion: Fire caused by materials which may combust at room temperature when exposed to air (such as lithium batteries, compost or hay) has been ruled out in the case of Wang Fuk Court as there is no evidence of such materials being present in the flat roof area.660

3. Electrical faults: The Electricity Legislation Division of the EMSD examined the light well platform suspected to be the seat of the fire and did not find any electrical installation or product.661 There were no signs of electrical fault in the electrical installations in areas closest to the suspected source of fire, including the bicycle shed and Flats 104 and 105.662 As such, the possibility of the fire having started from an electrical fault was ruled out.663

659 IFITF Final Report §6.1.3 [ER1/73] 660 [T26/35:16-20]

661 [ER2-1/655]

662 [ER2-1/645-654]

663 [ER2-1/656]

206

4. Gas leakage: LPG was supplied through heavy grade steel pipes on the right-hand side of the re-entrant between Flats 104 and 105 at Wang Cheong House (Block F). Inspections performed by the Gas Standards Office of the EMSD following the fire identified no instances of pipe rupture. There were no reports of suspected LPG leakage in the three months leading up to the fire. Nor was there any unusual gas consumption on the day of the fire. Moreover, the video footage of the fire did not exhibit any characteristics associated with a flame caused by LPG leakage. Thus, the EMSD ruled out gas leakage as the cause of the fire.664

Figure 4-7: Diagram illustrating LPG riser in the re-entrant of Wang

Cheong House, IFITF Final Report665

664 [ER2-1/657-670]; [T26/34:9-35:3]

665 Photo 1, EMSD Investigation Report [ER2-1/662]

207

5. Arson by the use of accelerants: Dr Lee Wing Man tested debris found on the flat roof outside Flats 104 and 105 of Wang Cheong House for ignitable liquid residue and found none. Dr Lee also inspected the concrete surface of the flat roof and noted that it was relatively unaffected by fire, with none of the concrete spalling which would typically be seen if the fire was started with accelerants.666 It was therefore concluded that the fire was unlikely to have been started with the use of accelerants.

D. Analysis of the Spread of the Fire

The Committee heard detailed evidence regarding the mode of spread of the fire from the Committee’s experts, Professors Usmani and Jiang, as well as from witnesses of the IFITF.

Both teams of experts agreed that the development of the fire involved three primary modes, namely (i) the rapid vertical fire spread up the reentrants, (ii) fire spread from the re-entrants into individual flats, and (iii) secondary ignitions from combustible materials on the façade.667

D1. Vertical fire spread

Chapter 3 described how the localised fire in the Wang Cheong House reentrant developed, within minutes, into a towering pillar of flame. Rapid vertical fires subsequently engulfed 11 other re-entrants during the fire.

Further, the evidence analysed in Chapter 3 establishes a significant correlation between the rapid re-entrant fires and the extent of interior damage, as well as the compromised tenability of staircases and corridors adjacent to the re-entrant fires.

666 [T25/41:36-42:7]

667 IFITF Final Report, Chapter 8 [ER1/127-174]; IC Expert Report, Chapter 3 [ER3/2166-2208]

208

The experts have analysed the key factors that caused the rapid ascent of flames along the re-entrants.

As Professors Usmani and Jiang explained, the geometry of the re-entrant strongly influenced the height and velocity of the flames. Under the stack effect (or the chimney effect), hot combustion gases rise within a vertical shaft or semi-enclosed space, creating negative pressure at the base that increased inflow of air to enhance oxygen supply and thereby accelerating combustion. The geometry of the re-entrants resulted in them acting as partial chimneys, allowing for the rapid vertical propagation of flames and smoke.668

Simulations demonstrate that had the fire occurred against a single flat wall or even a corner, the flames would not have reached the full height of Wang Cheong House and would have spread far less rapidly.669

Likewise, the IFITF found that the re-entrants, like other structural shafts such as lift shafts, “naturally channelled rising smoke and hot gases”, allowing the fire to rapidly engulf multiple floors in a short timeframe.670

Nevertheless, the geometry of the re-entrant alone could not have led to the rapid fire spread. The experts agree that the accumulation of large quantities of combustibles within the re-entrants was a key factor that caused a localised fire to develop into a rapid vertical blaze.671

1. The combustible materials provided an abundant fuel load to sustain and intensify the fire.672

668 IC Expert Report, Appendix A §1.2 [ER3/2267-2268]

669 IC Expert Report, Appendix A §§1.3-1.4 [ER3/2269-2271]

670 IFITF Final Report §§6.2.1.6, 10.2.3 [ER1/80, 203]

671 IFITF Final Report §8.2.7.1 [ER1/132]; IC Expert Report §§3.10.3-3.10.7 also 6.3.1 [ER3/2205-2207, 2245]

672 IFITF Final Report §8.4.6.4 [ER1/164]

209

2. Moreover, when a large volume of combustible materials is present in a re-entrant, the chimney effect will propel the flames upward, igniting more combustibles along the re-entrant. This process created a feedback loop that exponentially accelerated both the vertical fire spread and upward flow of hot gases.673

The final key factor is the presence of non-fire-retardant scaffolding nets and canvases.

As addressed in Chapter 2, Professor Yuen’s opinion is that, if the safety nets and canvases at Wang Fuk Court were fire retardant, the initial fire “would have self-extinguished” and not caused the combustible materials inside the re-entrant to catch fire.674 He therefore agreed with Counsel for the Committee that, with all other conditions on site remaining the same, the rapid vertical fire along the Wang Cheong House re-entrant would not have developed had the scaffolding nets and canvases used on site possessed fire-retardant properties.675

Professors Usmani and Jiang were in general agreement with Professor Yuen’s analysis. However, Professor Usmani expressed his view more cautiously in that, had the scaffolding nets been fire-retardant, the initial fire “may” have self-extinguished.676

It was reasonable for Professor Usmani to take a cautious approach. The full-scale fire tests conducted by the IFITF at the Sichuan University of Science and Engineering (四川輕化工大學) demonstrated that if the fire

size was sufficiently large, all combustible materials within the re-entrant would likely be consumed irrespective of whether they were fireretardant.677 Professor Yuen clarified in evidence that these large fire size

673 IC Expert Report §3.10.7 [ER3/2207]

674 Professor Yuen’s Final Expert Report §2.13.3 [ER2-2/1250] 675 [T26/19:18-24]

676 [T27/62:6-63:9, 86:5-10]

677 Professor Yuen’s Final Expert Report §2.10.7 [ER2-2/1216]

210

tests involved a large ignition source (火源)678 with a heat release rate of

5 MW.679

Therefore, Professor Yuen’s conclusion is dependent on the size of the ignition source at Wang Cheong House. In this regard, Professor Yuen agreed that the fire very likely began as a small ignition source (極有可能

係一個細火). He opined that the footage showed the fire going largely

unnoticed at its inception, which strongly suggests that it was a small initial fire.680 This is consistent with our conclusion in Section C above.

In the case of a small ignition source, the non-fire-retardant scaffolding nets likely played a critical role in the development of the fire:

1. The experiments conducted by the IFITF and the Committee’s experts both showed that, when exposed to a small ignition source681 (i) fire-retardant safety nets self-extinguished; whereas (ii) non-fire-retardant safety nets continued to spread fire and generated flaming droplets.682

2. During fire tests in Sichuan, when non-fire-retardant scaffolding nets and canvases were exposed to a small ignition source, they caused the fire to spread to combustibles resulting in the ignition of bamboo members. This test (Test 13) yielded a total energy release of 10,155.92 MJ, compared with a total energy release of

678 [T26/12:27-33]

679 Professor Yuen’s Final Expert Report §2.7.2 [ER2-2/1197]; Professor Yuen clarified that the 2.5 MW heat release rate is measured within a re-entrant [T26/16:15-24, 19:8-12].

680 [T26/18:17-25]

681 Professor Yuen’s Final Expert Report §2.7.2 (1.5 MW) [ER2-2/1197]; IC Expert Report §3.6.8 (90 kW or 0.09 MW) [ER3/2181-2182]

682 Professor Yuen’s Final Expert Report §2.13.3 [ER2-2/1250]; IC Expert Report §3.6.8 [ER3/2181-2182]

211

65 MJ where fire-retardant scaffolding nets and canvases were used – representing a 27-fold increase.683

3. The Sichuan tests illustrate the role of non-fire-retardant material in unlocking the energy contained in bamboo, which is not easy to ignite, but will ignite if exposed to significant heat.684

4. The Committee’s experts likewise conducted experiments which showed that the non-fire-retardant nets seized by the Police from Wang Chi House (Block H) dripped and distributed flames to combustible materials, allowing the fire to grow sufficiently large to ignite bamboo.685

5. Professor Yuen’s computational fluid dynamics simulations also compared fire-retardant nets with non-fire-retardant nets under a small ignition source of 700 kW. When fire-retardant nets were used, the simulation showed no rapid fire spread in the re-entrant and peaked at 35 MW, demonstrating that fire-retardant nets suppressed early fire growth. In contrast, a large re-entrant fire developed when non-fire-retardant nets and Wang Chi House nets were used, peaking at over 700 MW.686

Ultimately, Professors Usmani and Jiang agreed with Professor Yuen’s conclusion that the lack of fire-retardant qualities in the safety nets and canvases played an important role in the rapid spread of the fire.687

683 Professor Yuen’s Final Expert Report, Fire Load Analysis of Tests 11-13 [ER2-2/1243] 684 [T27/61:2-6]

685 [T27/60:4-21]; IC Expert Report §3.6.21 [ER3/2186]

686 Professor Yuen’s Final Expert Report, Appendix D §4.2 [ER2-2/1497-1499]

687 [T27/62:6-63:9, 86:5-10]

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D2. Fire spread into flats

The lateral spread of fire from the façade into individual flats was also addressed by the experts.

The IFITF’s report analysed several modes of internal fire spread:

1. The IFITF’s hypothesis posits that the fire predominantly spread into units through openings such as open or broken windows.688 This is supported by the evidence that units with living room windows immediately adjacent to re-entrants with rapid fire spread sustained far greater damage.689

2. The IFITF observed from the Sichuan fire tests that the radiant heat flux may have been sufficient to ignite combustibles within units without breaking the windows.690

3. The IFITF analysed units which suffered severe interior damage but showed no severe damage on the external wall, such as Flat 2004 of Wang Yan House (Block A). The fire likely spread internally from other units through the destruction of entrance doors.691

The Committee’s experts also conducted detailed analysis on how the external fire infiltrated the internal units through living room windows adjacent to re-entrants that were engulfed in rapid vertical fires.

The evidence indicates that the heat of the rapid re-entrant fires was strong enough to break living room windows immediately adjacent to the reentrant. It is notable that all living room windows of Flat 5 from 8/F to 31/F

688 IFITF Final Report §8.3.2.1 [ER1/136]

689 IFITF Final Report §8.3.4.5 [ER1/137]

690 IFITF Final Report §8.3.2.1 [ER1/136]; Professor Yuen’s Final Expert Report §2.6.15 [ER2-2/1195]

691 IFITF Final Report §8.3.6 [ER1/148-157]

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of Wang Cheong House (Block F) and of Flat 2 from 8/F to 31/F of Wang Tao House (Block B) were broken during the fire.692

There was also a clear correlation between the orientation of the large living room windows and the extent of internal damage. For example, the living room windows of Flat 5 of Wang Cheong House were immediately adjacent to the re-entrant. These units suffered substantially more severe damage than Flat 4 units, which were equidistant to the re-entrant but only had small bathroom windows adjacent to the re-entrant.693

Figure 4-8: Diagram illustrating configuration of re-entrant, taken from IC experts’ presentation on 25 June 2026694

Although the kitchen windows were within the re-entrants and in closest proximity to the rapid vertical fire, they did not substantially contribute to internal fire spread. Professor Jiang explained that fire spread within room units depends on the ignition of combustibles, but the area near the kitchen

692 Corrigendum, Revised Table 3.3 of the IC Expert Report [ER8/2753] 693 [ER6/2695, 2698]

694 [ER6/2693]

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windows would not normally contain combustibles.695 Another possible reason is that kitchen doors at Wang Fuk Court were built as 30-minute fire-rated doors, in accordance with the Code of Practice on Provision of Means of Escape In Case of Fire and Allied Requirements 1976.696

As mentioned above, the IFITF also observed an asymmetry in the damage sustained by flats adjacent to re-entrants which was “likely attributable to the larger window openings in the living room and the higher fire load present within that space”. The IFITF noted that the asymmetry appears to be unrelated to the kitchens.697

Once the fire spread internally and became fully developed indoors, the fire could spread to adjacent units through the front door. As noted above, the IFITF cited the example of fire spread to Flat 2004 of Wang Yan House (Block A).698 Professor Jiang referred to the internal spread of fire through the front door of Flat 2704 of Wang Cheong House (Block F) to Flat 2703,699 noting that Flat 2703 was not exposed to a re-entrant fire.700

Another mode of fire spread was “leap-frogging”. When internal fires go into a flashover, they may break through a window, causing flames to leap out of the window, stick to the wall and break the window of the room above.701 Video footage showed ejecting flames from room fires spreading the fire to flats above through this mechanism.702

The fuel load in the flats continued to contribute to the lateral and vertical spread of the fire and prolonged the blaze. As Professor Jiang described it,

695 [T27/17:9-17, 19:12-20:16]

696 IC Expert Report §3.9.3 [ER3/2204]

697 IFITF Final Report §8.3.4.5 [ER1/137]

698 IFITF Final Report §8.3.6 [ER1/148-157]

699 [T27/23:1-9]

700 [ER6/2700]

701 [T27/9:10-20]; IC Expert Report §2.3.1(b) [ER3/2165] 702 [ER6/2699]

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after the re-entrant vertical fires developed into room fires, the various modes of fire spread described above caused the fire to develop into multipoint unit fires.703

These multi-point room fires were difficult to contain. This may explain why, although the last of the rapid re-entrant fires occurred at 18:32 on 26 November 2025,704 firefighting operations continued until 10:18 on 28 November 2025, nearly 40 hours later.

D3. Secondary ignitions

The issue of secondary ignition is important. As mentioned above, it explains how a small, localised fire developed into a sufficiently large fire to trigger a rapid re-entrant fire. Secondary ignition also explains how the fire spread to different locations along the scaffolding net, and eventually across multiple buildings.

The rapid re-entrant fires only lasted minutes before entering their decay stage. 705 Nevertheless, the secondary ignition of materials enabled decaying fires to spread to new areas, ignite combustibles and potentially trigger the next re-entrant fire.

The IFITF’s experiments in Sichuan demonstrate that, even as the fire in a re-entrant began to decay, secondary ignition occurred during tests with safety nets lacking fire-retardant properties. It was observed that fire propagated along non-fire-retardant safety nets, resulting in secondary ignitions at various locations on the scaffolding between 50 and 120 minutes after the re-entrant fire entered the decay stage. 706 The fire would

703 [ER6/2701]; [T27/23:10-18]

704 IC Expert Report Figure 3-3 [ER3/2168]

705 IC Expert Report §3.3.3 [ER3/2169]

706 Professor Yuen’s Final Expert Report §§2.3.4-2.3.5 [ER2-2/1180-1181]

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therefore propagate until it encountered and set fire to suitable combustibles, further developing and sustaining the fire.707

The foam boards also played a role in the fire spread. Experiments conducted by Professors Usmani and Jiang showed that the polystyrene foam boards on windows would melt and fall off when heated. The foam boards produced burning droplets which assisted secondary ignition, as well as toxic smoke.708 Professor Yuen also observed that the foam boards, once detached from the windows and fallen, acted as a new source of fire.709

Professors Usmani and Jiang also observed that the fire spread from the first re-entrant to others within the same building and subsequently to neighbouring buildings because of high-velocity fountains of airborne embers, which were light enough to be carried long distances by high winds without extinguishing. They opined that all of the combustibles (including non-fire-retardant nets) were likely to have contributed to these firebrands.710

Likewise, the IFITF also considered that the re-entrant fires lifted embers to great heights, allowing them to follow the wind and travel considerable distances before falling.711 If the re-entrant fires propelled embers and burning debris to other re-entrants, this could trigger another rapid fire spread within those re-entrants.712

Finally, extraneous factors such as the low humidity and high winds on the day further exacerbated the chain of events.713 The average wind speed

707 IFITF Final Report §§8.4.7.3-8.4.7.4 [ER1/168]

708 IC Expert Report §§3.6.1-3.6.5, 3.9.4 [ER3/2179-2180, 2204]. 709 Professor Yuen’s Final Expert Report §2.11.5 [ER2-2/1220] 710 IC Expert Report §7.2.8 [ER3/2251]

711 IFITF Final Report §8.4.4.1 [ER1/158]

712 IFITF Final Report §8.4.5.2 [ER1/161]

713 IC Expert Report §7.2.9 [ER3/2251]

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recorded at Tai Po Kau at 15:00 on 26 November 2025 was approximately 14 km/hour.714 The winds intensified the fire’s progression by supplying additional oxygen to the flames, which increased the fire’s heat, and further carried burning fragments of construction materials over considerable distances.715

E. Causes of Heavy Casualties

E1. Factors which led to heavy casualties

The IFITF identified several critical factors that led to the heavy casualties. Most of these factors reduced the time for evacuation, especially in Wang Cheong House (Block F) and Wang Tai House (Block E):

1. The extreme rate of vertical spread of fire increased the risk of entrapment, as dense smoke obstructed evacuation efforts.716

2. Flaming bamboo and other debris piled up on the ground level, blocking building entrances.717

3. Means of escape were also compromised, as openable lift lobby windows and worker access openings in the staircases allowed smoke to infiltrate the protected means of escape at an early stage.718

The reasons for the rapid fire spread have been addressed. The role of the access openings in the staircases warrants specific mention:

714 IFITF Final Report §7.3.2.1 [ER1/113]

715 IFITF Final Report §§6.2.3.7-6.2.3.8 [ER1/86] 716 IFITF Final Report §10.2 [ER1/203-207]

717 IFITF Final Report §10.3 [ER1/208-214]

718 IFITF Final Report §10.6 [ER1/225-235]

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1. The majority of deaths were caused by the inhalation of smoke,719 rather than by burns or exposure to heat. Consistently, many fatalities were found in corridors and staircases that had no combustible fuel to sustain flames.720

2. The evidence of residents shows that the staircases were completely filled with thick smoke by approximately 14:58, cutting off their primary means of escape. By that point, the available safe egress time for occupants in Wang Cheong House had effectively been reduced to zero.721

3. Post-fire inspections of the flame and soot deposition patterns near the fire-rated staircase doors revealed that the doors were closed and had withstood the flames in the common corridors.722 The smoke in the staircases was therefore the direct result of the access openings.

4. The evidence from the IFITF is that the fire-rated windows in the staircase of Wang Cheong House which had been installed as part of the BMR Works were able to withstand the rapid vertical fire in the re-entrant.723 Fire-rated windows would have maintained the staircase at an internal temperature of 56°C notwithstanding that the re-entrant fire reached a temperature of 1061°C. In contrast, for windows which had been replaced with an aluminium composite panel, the internal temperature reached 605°C.724

719 IFITF Final Report §9.3.1.3 [ER1/195]

720 IC Expert Report §§4.2.4, 4.3.12-4.3.16 [ER3/2217-2218, 2227-2230]

721 IC Expert Report §4.4.15 [ER3/2235]

722 [T26/47:21-29]

723 The only broken fire-rated windows were the result of steps taken by firefighters to vent smoke from the staircase in their later firefighting operations [T26/41:6-15].

724 IFITF Final Report §10.6.2.3 [ER1/230]

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5. The evidence of the Committee’s experts was to like effect. Their computational fluid dynamics simulations modelling the staircases with the access openings showed that smoke entered the staircases “within minutes of fire development”, and tenability limits were exceeded one minute later. Smoke could infiltrate the staircase through the gaps and holes in the movable boards for worker access openings, even before they were completely burned out. They concluded that “both the wooden board and aluminium composite panel are unsuitable for protecting the staircase openings”.725

Figure 4-9: Computational fluid dynamics simulation of smoke infiltrating staircases726

Other critical factors affected the residents’ awareness of the fire, including the opaque foam boards that covered their windows,727 and the shutdown of the fire alarm system. 728 These factors delayed the response and evacuation by residents.

725 IC Expert Report §§6.5.1, 6.5.3 [ER3/2246-2247] 726 [ER6/2727]

727 IFITF Final Report §10.5 [ER1/217-224]

728 IFITF Final Report §10.4 [ER1/215-217]

FFFFFFFFF

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As described by the IFITF in its Final Report, these factors resulted in an “extremely limited escape window for evacuees, particularly for those occupants at Wang Cheong House and Wang Tai House”.729

E2. Estimated time for escape

The factors identified by the IFITF to have led to the heavy casualties can be analysed with reference to the concepts of available safe egress time (ASET) and required safe egress time (RSET). Assistant Director Yiu Men Yeung of the FSD explained that ASET / RSET calculations are only undertaken for buildings adopting a performance-based design, where it is necessary to demonstrate that occupants can escape safely in a fire.730 Nevertheless, both the IFITF and the Committee’s experts have referred to the concept, which helpfully illustrates the time available to the residents to evacuate during a fire.

For any given fire, a successful evacuation can only be achieved if the total time required for evacuation – detection of the fire, decision making and physical movement – is less than the available safe egress time – being the time before evacuation pathways become untenable or impassable.731

729 IFITF Final Report §10.7.7 [ER1/237] 730 [T26/41:33-36]

731 IC Expert Report §4.4 [ER3/2232-2235]

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Figure 4-10: Timeline analysis illustrating the ASET/RSET concept, taken from IC experts’ presentation on 27 June 2026732

Based on our estimation from the evidence summarised in Section D of Chapter 3, the means of escape likely became smoke-logged for each block (and ground exits became obstructed in the case of Wang Cheong House (Block F) and Wang Tai House (Block E)) at the following times:

1. Wang Cheong House (Block F): approximately 14:58 when the first re-entrant fire was fully developed733 and the staircases and corridors had become smoke-logged,734 and at the latest by around 15:05 when both ground-level escape routes were blocked by burning debris.735

2. Wang Tai House (Block E): approximately 15:17 when staircases and corridors had become smoke-logged736 and at the latest by around 15:30 when both ground-level escape routes were blocked by burning debris.737

3. Wang Sun House (Block C): sometime after 15:22, when the CCTV video feed terminated,738 likely until approximately 15:45 when corridors were reported by firefighters to be smokelogged.739

4. Wang Tao House (Block B): approximately 16:09 when the CCTV video feed terminated and residents were seen covering

732 [ER6/2681]

733 IC Expert Report Figure 3-4 [ER3/2169]

734 CCTV footage from Flat 2603 of Wang Cheong House [O1/259]; [O2/1727-1728] 735 SStnO Hui Kin On WS §§14-15 [WS2/990]

736 Evidence of Mr Cheung Chi Lim George [T4/23:6-34]

737 IFITF Final Report §10.3.3 [ER1/208]

738 CCTV footage from staircase in Wang Sun House [A2/51]

739 Police statement from StnO Ma Man Ho [C19/2836-2837]

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their faces, and around when residents became trapped in their flats.740

5. Wang Shing House (Block G): approximately 16:21 when corridors and staircases had become smoke-logged.741

6. Wang Yan House (Block A): approximately 18:32, when the final rapid re-entrant fire occurred.742

7. Wang Kin House (Block D): the block experienced no rapid fire spread and evacuation may have remained tenable for substantially longer if not throughout the entire firefighting process. Unlike for other blocks where CCTV footage cut off in the early period of the fire, the Police were able to recover continuous CCTV footage from some cameras on Wang Kin House up until the next day and firefighters could be observed entering and exiting freely.743

8. Wang Chi House (Block H): not affected by the fire.

Since there is insufficient information to undertake a tenability analysis from a fire-engineering perspective, these estimates are largely drawn from CCTV footage and witness evidence and may not accurately reflect the actual tenability of the means of escape. Nevertheless, they provide a basis for understanding the very stark differences in the casualties across the different blocks at Wang Fuk Court.

According to our analysis of the fatalities and injuries in Section F of Chapter 3:

740 CCTV footage from lifts in Wang Tao House [C20/2863]

741 Evidence of Mr Leung Ho Hin, resident of Wang Shing House [T3/32:20-33:32]; [IE6/1522]

742 IC Expert Report Figure 3-9 [ER3/2171]

743 [A2/5]

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1. Nearly all of the fatalities (163 out of 168) were found in Wang Cheong House (Block F) and Wang Tai House (Block E), the first two blocks affected by the fire. The two blocks suffered severe internal fire damage.

2. Wang Sun House (Block C) also suffered severe internal fire damage, and Wang Tao House (Block B) and Wang Yan House (Block A) had severely damaged flats adjacent to the re-entrants that had rapid vertical fires. Yet, there were only two fatalities in Wang Sun House (Block C), two fatalities in Wang Tao House (Block B) and no fatalities in Wang Yan House (Block A).

The heavy loss of life in Wang Cheong House (Block F) and Wang Tai House (Block E) can readily be explained:

1. Reckoned from the moment the FSD was first informed of the fire at 14:51 to the moment burning debris obstructed the ground-level escape routes, residents had at most 14 minutes to escape Wang Cheong House, and at most 39 minutes to escape Wang Tai House.

2. In reality, the staircases and corridors were smoke-logged even earlier and may have become untenable before the ground entrances and exits were obstructed:

(a) It is estimated that the Wang Cheong House staircase became smoke-logged at approximately 14:58, around seven minutes from the initial 999 call. Had all the staircase windows been fire-rated, occupants in Wang Cheong House would have had another 7 minutes to escape before the front entrance was blocked by debris at around 15:05.

(b) Likewise, for Wang Tai House, the evidence shows that the staircases had become smoke-logged at around

224

15:17. 744 This was unlikely to have happened had the staircase windows not been altered into worker access openings. Had the staircases remained free of smoke, residents using the staircase leading to the rear exit would have had a further 13 minutes to escape (the rear exit was not blocked until 15:30), and those using the staircase to the front entrance would have had a further 4 minutes (the front entrance was engulfed in flames at around 15:21).745 It follows that some of the occupants who perished in the staircases may well have escaped had the staircases remained passable for those additional minutes.

3. The window to escape was also narrower because, with the fire alarms inoperative and foam boards blocking their view, residents were not even aware of the fire when the clock began to run:

(a) Had they not been switched off, the fire alarms would have been activated for Wang Cheong House at the latest by 14:54 by a resident on 15/F, and/or even earlier by Madam Chung Sui Ha.746

(b) For Wang Tai House, the fire alarms should have been activated once it was apparent that the fire was spreading from Wang Cheong House, around 15:00 when the first flaming droplets reached Wang Tai House. Had that been done, residents of Wang Tai House would have had around 15 to 20 minutes to escape.

744 Evidence of Mr Cheung Chi Lim George [T4/23:6-34]

745 [C6/2440]. The time shown in the footage was approximately 2 minutes behind reference time [ER1/178].

746 [T7/32:15-29]

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On the estimates set out above, Wang Sun House (Block C) residents had up to 54 minutes from the first 999 call to evacuate.

1. In a process where every minute mattered, this additional time likely made a difference. The evidence before the Committee summarised in Chapter 3 above suggests this additional time enabled Wang Sun House residents to learn of the fire and its spread from block to block through news reports and urgent calls from family members and neighbours.

2. It is also significant that Wang Sun House was one of only two blocks in which fire alarms sounded. 747 These features may explain why residents in over 70 units at Wang Sun House were able to escape and why only two residents perished despite every flat in the block sustaining some amount of fire damage.

The IFITF also attributes the low number of fatalities in Wang Sun House to the fact that the vertical fire spread in the re-entrant connected to the staircase only occurred at 16:41, nearly two hours after the initial report of fire.748

1. It follows that the staircases may have been less smoke-logged compared to Wang Cheong House and Wang Tai House which experienced re-entrant fires adjacent to the staircases at earlier points of the fire, until then.

2. However, the evidence suggests that corridors on multiple floors of Wang Sun House became smoke-logged at around 15:45, even before the occurrence of vertical fire spread.749

747 IFITF Final Report §10.4.9 [ER1/216] 748 IFITF Final Report §10.4.9 [ER1/216] 749 [C19/2836-2837]; [C20/2855-2861]

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3. Residents who observed smoke-logged corridors may not have dared to venture out of their flats and therefore would not know that the staircases were tenable. Furthermore, the evidence before the Committee does not suggest that residents were still able to escape from Wang Sun House after 15:45 – the last known escapes from Wang Sun House were at around 15:35 as described in Chapter 3.

Residents in all other blocks had more than an hour (and in most cases considerably longer) to be warned about the fire and to evacuate. This readily explains the small number of fatalities in these blocks.

These time estimates concern the feasibility of evacuation through means of escape. Depending on the situation in a particular room or compartment within the building, it may be possible for residents to remain inside the buildings for a longer period. The Committee has heard evidence of residents who managed – through a combination of luck and dynamic decision-making – to avoid smoke indoors for long enough to be rescued by firefighters.750

E3. Fatalities in blocks which had more time to evacuate

The feasibility of escape for individual occupants also depended on their age, mobility, health condition and awareness. While occupants of Wang Tao House (Block B), Wang Sun (Block C) and Wang Shing House (Block G) had more time to evacuate, there were nonetheless fatalities in those blocks.

1. There were two fatalities in Wang Tao House (Block B), one 75-year-old woman in Flat 2206, Madam Lee Lai Man and one 89-year-old woman in Flat 2207, Madam Ho Mee Bo.

750 For example, the evidence of Mr Cheung Chi Lim George [T4/21:12-26:26]

227

(a) Madam Lee and her husband Mr Chu Siu Hung discovered the fire at around 15:30 and decided to await rescue in their flat. Mr Chu survived the smoke and was rescued when he walked down to G/F the next day, but his wife sadly succumbed to smoke inhalation.751

(b) As for Madam Ho, she was in a wheelchair and succumbed to inhalation of smoke and ischaemic heart disease. Her flat was likely infiltrated with smoke as her domestic helper, Madam Supartini, had lost consciousness while awaiting rescue from the same flat.752

2. There were two fatalities in Wang Sun House (Block C): one 83-year-old woman in Flat 1405, Madam Ieong Vun Ieng, and one 40-year-old man in Flat 604, Mr Hung King Leong. As explained in Chapter 3, Madam Ieong was trapped in her flat by around 15:48 when the common corridor on her floor was already smoke-logged. Her flat was also severely damaged by the fire.753 As for Mr Hung, his flat suffered extremely severe fire damage 754 and he was discovered in an unrecognisable state.755

3. There was one fatality in Wang Shing House (Block G), a 77-yearold man in Flat 2802, Mr Chan Hon Bill. His cause of death was identified as inhalation of fire fumes and chronic obstructive pulmonary disease.756

751 [C21/2873-2878] 752 [C21/2879-2884] 753 [ER2-1/624] 754 [ER2-1/624] 755 [B13/5722]

756 [B13/5722]

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CHAPTER 5: EMERGENCY RESPONSE ON THE DAY OF THE FIRE

A. Firefighting Operations

A1. 14:51 to 14:55: Initial deployment

The first 999 call was placed by a passerby at 14:50. It was answered by a Police call operator at 14:50:07 and connected to the FSD’s Fire Services Communications Centre (“FSCC”) 28 seconds later, at 14:50:35.757

At 14:51:17, the FSCC dispatched seven fire appliances to the scene of the fire, comprising one Hydraulic Platform, three Major Pumps, two Light Rescue Units and one 37-metre Turntable Ladder from Tai Po, Sha Tin and Ma On Shan Fire Stations, the incident being logged as a “fire involving scaffolding on external wall with explosion occurred”.758

Notably, this turnout exceeded the standard pre-determined attendance:

1. Pursuant to the FSD’s General Orders Chapter 41 (Mobilizing and Communications, Mobilizing), the pre-determined attendance for No 1 alarm fire calls in urban residential areas is normally four fire appliances, comprising one Hydraulic Platform, one Major Pump, one Turntable Ladder or Aerial Ladder Platform and one Light Rescue Unit or Major Rescue Unit.759

2. Under the Contingency Plan formulated by the FSD for the major renovation works at Wang Fuk Court, one additional Major Pump and one additional Light Rescue Unit would be dispatched to any fire calls at Wang Fuk Court. Relevantly, the Contingency Plan stated that “As from year of 2024, high occupancy would be

757 [A2/9]

758 Tang Wing Wah WS §§8-11 [WS1/40] 759 [B2/2106]

229

remained throughout the major maintenance works take part, hence high evacuation risk is anticipated in case of any emergency”. The crews of these two additional appliances would be responsible for “massive evacuation with crowd control due to high occupancy of the concerned domestic buildings”.760

3. One further Major Pump was dispatched due to the notified shutdown of the FH/HR system at Wang Fuk Court in accordance with the Fire Services Departmental Policy Instructions.761

At 14:54:40, four further fire appliances were dispatched by the FSCC to the scene, including one Search and Rescue Team (“SAR Team”) comprising one Hydraulic Platform, one Light Rescue Unit and one Reserve Heavy Pump. This is a standard procedure under the FSD General Orders when a building fire is reported from two or more callers.

In total, 11 fire appliances and one ambulance, crewed by 61 FSD personnel, were dispatched within the first five minutes of the FSD receiving the initial 999 call.762

A2. 14:56 to 15:02: Initial firefighting efforts

The first fire appliance to arrive at the scene was a Hydraulic Platform from Tai Po Fire Station. It was crewed by one Senior Fireman and four Firemen, under the command of SStnO Hui. The crew arrived at the roundabout of Wang Fuk Court at 14:56:22. The remaining six fire appliances of the initial deployment arrived between 14:57:30 and 15:04:00.763

Upon arriving at the scene, SStnO Hui assumed the position of Incident Commander in accordance with FSD protocol. SStnO Hui gave evidence

760 Contingency Plan for Wang Fuk Court under Major Maintenance Works §5.6 [B2/2645] 761 DPI/IV/4.2.16 §3.1.2 [B2/2186]

762 Tang Wing Wah WS §14 [WS1/41]; [B5/4325]

763 Hui Kin On WS §8 [WS2/987]; [B13/5735-5738]

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that at the time, there was no fire or smoke on the façade facing the roundabout. He was led by a passerby to the rear façade of Wang Cheong House (Block F) via the pathway adjacent to Wang Shing House (Block G), upon which he saw the scaffolding structure well alight, with flames reaching the eighth or ninth floors.764

At 14:57, SStnO Hui reported his observations back to FSCC. His message reads “Scaffolding of about 8m in width and 30m in height at the external wall (towards Island House Lane side) of an RCC domestic building of 31 residential floors of about 30 x 25m (Wang Cheong House) well alight. 1 covering jet in use at openground outside Wang Cheong House”.765

According to SStnO Hui, he directed crews to lay two water jets for firefighting at the initial seat of the fire. At around 14:59, he then returned to the roundabout outside Wang Cheong House (Block F), where he saw a large plume of smoke rising above Wang Cheong House. He also observed the fire spreading from the rear façade to the west façade of Wang Cheong House and the east façade of Wang Tai House (Block E) at around 15:00.766

At 15:02, SStnO Hui upgraded the fire to a No 3 alarm. He explained in evidence that he did so because by then smoke and fire had almost engulfed the entirety of Wang Cheong House (Block F), and was at risk of spreading to other buildings. Furthermore, debris had begun to block the entrance of Wang Cheong House, trapping occupants inside. He therefore assessed that the initial turnout was insufficient to deal with a fire of that scale.767

In accordance with the pre-determined procedures under the FSD’s General Orders Chapter 41, eight further fire appliances, including one 55-metre Turntable Ladder and two Mobile Command Units, were dispatched to the scene at 15:03:32. Assistant Divisional Officer Cheung Lok Hang

764 Hui Kin On WS §9 [WS2/988]

765 [B13/5735]

766 Hui Kin On WS §11 [WS2/989]; [T11/11:20-27] 767 [T11/13:34-14:3], Hui Kin On WS §12 [WS2/990]

231

(張樂恒), Station Commander of Tai Po Fire Station (“ADO Cheung”),

was also dispatched to the scene.768

A3. 15:02 to 15:35: No 3 alarm

While ADO Cheung proceeded to the scene, SStnO Hui remained as Incident Commander for the initial stage of the No 3 alarm fire. SStnO Hui explained that at around 15:05, he deployed three additional water jets in the roundabout facing Wang Cheong House (Block F) and Wang Tai House (Block E) and directed firefighters to clear the debris blocking the entrance of Wang Cheong House and assist with the evacuation of residents. At around 15:20, he instructed the crew of the newly arrived 37-metre Turntable Ladder from Tai Po East Fire Station to apply a water monitor to Wang Shing House (Block G), which was by then alight.769

ADO Cheung arrived at the scene at 15:19:49 and assumed the role of Incident Commander at 15:19:58.770 He testified that he met SStnO Hui at the roundabout near Wang Tai House at 15:23 where SStnO Hui briefed him on the firefighting efforts, including a Mayday message which SStnO Hui received at around 15:22. ADO Cheung instructed SStnO Hui to continue firefighting efforts and the Mayday operation, and instructed crew members to lay an additional two hoses for firefighting at Wang Kin House (Block D) and Wang Sun House (Block C), bringing the total up to seven hoses.771

A 55-metre Turntable Ladder from Sha Tin Fire Station also arrived on the scene at 15:23. It was positioned outside Wang Tai House (Block E) on Tai Po Road – Yuen Chau Tsai.

768 [B13/5738]

769 Hui Kin On WS §§14-17 [WS2/990-991] 770 [B13/5746]

771 Cheung Lok Hang WS §§6-8 [WS2/995-996]

232

Figure 5-1: Map showing location and placement of fire hoses, water jets and turntable ladders at around 15:23772

In parallel to the developments on the ground, the Director of Fire Services, Yeung Yan Kin Andy, was informed of the fire at 15:14 and activated the Director’s Command Post (“DCP”) at 15:20.

Deputy Chief Fire Officer Fok Chun Ming led the DCP on the day of the fire. He testified that the DCP served as a supreme commanding post for the Director of Fire Services to coordinate the FSD’s response and liaise with other Government bureaux and departments. Due to the gravity of the situation, the DCP was directly activated at the Tier 2 level (entailing two senior officers, five subordinate officers and four other members) and was commanded by an Assistant Director (being two ranks senior to a Senior Divisional Officer, who would typically be in charge of the DCP).773

Upon the activation of the DCP, the DCP deployed 10 additional SAR Teams comprising 20 fire appliances with 105 personnel to handle the surge in assistance calls. The DCP also established a Support Centre with

772 [B10/5556]

773 Fok Chun Ming WS §§5-7 [WS2/1014-1016]

233

18 telephone lines to operate a call-back mechanism for assistance requests, as described further below. 774

The FSD informed the Water Supplies Department (“WSD”) of the fire at 15:19:12, following which duty staff from the WSD were deployed to the scene. Following the arrival of the duty staff at 16:00, they opened all relevant water main valves. Inspections of the street hydrants performed by the WSD recorded a continuous water supply of 7 to 7.5 bar, which was substantially higher than the FSD’s minimum requirement of 1.7 bar.775

At 15:29, Divisional Officer Lam Ho Chun (林浩俊), Deputy Divisional

Commander (New Territories East) (“DO Lam”) arrived at the scene and assumed the role of Incident Commander in accordance with the procedures in FSD General Orders Chapter 41.776 In his oral evidence, DO Lam described the scene at the time as unprecedented in its severity, with two blocks completely engulfed by smoke and three other blocks alight. Bamboo members and other debris continuously fell from height and pieces of scaffolding net drifted in the air.777

DO Lam was briefed by ADO Cheung at 15:32 and upgraded the fire to a No 4 alarm at 15:34.778 DO Lam explained that he decided to upgrade the fire because the resources available to him at the time were insufficient to handle the strength, magnitude and size of the fire, as well as the continuously increasing number of assistance requests received. He also considered that a higher level of commanding authority was needed to handle the situation. Under the FSD’s General Orders Chapter 41, a No 4 alarm fire is commanded by a Chief Fire Officer or a Deputy Chief Fire

774 Fok Chun Ming WS §§9-10 [WS2/1016-1017] 775 Tang Wing Wah WS §§4-6 [WS2/966-967] 776 [B13/5752]

777 [T11/46:4-10]

778 [B13/5756]

234

Officer, as opposed to a No 3 alarm fire which is commanded by a Senior Divisional Officer or a Divisional Officer.779

A4. 15:35 to 16:35: Initial stages of the No 4 alarm

Deputy Chief Fire Officer Wong King Man (黃景文 ) (“DCFO KM

Wong”) arrived at the scene at 15:35, one minute after the fire was upgraded to a No 4 alarm.780 He testified that, although officers of his rank were not required to attend No 3 alarm fires, his practice was to attend all No 3 alarm fires within his area, so as to be in a position to assume the role of Incident Commander as soon as possible should the fire be upgraded to a No 4 alarm. He accordingly set off for the scene upon being notified of the fire by the FSCC at 15:11, while the fire was still a No 3 alarm.781

Upon arriving at the scene and assessing the situation, DCFO KM Wong instructed the FSCC to issue a press release regarding the fire at 15:38. After enquiring with the FSCC regarding the number of Turntable Ladders dispatched, he ordered the deployment of three additional Turntable Ladders to the scene (bringing the total number dispatched to six).782

DCFO KM Wong formally assumed the role of Incident Commander at 15:50:51. In accordance with FSD procedure, he implemented the Incident Command System for the No 4 alarm fire. At around 16:05, he was briefed by DO Lam that Fn Ho had been located at the open ground in front of the entrance of Wang Tai House.783

Meanwhile, more senior officers arrived at the scene. At 15:50, Chief Fire Officer Tang Wing Wah (鄧榮華), Assistant Director in charge of the New

Territories North Command (“AD Tang”), arrived at the scene. Deputy

779 [T11/46:34-47:1]

780 [B13/5757]

781 Wong King Man WS §5 [WS2/1006-1007] 782 Wong King Man WS §§6-8 [WS2/1007-1008] 783 Wong King Man WS §12 [WS2/1009]

235

Director (Operations) Derek Armstrong Chan (陳慶勇) (“DD(Ops) Chan”)

arrived at 16:10.784

The following steps were taken by AD Tang and DD(Ops) Chan over the remaining course of the No 4 alarm fire.

At 16:13, AD Tang directed DO Lam to take a roll call to ensure that no further crew members were unaccounted for after Fn Ho was located. The roll call was completed without incident.785

At 16:18, AD Tang assumed the role of Incident Commander. On the instructions of DD(Ops) Chan, he directed that the FSCC dispatch all available senior officers from the New Territories North and New Territories South commands to the scene.786

At 16:23, AD Tang assigned DCFO KM Wong to be the Rescue Officer in charge of all Search and Rescue operations (“SAR”).787

At 16:28, the Compartment Fire Specialists team arrived at the scene and were deployed to assist in the firefighting operations at Wang Cheong House (Block F).788

From around 16:30, the FSD deployed drones with livestreaming and thermal imaging capabilities to provide coverage of the fire.789

784 [B13/5769]; [B13/5780]

785 Tang Wing Wah 2nd WS §11 [WS2/968]

786 Tang Wing Wah 2nd WS §14 [WS2/969]; [B13/5784]. 787 Tang Wing Wah 2nd WS §12 [WS2/968]

788 Tang Wing Wah 2nd WS §13 [WS2/969]

789 Tang Wing Wah 3rd WS §13 [WS6/1864]

236

A5. 16:35 onwards: Later stage of the No 4 alarm

At 16:35, DD(Ops) Chan instructed AD Tang to implement a building-bybuilding command strategy by setting up eight operation sectors, each corresponding to one block at Wang Fuk Court. Each operational sector was commanded by a senior officer (i.e. a Senior Divisional Officer or Divisional Officer) responsible for firefighting within that building, and another senior officer as SAR leader. DD(Ops) Chan testified that he decided to adopt this command structure in light of the unprecedented spread of the fire across multiple high-rise residential blocks, with each block exhibiting its own fire and smoke behaviour and requiring differing levels of assistance demands.790

At 16:44, AD Tang requested FSCC to dispatch another four fire appliances and one Turntable Ladder. He also requested a further Breathing Apparatus Pod at 17:24 to provide additional breathing apparatus cylinders and breathing apparatus sets.791

790 Derek Armstrong Chan WS §12 [WS8/1924-1925]. 791 Tang Wing Wah 2nd WS §17 [WS2/970]

237

Figure 5-2: Map showing location and placement of fire hoses, water jets and turntable ladders at around 18:00792

The FSD was only able to make limited firefighting progress in this period in light of the extremely challenging environment at the scene. The Incident Commanders all testified that the debris continuously falling from height posed great difficulty for their firefighting efforts. 793 AD Tang explained that the falling debris threatened the physical safety of firefighters and, when accumulated on the ground, prevented the placement of aerial appliances at the emergency vehicular accesses in and around each block, thereby limiting the number of aerial appliances that could be used at any time and the effectiveness of appliances which could be used.794 Multiple fire appliances were also struck and damaged by the falling debris.795

The internal environment of each block was equally hostile:

1. In the initial stages of firefighting, crew members who attempted to enter Wang Cheong House (Block F) and Wang Tai House (Block E) were forced to retreat due to intense heat and smoke conditions, and only narrowly avoided being blocked by fallen debris and flames.796

2. Progress was also slowed by the smoke-logged staircases and by the fires on the lower floors, which had to be brought under control before firefighters could advance upwards, lest their retreat routes be cut off.797

792 [B10/5557]

793 [T11/23:32-24:13, 33:6-7, 46:4-10, 48:35-49:1]; Tang Wing Wah 3rd WS §§15-16 [WS6/1865-1866]

794 [T19/10:4-11:8]

795 Hui Kin On WS §17 [WS2/991]; [T19/11:23-33]

796 Tang Wing Wah 3rd WS §§17-19 [WS6/1866-1867]

797 [T18/19:26-20:2]

238

Under these circumstances, it was not until 17:30, some two and a half hours after the FSD’s initial attendance, that the FSD was able to clear a passage up to 2/F of Wang Cheong House (Block F).798 Once the passage was cleared, firefighters rescued three residents from Flat 202 at 17:40.799

A6. 18:22 onwards: No 5 alarm

At 18:22, DD(Ops) Chan upgraded the fire to a No 5 alarm. It was the first No 5 alarm fire in Hong Kong since 2008.

DD(Ops) Chan explained that the upgrade was not required for the purpose of deploying further resources. By that time, a total of 116 fire appliances and 37 ambulances with 718 crew members had been dispatched to the scene. That was approximately 6.5 times the pre-determined attendance of a No 5 alarm fire. Rather, the primary objective of the upgrade to a No 5 alarm was to enhance the command authority by personally taking control of firefighting efforts. DD(Ops) Chan explained that 18:22 was a suitable time to upgrade because of the increasing severity of the situation coupled with the onset of darkness, which increased the risks faced by frontline personnel.800

DD(Ops) Chan reported in the FSD’s incident occurrence log at 18:30 that firefighters were tackling blazes across all seven blocks. Firefighting was in progress at G/F and the external walls of Wang Yan House (Block A) and Wang Tao House (Block B), on G/F of Wang Sun House (Block C), on G/F of Wang Kin House (Block D), at G/F to 6/F of Wang Tai House (Block E), at G/F to 2/F of Wang Cheong House (Block F) and G/F to 1/F of Wang Shing House (Block G). Firefighters were also applying a

798 Tang Wing Wah 3rd WS §19 [WS6/1867]

799 [B13/5808]

800 Chan Derek Armstrong WS §24 [WS8/1930-1931]; [T18/17:22-18:10]

239

covering jet at G/F of Wang Shing House to prevent fire spread to Wang Chi House (Block H).801

Following the upgrade to a No 5 alarm fire, firefighters succeeded in conducting several snatch rescues of individual occupants at higher floors despite the conditions at lower floors remaining severe. For example, firefighters succeeded in rescuing Mr Cheung Chi Lim George, his wife Madam Liu Chunyu and their neighbour Madam Yip Kam Fong from Flat 1006 of Wang Tai House (Block E) at around 20:00, and rescued Madam Sin Sin Hing from Flat 1406 at Wang Tai House at around 21:00.802

At around 22:00, an attempt was made to secure access to 10/F of Wang Tai House (Block E) from the exterior using a Turntable Ladder, to establish a bridgehead where firefighters could be re-supplied with breathing apparatus and equipment. However, the bridgehead could not be maintained due to reignition of lower floor fires and an escalation in heat and smoke conditions. Firefighters eventually had to retreat for their personal safety.803

The non-functioning FH/HR system meant that the FS booster pumps across all blocks were non-operational. This added to the challenges of internal firefighting. Water was pumped by fire appliances on the ground level into the buildings through FS inlets. However, the failure of the FS booster pumps limited the water pressure for firefighting on upper floors. As a result, firefighters had to carry compact portable booster pumps each weighing 80 kg while ascending the staircases to upper floors to ensure that water pressure remained adequate at higher levels.804

801 [B13/5822]

802 Tang Wing Wah 3rd WS §20 [WS6/1867]

803 Chan Derek Armstrong WS §20 [WS8/1929]; [T18/20:20-30] 804 Tang Wing Wah 2nd WS §31 [WS2/974-975]

240

The IFITF opined that the frontline personnel successfully navigated the difficulties posed by the shutdown of the FH/HR systems, such that it had a minimal impact on the firefighting operations.805

The evidence shows that firefighters made every effort – on occasion placing their own safety at risk – to save others. DD(Ops) Chan and Divisional Officer (Breathing Apparatus) Tung Wing Kei (董永基) (“DO

Tung”) referred to instances of firefighters holding off activating their breathing apparatus until absolutely necessary after entering the scene of the fire, in order to conserve the air supply.806 Consistently with this, the breathing apparatus logs produced by the FSD showed crews exceeding the rated working durations of their sets. In one instance, a crew member was deployed for 47 minutes on a cylinder rated for 29 minutes of working time.807

By 22:30, 174 fire appliances (including eight Turntable Ladders), 47 ambulances and 989 personnel had been deployed to the scene.808 This was nine times the pre-determined attendance for a No 5 alarm fire.

805 IFITF Final Report §§5.4.7.3-5.4.7.6 [ER1/71-72] 806 Tung Wing Kei WS §8.2 [WS4/1812]; [T18/20:8-13] 807 [B9/4623]

808 Tang Wing Wah 3rd WS §8 [WS6/1861-1862]

241

Figure 5-3: Map showing location and placement of fire hoses, water jets and turntable ladders during No 5 alarm fire809

On 26 November 2025, a total of 112 appliance crews were deployed in operations involving the use of breathing apparatus. Of these, crews from 43 appliances were deployed to Wang Cheong House (Block F) and 33 to Wang Tai House (Block E). Nine appliance crews were deployed to each of Wang Kin House (Block D), Wang Tao House (Block B) and Wang Shing House (Block G). Six appliance crews were deployed to Wang Sun House (Block C), two to Wang Yan House (Block A) and one to Wang Chi House (Block H).810

A7. 27 November 2025

The fire was progressively contained by the FSD over the course of 27 November 2025.

Firefighting was first completed at Wang Tao House (Block B) at 16:00 on 27 November 2025. By then, firefighting efforts reached up to 19/F at

809 [B10/5558] 810 [B5/4392-4394]

242

Wang Shing House (Block G), 21/F at Wang Cheong House (Block F), 23/F at Wang Tai House (Block E), 16/F and 29/F at Wang Kin House (Block D), 17/F at Wang Sun House (Block C) and 18/F at Wang Yan House (Block A).811

At 18:00, relief crews were rotated in for all units, involving a total of 16 Hydraulic Platforms, 17 Major Pumps and 18 Light Rescue Units. At the time, it was reported that firefighting at Wang Shing House (Block G) had been completed. 812

The fire was declared surrounded by DD(Ops) Chan at 21:31, meaning that the fire was unlikely to spread to unaffected units.813 Firefighting efforts were declared completed at Wang Cheong House (Block F) at 23:00. Firefighting efforts continued at Wang Tai House (Block E), Wang Kin House (Block D), Wang Sun House (Block C) and Wang Yan House (Block A).814

A8. 28 November 2025

The fire was declared under control at 03:15 on 28 November 2025.815 Firefighting efforts at the remaining blocks were completed over the following hours: 04:00 at Wang Kin House (Block D), 05:00 at Wang Yan House (Block A) and 08:00 for each of Wang Tai House (Block E) and Wang Sun House (Block C).816

At 10:18, a “Stop” message was issued by DD(Ops) Chan. This denoted that there were sufficient resources on the scene and that no further mobilisations were necessary. At the time, 143 fire appliances and 635

811 [B13/6035]

812 [B13/6050]

813 [B13/6076]; [T18/23:11-28] 814 [B13/6086]

815 [B13/6099]; [T18/23:15-28] 816 [B13/6103, 6105, 6116-6117]

243

crew members remained on site to complete damping down efforts and to attend to outstanding assistance requests.817

B. Involvement of the Police

The Police also participated in the emergency response.

The first Police officers arrived at the scene at 14:59. Between 14:50 and 16:00, a total of 145 Police officers responded to the incident and arrived at the scene.818 All available Police Tactical Unit (“PTU”) platoons were directed to the scene and arrived by 17:30. They assisted with cordon control, casualty clearing, site traffic management, communication with relatives of victims, casualty documentation and media reception.819

Between 26 and 28 November 2025, a total of 3,694 Police officers were deployed to handle the incident.820

Notably, between 16:13 and 16:40, four teams of PTU officers were deployed to Wang Chi House (Block H) and Wang Yan House (Block A) to evacuate residents. They searched 27/F to 31/F of Wang Yan House and 22/F to 31/F of Wang Chi House, successfully evacuating nine residents from six flats. However, the operation was halted and the officers were ordered to withdraw at around 16:50 in view of safety concerns. 821

In terms of the command structure of the Police operation:

1. Overall strategic command was initially assumed by the Duty Controller of the New Territories Regional Command and Control Centre (“RCCC NT”). At 15:40, the Higher Command

817 Chan Derek Armstrong WS §23 [WS8/1930]

818 Lam Wing Sze Emma 2nd WS [WS2/1208-1212] 819 Yu Siu Chuen WS §17 [WS2/1178]

820 Lai Wing Sze Emma WS Annex 2 [WS2/1166-1168] 821 Cheung Lui WS [WS17/2203-2207]

244

(“HICOM”) at the New Territories North Regional Police Headquarters, Tai Po was activated to take over strategic command. Following the declaration of a Major Incident by Assistant Commissioner of Police (Operations) David Jordan at 17:36, an Incident Command Centre comprising 11 officers was activated at HICOM.822

2. At the scene, Senior Inspector Lam Kwong Choi, Assistant Divisional Commander of Tai Po Division, assumed the role of Tactical Commander at 15:15. The position was taken over by Senior Superintendent Lai Ho Fai Edmund, Deputy Commander of Tai Po District at 15:44, followed by Chief Superintendent Lau King Lun at 18:00.823

The Security Bureau was informed of the fire at 15:24. It activated the Emergency Monitoring and Support Centre (“EMSC”), which facilitated collaboration with other Government departments.824

Other specialist units within the Police were also activated.

1. The Casualty Enquiry Unit (“CEU”) was mobilised at 17:36 and commenced operations at 18:32 to handle public enquiries relating to casualties. 825 The CEU had last been activated in 2018, in response to the Tai Po Road bus accident.826

2. From 26 November 2025 to 13 January 2026, the CEU handled a total of 489 missing person reports. These reports were catalogued

822 Lam Wing Sze Emma WS §§20, 29 [WS2/1159, 1161] 823 Yu Siu Chuen WS §§8, 16 [WS2/1172-1174, 1178] 824 Yu Siu Chuen WS §§11, 18 [WS2/1176, 1179]

825 Tsang Shuk Yin WS §§20-25 [WS1/238]

826 [T12/70:16-19]

245

and matched against Government databases and other sources of information. Of the 489 cases: 827

(a) 196 cases related to 166 persons who were confirmed dead;

(b) 40 cases related to 37 persons who were injured;

(d) 37 related to persons who had passed away or left Hong Kong prior to the incident;

(e) 31 were classified as non-pursuable due to insufficient information; and

(f) 1 case involved a caller who did not intend to make a missing person’s report.

3. A Casualty Documentation Team was also mobilised to hospitals to assist with hospital enquiries at 17:23.828

4. The Disaster Victim Identification Unit (DVIU) was mobilised in the evening of 26 November 2025 to recover and identify the fatalities in the fire. A total of 605 officers were deployed by the DVIU.829

C. Receipt and Handling of Assistance Requests

The Police and FSD received and handled a significant number of assistance requests over the course of the fire.

827 Tsang Shuk Yin WS §26 [WS1/238]; [T12/73:21-33] 828 Yu Siu Chuen §8 [WS2/1173]

829 Cheng Ka Chun WS §17 [WS1/274-275]

246

C1. 999 calls

Under the procedures for handling 999 calls at the time, all calls to the 999 emergency line were received by the Police in the first instance. If a call related to fire, it was transferred to the FSD. The Police call operator would establish a three-way phone conference with the FSCC so that the caller could directly communicate details to the FSD. The Police call operator would remain on the line to provide assistance where necessary.830

The Police received more than 520 calls concerning the incident to the 999 emergency line over the course of the fire. Of these, 406 were received between 14:00 and 23:59 on 26 November 2025. These represented approximately 9.7% of all 999 calls handled by the Police in this period territory-wide.831

Most 999 calls in this period were between 15:00 and 15:59, when a total of 111 calls relating to the fire were placed. In this period, the average waiting time for a Police call operator to pick up a 999 call increased from an average of seven seconds between 14:00 and 14:59 to an average of 38 seconds between 15:00 and 15:59. At 15:08, five additional call operators were deployed as reinforcement at the Police’s New Territories Regional Command and Control Centre (RCCC NT), bringing the total number of operators on duty at RCCC NT to 17. 832 The average waiting time decreased to 23 seconds between 16:00 and 16:59 and then to seven seconds between 17:00 and 17:59.833 During this period, RCCC NT did not reach its maximum handling capacity of 69 calls at any one time.834

830 Wong Sze Lut Sunny WS §4.2.3 [WS1/161-162]

831 Ho Kit Yee WS §§10-11, Annex 3 [WS2/1061-1062, 1133] 832 Chow Wing Yee WS §15 [WS2/1139-1140]

833 Ho Kit Yee WS Annex 3 [WS2/1133]

834 Chow Wing Yee WS §15 [WS2/1139-1140]

247

Under manning arrangements in force at the time of the fire, the FSCC was equipped with 30 telephone lines and staffed with 37 personnel during daytime hours and 31 personnel during night hours.835

Given the volume of 999 calls and the disparity between the number of phone lines operated by the Police and the FSCC, the FSCC was overloaded and became a bottleneck in processing the calls.

A substantial number of 999 calls relating to the fire had to be placed on hold for several minutes before connecting to the FSCC. The longest wait time identified, involving an assistance request for an individual in Flat 2807 of Wang Tai House (Block E), lasted 15 minutes and 40 seconds.836 On some occasions, calls were disconnected before they were connected to the FSCC. In those cases, Police operators usually stayed on the line to relay information they obtained from the caller whilst waiting for the connection to the FSCC. In other cases, they relayed the information to the FSD by fax or by email.837

After the activation of the DCP at 15:20, the FSD established a Support Centre manned with 18 lines to handle call-backs to persons awaiting assistance. This helped relieve the FSCC’s workload and the FSCC was “able to answer calls within an average of one minute for the rest of the day”.838

In the first few hours of the fire, there were instances where the call handling procedures were not fully followed by frontline operators. In particular, the Police’s procedures for handling 999 calls stated that all calls reporting a fire or requesting provision of either an ambulance or fire appliance should be “immediately” connected to FSCC and that the call operator should not seek to establish the location of the incident or the

835 Wong Sze Lut Sunny WS §4.4.1 [WS1/163] 836 [C9/2576-2578]

837 [T12/17:1-33, 58:7-9]

838 Wong Sze Lut Sunny 2nd WS §4.5.1 [WS1/164]

248

identity of the caller.839 However, there was one instance where a caller reported smoke filling her room, but was not patched to FSCC and was instead told to call back later if she needed assistance.840

Information received by FSCC personnel during the calls was typed into the FSD’s computerised mobilising system (“CMS”). FSCC staff then used a mobile device to take a photograph of the information shown in the CMS interface on the computer screen. The image was then sent through an internal messaging application known as FSD Messenger.841 Deputy Chief Fire Officer Wong Sze Lut Sunny (黃思律) (“DCFO Sunny Wong”)

explained that this procedure was implemented because frontline personnel were unable to directly access information on the FSCC’s CMS at the scene of the fire.842 The chain of communication was rudimentary and obviously inefficient.

The FSD acknowledged that a large number of calls recorded at the scene of the fire had been duplicated, and that this caused difficulties in operations. 843 Over 600 assistance requests were sent through FSD Messenger. After deduplication, these requests were confirmed to only relate to 309 individual locations.

C2. Other channels of communication

In addition to 999 calls, 195 assistance requests were also received by FSD personnel at the scene and 34 assistance requests were received by the FSD through the DCP (which obtained information from various sources such as the EMSC operated by the Security Bureau).844

839 Chow Wing Yee WS Annex 1 §3 [WS2/1144]

840 [C6/2463-2465]

841 [T12/51:5-9, 53:14-24]

842 [T12/53:36-54:4]

843 Wong Sze Lut Sunny 2nd WS §4.7.4 [WS1/165-166] 844 [T17/52:13-27]

249

This information was collated by staff in the Mobile Command Unit at the scene. The assistance requests were then relayed to frontline personnel.

C3. Handling of assistance requests

In total, after deduplication, the FSD received 373 unique assistance requests relating to 347 units.845

Given the challenging conditions described above, only a limited number of assistance requests could be attended to at the initial stage of the fire. Requests from blocks that remained substantially unaffected by the fire – where the immediate danger to residents was lower – were not actioned in that period, as resources were prioritised for the blocks in greatest danger.

Consequently, some assistance requests from Wang Chi House (Block H) and Wang Kin House (Block D) were only attended to up to nine hours after the requests. At the height of the incident, there was a backlog of 174 outstanding assistance requests.846

A breakdown of the number of assistance requests received and handled over the course of the fire is set out in the following table:

Table 5-1: Assistance requests received and handled by the FSD during rescue operations

Requests Received

Requests Handled

26 November 14:51 – 15:59

16:00 – 17:59

18:00 – 19:59

20:00 – 21:59

22:00 – 23:59

27 November

845 Tang Wing Wah WS §47 [WS1/49-50] 846 [B13/6185-6201]

250

00:00 – 03:59

04:00 – 07:59

08:00 – 11:59

12:00 – 15:59

16:00 – 19:59

20:00 – 23:59

28 November 00:00 – 03:59

04:00 – 07:59

08:00 – 11:59

12:00 – 15:59

For those awaiting rescue, the Support Centre operated a call-back mechanism. The Support Centre telephoned callers who had previously requested assistance to obtain updates on their condition and location and to provide safety guidance. Over the course of the fire, 1,581 call-backs were placed, of which 741 calls were answered and 840 went unanswered.847 The Committee heard evidence that these calls provided those awaiting rescue with some measure of reassurance.848

All in all, the FSD rescued 62 people alive and recovered 106 fatalities from the scene. The FSD also recovered 60 pets and 62 pet bodies.849

Among these rescues were two workers on the roof of Wang Tai House (Block E), who were located by the FSD by drone at around 00:20 and rescued at around 02:15 on 27 November 2025.850

The rescues continued throughout the day, including rescues at 15/F and 28/F of Wang Cheong House at around 12:00.

847 Tang Wing Wah WS §50.3 [WS1/51]; [B13/5720] 848 [T4/13:21-14:2]

849 [B13/6153-6155, 6185-6201]

850 Tang Wing Wah 3rd WS §13 [WS6/1864]

251

The last person rescued alive from the fire was an individual found in the staircase of Wang Tao House (Block B) at around 18:30.851

D. Fireman Ho Wai Ho

The Committee heard evidence of the circumstances in which the late Fireman Ho Wai Ho (Fn Ho), posthumously promoted to Senior Fireman, tragically lost his life in the line of duty.

Fn Ho was a fireman stationed at Sha Tin Fire Station. He was 37 years old. Fn Ho began his shift that day at 09:00 and was assigned to the Light Rescue Unit alongside Fn 17569 Yeung Ching (楊程) (“Fn Yeung”) and

Fn 22662 Siu Tsz Ho (蕭梓浩) (“Fn Siu”).852

In accordance with usual FSD procedures, Fn Ho conducted a daily test of his breathing apparatus set at 09:30. No defects were noted. As part of the same testing process, he recorded that the remaining air content of his gas cylinder was 285 bar, which would have provided a working duration of approximately 30 minutes.853

The Sha Tin Light Rescue Unit was one of the first fire appliances to be deployed to the scene in response to the No 1 alarm fire. It arrived on the scene at 15:01:34.854

At 15:03, SStnO Hui received a message from the FSCC regarding an assistance request from Flat 2701 of Wang Cheong House (Block F). SStnO Hui ordered Probationary Station Officer Liao Kong Lap (“PStnO Liao”), the officer-in-charge of the Major Pump at Sha Tin Fire Station, to

851 [B13/6155]

852 [WS2/990]

853 [B9/4820]

854 [B13/5734, 5736]

252

handle the assistance request. PStnO Liao instructed Fn Ho, Fn Yeung and Fn Siu to handle the assistance request.855

In accordance with PStnO Liao’s instructions, at around 15:15,856 Fn Ho, Fn Yeung and Fn Siu proceeded towards Wang Cheong House (Block F). They passed by the bicycle shed where some residents, including an elderly person in a wheelchair, were present.

When they passed by, Fn Ho, Fn Yeung and Fn Siu signalled that the residents should evacuate towards Wang Kin House (Block D). Fn Ho briefly stopped to assist the elderly person in the wheelchair. Fn Yeung and Fn Siu continued to proceed through the bicycle shed towards Wang Cheong House (Block F), not noticing that Fn Ho was left behind. The images below depict (i) all three firefighters entering the bicycle shed, (ii)-(iii) Fn Yeung and Fn Siu passing through the bicycle shed towards Wang Cheong House and (iv) Fn Ho assisting the elderly person in the wheelchair.

855 [WS2/990]

856 Timestamps in the CCTV footage were approximately 2 minutes behind reference time.

253

Figure 5-4: Still images taken from CCTV footage of bicycle shed at Wang Tai House (15:13:26, 15:13:29, 15:13:34, 15:13:41)857

The evidence from Fn Yeung and Fn Siu is that, when they reached Wang Cheong House (Block F) and surveyed the area, they saw that all the entrances had been blocked by flaming debris. They therefore commenced firefighting operations near the main entrance. They noticed several firefighters in heat resistant suits nearby who were assisting in the firefighting effort and believed that Fn Ho was among them. They therefore did not notice that Fn Ho had gone missing.858

In fact, Fn Ho did not proceed to Wang Cheong House (Block F). Instead, after assisting the elderly person in the wheelchair, he proceeded to Wang Tai House (Block E) at around 15:17 intending to catch up with his colleagues (Fn Yeung and Fn Siu). After entering Wang Tai House, Fn Ho took the lift up to 25/F, exiting the lift at around 15:18.

The FSD’s standard procedures for responding to an assistance request required firefighters to exit a fireman’s lift two floors below a reported floor and ascend by stairs to avoid being overwhelmed by smoke. The clear inference from Fn Ho taking the lift to 25/F was that he believed he was within Wang Cheong House (Block F) and was responding to the call for assistance at Flat 2701 of that block.

The photographs below depict (i) Fn Ho passing through the bicycle shed (approximately 15 seconds after Fn Yeung and Fn Siu had passed through), (ii) Fn Ho turning right and proceeding to the front entrance of Wang Tai House (instead of proceeding across the courtyard towards Wang Cheong House), (iii) Fn Ho entering Wang Tai House, and (iv) Fn Ho exiting the fireman’s lift at 25/F of Wang Tai House. It is noted that the area outside

857 [A2/62-63]

858 [WS15/2185-2192]

254

the ground floor of Wang Tai House was already filled with smoke, but the 25/F corridor remained relatively clear at that point.

Figure 5-5: Still images taken from CCTV footage of bicycle shed, front

entrance and lift of Wang Tai House (15:13:49, 15:13:53, 15:15:00,

15:15:54)859

At 15:22, Fn Ho dispatched a Mayday message through his radio telephone. The message was heard by SStnO Hui who heard the words “Mayday Mayday Mayday … 而家被困係 30樓” (Mayday Mayday Mayday, I am

now trapped on the 30th floor) with the rest of the transmission muffled. SStnO Hui responded to acknowledge the Mayday message and asked for the location of the firefighter. There was no response to his message.860

Believing that a firefighter was trapped in Wang Cheong House (Block F), SStnO Hui formed four emergency response teams to clear access to the interior of Wang Cheong House. SStnO Hui then met with PStnO Liao who informed him that the sender of the Mayday message was Fn Ho.

859 [A2/49, 63]; [C6/2440]

860 Hui Kin On WS §19 [WS2/991]

255

PStnO Liao was instructed by SStnO Hui to form a fifth emergency response team for Fn Ho.861

At around 15:55, DO Lam noticed several firefighters clearing debris on the open ground outside the front entrance of Wang Tai House (Block E). When he reached that location, he saw Fn Ho lying motionless on a pile of burning bamboo and debris.862

Fn Ho was freed from the debris and handed to the care of ambulance personnel at the scene. 863 He was conveyed to the Prince of Wales Hospital, where he was pronounced dead at 16:41.

The autopsy report of Fn Ho prepared by Dr Kwok Ka Ki, Senior Medical and Health Officer, Forensic Pathology Service, recorded (i) extensive skin burns on various body parts, (ii) multiple bruises and lacerations including on the head, (iii) fractures of the spine, left-sided ribs, left pelvis, left shoulder, left arm bone and left forearm bone and (iv) brain haemorrhage. These injuries were suggestive of an impact on the left side of the body against a hard surface, such as during a fall. There was also soot deposition in small airways in his lungs with a carboxyhaemoglobin level of 26%, indicating that he was breathing and alive during the fire and had inhaled carbon monoxide fumes at the scene. The autopsy identified the cause of death of Fn Ho as being the inhalation of fire fumes and extensive burns with head and neck injuries as a significant contributing condition.864

When Fn Ho was located outside Wang Tai House (Block E), he was wearing his standard issue T-shirt and trousers, PBI matrix trousers, antiflash hood, radio telephone and fire-retardant glove on his right hand. His

861 Hui Kin On WS §§20-21 [WS2/992] 862 Lam Ho Chun WS §10 [WS2/1002] 863 Lam Ho Chun WS §11 [WS2/1003] 864 [ER2-3/1600]

256

clothing was charred and torn in multiple areas, and his left glove, helmet, hammer, breathing apparatus, face mask and rubber boots were missing.

Fn Ho’s breathing apparatus, helmet and face mask were found in the 31/F lift lobby. His left glove and hammer were found on the windowsill in the same lift lobby, in front of a broken window. His boots were recovered on the ground outside Wang Tai House.

Figure 5-6: Photo of windowsill of 31/F lift lobby of Wang Tai House and map showing location of discovery of Fn Ho’s fire boots865

865 [ER1/189]

257

Subsequent examination and testing of Fn Ho’s breathing apparatus set and ancillary equipment revealed that:

1. The fabric bag enclosing Fn Ho’s breathing apparatus had been damaged, the cylinder valve had been damaged and the gas cylinder was empty.866

2. Fn Ho’s alphaSCOUT device (an electronic device attached to the breathing apparatus designed to record gas consumption and emit noise if no movement is detected) suffered from data loss due to submersion in water.867

3. The personal transmitter of the Firefighter Locator System (“FLS”) attached to Fn Ho’s breathing apparatus (which emits a radio signal enabling SAR Teams to locate firefighters in distress) was not actuated, as the red activation key was still inserted in the unit.868

Under prevailing procedures, an FLS personal transmitter is activated by firefighters at the Entry Control Point by removing the attached red activation key and handing it to the Entry Control Officer. However, as Fn Ho did not pass through any Entry Control Point when entering Wang Tai House (Block E), the red activation key was never removed from his personal transmitter. SStnO Hui explained that the intention was to set up an Entry Control Point within Wang Cheong House (Block F), but firefighters had not been able to gain access to the block due to the obstruction of entrances. 869 In any event, Fn Ho did not enter Wang Cheong House and entered Wang Tai House instead.

866 [B9/4791-4792]

867 [B9/4799]

868 [B9/4795, 4798]

869 Hui Kin On 2nd WS §6 [WS15/2194]

258

DO Tung testified that the FSD had no clear hypothesis for how the cylinder valve came to be damaged. He noted that this was a very rare occurrence, as the cylinder valve was made of durable metal and was protected by a rubber shock absorber. One possibility was that it was damaged from a hard impact. However, it was not possible to ascertain when the impact occurred. Regrettably, no data could be recovered from the alphaSCOUT, with the result that the FSD had very little visibility into Fn Ho’s last moments.870

Nevertheless, the Committee has received circumstantial evidence that may enable it to reconstruct Fn Ho’s last movements. It is likely that Fn Ho broke the glass window in the lift lobby of 31/F of Wang Tai House (Block E), took off his breathing apparatus, and climbed out onto the scaffolding in an attempt to escape life-threatening conditions in the higher floors of Wang Tai House, whereupon he fell from height.

Finally, Assistant Director Yiu Men Yeung testified that Fn Ho’s air cylinder still had a working duration of some 30 minutes when he arrived at 25/F of Wang Tai House, which was sufficient for him to have withdrawn to safety had he chosen to do so. He did not. The evidence instead indicates that he continued upwards and, in all likelihood, remained on the upper floors of Wang Tai House in an effort to reach residents trapped there.871 All the evidence suggests that Fn Ho sacrificed his life in the performance of his duty, in conditions of extraordinary danger, while attempting to save others.

870 [T18/6:13-33] 871 [T26/45:27-31]

259

E. Evaluation of Firefighting, Evacuation and Emergency Call Operations E1. Overview

The fire at Wang Fuk Court was unprecedented in both its scale and its circumstances.872 No other fire in recent memory has engulfed the façades of multiple high-rise buildings, still less at such velocity.

The FSD faced a difficult task on the day of the fire, one made even more difficult by falling debris, disabled fire alarms and the modified worker access openings in the protected staircases. ADO Cheung, one of the initial Incident Commanders, acknowledged that the FSD’s operational strategies were simply not designed for a fire of this nature.873

The Committee heard many examples of firefighters putting their personal safety at risk in order to save lives.874 They are to be commended for their heroism in such perilous circumstances.

The Director of Fire Services, Yeung Yan Kin Andy, testified that there is at present “no obviously superior firefighting or fundamentally different operational approach that fire brigades elsewhere could realistically have adopted to contain such a conflagration effectively under the circumstances”. Consequently, “the strategic focus should shift from how to extinguish the fully developed blaze to how to prevent its occurrence or limit its development at the very initial stage”.875 This evidence was echoed by other FSD witnesses.876

There can be no dispute that prevention is better than cure. The Committee is, however, tasked with examining the causes and circumstances of the

872 [T27/45:6-7]

873 [T11/34:35-35:11]

874 Tung Wing Kei WS §8.2 [WS4/1812]; [T18/20:8-13] 875 Yeung Yan Kin Andy 2nd WS §§5-6 [WS2/1028-1029] 876 [T12/62:27-63:1]

260

rapid fire spread and resulting casualties and property damage, and with making recommendations in that regard. This task requires a critical evaluation of the response by the FSD and the Police on the day of the fire, to ensure that lessons are learnt for the future. That evaluation in no way detracts from our collective gratitude for the gallantry, dedication and personal sacrifice of the firefighters who fought the fire.

E2. Initial response and escalation

The FSD responded swiftly to the initial report of the fire. The first fire appliances arrived at the scene at 14:56:22, five minutes and five seconds after the incident was reported to the FSCC at 14:51:17.877 The initial turnout was also substantially larger than normal, in accordance with the Contingency Plan in force for the renovation works at Wang Fuk Court. This is a testament to the FSD’s operational readiness and the utility of its contingency planning.

Upon their arrival at the scene, the FSD rightly escalated its response to the fire, upgrading the fire to a No 3 alarm six minutes after the arrival of the first fire appliances and No 4 alarm 32 minutes later.

However, with the benefit of hindsight, it would have been preferable had these steps been taken earlier, so that resources could have been deployed to the scene more promptly. This was fairly acknowledged by DD(Ops) Chan in his evidence and the Government in its Closing Submissions:878

1. The FSD’s Guidelines on Upgrading Fire Alarms states that a No 1 or No 2 alarm should be upgraded to a No 3 alarm “if the fire cannot effectively be dealt with by the initial attendance”. Upon arriving at the scene, the Incident Commander is required to estimate whether the resources available to him are sufficient to deal with the incident effectively and in a timely manner. Saliently,

877 [B13/5734]

878 [T18/27:34-28:18]; Government’s Closing §§805-811

261

“unless the [Incident Commander] has fully apprised the size and location of the fire, and is confident that the fire can be contained within a short period of time to eliminate the risks to occupants, the fire should be upgraded immediately” (emphasis original).879

2. The Guidelines conclude with a “Golden Rule” where the Incident Commander is directed that “if in doubt, err on the safe side and raise the alarm” (emphasis added).

3. As SStnO Hui reported to the FSCC at 14:57, the fire had already reached 8 metres in width and 30 metres in height. He had also noted that the rear entrance of Wang Cheong House (Block F) had been blocked by debris. By 14:59, the fire had also rapidly spread up the entire re-entrant. As DD(Ops) Chan accepted, there were already sufficient grounds to upgrade the alarm to a No 3 alarm at that moment in time.

879 [B9/4854-4858]

262

Figure 5-7: Still images from videos captured by Mr Yip Fai (14:56:58, 14:57:38 and 14:57:57)880

4. Likewise, the fire was only upgraded to a No 4 alarm after the fire had spread to a total of five blocks,881 after vertical fires had spread in six re-entrants, and after the entrances of Wang Cheong House and Wang Tai House had been completely blocked by debris. By that point, the FSD had already received 37 assistance requests. It had also received a Mayday call from Fn Ho, which necessitated the diversion of resources from the FSD’s other tasks. The situation justified upgrading the alarm at an earlier stage.

While the differences may have amounted only to minutes, these decisions directly affected how quickly fire appliances and personnel reached the scene in the critical early stages of the fire. Every second counted: an earlier deployment that contained the fire before it developed rapidly might have made a difference to the outcome.882

Indeed, the manpower levels at the initial stage of the fire resulted in the FSD having to make difficult trade-offs in its firefighting operations.

1. DD(Ops) Chan acknowledged that at the early stages the FSD focused their efforts on fighting the fire at Wang Cheong House and Wang Tai House (Blocks F and E) and were unable to spare manpower to evacuate the other blocks floor by floor. 883 The FSD’s evidence is that this prioritisation of resources “likely delayed the spread of the fire [to other blocks]”,884 but this may be questionable given that the fire primarily spread through flying embers and debris high in the air whereas the FSD’s firefighting

880 [A2/11, 12]

881 [B13/5756]

882 Evidence of Deputy Chief Fire Officer Lam Kin Kwan [T25/26:1-4] 883 [T18/26:9-28]

884 [ER1/198]

263

efforts in the initial stage were primarily focused on clearing entryways into Wang Cheong and Wang Tai House on the ground. In any event, such decisions have unavoidably resulted in questions by some family members of victims in other blocks, such as by Madam Chong Sio Pek whose mother passed away in the fire, as to whether their loved ones had not been properly prioritised by the FSD.885

2. Even later on during the fire, there were instances of manpower constraints. DCFO KM Wong explained that SAR Teams were allocated to different blocks based on how seriously they were affected by the fire, resulting in some assistance requests for Wang Chi House (Block H) and Wang Kin House (Block D) taking over nine hours to be handled.886

None of these observations detracts from the extremely difficult situation which the Incident Commanders faced at the scene. Nevertheless, it is incumbent on the FSD to review its guidelines and enhance its training for officers who may take on the role of Incident Commander, to ensure that fires of a similar nature are upgraded at the first possible opportunity. It is noted that the Government has in its Closing Submissions committed to conducting such a review.887

In recognition of the extreme fire risks posed by BMR Works, the FSD should also critically review the sufficiency of the pre-determined attendances for such fires. In this regard, other high-risk fires such as hotel fires, hospital fires, fires in places with limited water supply and dangerous goods fires are pre-determined as No 2 alarm fires:

1. Presently, the FSD classifies fires in buildings undergoing renovations as No 1 alarm fires but provides for the deployment of

885 [IE1/4]

886 [T11/58:5-23]

887 Government’s Closing §815.

264

additional fire appliances by way of contingency plans. It is the evidence of DD(Ops) Chan that their present approach provides the FSD with greater flexibility.888

2. Given the severe risks of fire in buildings undergoing BMR Works, the classification of façade fires in these situations to a No 2 alarm or above would provide a minimum standard response to such fires and would avoid inconsistent decision-making by officers who are tasked with formulating contingency plans. We welcome the Government’s support of a specific review of its alarm level system in relation to buildings undergoing large-scale renovation works.889

3. The Committee will note that the contingency plan for Wang Fuk Court provided for the deployment of an additional Major Pump and Light Rescue Unit in the event of fire, 890 without differentiation between internal and façade fires, the time of day and the number of buildings affected, all of which could have affected the scale of the firefighting operations required. The FSD may wish to consider whether its guidelines on the formulation of contingency plans should be reviewed in this regard.

In addition to examining the timing by which the fire was upgraded, the Committee also heard evidence on whether the fire should have been upgraded beyond a No 5 alarm to a Disaster alarm. The evidence suggests that such a step was not warranted:

1. Under the FSD’s General Orders, a Disaster alarm denotes a “wide-spread incident, or series of simultaneous incidents likely to engage the entire resources of the Service for a protracted period,

888 [T18/28:35-29:11]

889 Government’s Closing §818. 890 [B2/2645]

265

and possibly requiring the assistance of the garrison stationed in Hong Kong”.891

2. The firefighting operations that day did not engage the entire resources of the FSD on the day, nor was it practical to do so either given physical site constraints.

3. Further, the evidence shows that the FSD did deploy resources beyond a No 5 alarm as and when required – at the height of the FSD’s operations, staffing levels exceeded the pre-determined attendance of a No 5 alarm by approximately nine times.

Finally, the operational tactics adopted by the FSD in the fire may provide useful lessons for future fires. For example, the Committee heard evidence of the adoption of a building-by-building command strategy to cater for the different circumstances of each block, which strategy was unprecedented in the history of the FSD’s operations.892 Whether such measures should be incorporated as a standard protocol in multi-building fires is a matter that the FSD may wish to take into account as part of its holistic review.

E3. Deployment of firefighting appliances and equipment

Several aspects of the FSD’s operational capabilities were explored in the course of the evidence before the Committee.

(i) Turntable Ladders

One key issue which has been the subject of public discussion is the use of Turntable Ladders (also known as aerial appliances). As described above, the first Turntable Ladder arrived at the scene at 15:02. At the height of the firefighting operations, a total of eight Turntable Ladders were engaged.

891 [B2/2089]

892 [T18/40:11-13]; Tang Wing Wah WS §50.5 [WS1/51]

266

The FSD’s position is that the number of Turntable Ladders deployed to Wang Fuk Court was adequate in the circumstances. It is said that the primary firefighting suppression strategy for building fires is internal firefighting, that external water streams are unable to accurately and fully reach fires inside enclosed buildings, and external crews are unable to locate and extract trapped occupants as effectively as internal search and rescue. Moreover, if external water monitors are not applied with care, the steam generated by vaporised water may endanger individuals awaiting rescue and firefighters inside the building. As such, external water monitors are typically employed as water curtains and sprinklers to forestall fire spread rather than directly suppress the fire.893

The highest reaching appliances currently in use by the FSD are 56-metre Turntable Ladders which are approximately 17 storeys high. It is the FSD’s evidence that:894

1. The height of reach is constrained by the design of emergency vehicular accesses in Hong Kong which are required to be no less than six metres in width and have a weightbearing capacity of 30 tonnes.

2. While 100-metre Turntable Ladders are commercially available, such appliances weigh 60 tonnes and require outriggers of 10 metres, making them impractical for operation on most emergency vehicular accesses in Hong Kong.

3. In the case of Wang Fuk Court, the closest viable location for deployment of 100-metre aerial ladder platforms was at Tai Po Road – Yuen Chau Tsai, approximately 46 metres away from Wang Sun House. At this distance, the rescue cages could not have

893 Wong Sze Lut Sunny WS §8.1 [WS1/65-66]; Tang Wing Wah 3rd WS §35 [WS6/1872-1873]

894 Wong Sze Lut Sunny WS §8.2-8.4 [WS1/66-69]

267

approached the building to effect aerial rescues, and water jets would have been subject to significant deflection.

In assessing the FSD’s explanation, it is important to note that the FSD did deploy Turntable Ladders to conduct external firefighting on the day of the fire. External firefighting was important in Wang Fuk Court to contain the rapid spread of the fire along the façades of the buildings.

Furthermore, the FSD’s own evidence was that internal firefighting was delayed in light of obstructions to the entrances of Wang Cheong and Wang Tai House (Blocks F and E). As a result, the FSD could only carry out external firefighting operations at the earlier stages of the operations.895

Since external firefighting was both effective and, in the early stages, the only available mode of firefighting, there are legitimate questions as to whether the FSD should have deployed greater numbers of Turntable Ladders at earlier stages of the fire, to limit the speed and scope of external fire spread.

Compared with fires originating inside a building, façade fires carry a significantly higher risk of rapid and uncontrolled fire spread. That risk may justify an enhanced pre-determined deployment of aerial appliances for suspected façade fires, so that effective external firefighting can be undertaken at the earliest opportunity. It is submitted that the FSD should develop specific protocols for responding to façade fires, addressing the matters set out above.

The FSD should also keep the number and specifications of its Turntable Ladders and standards surrounding emergency vehicular access under continuous review to ensure that its capabilities keep pace with technological and societal developments and are sufficient to tackle complex high-rise fires in such a dense urban environment as Hong Kong.

895 IFITF Final Report §5.2.2.7-5.2.2.8 [ER1/45]

268

(ii) Water pressure

The Committee heard allegations by residents that the firefighting response was hampered by insufficient water pressure at the initial stages of the fire, and that water jets could not reach beyond the first floor of Wang Cheong House (Block F).896

When SStnO Hui was asked about this in his evidence, he testified that water supplies were adequate that day, and that there were no issues with water pressure as water is normally pumped through their fire appliances into their hoses which ensures adequate pressure.897 As mentioned above, the FSD also adduced evidence that the WSD had deployed staff to the scene to increase the water pressure to around 7 to 7.5 bar at around 16:00.898

The photographic and videographic evidence received by the Committee shows that frontline personnel were able to deploy hoses and water monitors (examples of which are shown below). There is no direct evidence that the water pressure was insufficient, or that this hampered the firefighting operations.

896 [T4/9:33-10:5]

897 [T11/22:33-35, 27:30-36]

898 Tang Wing Wah WS §§4-6 [WS2/966-967]

269

Figure 5-8: Still images taken from footage taken by bystanders (at around 15:11, 15:16, 15:45) and from CCTV footage of bicycle shed of Wang Tai House (15:17:42)899

(iii) Breathing apparatus and other equipment

The Committee heard evidence on the adequacy of the personal equipment worn by firefighters. The evidence from firefighters was that the provisions were of a high standard and are continually reviewed and upgraded.900

In particular, DO Tung explained that the FSD had replaced its 6.7-litre,

5 kg air cylinders with 8-litre, 7.3 kg MSA air cylinders in May 2014, increasing air storage capacity while reducing the weight of air cylinders. In January 2026, the MSA air cylinders were further replaced with 8-litre

1 kg Interspiro air cylinders, which were also equipped with a “TeamTalk” function to facilitate communication within teams and an Emergency Breathing Safety System to enable air-sharing between team members. The

899 [A2/60]; [C20/2872]; [IE4/1466]; [A2/63] 900 [T11/26:32-27:3, 61:32-62:1]

270

FSD has therefore reduced the weight of the breathing apparatus cylinders used by its firefighters over the years without compromising air capacity.901

DO Tung also explained that although the FSD possesses twin-cylinder breathing apparatus equipment which would have allowed firefighters to remain at scene for an additional 20 minutes, these sets would have been much bulkier and heavier (20.5 kg versus 14.5 kg), making it impractical for firefighters to carry them up and down staircases. Other forms of breathing apparatus such as a closed-circuit breathing apparatus (with a 3-hour theoretical working duration) and the Airliner (with a theoretically infinite duration) were similarly unsuitable – the former could not be exposed to naked flames or radiant heat, whereas the latter required firefighters to be attached to an air hose with a maximum length of 90 metres.902

Finally, as DO Tung explained, there were also practical reasons of operational safety for limiting firefighter working durations to 33 minutes, namely concerns regarding fatigue and heat stress.903

For these reasons, it is submitted that the personal equipment used by firefighters at Wang Fuk Court was adequate and was not a limiting factor for the FSD’s operations on the day.

E4. Breathing apparatus operation logs

In contrast, the fire exposed limitations in the FSD’s existing procedures for documenting and keeping track of firefighting operations.

Under the FSD’s operational guidelines, all firefighters are required to pass by an Entry Control Point (identified by an amber flashing lamp) before entering the fire scene. At the Entry Control Point, the team member

901 Tung Wing Kei 2nd WS §§5-9 [WS15/2196-2197] 902 Tung Wing Kei 2nd WS §§10-13 [WS15/2197-2198] 903 [T18/3:8-12]

271

serving as the Entry Control Officer is then required to complete a preentry checklist for the team members and record details on an entry control logbook. FS Manual Chapter 6, §5.16 provides that “record will be kept for each and every wearer passing through the entry control point and such information shall be forwarded to the respective stations for entry into the FS 91”.904

As DO Tung acknowledged, the breathing apparatus operation log sheets generated during the firefighting operations were incomplete. The log sheets were handwritten. Some entry control officers erased previous entries and overwrote them with new records after log sheets had been used up. DO Tung accepted that there were “extenuating circumstances under which this procedure might not have been fully observed”.905

The inaccuracies in, and the incompleteness of, breathing apparatus operation logs are unsatisfactory, even if no operational difficulty has been shown to have resulted in this case. Such logs are essential for keeping track of firefighters at the scene of a fire and are important for reconstructing the sequence of operations afterwards. It is welcome that (as DO Tung confirmed in his evidence) the FSD is implementing electronic entry control logs to reduce the risk of human error in the future.906

E5. Operational safety – lessons learned from the loss of Fn Ho

There are also painful lessons to be learned from the tragic death of Fn Ho. The FSD’s assessment that “no negligence or non-observance of procedures was identified on part of [Fn Ho or his team members]”907 serves to illustrate that the problem may lie more deeply in the existing procedures themselves.

904 [B2/2349]

905 Tung Wing Kei WS §8 [WS4/1811-1813] 906 [T18/13:7-11]

907 IFITF Final Report §9.2.7.4 [ER1/193]

272

First, the FSD will need to consider measures to reduce the risk of firefighters becoming separated from other crew members at the scene of a fire. This may entail measures to enable firefighters to identify and keep track of their team members.

The evidence indicates it took only several seconds for Fn Ho to be separated from his teammates. The presence of other firefighters nearby in identical gear meant that Fn Yeung and Fn Siu did not realise that Fn Ho was missing.908

Second, the FSD will need to consider how to ensure that firefighters responding to fires in multi-block residential estates are able to differentiate between individual blocks.

The difficulties faced by frontline firefighters at Wang Fuk Court were particularly grave given the lack of prominent signage on the ground (including some signage which was obscured by scaffolding).

Figure 5-9: Photos of entrance of Wang Tai House before renovation works and entrance of Wang Cheong House during renovation works909

The evidence suggests that instances of confusion between blocks by firefighters were not isolated and certainly not limited to Fn Ho. Approximately one minute after Fn Ho entered Wang Tai House (at around

908 [WS15/2185-2192] 909 [C7/2540, 2542]

273

15:18), 910 another firefighter was captured by CCTV footage entering Wang Tai House (Block E) at a time when the only assistance requests which had been received concerned Wang Cheong House (Block F). That firefighter narrowly escaped Wang Tai House before the lift lobby was consumed by fire.

Figure 5-10: Still images taken from CCTV footage of entrance of Wang Tai House (15:16:37, 15:17:17)911

The FSD’s evidence in this regard is that each fire appliance is equipped with a mobile data terminal from which firefighters are able to access

910 Timestamps in the CCTV footage were around 2 minutes behind reference time. 911 [C6/2440]

274

geospatial maps of the scene. Furthermore, the Mobile Command Units (the first of which arrived at the scene at 15:42) are also able to display layout plans of individual estates.912

These tools, however, did not prevent the confusion described above. It is submitted that the FSD should review how first responders are enabled to identify individual blocks in multi-block estates. The Government may also wish to require that in multi-block estates undergoing large-scale BMR Works, prominent signage be erected to identify each block and its entrances, and that such signage remain clearly visible notwithstanding any scaffolding or netting erected for the works.

Third, the equipment and procedures designed to locate firefighters in distress proved inadequate in the case of Fn Ho:

1. As described above, Fn Ho wore a Firefighter Locator System (FLS) personal transmitter on his breathing apparatus when he entered Wang Tai House. Firefighters are required to activate their personal transmitter at the Entry Control Point by removing a red activation key from the personal transmitter and handing the key to the entry control officer. After the personal transmitter is activated, in the event that the firefighter is motionless for 45 seconds or manually activates the alarm button, the personal transmitter would emit audible and visual alarms and transmit a radio signal with its unique identifier which can be detected by firefighters using a handheld receiver. Emergency rescue teams would then be able to rely on the radio signal to locate the crew member in distress. 913

912 [T11/3:18-24, 18:1-3]; Wong King Man WS §11 [WS2/1008] 913 Tung Wing Kei WS §§7.1-7.4 [WS4/1809-1810]

275

2. Since Fn Ho did not pass through any Entry Control Point when he entered Wang Tai House, his FLS personal transmitter was not activated and could not be used to locate him.

3. DD(Ops) Chan testified that, for a single unit fire, the Entry Control Point would typically be established two floors below the affected unit at a location unaffected by smoke. Accordingly, Fn Ho would only have realised that there was no Entry Control Point when he arrived at 25/F of Wang Tai House.914

4. If that is the case, there is scope to improve the FSD’s procedures on (i) how Entry Control Points are established, (ii) how their locations are communicated to firefighters, and (iii) whether firefighters who cannot locate their Entry Control Point should retreat and/or immediately activate their personal transmitters.

5. Furthermore, the FSD’s prevailing procedures simply provide that “the entry control point shall be set up in a safe and convenient place as near to the entrance of the affected premises as possible but is not affected by smoke or fumes”915 without guidance on how that assessment should be made. With the benefit of hindsight, had Fn Ho’s Entry Control Point been set up outside the affected buildings (as was done for another unit assigned to respond to the same assistance request),916 his personal transmitter might have been activated in accordance with the entry control procedures, and his colleagues might then have been able to locate him.

6. In its Closing Submissions, the Government submits that the inactivation of Fn Ho’s FLS was a consequence of the “speed and chaos of the initial stage” rather than a “systemic failure of [entry

914 [T18/34:10-26]

915 [B2/2346]

916 The Siu Lek Yuen Station Light Rescue Unit, which was also assigned to handle the assistance request at Flat 2701 of Wang Cheong House, at around 15:01 hours established their Entry Control Point next to Tai Po Baptist School [C6/2442].

276

control point] procedure”.917 While the situation on the ground was certainly difficult and chaotic, it seems to us to be an unsatisfactory answer when entry control procedures are by their nature intended to be implemented in emergency situations. That said, the Government has confirmed in its Closing Submissions that the FSD is reviewing entry control point procedures to specifically address multi-block fires and improved block identification mechanisms for frontline personnel. 918 This is certainly to be welcomed.

This is not the first instance in which a firefighter in distress could not be located due to an inactivated transmitter. The No 4 alarm fire at Amoycan Industrial Centre on 21 June 2016 involved the tragic loss of two firefighters, one of whom entered the scene of the fire without his alphaSCOUT device having been activated.919 The IFITF for that incident noted that the failure to activate the device “would carry significant bearing on the search and rescue operation” to locate the firefighter.920 It is a matter of regret that, in two recent firefighter fatalities in Hong Kong, the operational safety systems designed to locate firefighters in distress were never brought into operation.

Separately, the FSD’s evidence is that even if Fn Ho’s personal transmitter had been activated, its signal may not have reached the emergency response teams at ground level. According to DO Tung, the practical range of personal transmitter signals in high-rise buildings is around 23 vertical storeys. In a city of high-rise buildings, this is a technological limitation which the FSD needs to address. DO Tung confirmed that the FSD had

917 Government’s Closing §855

918 Government’s Closing §855

919 [B5/3016]. At the time of that incident, firefighters had not yet been equipped with the Firefighter Locator System and were only equipped with the alphaSCOUT which would emit an audible warning system in case of distress.

920 §7.1.5.2 [B5/3016]

277

been testing a next-generation FLS that addresses this limitation. It is deeply unfortunate that it had not yet been deployed by the day of the fire.

E6. Evacuation

(i) Overview

The evacuation of residents at Wang Fuk Court was hampered by their delayed awareness of the fire.

Frontline personnel from the FSD noticed the absence of fire alarms and took steps to activate them. SStnO Hui testified that he instructed crew members to enter Wang Cheong House (Block F) to activate the fire alarms, but owing to the burning debris outside the front entrance, they were unable to enter the block. 921 There is evidence that fire crews may 922 have attempted unsuccessfully to activate the fire alarms in Wang Tao House (Block B), Wang Sun House (Block C) and Wang Kin House (Block D) at around 15:35 or 15:40.923 Finally, members of the Fire Protection Facilities Supervision Division also arrived at the scene at 15:54 and attempted to activate the fire alarms at Wang Yan House (Block A), Wang Tao House (Block B) and Wang Chi House (Block H), to no avail.924

With the fire alarms in six of the eight blocks inoperative, most residents learned of the fire from neighbours, family members or friends, from the smell of smoke, or from the sounds of the fire and the sirens of emergency vehicles. This is illustrated by the following summary compiled by the IFITF from the witness statements and questionnaires:925

921 [T11/12:7-13]

922 The qualification relates to the fact that, by 15:35, the fire alarms at Wang Sun House should have already been activated by Mr Lam Man Yan: see [IE2-2/887-889].

923 [T11/22:22-25]

924 Keung Sai Ming 3rd WS §4 [WS4/1799-1801]

925 [ER1/218]

278

Means of Discovery

Resident Witness

Statements

Resident

Questionnaires

Witnessed fire or smoke

Smelled smoke

110

Heard sound of burning

Heard sirens / saw fire appliances

Heard fire alarm

Informed by others

157

340

Total

291

100%

579

100%

There is evidence that property management staff from ISS also used loudhailers to alert residents to the fire in the open area near Wang Yan House (Block A) and Wang Tao House (Block B).926 This did not appear to have successfully alerted residents to the fire. Of all the residents who had submitted questionnaires to the Police, only one suggested he or she had been alerted to the fire by loudhailers.

Given the above, there are legitimate questions as to whether the FSD could and should have taken more steps to evacuate residents from all the blocks of Wang Fuk Court once it became obvious that the fire was spreading from one block to the next. Even if, as the Government submits in its Closing Submissions, the possibility of fire spreading by flying embers was “not predictable from the initial stage”,927 it was certainly predictable by the time the fire spread to Wang Tai House (Block E) at 15:00.

Had residents of Wang Tao House (Block B) and Wang Shing House (Block G) been alerted to the fire promptly, there should have been sufficient time for them to evacuate. Those blocks only suffered rapid vertical fire spread over an hour after the FSD arrived at the scene. Early

926 [H1-3/6776]; [T6/86:32-34] 927 Government’s Closing §801

279

warning may have averted the three fatalities in those blocks. Likewise for Wang Sun House (Block C), had the fire alarms been activated even earlier than they were by Mr Lam Man Yan (sometime between 15:23 and 15:35928), that may have enabled Madam Ieong Vun Ieng and Mr Hung King Leong to become aware of the fire at a time when they were still able to evacuate from the building.

As mentioned above, DD(Ops) Chan’s evidence is that the FSD focused its available resources on tackling the blaze at Wang Cheong and Wang Tai House (Blocks F and E) and was unable to spare manpower for the evacuation of residents from other blocks.929 While the Police did conduct an evacuation operation, it was limited to several floors on Wang Yan and Wang Chi House (Blocks A and H) and only began at 16:13, by which time most other blocks had already been engulfed in smoke.

This evidence only highlights that operations could have been more effective had the FSD escalated its response and deployment even more quickly on the day. There is also a need for the FSD and the Police to devise clearer and more comprehensive protocols for evacuating occupants from building fires at the initial stage of its response in the future, instead of only initiating such operations on an ad hoc basis after the fire has taken hold. The FSD may also need to consider clearer protocols for escalating its response should it discover faulty fire alarm systems or other fire service installations.

(ii) Sirens

Another matter which may need to be reviewed by the FSD is its policy regarding the use of sirens on fire appliances. As SStnO Hui and DO Lam

928 [IE2-2/888]

929 [T18/25:36-26:8]

280

confirmed, prevailing FSD policy required fire appliances to switch off their sirens upon arrival to minimise noise.930

While this practice makes good sense generally, the sirens could have alerted residents to the fire in circumstances where the fire alarms were deactivated. Various residents described the scene of the fire as eerily quiet. Little could be heard but the crackle of burning bamboo. Consequently, residents in their flats may not have realised anything was wrong until too late. The FSD may wish to consider revising its policy so that, where a building’s fire alarms are inoperative, fire appliances should keep their sirens on to maximise the chance of alerting occupants.

(iii) Emergency Alert System

Finally, the Government established an Emergency Alert System (“EAS”) to disseminate emergency messages to mobile phones through local mobile network operators. The EAS was used once during the COVID-19 pandemic but has not been used since. The EAS was not used to alert Wang Fuk Court residents to the fire on the day.

The FSD explained that, under the relevant guidelines in force at the time of the fire (namely, General Circular 5/2020), the EAS could only be used for territory-wide incidents such as abrupt changes in weather conditions, public riots, bomb disposals and breakdown of critical infrastructure instead of localised incidents.931 DD(Ops) Chan added that it would have been dangerous to send a message through EAS without the content of the message having been carefully thought through and prior public education. An unfamiliar emergency alert might prompt trapped residents to react in unpredictable ways which may endanger their personal safety.932

930 [T11/7:24-8:5, 48:9-12]. The Contingency Plan in place for Wang Fuk Court provided that “when travelling in the vicinity of the incident, fire appliances should switch on the flash lights only. Siren should only be used if the situation is needed” [B2/2646].

931 [B2/1323]

932 [T18/30:4-35:19]

281

Furthermore, General Circular 5/2020 required approximately one hour of lead time before dissemination.933 Even if the FSD had attempted to use the EAS on the day of the fire, the dissemination could not have alerted residents to the fire in a timely manner.

It is regrettable that the relevant guidelines at the time prevented the EAS from being used in the Wang Fuk Court fire. DD(Ops) Chan accepted that, with the fire alarms disabled and the windows covered, the EAS was in practical terms the only remaining means of alerting residents to the fire.934 Furthermore, given its severity and the number of people affected (including residents at work, and friends and family anywhere in the territory), the fire was very arguably not merely a localised incident.

After the fire, the Government upgraded the EAS to allow messages to be sent district by district, and is preparing preset messages for fires and other specific emergencies. 935 Beyond this, there is a need to ensure that messages can be sent as promptly as possible. It is unacceptable that a system designed for emergencies could not deliver urgent messages to those affected.

E7. Handling of assistance requests

(i) Communications with “999” callers

The FSCC was unable to cope with the volume of 999 calls received during the early stage of the fire. It was unsatisfactory for distressed callers to be kept on hold for 15 minutes, and the waiting times resulted in some callers hanging up before their calls were answered.

It is true that conditions at the scene effectively prevented firefighters from entering the buildings to carry out rescues at that stage. However, prompt

933 [B2/1319]

934 [T18/31:2-7]

935 Government’s Table of Improvement Measures §A12(iv)

282

advice from the FSCC could well have affected the decisions of residents on whether to stay put or evacuate.

The FSD’s recent enhancements to its emergency call handling systems, announced in the course of the Evidential Hearings, are therefore much needed and welcome. The FSD has increased the number of available lines to 68 and expects to increase it further to 100 when the Fourth Generation Mobilising System is rolled out next year.936 These improvements will need to be coupled with adequate staffing levels and surge capacity if a repeat of the situation on the day of the fire is to be avoided.

As to the calls themselves, it is imperative that the Police and the FSD impress on frontline operators the need to follow call handling procedures faithfully (such as by immediately transferring calls to the FSD where a fire is reported, rather than pressing for more information). The Committee heard evidence of a resident being told to call again later despite reporting smoke, contrary to procedures which required the call to be directed to the FSCC. It also heard evidence of residents on higher floors being incorrectly reassured that the fire was only at ground level and that there was nothing to worry about as the situation was being handled.937

The FSD should also consider revising its call procedures so that safety advice is given to all persons calling from the scene of a fire. Under the FSD’s policies at the time of the fire, operators making call-backs under the call-back mechanism advised callers to check whether there was smoke in the corridor and staircases, and to attempt an escape if the path was clear.938 However, the FSD has no policy of providing such advice when answering 999 calls in the first instance.

When this discrepancy was put to DCFO Sunny Wong, he defended the current practice, saying that FSCC operators would be distracted from

936 Government’s Table of Improvement Measures §A12(ii) 937 [A2/45]

938 [B3/2709]

283

gathering information from callers if they were required to give such advice on every 999 call, and that the advice is only given on request.939

DCFO Sunny Wong’s explanation is unconvincing. Safety advice is clearly best given at the earliest opportunity. By the time a person awaiting assistance receives a call-back from the FSCC, the corridor and staircases may already have filled with smoke, and the opportunity to escape may have been lost. The suggestion that giving advice would distract the FSCC operators from other tasks is inconsistent with the fact that they are already trained to provide post-dispatch first-aid advice to callers seeking ambulance assistance.

Finally, the FSD should consider establishing mechanisms for personnel at the scene to relay critical information to FSCC call operators, so as to minimise confusion during calls and ensure that call operators can offer appropriate advice to callers. For example, some call operators were confused by reports of fire in blocks other than Wang Cheong House (Block F), unaware that the fire had spread. It would also have been useful for call operators to know that a floor-by-floor evacuation operation was being conducted in certain blocks, so that they could advise residents to evacuate if possible.940

(ii) Communication of information to frontline personnel

There is also room for improvement in the manner in which assistance requests were collated and transmitted to personnel at the scene.

First, DCFO Sunny Wong testified that, where 999 calls were disconnected before they could be patched from the Police to the FSCC, the Police would relay the caller’s information to the FSCC by fax or

939 [T12/39:22-44:8] 940 Cf. [T12/48:2-15]

284

email. 941 As the Government acknowledges,942 fax in particular was a dated medium inadequate for conveying urgent, life-critical information in a large-scale incident in 2025. In any event, a formalised mechanism is necessary to ensure that information is not delayed, overlooked or lost. In the case of the Wang Fuk Court fire, there were instances where assistance requests made by 999 callers were only received by the FSD over 30 minutes later or through other means.943

Second, the Police and the FSD may need to consider mechanisms for sharing information between the CEU and the FSCC. There were instances where friends and relatives of trapped residents called the CEU’s hotline enquiring about the status of their loved ones, but the FSD only became aware of persons potentially trapped in their flats much later. For example, the CEU first received an enquiry regarding Madam Pak Shui Lin of Flat 1701, Wang Tai House (Block E) at 18:41, but the FSD first logged an assistance request regarding her at 19:39, some 58 minutes later.944 In three cases, the FSCC’s assistance requests were created more than a day after enquiries had first been made to the CEU.945

Third, the FSD must consider upgrading its computerised systems so that assistance requests can be catalogued and relayed effectively. Frontline personnel had no means of viewing the CMS at the scene. As a result, on the day of the fire, FSCC operators photographed the CMS interface on a computer screen and sent the image to the frontline through FSD Messenger, where commanders had to open each photograph to read its contents. This meant that frontline staff received over 600 photographs of

941 [T12/17:1-9, 58:7-16]

942 Government’s Closing §825-826

943 For example, FSA-066 related to a 999 call which was received by the FSD at 15:53 on 26 November 2025 but was only logged by the FSD at 16:23; FSA-184 related to a 999 call which was received by the Police at 21:26 but was only received by the FSD from a person at the scene on 22:11.

944 [T5/5:20-24]; [T12/74:35-75:9]

945 FSA-314, FSA-318, FSA-344

285

the CMS interface on the day of the fire.946 This laborious and rudimentary means of conveying life-critical information entailed a risk of human error, gave rise to many duplicated assistance requests, and took up precious time which frontline staff could have devoted to the rescue effort. The Government candidly accepts in its Closing Submissions that this was a “weakness in the information relay mechanism”947 and improvements are eagerly awaited.

In the reverse direction, records of assistance cases received or completed at the scene were consolidated by frontline personnel and sent back to the FSCC by way of Excel spreadsheets, which FSCC staff then had to type manually into the CMS.948 This again appears unnecessarily cumbersome and inefficient, especially having regard to the time-sensitive nature of the FSD’s work.

It is therefore right that, as Director of Fire Services Yeung Yan Kin Andy confirmed, the FSD is seeking to address these issues in the Fourth Generation Mobilising System.949

(iii) Call-back mechanism

The evidence before the Committee shows that the call-back mechanism did substantially achieve its purposes of obtaining updated information regarding assistance requests and providing reassurance and advice to persons awaiting rescue.

That is not to say that the operation of the call-back mechanism was completely without criticism. For example, Ms Chong Sio Pek, whose mother perished in Wang Sun House (Block C), recounted that a firefighter took her sister’s telephone number when she pressed for her mother’s

946 [T12/51:5-9, 53:14-24, 53:36-54:12] 947 Government’s Closing §836

948 [T12/54:36-55:5]

949 [T19/35:28-36:12]

286

rescue, yet the calls her sister later received from the FSD enquired about her sister’s safety, not that of her mother who was trapped inside the building.950

Given the volume of assistance calls and the absence of any dedicated system by the FSD to catalogue and track them, the information available to operators may have been incomplete or misread under pressure.

There are certainly areas for improvement in the call-back mechanism:

1. The FSD deployed 80 personnel to operate the call-back mechanism. However, the Support Centre only had a maximum of 18 telephone lines which could be used at any given time.951

2. The FSD’s operational procedures provide that callers awaiting assistance are to be contacted at reasonable intervals of approximately 15 to 20 minutes until they are rescued or brought to safety.952 With the volume of assistance requests faced by the FSD, this target was not met. Indeed, some trapped residents were only called back several hours after their requests had been logged.953

3. Of the 373 assistance requests received by the FSD, call-backs were only conducted for approximately half (188) of them. For the remainder, the FSD had no contact details, whether of the informant or of any persons who might have been trapped inside. The FSD will have to consider how to gather such information systematically in the future so as to maximise the utility of its callbacks.

950 [IE1/4]

951 [T12/55:15-29]

952 [B3/2708]

953 For example, for FSA-209, the FSD first logged an assistance request at 01:36 on 27 November 2025, but only placed a phone call under the call-back mechanism at 17:08.

287

4. Call operators had little information on the status of assistance requests. In many instances, call operators asked informants whether their family members or loved ones had yet been rescued by the FSD. On other occasions, operators called informants despite having been told in earlier calls that their loved ones had already been rescued.954

5. The advice given to trapped residents varied. While most residents were advised to avoid smoke and seal door gaps with wet towels, not all were asked about the smoke conditions around them – even though under the FSD’s own policies, residents should have been advised to check whether the corridor and staircases were smokefree and, if so, to attempt an escape. 955 The FSD may also wish to consider the advisability of asking callers a general question of whether they were “safe” when this does not admit of a straightforward “yes” or “no” answer for persons trapped in a burning building.

6. The FSD had contact details of some trapped persons which, as far as the available records show, the FSD did not attempt to contact under the call-back mechanism.956

7. Information was also passed from the call-back mechanism back to the frontline in a haphazard manner. According to DCFO Sunny Wong, only one staff member in the Support Centre could input data into the CMS, owing to data security concerns. Alternatively, information was delivered to the FSCC in person by Support Centre staff members, the Support Centre being located four floors above the FSCC in the same building.957 This necessarily affected

954 CB229, CB364

955 For example, CB052. 956 CB371

957 [T12/56:26-33]

288

how quickly the FSD could adjust its operations in light of information received through the call-back mechanism.

E8. Alternative firefighting strategies

Finally, the Committee also heard evidence on the viability of three firefighting strategies which were discussed on social media in the aftermath of the fire, namely (i) the use of firefighting drones, (ii) the use of helicopters, and (iii) the obtaining of assistance from Mainland fire and rescue services. The evidence shows that these strategies were not realistic options on the day of the fire.

(i) Firefighting drones

As explained above, the FSD did in fact deploy unmanned aerial vehicles on the day of the fire. These drones were equipped with livestreaming and thermal imaging capabilities, which enabled the FSD to analyse the fire situation from higher vantage points and monitor individual flats for reignition. The aerial surveillance also enabled the FSD to locate two civilians who were trapped on the rooftop of Wang Tai House (Block E).958

958 Tang Wing Wah 3rd WS §13 [WS6/1864]

289

Figure 5-11: Still image taken from drone footage of Wang Tai House at around 00:25 on 27 November 2025959

The drones used on the day of the fire were not used for actual firefighting.

The FSD’s evidence is that firefighting drone technologies remain at the research and development stage, and there are no known cases of fire departments using drones for fire suppression in real-world incidents. The effectiveness of firefighting drones is inherently limited by their carrying capacity. The weight of the water hoses used by the FSD exceeds the lifting capacity of commercially available drones.960

According to the minutes of a meeting between the FSD and DJI, a leading drone manufacturer, DJI’s flagship industrial model at the time, the FC 100, has a maximum lifting capacity of approximately 85 kg and has only been tested by the Mainland China Fire and Rescue Corps with 40 mm hoses.961

959 [B17/6398] 960 [T12/58:18-33] 961 [B2/2610]

290

Furthermore, drones built to carry larger loads would in turn create dangerous downdrafts which may exacerbate the spread of fire.962

In short, the evidence suggests that firefighting drones could not have played any material role in tackling the fire at Wang Fuk Court at the present state of their technological development. As DCFO Sunny Wong confirmed, the FSD is trialling various other forms of firefighting technology (such as firefighting robots) to modernise its capabilities.963

It is hoped that technological advancements, when deployed, will enhance both public safety and the effectiveness of frontline personnel in future operations.

(ii) Helicopters

The FSD did not conduct any aerial water-bombing operations at Wang Fuk Court. The FSD adduced a memorandum from the Government Flying Service (“GFS”) dated 24 December 2025 explaining that, given the dense smoke in the area,964 helicopters could not approach the buildings to aim their water bombs accurately towards the fire (water bombs are typically released at a height of approximately 50 to 70 metres above their target).

Moreover, there were serious concerns that, unlike in forest fires or ordinary building fires, the downwash and the release of up to one tonne of water could dislodge bamboo scaffolding and construction debris, endangering firefighters and civilians on the ground.965

962 [T12/59:1-11]

963 [T12/67:10-30]

964 [B2/2607]

965 Wong Sze Lut Sunny §10.2 [WS1/73]

291

Figure 5-12: Aerial photo of Wang Fuk Court fire supplied by the GFS966

The FSD also drew on past operational experience from the Garley Building fire. In the Final Report of the Commission of Inquiry into that fire, Mr Justice Woo (as he then was) noted that the use of helicopters to rescue four persons trapped on the roof of the building resulted in downwash stirring up smoke, loose objects falling to the ground, and noise disturbances to the FSD’s ground operations.967

Accordingly, the evidence indicates that aerial water-bombing was not a workable firefighting strategy on the day of the fire.

966 [B2/2608]

967 [B2/2613-2614]

292

(iii) Manpower support from the Mainland

At around 22:00 on 26 November 2025, the Guangdong Provincial Fire and Rescue Corps mobilised approximately 20 fire appliances and 100 personnel to stand by at Liantang Port in case further manpower support was required. This was done at the initiative of the Mainland authorities, not at the request of the FSD. After the FSD was notified of the deployment, DD(Ops) Chan, as the Incident Commander at the time, decided that additional manpower was not required. The FSD instead borrowed from the Mainland authorities 10 unmanned aerial vehicles equipped with optical cameras and thermal imaging devices, and 20 sets of exoskeleton equipment, for use in its firefighting efforts. 968

The FSD further explained that, at the time, approximately 980 personnel had been dispatched to the scene, out of around 1,700 personnel on duty in Hong Kong at any given time.969 In other words, the FSD itself still had sufficient manpower to deploy to the scene had it been necessary.

Rather, the number of personnel that could effectively be deployed at the scene was constrained by the physical dimensions of Wang Fuk Court and the internal areas of each block. Staircases and corridors were dark and narrow (some measuring only one metre wide) and firefighters had laid multiple hoses through them. Conditions were made worse by smoke, extreme heat and water continually gushing down the steps.970

The FSD also pointed to significant differences between Hong Kong and Mainland Chinese equipment standards, operational procedures and fire protection systems. These would have increased risks for all involved had

968 Wong Sze Lut Sunny WS §11 [WS1/74-79] 969 [T12/65:12-17]

970 [T12/60:2-11]; [T19/8:33-9:2]

293

a joint operation been conducted, and could have resulted in catastrophic consequences. As DCFO Sunny Wong explained:971

1. Hong Kong and Mainland Chinese firefighters use different terminology and communication protocols, including different distress signals and emergency evacuation signals. In an emergency, there was a risk that firefighters would not recognise distress or emergency signals sent by their counterparts, which could have fatal consequences.

2. Hong Kong and Mainland Chinese firefighters use different brands of breathing apparatus, which do not have cross-compatible emergency air supply mechanisms. In a firefighter emergency, other firefighters would not have been able to perform basic emergency air-sharing procedures, compromising firefighter safety.

3. Fire service installations and street hydrants in Hong Kong and the Mainland are installed to different standards: local water supply outlets use instantaneous couplings conforming to British Standards, while Mainland outlets use Storz couplings under Guobiao standards. Mainland personnel and fire appliances would therefore not have been able to obtain water from Hong Kong’s hydrant systems without specialised adapters.

4. Finally, Mainland firefighters have not been trained in the operation of the portable pumps used by firefighters in Hong Kong (which were used in upper floors at Wang Fuk Court due to the FH/HR systems being inoperative). Operational errors arising from unfamiliar controls and different pressure settings would have been dangerous, potentially leading to pump failure and loss of water supply.

971 Wong Sze Lut Sunny WS §11 [WS1/74-79]

294

Therefore, cross-border exercises have to date been limited to responses to natural disasters such as earthquakes and floods where the compatibility between Mainland and Hong Kong equipment and protocols was less of an issue. Nonetheless, the FSD has explained that, in the longer term, it hopes to have cross-border cooperation protocols in place should such a largescale fire ever recur.972

The upshot is that it was not possible for Mainland fire and rescue personnel to be deployed to Wang Fuk Court on an urgent basis, and the FSD itself had sufficient local manpower to deploy to the scene if needed.

F. Conclusion

Our emergency services cannot be criticised in respect of their overall firefighting and rescue response on the day of the fire. The FSD and the Police were faced with an unprecedented situation and devoted every effort to saving lives and suppressing the fire. Their heroism and sacrifice are commendable.

Nevertheless, it is necessary to seriously identify areas for improvement and lessons to be learned in the firefighting and rescue operations. To the extent that operational strategies were not hitherto designed for fires of this nature, it is now incumbent to do so. Where, as the Government accepts,973 the fire revealed areas for improvement in the Police and the FSD’s operational decisions and systemic arrangements, it will be necessary to consider how these improvements are to be made. It is hoped that the evaluations conducted in this Chapter will assist in enhancing their capabilities in the face of another large-scale fire in the future.

972 [T12/66:3-12]

973 Government’s Closing §781

295

CHAPTER 6: RESPONSIBILITY OF CONTRACTORS AND PRIVATE PARTIES TO THE WORKS

A. Overview

This Chapter analyses the responsibility and accountability of the various contractors and other parties whose works were material to the large-scale BMR Works at Wang Fuk Court. These parties include, most significantly, PC&E and Will Power (the main contractor and the consultant for the project) who were in charge of the project, as well as other parties whose scope of work were more specific.

PC&E and Will Power had overall responsibility for the works. The evidence demonstrates that they cut corners in numerous aspects which directly contributed to the fire and the heavy casualties. Worse still, PC&E and Will Power deceived the regulators and the owners alike through certificates later suspected to be fabricated, staged compliance of inspections and outright lies.

The evidence also reveals an array of registered contractors and registered building professionals who conducted no substantive work and were only asked to lend their name to rubber-stamp statutory forms in return for a fee. The regulators were accordingly deceived into thinking that registered contractors and registered professionals were properly engaged to conduct and supervise the works – when they were not.

Their sustained course of deception concealed the non-compliance by a whole host of actors from every regulator, and merits the Committee’s strongest condemnation.

296

B. Overall Failures of PC&E and Will Power B1. PC&E

At the outset, it is appropriate to begin with an analysis of the general responsibilities and failings of PC&E and Will Power, given their central roles in the project.

The Committee is familiar with the legal framework governing BMR Works. The regulatory framework concerning BMR Works, and the statutory and regulatory duties of the stakeholders engaged in them, are set out in Section F of the Government’s Closing. They were comprehensively addressed in the witness statements of the Government’s witnesses. These submissions do not intend to repeat these matters, save where a specific provision bears directly on the analysis that follows.

PC&E was a registered contractor (RC) and the main contractor who was awarded the Works Contract at the price of HK$336 million. It was responsible for designing, carrying out and supervising the renovation works, and was under a duty to ensure that such works are carried out in accordance with all relevant laws and regulations (such as those stipulated in the Buildings Ordinance (Cap. 123) and its subsidiary regulations) and to rectify any irregularities that are identified.974

Furthermore, PC&E was also under a contractual duty to comply with all its obligations under the Works Contract. In entering into the Works Contract with PC&E, the residents of Wang Fuk Court committed to paying PC&E the very substantial sum of HK$336 million, and they were fully entitled to expect PC&E to honour its contractual promises. Amongst other obligations, PC&E was contractually required to comply with all relevant laws and regulations, reinforcing the duty to comply with them

974 Pang Yuk Lung, Michael WS §7(c) [WS1/708]

297

under the general law (Clause 11).975 The contractual obligations of PC&E under the Works Contract have been addressed in Chapter 2.

PC&E, as the party that had overall responsibility for the entire project, ought to have maintained proper oversight at every level of the works, to ensure that both its regulatory and contractual duties are discharged. The evidence demonstrates that PC&E has fallen far short of these duties. Its failures and deceptive conduct permeate every section in this Chapter.

B2. Will Power

In relation to prescribed repairs under the MBIS, the Registered Inspector (RI) is responsible for providing proper supervision of prescribed repairs, ensuring that the repair materials are not defective and comply with all relevant laws and regulations, and ensuring that the buildings were safe or have been rendered safe.976 The RI’s duties to supervise prescribed repairs primarily stem from section 30D of the Buildings Ordinance (Cap. 123).

As mentioned in Chapter 2, the RI is the natural person whose name appears on the register of inspectors kept by the Building Authority under section 3. The RI was therefore not Will Power.

Nevertheless, it is no answer for Will Power to say that the statutory duties rested on the RI personally. Will Power was engaged by the owners to provide the services of an RI, and was responsible for providing an RI within its organisation who complied with the statutory duties.

In this regard, Will Power was a party to the Works Contract. In particular, under Clause 3 of the Works Contract, Will Power was responsible to the IO for reviewing and supervising the repair works conducted by PC&E, including certifying the standard of works and directing PC&E as to how

975 [F1/26]

976 Cheung Yuk Ching, Karen WS §23 [WS1/785-786]

298

the works were to progress.977 In other words, Will Power was to act as an independent supervisor of PC&E.

The works at Wang Fuk Court officially commenced on 16 July 2024, with the preliminary works (such as the installation of a temporary office and toilet) commencing in mid-June 2024.978

By the time the works commenced, Will Power’s previous RI, Mr Shum Kui Chung, had passed away over two years earlier.979

Under section 27 of the Building (Inspection and Repair) Regulation (Cap. 123P), if an RI becomes unwilling or unable to act, he must notify the Building Authority in writing of that fact within seven days after the date on which he has ceased to act.

Mr Shum Kui Chung having passed away, it was incumbent on Will Power to inform the ICU of that fact. Yet, Will Power failed to report Mr Shum’s death to the ICU. The ICU only discovered Mr Shum’s demise through a complaint received more than two years later.980

On 10 October 2024, Will Power belatedly submitted a Form MBI1 purporting to appoint Mr Ng Yeuk Wilson as the RI for Wang Fuk Court,981 only after repeated chasers from the ICU.982

By allowing the repair works to commence in July 2024 (and the preliminary works a month earlier) without an RI supervising the works, Will Power had abdicated its duties right at the outset of the works.

977 [F1/32]

978 [H1-3/6135]

979 [I1-4/8776-8778]; [O2-831] 980 [T22/26:1-12]

981 [I1-2/1839-1841]

982 [T22/26:13-32]

299

After 10 October 2024, Will Power was responsible for ensuring that its director, Mr Ng Yeuk Wilson, performed his statutory duties as an RI. Nevertheless, the evidence demonstrates that Mr Ng merely lent his name as RI to rubber-stamp documents, without having actually conducted any inspection personally. That is symptomatic of the general failure of Will Power to provide independent supervision of numerous aspects of PC&E’s works. Mr Ng’s responsibilities are addressed in the following section.

This Chapter addresses a substantial volume of evidence demonstrating that Will Power failed to supervise PC&E on numerous issues relevant to fire safety. Will Power left the residents to fend for themselves.

Apart from fire safety issues, residents frequently raised concerns that Will Power was siding with PC&E on other aspects of the works:

1. Mr Tai Chi Man described how residents raised issues concerning the proposed solar panels, being non‑mandatory additions that they considered had pushed household costs to an intolerable level. They suspected that PC&E was behind the escalation of costs.983

2. Mr Yip Ka Kui Sdanni testified that, in the whole process, Will Power took the side of PC&E in relation to the choice of materials. When a proposal emerged to replace mosaic tiles with alternative tiles on what residents suspected was a false premise that the original mosaic tiles of the estate had “ceased production”, Will Power produced a comparison presenting the new tiles as significantly better than mosaic tiles.984

3. The proposal to change the tile material was put to the owners for a vote at the 5 October 2024 EGM. Will Power’s stated position was that, unless procurement of the original material became impossible, the works should proceed on its original contract terms.

983 [T13/17:25-32, 35-36, 18:18-24] 984 [T5/10:4-12]

300

However, the substance of what Will Power told the owners at the meeting pointed the other way. It explained that the switch away from mosaic tiles would cost more on PC&E’s figures, but that PC&E agreed in writing to absorb the difference so that the contract price would remain the same. The change of tiles proposed by PC&E would be costless, safe and lawful. The residents still voted to reject the change.985

4. Mr Lee Kwok Hung expressed frustration that Will Power allowed PC&E to depart from various written contractual terms without issuing any professional reprimand. He made several complaints relating to the failure of PC&E to follow the Works Contract.986 None were taken up by Will Power.

B3. Ng Yeuk Wilson as the RI

Mr Ng Yeuk Wilson was appointed the RI of Wang Fuk Court on 10 October 2024. 987 It follows that he had a personal responsibility to supervise the prescribed repairs under section 30D(4) of the Buildings Ordinance.

He therefore bore a personal statutory responsibility for supervising the repair works. He sat at the centre of the regulatory framework.

Will Power also represented in its tender that the RI would personally carry out a total of 46 days of work relating to the MBIS repairs.988

Serious questions arise as to what Mr Ng Yeuk Wilson actually did in discharge of his statutory duties.

985 [G1-2/1521-1522] 986 [T13/54:10-25] 987 [I1-2/1840-1841] 988 [E1-4/8281]

301

Mr Ng’s engagement as the RI at Wang Fuk Court should be considered in light of the evidence that he was under full-time employment (at some point he was employed by Swire Properties989) and was simultaneously engaged as RI for over 50 projects. It was therefore impossible for him to have properly discharged his statutory duties.

WhatsApp communications extracted from the mobile phone of Mr Ng Yeuk Wilson (seized by the Police) shed considerable light on this topic.990

1. The content of the messages suggested that the messages were drafted by Mr Ng Yeuk Wilson (and sent to himself) to provide an explanation to his full‑time employer why he had taken on freelance RI work for Will Power.

2. In these messages, Mr Ng begins by stating that he wishes to provide “a factual account” of his involvement in the Wang Fuk Court fire. He apologised for his failure to declare his role at Wang Fuk Court and remuneration to his employer. He also makes several admissions:991

(a) He acknowledges that the Form MBI1 lists him as the RI, but had “doubts about the legitimacy of the signature”, saying he did not know when or how it was executed.

(b) He admits he had a connection with Will Power: after the original RI died, a director of Will Power approached him to act as RI on a freelance basis. He was paid HK$15,000 per month, plus bonuses, for “acting as RI under my signature and accountability”. He received HK$190,000 in total.

989 [J1-3/7184]

990 The messages may be found at [A2/170, 171, 172, 173]. 991 [A2/170]

302

(c) He states that his involvement was “limited primarily to signing prescribed forms and inspection reports”, rather than conducting any actual MBIS inspections or supervision.

3. Since Mr Ng Yeuk Wilson was the only RI at Will Power – and the only RI listed for Wang Fuk Court since October 2024 – this admission is deeply troubling. The truth was that no qualified RI had ever supervised the works.

4. Other WhatsApp messages from Mr Ng’s seized mobile device indicate that Wang Fuk Court was not his only “dummy” RI role. In those messages, Mr Ng sought to negotiate a new freelance arrangement in November 2025. The proposed deal involved paying Mr Ng the sum of HK$150,000 to sign whatever documents were put before him (齋簽) and to “pretend” during the

BD’s inspections. When Mr Ng counteroffered HK$180,000, the middleman asked whether he would be amenable to signing back‑dated documents, as that would make Mr Ng’s offer more attractive. Mr Ng agreed.992

The Committee may note Mr Ng Yeuk Wilson’s assertion that his signatures on the statutory forms may have been forged. The Committee is not invited to make any finding of forgery, and may simply note the possibility that some of his signatures may have been signed by others.

However, Mr Ng’s admissions to his employer in the WhatsApp messages seen above clearly demonstrate that he agreed to his appointment as RI at Wang Fuk Court. Even if he did not personally sign on one or more of the statutory forms bearing his signature, he would have authorised others to sign on his behalf in return for a fee.

992 [A2/171]

303

The fact that Mr Ng was aware of his own involvement in Wang Fuk Court is supported by a WhatsApp exchange between Mr Ng and Mr Wong Hap Yin Jason of Will Power. In those messages, Mr Wong Hap Yin consulted Mr Ng Yeuk Wilson on one narrow issue: the additional works relating to air‑conditioning hoods. Apart from that exchange, there is no evidence of Mr Ng providing any substantive input on the Wang Fuk Court repair works. Importantly, the final messages were payment records sent to Mr Ng – reinforcing the inference that he was simply paid to lend his name and signature.993 These contemporaneous records directly contradict any possible claim by Mr Ng that he was unaware of his role in the project.

There is no other evidence of Mr Ng Yeuk Wilson having conducted any actual work as an RI on the Wang Fuk Court project. No one has seen him on the site. The ICU never met Mr Ng in person, or received an email from him. 994 Attempts to contact him, such as emails arranging critical site walks, went unanswered. On 23 October 2024, the ICU attempted to arrange an inspection on 28 October 2024. It was Mr Wong Hap Yin Jason of Will Power who replied, telling the ICU that “our RI Mr Ng is not available”.995

Consistently, Mr Tsui Moon Come Tony testified that he did not know Mr Ng Yeuk Wilson and never met him.996

B4. Deception of regulators and owners

The evidence demonstrates that PC&E and Will Power cut corners in numerous aspects. These directly contributed to the fire and the heavy casualties. Among other failings: PC&E procured non-fire-retardant scaffolding nets, created staircase access openings for the convenience of workers, allowed combustible rubbish to accumulate on the scaffolding

993 [A2/172]

994 [T22/29:24-30:2]

995 [I1-4/8752-8753]

996 [T14/52:34-36, 73:2-8]

304

and lightwell flat roofs, installed polystyrene foam boards known to be flammable on the windows, and failed to curb persistent smoking by workers on the site. Not once did Will Power intervene in these matters.997

Worse still, PC&E and Will Power deceived regulators and owners alike. PC&E produced fire-retardancy certificates that are suspected to be bogus and recycled the same certificate to the ICU and the LD for a different batch of nets. Upon receiving advance notice of the ICU’s intention to test scaffolding nets in an inspection, PC&E urgently ordered 115 sheets of compliant safety nets to stage compliance. PC&E assured the ICU that foam boards would only be used temporarily during hacking-off works, when they in fact remained affixed on windows for over a year.

The egregious failures and deceptive conduct of PC&E and Will Power are addressed in detail in this Chapter and in Chapter 7.

The evidence also reveals an array of registered contractors and building professionals who conducted no substantive work, lending their registered status to sign statutory forms in return for a fee. As elaborated below, Will Power falsely told the ICU that Mr Ng Yeuk Wilson had taken over as RI immediately upon Mr Shum Kui Chung’s death. Not only was that untrue, Mr Ng in fact did no work at all,998 simply rubber-stamping whatever statutory forms were put before him.

Likewise, China Status was engaged purely to submit shutdown notices to the FSD, and Chi Fu Construction and Motive Design admitted that they were engaged only to sign the MW submissions for the staircase works – works in fact carried out by Wealth Pinnacle.

997 Save for Will Power’s initial attempt to dissuade PC&E from using flammable foam boards – a position it soon abandoned by approving PC&E’s proposal to use them.

998 Save for answering one WhatsApp query from Mr Wong Hap Yin Jason [A2/172].

305

This sustained course of deception by PC&E, Will Power and other registered personnel concealed their non-compliance from every regulator, and merits the Committee’s strongest condemnation.

B5. Failure to implement phasing of works

Much of the evidence at the Evidential Hearings focused on the propriety of the use of various temporary building materials and protective measures, the creation of temporary access openings and the shutdown of the FAS. PC&E and Will Power have a major responsibility in those matters. The failings and deceptive conduct of PC&E and Will Power on these distinct issues are addressed in Section C onwards in this Chapter.

Before we turn to those topics, there are overarching failures by PC&E and Will Power which are attributable to these two companies in light of their overall responsibilities for conducting and supervising the works.

The first is the issue of whether scaffolding should be erected and works conducted simultaneously for a substantial period in all eight blocks. This issue is material as the simultaneous enclosure of all eight blocks with scaffolding, scaffolding nets and foam boards has contributed to the rapid spread of fire at Wang Fuk Court.

1. Chapter 2 addresses the evidence that the repair works took place in rolling phases (流水式分期作業方式),999 in practice meaning

that while scaffolding was erected in three sequential phases, the substantive works across the three phases overlapped and were carried out concurrently for almost a year until the day of the fire. The works were conducted on (with scaffolding enclosing) all eight blocks simultaneously for a substantial amount of time.

2. Shortly after Mr Tsui Moon Come Tony became the Chairman of the IO on 6 September 2024, the new IO requested PC&E to

999 [H1-3/6126]

306

conduct the works by phases such that Phase II would only commence after the completion of Phase I, and Phase III would only commence after the completion of Phase II.1000 In particular, the new IO told PC&E about residents’ concerns that the simultaneous enclosure of all eight blocks with scaffolding and scaffolding nets would create fire safety risks.1001

3. Instead of complying with the request of the new IO, PC&E refused the request by citing various costs and labour issues as its excuse.1002 This excuse is wholly unjustified. It was PC&E’s own responsibility to provide sufficient labour to carry out the works (Clause 4.3) and to complete the works at the capped or fixed contract price of HK$336 million (subject to limited exceptions) under the Works Contract. 1003 In any case, neither concern is sufficient to outweigh significant fire safety risks.

4. Furthermore, PC&E asserted that the old IO had already approved the plan for the phases to proceed in an overlapping manner.1004 This assertion, even if true, is untenable because the IO for the time being had the final say on the timetable for the works under the Works Contract.1005 In any event, the factual premise was not established: the new IO did not verify PC&E’s claim against the records,1006 and the minutes recorded no more than approval of a rolling sequence for the erection of scaffolding in general

1000 [T14/21:1-7]

1001 [T14/21:15-24]

1002 [T14/21:8-10, 30-35; 22:12-15]

1003 [F1/27]

1004 Reply from the 12nd Management Committee §19(2) [WS3/1660]

1005 According to the Appendix to the Works Contract, the renovation project should, subject to the decision of the IO depending on the actual circumstances, take place in phases, with one block under Phase I, three blocks under Phase II, and four blocks under Phase III [F1/41].

1006 [T14/22:2-8]

307

terms.1007 They do not evidence a decision by the old IO that all substantive works should be conducted on all eight blocks simultaneously.

Will Power and RI did not discharge their supervisory role. There is no evidence that they had ever directed PC&E to comply with the new IO’s request pursuant to the requirements of the Works Contract. Will Power also did not address the residents’ concern for fire safety and allowed PC&E’s conduct to pass by without advancing the residents’ interests.1008

The Committee is not invited to make findings against the old IO merely by reason of PC&E’s assertion that it had approved the plan to conduct the works in an overlapping manner across all eight blocks. There is no record of the old IO having been asked to consider – still less having approved – the fire safety implications of all eight blocks being simultaneously enclosed with combustible scaffolding, safety nets and foam boards. Those were matters on which PC&E and Will Power were duty-bound to advise the IO (both old and new) – yet they failed to do so.

B6. Failure to monitor and curb smoking

Another overarching failure of PC&E and Will Power is their failure to curb smoking by workers on site. The expert evidence addressed in Chapter 4 above indicates that a lit cigarette end is likely to have caused the start of the fire in this case. The issue of smoking is significant as it is the most probable cause of the fire and was the subject of constant complaints by residents.

Section C1 of Chapter 4 summarises the evidence of workers smoking on the scaffolding. This was a matter of persistent complaints by residents. PC&E and Will Power were aware of the complaints (many of which were supported by photographs and videos) not least because these complaints

1007 [H1-3/6126] 1008 [T14/22:12-18]

308

were relayed to them in their WhatsApp group with the Management Committee.1009 Smoking by workers in and around the scaffolding was prevalent, and PC&E and Will Power knew about it.

There is evidence that PC&E designated specific areas for smoking. The evidence also suggests that there was a policy of penalising workers who are caught smoking in or around the scaffolding, with the penalty being a warning plus a HK$1,000 fine for the first offence, and termination of employment for the second offence.1010 The level of fine for the first offence was subsequently raised to HK$2,000 in or about March 2025.1011

However, such penalties were not effectively enforced. Instead, as the WhatsApp record between IO members shows,1012 the residents observed that the smoking situation did not improve and the complaints fell on deaf ears. Mr Tsui Moon Come Tony testified that despite the measures taken by PC&E to curb smoking, the problem about on-site smoking had not been satisfactorily resolved, and the complaints continued throughout.1013 The IO on occasion withheld payment from PC&E to extract undertakings on smoking and related safety issues, and on one occasion Mr Hau Wa Kin attended personally and undertook that enforcement would be stepped up. The smoking nevertheless continued.1014

Indeed, there is direct evidence of workers smoking at the site on the day of the fire: see Section C1 of Chapter 4 above.

1009 [F4/1041, 1269, 1285] 1010 [A2/64/221]

1011 [A2/65/224]

1012 [F4/1041, 1269, 1285] 1013 [T14/48:33-51:4]

1014 [T14/49:17-50:25]

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B7. Failure to conduct fire safety briefings and assign fire watch

Furthermore, the evidence establishes that PC&E and Will Power failed to ensure that workers were trained to immediately report a fire should a fire be detected by them.

This issue is material because there is evidence of workers on the lower floors of Wang Cheong House who discovered the fire at about 14:42.1015 The IFITF opined that, had these workers made an emergency call immediately, the FSD could have been notified at least a few minutes earlier than the initial 999 call it received at 14:51. Even a few extra minutes may have been critical in enabling the FSD to contain the fire whilst it was at a comparatively earlier stage of development and thus limit the subsequent rapid fire spread.1016

The Committee has heard evidence from various construction workers. They testified that the safety briefings they received did not touch upon fire safety related issues,1017 or that the briefings lasted only for a few minutes and they were unable to recall the details.1018

As shown in the CCTV footage of the 5/F access openings of Wang Cheong House,1019 construction workers discovered the fire from around 14:42 to 14:45. Yet, they spent precious time debating the cause of the fire (one worker asking who had set things alight by smoking) and trying to put out the fire (in vain).1020 Had they immediately alerted the FSD, the extra five minutes or so may have been critical in containing the fire.

1015 [A2/7]

1016 IFITF Final Report §§5.1.3-5.1.8 [ER1/40-41]; [T25/25:12-26] 1017 [T4/45:8-15; 52:1-9]

1018 [T13/25:8-21]

1019 [A2/7]

1020 [T1/8:31-34]

310

In fairness to the workers, they were labourers confronted with a sudden emergency. Nevertheless, it was PC&E and Will Power’s duty, with the assistance of safety officer Mr Wong Siu Tai Arthur (who was engaged by PC&E but employed by Excel Target International Limited), to train the workers and ensure that proper protocols were in place in the event of a fire.

Relatedly, there is no evidence that PC&E assigned or maintained any fire watch to detect fire hazards or raise the alarm in the event of a fire, despite the obvious risks created by enveloping eight occupied blocks in combustible materials. The consequence was that those on site were unprepared when fire broke out. The initial report to the FSD was left to a passer-by, and the FSD was accordingly notified later than it could have been, delaying the commencement of the firefighting response.

B8. Failure to clear accumulated combustibles on scaffolding

Another aspect of failure by PC&E and Will Power was the accumulation of building materials, debris and rubbish in and around the scaffolding.

1. Under Clause 13 of the Works Contract, PC&E was under an express duty to keep the work site clean, and to remove all debris and materials from the work site and store them at a designated spot; and accumulation of debris is expressly prohibited.1021

2. The evidence suggests that PC&E failed to clear the combustible rubbish adequately, and Will Power failed to supervise it. For example, according to the evidence of a resident living in Flat 305 of Wang Cheong (i.e. a few floors above the flat-roof where the fire is believed to have started), there was a lot of debris accumulated on the flat roof, and every day she heard debris (such

1021 [F1/45-46]

311

as concrete and other building materials) being dumped onto the flat roof.1022

3. This is consistent with the observations of Dr Lee Wing Man – she found that the flat roof accumulated a lot of debris, including cardboard boxes containing tiles, foam boards, plastic bottles, used disposable cutlery, and a cigarette end.1023 Apart from the flat roof, Dr Lee Wing Man also observed that a lot of debris were stored along different levels at the scaffolding, including cardboard boxes near the catch fan.1024

These are but some examples of PC&E and Will Power’s general failure to properly supervise and oversee the entire project. The remainder of this Chapter will consider aspects of the works highly material to fire safety, which were explored extensively in the Evidential Hearings.

C. Temporary Building Materials and Protective Measures

As explained in Chapter 4, the use of numerous temporary building materials without fire-retardant qualities has contributed significantly to the spread of fire.

The respective responsibilities and failures of parties that led to such a dangerous state of affairs are addressed below. Particular focus is placed on PC&E and Will Power, whose representatives were demonstrably aware of the hazardous nature of the measures that were implemented, but nevertheless directed or allowed their use.

1022 [T4/4:1-12]

1023 [T25/34:29-33; 35:1, 23-26] 1024 [T25/36:36-37:6]

312

C1. Scaffolding nets and plastic sheeting

As principal contractor and consultant of the works, PC&E and Will Power had the primary responsibility to ensure that the scaffolding works, and the associated materials used for the purpose of the scaffolding, were carried out safely. They were well aware of the requirement that the scaffolding nets had to be fire-retardant, and must also have been aware that the same applied to the plastic sheeting:

1. At the 30 May 2024 works meeting, PC&E represented that the scaffolding nets would be of fire-retardant quality (外牆棚網具有

阻燃性).1025

2. At a subsequent works meeting on 17 June 2024, Will Power reminded PC&E to strictly adhere to the requirements of the Buildings Department’s Practice Note APP-70 and submit the fireretardancy certificate for the scaffolding nets (工程顧問提醒承建

商必須嚴格按照屋宇署作業守則 APP-70 方面的規定並提交

遮布棚網耐燃証書).1026

3. The express reference to APP-70 is important. That Practice Note regulates “screens, fans, catch platforms or similar protective measures”, such as polyvinyl and plastic sheeting. It advises that such sheeting should be of a flame-retardant quality.1027 Having had APP-70 expressly drawn to their attention, PC&E and Will Power must have been aware that not only the scaffolding nets but also the plastic sheeting and any similar protective materials had to be of a fire-retardant quality.

1025 [H1-3/6134-6135] 1026 [H1-3/6131]

1027 [J1-1/688]

313

4. Representatives from the IO and ISS were present at both meetings, and were also aware of the need for fire-retardancy of the scaffolding nets and plastic sheeting.

The scaffolding sub-contractor Gain Profit expressly stated at item 3 of its quotation issued on 29 May 2024 that it would install fire-retardant scaffolding nets (阻燃網).1028 Under the scaffolding sub-contract between

PC&E and Gain Profit, it is also stated that the scaffolding nets must comply with all relevant laws and regulations. Mr Chan Yiu Fai’s evidence was that he knew the contract included a requirement that the scaffolding nets be of a fire-retardant quality.1029

Against this background, the analysis will be divided into two parts: pretyphoon and post-typhoon in mid-2025.

Insofar as the pre-typhoon period is concerned:

1. As explained in Chapter 4, the ICU inspected scaffolding nets at both the roof and ground floors of a block in Wang Fuk Court on 28 October 2024. The quick tests conducted showed that a portion of scaffolding net was lit by a lighter for 15 seconds, subsequently catching fire and continuing to burn on its own for 10 seconds until someone blew out the flame to extinguish it. Both PC&E’s and Will Power’s representatives were present.1030

2. Two points arise from this quick test. First, according to the relevant fire-retardancy certificate, the after-flame time (續燃時

間) of the scaffolding nets should be zero seconds. The result of

the quick test was inconsistent1031 by a significant margin with

1028 [Q1/11]

1029 Chan Yiu Fai WS §6 [WS2/1432]

1030 Ku Siu Ping WS §48 [WS1/640-642]; [I1-4/8988] (video taken on R/F entitled “1_20241028_RF”)

1031 [D1/1601]

314

what was stated on the face of the certificate. Yet, there is no evidence of any follow-up action by PC&E or Will Power.

3. What followed was even more egregious. Instead of following up on the quick test result to ensure that the nets were fire-retardant, PC&E and Will Power deceptively concealed the failed test result from the residents. Videos of the quick test produced by PC&E, the IO and the ISS did not include the part showing the after-flame time of 10 seconds, whereas the video produced by the ICU did.1032

4. The inference is that PC&E or Will Power deleted part of the video (the part that showed the failed quick test) before sending it out to the IO and ISS. In any event, there is no evidence that they had ever disclosed the failed result to the IO.

Turning to the post-typhoon period, after the successive typhoons had damaged the scaffolding nets, PC&E decided to purchase non-fireretardant scaffolding nets as a replacement. The events are recounted in detail in Chapter 2. The evidence reveals a deliberate decision by PC&E and Will Power to do so as a cost-saving measure at the expense of the safety of the residents.

1. Under Clause 4 of the Works Contract, PC&E was under a duty to repair the scaffolding and scaffolding nets from time to time including if the same is damaged by typhoons, and that the costs of such repair had already been included in the contract price and PC&E is not entitled to seek further reimbursement from the IO.1033

2. The evidence of Lam Kee (the supplier of the replacement nets) was that none of the replacement nets sold to Gain Profit (save for one batch ordered on 27 October 2025 to stage compliance) were

1032 [I1-4/8988] 1033 [F1/53-54]

315

fire-retardant. This is accepted by Mr Chan Yiu Fai of Gain Profit. He explained that he was instructed to order non-fire-retardant nets by Mr Gordon Ho of PC&E, and asserted that Mr Ho said to him that: “If I tell you to order then order, there’s no need to talk so much, if you order fire-retardant nets you won’t be reimbursed” (叫你訂就訂，唔使講咁多，你訂阻燃網都唔會找數俾你).1034

3. The Committee does not have a contemporaneous record of the conversation between Mr Chan Yiu Fai and Mr Gordon Ho. Nevertheless, Mr Chan’s account was not disputed by Mr Gordon Ho in his witness statement dated 2 July 2026.1035

4. According to Mr Chan Yiu Fai, he made a phone call to Mr Hau Wa Kin of PC&E noting his exchange with Mr Ho, to which Mr Hau instructed him to follow Gordon’s instructions.1036 Mr Chan therefore arranged for ordering of the non-fire-retardant nets.

5. It can be inferred that PC&E’s instruction to Gain Profit to use non-fire-retardant nets was a deliberate decision to cut costs. Fireretardant nets were roughly double the price of non-fire-retardant ones.1037

6. On 27 October 2025, Mr Yeung of Will Power received notice from the ICU that Mr Andy Ku intended to conduct an inspection at Wang Fuk Court on the following afternoon to check the fire retardancy of the scaffolding nets.1038 This was then relayed to Mr

1034 Chan Yiu Fai WS §14 [WS2/1437]

1035 Gordon Ho 2nd WS §§32-33 [WS24/2634] 1036 Chan Yiu Fai WS §14 [WS2/1437]

1037 [S1/1, 12]

1038 [A2/96]

316

Sam Tam of PC&E, who forewarned his colleagues about the upcoming inspection:1039

“（不公開）明天下午預 ICU 到地盤預要燒棚網 check

定邊啲 ok)”

“(Not to be disclosed) Tomorrow afternoon - expect ICU to arrive at the site; expect the scaffolding nets to be burn-tested; Check in advance which ones are ok”

7. Mr Chan Yiu Fai’s evidence was that, on the same day, PC&E urgently instructed him to order a batch of 115 units of fireretardant scaffolding nets. He was instructed to replace the scaffolding nets at the bottom of the scaffolding, in anticipation of an upcoming inspection by the LD (Mr Chan was not apparently aware that the inspection would be conducted by the ICU instead).1040

8. These matters evidence the fact that PC&E knew full well that the scaffolding nets installed at the time would not have passed the inspection. There was otherwise no need to “check which ones are ok”, let alone urgently instruct Gain Profit to place a much smaller order of 115 fire-retardant nets.1041 In comparison, the other orders for replacement nets were for a total of 1,400 units at half the price of the fire-retardant nets.1042

9. The evidence reveals a cynical attempt by PC&E to deceive the ICU by ordering a portion of fire-retardant nets and placing them at strategic locations where it was expected that the ICU would

1039 [A2/95]

1040 Chan Yiu Fai WS §17 [WS2/1439-1440] 1041 [S1/12]

1042 [S1/6-9]

317

inspect. In his second witness statement, Mr Gordon Ho did not deny the damning evidence given by Mr Chan.1043

10. PC&E’s deliberate concealment of the use of non-fire-retardant nets continued. On 20 November 2025, during an inspection by the LD, the LD requested a certificate of the fire-retardant standards of the latest batch of replacement nets, because they knew that “some nets were damaged during typhoon and replaced afterwards”.1044

11. Later that day, PC&E sent the LD a copy of the certificate obtained for the very initial batch of scaffolding nets (rather than the replacement nets).1045 The implied representation was that both the old batch and the new replacement batches were the same. That representation was plainly false.

Gain Profit cannot escape responsibility by blaming PC&E:

1. Mr Chan Yiu Fai admitted that he was aware of the requirement that scaffolding nets had to be of a fire-retardant quality. As an experienced scaffolding contractor, he must have known that this was not only a contractual requirement, but also a legal and regulatory requirement. He could have (and should have) rejected the instruction by Mr Gordon Ho and Mr Hau Wa Kin to purchase replacement nets of a non-fire-retardant quality.

2. Under Clause 25 of the sub-contract between PC&E and Gain Profit, the sub-contract price covered the following scope of work:

(i) erect the scaffolding; (ii) conduct one repair of the scaffolding after external wall works are completed; and (iii) dismantle the

1043 Gordon Ho 2nd WS §§32-33 [WS24/2634] 1044 Lam Sau Ching WS §83 [WS1/379]

1045 [D1/1685-1689]

318

scaffolding net.1046 According to Mr Chan Yiu Fai of Gain Profit, that one-off repair had been completed in May 2025 and that, apart from the final dismantling of the scaffolding, the contractual duties of Gain Profit had been completed by then.1047

3. It follows that, on Mr Chan’s own evidence, Gain Profit was not contractually bound to accede to PC&E’s request to purchase the replacement nets. Mr Chan’s explanation was that he acceded to PC&E’s request because PC&E threatened not to pay him.1048 In other words, Mr Chan ultimately placed his economic interests over the safety of the residents.

4. Additionally, after the fire broke out, Mr Chan received a voice message from his wife Ms Zhong Fengping (鍾鳳平) saying:1049

“我哋後期送啲網過去，阿添叫你解畫，夾好口供解話

打俾佢，因為我哋嗰啲唔係阻燃網嚟㗎”

“One more thing – about the nets we delivered at the later stage: Ah Tim has asked you to give an account of them. Let’s get our story straight on how to explain it before you call him back, because those nets of ours are not fire-retardant.”

5. Not only does this betray Gain Profit’s knowledge that using nonfire-retardant scaffolding nets was illegal, it also indicates a potential attempt to mislead the authorities investigating the fire.

Will Power cannot deny responsibility either.

1. Will Power participated in the deceptive staging of compliance, which misled the ICU on 28 October 2025. It is difficult to imagine

1046 [Q1/10]

1047 Chan Yiu Fai WS §11 [WS2/1435] 1048 Chan Yiu Fai WS §14 [WS2/1437] 1049 [A2/112]

319

that Will Power was unaware of the status of the scaffolding nets, given their different colour and translucency compared to the original batches.

2. In the very unlikely event that Will Power was unaware of the fireretardancy of the nets, this would plainly amount to a dereliction of its supervisory duties to certify the materials used by PC&E. The Works Contract provides that all materials used for the repair works must be first approved by Will Power (任何工程中所採用

之材料，必須經工程顧問代表認同及批准方可使用).1050

Although there is less evidence regarding the procurement and use of plastic sheeting and canvas, the requirement of fire-retardancy was known to PC&E and Will Power. The tests conducted by Dr Lee Wing Man after the fire show that they did not meet such standards. The inference is that PC&E and Will Power failed to comply with these standards as far as the plastic sheeting was concerned.

For these reasons, the Committee is invited to find that PC&E and Gain Profit are primarily responsible for the procurement and use of non-fireretardant scaffolding nets to replace the nets that were damaged by two typhoons. PC&E is ultimately responsible for the use of non-fire-retardant plastic sheeting as well. Finally, Will Power is responsible for its failure to supervise PC&E and its choice of materials.

For completeness, there is no evidence suggesting that the IO (whether the old IO or the new IO) knew of the improprieties identified above. The evidence indicates that the IO was itself misled. For example, on 8 November 2025, a renovation works progress meeting was held in which Will Power reported that the ICU inspected the scaffolding nets and

1050 Clauses 4.4-4.6 (COT/03-04) of Part 4, Works Contract [F1/27-28]

320

confirmed that they were compliant with fire retardancy standards (獨立

審查組 (ICU) 上星期到本苑巡視，期間測試棚網阻燃合乎標準).1051

As to the suppliers:

1. Customers were at liberty to place orders for either fire-retardant or non-fire-retardant nets with Lam Kee and Binzhou Yuanjin. The evidence suggests that the decision to order non-fire-retardant nets with these suppliers lay with Gain Profit (as instructed by PC&E).

2. As to Shandong Chenxu, it provided a fire-retardancy certificate that may have been fabricated. The certificate was issued in the name of the National Quality Supervision and Inspection Centre for Labour Protection Products (Beijing) (國家勞動保護用品質

量監督檢驗中心（北京） ). 1052 That however was the

institution’s former name. Mr Andy Ku of the ICU accepted in evidence that after the fire, the ICU checked the accreditation number on the certificate and noted the difference in the name of the issuing institution. The ICU’s post-fire checks therefore establish that the certificate was not genuine.1053

3. If the original batches of scaffolding nets were not fire-retardant, the evidence suggests that Shandong Chenxu may be to blame. The Committee should note that the expert evidence of Dr Lee Wing Man on this issue is inconclusive, given the conditions at the scene of the fire.1054

1051 [F1/321]

1052 [D1/1599]

1053 [T22/51:26-29, 52:11-20] 1054 [T25/43:13-22]

321

C2. Foam Boards

The Works Contract required PC&E to implement appropriate protection to the building such as covering and protecting the building. 1055 All materials used in the works had to comply with the requirements of the Works Contract and/or be approved by Will Power.1056

Further, under the Works Contract, Will Power had power to, inter alia, direct PC&E on the works, including on the quality of the materials used for the works.1057

Therefore, both PC&E and Will Power are responsible for the choice of materials used as protective covering, as well as the way in which such materials are used (e.g. how many windows to be covered at a time, when the coverings should be removed). The evidence shows that they have failed to discharge this responsibility.

As early as the works meeting on 17 June 2024, there had already been discussion between PC&E and Will Power about the flammability of foam boards and possible alternatives that could be used:1058

1. At the meeting, Will Power expressed particular concern regarding the flammability of foam boards and their tendency to generate a large amount of smoke (工程顧問表示發泡膠為易燃物品並於

火災時產生大量濃煙). PC&E responded that “boards” were less

protective than foam boards, and insisted on using the latter (承建

商表示甲板對窗戶保護能力欠佳，相反發泡膠效果較佳).

2. Will Power then replied that each material has its pros and cons, but remained of the view that foam boards carried a greater risk

1055 [F1/57] 1056 [F1/46] 1057 [F1/32, 34] 1058 [H1-3/6131]

322

and, if PC&E proceeded to use foam boards, it should consider such risks and implement appropriate measures (各樣物料均有其

好壞處，但始終認為發泡膠板存在較大風險，如承建商堅持

使用，必須自行考慮風險及制定應變方案).

Despite Will Power requesting PC&E to consider the risks of using foam boards and the implementation of appropriate measures, there is no evidence that this was done. Instead, PC&E sent a letter dated 17 July 2024 addressed to Will Power, seeking its approval for the use of foam boards as temporary protective covering.1059 That letter was counter-signed by Will Power with the words “reviewed and approved”. The letter did not propose any measures to mitigate the fire risks of using flammable foam boards. There is no evidence that Will Power critically reviewed this proposal, beyond what was discussed on 17 June 2024.1060

As Mr Kong Cheung Fat said, this was an abrupt and complete reversal of position within a few weeks.1061 No apparent or rational reason for the reversal of Will Power’s position on foam boards has been identified.

The works then proceeded. As detailed in Chapter 4, foam boards were ordered in late August. At least a portion of them were not fire-retardant. The foam boards began to be placed on residents’ windows under Phase I, i.e. Wang Cheong, Wang Shing and Wang Chi House (Blocks F, G and H), in mid-September 2024.

Meanwhile, concerns regarding flammability of the foam boards continued to resound amongst residents, with some complaints being raised and discussed at a meeting held on 12 September 2024. At the meeting:

1059 [M1/240]

1060 [H1-3/6131] 1061 [T15/22:30-32]

323

1. The Management Committee informed PC&E that they received videos from residents of burning foam boards, and inquired as to the flammability of the material.1062

2. In response, PC&E explained that the foam boards would not catch fire if they came in contact with cigarette flames, but the situation would be different if continuous naked flames were present (宏業

解釋現時選用的封窗物料是不會因煙頭接觸而燃燒起來，但

如用明火持續燃燒則另作別論).1063

This is not a satisfactory explanation. Even assuming that the foam boards would not catch fire from one single lit cigarette end, that was not the only possible cause of a fire. In any event, a single lit cigarette end could ignite the combustible debris and building materials (including cardboard boxes and backing paper for the mosaic tiles) that accumulated in and around the scaffolding, and cause a larger fire which could ignite the foam boards.

In view of the residents’ persistent concerns, the IO pressed for the use of replacement materials with better fire-retardancy qualities. However, Mr Gordon Ho explained on 13 September 2024 in the WhatsApp group “宏

福苑大維修 group”, which involved the Management Committee, PC&E,

Will Power and ISS, replacement materials such as corrugated plastic boards can only be used in Phase II of the works, as the existing materials have arrived at the site and have been installed (如要更換物料, 要待第 2

期才可用, 因第 1 期保護工程已進行中及物料已到地盤).1064

This, again, is problematic on numerous levels.

1. First, it records PC&E’s acknowledgment that window covering materials with better fire-retardancy qualities were commercially

1062 [H1-3/6019] 1063 [H1-3/6019] 1064 [F4/1035]

324

available. No satisfactory reason was provided as to why those more fire-retardant materials were not used when the foam boards for Phase I were placed.

2. Second, the justification given by Mr Gordon Ho for not switching to a different window protection material was, effectively, to save costs. Where a contractor acquired building materials that were not fit for purpose and potentially illegal, it was incumbent on the contractor to rectify the situation at its own cost. Profit was again preferred at the expense of the safety and lives of residents.

3. Third, Will Power knew (and advised at the outset1065) that foam boards were flammable – but did not intervene. Worse, Will Power proceeded to support PC&E’s use of flammable foam boards.

4. On 13 September 2024 at 10:31 pm, Mr Wong Hap Yin Jason circulated Will Power’s written opinion on the matter. 1066 He asserted that no law required protective materials used during external wall renovation works (other than scaffolding nets) to be fire-retardant; that external repair works on existing buildings would not ordinarily pose a serious fire risk; and that foam boards were less likely than scaffolding nets to spread fire.1067

5. This was a non sequitur. The legal position, as the Committee will note, was incorrectly stated and does not reflect the position of the BD. But even if there were doubts about the legality of the use of foam boards, the dangers of using flammable cladding on the façade of buildings were well known after the Grenfell Tower. Will Power must have known that the use of flammable material such as polystyrene foam boards to cover windows gives rise to

1065 [H1-3/6131]

1066 [O2/1154]; note that the same message does not appear in the copy of the WhatsApp group messages supplied by Mr Tsui Moon Come Tony [F4/1039]; written opinion [O2/1403]. 1067 [O2/1403]

325

unacceptable fire risks, irrespective of whether specific regulations exist to address this particular type of material.

According to Mr Kong Cheung Fat, a further reason given by PC&E for use of the foam boards was that the batch of foam boards had already been approved by the previous IO.1068 However, Mr Kong was not able to say whether such approval was indeed made by the old IO, because he did not personally participate in that decision during his tenure.1069 On the other hand, Mr Tsui Moon Come Tony was under the impression that he was provided a copy of the approval and had submitted the same to the Committee.1070 Mr Tsui has not since identified the document he was referring to.

The notion that the old IO had approved the foam boards finds some support in the WhatsApp records. Will Power, in preparing for briefing sessions with the residents (解說會) in late September 2024 explained that

the old IO had already confirmed the order of foam boards, and that if alternative materials were to be used, this would require extra costs (早前

經上屆管委會確認收宏業已訂料，現時轉換可能涉及額外費用，需

由宏業提供其他物料選擇，如需要額外費用，可能需要業戶投

票).1071

There was no basis for PC&E to charge the owners for replacement costs, when the need for replacement arose because of its failure to provide appropriate materials for the window coverings, in breach of the Works Contract,1072 in the first place. Moreover, Will Power had the power to direct PC&E to remove the sub-standard materials and replace the same (工程顧問可發出指示，將任何不符合規格之材料及已做工程拆卸重

1068 [T15/22:25-29] 1069 [T15/23:19] 1070 [T14/36:16-19] 1071 [F4/1072]

1072 [F1/57]

326

做 ). 1073 Instead of invoking that contractual provision, Will Power

supported PC&E’s indefensible position and sought to dissuade residents from pursuing their demands for replacement materials.

The next material event is the private WhatsApp conversations between Mr Gordon Ho and Mr Tsui Moon Come Tony in early October 2024.1074

1. The record shows that on 2 October 2024, at 12:30 pm, Mr Ho asked Mr Tsui that, in light of the significant concerns by residents regarding foam boards, whether corrugated plastic boards should be used for Phases II and III instead of foam boards. Mr Tsui replied, at 12:31 pm, asking whether it was possible to continue using foam boards albeit less flammable ones.

2. Mr Tsui explained that the switch to corrugated plastic boards had already been rejected by PC&E in September 2024 because they were more rigid and it was difficult to cut them at the scene.1075 However, Mr Tsui accepted that PC&E’s explanation was hardly convincing, as PC&E could cut the boards as per the standard dimensions of the windows at Wang Fuk Court beforehand. In any event, in his WhatsApp message, Mr Ho was himself suggesting the switch to corrugated plastic boards, which indicated that he considered that the practical difficulties he mentioned about the rigidity of the material could be resolved.1076

3. In fairness to Mr Tsui, he had actively searched for fire-retardant window covers, and was proposing to use foam boards that had fire-retardant qualities. The messages show that he sent Mr Ho a link to a supplier’s video to demonstrate that foam boards with fire-retardant properties were commercially available. Mr Tsui

1073 [F1/34]

1074 [A2/119]

1075 [T14/37:12-14] 1076 [T14/31:22-28]

327

then asked Mr Ho to check whether foam boards with better fireretardant qualities could be used. Mr Ho replied that he would ask his supplier, although he could not guarantee. Mr Tsui then asked Mr Ho to take a video of a fire-retardancy test on the new foam boards, and so long as the flame self-extinguishes that would suffice without the need for a fire-retardancy certificate.1077 Mr Tsui also asked that the video of the fire-retardancy test should not be as unconvincing (唔好咁流) as the video from the supplier that

he showed Mr Ho.

4. Mr Ho replied that he would proceed as suggested, and that if he managed to order such foam boards with greater fire-retardancy, he would use them in Phases II and III, but would not replace the old foam boards under Phase I. Mr Tsui appeared to accept this.

Mr Tsui was a layman. He was entitled to rely on the professional expertise of Will Power and PC&E. When the responses from both indicated they had no concern for fire safety, he researched (as far as he could as a layman) into alternative materials that were more fire-retardant. The end result was, he requested PC&E to acquire fire-retardant foam boards.

The evidence suggests that PC&E did proceed to acquire foam boards with some fire-retardant qualities, but did not follow Mr Tsui’s instructions fully:

1. As Dr Lee Wing Man observed, there were two types of foam boards retrieved from the scene, one with a rhombus pattern and another with a square within a square pattern, the latter (which was more extensively used) being more flammable and would combust

1077 Mr Tsui testified that, at the time, PC&E and Will Power had already repeatedly stressed that since there was no regulation specifically requiring foam boards to be fire-retardant, it was difficult to source foam boards accompanied by fire-retardant certificates, and that if the new IO insisted on only purchasing foam boards accompanied by such certificates, the works could not proceed forward [T14/37:15-26].

328

after about 15 seconds of contact with a flame whereas the former did not catch fire once the source of flame was removed.1078

2. The evidence suggests that the foam boards with the rhombus pattern are the relevantly fire-retardant foam boards ordered for the purpose of Phases II and III after the exchange between Mr Ho and Mr Tsui in early October 2024.

3. However, Dr Lee’s observation that the foam boards with the square-within-a-square pattern were far more extensively found suggests that PC&E had used the first batch of non-fire-retardant foam boards even for Phases II and III. If Phases II and III used fire-retardant foam boards comprehensively, one would have expected a majority of foam boards found on the scene to have a rhombus pattern.

4. Indeed, the evidence suggests that the sub-contractors did not pay particular attention to which batch of foam boards collected at the site were used for installation at which blocks.1079

5. It is to be inferred that PC&E failed to keep its promise to Mr Tsui to use the new material for the entirety of Phases II and III. The reason is obvious: the new orders for fire-retardant foam boards were priced at more than double the unit price of non-fire-retardant foam boards ordered from Hubei Yubo for Phase I: see Section D5 of Chapter 2.

It is appreciated that Mr Tsui could have done more to explain his decision to residents, and present alternative proposals for the owners to decide in an EGM (as was done in relation to other aspects of the works). Yet, the only alternative window cover material contemplated at the time was a type of corrugated plastic board. It is not apparent that corrugated plastic boards

1078 [T25/51:22-35] 1079 [T13/34:29-31]

329

are more fire-retardant than foam boards. According to Dr Lee Wing Man’s laboratory tests, she observed sustained burning on all tests of corrugated plastic boards found on site, with the 2mm and 5mm corrugated boards further generating flaming droplets with no signs of self-extinguishing, whereas the 9mm corrugated boards were less susceptible to ignition.1080

There is another aspect relevant to the polystyrene foam boards, which is the extent and duration of use. What made the use of foam boards particularly dangerous was the extensive use of foam boards to cover all windows for an extended period of time:

1. According to the evidence of workers engaged in external wall repairs, the hacking off of external wall tiles was conducted zoneby-zone within a building.1081 However, when hacking off was still being conducted in one zone, the windows of other zones would already begin to be covered by foam boards.1082 Moreover, after hacking off in one zone is completed, workers were instructed not to remove the foam boards installed in the windows of that zone.1083

2. There can be no dispute, therefore, that foam boards were used to cover windows both during and after the hacking-off works for the unit had completed.

3. Concerns were raised by residents regarding the extensive use of foam boards for an extended period of time.1084 According to Mr Tsui, he raised this concern with PC&E, who informed him that it was necessary for foam board coverings to remain on floors that

1080 [ER4/2481]; [ER2-1/470-471] 1081 [T13/29:14-30]

1082 [T13/29:31-32]

1083 [T13/36:23-37:3]

1084 [F4/1028]

330

had no hacking-off works to avoid debris from works done on other floors breaking the windows.1085

4. When it was put to him, Mr Tsui accepted that a potential solution would have been to conduct works in stages, where works would complete on one side (e.g. north, south, west and east) before proceeding to the next. Nevertheless, PC&E never proposed this to the Management Committee as an option.1086

PC&E and Will Power were aware of the fire risks attendant on the simultaneous enclosure of all eight blocks with foam boards. They should have properly advised the IO and devised a safe working methodology. They failed to do so.

Their knowledge of the risks of the extensive and prolonged use of foam boards is further demonstrated by the ICU’s evidence.

1. Mr Andy Ku’s evidence was that, at the ICU’s inspection on 28 October 2024, he told PC&E of his concern that foam boards “could pose a fire hazard to residents”.1087 He also expressed concern that the foam boards would affect natural lighting and ventilation. PC&E responded that foam boards were only used temporarily during hacking works (three floors at a time) and would be removed immediately after hacking was completed.1088

2. This assurance was demonstrably false: the foam boards were installed across entire blocks and remained affixed for over a year, up to the day of the fire. But the assurance also illustrates PC&E’s awareness of the risks of extensive and prolonged use of foam boards to cover windows. A contractor with nothing to hide does

1085 [T14/29:14-28]

1086 [T14/29:29-35]

1087 Ku Siu Ping 3rd WS §63 [WS14/2151]

1088 Ku Siu Ping 3rd WS §§61-63 [WS14/2150-2151]

331

not reassure a regulator by misdescribing its own works. PC&E told the ICU precisely what it considered to be a safe methodology – localised covering, promptly removed. Yet, it knew full well that what it was actually doing was neither.

For the foregoing reasons, the Committee is invited to find that PC&E and Will Power are primarily responsible for the improper use of foam boards.

D. Staircase Access Openings (生口)

The creation of illegal access openings in the staircases is also a significant issue. By the time of the fire, all staircase windows except the access openings were converted into fire-rated windows. Had the staircases been protected from the façade fire with these fire-rated windows, the staircases could have been viable means of escape for a longer period. Many lives might have been saved. Accordingly, the creation of access openings is a major cause of the heavy casualties on the day of the fire: see Chapter 4.

The evidence reveals that the first access openings were created on the fifteenth floor of each block. The sub-contractors were then instructed by PC&E to make access openings on every five floors in the staircases. For example:

1. Mr Ng Pui Kwan (sub-subcontractor for Blocks D, E and F) said PC&E had told him to open a worker access opening in the rear staircase every five floors (叫我每隔五層樓就喺後樓梯開一個

生口位), and that when he asked whether this was permissible he

was “told to do it” (我有問過佢，佢嗌我做).1089

2. Mr Ng Pui Kwan accepted that the access opening was a measure for the convenience of workers and, whilst it was common practice, it was not technically necessary. He did not consider the effect on

1089 [T13/31:16-19, 32:3]

332

the means of escape of breaching the rear staircase — he said that “these things I don’t understand” (呢啲我唔識).1090

Will Power knew about and approved PC&E’s proposals to create the access openings.

1. The first proposal was dated 1 August 2024. PC&E proposed to create a staircase opening on 15/F of each block. Will Power marked its approval of the submission on the same day.1091 There is no evidence that Will Power gave a moment’s thought to the obvious risks involved, or indeed to the necessity of the access openings at all. As mentioned above, the sub-contractors responsible for the hacking-off works accepted that they did not require the access openings to carry out their work.1092

2. On 22 August 2024, PC&E wrote to Will Power seeking its approval to create further worker access openings on the fifth, tenth, twentieth and twenty-fifth floors of each block. Again, Will Power marked its approval on the same day.1093 The speed with which Will Power gave its approval is an indicator of the lack of critical review.

The fire risk of the access openings was drawn to the attention of PC&E and Will Power at an early stage. Records of WhatsApp group messages between PC&E and the former Management Committee, show that, on 7 August 2024, Mr Tang Kwok Kuen enquired whether the window position should use fire-retardant or fire-resistant material (該窗位應否選用防火

或耐火物料).1094 There is no record of any further discussion of the fire

1090 [T13/31:26-32:25] 1091 [O2/944]

1092 [T13/33:1-9, 41:19-27] 1093 [O2/1081]

1094 [O2/840]

333

risks of worker access openings. 1095 A risk which occurred to a selfdescribed layman (外行人) was not addressed by the professionals.

According to Mr Tsui, the new Management Committee relied on the expertise and advice of PC&E and Will Power, and did not think there would be serious fire risks arising as a result.1096

The creation of access openings was dangerous and unlawful. No justification for them has been offered. Mr Hau Wa Kin and Mr Gordon Ho did not attempt to justify them in their witness statements. The Committee is invited to find that PC&E, which created and directed the creation of the openings, and Will Power, which did nothing to intervene, bear the primary responsibility for the access openings.

There were other contractors and building professionals who noticed these access openings. The sub-contractors engaged for the works to replace the staircase windows were addressed in Chapter 2. These works were subcontracted to Wealth Pinnacle. According to Chi Fu Construction, it was then engaged by Wealth Pinnacle to submit MW submissions for Wang Sun to Wang Chi House (Blocks C to H), while Motive Design was engaged by Mr Lai Ka Wing for the remaining blocks (Blocks A and B).

As these window replacement works were classified as Class I MW works, Chi Fu Construction and Motive Design had to submit Forms MW01 to the ICU. These submissions included Supervision Plans (監工計畫書),

which specified that site inspections would be conducted by: (i) Mr Lai Ka Wing (as Authorised Person); (ii) Mr Joseph Chi (as Registered Structural Engineer); and (iii) Mr Mown Koon Ho (as Authorised Signatory and Representative of Motive Design), Mr Kwong Kwok Siu (as Authorised Signatory and Representative of Chi Fu Construction), Mr Tsang Kai

1095 [T15/36:8-24] 1096 [T14/48:2-7]

334

Kwong and Mr Chong Po Chung (as Technically Competent Persons for both Chi Fu Construction and Motive Design).1097

However, in their letters to the Committee, Chi Fu Construction and Motive Design stated that they were hired only to submit the MW01 forms and Supervision Plans, and had no involvement in carrying out the works.1098 As submitted above, that is highly unsatisfactory. Relevantly, Motive Design1099 and Chi Fu Construction both confirmed that they were aware that access openings were created in the staircases.1100

The Supervision Plans also stated that site inspections would be carried out by Mr Tsang Kai Kwong and Mr Chong Po Chung as Technically Competent Persons “under the RC’s stream” (隸屬於註冊承建商工作班

子之下的地盤監督適任技術人員), i.e. under Chi Fu Construction and

Motive Design.1101 That was materially misleading, as Mr Tsang and Mr Chong were in fact foremen employed by PC&E.1102

As to Mr Lai Ka Wing and Mr Joseph Chi, they claimed to have conducted regular inspections. It is unnecessary for the Committee to determine whether they had in fact done so, because both of them admitted that they noticed the access openings, but neither considered them to be problematic. They explained that the original windows were not fire-rated and were openable windows, and would have allowed fire and smoke to enter the staircases even without the access openings. They therefore considered that

1097 See, for example, [I1-2/2484, 2486, 2490, 3902, 3904, 2908]

1098 Letter from Chi Fu Construction to the Committee §§1, 2, 8(b) [WS21/2367]; letter from Motive Design to the Committee §§2(d), 2(e), 7, 8(c), 8(d), 8(e) [WS21/2375-2378]

1099 [WS21/2378]

1100 [WS21/2367]

1101 [I1-2/2490, 3177, 3908, 4668]; [I1-3/5480, 6268, 7207, 8008]

1102 [I1-2/4678, 4682]

335

the replacement of the original windows with temporary access openings did not exacerbate the situation.1103

This response is also unsatisfactory. The purpose of replacing the original wired windows with fire-rated ones was to prevent fire and smoke from entering the protected staircase. As stated in Chapter 2, on the day of the fire, all the staircase windows had been replaced save for the access openings. This was confirmed by the FSD’s witness, Mr Lam Kin Kwan (Deputy Chief Fire Officer, New Territories South).1104

For the above reasons, the Committee is invited to find that:

1. The primary responsibility for creating the access openings rests on PC&E. PC&E created and directed the creation of the openings. Will Power also bears primary responsibility, having failed to critically assess the risks of the access openings and to intervene.

2. Chi Fu Construction, Motive Design, Mr Lai Ka Wing and Mr Joseph Chi bear responsibility for their silence. They were not bystanders. They were respectively the registered minor works contractors and registered building professionals who signed the submissions to the ICU in respect of the staircase works. Fully aware of the access openings, they failed to report them to the ICU. Instead, they continued to lend their names and registered status to the submissions, representing to the ICU that the staircase works were being conducted safely and in compliance with the relevant laws and regulations when they were not.

1103 Email from Lai Ka Wing §8 [WS21/2387]; Response to Request for Information from Mr Chi Wuh Jian Joseph Duncan §9(c) [WS21/2407]

1104 [T25/23:20-34]

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E. Shutdown of FAS and FH/HR Systems

This Section will now turn to the responsibilities of those involved in the shutting down of the FAS and FH/HR systems in Wang Fuk Court. As explained in Chapter 2, both systems were controlled by the same master power switch in each block, and the master power switches of all eight blocks had been turned off by mistake by an ISS employee to assist PC&E’s repairs to the FS Tank. That unfortunate state of affairs was maintained until the day of the fire.

The evidence from the IFITF is that the shutting down of the FH/HR system did not have a significant influence on the outcome of firefighting efforts by the FSD in the unprecedented circumstances of the fire.1105

Therefore, the more serious consequence of the turning off of the master power switch was that the fire alarms did not sound on the day of the fire. This contributed to the heavy fatalities and casualties because residents did not receive timely warnings, leading to delayed evacuation.1106

The FAS and FH/HR Systems were shut down in order to carry out repair works to the FS Tank. A number of issues arise in this regard:

1. Was it in fact necessary to carry out works to the FS Tank?

2. Was it necessary to shut down the FAS system?

3. Why was the mistake not rectified before the day of the fire?

China Status was the RFSIC who submitted Shutdown Notices (“SDNs”) to the FSD, notifying the FSD of the shutdown of FSIs in Wang Fuk Court for the purpose of repair works to the FS Tank. The FSD relied on China Status for accurate reporting and supervision of the shutdown. However,

1105 IFITF Final Report §5.4.7 [ER1/71-72] 1106 IFITF Final Report §10.4 [ER1/215]

337

China Status was a “dummy” RFSIC. It simply acted as a rubber stamp and submitted SDNs to the FSD at PC&E’s behest without doing any work.

On the admission of Mr Leung Ping Kay Ivan, representative of China Status, he understood it was a legal requirement that the FSIs had to be shut down personally by a RFSIC or under the supervision of a registered FSI contractor,1107 but:

1. “Prior to submitting [the SDNs], no representative of China Status attended Wang Fuk Court for the purposes of understanding firsthand the FH / HR System in place, the relevant renovation works proposed to be conducted there, the necessity of shutting down the FH / HR System for such renovation works…”;1108

2. “[Mr Leung Ping Kay Ivan] did not attend Wang Fuk Court to personally shut down the FH / HR Systems, and [he understood] that no personnel of China Status did”;1109 and

3. “[Mr Leung Ping Kay Ivan] did not carry out any inspection at Wang Fuk Court during the period the FH / HR System was shut down. It [was his] understanding that no personnel of China Status did so during this period”.1110

The representative of China Status, Mr Leung Ping Kay Ivan, gave evidence to the Committee and sought to justify the conduct of China Status. His evidence is unsatisfactory.

First, his evidence changed fundamentally between his two witness statements, which damages his credibility. Initially, in his first witness statement, he stated that he did not personally attend the site to shut down

1107 Leung Ping Kay WS §36 [WS2/1515] 1108 Leung Ping Kay WS §30 [WS2/1514] 1109 Leung Ping Kay WS §35 [WS2/1515] 1110 Leung Ping Kay WS §48 [WS2/1517]

338

the FSIs because he was informed that the estate’s building management would handle the matter and in any event would not allow China Status inside their premises.1111 However, in his second witness statement, he said that he thought PC&E was an RFSIC and considered it acceptable to the FSD for China Status to submit SDNs without actually supervising the shut down, so long as another RFSIC (i.e. PC&E) conducted the supervision.1112 That was a completely different explanation which was absent from his first response, indicating that it was a recent fabrication.

Second, his explanations are incredible.

1. As to the first explanation, given its duties as RFSIC to properly supervise and handle the shutdown of FSIs, the obvious response (if China Status was told that it could not enter Wang Fuk Court) would be to refuse to submit the SDNs.

2. As to the second explanation, not only is PC&E in fact not an RFSIC, the alleged practice would in any event not be acceptable to the FSD. According to the FSD Circular Letter No. 1/2021,1113 as RFSICs will be engaged by the FSI owners to inspect FSIs to see whether they have to be shut down for maintenance, modification or repair, “the RFSIC is therefore the most appropriate person to notify the FSD accordingly”.

3. At paragraph (A), the Circular Letter further provides: “when an RFSIC is employed to maintain / inspect / modify / repair the following FSI(s) of which work(s) is / are expected to be carried out overnight or for more than 24 hours continuously, the RFSIC should notify the FSD the defect(s) as soon as possible within 24

1111 Leung Ping Kay WS §37(i) [WS2/1515] 1112 Leung Ping Kay 2nd WS §44 [WS7/1883] 1113 [B2/1302]

339

hours after the defect(s) is / are identified literally” (emphasis added).

4. Further, at paragraph (G), the Circular Letter provides: “on the other hand, if the RFSIC is no longer employed for the work(s), a written notification to the FSD should be submitted before the previously scheduled date of completion, and the owner(s) of FSI should be informed of the details of the FSI shutdown without delay”.

5. Lastly, at paragraph (I), the Circular Letter provides: “[Qualified Person] / [Authorized Signatory] of RFSIC should critically review the need for extension of FSI shutdown and personally confirm such need / resumption of FSI vide the written notification”.

6. The aforesaid passages from Circular Letter No. 1/2021 make clear that the RFSIC who submits the SDNs must be the same RFSIC who personally conducts the shutdown of relevant FSIs and critically reviews the necessity of the shutdown.

7. No credible explanation has been offered as to why an RFSIC which carried out works on the FSIs (on Mr Leung’s account, PC&E) could not submit the SDN itself but needed to rely on another RFSIC to submit it on its behalf.

Given China Status’s role as the RFSIC who submitted the SDN, it bears significant responsibility in relation to the functioning of the fire alarm and FH/HR systems. However, it is not the only party responsible. The following sections will further consider the responsibilities of other parties.

E1. Necessity of the works to the FS Tanks

The necessity of the works to the FS Tanks is logically the first issue to be considered.

340

A key issue that emerged is whether the FS Tanks were leaking, thus requiring FS Tank works. The evidence in this regard is as follows.

First, according to the Inspection Reports by Will Power, their conclusions on the FS Tanks of the various Blocks are as follows:

1. Block A (report dated 3 April 2019): It was observed that various covers of the water tanks on the rooftop were not compliant with relevant laws and regulations (天台各水缸蓋不合規格), and the

FS Tank was filthy (污垢嚴重).1114 It was recommended that

works generally be done to matters related to FSIs (including the Upfeed Pump, the FH/HR system and the control panel) as part of the “non-core” items (非主要項目).1115

2. Block B (report dated 3 April 2019): It was observed that various covers of the water tanks on the rooftop were not compliant with relevant laws and regulations (天台各水缸蓋不合規格 ).

Specifically, with respect to the FS Tank, there was concrete falling off at the entrance, rust stains in the inner walls, and the metal box for the signal wiring was rotten and mouldy (消防缸缸

口石矢剝落，內牆有銹漬，缸面訊號線鐵箱霉爛).1116 It was

recommended that works generally be done to matters related to FSIs (including the Upfeed Pump, the FH/HR system and the control panel) as part of the “non-core” items (非主要項目).1117

3. Block C (report dated 3 April 2019): It was observed that various covers of the water tanks on the rooftop were not compliant with relevant laws and regulations (天台各水缸蓋不合規格). There

1114 [E1-2/1579] 1115 [E1-2/1581] 1116 [E1-2/2038] 1117 [E1-2/2040]

341

was no specific observation with respect to the FS Tank.1118 There was neither a general recommendation for works to be done to matters related to FSIs (in contrast to the Inspection Reports for Blocks A and B), nor a recommendation for works to be done to the FS Tanks specifically.1119

4. Block D (report dated 30 July 2019): It was observed that various covers of the water tanks on the rooftop were not compliant with relevant laws and regulations (天台各水缸蓋不合規格 ).

Specifically, with respect to the FS Tank, there was serious rusting of the mercury container.1120 In the recommendation, there was neither a general recommendation for works to be done to matters related to FSIs, nor a recommendation for works to be done to the FS Tanks specifically.1121

5. Block E (report dated 30 July 2019): the observations and the recommendation were in materially identical terms to those for Block D.11221123

6. Block F (report dated 30 July 2019): the observations and the recommendation were materially identical to those for Block D.11241125

1118 [E1-2/2512] 1119 [E1-2/2514] 1120 [E1-2/2984] 1121 [E1-2/2987] 1122 [E1-2/3485] 1123 [E1-2/3487] 1124 [E1-3/4002] 1125 [E1-3/4004]

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7. Block G (report dated 30 July 2019): the observations and the recommendation were materially identical to those for Block D.11261127

8. Block H (report dated 30 July 2019): the observations and the recommendation were materially identical to those for Block D.11281129

Second, Victory Fire (the RFSIC engaged by ISS to perform annual inspection of the FSIs of all eight blocks of Wang Fuk Court) found no structural defects or leakage in the FS Tanks.

1. In accordance with its Fire Services System Maintenance Agreement entered with ISS,1130 Victory Fire conducted annual inspection of the FSIs in all eight blocks of Wang Fuk Court in early 2025. Actual inspection was conducted between 24 to 26 March 2025.1131

2. Following annual inspection, Victory Fire submitted FS251 certificates for all eight blocks of Wang Fuk Court,1132 in which various defects were noted in relation to the plumbing of the FH/HR System (e.g. “HR Gate valve x1 no. defective” was noted for Block A).1133 However, no defect in the FS Tanks (and in particular, no defect requiring retiling/water-proofing works) was noted in any of the FS251 certificates.

1126 [E1-3/4504]

1127 [E1-3/4508] 1128 [E1-3/5061]

1129 [E1-3/5063] 1130 [H1-1/31-34] 1131 [C1-2/1149] 1132 [H1-3/6693-6710] 1133 [H1-3/6702]

343

3. The evidence of all Victory Fire representatives attendant at the annual inspection corroborated the FS251 certificates: no FS Tank leakage or structural issues were present. When inspecting the interior of the FS Tanks, Mr Wong Kin Wa (a Victory Fire electrician) stated that he did not notice any structural defects in the FS Tanks. 1134 Mr Li Chun Yin (electrician of Victory Fire) agreed. 1135 Dr Chung Kit Man (Director of Victory Fire) also agreed that there was no leakage, adding that any leakage would have been obvious upon inspection.1136

Third, there is contradictory evidence suggesting that the FS Tanks may have been leaking, but that evidence does not appear to be reliable.

1. Mr Wu Rizhao, a cement worker of Red Sun, one of PC&E’s subcontractors responsible for the FS Tank works, noted that the conditions of the FS Tanks were very poor, with leakage and structural issues and significant sediment collected in the tanks (我

亦見到水缸的狀態非常差，都有滲水，漏水的結構上問題，

亦有好多沉積物).1137

2. However, Mr Wu’s observations were made in about mid-2025, when the renovation works had been well under way. When he observed leakage of the FS Tank, water was being released to facilitate works – in those circumstances, it would be difficult to differentiate whether water was being released as part of that process or whether there was structural water leakage.

3. According to the FS251 certificates issued by China Status for all eight blocks, it was recorded that the FS Tanks had “Water

1134 [T5/59:18-20]

1135 [T6/64:25-28]

1136 [T6/10:30-36; 11:1-4] 1137 [C1-2/1191]

344

Leakage” that “Need To Repair”.1138 However Mr Leung Ping Kay Ivan admitted that no one from China Status ever visited Wang Fuk Court to inspect the FSIs. Mr Leung admitted that China Status could not possibly have known whether there was leakage, and that he only assumed that there was leakage because that was the usual reason for water-proofing works to be carried out.1139

4. For completeness, Madam Cheng Tsz Ying of ISS was not sure about whether the FS Tanks had water leakage issues. She only received complaints from residents at 31/F about water leakage from rooftop to the 31/F residents but she could not confirm the source of such leakage.1140

On balance, the evidence suggests that there were no significant structural defects in the FS Tanks. At most, the FS Tank in Wang Yan House (Block A) was described as “filthy”. The state of the FS Tank in Wang Tao House (Block B) was comparatively worse than the other blocks, but even then it is not clear from Will Power’s Inspection Reports whether repairs to the Block B FS Tank (described as a “non-core” item) were truly necessary. For the FS Tanks in the remaining blocks, the evidence is clearer: there were no obvious structural defects with those tanks.

Even if there were structural defects of the FS Tanks, the question arises as to exactly what kinds of repairs were required.

1. Under the Works Contract, all water tanks at the rooftop of the eight blocks (i.e. including the FS Tanks) were to undergo repairs in the following sequence: (i) hacking-off of the internal walls; (ii) repair of the underlying cement structure and waterproof layering;

1138 [C1-2/1418-1425]

1139 [T9/69:34-36; 70:1-23]

1140 [T8/66:13-20, 23-24; 68:31-33]

345

(iii) testing of new waterproof layering; and (iv) tiling of the new internal wall with white tiles.1141

2. According to Dr Chung Kit Man of Victory Fire, FS Tanks do not generally need to be tiled. The water stored in FS Tanks is for firefighting. The FS Tanks do not need to be tiled for cleanliness nor does it need to reach a potable standard. Dr Chung did not know why tiling of the FS Tanks was arranged.1142 However, he qualified his evidence by stating that his firm does not carry out FS Tank repairs.1143

3. In light of Dr Chung’s evidence, it is doubtful whether any of the repairs to the internal walls and waterproof layering in the FS Tanks as stipulated in the Works Contract were in fact necessary (save, perhaps, for Wang Tao House (Block B)).

4. Further, as explained in Chapter 2, PC&E did not provide any temporary water tank, but chose to use the renovated FS Tanks as temporary fresh water tanks whilst they underwent renovation. This was in violation of fire safety regulations as it entailed the prolonged and unacceptable shutdown of the FH/HR.1144 But for the plan to convert the FS Tanks into fresh water tanks, the FS Tanks of at least those Blocks would likely have resumed operations on the day of the fire.

5. PC&E’s decision to repurpose the renovated FS Tanks as fresh water tanks was also contrary to the Works Contract, which provided that, if necessary, PC&E was to provide a temporary tank for use during the renovation of the relevant water tank(s).1145 If

1141 [F1/101]

1142 Chung Kit Man WS §19 [WS2/1535]; [T6/13:36; 14:1-4; 15:11-15] 1143 [T6/15:6-9]

1144 [T10/76:1-14]

1145 [F1/79]

346

the alternative to a temporary water tank was to repurpose the FS Tank in breach of the law, a temporary water tank was obviously necessary.

Although the plan to repurpose the renovated FS Tanks as temporary fresh water tanks was disclosed to and known by inter alia the new IO and ISS,1146 neither party should be responsible for this aspect of the works.

1. Insofar as the new IO is concerned, Mr Tsui explained that the new IO did not consider the provision of a temporary tank as required in the Works Contract.1147 This is understandable as the new IO must rely on the professional judgment of PC&E and Will Power on how best to carry out the works.

2. As to ISS, Madam Lok Sin Ying recalled that there were discussions in various work progress meetings (attended at least by residents and PC&E) on the arrangement for temporary water tank, though she could not recall the details of the discussions.1148

E2. Shutdown of FAS system was wholly unnecessary

As explained in Chapter 2, the evidence on how the master power switches came to be turned off in the FS pump rooms is clear. In summary:

1. PC&E requested assistance from ISS for the drainage of the FS Tank. In turn, various job orders were issued by ISS instructing Mr Law Kwok Shui (ISS’s electrician) and Mr Lee Shing Foo (ISS’s carpenter) to assist PC&E. In complying with the job order and assisting PC&E, Mr Law switched off the master power switches

1146 [H1-3/6034, 6077, 6113] 1147 [T14/45:9-14]

1148 [T7/4:3-5]

347

of all eight blocks thus resulting in the turning off of the FH/HR and the FAS systems.

2. The shutting down of both the FH/HR and the FAS systems by way of turning off the master power switches was unnecessary. For the purpose of draining the FS Tanks, the FAS system did not need to be turned off. Although the FS booster pumps had to be turned off in the process of draining the FS Tanks, this only required switching off the pump isolator switches in the main panel within the FS pump room.

Given that Mr Law Kwok Shui (an employee of ISS) admitted to switching off the master power switches, ISS bears significant responsibility in relation to the inoperative fire alarms. In particular:

1. According to Mr Law Kwok Shui, when he received the various job orders, he noticed that they included works related to the FS Tanks, which were FSIs. As he was aware that only a licensed person could operate FSIs, he enquired of Madam Lok Sin Ying (ISS Office Clerk) whether he could still carry out the work order. According to him, Madam Lok’s response was that since he was an electrician and it was PC&E’s request, he should accompany PC&E’s staff and assist.1149 Mr Law thus obeyed the work order and proceeded to assist in drainage of the FS Tanks, despite the fact that he did not have the requisite licence.

2. Madam Lok denied Mr Law’s account.1150 According to her, she was asked by PC&E whether ISS’s staff could assist with the drainage of the FS Tanks. She did not know exactly what steps or what kind of assistance ISS’s staff was asked to provide – and so

1149 Law Kwok Shui WS §19 [WS2/1233]; [T7/47:25-26; 48:1-8] 1150 [T6/82:29-34]

348

she asked Mr Law and Mr Lee if they were happy to assist, and they were happy to do so.1151

3. It is for the Committee to decide, having heard the evidence of Mr Law and Madam Lok, who is to be believed.

4. However, whichever version of events is accepted, it is plain that ISS cannot escape responsibility. Both Mr Law and Madam Lok were employed by ISS, which is vicariously liable for their acts and omissions. ISS also has primary responsibility for training and instructing its staff not to operate or deal with any FSIs.

PC&E, Will Power and China Status should also bear responsibility.

They (or one or more of them) were responsible for the arrangement of China Status as a “nominal” RFSIC, and for instructing China Status to simply file FS251 certificates and SDNs without actually doing any work.

1. According to the quotation provided by China Status to PC&E, it was responsible for three items of work, namely (i) provision of 9L fire extinguishers for all eight blocks (16 extinguishers for each Block to be placed on alternate floors, i.e. 128 extinguishers in total); (ii) submissions of SDNs to the FSD (with an estimated shutdown of one year); (iii) submission of FS251 certificates upon completion of works.1152

2. Item (b) of the quotation is a record of the parties’ expectation that China Status would be submitting SDNs repeatedly for a year.1153 Whatever Mr Leung’s understanding of the reference to “one year”

1151 [T6/81:3-19]

1152 [R1/1]

1153 Mr Leung suggested that the wording in item (b) of the quotation was merely a general reference to avoid unnecessary complication, for his own record and general understanding, but did not denote or imply that China Status would robotically submit SDNs for one year: Leung Ping Kay 2nd WS §§48-52 [WS7/1884].

349

in the quotation might have been, the fact that the parties predetermined that a lengthy period of shutdown was needed is also borne out by the WhatsApp communications between PC&E and China Status. In their messages, China Status automatically sent SDNs upon the imminent expiry of the 14-day deadline, without questioning the necessity of the extension. 1154 In some cases, China Status sent multiple documents required for a three-month period of shutdown in one go.1155 PC&E must have known that China Status was only a rubber-stamp which would not critically evaluate the necessity of the continued shutdown.

3. Mr Leung Ping Kay explained that he spoke with “Mr Cheung” (i.e. Mr Chong Po Chung) of PC&E prior to submitting SDNs.1156 However, he subsequently admitted that he only contacted “Mr Cheung” occasionally (i.e. not in respect of each SDN). In any event, a telephone enquiry with the main contractor cannot possibly discharge the obligation of an RFSIC to carry out inspections.

As to Will Power, as the entity in charge of supervising PC&E, it failed to prevent the plainly irresponsible arrangement with China Status from taking place. Once again, Will Power did nothing to supervise PC&E.

In the end, a total of 93 SDNs were submitted to the FSD in respect of the shutdowns of the FH/HR system, with the consequence that the fire alarms were unintentionally disabled for the same period:

Block Name

Total SDN Shutdown From Duration to Fire

Wang Yan1157

4 Sep 2025

83 days

1154 [R1/8-9, 11-12, 18] 1155 [R1/37-40]

1156 [T9/79:13-25]

1157 [C1-2/1426-1431]

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Block Name

Total SDN Shutdown From Duration to Fire

Wang Tao1158

11 Jul 2025

139 days

Wang Sun1159

4 Jul 2025

146 days

Wang Kin1160

16 May 2025

195 days

Wang Tai1161

7 Apr 2025

234 days

Wang Cheong1162 6

4 Sep 2025

83 days

Wang Shing1163 12

16 Jun 2025

164 days

Wang Chi1164

7 Apr 2025

234 days

Total: 93 Longest shutdown:

7 Apr 2025 to 26 Nov 2025

234 days

On 3 October 2025, China Status informed PC&E that it was requested by the FSD to submit an FS251 certificate to accompany each SDN.1165 In a WhatsApp message, China Status urged PC&E to resume the operations of the FSIs as soon as possible, as it could not hold off the FSD for much longer (另外最好盡快攪好回復系統，頂唔到消防處太耐).1166

Explaining this WhatsApp message, Mr Leung said that the FSD was getting concerned after an extended period of shut down.1167 This implies that PC&E and China Status both knew that their prolonged extension of the shutdown would not be acceptable to the FSD. Yet, the arrangement continued to the day of the fire.

1158 [C1-2/1432-1441]

1159 [C1-2/1442-1452]

1160 [C1-2/1453-1466]

1161 [C1-2/1467-1483]

1162 [C1-2/1484-1489]

1163 [C1-2/1490-1501]

1164 [C1-2/1502-1518]

1165 Cf. Assistant Director Keung Sai Ming’s evidence that no one at the FSD had chased China Status to submit a FS251 certificate [T10/70:18-32, 71:8-15].

1166 [R1/48]

1167 [T9/82:11-17]

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E3. Why was the FAS shutdown not rectified before the fire?

The evidence shows that the erroneous shut down of the FAS system could and should have been identified and rectified prior to the day of the fire.

It is in this context that the role of Victory Fire, the RFSIC engaged by ISS to carry out annual inspection and rectification of the FSIs, is relevant.

Following its annual inspection of Wang Fuk Court from 24 to 26 March 2025, Victory Fire noted various defects in relation to:

1. Plumbing of the FH/HR Systems of some blocks (e.g. “HR Gate valve x1 no. defective” was noted for Wang Yan House (Block A)) (“Plumbing Defects”).1168

2. The FAS (e.g. “Alarm bell x 1 no. defective” was noted for Wang Tao House (Block B)) (“Alarm Defects”).1169

3. The lighting in the fire escape staircase (e.g. “Emergency fluorescent lamp x 9 no.s defective” was noted for Wang Sun House (Block C)) (“Lighting Defects”).

Victory Fire provided a quotation to ISS to perform repairs of the Plumbing Defects, Alarm Defects and Lighting Defects for all eight blocks of Wang Fuk Court (“Plumbing Repairs”, “Alarm Repairs” and “Lighting Repairs”, collectively, the “FSI Repairs”).1170 Victory Fire was engaged to conduct the FSI Repairs, which it did in October and November 2025.

The Plumbing Repairs were conducted by Mr Tong Hing Lun, Mr Tong Siu Ming and Mr Tsoi Kam Lung on 16 and 17 October 2025.

1168 [H1-3/6702] 1169 [H1-3/6703] 1170 [R1/751-760]

352

The Lighting Repairs were conducted1171 by Victory Fire’s sub-contractor Mr Leung Man Zong on 17 to 19, 22, 24 to 26 November 2025.

The Alarm Repairs were conducted1172 by Mr Wong Kin Wa and Mr Li Chun Yin on 19 November 2025, and by Mr Li Chun Yin himself on 21 November 2025.1173

Mr Tong Hing Lun first discovered that the FS Tanks of Wang Yan, Wang Tao and Wang Sun House (Blocks A to C) were empty on 16 October 2025. In particular, when he was trying to test the newly repaired parts of the Plumbing Repairs in Blocks A to C, he discovered that no water came out of the FH/HR system. Accordingly, he proceeded to check the FS Tanks at the rooftop of those blocks and discovered that they were empty.1174

According to Mr Tong, upon discovery that the FS Tanks in Blocks A to C were empty on 16 October 2025, he informed Dr Chung Kit Man who instructed Mr Tong to ask Mr Lam Man Yan of ISS whether an SDN had been submitted.1175

Mr Tong’s evidence is that he then enquired with Mr Lam Man Yan of ISS, and was told that SDNs had been submitted for renovation of the FS Tanks of all eight blocks, and all the water in the FS Tanks had been drained for such works.1176 Mr Lam did not deny this conversation.1177 Mr Tong says that he then relayed this message back to Dr Chung.1178

1171 Tong Hing Lun WS §§5-6 [WS2/1542]

1172 Leung Man Zong WS §4 [WS2/1550]

1173 Li Chun Yin WS §§5-6 [WS2/1538]

1174 Tong Hing Lun WS §5 [WS2/1542]

1175 [T9/7:27-33]

1176 Tong Hing Lun WS §5 [WS2/1542]; [T9/7:34-35] 1177 [T7/79:3-6]

1178 [T9/8:1]

353

The next day, on 17 October 2025, the same three persons went to Blocks D to H to complete the Plumbing Repairs of those blocks. When they tried to test the newly repaired parts of the Plumbing Repairs in those blocks, they noted that no water came out of the FH/HR system. Given what Mr Tong had been told by ISS the previous day, they did not go to check the FS Tanks of those Blocks and left Wang Fuk Court.1179

At this stage, Victory Fire had reached an impasse preventing completion of the Plumbing Repairs. The last stage of the repairs required Victory Fire to issue an FS251 certificate, which could only be done after tests were conducted on the newly repaired parts of the FH/HR system with water supply from the FS Tanks.

We turn to examine the steps that Victory Fire took to ensure it could complete the repair works (including testing) as soon as possible.

The WhatsApp conversation between Dr Chung and Madam Cheng Tsz Ying of ISS on 9 October 2025 recorded that FSD had urged ISS to complete the repair works identified at the annual inspection as soon as possible.1180

According to Dr Chung, after he was informed by Mr Tong that the FS Tanks were empty on 16 October 2025, he deduced that the Upfeed Pump was switched off (otherwise water would be pumped from the Transfer Tank and fill the FS Tank), and in all likelihood the FS Pump was also switched off (as this was common practice).1181

Dr Chung further explained that, on 17 October 2025, he made a phone call to Madam Cheng Tsz Ying of ISS at 12:06 pm, in which he asked whether an SDN had been submitted. According to him, Madam Cheng replied in the affirmative, explaining that there were works to the FS Tanks.

1179 Tong Hing Lun WS §6 [WS2/1542] 1180 [H4/6802]

1181 [T6/16:8-12; 19:3-13]

354

Dr Chung then requested Madam Cheng to give him a copy of the SDN (with a completed Part III verifying the resumption of the FSI) and the relevant FS251 certificate upon completion of the works to the FS Tanks.1182 According to Madam Cheng’s call records there was indeed a call with Dr Chung on 17 October 2025 for about 1 minute 6 seconds. However, Madam Cheng could not recall the contents of that call.1183

It is not disputed that on 17 October 2025, Dr Chung did not receive any SDN from Madam Cheng.1184

On 22 October 2025, Madam Cheng sent Dr Chung a photo of a letter from the FSD requesting that the FSI defects be repaired and the FSIs be resumed as soon as possible. Dr Chung replied “understood”.1185

On 28 October 2025, Madam Cheng followed up with Dr Chung, asking when Victory Fire could come to Wang Fuk Court to finish the repairs. Dr Chung then enquired whether the FS Tanks had been re-filled with water since the repairs could not be completed without that procedure, to which Madam Cheng then replied that the FS Tanks had been refilled with water.1186 No evidence of the re-filling of the FS Tanks was provided to Dr Chung at that stage.

Dr Chung accepts that, between 17 October 2025 (when he spoke with Madam Cheng) and 17 November 2025 (when the remaining repairs began), he did not ask Madam Cheng for a copy of the SDN.1187

According to the WhatsApp records, on 5 November 2025, Dr Chung notified Madam Cheng that the remainder of the FSI Repairs (i.e. the

1182 [T6/19:26-36; 20:1-4] 1183 [T8/34:20-22]

1184 [T6/41:1-35]

1185 [H4/6804]

1186 [H4/6804-6805]

1187 [T6/41:24-35]

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Lighting Repairs and the Alarm Repairs) would be conducted on or about 14 November 2025.1188 Those repairs began on 17 and 19 November 2025 respectively.

On 19 November 2025, Mr Wong Kin Wa and Mr Li Chun Yin arrived at Wang Fuk Court to conduct the Alarm Repairs. To avoid electrocution, they went to the FS pump rooms to turn off the master power switches. Yet, when Mr Li Chun Yin entered the FS pump rooms of all eight blocks, he discovered that the master power switches had already been turned off.1189

Accordingly, both Mr Wong and Mr Li appreciated at the time that the FH/HR System and the FAS system were disabled.1190 Upon discovery, Mr Li reported to Mr Leung Man Zong (another worker of Victory Fire) and Ms Cheung (a clerk of Victory Fire) in a WhatsApp group that the FS Pumps of at least seven blocks had been switched off.1191

According to Dr Chung, Ms Cheung then spoke with Mr Li, and then specifically relayed that message to Dr Chung.1192 He instructed his staff to continue with the Alarm Repair. However, he understood that Victory Fire would not be able to test the repaired parts (and therefore complete the repairs) yet.1193

Around this time, Mr Wong Kin Wa also discovered that the Upfeed Pump in Block G had been dismantled, and that the pump switches for the Upfeed Pump had been switched off in at least Blocks F, G and H. He took videos recording the aforesaid.1194 Dr Chung was made aware of this. He testified that he realised by then that the works to FSI at Wang Fuk Court were not

1188 [H4/6806]

1189 Wong Kin Wa WS §6 [WS2/1546]; Li Chun Yin WS §5 [WS2/1538] 1190 Wong Kin Wa WS §6 [WS2/1546]; Li Chun Yin WS §5 [WS2/1538] 1191 [R1/686-692]

1192 [T6/23:32-36; 24:4-7]

1193 [T6/24:34]

1194 [R1/835-836]

356

limited to the FS Tanks, but since he was not sure exactly what works were being conducted, he instructed his staff to inform Madam Cheng about their discovery.1195

Thereafter, Mr Wong testified that he went to ask Madam Cheng about the situation, and was told by Madam Cheng that works were being done to the FSI and that was why the master power switches were turned off. According to Mr Wong, Madam Cheng informed him that PC&E found its own RFSIC to shut down the system. Mr Wong says that he asked if they had submitted an SDN and asked to see a copy. He said that Madam Cheng could not find it at the time.1196

Madam Cheng accepts that a conversation took place with Mr Wong on 19 November 2025, but denies that Mr Wong had requested to see a copy of the SDN.1197 She accepted that Victory Fire, as the estate’s regular RFSIC, ought to have been given sight of the SDN. It did not occur to her, however, to provide it.1198

On 21 November 2025, Mr Li Chun Yin returned to Wang Fuk Court to conduct the Alarm Repairs in Wang Chi House (Block H). On that day, he noticed that the master power switch of Wang Chi House was still turned off. After finishing the repairs, he left at 3:30 pm.1199

At around the same time, on 21 November 2025 at 2:20 pm, Madam Cheng sent via WhatsApp: (i) 15 photos to Dr Chung, with an accompanying message that those photos demonstrate the FS Tanks had been re-filled with water, asking whether Victory Fire could finish the FSI Repairs and

1195 [T6/26:18-22]

1196 [T5/60:16-30]

1197 [T8/37:19-25]

1198 [T8/38:2-6]

1199 Li Chun Yin WS §6 [WS2/1538]

357

sign the FS251 certificate to the FSD; and (ii) an enquiry whether Victory Fire had installed a new Upfeed Pump to Block C.1200

Dr Chung’s evidence is that, on 21 November 2025 at 3:20 pm, he made a phone call to Madam Cheng to ask for the SDN himself.1201 However, the contemporaneous records indicated otherwise. Madam Cheng’s phone record shows that, on 21 November 2025 there was only one phone call from Dr Chung at 3:20 pm – which was a missed call.1202 Dr Chung’s own phone record showed that the alleged call (also at 3:20 pm) lasted for nine seconds only – more consistent with a missed call than a proper telephone conversation.1203

When confronted with these call records, Dr Chung alleged that Madam Cheng returned a call to him at 4:57 pm. However, his own phone records show that that alleged call lasted only six seconds, which is even shorter than the alleged call at 3:20 pm and it is all the more unlikely for any conversation of any substance to have taken place then.1204

Therefore, the Committee is invited to reject Dr Chung’s evidence that he called Madam Cheng to ask for the SDN on 21 November 2025. That finding does not, however, carry over to Mr Wong. His evidence that he asked to see the SDN on 19 November 2025 stands on a different footing. A copy of the SDN was the obvious thing for an RFSIC to request in the circumstances.

At this juncture, it should be noted that the photos sent by Madam Cheng to Dr Chung on 21 November 2025 were in fact photos of the FS Tanks taken on a range of dates from 20 August 2025 to 13 November 2025.1205

1200 [H4/6807]

1201 [T9/32:8-11] 1202 [H5/6815]

1203 [R2/851]

1204 [T9/33:25-34] 1205 [H6/6820-6834]

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The fact that some of the photos were outdated was apparent on their face. Moreover, Mr Tong Hing Lun had observed on 16 October 2025 that the FS Tanks of at least Wang Yan, Wang Tao and Wang Sun House (Blocks A to C) were empty.

Dr Chung testified that, when he received the photos, he realised that they were outdated, but he did not ask Mr Wong Kin Wa or Mr Li Chun Yin to check the FS Tanks because the pumps had been switched off anyway so the FH/HR System would not have operated in any event.1206

Madam Cheng explained that she had sent these old photographs to Dr Chung to see if these were sufficient proof for Dr Chung’s purposes that the FS Tanks had been re-filled with water or whether he needed other assistance as well before he could issue FS251 certificate.1207

Based on the evidence as summarized above, both Victory Fire and ISS had a role and bear responsibility in the failure to rectify the shutdown of the FAS. While factual disputes exist between these parties, the Committee’s findings do not need to rest on these disputes.

As to Victory Fire, it was the RFSIC engaged to conduct the annual inspection and subsequent repair works. It was duty-bound to complete the FSI Repairs with due diligence and to notify the FSD of any situation which puts the building in jeopardy in the event of fire. However, it acted passively, and failed to ensure that the FSIs were fully operational or would resume full operations as soon as possible.

1. As early as October 2025, Victory Fire already demonstrated a passive attitude in the repairs, requiring repeated chasers from ISS as to when it would begin, resume, and complete, the works.

1206 [T9/25-26] 1207 [T8/36:16-18]

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2. After discovering that the FS Tanks were empty in October 2025, Victory Fire failed to ensure that it saw a copy of the relevant SDN, in order to satisfy itself that another RFSIC was indeed supervising the relevant works to the FS Tanks and the relevant fire safety risk was being assessed by the RFSIC and notified to the FSD.

3. There are factual disputes as to whether or not Victory Fire had ever asked for a copy of the SDN. It is telling that Victory Fire never saw fit to put its request for the SDN in writing, despite the seriousness of the situation.

4. Besides, if Victory Fire did request an SDN, but none was provided, Victory Fire should have proactively reported the matter to the FSD or taken steps to reinstate the FH/HR and FAS systems.

5. Victory Fire discovered that the master power switches in the FS pump rooms had been turned off on 19 November 2025. Victory Fire knew that FS Tank repairs did not require the master power switches to be turned off. This was a significant red flag that should have prompted immediate proactive action. If ISS failed to give a timely response backed by supporting documents (including by providing a copy of the SDN), Victory Fire should have reported the matter to the FSD itself.

6. Victory Fire’s attitude is best summarised by the words of Dr Chung himself. He said that since there was another RFSIC in charge, it was not his place to interfere (佢已經搵咗另外一間

做 …唔好教人做嘢，唔係自己嘅嘢). That was despite the fact

that he sensed that there was “something wrong” (我自己覺得唔

妥都好).1208

1208 [T6/46:32-33]

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7. That decision contravened the requirement in Circular Letter No. 1/2021, which provides that if an RFSIC discovers a situation that “may, in the event of fire, put the entire building in jeopardy”, written notification must be submitted to FSD. 1209

8. Victory Fire knew that the FAS and FH/HR systems were turned off. Dr Chung sensed that something went wrong. Taking its case at its highest, all Victory Fire did was to request a copy of the SDN filed by another RFSIC. That was plainly not enough, not least because (as it is undisputed) ISS never gave Victory Fire a copy of any SDN before the fire. Had Victory Fire discharged its duty, it should have sought to re-activate the FAS system for the time being until the situation was fully understood, or should have at least notified the FSD that the fire alarms had been disabled apparently for a prolonged period. Had it done either, the FAS could have been operational on the day of the fire.

As for ISS, it should not have simply relied on Victory Fire. Leaving aside that Mr Law Kwok Shui should never have touched the master power switch in the FS pump rooms, ISS is responsible for the following failures:

1. First, ISS should have ensured that, where multiple contractors were engaged, they were each aware of the status of the works. Whether or not Victory Fire had requested a copy of the SDNs, ISS should have proactively informed Victory Fire of the progress of the works in writing, and should have provided the SDN and any other official record to Victory Fire so that it understood the position. That was the obvious and responsible thing for the management office to do.

2. Second, the sending of outdated photos to Dr Chung on 21 November 2025 was unhelpful, to say the least. The reporting mechanism to the FSD is not simply a paper-filling exercise, but

1209 [B2/1303]

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seeks to ensure that the FSIs have truly been repaired and the relevant fire safety risks properly assessed by an RFSIC.

3. Had ISS been more proactive in ensuring that Victory Fire was aware of the scope and status of the works done to the FS Tanks, this would have facilitated Victory Fire’s understanding of the necessity of shutting down the various FSIs.

Had Victory Fire and ISS discharged their duties, the FAS would, in all likelihood, have been restored to operation on the day of the fire.

F. ISS

This Section will consider two further aspects of ISS’s responsibilities in relation to the Wang Fuk Court renovation works.

First, there is the issue of smoking. As stated at the outset of this Chapter, the issue of smoking by construction workers was a recurrent problem, with a failure by PC&E and Will Power to properly handle this issue.

The evidence reveals that ISS was well aware of this issue:

1. ISS maintained a Complaints Logbook, which contained entries recording smoking complaints from as early as 29 July 2024 (entry no. 5: “有住戶投訴有棚工人在起棚時吸煙”) through to at least 24 February 2025 (entry no. 391: “投訴有工人在棚內吸煙，要

求宏業回覆，不要只係勸喻，要有罰則，否則不滿意”), with the handling entry typically reading “已通知宏業” (“notified PC&E”) or “通知宏業及法團” (“notified PC&E and the IO”).1210

2. ISS’s guards were instructed to require workers to stop if seen smoking on patrol, and “no-smoking” notices were posted by the

1210 [C1-1/749, 759, 766]

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guards in the common areas and by PC&E on the scaffold and external walls.1211

3. However, Madam Cheng Tsz Ying acknowledged that the situation did not improve. She considered that the front-line staff did not have the power to, and in practice could not, control what PC&E’s construction workers did.1212

4. The response of ISS to smoking complaints once again reflects an attitude of passivity. There was no point in simply relaying the complaints to PC&E. Had ISS (in its capacity as the property management company (“PMC”) at Wang Fuk Court) proactively reported the prevalence of smoking by workers to the LD, it would have given more legitimacy to the complaints and made it known to the LD that this was a serious, recurring issue. This may have led to the LD’s enforcement action.

Second, there is the issue of access openings. ISS’s evidence was that they were aware of the use of access openings in Wang Fuk Court:

1. Madam Cheng said that she became aware in approximately August 2024 that PC&E had converted some staircase windows into access openings. She explained that ISS’s only instruction to its guards regarding the access openings was to lock any that were found unlocked, on grounds of security rather than fire safety. 1213

2. Madam Cheng also acknowledged that ISS was not particularly aware of the fire safety risks that such access openings would bring, since Will Power had been engaged as consultant and it was

1211 [T8/72:10-15]

1212 [T8/25:23-30]

1213 Cheng Tsz Ying WS §§46-47 [WS2/1267-1268]

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believed that Will Power would exercise its professional judgment regarding any such risks.1214

3. It was understandable that ISS relied on Will Power’s professional judgment. However, ISS should still have been alert to the risk of fire. According to ISS’s Security Manual, a purpose of patrolling by building attendants is to prevent and detect risks of fire. It was noted that building attendants patrolling should pay particular attention to areas with scaffolding.1215

4. Further, according to the same Security Manual, one of the matters to which building attendants patrolling should pay particular attention is to check whether the fire doors to the fire escape staircases are all properly closed.1216 The purpose of this was to ensure that the fire escape staircase remained an enclosed area that can properly provide a safe passage for residents to escape in a fire. The access openings would defeat this function and ISS should have been alert to such issue. ISS could and should at least have raised the issue with the new IO, PC&E and/or Will Power – failing which it should have reported the issue to the ICU.

5. Yet, ISS did nothing about the access openings.

By reason of the above matters, whilst ISS is not the primary entity responsible for the issues of smoking or creation of access openings, it should have acted more proactively to address those issues.

1214 [T8/26:15-20] 1215 [H1-3/6639-6640] 1216 [H1-3/6640]

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CHAPTER 7: RESPONSIBILITY AND ACCOUNTABILITY OF GOVERNMENT BODIES

A. Overview

This Chapter analyses the responsibility and accountability of various Government bodies involved in oversight of the BMR Works from the perspective of paragraph 1 of the Terms of Reference.

The Committee has received evidence of a large volume of complaints by Wang Fuk Court residents to various Government departments. There are serious questions as to whether hazards that ordinary citizens recognised as fire risks were adequately investigated by the bodies charged with oversight. Complaints were passed from one Government department to another, and ultimately left without satisfactory resolution.

The evidence therefore justifies the concerns raised by members of the Committee on Day 17 of the Evidential Hearings, concerns that permeate the issues considered in this Chapter:

1. The learned Chairman observed that the handling of residents’ fire-safety complaints in the present case had fallen into a grey area that the fire brought fully to the surface.1217

2. Dr Rex Auyeung noted that, while the FSD would naturally be an ordinary citizen’s first port of call on fire safety, an ordinary member of the public would not know about the division of labour between departments.1218

3. Mr Chan Kin Por asked whether there could be a system with somebody ultimately responsible (兜底嘅制度) for serious fire

risks, since otherwise a complaint could be passed from one

1217 [T17/16:15-19] 1218 [T17/26:12-17]

365

department to another without anyone actually dealing with it (冇

人去處理…結果就不了了之).1219

While the Government’s witnesses rejected suggestions of a regulatory vacuum in relation to fire risks at Wang Fuk Court before the fire,1220 the end result was that no Government department took effective ownership, and complaints about fire hazards fell into precisely such a vacuum.

Most Government departments regarded the ICU as having the primary responsibility for the fire risks arising from the renovation works at Wang Fuk Court (i.e. scaffolding nets, foam boards and worker access openings). Yet the ICU outsourced its supervisory function to (i) complaints from the residents, and (ii) self-regulation by the registered contractor (RC) and the registered inspector (RI). This was clearly insufficient: residents lacked the expertise to identify many of the hazards, and an RC or RI acting in breach could not be expected to report itself. Worse still, when photographs of worker access openings passed through the ICU’s hands in a minor works submission, its senior staff looked at them and noticed nothing.

The same theme recurs in the evidence concerning the FSD’s oversight of active FSIs at Wang Fuk Court. The FSD relied on self-regulation by registered fire service installation contractors (RFSICs), accepting their certificates and stated reasons for the shutdown of FSIs at face value without adequate site verification. The FSD accordingly remained unaware that the fire alarm systems had been disabled until the day of the fire.

The same pattern is evident in respect of the other departments examined in this Chapter. The BD, having delegated its building-control functions over Wang Fuk Court to the ICU, never once audited the ICU’s work in MBIS matters. The LD accepted fire-retardancy certificates at face value – for the replacement scaffolding nets, it received the identical certificate that

1219 [T17/27:3-13]

1220 Evidence of Yung Kam Hung, Michael [T17/17:3-12]; Yeung Yan Kin, Andy [T19/26:17-25]

366

it had been given 16 months earlier for the original nets, without noticing it (see Section E4(ii) below).

Nor is it any answer that the contractors and consultants set out to deceive the regulators. Deception succeeded because the regulators’ own practices enabled it: the ICU’s inspections were pre-announced, giving time to stage compliance, and across multiple departments, the documents relied upon were supplied by the very parties under scrutiny and accepted without verification. In each case, the regulator’s reliance on the good faith of the regulated parties left obvious fire hazards uninvestigated. A regulatory system that can be defeated by the say-so of those it supervises is not an effective system of oversight.

The Committee is accordingly invited to find that the failings identified in this Chapter were systemic and pervasive. As Counsel for the Committee foreshadowed during the directions conference and opening address, the materials disclosed a series of unacceptable systemic problems that cannot be ignored. This has been established by the evidence before the Committee. There is therefore an urgent need for structural reform. The recommendations in Chapter 8 are directed to these issues.

B. The Independent Checking Unit (ICU)

B1. Establishment of the ICU and building control duties

The ICU was established under the Director of Housing in November 2000 to conduct objective third-party vetting on developments of the Housing Authority. With effect from 1 July 2022 upon reorganisation of Government Secretariat, the ICU was subsumed under the Office of the Permanent Secretary for Housing.1221

According to Clauses 2.1 to 2.2 of the Memorandum of Understanding (“MOU”) between the BD and the Housing Authority dated 1 July 2022,

1221 Lau Fu Kwok WS §6 [WS1/601-602]

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the establishment of ICU is to ensure that the independent checking on HA projects is consistent with BD’s practice. 1222 This is also the BD’s understanding of the ICU’s role.1223

Furthermore, under Clause 2.4 of the MOU, the ICU exercises statutory building control under delegated authority from the Director of Buildings over Home Ownership Scheme (“HOS”) buildings which were partly or wholly sold (such as Wang Fuk Court).1224

Under Clause 3 of the MOU,1225 several mechanisms exist to ensure the ICU’s standards remain consistent with the BD:

1. The BD seconds senior professional officers to the ICU to perform bridging functions and to channel guidelines from the BD (clause

2. The ICU officers serve on the BD’s various committees (clause

3. The ICU submits progress reports to the BD every six months; the BD may conduct audit checks on ICU when necessary to ensure consistency of standards (clause 3.2).

The ICU’s semi-annual progress reports to the BD (e.g., Report No. 41)1226 focused on policy or overall operational issues and did not capture details of individual projects, including Wang Fuk Court.1227 The BD made clear that while these reports and liaison meetings need not discuss every case, cases warranting the BD’s attention or requiring BD’s input could be raised

1222 [J1-1/2043, 2045]

1223 [T20/14:3-8, 30-34]

1224 [J1-1/2046]

1225 [J1-1/2047]

1226 [I1-4/9175]

1227 Lau Fu Kwok WS §21 [WS1/613]

368

for discussion.1228 Yet, discussion of individual cases appears to have been rare.

Additionally, the BD and the ICU hold regular meetings to ensure the ICU keeps pace with BD’s standards and practices.

Ultimately, the ICU acknowledges that it is responsible for, inter alia, implementing the MBIS in Wang Fuk Court, carrying out site monitoring of alteration and addition (“A&A”) works and minor works (“MW”) as necessary, and processing MW submissions under the Minor Works Control System (“MWCS”).1229

The evidence from Government witnesses was consistent. The ICU had the responsibility of supervising passive fire safety and building materials during the large-scale renovation at Wang Fuk Court:

1. The BD: according to its Assistant Director of Mandatory Building Inspection, Ms Cheung Yuk Ching, Karen (“Karen Cheung”), the BD having delegated its authority to the ICU in respect of Wang Fuk Court, the supervision of whether the RC and RI had properly discharged their responsibilities at each stage was the duty of the ICU, not the BD.1230

2. Ms Karen Cheung was also asked whether the ICU would refer disciplinary matters concerning RIs or RCs back to the BD. She answered in the affirmative, however adding that the ICU must complete its own investigation before passing the case to the BD.1231

1228 Pang Yuk Lung, Michael WS §60 [WS1/735] 1229 Lau Fu Kwok WS §13 [WS1/605-606]

1230 [T20/12:32-35]

1231 [T20/12:36-13:6]

369

3. The ICU: in the case of Wang Fuk Court, Mr Andy Ku confirmed that supervision of whether appropriate construction methods and procedures were adopted, and whether appropriate precautionary measures were being taken fell within the responsibility of the ICU.1232

4. The FSD: Assistant Director (Fire Safety) Yung Kam Hung, Michael (“Michael Yung”) accepted that if Wang Fuk Court residents observed worker access openings in staircases,1233 foam boards covering windows, 1234 or problems with scaffolding nets,1235 these should all be reported to the ICU. He described the division of responsibilities for passive fire provisions as between the FSD and the BD / ICU as well-defined.1236

Specifically, the ICU has a supervisory role in respect of compliance with the Building (Construction) Regulation (Cap. 123Q). In particular:

1. Whether, pursuant to section 16, works have been carried out using appropriate construction methods and procedures, and whether “appropriate precautionary measures” have been taken;1237 and

2. Whether, under sections 3(1) and (2), all materials used in building works are of a nature and quality suitable for their intended use or purpose, as verified through adequate recognised testing.1238

Nevertheless, it will be explained below in the context of the FSD’s responsibility, that the FSD ought also to bear responsibility for fire risks

1232 [T22/22:35-23:10] 1233 [T17/3:19-20] 1234 [T17/3:21-25] 1235 [T17/3:28-33] 1236 [T17/6:8-10]

1237 [B2/661]

1238 [B2/653]

370

arising from the BMR Works at Wang Fuk Court insofar as these matters constitute “fire hazards” within sections 2, 7 and 9 of the Fire Services Ordinance (Cap. 95), since the FSD has a concurrent power to abate them.

B2. Individual roles of the ICU’s witnesses

(i) Rudolf Lau

Mr Rudolf Lau served as the Head of the ICU from July 2022 until February 2026, when he was succeeded by Ms Haroon Hamidah.

He was therefore Head of the ICU throughout the period when the actual renovation works were being carried out in Wang Fuk Court.1239

The ICU has 333 staff, of whom 154 are responsible for statutory building control, including architects, surveyors and other professionals.1240 Mr Lau was ultimately responsible for managing and supervising these staff.

Mr Rudolf Lau’s responsibilities as Head of the ICU included:1241

1. To study, formulate and develop policies in relation to regulatory compliance of HA projects, including consulting the BD;

2. To review and develop independent checking practices for all submissions and approvals;

3. To formulate the appropriate organisation structure, manpower requirements and practices of the ICU;

4. To oversee the building control work on HOS courts carried out under delegated authority from the Director of Buildings.

1239 Lau Fu Kwok WS §1 [WS1/599] 1240 Lau Fu Kwok WS §16 [WS1/607] 1241 Lau Fu Kwok WS §1 [WS1/599-600]

371

(ii) Andy Ku

Mr Andy Ku joined the ICU in 2014. In 2018, he joined the Housing Department as a Senior Maintenance Surveyor. He rejoined the ICU on 4 January 2024, though he had held his current rank since March 2018.1242 He submitted three witness statements.1243

During the Wang Fuk Court renovation period until the date of the fire, Mr Andy Ku led the MBIS Team of the ICU, responsible for supervising mandatory building inspection and the BMR Works of Wang Fuk Court.1244

Mr Ku’s MBIS Team comprised five professional officers and 12 nonprofessional staff.1245

One of Mr Ku’s subordinates was Ms Lau Ka Man (Amanda Lau), Maintenance Surveyor. Ms Lau did not submit a witness statement nor give evidence at the hearing. As will be stated below, she had personally handled various matters relating to the BMR Works of Wang Fuk Court under Mr Ku’s supervision.

(iii) Nick Yung

Mr Nick Yung joined the ICU on 14 October 2020. He joined ICU’s Minor Works Team (“MW Team”) on 26 September 2024. Mr Yung is a Senior Maintenance Surveyor. He submitted two witness statements.1246

1242 [T22/1:19-33]; Ku Siu Ping WS §1 [WS1/621] 1243 [WS1/621, 673]; [WS14/2127]

1244 Ku Siu Ping WS §1(a) [WS1/621]; [T22/2:14-20] 1245 Ku Siu Ping 3rd WS §7 [WS14/2129]

1246 [WS1/654]; [WS14/2116]

372

Mr Yung led the MW Team, responsible for managing and supervising submissions relating to minor works, including vetting work.1247

As the MW Team’s leader, Mr Yung also served as the Senior Professional Officer (“SPO”) who endorsed Audit Fundamental Check results.1248

(iv) Franco Tse

Mr Franco Tse was a Senior Building Surveyor at the BD, subsequently seconded to the ICU from 25 April 2023 until his retirement in July 2025. He submitted two letters to the Committee.1249

Mr Franco Tse’s role at the ICU involved providing professional advice and channelling the BD’s guidelines to ICU staff, i.e. the bridging function described in the MOU.

B3. The ICU’s policy-level failures

(i) ICU’s failure to review its own practices

As stated above, one of Mr Rudolf Lau’s duties as Head of the ICU included formulating and reviewing ICU’s policies, consulting the BD in the process. Mr Lau did not however accept that his duties included reviewing policies when it came to statutory building control, accepting that the ICU would blindly follow the BD’s practices (你係真係依書直

說，盲目咁跟隨 BD 嘅做法? … 係).1250

It cannot seriously be denied that not all RCs and RIs are law-abiding. Some cut corners or employ various means to mislead. Precisely because

1247 Yung Siu Lun WS §1 [WS1/654]

1248 Yung Siu Lun WS §32 [WS1/666] 1249 [WS3/1682-1688]; [WS16/2199-2202] 1250 [T24/31:18-28]

373

of that risk, a regulator must keep its own practices under review, asking whether and how they might be exploited by those under supervision.

That should have been the ICU’s function and on Mr Lau’s evidence it was not performed. The ICU blindly followed the BD’s practices, reducing itself to a conduit for another department’s procedures. A supervisory body that never asks whether its practices are being abused cannot expect to detect abuse, still less to prevent it.

The ICU’s duty was accordingly to identify problems and loopholes in its practices and raise them with BD as appropriate in order to improve the overall regulatory system. Amongst other matters, the ICU should have reviewed whether the regulatory mechanisms were adequate to monitor contractors and professionals directly involved in the renovation works.

(ii) No site safety inspections during construction

The evidence from ICU witnesses Mr Andy Ku and Mr Nick Yung confirmed the following prior to the fire:

1. During MBIS works and MW construction, the ICU conducted no site safety inspections whatsoever.

2. The ICU did not require any site safety inspection before completion. It would only visit a site upon receiving a complaint.

3. The ICU’s vetting work mainly consisted of document review, sampling documents to check that the documents are on their face complete.

Thus, Mr Nick Yung agreed that although major renovation works, with scaffolding and combustible materials surrounding buildings, posed a significant fire risk, the ICU would not be able to detect construction safety

374

problems during the renovation, because it did not conduct any site inspections until after works were completed.1251

When asked whether the ICU noticed the creation of temporary access openings at the staircases, Mr Nick Yung further acknowledged that the ICU would ordinarily not have detected access openings created in the middle of the renovation and removed (i.e. replaced with a proper window) upon completion, unless for some reason it had gone to the site to inspect.1252

To put it another way, if the ICU conducted no site inspections during the renovation works, as long as no member of the public complained, it was impossible for ICU to detect whether a contractor was complying with the requirements of section 16 of the Building (Construction) Regulation during construction, including whether dangerous methods or materials were being used.

Mr Andy Ku agreed that this was the ICU’s modus operandi. He agreed that, from the commencement to completion of works, the ICU had no mechanism to properly supervise the RI. When Mr Ku was asked whether, however long construction continued, the reality was that no one was monitoring the RI, he answered “under the system, right” (個制度上

係).1253

Therefore, the ICU’s approach to site safety of MBIS and minor works before the fire was to rely entirely on self-regulation by the RC and RI, supplemented only by complaints from ordinary members of the public. Mr Rudolf Lau’s evidence was that he considered this approach adequate

1251 [T23/12:22-34] 1252 [T23/21:31-22:4] 1253 [T22/24:8-31]

375

at the time. In hindsight, he accepted that this was a blind spot within the system (盲點).1254

This approach was indeed systemically flawed:

1. Ordinary residents lack expertise in large scale renovation and fire safety risks. For instance, upon seeing worker access openings in staircases, residents may not know if this was an illegal fire hazard so as to prompt them to complain.1255 The ICU should not have delegated its supervisory function to ordinary residents.

2. As for the RC and RI, if they violate the law (deliberately or otherwise), it is reasonable to assume that they would not report themselves to the Government bodies such as the ICU.

3. One illustration is the treatment of plastic sheeting and canvases used at Wang Fuk Court. The ICU did not investigate the fireretardancy of those materials before the fire. They became a focus of the Government’s attention only after the experts gave evidence of their lack of fire-retardancy. The likely explanation is simple: since no resident ever complained about them, under the complaints-driven approach, the fire-retardancy of plastic sheeting and canvases went unexamined. To the ICU, the absence of complaint meant there was no problem.

By effectively handing its supervisory responsibilities in the course of BMR Works to ordinary members of the public, and by relying on contractors and professionals to regulate themselves, the ICU failed to perform an important aspect of its supervisory responsibilities.

1254 [T24/35:9-12, 36:14-16] 1255 [T24/35:29-36:9]

376

(iii) Minor works audit volumes – minimal coverage

In 2025, the ICU received 27,585 minor works submissions. The total audit target was 1,275. This meant around 95% received no audit of any kind.1256

Of the 1,275 audited:

1. 1,070 were the subject of Audit Fundamental Checks (“AFC”) (desktop document reviews only – no site visit). 1257

2. 180 were Site Audit Checks (post-completion site checks only).1258

3. 25 were Pre-commencement Site Audit Checks (“PSAC”) (checks whose sole purpose is to see if contractors have ‘jumped the gun’ in commencing works, contractors being legally required to wait seven days after MW submissions to commence work).1259

As described further below, the BD adopted a policy of conducting site safety inspections in 2023, which the ICU was unaware of until after the Wang Fuk Court fire. As such, the ICU conducted no site inspections of minor works whilst works were underway. However, even if it adopted the BD’s 2023 policy, only approximately 0.8% of the total submissions would be selected for site inspections. There are serious questions as to whether this percentage was adequate.

(iv) MBIS checking – reliance on RI without verification

The vetting of inspection reports by the ICU’s MBIS Team was essentially a paper exercise:1260

1256 Yung Siu Lun WS §24 [WS1/663]

1257 Yung Siu Lun WS §14 [WS1/660]

1258 Yung Siu Lun WS §15 [WS1/661]

1259 Yung Siu Lun WS §17 [WS1/661]

1260 Ku Siu Ping WS §§29-33 [WS1/632-634]

377

1. Preliminary Check (all submissions): merely verified RI registration status and signature.

2. Audit Check (fixed at 16 balloted cases per month): only one-third of these 16 cases proceeded to a site audit. Site audits only checked whether conditions were generally in agreement with the RI’s inspection report.1261 In other words, the site audits only checked the conditions of the building against the RI’s prescribed inspection under the MBIS and were not site inspections conducted to ensure site safety after the actual works had commenced.1262

3. Fundamental Check (submissions not selected for Audit Checks): merely confirmed the report was submitted, completed and signed without verifying content truthfulness.

It follows that, as summarised above, under the MBIS regime the ICU was not required to conduct site inspections of the actual renovation works, unless the MBIS Team received complaints. 1263 The Government also states that the MBIS regime is designed as a “two-point monitoring mechanism” whereby the ICU monitors the RI at submission of inspection report and at completion (but not in between, unless complaints are received).1264 In other words, the ICU had to rely on the RI to supervise the RC during the conduct of the works.

Nevertheless, the ICU’s relationship with the RI at Wang Fuk Court was characterised by complete detachment:

1261 Ku Siu Ping WS §31 [WS1/633] 1262 [T22/15:23-25, 30:19-27]

1263 [T22/15:23-25, 30:19-27]

1264 Government’s Closing §523

378

1. The original RI, Mr Shum Kui Chung, passed away in July

1265 The ICU only learned of this over two years later, in September 2024, through a complaint – demonstrating that the ICU had no contact with Mr Shum.1266

2. On 8 October 2024, the ICU wrote to Will Power to highlight that repair works had been ongoing at Wang Fuk Court since June 2024 without any RI and continued chasing for the submission of a Form MBI1 for the change of RI.1267 The situation was regarded as a serious one, as the ICU directed that no prescribed repair works should be carried out before the RI is formally appointed.1268

3. After multiple reminders, Will Power submitted a Form MBI1 on 10 October 2024 for the replacement of the RI with Mr Ng Yeuk Wilson. Will Power’s letter claimed the supervision of the repair works at Wang Fuk Court had been handed immediately (即時) to

Mr Ng upon Mr Shum’s death.1269

4. This was a lie: far from an immediate handover, Will Power first replaced Mr Shum with another RI, Mr Chan Siu Wah Hardy (陳

兆華), who became a director and shareholder on 28 February

2023, some seven months after Mr Shum’s death. Mr Ng Yeuk only became a director and shareholder of Will Power when Mr Chan transferred his 20,000 shares to him on 12 December 2023, some 17 months after the death of Mr Shum Kui Chung.1270

5. Nevertheless, the ICU accepted Will Power’s representation without question. Despite knowing that works had proceeded for

1265 [O2/831]

1266 [T22/26:6-12] 1267 [I1-4/8776-8777] 1268 [I1-4/8776]

1269 [I1-2/1839]

1270 [WS2/1298]

379

months while the only RI on record had passed away two years earlier, Mr Ku conceded that the ICU asked nothing, saw no red flag, and that its only concern was whether a Form MBI1 had been filed so that an RI appeared on the record.1271

6. The ICU never met Mr Ng Yeuk in person and never received any email directly from him, and never verified whether Will Power representatives were truly authorised by him. 1272 When ICU attempted to arrange an inspection on 23 October 2024 (which eventually took place on 28 October 2024), it was Mr Wong Hap Yin Jason of Will Power who replied.1273

Under section 30D of the Buildings Ordinance (Cap. 123), prescribed repair works must be supervised by a registered inspector – a natural person on the register, not a company.1274 Despite total reliance on the RI to regulate itself and the RC, the ICU never confirmed the RI’s actual involvement.

B4. ICU’s divergence from the BD’s practices

(i) The 2023 site safety inspection policy

In April 2023, the BD introduced a policy of randomly selecting not less than 20% of Class I MW cases (where supervision plans were submitted for audit) for site safety inspections. The ICU’s position is that it only became aware of this site safety inspection policy on 22 December 2025 –nearly three years after the BD adopted it.1275

1271 [T22/29:24-29]

1272 [T22/29:24-30:2]

1273 [I1-4/8752-8754]

1274 [B2/256, 402]

1275 Yung Siu Lun WS §42 [WS1/670]

380

The significance of this is obvious. As Mr Nick Yung stated, had ICU been aware of this policy and implemented it, there would have been a “fairly high chance” that a site inspection of the staircases would have been arranged by the ICU.1276 One may add that other fire safety risks (such as the extensive use of foam board coverings) might also have been identified through such site inspections.

The mis-communication between the ICU and BD is reflected in the ICU’s email dated 24 December 2025 to BD as follows:1277

“We recorded that we did not receive notifications through any channels, including the sharing session between BD’s SMS and ICU’s SMT held on 22 March 2023; information from BD to ICU through SSE/Adv.; telephone conversations and/or emails between BD’s SMS and ICU’s SMT, that BD’s SMS carry out site audit on Class I MW sites since April 2023 before your email dated 22/12/2025.”

On 6 January 2026, the BD finally notified the ICU of the updated Site Monitoring Manual reflecting this arrangement.1278

This is not an acceptable situation and reflects a failure of proper and effective communication (with responsibility on both the ICU and BD), notwithstanding the following communication channels:1279

1. The ICU and BD held regular meetings, including meetings specifically addressing the MW regime.

2. The BD seconded senior professional officers to the ICU precisely to serve as a bridge to convey BD’s latest guidelines and practices.

1276 Yung Siu Lun WS §43 [WS1/671]

1277 [I1-4/8982]

1278 [I1-4/8986]

1279 Lau Fu Kwok WS §§21-23 [WS1/613-614]

381

3. The ICU submitted semi-annual progress reports to BD for review.

Furthermore, the ICU’s Semi-Annual Report No. 41 reported on the Site Monitoring Team’s work,1280 which is said to include “monitoring and auditing building sites with works in progress, through inspections, in order to detect safety and quality supervision related irregularities” (at §16, emphasis added). It was not disclosed that these site inspections did not in fact apply to minor works (MWs). This meant that the BD was not alerted to the divergence in practice between the ICU and BD.

The divergence in the BD and ICU’s practice was in fact discoverable from public sources:

1. An archived version of the BD’s website dating from 2019 described the remit of the BD’s Site Monitoring Section (地盤監

察組) as covering not only building works requiring approval and

consent, but also Class I minor works. The BD stated that officers from the BD would carry out inspections of these sites (地盤監察

組處理… 第一級別小型工程… 本署人員會對所有這些建築

地盤進行審核視察).1281

2. Mr Rudolf Lau accepted that the ICU’s staff visited the BD’s website from time to time, but he had not noticed this passage. He explained that the website was a general introduction to the BD’s work for the public, whereas the ICU’s practice followed the BD’s internal manuals, and the manuals did not require site inspection for minor works at the time.1282

3. The statement on the BD’s website, which was accessible to any member of the public, disclosed that the BD’s site monitoring

1280 [I1-4/9179] 1281 [A8/879]

1282 [T24/43:3-36]

382

extended to Class I minor works (MW). Had this been noticed by the ICU, the inconsistency with the ICU’s own practice could have been raised with the BD and corrected years before the fire.

Mr Rudolf Lau ultimately agreed with Counsel for the Committee that on these safety inspection matters the ICU could not simply lay the fault at the BD’s door (責無旁貸…唔可以就咁賴屋宇署).1283

The concession was rightly made, and the Government has also now acknowledged that the communication between BD and the ICU should be improved. 1284 The ICU’s stated justification for not conducting any independent review of its practices was that it faithfully followed the BD’s practices. The ICU’s failure to notice – through regular meetings, seconded officers, semi-annual reports or the BD’s own website – that it had been out of step with the BD’s practices, meant that buildings under the ICU’s charge received a materially lower standard of site monitoring than private buildings under the BD’s remit, without anyone in either department being aware of it.

(ii) Pre-notification of inspections

A further divergence from the BD’s practice was the ICU’s habit of prenotifying the RI and RC before conducting inspections in response to complaints.

The BD’s evidence was unequivocal:

1. The BD’s general practice for site inspections and site audit checks, whether for new or existing buildings, is not to notify the RI and RC in advance. Only in exceptional circumstances (e.g. where

1283 [T24/44:7-12]

1284 Government’s Closing §648

383

specialist equipment is needed or for urgent public safety matters) would prior notification be given.1285

2. The BD’s Minor Works Site Monitoring Manual (April 2025) states that site audit checks and periodic safety inspections must be surprise inspections “without prior notification to AP / RSE / RGE / RC” (at §1.1).1286 The BD’s surprise inspection arrangement applies to inspections of existing buildings following complaints as well, including complaints about site safety and the misconduct of RIs and RCs.1287

3. When the BD receives a complaint, it visits the site first, ascertains the situation, and only afterwards contacts the RC and RI if necessary for follow-up.1288

Other Government departments adopted the same approach:

1. The FSD’s Assistant Director Keung Sai Ming stated that FSD inspections in response to complaints are conducted without prior notice to any party, to avoid compromising the integrity and fairness of the investigation.1289

2. The LD’s Ms Lam Sau Ching stated that all inspections at Wang Fuk Court were conducted without prior notice to the RC, RI or management office.1290

1285 Yue Chak Sang 2nd WS §7 [WS14/2171-2172]

1286 [J2/7919]

1287 Yue Chak Sang 2nd WS §8(I)(a) [WS14/2172-2173] 1288 [T20/30:34-31:15, 32:5-10]

1289 Keung Sai Ming 4th WS §4 [WS8/1909]

1290 Lam Sau Ching 2nd WS §5 [WS13/2107]

384

The purpose of surprise inspection is to deny a contractor the opportunity to stage compliance or conceal non-compliance before inspectors arrive.1291 This accords with common sense.

Mr Andy Ku acknowledged that pre-notification was the ICU’s longstanding practice for a majority of cases, rather than a case-specific decision (呢個做法我哋一路都係做開).1292

In fairness to Mr Ku, when it was put to him that pre-notification gives an RI or RC the opportunity to conceal a contravention, he did not accept it. According to Mr Ku, the ICU notifies the RI whose duty is to supervise the RC. Therefore, the RI should not notify the RC about the pre-notification and the risk that the RC is notified arose only in theory.1293

This explanation is however untenable:

1. In practice, the ICU informed not only the RI in advance of inspections, they also requested the RI to inform the RC of the visit. The messages between Ms Amanda Lau and Will Power on 27 October 2025 illustrated this: at 10:10 am, Ms Lau asked Mr Yeung of Will Power to arrange for Mr Sam Tam of PC&E (i.e. the RC) to attend the inspection.1294

2. The explanation is also problematic for it assumes that the RI invariably carries out its supervisory role properly and independently from the RC. This is not always the case.

The Government has fairly accepted that the aforesaid inconsistency was “an operational area requiring improvements in terms of the discrepancy in practice”, and that the ICU’s practice “assumed good faith on the part

1291 [T20/30-32]

1292 [T22/33:1-35:5]; see also [T22/42:30-32] 1293 [T22/36:16-20]

1294 [I1-4/8766-8767]

385

of the professional subject to it, an assumption that the evidence demonstrates was deviously exploited and undermined”.1295 Mr Ku also confirmed that, after the fire, the ICU no longer informs RIs about inspections in advance. In other words, the ICU has now aligned its approach on surprise inspections with the approach taken by other Government departments before the fire.1296

The change in the ICU’s approach is a step in the right direction. However, it also raises the question of why there was a divergence in the first place, in particular with the BD’s practice, given the numerous communication channels between the two Government bodies.

(iii) Audit sampling methodology

The BD adopts the ISO-2859-1 international standard for determining sample sizes in its MBIS random audit checks, adjusting sample size according to lot size.1297

By contrast, the ICU’s computer system simply selected by ballot a fixed 16 cases per month for audit regardless of how many submissions were received that month.1298

The ICU’s witnesses did not accept that this involved any divergence from the BD’s approach. Mr Rudolf Lau’s evidence was that the 16 per month figure had been calibrated to the BD’s ISO-derived annual audit target of approximately 1,725 cases, the ICU’s caseload being roughly one quarter of that of the BD and that, submissions having since declined, the effective sampling rate was now higher than the ISO proportions would produce.1299

1295 Government’s Closing §535

1296 [T22/42:20-35]

1297 [T20/9:3-12]; Cheung Yuk Ching WS §61 [WS1/799-800]

1298 Haroon Hamidah WS §7 [WS1/596]; Ku Siu Ping WS §29 [WS1/632] 1299 [T24/44:26-45:17]

386

Furthermore, Mr Ku explained that in 2025 there were fewer than 16 MBIS submissions in most months, such that nearly all submissions that year were audited.1300

These explanations fail to address the underlying criticism, which is one of methodology rather than arithmetic. Under the BD’s approach (which follows ISO-2859-1), the sample size responds to the lot size. Under the ICU’s approach, it would not. A surge in submissions would silently dilute the sampling rate, with no mechanism to detect the shortfall.

Besides, the ICU cannot have it both ways: if its mandate was to follow the BD without question, the obvious course was to adopt the BD's ISO-based methodology itself, and not to derive a fixed quota from it and leave the figure thereafter untouched as circumstances changed.

(iv) Summary on the ICU’s divergence from BD’s practice

The evidence demonstrates that ICU’s practices diverged materially from BD’s standards in at least the following critical respects:

1. Pre-notification of complaint inspections;

2. Site safety inspections during construction;

3. Monthly sampling for audit check;

4. Understanding of the legality of use of foam boards to cover windows (see Section B7(v) below); and

5. The use of ‘quick tests’ to burn scaffolding nets on-site (see Section B8(iv) below).

1300 [T22/14:14-25]

387

These divergences were not merely a result of the ICU not having been informed of what BD’s practices were. The ICU itself could have, and should have, ensured that its practices were consistent with the BD.

B5. Complaints received by the ICU

(i) Overview: ICU’s policy of complaints-only inspections

The evidence establishes that the ICU’s policy of only conducting site inspections in response to complaints was not only a blind spot within the system (盲點 ), 1301 it was also inconsistent with the BD’s practice of

randomly selecting not less than 20% of Class I MW cases (where supervision plans were submitted for audit) for site safety inspections.1302

It follows that, within the complaints-driven system that the ICU had adopted, everything turned on how complaints were handled. If site inspections occurred only when residents complained, the complaints were the sole trigger for scrutiny under that system.

The ICU did receive a significant volume of complaints from Wang Fuk Court’s residents. A regulator that inspects only on complaint must, at the very least, properly investigate the complaints it receives. The ICU did not. Its response to the complaints received was inadequate: there were numerous instances of a failure to adequately investigate, where the ICU simply accepted the RC’s and RI’s explanations at face value.

1301 [T24/35:9-12, 36:14-16]

1302 Yung Siu Lun WS §42 [WS1/670]

388

(ii) Volume and nature of complaints

According to the available records, the ICU received or was involved in approximately 41 separate complaints or enquiries between February 2024 and November 2025.1303

The ICU’s standard responses fell into the following categories: (i) telling complainants the matter was “not related to ICU”; (ii) conveying the complaint to Will Power without independent verification; (iii) telling complainants to contact the IO, management company, or contractor directly; or (iv) closing cases where no contact details were provided.

The complaints specifically raising fire safety issues included:

Date

Complaint

Comment on ICU's response / follow-up

13 Sep – 17 Oct 2024

Foam boards

To ICU: on 17 Sep,1304 23

Sep,1305, 16 Oct,1306 17 Oct

1307

ICU’s reply of 7 Nov 20241308 addressed scaffolding nets and referred smoking to LD, but failed to address the foam

boards.

5 Oct 2024 – 23 Oct 2025

Scaffolding-net flammability – at least three complaints:

To ICU: on 5 Oct 20241309; 29

Sep 2025;1310 23 Oct 2025

(expressly referencing the

Chinachem Tower fire and

Handling addressed below.

1303 [I1-4/8138-8743] 1304 [I1-4/8221-8228] 1305 [I1-4/8229-8251] 1306 [I1-4/8297]

1307 [I1-4/8274-8285] 1308 [I1-4/8285]

1309 [I1-4/8252-8257] 1310 [O1/45-47]

389

Date

Complaint

Comment on ICU's response / follow-up

warning the nets were combustible).1311

6 Nov 2025 (20 days

before the fire)

Scaffolding safety –

Stones falling from height;

concern about ageing

scaffolding nets.1312

ICU conveyed the complaint to Will Power; Will Power

attached an incident report.1313

11 Aug 2024 Smoking –

Smoking at the construction site.1314

No record of any ICU followup.

The overall picture is that residents were raising alarm about fire safety at Wang Fuk Court repeatedly over an extended period.

(iii) ICU’s inadequate handling of complaints

The ICU’s handling of the complaints it received was characterised by the following deficiencies:

1. Closing cases without meaningful investigation: An anonymous complaint about foam boards on 17 September 2024 was closed by ICU because no personal contact details were provided,1315 despite the complaint raising a fire safety concern that warranted investigation regardless of whether the complainant could be contacted. Similarly, when Mr Kong Cheung Fat’s 23 October 2025 complaint referenced the Chinachem Tower scaffolding fire and warned that Wang Fuk Court’s nets may be combustible,1316 the ICU replied on 24 October 2025 merely stating that ICU had

1311 [O1/48-52]

1312 [O1/59-62]; [I1-4/8930-8946] 1313 [I1-4/8930]

1314 [I1-4/8199]

1315 [I1-4/8221-8228]

1316 [I1-4/8700]

390

“earlier conducted an inspection at Wang Fuk Court and understood the situation” without addressing the fire-retardancy concern raised.1317

2. Directing complainants back to the parties who were the subject of complaint: in the ICU’s reply to a foam board complaint, the ICU recommended that, if there were further enquiries, residents may directly contact the IO, management company or the contractor (業戶可直接聯絡業主立案法團/管理

公司/承辦商).1318 On 22 October 2024, the ICU sent an email to

Will Power, requesting the RI (Mr Ng Yeuk) to address concerns about foam boards and scaffolding net fire-retardancy.1319

3. Failing to address all issues in a complaint: A complaint received on 2 October 2024 raised issues on scaffolding nets, worker smoking, and foam boards. 1320 The ICU’s reply on 7 November 2024 addressed scaffolding nets and referred the smoking issue to the LD, but failed to address the foam board issue entirely.1321

4. Refusing to disclose RI information: Upon receipt of an enquiry about the identity of the RI,1322 the ICU refused disclosure because Will Power stated: “We do not want to disclose RI details to any third party enquiry”.1323 Because ICU did not supervise the RI, and simultaneously prevented the public from knowing who the RI was and how to contact him, residents were unable to exercise the

1317 [I1-4/8700-8701] 1318 [I1-4/8251]

1319 [I1-4/8753-8754] 1320 [I1-4/8281]

1321 [I1-4/8285]

1322 [I1-4/8445]

1323 [I2/9716]

391

basic oversight of site supervision that the ICU’s system handed to them.

5. Disclaimed responsibility: Further, the ICU also routinely declined to address complaints it deemed outside its scope, even where the complaints related to the renovation project it was responsible for overseeing:

Date

Complaint

ICU's response / follow-up

17 Mar 2024 Dr Lau –false representations made by PC&E and Will

Power.1324

Replied it “would not reply as it was not related to them.”

17 Jan 2025 Mr Cheung – IO

irregularities concerning the repair project.1325

Replied “the matters raised were not related to ICU.”

18 Mar 2025 Ms Lam (林女士) – structural defects.1326

Replied it was “unable to handle the matter raised.”

12 May 2025

Mr Chan (陳先生) – structural defects.1327

Replied it was “unable to handle the matter raised.”

6 Sep 2025 Anonymous – suspected illegal workers1328

Replied the matter “should be raised with the relevant department.”

Taken together, these deficiencies hollowed out the one safeguard on which the ICU’s complaints-driven system depended. Complaints were closed without investigation, answered without addressing the concern raised, or redirected to the very parties complained of. Complaints were the sole trigger for action by the ICU, yet when they were made – as they repeatedly were at Wang Fuk Court – they were not properly investigated.

The residents were understandably disappointed with the ICU. As the IO’s Chairman Mr Tsui Moon Come Tony observed in the WhatsApp group on

1324 [I1-4/8145-8164] 1325 [I1-4/8558-8564] 1326 [I1-4/8614-8625] 1327 [I1-4/8626-8637] 1328 [I1-4/8672-8688]

392

3 June 2025, he had hoped the ICU would follow up on complaint cases and it seemed that they did not care.1329

B6. ICU’s failure to notice worker access openings

(i) The practice of creating worker access openings

Chapter 2 examined the creation of worker access openings known as “saang hau” (生口) approximately every five floors in the staircases, by

removing the window and replacing it with wooden or aluminium composite boards that acted as a door.

These worker access openings were an obvious fire-safety hazard that a competent regulator exercising ordinary care ought to have identified and prevented. Chapter 4 examined how these openings caused a significant number of deaths and injuries at Wang Fuk Court.

The following laws and regulations are relevant in this context:

1. Section 35 of the Building (Construction) Regulation requires buildings to be designed and constructed to “inhibit the spread of fire within the building” (reg. 35(a)) and to have “adequate resistance to the spread of fire and smoke” (reg. 35(b)).1330

2. Section 16 of the Building (Construction) Regulation requires “appropriate methods of construction and procedures” to be adopted.1331

3. Under the Code of Practice for Fire Safety in Buildings (2011 edition):

1329 [F4/1349] 1330 [J1-2/5751] 1331 [B2/661]

393

(a) Clause F5.6(a) provides that: “All means of escape should be maintained at all times. It should be free from obstruction and adequately signed and lit.”1332

(b) Clause E13.1(a) requires escape staircase enclosure walls to meet the non-combustible requirements of Table E1, Item A1.1333

4. The Code of Practice for MBIS (2023 version), §3.5.2(E) requires the RI to notify the Building Authority of, inter alia, unprotected openings in enclosure walls of exit routes and alterations to escape routes resulting in deficiencies in fire safety.1334

Ms Karen Cheung confirmed on behalf of the BD that removing fire-rated staircase windows to create worker access openings was obviously illegal (明顯違法), contravening the Building (Construction) Regulation and the

Code of Practice for Fire Safety in Buildings.1335

Mr Nick Yung agreed with that view. He accepted that there simply should not be worker access openings within the staircase.1336 Nonetheless, Mr Yung accepted that the ICU had not turned its mind to the problem of worker access openings before the fire.1337

(ii) ICU failed to detect worker access openings through audit checks

The ICU received a total of 48 minor works submissions relating to the Wang Fuk Court renovation. Of these 48, two were randomly selected by the Minor Works Management System (“MWMS”) for an Audit

1332 [B2/1158]

1333 [B2/1139-1140]

1334 [J1-2/4881-4882]

1335 [T20/27:3-29]

1336 [T23/19:16; 20:21-28] 1337 [T23/19:11-14]

394

Fundamental Check (AFC). The two selected submissions were MWBO2504820 and MWBO2504821, relating to Wang Cheong House and Wang Chi House (Blocks F and H).1338

Both MW01 forms were submitted on 2 May 2025 and related to erection of protective barriers and alteration of windows in the staircase of Wang Cheong and Wang Chi House (Blocks F and H).1339

Critically, the MW01 submissions included pre-commencement photographs which clearly showed escape staircase windows that had been converted into worker access openings:

1. The photographs of the staircases at Wang Chi House (Block H) clearly show a window converted into a worker access opening, with the door fully open.1340

2. The photographs of the staircases at Wang Cheong House (Block F) show worker access openings with locks, warning stickers reading “Danger” and illustrations warning against climbing out.1341

1338 Yung Siu Lun WS §§34-37 [WS1/666-668] 1339 [I1-3/6212, 7954]

1340 [I1-3/7971]

1341 [I1-3/6232, 6227]

395

Figure 7-1: Pre-commencement photographs of Wang Cheong House staircase included in submission MWBO25048201342

Despite examining these photographs, the ICU’s MW Team confirmed the submissions to be “in order”.1343 The AFC’s checklist item 12 merely asked whether pre-commencement photographs had been provided and were clear (“Plans / Photographs showing the physical condition of the premises immediately before the commencement of MW have been provided / are clear”).1344 The ICU ticked “Yes”. One may question the utility of an audit that simply asks if the plans or photographs have been provided and are clear, with no scrutiny of the contents of photographs that indicate an obvious fire risk.

Nevertheless, Mr Nick Yung explained that the pre-commencement photographs in the MW01 forms revealed that works may have

1342 [I1-3/6232, 6227]

1343 Yung Siu Lun WS §34 [WS1/666-667] 1344 [I1-3/6370]

396

commenced before the seven-day notification period had expired (i.e. the contractor may have jumped the gun in commencing the works). Under a PSAC, this would have raised a red flag. But because the MW01 forms had been sampled for audit under AFCs rather than PSACs, the irregularity went undetected. 1345 The rigid audit categories thus meant that an irregularity apparent on the documents was missed simply because it belonged to a different pigeon-hole. And the pigeon-hole was remarkably small: the ICU conducted a maximum of 25 PSACs per year, meaning the vast majority of works would never be subject to site inspection for precommencement violations.

The MWMS records therefore confirmed that the “submission was checked in order and ‘PASS’ recommendation for subject audit assessment is supported”.1346 Mr Yung, as the Senior Professional Officer (SMS/ICU3), endorsed this recommendation. He testified that he personally checked all the documents and found that the MW submission passed the checks.1347

As Mr Nick Yung admitted, “[w]ith the benefit of hindsight, it is noted that there were some pre-commencement photos… showing certain windows covered with boards”.1348 As he went on to acknowledge, “it did not occur to me at the time that those were openings put in place specifically to become workers’ access to and egress from the scaffolding.”1349

Mr Yung’s evidence at the Evidential Hearings was that he did review the photographs of the access openings, but was not aware that they were openings for workers to get in and out. He believed the windows were

1345 Yung Siu Lun WS §41 [WS1/670]

1346 [I1-3/6372]

1347 [T23/15:29-16:1]

1348 Yung Siu Lun WS §40 [WS1/669]

1349 Yung Siu Lun 2nd WS §28 [WS14/2125]

397

broken, so temporary covers had been used to protect them. That explanation did not survive his oral evidence.1350

1. Mr Yung was then shown several photographs from the submissions he reviewed, which revealed openings at every five floors. He accepted that he did not pay attention to this pattern at the time of his review.1351

2. He was then shown photographs of one of the access openings in Wang Cheong House, which had a lock on the left-hand side and a warning label on the right (see Figure 7-1 (right)).1352 Counsel for the Committee suggested to Mr Yung that if the temporary covers were there to protect a broken window, there was no need for a lock. Mr Yung agreed: “如果好留意去睇, 係嘅”.1353

3. Finally, Mr Yung was shown another photograph and agreed that the window covers were in fact openable doors, and that he could not have come to the conclusion that these covers were only for protecting the windows (如果你有心睇一啲開到，擺到明係一

個出入口嘅相，你就冇可能覺得係愛嚟做保護喎… 同意).1354

1350 [T23/18:11-15]

1351 [T23/18:16-19]; [I1-3/7963, 7966, 7968, 7971, 7973] 1352 [I1-3/6227]

1353 [T23/22:5-17]

1354 [T23/22:18-22]

398

Figure 7-2: Pre-commencement photographs of Wang Chi House staircase included in submission MWBO25048211355

The photographs, in short, told anyone who looked at them that these were purpose-built worker access openings, recurring at every fifth floor of a fire escape staircase. In answer to a question from Counsel for the Government, Mr Yung all but admitted that had he paid more attention to the photographs, he would have become aware that these were access openings.1356

The Minor Works Manual provides that if an AFC reveals “obvious contravention of the BO,” a Site Audit Check should be conducted (at §10).1357 The photographs disclosed exactly such an obvious contravention,

1355 [I1-3/7971] 1356 [T23/37:7-11] 1357 [I1-1/525]

399

but because no one bothered to examine what they showed, no site audit inspection took place.

On Mr Yung’s own evidence, a site inspection would have found the access openings.1358 But none ever took place. Under the ICU’s complaints-driven policy, an inspection required a complaint, and no complaint about the openings was ever made – residents lacked the expertise to recognise them as a fire hazard: see Section D7 of Chapter 2.1359 Everything therefore turned on the AFC desk review, and the desk review failed. The residents could not see the danger in the access openings; the MW Team, which could have, did not look closely enough to notice it.

The Government has also now acknowledged that the supervisory design of relying on AFC (the purpose of which is on procedural compliance rather than identification of safety hazards visible in the photographs submitted) is a weakness in terms of safety concerns visible on the face of the submissions.1360

B7. Foam boards

(i) ICU’s knowledge of foam board use

The ICU first received information about foam boards being used to cover windows at Wang Fuk Court in September 2024. As detailed above, ICU received at least four direct complaints about foam boards between September and October 2024.

The first complaint through the 1823 system stated:1361

1358 [T23/22:2-4]

1359 [T17/29:23-27]; [T22/24:35-25:1]; [T24/35:29-36] 1360 Government’s Closing §653

1361 [I1-4/8230]

400

“大埔宏福苑現在進行大維修。現時在 FGH 座旁存放大量發泡

膠。有居民自行拿了屋旁的碎料發泡膠進行測試，發現這些發泡膠是易燃物料，不是有阻燃的特性…管委會說會使用這些發泡膠，貼在每戶的窗上做保護”

(Wang Fuk Court is currently undergoing major renovation. Large quantities of foam are stored beside Blocks F, G and H. Residents tested fragments and found them to be flammable without fireretardant properties… The Owners’ Management Committee said these foam boards would be applied to every household’s windows for protection.)

From this initial complaint, the ICU knew that: (i) the foam boards were flammable; (ii) they were intended for “every household’s windows” (每戶的窗上), i.e. intended to be used extensively across all 1,984 units in the estate; and (iii) large quantities were stored on site.

(ii) ICU’s inspections and observations

On 25 September 2024, Mr Andy Ku and Ms Amanda Lau conducted ICU’s first site inspection at Wang Fuk Court. According to Mr Ku:1362

1. He observed large quantities of foam board materials stored on the ground, with packaging labelled “CO2 生態健康地暖板 .” Photographs confirm substantial quantities on site.1363

2. He took a lift to an upper floor and observed a foam board affixed to and covering a glass window in the lift lobby.1364

On 28 October 2024, Mr Andy Ku conducted a further inspection. He told PC&E his concerns that foam boards “could pose a fire hazard to

1362 Ku Siu Ping 3rd WS §§51-52 [WS14/2146-2147] 1363 [I1-4/8991, 8992, 8997, 8999]

1364 [I1-4/8994]

401

residents”.1365 He also expressed concern that the foam boards would affect natural lighting and ventilation. PC&E responded that foam boards were only used temporarily during hacking works (three floors at a time) and would be removed immediately after hacking was completed. PC&E also said it would use non-combustible material in future.1366 No written record was made of this inspection or these discussions.

(iii) The alleged oral consultation with Franco Tse

Mr Andy Ku claimed that shortly after the 25 September 2024 inspection, he verbally consulted Mr Franco Tse (a BD officer seconded to ICU) regarding the use of foam boards. According to Mr Ku:1367

1. Mr Tse advised that temporary use of foam boards to cover windows was not considered as building works;

2. There was no requirement on the fire-retardant properties of the foam boards used; and

3. Since such use would not be considered unauthorised building works, it would not be “actionable.”

No written record exists of this conversation.1368 Mr Tse says that Mr Ku did not provide him with the complaint, photographs, site inspection observations, or any details about the scale of foam board use.1369 Mr Ku himself admitted that he did not tell Mr Tse how many windows were

1365 Ku Siu Ping 3rd WS §63 [WS14/2151]

1366 Ku Siu Ping 3rd WS §§61-63 [WS14/2150-2151]

1367 Ku Siu Ping WS §60(i) [WS1/650]; Ku Siu Ping 3rd WS §57 [WS14/2149]

1368 Mr Ku’s evidence was that the ICU’s guidance did not require preparing written records of these oral conversations, and that it was not standard practice [T22/65:31-34].

1369 [T20/44:10-24]

402

covered or for how long.1370 This accords with Mr Tse’s own recollection that he had received no detailed information at all.1371

In Mr Franco Tse’s first letter to the Committee, he stated:1372

“I would definitely treat this as an unfair allegation against me. In fact, from professional point of view, the statement made by Mr. Ku in his 1st and 2nd Witness Statements … is obviously unsound.”

Mr Tse explained that he had assisted in the follow-up works in Hong Kong after the Grenfell Tower fire in 2017, where foam material in external cladding was a crucial cause: “I am very mindful on foam material to be used at the external wall. The allegation as in point (B) and (C) of the statement were unlikely to be my comments due to my past experience.”1373

At the Evidential Hearings, Mr Tse confirmed that he did not recall the specific conversation with Mr Ku, had not seen the complaint, did not know which estate was involved, had not seen any inspection report or photographs, and was not shown ICU’s reply to the complainant.1374 He agreed, when asked by Counsel for the Committee, that the practice of extensive foam board coverage of windows over a prolonged period could not possibly comply with section 16 of the Building (Construction) Regulation.1375

In his second letter to the Committee, Mr Franco Tse clarified that if foam boards were used on only one or two units or for a very short duration, it might not necessarily constitute a contravention – but this is far removed from the actual situation in Wang Fuk Court which, as is undisputed by

1370 Ku Siu Ping 3rd WS §58 [WS14/2149-2150] 1371 [T20/44:10-31]

1372 [WS3/1683]

1373 [WS3/1683]

1374 [T20/44:10-31]

1375 [T20/45:15-47:34]

403

either Mr Ku or Mr Tse, was not fully conveyed to Mr Tse during the oral consultation.1376

Even taking Mr Andy Ku’s account at face value, the alleged advice that Mr Franco Tse gave (viz. foam boards are not building works and not unauthorised building works) does not lead to the conclusion that using foam boards to cover windows was lawful. Section 16 of the Building (Construction) Regulation applies to “precautionary measures” taken during building works, regardless of whether the measure constitutes “building works.”

(iv) ICU’s failure to follow up until the day of the fire

After the 28 October 2024 inspection, ICU did not meaningfully follow up on the foam board issue despite numerous opportunities:

1. The ICU never required PC&E or Will Power to provide any certificate, test report, or material specification proving the foam boards were non-combustible or fire-retardant.

2. The ICU never asked how long hacking works on each section would take, or how long foam boards would remain affixed.

3. On 18 November 2024 (the last inspection addressing foam boards), the ICU merely asked PC&E whether it had followed up on matters promised on 28 October 2024. PC&E answered in the affirmative. The ICU did not verify this claim.1377

Mr Andy Ku’s evidence, as mentioned above, was that PC&E assured him that the foam boards were temporary and were only in place during the hacking-off works. 1378 Mr Ku acknowledged that, because no further

1376 [WS16/2200]

1377 Ku Siu Ping 2nd WS §10 [WS1/676-677]; Ku Siu Ping 3rd WS §66 [WS14/2152] 1378 Ku Siu Ping 3rd WS §§61-63 [WS14/2150-2151]

404

complaints were received after October 2024, the ICU considered there to be no “strong evidence” to contradict PC&E’s assurances. 1379 Mr Ku accepted in his oral evidence that the absence of complaints was the main reason why nothing more was done on the foam board issue.1380 To the ICU, no complaints meant there was no problem.

But the absence of further complaints was of the ICU’s own making:

1. The ICU’s reply to the complainant on 12 November 2024 asserted that no regulation required the temporary materials to be fireretardant and directed any further enquiries to the IO, management company or contractor.1381 Not only did the ICU misstate the legal position to the complainant (i.e. there is no regulation that requires foam boards to be fire-retardant), it directed the complainant back to the very parties who were the subject of the complaint.

2. The effect of this reply, as Mr Ku accepted, was that residents stopped complaining to the ICU about the foam boards.1382 There were no further complaints from residents about foam boards after 19 October 2024.1383

The upshot is that the ICU remained unaware of a state of affairs that thousands of the residents could observe daily to be contrary to what the contractor had assured the ICU.

In reality, foam boards remained affixed from around late August 2024 continuously until the fire in November 2025 – a period of approximately 15 months. Their continuous and extensive use was visible to anyone visiting the site and was widely known to all residents. PC&E’s assurance

1379 Ku Siu Ping 2nd WS §35 [WS1/686] 1380 [T22/77:8-12]

1381 [I1-4/8251]

1382 [T22/74:24-75:9, 77:23-78:10] 1383 [D1/1122]

405

to the ICU as to the temporary nature of the foam boards was false, and the falsity would have been apparent to anyone who bothered to look – as the ICU, despite multiple site visits during those 15 months, never did.

The ICU plainly had the means to investigate whether foam boards were being used more extensively and for a longer period than PC&E had claimed. All the ICU needed to do was visit Wang Fuk Court and ask any resident how many windows were covered and for how long. There was no difficulty in ascertaining the extent of the use.

Over subsequent months, the ICU received copious photographic evidence clearly showing foam boards covering windows – yet noticed nothing:

1. On 11 November 2024, the ICU received complaint photographs that showed foam boards.1384 Mr Ku admitted in hindsight he only later realised the windows were covered by foam boards.1385

2. On 21 January 2025, the ICU’s own inspection photographs plainly showed foam boards.1386 Mr Ku admitted in hindsight these were likely foam boards.1387

3. On 12 March 2025, Will Power sent the ICU a PowerPoint presentation1388 and two videos. At least 21 photographs clearly showed foam boards.1389 The videos also clearly showed foam boards.1390

1384 [I1-4/8467]

1385 Ku Siu Ping 2nd WS §7 [WS1/675-676]

1386 [I1-4/9066]

1387 Ku Siu Ping WS §16 [WS1/679]

1388 [I2/9634]

1389 [I2/9665-9666, 9668-9670, 9672, 9674-9684, 9708, 9710-9712] 1390 [I2/C(2)23B. 250312]

406

4. On 3 June 2025, the ICU’s own inspection photographs clearly showed foam boards affixed to windows. 1391 The inspection purpose (checking air-conditioning hoods) necessarily involved looking at the structures adjacent to windows.

5. On 27 June and 2 July 2025, representatives of PC&E and Will Power sent photographs via WhatsApp to the ICU, eight of these showed foam boards.1392

Despite the photographic evidence, no one at the ICU asked the obvious questions: Why are foam boards still there? How long will they remain? Has the use become permanent? How many windows are covered?

The reasons emerged in oral evidence. The ICU had kept no written record of the ICU’s discussions with PC&E, and Mr Ku accepted he may simply have forgotten it.1393 The only trigger the ICU recognised was a complaint, and its own reply had ensured that no one would complain. In this regard, the Government had to accept, in view of the evidence, that the ICU “had not followed up thoroughly on the foam board issue despite multiple inspections and documents received after October 2024”.1394

(v) Illegality of use of foam boards as window covers

The BD’s position, confirmed through multiple witnesses, is that extensive use of foam boards on external walls and windows contravenes the law:

1391 [I1-4/9083]

1392 [I1-4/8876-8880]

1393 [T22/78:21-23]

1394 Government’s Closing §589

407

1. According to Mr Yue Chak Sang of the BD: “Subject to further investigation, the extensive use of foam boards at the external walls is in contravention with the above requirements.”1395

2. Ms Karen Cheung stated at the hearing that BD considers such use does not comply with the requirements of section 16 of the Building (Construction) Regulation. 1396 She further stated that foam boards covering windows also contravened regulation 30 of the Building (Planning) Regulations (Cap. 123F) as they cannot satisfy lighting and ventilation requirements.1397

3. The Code of Practice for Fire Safety in Buildings (2011 edition), clause F5.6(f) requires: “Any inflammable and combustible materials to be kept in the building should be stored under safe custody and avoid accumulating excessive quantity.”1398 Largescale use of foam boards on windows contravenes this requirement.

4. Practice Note APP-70 (1995) requires that materials covering external walls must not obstruct natural ventilation and lighting.1399 Opaque foam boards covering windows violate this requirement and would also prevent residents from observing fire conditions outside.

Mr Andy Ku’s position in his evidence – that “we cannot deduce that the use of foam boards is a contravention of section 16 of B(C)R”1400 – is therefore contrary to the BD’s view and reflects an unduly narrow interpretation of the relevant regulations.

1395 Yue Chak Sang WS §§70-72 [WS1/836] 1396 [T20/23:20-33]

1397 [B2/547]; [T20/24:9-25:10]

1398 [B2/1159]

1399 [J1-1/688]

1400 Ku Siu Ping WS §59 [WS1/648-649]

408

Notably, Mr Ku admitted that had he known the use of foam boards was so extensive, a Cease Works Order would have been considered.1401 This admission undermines his position that the use of foam boards was not regulated – if it were truly unregulated, on what basis would a Cease Works Order be issued?

If there was any doubt about the position, the ICU could have consulted the BD. Yet, the ICU never formally referred the foam board question to the BD for its opinion, and no written record shows the ICU consulting the BD on this issue. This was despite Mr Ku’s acknowledgement that the ICU “shall defer to BD, as the prosecution authority under the BO, to consider if the use of foam boards is a contravention of section 16 of B(C)R.”1402

Furthermore, the ICU’s email to the BD on 29 October 2024 reporting on the 28 October 2024 inspection omitted any mention of the foam board issue, despite foam boards being one of the subjects of the inspection.1403 The ICU only reported on the scaffolding net test results.

On 16 March 2026, the BD issued a Circular Letter stating that:1404

1. Combustible materials (e.g. foam boards) must not be laid on external walls and windows (可燃物料（例如發泡膠板）不得

鋪設於外牆及窗戶).

2. Windows must not be covered (except brief, localised covering during specific works such as hacking using non-combustible materials), so as not to obstruct lighting and occupants’ line of sight, which would make it difficult to detect a fire.

1401 Ku Siu Ping 3rd WS §58 [WS14/2149] 1402 Ku Siu Ping WS §59 [WS1/648-649] 1403 [I1-4/8252]

1404 [B13/5718]

409

The post-fire Circular Letter confirms the BD’s position, now made explicit, that foam boards should never have been used as they were at Wang Fuk Court. The Circular Letter created no new obligation. It spelt out what the existing statutory framework, in particular section 16 of the Building (Construction) Regulation, already required.

B8. Scaffolding nets

(i) Fire-retardancy standards

Multiple regulatory instruments require scaffolding nets to possess fireretardant properties:

1. Practice Note APP-70 (1995): plastic sheeting used to cover scaffolding must possess fire-retardant properties.1405

2. The BD Circular Letter dated 21 March 2023: all protective nets, screens, tarpaulins or plastic sheeting installed to cover external walls should possess appropriate fire-retardant properties meeting recognised standards, including GB 5725-2009, BS 5867-2:2008, and NFPA 701:2019.1406

3. The BD’s Circular Letter dated 21 October 2025 (issued after the Chinachem Tower scaffolding fire): all Prescribed Building Professionals (“PBPs”) and RCs to “take immediate action to inspect and ascertain” protective materials possess appropriate fire-retardant properties.1407

1405 [J1-1/688-689] 1406 [J1-2/5915] 1407 [J1-2/6192]

410

4. According to the BD’s evidence, 1408 scaffolding nets also constitute “precautionary measures” under section 16 of the Building (Construction) Regulation.1409

5. Under section 3(1)-(2) of the Building (Construction) Regulation, PBPs (including RIs) and RCs have a responsibility to ensure scaffolding nets meet fire-retardant standards, verified through certificates from accredited laboratories.1410

(ii) Complaints about scaffolding nets

The ICU received many complaints which raised concerns about the fireretardancy of scaffolding nets:

1. On 5 October 2024, a complaint was made to the ICU and the LD about flammable scaffolding nets. The complaint explicitly accused the LD’s reply (authored by Ms Lam Sau Ching) of being “misleading to [the] public” regarding the flame retardancy requirements for scaffolding nets.1411

2. On 29 September 2025, a complaint was made by Mr Kong Cheung Fat through the 1823 system about damaged scaffolding nets following typhoons, supplemented with photographs showing differences between old and new nets.1412

3. On 23 October 2025, a follow-up complaint was made by Mr Kong, explicitly referencing the Chinachem Tower fire in Central (近日

1408 Yue Chak Sang WS §28 [WS1/819] 1409 [B2/661]

1410 Yue Chak Sang WS §35 [WS1/823] 1411 [I1-4/8255-8256]

1412 [O1/45-47]

411

中環發生棚架大火，所有棚網都助燃，另火勢一發不可收拾，

本屋苑居民十分擔心).1413

4. On 6 November 2025, a complaint was made by Mr Kong about stones falling from height and raised concerns about ageing scaffolding nets.1414

Despite these repeated and escalating warnings from residents – the final complaint arriving just three weeks before the fire – the ICU’s response remained inadequate, as detailed below.

(iii) Pre-notification of inspections and its consequences

The ICU conducted scaffolding net inspections at Wang Fuk Court on three occasions: 28 October 2024, 18 November 2024 and 28 October 2025.1415 On each occasion, Will Power and PC&E were given prior notification.

The consequences of pre-notification were demonstrated by the events of 28 October 2025. These events were addressed in earlier Chapters and are summarised again below:

1. On 27 October 2025 (one day before the inspection), the ICU’s Ms Amanda Lau notified Will Power via WhatsApp that the ICU wanted to understand the specifications and fire-retardancy of old and new nets replaced after the typhoon, and Mr Andy Ku wanted to arrange sampling tests at each block.1416

2. PC&E received notice of the inspection almost immediately. By 9:54 am, Mr Sam Tam messaged Mr Hau Wa Kin in a PC&E WhatsApp group chat, marked “not to be disclosed” (不公開), that

1413 [I1-4/8700]

1414 [O1/59-62]

1415 Ku Siu Ping WS §48 [WS1/640] 1416 [I1-4/8766-8767]

412

the ICU would attend the site the next afternoon to burn-test the nets (明天下午預 ICU到地盤預要燒棚網 check定邊啲 ok).1417

3. Mr Chan Yiu Fai stated that, on the same day, he received notice from PC&E requiring him to urgently order 115 sheets of fireretardant nets to deal with the inspection (which he assumed was an inspection by the LD).1418

Pre-notification thus directly enabled PC&E to substitute non-compliant materials with compliant ones before the inspection – precisely the outcome that surprise inspections are designed to prevent.

Mr Andy Ku’s ex post facto justification for the pre-notification was that “the RI and RC must focus their efforts and take targeted appropriate follow-up actions on the specific issue of scaffolding safety”. 1419 The explanation is unconvincing. Mr Ku himself acknowledged that the ICU’s standard practice was always to pre-notify – this was not a case-specific decision requiring special justification.

Furthermore, there is no contradiction between the need for surprise inspections and the ICU’s stated concern to ensure that the RI and RC took follow-up actions. The ICU could have: (i) conducted a surprise inspection, then directed the site foreman to assist with sampling for laboratory testing; or (ii) conducted a surprise inspection to photograph the site conditions and subsequently notified the RI of the need for laboratory testing, comparing the actual conditions observed during the surprise inspection with what was presented after notice was given.1420

That an unannounced first inspection was feasible is proved by the ICU’s first visit to Wang Fuk Court on 25 September 2024, which Mr Ku

1417 [A2/95]

1418 Chan Yiu Fai WS §17 [WS2/1439-1440]

1419 Ku Siu Ping 3rd WS §38 [WS14/2141-2142]

1420 The latter was indeed the practice of the BD [T20/32:1-16]

413

described as a “low-profile” site inspection. Mr Ku accepted that this visit was a surprise inspection.1421 Further, as stated above, the Government now accepts that the ICU’s practice of pre-notification is vulnerable to exploitation and diverges from the practices of other departments.

(iv) ICU’s quick burn tests – inadequate methodology

The ICU conducted “quick tests” (快速測試) of scaffolding nets using a

cigarette lighter on site. Ms Karen Cheung of the BD confirmed that the BD has never conducted on-site tests of scaffolding nets, because the fireretardancy testing standards require tests to be conducted in a specific controlled laboratory environment.1422

Mr Ku himself acknowledged:1423

“It is however worth noting that, unlike laboratory tests which are performed in a controlled environment in strict accordance with wellestablished standards, there is no well-recognised industry standard for conducting onsite quick tests.”

The ICU’s deviation from the BD’s practice – using scientifically unreliable quick tests instead of laboratory testing – was not justified and may have created a false sense of security for residents.

Furthermore, on all occasions where the quick tests were conducted, the ICU only tested scaffolding nets at the ground floor and rooftop – the most accessible locations. ICU never tested nets at mid-levels of the buildings.

This predictable pattern made it easy for PC&E to place compliant nets at accessible levels. PC&E needed only to ensure the ground floor and

1421 [T22/33:15-25]; [I1-4/8751]

1422 [T20/19:30-36]

1423 Ku Siu Ping 3rd WS §21 [WS14/2135-2136]

414

rooftop nets would pass. The vulnerability was compounded by the advance notice that ICU provided of its inspections.

(v) The rooftop test of 28 October 2024

On 28 October 2024, the video of the rooftop test clearly shows:1424

1. The scaffolding net caught fire after approximately 15 seconds of exposure to a lighter flame;

2. The net continued to burn on its own for approximately 10 seconds after the flame was removed; and

3. Someone blew out the fire.

The fire-retardant certificate provided by PC&E to ICU stated at item 10 that the after-flame time (續燃時間) was zero seconds, with the standard

requiring less than four seconds. Yet the observed after-flame time was at least ten seconds – completely inconsistent with the certificate.1425

Mr Ku acknowledged he was “concerned” about the first test result. However, because PC&E immediately re-tested the same sample twice without it catching fire, Mr Ku considered it acceptable: “At that time, we considered such arrangement acceptable since it is not uncommon to retest the same sample to confirm the test result after a failed attempt for the first time.”1426

However, the ICU did not consider whether the lighter positioning and distance from the net differed between the first and subsequent tests – a doubt raised by Dr Lee Wing Man in her evidence. Dr Lee opined that,

1424 [I1-4/8988] (video taken on R/F entitled “1_20241028_RF”) 1425 [I1-4/8793]

1426 Ku Siu Ping 3rd WS §26 [WS14/2137]

415

based on the overall results of the quick tests, it was worth taking the samples for a laboratory test.1427

Nor did the ICU consider that there was an inconsistency between the certificate (0 seconds after-flame) and the first quick test result (over 10 seconds), and whether that called the certificate’s authenticity into question.

The ICU’s attitude was that as long as the RI’s “assigned person” raised no concern, the ICU would not investigate.1428 ICU effectively outsourced its regulatory function to the very parties it was supposed to regulate.

On 29 October 2024, Mr Ku reported to the BD:1429

“During our inspection on 28 October 2024, the contractor provided

a test report confirming that the protective nets complying with the

requirements of the App-70 for our inspection. The RI also advised

us that on-site flame tests were conducted on the protective nets to

verify their flame retardant properties. Additionally, they performed

sampling tests during our visit to demonstrate that the nets meet flame

retardant standards as well… In light of the above, there is currently

no evidence to suggest that the protective nets do not meet the flame

retardant requirements.”

This report failed to disclose that one of three tests showed the net burning for over 10 seconds and requiring someone to blow out the flame. Had it done so, the BD may well have advised the ICU to obtain samples to conduct laboratory tests (as Dr Lee Wing Man recommended when shown the video of the ICU’s quick tests).1430

The Government now accepts that the quick test on 28 October 2024 had “room for improvement”, and emphasises that on 18 November 2024

1427 [T25/46:6-8]

1428 Ku Siu Ping WS §48(i) [WS1/642] 1429 [I1-4/8252]

1430 [T25/46:6-8]

416

follow-up quick tests were conducted.1431 However, the more appropriate follow-up action would have been to send a sample for laboratory testing (which Dr Lee Wing Man also considered worthwhile).

(vi) Failure to verify certificates (October 2024)

On the day of the 28 October 2024 inspection, PC&E provided via WhatsApp a fire-retardant certificate dated 8 January 2024.1432

The ICU’s document review consisted solely of checking whether the certificate stated compliance with GB 5725-2009.1433 The ICU conducted no further verification:

1. Contrary to the BD’s standard practice, the ICU did not verify whether the testing laboratory was a Government-designated or a Hong Kong Laboratory Accreditation Scheme (“HOKLAS”) accredited laboratory.1434

2. The ICU did not contact the laboratory to verify the certificate’s authenticity.

3. The ICU did not check (for example by verifying delivery records) whether the batch of nets in use corresponded to the certified batch.

As stated in Chapter 2, the fire-retardancy certificate submitted by PC&E may not be genuine. Mr Andy Ku accepted that, after the fire, the ICU checked the accreditation number on the certificate and noted that the difference in the name of the issuing institution (i.e. 國家勞動保護用品

質量監督檢驗中心（北京）as opposed to 國家勞動保護用品質量檢驗

1431 Government’s Closing §528 1432 [I1-4/8790-8791]

1433 [T22/51:1-3]; [I1-4/8792] 1434 [T20/18:11-26]

417

檢測中心（北京）). The ICU’s post-fire checks therefore suggest that the

certificate was not genuine.1435

The same checks which revealed to the ICU that the certificate was bogus could have been done before the fire. All they required was a desk exercise, one that the ICU in fact performed after the fire. Had that exercise been performed when the certificate was first received in October 2024, the fraud would have been exposed more than a year before the fire.

(vii) Failure to obtain certificate for new nets (October 2025)

By the 28 October 2025 inspection, the ICU was aware that scaffolding nets had been replaced following damage by Super Typhoon Ragasa. Residents had observed that the replacement nets were lighter in colour. Mr Kong Cheung Fat’s enquiry on 2 October 2025 via 1823 specifically stated that the lighter-coloured ones are newly replaced nets (淺色嘅係新

更換棚網 ). 1436 The ICU’s own photographs showed the colour

difference.1437

Despite knowing that the nets had been replaced (i.e. were a different batch from those previously certified), the ICU did not request a fire-retardant certificate for the new batch. The January 2024 certificate was obviously inapplicable to nets procured and installed in October 2025.

Mr Ku’s evidence was that the ICU “relied primarily on the test certificates” for assessing fire-retardancy.1438 Yet for the new nets, ICU never examined any certificate for the replacement nets, meaning the primary method of verification was simply not applied. This failure to inspect a new fire1435 [T22/51:26-29, 52:11-20]

1436 [O1/47]

1437 [I1-4/9100]

1438 Ku Siu Ping 3rd WS §21 [WS14/2135-2136]

418

retardant certificate is particularly significant, since (as the evidence now reveals) the new batch of replacement nets was in fact not fire-retardant.

Mr Ku’s explanation was that the ICU asked for but was not provided fireretardancy certificates for the new nets. He explained that this was because Will Power represented to the ICU that the old and new nets were provided by the same supplier and that the same certificate was used (新棚網都仲

係用舊棚網嗰份證書).1439

However, the certificate produced by PC&E was dated 8 January 2024 – nearly 22 months before the inspection and issued for nets supplied long before the typhoon replacements. The new and old nets were, moreover, visibly different in colour and translucency. There was therefore every reason to test Will Power’s representation rather than accept it at face value.

Yet Mr Ku accepted that the ICU never considered whether the certificate corresponded to the nets actually hanging on the scaffolding,1440 and took no supporting documents of any kind – no delivery notes, no supplier details.1441 A single request for documentary proof that the replacement nets came from the same manufacturer would have laid the falsity bare: the replacements had been bought from different suppliers and were expressly ordered as non-fire-retardant.

(viii) ICU’s reply to complainant (October 2025)

Following the 28 October 2025 inspection, the ICU replied to the complainant:1442

“針對你的反映，本組已聯同註冊檢驗人員進行實地視察，並向

承建商了解情況。視察發現，部分外牆保護設施仍有欠妥之處，

1439 [T22/56:19-35] 1440 [T22/50:19-24] 1441 [T22/50:33-36] 1442 [I1-4/8706]

419

包括橋板鋪設、棚架物料及棚網出現穿洞情況。根據承建商的解釋，自上個月颱風後，他們已逐步修復受損的棚架及棚網，現場可見許多棚網已更換。就上述問題，本組已指示承建商盡快完成修復，並由合資格人士檢驗及簽發證明，證實棚架安全後方可使用。”

(Our team conducted a site inspection with the RI and made enquiries with the contractor. The inspection found deficiencies including holes in scaffolding nets. According to the contractor, since last month’s typhoon they have progressively replaced damaged nets. We have instructed the contractor to complete repairs and have a qualified person certify scaffolding safety.)

The complainant’s actual question was about fire-retardancy – whether the nets could withstand fire, referencing the Chinachem Tower blaze. The ICU’s reply addressed physical damage and holes but said nothing about whether the nets met fire-retardant standards. The specific safety concern raised was therefore not addressed. The Government has acknowledged that there is room for improvement in this regard.1443

(ix) Post-fire developments (PNRC 85)

On 19 December 2025, the BD issued Practice Note for Registered Contractors (“PNRC”) 85, introducing a new regime to address the problem of fraudulent test reports:1444

1. Before any protective materials are installed, the RC must arrange a third party to randomly sample materials and submit them to a Government-designated, HOKLAS accredited laboratory. 1445 Currently 17 such laboratories hold this designation.

1443 Government’s Closing §539 1444 [J1-2/6200]

1445 [J1-2/6202]

420

2. If any sample fails, the entire batch cannot be used.1446

3. The BD will conduct site inspections by randomly selecting samples from different floors and different positions, and sending them to Government laboratories for testing.1447

This regime is significantly more rigorous than the pre-fire system adopted by the ICU, which was wholly inadequate.

B9. Summary of the ICU’s failures

The evidence demonstrates that the ICU’s failures in relation to the Wang Fuk Court fire were systemic and multi-faceted:

1. Systemic failure to conduct site inspections: the ICU had no mechanism for site safety inspections during the construction phase. The only trigger for site visits was complaints from the public – yet the complaints were handled inadequately.

2. Total detachment from the RI: the ICU never met, contacted, or verified the existence or involvement of the RI, and failed to treat obvious red flags as cause for scrutiny.

3. Volume of warnings ignored: the ICU received numerous complaints and enquiries about fire safety concerns at Wang Fuk Court. Despite this, the ICU failed to identify or address any of the fire risks that materialised on the day of the fire.

4. Failure to detect worker access openings: despite clear photographic evidence of worker access openings in the MW01 submissions, the MW Team failed to notice a breach of fire safety.

1446 [J1-2/6203] 1447 [J1-2/6203]

421

5. Failure to address foam board use: the ICU accepted PC&E’s assurance that the foam boards were temporary protection used only during hacking-off works – a falsehood laid bare by the conditions on site and by copious photographic evidence. The ICU never followed up, relying on the fact that residents had ceased to complain. But their silence was of the ICU’s own making: the ICU deterred residents from complaining by telling them that the foam boards were not regulated, a position which was wrong in law.

6. Inadequate scaffolding net inspections: the ICU pre-notified inspections, failed to verify certificates and failed to request certificates for replacement nets.

7. Communication failures with BD: the ICU remained ignorant of the BD’s site safety inspection policy for nearly three years, failed to adopt the BD’s surprise inspection practice, took a different view from the BD’s view on the legality of foam boards, and adopted a quick on-site burning test for scaffolding nets that was unreliable, unscientific and not used by the BD.

These failures collectively meant that the ICU provided no effective regulatory oversight of the Wang Fuk Court renovation during the critical construction period. Residents repeatedly raised concerns but the ICU repeatedly failed to investigate. In light of the causative impact of the nonfire-retardant safety nets and worker access openings on the heavy casualties at Wang Fuk Court in particular (see Chapters 2 and 4), the consequences of these systemic failures were catastrophic.

C. The Buildings Department (BD)

C1. BD’s role, delegation to ICU, and duty of oversight

The BD is the principal authority responsible for building control in Hong Kong. The BD administers the Buildings Ordinance (Cap. 123) and its

422

subsidiary legislation, including the Building (Construction) Regulation (Cap. 123Q).

As explained above, the BD has delegated its building control powers to the ICU pursuant to formal Delegation Instruments.1448

The MOU dated 1 July 2022 establishes mechanisms to ensure the ICU maintains the BD’s standards:1449

1. The BD seconds three senior professional officers permanently to ICU to perform bridging functions (Clause 3.1). Ms Karen Cheung also described their role as a bridge ensuring consistency between the two organisations.1450

2. The ICU submits progress reports every six months (Clause 3.2).

3. The BD “may conduct audit checks on ICU when necessary” (Clause 3.2).1451

Ms Karen Cheung confirmed that the BD itself had no participation in monitoring PC&E or Will Power during the BMR Works at Wang Fuk Court. The supervision of the RC and RI was entirely the ICU’s responsibility.1452

However, delegation does not absolve the delegator. Ms Karen Cheung agreed the purpose of the MOU mechanisms was to ensure that the ICU’s standards remained consistent with those of the BD.1453 The BD therefore

1448 [T20/12:22-31] 1449 [J1-1/2043] 1450 [T20/14:1-8] 1451 [J1-1/2047] 1452 [T20/14:21-28] 1453 [T20/13:32-34]

423

bears responsibility in terms of policy formulation and proper supervision over the ICU.

C2. BD’s failure to audit ICU or communicate policies

(i) BD never audited ICU

Under Clause 3.2 of the MOU, the BD may conduct audit checks on the ICU when necessary to ensure consistency of standards. Ms Karen Cheung confirmed that, to her knowledge, the BD had never audited the ICU’s MBIS work (據我嘅認知，譬如好似係嗰個強制驗樓底下，我哋冇抽

佢哋啲工作嚟做 [audit] 嘅).1454

When asked why, given the MOU expressly provides for such audits, Ms Cheung could not answer (呢個位置我答唔到).1455

Mr Rudolf Lau also agreed that, to his knowledge, the BD had never audited the ICU’s MBIS work.1456

It follows that the BD did not exercise its audit function under the MOU as far as MBIS work was concerned, and the ICU did not proactively seek a review of its practices to ensure alignment with the BD.

Had the BD exercised its audit function at any point, it would likely have discovered the ICU’s systemic deficiencies as identified above, including conducting zero site safety inspections during Class I minor works and providing pre-notification of complaint inspections.

1454 [T20/35:5-6] 1455 [T20/35:11]

1456 [T24/40:21-41:3]

424

(ii) BD failed to communicate the 2023 policy

As stated above, the ICU’s evidence is that the ICU only learned on 22 December 2025 that the BD had adopted a policy in April 2023 of selecting 20% of Class I MW with supervision plans for site safety inspections.1457 The evidence of Mr Nick Yung was that, had the ICU known of this policy, there was a “fairly high chance” the worker access openings would have been detected through site inspections.1458

When shown the ICU’s evidence, Ms Karen Cheung acknowledged that better communication would have been desirable, but could not explain why the ICU did not know about the BD’s site supervision policy.1459 No good reason has been provided for the failure to communicate BD’s site supervision policy to the ICU.

C3. BD’s classification of major renovation as minor works

(i) Minor Works Control System – classification problem

The Wang Fuk Court renovation, with a total value of approximately HK$330 million and involving the full external wall renovation of eight blocks of high-rise residential buildings occupied throughout by thousands of residents, was classified as minor works rather than major works requiring the ICU’s approval and consent.

The BD’s Site Monitoring Section Manual, Section 2, Instruction No. 11 classifies external A&A works requiring the “renovation of the whole building including exterior facade” as a “high-risk” site.1460 Yet the same works at Wang Fuk Court were treated as lower-risk minor works.

1457 Yung Siu Lun WS §42 [WS1/670-671] 1458 Yung Siu Lun WS §43 [WS1/671] 1459 [T20/30:6-10]

1460 [I3/9878-9879]

425

Ms Karen Cheung explained that the simplified minor works procedure existed to facilitate owners (便利業主).1461 The objective is certainly

legitimate for genuinely minor works. But applied to the BMR Works at Wang Fuk Court, the classification removed the prior-approval and supervision safeguards that a project with this level of risk demanded.

As the learned Chairman observed, the large-scale renovation at Wang Fuk Court was a most dangerous type of works because people were living inside the works site, yet the applicable oversight might be more relaxed than that for a construction site for a new building – where no one lives at all.1462 Ms Cheung acknowledged this concern.

The classification of the BMR Works as minor works troubled the Committee. Dr Rex Auyeung pressed the BD on whether a project of this scale ought properly to be characterised as minor works, given that this distinction bore directly on the level of prior approval and supervision required.1463

In response to Dr Rex Auyeung’s question, Ms Karen Cheung confirmed that post-fire legislative amendments would elevate large-scale BMR Works to Class I minor works, which would1464:

1. Require supervision by a third-party AP independent of the RC;

2. Require submission of specified plans detailing work procedures and protective measures; and

3. Require BD/ICU approval before commencement.1465

1461 [T20/36:32-37:6] 1462 [T20/37:21-24] 1463 [T20/36:36]

1464 [T20/37:9-13] 1465 [T20/8:3-11]

426

In short, as Ms Cheung stated, the post-amendment regime for Class I minor works would be significantly more stringent. Significantly, she accepted that the reformed regime would in effect resemble the approval and consent regime.1466 The reforms are welcome, but every safeguard now being introduced is one that was absent while eight occupied towers stood wrapped in bamboo, scaffolding nets and foam boards for over a year.

C4. BD relied on fire-retardancy certificates for scaffolding nets

Ms Karen Cheung confirmed that, before the fire, the BD’s own practice for scaffolding nets was limited to reviewing certificates, it conducted no site sampling for subsequent laboratory testing. Her evidence was understood to mean that, before the fire, the BD would check which laboratory had issued the certificate and whether it was HOKLASaccredited or covered by mutual recognition.1467 This description of the BD’s pre-fire practice was put to Mr Ku, who did not dispute it, though he noted that it was not stated in the guidelines or Practice Notes issued by the BD before the fire.1468

Even that limited check was not without value. Had the BD been the responsible department and received the certificate produced by PC&E, checking the issuing institution against the accreditation register may well have exposed the fraud, since the named institution had ceased to exist under that name years before the certificate was issued.

Nevertheless, the limits of any paper-based checks must be acknowledged. Had a spurious certificate correctly stated the name of an accrediting testing laboratory on its face, the BD’s pre-fire practice would not have detected the fraud either. That is why meaningful verification requires what neither the BD nor the ICU did before the fire, sampling the nets actually

1466 [T20/37:9-13]

1467 [T20/17:16-18, 18:11-32] 1468 [T22/53:2-11]

427

hanging on the building and testing them in a laboratory, and it is what the post-fire regime now requires.

Systematic verification by the BD only came after the fire. The BD discovered fraudulent certificates across multiple buildings, leading to nets being ordered to be removed from some 230 private buildings. The BD subsequently introduced a new mechanism for verifying certificates as set out in PNRC 85.1469

C5. BD's institutional responsibility – conclusion

The BD’s shortcomings that are directly material to this fire can be summarised as follows:

1. Never auditing the ICU: Despite the MOU’s audit provision, the BD never exercised this power in respect of MBIS works. This allowed the ICU’s systemic deficiencies to persist undetected.

2. Failing to communicate policies: the BD did not inform the ICU of the 2023 site safety inspection policy. As a result, the ICU did not adopt a mechanism that might have detected the worker access openings.

3. Failure of the bridging function: Three BD staff were stationed at the ICU to ensure consistency. Yet the ICU adopted practices that were inconsistent with the BD’s own approach.

4. Under-classification of minor works: the BD’s policy of treating large-scale renovation as minor works created a structurally inadequate regulatory framework.

The post-fire reforms by the BD, including PNRC 85 (laboratory testing and site sampling for scaffolding nets), the March 2026 Circular Letter

1469 Yue Chak Sang WS §53 [WS1/829]; [J1-2/6205]

428

(prohibiting foam boards) and pre-commencement approval of minor works involving large-scale BMR Works, collectively confirm that the prefire framework was inadequate. The BD bears institutional responsibility both for the inadequacy of its own standards and for its inability to ensure the ICU – operating under delegated authority – maintained even those standards that the BD did have.

Finally, Section D5 below examines how the risk of fire in large-scale BMR Works of buildings occupied by residents was foreseeable. Wang Fuk Court was not the first rapid vertical fire on a combustible building façade. Grenfell Tower in 2017 was a most prominent recent example. The central lesson from Grenfell Tower, that combustible material on the exterior of an occupied high-rise building can turn a localised fire into a catastrophe, had been studied by the BD and the FSD.

The hazards at Wang Fuk Court went unabated not because they were novel, but because no department (the BD included) appreciated that the same phenomenon could recur in building renovation works. 1470 The failure to foresee the foreseeable is as much the responsibility of the BD as of the FSD.

D. The Fire Services Department (FSD)

D1. FSD’s overall role and statutory responsibility

(i) Statutory duties

The FSD bears broad statutory duties under the Fire Services Ordinance (Cap. 95). Section 7 provides:1471

“The duties of the Fire Services Department shall be to – (a) extinguish fires; (b) protect life and property in case of fire or other

1470 [T27/9:22-25, 11:14-12:9] 1471 [B2/82]

429

calamity; (c) give advice on fire protection measures and fire hazards as occasion requires…”

“Fire hazard” is defined broadly in section 2 to include:1472

“(f) any other matter or circumstance which materially increases the likelihood of fire or other calamity or the danger to life or property that would result from the outbreak of fire or the occurrence of any other calamity, or which would materially hamper the Fire Services Department in the discharge of its duties in the event of fire or other calamity.”

The FSD possesses express enforcement powers:

1. Section 8(1)(c) of the Fire Services Ordinance (Cap. 95): the Director of Fire Services may enter any premises at all reasonable times to ascertain whether a fire hazard exists.1473

2. Section 9: the Director of Fire Services may serve a Fire Hazard Abatement Notice (“FHAN”) requiring any person to abate a fire hazard.1474

3. Section 4 of the Fire Services (Fire Hazard Abatement) Regulation (Cap. 95F): if the person fails to abate the hazard, the Director of Fire Services may carry out works necessary to abate it.1475

The Director of Fire Services, Yeung Yan Kin Andy, confirmed in his oral evidence the breadth of these powers. He agreed that the section 8(1)(c) entry power was one that other departments may not have (其他部門未必

有).1476 He agreed that where a building’s common areas hold a large

1472 [B2/77]

1473 [B2/83]

1474 [B2/89]

1475 [B2/190]; [T19/21:17-22] 1476 [T19/20:28-36]

430

quantity of combustible material, the FSD is the department empowered to take enforcement action by serving a FHAN under section 9.1477

Under regulation 8 of the Fire Service (Installations and Equipment) Regulations (Cap. 95B), the legal responsibility for maintaining FSI (fire service installations) in efficient working order rests on the building owner. Owners must engage an RFSIC (registered fire service installation contractor) to inspect FSI at least once every 12 months.1478

The FSD’s primary mechanism for monitoring RFSICs is the FS251 certificate: after inspection, an RFSIC must issue a certificate within 14 days stating whether the system is in efficient working order and forward a copy to the Director.1479

(ii) FSD’s powers are not limited to active FSIs

In U Storage Group Ltd v Director of Fire Services [2020] HKCFI 2114, Mr Justice Wilson Chan rejected the argument that FSD’s powers were confined to FSI or non-building works. The learned Judge held that:1480

1. It is readily apparent from the Long Title and section 7 of the Fire Services Ordinance that the Director of Fire Services has extensive and comprehensive duties and powers to safeguard and promote fire safety. Such duties and powers are not confined to fire service installation and equipment or ‘non-building works’ (at §38).1481

1477 [T19/21:1-16]

1478 Keung Sai Ming WS §§ 5.3.1, 5.5.1 [WS1/104-105, 108] 1479 Keung Sai Ming WS §5.4.2 [WS1/106]

1480 [A5/769]

1481 [A5/792]

431

2. Section 2 of the Fire Services Ordinance is deliberately couched in wide terms to cater for fire hazards which may arise from different and constantly evolving circumstances (at §47).1482

3. While it is true that the BD has a role to play in fire safety in buildings, it does not follow that the Director of Fire Services need not concern itself with the same subject matter (at §57).1483 In this regard, the BD does not possess the requisite expertise to determine, for example, what would “materially hamper the FSD in the discharge of its duties in the event of fire” (at §52).1484

4. According to the FSD’s submissions to the Court, the Director of Fire Services is the statutory body having the expertise in extinguishing fires and giving advice on fire protection and measures and fire hazards. The Director of Fire Services is exclusively tasked with applying its expert knowledge to devise appropriate fire abatement measures (at §134(1)).1485

The Director of Fire Services, Yeung Yan Kin Andy, was taken through this judgment on Day 19.

1. He agreed that the applicant in the judicial review had argued that the FSD’s powers were confined to fire-service installations and equipment, and that the Court had accepted the FSD’s submission that the fire-hazard definition was broad enough to cover the structure and compartmentation of premises.1486

2. He agreed that the fire hazards present in mini-storages (blocked windows, poor fire separation, locked escape routes) were not

1482 [A5/796]

1483 [A5/802-803] 1484 [A5/799]

1485 [A5/837]

1486 [T19/23:22-36]

432

exclusively within the BD’s remit and fell within the FSD’s jurisdiction as well.1487

3. He agreed that it would not be right to rigidly state that passive FSIs did not fall within the FSD’s jurisdiction.1488

(iii) FSD’s division of labour with BD

Despite these broad powers, the FSD’s evidence is that it had a clear division of labour with the BD.

Mr Michael Yung testified that all building materials (scaffolding nets, foam boards) and passive FSIs (e.g. staircases) were the responsibility of the BD/ICU:

1. His evidence was categorical: residents’ concerns about the foam boards, the scaffolding nets and the staircase access openings should all go to the ICU.1489

2. He agreed that the division of labour was not discernible from the Fire Services Ordinance.1490

3. However, Mr Yung accepted that a propped-open smoke door (a passive fire provision) would be dealt with by the FSD as a fire hazard.1491 This appears to contradict his categorical evidence that passive FSIs would be dealt with by the BD/ICU.

The evidence of the Director of Fire Services, Yeung Yan Kin Andy, was more nuanced:

1487 [T19/23:14-19] 1488 [T19/27:11-14] 1489 [T17/3:19-33] 1490 [T17/15:21-24] 1491 [T17/6:12-13]

433

1. Although he did not disclaim FSD jurisdiction over foam boards and worker access openings, his evidence was that the responsibility of enforcement rested with the BD. He distinguished the mini-storage case on the basis that a genuine legal vacuum existed (法例真空 ) in that case, so the FSD and BD had to

complement one another.1492 In contrast, foam boards and access openings were already regulated by the BD under its Code of Practice for Fire Safety in Buildings 2011 (2024 edition) (“FS Code”), so the FSD’s enforcement would duplicate with the BD’s role.1493

2. Nevertheless, he accepted that the FSD could regulate these matters and would not mind bearing the responsibility if the division of labour were so agreed.1494

Counsel for the Government also sought to establish that the division of labour between the FSD and the BD was properly documented.

1. Mr Michael Yung was taken to the FS Code, and its distinction between active and passive fire safety provisions.1495 His evidence was that the division of work could be seen from the FS Code.1496

2. Mr Yung was also taken to a standard memo template for referrals of unauthorised building works by the FSD to the BD. One of the matters for referral was an “opening in staircase enclosure”.1497

1492 [T19/38:14-17] 1493 [T19/26:26-27] 1494 [T19/27:7-10] 1495 [B2/1154]

1496 [T17/27:23-29:22] 1497 [B6/4469]

434

Mr Yung stated that, if FSD colleagues became aware of such an issue, they would refer it to the BD.1498

3. When asked whether there was a relatively clear division of responsibility under the Fire Services Ordinance, the FS Code and the inter-departmental memos, the Director of Fire Services agreed.1499

The Committee is invited to consider whether this division of labour is adequate to address fire-safety risks, and whether the documentation in fact supports a division as clear as the witnesses asserted:

1. The materials relied on are the BD’s FS Code and the FSD’s referral templates. The Government has not identified any joint memorandum or agreement executed by both departments that records the agreed division of enforcement responsibility between the FSD and BD/ICU.

2. Even if such an instrument existed, the division of labour would only be known to the departments, not the public. As Dr Rex Auyeung noted that, while the FSD would naturally be an ordinary citizen’s first port of call on fire safety, an ordinary member of the public would never know of the allocation of duties between departments.1500

3. The learned Chairman similarly observed that fire safety issues in the present case had fallen into a grey area.1501 Mr Chan Kin Por asked whether there could be a system with somebody ultimately responsible (兜底嘅制度), as otherwise a complaint could be

1498 [T17/27:23-29:22] 1499 [T19/45:4-14] 1500 [T17/26:12-17] 1501 [T17/16:24-25]

435

passed from one department to another without anyone actually dealing with it.1502

4. These concerns were well-founded. Whatever the precise allocation between the FSD and BD/ICU, the evidence in this Chapter shows that fire-safety risks at Wang Fuk Court fell into a vacuum in practice.

5. Take one template item as an example: the “opening in staircase enclosure”. 1503 The referral mechanism presupposes the FSD noticed something to refer to the BD. It can work only if the FSD has first inspected the staircase, looked for fire hazards, and identified the access opening. Otherwise, there is nothing to refer.

6. If anything, the “opening in staircase enclosure” entry in the FSD’s own referral template is an acknowledgment that such openings were the FSD’s business to spot, and the BD’s to remedy. However, as the evidence analysed below shows, the FSD did not once inspect the staircases at Wang Fuk Court over its 26 visits. The referral mechanism was never engaged at all.

7. That the BD may be better placed to take enforcement action does not diminish the FSD’s duty to conduct routine inspections apt to detect fire hazards, including of passive fire safety provisions and construction materials. Overlapping vigilance is a feature of a sound system. As Professor Usmani opined in a different context, the more eyes on potential fire risks, the greater the likelihood of early fire detection.1504

The practical consequence is that, because the FSD treated the foam boards and staircase access openings as outside its concern, it never looked for

1502 [T17/27:3-6]

1503 [B6/4469]

1504 IC Expert Report §7.4.4 [ER3/2255]

436

these fire hazards at Wang Fuk Court. Had the FSD inspected the staircases on any of its 26 visits, it could not have missed the worker access openings, and having seen them, it would have had two courses open: abate the fire hazard itself or refer it to the BD under its referral template.

D2. FSD’s handling of complaints

(i) The classification system

The FSD’s complaint-handling system required initial classification of all incoming communications as either a complaint (requiring site inspection) or an enquiry. The practical effect of classifying a matter as an “enquiry” was that FSD would not attend the premises.1505

The FSD’s Departmental Policy Instructions defined “Complaints about Fire Safety Matters” as “reports on or allegations of fire hazard or breach of dangerous goods/fire safety legislation which require investigation”.1506 Matters falling outside this definition were classified as “enquiries” and received no site attendance.

High-priority complaints – those “alleging imminent danger arising from a situation where in the event of a fire, occupants… may not be able to escape to a place of safety” – had to be investigated within 24 hours.1507

(ii) Foam board complaints – FSD disclaimed jurisdiction

The FSD received multiple complaints about flammable foam boards at Wang Fuk Court. In every case, FSD either disclaimed jurisdiction, took no substantive action, or closed the case without meaningful investigation. The following are non-exhaustive examples of such complaints:

1505 Fok Chun Ming 2nd WS §§5-8 [WS2/1042-1044] 1506 [B2/2168]

1507 [B2/2172]

437

Date

Complaint

FSD’s response / follow-up

13 Sep 2024 Obstruction of means of escape by foam board.1508

FSD inspected the same day,

found construction materials

outside Wang Chi House, but

concluded: “the location is not a MoE or EVA. As such, the

complaint is not justified”.1509

FSD provided unspecified “fire safety advice” to the management office and closed the case. FSD ignored the fire hazard posed by large quantities of foam boards.

13 Sep 2024 The risk of covering windows with foam board.1510

FSD’s operator replied: there is no specific regulation regulating

materials covering windows.

18 Sep 2024 Complaint about “fire danger

concerns” (火警危險擔憂),

stating that residents had tested foam board fragments and found them to be flammable. Asked

whether FSD had guidelines and whether the arrangement met fire safety standards.1511

Inspected on 25 September (i.e.

more than one week later), noted “no FS irregularities were noted at scene,” and closed the case on 3 October 2024. FSD’s inspection did not assess the foam boards’

flammability or the fire hazard

raised.

30 Sep 2024 Same complainant as 13

September 2024 called again. FSD gave the same answer and directed him to enquire with the BD.1512

FSD maintained its position that foam boards were not its concern, directing the resident to the BD.

4 Oct 2024 Email from Vice Chairman of

the Management Committee

(Benny Mak) to FSD stating:

“With most of the windows

covered by Foamboard, we are at high risks as the Foamboard is

found to be highly flammable,

Telephone reply on 6 October,

advising complainant to “seek

professional advice from the BD” gave unspecified “fire safety

advice,” and took no further

action.1514 FSD classified this as an “enquiry” rather than a

1508 [B2/1737-1739]

1509 [B2/1737]

1510 [B7/4538-4539]

1511 [B2/1337-1352]

1512 [B7/4540-4541]

1514 Ng Wing Kwong WS §§ 6-7 [WS2/1056]

438

Date

Complaint

FSD’s response / follow-up

coupled with the smoking hazard posed [by] the artisans. We

desperately need your help on

site inspection, materials

testing.”1513

“complaint”, meaning no site inspection was conducted.

16 Oct 2024 Enquiry by phone about foam boards covering all windows of his unit. FSD replied

approximately two weeks later that “there is no regulation

regulating window covers.”1515

FSD’s position appears to be that there is no record of this complaint or enquiry.

(iii) Smoking complaints – jurisdictional confusion

The FSD received multiple complaints about workers smoking on scaffolding. The following are non-exhaustive examples:

Date

Complaint

FSD’s response / follow-up

20 July 2024 A citizen complained through the government’s occupational

safety and health (OSH)

complaint platform about

workers smoking on scaffolding. LD forwarded it to FSD on 22

July because it involved fire

risk.1516

FSD rejected the complaint on the same day: “the subject matter is not under the jurisdiction of FSD. You may wish to refer the case to the relevant department”.1517

11 Aug 2024 Email to ICU (and apparently FSD) complaining about

smoking at the construction site.1518

FSD replied the same day that

smoking was the Department of Health Tobacco Control Office’s responsibility.1519

11 Oct 2024 Email to FSD about fire risks including worker smoking and

FSD’s response: SStnO Hui contacted complainant by

1513 [B6/4506-4508] 1515 [IE1/199-203] 1516 [B6/4495-4501] 1517 [B6/4495]

1518 [I1-4/8199] 1519 [B12/5710]

439

Date

Complaint

FSD’s response / follow-up

leftover garbage on scaffolding.1520

telephone, “advised them to step up security patrols and strengthen renovation site management by

prohibiting smoking among

workers”.1521 FSD did not visit the site, did not refer the matter to LD, and took no enforcement action.

12 Nov 2025 Just two weeks before the fire, a Wang Cheong House resident

emailed multiple departments

including FSD, attaching

photographs of workers smoking on scaffolding. He expressed fear of a “scaffolding fire”.1522

FSD replied on 14 November:

“site safety” and “smoking

activities” at construction sites

“are not within the jurisdiction of FSD”.1523 FSD did not refer the complaint to another department, noting that the email had been

copied to LD and the Tobacco

Control Office.

The treatment of smoking complaints exemplifies the departmental merrygo-round. Confronted with complaints that workers were smoking on the scaffolding, on a site wrapped in combustible netting, foam boards and bamboo, the FSD’s responses followed no consistent principle. Sometimes the FSD said smoking was the LD’s responsibility, sometimes it said it was the Tobacco Control Office’s issue, and sometimes it declined to act or even refer the complaint elsewhere. When the LD referred one case to the FSD as involving fire risk, the FSD rejected the referral. The result was that every complaint to the FSD about smoking fell through the cracks, and no department took any effective action against what proved to be the most likely cause of the fire.

1520 [B6/4509-4511]

1521 Hor Herman WS §11 [WS2/1053]; [B6/4508] 1522 [B6/4512-4513]

1523 [B6/4512]

440

(iv) Fire escape route complaints

The FSD received numerous complaints about obstruction of fire escape routes at Wang Fuk Court from 2022 to 2024, including on 7 May 2022,1524 12 May 2022,1525 16 May 2022,1526 12 January 2023,1527 6 June 2023,1528 20 July 2023, 1529 2 September 2024, 1530 2 September 2024, 1531 17 November 2024,1532 19 November 2024,1533 23 December 2024.1534

There is no evidence that the FSD, in response to any of these complaints, inspected the staircases. The staircase access openings, which posed an imminent danger to occupants, were never detected by any department.

(v) Summary: pattern of complaint handling failures

The complaint record reveals a consistent pattern:

1. Foam board complaints (at least seven complaints/enquiries to FSD between September and October 2024): FSD disclaimed jurisdiction in every case, told residents to contact the BD or the LD, and never investigated the fire hazard.

2. Smoking complaints (at least five to FSD between July 2024 and November 2025): the FSD handled these inconsistently, but never

1524 [B2/1711-1715] 1525 [B2/1716-1728] 1526 [B2/1729-1730] 1527 [B2/1520-1532] 1528 [B2/1586-1594] 1529 [B2/1733-1736] 1530 [B2/1378-1380] 1531 [B2/1381-1383] 1532 [B2/1353-1366] 1533 [B2/1386-1387] 1534 [B2/1674-1676]

441

conducted enforcement action or site visit specifically to address the smoking risk.

3. Fire escape complaints (at least 12 to FSD between 2022 and 2024): the FSD inspected some but found no obstruction. The worker access openings were never detected.

The FSD’s Assistant Director Keung Sai Ming agreed, in response to a question from the Chairman, that the fire risks during large-scale BMR Works are close to the highest there is (大維修工程入面，其實個火警風

險係差唔多最高).1535

Nevertheless, the FSD’s complaint-handling system treated most fire safety concerns raised by Wang Fuk Court residents as either outside its jurisdiction or unsubstantiated. What the responses never displayed was an appreciation of the cumulative fire hazard that the complaints were describing: eight occupied high-rise buildings shrouded in a combustible envelope of bamboo, scaffolding nets, foam boards and flammable waste, in which a single lit cigarette could bring about catastrophe. No one from the FSD appears to have considered what the complaints, taken together, were saying about the fire hazards at the site.

It is right to acknowledge that this assessment is made with a measure of hindsight. But the risk did not require hindsight to see. As Professor Usmani opined, the risk was foreseeable but not foreseen.1536

1535 [T10/51:31-33] 1536 [T27/70:5-9]

442

D3. FSD’s failure in monitoring FSI shutdown

(i) How the fire hydrant/hose reel system works

Each block at Wang Fuk Court had an FH/HR system (fire hydrant and hose reel system) comprising:

1. A ground-level FS Transfer Tank (2,000 litres), connected to the mains water supply;

2. An FS Water Pump (消防上水泵) that pumps water from the FS Transfer Tank to the rooftop FS Tank;

3. A rooftop FS Tank (18,200 litres) that directly supplies water to fire hoses on each floor; and

4. An FS Booster Pump (消防加壓泵) that ensures adequate water pressure throughout the building.1537

As explained in Chapter 2, the FS Pump Room in each block had a single master power switch (刀掣) that simultaneously controlled power to both the FH/HR system and the FAS (Fire Alarm System). Switching this main switch to “OFF” deactivated both systems simultaneously.1538

The control panel also had two separate “Pump Isolator” switches, which could independently interrupt power to the two pumps of the FH/HR system while leaving the FAS operational. It was therefore possible to shut down the FH/HR system by switching off the pump isolators, without affecting the FAS.1539

1537 [B11/5628-5633]

1538 Keung Sai Ming WS §10.3 [WS1/138] 1539 Keung Sai Ming WS §10.3 [WS1/138]

443

The interconnected power supply was a design mandated by the 1982 Code of Practice. It required the fire alarm operating means to be “interconnected with the means of operating fixed fire pumps of fire hydrant/hose reel installations.”1540

(ii) The master power switch was incorrectly turned off

Post-fire investigation revealed that in seven of the eight blocks, the master power switch in the FS Pump Room was in the “OFF” position. This meant that both the FH/HR system and the FAS were deactivated.1541

Chapter 2 addressed how ISS’s electrician, Mr Law Kwok Shui, assisted with draining the FS Tank by turning off the master power switch, not noticing that this deactivated the FAS. Mr Law was not an RFSIC, and was not qualified to operate the master power switch.

If the work had been conducted by or supervised by an RFSIC, the contractor would have known to use the pump isolator switches to shut down the FH/HR system, leaving the FAS operational. Assistant Director Keung confirmed that what Mr Law had done was an elementary error.1542

The FSD’s Code of Practice for Inspection, Testing and Maintenance of Installations and Equipment (2022 edition) (“2022 Code of Practice”), Appendix 4 requires warning labels to be affixed near main switches that simultaneously control the fire alarm system, stating: “Warning: this switch simultaneously controls the fire alarm system power supply” (at §3.8.2).1543

1540 [T10/15:18-16:13]

1541 Keung Sai Ming WS §10.3 [WS1/138] 1542 [T10/10:24-26]

1543 [B2/919]

444

No such warning label was present at Wang Fuk Court. If it had been, ISS staff or the contractor might have realised that turning off the main switch would deactivate the fire alarm.

The FSD’s position is that the labelling requirement under the 2022 Code of Practice did not apply to Wang Fuk Court.1544

However, §1.14 of the 2022 Code of Practice distinguishes between: (i) “provision and specification of FSIs” (which follows the Code of Practice in force when building plans were first submitted); and (ii) “inspection, testing and maintenance” (which follows the current Code of Practice).1545 Since the labelling requirement appears in Appendix 4 and relates to maintenance and inspection, on one interpretation of the 2022 Code of Practice, it should apply to all buildings regardless of age.

Whatever the correct legal position may have been, the FSD accepted that a warning label would have reduced the chances of unqualified personnel accidentally turning off the master power switch.1546

That being the case, the FSD should issue clearer guidance to require warning labels on all buildings, regardless of age, where a single power switch controls both the FH/HR and FAS systems.

(iii) The SDN system – structural deficiencies

The Shutdown Notice (SDN) system is governed by Circular Letter No. 1/2021. Its stated purpose is to ensure the FSD is “promptly notified of the FSI shutdown so that the units of the FSD may formulate appropriate

1544 [T10/78:36-79:4] 1545 [B2/883]

1546 [T10/79:5-13]

445

contingency plan and advise the owners/occupiers… to take additional fire safety measures during the shutdown period.”1547

However, the system was merely a notification system – not an approval system.1548 The RFSIC did not need FSD’s permission to shut down or extend the shutdown. The RFSIC bore the ultimate responsibility for the shutdown.

The system’s structural deficiencies included the following:

1. If the RFSIC’s SDN stated only that the FH/HR system was shut down, but the FAS had also been affected, the FSD would not know. The FSD’s working assumption was that systems not mentioned in the SDN remained operational.

2. The FSD did not verify whether the reason given by the RFSIC for shutdown (e.g. water tank leakage reported in FS251 certificates) was accurate. The risk assessment visits at Wang Fuk Court did not include checking the water tank.

3. SDN extensions could be filed repeatedly, 14 days at a time, without the FSD demanding justification or evidence of progress in repairing the FSI shutdown.

The evidence of Director of Fire Services Yeung Yan Kin Andy confirmed the loopholes with the SDN system. He accepted that the structural reliance on the RFSIC’s self-report was defective. He accepted that, before 2026, the FSD relied on the RFSIC that filed the SDN to tell it whether one or two systems were affected. 1549 He confirmed that where a colleague attended the scene following the receipt of an SDN, the focus was on the alternative measures (for example, whether fire extinguishers had been

1547 [B2/1302]

1548 Keung Sai Ming 4th WS §9 [WS8/1911] 1549 [T19/41:3-4]

446

positioned) rather than on the installation being shut down itself.1550 The Government also now accepts that these are weaknesses in the supervisory mechanism.1551

The Director described the following reforms to the SDN system since the fire: (i) the FSD will scrutinise every incoming SDN for the reason for the shutdown, (ii) mandating the filing of an electronic FS251 certificate within 14 days and linking that with the SDN, (iii) enquiring into whether extensions of shutdown are justified; (iv) imposing a 60-day indicative upper limit for extensions of shutdowns, beyond which the FSD may issue a FHAN,1552 and (v) on attendance, the FSD checking the affected systems rather than relying on the RFSIC.1553

Importantly, Assistant Director Keung Sai Ming confirmed that legislative amendments will be introduced to convert the SDN regime from a notification system to one requiring the FSD’s prior approval for the shutdown of fire service installations.1554

Each reform answers a deficiency that existed at the time of the Wang Fuk Court works. These will be addressed below.

(iv) FSD’s on-site risk assessment visits inadequate

The FSD’s Departmental Policy Instructions DPI/IV/4.2.16 require that following receipt of an SDN, the local fire station conducts an “on-site risk assessment” within 24 hours.1555

1550 [T19/33:9-11]

1551 Government’s Closing §760

1552 [T19/45:33-46:5]

1553 [T19/41:21]

1554 [T10/19:1-4]

1555 [B2/2186]; Keung Sai Ming WS §§6.3, 8.3 [WS1/111, 120]

447

In practice, these “risk assessments” at Wang Fuk Court involved no more than:

1. A telephone call to the RFSIC asking about the situation;

2. A visit to deliver a standard advisory letter to the management office; and

3. A check of whether fire extinguishers had been placed on alternate floors.

Statements from FSD officers who carried out on-site risk assessments at Wang Fuk Court clearly demonstrate that no one verified the need or asserted reason for the shutdown of the FSIs. Station Officer Fung Yuk Lun (馮鈺麟) (“StnO Fung”) gave the following answer to the Police about his visit on 8 April 2025:1556

“Q: Did you inspect the building’s FSI? A: Checked the temporarily placed fire extinguishers.

Q: Did you check the FH/HR system status? Was there water supply? A: Did not check.

Q: Did you check the fire alarm? Was it working? A: Did not check. Q: Did you enter the FS Pump Room? A: No.

Q: Did you know the state of the main power switch? A: Did not know. Q: Did you know the booster pump and fire alarm share the same main switch? A: Did not know.

Q: Did the management office mention the fire alarm was shut down? A: No.

Q: Did you notice any shutdown notices posted prominently? A: Did not notice.”

StnO Fung nevertheless recorded in the Integrated Licensing, Fire Safety and Prosecution System (“LIFIPS”) that “the defects of the FH/HR System

1556 [C3-1/1826]

448

was found to be the same as stated on the relevant Shutdown Notice”.1557 But nothing had been “found”: StnO Fung inspected none of the FSIs, let alone their defects, and did not enter the FS pump room. He simply repeated what the RFSIC said.

Probationary Station Officer Ng Chun Chung (吳振中) gave the same

answers to a police officer about his on-site risk assessment on 9 September 2025: he did not check FH/HR system, did not check fire alarm, did not enter pump room, did not know main switch state, did not know systems shared one switch.1558 Yet he recorded in the LIFIPS: “it was found that the situation matched with the description of RFSIC.” 1559 The same formula was applied.

Assistant Director Keung Sai Ming’s characterisation of the on-site risk assessment on 9 September 2025 confirms the inadequacy of the visit:1560

“[T]here was no inspection of any FSI other than a random sampling of the fire hose (消防喉轆) to ascertain the fire extinguishers as standby means were in place. Based on the information available to him, the officer did not inspect other FSI (including the FAS) as he had no reason at the time to go behind or to doubt what had been positively represented to him.”

This repeats the same theme that was seen in the ICU’s supervision of RCs and RIs. The FSD relied on the representations by RFSICs on the need and reasons for the shutdown of FSIs. The FSD did not independently verify these representations, nor assess whether there was a genuine need for the shutdown, and if so for how long.

While strictly unrelated to SDNs, the FSD visited Wang Fuk Court on 19 October 2025 as a risk-based building fire safety visit designed to enable

1557 [B2/1606]

1558 [C3-1/1805-1806]

1559 [B2/1649]

1560 Keung Sai Ming 4th WS §16 [WS8/1916]

449

crews to have a better grasp of the conditions of the buildings.1561 However, only emergency vehicular access and fire hydrants were visually inspected during this visit.1562 The FSD’s attending officer confirmed that during this visit, the crew did not enter any FS pump room, did not know the state of any master power switch, did not know the electrical configuration of the fire systems and did not notice any shutdown notices posted in prominent locations.1563

Chapter 6 addresses how the RFSICs (primarily China Status) exploited the SDN system. The FSD’s answer is that it had no reason to doubt the RFSICs’ representations about the state of the FSIs. It had no reason to doubt because it never gave itself one. An on-site assessment that does not check the alleged defects in the FSIs will never find anything to question. The FSD’s officers were never asked to look behind what the RFSIC said and took it at face value.

Under the SDN regime, the on-site assessment was the sole occasion for independent verification. What the FSD’s officers checked were the contingency measures: specifically, ensuring that substitute fire extinguishers were in place and addressing matters bearing on operational deployment in the event of a fire.1564 No other on-site assessment was conducted.1565 What they never verified was the need for the shutdown itself, which FSIs were down, whether they needed to be, and for how long.

1561 Keung Sai Ming WS §7.1.4 [WS1/115-116] 1562 [B2/1371]

1563 [C3-1/1794-1795]

1564 [T10/41:17-25]

1565 [T10/42:23-25]

450

(v) Failure to enforce time limits under FSD’s policy

Under the FSD’s Circular Letter No 1/2021, the “undue, arbitrary or deliberate delay of FSI works” may constitute improper conduct or negligence, warranting referral to the disciplinary board.1566

The FSD’s own policy (DPI/IV/4.2.16) provides that:1567

1. Shutdowns of FH/HR systems shall not exceed two months without reasonable justification (at §3.4.5(a)).

2. After 60 days without completion or an FS251 certificate, the FSD should consider taking necessary enforcement action (at §3.4.7).

3. The fire station shall maintain periodic contact with the owners, the management company and the RFSIC to monitor the progress of the works (at §3.4.4).

Nevertheless, the FH/HR system in Wang Tai House (Block E) was shut down from 7 April 2025 until the day of the fire through the filing of 17 successive SDNs. During this seven-month period:

1. The FSD did not demand a detailed written explanation for the prolonged shutdown;

2. The FSD did not conduct any site inspections to verify whether continued shutdown was necessary;

3. The FSD considered no enforcement action, despite the 60-day period having passed twice over (although in fairness Assistant Director Keung Sai Ming’s evidence is that the 60-day

1566 [B2/1307]

1567 [B2/2189-2190]

451

requirement is only triggered where contractor misconduct has been reported);1568

4. The LIFIPS records show the FSD merely noted “BU 4 months to review the situation” and, on 23 October 2025, deferred review for a further period;1569 and

5. China Status did not submit an FS251 certificate identifying the defect until 3 October 2025, nearly six months after the first SDN was submitted.1570

Assistant Director Keung Sai Ming explained that the FSD’s enforcement priorities were directed at buildings with no annual inspection at all or defects no RFSIC was following up on. Where an RFSIC remained engaged, the FSD would not take enforcement action for shutdown extensions under one year. Rather than refuting the criticism, the explanation confirms the vulnerability. On his evidence, so long as an RFSIC kept filing SDNs, no mechanism required any explanation of why the works remained incomplete, however many SDNs were filed, provided the shutdown ran short of one year.1571 Moreover, he also accepted that the threshold of one year was not documented in the FSD’s own written policies.1572

Whatever the explanation was, the fact remains that the FH/HR systems at Wang Fuk Court were kept shut down under a total of 93 SDNs filed by China Status across the eight blocks, among which 85 SDNs were for extensions. For Wang Tai House, the shutdown ran for over seven months on 16 successive SDNs. Mr Keung agreed that the prolonged shutdown

1568 [T10/58:20] 1569 [B2/1611] 1570 [B2/1628] 1571 [T10/75:9-25] 1572 [T10/64:3-5]

452

was undesirable. 1573 He ultimately accepted that, under the pre-fire mechanism, no matter how many SDNs were filed, the FSD had no mechanism whatsoever to follow up any shutdown lasting under a year, and that this state of affairs was unsatisfactory.1574

(vi) FS251 certificate processing – delays and gaps

Under regulation 9 of the Fire Service (Installations and Equipment) Regulations (Cap. 95B), where an RFSIC installs, maintains, repairs or inspects any FSI, he shall within 14 days of completion of the work issue a certificate and forward a copy to the FSD.1575 The certificate is known as the FS251 certificate.

The evidence reveals three major inadequacies in the FSD’s processing of FS251 certificates.

First, there was no mechanism to detect inconsistent certificates:

1. On 31 March 2025, Victory Fire submitted FS251 certificates for all eight blocks, certifying the FH/HR systems were in working order.1576 Just seven days later, on 7 April 2025, China Status submitted an SDN stating the FH/HR system needed to be shut down due to water tank leakage.1577

2. The FSD received these documents within days of each other but did not flag the apparent discrepancy. The LIFIPS record for Wang Tai House shows the FS251 was recorded as “FS251 Audited

1573 [T10/59:9]

1574 [T10/74:36-75:9]

1575 [B2/179]

1576 [B2/1440-1441; 1483-1484; 1513-1514; 1578-1579; 1645-1646; 1670-1671; 1706-1707; 1769-1770]

1577 [B2/1612]

453

without Inspection”, meaning the FSD conducted a paper review only, with no site visit.1578

Second, the FSD did not follow up on FS251 certificates that were required to be promptly submitted to report defective FSIs:

1. China Status filed its first SDN for Wang Tai House on 7 April

The corresponding FS251 certificate – identifying the defect as water leakage from the FS Tank – did not reach the FSD until 3 October 2025, nearly six months later.1579

2. Mr Keung accepted that, in those six months, no one at the FSD could look at a certificate to ascertain the nature of the defect and whether it was a major one. Despite this, his enquiries showed that no one at the FSD had chased China Status for the FS251 certificate at all. As Counsel for the Committee put to him, that was a serious problem: six months passed without anyone even noticing the FS251 certificate was missing. Mr Keung accepted the position was unsatisfactory.1580

Third, the FSD’s data entry system for FS251 certificates suffered from chronic delays:

1. In one example, an FS251 signed by Victory Fire in December 2023 was not faxed to the FSD until 2 August 2024 – eight months late, when the certificate should have been submitted within 14 days. The FSD’s own stamp on the certificate then shows that the FSD only processed the FS251 in November 2024.1581

1578 [B2/1599]

1579 [B2/1628]

1580 [T10/70:18-32, 71:8-15] 1581 [B2/1596]; [T10/53:20-54:7]

454

2. Mr Keung explained that data entry required information input officers to enter the data manually1582 from hard copies of FS251 certificates. This process could take up to several months.1583

The practical consequence of the above is that the statutory requirement for RFSICs to submit FS251 certificates within 14 days was meaningless: the FSD never followed up on delayed FS251 certificates, and when the certificates were received, it took another few months to process the information. Mr Keung accepted that these delays were absolutely unsatisfactory and that the consequences of the delay could be serious.1584

D4. The upshot: access openings and disabled fire alarms went unnoticed

The evidence reviewed indicates that, across every FSD attendance at Wang Fuk Court, be it the on-site risk assessments that followed each SDN or the 19 October 2025 risk-based fire safety visit, no officer once entered the FS pump room. None saw the master power switch. The disablement of the FSI system that mattered most therefore went unnoticed by the FSD. The fire alarms protecting eight occupied blocks had been silently switched off and remained so until the day of the fire.

Had the FSD inspected the staircases on any of its 26 visits, it could not have missed the worker access openings. The FSD is the statutory authority on fire hazards, and its personnel are trained firefighters. As Mr Michael Yung accepted, any officer who saw these access openings would immediately have recognised that something was wrong.1585

Had such openings been reported to the FSD, they would have ranked as the highest priority among all fire safety complaints under the FSD’s own guidelines, an “imminent danger arising from a situation where in the event

1582 [T10/33:17] 1583 [T10/54:1-13] 1584 [T10/54:1-13] 1585 [T17/21:27-30]

455

of a fire, occupants… may not be able to escape to a place of safety”.1586 No specific complaint about worker access openings was received by the FSD. The two fire escape complaints it did receive in November 2024, were referred to the ICU.1587

The FSD’s division of labour with the BD meant that it treated the protected staircases as within the remit of the BD / ICU. For the reasons given above, that division did not absolve the FSD from conducting routine inspections apt to detect fire hazards. Overlapping vigilance is a feature of a sound system, and the FSD’s own referral template (which lists “opening in staircase enclosure” among the items referable to the BD), presupposes that its officers would be looking for these issues.1588

The upshot is that the department bearing primary responsibility under the Fire Services Ordinance for identifying and abating fire hazards failed to notice at least two life-threatening fire hazards – the disablement of fire alarms and the worker access openings cut into escape staircases – both of which contributed to the catastrophic loss of life at Wang Fuk Court.

Moreover, had the FSD’s officers investigated the status of the FS Tank and made inquiries during the on-site risk assessments, they may have realised that PC&E’s plan, as known to the IO and ISS, was to first repair the FS Tank, and temporarily repurpose it as a fresh water tank (while the residential fresh water tank was being repaired). 1589 This plan would further delay restoration of the FH/HR system and was plainly inappropriate.1590 It was a basic requirement that the water supply for fire rescue and residential use be kept separate.

1586 [B2/2172]

1587 [B2/1353-1366; 1386-1387]

1588 [B6/4469]

1589 [H1-3/6034]

1590 Keung Sai Ming 5th WS §29 [WS9/1946]

456

D5. Foreseeability of the risks in Wang Fuk Court

By November 2025, the FSD possessed comprehensive knowledge of Wang Fuk Court’s fire risk profile:

1. Eight blocks of 31-storey residential buildings undergoing major renovation with extensive bamboo, scaffolding nets and other combustible materials;

2. Multiple complaints about flammable foam boards covering windows (September to October 2024);

3. Multiple complaints about workers smoking on scaffolding (July 2024 to November 2025);

4. The FH/HR systems shut down in multiple blocks for months;

5. The Chinachem Tower fire (October 2025) highlighted the risks of scaffolding fires; and

6. The FSD’s own Contingency Plan acknowledged fire risk and restricted water supply.1591

The elevated fire risk of large-scale BMR Works is common ground. As the Chairman observed and Assistant Director Keung Sai Ming agreed, the fire risks during large-scale BMR Works are close to the highest there is, as the fire hazards of construction sites are superimposed on buildings full of occupants.1592 Measured against the risk both the Chairman and the FSD recognised, the 26 attendances by the FSD were no answer at all.

The severe fire risks of combustible materials on building facades were foreseeable. Professor Usmani emphasised that Wang Fuk Court was

1591 [B2/2642-2649] 1592 [T10/51:31-33]

457

strictly not the first instance of its kind, except for its magnitude. The Grenfell Tower fire was one recent example.1593

Indeed, the Grenfell Tower fire inquiry Phase 1 Report (October 2019) made findings directly applicable to Wang Fuk Court:1594

1. Combustible materials on external walls were the primary cause of rapid fire spread (at §33.6);

2. Firefighters were unaware of the combustible nature of the materials and could not formulate a contingency plan for a fire of this kind (at §33.9); and

3. Crews who visited the building during its refurbishment were not trained to carry out the inspections properly (at §33.11).

These findings mirror the Wang Fuk Court situation. The FSD was unaware of the combustible nature of foam boards and scaffolding net materials. The FSD’s Contingency Plan did not contemplate a multi-block external fire. The FSD’s crews attending the site during the renovation conducted no meaningful inspections of the fire safety provisions which mattered – the fire alarms and the staircases.

In fairness to the FSD, it took prompt action after Grenfell. The Director of Fire Services, Yeung Yan Kin Andy, testified that, after Grenfell, the FSD and BD searched Hong Kong for buildings with combustible externalwall cladding, made contingency and emergency plans, and delayed the introduction of the registered fire engineer scheme in order to plug the loopholes Grenfell had exposed.1595

1593 [T27/9:22-25, 11:14-12:9] 1594 [A4/700-707]

1595 [T19/18:3-12]

458

However, that exercise was directed at permanent cladding built into external walls. What Grenfell Tower did not prompt was a corresponding review of the temporary combustible envelope which covered occupied buildings during the renovation works.

Professor Usmani opined that the failure to abate the fire hazards at Wang Fuk Court resulted from a failure to connect the dots from previous building fires.1596 After Grenfell Tower, the FSD and the BD understood the risks of combustible material on the external face of occupied buildings. They however did not bring that knowledge to bear on the temporary materials found in Wang Fuk Court.

D6. Summary of FSD’s pre-fire failures

The FSD’s pre-fire failures were therefore systemic:

1. Self-imposed limitation of remit: the FSD adopted a selfimposed limitation on its role in abating fire hazards, treating building materials, construction fire hazards and passive fire provisions as exclusively the BD/ICU’s responsibility. The result was that no regular inspections were ever directed at these hazards.

2. Complaint handling failures: the FSD received at least 20 complaints and enquiries raising fire safety concerns about Wang Fuk Court from 2022 to November 2025. Foam board complaints were dismissed as outside the FSD’s jurisdiction. Smoking was handled inconsistently and ineffectively. Fire escape complaints did not lead to any inspection of the staircases. Not a single complaint led to sustained enforcement action.

3. SDN system failure: the FSD allowed the FH/HR systems to remain shut down for months without verification, enforcement or meaningful oversight. The FSD’s on-site risk assessment visits did

1596 [T27/9:22-25, 11:14-12:9]

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not seek to verify the alleged FSI defects. The FSD simply took the word of China Status at face value.

4. Fire alarm deactivation undetected: the FSD never discovered that fire alarm systems had been deactivated. On the statements of the FSD’s own officers, none of them entered any FS pump rooms on any of their attendances.

5. FS251 processing failure: Chronic delays in both data entry and the follow-up of missing FS251 certificates rendered the statutory 14-day submission requirement meaningless.

It must be emphasised that the submissions above are not directed at, and imply no criticism of, the firefighters who fought the fire at Wang Fuk Court. Their courage and self-sacrifice, including that of Fn Ho, command the deepest respect. Rather, the criticisms in this Section concern the prefire systems of inspection and enforcement which enabled fire hazards to accumulate and contribute to the catastrophe at Wang Fuk Court.

E. The Labour Department (LD)

E1. LD’s role and statutory responsibility

(i) Statutory mandate

The LD is responsible for administering and enforcing occupational safety and health (“OSH”) legislation, principally the Occupational Safety and Health Ordinance (Cap. 509) and the Factories and Industrial Undertakings Ordinance (Cap. 59) and its subsidiary regulations, including the Construction Sites (Safety) Regulations (Cap. 59I).

Wang Fuk Court’s renovation works, being construction works within the meaning of the legislation, fell within the LD’s regulatory jurisdiction. The LD received notification of commencement of works and was responsible for conducting inspections to ensure worker safety.

460

LD’s enforcement powers include:1597

1. Criminal prosecution;

2. Issuing Suspension Notices (requiring cessation of works: Cap. 509, s.10);

3. Issuing Improvement Notices (requiring rectification within a deadline: Cap. 509, s.9); and

4. Issuing Warning letters and Construction Site Inspection Reports.

The LD’s internal Standing Order No. C-2 (13 November 2023) classifies situations by severity:1598

1. Group 1: hazardous work posing imminent risk of death or serious bodily injury: warrants Suspension Notice and prosecution.1599

2. Group 2: breaches posing risks of serious bodily injury or considerable fire hazards: warrants immediate prosecution and Improvement Notices.1600

3. Group 3: less serious breaches: warrants Improvement Notices.

4. Group 4: breaches not normally giving rise to imminent or serious risks: warrants warnings only.

1597 Li Man Pong WS §§12-14 [WS1/336] 1598 [D1/1724]

1599 [D1/1738]

1600 [D1/1739]

461

(ii) LD’s inspections at Wang Fuk Court

During the renovation period, the LD conducted 17 inspections at Wang Fuk Court. 1601 These comprised initial inspections, normal inspections (every 1–2 months), complaint investigations, and one step-up surprise surveillance visit.

All inspections were conducted as surprise inspections.1602 Ms Lam Sau Ching confirmed that the LD officers attend in plainclothes, initially observing without alerting anyone, and only later contacting the contractor’s site representative if necessary.1603

E2. LD’s failure to address smoking on scaffolding

(i) Volume of smoking complaints

The LD received nine formal complaints about workers smoking on scaffolding at Wang Fuk Court from July 2024 to November 2025. These are complaints #5, 8, 11, 22, 24, 26, 31, 33, and 39 on the LD’s summary table.1604

The smoking complaints directed to the LD include:

1. On 20 July 2024, an anonymous complaint about construction workers smoking during work. 1605 The complainant provided photographs showing a worker smoking on scaffolding.1606 The LD inspected on 22 July 2024 but no workers were found smoking on the site during the visit. No cigarette stubs were found. No

1601 Lam Sau Ching 2nd WS §7 [WS13/2108]

1602 Lam Sau Ching 2nd WS §§5-6 [WS13/2107-2108]; [T16/3:33-36] 1603 [T16/4:7-15]

1604 [D1/896-905]

1605 [D1/925–930]

1606 [D1/928]

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flammable substances or materials were found. The LD concluded that the complaint was not justified.1607

2. On 1 August 2024, there was a complaint about workers smoking on the bamboo scaffolding.1608 The LD warned the persons in charge.1609 Yet, it concluded that the complaint was not justified.

3. On 14 August 2024, the LD received a complaint about smoking on the bamboo scaffolding.1610 The LD warned the persons in charge.1611 Again it concluded that the complaint was not justified.

4. On 6 September 2024,1612 the LD received a complaint about smoking with multiple follow-up enquiries. The LD made several substantive replies. 1613 The complaint was again found not justified.

5. On 19 October 2024, the LD received a complaint about foam boards, workers smoking and leaving cigarette butts at the construction site, and workers conducting works without safety belt and helmet.1614 The LD replied that the complaint could not be established.1615

6. On 24 February 2025,1616 there was a complaint about workers smoking at the construction site and working without a safety

1607 [D1/950]

1608 [D1/965-967] 1609 [D1/1455]

1610 [D1/987-992] 1611 [D1/1455]

1612 [D1/1026-1046] 1613 [D1/1461-1470] 1614 [D1/1120-1126] 1615 [D1/1497-1502] 1616 [D1/1308-1310]

463

helmet. The LD stated that the complaint could not be established after surprise inspection.1617

7. On 30 April 2025, there was a complaint about workers smoking at the construction site, conducting works without safety belts, and about suspected illegal workers.1618 The LD again stated that the complaint could not be established.1619

8. On 12 November 2025, just two weeks before the fire, the LD received a complaint about workers smoking at the construction site.1620 The LD stated that the complaint could not be established after inspection.1621

(ii) Every smoking complaint found “not justified”

Despite receiving these smoking complaints over 16 months, which were supported in at least one case by photographic evidence of a worker smoking on the scaffolding,1622 the LD concluded in each case that the complaint was “not justified” (投訴內容，不能確立).

Ms Lam Sau Ching testified that this conclusion meant the LD’s officers did not personally witness smoking during their visits or find evidence of smoking during the inspection.1623

1617 [D1/1529-1534] 1618 [D1/1345-1351] 1619 [D1/1535-1539] 1620 [D1/1409-1413] 1621 [D1/1548]

1622 [D1/928]

1623 [T16/6:34-7:2]

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She agreed that the phrase “not justified” did not mean that the smoking on scaffolding did not occur.1624

The Committee heard extensive evidence from residents, and has seen multiple photographs, videos and WhatsApp messages confirming that smoking on scaffolding at Wang Fuk Court was a prevalent and persistent issue (see Chapter 4). The LD’s repeated finding that complaints were “not justified” was simply contrary to the reality of the situation.

(iii) The practical impossibility of LD’s enforcement approach

The LD’s enforcement approach required officers to personally witness workers smoking during their surprise visits. This was practically impossible because:

1. Workers would immediately extinguish cigarettes upon seeing any unfamiliar person approach;

2. Workers could easily alert each other (通水) when LD officers entered the site;

3. The LD officers attended in plainclothes but were limited to ground-level observation; and

4. Visits were necessarily of limited duration.

Mr Li Man Pong of the LD confirmed that the LD had never taken any enforcement action for smoking at Wang Fuk Court. Only warning letters were issued.1625

1624 [T16/17:34-18:2] 1625 [T16/37:27-34]

465

(iv) LD’s failure to use available powers

Under regulation 53 of the Construction Sites (Safety) Regulations (Cap. 59I):1626

“Where, in any construction site, any flammable liquid or any mixture containing any such liquid or substance or thing which in the opinion of the Commissioner involves danger from fire is used or intended to be used, the Commissioner may by order in writing prohibit smoking and the use of naked lights in such construction site.”

Mr Li Man Pong’s position was that issuing a no-smoking order was “quite uncommon” because it required the presence of flammable substances on site.1627 He considered foam boards not to be a substance or thing which involves danger from fire within the meaning of regulation 53.

As mentioned above, the FSD’s Assistant Director Keung Sai Ming agreed with the Chairman that fire risk during large-scale BMR Works is close to the highest there can be.1628 The external walls of Wang Fuk Court were covered in bamboo scaffolding, nets, wooden planks, cardboard and foam boards, all combustible materials that would sustain and accelerate fire if ignited by a cigarette butt.

The LD’s narrow interpretation of regulation 53, requiring flammable liquids rather than recognising the broader category of “substance or thing which… involves danger from fire” was unduly restrictive and failed to address the obvious fire risk that materialised.

Even without a no-smoking order, the LD could have pursued enforcement under section 6(d)(i) of the Occupational Safety and Health Ordinance (Cap. 509). Under that section, it is an employer’s duty to maintain workplaces in a condition that is safe and without risks to health, so far as

1626 [D1/186]

1627 Li Man Pong WS §44 [WS1/347] 1628 [T10/51:31-33]

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is reasonably practicable.1629 Persistent smoking on scaffolding surrounded by combustible materials plainly engaged this duty.

(v) Upcoming legislative amendments

Mr Yuen Tsz Lok, Murphy confirmed that the LD is planning the following legislative amendments:1630

1. Amending the Smoking (Public Health) Ordinance (Cap. 371) to designate construction sites as no-smoking areas;

2. Amending the Fixed Penalty (Smoking Offences) Ordinance (Cap. 600) to provide $3,000 fixed penalties; and

3. Amending regulation 56 of the Construction Sites (Safety) Regulations (Cap. 59I) to require contractors to take all reasonable steps to ensure no smoking occurs on site.

However, there are concerns that the legislative amendments will face the same practical enforcement difficulties if the LD’s position remains that it is necessary for an officer of the LD to observe smoking for enforcement action to be justified. Alternative measures to prove infringement will need to be considered, including the acceptance of photographic and video proof from residents, and the use of drones.

E3. LD’s failure to address foam board fire hazards

When a complaint in October 2024 specifically raised the flammability of foam boards as a concern,1631 the LD’s response was to investigate only the scaffolding safety issue. It did not address the foam board concern at all.1632

1629 [D1/19]

1630 [T16/54-55]

1631 [D1/1120-1126]

1632 [T16/14:33-35; 15:1-2]

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On 11 November 2024, the LD wrote to the ICU returning the complaint and noting only the scaffolding issues it had addressed.1633 The foam board fire hazard was passed back to ICU without LD offering any opinion or recommendation.

Ms Lam Sau Ching confirmed that foam boards were not the focus of the LD’s inspections, because building materials are not within its remit.1634

However, the use of foam boards on the external walls adjacent to the scaffolding where workers operated daily posed a fire risk to workers themselves. The LD’s position that building materials were outside its scope is also inconsistent with its Code of Practice for Bamboo Scaffolding Safety, which requires scaffolding nets to meet fire-retardant standards. If the LD is responsible for ensuring that scaffolding nets are fire-retardant to protect workers, the same logic should apply to foam boards.

E4. LD’s failure to verify scaffolding net fire-retardancy

(i) LD’s approach: certificates without verification

In respect of scaffolding nets, the LD’s approach to supervising their fireretardancy was limited to requesting fire-retardancy certificates from the contractor. Mr Li Man Pong confirmed that:1635

1. The LD would request certificates if it perceived fire risk or received complaints about scaffolding fire risk;

2. If the contractor could not provide a certificate, the LD would refer the case to the ICU or BD;

1633 [D1/1162]

1634 [T16/17:3-5]

1635 Li Man Pong WS §§28-30 [WS1/341-342]

468

3. The LD would not verify the certificate’s content or authenticity because “the capability of OSOs in authenticating or verifying the authenticity of the certificates is restricted by the lack of expertise in this regard.”

In July 2024, the LD requested and received a fire-retardancy certificate and delivery notes from PC&E.1636 The certificate was the same certificate dated 8 January 2024 that the ICU now believes to be bogus.

(ii) The November 2025 certificate – same document resubmitted

On 20 November 2025 (six days before the fire), following typhoon damage and net replacement, the LD requested a new certificate for the replacement nets.1637

PC&E provided a certificate that was, in fact, identical to the one provided 16 months earlier in July 2024.1638 The certificate could not have certified the replacement nets procured in late 2025: see Section B8(vi) above.

Ms Lam Sau Ching admitted that neither she nor her colleagues noticed this was the same certificate, stating that she focused only on the test results.1639 The Government accepts that this failure to notice the same certificate is an area for improvement.1640

Furthermore, the LD did not require delivery notes for the new batch of safety nets. There was no way to connect the certificate to the actual nets in use.

1636 [D1/1599-1600, 1604]

1637 Lam Sau Ching WS §83 [WS1/379] 1638 [D1/1685-1686]

1639 [T16/21:20-24]

1640 Government’s Closing §543

469

(iii) Ms Lam’s reply to a resident

On 4 October 2024, Ms Lam Sau Ching approved a reply to a resident’s enquiry about scaffolding net fire-retardancy:1641

“根據現時勞工處所執行適用於建築地盤的安全條例中，並沒有

涵蓋於棚網或任何物料的阻燃標準。此外，根據本處人員對該

地盤視察所得，該維修工程並不需要在竹棚架上進行熱工序、

使用火或易燃物品等等，而地盤內亦有提供合適的滅火設施。

因此，棚網發生火災的風險相對為低”

(According to LD’s applicable construction site safety regulations, there is no fire-retardant standard covering scaffolding nets or any material. Furthermore, the maintenance works do not require hot works, use of fire or flammable items on the scaffolding, and proper fire extinguishing facilities were provided on site. Therefore, the risk of scaffolding net fire is relatively low.)

This reply was inaccurate. As Ms Lam Sau Ching confirmed at the Evidential Hearings:1642

1. The 4th edition Code of Practice (then in force) did require all scaffolding protective screens to be made of fire-retardant material.1643 That requirement did not apply merely to tarpaulin.

2. The 5th edition (effective 19 October 2024) would make this even more explicit.

3. The LD had been requesting fire-retardant certificates from PC&E since July 2024. This was inconsistent with telling residents there was no applicable standard.

1641 [D1/1462]

1642 [T16/27:15-16; 28:1-8] 1643 [D1/654]

470

4. The statement that fire risk was “relatively low” was, in light of subsequent events, manifestly wrong.

Ms Lam stopped short of conceding that the reply was inaccurate, stating that in hindsight, the reply could have been written better.1644

E5. LD’s failure to address worker access openings

Regulation 54 of the Construction Sites (Safety) Regulations (Cap. 59I) provides:1645

“(1) The contractor responsible for a construction site shall maintain in good condition and free from obstruction all the means of escape in case of fire and all fire-fighting appliances provided in such construction site…

(2) No person shall wilfully alter, damage, obstruct or otherwise impair any such means of escape, or fire-fighting appliance.”

Mr Li Man Pong’s position was that regulation 54 applies only to unoccupied construction sites (e.g. new buildings under construction). For occupied buildings undergoing renovation, the LD considered escape route integrity to be the BD’s or FSD’s responsibility.1646

This distinction has no basis in the text of regulation 54, which applies to “a construction site” without qualification. Wang Fuk Court during renovation was a “construction site”, as confirmed by the LD’s exercise of jurisdiction over other safety matters on the site.

Moreover, workers themselves needed to use the staircases. Worker access openings compromised the fire safety of routes that workers (and not just residents) would use to evacuate in an emergency. Two workers, Mr Yiu Shun Yau and Ms Huang Zulian, were trapped on the roof during the fire

1644 [T16/28:1-2]

1645 [D1/186]

1646 Li Man Pong WS §§49-50 [WS1/348-349]; [T16/46:1-12]

471

because the staircases were smoke-logged and could not be used to escape.1647

Mr Murphy Yuen went so far as to state that the LD did not oppose the practice of creating worker access openings, viewing them as having a legitimate occupational safety purpose (allowing workers to avoid climbing scaffolding extensively). 1648 However, he confirmed that the decision of where and how to create openings required proper risk assessment and consultation with consultants or relevant government departments.1649

Other evidence confirmed that staircase access openings were far from indispensable. The BD found after the fire that of some 400 other buildings under major repair, only 8 buildings had access openings. For the vast majority of these repair works, workers were able to reach the scaffolding from rooftops and podiums. 1650 Indeed, at Wang Fuk Court workers initially descended the scaffolding from the roof. 1651 In the Housing Department’s works, gondolas were used in phases and openable windows in common areas served the same purpose.1652

Despite conducting 17 inspections at Wang Fuk Court, the LD’s officers never inspected the staircases for fire safety issues and never noticed the worker access openings, let alone assessed whether these openings compromised the means of escape.

1647 [T4/53:23-26] 1648 [T16/58:6-22] 1649 [T16/58:10-22] 1650 [T20/26:13-26] 1651 [T13/28:12-18] 1652 [T23/21:9-12]

472

E6. Inter-departmental referrals

The LD’s handling of Wang Fuk Court complaints revealed a concerning pattern where the LD referred fire-related issues to other departments without ensuring they were actually addressed:

1. Smoking: the LD referred a smoking complaint to FSD on 22 July

1653 The FSD rejected it as outside its jurisdiction. The complaint was not effectively addressed by either department.

2. Foam boards: the October 2024 complaint about foam boards was partly referred to ICU for the scaffolding net issue.1654 The foam board issue itself was not addressed by the LD and (as it was seen above) not adequately investigated by the ICU.

3. Scaffolding nets: the LD’s November 2024 memo to the ICU noted that scaffolding net fire-retardancy raised public safety concerns beyond the LD’s worker safety mandate, recommending the ICU to take parallel action.1655 However, the LD did not follow up to confirm that the ICU took action.

The result was that fire safety issues at Wang Fuk Court fell through the cracks between departments. The LD addressed only worker-specific OSH matters but disclaimed responsibility for fire-related hazards that equally affected workers.

E7. Summary of LD’s pre-fire failures

The LD’s failures can be summarised as follows:

1653 [D1/930] 1654 [D1/1162] 1655 [D1/1162]

473

1. Smoking enforcement failure: Despite nine complaints over 16 months, every complaint was found not justified. The LD’s enforcement approach required officers to personally witness smoking, which was practically unworkable and resulted in zero effective enforcement of a practice that most likely caused the fire.

2. Failure to use no-smoking order powers: the LD interpreted regulation 53 narrowly, refusing to recognise that large quantities of combustible materials on scaffolding constituted a substance or thing involving danger from fire. The result was that the LD did not issue a no-smoking order.

3. Scaffolding net certificate failure: the LD requested certificates but could not verify them, accepted the same certificate twice without noticing, and did not request delivery documentation for the replacement nets.

4. Inaccurate reply to resident: the LD told a resident there was no fire-retardant standard for scaffolding nets – a statement that was inaccurate even under the 4th edition Code of Practice and inconsistent with LD’s own practice of requesting certificates.

5. Foam board disclaimer: the LD declined to address foam board fire hazards, treating them as building materials outside its scope.

6. Worker access opening failure: the LD did not inspect escape staircases, did not detect worker access openings, and adopted an unjustified legal position that regulation 54 does not apply to occupied buildings. This was despite the fact that the access openings compromised the tenability of staircases that could have been used by workers to escape in the event of a fire.

7. Inter-departmental failures: the LD referred fire-related issues to other departments without follow-up, contributing to a regulatory vacuum that left fire hazards unaddressed.

474

In summary, had the LD exercised its powers more robustly, it could have contributed to preventing or mitigating the catastrophe.

F. The Police

The Police have no statutory role in the regulation of building works, fire service installations, or fire safety. None of the pre-fire regulatory failures examined in these submissions – the worker access openings, the foam boards, the scaffolding nets, the deactivated fire alarm systems, smoking on the scaffolding – fell within the Police’s remit.

The Police’s role lay only in the emergency response on the day of the fire, which has already been examined in Chapter 5 above.

As examined there, the evidence disclosed a well-understood division of responsibility at a fire scene. The FSD concentrated on firefighting and rescue, while the Police assisted in the evacuation of nearby residents.1656 The Police also operated the Casualty Enquiry Unit (CEU) and the Disaster Victim Identification Unit (DVIU).

As to evacuation, we have already noted questions as to whether more Police manpower might have been directed to evacuate the blocks not yet affected, for example, in the one-hour window between 3:30 and 4:30 pm, when Wang Sun House (Block C) and Wang Tao House (Block B) might have been fully evacuated.1657 The Chairman asked whether the Police should have gone up into the blocks to conduct evacuation, given that those blocks were liable to become fire sites.1658

1656 [T11/12:20-21] 1657 [T18/26:23-25] 1658 [T18/37:27-28]

475

The wider question of whether the response could have evacuated more residents, sooner, from the blocks not yet affected is largely an operational matter for the FSD.

G. Other Government Departments Referred to in the Evidence G1. The Home Affairs Department (HAD)

The HAD is responsible for policy on building and property management and for supporting owners and Owners’ Corporations (“OCs”) in discharging their management responsibilities. Deputy Director Te Chi Wang (易志宏 ) confirmed that its role was building and property

management policy,1659 and that HAD’s role was to assist and coordinate owners in carrying out building-management work.1660

The HAD is not a fire safety regulator. Its direct involvement with Wang Fuk Court before the fire concerned building-management governance, not fire safety. These governance and procurement matters fall outside the firesafety scope of this Chapter and are not pursued here.

G2. The Urban Renewal Authority (URA)

The URA’s relevant role was the facilitation of building rehabilitation – administering a scheme under which assistance and consultancy support are made available to owners undertaking maintenance works. Similar to the HAD, the URA is not a building-control or fire-safety authority.

The URA’s witness Mr Matthew Chan was clear that the URA does not assume the role of the works consultant and that enquiries or complaints

1659 [T24/1:17] 1660 [T24/11:29-30]

476

touching the conduct of the works, or building and fire-safety matters, were directed to the responsible departments, namely the BD and the FSD.1661

The URA therefore had no regulatory responsibility for fire safety at Wang Fuk Court.

G3. Conclusion

The Committee is accordingly invited to find that, among the Government bodies before it, the responsibility for the fire-safety failures lay with the ICU/BD, the FSD and (in respect of occupational fire risk) the LD.

1661 [T21/34:27-28; 38:9]

477

CHAPTER 8: RECOMMENDATIONS ON FIRE SAFETY MATTERS

A. Introduction

In the course of the Evidential Hearings, the Committee has examined the circumstances surrounding the Wang Fuk Court fire: its origin, its rapid and destructive development, and the actions taken by the FSD and other emergency responders in the minutes and hours that followed. The Committee has also considered the adequacy of training provided to frontline officers in relation to high‑rise fires; the systems by which fire safety risks in occupied buildings are identified, assessed and escalated; and the regulatory framework within which owners, contractors and public authorities discharge their respective responsibilities.

Although the Committee’s remit has been directed to a single incident, the evidence has revealed systemic deficiencies and regulatory failings of broader significance for the safety of residents in multi‑storey buildings.

A substantial number of recommendations have been advanced by core participants, expert witnesses and professional bodies.1662 Their proposals range from targeted operational reforms to more structural changes in the regulation, approval and management of high‑rise residential buildings. As is often the case in matters of this kind, the views expressed were far from uniform.

We have considered all such proposals, but it is essential that any recommendations made by this Committee rest squarely on the facts

1662 These include inter alia the Government’s Table of Improvement Measures, the Proposed Improvements submitted by nine Wang Fuk Court residents on 15 June 2026 (“Residents’ Recommendations”), and the Hong Kong Institute of Surveyors’ Recommendations issued on 30 June 2026 (“HKIS Recommendations”). We have also considered the suggestions proposed by the Involved Parties in their Closing Submissions.

478

established by the evidence, and that they are capable of commanding the confidence of those with practical experience in the field.

The recommendations that follow are therefore grounded exclusively in the evidence heard and the issues covered by the Terms of Reference. They do not purport to anticipate further evidence that may emerge in other fora, nor do they attempt to resolve questions that were not the subject of detailed examination. In determining what should properly be recommended at this stage, these submissions have focused on measures that are capable of making a meaningful and immediate contribution to the safety of residents in high‑rise buildings.

When considering improvements to fire safety in high‑rise buildings, certain realities must be kept firmly in view. Fires of the kind seen at Wang Fuk Court are rare, but the increased use of combustible materials in external works, the complexity of modern building systems, and the prevalence of renovation activities in occupied buildings have introduced new vectors of risk. Strengthened regulation, more rigorous testing and certification of materials, and clearer lines of responsibility between owners, contractors and regulators will be essential to mitigating those risks. The recommendations that follow are directed to ensuring that those responsible for the design, approval, management and emergency response of high‑rise buildings are equipped to meet that imperative.

Our recommendations below are divided into two categories: those requiring immediate implementation, and those representing longer‑term structural reforms for consideration. This structure is intended to assist policymakers in prioritising measures that can deliver prompt safety benefits while laying the groundwork for more comprehensive reform.

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B. Recommendations for Immediate Implementation1663

B1. Immediate ban on combustible temporary works on high‑risk façades

In renovations of high-rise buildings, contractors commonly wrap entire buildings in scaffolding nets and canvases to contain falling dust and debris. As analysed in Chapter 4, when these temporary works are made of combustible materials, they form a continuous vertical fuel source. If a fire ignites on the façade, the nets and canvases burn intensely and melt, producing “flaming droplets” – a rain of liquid fire that cascades downwards, igniting lower elevations and trapping residents.1664

This mechanism was central to the rapid vertical fire spread at Wang Fuk Court. The combustible scaffolding nets and canvases materially accelerated the fire’s upward progression. The experts agreed that had fire‑retardant nets and canvases been used, the initial fire may have self‑extinguished without propagating vertically.1665 Instead, the intense heat triggered pyrolysis, turning the structural bamboo scaffolding into a large‑scale fuel source.1666

Likewise, the evidence demonstrates that highly flammable polystyrene foam boards used to cover residents’ windows served as a significant factor in spreading the fire laterally from flat to flat. 1667 These foam boards quickly melted off and dropped from glass panels when subjected to

1663 These immediate recommendations are meant to be temporary, “extra‑cautious” safeguards for buildings that are currently occupied and under repair. They are intentionally protective and err on the side of safety. As the experts explained, once the Government has carried out a thorough public consultation and designed tailored long‑term measures, these strict interim steps can be eased gradually where appropriate: [T27/52:12-53:3, 61:17-62:5].

1664 Professor Yuen’s Final Expert Report §2.13.3 [ER2-2/1250]; IC Expert Report §3.6.8 [ER3/2181-2182]

1665 Professor Yuen’s Final Expert Report §2.13.3 [ER2-2/1250]; [T26/19:18-24]; [T27/62:6-63:9, 86:5-10]

1666 IFITF Final Report §6.2.1.11 [ER1/82]; IC Expert Report §§3.6.7-3.6.9, 3.6.19-3.6.23,

8.4-3.8.5 [ER3/2181-2183, 2186-2187, 2200, 2245]; [T27/59:17-60:3]

1667 [T27/86:11-87:17]

480

intense heating. Once fallen off, boards propagated sustained flames onto other combustibles.1668

We therefore recommend an immediate prohibition on:

1. the use of combustible temporary materials (such as non-fireretardant safety nets, plastic sheeting, and polystyrene foam boards) in or adjacent to re-entrant spaces. By banning these materials in adjacent areas, the continuous path of fuel is broken.1669

2. The storage of flammable temporary materials, timber planks, or structural scaffolding materials above ground level exits to prevent falling debris from trapping residents or blocking firefighters during an emergency.1670

3. the use of combustible materials (such as foam boards) on windows and external walls.

These recommendations aim to stop fire from having an easy, unbroken path of flammable materials to travel along – whether between buildings, above exits, or across windows and walls – so that residents have time to escape and firefighters can perform their duties safely.

It is encouraging that, since the fire, the BD and the ICU have launched surprise inspections to check whether combustible materials like polystyrene foam boards have been affixed to external walls and windows. RIs and RCs are now requested to strictly “refrain from affixing combustible materials (such as foam boards) to external walls and

1668 IC Expert Report §§3.6.2-3.6.3 [ER3/2179-2180]

1669 IC Expert Report at §7.3.1(e) [ER3/2253]. As the experts clarified during the hearings, a complete ban on combustibles across all scaffolds may not be necessary if the scaffolding is completely remote from re-entrants. Once a standardised, scientific risk assessment framework is established on a project-by-project basis, contractors can be permitted to use certified fire-retardant materials if the thermodynamic simulation proves the chimney effect risk is contained: [T27/31:3-16, 60:22-62:5, 75:11-21].

1670 [T27/54:2-9]

481

windows”. 1671 These flow from the BD’s March 2026 circular, 1672 expressly banning the use of such materials on external walls or windows. We further understand that the Government has been reviewing the Buildings Ordinance (Cap. 123) to establish prescriptive material safety standards directly in the law, making non-compliance a criminal offence; we agree that such a review is necessary, and support the creation of the offence.1673

B2. Immediate ban on access openings

To facilitate worker movement between the concrete staircases and the bamboo scaffolding, the contractors at Wang Fuk Court removed the staircase windows every five floors, creating temporary openings commonly known as access openings. These openings were then covered with thin wooden boards and aluminium panels – materials offering no meaningful fire resistance.

The contribution of these access openings to the scale of the tragedy is beyond dispute. As analysed in Chapter 4, the evidence shows that smoke infiltrated through gaps in the temporary boards long before they burned through,1674 whereas proper fire‑rated windows would have kept internal temperatures tenable even as the re‑entrant fire exceeded 1,000°C.1675 Because the aluminium panels and wooden boards failed, smoke penetrated rapidly, reducing residents’ safe evacuation time.

We therefore recommend an immediate prohibition on the use of access openings at all means of escape, including staircases and lift lobbies. Furthermore, all windows at means of escape should be fitted with

1671 Government’s Table of Improvement Measures §B3(v)

1672 [B13/5714-5719]. See also Government’s Closing §982

1673 Government’s Closing §602

1674 Professor Yuen’s Final Expert Report §§2.6.6-2.6.7 [ER2-2/1190-1191]; IC Expert Report §6.5.1 [ER3/2246-2247]

1675 IFITF Final Report §10.6.2.3 [ER1/230]

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fire‑rated glazing or fire‑resistant glass (for example, Class B fire‑rated windows engineered to resist fire and smoke for at least 60 minutes) 1676 to prevent burn‑through and smoke or heat ingress.1677

Relatedly, we note that some older buildings retain staircase windows with upper ventilation panels that can be opened as well as lift lobbies with openable windows. We recommend that where similar designs exist, a temporary warning should be issued to keep these windows closed, and in the longer term, a review should be undertaken to determine whether they should be replaced with sealed, fire-rated windows.

B3. Immediate implementation of staged external wall repairs across multi‑building estates

We agree with the Government’s recommendation that for large-scale renovations involving more than one building in a court, “all repair of external walls must be carried out in phases”.1678

By requiring the contractor to repair the estate in distinct phases, the contractor is prevented from wrapping multiple residential blocks in a single, continuous envelope of combustible scaffolding and plastic netting (which should in any event be prohibited: see §1198 above). This structurally confines any potential fire spread to a single, isolated block.

1676 See [ER2-2/1223] at fn 29; [T26/26:7-12, 28:22-30]

1677 Cf. Government’s Table of Improvement Measures §E5; [WS8/1918-1919]; Government’s Closing §§657, 986, suggesting that any access opening in escape staircases should be protected by a temporary fire barrier with a fire rating property equivalent to that of the original provision pursuant to BD’s 16 March 2026 circular letter §2(d) [B13/5714].

1678 Government’s Table of Improvement Measures §B3(v). See also HKIS Recommendations

at pp 56-57, emphasising the “應修必修、急修先修” principle and recommending nonurgent works to be completed in phases.

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C. Recommendations for Long-Term and Systemic Policy Reforms C1. Fire‑safety testing and accreditation of construction materials

The Committee received clear evidence that, in the period leading up to the fire, the building control system operated on a largely passive, paper‑based model of compliance. The ICU and LD inspectors relied heavily on test certificates submitted by the contractor, without independent verification. PC&E, in turn, was able to mislead both departments by providing questionable certificates (which the ICU failed to verify) and manipulating on‑site lighter tests. The evidential picture is one of a regulatory process that assumed honesty but invited exploitation.

There was also a serious deficiency in the manner of on‑site testing. As we have seen, the ICU’s inspectors attempted to conduct informal “quick tests” using a hand‑held lighter to burn small pieces of netting. The process is inherently unscientific and easily manipulated. When a sample ignited for ten seconds and failed, the contractor simply directed inspectors to another non‑flammable spot for a “re‑test”, which was then accepted. What is plain is that such tests provide no reliable indication of fire performance and create a false sense of assurance.

The regulatory gap is stark. Temporary materials capable of accelerating fire spread were permitted on occupied buildings without any verified fire performance standard.

We therefore recommend:

1. Expanding the testing regime to include surprise inspections, direct checking of fire‑retardant treatments, and independent verification of all laboratory certificates through HOKLAS or recognised partner labs.

2. Subjecting all temporary vertical wrapping materials (including plastic sheeting, tarpaulins and toe boards) to the same rigorous

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testing and certification standards as safety nets. This is consistent with the Government’s recommendations.1679

3. Prohibiting the use of on-site lighter tests as evidence of compliance with fire performance standards. These tests are arbitrary, prone to manipulation, and may create a dangerous illusion of compliance. Verification of fire performance must rely exclusively on accredited HOKLAS laboratory testing.

These recommendations are broadly reflected in the new PNRC 85.1680 In essence, RCs are now required to: (i) obtain official fire‑retardant test reports from suppliers; (ii) conduct random sampling of each lot of safety nets using an accredited laboratory (including HOKLAS‑accredited and mutually recognised Mainland laboratories); and (iii) submit e‑reports with secure digital signatures directly to the BD. 1681 We agree that these measures represent a material improvement over the previous regime.

Nevertheless, several aspects warrant further consideration:

1. When contractors sample materials off‑site, PNRC 85 §6(j) allows them to operate their own tracking systems (QR codes, RFID chips) to demonstrate that the nets delivered to the site are the same as those tested.1682 The evident rationale is to create a traceable chain between laboratory‑tested samples and the materials ultimately installed on the scaffolding.

2. Yet, allowing a contractor to manage its own tracking database presents a fraud risk. Without continuous independent custody from the warehouse stage through to installation on the façade, a

1679 Government’s Table of Improvement Measures §E2

1680 [J1-2/6200]. See also Government’s Closing §§544-548 as to how PNRC 85’s requirements have been implemented by various public bodies.

1681 Government’s Table of Improvement Measures §C1

1682 [J1-2/6202]. See also Yue Chak Sang WS §55(d) [WS1/830]

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dishonest contractor may be able to transfer a digital tag from a compliant material to a non-compliant substitute. In these circumstances, the Government should consider what further safeguards should be put in place to ensure that the material tested in the laboratory is the same material ultimately installed on the façade.

3. Furthermore, PNRC 85 currently requires the BD to give contractors up to three working days’ notice before conducting random site audits, because the BD relies on the contractor’s own scaffolders to climb and cut samples.1683 This notice period affords contractors a three-day opportunity to replace substandard nets with compliant ones.

4. To preserve the integrity of surprise inspections, the Government may consider retaining its own independent scaffolding teams. Ideally, the BD and the ICU’s inspectors should be able to attend any site without notice, ascend the scaffolding immediately, and obtain random samples on the spot. Although the scientific determination of fire performance must ultimately be made under controlled laboratory conditions (as noted above), unnotified on‑site selection can ensure that the material tested is the material actually being used on the building façade.

C2. Bamboo and plastic nets: potential transition to non-combustible materials in appropriate scenarios

Traditional bamboo and combustible plastic nets are relatively inexpensive and adaptable. But the evidence shows that the heat generated by the façade fire at Wang Fuk Court initiated pyrolysis of the bamboo scaffolding, effectively transforming the entire exterior envelope into a vertical fuel

1683 See “Interim Guideline on Checking of Protective Materials for Scaffolding under Practice Note for Registered Contractors (PNRC) 85” §2.4 [I3/9891]; Yue Chak Sang 2nd WS p.7 [WS14/2176].

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source. Once pyrolysis began, the scaffold structure itself contributed materially to the intensity and upward spread of the fire.

The Committee will recognise that the question of reducing reliance on bamboo scaffolding is complex and, in some quarters, contentious. An outright ban would have significant financial and logistical consequences. There are also circumstances in which bamboo remains practical, safe and even necessary – for example, smaller scale works or sites located on narrow streets where metal systems cannot be deployed.1684 Any potential transition therefore requires a balanced and evidence-based approach.

We therefore recommend exploring (and possibly funding and subsidising) a potential transition away from traditional bamboo scaffolding and combustible plastic wraps. This may include, in appropriate cases, greater use of metal scaffolding systems in place of bamboo scaffolding, and the replacement of combustible plastic nets or wraps with fire-rated fibreglass mesh, stainless‑steel mesh wraps, or flame‑resistant tarpaulins.1685 The Government should establish a strategic task force with industry stakeholders to research, develop and support this potential long‑term transition. The Committee will note that the Development Bureau and the Construction Industry Council have already commenced formal discussions on a “roadmap to switch from bamboo scaffolding to metal scaffolding” where structurally and logistically appropriate.1686

C3. Fire safety systems and SDNs

An SDN is a formal notification submitted by an RFSIC to the FSD stating that a building’s FSIs will be temporarily deactivated for maintenance. It is intended to be an administrative safeguard: a mechanism by which the

1684 See e.g. Ms Bernadette Linn’s comments as summarised in a press release dated 27 November 2025 [J1-3/7840], and Yue Chak Sang WS §§58-61 [WS1/831-832].

1685 As suggested by the IC experts: [ER6/2746].

1686 Government’s Table of Improvement Measures §G2

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FSD is alerted to periods when a building’s fire‑protection systems are inoperative.

At Wang Fuk Court, the SDN system was gravely abused. The fire alarms and hydrants of each building were shut down for extensive periods. Residents were left unaware of the exterior fire until smoke had already entered their homes. Yet, no representative of China Status ever attended the estate, inspected the pump room layout, or supervised the physical shutdown. The SDN regime, designed as a notification safeguard, was relegated to a paper formality.

Further, the water pumps were deactivated not by using the individual isolator switches designed to cut power to the pumps alone, but inadvertently by non-RFSIC personnel turning off the master power switch. Because the master power switch simultaneously controls electricity to both FH/HR pumps and the FAS, this action silenced the fire alarms across all buildings (until some were manually switched back on during the fire). Without conducting any on-site checks, China Status submitted SDNs with the “FH/HR” box ticked but left the “FAS” box blank, misleading the FSD into believing the fire alarms remained operational.

We recommend:1687

1. Legislating that no major FSIs (including the FAS, FH/HR or sprinkler systems) may be deactivated for more than 24 hours without prior written statutory approval from the Director of Fire Services. Applications should be lodged at least 14 days in advance and be accompanied by: (i) an independent engineering risk assessment of cascading effects on other FSIs; and (ii) a physically verified standby‑safety plan (such as temporary redundant sprinklers or external water manifolds). Even if RFSICs may apply for 14-day extensions, the cumulative shutdown period

1687 Recommendations regarding on-site risk assessments in relation to shutdown of the FSIs are further addressed below.

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of a major FSI should be strictly capped at 60 days, with reasons given and scrutinised by the FSD. This shifts the law from a passive notification model to a strict pre‑commencement approval regime, and imposes a maximum duration that a building’s FSIs may remain inoperative while undergoing repairs.1688

2. Legislating a new offence penalising any RFSIC who submits an SDN or signs an FS251 certificate for works they did not personally execute or directly supervise.

3. Introducing management criminal liability for PMCs under a statutory “FSI Responsible Persons” regime, as the Government has helpfully suggested in its recommendations.1689 PMCs should bear a direct, non‑delegable duty to coordinate site safety, and in particular ensure that FSIs (including the FAS) remain fully operational throughout major renovation works.

4. Mandating tamper‑evident seals for all high‑rise FSI pump rooms. Under normal conditions, the master power switch should be locked in the “ON” position using a serialised, green tamper‑evident seal. If the seal is ruptured, a white “VOID” indicator is exposed. PMC building attendants should be legally required to inspect seals during daily patrols and report any breach to the FSD and PMC within two hours. We note that a similar measure has already been implemented by the FSD by way of its Circular No. 1/2026.1690

1688 See in this regard Keung Sai Ming 4th WS §25 [WS8/1919]. See also [B14/6272]; Government’s Closing §§771-772, 981

1689 Government’s Table of Improvement Measures §A1. See also Keung Sai Ming 4th WS §25 [WS8/1919]; “Consultation Paper on Proposed Amendments to the Fire Services Ordinance (Cap. 95) and its related Subsidiary Legislation” (May 2026) (“Consultation Paper”) §§34-35 [B14/6287-6288]. See also Government’s Closing §§774.4, 981; [B14/6275].

1690 [C3-1/1979]

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5. Requiring prominent, engraved red warning labels on FSI electrical panels. The evidence showed that Wang Fuk Court’s switches carried no warning that they also controlled the fire‑alarm system, and there was uncertainty (particularly on Victory Fire’s part) about whether the 2022 Code of Practice, which contains such a requirement,1691 applied to a 1980s estate like Wang Fuk Court.1692 Clarification is needed. All buildings of similar vintage should be retrofitted with bilingual warnings stating: “WARNING: THIS SWITCH ALSO CONTROLS THE POWER SUPPLY TO THE FIRE ALARM SYSTEM. DO NOT TURN OFF FOR ROUTINE PUMP/TANK MAINTENANCE”.

6. Issuing an FSD circular making it a disciplinary offence for an RFSIC to permit or execute a master power shutdown where pump‑level isolation would suffice.

7. Increasing penalties under Regulation 8 of the Fire Service (Installations and Equipment) Regulations (Cap. 95B) to HK$500,000 and 12 months’ imprisonment for any unregistered individual who switches off or alters a building’s primary fire‑control systems. The current Level 5 fine (HK$50,000) hardly provides sufficient deterrence, particularly to sizeable contractors.1693

We also support the Government’s proposed legislative amendments to raise the legal and financial stakes of non‑compliance:1694

1691 See [B2/919/§3.8.2]

1692 [T6/51:25-52:11]; [T10/21:1-22:16]

1693 A point recognised by Assistant Director Keung Sai Ming during his oral evidence:[T10/11:16-31].

1694 Government’s Table of Improvement Measures §A10(iii)-(v); Consultation Paper §§19, 34-35, 43(b) [B14/6278, 6287-6288, 6295]

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1. Raising the maximum penalty for issuing false or misleading FS251 certificates from HK$50,000 to HK$3,000,000 and three years’ imprisonment.

2. Implementing provisions under which directors, authorised signatories and qualified persons are personally liable if an FSI offence is committed with their consent, connivance, neglect or omission. See also §1219.3 above.

3. Abolishing permanent RFSIC licences and transitioning to mandatory five‑year renewals subject to strict vetting by the Police and ICAC.

The Committee will also recall the involvement of Victory Fire. In October and November 2025, Victory Fire’s licensed technicians returned to execute remedial works. They observed empty water tanks and master power switches inside the pump room in the “OFF” position, the latter rendering the FAS inoperative. Yet they did not notify the FSD, believing it was not their responsibility to “overstep” their mandate and interfere with another RFSIC (i.e. China Status)’s scope of work.

The failure to alert others to an obvious and serious danger is plainly unsatisfactory. We recommend amending the Fire Service (Installations and Equipment) Regulations (Cap. 95B) to introduce an absolute statutory duty to report. If any RFSIC, qualified person or registered technician discovers that a major FSI is disabled, such as empty tanks or a deactivated master power switch, they must notify the FSD (via an emergency hotline or dedicated email address) within 24 hours. Failure to report should automatically constitute professional misconduct, triggering immediate suspension and personal criminal liability. This is in line with the Government’s proposal.1695

1695 Government’s Table of Improvement Measures §A8; Consultation Paper §11[B14/6273-6274]

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We further note that the FSD has upgraded its electronic submission system. With effect from 1 July 2026, all RFSICs are legally required to submit FS251 certificates through the FSD’s designated digital platform, replacing the slow, paper‑based mailing system. Each electronic FS251 will carry a unique QR code, enabling members of the public, building owners and PMCs to verify the certificate’s authenticity instantly using a smartphone.1696

We support these reforms and suggest the following enhancements:

1. Under the old regime, RFSICs need only to produce the Annual Inspection Checklists “upon request” during the FSD’s random audit process – a practice that is inadequate for high‑risk, high‑rise estates.1697 The new digital gateway should not merely accept the FS251 cover sheet. It should instead require the upload of the completed checklist as a mandatory attachment, and the FSD should be required to audit these checklists as a matter of course. A mandatory upload and routine audit mechanism would create a reliable, centralised diagnostic record.

2. The importance of this requirement is illustrated by the events at Wang Fuk Court. Victory Fire’s Dr Chung signed FS251 certificates while omitting any mention of the water storage defects recorded on his technicians’ checklists, certifying the systems as fully compliant. Had Victory Fire been required to upload its detailed checklist in March 2025, under the new proposed system, the FSD’s central database could have automatically cross‑referenced the checklists against the FS251 certificates. This discrepancy would then have been flagged,

1696 Government’s Table of Improvement Measures §A9; Government’s Closing §§761, 960, 981

1697 [T10/35:5-15]

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triggering a physical audit and possibly revealing that the building’s FAS had been deactivated months before the blaze.

3. Moreover, although the Government is exploring 1698 a general shortening of the 14‑day submission window, we recommend that where a major high‑rise FSI is shut down or found defective, any interim inspection or incomplete repair status must be reported electronically within 24 hours. Under such a rule, when Victory Fire’s technicians entered the pump room on 19 November 2025 and found the master switch turned off, they would have been required to submit an interim electronic status update within 24 hours – alerting the FSD to the deactivation of the fire alarms well before the fire occurred.

4. Just as importantly, the FSD should review its protocols and implement a robust FS251 audit system that (i) automatically flags inconsistent certificates, (ii) triggers prompt follow‑up when certificates are not received within the statutory 14‑day (or 24-hour) period, and (iii) ensures timely electronic processing. The pre-fire arrangements failed to detect inconsistencies between Victory Fire and China Status’ certificates submitted in quick succession,1699 allowed missing certificates to go unnoticed for half a year1700, and processed others many months late, rendering the statutory submission requirement ineffective. A modernised verification system is essential to ensure that defects in FSIs are identified and acted upon without delay.

1698 Government’s Table of Improvement Measures §A9

1699 On 31 March 2025, Victory Fire submitted FS251 certificates for all eight blocks, certifying the FH/HR systems were in working order. Just seven days later, on 7 April 2025, China Status submitted an SDN stating the FH/HR system needed to be shut down due to water tank leakage. The FSD did not raise any questions regarding the inconsistent descriptions in the two SDNs which were submitted within a short period of time.

1700 China Status filed its first SDN for Wang Tai House on 7 April 2025. However, the corresponding FS251 certificate – identifying the defect as water leakage from the FS Tank – did not reach the FSD until 3 October 2025, nearly six months later.

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C4. Case-specific engineering risk management in appropriate cases

During the hearings, Professor Jiang testified that one of the central lessons emerging from the seven‑year Grenfell investigation is the grave danger of over-relying on the fact that individual materials have passed isolated testing standards.1701

That lesson applies with equal force to Wang Fuk Court. The safety nets used during the works may have possessed some degree of fire‑retardant treatment, but once draped over highly combustible bamboo, adjacent to timber planks, loose cardboard boxes and polystyrene window boards, they formed a continuous fuel load. The evidence demonstrates that materials which perform adequately in isolation can behave catastrophically when combined into a real-world system. It follows that there should, ideally, be an engineering risk assessment in advance as to how all temporary materials will interact on the geometry of the specific building before any scaffolding is erected.

The Committee also heard evidence that the existing Building Code benchmarks are premised on generalised community expectations and cost‑benefit assumptions applicable to typical, vacant construction sites. They do not contemplate major, high‑risk renovation works being undertaken while thousands of residents remain in occupation. The regulatory framework must recognise the heightened risks inherent in renovation works in respect of occupied buildings.1702

For these reasons, we recommend empowering the FSD to direct high‑rise renovation projects, particularly those undertaken while residents remain in occupation, to undergo a case‑specific engineering risk assessment where the circumstances warrant it. As the Committee’s experts pointed

1701 [T27/72:5-18]

1702 As noted by the Chairman during the hearings: [T27/74:3-16]. See also Code of Practice for Fire Safety in Buildings 2011 §G2.1 on “Deemed-to-Comply” provisions [B2/1168].

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out during the hearings1703, qualified fire engineers may be required to conduct a bespoke thermodynamic analysis for each building before scaffolding is approved, evaluating how temporary materials will behave together in practice rather than in isolation. Only by adopting a building specific, system‑based approach can the risks of uncontrolled fire spread be properly mitigated. It is recognised that imposing such assessments across all buildings may not be realistic, but enabling the FSD to require a specific assessment in elevated risk cases would strengthen safeguards against façade fire spread.

This proposal also addresses a major deficiency in the current framework: building regulations focus primarily on the permanent, finished façade. Because renovation scaffolding, safety nets and protective sheets are classed as “temporary”, contractors are permitted to wrap occupied towers in large quantities of combustible materials without any engineering risk assessment. As the events at Wang Fuk Court have shown, when a 30‑storey residential block remains enclosed in scaffolding and plastic sheeting for more than a year, it is artificial to describe the works as “temporary”. Ideally, occupied high‑rise renovations should be capable of being directed into a risk‑based engineering approval process, regardless of whether the works are labelled “temporary” or not. See further §1262 below on the regulation of “temporary” works.

It is right to note that the Code of Practice for Fire Safety in Buildings already provides a framework for performance‑based fire engineering, including the use of the six fire safety sub‑systems, computational fluid dynamics modelling and qualitative hazard analysis. At present, however, that framework is treated as an optional alternative, typically invoked only for unusual or complex new developments presenting “special hazards”

1703 [T27/57:12-25]. See also their recommendations for policy level changes [ER6/2747]; and IC Expert Report §7.5 [ER3/2255]

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where “there is genuine difficulty in complying with the Deemed-toComply provisions in this Code”.1704

The FSD should consider requiring this level of scientific rigour when approving renovation and rehabilitation works in certain occupied high‑rise buildings carrying heightened risks. The approval process should ensure that the same analytical discipline applied to new construction is brought to bear on temporary works that may expose residents to significant fire risk.

C5. Smoking ban

(i) Proposed legislation

The Committee understands that the Government has formally proposed a comprehensive statutory smoking ban for all construction sites. As at the date of these submissions, the proposals are progressing through the legislative pipeline but have not yet been brought fully into force.

We support and adopt the legislative proposals introduced by the Government in May 2026: the Construction Sites (Safety) (Amendment) Regulation 2026, the Smoking (Public Health) Ordinance (Amendment of Schedule 2) Order 2026, and the Fixed Penalty (Smoking Offences) (Amendment) Notice 2026.1705

It is particularly notable that the Government has proposed a new blanket prohibition on smoking on all construction sites in all circumstances, removing the former requirement to prove the active presence of “flammable liquids” or other specific fire hazards.1706 This addresses a

1704 [B2/1175-1176]. In summary, for buildings of special hazards, the Building Authority may accept a performance-based design as an “Alternative Solution”. Currently, this requires developers to submit a massive, expensive document called a Fire Safety Assessment Report (FSAR). For the fire safety sub-systems, see [B2/1181].

1705 [D4/1988-2004]

1706 LegCo Brief for amendment bill §§7-14 [D4/1990]

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longstanding lacuna in the old Regulation 53 under the Construction Sites (Safety) Regulations (Cap. 59I), under which a Prohibition of Smoking Notice could only be issued if volatile liquids or substances posing a specific fire danger were actively being used or stored on site.

We recommend that these amendments be enacted and brought into force without delay to establish a complete prohibition of smoking on all highrise construction and building maintenance sites in Hong Kong.

In this regard, to ensure this ban is meaningfully enforceable on active scaffolding, we suggest the following enhancements:

1. The newly drafted Regulation 53 requires contractors to “take all reasonable steps” to ensure no person smokes or carries a lighted specified smoking product on‑site.1707 In the longer run and having considered the effectiveness of the new Regulation 53, the Government may consider the possibility of replacing this with a strict liability standard, similar to the existing strict liability offences under section 11 of the Occupational Safety and Health (Display Screen Equipment) Regulation (Cap. 509B). 1708 Contractors should not be able to rely on generic safety briefings or warning signs as exempting liability. A stricter standard would compel active, physical site‑entry controls (such as confiscating lighters and cigarettes at the gate).

2. In any event, even if a reasonableness standard were to be employed, the principal contractor should be required to conduct a fire safety induction for every worker entering the site and to hold weekly briefings focused exclusively on the smoking ban. Written logs of these briefings, signed by workers, must be

1707 LegCo Brief for amendment bill §7(b) [D4/1991]; Government’s Closing §482.3 1708 [D1/589]

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maintained and made available to the LD’s inspectors during random audits.

3. Any contractor or subcontractor convicted under the amended Regulation 53, or whose workers receive multiple fixed penalty notices on a single site, should automatically accrue demerit points on a centralised database managed by the BD. This safety record should be linked directly to the URA’s “Smart Tender” bidding platform (see Chapter 9 below), ensuring that negligent contractors face financial consequences by being barred from bidding for public and private residential renovation works.

4. A maximum fine of HK$400,000 may not provide meaningful deterrence for a main contractor executing multi‑million‑dollar renovations. We recommend increasing the maximum penalty for contractor violations of Regulation 53 to HK$3,000,000 on summary conviction and HK$10,000,000 on indictment, matching the gravity of the general duty provisions under the Factories and Industrial Undertakings Ordinance (Cap. 59).1709

(ii) Drone-based aerial surveillance

We support the Government’s proposal to deploy drone-based aerial surveillance to detect construction site smoking, which can be a highly effective and modern enforcement tool.1710

As already noted, reducing the physical fuel load (by banning combustible nets and foam boards) is essential to controlling the consequences of a fire. Eliminating the ignition source through modern surveillance technology is the necessary counterpart to a complete fire safety strategy. The evidence from Wang Fuk Court illustrates this with clarity:

1709 [D1/414]

1710 Government’s Table of Improvement Measures §E1. See also Government’s Closing §986.

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1. Residents repeatedly photographed workers smoking on the scaffolding, yet the LD’s inspections consistently concluded that complaints were “unsubstantiated” or “could not be justified”.

2. For obvious reasons, workers do not smoke in front of an inspector walking the site on foot. Drones can bypass this limitation. Launched from outside the site boundary, they can monitor exterior scaffolding at altitude and capture direct evidence of violations before workers have time to conceal cigarettes.

3. While residents may also observe workers smoking directly outside their windows, many would understandably worry about retaliation if they were seen filming workers or lodging complaints. 1711 Shifting surveillance to drones (which are generally less predictable and do not expose residents to confrontation) may help create a deterrent effect that reduces the need for direct reporting.

To strengthen the Government’s proposal, we suggest consideration of equipping drones used for safety surveillance with thermal‑imaging capability rather than relying solely on standard visual cameras. 1712 Workers often smoke behind thick green nets, plastic sheeting, or inside deep re‑entrants. A standard camera may not be able to penetrate these materials. Employing thermal sensor imaging may enable regulators to detect the temperature signature of a lit cigarette tip (or an unauthorised welding spark) even through heavy netting. Consideration should however be given to the privacy of residents, given that surveillance would be conducted in occupied buildings.

1711 [T14/49:28-50:2]

1712 See in this regard the Government’s Closing §§872, 875 on FSD drones equipped with thermal imaging capabilities being used for aerial surveillance during rescue operations.

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(iii) Photographic and video evidence of smoking

We recommend that the LD should revise its enforcement guidelines to expressly accept high‑resolution, time‑stamped photographs and video evidence submitted by residents or estate security personnel as a valid and sufficient basis for issuing fixed penalty notices. Residents have also proposed this reform.1713

To the extent legislative or regulatory amendments are required, they should be pursued without delay. After all, enforcement officers will not always be able to attend the scene (or a drone may not be deployed) in time to witness a contravention. In such circumstances, properly authenticated photographic or video evidence from the complainant should be treated as sufficient to substantiate the complaint for purposes of issuing a fixed penalty notice.

C6. Enhanced co-operation among Government bodies

The Wang Fuk Court fire exposed a systemic failure of coordination between the Government bodies responsible for building safety, temporary works regulation, labour enforcement, fire safety and renovation oversight. No single department had full situational awareness of the risks accumulating on the façade. Each department acted within its own silo, and no mechanism existed for cross‑checking information, escalating concerns, or intervening jointly.1714

The tragedy shows that safety cannot be achieved if Government bodies function in isolation. They must be required to share data, complaints and inspection records within a unified, continuous safety loop.

We therefore recommend establishing a formal, cross-departmental communication and enforcement protocol uniting the BD, the ICU, the

1713 Residents’ Recommendations §§12-16

1714 As noted in HKIS Recommendations at pp 4-5

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FSD, the LD and the HAD. The following examples are illustrative only and will require further exploration under a broader framework for integrated regulatory oversight.

First, steps should be taken to strengthen digital integration and information‑sharing between the BD, the ICU, the FSD and the LD.1715 Whether achieved through a single, centralised registry or through enhanced inter‑operability between existing databases, the objective is the same: to ensure that key safety information (FSI shutdown notices, scaffolding records, MW data, the LD’s inspection findings etc.) is accessible across departments within a unified data‑sharing framework.

Improved digital integration would allow immediate cross‑referencing of risk signals and directly address the entrenched “communication gap”. The hearings showed, for example, that the ICU was entirely unaware of crucial changes to the BD’s site safety audit protocols because the departments only held infrequent, formal liaison meetings. Under an enhanced data‑sharing system, any revision to the BD’s audit guidelines or registration of a non‑compliant contractor should be visible to the ICU immediately, ensuring consistency and coherence in building safety control across both the private and public housing sectors.

Second, as regards the ICU and the BD, we further recommend ending the practice of relying on informal “verbal advice”. All consultations between the two departments should be approved by a directorate level officer and recorded in a central database, as the Government has proposed. It is also encouraging that liaison meetings have increased from annual to quarterly, and that a mutual secondment scheme between the BD and ICU’s staff has been introduced to align inspection practices. These steps

1715 It appears that real-time data sharing between ICU and the BD was discussed in ICU’s reports to the BD, see e.g. [J1-3/6674/§23].

源文件：06_境外及港澳台调查报告/2025/港澳台/2025_港澳台_香港大埔宏福苑-特别重大火灾事故调查报告(委员会代表结案陈词627页).md

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