港澳台_香港大埔宏福苑-特别重大火灾事故调查报告(政府结案陈词)

分类：06_境外及港澳台调查报告 / 2025/港澳台年份：2025 大小：742.6 KB 知识库创建：2026-08-05 08:52:43 抓取时间：2026-10-22 09:08:22

8 1

Independent Committee in relation to

the fire at Wang Fuk Court in Tai Po

Written Closing Submissions of

the Relevant Bureaux and Departments of the Government

PART I: INTRODUCTION ................................................................................................................ 9

THE WANG FUK COURT (“WFC”) FIRE ............................................................... 9

A1. THE WFC FIRE ....................................................................................................................... 9

A2. THE GOVERNMENT’S IMMEDIATE RESPONSE – THE THREE TASK FORCES ............................. 11

ESTABLISHMENT OF THE INDEPENDENT COMMITTEE ............................. 13

B1. THE CHIEF EXECUTIVE’S DECISION TO SET UP THE INDEPENDENT COMMITTEE

(“COMMITTEE”) ................................................................................................................................ 13

B2. THE COMMITTEE’S TERMS OF REFERENCE (“TOR”) ............................................................. 15

B3. THE INVOLVED PARTIES ........................................................................................................ 17

B4. LEGAL REPRESENTATION OF THE INVOLVED GOVERNMENT BUREAUX / DEPARTMENTS ....... 18

B5. HOW THE INVOLVED GOVERNMENT BUREAUX / DEPARTMENTS HAVE ASSISTED THE

COMMITTEE’S WORK, AND THEIR OVERALL APPROACH TO THE INQUIRY .......................................... 19

THE COMMITTEE’S TREATMENT OF EVIDENCE AND MAKING OF FINDINGS 21

C1. THE PURPOSE OF THE INQUIRY .............................................................................................. 21

C2. THE HANDLING OF EVIDENCE RECEIVED BY THE COMMITTEE ............................................... 22

C3. BURDEN/STANDARD OF PROOF ............................................................................................. 24

C4. “CAUSATION” IN THE LEGAL CONTEXT ................................................................................. 28

OVERVIEW OF THE GOVERNMENT’S CASE .................................................... 31

PART II: BACKGROUND TO WFC AND THE WFC FIRE ...................................................... 42

WFC ............................................................................................................................... 42

E1. WFC AND THE SURROUNDING AREA ..................................................................................... 42

E2. MANAGEMENT OF THE WFC AFFAIRS AT THE MATERIAL TIME ............................................. 44

(i) The PMC .......................................................................................................................... 44

(ii) The IO and MC ................................................................................................................ 46

E3. INTRODUCTION TO THE FSI SYSTEM AT WFC ....................................................................... 47

E4. STATUTORY CONTROL OF WFC BY THE ICU ........................................................................ 52

(i) The background of delegation from the BD to ICU ......................................................... 52

(ii) “Administrative control” vs. “statutory control” ........................................................... 56

(iii) The scope of delegation ................................................................................................... 58

E5. ISSUANCE OF THE STATUTORY NOTICES TO WFC UNDER THE MBIS..................................... 61

E6. THE WFC RENOVATION WORKS FOLLOWING COMPLETION OF THE MBIS INSPECTION –

MAINLY GOVERNED BY THE MWCS ................................................................................................. 63

E7. BEFORE THE WFC FIRE – THE MARINERS’ CLUB INCIDENT (2023) AND CHINACHEM TOWER

INCIDENT (OCTOBER 2025, SHORTLY BEFORE THE WFC FIRE) .......................................................... 64

THE REGULATORY FRAMEWORK UNDER EACH RELEVANT AREA AND

STAKEHOLDERS’ ROLES AND RESPONSIBILITIES ............................................................ 69

F1. GENERAL BUILDING MANAGEMENT UNDER PRIVATE OWNERSHIP ......................................... 69

(i) The regulatory framework and model.............................................................................. 69

(ii) The Government’s facilitative role (for the case of WFC) .............................................. 71

(iii) The other stakeholders’ responsibilities - owners and the PMC ..................................... 72

F2. OWNERS’ ENGAGEMENT OF PROFESSIONALS FOR MAINTENANCE OF THE FSI SYSTEM .......... 73

(i) The regulatory framework and model for ownership and maintenance of FSIs ............. 73

(ii) The Government’s facilitative role .................................................................................. 74

(iii) The other stakeholders’ responsibilities – owners, the PMC, contractors, consultant and

RI .................................................................................................................................... 76

F3. OWNERS’ ENGAGEMENT OF BUILDING PROFESSIONALS FOR CARRYING OUT BUILDING- OR

ESTATE-WIDE INSPECTIONS AND RENOVATION WORKS ...................................................................... 77

(i) The regulatory framework and model.............................................................................. 77

(ii) The Government’s facilitative role .................................................................................. 78

(iii) The other stakeholders’ responsibilities – owners and the PMC .................................... 80

F4. MANAGEMENT OF FIRE RISKS AND MAINTENANCE OF FSI ..................................................... 81

(i) The regulatory framework and model.............................................................................. 81

(ii) The Government’s supervisory role - the BD and FSD ................................................... 83

(iii) The other stakeholders’ responsibilities – owners, the PMC and RFSICs ...................... 88

F5. REGULATION AND SUPERVISION OF CONSTRUCTION METHODS, PROCEDURES AND USE OF

MATERIALS UNDER THE MBIS AND MWCS...................................................................................... 89

(i) The regulatory framework and model.............................................................................. 89

(ii) The Government’s supervisory role ................................................................................. 92

(iii) The other stakeholders’ responsibilities – owners, the PMC and building professionals

........................................................................................................................................ 94

F6. REGULATION AND SUPERVISION OF BUILDING PROFESSIONALS – REGISTERED INSPECTORS

(I.E. RI) UNDER THE MBIS AND REGISTERED CONTRACTORS (I.E. RC) FOR CARRYING OUT WORKS .. 95

(i) The regulatory framework and model.............................................................................. 95

(ii) The Government’s supervisory role ................................................................................. 97

F7. REGULATION AND SUPERVISION OF OCCUPATIONAL HEALTH AND SAFETY ......................... 100

(i) The regulatory framework and model............................................................................ 100

(ii) The Government’s supervisory role ............................................................................... 101

(iii) The other stakeholders’ responsibilities – owners, the PMC and building professionals

...................................................................................................................................... 103

PART III: TOR 1 ............................................................................................................................. 104

THE CAUSES AND ORIGIN OF THE FIRE, SPREAD OF FIRE AND HEAVY CASUALTIES - THE INTER-DEPARTMENTAL FIRE INVESTIGATION TASK FORCE’S

GENERAL FINDINGS ................................................................................................................... 104

G1. A BRIEF CHRONOLOGY OF THE FIRE WITH ALL OF THE FACTORS CONTRIBUTING TO THE FIRE,

SPREAD OF FIRE AND HEAVY CASUALTIES SUMMED UP .................................................................... 104

G2. THE INTER-DEPARTMENTAL FIRE INVESTIGATION TASK FORCE ......................................... 107

G3. THE IFITF’S GENERAL FINDINGS ON THE CAUSE AND ORIGIN OF THE FIRE .......................... 108

G4. THE IFITF’S GENERAL FINDINGS ON THE RAPID SPREAD OF THE FIRE ................................. 110

G5. THE IFITF’S GENERAL FINDINGS ON THE HEAVY CASUALTIES CAUSED BY THE FIRE ........... 115

G6. THE COMMITTEE’S INDEPENDENT EXPERT EVIDENCE AND AREAS OF AGREEMENT ............ 122

PART III(A): ON THE FIREFIGHTING AND RESCUE OPERATIONS .............................. 128

THE EVENTS FROM 26 TO 28 NOVEMBER 2025 ............................................. 128

H1. THE FSD ............................................................................................................................. 128

H2. EVIDENCE ON THE FIREFIGHTING OPERATION – DIFFERENT PHASES OF THE WFC FIRE WITH

REFERENCE TO THE FIRE ALARM LEVELS AND DEPLOYMENT OF RESOURCES ................................... 129

(i) Breakout of the fire (No. 1 Fire Alarm) ......................................................................... 129

(ii) No.3 Fire Alarm (including setting up of the Director’s Command Post) .................... 133

(iii) No.4 Fire Alarm ............................................................................................................. 136

(iv) No.5 Fire Alarm ............................................................................................................. 138

(v) Handover of command at 0935 hours on 2025.11.27 .................................................... 141

(vi) Declaration of the fire being “surrounded”, “under control” and delivery of the

“STOP” message .......................................................................................................... 141

H3. EVIDENCE ON THE RESCUE OPERATION ............................................................................... 142

(i) Handling of 999 calls since the first call received ......................................................... 142

(ii) Evacuation at the early stages of the fire, in particular the status of the fire alarms at

each of the eight blocks ................................................................................................ 145

(iii) The rescue operation...................................................................................................... 147

H4. EVIDENCE ON THE CHALLENGES AND DIFFICULTIES FACED BY THE FSD FRONTLINE OFFICERS 150

H5. EVIDENCE ON THE SETTING UP OF THE COMMAND POST FOR THE DISASTER VICTIM

IDENTIFICATION UNIT (“DVIU”) ON 2025.11.28 AND DVIU’S OPERATION ................................... 155

H6. EVIDENCE ON CASUALTIES AND DAMAGE ........................................................................... 158

(i) The passing of Senior Fireman Ho Wai-ho ................................................................... 158

(ii) Other casualties and the Police’s Casualty Enquiry Unit (“CEU”) ............................. 161

(iii) Damage to property ....................................................................................................... 162

PART III(B): START OF THE FIRE ........................................................................................... 164

WORKERS SMOKING ONSITE ............................................................................ 164

I1. PREVALENCE OF WORKERS SMOKING ONSITE ...................................................................... 165

(i) The various complaints made by the WFC residents / IO to Prestige / Will Power, the

PMC and LD ................................................................................................................. 165

(ii) The presence of photographic / video, contemporaneous and other factual evidence

showing workers smoking onsite .................................................................................. 167

I2. HOW WORKERS SMOKING ONSITE RESULTED IN START OF THE FIRE .................................... 168

(i) The relevant factual evidence ........................................................................................ 168

(ii) The IFITF’s investigations ............................................................................................. 168

I3. THE PRIMARY AND SUPERVISORY RESPONSIBILITIES FOR SUCH CONTRIBUTING FACTOR ..... 169

(i) The regulatory and supervisory regime for workers smoking onsite ............................ 169

(ii) The primary responsibilities of Prestige and the PMC, including site management .... 171

(iii) The Government’s supervisory responsibilities ............................................................. 172

(iv) The actions taken by the LD at WFC ............................................................................. 174

(v) The role of the FSD ........................................................................................................ 175

I4. SYSTEMIC AND/OR OPERATIONAL WEAKNESSES ON THE REGULATORY LEVEL .................... 176

PART III(C): RAPID SPREAD OF THE FIRE ........................................................................... 180

THE USE OF SCAFFOLDING NETS UNCERTIFIED FOR FR PROPERTIES 180

J1. USE OF SCAFFOLDING NETS UNCERTIFIED FOR FR PROPERTIES AT WFC ............................. 180

(i) The various complaints made by the WFC residents / IO to Prestige / Will Power, the

PMC and Government Departments ............................................................................ 184

(ii) The relevant conversation records and other factual evidence ..................................... 185

(iii) The unreliable test certificate presented by Prestige ..................................................... 186

J2. HOW THE USE OF SCAFFOLDING NETS UNCERTIFIED FOR FR PROPERTIES RESULTED IN RAPID

SPREAD OF THE FIRE ........................................................................................................................ 187

(i) The relevant factual evidence ........................................................................................ 187

(ii) The IFITF’s investigations and expert evidence ............................................................ 187

J3. THE PRIMARY AND SUPERVISORY RESPONSIBILITIES FOR SUCH CONTRIBUTING FACTOR ..... 188

(i) The FR standards and other requirements applicable to scaffolding nets administered by

the BD ........................................................................................................................... 188

(ii) The primary responsibilities of Prestige and the RI ...................................................... 190

(iii) The Government’s supervisory responsibilities ............................................................. 192

(iv) The actions taken by the ICU at WFC, including the ICU’s practice of giving advance

notice ............................................................................................................................ 193

(v) The actions taken by the LD at WFC ............................................................................. 197

J4. SYSTEMIC AND/OR OPERATIONAL WEAKNESSES ON THE REGULATORY LEVEL .................... 198

THE USE OF POLYVINYL CHLORIDE FOAM BOARDS AS COVERS ON

WINDOWS AS TEMPORARY PROTECTION .......................................................................... 204

K1. EXTENSIVE USE OF FOAM BOARDS ...................................................................................... 205

(i) The various complaints made by the WFC residents / IO to Prestige / Will Power, the

PMC and Government Departments ............................................................................ 207

(ii) The relevant conversation records and other factual evidence ..................................... 207

(iii) The actual manner of use of foam boards at WFC ........................................................ 209

K2. HOW THE EXTENSIVE USE OF FOAM BOARDS TO COVER UP WINDOWS RESULTED IN RAPID

SPREAD OF THE FIRE AND HEAVY CASUALTIES ................................................................................ 210

(i) The relevant factual evidence ........................................................................................ 210

(ii) The IFITF’s investigations and expert evidence ............................................................ 210

K3. THE PRIMARY AND SUPERVISORY RESPONSIBILITIES FOR SUCH CONTRIBUTING FACTOR ..... 211

(i) The standards and requirements applicable to the use of foam boards as protection .. 211

(ii) The primary responsibilities of Prestige and the RI ...................................................... 214

(iii) The Government’s supervisory responsibilities ............................................................. 214

(iv) The actions taken by the ICU at WFC ........................................................................... 217

(v) The actions taken by the FSD at WFC ........................................................................... 219

K4. SYSTEMIC AND/OR OPERATIONAL WEAKNESSES ON THE REGULATORY LEVEL .................... 220

THE USE OF OTHER NON-FR CONSTRUCTION MATERIALS -

SPECIFICALLY, PLASTIC SHEETS / CANVAS ...................................................................... 225

L1. USE OF OTHER NON-FR CONSTRUCTION MATERIALS – THE RELEVANT EVIDENCE ............... 225

L2. HOW THE USE OF OTHER NON-FR CONSTRUCTION MATERIALS RESULTED IN RAPID SPREAD OF

THE FIRE .......................................................................................................................................... 229

(i) Plastic sheets and canvas............................................................................................... 229

(ii) Toe-boards, wooden planks, nylon strips ...................................................................... 230

L3. THE PRIMARY AND SUPERVISORY RESPONSIBILITIES FOR SUCH CONTRIBUTING FACTOR ..... 231

(i) The FR standards and other requirements applicable to such other construction

materials ....................................................................................................................... 231

(ii) The primary responsibilities of Prestige and the RI ...................................................... 232

(iii) The Government’s supervisory responsibilities on the use of such other construction

materials ....................................................................................................................... 232

L4. SYSTEMIC AND/OR OPERATIONAL WEAKNESSES ON THE REGULATORY LEVEL .................... 233

PART III(D): OTHER FACTORS CONTRIBUTING TO THE HEAVY CASUALTIES ..... 236

UNTENABILITY OF THE MEANS OF ESCAPE CAUSED BY CREATION OF ACCESSES 236

M1. CREATION OF WOODEN OR METALLIC ACCESSES AT ESCAPE STAIRCASES AT EVERY FIVE

LEVELS OF WFC – THE RELEVANT CONVERSATION RECORDS AND OTHER FACTUAL EVIDENCE

SHOWING THE MANNER OF CREATION OF SUCH ACCESSES AT WFC ................................................ 237

M2. HOW THE CREATION OF SUCH ACCESSES AT ESCAPE STAIRCASES RESULTED IN RAPID SPREAD,

AS WELL AS SUCH HEAVY CASUALTIES ............................................................................................ 239

(i) The relevant factual evidence ........................................................................................ 239

(ii) The IFITF’s investigations ............................................................................................. 240

M3. THE PRIMARY AND SUPERVISORY RESPONSIBILITIES FOR SUCH CONTRIBUTING FACTOR ..... 240

(i) The standards and requirements applicable to the creation and use of such accesses and

the LD’s occupational health and safety perspective ................................................... 240

(ii) The primary responsibilities of Prestige and the RI ...................................................... 243

(iii) The Government’s supervisory responsibilities ............................................................. 244

(iv) The actions taken by the ICU in the case of WFC ......................................................... 246

M4. SYSTEMIC AND/OR OPERATIONAL WEAKNESSES ON THE REGULATORY LEVEL .................... 246

THE FAILURE OF ALL FIRE ALARMS AT WFC ............................................. 250

N1. THE FAS AT EACH BLOCK OF WFC BEING SHUT DOWN ...................................................... 251

(i) The part of WFC renovation works touching on the FH/HR System ............................. 251

(ii) The engagement of China Status as the RFSIC ............................................................. 253

(iii) How the FAS was eventually deactivated by a staff member of the PMC ..................... 256

(iv) The maintenance and repair works carried out by Victory Fire at WFC from October to

November 2025 up to the day of the fire ...................................................................... 259

N2. HOW THE SHUTDOWN OF THE FAS RESULTED IN SUCH HEAVY CASUALTIES ....................... 262

(i) The relevant factual evidence ........................................................................................ 262

(ii) The IFITF’s investigations and expert evidence ............................................................ 263

N3. THE PRIMARY AND SUPERVISORY RESPONSIBILITIES FOR SUCH CONTRIBUTING FACTOR ..... 264

(i) The regulatory and supervisory regime for the shutdown of FSI .................................. 264

(ii) The primary responsibilities of Prestige and the RI ...................................................... 267

(iii) The primary responsibilities of China Status................................................................. 269

(iv) The primary responsibilities of the PMC ....................................................................... 272

(v) The primary responsibilities of Victory Fire ................................................................. 274

(vi) The Government’s supervisory responsibilities: ........................................................... 275

(vii) The FSD’s handling of the FS251s and SDNs in the case of WFC and actions taken .. 280

N4. SYSTEMIC AND/OR OPERATIONAL WEAKNESSES ON THE REGULATORY LEVEL .................... 282

PART III(E): CONCERNS ON THE FIREFIGHTING AND RESCUE OPERATIONS ....... 291

THE GOVERNMENT’S REVIEW OF THE FIREFIGHTING AND RESCUE

OPERATIONS ................................................................................................................................. 291

O1. THE TACTICAL CONSIDERATION TO CONTROL THE FIRE AT EACH AFFECTED BUILDING

ACCORDING TO THE CIRCUMSTANCES AT THE EARLY STAGE OF THE FIRE INSTEAD OF DEPLOYING

MANPOWER TO CARRY OUT EVACUATION ....................................................................................... 293

(i) The FSD’s understanding with the Police ..................................................................... 293

(ii) The FSD’s tactical consideration and difficulties in carrying out evacuation .............. 295

(iii) Whether sufficient weight had been given to the failure of the fire alarms in deciding not

to deploy manpower on evacuation .............................................................................. 298

(iv) Whether there was sufficient attention paid on the horizontal spread of fire from Wang Tai House to other blocks and inward spread of fire from the façade into the building

...................................................................................................................................... 299

O2. THE ESCALATION OF FIRE ALARM LEVELS ........................................................................... 300

(i) Whether the fire could be escalated to higher fire alarm levels earlier for deployment of

further resources to the fire scene ................................................................................ 300

(ii) Whether the current fire alarm levels are capable of covering varying features at

different fire scenes, e.g. the fire risks arising from large-scale renovation projects .. 304

O3. THE JOINT-HANDLING OF 999 CALLS BY THE POLICE AND FSD IN THE CASE OF FIRE .......... 305

(i) The discretion on the Police’s side to decide whether to refer a call to the FSD’s side305

(ii) The waiting time for some calls to be referred to the FSD ............................................ 307

(iii) The repetition of requests for information and questions on the FSD’s side ................ 308

(iv) The advice given to callers, in particular whether callers should generally be advised to

evacuate ........................................................................................................................ 309

(v) The sharing of information within the FSD on requests for rescue, and the FSD’s

recording of information .............................................................................................. 310

(vi) The call-back arrangement ............................................................................................ 311

O4. THE SUFFICIENCY OF THE FSD’S VARIOUS COMMUNICATION SYSTEMS AT THE FIRE SCENE

AND BETWEEN THE FSD CALL CENTRE / DIRECTOR’S COMMAND POST AND THE FIRE SCENE ......... 312

O5. THE SAFETY AND TRACKING OF FIREFIGHTERS ENTERING THE BLAZE ................................. 314

(i) The sufficiency of breathing apparatus and other equipment generally used by

firefighters at the fire scene .......................................................................................... 314

(ii) The sufficiency of the Firefighter Location System ........................................................ 316

(iii) The (lack of) ECP at the early stage of the fire ............................................................. 317

O6. RESPONSE TO OTHER QUERIES / CRITICISMS RAISED ............................................................ 317

(i) Coordination among different teams of the FSD at the scene to be enhanced? ............ 317

(ii) The bamboo scaffolds should be dismantled first? ........................................................ 319

(iii) The EAS should be invoked? .......................................................................................... 320

(iv) Helicopters and other advanced technologies such as drones should be used in the

firefighting operation? .................................................................................................. 322

(v) Additional support from the Chinese Mainland should be sought? .............................. 324

O7. REVIEW ............................................................................................................................... 325

(i) Improvements already introduced ................................................................................. 325

(ii) Improvements to be introduced, and further studies to be conducted ........................... 327

PART III(F): SYSTEMIC ISSUES ................................................................................................ 330

ABUSE OF THE SYSTEM BY PROFESSIONALS AND OTHER NONGOVERNMENTAL PARTIES ...................................................................................................... 330

P1. PRESTIGE CONSTRUCTION & ENGINEERING COMPANY LIMITED ........................................ 331

P2. WILL POWER (CONSULTANT PURPORTEDLY PROVIDING RI SERVICES) AND NG YEUK (THE RI)333

P3. CHINA STATUS .................................................................................................................... 335

P4. VICTORY FIRE ..................................................................................................................... 336

P5. ISS (THE PMC) ................................................................................................................... 337

P6. RESIDENTS AS VICTIMS OF THE CUMULATIVE EFFECT OF PRIVATE-ACTOR FAILURE ............ 339

SYSTEMIC ISSUES ACROSS KEY CONTRIBUTING FACTORS ................... 341

Q1. RELIANCE ON THE SELF-REGULATION OF PROFESSIONALS, AND SUFFICIENCY OF AUDIT

CHECKS AND SITE INSPECTIONS ....................................................................................................... 343

Q2. SUPERVISION OF PROFESSIONALS – RCS, RIS AND RFSICS ................................................ 344

Q3. SUFFICIENCY OF THE RELEVANT PROCEDURAL GUIDELINES, CODES OF PRACTICE, ETC. ...... 345

Q4. INTERNAL AND EXTERNAL COMMUNICATIONS .................................................................... 348

(i) Internal communications between the BD and ICU under the delegation arrangement

...................................................................................................................................... 348

(ii) Internal communications between the Police and FSD during the firefighting and rescue

operations ..................................................................................................................... 348

(iii) Internal communications across departments and referrals of complaints / enquiries –

the roles of the 1823 hotline, the HAD and other relevant Government Departments

under ToR 1 in referring complaints and enquiries to the appropriate Department(s) for

handling ........................................................................................................................ 349

(iv) External communications with residents ....................................................................... 350

(v) External communications with building professionals .................................................. 350

Q5. STATUS OF TECHNOLOGY APPLICATION .............................................................................. 351

THE GOVERNMENT’S SUBMISSIONS IN CONCLUSION OF TOR 1 ........... 353

R1. CONCLUSIONS ON THE DIRECT CAUSES OF THE FIRE, SPREAD OF FIRE AND HEAVY CASUALTIES 353

R2. CONCLUSIONS ON RESPONSIBILITIES OF PROFESSIONALS AND OTHER NON-GOVERNMENTAL

PARTIES ........................................................................................................................................... 355

R3. CONCLUSIONS ON THE GOVERNMENT’S SYSTEMIC AND OPERATIONAL ISSUES ................... 356

(i) The weaknesses of the self-regulation regime for the supervision of building

professionals under the MBIS and MWCS, and RFSICs .............................................. 357

(ii) Areas for improvement concerning the audit checks and inspections to identify risks and

problems ....................................................................................................................... 358

(iii) Inadequacies in the relevant procedural guidelines, codes of practice, etc. ................. 359

(iv) Weaknesses in internal communications and exchanges between the BD and ICU under

the delegation arrangement .......................................................................................... 359

(v) The trailing in the use of more advanced technologies to assist work and/or manage

risks ............................................................................................................................... 359

R4. EXECUTIVE SUMMARY OF IMPROVEMENTS AND IMMEDIATE STEPS TAKEN BY THE

GOVERNMENT AFTER THE FIRE ....................................................................................................... 360

R5. THE GOVERNMENT’S RESPONSE TO MEASURES RECOMMENDED BY THE COMMITTEE’S

EXPERTS .......................................................................................................................................... 364

PART IV: TOR 2 ............................................................................................................................. 369

OUTLINE OF THE SYSTEMIC ISSUES AS IDENTIFIED FROM THE EVIDENCE 369

S1. BID-RIGGING AND OTHER ANTI-COMPETITIVE / UNLAWFUL CONDUCT – CONSULTANTS / RIS

AND CONTRACTORS ......................................................................................................................... 370

S2. BRIBERY – CONSULTANTS / RIS AND CONTRACTORS BRIBING THE RELEVANT STAKEHOLDERS,

E.G. THE PMC AND MEMBERS OF THE MC OF THE IO ...................................................................... 373

S3. OTHER MISCONDUCT OR DISHONEST CONDUCT IN THE TENDERING AND QUOTATION

PROCESSES ...................................................................................................................................... 373

S4. ABUSE OF THE PROXY SYSTEM ............................................................................................ 374

S5. THE FAILURE OF THE PMCS IN DISCHARGING THEIR DUTIES ............................................... 375

THE INVOLVEMENT OF THE GOVERNMENT AND RELATED BODIES . 377

T1. THE URA ............................................................................................................................ 377

T2. THE COMPETITION COMMISSION ........................................................................................ 380

T3. THE ICAC........................................................................................................................... 382

T4. THE POLICE......................................................................................................................... 384

THE ROLES AND RESPONSIBILITIES OF THE HAD ..................................... 387

U1. THE REGULATORY CONTEXT FOR THE HAD’S INVOLVEMENT ............................................. 387

(i) The HAD’s roles and responsibilities in facilitating building management.................. 387

(ii) The HAD’s powers under the Building Management Ordinance (Cap. 344) ................ 388

U2. THE CONDUCT OF THE RELEVANT WFC IO / DISPUTES AND CHALLENGES, AND THE HAD’S

INVOLVEMENT AT DIFFERENT STAGES ............................................................................................. 389

(i) The stage of compliance with the MBIS and engagement of Will Power as the consultant

providing RI services .................................................................................................... 389

(ii) The stage of renovation design and project procurement, and engagement of Will Power

as the consultant for the subsequent renovation works ................................................ 390

(iii) The stage of contractor tendering and selection............................................................ 391

(iv) The stage of contract finalisation and execution ........................................................... 393

(v) The stage of re-election of the MC up to the fire ........................................................... 394

U3. SYSTEMIC AND/OR OPERATIONAL WEAKNESSES ON THE REGULATORY LEVEL .................... 396

IMPROVEMENT MEASURES (RELEVANT TO TOR 2) PROPOSED BY THE

GOVERNMENT AS A WHOLE ................................................................................................... 404

PART V: ENDING REMARKS ..................................................................................................... 407

ENDING REMARKS ................................................................................................. 407

PART I: INTRODUCTION

A. THE WANG FUK COURT (“WFC”) FIRE

A1. The WFC Fire

On 26 November 2025, a fire broke out at WFC, a Home Ownership Scheme (“HOS”) estate in Tai Po, New Territories, comprising eight high-rise residential blocks built in 1983.

At the time of the incident, all eight blocks were undergoing concurrent exterior maintenance and renovation works, and were enveloped in bamboo scaffolding and protective netting that wrapped the towers from the ground to the upper floors. The renovation project, valued at approximately HK$336 million, was entrusted to registered professionals and a registered contractor (“RC”) who bore primary statutory obligations under, inter alia, the Buildings Ordinance (Cap. 123) (“BO”), Fire Services Ordinance (Cap. 95) (“FSO”), Occupational Safety and Health Ordinance (Cap. 509) (“OSHO”), and Factories and Industrial Undertakings Ordinance (Cap. 59) (“FIUO”) to ensure that the works were carried out safely and in compliance with legal and regulatory requirements. They had each failed their responsibilities and the public’s expectations.

The fire was first reported to the Fire Services Communications Centre (“FSCC”) at 1451 hours. The caller reported a fire with explosion at scaffolding installed along the external wall of Wang Cheong House. On the evidence presently available to the Committee, the fire originated from the flat roof outside Flats 104 and 105 of Wang Cheong House. CCTV footage and videos taken by members of the public point consistently to that location as the place where the initial fire took hold.

The fire spread with extraordinary speed. Within approximately 20 minutes of

the first fire appliance arriving at the scene, the fire had spread from its point of origin to multiple locations across Wang Cheong House, extending to multiple façades and the open ground surrounding the building, and had reached Wang Tai House. In certain blocks, the fire spread across multiple levels within an extremely short period of time, driven by the chimney-like configuration of the re-entrant, which confined and directed hot air, smoke and combustible gases upward. Wind-carried embers then spread the fire horizontally from building to building. By the conclusion of the incident, 12 instances of rapid vertical fire spread were observed along the re-entrants across 6 buildings.

The fire burned for approximately 43 hours and was declared “surrounded” at 2131 hours on 27 November 2025, “under control” at 0315 hours on 28 November 2025, and largely extinguished at 1018 hours on 28 November 2025. At its peak, the response involved 174 fire engines, 47 ambulances, and 989 FS personnel, the largest deployment in the history of the Fire Services Department (“FSD”). Over the course of the entire 43-hour operation, the cumulative deployment comprised 581 fire appliances, 217 ambulances, and 3,531 FS personnel (including 2,643 firefighters, 224 fire officers, 585 ambulance personnel and 79 ambulance officers).

The scale and severity of the fire was without precedent in Hong Kong’s postwar history. With seven of the eight towers affected, thousands of residents lost their homes or found them uninhabitable due to fire damage, smoke, water and structural risks. The displacement of nearly 5,000 people created rehousing, welfare and support needs that required sustained Government attention.

A2. The Government’s immediate response – the three Task Forces

The Government responded swiftly and comprehensively to the incident. On 2 December 2025, the Chief Executive announced that three cross-bureau Task Forces had been established to coordinate the relief, investigation and rehousing work.

The first was the Task Force on Investigation and Regulation, led by the Chief Secretary for Administration, which was tasked with coordinating the technical and regulatory probes into the fire’s causes, performance of FSIs, and adequacy of construction safety and building maintenance practice. This Task Force brought together relevant bureaux and departments, including the FSD, Hong Kong Police Force (“Police”), Buildings Department (“BD”), Labour Department (“LD”) and other relevant regulators to investigate the fire scene, examine materials and design features, assess compliance with safety legislation, and identify immediate risks at similar construction sites across the territory, and formulate improvement measures to enhance the current regulatory system. The Inter-departmental Fire Investigation Task Force (“IFITF”), whose Final Investigation Report (May 2026) forms a primary evidential foundation for the Committee’s work under ToR 1, was established within this structure.

The second was the Task Force on Emergency Support and Fund-Raising, led by the Deputy Chief Secretary for Administration, which focused on immediate financial assistance, social welfare and community support. The Support Fund for WFC in Tai Po was established, seeded with HK$300 million in government capital and supplemented by public and corporate donations. An emergency subsidy of HK$10,000 per affected household was disbursed within days; by 2 December 2025, nearly 1,916 households had received this payment. A “one social worker per household” model was implemented, assigning dedicated case workers to coordinate welfare services, counselling and administrative support.

An online platform (taipodonation.hk) was established to register and coordinate

offers of supplies and donations from the public under the coordination of this Task Force.

The third was the Task Force on Emergency Accommodation Arrangements, led by the Deputy Financial Secretary, which addressed the logistical challenge of rehousing thousands of people. By early December 2025, over 1,000 residents had been placed in youth hostels, camps or hotel rooms, while over 1,600 had moved into transitional housing units or flats provided by the Hong Kong Housing Society. Temporary shelters were maintained, and the Government assessed residents’ actual needs and matched donated supplies accordingly. Tens of thousands of items were distributed to affected residents and temporary accommodation facilities.

These three Task Forces’ activities represented an immediate comprehensive crisis response combining operational firefighting and investigation, social and financial support, housing solutions, and legal facilitation. At the same time, given the scale and severity of the incident, the Government has gone above and beyond routine administrative follow-up and the Chief Executive took the swift initiative of establishing a mechanism for independent, public scrutiny, i.e. the setting up of the Independent Committee.

B. ESTABLISHMENT OF THE INDEPENDENT COMMITTEE

B1. The Chief Executive’s decision to set up the Independent Committee (“Committee”)

On 2 December 2025, while announcing updates on the three Task Forces, the Chief Executive stated that an Independent Committee would be established to examine the causes and related issues of the WFC fire. A formal Government announcement on 12 December 2025 confirmed that the Committee had been set up, with a clear mandate to complete its work within nine months.

In particular, the Chief Executive made clear that we are to ensure that justice is done, and to ensure that we will prevent such a tragedy from happening again. The Chief Executive made a call for a thorough investigation and serious reform, and promised to pursue accountability regardless of who he or she is. The primary aim is to uncover the truth, ensure that justice is served, let the deceased rest in peace and provide comfort to the living1.

On 19 December 2025, the Committee convened its first meeting and formally commenced its work. The decision to appoint a sitting High Court Judge as Chairman and to identify the body as “independent” was a deliberate measure to ensure impartiality and professionalism (which have unsurprisingly been demonstrated by the Committee in its work hitherto), drawing on Hong Kong’s established tradition of judge-led inquiries in major public safety incidents.

The Chief Executive emphasised that the Committee faced a substantial investigative task in examining two broad issues.

1 Remarks by the Chief Executive on matters related to the WFC fire in Tai Po at a media session on 2 December 2025 (https://www.info.gov.hk/gia/general/202512/02/P2025120200489.htm)

1. The first related directly to the fire: the causes and circumstances that led

to the blaze, including FSIs and their supervision; the adequacy of construction safety requirements and supervision in building maintenance and renovation works; the comprehensiveness of safety-compliant materials lists; the effectiveness of verification and testing systems; the roles and responsibilities of government officers, authorised professionals, contractors and others; and the liabilities arising from the aforementioned issues.

2. The second concerned systemic problems in large-scale building maintenance and renovation, including undue connected interests, conflicts of roles, improper collusion, bid-rigging corruption and irregularities in tendering processes.

As to the legal nature of the Committee, the Chief Executive explained that rather than immediately invoking the Commissions of Inquiry Ordinance (Cap. 86), which provides statutory powers of compulsion, he had opted to appoint the Committee under the general executive authority. He stated that a reserve power had been given to the Committee: if, in the course of its work, it considered that exercising powers equivalent to a statutory Commission of Inquiry would help it complete its tasks, the Chief Executive would be “very willing to consider” 2 appointing it as such, following the legal procedures for a Commission of Inquiry under existing ordinances.

This formulation placed the Committee in a position whereby it operates as an executive-appointed body, relying primarily on voluntary cooperation and the authority of its composition for evidence gathering, while retaining the explicit potential for transition to a Commission of Inquiry exercising all such statutory

2 Remarks by CE on matters related to the WFC fire in Tai Po at a media session on 12 December 2025 (https://www.info.gov.hk/gia/general/202512/12/P2025121200776.htm)

powers as are necessary. The adoption of this form of inquiry was aimed at

ensuring that the investigative work could proceed in a more flexible and expeditious manner while upholding the principles of openness and transparency.

The Government expressly supports this mode of inquiry. The Government immediately pledged its full support, and continues to pledge its full support, to the work of the Committee, in order to fulfil the expectations of the families of the deceased, the residents of WFC and the wider public for a full account of the truth behind this fire. As it turned out, 27 factual witnesses being current or former officers and representatives from different Bureaux and Departments of the Government, gave oral evidence (in addition to numerous written statements/submissions filed over the course of the proceedings).

As the Chairman neatly put it, what the Committee is trying to do is to reassess the risks and try to make it as best as it can. The Committee cannot be overly idealistic – there are other considerations to be taken into account and what the Committee is suggesting is that it will set the path forward. Stakeholders’ interests will be debated and what the Committee is trying to do is to try to raise awareness of the whole public about the risks associated with large-scale building maintenance and renovation projects in the future [Day 27/101/2-13].

B2. The Committee’s Terms of Reference (“ToR”)

The Committee’s ToR, published on 12 December 2025, define the boundaries of the inquiry and illuminate its purpose. They may be summarised as identifying the Committee’s tasks in four parts.

ToR 1 concerns the events of 26 November 2025: what happened at WFC, why the fire occurred, and what factors led to the heavy casualties. This includes an examination of the initial ignition, the role of construction materials and design

features in the fire’s rapid spread, the functioning and supervision of FSIs, the

adequacy of construction safety requirements, standards, supervision and day-today maintenance for the building maintenance and renovation works, whether the prevailing list of materials meeting safety standards is comprehensive and whether the related verification and testing systems are effective, the roles and responsibilities of personnel with supervisory roles across all stages (including government officers, authorised professionals, contractors and others), and the liabilities arising from the aforementioned issues.

ToR 2 moves from the particular to the general, asking whether there exist wider systemic problems in large-scale building maintenance and renovation works, including undue connected interests, conflicts of roles, or improper collusion across all stages, and whether bid-rigging corruption or irregularities were involved in the tendering process.

ToR 3 requires the Committee to examine whether regulation and penalties under relevant existing laws are adequate in respect of both matters above.

ToR 4 requires the Committee to make recommendations regarding matters in ToR 1 to 3.

The ToR therefore position the Committee as a fact-finding body, with recommendations regarding the relevant matters to be made. A critical feature of the ToR, as addressed further below, is to clearly demarcate the role of the Committee and that of law enforcement agencies and relevant courts/tribunals, with the latter being responsible for addressing any questions and determinations of legal liability (which fall outside the scope of the ToR) [A1/4].

B3. The involved parties

Given the complexity of the fire and breadth of the ToR, the Committee (rightly) adopted a structured approach to participation, identifying a category of “involved parties” which could participate in the evidential hearings, including rights to be legally represented, to call witnesses and/or to make submissions. The Rules of Procedure for the Evidential Hearing set out the mechanisms for parties to apply for participation and the logistical framework for hearings.

As at today, a total of 42 involved parties have been permitted by the Committee to participate in the Evidential Hearing. These comprise the following:

1. Six Government departments (the Police, FSD, LD, BD, Housing Department (“HD”, specifically the Independent Checking Unit (“ICU”)), and Home Affairs Department (“HAD”));

2. Three statutory or regulatory bodies (the Competition Commission, Independent Commission Against Corruption (“ICAC”) and Urban Renewal Authority (“URA”));

3. Ten residents of WFC (Ms Chow Yim Ling, Mr Lee Kwok Hung, Mr Leung Ho Hin, Ms Lo Hiu Kei, Mr Lo Hiu Kin, Mr Yip Ka Kui Sdanni, Mr Yip Shun Ting, Mr Yip Shun Yin, Mr So Hiu Fung and Ms Chong Sio Pek);

4. Fourteen current or former office-holders of the 12th MC of the IO of WFC (Mr Tsui Moon Come Tony as Chairperson, Mr Mak Chi Hung as Vice Chairperson, Mr Ho Chung Hang as Secretary, Ms Cheung Tsz Wan as Treasurer, and ten Members);

5. Two property management entities (ISS and Hop On Management

Company Limited (“Hop On”));

6. Victory Fire (an RFSIC);

7. Mr Leung Ping Kay (Director of China Status);

8. Mr Wong Hap Yin (Director of Will Power);

9. Mr Hau Wa Kin and Mr Ho Kin Yip (Directors of Prestige);

10. Mr Wong Chung Kee Steve (Authorised Signatory (“AS”) of Prestige); and

11. China Taiping Insurance (HK) Company Limited.

The inclusion of residents and former Management Committee members among the involved parties has demonstrably allowed them to articulate their concerns, present evidence on the handling of safety complaints and tendering process, and participate in the proceedings of the Committee (with some benefitting from legal assistance and representation).

The participation of the Competition Commission and ICAC is a recognition that the systemic dimension under ToR 2 includes potential breaches of competition and anti-corruption laws. Their involvement has evidently enriched the Committee’s evidentiary base on sector-wide practice and vulnerabilities.

B4. Legal representation of the involved Government Bureaux / Departments

The relevant Government bureaux and departments — namely the Police, FSD, LD, BD, ICU of the HD, and HAD — are represented in these proceedings by (1) the Department of Justice and (2) a team of Counsel comprising Mr Jenkin Suen SC, Mr Calvin Cheuk SC, Mr Michael Lok and Mr Charlie Liu.

B5. How the involved Government Bureaux / Departments have assisted the Committee’s work, and their overall approach to the inquiry

The Government has adopted a proactive approach to cooperate with and support the work of the Committee. Since the Committee was set up, various departments and bureaux have actively responded to letters and requests issued by the Committee’s legal team, whilst simultaneously and proactively taking the initiative of submitting documentary evidence, information as well as witness statements relevant to the ToR to the Committee before relevant requests were made on the Committee’s behalf. As illustration, the Government has, as recently as 29 June 2026, submitted a further witness statement dated 25 June 2026 in relation to the examination of plastic sheeting by Dr Lee Wing-man of the Government Laboratory to provide a fuller picture to the Committee.

The scale of cooperation has been substantial. Since the Committee commenced its work in December 2025, the relevant Government departments have submitted a large volume of witness statements and documentary materials within a short period. The Committee has received nearly one million individual documents from Government departments, law enforcement agencies, contractors and members of the public, along with hours of CCTV footage and digital materials. The total volume of data exceeds one terabyte.

Government departments have contributed to this evidential base in multiple ways.

1. They have provided formal witness statements and made witnesses available for oral evidence, in some cases over several days. Witness statements have been published on the Secretariat’s website subject to necessary redactions.

2. In all, during the course of the evidential hearings, 31 witnesses from the

six Government departments represented in these proceedings and the IFITF gave oral evidence across 13 hearing days between 10 April and 25 June 2026. Of these, 19 witnesses were from the FSD and the IFITF, giving evidence over 8 hearing days (Days 10–12, 17–19 and 25–26), spanning every level of the organisation from frontline Senior Station Officers to the Director of Fire Services (“DFS”); 3 were from the LD, giving evidence on 1 hearing day (Day 16); 1 was from the BD, giving evidence on 1 hearing day (Day 20); 3 were from the HAD, giving evidence across 2 hearing days (Days 20 and 24); 3 were from the ICU of the HD, giving evidence across 3 hearing days (Days 22, 23 and 24); and 2 were from the Police, giving evidence on 1 hearing day (Day 12).

3. Witnesses have been examined by Counsel for the Committee and by other involved parties’ counsel on specific issues including the division of responsibility for assessing flammable materials, functioning and supervision of fire alarms, enforcement of occupational safety rules, and handling of building maintenance complaints.

4. In addition to those witnesses who gave oral evidence, a large number of Government witnesses provided witness statements to the Committee which were admitted into evidence without being called to give oral testimony.

5. They have also disclosed internal records relating to the supervision of the WFC maintenance works and their follow-up actions in response to complaints.

In tandem with the work of the Committee, the Government departments have begun implementing improvement measures even before the Committee’s final

report, reflecting a proactive, learning-oriented stance. These measures are

addressed in detail below.

The Government will continue to cooperate fully with the work of the Committee throughout the course of the hearings and beyond, so as to present an objective and complete picture of the incident to the Committee and the public.

C. THE COMMITTEE’S TREATMENT OF EVIDENCE AND MAKING OF FINDINGS

C1. The purpose of the inquiry

The purpose of the Committee’s inquiry is to investigate the matters set out under the ToR. It includes a fact-finding exercise based on the available evidence, with a view to making recommendations for the prevention of recurrence.

It is not an exercise in determining any party’s legal liabilities, civil or criminal. This distinction (from the role of law enforcement agencies and relevant courts/tribunals) is fundamental to the proper understanding of both the Government’s submissions and the Committee’s findings. Specifically, the Government takes the position that neither (1) the Government’s submissions in these proceedings nor (2) the Committee’s findings, assessments and conclusions should be understood to imply guilt or any civil, criminal or other legal liabilities on the part of any person or body. The issues relevant to legal liabilities are properly left for the relevant bodies to determine in other appropriate fora.

The Committee has itself recognised this distinction. The Note to the ToR expressly exclude determinations of legal liability from the scope of the inquiry [A1/4]. By way of illustration, Counsel for the Committee has explained that ongoing criminal investigations proceed in parallel, that if a prosecution is brought the determination of guilt will be a matter for the courts, and that the

Committee’s role is to provide clarity and accountability rather than to substitute

for judicial processes.

This separation ensures that the Government will have the benefit of the Committee’s findings and recommendations in considering further improvement measures without awaiting the conclusion of what may be protracted legal proceedings.

C2. The handling of evidence received by the Committee

The Committee has received evidence in multiple forms: witness statements from government officers, contractors, consultants, property management staff, FSI contractors, residents and others; documentary exhibits including contracts, correspondence, photographs, meeting minutes, statutory submissions, circulars, codes of practice and legislation; CCTV footage from the day of the fire; digital communications records; expert reports; and the Final Investigation Report of the Inter-departmental Fire Investigation Task Force (May 2026).

The Committee conducted public evidential hearings over 27 hearing days (between 19 March and 25 June 2026), during which 73 factual witnesses and 7 expert / IFITF witnesses gave evidence and were examined on their respective areas. Witnesses were examined by Counsel for the Committee, Counsel for the involved parties, and by the Chairman and Members of the Committee.

The Government takes note of the Committee’s decision, announced by the Chairman on 22 June 2026, not to recommend to the Chief Executive that the Committee be converted into a statutory Commission of Inquiry under the Commissions of Inquiry Ordinance (Cap. 86). As the Chairman explained, the Committee reached this decision after careful consideration of five factors: (i) the Committee had already obtained sufficiently comprehensive information to

identify what happened and why, and was confident it could analyse and draw

conclusions on all matters within the ToR; (ii) conversion to a statutory inquiry would inevitably prolong the proceedings due to the procedural complexity inherent in statutory inquiries, at a time when the public interest demanded timely completion (with the UK’s Grenfell Tower Inquiry as a counter-example); (iii) conversion might affect or at least delay ongoing or subsequent criminal and civil proceedings, and could complicate the work of the law enforcement agencies; (iv) the current modus operandi afforded greater flexibility and openness in the conduct of the inquiry; and (v) investigations into bid-rigging or irregularities at WFC specifically were more appropriately pursued by the law enforcement agencies, which had already laid charges and had not ruled out further enforcement action. The Government respectfully supports the Committee’s approach which we believe cast a proper and appropriate balance between the need for completeness in the evidence and other relevant considerations such as timing. The Government particularly echoes the Committee’s position that this decision does not diminish the Committee’s ability to make factual findings and draw appropriate inferences from the evidence before it. After all, as has been made clear from the outset and emphasised throughout, it was and remains a matter for the Committee to determine what, if any, additional powers it may require in order to complete its work.

In particular, the absence of certain involved parties and/or their failure to give evidence before the Committee does not preclude the Committee from drawing (adverse) inferences from that absence or failure, and/or from making (adverse) factual findings based on the totality of the evidence available. Ultimately, and by way of illustration, whether any adverse inference is to be drawn “is or ought to be just a matter of ordinary rationality. So far as possible, tribunals should be free to draw, or decline to draw, inferences from the facts of the case before them using their common sense without the need to consult law books when doing so.

Whether any positive significance should be attached to the fact that a person has not given evidence depends entirely on the context and particular circumstances”: ANZ Commodity Trading Pty Ltd v Excellence Raise Overseas Ltd [2025] HKCA 701 at §121 per Kwan VP; citing Efobi v Royal Mail Group Ltd [2021] 1 WLR 3863 at §41 per Lord Leggatt JSC. Echoing the above, as observed by the Chairman when explaining the Committee’s decision (per paragraph 42 above) on 22 June 2026: “On the other hand, even if the stakeholders have given up the opportunity to testify in front of the public, the Committee can still make an adverse finding against them with the information we have already had. In other words, even though witnesses refused or choose not to attend the hearing to give testimony, this will not affect our ruling in terms of roles and accountability” [Day 25/9/13-20].

The Government submits that in the present case, where a party with knowledge of relevant facts has chosen not to give evidence (and a fortiori where they have declined an invitation by the Committee to do so), and the available evidence from other sources permits a finding of fact on the balance of probabilities, the Committee is fully entitled to make that finding insofar as is necessary. In any case, the Committee should be entitled to consider the totality of evidence (or its absence) before it to draw its conclusions using its common sense as appropriate.

The admissibility of and weight to be given to uncontested evidence, the inferences to be drawn from silence, and the assessment of credibility where accounts conflict are all matters for the Committee’s judgement, exercised in light of the circumstances of the case and gravity of the findings concerned.

C3. Burden/Standard of Proof

The Committee is not constituted as a formal Commission of Inquiry under the Commissions of Inquiry Ordinance (Cap. 86). Nevertheless, its fact-finding

function is materially akin to that of a statutory commission. The Government

respectfully invites the Committee to consider and, where appropriate, apply the principles developed in the context of commissions of inquiry and analogous inquisitorial proceedings in Hong Kong, as summarised below.

As the Commission of Inquiry into the Construction Works at and near the Hung Hom Station Extension under the Shatin to Central Link Project stated in its Final Report at §115, while “parties before a commission of inquiry may not be required to discharge any formal burden of proof, a commission must come to its determinations according to the measure of objective standards.” This approach is consistent with the Court of Appeal’s decision in Securities and Futures Commission v Cheng Chak Ngok [2018] 4 HKLRD 612, in which Cheung JA held at §9.9 that “the orthodox approach that in an inquisitorial inquiry by a tribunal there is no place for the requirement of burden of proof is the guiding principle,” reasoning that “[i]f there are no adversaries as such then it is meaningless to talk about a party carrying a burden.” An analogous approach was taken in Riady, Tjondro Stephen v Insider Dealing Tribunal (unrep., CACV 310/2002, 9 January 2003), where Ma JA (as he then was) held that an Insider Dealing Tribunal “does not have parties before it in the sense of a prosecution and accused or a plaintiff and defendant. Its function is not to adjudicate between rival claims or positions but to inquire into the question of insider dealing. The proceedings are not accusatorial but inquisitorial. There is no lis as such.”

The Government respectfully submits that the Committee can adopt a similar approach. No party before the Committee carries a formal burden of proof. The Committee’s task is to inquire into the matters set out in the ToR, to receive and evaluate the evidence placed before it, and to make findings according to objective standards.

As to the standard of proof, i.e. how the Committee may be satisfied that a finding

of fact is sufficiently supported by the evidence (noting that there is no party which carries a formal burden of proof so that this is an exercise for the Committee with reference to the available evidence), the Committee may wish to note that the Commissions of Inquiry Ordinance (Cap. 86), whilst providing that a commission of inquiry is a “judicial proceeding” (s. 11(1)), makes no mention of the standard of proof to be applied.

Against such background, public inquiries have consistently reserved to themselves the flexibility to determine what standard of proof they require in order to make their findings. The standard of proof applicable to the Committee’s findings of fact is, in general, the civil standard: the balance of probabilities. A fact is established if the Committee is satisfied that it is more probable than not. This civil standard has been consistently adopted in Hong Kong public inquiries: the Report of the Commission of Inquiry on Allegations relating to The Hong Kong Institute of Education (2007) at §2.18; the Report of the Commission of Inquiry into the Collision of Vessels near Lamma Island on 1 October 2012 (2013) at §32; and the Final Report of the Commission of Inquiry into the Construction Works at and near the Hung Hom Station Extension under the Shatin to Central Link Project (2020) at §116.

The standard is not, however, applied mechanically. It calls for a degree of satisfaction which varies according to the gravity of the facts to be established. As the Court of Final Appeal explained in HKSAR v Lee Ming Tee (2003) 6 HKCFAR 336 at 361-362 per Sir Anthony Mason NPJ, and as Lord Nicholls held for the majority in Re H [1996] AC 563 at 586D-F:

“The balance of probability standard means that a court is satisfied an event occurred if the court considers that, on the evidence, the occurrence of the event was more likely than not. When assessing the probabilities the court will have in

mind as a factor, to whatever extent is appropriate in the particular case, that the more serious the allegation the less likely it is the event occurred and, hence, the stronger should be the evidence before the court concludes that the allegation is established on the balance of probability. Fraud is usually less likely than negligence. Deliberate physical injury is usually less likely than accidental physical injury…… Built into the preponderance of probability standard is a generous degree of flexibility in respect of the seriousness of the allegation.”

Public inquiries may also, in appropriate circumstances, call for a higher standard

for specific issues of particular gravity. “It has been observed that public inquiries

‘have consistently reserved to themselves the flexibility to determine what

standard of proof they require in order to make their findings’, and the lack of

any stipulation or guidance in the Ordinance tends to support the pragmatic

principle of flexibility”: Commissions of Inquiry in Hong Kong at §7-24.

By way of illustration, in the Hung Hom Station Extension Commission of

Inquiry, the Commission chose to adopt the civil standard of proof in general,

save for the primary issue of structural safety. On that issue, the Commission

adopted a standard akin to the criminal standard, stating at §117 as follows:

“The Commission recognises that it would not be in the public interest - indeed it would manifestly be contrary to public interest - if it was to go no further than to determine that the structural works which are the subject of this expanded inquiry are more likely than not to be safe or unsafe. What (by clear inference) the Terms of Reference require, and what the public seeks, is an unequivocal assurance of safety or a clear statement of concern as to lack of safety. Accordingly, whatever language may conveniently be used in context, any and all findings as to structural safety will be made on the basis that, having given anxious consideration to all relevant evidence, the Commission is satisfied so that it is sure of such findings.”

In the present case, it is submitted that where the findings to be made involve

attribution of responsibility or criticisms of the conduct of specific entities or

stakeholders (whether in the construction industry, in property management, or

in the supervisory regime, etc.), the Committee may consider whether it is

satisfied, on the balance of probabilities, that such findings are supported by evidence commensurate with their gravity. A major distinction between the present case and the Hung Hom Station Extension Commission of Inquiry is that the latter adopted a standard akin to the criminal standard precisely because its Terms of Reference required it to address “concerns about public safety” (§29), a category of finding for which it may well be contrary to the public interest to go no further than to determine that the structural works were more likely than not to be safe or unsafe.

Conversely, where a finding concerns a systemic or structural deficiency (such as inadequacies or insufficiencies in industry standards, professional self-regulation, statutory control, regulatory and supervisory framework, contingency measures or resource allocation), it does not necessarily involve attribution of responsibility in the same sense and might not require the same degree of circumspection. The Government accepts that where the evidence demonstrates systemic weaknesses, the Committee should not hesitate to say so clearly.

C4. “Causation” in the legal context

The ToR require the Committee to examine “the causes and circumstances that led to the fire” and the factors that led to the heavy casualties. This necessarily involves questions of causation: whether, and to what extent, particular acts, omissions or conditions contributed to the outbreak of the fire, its rapid spread, or the severity of casualties.

The Government recognises that the Committee’s inquiry is not litigation, and that questions of causation do not arise in the Committee’s proceedings in the same manner as they do in a civil action or a criminal prosecution. The Committee

is not required to determine legal liability or to apportion fault in the technical

legal sense.

Nevertheless, certain principles developed in the law of causation may, by analogy, provide a useful framework for the Committee’s analysis — particularly where the evidence discloses multiple contributing factors and the Committee is called upon to assess the relative significance of each of them.

In Stapley v Gypsum Mines Ltd [1953] AC 663, Lord Asquith of Bishopstone observed at 687 that “Courts of law must accept the fact that the philosophic doctrine of causation and the juridical doctrine of responsibility for the consequences of a negligent act diverge. To a philosopher… the whole legal doctrine of responsibility must seem anomalous. To him, if event C could not occur unless each of two previous events — A and B — had preceded it, it would be unmeaning to say that A was more responsible for the occurrence of C than was B, or that B was more responsible for its occurrence than was A. The whole modern doctrine of contributory negligence, however, proceeds on the contrary assumption… But the fission between law and strict logic goes deeper than that. For I am persuaded that it is still part of the law of this country that two causes may both be necessary pre-conditions of a particular result — damage to X — yet the one may, if the facts justify that conclusion, be treated as the real, substantial, direct or effective cause, and the other dismissed as at best a causa sine qua non and ignored for purposes of legal liability.”

Lord Reid expressed similar sentiments at 681: “To determine what caused an accident from the point of view of legal liability is a most difficult task. If there is any valid logical scientific theory of causation, it is quite irrelevant in this connection… The question must be determined by applying common sense to the facts of each particular case. One may find that as a matter of history several

people have been at fault and that if any one of them had acted properly the accident would not have happened, but that does not mean that the accident must be regarded as having been caused by the faults of all of them. One must discriminate between those faults which must be discarded as being too remote and those which must not. Sometimes it is proper to discard all but one and to regard that one as the sole cause, but in other cases it is proper to regard two or more as having jointly caused the accident. I doubt whether any test can be applied generally.”

These passages were cited with approval by our Court of Appeal in Cheng Kin Ping v Woo Cho Wing John (unrep., CACV 252/1999, 26 January 2000) at 9-10. The Court further noted that no definitive test has been formulated to enable questions of causation to be answered universally: the “but for” test might not be universally applicable, and it all depends on the facts of each case.

After all, the Government is confident that the Committee (chaired by a highly experienced High Court Judge) is well placed, having heard extensive evidence over many hearing days, to apply common sense to the facts and to discriminate between those factors which were the real, substantial and effective causes of the fire, its spread and the casualties, and those which (while they may have been background conditions or which, if remedied, might have reduced the probability or severity of the fire) were not causally decisive in the same way.

D. OVERVIEW OF THE GOVERNMENT’S CASE

The evidence before the Committee paints a coherent and clear picture. A renovation project valued at approximately HK$336 million, affecting eight residential towers housing nearly 5,000 people, was entrusted to professionals and contractors who bore primary statutory and contractual obligations to ensure the safety and quality of the works.

It is now clear that those professionals and contractors have failed their duties and have abused the system through a combination of deliberate cheating, conspiracy, collaboration, neglect, contraventions and non-compliance that directly caused the fire, its rapid spread, and the death of 168 people.

The Government’s overall case may be summarised in the following terms.

The regulatory framework for building maintenance and renovation in Hong Kong has long been founded on a model of professional self-regulation, underpinned by statutory obligations, registration requirements, and supervisory mechanisms. This was based on the trust and confidence that the Government had reposed in the professionals in the construction industry.

This model was not developed in a vacuum; it has developed and modified over all the six terms of HKSAR Government. Over the years, there have been consistent calls from the industry, the legislature and indeed the public for the Government to streamline regulatory framework and procedures so as to reduce costs and delays for building owners, particularly in the context of building maintenance and minor works.

1. As informed to the Legislative Council during the development of the MWCS (first proposed in 2007 and fully implemented on 31 December

2010), prior to its implementation the building control system under the

BO applied to all building works regardless of their scale and complexity, requiring approval of building plans and consent to commence building works from the BA before commencement; and “the costs and time involved in complying with these requirements were often disproportionate to the scale of the works” with the result that “many minor building works were carried out without complying with BO, and therefore became unauthorized building works” (LC Paper No. CB(1)1116/11-12(08)3, §2).

2. The MWCS was introduced in 2010 precisely to “facilitate members of the public to carry out minor works in private buildings lawfully through simplified procedures and thereby improving building safety in Hong Kong” (LC Paper No. CB(1)1116/11-12(08), §3).

3. Similarly, the MBIS (first announced in 2007, enacted in 2011 and brought into full operation on 30 June 2012) was introduced following extensive Legislative Council scrutiny with the objective of ensuring that building owners would “undertake the responsibility for keeping their buildings in good conditions, including shouldering the financial commitment”, given that “[b]uilding neglect has been a long-standing problem in Hong Kong. The presence of aging buildings lacking proper care and maintenance poses potential threats to residents and the public at large” (LC Paper No. CB(1)343/13-14(04) 4 , §2), with the system relying on registered professionals to carry out and supervise the prescribed inspection and repair works.

4. The degree of reliance on professional self-regulation in both schemes was thus a considered policy decision, developed against a background of

3 https://www.legco.gov.hk/yr11-12/english/panels/dev/papers/dev0228cb1-1116-8-e.pdf 4 https://www.legco.gov.hk/yr13-14/english/panels/dev/papers/dev1126cb1-343-4-e.pdf

sustained demand for a more efficient and business-facilitating regulatory

environment, and endorsed by the legislature on the (not unreasonable) understanding and expectation that professionals would ordinarily and as a matter of principle honour and discharge their statutory obligations and that audit checks and disciplinary mechanisms would serve as sufficient safeguards against aberrations (and it was hardly envisioned that such professionals would, whether on their own or in collusion with one another, deliberately circumvent the system and the relevant authorities by active deception and manipulation). The bottom line is that these professionals who (i) should have requisite expertise and integrity, (ii) are bound by professional ethics or code of conduct, and (iii) would otherwise have their qualifications and reputation at stake, can be reasonably expected and relied upon to comply with the relevant legal and regulatory requirements.

Thus, this model entrusts and places the primary responsibility for the safety and quality of works squarely upon the registered professionals, contractors and other private actors engaged by building owners to plan, carry out and supervise such works.

The Government, in turn, sets standards, maintains registers, conducts audit checks and inspections, responds to and follows up on enquiries and complaints, liaises with the relevant parties and enforces where non-compliance is detected.

The model is premised on the integrity, competence and good faith of the professionals upon whom it confers responsibilities.

At WFC, that premise was systematically violated.

1. The main contractor, Prestige, chose not to appear in the Committee’s hearings. However, it is now clear that (among others):

(1) It deliberately supplied and used, and directed the purchase and use,

of scaffolding nets uncertified for FR properties to achieve greater profit margins and went as far as selectively replacing scaffolding nets uncertified for FR properties with compliant ones before inspections and furnishing a test certificate (which is at least suspected to have been fabricated) to frustrate governmental oversight and conceal the ongoing non-compliance.

(2) It used combustible foam boards extensively and for a prolonged period to cover windows across the estate, in direct breach of its own express representation to the relevant Government officer to (i) use non-combustible foam boards (ii) for localised use (every 3 floors in turn) and (iii) for a transient period only.

(3) It both created and directed the creation of access openings at escape staircases at regular five-floor intervals across all eight blocks at WFC, compromising the protected means of escape.

(4) It (i) directed a non-RFSIC to drain the FS Water Tanks without supervision of an RFSIC which led to the shutdown of the main power switch controlling both the FH/HR System and FAS in all eight blocks, depriving residents of the fire warning they needed to evacuate; (ii) engaged non-RFSICs to undertake renovation works on rooftop FS Water Tanks which are integral components of the FH/HR System without supervision of an RFSIC (let alone the same RFSIC who signed the relevant Shutdown Notices (“SDNs”) and FS 251 forms (“FS251”) submitted to the FSD); and (iii) engaged an RFSIC on paper to undertake administrative works (submissions of SDNs and FS251 to the FSD) as a rubber stamp to create a false

image of engagement of an RFSIC for the aforesaid repair works on

the rooftop FS Water Tanks and to mislead and conceal the true picture from the FSD.

(5) It failed to enforce an effective no-smoking regime on site despite repeated complaints from residents, despite its own in-house rules recognising the problem, and despite warnings from the LD.

(6) And it failed to ensure frequent clearance of combustible construction debris from the point where the fire originated.

2. Will Power and its purported staff Ng Yeuk, respectively appointed as the consultant and Registered Inspector (“RI”) with primary statutory responsibility for supervising the works and ensuring compliance with the BO, similarly did not appear in the Committee’s hearings. The evidence demonstrates that Will Power and the RI have wholly neglected their duties and failed to discharge their supervisory obligations in any meaningful sense. The evidence before the Committee discloses no real or effective supervision by Will Power and the RI over any of the five contributing factors: the non-FR certified scaffolding nets, the extensive foam board use, the access openings at escape staircases, the site management failings that permitted smoking and debris accumulation, or the shutdown of FSIs.

3. China Status, the RFSIC engaged by Prestige to submit SDNs and FS251 to the FSD for the shutdown of the FH/HR System, admitted in oral evidence that it never visited the site, never independently assessed the need and consequences for shutdown of the relevant FSI systems, nor effected the shutdown of those FSI systems themselves, and functioned only as a “rubberstamp”. It submitted SDNs and thereby falsely represented to the FSD that it was the RFSIC carrying out the relevant

repair works and that the shutdown of the relevant FSI systems was due to

repairs needed as a result of “leakage of F.S water tank” (without mentioning “empty tanks”, let alone the plan to use the FS Water Tanks for other purposes). The SDNs were further submitted with only the FH/HR System box ticked (indicating that this was the only FSI being shut down while the FAS was and remained simultaneously inoperative), thereby misleading and concealing from the FSD albeit unknowingly the full extent of the condition / status of the FSI thereat.

4. Victory Fire, the long-standing RFSIC responsible for annual inspections, discovered in October and November 2025 during their repair works on the FH/HR System and FAS at WFC that WFC’s FS Water Tanks had been drained and the main power switches had been switched off, which would shut down the FAS. Yet, notwithstanding its knowledge that WFC’s FAS was shut down for a period of time (possibly well over a month, as accepted by Chung Kit-man of Victory Fire: [Day 6/89/3-6] and [Day 6/55/2-4 (Chinese transcript)]), and despite its admission that it considered such shutdown abnormal or unusual and needed to turn the main power switches back on to test their own repair works, Victory Fire made no attempt to notify the FSD of the FAS shutdown (let alone the empty FS Water Tanks which would jeopardise the fire safety of the whole building); nor did it ever contact and follow up with China Status, the RFSIC supposedly responsible for the FAS shutdown.

5. ISS, the licensed PMC, issued job orders directing its own unlicensed electrician to operate FSIs, failed to coordinate between two simultaneously engaged RFSICs, and confined its response to persistent fire safety complaints to the role of a passive intermediary.

Following the fire, the Police and ICAC swiftly set up the largest joint

investigation task force in recent years to conduct comprehensive investigations5. On 10 June 2026, the Police and ICAC laid charges against seven individuals (including the directors of Prestige and Will Power, and the RI Ng Yeuk) and two companies (Prestige and Will Power) with a total of 25 counts of offences, including manslaughter, conspiracy to defraud, dealing with property known or believed to represent proceeds of an indictable offence, attempting to pervert the course of public justice and tax evasion, in relation to the WFC fire and the renovation project. The Government notes that the relevant investigations are continuing and further law enforcement actions have not been ruled out. While the determination of guilt is a matter for the courts in due course, the laying of these charges confirms that there is at least a prima facie case of serious criminal wrongdoings on the part of the key private actors identified in these submissions.

Two features of this pattern of abuse warrant emphasis.

The first is the scale of the financial incentives involved. The WFC renovation contract was valued at approximately HK$336 million. Against rewards of this magnitude, the existing deterrents were insufficient. The maximum penalties for contravention of safety legislation, the disciplinary sanctions available under the BO, and the prospect of prosecution under occupational health and safety legislation may be modest in comparison with the profit that could be extracted from a project of this scale by cutting corners on materials, fabricating certificates, and circumventing safety requirements. When the potential gain from abuse vastly exceeds the cost of compliance and risk of sanction, the economic incentive for unscrupulous actors is to abuse the system rather than to comply with it (even at the expense of health and safety).

5 See Press Release from the Police dated 10 June 2026: https://www.police.gov.hk/ppp_en/03_police_message/pr/pressrelease-detail.html?refno=P202606100004

The second is the collaborative nature of the abuse. The safeguards built into the

regulatory framework depend for their efficacy on the integrity of the professionals to whom responsibilities are allocated and who are expected to regulate and supervise each other. Instead, they chose to collude with each other. When the RI who is supposed to supervise the works becomes a collaborator rather than a check on the contractor; when the RFSIC who is supposed to certify FSIs becomes a paid conduit for false notifications; when the PMC who is supposed to monitor fire safety becomes a passive issuer of job orders without enquiring whether the work requires specialist authorisation, the entire system of mutual checks ceases to function, and the regulatory framework can be significantly weakened in its function of protecting the public it was established to serve.

As with any system, the Government does not suggest that the existing regulatory and supervisory framework was without weaknesses and room for improvements. However, if the relevant parties colluded to circumvent the system with a clear and deliberate intention to bypass it, it would be difficult if not impossible for such system to have all systemic loopholes plugged whilst maintaining workable efficiency and appropriate checks and balances.

As the analysis in the sections that follow demonstrates, in light of such widespread and deceptive acts of circumvention, there can now be identified a number of areas susceptible to abuse in, for example, over-reliance on the selfregulation 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 inter-departmental communication; and a supervisory architecture that was not designed to address collaborative and coordinated concealment. The Government acknowledges these systemic weaknesses

candidly, and responded swiftly in reviewing the measures and practice in a

number of crucial areas and took the initiative to introduce timely and comprehensive improvement measures.

The Government’s case is, however, that these areas for improvements (in and of themselves) should not be equated or identified as primary causes of the fire, its spread, or the casualties. The Government also acknowledges, as the Committee’s independent experts observed, that “strong firefighting performance and fast response from the FSD cannot fully compensate for weaknesses in building design, maintenance, management or user behaviour” (IC Expert Report §8.4.7(a) [ER3/2262]; [ER6/2740]).

The evidence of the Committee’s experts, and the exchanges between the Chairman and those experts during the evidential hearing, brought into focus a further observation. The Chairman stated directly: “regulation by itself is not the end... Even if they pass regulations, it may still cause --” [Day 27/73/14-17].6 In the same vein, the Committee’s experts agreed and explained: “since every building project is different and may have features that may throw up unforeseen challenges to occupant safety, a certain level of rigour and engineering judgement should be mandated through the approval process, whether it is for new projects or for building repair, rehabilitation or renovation projects” (IC Expert Report §7.5.2 [ER3/2256]).

The Government accepts these observations, which highlight the importance of risk assessment. A compliance-driven approach to fire safety, even where the regulations are themselves sound, cannot always account for the unique combination of risks presented by each individual project. The approach must be proportionate and practicable; as the Chairman observed, “we cannot make it

6 References to the oral evidence in these submissions are in the form [Day X/Y/Z], denoting the Day of the Evidential Hearing / page number / line number of the English transcript, unless otherwise stated.

[foolproof] and use all costs, but we really have to look at the risk and assess the risks from a different angle” [Day 27/76/17-20].

The primary causes remained the deceit, inaction and deliberate omissions of private actors who abused their positions of trust, statutory responsibility and public confidence. Whilst (with the benefit of hindsight) the system may have placed over-reliance on the self-regulation of professionals, no matter how well it may have been designed, it has to count on the people involved to run it; therefore it is not unreasonable (indeed it is necessary) for the Government and for any regulatory system to be founded upon the premise that those subject to it will comply with the relevant laws and regulations that govern their conduct.

In these submissions, the Government addresses each contributing factor and the primary responsibilities of the private actors, and discusses the need for improvement measures to enhance the Government’s supervisory role, in that order and with that emphasis in mind.

The Government then turns to the systemic issues that cut across the contributing factors, and the improvement measures already introduced.

Throughout, the Government maintains the distinction between direct causes (the five contributing factors) and other systemic weaknesses and areas for improvements, and between the facilitative role of the Government in certain areas and its supervisory role in others. The nature of the issues that can properly be attributed to the Government differs according to which role it was exercising in the respective areas.

The Government’s submission concludes with an account of the improvement measures that have been implemented since the fire and those currently underway. These measures are directed not merely at incremental enhancement of the pre-

fire regime but at significant changes to the supervisory architecture for largescale renovation works, designed to ensure that the system can no longer be undermined by the kind of organised, collaborative and deliberate abuse that occurred at WFC.

The Government respectfully invites the Committee to note that a number of the improvement measures which were mentioned during the evidential hearings as proposals or matters under consideration have, by the time of the submission of the Government’s Table of Improvement Measures on 15 June 2026, already been implemented; the Committee is invited to consider the progress in that regard as set out in the Table.

On top of the current improvement measures already undertaken by the Government (as set out in the Government’s Table of Improvement Measures), the Government will continue to review and act robustly on further improvement measures to address the problems including those to be identified by the Committee in due course.

PART II: BACKGROUND TO WFC AND THE WFC FIRE

E. WFC

E1. WFC and the surrounding area

WFC is a HOS estate in Tai Po, New Territories, Hong Kong, completed in 1983 and comprising eight high-rise residential blocks. Each block is identified by both a letter designation and a Chinese name: Wang Yan House (Block A), Wang Tao House (Block B), Wang Sun House (Block C), 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).

WFC is situated near the Tolo Highway in Tai Po, New Territories. To the north lies Kwong Fuk Estate, a public rental housing development, and Tai Po Baptist Public School, which is located within or immediately adjacent to the WFC estate grounds. The school served as the on-site command post during the firefighting operation. To the south, the estate connects to Tai Po Road and the Tolo Highway. The estate is bounded by Island House Lane to the east and Kwong Wang Street to the west. The proximity of the eight residential blocks to one another within the estate compound is relevant to the mechanisms of inter-building fire spread addressed in Section G below; the analysis of wind-carried embers and falling debris as vectors of horizontal spread was directly influenced by the spatial configuration of the estate.

Each block has thirty-one floors, with each floor divided into eight residential units (numbered 1 to 8) connected by a corridor, with the lift lobby located at the centre of the corridor. The estate comprises a total of approximately 1,984 flats.

According to the 2021 census data, there were some 4,600 residents in WFC, of whom more than one-third (approximately 1,700) were aged 65 or above, and

approximately 420 residents were aged below 14. This demographic profile is

significant: the high proportion of elderly residents materially affected the speed at which residents could respond to the fire and evacuate, a factor reflected in the casualty data which records that 114 of the 168 fatalities were individuals aged 65 or older (IFITF Report §9.3.1.2 [ER1/195]).

Opposite the lift lobby on each floor, there are two interlocking staircases (commonly known as ‘scissor stairs’) serving as means of escape in case of fire. Both staircases run from the thirty-first floor at the top down to the ground floor, but only one of them provides access to the rooftop. This design feature is directly relevant to the evacuation difficulties experienced during the fire, as addressed in Section M of these submissions.

A critical design feature of each block is the vertical re-entrant between the two wings, extending from the 1st floor to the roof. The IFITF found that this chimneylike configuration “naturally channelled rising smoke and hot gases” and “confined and directed their upward movement, allowing the fire to spread rapidly and engulf multiple floors in a short timeframe” (IFITF Report §6.2.1.6 [ER1/80]). There are four re-entrants surrounding each block, located between the building façades, with a flat roof on the first floor closed off via a metal gate. The fire originated from the flat roof at the bottom of the re-entrant outside Flats 104 and 105 of Wang Cheong House, as addressed in Section G below.

At the time of the incident, all eight blocks were undergoing concurrent exterior maintenance and renovation works, and were enveloped in bamboo scaffolding and protective netting that wrapped the towers from the ground to the upper floors. The renovation works had commenced in July 2024 with a final contract price of HK$336 million.

The social context of the estate is relevant to the Committee’s assessment of the

incident’s impact: WFC housed a long-standing community, and the displacement of nearly 5,000 people created complex rehousing, welfare and support needs that required sustained government attention.

E2. Management of the WFC affairs at the material time

(i) The PMC

ISS was the PMC responsible for the day-to-day management and administration of WFC at the material time. ISS is a subsidiary of the Denmark-based ISS group and held a licence under the Property Management Services Ordinance (Cap. 626).

The evidence before the Committee demonstrates that ISS occupied a central position in the management of the estate, with contractual responsibilities that placed it at the intersection between the residents, IO, and various contractors engaged for the renovation works.

ISS’s contractual obligations under the Property Management Agreement [H1-1/1-24] included responsibilities that are directly relevant to the fire safety failures addressed in Sections I to N of these submissions. Cheng Tsz-ying of ISS confirmed in oral evidence that “in relation to fire risk complaints it seems ISS has a contractual obligation to record, investigate and liaise and follow up on the matter with the relevant government department” [Day 8/34/10-16]. The ISS Security Manual treated the identification of potential fire risks as a core purpose of security patrol [H1-3/6639]. These obligations placed ISS in a position where it bore responsibility for monitoring the fire safety environment of the estate, including during the renovation period when the fire risk was materially elevated.

The Property Management Services Authority (“PMSA”) Code of Conduct also

specifically requires licensed PMCs to monitor the progress of the RFSIC’s work, follow up timely with the RFSIC on required rectifications, follow up timely with the RFSIC that it has notified the DFS of FSI shutdowns, and assist FSD officers during visits [B2/2631].

ISS’s staff also played a direct and significant role in the events that led to the deenergisation of the FSIs at WFC. As addressed in detail in Section N of these submissions, Law Kwok-shui, an electrician employed by ISS, physically switched off the main power switches in the booster pump rooms of all eight blocks, simultaneously deactivating both the FH/HR System and FAS, on the instruction of Prestige to drain the FS Water Tanks without supervision of an RFSIC and pursuant to job orders issued by ISS management. The evidence establishes that ISS issued these job orders for work that required RFSIC engagement without ensuring that engagement was so made; this arrangement was “against the law” [Day 10/18/24 – 19/2].

The evidence establishes that ISS bore responsibility for multiple failures that contributed to the conditions in which the fire occurred: issuing job orders directing non-RFSIC staff to operate FSI; failing to coordinate between the two simultaneously engaged RFSICs; failing to ensure that FSIs were maintained in efficient working order; and confining its response to resident complaints about smoking and fire safety hazards to the role of a passive intermediary rather than an active safety monitor. The primary responsibility for the fire safety failures addressed in the contributing-factor sections of these submissions lies with the private actors identified in those sections; ISS’s failures compounded and facilitated those primary failures.

(ii) The IO and MC

The IO of WFC was the legal entity responsible for the collective management and maintenance of the estate’s common areas and facilities, operating under the framework established by the Building Management Ordinance (Cap. 344) (“BMO”) [G1-1/1-250].

Under the BMO, the IO possesses powers including the power to engage and remunerate staff, accountants, managers or other professionals; improve and maintain common areas; carry out renovation, improvement or decoration works on common parts; and act on behalf of the owners in matters of common interest. Individual owners have rights to monitor the work of the IO and its MC, including the right to inspect financial statements and to require the MC chairman to convene an OC general meeting for specified purposes at the request of not less than 5% of the owners.

What emerges from the evidence is that the residents of WFC were not passive in the face of the concerns many of which would later prove to have been wellfounded. Residents questioned the appointment of Prestige, sought to exercise their statutory rights to convene meetings, raised concerns about proxy irregularities, challenged the adequacy of safety measures during the renovation, and raised numerous enquiries and complaints.

Relatedly, the responses they received from the various government departments and the extent to which those complaints were substantively addressed are matters examined in the systemic sections of these submissions.

The critical point for the present background section is that the IO and MC structure at WFC, while functioning within the BMO framework and having the professional assistance from a PMC, was confronted with a renovation project of

exceptional scale and complexity that strained the capacity of lay MC members

to exercise effective oversight, particularly in circumstances where, as the evidence has revealed, the consultant and contractor engaged to carry out the works failed to discharge their professional and statutory obligations.

The key events are addressed in detail in Part IV (ToR 2) below.

E3. Introduction to the FSI system at WFC

This section provides the descriptive foundation for understanding the FSIs at WFC, how they were designed to operate, who was engaged to maintain them, and the state of the annual inspection regime immediately preceding the fire. It establishes the technical baseline against which the responsibilities and failures addressed in Section N are to be assessed.

WFC comprises eight identical 31-storey domestic buildings, all of which share an identical design [B11/5626-5627]. The required FSIs in each building are: a FAS, a FH/HR System, and fire extinguishers [B11/5627].

The FSIs were installed in accordance with the 4th version of the Code of Practice for Minimum Fire Service Installations and Equipment (November 1979), being the version in force when the first General Building Plan for the development of WFC was submitted in October 1980.

The FAS at WFC is a manually-operated system. Each floor from the ground floor to the 31st floor is equipped with one manual call point (a break-glass unit “BGU”) and one alarm bell, positioned adjacent to the hose reel [B11/5627]. An independent alarm panel was not required for a manually operated FAS under the 1979 Code of Practice. The mechanism is straightforward: breaking the glass releases a micro-switch, which actuates the alarm.

The FH/HR System provides coverage across the entire building, from the ground

level to the roof. Its major components comprise: a rooftop FS Water Tank (minimum effective firefighting quantity 18,200 litres [B2/1896]), which supplies hose reels and hydrant outlets; a ground-floor FS Transfer Tank (2,000 litres), which prevents backflow contamination; an upfeed pump on the ground floor, which relays water from the FS Transfer Tank up to the rooftop FS Water Tank; two FS/intermediate booster pumps on the ground floor (one duty and one standby), which pressurise water from both the FS inlet and FS Water Tank for the FH/HR System; an FS inlet; hydrant outlets at every staircase half-landing; and hose reel points on every floor from the ground floor to the 31st floor [B11/5628-5633].

A critical design feature is that the FH/HR System and FAS are interconnected in operation. AD Keung Sai-ming of the FSD confirmed this during oral evidence: [Day 10/15/18 - 16/13]. The interconnection is deliberate: triggering the BGU also triggers the booster pump so that water is available when a fire is reported. The applicable Code of Practice provision (as referred to in AD Keung’s oral evidence) states that “the means of operating fire alarms shall be interconnected with the means of operating fixed fire pumps of fire hydrant/hose reel installations” [Day 10/15/18 - 16/13].

Each block has two pump rooms on the ground floor: a general (main) pump room and a separate FS booster pump room [Day 10/7/5-8] [C1-2/1627].

1. The general pump room houses the FS Transfer Tank, the upfeed pump, and three control panels. Of these, the red panel is the control panel of the FS upfeed pump; the white and green panels control the flushing-water system and fresh-water system respectively [Day 10/8/5-23] [C1-2/1651].

2. The FS booster pump room houses the two booster pumps (duty and

standby), a larger control panel, and a separate, smaller main power switch. The larger control panel on the left-hand side controls the automatic operation of the FS booster pump [Day 5/92/1-4] [C1-2/1640-1642]. The smaller unit is the main power switch of the FS system [Day 10/10/5-7].

The larger booster-pump panel carries individual controls including: pump 1 and pump 2 isolator switches, a “silence alarm” switch, a normal-test switch, running and failure indicator lamps, a system reset, and three-phase power indicator lamps. AD Keung confirmed that “the on and off of the two pumps, even with main power connection on, these switches can control the on and off of the individual pumps” [Day 10/12/13-16] [C1-2/1640-1642].

The single main power switch simultaneously controls the power supply to both the FH/HR System (booster pumps) and FAS. Switching it to the “OFF” position deactivates both systems. AD Keung confirmed this unequivocally in oral evidence: when asked “to turn off the main power switch, the fire alarm system, booster pump and upfeed pump will all lose power?”, he answered “Right” [Day 10/10/14-17] [C1-2/1642].

It is, however, possible to isolate the FH/HR System without cutting the main power switch. The control panel is equipped with two pump isolator switches capable of interrupting power to the two pumps of the FH/HR System even when the main power switch remains in the “ON” position. AD Keung’s witness statement confirms that “it is possible to shut down solely the FH/HR system by simply switching off the pump isolators, rather than by switching off the main

power switch, which would otherwise cut the power supply to both the FH/HR system and the FAS”7 [WS1/138] [C1-2/1641].

To drain the rooftop FS Water Tank (which was the purpose of the renovation works touching on the FH/HR System, addressed in Section N below), the technically necessary step is to switch off the upfeed pump in the main pump room and use the tank-side drain or gate valve on the roof. Nothing about the drainage process requires cutting the booster-pump main power switch. This is confirmed by both AD Keung [Day 10/16/14-18] and Chung Kit-man of Victory Fire [Day 6/29/9-11] [Day 9/27/17-24].

Turning now to the inspections of FSI at WFC, Victory Fire was the RFSIC engaged by ISS to conduct annual inspections of the FSIs at WFC. Victory Fire had held this role for approximately nine consecutive years (from about 2016), save for one intervening year8 [WS2/1270].

The scope of Victory Fire’s annual contract included quarterly and annual FSI inspections and submission of FS251 certificates to the FSD. The contract covered the emergency lighting, FH/HR System, FAS and fire extinguishers for all eight blocks9 [WS1/136]. As elaborated below, the FS251 certificate is the primary documentary mechanism by which the FSD monitors RFSIC performance.

Victory Fire carried out the annual inspections of all eight blocks on 24 March 2025 (works 24 to 26 March) and issued FS251 certificates dated 31 March 2025 [B2/1440, 1484, 1505, 1579, 1604, 1671, 1707, 1770]. AD Keung’s witness statement records that “According to the FS251s dated 31.3.2025, all the FSIs

7 KEUNG Sai Ming 1st WS §10.3

8 鄭芷盈 (Cheng Tsz-ying, ISS) 1st WS §55 9 KEUNG Sai Ming 1st WS §9.1

provided in Wang Fuk Court were in compliant with FSD requirements, certifying that all FSIs, including the FAS, should be operable” 10 [WS1/136].

The March 2025 FS251s did, however, record several minor defects requiring follow-up or repair action, including manual call point (a FAS component) defects at some locations11 [WS1/136]. A rectification contract to remedy these defects was awarded to Victory Fire in October 2025 following a separate tender exercise, and the rectification works were undertaken from 16 to 17 October 2025, and from 19 to 26 November 202512 [WS1/136; WS2/1270-1271; WS2/1529-1530].

The annual inspection was conducted using FSD-prescribed checklists. These checklists need not be submitted with the FS251 to the FSD, but the RFSIC must retain them for seven years for potential FSD audit [Day 10/58/17-21]. The FSD’s audit of annual inspection checklists is conducted on a random sampling basis. AD Keung confirmed that approximately 300 checklists out of approximately 60,000 buildings per year (approximately 0.5%) are document-checked [Day 10/59/3 – 61/1]. Victory Fire’s WFC annual inspection checklists had not been selected for checking across approximately nine years [Day 10/59/3-9].

The technical description set out above establishes three matters of particular significance for the analysis in Section N below.

1. First, the FH/HR System and FAS share a single main power switch found in the booster pump room; switching it off deactivates both systems simultaneously, yet (by design and known to any qualified personnel) (i) the drainage of the FS Water Tank does not necessitate the switching off

10 KEUNG Sai Ming (AD Licensing & Certification of FSD) 1st WS §9.2

11 KEUNG Sai Ming 1st WS §9.

12 KEUNG Sai Ming 1st WS §9.3; Cheng Tsz-ying (ISS) 1st WS §§60-62; 鍾傑文 (Chung Kit-man, Victory Fire) 1st WS §§5-8

of the FH/HR System (as opposed to the upfeed pump which is controlled,

not by way of the single main power switch in the booster pump room, but by way of the upfeed switch found in the general pump room) and (ii) even if it does require the switching off of the FH/HR System, this does not (and should not) require the main power switch to be turned off at all.

2. Second, the system as designed places primary reliance on the RFSICs (Victory Fire and China Status, in the case of WFC) to inspect, certify and maintain the FSIs, with the FSD exercising a supervisory role through proactive audit check rather than continuous oversight.

3. Third, as at March 2025, Victory Fire certified all FSIs as operable; yet by 26 November 2025, the FAS in all eight blocks had been de-energised and incapable of alerting residents. The post-fire investigation by the FSD’s Fire Protection Facilities Supervision Division (“FPFS”) further revealed that the main power switches in seven of the eight blocks were found in the “OFF” position, and that the control fuses in the pump panels of all blocks (except Wang Cheong House) had blown. The consequence was that even after the main power switches were restored to the “ON” position, the FAS and intermediate booster pumps in the majority of blocks still could not be actuated [B11/5643]. How that transition occurred, and where responsibility for it lies, is the subject of Section N.

E4. Statutory control of WFC by the ICU

(i) The background of delegation from the BD to ICU

The statutory control of WFC by the ICU, rather than by the BD directly, arises from a delegation arrangement with a history spanning more than three decades since the early 1990s.

The origins of this arrangement, its rationale, and the mechanisms through which

it operates are essential to understanding the supervisory framework under which the WFC renovation works were conducted, and the boundaries of each body’s responsibility for the safety failures that the Committee has examined.

The starting point is the legislative framework governing Hong Kong’s public housing. The BO provides for the planning, design and construction of buildings and associated works, and for related safety requirements. However, section 41(1)(aa) of the BO exempts from its provisions “buildings upon any land vested in the Housing Authority or over which the Housing Authority has control and management,” subject to sections 18(2) and (3) of the Housing Ordinance (Cap. 283) (“HO”).

The effect of this exemption is that buildings designed and constructed by the Housing Authority (“HA”) are not subject to the BO during the construction phase. The Government has been providing public housing since 1954, and when the HO was enacted in 1973 it also amended the BO to exempt public housing buildings designed and constructed by the HA from the application of the BO.

The position changed with the introduction of the HOS. Section 18 of the HO was amended in 1978 so that the BO would apply to any HA building if, after its construction was completed, any part of it was sold or otherwise disposed of under section 17A of the HO 13 [WS1/725]. The consequence is that HOS buildings, once sold to private owners, become subject to the control of the BO. WFC, as a sold HOS estate built in 1983, therefore falls within this category: it was exempted from the BO under section 41(1)(aa) at the time when it was built,

13 PANG Yuk Lung, Michael (AD Corp Services, BD) 1st WS §40

but came under the purview of the BO by virtue of section 18 of the HO after its

units were sold to individual private owners14 [WS1/726].

When sold HOS buildings first came under the BO following the 1978 amendment, building control was exercised by the then Buildings Ordinance Office (the predecessor of the BD, “BOO”). However, the BOO was not provided with as-built drawings of completed HOS blocks, which inhibited its enforcement of the BO. The HA, as the Deed of Mutual Covenant (“DMC”) manager, was better placed to exercise control by virtue of its powers under the DMC entered into by all flat owners at the time of purchase15 [WS1/726].

Following a series of internal discussions and approvals, the formal delegation process commenced. In June and July 1991, the BOO proposed the secondment of experienced BOO officers to assist the HA in achieving consistency in the interpretation of the BO. In February 1992, the HD provided a draft paper recommending that the HA take up building control of sold HOS buildings by way of authorisation under the BO for a trial period of three years, and this was endorsed by the BOO. On 1 June 1992, the then Secretary for Planning, Environment and Lands gave formal approval to the authorisation. The first authorisation instrument was issued on 25 June 1992, authorising certain officers of HD to act on behalf of the Building Authority (“BA”) in matters arising from specified provisions of the BO, including sections 22 to 28, 32A, 32B, 33 and 3416 [WS1/727-730].

A further impetus for the development of the ICU came from a series of piling scandals in the late 1990s, which triggered a fundamental reform of the HA’s construction quality assurance processes. AD Michael Pang of the BD confirmed

14 PANG Yuk Lung, Michael 1st WS §41

15 PANG Yuk Lung, Michael 1st WS §42

16 PANG Yuk Lung, Michael 1st WS §§44-51

that in January 2000, the HA issued a paper entitled “Building Homes with Care”

for public consultation, and in April 2000 approved a plan to implement 50 quality housing measures to enhance housing standards 17 [WS1/729]. To introduce independent third-party reviews of HA development projects, the HD established the ICU in November 2000, which reported directly to the Director of Housing over the conduct of third-party reviews of HA projects.

Since 2004, the authorisation of HD officers under the BO to exercise building control for sold HOS buildings has been redirected to officers of the ICU. The first authorisation instrument involving officers of ICU was issued on 28 April 2004, authorising officers to act on behalf of the BA in matters arising from an expanded list of BO provisions18 [WS1/730]. The delegation has been updated periodically since then. AD Michael Pang of the BD confirmed that the delegation instruments are renewed at intervals, with the most recent pre-fire instrument having been signed by the Director of Buildings on 12 December 2023, authorising officers of the ICU to act on behalf of the BA in matters arising from sections 22(1), 23, 24, 24A, 24AA, 24B, 24C, 25, 26, 26A, 27, 27A, 27B, 27C, 28, 29, 29A, 30, 30B, 30C, 31, 32A, 32B, 33, 34, 36C, 36F, 36G, 36H, 40(1BE), 44, 51, 52 and 53, and Schedule 7 of the BO, and all sections of the Building (Appeal) Regulation, and all matters arising under the BO in respect of alteration and addition (“A&A”) works, and minor works (“MW”) commenced under the simplified requirements19 [WS1/731].

To underline its impartiality, the ICU was detached from the HD and placed under the direct control of the Office of the Permanent Secretary for Transport and Housing (Housing) in 2015, and following a further government reorganisation

17 PANG Yuk Lung, Michael 1st WS §50

18 PANG Yuk Lung, Michael 1st WS §51

19 PANG Yuk Lung, Michael 1st WS §§54-55

in July 2022, the ICU now reports to the Permanent Secretary for Housing20

[WS1/731]. AD Michael Pang of the BD confirmed that “the scope, extent and nature of the powers and duties delegated by DB to the officers of ICU are the same as that delegated to the officers of BD in handling all matters in connection with building control of existing buildings, the MBIS, the MWIS and the MWCS, as performed by the Existing Buildings Divisions 1 & 2, Mandatory Building Inspection Division and Corporate Services Division of BD” 21 [WS1/732].

The conclusion to be drawn from this history is that the delegation arrangement was not a temporary or expedient measure but the product of a deliberate, decades-long policy to concentrate building control of sold HOS estates within a specialised body that could draw upon the HA’s institutional knowledge of those estates while exercising the BA’s statutory powers. When the WFC renovation works were underway, it was the ICU that exercised statutory building control over the estate.

(ii) “Administrative control” vs. “statutory control”

The ICU’s work is divided into two distinct regimes, the distinction between which is fundamental to understanding the nature and limits of its authority over WFC. Lau Fu-kwok, then Head of the ICU, explained these as the “administrative building control” regime and “statutory building control” regime22 [WS1/601].

The administrative building control regime applies to HA buildings that remain exempt from the BO, including new construction sites of the HA and existing public rental housing estates without any part sold or otherwise disposed of by the HA. For these buildings, the BO does not apply as a matter of law by virtue of section 41(1)(aa) of the BO read with section 18(2) of the HO. Nevertheless,

20 PANG Yuk Lung, Michael 1st WS §§54-55

21 PANG Yuk Lung, Michael 1st WS §56

22 LAU Fu Kwok (then Head of ICU) 1st WS §6

by way of a Memorandum of Understanding between the Director of Housing

and Director of Buildings (the latest version dated 1 July 2022) (“MOU”) [I1-1/54-59], the HA and HD have committed administratively to adhering to the requirements under the BO, its subsidiary legislation and codes of practice and guidelines issued by the BD at all times for the design and construction of HA buildings. Pursuant to clause 2 of the MOU [I1-1/56], the ICU is responsible for this administrative building control in line with the BO and related requirements, covering the approval of building plans, the granting of consent to commencement of works, site monitoring for buildings under construction and existing buildings with A&A works in progress, and conducting final inspections for the issue of occupation permits or acknowledgement of completion.

The statutory building control regime, by contrast, is the regime under which the ICU exercises the BA’s delegated powers under the BO itself. This regime applies to buildings developed by the HA where any part has been sold or otherwise disposed of under sections 4(2)(a) and 17A of the HO, so that those buildings are brought within the BO by operation of section 18(3) of the HO23 [WS1/603-606]. The ICU’s evidence identifies these functions as including: processing building and structural plan submissions, consent applications and reports of completion for A&A works; carrying out site monitoring of A&A works and MW as necessary; implementing the MBIS and MWIS; processing MW submissions under the MWCS; exercising building control regarding unauthorised building works and dilapidated buildings and building elements; conducting planned surveys to identify UBW and building defects for follow-up actions; and providing emergency services related to building and drainage defects 24 [WS1/605-606].

23 LAU Fu Kwok 1st WS §§10-15 24 LAU Fu Kwok 1st WS §13

(iii) The scope of delegation

The scope of the delegation from the BA to the ICU is defined by the delegation instruments issued under section 2(2) of the BO, the most recent of which (prior to the fire) was dated 12 December 2023 [I1-1/11-18]. As set out above, those instruments authorise officers of the ICU to exercise the BA’s powers under a comprehensive list of BO provisions, encompassing the full range of existingbuilding control functions.

The delegation does not, however, extend to all functions of the BA. As noted above, prosecution powers under section 40 and disciplinary powers under sections 7 and 13 of the BO have not been delegated to the ICU. Nor does the delegation extend to the regulation of registered building professionals and contractors as such; the registers of RIs and RCs are maintained by the BD, and the registration, renewal and de-registration processes are administered by the BD25 [WS1/607].

The relationship between the BD and ICU is maintained through several institutional mechanisms.

1. First, the ICU submits six-monthly reports to the BD covering its statutory building control activities, and a management-level liaison meeting between Head(ICU) and the Deputy Director of the BD is held at sixmonthly intervals to discuss these reports. Lau Fu-kwok acknowledged, however, that “as the progress reports cover mainly policy or overall operational issues, hence details of individual projects (including the renovation details of Wang Fuk Court) would not be, and were not as a matter of fact, captured therein”26 [WS1/613]. The WFC renovation was

25 LAU Fu Kwok 1st WS §15 26 LAU Fu Kwok 1st WS §21

never mentioned in the six-monthly reports, nor was it raised in the

management-level liaison meetings.

2. Second, working-level meetings are held between specific teams: the MBIS Liaison Meeting between the MBIS teams of the ICU and BD; the MWCS Liaison Meeting between the MW teams; and Sectional Meetings attended by the Senior Building Surveyor seconded from the BD 27 [WS1/735]. These meetings serve to align policies, standards and practice, and to share experience or discuss difficult cases. AD Michael Pang of the BD confirmed that “BD was given to know that ICU has been following the BO and BD’s policies, standards and practices in exercising its delegated duties” 28 [WS1/737] through these channels.

3. Third, the BD seconds three senior professional officers to the ICU: a Senior Building Surveyor/Building Control (SBS/BC), a Senior Building Surveyor/Advisory (SBS/Adv), and a Senior Structural Engineer/Advisory (SSE/Adv) 29 [WS1/738-743]. These seconded officers provide guidance to the ICU on the interpretation of BO provisions and legislative requirements. The SBS/BC in post at the material time (25 April 2023 to 6 July 2025) was Mr Franco Tse Kam-ming, whose role in the foam board issue is addressed in Section K of these submissions. Mr Franco Tse gave evidence on Day 20. These seconded officers are under the direct supervision of Chief Maintenance Surveyor/ICU and Chief Structural Engineer/ICU respectively, with their performance appraised by their supervisors within the ICU rather than by the BD.

27 PANG Yuk Lung, Michael 1st WS §61

28 PANG Yuk Lung, Michael 1st WS §66

29 PANG Yuk Lung, Michael 1st WS §§67-74

4. Fourth, clause 3.2 of the MOU [I1-1/58] provides that “BD may conduct

audit checks on ICU when necessary to ensure that the standards of checking by ICU are consistent with those of BD”. In practice, the audit function was discharged through the BD secondees serving as advisors within the ICU, who played the role of auditor as well during their daily work in relation to A&A works submissions, giving advice to the vetting team on the interpretation of the BO [Day 24/71/7 - 72/2]. While no separate formal audit checks were conducted by the BD on the ICU’s MBIS work specifically, the presence of BD secondees within the ICU provided a standing and practicable mechanism for ensuring alignment of standards and practice between the two bodies.

The scope of the delegation, taken as a whole, gave the ICU the statutory authority to exercise building control over WFC in the same manner as the BD exercises control over private buildings generally. The evidence demonstrates, however, that the delegation was accompanied by institutional constraints and resource pressures within the specialist teams. By way of illustration, the evidence of Andy Ku of the ICU provides a revealing account of the MBIST’s workload.

1. In 2025 alone, the team issued 21 MBIS statutory notices and nearly 17,000 MWIS statutory notices; handled approximately 32,000 MWIS submissions; issued 275 fixed penalty notices; investigated 25 prosecution cases under the MWIS; and handled 1,300 complaints or enquiries under the MBIS and MWIS (excluding verbal telephone enquiries) 30 [WS14/2129-2130].

2. Ku confirmed that “almost 90% of the MBIST’s time and efforts is dedicated to the MWIS” 31 [WS14/2129-2131], and that in addition to

30 KU Siu Ping (Senior Maintenance Surveyor, ICU) 3rd WS §8 31 KU Siu Ping 3rd WS §§8-9

newly issued statutory notices, the MBIST was required to attend to

statutory notices previously issued but not yet complied with in 42 courts and estates at various stages of the process.

The evidence demonstrates the significant resource constraints under which the MBIST operated, and contextualises the level of attention that was available for any individual renovation project, including the WFC renovation. These constraints are relevant to the Committee’s assessment of the ICU’s supervisory performance during the WFC renovation works. As to the MWT, Yung Siu Lun of the ICU confirmed that in 2025, the MWT (comprising only 10 professional and technical staff in total) received 27,585 MW submissions, of which 1,425 (5.17%) were audited [WS14/2119]32 . He stated that “on average, each PO handled over 350 audited MW submissions in 2025” and that “in addition to the random audit arrangement, MWT also conducted form screening for around 4,000 MW submissions related to windows and external wall repairs in 2025” [WS14/2119] 33. The MWT was also “responsible for performing other MWCSrelated duties including handling enquiries/complaints, uploading signboard information online for public viewing and enhancing the Minor Works Management System” [WS14/2119] 34. As a matter of fairness, these constraints ought to be taken into account in the Committee’s assessment of the ICU’s supervisory performance during the WFC renovation works.

E5. Issuance of the statutory notices to WFC under the MBIS

WFC was selected as a target building under the MBIS in 2013. The secretary of the ICU’s Selection Panel identified all HOS/TPS/BRO/GSH courts aged over 30 years, prepared building scores for each eligible building, and finalised a nomination list. The ICU nominated five courts; WFC ranked fourth with a score

32 YUNG Siu Lun (Senior Maintenance Surveyor, ICU) 2nd WS §10 33 YUNG Siu Lun 2nd WS §11

34 YUNG Siu Lun 2nd WS §12

of 3235 [WS1/627-628]. The Selection Panel meeting was held on 13 December

2013; members did not raise any concern in relation to WFC 36 [WS1/628]. Following verification that WFC had not carried out inspection or prescribed repair works relevant to the MBIS, all eight blocks were selected as target buildings. The final list was approved by the then CMS/ICU on 12 March 201437 [WS1/629].

Under the building score system then in force [I1-2/1632-1634], a higher score was accorded to buildings with an OC on the basis that the prospect of compliance with MBIS notices would be better for such buildings. Ku confirmed in oral evidence that this scoring criterion has since been revised; under the current system [J1-2/4740-4742], higher scores are instead accorded to ‘three-nil’ buildings lacking proper building management [Day 22/9/14 - 10/24].

The ICU sent a pre-notification letter for the MBIS to the WFC IO on 29 April 2014 [I1-2/1678-1685]. The statutory notices were issued on 10 June 2016, served on the WFC IO under section 30B(3) of the BO [I1-2/1686]. Following the issuance of the statutory notices, and given active progress by the WFC IO, the ICU approved extensions of time for compliance on five occasions between June 2017 and October 201938 [WS1/629].

The WFC IO appointed Will Power as the inspection consultant (covering the provision of RI services – as the RI must be an individual) in January 2019. Will Power engaged an individual known as Mr Shum Kui Chung to take up the duties of an RI (at least on paper, see e.g. Certificate of Building Inspection (Form MBI 3) of Wang Yan House [I1-2/1881]) and submit Inspection Reports together with

35 KU Siu Ping 1st WS §§15-16

36 KU Siu Ping 1st WS §17

37 KU Siu Ping 1st WS §18

38 KU Siu Ping 1st WS §20

Forms MBI 3; the said Inspection Reports and Forms MBI 3 were submitted to

the ICU on 10 December 2019. Of these eight submissions, the one for Block E was sampled for a full audit check (document audit and site audit) under the MBIS; the remaining seven were subject to preliminary and fundamental checks only. Both the document audit and site audit results for Block E were satisfactory39 [WS1/634].

E6. The WFC renovation works following completion of the MBIS inspection – mainly governed by the MWCS

Based on Will Power’s Inspection Reports submitted in December 2019, the proposed prescribed repair works for WFC comprised only MW and exempted works under the BO. No works requiring prior plan approval and consent from the BA were identified. The renovation works under the MBIS and those outside the scope of MBIS were therefore carried out principally under the MWCS, the regulatory framework and model of which are described in Section F below.

At the time of the fire, there were 48 MW submissions related to renovation works in the common areas of WFC that were still ongoing. These comprised 24 Forms MW01 (notices of commencement of Class I MW) and 24 Forms MW03 (notices of commencement of Class II MW). No certificate of completion had been received by the ICU before the fire, as the works were still in progress.

Of these 48 submissions, two Class I MW submissions were randomly selected for the Audit Fundamental Check (“AFC”) under the MWCS: MWB02504820 and MWB02504821, both submitted on 2 May 202540 [WS1/665]. These related to the erection of protective barriers and alteration of windows along the staircases of Blocks F and H respectively. The window works they covered were

39 KU Siu Ping 1st WS §34

40 YUNG Siu Lun 1st WS §31

the very works that involved the replacement of staircase windows with the

access openings addressed in Section M.

The remaining 46 of the 48 submissions received no further check beyond the Form Screening Check and Preliminary Check, because they either did not fulfil the criteria for priority selection or were not selected through the random ballot41 [WS1/668].

The WFC renovation, valued at approximately HK$336 million and involving extensive exterior modifications to eight 31-storey residential buildings housing thousands of residents, was classified and processed through the regulatory framework applicable to minor works, i.e. the MWCS. Whether this classification was adequate for a project of this scale and complexity is a systemic question addressed in Section Q.

E7. Before the WFC fire – the Mariners’ Club incident (2023) and Chinachem Tower incident (October 2025, shortly before the WFC fire)

Two significant fire incidents involving scaffolding on high-rise buildings preceded the WFC fire and are relevant to the Committee’s assessment of the regulatory and supervisory response to known fire risks in renovation works. The first was a fire at the Mariners’ Club building in Tsim Sha Tsui in March 2023; the second was a fire at Chinachem Tower in Central on 18 October 2025, just five weeks before the WFC incident.

The Mariners’ Club fire occurred on 2 to 3 March 2023 and involved a building that was under construction with scaffolding erected at the upper levels. The fire was classified as a No. 4 alarm fire. It is relevant that the incident involved the

41 YUNG Siu Lun 1st WS §38

spread of fire along scaffolding of a high-rise building, a mechanism of spread

that would later prove catastrophic at WFC.

The significance of the Mariners’ Club fire for the present inquiry lies in the regulatory response it prompted. Following the Mariners’ Club fire:

1. The BD issued a circular letter to all prescribed building professionals and RCs on 21 March 2023 on the subject of “Use of Fire Retardant Protective Net/Screen/Tarpaulin/Plastic Sheeting on Façade of Buildings under Construction, Demolition, Repair or Minor Works” [J1-2/5915]. This circular letter specifically stated that “protective net, screen, tarpaulin/plastic sheeting installed to cover the façade of buildings under construction, demolition, repair or minor works should have appropriate fire retardant properties in compliance with a recognised standard,” and listed three examples of recognised standards: GB 5725-2009, BS 5867-2:2008 (Type B performance requirements), and NFPA 701:2019 (Test Method 2) [J1-2/5915].

2. In addition, the FSD issued Circular Letter No. 2/2024 dated 21 March 2024 [B2/1312-1317], which introduced revised requirements on fire protection measures in high-rise buildings under construction with a designed construction height of 30 metres or above. The circular required the provision of a closed-circuit type water relaying system and other fire protection measures to facilitate firefighting operations in such buildings. The circular further required the responsible registered general building contractor or authorised person to inform the local fire station of any circumstances that may lead to the unavailability of the system or the failure to maintain its performance, including defects and temporary shutdowns, and to adopt suitable alternative measures without delay. The

FSD Circular Letter No. 2/2024 took effect from 1 July 2024 and applied

to buildings under construction rather than existing buildings undergoing renovation.

The Chinachem Tower fire on 18 October 2025 was a more proximate and directly relevant precedent. Chinachem Tower, a commercial building in Hong Kong’s Central Business District, was undergoing renovation works when a fire broke out on exterior scaffolding. The fire was classified as a No. 3 alarm fire and spread rapidly along the exterior scaffolding, generating heavy smoke visible from across Victoria Harbour. At least four persons were hospitalised. The BD subsequently assessed the building as structurally sound, and the fire was brought under control without fatalities.

The Chinachem Tower fire prompted a more intensive regulatory response than the Mariners’ Club incident. On 21 October 2025, the BD issued a further circular letter [J1-2/6192-6193] to all PBPs and RCs, requiring them “to take immediate action to inspect and ascertain the fire-retardant property of the protective materials on the façade of buildings with building works under their charge”42 [WS1/825]. The circular letter stated that if contractors were found to be using protective materials with inadequate FR properties, the BD would take appropriate actions including consideration of instigating prosecution and disciplinary actions.

Ku confirmed that the Chinachem Tower fire also prompted the ICU to take proactive steps in relation to the courts / estates under its purview. On 23 October 2025, the ICU sent an email to the RIs appointed to the five courts / estates undergoing repair works under the watch of the MBIST, including the RI of WFC, reminding them “to give clear instruction to all parties including the contractors,

42 YUE Chak Sang (AD NB1, BD) 1st WS §41

site supervision staff and their team members to prioritise fire safety” and “to

ensure that the scaffolding was in good condition and that the fire-retardant properties of the scaffolding nets fully complied with the requirements of BD circular and the Code of Practice for Bamboo Scaffolding Safety issued by LD, given the scaffolding had been in use for an extended period and some scaffolding nets had been replaced after the typhoon”43 [Il-4/8903-8912] [WS1/645-646].

The ICU also attached information regarding fire safety at construction sites issued by the Construction Industry Council and an FSD’s circular letter regarding fire protection measures in high-rise buildings under construction. On 27 October 2025, the ICU sent a further email to the same group of RIs, reminding them to comply with the requirements set out in the BD’s circular letter of 21 October 202544 [Il-4/8913-8918] [WS1/646]. The site inspection at WFC on 28 October 2025, at which further quick tests of scaffolding nets were conducted, was partly prompted by this heightened concern following the Chinachem Tower incident45 [WS14/2140-2142].

Following the Chinachem Tower fire, the FSD also offered to assist the BD in conducting fire tests on scaffolding nets. AD Yung Kam-hung confirmed that “the FSD learned from the BD that they were conducting further reviews on the use of scaffolding nets, and offered to assist in the process. A fire test for scaffolding nets was subsequently scheduled for 12 December 2025 at the Fire and Ambulance Services Academy of the FSD. However, the test was withheld due to the fire incident at Wang Fuk Court on 26 November 2025”46 [WS1/98-99]. AD Yung also confirmed that although no additional active fire safety provision was considered necessary for buildings under renovation following the

43 KU Siu Ping 1st WS §51

44 KU Siu Ping 1st WS §52

45 KU Siu Ping 3rd WS §§34-41

46 YUNG Kam Hung, Michael (AD Fire Safety of FSD) 1st WS §20.2

Chinachem Tower fire, the FSD’s assistance to the BD in reviewing scaffolding

nets represented inter-departmental cooperation on a matter that, while primarily within the BD’s regulatory purview, had direct implications for firefighting operations47 [WS1/99].

The circular letters, reminder emails and site inspections that followed the Chinachem Tower fire represented a measurably heightened level of regulatory attention. The two preceding fire incidents provided a clear warning; the question for the Committee is whether the regulatory response to those warnings was sufficient, and what systemic reforms are needed to ensure that comparable warnings produce more effective protective actions in a pre-emptive manner in the future.

47 YUNG Kam Hung, Michael 1st WS §20.2

F. THE REGULATORY FRAMEWORK UNDER EACH RELEVANT AREA AND STAKEHOLDERS’ ROLES AND RESPONSIBILITIES

(I) Areas in which the Government has a facilitative role

F1. General building management under private ownership

(i) The regulatory framework and model

The regulatory framework for building management in Hong Kong is premised on the principle of private ownership. The right to private property is enshrined in Articles 6 and 105 of the Basic Law of the Hong Kong Special Administrative Region. The Government takes the view that the right to private property carries with it the inherent responsibility for its proper management, including upkeeping and maintenance. Government intervention in private property management should be premised on safeguarding the public interest, and should be exercised with caution and restraint given the right of private ownership48 [WS1/486].

The BMO provides the principal legislative framework. It is enacted to provide for the IOs, and the management and maintenance of their buildings. The Secretary for Home and Youth Affairs (“SHYA”) is the Authority under the BMO, and the HAD is her executive arm [WS1/486]49. For a building in which owners hold undivided shares, the responsibility for managing the common parts is to be discharged collectively and jointly; the BMO provides the legal mechanism for owners to form a legal entity, namely the Owners’ Corporation OC, to assume and discharge their shared responsibility on building management50 [WS1/486].

48 TE Chi Wang (Deputy Director, HAD) 1st WS §7

49 See also section 2 of the BMO [G1/11] and [Day 24/8/26-35 (Chinese transcript)] 50 TE Chi Wang 1st WS §8

The BMO sets out the duties and powers of OCs and MCs with regard to the

management and maintenance of common parts of buildings. Pursuant to section 18(2) of the BMO, an OC possesses powers including the power to engage and remunerate staff, accountants, managers, or other professionals; to improve and maintain common areas; to carry out renovation, improvement or decoration works on common parts; and to act on behalf of the owners in matters of common interest. The BMO also confers on individual owners the rights to monitor the work of the OC and its MC, including the rights to inspect financial statements and, if applicable, accountants’ reports, and to require the MC chairman to convene an OC general meeting for specified purposes at the request of not less than 5% of the owners51 [WS1/486].

The SHYA has issued two Codes of Practice pursuant to sections 44(1)(a) and 44(1)(b) of the BMO: the Code of Practice on Procurement of Supplies, Goods and Services [G-1/251-260] and Code of Practice on Building Management and Safety [G-1/261-284]. Recognising that MCs are often comprised of owners who are laymen and serve on a voluntary basis, these Codes of Practice provide practical guidelines and benchmarks for reasonable conduct in their respective areas52 [WS1/491]. While under section 44(2) of the BMO, a failure to follow any of the Codes does not of itself constitute a criminal offence, in any civil or criminal proceedings such a failure may be relied upon as admissible evidence relevant to establishing or disputing liability53 [WS1/491].

The regulatory model is therefore one of self-governance by owners, supported by a statutory framework that provides the mechanism for collective decisionmaking. The Government’s role is facilitative: to assist owners in forming OCs,

51 TE Chi Wang 1st WS §9 52 TE Chi Wang 1st WS §18 53 TE Chi Wang 1st WS §19

to provide consultative and support services, and to intervene where public

interest demands and the self-regulatory mechanisms are inadequate.

(ii) The Government’s facilitative role (for the case of WFC)

The HAD, through District Building Management Liaison Teams (“DBMLTs”) in each of the 18 District Offices, provides a range of services to OCs and owners. These include: assisting in OC formation; attending owners’ meetings upon invitation and providing advice according to the BMO; advising parties of noncompliance and requesting rectification; answering BMO enquiries; and organising training and briefings for MC members and owners54 [WS1/487-488].

In the case of WFC, the Tai Po District Office (“TPDO”) assisted owners in the operation of the OC and dealing of building management matters, including attending owners’ meetings and providing information to owners as and when necessary (including meetings on 25 January 2019, 13 December 2019, 11 December 2021, 4 March 2023, 28 January 2024, 25 May 2024, 6 September 2024, 5 October 2024, 21 March 2025 and 13 September 2025); giving advice on operational procedures of meetings; handling enquiries and complaints relating to building management; and, for matters not under the BMO, referring complaints and requests to responsible departments and relevant bodies such as the BD, URA, and Competition Commission where appropriate55 [WS1/504].

The HAD’s attendance at WFC meetings was in line with the usual role of HAD representatives at owners’ meetings, namely “to observe the meeting to provide advice when any irregularity is spotted” 56 [WS1/504]. HAD representatives maintain impartiality and professionalism, offering advice solely on BMO

54 TE Chi Wang 1st WS §10

55 CHAN Hau Man (former DO Tai Po, HAD) 1st WS §7 56 CHAN Hau Man 1st WS §7

provisions, especially those governing procedures relating to the conduct of

owners’ meetings and the rights and powers of the IO and owners.

Section 40A(1) of the BMO empowers the Authority (i.e. the SHYA) or an authorised officer to inspect common parts of a building, attend OC general meetings, and inspect or obtain copies of OC budgets, accounts, documents and records, for the purpose of ascertaining how a building is being controlled, managed, or administered57 [WS1/492]. Given the HAD’s facilitative role, in most cases OCs and owners are willing to work with the HAD in a voluntary and cooperative manner, and section 40A serves mostly as a “last resort” for exceptional cases58 [WS1/492]. In the case of WFC, the buildings were at all material times managed by a functional MC, there was an elected body operating within the framework of the BMO with the assistance of a licensed PMC, and both the MC and PMC had been cooperative; accordingly the HAD did not see the need to trigger the powers under section 40A against WFC59 [WS1/493].

The facilitative model had been operating effectively in the majority of circumstances at WFC. Its systemic design which defines the HAD’s role, particularly in the context of large-scale renovation procurement where owners would face complex decisions without the benefit of specialist expertise, is addressed in Section U below.

(iii) The other stakeholders’ responsibilities - owners and the PMC

Under the BMO and regulatory model described above, it is the owners, acting through the OC and MC, who bear primary responsibility for the management of their building. The decision whether to carry out renovation works, what scope of works to undertake, which consultant and contractor to engage, and how to

57 TE Chi Wang 1st WS §21 58 TE Chi Wang 1st WS §22 59 TE Chi Wang 1st WS §24

supervise the works are all decisions that the BMO allocates to the owners

collectively.

Section 18(2)(fa) of the BMO stipulates that it is the OC’s duty to “carry out any renovation, improvement or decoration work to the common parts” of the building60 [WS1/504]. Section 18(2)(g) states that the OC may act on behalf of the owners in respect of any other matter in which the owners have a common interest61 [WS1/504].

The PMC engaged by the OC assumes responsibility for the day-to-day management of the building on behalf of the OC.

In the case of WFC, the owners made the decisions to engage Will Power as the consultant providing RI services, to approve the renovation option, and to appoint Prestige as the main contractor. ISS served as the licensed PMC. Both of the above decisions, and the subsequent supervision of the works, were the primary responsibility of the owners (including through their IO/MC) and professionals they engaged; again, the Government’s role was facilitative.

F2. Owners’ Engagement of professionals for maintenance of the FSI system

(i) The regulatory framework and model for ownership and maintenance of FSIs

The regulatory framework for ownership and maintenance of FSIs in residential buildings is established by the FSO (Cap. 95) and its subsidiary legislation, principally the Fire Service (Installation Contractors) Regulations (Cap. 95A) and Fire Service (Installations and Equipment) Regulations (Cap. 95B)62 [WS1/104].

60 CHAN Hau Man 1st WS §7

61 CHAN Hau Man 1st WS §7

62 KEUNG Sai Ming 1st WS §5.3.1

Under Regulation 8 of Cap. 95B [B2/177], the owner of any FSI has a legal

responsibility to keep such installation or equipment in efficient working order at all times, and shall arrange for inspection of such FSI by an RFSIC at least once every 12 months.

Under Regulations 6 and 7 of Cap. 95B [B2/176-177], only an RFSIC shall install, maintain, inspect, or repair any FSI that is required by or pursuant to law to be installed63 [WS1/105]. This requirement places the execution of FSI maintenance in the hands of professionally qualified contractors who are registered with and subject to the disciplinary oversight of the FSD, while the responsibility for engaging such a contractor and ensuring annual inspections are conducted rests with the building owners.

The model is therefore one of owner responsibility for engagement combined with RFSIC responsibility for execution: it is for the owners (or the OC, or in appropriate cases the PMC acting on the OC’s behalf) to select and engage a suitably registered RFSIC; it is for the RFSIC to carry out the maintenance, inspection or repair in accordance with the applicable Codes of Practice and to certify the result to the FSD by way of an FS251 certificate.

(ii) The Government’s facilitative role

The FSD’s engagement with building owners in the context of FSI maintenance is primarily through the FS251 audit mechanism and SDN regime, addressed in Section F4 below. The FSD also maintains the register of RFSICs and makes it publicly accessible so that owners may select a contractor.

The regulatory framework is premised upon the OC and PMC’s prompt actions in engaging an RFSIC to inspect and maintain FSIs, and the contractual

63 KEUNG Sai Ming 1st WS §5.4.1

arrangement between them. As AD Keung confirmed, the FSD “is not privy to

the engagement process nor the contractual negotiations and therefore will not be directly involved in the technical content of the works”64 [WS8/1911]. The RFSIC engaged will inspect the FSI and, if there is a need for the FSI to be shut down for maintenance, modification or repair overnight or for more than 24 hours continuously, the RFSIC will notify the FSD of the shutdown. The notification system for FSI shutdown is not an approval mechanism; the RFSICs bear the ultimate responsibility in certifying the FSIs are in efficient working order and are expected to exercise their professional skills and judgement accordingly [WS8/1911].

As part of its enforcement priority, the FSD focuses more on buildings that are unable to have any RFSIC engaged for FSI maintenance, in which circumstances the FSD will take enforcement actions. AD Keung confirmed in oral evidence: “for our priorities, we are more worried that there’s no one doing annual maintenance. And if annual maintenance is being done, if no one is following up on the defects, it is also a problem” [Day 10/147/8-13]. WFC had a functioning OC, an engaged PMC (ISS), and an RFSIC (Victory Fire) under contract for annual inspections.

In the case of WFC, Victory Fire was engaged, annual inspections were conducted (March 2025), FS251 certificates were submitted, and the FSD received and processed them. The systemic problems that subsequently arose in the FSI regime stemmed from failures in the execution of primary responsibilities by private actors; these are addressed in Sections F4 and N.

64 KEUNG Sai-ming 4th WS §9

(iii) The other stakeholders’ responsibilities – owners, the PMC, contractors,

consultant and RI

As stated above, Regulation 8 of Cap. 95B imposes on the owner the legal responsibility to keep the FSI in efficient working order at all times and to arrange for annual inspections by an RFSIC65 [WS1/108]. In practice, for an estate such as WFC where a PMC is engaged (i.e. ISS), the OC normally delegates the dayto-day management of the FSI (including the engagement of an RFSIC and follow-up on defects) to the PMC. The DMC typically stipulates that FSIs in common areas are common parts, and the OC is responsible for their maintenance66 [WS1/109].

Under the Property Management Services Ordinance (Cap. 626), licensed PMCs are required to comply with the codes of conduct issued by the PMSA. In the context of FSIs, the PMSA Code of Conduct for Handling Fire Safety Work [B2/2631-2633] requires the PMC to clearly stipulate in the RFSIC contract that the RFSIC must comply with the FSD requirements, to monitor the progress of the RFSIC’s work, to follow up timely with the RFSIC on required rectifications and keep relevant documents, to follow up timely with the RFSIC that it has to notify the DFS of any FSI shutdowns, and to assist FSD officers during visits, inspections or investigations67 [WS1/109].

In the case of WFC, ISS engaged Victory Fire as the RFSIC for the annual inspections and rectification works of the FSIs. In addition, to the knowledge of ISS, Prestige engaged China Status ostensibly as the RFSIC for renovation works of the FS Water Tanks (which were an integral part of the FSIs). Yet, ISS also received requests from Prestige to assist with the drainage of the FS Water Tanks, which led to the shutdown of the main power switch by ISS’s own electrician (a

65 KEUNG Sai Ming 1st WS §5.5.1 66 KEUNG Sai Ming 1st WS §5.5.3 67 KEUNG Sai Ming 1st WS §5.5.3

non-RFSIC). The primary responsibility for ensuring that only an RFSIC

operated the FSI, and for coordinating between the two simultaneously engaged RFSICs (Victory Fire and China Status), rested with ISS as the PMC, the OC as the owners of the FSI, Prestige as the contractor engaged by the owners to undertake renovation works of FS Water Tanks, and Will Power and Ng Yeuk appointed as consultant and RI for supervising the renovation works as a whole. Their failures in discharging these responsibilities are addressed in detail in Section N.

F3. Owners’ engagement of building professionals for carrying out building- or estate-wide inspections and renovation works

(i) The regulatory framework and model

Under the MBIS introduced by the BO, building owners of private buildings aged 30 years or above who are served with a statutory notice are required to appoint a RI to carry out prescribed inspection and a RC to carry out any necessary rectification and repair works under the supervision of the RI68 [WS1/779]. The registers of RIs and RCs are maintained by the BD.

The BA has no involvement in the appointment of the RI and RC. It is the IO’s decision which RI and RC to engage; the IO is also responsible for deciding whether to employ a consultant, and if so, which one. The system is designed to respect the owners’ autonomy in making these commercial decisions, while requiring that whoever is appointed must be suitably registered and is qualified under the BO.

There is no mandatory requirement under the BO for the employment of consultants for the MBIS. It is the IO’s decision whether to employ any, and if so, the IO should also be responsible for taking the necessary steps for the

68 CHEUNG Yuk Ching, Karen (AD MBI, BD) 1st WS §11

engagement of the consultant. The BD or ICU has no role in reviewing or

confirming the quality, reliability and integrity of consultants69 [WS1/626].

The model is therefore one of owner-led procurement underpinned by professional registration requirements. The BA sets the standards for registration and maintains the registers; the owners select from the registered pool; and the professionals bear primary statutory responsibility for the quality, safety and compliance of the works they carry out and supervise.

Legislation and related mechanisms exist to guard against improper collusion, bid-rigging corruption and other irregularities in the procurement process. These include the Prevention of Bribery Ordinance (Cap. 201), Competition Ordinance (Cap. 619), and Building Management (Amendment) Ordinance 2024 70 (effective July 2025) which introduces enhanced declaration of interest requirements for high-value procurement and a “voting-in-person” threshold for large-scale maintenance procurement. The Government’s approach recognises that the owners’ collective decision-making process is vulnerable to manipulation and provides legal safeguards while preserving the foundational principle that the decisions themselves are the owners’ to make.

(ii) The Government’s facilitative role

The Government’s facilitative role in the engagement of building professionals for inspection and renovation works operates through multiple channels.

The HAD, through the Central Platform on Building Management established since 2018, organises monthly briefings for OCs and owners at which relevant

69 KU Siu Ping 1st WS §11

70 While these BMO amendments were in force at the time of the WFC fire, they post-dated the engagement of Will Power (2019) and Prestige (January 2024) and were therefore not applicable to the procurement decisions in the case of WFC.

government departments (including the BD, FSD, Electrical and Mechanical

Services Department (“EMSD”), LD and Police) and institutions (including the ICAC, URA and Competition Commission) may be invited to introduce their services and schemes on building management and maintenance, including details of services, application procedures, and channels for making further enquiries. These briefings are particularly directed at owners and OCs that have received MBIS notices71 [WS1/489-490; Day 24/3/17 – 4/13]. DBMLTs also organise seminars, workshops and briefings for OCs and owners in their respective districts by inviting the relevant departments and organisations to introduce information related to building management and maintenance, so owners can better fulfil their responsibilities in managing their buildings 72 [WS1/490].

The URA provides further facilitative support through the Smart Tender scheme (addressed in Section U1 below), which offers an e-tendering platform designed to reduce the risk of bid-rigging in contractor procurement. The HAD, through its Free Legal Advice Service on Building Management and dispute resolution services, provide mechanisms for owners facing disagreements about renovation decisions73 [WS1/489].

The BD has also published guidance materials to assist owners in the appointment of RIs and RCs, including the Practice Note for Mandatory Building and Window Inspection Schemes 2 (“PNBI-2”) [J1-2/4975-4977] on best practice for tendering procedures, a Fact Sheet on mechanisms for fostering a fair and healthy building inspection and repair service market [J1-2/5934-5935], and the Building Maintenance Guidebook [J1-1/1139-1467] [WS1/791-792]74. These publications

71 TE Chi Wang 1st WS §§13-14

72 TE Chi Wang 1st WS §16

73 TE Chi Wang 1st WS §13

74 CHEUNG Yuk Ching 1st WS §34

provide comprehensive guidance on combatting corruption, preventing bidrigging, and services in tender and contract management.

The facilitative model is intended to equip owners with the information, services and legal safeguards needed to make informed decisions about the professionals they engage for building maintenance and renovation, without the Government itself directing the commercial choices that owners make about their own property.

(iii) The other stakeholders’ responsibilities – owners and the PMC

The primary responsibility for the engagement of building professionals rests with the owners acting through their OC and MC. They must decide which RI and RC to appoint, evaluate competing bids, and satisfy themselves as to the suitability and competence of the professionals they select. Where owners choose to engage a consultant to advise them on the procurement process, that too is their decision and their responsibility.

In the case of WFC, the IO appointed Will Power as the consultant to provide, among other things, RI services, and subsequently appointed Prestige as the main contractor, through owners’ meetings at which the decisions were approved by majority vote. Neither the HAD, nor the ICU, nor the BD had any involvement in these appointment decisions. The professionals so appointed bore the primary statutory obligations under the BO for the safety and compliance of the works; the owners bore the responsibility of having selected them.

The evidence before the Committee demonstrates that in the building maintenance sector, the procurement process is vulnerable to manipulation by organised syndicates, as documented by the Competition Commission, ICAC and Police (addressed in detail in Section S below). The Government’s facilitative

model, while respecting the principle of private ownership, depends for its

efficacy on the integrity of the professionals from whom owners must choose and on the enforcement mechanisms available when that integrity is absent.

(II) Areas in which the Government has a supervisory role

F4. Management of fire risks and maintenance of FSI

(i) The regulatory framework and model

The regulatory framework for FSIs is established by statute and designed to ensure that all FSIs remain in efficient working order at all times. The FSD administers a framework that “clearly delineates responsibilities amongst the regulator, accredited contractors, and building owners or their agents” 75 [WS1/104]. The framework operates through three principal legislative instruments: section 16(1)(b) of the BO, which requires buildings to be provided with the minimum FSIs required for their intended use; the Fire Service (Installation Contractors) Regulations (Cap. 95A), which empowers the DFS to regulate the conduct of RFSICs; and the Fire Service (Installations and Equipment) Regulations (Cap. 95B), which empowers the DFS to control the installation, repair, maintenance and inspection of FSIs76 [WS1/104].

The regulatory model distinguishes between passive fire safety provisions and active fire safety provisions. As AD Keung and AD Yung of the FSD confirmed, to achieve the fire safety objective, there shall be active and passive fire safety provisions within every building77 [WS1/91, 104]. Reference can be made to the BD’s Code of Practice for Fire Safety in Building 2011 (2024 Edition) (“FS

75 KEUNG Sai Ming 1st WS §5.2

76 KEUNG Sai Ming 1st WS §5.3

77 YUNG Kam Hung 1st WS §6; KEUNG Sai Ming 1st WS §5.1

Code”) [J1-2/3983], which recognises the distinction between passive and active

fire safety provisions.

1. Passive fire safety provisions [J1-2/4008] “means permanent building features and architectural aspects of a building that prevent fire development and spread. Examples include required staircases, fire rated doors, spandrels, fire barriers, linings with low combustibility etc.”

2. Active fire safety provisions in turn concern FSIs and equipment (FAS, FH/HR System, sprinkler systems, fire detection systems, smoke extraction systems and the like), which fall primarily under the regulatory control of the FSD.

AD Yung of FSD confirmed this division in both his witness statement and oral evidence. His witness statement states that “From a technical perspective, fire safety in buildings can be divided into two main categories: ‘active fire safety provisions’ and ‘passive fire safety provisions’, both of which work together to ensure safety. In fact, it is clearly stated in the ‘Code of Practice for Fire Safety in Buildings 2011’ issued by the BD that fire safety provisions include active fire safety provisions and passive fire safety provisions” 78 [WS1/91]. In oral evidence, AD Yung confirmed that the FSD is responsible for regulating active fire safety provisions, while passive fire safety provisions fall primarily under the BD (and, for WFC, the ICU): “For these passive provisions or facilities, they would have a clear division of labour with the BD or the ICU. As I say in my witness statement, we focus on the active part” [Day 17/11/11-14]. AD Yung explained that the rationale for this division of work is to ensure that the most appropriate department with the relevant professional expertise handles the matter. As he put it, “It is because we need to have the most appropriate department to deal with

78 YUNG Kam Hung 1st WS §6

it” [Day 17/41/6-7], elaborating that the BA has the professional expertise and

oversight over construction practices, and the FSD lacks the expertise to determine whether certain construction arrangements (such as access openings) are warranted as part of the works, “They have the professional expertise and we need to look at the practice” [Day 17/43/15-16].

Notwithstanding the above distinction as a matter of technical demarcation and internal division of labour in general, however, AD Yung readily confirmed, that the FSD’s remit “goes beyond just active provisions” under section 7(c) of the FSO, which imposes a duty to give “advice on fire protection measures and fire hazards as occasion requires” [Day 17/9/17 - 10/1] [B2/82]. The definition of “fire hazard” under section 2 of the FSO (Cap. 95) is broad, encompassing “matter or circumstances which materially increases the likelihood of fire or other calamity or the danger to life or property” [Day 17/10/6-13] [B2/77].

Under Regulation 8 of Cap. 95B [B2/177], the owner of any FSI has a legal responsibility to keep such installation or equipment in efficient working order at all times, and shall arrange for inspection by an RFSIC at least once every 12 months. The FSD monitors compliance with this responsibility through the FS251 certificate mechanism and through visits and inspections conducted on a riskbased and complaint-driven basis.

(ii) The Government’s supervisory role - the BD and FSD

(1) Passive FSI

The BD is generally the authority responsible for regulating the design and construction of passive fire safety measures in private buildings. These include the design and construction of exit staircases, smoke lobbies, corridors, compartmentation, fire resisting ratings of fire barriers (walls, doors and fixed

lights), and the design and construction of emergency vehicular access (“EVA”)

and means of access for firefighting and rescue79 [WS1/807].

The relevant statutory provisions, among others, are found in (1) Part V of the Building (Planning) Regulations (Cap. 123F) (“B(P)R”) [J1-1/46-55], which e.g. provides for the provision of means of escape in case of fire (regulations 39 to 41) and means of access for firefighting and rescue (regulations 41A to 41D); and (2) Part 10 of the Building (Construction) Regulation (Cap. 123Q) (“B(C)R”) [J1-2/5751], under which a building must be designed and constructed so as to inhibit the spread of fire within the building and to buildings nearby, provide adequate resistance to the spread of fire and smoke, maintain the stability of the building to allow adequate time for safe evacuation, rescue and firefighting, and avoid consequential damage to buildings nearby; as well as (3) section 16 of the B(C)R [J1-2/5735-5736], which requires that in carrying out building works or street works, appropriate construction methods and procedures must be adopted and appropriate precautionary measures must be taken. Section 16 is a provision of general application that governs not only the permanent design and construction of fire safety elements but also the manner in which works are carried out, including the precautionary measures that must be in place during the course of renovation to protect building occupants and the public from fire risk.

The FS Code, published by the BD, provides the detailed prescriptive requirements deemed to comply with the statutory requirements of the B(P)R and B(C)R. Parts B and C of the FS Code outline the prescriptive requirements on provision of means of escape and fire resisting construction of buildings respectively. Clause F5.6 of the FS Code [J1-2/4169-4170] stipulates that when carrying out alterations, additions, renovations and repair works, certain major fire safety requirements must be observed, including: all means of escape should

79 CHEUNG Yuk Ching 1st WS §84

be maintained at all times; alternative measures for ensuring adequate standard

of fire safety should be provided if any means of escape, fire rated doors, fire barriers have to be temporarily removed; any inflammable and combustible materials should be stored under safe custody and accumulation in excessive quantity should be avoided.

For buildings under the purview of the ICU (such as WFC, a sold HOS estate), the BD’s regulatory functions with respect to passive fire safety measures are now exercised by the ICU under delegated authority. The nature and effect of this delegation arrangement is addressed in Section E4 above. It bears reiteration that WFC was constructed at a time when it was exempt from the provisions of the BO by virtue of section 41(1)(aa), as a building upon land vested in the HA. WFC was therefore not required to comply with the BO, its subsidiary legislation, or the relevant codes of practice and guidelines at the time of its design and construction (although they were in fact complied with on a voluntary basis).

(2) Active FSI and their maintenance

The FSD is the authority responsible for regulating active fire safety measures involving FSIs and equipment. Active FSIs include FAS, FH/HR System, sprinkler systems, emergency lighting, fire detection systems, smoke extraction systems, staircase pressurisation systems, dry riser systems and water spray systems.

Under section 21(6)(d) of the BO [B2/340], the BD will not issue an occupation permit unless the DFS certifies that the required FSIs shown on the vetted building plans have been properly installed and are up to the required standard. Thereafter, the primary monitoring mechanism for the continued operability of FSIs is the mandatory FS251 certificate. Under Regulation 9(1) of Cap. 95B [B2/179], whenever an RFSIC installs, maintains, repairs or inspects any FSI, it

must within 14 days after completion of the work issue a certificate to the person

on whose instructions the work was undertaken and forward a copy to the DFS. The certificate must state the address, a description of the FSI concerned, the date of completion, the nature of the work, and whether the FSI is in efficient working order.

The FSD monitors RFSIC performance through an audit-check mechanism comprising three distinct activities: document review of FS251 certificates submitted by RFSICs to ensure compliance with statutory requirements; verification inspection to verify accuracy of the FS251 certificate; and functional test of FSI to ensure its efficient working order80 [WS1/107]. The FSD conducts proactive audit checks on a percentage of submitted FS251 certificates. For certificates indicating no defects, the local fire stations would also conduct a significant number of on-site verification inspections annually. Throughout the process, any defects or discrepancies identified are followed up, and instances of non-compliance or misconduct by RFSICs may be uncovered81 [WS1/107].

Where FSIs are found defective and major defects are reported via FS251, the local fire station visits the affected premises within 24 hours [B2/2191], conducts an on-site risk assessment for further formulation of contingency plan, issues an advisory letter to the FSI owner requiring provision of standby means and expedited rectification, and monitors compliance through a 72-hour reinspection82 [WS1/115].

In general, visits and inspections to a domestic estate such as WFC by various units of the FSD are initiated from three aspects: fire hazard complaints, FSI80 KEUNG Sai Ming 1st WS §5.4.2 81 KEUNG Sai Ming 1st WS §5.4.2 82 KEUNG Sai Ming 1st WS §7.1.2

related visits and inspections, and proactive visits by local fire stations under the

Risk-based Building Fire Safety Visit Programme83 [WS1/115].

Between July 2024 and November 2025, the FSD conducted a total of 26 visits/inspections at WFC: 18 FSI-related visits/inspections (6 relating to defective installations and 12 relating to shutdowns), 7 complaint inspections (2 relating to EVA, 3 relating to means of escape, and 2 relating to other matters), and 1 proactive visit84 [WS1/116-118].

(3) The RFSICs

The RFSIC registration system is governed by Cap. 95A. Three classes of RFSICs are designated: Class 1 (for any FSI containing an electrical circuit or other apparatus for the detection and warning of smoke or fire); Class 2 (for any FSI containing pipes and fittings designed to carry water or some other fire extinguishing medium, or any type of electrical apparatus other than those in Class 1); and Class 3 (for any portable equipment)85 [WS1/105]. During the registration process, applicants and their proposed qualified persons must produce supporting documents, participate in an interview, and undergo a workshop inspection demonstrating the use of required equipment86 [WS1/105].

For RFSICs who violate regulations, the FSD will initiate investigations, prosecute the RFSICs concerned, and refer matters to the Registered Fire Service Installation Contractors Disciplinary Board for inquiry, with the maximum punishment being removal from the register 87 [WS1/107]. The FSD mainly prosecutes RFSICs in breach of Regulation 9(1) (failing to issue the certificate), Regulation 9(2A) (signing a false or misleading certificate), and Regulation

83 KEUNG Sai Ming 1st WS §7.1.4 84 KEUNG Sai Ming 1st WS §7.2

85 KEUNG Sai Ming 1st WS §5.4.1 86 KEUNG Sai Ming 1st WS §5.4.1 87 KEUNG Sai Ming 1st WS §5.4.3

9(3)(b) (issuing or forwarding a false or misleading certificate) of Cap. 95B88

[WS1/107] [B2/179].

The FSD also operates a Demerit Points System for RFSICs. Under this system, inspection levels are determined based on the accumulation of points. RFSICs prosecuted for violating ordinances or punished by the Disciplinary Board are assigned demerit points, as is a finding of non-compliance during an on-site inspection. RFSICs with higher accumulated points are subject to more on-site inspections and proactive audit functional tests89 [WS1/108].

(iii) The other stakeholders’ responsibilities – owners, the PMC and RFSICs

The entire FSI regulatory regime involves responsibilities from multiple parties: the owners and OC as the owners of FSIs with the ultimate responsibility to ensure that FSIs are in efficient working order at all times, the RFSICs engaged by owners (or other contractors in turn) as the party responsible for maintenance and execution of works over FSIs, and the FSD as the regulator. According to Regulation 8 of Cap. 95B [B2/177], the owner must have such installations inspected by an RFSIC at least once every 12 months. Where no FS251 has been received, it is a prima facie case of non-compliance by the owners, and the FSD will take necessary enforcement actions90 [WS1/109].

The PMC, according to the Property Management Services Ordinance (Cap. 626) and its Code of Conduct, has a responsibility to assist the OC in fulfilling these duties, including monitoring the progress of the RFSIC’s work, following up timely with the RFSIC on required rectifications, following up timely with the

88 KEUNG Sai Ming 1st WS §5.4.3 89 KEUNG Sai Ming 1st WS §5.4.4 90 KEUNG Sai Ming 1st WS §5.5.2

RFSIC that it has to notify the DFS of any FSI shutdowns, and assisting FSD

officers during visits, inspections or investigations91 [WS1/109].

The RFSIC engaged by the owner bears the professional responsibility for the proper execution of FSI maintenance, inspection and repair. Under Cap. 95B, only an RFSIC shall maintain, inspect or repair any FSI required to be installed in premises. It is the RFSIC’s obligation to inspect the FSI, to assess the need for shutdown, to notify the FSD via an SDN where shutdown is required, to carry out or supervise the repair works, and to certify completion via FS251. Where an RFSIC issues a certificate which is false or misleading in any material particular, it commits an offence under Regulation 9(2A) and 9(3) of Cap. 95B [B2/180].

The evidence before the Committee demonstrates that at WFC, both RFSICs engaged (albeit for different purposes) failed in their primary responsibilities, the PMC (ISS) failed in its duty to coordinate between the two RFSICs and to ensure FSI operability, and the contractor (Prestige), consultant (Will Power) and RI (Ng Yeuk) failed in their responsibility to oversee and ensure that renovation and maintenance works over FSIs were conducted only by an RFSIC. These failures are a direct and proximate cause of the FAS shutdown and are addressed in detail in Section N.

F5. Regulation and supervision of construction methods, procedures and use of materials under the MBIS and MWCS

(i) The regulatory framework and model

(1) The MBIS

The MBIS, introduced under the BO in 2012, applies to private buildings aged 30 years or above (except domestic buildings not exceeding three storeys in height). Under the MBIS, building owners served with a statutory notice are

91 KEUNG Sai Ming 1st WS §5.5.3

required to appoint an RI to carry out prescribed inspection and an RC to carry

out any necessary rectification and repair works under the supervision of the RI.

The building elements to be covered under the MBIS prescribed inspection are clearly defined: external elements and other physical elements; structural elements; fire safety elements; drainage system; and identification of unauthorised building works in common parts of the building, on the exterior other than the common parts, or on the street on which the building fronts or abuts92 [WS1/780].

A critical feature of the MBIS is that inspection does not necessarily lead to major building repairs. Whether repair works are required, and if so, their extent, will be dependent on the outcome of the inspection as set out in the report submitted to the BA by the RI. The majority of prescribed repair works carried out under the MBIS should be MW or exempted building works under section 41 of the BO, and the repair proposal normally does not require the BA’s approval or consent before commencement of work.

Under the MBIS regime, the ICU (for buildings under its statutory control, such as WFC) conducts audit checks on the relevant submissions made by the RI at two points in time: upon completion and submission of the Inspection Report (Form MBI 3), and upon submission of the Completion Report after completion of the prescribed repair works (Form MBI 4) 93 [WS14/2128]. There is no statutory requirement for the ICU to supervise and conduct regular or ad hoc inspections of works during the course of inspection and renovation works.

Under the MBIS, the ICU conducts preliminary check (verification of RI registration status), fundamental check (ensuring reports and proposals have been

92 CHEUNG Yuk Ching 1st WS §12 93 KU Siu Ping 3rd WS §5

duly completed and signed), and audit check (document audit and site audit on

randomly sampled cases)94 [WS1/631-634].

Specifically for audit check, it consists of document audit and site audit. For each month, 16 cases are sampled for audit check; of the cases sampled for document audit, one-third further proceed to site audit95 [WS1/632-633].

(2) The MWCS

For repair works that are relatively smaller in scale, less complex and of lower risk, the works may follow the simplified procedures under MWCS introduced in 2010 without the need to obtain prior approval of plans and consent for commencement of works from the BA. There are currently 187 items of building works designated as MW under Part 3 of Schedule 1 to the Building (Minor Works) Regulation (Cap. 123N) (“B(MW)R”), classified into three classes according to their scale, complexity and risk to safety96 [WS1/656-658].

For Class I MW, both Prescribed Building Professionals (“PBPs”) and Prescribed Registered Contractors (“PRCs”) are required to be appointed, and they are required to submit notifications, plans and documents before commencement and after completion of works. For Class II MW, only a PRC is required who should also submit notifications, plans and documents before commencement and after completion of works. For Class III MW, only a PRC is required and submissions are made after completion rather than before commencement.

As expressly stated as background in the BD’s manual on MW [J1-2/5139], “the Minor Works Control System (MWCS) is a self regulatory system”. The spirit of the MWCS primarily relies on self-regulation of the construction industry’s

94 KU Siu Ping 1st WS §§26-33 95 KU Siu Ping 1st WS §30-31 96 YUNG Siu Lun 1st WS §8

professionals for its implementation, having regard to the relevant background

and context.

Under the MWCS, the PBPs and PRCs are required to supervise the carrying out of MW, notify BA of any contraventions of the regulations which would result from the carrying out of MW, and comply with the BO. Sections 42 and 43 of the B(MW)R set out the duties of the PBPs and PRCs: they must give periodical and continuous supervision to ensure that there is no material divergence or deviation from the prescribed plans and details submitted, and are responsible for ensuring the works are carried out in accordance with the BO.

(ii) The Government’s supervisory role

The Government’s supervisory role in relation to construction methods, procedures and use of materials operates at different intensities depending on the nature and risk level of the works.

For works requiring the BA’s prior approval and consent (new buildings, A&A and demolition works), the BD scrutinises and approves building plans, grants consent to commencement, conducts periodic surprise site inspections during construction, and inspects the completed works before issuing an occupation permit97 [WS1/715-716]. The BD regularly carries out inspections and audit checks to building works sites on a risk basis; high-risk activities such as demolition works are inspected every one to three weeks, while superstructure works are inspected every eight to sixteen weeks98 [WS1/718-719].

For repair works under the MBIS, the Government’s supervisory role is exercised through the audit-check mechanism described above. As confirmed by the BD, the submitted certificates on completion of prescribed building inspection or

97 PANG Yuk Lung 1st WS §§17-19 98 PANG Yuk Lung 1st WS §§23-26

repair by RIs are sampled for audit checks comprising document audit and site

audit, carried out in accordance with the MBI Manual99 [WS1/798]. The BD has adopted the ISO-2859-1 “Sampling Procedures for Inspection by Attributes” to guide the selection of MBIS submissions for audit checks, requiring successfully conducting a minimum of 315 samples of submissions in order to achieve an acceptable level of quality control over RIs’ and RCs’ performance under the BO100 [WS1/800].

The ICU adopts the same ISO-based standard in determining the number of cases selected for audit checks. As Lau Fu-kwok explained, the ICU’s practice of selecting 16 submissions per month for audit check was originally derived from the BD’s ISO-based ratio, applied pro rata to the ICU’s caseload; and for the final work audit check (approximately 1,725 cases per year), this was likewise based on the BD’s standards set on the basis of ISO, representing approximately onefourth of the total caseload [Day 24/78/12 - 80/4].

The degree of pre-works checking, audit checking during the course of works, post-works checks and handling of complaints differs between the approval-andconsent system, the MBIS and MWCS. For the MWCS in particular, the simplified procedures mean that the BA does not vet, approve or consent to the works before they commence; its supervisory role is generally exercised before the commencement of works and after the completion of works through random audit sampling. Under the MBIS, no regular inspections during the course of works are required; site inspections would generally be arranged in response to complaints or enquiries. This design reflects the self-regulatory nature of the system, which places primary reliance on the registered professionals for supervision and compliance during the works period.

99 CHEUNG Yuk Ching 1st WS §57 100 CHEUNG Yuk Ching 1st WS §61

In the case of WFC, the prescribed repair works were MW and exempted works

under the BO. No plan submission for prior approval and consent by the ICU was required. The ICU’s supervisory role during the renovation under the MWCS was therefore limited to: processing MW submissions and conducting audit checks on those randomly selected; handling complaints and enquiries as they arose; and conducting site inspections in response to those complaints. Thus, for professionals who are minded to abuse or circumvent the systems, their proneness to abuse and the opportunity for such abuse exists from the very commencement of works.

(iii) The other stakeholders’ responsibilities – owners, the PMC and building professionals

The primary responsibility for ensuring that construction methods, procedures and materials comply with the BO rests with the PBPs and RCs. Under section 30D(4) of the BO, an RI appointed under the MBIS is responsible for providing proper supervision of the carrying out of the prescribed repair, ensuring that the repair materials to be used are not defective and comply with all relevant Ordinances and Regulations, codes of practice and practice notes, and ensuring the building is safe or has been rendered safe101 [WS14/2128].

Under sections 3 and 16 of the B(C)R [J1-2/5727, 5735-5736], all materials used in building works must be of a nature and quality suitable for their intended use, adequately tested by recognised tests, and appropriate construction methods and procedures must be adopted with appropriate precautionary measures taken. The PBPs and RCs are required to ensure that protective materials meeting the required standards are used in building works.

101 KU Siu Ping 3rd WS §4

Under the Code of Practice for the Mandatory Building Inspection Scheme and

the Mandatory Window Inspection Scheme [J1-2/4746-4970], the RI and RC each has a role to play in safety and quality management during the course of rectification and repair works. The supervision and control to be exercised by RIs and RCs during the course of works shall cover adequate measures to ensure a safe working environment and adequate control on the sequence of rectification and repair works, the erection and maintenance of scaffolds. RIs and RCs “should fully understand the potential fire risks involved in the course of repair works and adopt appropriate precautionary measures accordingly in carrying out the works”102 [WS1/797].

For the case of WFC, Will Power (as consultant providing the RI services) and the RI bore primary statutory responsibility for supervising the repair works and ensuring that materials and methods complied with the BO. Prestige (as RC) bore primary responsibility for carrying out the works in compliance with the BO and for ensuring that the part of the building for which it was appointed was rendered safe. The said parties were required to certify completion of works in compliance with the BO. The failures of such parties in these primary responsibilities are the central subject of Sections I through N below.

F6. Regulation and supervision of building professionals – registered inspectors (i.e. RI) under the MBIS and registered contractors (i.e. RC) for carrying out works

(i) The regulatory framework and model

The registration systems for RIs and RCs under the BO serve as the gateway control through which only suitably qualified professionals and contractors may undertake building works. The primary aim is to ensure that only competent professionals and contractors take up the roles, duties and obligations to prepare

102 CHEUNG Yuk Ching 1st WS §55

plans, supervise, carry out and certify building works in accordance with the

BO103 [WS1/709].

The RI registration system under the BO permits registration of persons holding the qualification of Authorised Person (“AP”), Registered Structural Engineer (“RSE”), Registered Architect, Registered Professional Engineer in specified disciplines, or Registered Professional Surveyor in specified divisions, provided they also possess the relevant practical experience in building construction, repair and maintenance104 [WS1/747-749]. It bears emphasis that the aforesaid persons are already subject to the registration requirements applicable to their professions as appropriate to begin with. Leaving that aside, for applicants who are not AP or RSE, they must attend an interview conducted by the Inspectors Registration Committee under section 3(5CB) of the BO, which examines qualifications and experience and advises the BA whether to accept, defer or reject the application.

Registration for an RI is valid for five years. To renew registration, the RI must apply within the time limits specified in section 3(9C)(b) of the BO. The BA shall refuse renewal unless the applicant continues to possess the necessary qualifications105 [WS1/750].

For RCs, applicants must satisfy the BA as to the adequacy of their management structure (if a corporation), the appropriate experience and qualifications of their personnel, their ability to have access to plant and resources, and the ability of the person appointed to act for the applicant to understand building works through relevant experience and a general knowledge of basic statutory requirements106 [WS1/754]. Applications are referred to a Contractors Registration Committee

103 PANG Yuk Lung 1st WS §9

104 PANG Yuk Lung 1st WS §§84-89 105 PANG Yuk Lung 1st WS §§91-92 106 PANG Yuk Lung 1st WS §106

(“CRC”) for interview and assessment107 [WS1/752]. The validity period for

registration is three years108 [WS1/756].

The model therefore relies on a well-defined registration system serving as the gatekeeper for professional competence, combined with statutory obligations during works, certification upon completion, random audit checking by the BA, and sanctions (prosecution, disciplinary action, or refusal of renewal) for noncompliance. However, the model’s gatekeeping role cannot be conflated with the primary responsibilities which rest on qualified professionals at all times.

(ii) The Government’s supervisory role

The BA’s supervisory role over registered professionals and contractors operates through four mechanisms: the registration and renewal process itself (which serves as a periodic competence check); the audit-check system (which tests whether professionals are properly discharging their duties in the actual cases); the prosecution mechanism (for contraventions of the BO identified through audit checks, complaints or investigations); and the disciplinary mechanism (for misconduct or negligence rendering a professional unfit to remain on the register)109 [WS1/709-711, 721-723].

On renewal of registration, the BD retrieves conviction, disciplinary and suspension records covering the three years preceding the application date (or the current registration period preceding the date of submission of the renewal application). Where such records exist, the application is referred to the relevant registration committee for interview and assessment, and the BA may refuse

107 PANG Yuk Lung 1st WS §100

108 PANG Yuk Lung 1st WS §111

109 PANG Yuk Lung 1st WS §§8-10, 28-31

renewal if satisfied that the contractor is no longer suitable for registration110

[WS1/756, 758-759].

If PBPs or RCs are convicted of an offence relating to their professional duties or building works respectively, or have failed to discharge the duties or abide by the imposed requirements under the BO, or have been negligent or have misconducted themselves, the BD may instigate disciplinary action by referring the case to the relevant disciplinary board set up under the BO. The board may order permanent or temporary removal from the register, a reprimand, or a fine of up to $250,000. From 2021 to November 2025, a total of 75 cases were referred to disciplinary boards for proceedings111 [WS1/722-723].

Under the existing delegation arrangements, the ICU does not possess the delegated authority to initiate prosecution of offences under section 40 of the BO or administrative disciplinary actions against RIs and RCs under sections 7 and 13 of the BO; those powers remain vested with the BD. If the ICU identifies any non-compliance of the BO, it refers the relevant cases to the BD for assessment of prosecution and disciplinary actions112 [WS1/607]. Between 2006 and 2025, the ICU referred 852 cases to the BD for prosecution, resulting in a total of 1,064 summonses 113 [WS1/745]. Five cases were referred for disciplinary action between 2023 and 2025114 [WS1/746].

In the case of WFC, the RI appointed for the renovation was Ng Yeuk of Will Power. He was included in the register of RI on 31 May 2019 by virtue of being

110 PANG Yuk Lung 1st WS §§111-112, 117-121 111 PANG Yuk Lung 1st WS §30-31

112 LAU Fu Kwok 1st WS §15

113 PANG Yuk Lung 1st WS §80

114 PANG Yuk Lung 1st WS §81

an AP, and his registration was renewed on 22 March 2024 with expiry on 31

May 2029115 [WS1/761-762].

Prestige was first registered as a Registered General Building Contractor (“RGBC”) on 24 March 2006. In August 2023, it was disciplined under the BO for misconduct in building works, resulting in a fine of $50,000 and a four-month prohibition from certifying or undertaking any MW116 [WS1/762-763]. After Prestige’s application for renewal in December 2023, the AS who had been involved in the disciplinary matter failed the CRC interview on 6 March 2024; but since another AS with a clean record remained acting for Prestige, the renewal was granted on 21 March 2024 with the failed AS removed117 [WS1/763-764]. AD Karen Cheung of the BD confirmed in oral evidence that Prestige no longer holds any licence under the BD, as the relevant AS has since resigned.118

Prestige had also previously been registered as a Registered Minor Works Contractor (“RMWC”) (since 8 August 2013). During its application for renewal in May 2019, its AS was required to attend a CRC interview because of a record of 14 convictions on labour safety offences and 7 warning letters issued by the BD; the AS failed the interview and the application was refused, resulting in Prestige’s removal from the RMWC register on 4 October 2019119 [WS1/764].

The evidence therefore demonstrates that the registration system did subject Prestige to enhanced scrutiny at the point of renewal, and that on one occasion the renewal was refused. The broader question of whether the system could be

115 PANG Yuk Lung 1st WS §§126-129

116 PANG Yuk Lung 1st WS §130

117 PANG Yuk Lung 1st WS §131

118 [Day 20/10/24 (Chinese transcript; not reflected in the English transcript)] 119 PANG Yuk Lung 1st WS §132

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enhanced to better inform owners of contractors’ disciplinary histories is a

systemic issue addressed in Section Q below.

F7. Regulation and supervision of occupational health and safety

(i) The regulatory framework and model

The LD is responsible for administering and enforcing the OSHO and FIUO and their subsidiary legislation.

The LD’s primary mandate is to safeguard the occupational safety and health (“OSH”) of employees at work. The professional expertise of the LD is in OSH120 [WS1/312-313, 325].

The OSHO [D1/5-83] provides safety and health protection for employees in both industrial and non-industrial workplaces, covering almost all workplaces including construction sites. The FIUO [D1/84-132] provides safety and health protection for workers in the industrial sectors, including construction works, and its subsidiary legislation includes the Construction Sites (Safety) Regulations (Cap. 59I) (“CSSR”) [D1/133-204] and the Factories and Industrial Undertakings (Safety Management) Regulation (Cap. 59AF).

The general duty provisions of the legislation impose on employers (including principal contractors) the obligation, so far as reasonably practicable, to ensure the safety and health at work of all their employees. This encompasses the provision and maintenance of safe plant and systems of work, the provision of information, instruction, training and supervision, and the maintenance of a working environment that is safe and without risks to health121 [WS1/315].

120 YUEN Tsz Lok, Murphy (Chief OSO, LD) §§6-7, 39 121 YUEN Tsz Lok 1st WS §12

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In the specific context of Renovation, Maintenance, Alteration and Addition

(“RMAA”) works to existing buildings, the OSHO, FIUO and their subsidiary legislation (in particular the CSSR) are applicable to the protection of construction workers’ safety and health at work122 [WS1/315].

The fire safety provisions within the OSH legislation are found principally in Regulations 53 and 54 of the CSSR [D1/186].

1. Regulation 53 empowers the Commissioner for Labour to issue a written order prohibiting smoking and the use of naked lights at a construction site where any flammable liquid or any mixture containing such liquid or any substance or thing involving danger from fire is used or intended to be used.

2. Regulation 54(1) requires the contractor responsible for a construction site to maintain in good condition and free from obstruction all the means of escape in case of fire and all fire-fighting appliances. The penalties for noncompliance are a maximum fine of $400,000 for a contractor and $150,000 for a worker.

(ii) The Government’s supervisory role

Occupational safety inspections conducted by Occupational Safety Officers (“OSOs”) are surprise inspections. No prior notice is given to renovation contractors, RIs or building management. This has long been a well-established practice 123 [WS13/2107-2018]; an internal LD email of 4 December 2024 reminded all divisional officers that “inspections of workplaces shall be surprise in nature. No inspection schedules shall be disclosed to any third party, including consultants, in advance” [D2/1981].

122 YUEN Tsz Lok 1st WS §13

123 LAM Sau Ching 2nd WS §§5-6

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The inspection frequency for construction sites is determined on risk-based

principles. Taking into account the nature and risk levels of work processes and scale of works, the inspection frequency is generally set at one to two months124 [WS1/338; Day 16/3/19-23]. OSOs conduct complaint investigations as soon as possible; even if a construction site is not yet due for inspection according to schedule, OSOs will advance the next site visit upon receiving OSH complaints 125 [WS1/338].

The LD’s enforcement options comprise prosecution, suspension notices, improvement notices and written warnings (by way of Construction Site Inspection Reports (“CSIRs”)). Officers exercise professional judgement, discretion and common sense in selecting the appropriate response based on the gravity of the offence.

During inspections of RMAA sites, OSOs pay particular attention to: the readiness and proper use of fall arresting systems; competencies of workers engaging in scaffolding works; access to and egress from scaffolds; suitability and adequacy of planks to form working platforms; conditions of scaffolds and their scaffolding members; provision of catch-fans with suitable receptacle and nettings; and proper maintenance and inspection of scaffolds by competent persons 126 [WS1/339-340]. The focus is on the safety of workers at work; properties of construction materials used at the site (such as foam boards) are not the main focus of OSH inspections127 [WS1/332].

124 LI Man Pong (Senior Div. OSO, LD) 1st WS §22

125 LI Man Pong 1st WS §22

126 LI Man Pong 1st WS §25

127 LI Man Pong 1st WS §7

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(iii) The other stakeholders’ responsibilities – owners, the PMC and building

professionals

Under section 6A of the FIUO and section 6(1) of the OSHO, the employer (including the principal contractor) must, so far as reasonably practicable, ensure the safety and health at work of all the employer’s employees. Every employer must provide and maintain plant and systems of work that are safe and without risks to health, and must provide such information, instruction, training and supervision as may be necessary.

In the case of WFC, Prestige bore the primary statutory duty as the principal contractor to ensure the safety and health of its employees and others on site. This duty encompassed the provision of safe systems of work, provision of safety equipment, maintenance of scaffolding in safe condition, and management of fire risks at the construction site. The Factories and Industrial Undertakings (Safety Management) Regulation (Cap. 59AF) required Prestige as a specified contractor to develop, implement and maintain a safety management system containing an element of emergency preparedness.

The PMC and building professionals also bear responsibilities. In occupied buildings where construction works are carried out, the BD and FSD are the authorities responsible for enforcing fire safety construction aspects and FSIs which form common parts of the building, in accordance with the BO and Fire Safety (Buildings) Ordinance. The LD’s jurisdiction is directed at the safety of workers, while the BD and FSD are responsible for the safety of occupants in relation to passive and active fire safety provisions. This jurisdictional division is relevant to understanding the respective departments’ approaches to the contributing factors addressed below.

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PART III: TOR 1

G. THE CAUSES AND ORIGIN OF THE FIRE, SPREAD OF FIRE AND HEAVY CASUALTIES - THE INTER-DEPARTMENTAL FIRE INVESTIGATION TASK FORCE’S GENERAL FINDINGS

The starting point for the Committee’s analysis under the ToR 1 is the work of the IFITF, which has produced a comprehensive Final Investigation Report setting out the cause and origin of the fire, the mechanisms of its rapid spread, and the factors that contributed to the heavy casualties. This section summarises the IFITF’s general findings; the analysis of each contributing factor, and the establishment of causation for each factor, are addressed in Sections I to N below.

G1. A brief chronology of the fire with all of the factors contributing to the fire, spread of fire and heavy casualties summed up

The fire at WFC was first reported to the FSCC at 1451 hours on 26 November

The caller reported “a fire with explosion occurred at scaffolding installed along the external wall of Wang Cheong House” (IFITF Report §1.1.1, fn 1 [ER1/13]). A full No. 1 Alarm Fire Pre-determined Attendance (“PDA”), together with additional fire appliances dispatched in response to the renovation works and defective FSIs, was immediately mobilised.

The evidence establishes, however, that the fire started earlier than 1451 hours. CCTV footage captured embers falling onto the bicycle parking area of Wang Cheong House at approximately 1443 hours (IFITF Report §5.1.2 [ER1/40]). The IFITF concluded that the fire “started earlier, likely between 1430 hours and 1443 hours” and that “despite extensive efforts, the exact time of the fire’s occurrence could not be definitively determined” (IFITF Report §5.1.8 [ER1/41]).

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The IFITF observed that “even a difference of a few minutes in the timing of the

first emergency call may critically affect the stage at which firefighting operations can commence and, consequently, the prospects of limiting further fire spread” (IFITF Report §5.1.7 [ER1/41]). The significance of this observation lies in its illustration of the extreme rapidity of fire development: by the time the first fire appliance arrived at 1456 hours, the fire was already of substantial scale.

The speed with which the fire developed following the first appliance’s arrival was extraordinary. Within approximately 20 minutes of the FSD’s arrival at the scene, the fire had spread from its point of origin on the flat roof of Wang Cheong House to multiple locations, including “the open ground surrounding Wang Cheong House, multiple façades of the building and different re-entrant spaces,” and had “progressed across buildings, reaching Wang Tai House and its reentrant areas” (IFITF Report §5.2.3.6 [ER1/54]). The situation was “further exacerbated by flying scaffolding debris falling from the building, which blocked entrances and significantly obstructed firefighting efforts” (IFITF Report §5.2.3.6 [ER1/54]).

By the conclusion of the incident, the fire had produced 12 instances of rapid vertical fire spread across 6 of the 8 buildings at WFC (IFITF Report §8.7.2 [ER1/175]). A total of 1,736 flats were assessed, of which the interiors of 924 flats sustained varying degrees of fire damage (IFITF Report §5.3.1 [ER1/62]) (subject to the qualifications at §§436-437 below).

The fire was surrounded at 2131 hours on 27 November 2025, brought under control at 0315 hours on 28 November 2025, and largely extinguished at 1018 hours on 28 November 2025 (IFITF Report §1.1.5 [ER1/13]).

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79 individuals sustained injuries and 168 lives were lost, including one Fire

Services member, namely Senior Fireman Ho Wai-ho (“SFn Ho”)128. Over 100 persons were rescued by the FSD during the operation (IFITF Report §1.1.5 [ER1/13]).

The IFITF identified several key factors contributing to the high number of fatalities and injuries (IFITF Report §1.5.1 [ER1/15]). These are:

1. First, rapid and extensive fire spread driven by a combination of factors, which left residents with limited time to evacuate and increased the risk of entrapment;

2. Second, fire-damaged combustible envelope blocking exits;

3. Third, failure of fire alarms;

4. Fourth, polystyrene window covers obstructing residents’ awareness and contributing to fire spread; and

5. Fifth, compromised tenability in the means of escape.

Each of the relevant contributing factors, and the primary and supervisory responsibilities attaching to them, are addressed in detail in Sections I to N below.

128 SFn Ho was at the time of the WFC fire performing the duties of a Fireman (Fn), but he was posthumously awarded the honorary title of Senior Fireman in recognition of his outstanding service and selfless dedication to duty by the FSD.

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G2. The Inter-departmental Fire Investigation Task Force

Due to the severity of the fire damage and large number of casualties and fatalities, the IFITF was established on 28 November 2025 to investigate the incident (IFITF Report §2.1.1 [ER1/16]).

The IFITF comprises representatives from the FSD, Police, BD, EMSD, ICU under the HD, LD, and Government Laboratory, as well as fire engineering professionals (IFITF Report §2.1.2 [ER1/16]). The inclusion of an independent fire engineering professional, Prof Yuen Kwok-kit, Richard, together with the Government Laboratory’s independent analytical capability, ensured that the IFITF’s technical findings were subject to independent scientific scrutiny.

The IFITF’s terms of reference focused on two primary objectives: investigating the cause of the fire and how it spread, and determining the factors that led to heavy casualties (IFITF Report §2.3.1 [ER1/17]).

The investigation was conducted with reference to international standards, including XF/T 812-2008 and the National Fire Protection Association 921 “Guide for Fire and Explosion Investigations,” encompassing scene examination, evidence collection, witness interviews, and laboratory and expert analysis (IFITF Report §3.1.1 [ER1/18]). Collected samples were submitted to accredited laboratories for chemical analysis, material testing and combustion property testing. Bench-scale experiments, computer simulations and full-scale fire tests were also conducted, and autopsy reports were reviewed (IFITF Report §3.5.1 [ER1/18]). The full-scale fire tests, conducted in Sichuan, represent a notably thorough scientific validation exercise which confirmed the IFITF’s hypotheses regarding the mechanisms of fire spread.

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An Interim Investigation Report was issued in February 2026 and all findings

from that Interim Report have been incorporated into the Final Report. The Government acknowledges that the Report notes it “may require modification” if further information comes to light in other proceedings.

G3. The IFITF’s general findings on the cause and origin of the fire

The IFITF concluded that the fire originated from the flat roof outside Flats 104 and 105 of Wang Cheong House (IFITF Report §§1.3.1, 6.1.1 [ER1/14, 73]). Excavations at the suspected point of origin revealed debris up to 2 metres high, consisting of construction materials “such as safety nets, toe-boards, polystyrene window covers, carton paper boxes and backing paper from mosaic tiles” (IFITF Report §1.3.2 [ER1/14]). The accumulation of these combustible materials in the area “could have served as fuel for the fire” (IFITF Report §6.1.6 [ER1/74]).

The IFITF ruled out deliberate acts, electrical faults and gas-related causes. Neither traces of accelerants nor evidence of suspicious activity immediately prior to the fire were identified at the scene, and accordingly “a deliberate act with the use of accelerant is considered unlikely to be the cause of the fire” (IFITF Report §6.1.2 [ER1/73]). Post-fire inspections conducted by the EMSD “ruled out both electrical faults and Liquefied Petroleum Gas-related causes as potential causes of the fire” (IFITF Report §6.1.5 [ER1/73]).

Two cigarette ends were discovered at the site (IFITF Report §1.3.2 [ER1/14]). Evidence of smoking at the construction site was widespread: numerous cigarette ends were discovered on the bamboo scaffolding of Wang Chi House; CCTV footage captured construction workers smoking on the roof floor of Wang Cheong House; and at least five occupants of Wang Cheong House had occasionally noticed the smell of smoke or the presence of cigarette butts on the scaffolding (IFITF Report §6.1.8 [ER1/74]). More broadly, 105 out of 2,011

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residents who provided statements and questionnaires reported “witnessing

smoking, smelling cigarette smoke or noticing cigarette ends within Wang Fuk Court during the renovation period” (IFITF Report §6.1.8, fn 64 [ER1/74]).

Weather conditions on the day of the fire also materially contributed to the ignitability of materials at the point of origin. The Hong Kong Observatory issued a Red Fire Danger Warning, with relative humidity levels measuring between 40% and 50% from 1500 to 1800 hours. The IFITF found that these “low humidity levels reduced the moisture content in materials, rendering them more prone to combustion and more conducive to fire spread” and “facilitated the development of smouldering fires, which may initially go unnoticed, but could later develop into open flames” (IFITF Report §6.1.9 [ER1/74]).

Having excluded all other potential sources of ignition, the IFITF was satisfied that the fire was most likely accidental in nature: “Most probably: A glowing source, such as a lit cigarette end, ignited combustible materials, such as carton paper boxes, at the scene” (IFITF Report §6.1.10 [ER1/75]). The IFITF further observed that “while the windy and dry weather conditions contributed to its development, it was the abundant presence of combustible materials that played a crucial role in allowing the fire to grow in size, intensify and rapidly spread further to other combustibles within the re-entrant” (IFITF Report §8.2.5.3 [ER1/130]).

Prof Yuen confirmed in oral evidence that the fire at WFC necessarily started small. “When you start a fire, it always starts small. So you always go through the stage when the fire is small” [Day 26/36/7-9]. He further stated: “we have reason to think that when the fire was small, it already ignited other combustible items nearby” [Day 26/36/17-18]. This confirms the IFITF’s finding that the progression from a small glowing source to a catastrophic conflagration was not

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inevitable but was enabled by the presence of (i) sizable amount of combustibles

(such as carton boxes) that could be readily ignited by an ignition source (such as a lit cigarette end) and (ii) non-FR materials (such as safety nets and canvas) serving as a vertical plane that allowed the small fire to propagate and escalate to a size sufficient to ignite the bamboo scaffolding within the re-entrant, which represents the bulk (over 80%) of mass but is otherwise relatively difficult to ignite.

G4. The IFITF’s general findings on the rapid spread of the fire

The fire development at WFC was, in the IFITF’s assessment, “highly complex, with the modes of fire spread exhibiting intricate and multifaceted behaviours” (IFITF Report §1.4.1 [ER1/14]).

The IFITF identified three dominant and interconnected modes of fire spread (IFITF Report §1.4.1 [ER1/14]):

1. First, rapid vertical fire spread along the re-entrant, driven by intense heat and flames;

2. Second, façade fire turning into interior fires through openings such as windows, exhaust fans or by radiant heat; and

3. Third, secondary ignitions via embers, flaming droplets and falling debris.

These hypotheses were confirmed by full-scale fire tests conducted in Sichuan (IFITF Report §8.5.1 [ER1/174]). The IFITF also made key additional observations regarding (i) the FR properties of safety nets; (ii) the FR properties of canvas; (iii) fire spread into units via radiation ignition; (iv) ignition at groundlevel thereby further intensifying the fire and its damage; and (v) the extensive

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nature of the fire spread and involvement of multiple simultaneous outbreaks

across numerous indoor units (IFITF Report §8.6 [ER1/174-175]).

A critical structural feature of WFC was the vertical re-entrant between two wings of each block, extending from the 1st floor to the roof (IFITF Report §4.1.3 [ER1/19]). This chimney-like configuration “naturally channelled rising smoke and hot gases” and “confined and directed their upward movement, allowing the fire to spread rapidly and engulf multiple floors in a short timeframe” (IFITF Report §6.2.1.6 [ER1/80]). A heat release rate study conducted as part of the investigation demonstrated that the re-entrant configuration increased the peak heat release rate to slightly over 3 MW, compared with approximately 1 MW for an open configuration, and “exhibited a significantly faster growth rate” (IFITF Report §7.2.3.2 [ER1/94]).

The re-entrant design dates from 1983 and is therefore a pre-existing structural condition of the building which amplified the consequences of the combustible loading created by the renovation works.

The re-entrant contained large quantities of accumulated combustible materials forming a continuous fuel source across multiple levels. These materials included bamboo scaffolding, safety nets, wooden planks, toe-boards, canvas, nylon strips, and polystyrene window covers (IFITF Report §6.2.1.3 [ER1/79]). Amongst these materials, bamboo, safety nets, toe-boards and wooden planks were identified, and the impact of these identified combustibles were evaluated in the fire severity analysis. The fire severity analysis demonstrated that “the fire reached extreme levels of severity even when only the identified materials were included,” with the peak heat release rate for a three-storey mockup reaching 29 MW, “comparable to the peak fire HRR of a bus or heavy goods vehicle in a tunnel fire” (IFITF Report §8.2.4.2 [ER1/128]).

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Given that the actual re-entrants span 31 storeys and contained additional

combustibles beyond those modelled, “the fire severity could have escalated dramatically” (IFITF Report §8.2.4.2 [ER1/128]).

It was further identified in the test that when the fire reached the level of severity required, bamboo could become a dominant fuel source, contributing nearly 78% of the total energy released, followed by wooden planks at 14%; however, the IFITF found that “other materials, such as safety nets, toe-boards and wooden planks, ignited first due to their relatively lower thermal resistance” (IFITF Report §7.2.3.7 [ER1/95]).

The IFITF also identified the presence of safety nets potentially lacking FR properties as a critical factor in the rapid spread. The IFITF observed that “if these nets were made of FR materials, even if ignited, the fire would likely have selfextinguished after the removal of the heat source, thereby minimizing the risk of igniting other combustible materials and reducing the overall spread of the fire” (IFITF Report §6.2.3.4 [ER1/86]). The “presence of safety nets potentially lacking FR properties, combined with dry and windy conditions created an ideal environment for the fire to spread and for embers to spark additional fires” (IFITF Report §6.2.3.5 [ER1/86]).

The full-scale fire tests and simulations confirmed this analysis.

1. The IFITF noted that “the safety nets collected from Wang Chi House exhibited a more rapid spread, even when compared to Sample 3 (Non-FR) safety nets…the safety nets collected from Wang Chi House were completely consumed by the end of the tests” (IFITF Report §7.2.3.9 [ER1/97]).

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2. The IFITF concluded that “the use of safety nets and canvas with FR

properties is essential to effectively prevent the development and spread of fire” (IFITF Report §8.2.6.1 [ER1/130]).

3. The IFITF explained that “FR safety nets significantly reduced the likelihood of fire propagation by preventing secondary ignitions and selfextinguishing small fires once the external heat source was removed,” whereas “uncertified, non-FR safety nets and samples collected from Wang Chi House sustained small fire propagation and generated flaming droplets that ignited other combustible scaffolding components, such as nylon strips, toe-boards and wooden planks” (IFITF Report §8.6.1.1 [ER1/174]).

4. Computational fluid dynamics simulations demonstrated that in small fire size cases with FR-certified safety nets, “the fire could not sustain itself, with no rapid fire spread having occurred,” whereas with non-FR certified safety nets and samples collected from Wang Chi House, the result was “significant fire spread and severe fire development” (IFITF Report §7.3.5.2 [ER1/125]).

5. Dr To Chi-wing (expert witness of the FSD) also confirmed in oral evidence that had FR nets been used, the secondary ignition mechanism that spread the fire to adjacent blocks would likely not have operated [Day 26/71/16 - 72/7].

Canvas lacking FR properties further accelerated the fire.

1. Laboratory examinations revealed that both types of canvas used at WFC “were more susceptible to sustained burning after flame impingement than

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the safety nets, with some producing burning droplets” (IFITF Report

§6.2.1.8 [ER1/81]).

2. The IFITF found that non-FR certified canvas used on catch-fans “allowed small fires in the re-entrant area to escalate into widespread, intense blazes capable of consuming nearly all combustibles and spreading rapidly across multiple levels” (IFITF Report §8.6.2.1 [ER1/174]), and that catchfans “trapped flying embers, flaming droplets and burning debris” rather than performing their intended function of intercepting falling objects (IFITF Report §8.6.2.2 [ER1/174]).

The fire spread from Wang Cheong House to adjacent blocks through secondary ignitions caused by wind-carried embers, flaming droplets from melting safety nets, and falling burning debris (IFITF Report §§6.2.3.1–6.2.3.3 [ER1/85]). These mechanisms operated in a combustible environment created by the renovation works: the buildings’ external walls were “surrounded by scaffolding and construction related materials” which “created a combustible ‘envelope’ enclosing the buildings and provided an abundant fuel source for the fire” (IFITF Report §6.2.3.3 [ER1/85]). Within a two-hour period, 11 instances of rapid fire spread were observed at various re-entrants across multiple buildings, and “it is conservatively estimated that more than 470 units were affected by the fire within the two-hour timeframe” (IFITF Report §8.6.5.1 [ER1/175]).

Wind conditions on the day of the fire were an environmental factor beyond anyone’s control that materially amplified the spread. The average wind speed recorded at the Tai Po Kau Anemometer at 1500 hours was approximately 14 km/hr, blowing from the east to southeast (IFITF Report §7.3.2.1 [ER1/113]). Winds “intensified the fire’s progression by supplying additional oxygen to the

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flames, increasing the fire’s heat and causing it to grow more quickly and uncontrollably” (IFITF Report §6.2.3.7 [ER1/86]).

The wind profile also explains why Wang Chi House was the only unaffected building: “the wind did not carry embers towards Wang Chi House, which may account for its minimal damage” (IFITF Report §7.3.2.4 [ER1/117]).

The three modes of fire spread were not independent phenomena but “amplified and promoted the fire’s development through interconnected mechanisms” (IFITF Report §8.7.1 [ER1/175]). Rapid vertical spread along the re-entrant generated intense heat and flames which spread through windows and other openings or in some cases radiation ignition, transforming façade fires into interior fires; interior fires in turn ignited previously unaffected façades through the openings and windows of affected units; and burning fragments from intensifying fires ignited combustibles in nearby re-entrants, initiating new cycles of fire development.

The IFITF characterised this as a self-reinforcing cycle that “made containment significantly more difficult” (IFITF Report §8.7.2 [ER1/175]). By the conclusion of the incident, this cycle had produced 12 instances of rapid vertical fire spread across 6 buildings (IFITF Report §8.7.2 [ER1/175]).

G5. The IFITF’s general findings on the heavy casualties caused by the fire

The 168 fatalities comprised 58 males and 110 females, ranging in age from 6 months to 98 years. Notably, 114 of the fatalities were individuals aged 65 or older (IFITF Report §9.3.1.2 [ER1/195]).

The causes of death were attributed to adverse effects of fire (65), inhalation of fire fumes (91), inhalation of fire fumes and burns (4), inhalation of fire fumes

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and extensive burns (4), and multiple causes (4) (IFITF Report §9.3.1.3

[ER1/195]).

Of the deceased, 103 were found inside residential units, 64 were discovered in common areas or on the roof of the affected buildings, and 1 was located on the open ground outside a building (IFITF Report §9.3.1.4 [ER1/196]).

Wang Cheong House and Wang Tai House suffered the highest number of fatalities, with 81 and 82 lives lost respectively (IFITF Report §9.3.2.1 [ER1/196]).

As mentioned above, the IFITF identified five critical factors that contributed to the heavy casualties, working in combination to drastically compress the available evacuation window (IFITF Report §10.1.1 [ER1/203]). These are (IFITF Report §11.6 [ER1/239]):

1. Increased risk of entrapment due to rapid and extensive fire spread;

2. Fire-damaged combustible envelope blocking exits;

3. Failure of fire alarms;

4. Polystyrene window covers; and

5. Compromised tenability in means of escape.

First, the extreme rate of vertical fire spread “left residents with limited time to react, significantly reducing opportunities for safe evacuation and increasing the likelihood of entrapment” (IFITF Report §10.2.1 [ER1/203]). The IFITF recorded that “from a very early stage, the fire behaviour had already set a critical time pressure on both evacuees and first responders” (IFITF Report

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§10.2.2 [ER1/203]). The evidence of individual residents starkly illustrates how

rapidly conditions deteriorated: one resident observed that the common corridor outside her unit was free of smoke when she initially opened her entrance door at approximately 1430 hours, but “upon reopening the door a couple seconds later, she observed that the corridor was filled with dense black smoke” (IFITF Report §10.2.5.1 [ER1/204]).

Second, flaming bamboo scaffolding and other construction materials detached from the upper levels during the fire, collapsing and accumulating at ground level and “resulting in flaming blockages at building entrances” (IFITF Report §10.3.1 [ER1/208]). As a result, “both escape for evacuees and access for firefighting personnel were obstructed and in turn delaying escape, rescue efforts and fire suppression” (IFITF Report §10.3.1 [ER1/208]). The front entrance and rear exit of Wang Cheong House were blocked by collapsed burning scaffolding at about 1505 and 1457 hours respectively; for Wang Tai House, the front entrance and rear exit were similarly obstructed at about 1520 and 1530 hours respectively (IFITF Report §10.3.3 [ER1/208]).

Third, post-fire investigation revealed that the FAS of all eight blocks were shut down before the fire (IFITF Report §§5.4.7.1, 10.4.1 [ER1/71, 215]). As a result, “residents did not receive timely warnings, leading to delayed evacuation” and once they became aware of the fire “the means of escape might have already been exposed to smoke and heat, which contributed to the heavy casualties” (IFITF Report §10.4.1 [ER1/215]).

The IFITF recorded that Ms Chung Sui-ha, the security guard of Wang Cheong House, attempted to manually activate the FAS at about 1448 hours, three minutes before the fire was officially reported to the FSD (IFITF Report §10.4.3 [ER1/215]). Her attempt was unsuccessful. The IFITF observed that had the

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system been operational, “Ms. CHUNG’s activation attempt at 1448 hours could

have provided residents with a critical evacuation alert during the key escape window between 1448 hours and 1458 hours, when escape routes were still tenable” (IFITF Report §10.4.4 [ER1/215]). However, “as the FAS was not functional, residents remained unaware of the immediate danger until evacuation was no longer viable” (IFITF Report §10.4.5 [ER1/215]). The circumstances in which the FAS came to be shut down, and the responsibilities arising therefrom, are addressed in detail in Section N below.

Fourth, polystyrene window covers installed during the renovation worked as a protective measure from debris obstructed residents’ view of the external environment, “potentially hindering occupants from realizing the severity of the fire in neighbouring buildings as well as their own buildings, lowering their awareness and in turn delaying their response” (IFITF Report §10.5.1 [ER1/217]). The IFITF noted that among 291 witness statements, only 43 individuals (14.7%) reported seeing fire or smoke, and among 579 questionnaires, only 48 respondents (8.3%) indicated that they had witnessed the fire. The IFITF characterised these as “surprisingly low numbers for such a large fire” and concluded that “the installation of polystyrene window covers may have significantly hindered occupants’ ability to perceive the situation outside their units, thereby delaying their escape” (IFITF Report §10.5.3 [ER1/218]).

In addition to obstructing awareness, the combustible polystyrene panels “contributed to the vertical spread of the fire” and once windows were breached, “flames and smoke entered units easily and directly exposing residents to dangerous conditions” (IFITF Report §10.5.4 [ER1/218]). The combustion of polystyrene materials generated toxic gases including carbon monoxide. Toxicological reports indicated that 102 of the 168 fatalities had blood carbon

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monoxide saturation levels ranging from 15% to 80% (IFITF Report §10.5.4, fn

179 [ER1/218]).

Fifth, two distinct mechanisms compromised the tenability of the means of escape.

1. First, the upper ventilation parts of the windows in lift lobbies on some floors were left open during the fire, allowing smoke from the burning scaffolding to enter the lift lobbies and corridors and further shortening the time available for evacuation (IFITF Report §10.6.1.1 [ER1/225]). Security camera footage from Flat 1006 of Wang Tai House shows that the common corridor on the 10th floor was clear of smoke at 1516 hours, but “due to the rapid fire spread at the re-entrant adjacent to the lift lobby window,” the same corridor “was engulfed in dense smoke within the span of one minute” (IFITF Report §10.6.1.2 [ER1/225]).

2. Second, some windows in staircases were replaced with movable boards as access openings to the exterior scaffolding. During the fire, “these movable boards permitted smoke and heat to infiltrate the staircases” and “severe blackening of ceilings above the opening indicated heavy smoke penetration” (IFITF Report §10.6.2.1 [ER1/225]). The consequence was that “staircases intended to serve as protected escape routes were compromised, leaving residents without safe pathways for evacuation” (IFITF Report §10.6.2.1 [ER1/225]). The evidence demonstrates the effect of this compromise at Wang Tai House: of the 38 fatalities in the staircases and common areas of that building, 28 were found inside the staircase and the cause of death for all 28 was inhalation of fire fumes (IFITF Report §10.6.2.2 [ER1/225]; Corrigendum [ER9/2755]). The IFITF attributed this outcome to “the compromised openings in the staircase ... which allowed

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smoke and heat to infiltrate” and which “rendered the staircase, intended

as a protected escape route and temporary place of safety, incapable of providing a safe environment for evacuation” (IFITF Report §10.6.2.2 [ER1/225]).

Full-scale fire tests conducted in Sichuan confirmed that the wooden boards and aluminium composite panels used as access opening covers at WFC were wholly unsuitable for protecting staircase openings (IFITF Report §10.6.2.4 [ER1/231]).

1. During the fire tests, the wooden board ignited at 4 minutes 40 seconds and the aluminium composite panel ignited at 7 minutes 49 seconds (IFITF Report §10.6.2.3 [ER1/230]).

2. By contrast, the fire-rated glass window “remained intact and maintained a lower interior temperature, therefore ensuring a safer environment for evacuation” (IFITF Report §10.6.2.4 [ER1/231]).

3. This scientific conclusion was corroborated by evidence: Ms Tse Yuk-wa, the occupant of Flat 204 of Wang Cheong House, observed during her evacuation at approximately 1455 hours “a reflection of fire immediately outside the fire-rated windows along the staircase,” providing “direct confirmation of the effectiveness of the fire-rated glass window installed along the escape staircase, which successfully served a fire separation component and prevented smoke infiltration into the staircase under fire conditions” (IFITF Report §10.6.2.5 [ER1/231]).

The IFITF’s analysis confirms that the combination of the five factors “critically affected both the ASET and the RSET” (IFITF Report §10.7.6 [ER1/236]).

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1. On the one hand, the rapid fire spread “developed at the re-entrants at an

exceptionally fast rate, simultaneously compromising the means of escape and causing blockages at building exits,” thereby reducing the Available Safe Egress Time (“ASET”) (IFITF Report §10.7.6 [ER1/236]).

2. On the other hand, the “failure of the fire alarm systems, combined with the presence of polystyrene window covers, further delayed occupant response and evacuation,” thereby increasing the Required Safe Egress Time (“RSET”) (IFITF Report §10.7.6 [ER1/236]).

3. The result was “an extremely limited escape window for evacuees, particularly for those occupants at Wang Cheong House and Wang Tai House,” who “were confronted with a dire situation during evacuation, as the means of escape had already been compromised at the very early stage of the fire” (IFITF Report §10.7.7 [ER1/237]).

The IFITF’s conclusion is appropriately expressed in the following terms: “The fire at Wang Fuk Court on 26.11.2025 was one of the most devastating incidents in recent history, resulting in 168 fatalities, including one FS member and 79 injuries. The scale and severity of the incident highlighted critical issues related to fire safety, building management and renovation practices, requiring attention to prevent similar incidents” (IFITF Report §11.1 [ER1/238]). The IFITF also recorded that “notwithstanding the rapid fire spread, over 100 individuals were rescued” and that “special arrangements were implemented, including early activation of the DCP, strengthening of the command structure and deployment of substantial rescue resources to manage the situation as effectively as possible” (IFITF Report §11.2 [ER1/238]).

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G6. The Committee’s Independent Expert Evidence and areas of agreement

The Committee appointed Prof Asif Sohail Usmani and Prof Jiang Liming of the Hong Kong Polytechnic University (“PolyU”) as independent fire engineering experts. Their expert report dated 15 June 2026 [ER3/2154-2265] sets out their independent findings based on their own experimental tests (conducted at the PolyU fire laboratory on samples provided by the Police), computational fluid dynamics simulations, and review of the available video, photographic and documentary evidence.

The Committee’s experts and the IFITF’s expert (Prof Yuen) have worked independently over several months, conducting separate tests and using their own methodologies to simulate the fire.

Their conclusions129 are substantially consistent on all material matters.

During the evidential hearing on Day 27, the Committee’s two experts confirmed that the two teams had reached substantially similar conclusions in their respective reports [Day 27/84/3-8]. By way of illustration, the following key areas of agreement were also expressly confirmed (and which bear reiteration for present purposes):

129 For completeness, the Committee’s Expert Report at §5.3.6 (Table 5.1) [ER3/2241-2242] suggests that WFC may not have been fully compliant with the Code of Practice on the Provision of Means of Escape in Case of Fire 1976. The Government does not consider there to be non-compliance: as explored in cross-examination, the lift lobby configuration of WFC complies with Diagram 8 [B16/6373] of the Code [Day 27/93/11 – 97/21]. In any event, the Chairman indicated that the Committee would not make a finding of non-compliance: “If we are going into detailed interpretation as to whether this fulfil or not, since in this particular case it doesn't make a difference, we will not make any findings on that particular question … We note that there will be a difference of interpretation by the Government and the experts. That's it. We are not going to -- since in this case it does not make a difference” [Day 27/98/5-16].

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1. The lack of FR quality in the safety nets and canvases was an important

factor in the causation of fire in this instance (IC Expert Report §6.3.3 [ER3/2246]; confirmed at [Day 27/85/3 - 86/10]).

2. The re-entrant geometry created an uncontrolled chimney effect that was a key factor in the rapid vertical fire spread (IC Expert Report §6.2 [ER3/2245]; confirmed at [Day 27/84/13-23]).

3. The use of foam boards to cover windows was another important factor in the spread of fire and heavy casualties, despite their small mass (IC Expert Report §6.4.2 [ER3/2246]; confirmed at [Day 27/86/11 - 87/2]).

4. The alteration of staircase windows into access openings for workers was also an important factor in the spread of fire and heavy casualties (IC Expert Report §6.5.3 [ER3/2247]; confirmed at [Day 27/87/19 - 88/8]). The Committee’s experts agreed that fire and smoke infiltrated the staircases through gaps and holes in the movable boards for worker access openings, even before the boards were completely burned out, and that both wooden boards and aluminium composite panels were unsuitable for protecting staircase openings (IC Expert Report §6.5.3 [ER3/2247]; IFITF Report §10.6.2.1 [ER1/225]).

5. The unreported shutdown of the FAS lengthened the residents’ detection time of the fire. It was one of the contributing factors that led to heavy casualties because, together with the compromise of the means of escape through access openings and open lift lobby windows, it had reduced the time for escape of the residents in Wang Cheong House and Wang Tai House to practically zero (IC Expert Report §6.6.1 [ER3/2247]; IFITF Report §10.4.5 [ER1/215]).

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The Committee’s experts expressly agreed with Prof Yuen’s conclusion that if

the safety nets and canvases at WFC had been fire-retardant, the initial fire may have self-extinguished and not caused the combustible materials inside the reentrant to catch fire, so the fire might not have developed and the fire spread would have been much more minimal (IC Expert Report §6.3.3 [ER3/2245]). Prof Jiang confirmed this directly during his oral evidence when asked whether both teams agreed that the lack of FR quality in the safety nets and canvases was an important factor in the causation of fire in this instance: “Yes, correct” [Day 27/85/16]. Prof Usmani likewise confirmed: “That would be fair” [Day 27/86/10].

Prof Yuen reached the same conclusion from his experiments. When asked whether, assuming all other factors being equal and the only difference being that FR nets and canvas were used, the re-entrant fire at Wang Cheong House would have developed as it did, Prof Yuen stated: “According to my scientific analysis, the answer is no” [Day 26/38/3-4]. He further confirmed that with FR materials, the fire “would not be as severe” and that while it “may burn for a while, and some materials might be ignited... for the development, it would not be as severe” [Day 26/38/10-13].

The Committee experts’ findings on the role of non-FR canvas are also consistent with the IFITF’s conclusions. The experts noted that Tests 12 and 13 of the fullscale fire tests (which used identical safety nets from Wang Chi House but differed only in whether FR or non-FR canvas was used) yielded dramatically different outcomes: Test 12 (FR canvas) produced a peak heat release rate (“HRR”) of 0.62 MW with bamboo unaffected, whereas Test 13 (non-FR canvas) produced a peak HRR of 11.58 MW with bamboo sticks ignited (IC Expert Report §3.6.16 [ER3/2184]). The IFITF likewise concluded that “non-FR canvas accelerated fire growth, transforming limited and localized fires into a

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widespread intense blaze with excessive heat release sufficient to ignite bamboo sticks” (IFITF Report §§7.2.3.19 & 8.6.2.1 [ER1/104 & 174]).

Both teams therefore agree that non-FR canvas was a critical accelerant that transformed small localised fires into uncontrollable conflagrations.

In the specific context of the WFC fire, the original fire source was likely to come from one or more cigarette. Further, the secondary fire spread from Wang Cheong House to adjacent blocks was caused by embers drifting [Day 26/62/14-19]. Those were relatively small sources of fire [Day 26/71/22-25]. As Prof Yuen put it, “When the fire started, barely anyone noticed. There were some droplets. At that point the fire was probably a small fire” [Day 26/36/20-22]. Echoing the above, Dr To Chi-wing confirmed that the small fire that came into contact with the combustibles on the flat roof outside Flats 104 and 105 of Wang Cheong House “would probably look more like the small fire scenario mentioned by Prof Yuen” [Day 26/63/10-15].

In contrast, even in the so-called small fire conducted by Prof Yuen’s team (with fire size below 1.5 MW or 1,500 KW), wooden cribs with 10 wooden sticks were used as the fire source (as in all other tests) [ER1/92, Photo 7-2(a), (b); ER2-2/1423]. There is apparently little evidence to suggest that the fire source of the WFC fire (at least at the incipient stage) exceeds the scale of the set-up in Prof Yuen’s tests, which are thus at least comparable.

As Prof Yuen explained, “We can talk about it at different stages. If it is a small fire, if we assume that the combustibles have caught fire, at the incipient stage the situation would be similar because the fire started at a lower level. Even with a long shaft, the development has yet to take place. So at the initial stage it’s comparable” [Day 26/28/19-25].

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In these circumstances, the use of FR materials would have likely caused an initial

fire to self-extinguish, thereby preventing both the primary vertical fire spread within the re-entrant and the secondary fire spread to adjacent blocks. This is borne out by Test 11 conducted by Prof Yuen [ER1/106, Figure 7-4 & Photo 7-6(a), (b)].

The Committee experts’ additional emphasis was directed at a complementary point: the re-entrant geometry is inherently prone to amplifying any fire that takes hold within it, regardless of the ignition source. Their CFD simulations demonstrated that for a 50 MW fire at the base of a re-entrant, flames exceeded 100 metres in height within seconds, whereas a single flat wall produced flames of only 33 metres under identical conditions (IC Expert Report §6.2.1, Appendix A §1.4 [ER3/2245, 2270-2272]).

Both teams’ simulations also independently confirm that once the critical HRR threshold is exceeded, the re-entrant geometry drives exponential fire growth to the point where all combustibles are eventually consumed. The Committee experts’ simulations showed HRRs of 700–800 MW for a 31-storey building (IC Expert Report §3.7, Appendix A §1.5 [ER3/2187-2198, 2273-2275]); the IFITF’s CFD simulations produced comparable results of 755–834 MW across Cases 1 to 3 (IFITF Report §7.3.4.2 [ER1/122]).

The Government notes that the convergence of the two independent expert teams’ conclusions, arrived at through separate methodologies, provides a robust scientific evidential foundation for the Committee’s findings on causation.

The Government notes further Prof Usmani’s evidence that whilst he accepts that a small fire might self-extinguish and the use of FR materials would substantially reduce the probability of exponential growth of fire, he is naturally concerned that the consequence is grave once such probability materialises [Day 27/62/15 - 63/1-

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9]. His concern is that once a certain threshold point is reached then all

combustibles including bamboo will be burnt within a re-entrant. As Prof Usmani put it, risk is the product of probability and consequence [Day 27/50/21 - 51/7]. In the ideal world, of course all measures should be taken to address both, and the Committee’s Experts advocate use of non-combustible materials only at reentrant spaces. Prof Usmani added that, if not, he would insist that all windows facing a re-entrant should be FR windows [Day 27/63/12-16]. That said, the Committee’s Experts fairly accepted that they said so from a fire engineering point of view, while other factors such as socio-economic considerations are also at stake [Day 27/99/1-9]. Whilst the Government will give serious considerations to all these, at this juncture the Committee may note that there are various measures (or combination of measures) at play. Some of them may affect both probability and consequence, whilst others target only one (but not both). For instance, FR materials could reduce probability of a big fire as well as its consequence (i.e. even if a fire is to fully develop, it would still need more time), whereas an uncompromised staircase (without opening) limits the consequence, i.e. it does not reduce the probability of a fire but effectively averts the consequence by affording residents a safe passageway for escape, thus substantially increasing the ASET. At the end of the day, it is a balancing exercise, and the question boils down to risk assessment: see Section R5 below.

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PART III(A): ON THE FIREFIGHTING AND RESCUE OPERATIONS

H. THE EVENTS FROM 26 TO 28 NOVEMBER 2025

H1. The FSD

The FSD is led by the DFS with the support of the Deputy Director (Operations) (“DD(Ops)”) and Deputy Director (Public Safety and Corporate Strategy) (“DD(P&C)”). The senior management comprises 22 directorate officers, including 21 uniformed officers and one civilian officer130 [WS1/38].

The organisational structure at the material time provided for four Operational Commands: the Operational Support and Professional Development Command, Ambulance Command under DD(Ops), the Corporate Strategy Command, Fire Safety Command, Licensing and Certification Command and Administration Branch under DD(P&C) 131 [WS1/38].

The firefighting and rescue operation at WFC involved a large number of FSD officers across multiple ranks, units and commands. The evidence before the Committee includes witness statements and oral testimony from officers who served at every level of the command structure, from the initial attending crew to the DFS himself. DD Chan confirmed this was “the largest scale deployment ever” in the FSD’s history [Day 18/47/22 - 48/2].

The Incident Occurrence Log at [B13/5734-6152] contains a granular record of the entire firefighting and rescue operation from the FSD’s perspective, including all radio messages, resource deployments, and SAR updates. The Committee may wish to refer to the same for a comprehensive account of the timing and sequence of the operational decision, deployment and communication throughout the

130 TANG Wing Wah (AD NTN, FSD) 1st WS §5 131 TANG Wing Wah 1st WS §5

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incident; the narrative that follows draws upon that record together with the

witness statements and oral evidence of the officers involved.

In the narrative that follows, the Government draws upon the evidence of those witnesses to present a chronological account of the operation organised by reference to the successive fire alarm levels.

H2. Evidence on the firefighting operation – different phases of the WFC fire with reference to the fire alarm levels and deployment of resources

(i) Breakout of the fire (No. 1 Fire Alarm)

At 1451 hours on 26 November 2025, the FSCC received the first fire call. The caller reported that a fire with explosion had occurred at scaffolding installed along the external wall of Wang Cheong House132 [WS1/40]. SStnO Hui Kin-on confirmed that the information relayed was: “fire involving scaffolding on external wall with explosion occurred”133 [WS2/987].

Pursuant to the PDA for a No. 1 Alarm Fire [B2/2106], one Hydraulic Platform, one Major Pump (“MP”), one Light Rescue Unit (“LRU”), one Turntable Ladder (“TL”) and one Ambulance were immediately dispatched.

Additionally, by reason of the contingency plan for WFC dated 13 November 2024 [B2/2642-2649], one additional MP and one additional LRU were dispatched upon receipt of the first fire call.

Furthermore, due to the shutdown of the FH/HR System at Wang Cheong House, one additional MP was dispatched pursuant to the FSD Departmental Policy Instructions.

132 TANG Wing Wah 1st WS §8

133 HUI Kin On (SStnO, FSD) 1st WS §7

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Upon receipt of more than one fire call, a further SAR team comprising one HP

and one LRU was dispatched at 1454 hours, together with one Reserve Heavy Pump134 [WS1/40].

In total, 12 fire appliances and 1 ambulance with 61 FS members were dispatched during the initial stage. It was stated that “the magnitude of manpower deployment at that time had already reached around 80% of the PDA for a No. 3 Alarm Fire (i.e. 79 FS members)” 135 [WS1/41].

SStnO Hui Kin-on was the officer-in-charge of the first fire appliance (HP of Tai Po Fire Station) to arrive at WFC. He arrived at 1456 hours (five minutes after the first call) and became the initial Incident Commander136 [WS1/40; WS2/987]. There was no copy of the contingency plan on board the fire engine, but SStnO Hui was aware of its content from having been involved in its formulation [Day 11/8/6-10]. The mobile data terminal informed SStnO Hui of a defective FSI [Day 11/6/2-23].

Upon arrival, no fire or smoke was visible on the façade of Wang Cheong House facing Kwong Wang Street. A passer-by led SStnO Hui to the rear façade facing Island House Lane, where the scaffolding was “well alight” from the ground floor to approximately the 8th or 9th floor, measuring approximately 8 metres in width by 30 metres in height 137 [WS2/988]. “Well alight” is a professional term indicating a serious, intense fire [Day 19/7/20-25]. The fire was therefore already of enormous scale five minutes of the first call.

At approximately 1457 hours, SStnO Hui directed crew members to lay fire hoses and deploy two water jets towards the lower portion of the scaffolding at the

134 TANG Wing Wah 1st WS §12

135 TANG Wing Wah 1st WS §14

136 TANG Wing Wah 1st WS §9; HUI Kin On 1st WS §5 137 HUI Kin On 1st WS §9

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exterior of Wang Cheong House facing Island House Lane. He observed that the

fire was “vertically spreading upward along the scaffolding structure rapidly” and that “a large quantity of burning bamboo, wooden planks, and miscellaneous articles were falling from height of Wang Cheong House to the open ground on ground floor,”138 blocking the rear exit [WS2/990].

At approximately 1459 hours, SStnO Hui returned to the roundabout and observed that the fire had already spread from the rear façade of Wang Cheong House to its west façade via flying embers. At 1500 hours, he observed fire spread from Wang Cheong House to the east façade of Wang Tai House139 [WS2/989]. DD Chan confirmed in oral evidence that this building-to-building spread within approximately 10 minutes was “unprecedented” and that in his years of experience with the FSD he had “never” encountered a situation in which “within such a short space of time so many blocks would be involved” [Day 18/30/7-18]. He agreed that “everything was unprecedented” [Day 18/30/19–22].

The fire appliance sirens were turned off after arrival at the scene. SStnO Hui confirmed this was to prevent the substantial sound volume of the sirens from affecting proper communications between firefighters at the fire scene; the sirens had served its alerting function en route [Day 11/14/1-8] – particularly bearing in mind the arrival of numerous fire appliances one after another at the scene.

No fire alarm sounded at Wang Cheong House or any other block. SStnO Hui confirmed he did not hear any fire alarm [Day 11/21/18 - 22/4]. He attempted to gain access to activate the break-glass unit, but both the front entrance and rear exit of Wang Cheong House were blocked by falling burning debris. As SStnO Hui stated: “I tried to ask my colleagues to get in to the building to see why there was no fire alarm. A lot of times we were the ones who activate the fire alarm

138 HUI Kin On 1st WS §14 139 HUI Kin On 1st WS §11

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system. At the rear entrance of Wang Cheong House, we couldn’t get in, and when we went to the front entrance there were many burning debris falling from height... We couldn’t get in from the front entrance so we couldn’t get into Wang Cheong House to activate the fire alarm system” [Day 11/22/4-13].

No representative of the PMC approached SStnO Hui or any other officer at the scene during the period of SStnO Hui’s command [Day 11/21/10-17].

At 1502 hours, SStnO Hui observed rapid fire spread among different façades of Wang Cheong House, with the mid-lower level of the east façade of Wang Tai House “well alight.” Noting that there were no evacuees from the front entrance of Wang Cheong House, and in view of the fire development and potential large number of residents trapped therein, he upgraded the fire to No. 3 Alarm so as to request additional manpower and appliances resources to the scene140 [WS2/990]. The decision was made six minutes after SStnO Hui’s arrival and 11 minutes after the first call.

AD Tang Wing-wah confirmed the initial firefighting tactics: two jets were immediately deployed towards the scaffolding structures at the exterior of Wang Cheong House where the fire started and was vertically spreading, specifically at “the side where Rooms 104 and 105 are located”. At the material time, “the fire had spread to Wang Tai House” 141 [WS1/41]. This unit-specific reference crossreferences the IFITF’s fire investigation findings on the point of origin addressed in Section G above.

At approximately 1503 hours, immediately after upgrading to No. 3 Alarm, SStnO Hui received a message from the FSCC of an assistance call at Room 2701 of Wang Cheong House. He ordered PStnO Liao Kong-lap, officer-in-charge of

140 HUI Kin On 1st WS §12

141 TANG Wing Wah 1st WS §15

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the Sha Tin Major Pump, to handle this assistance call. PStnO Liao then

instructed PFn Chan Chun-man, officer-in-charge of the Sha Tin Light Rescue Unit to organise the rescue, who in turn instructed SFn Ho, Fn Yeung Ching and Fn Siu Tsz-ho to respond142 [WS2/990; WS15/2186 & 2190]. This is the direct chain of instruction leading to SFn Ho’s entry into the fire, addressed in detail at Section H6(i) below.

(ii) No.3 Fire Alarm (including setting up of the Director’s Command Post)

At 1519 hours, ADO Cheung Lok-hang arrived at the scene and took over as Incident Commander143 [WS2/995]. Upon arrival, he observed that the northwest façade of Wang Cheong House and east façade of Wang Tai House were “well alight”, that the fire had spread to Wang Shing House with its southwest façade (middle to upper floors) also alight, and that burning bamboo sticks and debris were continuously falling from Wang Cheong House144 [WS2/995].

At approximately 1523 hours, ADO Cheung met SStnO Hui at the roundabout near Wang Tai House. SStnO Hui reported firefighting and rescue operations in progress at Wang Cheong, Wang Tai and Wang Shing Houses, and reported that a Mayday message was received at approximately 1522 hours via radiotelephone. The message content was muffled; the identity of the distressed member and building location could not be confirmed from the message145 [WS2/996].

In response to the Mayday message, SStnO Hui formed four Emergency Response Teams, with crew members of TP/MP and TP/HP directed to apply water jets to the front entrance of Wang Cheong House to suppress the fire and clear an access as quickly as possible for the rescue operation. A fifth Emergency

142 HUI Kin On 1st WS §13

143 CHEUNG Lok Hang (Stn Cmdr Tai Po, FSD) 1st WS §6 144 CHEUNG Lok Hang 1st WS §6

145 CHEUNG Lok Hang 1st WS §7

134

Response Team (“ERT”) was subsequently formed on PStnO Liao’s request after

Liao confirmed that the Mayday sender was SFn Ho of ST/LRU146 [WS2/991-992]. The ERTs could not enter Wang Cheong House as both its front entrance and rear exit were blocked by burning bamboo sticks and debris147 [WS2/1001].

At 1529 hours, DO Lam Ho-chun arrived at Tai Po Baptist Public School inside WFC and took over as Incident Commander of the No. 3 Alarm Fire. At the material time, DO Lam noted that fire had scattered on the middle and upper portions of the scaffoldings installed along the external walls of the east façade of Wang Sun House and southeast façades of Wang Kin House and Wang Shing House, whilst fire had spread along the scaffoldings on the southwest façade of Wang Cheong House and east façade of Wang Tai House148 [WS2/1000-1001].

Simultaneously with the No. 3 Alarm at 1520 hours, the DFS activated the Director’s Command Post (“DCP”) at Tier 2 Response and mobilised approximately 80 uniformed members from non-operational units to establish a Support Centre with 18 dedicated hotlines149 [WS1/44]. In light of the rapid development of the fire and continued increase in assistance calls, DCP prioritised the immediate augmentation of rescue manpower: two additional Search and Rescue (“SAR”) teams were deployed through the FSCC at 1520 hours, four additional SAR teams at 1533 hours, and four further SAR teams at 1548 hours (totalling 10 additional SAR teams comprising 20 fire appliances with 105 FS members, all dispatched on the Director’s instruction) 150 [WS2/1016]. All 10 additional SAR teams were dispatched during the No. 3 Alarm period, before the No. 4 upgrade at 1534 hours.

146 HUI Kin On 1st WS §§19-21

147 LAM Ho Chun (Dep. Div. Cmdr NTE) 1st WS §7

148 LAM Ho Chun 1st WS §§5-6

149 TANG Wing Wah 1st WS §28

150 FOK Chun Ming (DCFO Corp Strategy, FSD) 1st WS §9

135

At 1534 hours, in view of the rapid fire spread at Wang Cheong House and Wang

Tai House, and the fire development at Wang Shing House, Wang Kin House and Wang Sun House, Lam upgraded the fire to No. 4 Alarm. He simultaneously tasked ADO Cheung to continue firefighting operations at Wang Kin House and Wang Sun House, ADO Chow Tsz-ho to assist with the Mayday rescue operation, and SSO Hui to tackle fire at Wang Shing House, Wang Cheong House and Wang Tai House and to gain clearer access for the ERTs into Wang Cheong House151 [WS2/1002].

At approximately 1545 hours, a massive collapse of ignited scaffolding sent a torrent of burning bamboo sticks and debris cascading onto the open ground between Wang Cheong House and Wang Tai House. Lam made an immediate call to pull back all crew members from the impact zone. In approximately 30 seconds, crew members resumed firefighting operations with three jets in use at the open ground between the two buildings152 [WS2/1002].

At approximately 1538 hours, DCFO(NTN) Wong King-man, having arrived at the scene at 1535 hours, directed the FSCC to collaborate with the Public Safety and Communication Division to issue a Special Announcement via press release and FSD social media to alert the public about the fire 153 [WS2/1007]. At approximately 1539 hours, DCFO(NTN) Wong observed six buildings ablaze: Wang Shing House (southwest façade), Wang Cheong House (multiple façades, well alight), Wang Tai House (multiple façades, well alight), Wang Kin House (southwest façade), Wang Sun House (south façade) and Wang Tao House (middle-upper portion, southwest façade). The fire had just spread to Wang Tao

151 LAM Ho Chun 1st WS §8

152 LAM Ho Chun 1st WS §9

153 WONG King Man (DCFO NTN, FSD) 1st WS §7

136

House. DCFO(NTN) Wong immediately ordered the attendance of three

additional TLs154 [WS2/1007].

The No. 3 Alarm firefighting tactics included three additional jets deployed at the open ground outside Wang Cheong and Wang Tai Houses, and two jets deployed to Wang Kin and Wang Sun Houses. Two TLs were dispatched: the first arrived at 1504 hours and was positioned at the roundabout to suppress fire spread among Wang Cheong, Wang Tai and Wang Shing Houses; the second arrived at 1523 hours and was strategically repositioned to Tai Po Road near Wang Tai House155 [WS1/42]. Once the No. 3 Alarm was raised, the FSCC also deployed Compartment Fire Specialists, High-rise Building Firefighting Specialists, a BA Unit with specialists to monitor overall BA operations, and a Communications Support Team to maintain effective radio communication and battery checks156 [WS1/45].

(iii) No.4 Fire Alarm

DCFO(NTN) Wong King-man assumed the role of Incident Commander of the No. 4 Alarm Fire at 1550 hours, upon boarding the Mobile Command Unit (“MCU”) of Tsim Sha Tsui Fire Station. He immediately requested the MCU crew to provide a map detailing the names of the buildings at WFC to assist with planning the Incident Command System157 [WS2/1008].

At approximately 1600 hours, the Water Supplies Department (“WSD”) opened all relevant government water main valves, achieving a continuous water pressure of 7 to 7.5 bar at WSD street hydrants near WFC. This was significantly above the FSD’s minimum requirement of 1.7 bar, by a factor of 3.1 to 3.4 times. AD

154 WONG King Man 1st WS §8

155 TANG Wing Wah 1st WS §21 156 TANG Wing Wah 1st WS §29 157 WONG King Man 1st WS §11

137

Tang confirmed that “the availability of water from those street hydrants did not

pose a limitation on FSD’s firefighting efforts”158 [WS2/967].

At 1610 hours, DD Chan arrived at the scene. The fire had already spread to seven of the eight residential buildings, with Wang Chi House being the only block not yet directly involved by flame, and assistance calls were surging from multiple blocks. DD Chan promptly confirmed with DO Lam that occupants were evacuating from all blocks (with the help from the Police as per the usual understanding between the FSD and Police), and confirmed with the duty Senior Station Officer (Control) that the deployed manpower at that time (269 FS members) had already exceeded twice the PDA for a No. 5 Alarm (110 FS members)159 [WS8/1924].

At 1618 hours, AD Tang took over as Incident Commander from DCFO(NTN) Wong King-man. At 1623 hours, AD Tang assigned DCFO(NTN) Wong to take over the role of Rescue Officer and take charge of the overall Search and Rescue operations. AD Tang confirmed that assigning a DCFO to the Rescue Officer role was a first-ever initiative, reflecting the unprecedented scale of the SAR operation160 [WS2/968-969].

At 1635 hours, DD Chan instructed AD Tang to implement a building-bybuilding command strategy by setting up eight operation sectors (Ops 1 to 8), each corresponding to one of the residential buildings, each to be commanded by a Senior Officer responsible for firefighting, with one additional Senior Officer in each sector dedicated as SAR leader161 [WS8/1924].

158 TANG Wing Wah 2nd WS §6

159 CHAN Derek Armstrong (DD Ops, FSD) 1st WS §11 160 TANG Wing Wah 2nd WS §§10-12

161 CHAN Derek Armstrong 1st WS §12

138

AD Tang assigned specific SDOs and DOs to each block to lead and oversee the

firefighting operations thereat: Wang Shing House (SDO Wong Wang-leong), Wang Cheong House (DO Cheng Chun-kit), Wang Tai House (SDO Lai Waihei), Wang Kin House (DO Lam Ho-chun), Wang Sun House (DO Lai Kingleung, acting), Wang Tao House (DO Wong Chun-on), Wang Yan House (SDO Ho Chun-pong), and Wang Chi House (DO Chow Chin-choi for precautionary intervention) 162 [WS2/969]. The allocation of precautionary intervention to Wang Chi House (the only unaffected block) was a proactive decision that may have contributed to its remaining the sole building spared by the fire.

At 1534 hours, a total of 48 fire appliances and 13 ambulances with 269 FS members had been dispatched to the scene. The deployed manpower had already reached approximately twice the PDA for a No. 5 Alarm Fire 163 [WS1/45]. Within approximately one hour of the fire outbreak (by 1551 hours), three TLs had arrived; within another half-hour (by 1621 hours), six TLs were at the scene; and before the No. 5 Alarm was raised, seven TLs were deployed at strategic locations along the EVA of WFC, Tai Po Road (Yuen Chau Tsai), Island House Lane and Yuen Shin Road164 [WS1/46].

(iv) No.5 Fire Alarm

DD Chan upgraded the fire to No. 5 Alarm at 1822 hours. By that time, assistance calls had escalated to 82 units, and a total of 171 FS appliances with 718 FS members had been dispatched to WFC, with every building under the charge of designated Senior Officers for both firefighting and SAR operations. His written witness statement165 [WS8/1930-1931] explains the rationale for the upgrade in

162 TANG Wing Wah 2nd WS §15

163 TANG Wing Wah 1st WS §32

164 TANG Wing Wah 1st WS §34

165 CHAN Derek Armstrong 1st WS §24

139

terms that make clear it was driven by command-structure considerations rather

than resource inadequacy:

“At the time of my arrival at 1610 hours on 26.11.2025, the manpower at scene (269 FS members) had already exceeded twice the PDA for a No. 5 Alarm (110 FS members), and by 1822 hours a total of 116 fire appliances and 55 ambulances with 718 FS members had been despatched, such that the cumulative manpower deployed already exceeded 6.5 times the PDA for a No. 5 Alarm... I considered it appropriate to upgrade the fire to No. 5 Alarm at 1822 hours and assume overall command as Incident Commander, so as to provide a clearly defined strategic command for the whole scene and to ensure that firefighting and SAR operations across all sectors were coordinated under a single incident-wide framework”

The pattern is consistent across all three upgrade decisions: actual deployment ran well ahead of the formal alarm level. As AD Tang confirmed in his oral evidence: “Each officer at their respective post will know what resources they need and they can make the request directly... Colleagues at their respective posts will do their best instead of being classified in their approach” [Day 19/32/15–33/21].

When asked whether “if the incident commander is of the view that they require additional resources, say, for example, turntable ladders, regardless of the number of alarm, they can make that request,” AD Tang confirmed: “Yes. There are colleagues at different positions. At each block there is the sector officer, rescue officer and the incident commander. So each officer at their respective post will know what resources they need and they can make the request directly” [Day 19/32/25 - 33/5]. He further confirmed that in addition to the automatic PDA upon alarm escalation, “colleagues will, after taking into account the actual

140

situation, ask for additional resources or additional appliances or reinforcement”

[Day 19/33/16-21]. The Chairman confirmed his understanding of the design: “Every time when there was an upgrading of the level of alarm, you had established procedures as to the number of appliances to be deployed and therefore the commander at the scene already knew the number of appliances would be sent” [Day 19/28/21-25]. The effect of this established mechanism was that no officer needed to await a formal alarm upgrade before requesting specific resources.

At 2230 hours on 26 November, a cumulative total of 221 FS appliances and 989 FS members had been dispatched, approximately nine times the PDA for a No. 5 Alarm Fire. At that material time, the appliances and manpower of the Fire and Rescue Corps of Guangdong Province were known to be present at Liantang Port. DD Chan assessed that additional manpower support from them was not required, for reasons of scene capacity and operational incompatibility addressed in detail at Section O6(v) below.

Several unprecedented operational initiatives were implemented during the No. 5 Alarm period. AD Tang’s evidence records that these included: the DCP being activated at Tier 2 and led by AD(CS) at the very initial stage; both DD(Ops) and DD(P&C) proactively responding to the scene and EMSC respectively; the Support Centre making approximately 1,500 call-back calls; the assignment of a DCFO as Rescue Officer; the assignment of SDO or DO to lead both firefighting and SAR operations for all individual buildings; the deployment of AD(NTS) to monitor operational safety issues; the deployment of DCFO(FS) to facilitate SAR communications; and the presence of 25 Senior Officers and Directorate Officers

141

at the scene by 2100 hours on 26 November, including ranks from DO through to

Director166[WS1/50-52]; IFITF Report §5.4.6.1 [ER1/69-70].

(v) Handover of command at 0935 hours on 2025.11.27

DD Chan served as overall Incident Commander from 1822 hours on 26 November through the overnight period to 0935 hours on 27 November, over 13 hours of continuous command. At 0935 hours, he handed over to DD(P&C) Wong Ka-wing. At 2100 hours on 27 November, DD Chan returned to WFC and resumed the role of Incident Commander167 [WS8/1929-1930].

Proactive measures to sustain the prolonged operation included: a reserve of approximately 220 BA cylinders maintained at the BA Main Control; compact portable pumps stationed at the staging area for immediate deployment to various sectors; Unmanned Aerial System (“UAS”) aerial surveillance from 1615 hours; special manpower relief arrangements with officers called in 1.5 hours early and coaches arranged to convey fresh crews to the scene at 0900 hours on 27 November; and the establishment of a temporary on-site mortuary coordinated with the Chief Ambulance Officer upon the discovery of multiple casualties168 [WS8/1927–1928].

(vi) Declaration of the fire being “surrounded”, “under control” and delivery of the “STOP” message

“Fire surrounded” was declared at 2131 hours on 27 November 2025. At that time the FSCC recorded assistance calls for 355 locations, with 320 locations (90.1%) successfully attended by FS members169 [WS8/1929].

166 TANG Wing Wah 1st WS §50

167 CHAN Derek Armstrong 1st WS §§21-22 168 CHAN Derek Armstrong 1st WS §§17-19 169 CHAN Derek Armstrong 1st WS §22

142

“Fire under control” was declared at 0315 hours on 28 November 2025. Among

the assistance calls for 364 locations, 356 had been attended by FS members, with 129 FS appliances and 541 FS members deployed170 [WS8/1930].

The “STOP” message was delivered at 1018 hours on 28 November 2025, meaning further mobilisation of resources was no longer required. At that time 143 FS appliances and 635 FS members remained in attendance. As DD Chan explained: “We were dealing with a couple of things. For the affected units, we still had to spray water on them to prevent reignition. There were still officers on the scene and we had to keep an eye on the conveyance of the deceased. Firefighters would also be going upstairs to conduct thorough searches to make sure that we could locate all the deceased ones” [Day 18/47/12-21].

The total duration of the firefighting operation, measured from the first fire call at 1451 hours on 26 November 2025 to the delivery of the “STOP” message at 1018 hours on 28 November 2025, was approximately 43 hours.

H3. Evidence on the rescue operation

(i) Handling of 999 calls since the first call received

The FSCC received the first fire call at 1451 hours. Upon receipt of more than one fire call, a SAR team was dispatched at 1454 hours pursuant to the established protocol: a SAR team is automatically dispatched when a building fire is reported by two or more callers, comprising one pumping appliance and one rescue appliance, together with one Reserve Heavy Pump equipped with a PPV Blower and one ambulance171 [WS1/40; WS1/61].

170 CHAN Derek Armstrong 1st WS §23

171 TANG Wing Wah 1st WS §8; WONG Sze Lut, Sunny (DCFO OSPD, FSD) 1st WS §5.1.2

143

Upon receipt of the fourth assistance request, the FSCC dispatches an additional

SAR team comprising two fire appliances, as well as one MCU, and allocates an additional talk group exclusively for SAR operations172 [WS1/62]. Given the speed of call accumulation on 26 November, the MCU was effectively triggered at a very early stage of the incident.

The standard procedures for handling assistance requests comprise three steps: first, console operators collect essential information from the caller, including the location of persons requiring assistance, the number of persons along with their gender and age, and a contact phone number; second, all assistance requests are recorded in the Computer Mobilising System and relayed to the SAR Team Leader immediately; third, if the caller has doubts about evacuation, appropriate safety advice is provided173 [WS1/62]. Essential information is disseminated to the Incident Commander, SAR Team Leader and officer-in-charge of the MCU via FSD Messenger, the Department’s internal instant messaging application174 [WS1/62-63].

The Support Centre established at 1520 hours on the DFS’s instruction was separate from the 999 call system operated by the Police. Its function was to assist the FSCC in implementing the Call-back Mechanism thereby enabling the FSCC to maintain focus on receiving and handling incoming emergency calls while ensuring that callers who had reported their need for assistance would continue to receive attention and guidance in the changing circumstances175 [WS2/1023]. Upon termination of the three-way call involving the caller, FSCC and Police Control and Command Centre (“PCCC”), the Support Centre would call the caller back periodically to obtain updates on their situation and provide ongoing

172 WONG Sze Lut, Sunny 1st WS §5.1.4.1

173 WONG Sze Lut, Sunny 1st WS §5.1.3.1 174 WONG Sze Lut, Sunny 1st WS §5.1.5

175 WONG Sze Lut, Sunny 3rd WS §4.1.1

144

safety advice176 [WS1/44; WS2/1023]. In total, approximately 1,500 call-back

phone calls were made by the Support Centre to update the conditions and locations of affected residents 177 [WS1/51] [B13/1] [B15/1]. The Chairman specifically commended this mechanism at the hearing, observing that “callback is quite useful, as proven by this experience” [Day 12/108/12-16].

Despite the surge in the volume of calls after the fire broke out, with the establishment of the Support Centre, the FSCC was able to answer calls within an average of one minute for the rest of the day178 [WS1/164].

The Government acknowledges, however, that the large volume of duplicated calls “did cause difficulties to operations, underscoring the importance of effective filtering and streamlining processes in managing high-demand incidents” 179 [WS1/165]. The 4th Generation Mobilising System to be upgraded, currently in testing, will automate the transmission of assistance request information to all parties simultaneously, eliminating the manual steps of photographing and transmitting screen information that characterised the operation on 26 November 2025180 [WS1/166].

At 1520 hours, the DCP directed deployment of two additional SAR teams; four more at 1533 hours; four more at 1548 hours — totalling 10 additional SAR teams comprising 20 fire appliances with 105 FS members, all dispatched on the DFS’s instruction during the No. 3 Alarm period 181 [WS2/1016]. The proactive augmentation of SAR resources by the DCP significantly pre-dated the formal alarm escalation to No. 4 at 1534 hours.

176 TANG Wing Wah 1st WS §28; WONG Sze Lut, Sunny 3rd WS §4.1

177 TANG Wing Wah 1st WS §50.3

178 WONG Sze Lut, Sunny 2nd WS §4.5.1

179 WONG Sze Lut, Sunny 2nd WS §4.7.4

180 WONG Sze Lut, Sunny 2nd WS §4.8.2

181 FOK Chun Ming 1st WS §9

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(ii) Evacuation at the early stages of the fire, in particular the status of the fire

alarms at each of the eight blocks

The FAS failed to activate in seven of the eight buildings; only Wang Sun House’s FAS was “momentarily actuated at the incipient phase of the fire” [B11/5643]. AD Tang confirmed that “during the fire, the manual fire alarm systems failed to be activated in 7 out of 8 buildings and hence affected the evacuation of residents in those buildings”182 [WS1/56]. This was identified as one of the principal challenges delaying evacuation.

Crew members were sent to Wang Kin, Wang Sun and Wang Tao Houses to break the break-glass units and activate the FAS, but this failed. SStnO Hui confirmed: “I asked the crew members to turn on the fire alarm system of other blocks. There were crew members who have entered Wang Kin, Wang Sun and Wang Tao House to break the break-glass unit to turn on the fire alarm system, but in vain. At that time I realised that the FAS of Wang Fuk Court was problematic.” He estimated this realisation came “at around 3.35, 3.40 pm” [Day 11/43/11-20].

Over 250 residents from different buildings self-evacuated to the ground floor with the assistance of the Police and FSD. AD Tang clarified that this figure was “a sum of all the best estimates that the initial attending officers were able to make while they were also carrying out their own operational duties during the initial stage of the fire against the urgent and everchanging situation at the time”183 [WS2/976]. It is a visual estimate under operational pressure, not a precise count.

At the early stage of the fire, as the FSD’s first attending crews were largely engaged in firefighting operations and clearance of obstructions at the entrances and exits of various buildings, particularly at Wang Cheong House and Wang Tai

182 TANG Wing Wah 1st WS §63 183 TANG Wing Wah 2nd WS §35

146

House, assistance was sought from the Police to assist in evacuation. Police

personnel used the Public Address system in police vehicles and loudhailers to urge residents to evacuate, and evacuees were guided to places of safety on the ground level by the combined efforts of both the FSD and Police personnel184 [WS6/1861]. Specifically, 13 officers of PTU X4 entered Wang Chi House and Wang Yan House between approximately 1613 and 1640 hours to assist in the evacuation of residents from upper floors, successfully evacuating nine residents 185 [WS17/2204-2207]. The FSD was informed of these evacuation initiatives186 [WS17/2205]. In addition, at approximately 1604 hours, the Police deployed a drone (DJI Matrice 30T) from the rooftop of the WFC car park, which was used to conduct aerial surveillance of the fire scene with live-streaming to the New Territories North Command Centre and simultaneously broadcast evacuation messages in Cantonese, urging WFC residents to evacuate.187

The Emergency Alert System (“EAS”) was considered but not used. DD Chan explained that he “considered the EAS unsuitable for this incident because, at the material time, this situation required localised, one-on-one communication with specific residents in the affected buildings rather than broadcast to the general public due to the unpredictability of the dynamic fire development. This specific

184 TANG Wing Wah 3rd WS §7

185 CHEUNG Lui (PTU X Cmdr, Police) 1st WS §§4-7. In addition to the 13 officers of PTU X4 (Column 1-2) mentioned at CHEUNG Lui’s 1st WS, 4 more officers of PTU X4 (Column 3) also assisted in the evacuation by attending the 9th, 10th, 14th and 15th floors of Wang Yan House, though yielding no results: see the police witness

statements of SGT , SGT , PC

and PC

[7th Lists of Content submitted to the Committee by the Police, Part IX-A1-62, Part IX-A1-63, Part IX-A1-81, Part IX-A1-82]; and one officer of EU NTN attended Wang Tai House to assist the evacuation of a resident upon request by her family member: see the police witness statement of PC

[7th Lists of Content submitted to the Committee by the Police, Part IXA1-38] (Chinese only).

186 CHEUNG Lui 1st WS §7

187 Police witness statements of SIP Liu Wai-keung and SIP Li Shing-hon [5th Lists of Content submitted to the

Committee by the Police, Part IX-A1-4 and Part IX-A1-7], SGT

and PC

[7th Lists of Content submitted to the Committee by the Police, Part IX-A1-16 and Part IX-A1-26] (Chinese only).

147

need was met effectively by the Support Centre, which made approximately 1,500 callback phone calls”188 [WS8/1933].

The safety advice given to callers was provided on a case-by-case basis, tailored to the specific details each caller provided. As DCFO(OP) Wong Sze-lut, Sunny confirmed, the guiding principle was to avoid smoke: “If there is heavy smoke outside the unit, the caller will be advised to remain calm inside and seal the door gaps. On the other hand, if the corridor is clear of smoke, the caller will be advised to leave quickly using the nearest smoke-free staircase”189 [WS1/162].

The overriding aim was to ensure safe egress from the fire scene; the FSD did not specify particular evacuation routes or designate refuge locations within the building, as fire and smoke conditions could change rapidly190 [WS2/1024]. As to whether the rooftop was an advisable place of refuge, DCFO(OP) Wong confirmed there was “no hard and fast rule” — while the fire resulted in fatalities on rooftops, some casualties were also successfully rescued from rooftops191 [WS2/1024].

(iii) The rescue operation

The fundamental principle governing SAR operations was operational feasibility — specifically, whether prevailing conditions permitted SAR teams to safely access the locations where individuals required assistance. DCFO(NTN) Wong identified four primary determining factors: the status of firefighting progress; the availability of safe access and egress routes; the structural integrity and safety of the affected areas; and the clarity of the location information provided by the caller 192 [WS2/1010]. Order of receipt of assistant calls was not the only

188 CHAN Derek Armstrong 1st WS §28 189 WONG Sze Lut, Sunny 2nd WS §4.3.2

190 WONG Sze Lut, Sunny 3rd WS §4.2.1 191 WONG Sze Lut, Sunny 3rd WS §4.2.2 192 WONG King Man 1st WS §15

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consideration at the time; the SAR teams actively prioritised their deployment

decisions based on operational feasibility.

Rescue resources were prioritised for the most severely affected blocks; fewer resources were allocated to less-affected blocks such as Wang Chi House. By way of illustration, as DCFO(NTN) Wong confirmed: “Wang Chi, we did not deploy as much resources/manpower to Wang Chi House, because it’s somewhat untouched” [Day 11/114/11-20].

SAR teams made multiple attempts to surpass the floors undergoing firefighting to effect rescue on upper floors. DCFO(NTN) Wong confirmed that “despite challenges from flames, heat, and dense smoke, SAR teams would and did take risks to advance whenever opportunities arose” 193 [WS2/1011]. AD Tang confirmed that “the SAR teams accepted heightened risks at times advancing through burning floors or delaying the use of Breathing Apparatus to expedite their ascent”194 [WS6/1866]. DD Chan further corroborated this, noting instances where “SAR team members accepted heightened levels of risk in order to reach persons reported in distress, including advancing through burning floors or delaying the use of BA while moving upward through staircases filled with hazardous gases”195 [WS8/1935].

Prior to Sector Officers assuming their roles, the firefighting and SAR teams had already undertaken snatch rescue attempts at various buildings. AD Tang recorded a specific example: “a first responding officer entered Wang Cheong House and attempted to conduct snatch rescues and evacuate residents. However, the officer was compelled to retreat upon reaching the half-staircase landing of the front staircase due to intense heat and smoke conditions and narrowly

193 WONG King Man 1st WS §17

194 TANG Wing Wah 3rd WS §16

195 CHAN Derek Armstrong 1st WS §33

149

avoided being unable to withdraw when the front entrance of Wang Cheong House was subsequently blocked by fallen debris and engulfed in flames”196 [WS6/1866]. Separately, CCTV footage from the entrance of Wang Tai House [C6/1] played at the evidential hearing [Day 18/69/1-4], showed that at approximately 1516 hours FSD personnel entered Wang Tai House but were compelled to retreat almost immediately. These incidents illustrate how rapidly conditions deteriorated.

At approximately 1540 hours, the first team cleared a narrow access route into Wang Cheong House on the ground floor and rescued three unconscious residents from the ground-floor lobby — notwithstanding that the front entrance was being progressively obstructed by descending burning debris197 [WS6/1866; WS1/57]. This was the first confirmed internal rescue, achieved 49 minutes after the first call.

Senior Officers assumed their designated roles as Sector Officers starting from approximately 1630 hours. The incremental approach with tactical advancement strategy had been initiated at the outset and was consistently maintained throughout. At approximately 1730 hours, an access route to the 2nd floor became available in Wang Cheong House, and the SAR teams took the opportunity to rescue three residents in a unit on a lower floor198 [WS6/1867]. A turntable ladder was deployed to rescue three residents from Unit 202 of Wang Cheong House from outside the building [B10/5161; Day 19/19/22 - 20/17]. AD Tang explained that this rescue operation involved positioning the turntable ladder on a road that was not an EVA and extending the arm horizontally over a considerable distance

196 TANG Wing Wah 3rd WS §17

197 TANG Wing Wah 3rd WS §§16-18; 1st WS §64 198 TANG Wing Wah 3rd WS §§19-20

150

to reach the unit, with the loading alarm activating during the operation, requiring

the residents to be rescued one by one [Day 19/20/1-17].

At Wang Tai House, at approximately 1930 hours and 2100 hours on 26 November, crews identified and acted upon rescue opportunities, conducting snatch rescues on the 10th floor and 14th floor respectively while fire on lower floors was still severe199[WS6/1867].

In the whole operation, more than 100 persons were rescued from various locations in the affected buildings. Apart from attending the 347 units reported as requiring FS assistance, all remaining units on all floors of all affected buildings were attended by FS members to check for possible casualties200 [WS1/49].

H4. Evidence on the challenges and difficulties faced by the FSD frontline officers

The operational difficulties and challenges at WFC can be grouped under four heads, each of which connects to the key contributing factors addressed below.

The first challenge was the falling of bamboo scaffolding blocking entrances and EVA. Large quantities of burning bamboo, wooden planks and miscellaneous articles continuously fell from height from Wang Cheong House and Wang Tai House, piling up at ground level, blocking front entrances and rear exits of both buildings at the initial stage, engulfing ground-floor lobbies in flames, and severely hindering both resident escape and firefighter access.

1. AD Tang recorded that the “process was challenging because fallen objects continued to reignite and advances made through the debris continued to be closed off by more fallen objects,” and that “two firefighters working on

199 TANG Wing Wah 3rd WS §20 200 TANG Wing Wah 1st WS §47

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the periphery were injured by falling objects and required treatment in hospital” 201 [WS1/53-54]. In oral evidence, AD Tang confirmed that falling debris also covered the EVA between the blocks, rendering the designated turntable ladder positions inaccessible. He explained that “in most of the buildings there are EVAs” but that “they have already been covered by debris and other things, and therefore the only location where we can position our TLs... such locations might not no longer be available” [Day 19/22/13-25]. He confirmed that the requirement for EVAs is that they must “be at a distance of no more than 10 metres away from the block” with appropriate loading for fire appliances, but that falling bamboo sticks and debris prevented appliances from accessing these positions [Day 19/22/15 - 24/20]. As a consequence, turntable ladders were positioned on roads around WFC rather than at their designated EVA locations [Day 19/23/1-3].

2. Falling debris also covered part of the EVA, preventing turntable ladders from being positioned at their EVA-designated locations. The operational consequences of this were illustrated by the rescue at Unit 202 of Wang Cheong House described above: because the turntable ladder could not be positioned at the designated EVA close to the building, it had to be deployed on a road further away, requiring the arm to extend horizontally beyond its normal operating angle to reach the unit. AD Tang concluded that “given turntable ladders had already been deployed at available strategic positions for external firefighting around Wang Fuk Court and the EVA near the buildings became inaccessible due to fallen burning scaffolding materials and debris, further reinforcement of turntable ladders, regardless of their operational height, would not have effectively

201 TANG Wing Wah 1st WS §54

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met the operational objectives”202 [WS6/1873]. Two fire appliances were

also damaged by falling debris during the operation203 [WS6/1865].

The second challenge was heavy smoke and extreme heat penetrating buildings via access openings at staircases.

1. The fire “spread rapidly into different parts of the buildings through windows of units and corridors suspected to be covered with polystyrene boards and the modified worker access points on staircases, resulting in ignitions and smoke-logging of multiple units and floors simultaneously”204 [WS1/54].

2. Even worse, “the fire could spread with heavy black smoke rushing into the staircases through the modified worker access points on various floors” 205 [WS1/54].

3. Corridors and staircases, the primary escape routes for residents and access routes for firefighters, were invaded by smoke and flames from the exterior at an early stage, in circumstances where the staircase design “should effectively block flame and smoke during fire, with smoke stop doors and fire resisting construction providing sufficient protection” 206 [WS1/55]. In this fire, however, “staircases were invaded by smoke and flames from the exterior early on that resulted in high temperature, dense smoke and very low visibility at the access routes within the buildings, making firefighting operations extremely difficult” 207 [WS1/55].

202 TANG Wing Wah 3rd WS §39

203 TANG Wing Wah 3rd WS §15 204 TANG Wing Wah 1st WS §55

205 TANG Wing Wah 1st WS §55 206 TANG Wing Wah 1st WS §57 207 TANG Wing Wah 1st WS §57

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4. Firefighters advancing to upper floors found that reignition occurred in

lower levels, “potentially cutting off the retreat routes and making firefighters more dangerous,” requiring them “to move repeatedly between different floors for firefighting” 208 [WS1/47].

The third challenge was the failure of all fire alarms and impairment of the FH/HR System.

1. The FH/HR System in the affected buildings were under repair and the associated pumps were non-functional during the fire. Water fed from pumping appliances through FS inlets on the ground floor “could not be effectively boosted up by the FH/HR systems to the upper floors (i.e. around 20–23/F upwards) for very effective firefighting”209 [WS2/974].

2. To address this, numerous compact portable pumps (approximately 80 kg each) were deployed for water relay to upper floors. As AD Tang explained: “Bringing the compact portable pump (about 80 kg) to the upper floors, in addition to our basic personal protective equipment (about 23 kg), requires considerable physical effort from our frontline crews” 210 [WS2/974]. In oral evidence, AD Tang provided a more precise account of the operational constraint: without the building’s own booster pump, relying solely on the major pump, “the fire hose could still produce water up to the 20th floor. So for floors above the 20th floor, we needed to use portable pumps to pressurise the system so that the water could be used to put out the fire on floors above the 20th floor” [Day 19/18/4-11]. The portable pumps therefore needed to be transported “about 10-odd floors” up staircases that were only “1 metre wide” and “pitch dark” [Day 19/17/17-18/14]. When

208 TANG Wing Wah 1st WS §36 209 TANG Wing Wah 2nd WS §31 210 TANG Wing Wah 2nd WS §31

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asked whether the deactivation of the FH/HR System caused significant

impact to the operation, AD Tang confirmed: “There was an impact, but it could be overcome. Yes. An impact that could be overcome” [Day 19/18/18-19].

The fourth challenge was the unprecedented simultaneous multi-block external façade fire. The fire quickly spread upward through the re-entrant, trapping hot air, flames and flammable gases, allowing them to rise rapidly from lower to upper floors within individual blocks before spreading laterally to adjacent blocks due to unfavourable weather conditions. On the day of the fire, an east to southeast wind was blowing at about 14 km/hr at Tai Po Kau wind station, relative humidity of 40% was recorded at 1500 hours, and the Hong Kong Observatory issued a Red Fire Danger Warning211 [WS1/56]. Normal building fire design assumes fire originates internally and relies on passive fire safety provisions to contain spread. At WFC the fire originated externally and bypassed these provisions entirely.

Taken together, these four challenges created conditions never previously encountered in Hong Kong. The firefighters gave everything during the firefighting and rescue operations; they rescued over 100 persons, attended all 347 reported assistance locations and all remaining units, sustained nine hospitalisations among their own ranks, and lost one of their own. That they could not prevent the rapid spread of fire and heavy casualties is attributable to the presence of the contributing factors addressed below, factors for which the primary responsibility lies overwhelmingly with private actors.

211 TANG Wing Wah 1st WS §61

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H5. Evidence on the setting up of the Command Post for the Disaster Victim Identification Unit (“DVIU”) on 2025.11.28 and DVIU’s operation

The DVIU was established in 1975 and operates under the command of the Detective Training Centre, following the mode and standard of operation set out by INTERPOL. Its duty is to assist the Consultant Forensic Pathologist-in-charge in the identification of disaster victims in major incidents for investigation and subsequent court proceedings212 [WS1/270]. The DVIU reserves are trained to discharge duties at Command Post (including administration and logistics support), Recovery Teams, Dead Body Collection Point and Mortuary Team. After training, members return to normal policing duties in their parent formations but are mobilised when necessary213 [WS1/271].

For the WFC incident, a total of 605 DVIU officers were turned out: 1 Superintendent, 6 Chief Inspectors, 153 Senior Inspectors/Inspectors, 1 Police Station Sergeant, 71 Police Sergeants and 373 Police Constables214 [WS1/275]. On 28 November 2025, the Command Post was set up at Tai Po Baptist Public School with 64 members deployed; the Dead Body Collection Point was set up on the ground floor of the WFC Car Park with 64 members deployed; and the designated Mortuary was Fu Shan Public Mortuary in Tai Wai with 56 members deployed. A total of 94 Recovery Teams were formed, each comprising 4 members (1 Team Leader, 1 Recording Officer/Photographer and at least 2 Recovery Handlers), involving 376 officers215 [WS1/275].

The recovery operation proceeded in structured phases.

1. Between 29 November and 3 December 2025, Recovery Teams were deployed into the seven affected buildings to conduct the first and

212 CHENG Ka Chun (Supt, Det Training Centre, Police) 1st WS §§5-6

213 CHENG Ka Chun 1st WS §8

214 CHENG Ka Chun 1st WS §17

215 CHENG Ka Chun 1st WS §18

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preliminary search from the ground floor to the rooftop, covering all flats

(except 41 flats with potential safety concerns pending clearance by the HA), electricity metre rooms, garbage rooms, corridors, staircases and all other common areas. Designated areas were assigned to 8 to 10 Recovery Teams, led by a Zone Leader, to coordinate search efforts and ensure thoroughness216 [WS1/275].

2. On 3 December 2025, a second search was conducted against 12 flats where no missing persons had been found in the first search, together with the 41 previously inaccessible flats which had by then been cleared safe217 [WS1/275].

3. Between 4 December and 9 December 2025, Recovery Teams searched for any body or body part covered in soot, fallen scaffoldings and rubble scattered around the estate grounds, and checked the lift shafts of the affected buildings. Scaffolding adhering to outer walls inaccessible to Recovery Teams was searched with the assistance of Small Unmanned Aircraft Teams from the Police218 [WS1/276].

On 29 November 2025, no body or body part was recovered. From 30 November to 9 December 2025, a total of 74 bodies and/or body parts were found: Wang Cheong House (31), Wang Tai House (36) and Wang Sun House (7). No body or body part was found at Wang Yan House, Wang Tao House, Wang Kin House or Wang Shing House219 [WS1/276].

Each recovery was assigned a Unique Body Reference Number (“UBRN”). Documentation was completed using either paper or electronic Disaster Victim

216 CHENG Ka Chun 1st WS §19

217 CHENG Ka Chun 1st WS §20 218 CHENG Ka Chun 1st WS §21 219 CHENG Ka Chun 1st WS §24

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Recovery Booklets linked to the Major Incident Investigation and Disaster

Support System. Four tags bearing the UBRN were tied to a peg beside the body, the body itself, the inner body bag and the outer body bag respectively. Bodies were placed in an inner bag and then an outer bag before removal to the Dead Body Collection Point, where registry, initial pathological examination, phototaking and documentary checking were conducted before transportation to Fu Shan Public Mortuary220 [WS1/272, 276].

The breakdown of the 168 fatalities is as follows: 106 fatalities (including S/N 73) were recovered by the FSD; 61 fatalities were handled by the DVIU (S/N 103-153, 158-165, 167 and 168); and 1 fatality (S/N 166) was recovered by the forensic pathologist (not part of the DVIU) on 19 December 2025 221 [WS10/1952-1953].

Of the 74 suspected human tissue samples collected by the DVIU, 12 were found to be non-human (animal substance) and 2 were animal but not human tissues. Among the remaining 60, after further examination by pathologists, odontology experts and anthropologists, additional body parts were retrieved (that is, one bag of body and/or body parts carrying human tissues from more than one victim), resulting in a total of 65 identifiable bodies and/or body parts. Of these, 60 victims were identified by forensic methods of DNA and/or fingerprint comparison and/or odontology; 4 body parts were matched to 3 of those 60 victims (S/N 73, 112 and 119); and 1 body part (a skull found beside a body part confirmed by DNA to be S/N 112) was identified by circumstantial evidence as S/N 112’s daughter (S/N 167)222 [WS1/277-278; Day 12/151/18 - 152/15].

220 CHENG Ka Chun 1st WS §§11-12, 21-22 221 CHENG Ka Chun 2nd WS §§4-9

222 CHENG Ka Chun 1st WS §27

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The DVIU commander SP (DVIU) Cheng Ka Chun confirmed that the true death

toll does not exceed 168: “I think it’s impossible to find evidence that there is more than 168 victims. The reason is that excluding persons reported missing by their relatives, and also missing persons with no enquiries made, when we conducted this search... we have searched every inch of the scene... there would not be more than 168 victims” [Day 12/152/22 - 153/11].

H6. Evidence on casualties and damage

(i) The passing of Senior Fireman Ho Wai-ho

SFn Ho was a member of the Sha Tin Light Rescue Unit. He lost his life in the line of duty during firefighting operations at WFC on 26 November 2025.

SFn Ho’s assigned mission was to respond to an assistance call at Room 2701 of Wang Cheong House. The instruction came from PStnO Liao, who was himself directed by SStnO Hui in response to an FSCC assistance call message received at approximately 1503 hours223 [WS2/990].

CCTV footage shows that at 1516 hours, SFn Ho entered Wang Tai House rather than his assigned destination of Wang Cheong House. The evidence is that he had, out of compassion, stopped to assist an elderly resident in a wheelchair, became separated from his team, and mistook Wang Tai House for Wang Cheong House.

No Entry Control Point (“ECP”) had been established at Wang Tai House at the time SFn Ho entered. The standard ECP procedure (two floors below the rescue floor) could not yet be implemented because no BA team had been assigned to Wang Tai House at that stage; all attempts were directed at Wang Cheong House [Day 18/72/11-15].

223 HUI Kin On 1st WS §13

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Because no ECP was in place and SFn Ho entered without passing through a

control point, his Firefighter Locator System (“FLS”) Personal Transmitter (“PT”) red magnetic key was not removed and his PT was not activated. Even if the PT had been activated, the signal from SFn Ho’s position on the 30th and 31st floors of Wang Tai House “might not have been received by the HHR on G/F of either Wang Cheong House or Wang Tai House due to the long transmission distance, as well as environmental conditions and anything that might cause interference or reflection of PT signal”224 [WS4/1811]. This constraint of the existing FLS system for high-rise scenarios is addressed in Section O5(ii) below.

SFn Ho conducted the daily BA test at 0930 hours on 26 November and recorded no defects; the BA set was in good working condition225 [WS4/1808].

The Mayday message received at approximately 1522 hours stated: “Mayday, Mayday, Mayday, ...... 而家被困係 30 樓”. SStnO Hui responded via R/T asking “你喺咩位置” but could not hear any response 226 [WS2/991]. PStnO Liao subsequently confirmed to SStnO Hui at the roundabout near Wang Cheong House that the Mayday sender was SFn Ho of ST/LRU227 [WS2/992].

The IFITF noted that “Based on the post-fire investigation, it is believed that conditions deteriorated rapidly shortly after Fn HO arrived on the 25/F” and that “Equipped with proper PPE and BA, Fn HO was fully capable of escaping from Wang Tai House upon noting the deteriorating situation. However, it is believed that he stayed in Wang Tai House in an attempt to assist the evacuation of others” (IFITF Report, §§9.2.8.4 and 9.2.8.5 [ER1/193]). At approximately 1555 hours, DO Lam, whilst conducting assessment of hazards at the roundabout near the

224 TUNG Wing Kei (Div. Officer BA, FSD) 1st WS §7.7

225 TUNG Wing Kei 1st WS §6.4

226 HUI Kin On 1st WS §19

227 HUI Kin On 1st WS §21

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northeast façade of Wang Tai House, noted SFn Ho unconscious, lying on a

quantity of burning bamboo sticks and debris at the open ground in front of the front entrance of Wang Tai House228 [WS2/1002]. SFn Ho was believed to have exited the building via a broken window at the 31st Floor (IFITF Report, §9.2.8.6 [ER1/194]). At approximately 1600 hours, crew members removed SFn Ho from the burning debris and conveyed him to ambulance personnel229 [WS2/1003]. From the Mayday at 1522 hours to recovery at 1555 hours was 33 minutes; from recovery to removal was a further 5 minutes.

Post-fire examination of SFn Ho’s BA set confirmed: the cylinder valve and handwheel were damaged, consistent with severe impact; no burn marks appeared on the BA set; the BA Set Tally was still attached; the PT red magnetic key was still inserted; and the alphaSCOUT was found inoperable due to water damage. The BA set was recovered from the waterlogged Roof Floor of Wang Tai House at approximately 1733 hours on 27 November 2025, where the floor was submerged to a depth of approximately 10 to 20 cm. Rust accumulation and water infiltration into the alphaSCOUT motherboard were identified, consistent with approximately 16 hours of submersion230 [WS4/1808-1811]. The alphaSCOUT data is irrecoverably lost; the exact chronology of SFn Ho’s final minutes cannot be established.

The IFITF concluded that:

1. “[T]he evidence indicates that [S]Fn HO was engaged in a valiant effort to escape or obtain help under extreme conditions. His incapacitation — whether primarily due to smoke inhalation or traumatic injuries sustained

228 LAM Ho Chun 1st WS §10

229 LAM Ho Chun 1st WS §11

230 TUNG Wing Kei 1st WS §§6.4-6.6, 7.5-7.7

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during a fall — ultimately rendered him unable to remove himself from danger, leading to his tragic passing” (IFITF Report, §9.2.8.8 [ER1/194]);

2. The confirmed cause of death of [S]Fn HO was determined to be the adverse effects of fire and inhalation of fire fumes and smoke. Although the PPE was severely damaged due to prolonged contact with hot or burning objects, it continued to serve its intended purpose” (IFITF Report, §9.2.8.9 [ER1/194]);

3. “According to the Autopsy Report, [S]Fn HO died from inhalation of fire fumes and extensive burns, with head and neck injuries as other significant conditions contributing to the death.” (IFITF Report, §9.2.9.1 [ER1/194]).

Finally, the Government endorses the IFITF’s final remark that “[S]Fn HO demonstrated exceptional bravery and a deep sense of duty while responding to the incident. Despite the challenging and life-threatening conditions, he prioritized the safety of others over his own, exemplifying the highest standards of selflessness and dedication.” (IFITF Report, §9.2.9.2 [ER1/194]).

(ii) Other casualties and the Police’s Casualty Enquiry Unit (“CEU”)

Parallel to the DVIU’s physical recovery and identification work, the Police’s CEU served as the public-facing interface between the families of those affected and investigative machinery. Its role was to receive, collate and act upon enquiries from members of the public who believed their relatives or friends may have been involved in the fire, and to match that information against the casualty data being generated by the DVIU, hospitals and other sources.

As of 1800 hours on 13 January 2026, the CEU had received a total of 489 missing person reports. Of these: 196 reports related to 166 missing persons confirmed dead in the incident (165 by forensic examination, 1 by circumstantial

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evidence); 40 reports related to 37 missing persons confirmed injured; 31 reports

were non-pursuable due to insufficient information for further investigation; 1 was a misunderstanding; 31 related to individuals confirmed to have passed away before the fire; 6 related to individuals who had left Hong Kong before the fire; and 184 were confirmed safe231 [WS1/238, 240-244].

Nine firefighters who were carrying out firefighting and Search and Rescue Operations inside the blocks required hospitalisation due to heat exhaustion, physical exhaustion, breathing difficulties, smoke inhalation or being struck by falling objects232 [WS1/55].

The CEU operation was concluded on 26 January 2026, having operated continuously for two months. The sustained operation of the CEU across three progressively scaled-down phases ensured that every pursuable missing person report was resolved, and that the families of the deceased and injured were identified and notified through a single, coordinated channel.

(iii) Damage to property

The fire caused extensive damage to property across the WFC estate. Seven of the eight residential blocks were directly affected by fire; only Wang Chi House was spared from direct flame involvement, though it was not immune from the effects of smoke, water and falling debris in the surrounding area.

Across the seven affected buildings, a total of 1,736 flats were assessed. The IFITF Report records that the interiors of 924 flats sustained varying degrees of fire damage, while the interiors of the remaining 812 flats remained relatively unaffected, notwithstanding that the exterior of the buildings had been damaged by the high temperature with prolonged exposure to fire (IFITF Report §5.3.1

231 TSANG Shuk Yin (Chief Supt, CIIB, Police) §26, Annex 232 TANG Wing Wah 1st WS §60

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[ER1/62]). The damage ranged from total destruction of interior contents in units

directly penetrated by fire, to severe smoke damage, water damage from firefighting operations, and structural concerns arising from prolonged exposure to extreme heat.

The FSD conducted an internal assessment of all 1,736 units from a firefighting perspective. The DFS confirmed that this assessment was “just from the angle of firefighting” and constituted “an internal assessment by the FSD” that did not examine the buildings from a structural perspective [Day 19/104/16 – 105/10]. The IFITF also makes clear that such “figures and information about the residential flats…are only recording the observations of the interior condition of the flats, but not the assessment on the overall habituality of the concerned flats and the entire Wang Fuk Court” (IFITF Report §5.3.4 [ER1/63]).

Beyond the residential units, the fire caused significant damage to the common areas of the estate, including corridors, staircases, lift lobbies and rooftops. The bamboo scaffolding enclosing the buildings was largely consumed by the fire or collapsed onto the ground and surrounding roadways. The estate’s communal facilities, landscaping and vehicular access areas were also affected by the accumulation of burnt debris, fire-suppression water and operational footprint of the extended firefighting and recovery operation. The scale of property damage rendered WFC uninhabitable in the immediate aftermath, displacing the residents and necessitating the emergency accommodation arrangements described above.

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PART III(B): START OF THE FIRE

I. WORKERS SMOKING ONSITE

As mentioned, the IFITF concluded that the fire was most likely accidental in nature, caused by a glowing source such as a lit cigarette end igniting combustible materials at the flat roof outside Flats 104 and 105 of Wang Cheong House.

This section examines the evidence on the prevalence of workers smoking at the WFC construction site, the circumstantial link between smoking and the ignition of the fire, the primary responsibility of the contractor and PMC for site management, and the supervisory role of the LD.

As will be seen, the primary responsibility for this contributing factor lies squarely with Prestige as principal contractor, whose failure to enforce an effective no-smoking regime persisted despite repeated complaints from residents, documented observations by the PMC, and warnings issued by the LD.

Nevertheless, having regard to the WFC Fire, the Government acknowledges that the pre-fire regulatory framework warrants a review: smoking at construction sites was not an offence per se, and the threshold for the LD to exercise its prohibition power under Regulation 53 of the CSSR was high as it targets specific scenarios requiring the simultaneous presence threshold conditions. Such constraint in statutory control is being addressed through a legislative programme already underway.

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I1. Prevalence of workers smoking onsite

(i) The various complaints made by the WFC residents / IO to Prestige / Will Power, the PMC and LD

The evidence throughout the evidential hearings establishes that workers smoking at the WFC construction site was a persistent and well-documented problem throughout the renovation period.

The LD received nine complaints about smoking at the RMAA sites of WFC before the fire, lodged via multiple channels including the OSH Complaint Platform, email, OSH complaint hotline, and 1823 hotline 233 [WS1/352; WS1/356-376].

The PMC received repeated smoking complaints from residents, both by telephone and in person. Lok Sin Ying of ISS confirmed that residents would “complain by phone sometimes, and they would come face to face sometimes” [Day 6/122/7 – 123/11]. The PMC maintained a standalone Renovation Complaint Record logbook which contained multiple smoking entries, including workers smoking on the scaffolding [C1-1/749]. The recorded follow-up against these was consistently limited to “Inform Prestige” [Day 7/99/17-23].

Smoking complaints were raised in the WhatsApp group “宏福苑大維修” which served as a communication platform among the IO, ISS, Prestige and Will Power, as evidenced by the messages at [F4/1041, 1131, 1134, 1166, 1263, 1268, 1269, 1284, 1285]. Tsui Moon Come, the then Chairperson of the MC, confirmed in oral evidence that “there were many complaints from residents” in this regard [Day 14/92/11-12].

233 LI Man Pong 1st WS §62; LAM Sau Ching (Div. OSO, LD) 1st WS §§6-79

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Smoking complaints were also raised repeatedly in the regular renovation works

meetings, of which the PMC kept the minutes. These records document a persistent pattern across multiple months: on 12 September 2024, the IO raised workers smoking and proposed penalties with photo evidence; on 12 October 2024, Prestige blacklisted a scaffolder for smoking and not wearing a safety harness; on 4 January 2025, the IO again reminded Prestige to ensure no smoking on scaffolding; and on 15 March 2025, smoking was found to be persisting, and the IO gave Prestige one month to improve, with a designated smoking area to be set up and further breaches to be fined per occurrence234 [WS2/1268; C1-1/651]; [Day 8/44/22 - 45/15].

When asked whether there had been any improvement after the one-month deadline, Cheng Tsz-ying (Security Supervisor of ISS) confirmed “Not much improvement” [Day 8/45/6-18].

The PMC’s frontline staff also personally observed workers smoking onsite. Wong Pak-shing, a security guard, confirmed that from the start of the renovation works to the day of the fire, he personally took approximately four to five complaints about Prestige workers smoking onsite, and on one occasion went to Wang Yan House and found Prestige workers smoking near the 1st floor, shouting up from the ground floor to ask them to stop [WS2/1239]. Cheng confirmed that she “knew that there were construction workers smoking and there were complaints” and that she had personally seen “construction workers smoking” [Day 8/74/22 – 75/16].

234 Cheng Tsz-ying 1st WS §10

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(ii) The presence of photographic / video, contemporaneous and other factual

evidence showing workers smoking onsite

Beyond the complaints, direct evidence of smoking at the site was recovered after the fire. Prestige’s own in-house disciplinary measures provide further evidence of the recurring nature of the problem. Lam Sau-ching of the LD confirmed that Prestige had “in-house rules for prohibition of smoking on the site” under which “the worker would be fined by PC&E if he/she was found smoking on the site for the first time” and “if the worker was found smoking on the site again, he/she would not be allowed to work on the site anymore”235 [WS1/359]. SO-I Kwan of the LD was told by Prestige that “a worker had been banned from working on the site for violating the in-house rule of smoking” 236 [WS1/364]. The existence of these disciplinary measures confirms that smoking was sufficiently prevalent to require formal internal sanction.

Lam’s witness statement stated that, on the basis of the observations made during the inspections at WFC, “there is no cogent basis to suggest that smoking was prevalent in the renovation site at WFC” 237 [WS1/383]. Her evidence has to be understood in the context of the inspections conducted by reference to the narrow threshold requirements under Regulation 53 of the CSSR. In oral evidence, Lam candidly accepted the need for improvement in the initiative undertaken by the LD at WFC under existing legislation. When it was put to her that not personally seeing anyone smoking “doesn’t mean that nobody ever smoked there,” Lam fairly agreed. When it was further suggested that LD “could not gather the evidence successfully,” Lam confirmed: “Yes, you can put it this way. We could not get the evidence” [Day 16/13/19 - 14/11]. This is not to detract from the evidence from the complaints, CCTV footage, audio recording, Prestige’s own disciplinary record, and the PMC’s first-hand observations which now

235 LAM Sau Ching 1st WS §16 236 LAM Sau Ching 1st WS §33 237 LAM Sau Ching 1st WS §95

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collectively establishes that workers smoking at the WFC construction site was

prevalent throughout the renovation period. However, the point remains that such evidence alone would not suffice for the purpose of Regulation 53 of the CSSR: see Section I4 below.

I2. How workers smoking onsite resulted in start of the fire

(i) The relevant factual evidence

The fire originated from the flat roof outside Flats 104 and 105 of Wang Cheong House. CCTV footage and videos taken by members of the public point consistently to that location as the place where the initial fire took hold.

The debris excavated at the origin of the fire contained burnt remnants of carton paper boxes and other rubbish, together with cigarette ends. The accumulation of combustible waste materials at the point of origin, combined with the presence of cigarette ends, provides the evidential link between smoking and the ignition of the fire.

(ii) The IFITF’s investigations

The fire originated from the flat roof outside Flats 104 and 105 of Wang Cheong House. CCTV footage and videos taken by members of the public point consistently to that location as the place where the initial fire took hold.

As summariesd above, the IFITF concluded that the fire originated from the flat roof outside Flats 104 and 105 of Wang Cheong House (IFITF Report §§1.3.1,

1.1 [ER1/14, 73]). Excavations at the suspected point of origin revealed debris up to 2 metres high, consisting of construction materials “such as safety nets, toeboards, polystyrene window covers, carton paper boxes and backing paper from mosaic tiles” (IFITF Report §1.3.2 [ER1/14]). The accumulation of these

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combustible materials in the area “could have served as fuel for the fire” (IFITF

Report §6.1.6 [ER1/74]).

Two cigarette ends were discovered at the site (IFITF Report §1.3.2 [ER1/14]). Evidence of smoking at the construction site was widespread: numerous cigarette ends were discovered on the bamboo scaffolding of Wang Chi House; CCTV footage captured construction workers smoking on the roof floor of Wang Cheong House; and at least five occupants of Wang Cheong House had occasionally noticed the smell of smoke or the presence of cigarette butts on the scaffolding (IFITF Report §6.1.8 [ER1/74]). More broadly, 105 out of 2,011 residents who responded to statements and questionnaires reported “witnessing smoking, smelling cigarette smoke or noticing cigarette ends within Wang Fuk Court during the renovation period” (IFITF Report §6.1.8, fn 64 [ER1/74]).

I3. The primary and supervisory responsibilities for such contributing factor

(i) The regulatory and supervisory regime for workers smoking onsite

The principal legislative provision governing smoking at construction sites at the material time was Regulation 53 of the CSSR, which empowers the Commissioner for Labour to issue a written order prohibiting smoking and the use of naked lights at a construction site “where, in any construction site, any flammable liquid or any mixture containing any such liquid or any substance or thing which in the opinion of the Commissioner involves danger from fire is used or intended to be used.” A contractor responsible for a site in which such a prohibition is in effect must take “such steps to enforce the prohibition as the Commissioner may by notice direct.” Failure to comply is an offence punishable by a maximum fine of $400,000 for a contractor and $150,000 for a worker.

The LD’s prevailing interpretation of Regulation 53 of the CSSR required the coexistence of all three elements of the fire triangle (a source of ignition, fuel and

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oxygen) at the same place of work simultaneously. Li Man-pong of the LD stated:

“According to OSOs’ training, ‘involves danger from fire’ in regulation 53 of the CSSR means that all three elements of a fire triangle (i.e. a source of ignition, fuel and oxygen) are found to coexist at the same time at a place of work”238 [WS1/347]. In actual daily operation, this refers to the coexistence of (i) flammable liquid / substance / thing and (ii) naked lights for hot work / heats / smoking, or them being in proximity of each other [WS1/347]. He further confirmed that “the coexistence of these conditions is rarely seen on site, making the issuance of prohibition notices for smoking quite uncommon” 239 [WS1/347].

The consequence of this interpretation was a high threshold for enforcement. No prosecutions have been initiated under Regulation 53 of the CSSR in the past decade240 [WS1/353]. When asked whether the ban had ever been imposed, Murphy Yuen of the LD confirmed from memory that it had been imposed on some occasion, but no prosecution had been initiated under Regulation 53 of the CSSR for the past decade [Day 16/94/19-22]. No prohibition of smoking notice was issued in respect of WFC241 [WS1/384].

Li Man-pong confirmed in oral evidence that even the presence of foam boards on the scaffolding would not, in the LD’s pre-fire analysis, have triggered the threshold for a smoking ban, because foam boards are “combustible but they’re not flammable materials” within the meaning of Regulation 53 of the CSSR [Day 16/69/20 - 70/2]. The pre-fire regulatory position was therefore that smoking at a construction site was not an offence per se; it could only be prohibited where flammable substances were present and danger from fire was involved.

238 LI Man-pong 1st WS §43

239 LI Man-pong 1st WS §44

240 LI Man-pong 1st WS §63

241 LAM Sau Ching 1st WS §96

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(ii) The primary responsibilities of Prestige and the PMC, including site

management

Under section 6A of the FIUO and section 6(1) of the OSHO, the employer, including the principal contractor, must so far as reasonably practicable ensure the safety and health of all employees at work. This encompasses the provision and maintenance of safe systems of work, provision of information, instruction, training and supervision, and maintenance of a working environment that is safe and without risks to health.

Prestige bore primary responsibility for site safety management at WFC. The evidence establishes that Prestige had actual knowledge that workers continued to smoke outside the designated area notwithstanding the in-house rules. As mentioned in Section I1(i) above, smoking complaints were raised directly with Prestige through multiple channels: residents complained to the PMC by telephone and in person, and the PMC proceeded to liaise with Prestige; complaints were raised in the WhatsApp group which included Prestige as a participant; and smoking was raised repeatedly at the regular renovation works meetings attended by Prestige.

Yet the smoking persisted throughout the renovation period; the PMC confirmed “not much improvement” even after the March 2025 ultimatum imposed by the IO as mentioned above.

More broadly, Lam Sau-ching of the LD confirmed that the contractor bears responsibility for overall site safety management. It was “not acceptable” for workers not to have undergone safety induction training, and that “the contractors hire the safety officers, and the safety officers do have the duty about safety on site” [Day 16/12/18 – 13/5].

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The site management failure extended beyond smoking to the accumulation of

combustible debris at the point of origin. The failure to ensure frequent clearance of construction garbage and debris from the flat roof adjacent to Flats 104 and 105 was a site management failure squarely within Prestige’s primary responsibility as principal contractor.

The PMC’s role in relation to smoking was limited but not non-existent. ISS bore contractual obligations under the Property Management Agreement to identify and follow up on fire risks. Cheng of ISS confirmed that “in relation to fire risk complaints it seems ISS has a contractual obligation to record, investigate and liaise and follow up on the matter with the relevant government department” [Day 8/34/10-16]. The ISS Security Manual treated identification of potential fire risks as a core purpose of patrol [H1-3/6639]. However, ISS’s actual response to smoking complaints was limited to relaying them to Prestige. Wong Pak-shing of ISS agreed that the management office was “playing the role of passing on the message” [Day 7/100/21 - 101/11]. Cheng accepted: “We simply cannot control the Prestige workers. We cannot really dismiss them” [Day 8/47/13-25]. She further accepted that ISS “hasn’t taken any further action to deal with this” beyond referring complaints to Prestige [Day 8/48/1-5], and that ISS had “the responsibility to make sure everything is in order” [Day 8/52/2-7].

(iii) The Government’s supervisory responsibilities

The LD’s primary mandate is to administer and enforce occupational safety and health legislation to protect employees at work. Its professional expertise is in OSH, not building fire safety. As Murphy Yuen of the LD confirmed: “Materials such as foam boards used to seal residents’ windows are consequently not the focus of LD’s inspections. Also, fire safety measures in public places, including

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firefighting equipment, fire alarms, staircases servicing as means of escape, etc., are not within LD’s purview”242 [WS1/325].

The Chairman identified an apparent ‘oddity’ in this arrangement: “I find something odd. So the Labour Department focuses on OSH, occupational safety and health, so it’s about protecting workers. But the fire hazard has to do with a different group of people: the residents. Getting the Labour Department to take charge of such matters at the policy level seems weird.” Li Man-pong responded by clarifying that he was speaking from the workers’ perspective: “a fire hazard for the public also means fire hazard for workers” [Day 16/66/5-17]. Counsel for the Committee agreed with Li that “fire prevention, if this responsibility is put on you, it’s not fair to the Labour Department” and that “government departments should collectively play a monitoring and supervisory role”; Li agreed [Day 16/67/9-15].

The LD’s enforcement regime operates on a risk-based inspection model. Taking into account the nature and risk levels of work processes and scale of works, the inspection frequency is generally set at one to two months243 [WS1/338; Day 16/3/19-23].

For WFC specifically, OSOs conducted inspections in a frequency “higher than the normal frequency of once every one to two months” (i.e. almost every month [Day 16/5/11-17]) as a result of the number of complaints received244 [WS1/339].

The LD’s enforcement options range across four tiers: prosecution, suspension notices, improvement notices, and warning letters. Officers exercise professional

242 YUEN Tsz Lok 1st WS §39 243 LI Man Pong 1st WS §22

244 LI Man Pong 1st WS §24

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judgment, discretion and common sense in selecting the appropriate response

based on the gravity of the offence [D1/1724].

(iv) The actions taken by the LD at WFC

The LD conducted 16 inspections plus one surprise surveillance visit at WFC between July 2024 and 20 November 2025245 [WS1/356; WS13/2108].

All inspections were conducted on a surprise basis; no prior notice was given to contractors, RIs or building management246 [WS13/2107-2108]. This practice was confirmed by internal LD email: “inspections of workplaces shall be surprise in nature. No inspection schedules shall be disclosed to any third party, including consultants, in advance” [D2/1981].

Regarding the smoking complaints specifically, the consistent finding on every inspection was that no worker was observed smoking in working areas. Lam’s evidence is that “no worker was found smoking on the site during the inspection” 247 [WS1/357]. Workers were found smoking “at the designated smoking area set up by PC&E at the open ground between Wang Chi House and Wang Shing House”248 [WS1/359]. On some inspections, cigarette stubs were found in common areas of the estate, though it was unclear whether they were left by workers or others [Day 16/13/12-14].

The LD issued three Construction Site Inspection Reports (CSIRs) dated 2 August 2024, 9 August 2024 and 2 September 2024 reminding Prestige that steps shall be taken to ensure that “smoking or the use of naked lights is prohibited in

245 LAM Sau Ching 1st WS §6; 3rd WS §7

246 LAM Sau Ching 3rd WS §§5-6

247 LAM Sau Ching 1st WS §10

248 LAM Sau Ching 1st WS §15

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a site where flammable liquid or any mixture containing such liquid or any substance or thing which involves danger from fire is used”249 [WS1/358–360].

The LD also initiated criminal prosecution against Prestige and its scaffold subcontractor Gain Profit Shed Industry Limited (“GPSI”) for working-at-height offences, resulting in three summonses. On 3 October 2025, Prestige was convicted and fined $18,000, and GPSI was convicted and fined $12,000 250 [WS1/365].

(v) The role of the FSD

Workers smoking at construction sites generally does not fall within the enforcement purview of the FSD. When the LD referred 251 the smoking complaint to the FSD in July 2024, the FSD’s reply was that “the subject matter is not under the jurisdiction of FSD. You may wish to refer the case to the relevant department” [D1/930].

AD Yung confirmed this position in oral evidence. When asked which department should handle complaints about smoking on construction sites, he stated that such complaints should go to the LD [Day 17/6/22-23]. He acknowledged, however, that the FSD’s statutory concern under section 7(c) of the FSO “goes beyond just active provisions” and that the broad definition of “fire hazard” under section 2 of the FSO (Cap. 95) encompasses “matter or circumstances which materially increases the likelihood of fire or the danger to life or property” [Day 17/9/17-10/13]. AD Yung accepted that the FSD’s concern

249 LAM Sau Ching 1st WS §§13, 18, 23

250 LAM Sau Ching 1st WS fn 6

251 For the avoidance of doubt, the LD’s referral to FSD did not reflect any view on the LD’s part that smoking

at construction sites fell outside its own purview. The referral to the FSD was made because the complainant had expressly invoked the Fire Services Ordinance in the complaint, as confirmed in Lam’s oral evidence [Day 16/16/8-10].

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therefore extends beyond active fire safety provisions to any matter that

materially increases fire risk [Day 17/10/17-21].

I4. Systemic and/or operational weaknesses on the regulatory level

The evidence reveals three areas requiring review and improvements.

First, the high threshold under Regulation 53 of the CSSR meant that smoking per se was not an offence at construction sites, and no enforcement tool was available to the LD unless the threshold conditions under Regulation 53 were simultaneously present. This was a structural design of the existing legislative framework with regard to the policy intent – the CSSR focuses on workers’ safety rather than smoking. No prosecutions have been initiated under Regulation 53 of the CSSR in the past decade252 [WS1/353], demonstrating that the threshold was consistently rarely met across the industry, not merely at WFC. The result was that the Government did not have a specific regulatory mechanism in place to tackle the fire risk posed by workers smoking on scaffolding as such.

Second, the LD officers were unable to gather direct evidence of workers smoking in working areas during surprise inspections. The nature of the act (transient, easily concealed upon the approach of inspectors) made detection inherently difficult during inspections that OSOs conducted. In this regard, whilst the “could not be justified” language used in the LD’s complaint-disposal records might appear inapt when considered on a standalone basis focusing on the act of smoking per se, properly construed the conclusion that a complaint “could not be justified” in the context of Regulation 53 of the CSSR reflected only that the specific statutory threshold for enforcement action was not met on the evidence

252 LI Man Pong 1st WS §63

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available at the time; it did not mean (albeit that it may be perceived to suggest)

the complaint was baseless

In direct response to the identified regulatory constraint, the Government has on 19 May 2026 introduced into the Legislative Council a comprehensive legislative package [D4/1988-2003, 2004], as also outlined in Murphy Yuen’s oral evidence [Day 16/92-93], proposing to:

1. amend the Smoking (Public Health) Ordinance (Cap. 371) to designate all construction sites, irrespective of size, as no-smoking areas and to impose a fixed penalty of HK$3,000 under the Fixed Penalty (Smoking Offences) Ordinance (Cap. 600) on any person smoking at a construction site [D4/1990-1991].

2. amend the Fixed Penalty (Smoking Offences) Ordinance (Cap. 600) to empower an OSO to issue fix penalty notices to a person who is committing or has committed the smoking offence [D4/1992].

3. amend Regulation 53 of the CSSR to impose a positive duty on contractors responsible for a construction site to take all reasonable measures to ensure that no person smokes or carries a lighted specified smoking product (e.g. cigarettes) or uses naked light to light a specified smoking product in a construction site [D4/1991].

The combined effect of these improvement measures is expected to fundamentally alter the enforcement landscape.

1. First and foremost, the constraint which was the principal obstacle to enforcement at WFC, namely that smoking per se was not an offence under the OSH legislation, requiring the LD to prove the simultaneous presence

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of flammable materials before any enforcement action could be taken [Day

16/30/25 - 31/5], is being addressed. As a result, enforcement actions may be taken by the LD once any person is found to be smoking at a construction site. It is no longer necessary for the threshold conditions under Regulation 53 of the CSSR to be established before the LD may take enforcement actions.

2. Secondly, even if the officers of LD could not see anyone smoking at a construction site or could not ascertain the identity of the person smoking at a construction site, they may still take enforcement actions if the contractors fail to take all reasonable measures to prevent smoking at a construction site. As Lam of the LD confirmed: “After the Construction Sites (Safety) Regulation is amended, with a smoking ban in effect on the construction site, the contractor will be under a duty to prevent smoking. Even when officers do not see any workers smoking, we can rely on photos from residents or other people, and that will be enough evidence for us to pursue prosecution” [Day 16/55/24 - 56/16].

3. Thirdly, with the above obstacle of the threshold conditions removed, evidence of smoking (including photographic and video evidence from residents which could previously only serve as corroborative material [Day 16/31/17]) will become a sufficient basis for prosecution of the new offence [Day 16/100/10-12]. Yuen of the LD also confirmed the same: “If smoking is to be banned, then through the information given by the complainant, we can use the evidence as a basis to consider prosecution” [Day 16/100/10-12].

In terms of enforcement methodology, the LD is exploring the use of drones and other technology to assist evidence-gathering for the new smoking ban [Day

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16/100/10-17] (Table of Improvement Measures, Item E1). The Chairman

observed that “the government is looking into amending the law or maybe use drones in the future to help with enforcement” [Day 16/30/18-23].

Member Au-yeung also echoed the point that “what is difficult at the moment is that you need to see it with your own eyes. Other than raising the penalty, I do not see any changes made to enforcement” [Day 16/100/18-21]. In response to Member Au-yeung’s concern, the Government emphasises that the proposed improvement measures go beyond raising penalties: by making smoking per se an offence at construction sites and extending the liability to cover contractors’ failure to take all reasonable measures to prevent smoking, the expectation is to fundamentally change the enforcement landscape by removing the requirement to prove the coexistence of flammable materials, and by enabling the LD to rely on evidence from third parties (including residents’ photographs and videos) on top of direct observation by LD officers during inspections. For the avoidance of doubt, whilst it may be said that the LD could equally rely on evidence from third parties in the past, the point is that such evidence per se is not sufficient for prosecution in the past (and hence of limited value), whereas under the proposed new legislation, such evidence should suffice on its own to substantiate the bringing of prosecution. In this regard, the exploration of drone-assisted enforcement is also a direct response to this concern.

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PART III(C): RAPID SPREAD OF THE FIRE

J. THE USE OF SCAFFOLDING NETS UNCERTIFIED FOR FR PROPERTIES

The IFITF’s findings establish that the presence of scaffolding nets uncertified for FR properties was one of the most critical contributing factors to the rapid spread of the fire. In small fire size cases, the CFD simulations demonstrated that with FR-certified nets, the fire could not sustain itself; with non-FR nets, the result was significant fire spread and severe fire development.

This section examines the factual evidence on the use of such nets at WFC, the complaints raised, the unreliable certificate presented by Prestige, the causal link to fire spread established by the IFITF, and the respective responsibilities of the contractor, RI, and relevant Government departments.

The primary responsibility for this contributing factor lies with Prestige, which deliberately directed the supply and use of nets that were non-FR certified (in contravention of the recognised standards) and furnished a test certificate (which is at least suspected to have been fabricated) to conceal the non-compliance, and with Will Power and the RI, who bore the statutory duty to ensure compliance and failed to discharge it.

The Government also acknowledges that the supervisory mechanisms contained areas requiring review and improvements that the evidence has exposed. These areas are addressed below, together with the improvement measures that have since been introduced.

J1. Use of scaffolding nets uncertified for FR properties at WFC

The evidence before the Committee establishes that non-FR certified scaffolding nets were used at WFC.

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The witness statement of Chan Yiu-fai (of Gain Profit Shed Industry Limited

(“Gain Profit”), a supplier engaged by Prestige) establishes the chain of instruction from Prestige to the supplier. Chan states that after the first typhoon in July 2025, Gordon (Ho Kin-yip, a director of Prestige) contacted him and asked him to procure replacement nets. When Chan explained that the WFC project required FR nets and suggested using FR nets (whose cost with shipping was not significantly different from ordinary nets), Gordon instructed him: “叫你訂就訂，

唔使講咁多，你訂阻燃網都唔會找數俾你” (just order what I tell you to order, don't say so much; if you order FR nets I won't pay you for them)253 [WS2/1437].

Chan raised the issue with Hau Wa-kin (another director of Prestige), who told him to follow Gordon’s instructions. Chan accordingly procured 450 sheets of ordinary (non-FR certified) nets for Prestige254 [WS2/1437-1438].

The same pattern was repeated following Typhoon Ragasa in September 2025: Gordon again instructed Chan to order 4,500 sheets of ordinary nets, and when Chan once more explained that FR nets were required and that the price difference was modest, Gordon again insisted on ordinary nets255 [WS2/1438-1439].

Chan’s evidence further records that on 27 October 2025, Gordon called him to urgently order 115 sheets of FR nets because of a LD inspection prompted by the Chinachem Tower fire, requiring Prestige to selectively replace ordinary nets with FR nets ahead of the inspection256 [WS2/1439-1440]. This is corroborated by a WhatsApp message from Sam Tam of Prestige to Hau Wa-kin on 27 October 2025 at 09:54 am stating: “（不公開）明天下午預 ICU 到地盤預要燒棚網 check 定邊啲 ok” (confidential: tomorrow afternoon expect ICU to come to site,

253 Chan Yiu-fai 1st WS §14

254 Chan Yiu-fai 1st WS §14 255 Chan Yiu-fai 1st WS §16 256 Chan Yiu-fai 1st WS §17

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expect they will burn-test the scaffolding nets, check which ones are ok) [A2/item

95]. This demonstrates that Prestige was not only aware the nets on site were nonFR, but was internally coordinating to identify which nets would pass testing and to selectively replace non-compliant nets with compliant ones specifically to deceive the regulatory authorities during the anticipated inspection.

WeChat discussions between Chan and a Mainland manufacturer (濱州市源進

化纖繩網有限公司) in September 2025 confirm that Chan was actively seeking the supply of non-FR certified nets for WFC [A2/item 111].

1. Chan placed an order expressly specified as “綠色不阻燃” (green, nonFR), 1.8 by 17 metres, in a quantity of 2,500 sheets at RMB 24 per sheet (totalling RMB 60,000), for delivery to Guangdong/Shenzhen [A2/item 111]. The manufacturer confirmed the order and arranged shipment, with delivery expected around 1 to 3 October 2025.

2. On 13 October 2025, approximately ten days after the delivery, Chan asked the same manufacturer whether there was any FR agent (“阻燃劑”) that could be applied to the nets after they had already been erected (“等網掛上去，它要改阻燃的，有沒有那個阻燃劑可以賣給我 ”). The manufacturer replied: “不能後加. 這個都是一開始拉絲的時候添加進去的” (it cannot be added afterwards; it has to be added at the stage of drawing the filaments). When Chan pressed further, asking whether there was any FR agent that could be sprayed on the nets after installation (“也沒有那個阻燃劑可以後加噴一點在上面”), the manufacturer confirmed: “沒有那種的啊陳總” (there is no such thing). The manufacturer then suggested: “能不能跟工地商量一下，下次直接發阻燃的” (can you discuss with the site to just send FR ones next time) [A2/item 111]. This

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exchange demonstrates not only that the nets delivered in October 2025

were non-FR certified, but also that there was active consideration of how to disguise their non-compliance after installation, a consideration that was ultimately frustrated by the technical impossibility of retrofitting FR properties.

Further, WhatsApp messages between Chan Yiu-fai and Zhong Fengping (Chan’s wife) on 26 November 2025 (the day of the fire) provide further corroborating evidence that the nets which had been delivered to WFC were nonFR certified [A2/item 112].

1. Zhong sent WhatsApp voice messages to Chan (her husband) stating: “宏福苑火燭呀，你嗱嗱聲打電話搞掂佢啦” (Wang Fuk Court is on fire, hurry up and call to sort it out), followed immediately by: “仲有啊，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嘛” (Also, the nets we delivered later, Ah Tim is asking you to explain it away, align your story and call him, because ours are not FR nets) [A2/item 112].

2. This message constitutes an admission that the nets supplied by Chan to WFC were not FR-certified, and further demonstrates an immediate attempt to coordinate a cover story upon learning of the fire.

The forensic evidence from the Government Laboratory independently corroborates the above. Dr Lee confirmed that of 5 samples tested from Wang Cheong House (the block where the fire originated), 4 had after-flame times exceeding the 4-second threshold under GB 5725-2009, meaning 80% of available samples failed the standard [Day 25/103/7-14]. Dr Lee explained the apparent anomaly that some samples from other blocks appeared compliant: there

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were constraints at the scene because non-FR nets are more easily consumed by

fire. As Dr Lee confirmed: “the remaining samples, they can be tested. The percentage of them fulfilling the criteria would be high because all the non-FR nets might have already been burned through” [Day 25/100/18-23]. This selection limitation means that the proportion of non-FR nets actually present at WFC was likely significantly higher than the tested sample set indicates.

Taken together, this evidence demonstrates that Prestige, through its directors and its supply chain, knowingly supplied and used, and directed the purchase and use, of scaffolding nets uncertified for FR properties, and did so on multiple occasions including replacement batches supplied as recently as September 2025, just two months before the fire. The test certificate furnished to the LD and ICU purporting to demonstrate FR compliance did not correspond to the nets actually installed at WFC.

(i) The various complaints made by the WFC residents / IO to Prestige / Will Power, the PMC and Government Departments

Multiple complaints were made to government departments raising concerns about the FR properties of scaffolding nets at WFC.

On 5 October 2024, the ICU was copied in an email in which “the enquirer raised concerns on the fire risks of the WFC Renovation and stressed the importance of ensuring the fire-retardant properties of the scaffolding nets”257 [WS14/2134]. Around the same time, ICU also received “several other complaints and enquiries, covering issues including use of foam boards, quality of bamboo scaffolding, etc., pertaining to the WFC Renovation” 258 [WS14/2134].

257 KU Siu Ping 3rd WS §17 258 KU Siu Ping 3rd WS §17

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The ICU received a further complaint in October 2025 about aging of old

scaffolding nets following Typhoon Ragasa 259 [WS14/2141]. The ICU sent reminder emails to the RI and conducted a site inspection on 28 October 2025260 [WS14/2141-2142].

From the LD’s perspective, the FR issue was first engaged during the 1st Inspection of the site on 22 July 2024, when SO-I Kwan “proactively requested PC&E to provide the relevant test report(s) of scaffolding nets to confirm their compliance with the fire-retardant standards stipulated in the Code of Practice for Bamboo Scaffolding Safety (5th Edition), which was not yet in force at the time”261 [WS1/378].

(ii) The relevant conversation records and other factual evidence

In response to the LD’s request, Prestige furnished a test report on 24 July 2024 [D1/1550, 1599-1603].

1. The report stated that the FR property of the scaffolding nets met the standard of GB 5725-2009, which is one of the acceptable standards stipulated in the 5th edition CoP [D1/709] [WS1/378].

2. The certificate showed a specimen and manufacture date of 5 January 2024 and was issued on 8 January 2024.

3. SO-I Kwan also obtained a delivery note [D1/1604] from Prestige, which showed that the manufacturer made a direct delivery of the scaffolding nets to WFC after the FR test262 [WS1/379].

259 KU Siu Ping 3rd WS §38

260 KU Siu Ping 3rd WS §§38-40 261 LAM Sau Ching 1st WS §81 262 LAM Sau Ching 1st WS §82

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4. On the face of the documentation, the certificate appeared regular: issued

by a laboratory purportedly testing against GB 5725-2009, with a traceable delivery chain.

In view of the complaints and enquiries received involving multiple issues of concern in September and October 2024, the ICU issued an email to the RI on 22 October 2024 “requiring that he took immediate actions to address such issues, as well as asking for the arrangement of a site inspection for ICU to better understand the circumstances” 263 [WS14/2134]. The date and time of the inspection (10:00 am on 28 October 2024) were confirmed the following day264 [WS14/2134].

Following the Chinachem Tower fire in October 2025, the ICU took the initiative to send reminder emails to the RIs of all five courts under its purview, including WFC, on 23 October 2025 and 27 October 2025, “reminding them to ensure that the scaffolding was in good condition and that the fire-retardant properties of the scaffolding nets remained fully in compliance with the requirements of BD’s circular and LD’s Code of Practice for Bamboo Scaffolding Safety” 265 [WS14/2140-2141].

(iii) The unreliable test certificate presented by Prestige

It was only after the fire that the ICU discovered the test certificate provided by Prestige was unreliable. Ku of the ICU confirmed: “After the fire there is a number and there is some discrepancy regarding two characters in the name of the agency” [Day 22/92/7-22]. Ku also accepted that “if you just rely on the

263 KU Siu Ping 3rd WS §18

264 KU Siu Ping 3rd WS §18

265 KU Siu Ping 3rd WS §§35-36

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certificate or the standard thereon, it’d be difficult for you to check whether the scaffolding nets were not authentic” [Day 22/105/23 - 106/1].

From the LD’s perspective, the same test certificate was received a second time on 20 November 2025, during the 16th inspection, when replacement nets were installed after typhoon damage [D1/1685-1689, 1693]. The LD “focused on the test result but did not notice at the material time that the report received was the same as the one LD received on 24 July 2024”266 [WS1/379]. Lam accepted in oral evidence that this was “an area that should have been improved” [Day 16/37/23 - 38/9].

J2. How the use of scaffolding nets uncertified for FR properties resulted in rapid spread of the fire

(i) The relevant factual evidence

Witness accounts and CCTV footage revealed that burning safety nets melted and dripped as fire droplets onto lower floors, serving as an ignition source for other combustible materials on the scaffolding below. Wind-carried embers, including fragments of burning netting, travelled to nearby structures where they ignited safety nets, construction debris and other combustible materials on adjacent blocks (IFITF Report §§6.2.3.1-6.2.3.3 [ER1/85])

(ii) The IFITF’s investigations and expert evidence

The IFITF’s investigations, addressed in detail in Section G4 above, established that the presence of safety nets potentially lacking FR properties was a critical factor in the rapid spread. The IFITF Report concluded: “if these nets were made of FR materials, even if ignited, the fire would likely have self-extinguished after the removal of the heat source, thereby minimizing the risk of igniting other combustible materials and reducing the overall spread of the fire” (IFITF Report

266 LAM Sau Ching 1st WS §83

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§6.2.3.4 [ER1/86]). In small fire size cases, the CFD simulations confirmed that

“the use of Sample 2 (FR) safety nets showed that the fire could not sustain itself, with no rapid fire spread having occurred. In contrast, the use of Sample 3 (nonFR) safety nets... resulted in significant fire spread and severe fire development” (IFITF Report §7.3.5.2 [ER1/125]).

The full-scale fire tests conducted in Sichuan and CFD simulations “highlighted the critical role of FR safety nets in mitigating fire risks. FR safety nets significantly reduced the likelihood of fire propagation by preventing secondary ignitions and self-extinguishing small fires once the external heat source was removed. In contrast, uncertified, non-FR safety nets and samples collected from Wang Chi House sustained small fire propagation and generated flaming droplets that ignited other combustible scaffolding components, such as nylon strips, toe-boards and wooden planks” (IFITF Report §8.6.1.1 [ER1/174]).

J3. The primary and supervisory responsibilities for such contributing factor

(i) The FR standards and other requirements applicable to scaffolding nets administered by the BD

Before the fire, the BD’s regulatory framework (through multiple publications) already required scaffolding protective materials to possess FR properties meeting recognised standards.

The relevant publications included clause F5.6(e) of the FS Code [J1-2/4169], paragraph 4(a) of PNAP APP-70 [J1-1/688], paragraph 4(a) of PNRC 26 [J1-1/689], paragraph 6.15 under Part C of the Guidelines on the Design and Construction of Bamboo Scaffolds [J1-1/1983], clause 11.2.10 of the Technical Guidelines on the Minor Works Control System (2024 edition) [J1-1/2917], and

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the circular letter to PBPs and RCs dated 21 March 2023 267 [J1-2/5915]

[WS1/766].

The March 2023 circular letter, issued following the Mariners’ Club fire, specifically stated that “protective net, screen, tarpaulin/plastic sheeting installed to cover the façade of buildings under construction, demolition, repair or minor works should have appropriate fire retardant properties in compliance with a recognised standard,” and listed three examples: GB 5725-2009, BS 5867-2:2008 (Type B performance requirements), and NFPA 701:2019 (Test Method 2) [J1-2/5915].

The LD’s Code of Practice for Bamboo Scaffolding Safety reinforced similar standards.

1. The 4th edition (prevailing until October 2024) required protective screens to be of FR material, but only specified standards for tarpaulin, not for nylon nets [D1/654].

2. The 5th edition, gazetted on 19 April 2024 and effective from 19 October 2024, explicitly extended the FR requirement to “protective net, screen, tarpaulin/plastic sheeting installed on the face” [D1/709] and specified examples of recognised standards including GB 5725-2009, BS 5867-2:2008 and NFPA 701:2019.

3. The 5th edition was the product of inter-departmental collaboration: the BD was consulted on the proposed amendments [D1/1932-1934], and the LD incorporated the BD’s FR requirements to achieve “a set of unified

267 PANG Yuk-lung 1st WS §135

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requirements across the relevant government departments to facilitate the compliance of the industry”268 [WS1/321].

Lam of the LD confirmed that comparing the two editions, the 5th edition was “sufficiently clear” in extending the FR requirement to nylon nets [Day 16/42/11

43/9].

For WFC specifically, the building-safety regulation of scaffolding nets fell under the ICU (not the BD directly) by virtue of the ICU’s delegated authority under the BO for sold HOS buildings. Ku confirmed that the BD’s circular letter of 21 March 2023 set out the recognised FR standards and that “the test report we received demonstrated compliance with the GB 5725-2009 standard” 269 [WS14/2138].

(ii) The primary responsibilities of Prestige and the RI

Under the BO regulatory regime, the primary statutory obligation to ensure scaffolding protective materials met FR requirements lay with the RC and RI.

Sections 3 and 16 of the B(C)R require that all materials used in building works must be of a nature and quality suitable for their intended use, adequately tested by recognised tests, and that appropriate precautionary measures must be taken [J1-2/5727, 5735-5736]. As AD Lawsons Yue of the BD confirmed: “PBPs and RCs are required to ensure that protective materials meeting the required fire retardant standards are used in building works under sections 3 and 16 of the B(C)R”270 [WS1/822].

268 YUEN Tsz Lok 1st WS §31 269 KU Siu Ping 3rd WS §28

270 YUE Chak Sang 1st WS §35

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Under the MBIS, the RI has specific statutory responsibility. According to section

30D of the BO, an appointed RI “is responsible for providing proper supervision of the carrying out of the MBIS-prescribed repair and ensuring that the repair materials to be used are not defective and comply with all relevant Ordinances and Regulations, as well as codes of practice and practice notes”271 [WS14/2128].

The ICU does not separately verify or certify building materials under the MBIS: “Given the RI’s responsibility to ensure compliance of the materials with the relevant standards, there is no separate or additional requirement to seek approval from the ICU regarding the choice and use of building materials. Further, in line with BD’s practice, the ICU does not verify and certify building materials or carry out sample testing and periodical checks on the building materials used”272 [WS1/640].

The deliberate manipulation by Prestige demonstrated by the evidence set out at §§490-497 above (directing the supply and use of nets that were not FR-certified, furnishing an unreliable test certificate and, as the evidence indicates, selectively replacing nets to deceive inspectors), if proven, goes to the heart of primary responsibility. Ku stated: “We however could not have imagined and it was not foreseeable at that time that the RI / RC would deceive ICU or resort to the deliberate calculated moves through selective replacements of nets, noting that doing so would have required considerable effort and expense in sourcing and installing compliant nets specifically for the purpose of deceiving ICU. Such conduct, if proven, would represent a serious and deliberate subversion of the inspection process that ICU could not reasonably have been expected to anticipate or guard against”273 [WS14/2143].

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(iii) The Government’s supervisory responsibilities

The ICU agreed that issues relating to scaffolding net fire risks fall within its purview [Day 22/38/6-8]. The ICU’s supervisory role is exercised through complaint-handling and audit checks. As Ku confirmed: “A documentary audit will not enable you to spot whether the construction method is compliant or not; you can’t tell from a documentary check... You rely on the RI... Under the system” [Day 22/29/16-24].

The ICU had not met the RI (Ng Yeuk) at any point and received no replies from him directly [Day 22/53/24 - 54/1]. Under the MBIS regime, “there is no statutory requirement for the ICU to supervise and conduct regular/ad hoc inspections of works” 274 [WS1/638]. The system is designed as a two-point monitoring mechanism: the ICU monitors the RI at submission of the inspection report and at completion; “there is no one monitoring the RI during the construction process unless there are complaints against RI” [Day 22/30/5-8]. Ku of the ICU confirmed this directly, “For the MBIS, one document would cover the entire housing estate... Under the MBIS from the start to the end of works, there is no requirement regarding regular inspections. It mainly targets complaints, about the handling of complaints” [Day 22/30/5-8].

From the LD’s perspective, the supervisory role was complementary. The LD’s primary responsibility for scaffolding nets derives from the Code of Practice for Bamboo Scaffolding Safety and Regulation 49 of the CSSR, requiring contractors to provide FR protective nets on the faces of scaffolds. Inspection of FR certificates is conducted “on a need basis. If fire is a prevailing risk on site or there is any complaint in relation to fire risks on scaffolding, contractors will be requested to provide fire retardant certificates of scaffolding nets to confirm their

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compliance”275 [WS1/341]. The LD’s frontline officers “do not have the requisite

expertise to authenticate or verify the certificates” issued by specialist laboratories276 [WS1/342]. Lam of the LD confirmed: “we don’t have the relevant professional expertise. We do not do any sampling, we do not take this for testing” [Day 16/38/20-22].

The LD’s position is that the BD, as the authority setting the FR standards for scaffolding protective nets, “should also be the authority taking the lead in specifying whether and how checks and inspections, such as fire-retardant test or sample taking of protective nets for testing by recognised laboratories, should be conducted to ensure compliance of the relevant requirement in a coherent manner”277 [WS1/322].

(iv) The actions taken by the ICU at WFC, including the ICU’s practice of giving advance notice

The ICU conducted three site inspections involving scaffolding net quick tests: 28 October 2024, 18 November 2024, and 28 October 2025. Ku confirmed: “a total of 17 spots were randomly picked by me for conducting quick tests. No prior notice of the precise location of such spots was given to the RI/RC” 278 [WS14/2133-2134].

The ICU primarily relied on the (now known to be unreliable) test certificate; the quick tests “served to provide a practical (albeit rough) indication of the fireretardancy of the scaffolding nets under actual site conditions” and were “conducted to provide a further quick reference, as they could be administered

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readily without much time and costs as a handy cross-check”279 [WS14/2135-

2136].

On 28 October 2024, the first quick test on the rooftop showed the net igniting for more than 10 seconds. Ku of the ICU confirmed in oral evidence that this was “problematic” at the time [Day 22/82/1-2], but before any further action could be considered, the RC’s representative immediately blew out the flame and re-tested the same piece twice; for both subsequent attempts the sample was not ignited [Day 22/81/8 - 83/11]. Quick tests conducted at two other locations of WFC were also satisfactory on that day. Importantly, as Ku explained, there was room for improvement (such as what resulted from time constraints) in the inspection on 28 October 2024 which was concerned with a host of other issues. Hence, Ku took the initiative to conduct a more focused inspection on 18 November 2024 to conduct 12 additional quick tests of nets on random locations at WFC to verify the result and allay his concern. It is thus not entirely fair to expect Ku to focus only on a single quick test result whilst ignoring the rest especially given the immediacy of the re-tests on the same piece of sample. Even if one is to focus on the single quick test result alone, Ku explained that “we considered such arrangement acceptable since it is not uncommon to re-test the same sample to confirm the test result after a failed attempt for the first time” 280 [WS14/2137]. Given that the two re-tests produced negative results, and coupled with the test report provided by the RC’s representative and further quick tests conducted at a larger scale on 18 November 2024, the ICU did not raise further concerns on the whole. Whilst there is room for improvements, in fairness the matter should also be viewed holistically and in context. Further, without shying away from the above, the mitigation is that the underlying cause was deliberate deception

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through selective net replacement, which could not reasonably have been detected

by a quick test alone.

As mentioned, to allay Ku’s concern, on 18 November 2024, the ICU conducted 12 further quick tests across five blocks. Ku confirmed: “We had no specific concerns on all of the 12 samples tested. Taken together with our earlier review of the test report... the cumulative results of the quick tests across the inspections provided no ground to question the fire-retardant properties of the scaffolding nets at the time” 281 [WS14/2139-2140].

Thereafter, concerns over scaffolding nets resurfaced following the destruction of nets by typhoon and the Chinachem Tower fire in October 2025. These led to initiatives taken by the ICU itself, alongside complaints made by Mr Kong [WS2/1354-1358], a resident of WFC. They culminated in the inspection on 28 October 2025 which focused on the conditions and protective function of the old scaffolding nets. Other than that, quick tests on a few samples were also conducted as a cross-check. There were no specific concerns on the test results during this inspection282 [WS14/2142].

As to the ICU’s practice of giving advance notice before site inspections upon receipt of complaints:

1. Ku explained that “the purpose of such site inspections was to address complaints and enquiries, and that the RI is the responsible party under the MBIS regime and the Registered Contractor is the one who carries out actual works, it is imperative that the RI and/or RC (or their representatives) are present” so that ICU could “better understand the actual situation,” “assess whether the subject matter being complained or

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enquired about could be substantiated,” and “request the RI and/or RC...

to give explanations as well as make improvements/rectifications as necessary”283 [WS14/2131].

2. Ku further stated that “this inspection was not a site audit under the MBIS regime” and that “one of the priorities at the time was for the multitude of issues to be brought to the immediate attention of the RI and RC such that they could be addressed and dealt with sooner rather than later, with a view to protecting the interest of residents and the public”284 [WS14/2135].

The Government strenuously denies any allegation of collusion or intentional misconduct by the ICU in giving advance notice (although we understand from the examination stage that this does not seem to be the position being advanced by Counsel for the Committee). There is in any event no evidence before the Committee, whether direct or circumstantial, to support such a serious allegation. To the contrary, the evidence positively negates it.

1. First, Ku’s stated rationale for giving advance notice is not unreasonable on its face: the purpose of the site inspections was to address complaints and enquiries, which required the RI and/or RC (or their representatives) to be present so that the ICU could understand the actual situation, assess whether the complaint could be substantiated, and request explanations or rectifications as necessary. This is consistent with the self-regulatory spirit of the MBIS, under which the ICU’s role is to hold the RI to account rather than to conduct its own independent works supervision.

2. Second, the suggestion of collusion is wholly inconsistent with the affirmative steps the ICU took. If the ICU were colluding with the RC,

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there would have been no reason for Ku to conduct quick tests at 17

randomly selected locations, to raise fire hazard concerns directly with the RC at the 28 October 2024 inspection, to review the test certificate, to send reminder emails to the RI following the Chinachem Tower fire, or to conduct the further inspection on 28 October 2025. The totality of the ICU’s conduct is that of a supervisory body engaging actively, within the constraints of its system, with the issue as it understood it to be.

3. Third, the implausibility of collusion given the steps the ICU affirmatively took (quick tests, certificate review, follow-up inspections at 17 locations, reminder emails to the RI); and

4. Fourth, the deliberate deception by Prestige, through selective replacement of nets requiring “considerable effort and expense in sourcing and installing compliant nets specifically for the purpose of deceiving ICU” 285 [WS14/2143], constituted a “serious and deliberate subversion of the inspection process that ICU could not reasonably have been expected to anticipate or guard against” 286 [WS14/2143–2144].

(v) The actions taken by the LD at WFC

The LD conducted 16 site inspections and one surprise surveillance visit at WFC between July 2024 and 20 November 2025. On 22 July 2024, SO-I Kwan proactively requested the FR test certificate from Prestige. Upon receipt, the LD verified that the stated standard (GB 5725-2009) was one of the recognised standards. The LD also obtained the delivery note establishing a traceable supply chain287 [WS1/379]. On 11 November 2024, the LD made a referral to the ICU by memo, raising “the fire-retardant properties of scaffolding nets arising from

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286 KU Siu Ping 3rd WS §43

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previous complaints” and stating that “the case is referred to you for any actions

you may deem necessary” 288 [WS1/365].

J4. Systemic and/or operational weaknesses on the regulatory level

The MBIS has not required onsite inspections by the ICU in the course of works. This is not an ICU operational choice. The then Head of ICU, Lau Fu-kwok, accepted this directly: when asked whether the system at the time had provision for auditing or vetting the RI, Lau fairly accepted that in hindsight, the system had not addressed this “in terms of the design” [Day 24/64/4-14].

The ICU’s practice of carrying out inspections with advance notice given to the RI/RC did not align with the BD’s own practice. Both the FSD and BD conduct inspections without prior notification upon receipt of complaints [Day 22/61/8 - 62/23]. Ku accepted he was not aware of the non-alignment of the ICU’s practice [Day 22/61/8 - 62/23]. Lau accepted in oral evidence that “in hindsight” he should have taken a closer look at the inspection practice discrepancy [Day 24/82/24 - 83/5]. After the fire, the ICU changed its practice: “most of our checks will be conducted in a surprise manner. We will not disclose them in advance” [Day 24/80/23 - 82/23]. The Government acknowledges this was an operational area requiring improvements in terms of the discrepancy in practice. As with other aspects of the supervisory framework, the practice assumed good faith on the part of the professionals subject to it, an assumption that the evidence demonstrates was deviously exploited and undermined.

As to the pre-fire practice in respect of verifying the fire retardancy of scaffolding nets between the ICU and BD, there is apparent difference but the evidence is not unequivocal. On the one hand, the BD did not conduct any quick tests on scaffolding nets due to the uncertainty on the reliability of such tests, as they were

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not conducted in the laboratory under controlled conditions. In other words, they

rely on the test certificates. In contrast, the ICU conducted quick tests as supplementary measure or reference, alongside the test certificates. Whilst much may be said about their limitations, it seems fair to say that such quick tests (albeit not comparable to laboratory testing introduced post-WFC Fire) did offer a degree of check and balance. On the other hand, as to the test certificates, the BD checked laboratory accreditation against HOKLAS or mutual recognition schemes [Day 20/31/7 - 33/20]. In this regard, Ku explained that the BD’s circular letter of March 2023 did not expressly require HOKLAS accreditation, and that “before the fire we need to have HOKLAS or a mutually recognised organisation for testing. We don’t see this in the guidelines or in the code” [Day 22/94/1-10]. Post-fire, the encrypted and digitally signed verification system introduced under PNRC 85 [J1-2/6200-6209] removes any uncertainty and addresses any such systemic vulnerability.

As mentioned, the quick tests conducted by the ICU were merely an ancillary reference – they were never intended as a substitute for laboratory testing. Ku accepted: “Whether the scaffolding nets meets fire retardancy requirements, that is GB 5725, we need to draw reference from the laboratory tests” [Day 22/106/19

107/6]. However, Ku explained that prior to the introduction of PNRC 85, there was no established mechanism for the ICU to send scaffolding nets to the Government Laboratory for testing absent proof that the nets had been rigged or were otherwise non-compliant; in other words, if one could only rely on the certificate or the standard thereon, it would be difficult to check whether the scaffolding nets were not authentic [Day 22/105/5 - 106/1]. In this regard, Dr Lee confirmed in oral evidence that such on-site tests, while not equivalent to laboratory testing, can nonetheless serve as a reference: when discussing a burn test conducted on site, she observed that “if they want to have some reference” from such a test, they could have regard to the observable characteristics (such as

200

the net being ignited, the flame lasting for a period of time, and flaming droplets):

[Day 25/101/15-17; Day 25/102/4-9].

Furthermore, as Ku fairly pointed out when Counsel for the Committee suggested the quick tests gave residents a false sense of security: “Probably someone had rigged the scaffolding nets, not because we have conducted additional quick tests” [Day 22/107/11-21]. The false assurance arose from the rigged nets, not from the quick tests. The quick tests were a supplementary measure beyond what the system required; the fact that they could not serve as a definitive test is beside the point, as they are never intended as a substitute for laboratory tests; rather their purpose was to flag any obvious concerns, not to certify compliance as such.

The Government also acknowledges that the ICU’s reply to a complaint received in October 2025 about aging scaffolding nets following Typhoon Ragasa did not specifically address the fire retardancy concern raised by the complainant, as Ku of the ICU accepted during oral evidence [Day 22/104/9-16]. The reply to the complainant did not fully convey the specific follow-up actions being undertaken or address the particular concern raised, and there is room for improvement in this regard.

The LD’s enforcement methodology also relied on checking contractor-supplied FR certificates against the recognised standards, rather than independent sampling and testing. Li Man-pong explained: “Given the technical nature and variety of these requirements and standards, it is not feasible for OSOs, who do not have the relevant technical expertise, to conduct sampling and then reexamining of such plant, equipment or items to check for their compliance with all the standards mentioned in LD’s publications during inspections. Accordingly, inspection of testing certificates issued by laboratories and relevant authorities

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is the current method used by OSOs to perform compliance check”289 [WS1/345-

346]. This is an area for improvement of the LD’s enforcement framework, not specific to WFC.

Despite awareness of the FR concern from at least July 2024, the LD did not proceed further to consult the BD, ICU or the Government Laboratory about its lack of expertise in authenticating certificates [Day 16/39/13-19]. The Government acknowledges that consultation could have been made. The referral to the ICU on 11 November 2024 [D1/1162] was a partial response (in that it raised the FR issue with the ICU), it came approximately four months after the first certificate was received and was not accompanied by a request for laboratory testing.

The 4 October 2024 email reply to a complainant stated that scaffolding nets did not involve FR standards under safety regulations. Lam accepted in oral evidence that this statement was “incorrect” and that a complainant relying on the information would be “misled” [Day 16/48/6-25] – that said the Committee may note that well before such email reply the LD had in fact followed up and had asked for and obtained a FR test certificate beforehand (see Section J1 above). The email was written 15 days before the 5th edition CoP took effect; Lam had already (in July 2024) requested the FR certificate as a matter of practice and should have mentioned it, meaning there was an internal inconsistency between the LD’s own operational practice and the information given to the complainant. A corrective reply was later issued in December 2024 [D1/1096].

Separately, the fact that LD did not notice in November 2025 that the FR certificate submitted by Prestige for replacement nets was identical to the certificate submitted in July 2024 is also acknowledged as an operational area

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requiring improvements. Lam accepted that “looking back” this was “an area that

should have been improved” [Day 16/37/23-38/9].

Turning now to the improvements already and to be introduced, and further studies to be conducted, the BD has introduced PNRC 85 [J1-2/6200-6209], promulgated in mid-December 2025, with three main new requirements 290 [WS1/829] (Table of Improvement Measures, Item C1).

1. First, RCs must obtain FR performance test reports with each batch of scaffolding nets received and keep them on site for inspection at any time.

2. Second, before commencing works on an existing building, samples must be taken and a test report confirming compliance obtained before nets may be installed; inspection must be conducted by Government-designated accredited laboratories, and test reports must be encrypted and digitally signed.

3. Third, upon receipt of notification of scaffolding net installation, the BD will randomly select projects for on-site inspection; non-compliance results in immediate cease work orders.

The ICU has introduced site inspections at least once every four months for largescale MBIS renovation projects [Day 24/90/1-11]. The ICU has established a two-way communication channel with the FSD for large-scale renovation projects, under which the ICU provides lists to the FSD when works commence, and the FSD’s inspection findings are passed to the ICU for follow-up [Day 24/90/17 - 91/13]. The ICU now uses computer-randomised selection for inspection locations to prevent manipulation [Day 22/74/13-19]. The ICU also

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requires RIs to submit regular site supervision records during works 291

[WS1/618].

Since May 2026, the ICU has also implemented project-based integrated control for courts with large-scale renovation in progress. This approach is consistent with the risk-based methodology advocated by the experts before the Committee. Under this approach, the ICU conducts holistic risk assessments taking into account various minor works conducted in the same court concurrently, and formulates inspection and random check plans during the course of works based on the risk levels. These risk assessments and plans are regularly reviewed through internal meetings across teams chaired by ICU’s directorate staff (Table of Improvement Measures, Item B3(i)).

The FSD has established a mechanism with the BD and ICU under which, every two weeks, information is provided to the FSD on buildings with scaffolding nets. The DFS confirmed: “For the buildings with scaffolding nets, whenever there is any shutdown, we inform the BD or the Housing Department at once. We will not allow any works to continue because of the shutdown of the fire service system. There were five buildings having this situation and we already ordered works to be stopped” [Day 19/70/4-16]. As at April 2026, approximately 600 buildings under renovation have been inspected by the FSD [Day 19/71/12-13]. The FSD’s operational teams also formulate contingency plans with new elements specifically addressing the WFC scenario: “Having drawn reference from the Wang Fuk Court fire, if buildings nearby have scaffolding nets, in the contingency plan they need to detail how the fire will be handled in the case of any spread” [Day 19/70/22 - 71/5].

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The LD will amend the CoP to incorporate the BD’s PNRC 85 requirements292

[WS1/326] and has since January 2026 been deploying its staff to support the BD’s work in taking samples of scaffolding nets under PNRC 85 (Table of Improvement Measures, Item E4(ii)). The LD will also “explore opportunities to collaborate with BD and FSD for joint inspections to RMAA sites in respect of areas with common concern” 293 [WS1/327].

K. THE USE OF POLYVINYL CHLORIDE FOAM BOARDS AS COVERS ON WINDOWS AS TEMPORARY PROTECTION

The IFITF found that polystyrene window covers installed during the renovation obstructed residents’ awareness of the fire, delayed their response, and contributed to the vertical spread of fire. Toxicological reports indicated that 102 of the 168 fatalities had elevated blood carbon monoxide saturation levels, consistent with inhalation of toxic gases generated by the combustion of polystyrene materials.

This section examines the extent to which foam boards were used at WFC, the complaints raised, the representations made by the contractor, the causal link to fire spread and casualties established by the IFITF, and the respective responsibilities of the contractor, RI and relevant Government departments.

The primary responsibility for this contributing factor lies with Prestige, which both used and directed the use of combustible foam boards extensively and for a prolonged period in breach of its own express representation to use noncombustible materials in a specific manner, and with the RI (Ng Yeuk and Will Power which purportedly was engaged to provide RI services), who bore the

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statutory duty to ensure that construction methods complied with section 16 of

the B(C)R.

The Government acknowledges that the ICU, having raised the fire hazard concern at the 28 October 2024 inspection, could have followed up on the matter in a more proactive manner; such operational weakness, together with the lack of more specific prescriptive standards for temporary window protection materials under the pre-fire regime, is addressed below.

K1. Extensive use of foam boards

The evidence establishes that it was Prestige that directed the use of foam boards to cover windows at WFC.

Based on the meeting minutes [C1-2/1145], at the construction management meeting on 17 June 2024, Prestige proposed using foam boards despite Will Power’s express warning that foam boards are flammable objects and will cause a lot of smoke during fire and its suggestion to use protective boards instead. Prestige insisted on using foam boards, and Will Power stated that if the contractor insists, they have to bear their own risk.

On 18 July 2024, Prestige issued a letter to Will Power, confirming the use of foam boards [M1/240].

From August 2024 onwards, sub-contractors engaged by Prestige placed orders for foam boards. On 19 September 2024, Hoi Tak Construction Ltd (the subcontractor responsible for the facade works of Wang Kin, Wang Tai and Wang Cheong Houses [WS2/1457]) ordered foam boards expressly specified as nonFR (“非阻燃”) [C1-2/1099].

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Prestige’s instructions to sub-contractors to seal residents’ windows with foam

boards are further confirmed by the reply to the Committee by Yiu Kam-fai of Shing Construction Co., Limited, the sub-contractor responsible for the facade works of Wang Yan House and Wang Tao House. Yiu states that before commencing external wall repair works, Gordon Ho, a director of Prestige, orally instructed him to seal every household’s windows with foam boards to prevent stone debris from breaking residents’ glass windows during chiselling, and that the sealing had to be completed before any other external wall works could commence [WS2/1468].

There are also invoices indicating that foam boards were supplied to other blocks through another sub-contractor, New Nam Fong Construction Limited [C1-2/1128, 1130, 1132, 1134].

A WhatsApp exchange on 2 October 2024 [A2/item 124] between Gordon Ho of Prestige and the then MC Chairman Tsui Moon Come confirms that Prestige was aware that residents had strong objections to the foam boards (“居民覺得 FOAMBOARD 咁大意見”) and that the question of their fire retardancy was a live issue. Ho asked whether the second and third phases should switch to hollow boards instead. Tsui responded by asking whether foam boards that were less flammable could be found. Gordon replied: “我再問下廠，但即使佢話有我都

唔夠敢擔保一定有阻燃” (I’ll ask the factory again, but even if they say they have it, I wouldn’t dare guarantee it’s definitely fire-retardant). Tsui suggested that a video showing the board self-extinguishing after burning would suffice without needing a certificate. Gordon then confirmed: “收到，如我訂到可於第

二及三期工程轉用，但注意，第一期無法更換” (Understood. If I can order them, they can be used for phases 2 and 3, but note that phase 1 cannot be replaced). This exchange demonstrates that (at least) as at 2 October 2024,

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Prestige knew the foam boards already installed in phase 1 did not demonstrate

FR properties, and that they would remain in place without replacement.

(i) The various complaints made by the WFC residents / IO to Prestige / Will Power, the PMC and Government Departments

Multiple complaints were made to government departments raising concerns about the use of foam boards to cover windows at WFC. The ICU received a total of three complaints relating to the use of foam boards as temporary window protection between 17 September and 17 October 2024294 [WS14/2144]. The first enquiry, received on 17 September 2024, was titled “有關反映大埔宏福苑正進

行大維修工程使用發泡膠封窗是否符合安全規定” [I1-4/8221-8228]; the second, received on 23 September 2024 [I1-4/8229-8251], was also referred to the FSD and BD by the 1823 hotline295 [WS1/650].

(ii) The relevant conversation records and other factual evidence

The ICU’s site inspection on 25 September 2024 was its first direct observation. Ku observed that “some materials labelled as ‘CO2 生態健廉地暖板’ were stored on ground floor” and that the ICU “also entered into a block and took the lift to one of the upper floors and observed that a foam board was used to cover the window of the lift lobby from outside”296 [WS14/2147]. For the three blocks with scaffolding nets erected, the ICU “were unable to see the condition of the windows of the domestic flats by looking from the outside” 297 [WS14/2147].

The ICU’s site inspection on 28 October 2024 was the pivotal occasion. Ku asked the RI’s assigned person and RC about the process of hacking off external finishes, and “expressed concern on the temporary protection that would affect natural

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lighting and ventilation, and the possible complaints from residents” 298

[WS14/2150]. The RC’s explanation was that “the RC’s workers would proceed with the hacking off works every three floors at a time, and the foam boards were only used for temporary protection of window glazing around each floor during hacking off, and would be removed immediately upon completion of the hacking off works around each floor” 299 [WS14/2150-2151]. On the basis of this explanation, “the use of foam boards appeared to be both limited in scope and short in duration, confined to the immediate vicinity of the works being carried out at any given time” 300 [WS14/2151].

Critically, Ku also raised with the RC the concern “that the use of foam boards could pose a fire hazard to residents.” 301 The RC responded that “they would use non-combustible material for such temporary protection” 302 [WS14/2151]. Additionally, Ku “pointed out that the foam boards were piled up too close to the buildings and requested them to be moved away from the buildings. The contractor agreed to follow up on this” 303 [WS1/651-652]. The RC’s representation was subsequently reduced to writing and made known to residents by way of a Q&A published by the WFC IO on 23 November 2024: “問：為何

現時窗邊已沒有保護？答：宏業表示打鑿時才會有保護，完成打鑿後會拆

除窗外保護物” 304 [I2/9630] [WS14/2145].

After the three inspections in September to November 2024, the ICU received no further foam board complaints and did not follow up further on the issue. Ku explained: “on 28 October we thought that it was not an issue anymore. That’s

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303 KU Siu Ping 1st WS §60(ii) 304 KU Siu Ping 3rd WS §45(b)

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why we did not notice that” [Day 22/130/14-18]. He further gave explanations

for not detecting the extensive use: “There’s also one thing. Hacking and then removing the protective materials is an approach adopted by the trade. It is not infeasible” [Day 22/123/10-16].

(iii) The actual manner of use of foam boards at WFC

The reality, as it emerged after the fire, was that the foam boards were in place for far longer than the RC had represented. Ku accepted: “Looking at the papers, it has been more than a year” [Day 22/121/21 - 122/2]. When asked whether the ICU was unaware because there were no further complaints, Ku confirmed: “That’s one of the reasons. Afterwards, we saw from some documents in January 2025 — we saw exchanges between residents and the contractor. We wondered why the temporary protective materials were not there. The contractor said that that was there temporarily under the hacking process” [Day 22/122/11-19].

The IFITF’s post-fire investigation confirmed the extent of foam board coverage. The IFITF Report records that polystyrene window covers were “installed as a protective measure from debris on unit and common corridors windows” across the affected buildings (IFITF Report §10.5.1 [ER1/217]).

The scale of coverage is evidenced by the IFITF’s finding that among 291 witness statements, only 43 individuals (14.7%) reported seeing fire or smoke, and among 579 questionnaires, only 48 respondents (8.3%) indicated that they had witnessed the fire (IFITF Report §10.5.3 [ER1/218]). These figures are consistent with windows being covered on a widespread, not localised, basis across the estate.

The ICU’s witness statements acknowledged that upon close-up review in preparation of the witness statements, Ku identified that some windows in photographs from subsequent inspections (conducted for unrelated complaints

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such as A/C hoods and structural issues in January 2025 and June 2025) appeared

to be covered by foam boards. However, at the time of those inspections, the ICU’s focus was on the subject matter of those complaints; the ICU did not pay particular attention to window covers because the RC had represented foam boards would be temporary, and no further foam board complaints had been received after October 2024 [WS1/623, 632-635].

K2. How the extensive use of foam boards to cover up windows resulted in rapid spread of the fire and heavy casualties

(i) The relevant factual evidence

The IFITF’s investigations, addressed in Section G5 above, established that polystyrene window covers “obstructed residents’ view of the external environment... hindered occupants from realizing the severity of the fire in neighbouring buildings as well as their own buildings, lowering their awareness and in turn delaying their response” (IFITF Report §10.5.1 [ER1/217]). As mentioned above, among the 291 witness statements, only 43 individuals (14.7%) reported seeing fire or smoke; among the 579 questionnaires, only 48 respondents (8.3%) indicated they had witnessed the fire - “surprisingly low numbers for such a large fire” suggesting that the foam board covers “may have significantly hindered occupants’ ability to perceive the situation outside their units, thereby delaying their escape” (IFITF Report §10.5.3 [ER1/218]).

(ii) The IFITF’s investigations and expert evidence

Beyond obstructing awareness, the combustible polystyrene panels contributed to the vertical spread of the fire. The IFITF identified four key mechanisms: fueling the external fire spread as the panels burned readily on the building façade; falling as ignited debris that sparked fires beneath windows; generating burning fragments light enough to travel significant distances and ignite secondary fires; and producing burning droplets that dripped onto nearby combustibles, igniting

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them and causing additional fire spread (IFITF Report §10.5.6 [ER1/218-219]).

Dr To Chi-wing further confirmed in oral evidence that foam boards attached to windows, when ignited, could cause the breakage of the windows themselves, thereby facilitating the entry of fire and smoke into the units [Day 26/69/6-8, 17-23]. “Once windows were breached, flames and smoke entered units easily and directly exposing residents to dangerous conditions, not to mention the combustion of such polystyrene materials generated toxic gases such as carbon monoxide” (IFITF Report §10.5.4 [ER1/218]). Toxicological reports indicated that 102 of the 168 fatalities had blood carbon monoxide saturation levels ranging from 15% to 80% (IFITF Report §10.5.4, fn 179) [ER1/218]).

K3. The primary and supervisory responsibilities for such contributing factor

(i) The standards and requirements applicable to the use of foam boards as protection

Section 16(1) of the B(C)R [J1-2/5735] provides that “in carrying out building works or street works — (a) appropriate construction methods and procedures must be adopted; and (b) appropriate precautionary measures must be taken.”

This is a general provision that applies to all materials used in building works, including temporary protective materials. The oral evidence of AD Karen Cheung of the BD is unequivocal: “Extensive use of foam boards to cover windows is an improper work procedure and that may be against section 16 of the Building (Construction) Regulation” [Day 20/41/10 - 42/5]. When asked directly whether the BD would approve the use of foam boards, AD Karen Cheung of the BD stated: “We won’t approve that. Instead, we would take enforcement actions” [Day 20/42/18 - 44/7].

However, a degree of flexibility was identified in the other evidence. Franco Tse, the BD secondee at the ICU from April 2023 to July 2025, gave evidence that

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short-term, localised use of foam boards during active chiselling might not

contravene section 16: “When a certain floor is going through chiselling work, and let’s say you cover the windows with foam boards and you remove the foam boards after chiselling is completed, for such a short period of time I believe that it is not in contravention of any regulation or in contravention of section 16 of B(C)R. We need some sort of flexibility in our work” [Day 20/85/19 - 86/24]. The ICU’s Ku agreed with this view: “If it’s just a short time, several floors at a time, it doesn’t necessarily contravene section 16 of B(C)R” [Day 22/159/8-14].

Notably, AD Lawsons Yue of the BD said in paragraph 72 of his Witness Statement: “Subject to further investigation, the extensive use of foam boards at the external walls is in contravention with the above requirements.” 305 [WS1/836] It would appear that, in a similar vein, what AD Lawsons Yue of the BD took issue with is the “extensive use of foam boards” at the external walls, which leaves a degree of flexibility whether the use of the same for a short period at localised area might or might not contravene the law. He also opined that the foam boards “had brought about additional fire hazards to the buildings” and “might also have blocked the occupants’ sight of the severity of the fire and delayed their response to leave the buildings” 306 [WS1/836].

The distinction identified by both the BD (Karen Cheung) and ICU (Franco Tse and Andy Ku’s) position is therefore one of extent and duration: localised, shortterm use during active chiselling may be acceptable under a flexible reading of section 16; extensive, prolonged use covering windows across multiple blocks for over a year is not. The ICU was deceived about the extent and duration of use at WFC. The RC’s representation (that foam boards would be used only “three floors at a time during active hacking and removed immediately upon completion”

305 YUE Chak Sang 1st WS §72 306 YUE Chak Sang 1st WS §72

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for a short period) was not simply false: it was an outright lie. The extensive and

prolonged use was contrary to what the ICU was told, and constituted a further element of the wrongdoings by Prestige.

A further point arises under clause F5.6(f) of the FS Code, which requires inflammable and combustible materials in a building to be “stored under safe custody” [J1-2/4170]. Both Tse and Ku took the view that foam boards in use as window covers (as distinct from foam boards merely stored on site) do not fall within this “stored under safe custody” limb. Tse explained: “As the foam boards are not put in other places and yet it is already attached to the windows, I believe that this should not be regarded as needing to be stored under safe custody” [Day 20/89/4-8]. Ku agreed with Tse’s understanding [Day 22/161/20 - 162/23].

Before the fire, no specific prescriptive standard for temporary window protection materials existed in any regulation, code of practice or practice note. Ku confirmed: “the term ‘appropriate precautionary measures’ is a very broad concept, and there is no specific requirement in respect of the use or standards of foam board as temporary protection in statutory provisions”307 [WS1/648]. Ku was “unaware that there is any specific guideline on the use or standards of foam board in other documents (such as BD’s Code of Practice, Practice Notes for Authorized Persons, Registered Structural Engineers and Registered Geotechnical Engineers, Circular Letters, etc.), or any prosecution action taken previously against the use of foam board in contravention of section 16 of B(C)R” 308 [WS1/648]. This absence of specific guidance contextualises the regulatory environment in which the ICU and other departments were operating.

307 KU Siu Ping 1st WS §59 308 KU Siu Ping 1st WS §59

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(ii) The primary responsibilities of Prestige and the RI

Under the MBIS Code, the RI and RC bear primary statutory responsibility for ensuring repair materials comply with the BO: “the RI and RC shall comply with the BO and regulations and shall provide supervision to the rectification and repair works to ensure that the works are prepared, carried out and completed safely and up to the required standards” 309 [WS1/684-685]. The primary responsibility for the extensive and prolonged use of combustible foam boards to cover windows (in breach of the RC’s own express promise to use noncombustible materials) lies squarely with Prestige and Will Power / the RI (Ng Yeuk).

(iii) The Government’s supervisory responsibilities

Ku agreed that the question of whether foam board use contravenes section 16 of the B(C)R falls within the ICU’s purview [Day 22/38/2-5]. However, there was “neither statutory provision on the fire-retardant properties under the BO prohibiting or restricting the use of foam boards as temporary protection, nor clear guidelines from BD of the same that ICU could rely on to act on,” and ICU “hence could hardly take further actions in this regard. ICU also had no basis to raise doubt or demand a test, as there was no standard to test against in the first place” 310 [WS1/686]. That said, Ku confirmed: had he “been aware that the foam boards were used for covering up windows extensively, we would and must have taken follow-up actions” 311 [WS14/2152].

As to the FSD’s position, a complaint was received by the FSD on 23 September 2024 regarding polystyrene boards at WFC. The FSD inspected the site on 25 September 2024 and found polystyrene boards at open ground areas outside three

309 KU Siu Ping 2nd WS §31 310 KU Siu Ping 2nd WS §36 311 KU Siu Ping 3rd WS §67

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blocks; the finding was recorded as “not irregularity concerning the FSD”312

[WS1/99]. The complainant was informed on 3 October 2024 that the issue of fixing polystyrene boards on building windows “was not under the purview of FSD” 313 [WS1/99]. As the complaint was also sent to the ICU, no further referral was made by the FSD314 [WS1/99]. However, as addressed below, the DFS accepted in oral evidence that the FSD’s statutory powers are not confined to active FSIs and that the division of work with the BD is not calcified.

AD Yung accepted in oral evidence that, before the fire, the guidelines to frontline staff on how to handle such enquiries were “by no means clear” [Day 17/20/3-4]. He confirmed that the FSD has since implemented a new referral mechanism: “From now on, this is being practised, whether it is complaints or enquiries, if the residents have any questions about fire safety issues, we would seek consent and for referral to be done to the relevant departments” and that the FSD would follow up with the receiving department to confirm receipt [Day 17/18/17 - 19/7] (Table of Improvement Measures, Item A11).

The DFS addressed the inter-departmental division of work in relation to foam boards and access openings in more detail during his own oral evidence. His evidence establishes three propositions of significance for the Committee’s assessment of the FSD’s role.

1. First, notwithstanding the inter-departmental division of work in general, the FSD’s statutory powers are not confined to active FSIs. The DFS confirmed that the powers of the FSD under sections 7 and 8 of the FSO are “extensive and comprehensive” and “are not confined to fire service installation and equipment or ‘non-building works’, which are only a few

312 YUNG Kam Hung 1st WS §21 313 YUNG Kam Hung 1st WS §22 314 YUNG Kam Hung 1st WS §22

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amongst many aspects of fire safety and firefighting” [Day 19/53/1-8].

When asked directly whether it was correct that “We can’t rigidly say that passive FSIs are not under your portfolio. You are only in charge of active ones,” the DFS confirmed: “Right” [Day 19/60/17-22]. He further confirmed: “when it comes to fire safety, you have the statutory role to protect life and property and roles on fire protection and fire hazards. So you can’t say that if it is a passive FSI then you don’t have a role to play, because saying so would be incorrect” [Day 19/61/10-15].

2. Second, the division of work between the FSD and BD is “not calcified” and operates on a complementary, not exclusive, basis. The DFS stated: “our division of labour is not calcified. We do not have a silo portfolio; we share the same portfolio” [Day 19/58/3-4]. He confirmed that Wilson Chan J in the U Storage decision [A5/785] accepted that “when you both have power, your roles are complementary to each other” [Day 19/61/6-7]. The practical mechanism is sequential consultation: the FSD will “talk to the BD first” before issuing a Fire Hazard Abatement Notice on a matter within the BD’s regulatory portfolio, because the BD’s scope is wider and encompasses structural, lighting and ventilation considerations that the FSD would not independently assess [Day 19/84/14-19]. But this requirement for prior consultation does not negate the FSD’s power: “if you think there is a need to exercise the power, you will?” to which the DFS confirmed: “Yes” [Day 19/63/1-3].

3. Third, the DFS accepted that the ultimate responsibility for fire safety rests with the FSD. When asked: “Under section 7 of the FSO the gatekeeping function of the FSD, after all, it is the FSD that is responsible for fire safety. You may have to consult other departments. But the ultimate responsibility of fire safety rests with the FSD; is that correct?” the DFS confirmed:

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“Correct” [Day 19/87/23 - 88/3]. He further confirmed: “after consultation

with other departments concerning how to take law enforcement actions and remove the fire hazards, it is your responsibility; is that correct?” to which he answered: “Yes” [Day 19/88/4-8]. The Chairman also directly engaged with this point, observing: “I think, Director, you will agree that communication is very important. The BD may not be aware of all fire risks, so you’ll agree that enhanced communication is necessary?” to which the DFS again confirmed: “I agree” [Day 19/63/4-8].

In relation to foam boards specifically, the DFS confirmed that “both departments have the power to enforce the law” [Day 19/65/1-3]. He confirmed that the BD has since issued a circular letter in March 2026 stating that “foam boards should not be used to cover windows” and that “in this regard division of labour is clear. There are clear requirements that foam boards should not be used to seal windows, but we have a statutory duty. We will talk to the BD as to how it will be handled” [Day 19/65/8-13]. The FSD’s views summarised in §§581-583 are not only relevant to the issues dealt with in this Part K (use of foam boards), but also to other issues that are capable of bringing about significant fire risks.

(iv) The actions taken by the ICU at WFC

As mentioned above, the ICU conducted three inspections at which the foam board issue was touched upon: 25 September 2024, 28 October 2024 and 18 November 2024315 [WS14/2144]. On 25 September 2024, Ku observed foam board materials stored on the ground floor and one foam board covering a lift lobby window. On 28 October 2024, he raised the fire hazard concern with the RC, who represented to use non-combustible materials. On 18 November 2024, Ku enquired whether follow-up actions had been taken since 28 October, and “the

315 KU Siu Ping 3rd WS §44

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RC replied in the affirmative” 316 [WS14/2151-2152]. Thereafter, the ICU

received no further foam board complaint. Ku stated that had he “been aware that the foam boards were used for covering up windows extensively, we would and must have taken follow-up actions” 317 [WS14/2152].

As to the consultation with Franco Tse, the accounts of Ku and Tse diverge.

1. Ku’s account is that he “visited Mr Tse’s office after the inspection on 25 September 2024 to consult him whether there were any regulations or guidelines issued by BD regarding the use of foam boards to cover up the windows” 318 [WS14/2148-2149]. Ku stated he explained to Tse that his team had received an enquiry about the use of foam boards for temporary protection of windows, and that Tse “advised that the said use of foam boards was not considered as building works and that there was no requirement on the fire-retardant properties of the foam boards used” and that “as the said use of foam boards would not be considered as unauthorised buildings works, it would not be actionable”319 [WS14/2149]. Ku explained that he did not provide Tse with more detail because “I did not have information on the extent of the use of foam boards at that material time” 320 [WS14/2149].

2. Tse’s account is that he is “not able to recall that Mr. Ku Siu Ping has verbally consulted me regarding the use of foam boards to cover up windows at Wang Fuk Court” [WS3/1682]. In his second letter, Tse stated that the advice attributed to him “is obviously unsound” [WS3/1682]. However, Tse also acknowledged that “the context of the statement... may

316 KU Siu Ping 3rd WS §66 317 KU Siu Ping 3rd WS §67

318 KU Siu Ping 3rd WS §57 319 KU Siu Ping 3rd WS §57 320 KU Siu Ping 3rd WS §58

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be acceptable given that the coverage of the foam boards is only confined to few individual flat or a particular floor and the duration is short” [WS16/2200]. Tse confirmed during his oral evidence that “I really do not remember whether he has asked me or in what kind of format he asked me. I can only say that I didn’t have any detailed information. I have not seen any photos, I do not know which estate he was referring to” [Day 20/85/2-9].

The Committee is not required to resolve the divergence between Ku and Tse as to whether the consultation occurred as a matter of fact. Recollections may differ. Whether or not it did, the underlying operational concern remains: no written record was made of any such discussion, and insufficient background information was provided for the purposes of obtaining meaningful advice. Tse’s view that Ku “should have tried his utmost to obtain a full picture of the case” and could have verified the RC’s representation “by simply bring up the case for arranging further site re-inspection, say in 2 or 3 weeks time” [WS16/2201] is a valid point that the Government acknowledges: a follow-up inspection to verify the RC’s representation would have been better practice.

(v) The actions taken by the FSD at WFC

As mentioned above, the FSD conducted an inspection of the site on 25 September 2024 and did not consider the polystyrene boards found at the open ground areas per se to be an irregularity from the FSD’s perspective. The FSD’s response when consulted by the ICU was that foam boards were not dangerous goods. The FSD’s primary concern is with dangerous goods, not construction materials. The Government acknowledges that the FSD’s response, while reflecting the internal division of work, did not address the broader fire safety concern raised by the use of foam boards – that said the Committee may note that

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in context the matter was in fact taken up and followed up by the ICU who

undertook inspections and acted upon the representations given by the contractor.

K4. Systemic and/or operational weaknesses on the regulatory level

No specific standard for foam board fire retardancy existed before the fire, and section 16 of the B(C)R, while applicable, provides only a general requirement without prescriptive content321 [WS1/648; WS1/686]. The absence of specific standards or guidelines added to the difficulties on the ICU’s part to take decisive enforcement action: The ICU had no defined benchmark against which to measure the foam boards’ fire performance and no basis on which to demand a FR test (there being no standard to test against). The post-fire circular issued by the BD in March 2026 [B13/5714-5719], which expressly prohibits the use of combustible materials including foam boards on external walls or windows, directly addresses this gap.

The operational area requiring improvements is equally clear: the ICU did not proactively follow up thoroughly on the foam board issue despite multiple inspections and documents received after October 2024. The Chairman observed directly: “You did follow up, but you didn’t follow up thoroughly. For the foam boards, they have been used to seal up the windows and you didn’t follow up. You did follow up, as you said, but if you follow up more thoroughly, you must have picked this up.” Ku accepted: “It is with the benefit of hindsight, indeed there are areas that we could have done better” [Day 22/148/22 - 149/2].

The lack of written records of the contractor’s promise at the 28 October 2024 inspection and of the Tse consultation (if it occurred) is a further operational area requiring improvements. Ku accepted: “With the benefit of hindsight, if we had

321 KU Siu Ping 1st WS §59; 2nd WS §36

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the instructions written down, it would be a better approach” [Day 22/115/1-9].

The ICU now requires that “if safety or major concerns, high-risk issues or complaints are involved, then we ask our colleagues to compile comprehensive records, and when they do inspections, they need to complete the inspection forms” [Day 24/70/11-15].

A further operational weakness concerns the fact that the ICU did not communicate the RC’s representation on the manner of use of foam boards in its reply to the complainant or in any other correspondence with residents.

1. When the ICU replied to the complainant on 12 November 2024 [I1-4/8251], the reply stated that foam boards were used as temporary protection measures and that there is no legislation or regulation to require such protection materials need to meet fire-retardant requirements.

2. The ICU did not inform the complainant of the specific representation made by the RC at the 28 October 2024 inspection that foam boards would be used only three floors at a time during active hacking and would be removed immediately upon completion of the hacking works around each floor.

3. If residents were informed of what the RC had represented, they would have a clear benchmark against which to assess whether the contractor’s practice on the ground matched its undertaking. Ku accepted in oral evidence that the unintended consequence of the way the reply was framed was that “no resident would complain to you and they told a lie” [Day 22/141/9-12]. He further accepted that “with the benefit of hindsight indeed, in answer to the residents, it would be far better to make things clearer” [Day 22/141/15-16].

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The DFS’s evidence establishes that the FSD’s involvement in the foam board

issue was a result of the pre-fire division of work, but not by any absence or abnegation of statutory power.

The DFS confirmed that “before the fire, you each have your respective power to handle the matter” [Day 19/66/1-3], and that the FSD could in principle have issued a FHAN in relation to combustible foam boards as a fire hazard. However, the practical position was that the BD had specific legislation applicable to external wall materials and a wider expertise encompassing structural, lighting and ventilation considerations, and the FSD deferred to the BD’s lead regulatory role on this basis [Day 19/64/1-21].

As to foam boards specifically, the DFS stated that “there are existing regulations of the BD” and that “what happens now is that if the foam boards are not removed, the contractor will be prosecuted. In the future we will talk to them about enforcement” [Day 19/64/12-14].

The BD issued a circular letter in March 2026 that expressly addresses the foam board issue. AD Karen Cheung of the BD confirmed: “combustibles include foam boards; they cannot be put on external walls or windows” [Day 20/45/9 - 46/24]. A limited exception is preserved for temporary covering of windows during active chiselling works: “if there is some temporary chiseling work to be done,

(g) states that if it is a temporary covering of windows, it is allowed” [Day 20/46/6-9]. When asked whether this represented “a huge difference between the regulations before and after the fire,” AD Karen Cheung of the BD responded: “We just want to be clear” [Day 20/46/20-24]. The Government’s position is that the March 2026 circular clarified the regulatory context: the position that extensive foam board use was always in breach of section 16 of the B(C)R was correct both before and after the circular.

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The BD has also since December 2025 stepped up surprise inspections of largescale building repair works sites at least once every six months, with specific focus on whether combustible materials (such as foam boards) have been installed on windows (Table of Improvement Measures, Item B1).

The ICU’s, BD’s and FSD’s improvements set out in Section J4(iii) above, including regular site inspections, enhanced record-keeping requirements, and inter-departmental communication channels, apply equally to the detection of foam board use and other non-compliant construction practice.

The post-fire inter-departmental coordination mechanisms, including the biweekly information sharing with the BD/ICU and the FSD’s new referral-andfollow-up practice, are designed to ensure that fire safety concerns arising from construction practice are no longer left in a gap between departmental mandates.

Relatedly, the FSD has announced an optimised case referral and handling mechanism (in April 2026) under which, for fire safety cases involving matters within the professional purview of other government departments (such as construction materials on external walls), the FSD will, with the complainant’s consent, proactively refer the case to the most appropriate department, confirm that the referral has been taken over by the relevant department, and follow up until completion. Should a department contest a referral, the case will be escalated to the Assistant Director or Deputy Director level for inter-departmental coordination. This mechanism directly addresses the pre-fire gap whereby the FSD’s response to the foam board complaint was limited to confirming that foam boards were not dangerous goods without addressing the broader fire safety concern (Table of Improvement Measures, Item A11).

In addition, the BD has issued a fire safety guideline pamphlet for major renovation works, with the FSD’s specialised advice on firefighting and rescue

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operations, dangerous goods handling, and FSIs incorporated (Table of

Improvement Measures, Item A11) [B14/6327-6328]. This publication demonstrates the enhanced inter-departmental collaboration on fire safety matters arising from construction practice and provides accessible guidance to contractors, RIs and building owners in a single consolidated format.

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L. THE USE OF OTHER NON-FR CONSTRUCTION MATERIALS - SPECIFICALLY, PLASTIC SHEETS / CANVAS

Beyond the scaffolding nets and foam boards addressed in Sections J and K, the re-entrant at WFC contained a range of other combustible construction materials that contributed to the rapid spread of the fire. These included canvas used on catch-fans and working platforms, plastic sheeting, toe-boards, wooden planks and nylon strips.

The primary responsibility for the use of non-compliant materials across the scaffolding rests with Prestige and the RI under sections 3 and 16 of the B(C)R. The Government’s post-fire reforms, including the Secretary for Labour and Welfare’s announcement that the CoP will be revised to specify material requirements for toe-boards and the BD’s review of the BO to consider making non-compliance with material safety standards a new offence, directly address the identified inadequacies or gaps.

L1. Use of other non-FR construction materials – the relevant evidence

The IFITF Report established that two types of canvas were used at WFC, “mainly made of polyethylene or a mixture of polyethylene and polypropylene”. Laboratory examinations revealed that “both types of canvas were more susceptible to sustained burning after flame impingement than the safety nets, with some producing burning droplets. Therefore, if a fire were to be initiated in the working platform, the canvas would easily ignite, quickly spreading the fire to nearby combustibles and leading to rapid fire development” (IFITF Report §6.2.1.8 [ER1/81]).

These findings are corroborated by the independent laboratory analysis conducted by Dr Lee [ER2-1/478-481].

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1. Dr Lee examined plastic sheeting samples seized from WFC and control

samples obtained from construction material suppliers associated with the renovation works. The examination revealed that the plastic sheeting used at WFC was made of mainly polyethylene, or a mixture of polyethylene and polypropylene, in multi-layered configurations.

2. Of the six samples of plastic sheeting examined from the construction material suppliers (Lab Ref. 26C0714/1-6), five (items 26C0714/1, 3-6) sustained burning after removal of a flame, with some specimens largely consumed with flame reaching the top edge and producing burning droplets. Only one sample (item 26C0714/2), which was allegedly FR, did not sustain burning after removal of the flame [ER2-1/481].

3. The examination of plastic sheeting seized from the WFC scene itself produced consistent results. All five items of plastic sheeting tested with reference to Condition A of GB/T 5455-2014 were ignited, with average afterflame times ranging from 12.4 seconds to 30.7 seconds, substantially exceeding the 4-second threshold applicable to safety nets under GB 5725-2009. Specimens from four of the five items were found to have burnt to the top edge and were mostly consumed before extinguishing, with flaming droplets produced. Under the more stringent Condition B, average afterflame times ranged from 15.9 seconds to 41.1 seconds, again with specimens largely consumed and flaming droplets produced [ER2-1/485-486, 499-500].

4. Dr Lee confirmed in oral evidence that both types of canvas found at WFC were more susceptible to sustained burning than the safety nets: “even when the source of fire has been taken away, it continued to burn, and then it spread to the side and upward... basically it's spreading upward and then

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you can see the flame and droplets coming down all the time until the time when it's completely consumed” [Day 25/88/12 - 89/2]. When asked directly whether canvas was more combustible than safety nets, Dr Lee confirmed: “Yes... We didn't have to wait for 12 seconds. There are flames and they spread pretty rapidly and upwards. All the canvas, they were completely burned down” [Day 25/105/16-19]. Dr Lee described the fire performance of canvas as “dangerous” [Day 25/108/3] and confirmed that the use of such materials on scaffolding during renovation was “rather perilous in terms of fire risk” [Day 25/114/2-4].

Dr Lee’s further statement dated 25 June 2026 [C19/2826-2835] extends the analysis by comparing the plastic sheeting recovered from the WFC scene against control samples obtained from construction material suppliers associated with the renovation works, and by evaluating the burning behaviour of all samples upon surface ignition with reference to BS 5867-2:2008 (Type B performance requirements).

1. The comparison exercise established material links between the scene and the supply chain. The general appearance, weaving pattern, layer structure and chemical compositions of the green plastic sheeting recovered from the scene (items 25C2825/37, 40, 40A and 40B, from Wang Chi House) were found to agree with control samples from the supplier 林記建築材料 (items 26C0714/1 and 26C0714/4 respectively), suggesting that they could be of similar make. Similarly, the blue/white plastic sheeting recovered from the scene (items 25C2825/39, 40C and 41, from Wang Chi House) was found to agree with a control sample from 祥記帆布工程有限公司 (item 26C0714/5), again suggesting similar make [C19/2828-2829].

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2. Of the control samples tested, only two (items 26C0714/2 and 26C1071/1),

both alleged to be FR, were made of PVC-coated polyester fabric. These two samples did not sustain burning upon surface ignition: no part of any hole nor any part of the lowest boundary of any flame reached the top edge or either vertical edge, and no flaming debris droplets were observed [C19/2829].

3. By contrast, all remaining plastic sheeting items (whether recovered from the scene or obtained from suppliers) were made of mainly polyethylene or a mixture of polypropylene and polyethylene. In burning behaviour tests conducted with reference to BS 5867-2:2008, holes and the lowest boundary of flame reached the top edge or either vertical edge in at least five out of the set of six test specimens for every non-FR sample; flaming debris droplets were observed in more than three out of the set of six test specimens; and most test specimens were consumed in the tests [C19/2829].

4. An additional set of tests was conducted after cleaning the scene samples to remove surface-adhering foreign materials, with the same cleaning procedure applied to control samples for comparison. Dr Lee found no significant change in the burning test results with or without cleaning, confirming that the combustibility observed was an inherent property of the materials themselves rather than an artefact of contamination from the fire scene [C19/2829].

5. Dr Lee concluded that the non-FR plastic sheeting items “were found to be easily ignited after surface impingement by a small flame with remarkable upward and/or lateral spread as well as generation of burning droplets which could aid the spread of fire” [C19/2829].

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L2. How the use of other non-FR construction materials resulted in rapid spread of the fire

(i) Plastic sheets and canvas

As recorded in Dr Lee’s statement, photographic evidence from the scene confirmed that the plastic sheeting was “used extensively, such as covering construction materials and along the interior of the working platform” [ER2/486, 503]. In a similar vein, Dr To Chi-wing of the FSD confirmed, “[t]he buildings in Wang Fuk Court were undergoing major renovation at the time of the fire, which led to their external walls being surrounded by combustible construction materials. These materials included bamboo scaffolding, safety nets, polystyrene window covers, plastic skirting boards (toe-boards), canvas, wooden planks, etc. Together, these materials created a combustible ‘envelope’ enclosing the buildings and provided an abundant fuel source for the fire”322 [WS1/31]. By way of illustration, Dr To referred to a photograph of canvas used at Wang Tao House [B2/1865].

The IFITF’s findings establish that canvas lacking FR properties “allowed small fires in the re-entrant area to escalate into widespread, intense blazes capable of consuming nearly all combustibles and spreading rapidly across multiple levels” (IFITF Report §8.6.2.1 [ER1/174]). The catch-fans, designed to intercept falling debris, “trapped flying embers, flaming droplets and burning debris instead during the fire, especially with non-FR canvas used on the catch-fans, which increased the risk of ignition and enabled fires to spread horizontally along the catch-fans and onto the scaffolding” (IFITF Report §8.6.2.2 [ER1/174]).

Dr Lee concluded that “the plastic sheeting seized from the scene were found to be more susceptible to sustained burning after impingement of a flame than the safety nets,” and that “if a fire initiated in the working platform, the plastic

322 TO Chi-wing 1st WS §21.1

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sheeting materials would easily be ignited, spreading the fire quickly to the nearby combustibles leading to a fast development of fire” [ER2-1/486]. Prof Yuen’s Test 13 at Sichuan, which combined safety nets collected from Wang Chi House with non-FR canvas, corroborated this conclusion: the introduction of nonFR canvas “further accelerated the fire growth, transforming limited and localized fires into a widespread and intense blaze” and the “resulting excessive heat release was sufficient to ignite bamboo sticks on a large scale, significantly increasing the HRR” (IFITF Report §7.2.3.19 [ER1/104]).

(ii) Toe-boards, wooden planks, nylon strips

The IFITF Report identified that the re-entrant contained large quantities of accumulated combustible materials forming a continuous fuel source across multiple levels, including “bamboo scaffolding, safety nets, wooden planks, toeboards, canvas, nylon strips; and polystyrene window covers” (IFITF Report §6.2.1.3 [ER1/79]). The full-scale fire tests revealed that “bamboo was the dominant fuel source, contributing nearly 78% of the total energy released, followed by wooden planks (14%). Despite bamboo’s dominance as a fuel, the test revealed that other materials, such as safety nets, toe-boards and wooden planks, ignited first due to their relatively lower thermal resistance” (IFITF Report §7.2.3.7 [ER1/95]). The time-to-ignition data revealed that toe-boards (16s to 42s) and nylon strips (36s) exhibit relatively low TTI values, indicating a higher susceptibility to ignition, and that wooden planks ignite at about 58s to 79s while bamboo demonstrates a substantially higher TTI of over 110s (IFITF Report §7.2.3.16 [ER1/101]).

The significance of this finding is that materials with lower thermal resistance (specifically nylon strips, toe-boards and wooden planks) served as the ignition initiators that then spread fire to the dominant fuel (bamboo), creating the selfreinforcing cycle described in Section G4 above.

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L3. The primary and supervisory responsibilities for such contributing factor

(i) The FR standards and other requirements applicable to such other construction materials

The BD’s regulatory framework under sections 3 and 16 of the B(C)R provides the legal basis for requiring compliant materials and appropriate construction methods; these apply to all materials used in building works.

In relation to plastic sheeting used to cover scaffolding on the façade of buildings, the requirement for FR properties has existed since 1995, when PNAP APP-70 was first issued [J1-1/688]. Paragraph 4(a) of APP-70 expressly advises that “flame-retardant sheeting should be used” when plastic sheeting is used to cover scaffolding erected around the walls of buildings. The March 2023 circular letter [J1-2/5915], built upon this long-standing requirement by specifying particular recognised FR standards (GB 5725-2009, BS 5867-2:2008 (Type B performance requirements), and NFPA 701:2019 (Test Method 2)) applicable to protective net, screen, tarpaulin and plastic sheeting installed on the façade of buildings under construction, demolition, repair or minor works. The LD’s 5th edition CoP, which became effective on 19 October 2024, also incorporated corresponding FR standard requirements (at paragraph 4.4.4(d)) [D1/709]).323

The requirement that canvas and plastic sheeting on scaffolding must possess FR properties was therefore not a post-fire innovation but a regulatory requirement

323 Paragraph 4.4.4(d) of LD’s 5th edition CoP [D1/709] applies expressly to canvas and prescribes specific standards as follows:

“(d) On the face of the scaffold, suitable protective screen (such as nylon nets, plastic sheeting, canvas, etc.) should be provided to confine falling objects. Protective net, screen, tarpaulin/plastic sheeting installed on the face of the scaffold should have appropriate fire retardant properties in compliance with a recognised standard. Examples of recognised standards are listed below for reference:

(i) GB 5725-2009 - Safety nets (or formerly GB 16909-1997 – Fine mesh safety vertical net);

(ii) BS 5867-2:2008 (Type B performance requirements) – Fabrics for curtains, drapes and window blinds - Part 2: Flammability requirements - Specification; and

(iii) NFPA 701:2019 (Test Method 2) - Standard methods of fire tests for flame propagation of textiles and films

Other standards of equivalent fire retardant performance as per the above recognised standards may also be used.”

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of some three decades’ standing, with specific recognised standards identified

from March 2023 onwards.

However, no specific prescriptive FR standard existed for toe-boards, wooden planks or nylon strips used as scaffolding components before the fire. The prefire regime relied on the general requirements of section 16 of the B(C)R without prescriptive content for these specific materials.

(ii) The primary responsibilities of Prestige and the RI

The same primary responsibility framework as applicable to scaffolding nets applies to all other scaffolding protective materials. The primary obligation to ensure materials used in building works are of a nature and quality suitable for their intended use, and that appropriate precautionary measures are taken, rests with the RC and RI under sections 3 and 16 of the B(C)R.

(iii) The Government’s supervisory responsibilities on the use of such other construction materials

The ICU’s supervisory role under section 16 of the B(C)R extends in principle to all construction materials and methods. However, under the MBIS, no proactive inspection or testing regime for materials was in place; the ICU relied on the RI’s compliance and complaints. No action was taken by the ICU concerning the combustibility or FR properties of plastic sheets, canvas, toe-boards or nylon strips at WFC: but this must be seen in the proper context that no complaints on these specific materials were received and the MBIS does not require onsite inspections in the course of works, or the testing of construction materials in the absence any complaint or enquiry.

The LD had no enforcement power in relation to the FR properties of toe-boards and wooden planks used on scaffolding prior to the announced CoP revision. The

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LD’s focus was on the physical condition and safe working order of scaffolding

components (adequate to prevent falls) rather than their combustion properties.

The explanation for no specific action having been taken concerning the combustibility / FR properties of such other construction materials may lie in the regulatory framework: for toe-boards, no FR standard existed; for canvas and plastic sheeting, the FR requirement was set out in the BD’s circulars and LD’s CoP which was directed to contractors and RIs, with enforcement dependent on complaints or proactive site inspections by the BD/ICU.

L4. Systemic and/or operational weaknesses on the regulatory level

Before the fire, no legislation, CoP or practice note specified FR material requirements for toe-boards, wooden planks or nylon strips used as scaffolding components. This was a constraint that applied across the industry. The MBIS does not require onsite inspections in the course of works, and there was no basis for testing construction materials absent a complaint or enquiry specifically raising the issue.

For canvas and plastic sheeting, the FR requirement has existed in the BD’s circulars and LD’s CoP, but verification depended on the same certificate-check methodology addressed in Section J above.

The Secretary for Labour and Welfare has announced that the LD will revise the CoP to specify material requirements for toe-boards 324 [WS1/326] (Table of Improvement Measures, Item E2). This is a direct and proportionate response to the identified regulatory inadequacy.

324 YUEN Tsz Lok 1st WS §42

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The LD will also explore joint inspections with the BD and FSD for RMAA sites

with “areas of common concern,” which (post-fire) includes the FR properties of all materials on scaffolding. Murphy Yuen confirmed: “after BD issued PNRC

.. BD is inviting LD to assist them in carrying out sample collecting work for scaffolding protective nets.” 325 [WS1/327].

The BD’s post-fire reforms under PNRC 85 [J1-2/6200-6209], requiring encrypted digital certificates, sampling before installation, and random on-site inspections, extend to all protective materials on scaffolding, not only nets. The BD is reviewing the BO and considering legislative amendments to “empower BD to specify requirements over construction methods and procedures, and to clearly stipulate what constitutes ‘appropriate precautionary measures must be taken’ under current legislation” and will “include the safety requirements of building materials as statutory standards in BO and make non-compliance with such standards a new offence”326 [WS1/773]. These reforms address the general nature of section 16 of the B(C)R by providing specific prescriptive content that was previously lacking. More broadly, the Development Bureau (“DEVB”) and Construction Industry Council have commenced discussions with the industry on a roadmap to switch from bamboo scaffolding to metal scaffolding where appropriate, based on the needs of different work scenarios. Discussions commenced in December 2025 with a view to reaching consensus as soon as possible (Table of Improvement Measures, Item G2). The Construction Industry Council is also formulating a set of Good Practice Guidelines for the large-scale building maintenance industry, which will include recommendations on the subcontracting of such works to promote the healthy development of the

325 YUEN Tsz Lok 1st WS §45

326 PANG Yuk-lung 1st §144 (b) and (c)

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construction industry. The Guidelines are expected to be promulgated within

2026 (Table of Improvement Measures, Item G3).

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PART III(D): OTHER FACTORS CONTRIBUTING TO THE HEAVY CASUALTIES

M. UNTENABILITY OF THE MEANS OF ESCAPE CAUSED BY CREATION OF ACCESSES

The IFITF found that some windows in escape staircases were replaced with movable wooden boards or aluminium composite panels as access openings to the exterior scaffolding.

During the fire, these boards (and the openings left behind after the boards were burnt off) permitted smoke and heat to infiltrate the staircases, rendering them incapable of providing a safe environment for evacuation and a safe route for firefighters to proceed to higher levels of the buildings.

Of the 38 fatalities in the staircases and common areas of Wang Tai House, the cause of death for 28 was inhalation of fire fumes. The full-scale fire tests confirmed that the wooden boards and aluminium composite panels ignited within minutes, whereas the fire-rated glass windows already installed in replacement of the original non-fire-rated windows remained intact and maintained a lower interior temperature.

This section examines the evidence on the creation of access openings at WFC, the causal link to the heavy casualties, and the respective responsibilities of the contractor, RI, and relevant Government departments. The primary responsibility lies with Prestige (as RC) and Will Power/Ng Yeuk (as the consultant and RI), who created or permitted the creation of access openings at regular five-floor intervals across all eight blocks in contravention of multiple provisions of the BO and the FS Code. The RI bore a specific statutory obligation to identify and report “unprotected openings at enclosure walls of exit routes” to the BA; this obligation was not discharged.

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The Government acknowledges that the supervisory architecture contained areas

requiring improvements: the MWCS classification of the window works as MW meant no prior plan approval or consent was required; the AFC checklist focused on procedural compliance rather than safety hazard identification; the ICU was not aware of the BD’s 20% site safety inspection practice for MW until after the fire; and the LD regarded the means of escape in occupied buildings as falling outside its OSH jurisdiction. The result was that no department had detected the access openings before the fire. This was also, as the Chairman observed, a situation in which “the workers’ interests and the residents’ interests seem to be on a collision course.” The Government’s post-fire improvement measures are directed at resolving this tension.

M1. Creation of wooden or metallic accesses at escape staircases at every five levels of WFC – the relevant conversation records and other factual evidence showing the manner of creation of such accesses at WFC

The evidence establishes that during the renovation works at WFC, windows at the escape staircases were removed and replaced with movable wooden boards or aluminium composite panels at regular five-floor intervals across all eight blocks, creating access openings from the protected staircases to the exterior scaffolding. These openings permitted workers to enter and exit the scaffolding from the interior of the building without climbing the scaffolding itself.

On 21 February 2025, during the LD’s 10th inspection (a Special Enforcement Operation), a void was found between the scaffold and external wall outside the 25th floor of Wang Cheong House. The access to and egress from the bamboo scaffold was found unsafe since a worker “might be liable to fall more than 2 metres through the void.” As no worker was found working nearby, no prosecution was initiated. Two Improvement Notices were issued (one to Prestige and one to the scaffolding sub-contractor) requiring rectification of the hazardous

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condition regarding access and egress within 14 days327 [WS1/370]. Li Man-pong

confirmed in oral evidence that the LD’s action was directed at the fall risk for workers, not at the access openings [Day 16/81/2-9].

On the ICU’s end, the access openings were visible in photographs submitted as part of two Class I MW submissions for Blocks F and H (MWB02504820 and MWB02504821), which covered the erection of protective barriers and alteration of windows at escape staircases. They were randomly selected for AFC under the MWCS. The pre-commencement photographs (e.g. [I1-3/6227, 7971] showed windows already replaced by wooden boards with locks and warning signs, with some of the wooden boards partially opened.

Yung, the ICU officer responsible for the AFC, explained the focus of the AFC process in his evidence. “AFC is concerned with the final building product as it will stand upon completion”328 [WS14/2122]. The MW submissions in question had the particular intended purpose of replacing the original openable, non-firerated windows with fixed windows with fire-rated glass panels, a replacement regarded as an upgrade in terms of fire safety. Yung explained: “Since such replacement is regarded as an upgrade in terms of fire safety, the immediate existing condition of the original windows, which would be overtaken by event as they were meant to be replaced and would have been overtaken by the time the subject works were complete, was not a matter of primary concern during the relevant AFC. Consistent with the focus of AFC as described above, MWT's attention was directed at ensuring that the final building works resulted from the MW (i.e. the windows in replacement) would satisfy requirements under the BO” 329 [WS14/2124; Day 23/35/5 - 36/23]. In other words, the MWT’s primary

327 LAM Sau Ching 1st WS §56 328 YUNG Siu-lun 2nd WS §20 329 YUNG Siu-lun 2nd WS §25

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concern was whether the new fire-rated windows to be installed would comply

with the BO, rather than the pre-existing condition of the windows being replaced.

Notwithstanding the above, Yung explained that he examined the photographs but interpreted the wooden boards as temporary protective measures for windows that were to be replaced, not as access openings. He explained: “At that time when we look at this photo, we find that this is some temporary protective measures on the windows.. At that time I don’t think it is an access for people to go in and out” [Day 23/30/24 - 33/9]. Yung further accepted that had he examined the photos more carefully during the AFC, he may not have concluded that the wooden boards were intended merely as temporary protection [Day 23/33/10-21].

The BD received no complaints about access openings at WFC escape staircases before the fire330 [WS1/834]. The BD’s post-fire special inspection found only 8 out of approximately 400 inspected buildings (approximately 2%) with access openings at escape staircases [Day 20/46/25 - 47/9].

M2. How the creation of such accesses at escape staircases resulted in rapid spread, as well as such heavy casualties

(i) The relevant factual evidence

Of the 38 fatalities in the staircases and common areas of Wang Tai House, 28 were found inside the staircase. The cause of death for all 28 was inhalation of fire fumes [ER9/2755]. The IFITF concluded: “This tragic outcome can likely be attributed to the compromised openings in the staircase... which allowed smoke and heat to infiltrate. These openings rendered the staircase, intended as a protected escape route and temporary place of safety, incapable of providing a safe environment for evacuation” (IFITF Report §10.6.2.2 [ER1/230]).

330 YUE Chak Sang 1st WS §67

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(ii) The IFITF’s investigations

The IFITF’s findings, addressed in Section G5 above, established that the movable boards replacing staircase windows “permitted smoke and heat to infiltrate the staircases” and that “severe blackening of ceilings above the opening indicated heavy smoke penetration. As a result, staircases intended to serve as protected escape routes were compromised, leaving residents without safe pathways for evacuation” (IFITF Report §10.6.2.1 [ER1/230]).

The full-scale fire tests conducted in Sichuan demonstrated that “the wooden board ignited at 4 min 40 sec and the aluminium composite panel ignited at 7 min 49 sec,” while the fire-rated glass window “remained intact and maintained a lower interior temperature, therefore ensuring a safer environment for evacuation” (IFITF Report §10.6.2.3-10.6.2.4 [ER1/230-231]). A resident’s account provided direct real-world corroboration. According to Ms Tse Yuk-wa, the occupant of Flat 204, Wang Cheong House, “during her evacuation at about 1455 hours, she observed a reflection of fire immediately outside the fire-rated windows along the staircase. Her experience provides direct confirmation of the effectiveness of the fire-rated glass window installed along the escape staircase, which successfully served a fire separation component and prevented smoke infiltration into the staircase under fire conditions” (IFITF Report §10.6.2.5 [ER1/231]).

M3. The primary and supervisory responsibilities for such contributing factor

(i) The standards and requirements applicable to the creation and use of such accesses and the LD’s occupational health and safety perspective

The BD’s position on the legal status of the access openings is clear. AD Karen Cheung of the BD confirmed that access openings affecting the structure of the fire escape staircase are “in contravention of regulations” [Day 20/48/10-16], that they breach section 16 of the B(C)R because they are “not an appropriate work

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procedure” [Day 20/49/3-8], and that they contravene clause F5.6(a) of the FS

Code which requires that “all means of escape should be maintained at all times” [Day 20/49/9-16]. AD Lawsons Yue of the BD confirmed that when scaffolding was erected and “some windows of the exit staircases were removed and replaced with wooden access doors which are combustible, and the window openings are suspected to be misused for access of workers and delivery of materials to the scaffolding, all these allowed the exit route to communicate with the working area at the external wall, introducing additional fire hazard to, and adversely affecting the normal function of, the exit staircases”331 [WS1/833].

The LD’s perspective on the access openings and that of the BD’s can be summarised as below, reflecting their different mandate and the worker safety considerations that the access openings were intended to serve.

1. From an occupational safety standpoint, access openings might serve a worker safety function. Li Man-pong explained: “under the code of practice, it provides that we don’t allow the workers to climb on the scaffolding … In a High Court case 332 it says that climbing on the scaffolding would present danger” [Day 16/74/2-4, 74/6-7]. He confirmed that “the access openings would serve some purpose. In case there is fire on the scaffolding or the scaffolding is collapsing, the workers will have to flee, they don’t have to climb to the roof or down to the floor to escape” [Day 16/73/2-7]. When Counsel for the Committee asked whether access openings on the rear staircases presented any problems from the LD’s perspective, Li’s view was that “No, it’s not against the law” and that “how many they open and the way in which they do it, the Labour Department doesn’t impose any standard” [Day 16/73/8 - 74/20]. As the Chairman

331 YUE Chak Sang 1st WS §65

332 The judgment was subsequently submitted to the Committee [D3/1928-1987]

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followed upon, “having an access opening is all right in terms of

occupational health and safety?... Because workers need to go up and down and they are not supposed to climb on the scaffolding to reach other floors?” Li confirmed: “Yes” [Day 16/81/10-23].

2. At the policy level, Murphy Yuen provided a more nuanced position: “On the policy level, the access opening is not essential. The access opening is for exit and entry to the scaffolding, but there are many different ways to access the scaffolding.” He acknowledged that access openings have their use, “but we need to look at the location, the size, the number of openings. Contractors need to make a risk assessment and not just to make an opening where convenient. The access openings may involve structural problems and contractors may need to discuss this with the relevant departments before opening those accesses” [Day 16/97/19 - 98/20]. This framework represents the Government’s forward-looking position on how the competing safety interests identified by the Chairman should be balanced.

The Government submits that, properly understood, the positions of the BD and LD are consistent rather than divergent.

1. The BD’s position is that access openings at escape staircases contravene the BO because they compromise the fire resisting construction and the protected means of escape. The LD’s position is that workers require safe access to and egress from scaffolding and should not be required to climb the scaffolding itself.

2. These two positions are not in conflict: the LD’s occupational safety considerations identify a legitimate need for workers to access the scaffolding safely, but the BD’s position is that this legitimate need cannot

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be met by creating openings at the escape staircase, because to do so would

compromise the very fire safety provisions upon which both workers and residents depend.

3. In other words, the need for safe access is acknowledged, but the escape staircase is not an acceptable location at which to provide it.

(ii) The primary responsibilities of Prestige and the RI

Under the MWCS, the primary responsibility for ensuring compliance rests with the prescribed building professionals and prescribed registered contractors. They certified the MW submissions for the window works at WFC. Yung confirmed: the PBPs and PRCs “are required to supervise the carrying out of MW, notify BA of any contraventions of the regulations which would result from the carrying out of MW, and comply with the BO” 333 [WS14/2117]. The supervision plans submitted stated that the PBPs (Lai Ka Wing as AP and Chi Wuh Jian Joseph Duncan as RSE) would conduct weekly inspections, and the PRC representatives would conduct full-time and weekly inspections respectively334 [WS14/2125].

The RI bears obligations in relation to access openings at two distinct stages.

1. First, at the inspection stage, the MBIS Code requires the RI to inspect fire safety elements including “means of escape, means of access for fire fighting and rescue and fire resisting construction”335 [WS1/799]. The Code specifically requires that “unprotected openings at enclosure walls of exit routes or compartment walls, floors and ceilings” shall be identified and reported to the BA [J1-2/4774-4775]. Will Power, providing RI services for the WFC renovation and Ng Yeuk, i.e. the actual RI, bore

333 YUNG Siu Lun 2nd WS §30

334 YUNG Siu Lun 2nd WS §29

335 Cheung Yuk Ching 1st WS §58

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primary responsibility for identifying the access openings and reporting

them as contraventions. AD Karen Cheung of the BD confirmed: “RI’s responsibility in their inspection, they would need to check whether there are any contraventions, to see whether access openings are made” [Day 20/50/19 - 51/7].

2. Second, during the work process, Cheung confirmed that “RI has the responsibility to notify the BD when there are any contraventions” [Day 20/51/2-4].

Will Power, providing RI services for the WFC renovation, and Ng Yeuk, i.e. the actual RI, bore primary responsibility for notifying the ICU of such contraventions during the course of the works including the creation of access openings at escape staircases. This obligation was not discharged.

(iii) The Government’s supervisory responsibilities

As mentioned above, the ICU agreed that the question of whether access openings at rear staircases contravene section 16 of the B(C)R falls within its purview. Yung confirmed that there were only discussions that access openings should not be formed in rear staircases after the fire. Prior to the fire, they did not consider the issue. When Member Chan asked: “with the benefit of hindsight you found it necessary?” Yung confirmed: “Yes” [Day 23/38/21 - 39/10].

Under the MWCS, there is no requirement for the ICU to conduct regular inspections during the course of works unless complaints are received [Day 23/22/22 - 23/14]. No complaint about the access openings had been received by the ICU.

The AFC is a document check focused on procedural compliance of the B(MW)R; it is not a safety hazard assessment. The relevant checklist items require only that

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photographs “have been provided/are clear” and that “the information... as shown

on the plans/photographs tallies with the submitted form/are clear” 336 [WS14/2123; Day 23/34/9-14].

Of the 48 MW submissions related to renovation works at WFC, only two (for Blocks F and H) were randomly selected for AFC; the remaining 46 received no further check unless complaints were received [Day 23/24/15 - 25/4].

An area calling for improvements lies in the BD-ICU communication gap concerning site safety inspections.

1. The BD had been selecting 20% of Class I MW with supervision plans for immediate site safety inspections by the BD’s site monitoring team since April 2023; the ICU was not aware of such practice until December 2025.

2. Had the ICU followed the same practice, Yung confirmed there was “a fairly high chance that a site safety inspection could have been arranged by the ICU to the works site concerned (i.e. the windows along the staircases of Blocks F and H of Wang Fuk Court)”337 [WS1/671], because “the probability that one of the two Class I MW submissions of Wang Fuk Court... could have been selected for a site safety inspection is rather high”338 [WS1/671; Day 23/54 - 55/2].

3. Lau also confirmed the BD-ICU communication gap directly: “Yes, there is a gap” [Day 24/73/19-22]. He accepted that “in hindsight, agree” and ICU should have aligned its practice with BD’s [Day 24/82/24 - 83/5].

336 YUNG Siu Lun 2nd WS §22 337 YUNG Siu Lun 1st WS §54 338 YUNG Siu Lun 1st WS §54

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The Chairman observed that this evidence appeared to be shifting responsibility

to the BD. Yung made clear that this was not the intention: “Regarding communication with the BD, I am not passing the buck. It is just a case that after the incident, the site monitoring team made an enquiry and we found that the BD had this practice and we really did not know. I just wanted to explain this. It is not the case that I said we didn’t know and we didn’t do it. I’m just saying that if we had known this, we would have done so” [Day 23/58/5 - 59/5]. The Government is fully committed to supporting the Committee’s work in a full and frank manner, and the ICU would not conceal such communication gap from the Committee. In fact, once the ICU became aware of such communication gap, the ICU immediately aligned its practice with the BD from January 2026 onwards.

This goes to support that, as part of the improvement measures (which have been or are being put in place), there should be site safety inspection even for MW particularly in large-scale maintenance and renovation works.

(iv) The actions taken by the ICU in the case of WFC

As mentioned above, the ICU conducted the AFC on the two selected MW submissions (MWB02504820 and MWB02504821). The AFC checklist items were satisfied; the ICU’s Structural Vetting Team identified structural calculation issues which were resolved through correspondence with the PBP [WS1/666-668]. However, the pre-commencement photographs showing the access openings were not identified as a safety concern during the AFC process.

M4. Systemic and/or operational weaknesses on the regulatory level

The design for window replacement works to be classified as MW subject to control of the MWCS, without requiring prior plan approval or consent, meant there was no formal gateway for the ICU to review the design of the access

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openings before they were created as a matter of system design. AD Lawsons

Yue confirmed: “replacement of fire-rated glass panels for exit staircase can be carried out under the simplified requirements of MWCS as long as the fire resisting construction for the original design of the exit staircase will not be prejudiced. Plan submission for prior approval and consent by ICU... is not required under the BO” 339 [WS1/835]. This is a design of the MWCS classification system in line with its rationale of simplifying the procedures for certain types of works with lower risks.

The AFC checklist did not require identification of safety hazards visible in photographs; it required only that photographs were provided, clear, and tallied with the submitted form. The Government acknowledges that this checklist design, while consistent with the AFC’s intended purpose (procedural compliance), was a weakness in terms of safety concerns that were visible on the face of the submissions. The photographs did contain indicators (locks, warning signs, a regular five-floor pattern) that could, on careful examination, have suggested the boards were functioning as doors rather than temporary window protection. Yung accepted that had he looked more closely, he may not have concluded the boards were temporary protection [Day 23/33/10-21; Day 23/44/17 - 45/2].

Yung’s evidence was that he had never in 27 years of professional practice encountered access openings at fire escape staircases340 [WS14/2124], that the submissions were for a replacement window project representing a fire safety upgrade341 [WS14/2124], and that the duration and manner of use of temporary protective works “are not matters required to be disclosed in MW submissions”342

339 YUE Chak Sang 1st WS §68

340 YUNG Siu Lun 2nd WS §26 341 YUNG Siu Lun 2nd WS §25 342 YUNG Siu Lun 2nd WS §28

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[WS14/2125]. These are contextualising factors, not a complete answer; but they

are relevant to the characterisation of the issue.

The BD-ICU communication gap on site safety inspections is an operational weakness that affected the probability of detecting the access openings. Lau Fukwok accepted: “Yes, there is a gap” and confirmed that the ICU would “proactively reach out to BD to step up communications at different levels” [Day 24/73/19-22; Day 24/75/14-18].

Yung accepted directly that “before the fire, the supervision of major renovation seemed to be too lax”, though he qualified this by noting “I agree to the extent that we rely only on the contractors” [Day 23/13/23 - 14/15]. This acceptance, combined with the broader evidence that 46 out of 48 MW submissions received no audit whatsoever, and that the MWCS did not require site inspections during works, confirms that the pre-fire classification of major renovation as MW with minimal oversight may require reconsideration.

The ICU implemented the BD’s 20% site safety inspection practice for Class I MW with supervision plans in January 2026, immediately upon notification of the BD’s existing practice343 [WS1/671]. The ICU has increased the selection percentage to 30% for Class I minor works with supervision plans, effective since May 2026 ([Day 23/71/2-16]; Table of Improvement Measures, Item B3(ii)(c)). Enhanced inter-departmental communication has been established: BD-ICU quarterly meetings and a designated high-ranking professional liaison officer between BD’s SMT and ICU’s SMT [Day 24/97/15 - 98/5]. From the LD’s perspective, since 17 March 2026, the LD’s frontline staff has been directed to refer any non-conformity with the BD’s requirements on means of escape

343 YUNG Siu Lun 1st WS §44

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detected during site inspections to the BD and FSD for follow-up (Table of

Improvement Measures, Item E5).

The Committee’s observation at the hearing provides the constructive way forward: “We need to try to strike a balance and plug the loopholes. There is a grey area at the moment. So in the future we need to discuss with the FSD how we can have the access openings yet ensure fire safety. The access opening should be fire-retardant, and if it is locked then it can block out some of the flames and the smoke” [Day 16/81/24 - 82/10]. The Government endorses this approach: the solution lies in collaborative multi-departmental design.

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N. THE FAILURE OF ALL FIRE ALARMS AT WFC

The IFITF found that the FAS of all eight blocks of WFC were shut down before the fire. Residents did not receive timely warnings, leading to delayed evacuation. Once they became aware of the fire, the means of escape had already been exposed to smoke and heat. The IFITF concluded that had the FAS in Wang Cheong House been operational, the security guard’s activation attempt at 1448 hours “could have provided residents with a critical evacuation alert during the key escape window between 1448 hours and 1458 hours, when escape routes were still tenable” (IFITF Report §10.4.4 [ER1/215]).

This section examines how the FAS came to be shut down, the causal link between that shutdown and the heavy casualties, the primary responsibilities of the private actors whose conduct caused the shutdown, and the supervisory role of the FSD.

The primary responsibility for this contributing factor lies overwhelmingly with private actors: Prestige, which directed an unlicensed person to drain the FS Water Tanks without supervision of an RFSIC which led to the switch off of the main power supply; China Status, which submitted SDNs to the FSD without ever visiting the site, without assessing the need and consequences for shutdown nor to effect the shutdown of the relevant FSI systems themselves, and without discovering, let alone, disclosing that the FAS had been deactivated; ISS (the PMC), which issued job orders directing its own non-RFSIC staff to illegally operate FSI and failed to coordinate between two simultaneously engaged RFSICs; and Victory Fire, which discovered the shutdown in November 2025 but failed to notify the FSD or contact and follow up with China Status.

The Government also acknowledges that the FSD’s supervisory mechanisms contained areas requiring improvements that the evidence has revealed,

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principally an SDN regime that was notification-based and absent of verification

of the subject FSI / other remaining FSIs, the low audit rate for FS251 certificates, and absence of any mechanism to detect that a partial SDN concealed a wider FSI failure. These areas are addressed below together with the comprehensive reform programme that has since been initiated.

N1. The FAS at each block of WFC being shut down

(i) The part of WFC renovation works touching on the FH/HR System

As described in Section E3 above, the FS Water Tanks at WFC are integral components of the FH/HR System and are required to maintain a minimum water reserve of 18,200 litres for firefighting purposes [B2/1896]. The FS Water Tank is not a standalone structure; it is a named component of the FH/HR System under the applicable Code of Practice.

The supply tank is expressly identified as one of the “major components” of the FH/HR System under the Code of Practice for Minimum Fire Service Installations and Equipment (Specification of FH/HR System, para. 5.14(c)) [B2/860]. The consequence, as AD Keung confirmed, is that section 7(1) of Cap. 95B applies to the supply tank: any works on the supply tank that require the FH/HR System to be shut down must be carried out by, or under the direct supervision of, an RFSIC. It is contrary to the legislative intent for the installation, repair or maintenance of the supply tank to be carried out without the engagement and supervision of an RFSIC344 [WS9/1942]. It is also contrary to the legislative intent for the supply tank to be repaired by persons other than the RFSIC that is filing the relevant SDN; in other words, it is unacceptable for the RFSIC filing

344 KEUNG Sai Ming 5th WS §20

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the SDN to be “just a paid rubber stamp to sign the corresponding SDN” while

the actual works are carried out by non-RFSICs345 [WS9/1942-1943].

For the avoidance of doubt, nothing in the FSD’s website [R3/3/1039-1040] undermines the above. Whilst there is no “tick” of the appropriate classes of RFSICs in the entry under “Supply tank” in the “Table showing the systems/installations/equipment may be required to be installed in various premises under the “Code of Practice for Minimum Fire Service Installations and Equipment” and the appropriate classes of registered contractors for such works”, there is a “tick” in favour of Class 2 RFSICs in the entry under “fire hydrant/hose reel system” (which the “Supply tank” forms a component thereof) [WS9/1943].346 As explained by AD Keung of the FSD in his oral evidence, it is only if it is a standalone water tank not connected to any FS pipes (e.g. when the water tanks were constructed at the outset) that a RFSIC would not be required [Day10/173/25 – 174/2] – he nevertheless emphasized that even if the RFSIC has not been engaged at the time of pouring of concrete, the RFSIC should be there to inspect the process and also to check at the time of acceptance [Day10/173/14-24]. In the case of WFC, one is not concerned with the construction phase, but rather renovation (and repair) works of FS Water Tanks which form part of the FH/HR System. As such, RFSICs must be engaged.

Specifically, the renovation works at WFC included repair and re-tiling of the FS Water Tanks, which required drainage of the tanks. This was agreed by the IO and Prestige as part of the renovation contract. Ms Lok Sin-ying of ISS confirmed that “the suggested approach was to renovate the FS water tank so that it could be used as a freshwater tank, a potable water tank” as a temporary measure while the freshwater tank was being repaired [Day 7/6/19-22].

345 KEUNG Sai Ming 5th WS §§19-20 346 KEUNG Sai Ming 5th WS §21

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AD Keung confirmed that the use of an FS Water Tank simultaneously as a fresh

water tank is unacceptable under the Code of Practice. The Code provides that, under normal circumstances, “the reserve water supply for fire fighting shall be contained in a supply tank,” meaning a water tank containing a specified quantity of water reserved solely for firefighting [B2/860]. Using an FS Water Tank simultaneously as a fresh water tank would diminish the quantity of water reserved for firefighting purposes by reason of consumption for domestic use. Changing the use of an FS Water Tank to a fresh water tank during the course of repair would also affect the entire FH/HR System and cause undue delay to the resumption of the system, and is therefore also unacceptable347 [WS9/1946]. The arrangement proposed by Prestige and accepted by ISS, whereby the FS Water Tank would be repurposed as a potable water tank while the freshwater tank was being repaired, was therefore contrary to the requirements of the Code of Practice from its inception.

Minutes of the renovation works meeting held on 29 March 2025 record that Prestige reported FS Water Tank repair work would commence at Wang Tai House and Wang Chi House from 7 April 2025, that the FS Water Tanks would be suspended and an SDN submitted to the FSD, and that water-based fire extinguishers would be placed on odd floors [H1-3/6079-6080]. The decision to drain the FS Water Tanks was therefore a deliberate step in the renovation process.

(ii) The engagement of China Status as the RFSIC

China Status was engaged by Prestige [R1/1-2] to submit SDNs and FS251 certificates348 to the FSD in connection with the FS Water Tank repair works. China Status did not personally inspect the FSI or supervise the drainage works.

347 KEUNG Sai Ming 5th WS §29

348 Wang Yan House (Block A) [B2/1419-1420]; Wang Tao House (Block B) [B2/1473-1774]; Wang Sun House (Block C) [B2/1499-1500]; Wang Kin House (Block D) [B2/1569-1570]; Wang Tai House (Block E) [B2/1627-

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Leung Ping-kay, Director of China Status, confirmed in his witness statement that

in or around March 2025 he received a telephone call from Gordon Ho of Prestige “requesting a quote from China Status for submitting fire service installations Shutdown Notice(s) (‘SDN(s)’) to the Fire Services Department (‘FSD’) for the temporary shutdown of the fire hydrant or hose reel system (‘FH/HR System’) of 8 buildings in Wang Fuk Court, so that PC&E could carry out renovation works to the fire services water tanks of these 8 buildings”349 [WS2/1509].

Critically, Leung confirmed that “prior to submitting these applications, no representative of China Status attended Wang Fuk Court for the purposes of understanding first-hand 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, or the feasibility of putting in place additional fire services measures while the FH/HR System is shut down”350 [WS2/1514]. Leung also confirmed that he “did not attend Wang Fuk Court to personally shut down the FH/HR Systems” and that “no personnel of China Status did” 351 [WS2/1515].

In oral evidence, Leung also confirmed unequivocally: “you did not personally go to Wang Fuk Court to check any of the FSIs and you did not independently make a judgment call in relation to the shutting down of the relevant FSIs” — “Yes” [Day 9/111/16-24]; “in relation to the submission of applications, no one from China Status have attended Wang Fuk Court to look at what the FH/HR system was like and why the system needed to be shut down, as well as whether it was

1628]; Wang Cheong House (Block F) [B2/1660-1661]; Wang Shing House (Block G) [B2/1696-1697]; Wang

Chi House (Block H) [B2/1759-1760]

349 LEUNG Ping Kay (China Status) 1st WS §3

350 LEUNG Ping Kay (China Status) 1st WS §30

351 LEUNG Ping Kay (China Status) 1st WS §35. See also LEUNG Ping Kay (China Status) 2nd WS §63 [WS7/1886]

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necessary for the fire services still needed to be shut down” – “I never went there”

[Day 9/115/16 – 116/4].

When asked whether China Status, in submitting the SDN applications to the FSD, was “just a rubberstamp” doing only what it was asked to do, Leung answered: “Yes” [Day 9/116/19-23].

This concession is a significant adverse admission by China Status on the question of RFSIC conduct.

Leung was aware that the SDN regime required the filing RFSIC to have personally inspected the FSI and assessed the need for shutdown: “the QP or AS of RFSIC should critically review the need for extension of FSI shutdown and personally confirm such need. You understand that requirement; right?” — “Yes” [Day 9/105/1-5]. He acknowledged that on the information provided in the SDN, the FSD would be “of the understanding that [he was] the contractor” and that “the information of the FSD would be incorrect” [Day 9/123/1-4]. When asked whether he agreed that “FSD would be of the view that [he was] the one to check the FS water tank”, he replied that “they wouldn’t know that someone else was responsible” [Day 9/123/23-25 – 124/1-2]. He further acknowledged that according to the SDN as submitted, “[he] said that [he] went to check [the FS water tank], [he] saw that there was water tank water leakage and there was a need to repair”, and replied in the affirmative when asked whether the FSD relied on the information provided in the SDN: “the FSD relied on the information provided to you by the FSD. Do you agree?” — “Yes” [Day 9/126/21 - 127/6].

Although Leung initially insisted that it was “common practice” for one company to help another company to submit documents for FS water tanks [Day 9/160/22

161/12], he later admitted that the company filing the SDN would be held accountable for the acts committed by the other company [Day 9/164/19-25] and

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ultimately conceded that the RFSIC filing the SDN should take part in inspecting

or repairing the relevant FSI: “So the circular letter was very clear. In seeing that if the registered FSI contractor is required to notify the FSD, it would be because they are engaged in the inspection or the maintenance work. They shouldn't act just like a rubberstamp to notify the FSD. Do you agree with that?” — “Yes” [Day 9/193/2-8].

China Status had a prior disciplinary record [B2/2579]. In December 2021, China Status was penalised by the FSD’s Disciplinary Board for failing to notify the FSD of an FSI shutdown at a building in Kwai Chung. Leung confirmed this: “that was about you breaching requirements on a shutdown notice?” — “Correct” [Day 9/95/11-13]. Despite this prior sanction, and despite the enhanced inspection regime that should have applied under the Demerit Points System following that sanction, China Status was not deterred from repeating the same conduct again at WFC.

Importantly, the above not only implicates China Status, as it also implicates Prestige which, not being itself an RFSIC 352 [WS9/1938], deliberately (i) engaged non-RFSIC to undertake renovation works of rooftop FS Water Tanks which are an integral part of the FH/HR System and yet (ii) approached and engaged China Status [R1/1-2] on paper to submit the SDNs to the FSD as a rubberstamp which created a false image of engagement of and supervision by an RFSIC and conceals the true picture from the FSD.

(iii) How the FAS was eventually deactivated by a staff member of the PMC

As mentioned above, the FH/HR System and FAS at WFC share a single main power switch found in the booster pump room. The main power switch in the booster pump room of each of the eight blocks was physically switched off by

352 KEUNG Sai Ming 5th WS §7

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Law Kwok-shui, an electrician employed by ISS (the PMC), as a result of the

instruction of Prestige to drain the FS Water Tanks and pursuant to job orders issued by ISS management353 [WS2/1233-1234].

Law’s witness statement sets out the three steps he understood to be required for FS Water Tank drainage: turning off the upfeed switch to stop the upfeed pump; turning off the gate valves to drain the tanks at rooftop and ground floor; and closing the lever switch in the booster pump room to stop the booster pump. He understood this procedure from observations of Victory Fire during annual inspections354 [WS2/1234].

Law knew that operating FSIs required an RFSIC licence. When asked why he proceeded despite that knowledge, Law stated that he took the job order to Lok Sin-ying of the management office, who told him that “PC&E needed to empty the tanks and need my assistance because I have the electrician licence” [Day 7/85/21 - 86/10]. When pressed further — “since you know that you require a licence to operate the FSIs and even though Ms Lok told you to assist, you still did so. Why?” — Law answered: “Well, I just followed orders” [Day 7/86/11-16].

AD Keung of the FSD confirmed that a non-licensed PMC switching off the main power switch without the engagement of an RFSIC was contrary to law, unprecedented in his experience, and an elementary error: When asked whether there was any circumstance under which a PMC could turn on and off the switch without engaging a RFSIC, AD Keung answered: “That would be against the law.” When asked whether a third party turning off the switch was something rare or happened often, he confirmed: “I’d say the former... I’ve never seen somebody who does not belong to an RFSIC turning off the switch” [Day 10/18/24 - 19/12].

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He further confirmed: “just for draining the tank” there was no need to turn off

the main switch, and that if a RFSIC had performed this act it would have been “a grave error” [Day 10/17/4 - 18/10].

Lee Shing-foo, an ISS carpenter, assisted Law by opening the booster pump room doors with the ISS master key on each occasion. Lee confirmed he did not enter the pump room and was unaware that the main switch controlled the FAS [Day 7/70/5-21].

Between approximately May and August 2025, ISS received 8 job orders to assist Prestige with FS Water Tank drainage across the 8 blocks. ISS currently holds only 3 copies [H2/6779-6781] (dated 8 July 2025 for Wang Tao House, 18 August 2025 for Wang Cheong House, and 28 August 2025 for Wang Yan House)355 [WS2/1255].

There is a direct conflict of evidence between Law and Lok as to whether Law raised the RFSIC licence requirement with Lok before proceeding. Law’s account is that he raised the issue and was told to proceed because he was an electrician356 [WS2/1233]. Lok’s account is: “I have no impression that they raised that” [Day 6/134/12-16]. On either version, ISS management issued job orders for work that required the engagement of an RFSIC without ensuring an RFSIC was so engaged.

No proper record was kept of Prestige’s entry into the pump rooms to effect the release of water. Cheng Tsz-ying of ISS confirmed that Prestige workers “did not really do the registration because they were stationed in the complex. They were all in uniform” [Day 8/60/11-22]. The consequence was that the FSI shutdown occurred without documentation: “If the procedure was followed, then there should have been a form stating that there was a drainage, working permits were

355 李承富 (Lee Shing-foo, ISS) 1st WS §17 356 LAW Kwok-shui 1st WS §19

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issued and the entry of whether the fire alarm system would be affected would be filled in” — “Prestige workers did not really do the registration” [Day 8/60/11-19].

(iv) The maintenance and repair works carried out by Victory Fire at WFC from October to November 2025 up to the day of the fire

Victory Fire’s annual inspections in March 2025 found no structural problems with the FS Water Tanks. Wong Kin-wa (electrician of Victory Fire) confirmed: when asked whether during the March 2025 annual check anyone told him about leakage, he said “No”; when asked whether he found any structural problems with the water tanks on the rooftop, he said “No” [Day 5/97/14-17] [Day 5/106/11-16].

The rectification works contracted to Victory Fire in October 2025 concerned defects in the FAS components (BGUs, alarm bells) and hose reel components identified in the March 2025 FS251s. They did not concern the FS Water Tanks themselves357 [WS2/1529].

On 16 to 17 October 2025, Victory Fire’s plumbers attended WFC to replace hose reel nozzles and gate valves. They discovered the FS Water Tanks in all 8 blocks were empty, having been drained as part of the renovation works. Chung Kit-man of Victory Fire was informed by his colleague Tong Hing-lun, who had been told by ISS’s Lam Man-yan that the tanks were empty due to ongoing renovation358 [WS2/1529]. Chung accepted that he could not complete testing of the replaced components without water in the FS Water Tanks [Day 6/30/19-25 – 31/1-2]. Notably, there is no contemporaneous evidence that Victory Fire asked Lam Man-yan for a copy of any SDN during their discussion on 16 October 2025 [Day 9/20/17-25 – 21/1-9], nor is there any contemporaneous evidence that Victory

357 CHUNG Kit-man 1st WS §§5-6 358 CHUNG Kit-man 1st WS §§5-6

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Fire asked Cheng Tsz-ying of ISS for a copy of any SDN during the alleged call

to her on 17 October 2025 or until 17 November 2025 [Day 6/64/4-12, 66/7-25 – 67/1-21]. In the premises, it can be inferred on the available evidence that Victory Fire therefore made no attempt to verify the status of the FSI shutdown or to ascertain whether the FSD had been properly notified, despite having direct knowledge that the FS Water Tanks were empty across all eight blocks for more than one month and notwithstanding the hindrance it caused to the completion of their own repair works.

On 19 November 2025, Victory Fire’s electricians Li Chun-yin and Wong Kinwa discovered that the main power switches in the booster pump rooms of all eight blocks had been switched off (not to mention that the upfeed pump was removed). Li Chun-yin found that in all eight blocks of WFC, the ground floor fire pump main power switch had been switched off, which caused the FAS and FH/HR System to be simultaneously inoperative359 [WS2/1538]. He immediately informed Cheng Tsz-ying of ISS. Cheng told them that due to large-scale renovation works the fire system had to be suspended, that an SDN had been submitted to the FSD, and that temporary fire extinguishers had been placed as required by the FSD360 [WS2/1530]. Chung Kit-man admitted in oral evidence that after what transpired after 19 November 2025, when told about the major maintenance works, he “thought it was more than that” because the part related to the upfeed pump was removed and that “if it was work relating to the repair of the FS tank, that would not be necessary” [Day 9/47/243-25 – 48/1-21]. Nonetheless, Victory Fire’s electricians were instructed by Chung Kit-man to continue the repair works and notwithstanding that a test could not be conducted with the main power switched off [Day 6/38/22-25 – 39/1-7]. Once again, there is no contemporaneous evidence that Victory Fire asked Cheng Tsz-ying for a

359 李俊賢 (LI Chun Yin, Victory Fire) 1st WS §5 360 CHUNG Kit-man 1st WS §8

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copy of the SDN on 19 November 2025 [Day 5/112/24-25 – 113/1-5] [Day

6/72/19-23] [Day 6/114/21-25], nor did Victory Fire take any steps to verify that the SDN covered the FAS (as distinct from merely the FH/HR System), despite its direct knowledge that the FAS had been shut down for a period of time (possibly for over a month since 16 October 2025 [Day 6/89/3-6]) and notwithstanding the hindrance it caused to the completion of their own repair works; they simply turned a blind eye.

Contemporaneous documentary corroboration exists: at 11:51 to 11:54 am on 19 November 2025, Li Chun-yin sent WhatsApp messages to the block-specific WhatsApp groups stating the fire service pumps were switched off in relation to blocks B, A, C and others consecutively (e.g. [R1/686-692]).

Cheng did not tell Victory Fire that the main switch controlled the FAS, did not inform Victory Fire of the extent of the FSI shutdown, and did not pass the SDN documentation to Victory Fire. When asked why she did not show the SDN to Victory Fire or suggest coordination between the two contractors, Cheng answered: “it didn’t cross anyone’s mind that that needed to be done” [Day 8/70/17 - 71/13].

On 26 November 2025, Victory Fire’s workers completed their rectification works and left WFC by approximately 1:00 pm. No test of the FSI was conducted and no FS251 was issued. At 1:28 pm on the day of the fire, ISS’s Lam Man-yan called Chung Kit-man, who told him that for the connection system component, a certificate could not be issued because the FS Water Tanks had no water and the power supply to the water supply system and fire pump had been shut off361 [WS2/1531]. Less than two hours later, the fire broke out.

361 CHUNG Kit-man 1st WS §11

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N2. How the shutdown of the FAS resulted in such heavy casualties

(i) The relevant factual evidence

When the fire broke out at approximately 1451 hours on 26 November 2025, the FAS in all eight blocks was de-energised. The fire alarms did not sound at any block during the critical early phase of the fire, depriving residents of the warning they needed to evacuate.

Multiple resident witnesses confirmed they did not hear any fire alarm during the fire. Residents only became aware of the fire through neighbours knocking on doors, smelling smoke, or seeing flames. Lam Man-yan of ISS attended the booster pump rooms of Wang Yan House, Wang Tao House and Wang Sun House on the afternoon of the fire and physically switched the main power switches back to “ON.” In Wang Yan House the fire alarm sounded; in Wang Tao House it did not; in Wang Sun House it sounded362 [WS2/1217-1218].

The FSD’s FPFS arrived at WFC at approximately 1554 hours and attempted to reactivate the FAS at Wang Yan House, Wang Tao House and Wang Chi House (the three blocks not yet significantly affected by fire). The FAS failed to reactivate even after the main power switch was turned to “ON” at Wang Yan House, Wang Tao House and Wang Chi House. Wang Chi House was unaffected by fire and the FAS should have remained intact, yet testing revealed it was nonfunctional363 [WS4/1799-1801].

The comparative casualty data starkly illustrates the significance of the FAS failure. AD Keung was asked whether the FAS failure was “definitely one major cause” for the difference in the number of deaths between Wang Sun House (which experienced momentary FAS activation and suffered only two deaths

362 Lam Man-yan 1st WS §§20-23

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despite severe structural damage) and Wang Tai House (where the FAS never

activated and over 80 persons perished) and a factor that “should be given some weight”. AD Keung answered: “I cannot rule this out” [Day 10/47/4 - 48/2].

Had the FSD been notified of the FAS shutdown, particularly a shutdown of FAS (which is critical) for an excessive period lasting for a few months, the FSD could have taken immediate enforcement measures such as issuance of FHAN and refusal of extensions of SDNs. Meanwhile and at the very least, the FSD would have updated the contingency plan to deploy additional appliances, notified the local fire station, and required the owner to implement standby measures and notify residents. None of this occurred. AD Keung confirmed by reference to the FSD’s Circular Letter No. 1/2021: “it is imperative that the FSD should be promptly notified of the FSI shutdown so that the units of the FSD may formulate appropriate contingency plan and advise the owners/occupiers of the premises to take additional fire safety measures during the shutdown period”364 [WS9/1939].

(ii) The IFITF’s investigations and expert evidence

The IFITF’s findings on the FAS shutdown and its contribution to casualties are addressed in Section G5 above. The IFITF concluded that the security guard’s attempt to activate the FAS at Wang Cheong House at 1448 hours, had the system been operational, “could have provided residents with a critical evacuation alert during the key escape window between 1448 hours and 1458 hours, when escape routes were still tenable” (IFITF Report §10.4.4 [ER1/215]). Instead, “as the FAS was not functional, residents remained unaware of the immediate danger until evacuation was no longer viable” (IFITF Report §10.4.5 [ER1/215]).

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N3. The primary and supervisory responsibilities for such contributing factor

(i) The regulatory and supervisory regime for the shutdown of FSI

(1) FS251, its filing and response / following up upon receipt

Under Regulation 9(1) of Cap. 95B [B2/179], whenever an RFSIC installs, maintains, repairs or inspects any FSI, it must within 14 days after completion of the work issue a certificate (FS251) to the person on whose instructions the work was undertaken and forward a copy to the DFS. The certificate must state the address, a description of the FSI concerned, the date of completion, the nature of the work, and whether the FSI is in efficient working order. An RFSIC who signs or issues a false or misleading certificate commits an offence under Regulation 9(2A) and 9(3) of Cap. 95B.

The FSD’s processing of FS251s is predominantly manual and paper-based (approximately 95% of submissions are by fax or post), subject to significant time lags between signing, submission and inputting into the Integrated Licensing Fire Safety and Prosecution System (“LIFIPS”). AD Keung accepted that in one documented case, an FS251 signed in December 2023 was not faxed to the FSD until August 2024 and not inputted into LIFIPS until November 2024 [Day 10/105/16-24].

The FSD’s audit of FS251s operates on a random sampling basis. AD Keung confirmed that only approximately 300 annual inspection checklists out of approximately 60,000 buildings per year (0.5%) are document-checked [Day 10/60/12-22]. Such audit of checklists is, however, only one component of the FSD’s overall monitoring activity. The FSD also conducts document reviews of

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FS251 certificates submitted by RFSICs, on-site verification inspections, and

functional tests of FSI on a selective basis365 [WS1/107-108].

AD Keung explained these components in detail during oral evidence.

1. For document review, the FSD selects approximately 15,000 out of 300,000 certificates submitted annually for checking, including all 20,000-odd certificates relating to licensed premises (restaurants, guesthouses, bed spaces, dangerous goods stores) and approximately 30,000 certificates reporting defects, which are followed up individually [Day 10/57/18-24; Day 10/61/11-19]366. In other words, a total of 65,000 out of 300,000 certificates received annually will be audited by the FSD for follow up.

2. For verification inspections, the FSD conducts approximately 10,000 random on-site inspections per year, approximately 2,000 follow-up inspections arising from defect certificates, and approximately 1,000 targeted inspections of contractors with accumulated demerit points [Day 10/62/2-18].

3. For functional tests, the FSD conducts approximately 1,000 tests per year arising from reports of fire alarm mis-activation or actual fires, together with approximately 80 targeted functional tests of contractors with high demerit scores [Day 10/62/22 - 63/7].

365 KEUNG Sai Ming 1st WS §5.4.2

366 See Chinese transcript at [Day 10/31/29-34] for more clarity: “姜世明先生：係。咁剛才我講你入份證書畀我，我會抽一萬五千份。此外，嗰三十萬證書裏面其實有兩萬份係關於一啲持牌處所、餐廳食肆、酒店賓館、危險倉等等。咁嗰啲因為要同我哋續牌，或者係申請牌照呢，我哋都係份份都有所跟進。此外，三十萬份證書裏面約有每年三萬份，佢會喺個證書嘅第三部分係寫咗有一啲損壞事項，咁呢三萬份損壞事項我哋都有所跟進，咁呢個我將會歸落去我呢個（English Spoken）呢個類別。”

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4. AD Keung emphasised that these different activities should be viewed

collectively rather than in isolation [Day 10/60/20-24].

(2) The FSI SDN, its filing and response / following up upon receipt

The SDN mechanism under the FSD’s Circular Letter No. 1/2021 [B2/1302] was a notification (not approval) mechanism.

When defects requiring overnight or continuous shutdown of more than 24 hours are identified, the RFSIC is required to notify the FSD by submitting an SDN. Upon receipt, the local fire station must visit the premises within 24 hours, conduct a risk assessment, issue an advisory letter, and monitor progress. The system relies entirely on the accuracy / truthfulness and timeliness of the RFSIC’s reporting. AD Keung confirmed: “the whole mechanism is built on the contractor’s integrity and his effective and timely reporting of the shutdown” — “Agree”; “So if the contractor makes a mistake it’s not possible for the FSD to know” — “Well, unless it falls within the scope of random inspection” [Day 10/84/8-16].

The FSD’s Circular Letter No. 1/2021 explains the rationale for the notification system [B2/1302]: “it is imperative that the FSD should be promptly notified of the FSI shutdown so that the units of the FSD may formulate appropriate contingency plan and advise the owners/occupiers of the premises to take additional fire safety measures during the shutdown period, where necessary.” The RFSIC is identified as “the most appropriate person to notify the FSD accordingly” [B2/1302] because the RFSIC “will be engaged by the FSI owners to inspect FSIs to see whether they have to be shut down for maintenance/modification/repair”367 [WS9/1939].

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The notification system is not an approval mechanism. AD Keung’s witness

statement explains: “The FSD is not privy to the engagement process nor the contractual negotiations and therefore will not be directly involved in the technical content of the works. The RFSIC engaged will inspect the FSI and if there is a need for them to be shut down for maintenance / modification / repair overnight or for more than 24 hours continuously, the RFSIC will notify the FSD of the shutdown. However, the notification system for FSI shutdown is not an approval mechanism as the RFSICs should bear the ultimate responsibility in certifying the FSIs are in efficient working order”368 [WS8/1911].

The 14-day interval requirement for SDN extensions is designed to ensure that the RFSIC is “actively and consciously making a professional assessment that an extension is required” and to enable the FSD to verify that repair works are being overseen by an RFSIC, to identify the latest RFSIC responsible, and to ascertain whether the RFSIC may have been removed from the register369 [WS8/1912].

Where an extension notification pertains to the same defect as previously assessed, “no further visit/inspection or duplicated risk assessment would be required” under the pre-fire regime. The rationale given is that “the initial risk assessment had already been completed, the necessary mitigation measures had been implemented, and the relevant stakeholders including residents had been informed of the shutdown”370 [WS1/113].

(ii) The primary responsibilities of Prestige and the RI

Prestige, as the main contractor, (i) engaged non-RFSIC to undertake renovation works of the FS Water Tanks which are an integral part of the FH/HR System without supervision of an RFSIC and (ii) directed the drainage of the FS Water

368 KEUNG Sai Ming 4th WS §9 369 KEUNG Sai Ming 4th WS §10 370 KEUNG Sai Ming 1st §6.8

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Tanks as part of the renovation works which eventually resulted in ISS (a nonRFSIC) performing the physical shutdown of the main power switch. Under section 7(1) of Cap. 95B, “no person other than a registered contractor shall maintain, inspect or repair any fire service installation or equipment which is installed in any premises.” Shutting down any FSI is considered an act that can only be carried out by an RFSIC371 [WS8/1911]. AD Keung stated that this arrangement was “unacceptable”372 [WS9/1944].

When Prestige informed Leung Ping-kay of China Status at the outset that the building management (ISS, a non-RFSIC) would “handle the physical shutting down of the FH/HR Systems,” Leung raised no objection and sought no clarification. When asked whether this struck him as legally impermissible, he replied: “I don’t know how to answer you” [Day 9/175/7-13]. When asked who would actually perform the shutdown, he said he was simply told “someone would make the arrangement” [Day 9/174/24 - 175/5].

AD Keung confirmed that “from the FSD’s stance, under current law, it is explicit that they have to personally monitor the shutting down of the FS system” and that allowing a non-RFSIC to perform the act was “against the law” and “something that one must never do” [Day 10/39/9-20].

A further point requires emphasis. Prestige itself is not an RFSIC. AD Keung confirmed that although a separate entity bearing a similar name, Prestige Construction & Fire Engineering Co Ltd, holds RFSIC registration (RC1/0563 and RC2/0744), that company is distinct from Prestige and did not carry out any FSI-related works at WFC 373 [WS9/1938]. Prestige therefore possessed no qualification whatsoever to direct, arrange or supervise any works touching on

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FSIs. The arrangement was one in which a non-RFSIC contractor engaged nonRFSIC to undertake renovation works on FSIs and directed a non-RFSIC PMC to operate FSIs as part of the renovation works, with a third-party RFSIC engaged solely to provide the paperwork.

In short, every actor in this chain, save for the paper signatory, lacked the statutory authority to do what they did.

(iii) The primary responsibilities of China Status

China Status submitted SDNs to the FSD without conducting any site inspection 374 [WS2/1514], without personally assessing the need and consequences for shutdown375 [WS2/1517], without effecting the shutdown or verifying which FSI systems were actually being shut down376 [WS2/1515], and without ever discovering [Day 9/121/16-21], let alone, notifying the FSD that the FAS (as distinct from the FH/HR System) had been shut down.

China Status’s SDNs consistently ticked only the FH/HR System box, leaving the FAS box blank. Leung admitted this was because “we only knew that the water tanks was being worked on” and that he filled the forms out as Prestige asked him to [Day 9/121/16-21]. China Status never realised that the FAS had in fact been shut down, let alone, report it to the FSD because it never visited the site. As a result, the FSD received no notification that the FAS was also inoperative, and the contingency plan was never updated to reflect this critical additional risk.

AD Keung’s assessment was unequivocal, China Status also misrepresented to the FSD that it was the RFSIC carrying out the relevant repair works and that the repairs were needed as a result of leakage of the FS Water Tanks: “China Status

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not only failed the expectation of the public, but also breached the FSD’s trust by falsely representing to the FSD that it was the relevant RFSIC carrying out the relevant repair works based on the defect(s) as detected. Moreover, the relevant FS251s were not provided to the FSD with the corresponding SDNs until October 2025, and descriptions of defects in the concerned FS251s have misled the FSD by giving the impression that the shutdown of the FSI was due to repairs needed as a result of ‘leakage of FS water tanks’ (without mentioning ‘empty tanks’, let alone the plan to use the FS Water Tanks for other purposes, or indeed the shutdown of the FAS)”377 [WS8/1915]. Leung admitted that the FSD would be so misrepresented as to the identity of the RFSIC carrying out the relevant repair works [Day 9/122/13-18] [Day 9/123/1-4] [Day 9/123/19-25 – 124/1-2].

Leung admitted frankly that he did not exercise his discipline in looking at whether his acts breached the requirements in the circular letter [Day 9/136/3-16; Day 9/155/20 – 156/1], and that he “breached all of [his] obligations” shown to him in the circular letter [Day 9/156/2-5].

It is “never part of the notification system and... unacceptable for one RFSIC to sign the SDN while the actual works are carried out by another RFSIC (let alone, as it transpires in the case of Wang Fuk Court, by sub-contractors who are not even RFSICs). Such a practice circumvents statutory accountability and undermines the FSD’s ability to enforce disciplinary action against the responsible RFSIC should they fail to follow the relevant requirements” 378 [WS9/1939].

When the FSD made enquiries of China Status in October 2025 following multiple extension applications, Leung did not disclose to the FSD that China Status was playing a purely administrative role and was not the RFSIC

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conducting or supervising the works [Day 9/170/14-21]. The FSD therefore

remained under the false impression throughout the relevant period that China Status was the responsible RFSIC inspecting, supervising and certifying the FSI works at WFC [Day 9/122/13-18] [Day 9/123/1-4] and that the works were necessitated by leakage of the FS Water Tanks [Day 9/123/19-25 – 124/1-2] [Day 9/126/21-25 – 127/1-6].

Overall, AD Keung confirmed: it was “unacceptable for Tin Hung and Red Sun, both not being RFSICs, to carry out the concrete works at the water tanks particularly when China Status is just a paid rubber stamp to sign the corresponding SDN” 379 [WS9/1942].

AD Keung’s 5th Witness Statement elaborated on the specific obligations that China Status failed to discharge. The Code of Practice for Inspection, Testing and Maintenance of Installations and Equipment requires at clause 1.16 that the RFSIC “shall advise the residents/occupants/property management company to take preventative measures to mitigate the risk during the works period when any FSI is defective or shut down for inspection, maintenance, modification or repair” [B2/884]. Without attending the site and supervising the works, an RFSIC cannot properly discharge this advisory obligation. The same Code further provides at Appendix 9, Item (I), that the “QP/AS of RFSIC should critically review the need for extension of FSI shutdown and personally confirm such need” [B2/961].

Without attending the site, an RFSIC cannot critically review whether an extension is required or whether the system should be resumed to normal operation. China Status did neither: it never attended the site, never advised the residents or PMC of preventative measures from its own assessment, and never personally confirmed the need for any of the 85 extensions it submitted for all 8

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blocks at WFC. Each extension was filed mechanically on the basis of

information provided by Prestige, without any independent professional judgement and without any concern for the progress of the repair works. This was admitted by Leung: “You didn’t carry out any inspection, you just did what you were told to do, you didn’t explore for how long the system needed to be shut down and whether it could be shut down for a shorter period of time. And this is against the circular letter we went over just now. Do you agree? […] What does ‘mm’ mean? Does it mean you agree?” – “Yes” [Day 9/129/11-20].

(iv) The primary responsibilities of the PMC

The PMSA Code of Conduct specifically requires licensed PMCs to monitor the progress of the RFSIC’s work, follow up timely with the RFSIC on required rectifications, follow up timely with the RFSIC that it has notified the DFS of FSI shutdowns, and assist FSD officers during visits [B2/2631]. AD Keung confirmed: “had ISS monitored or checked the guidelines, then this should not have happened” — “I agree. It should not have happened” [Day 10/21/12-20].

ISS bears the responsibility for: issuing job orders directing non-RFSIC staff to operate FSI; failing to coordinate between the two engaged RFSICs (Victory Fire and China Status); and failing to ensure FSI were in efficient working order.

Lok Sin-ying of ISS confirmed that she knew the water tank was part of the FSI: “Did you know that the water tank is part of the FSI?” — “Yes” [Day 7/31/17-19]. Yet when asked whether it occurred to her that draining the FS Water Tank should be done by a RFSIC rather than the property company, she answered: “No, it did not occur to me” [Day 7/33/19-24]. She did not ask Prestige whether they would engage a RFSIC [Day 7/33/14-18].

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Cheng Tsz-ying, ISS’s property officer, confirmed she understood it was her

responsibility to know when the fire systems were suspended and when they would be resumed, describing this as “a serious matter” [Day 8/40/25 - 41/4]. Yet despite this knowledge, she never followed up on the duration of the shutdown, never coordinated with Victory Fire, and never passed the SDN documentation to Victory Fire [Day 8/70/17 - 71/13].

Lam Man-yan, who rejoined ISS in October 2025, confirmed he had not seen any SDN and did not know the tanks in all eight buildings were empty until the day of the fire. When asked “nobody told you?”, he answered: “Yes” [Day 7/141/5-17]. He confirmed he did not have a chance to see any SDN documentation up to the point of the fire [Day 7/158/8-15]. This is reinforced by the evidence of the WhatsApp exchange between Lam and Chung Kit-man on the night of the fire: Lam asked Chung “how to get those forms because I’ve never downloaded them before” and asked whether there were any certificates in relation to WFC’s buildings [Day 7/147/11-25 - 148/1-2], and Chung texted Lam a link to the SDN standard form [H3/6798]. This is conduct consistent only with Lam never having previously seen or received any SDN documentation in relation to the FS Water Tank shutdown.

AD Keung further identified a systemic gap in coordination: “I have seen instances like this... coordination is very important. We haven’t really seen much problem with coordination before but we have seen in this incident coordination is an issue” [Day 10/28/23 - 29/19]. There was no express regulatory requirement compelling PMCs to coordinate between multiple simultaneously engaged RFSICs, and the evidence demonstrates that ISS did not do so.

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(v) The primary responsibilities of Victory Fire

Victory Fire was engaged for the annual inspection and rectification works at WFC. When its staff discovered during their repair works on the FH/HR System and FAS at WFC that the FS Water Tanks were empty (16 October 2025) and the main power switches were switched off (19 November 2025), Victory Fire had an obligation under the FSD’s circular letter No. 1/2021 to notify the FSD. Not only did it fail to do so, it did nothing to reinstate both FSI systems even though their repair works on the FH/HR System [Day 6/30/19-25] and FAS could not be tested as a result [Day 5/108/22-25 – 109/1-5] [Day 6/38/22-25 – 39/1-7].

AD Keung rejected Victory Fire’s position that it had done what it was “supposed to do”: “I won’t accept what he said because, in this trade, we work with fire services installations and the ultimate goal is to protect residents. If the power supply is cut off, even if the system is operational, it does not achieve the intended effect. The alarm will not sound, there’s no water. And we have already reminded them in the circular letter to notify us so that we can implement other measures... deploy more appliances, notify the residents” [Day 10/32/5-24].

By 16 October 2025, Chung Kit-man’s own evidence establishes that he knew the FS Water Tanks in all eight blocks had no water and that the upfeed pumps had been switched off [Day 6/28/23 - 29/14]. He acknowledged that he had considered that the main switch could have already been shut off for more than one month from 16 October to 19 November; “And did you also think that the lever switch had been turned off for a month, since 16 October?” – “Yes” [Day 6/89/3-6]380.

Yet Victory Fire took no steps to submit its own SDN, made no enquiry of China Status, did not ask ISS to restore power before testing, and did not notify the FSD

380 More clearly reflected in Chinese transcript at [Day 6/55/2-4]

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of the FAS shutdown, let alone the empty water tank. When asked whether he

considered conducting an inspection to check the situation during the one-month period between 17 October and 17 November 2025, Chung confirmed: “we didn’t consider this” [Day 6/63/12-18].

When Victory Fire’s electricians discovered the lever switches were turned off on 19 November 2025, Wong Kin-wa accepted the management office’s explanation without further enquiry: “we felt that, well, if a contractor was involved, the contractor should know what they were doing” [Day 5/126/14-21]. He confirmed he did not ask Prestige, and did not ask China Status directly [Day 5/114/19 – 115/4].

AD Keung confirmed that the obligation to notify the FSD fell on both Victory Fire and China Status: “Both of them” [Day 10/33/11 - 34/16]. Victory Fire could not shelter behind the existence of China Status’s SDN for the FH/HR System: quite apart from the issue of the empty water tank, it knew the FAS had been shut down for over 24 hours (and possibly for over a month) and yet did not obtain copies of the SDN to check whether the FAS was covered by them despite the admitted unusualness in the situation [Day 6/90/8-12].

(vi) The Government’s supervisory responsibilities:

(1) The audit-check system for all submissions received, and the FSD’s focus

The FSD’s monitoring of RFSIC performance operates through various distinct mechanisms: document review of FS251s; verification inspection; and functional test of FSI. These are separate activities conducted on different occasions and on a selective basis.

The FSD conducts proactive audit checks on a percentage of submitted FS251s. For certificates indicating no defects, the local fire stations also conduct a

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significant number of on-site verification inspections annually. Throughout the

process, any defects or discrepancies identified are followed up, and instances of non-compliance or misconduct by RFSICs may be uncovered381 [WS1/106-107].

In general, visits and inspections to a domestic estate like WFC by various units of the FSD are initiated from three aspects: fire hazard complaints, FSI-related visits and inspections, and proactive visits by local fire stations under the Riskbased Building Fire Safety Visit Programme382 [WS1/114-116].

High-priority complaints (involving “imminent danger” to life such as locked escape routes) trigger a response within 24 hours. Normal-priority cases trigger inspection within 10 working days383 [WS1/114].

The Risk-based Building Fire Safety Visit Programme, launched in 2018, provides for proactive risk-based visits across the territory to promote fire safety education. WFC was not selected under this programme during the renovation period [Day 10/96/13].

(2) The FSD’s response upon receipt of SDNs, complaints or enquiries, in particular when site inspections would be carried out

AD Keung’s evidence established that the FSD visits and inspections at WFC were initiated from three aspects: fire hazard complaints, FSI-related visits/inspections (including defective FSI and shutdown cases), and proactive visits by local fire stations [Day 10/95/10-16].

Between July 2024 and November 2025, the FSD conducted a total of 26 visits/inspections at Wang Fuk Court: 18 FSI-related visits/inspections (6 relating to defective installations and 12 relating to shutdowns), 7 complaint inspections

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(2 relating to EVA, 3 relating to means of escape, and 2 relating to other matters),

and 1 proactive visit384 [WS1/114-119].

For complaint-driven inspections, the FSD operates under a priority classification system. “High priority” complaints alleging imminent danger to life, such as locked escape routes, require investigation to commence within 24 hours, while “normal priority” cases trigger inspection within 10 working days385 [WS1/117; Day 10/69/20-25]. AD Keung confirmed that for complaint-led investigations, no prior notification is generally given because this could compromise the investigation386 [WS8/1909; Day 10/70/9-14].

Among the complaint inspections at WFC, two related to matters other than the means of escape or EVA. One concerned a public complaint via 1823 about the storage and potential use of large quantities of polystyrene boards (25 September 2024), and the other concerned a complaint about the installation of solar panels on the roof floor (17 November 2024)387 [WS1/118]. In each case, the FSD conducted a site inspection focused on the subject matter of the complaint.

1. For the complaint about the storage and potential use of the polystyrene boards, no breach of the FSO was found, and as the case had already been referred by 1823 to the ICU, no further referral was made by the case officer.

2. The solar panel complaint was referred to the ICU for follow-up.

In relation to the complaint inspection on 25 September 2024, it was preceded by another complaint inspection at or around the same period. The FSD received a

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complaint in the morning of 13 September 2024 that polystyrene boards were

obstructing the means of escape and the FSD carried out inspection in the afternoon of 13 September 2024, finding that there was no obstruction to the means of escape or EVA [B2/1737-1739]. This was explained further by AD Yung in his oral evidence [Day 17/20/9 – 22/14].

For the proactive visit to WFC, AD Keung explained in oral evidence that the visit to WFC took place on 19 October 2025. During such visit, officers of the FSD checked whether the EVA was obstructed and tested the street fire hydrants [Day 10/96/1-25].

In addition to FSI-related visits, complaint inspections and proactive visits, the FSD also responded to enquiries from stakeholders. For example, the FSD organised a fire safety talk at Wang Fuk Court attended by approximately 100 residents. Station Commander Herman Hor explained that such talks are arranged upon application by members of the public and are not automatically triggered by major renovation works [Day 17/68/1-25].

As to the response to SDNs, upon receipt of an SDN, the objectives of the on-site risk assessment are twofold: “to assess the risk from an operational perspective” and “to assess the scale and type of additional fire safety measures to be taken by FSI owner(s) during the shutdown period” 388 [WS1/111]. The assessment focuses on building type, configuration, type of occupancies affected, availability of water supply for firefighting purposes, state of housekeeping, and information provided by the RFSIC about the types of FSI that are inoperative or shut down389 [WS1/112].

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The structural design and perhaps a weakness of this mechanism is that it is

designed to verify compliance with standby measures rather than to check the accuracy / truthfulness of the SDN or the condition of other FSI systems. AD Keung confirmed: “Because it’s just a partial shutdown, you would assume that other systems would still be in working order?” — “Correct” [Day 10/84/4-7].

This (valid and natural) assumption is the vulnerability that China Status’s declarations exploited.

When the FH/HR System SDN was received, the FSD acted on the information as stated on the SDN and did not proceed further to verify the condition of the FAS or any other remaining parts of the FSI systems. AD Keung accepted: “before the incident, when a fire safety system is defective, the Fire Services Department has not checked other systems to see if they’re in working order... if you’re talking about that case, then that is true” [Day 10/86/5-11].

The 8 April 2025 on-site inspection following receipt of China Status’s first SDN illustrates the operational weakness in the SDN regime. AD Keung explained that verifying FSI operability requires more than visual inspection: “You can’t just conduct visual inspection to check if the system is in efficient working order. You need to conduct functional tests, and for some buildings they may have not only two systems, but seven” [Day 10/85/7-14]. The SDN regime did not require the attending officer to enter the booster pump room, check whether the main switch was in the correct position, check the FAS independently, and verify the condition of the FS Water Tank; for other circumstances, the FSD had “other kinds of audits and check” [Day 10/86/9-11]. AD Keung accepted that the officer’s finding that “defects were the same as stated on the shutdown notice” was based on an assumption rather than independent verification [Day 10/122/16-25], and that

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“based on the mechanism then, that was adequate, but we think there’s room for

enhancement” [Day 10/123/7 - 124/2].

The FSD conducted one proactive visit to WFC during the entire renovation period (19 October 2025), and this visit was limited to checking the EVA and street fire hydrants; no inspection of FSI, pump rooms or main switches was conducted. AD Keung confirmed: “while Wang Fuk Court was undergoing major repairs, that was the only visit that was done” [Day 10/97/15-17] and that “before the fire in relation to Wang Fuk Court” there would not be a surprise check arising specifically from major renovations [Day 10/73/14-18].

The Chairman observed: “Do you agree — of course with hindsight is what we’re doing now — the fire risk of buildings under major renovation is almost the highest because, in addition to existing fire risks, there are also people living there?” AD Keung confirmed: “Well, speaking today, I agree with what you say” [Day 10/101/6-12]. The Government accepts this observation and acknowledges the absence of a specific arrangement for enhanced FSI inspection or surprise checks triggered by major renovation works as an area requiring improvements.

(vii) The FSD’s handling of the FS251s and SDNs in the case of WFC and actions taken

By way of illustration, China Status submitted the first SDN for Wang Tai House on 7 April 2025 (estimated completion 20 April 2025). The FH/HR System remained suspended through 16 further extension notices until the day of the fire on 26 November 2025, a total shutdown period of approximately 7.5 months. The same pattern repeated at Wang Chi House (also 7 April 2025, 16 extensions). The

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FSD’s block-by-block response across all eight blocks is set out in detail in AD

Keung’s witness statement390 [WS1/123-135].

AD Keung did explain that under the pre-fire practice, the FSD may intervene if there are extensions for a long time. However, he frankly admitted that based on the data available to the FSD, many works concerning FSIs may take more than several months to complete by reason of inter alia the time required for owners to engage RFSICs to undertake the work, etc. He also explained that what the FSD was most concerned with at the time were buildings which do not even have RFSICs or conduct annual inspections. Against such context, the FSD did not question the extension notices at WFC (including the 16 extension notices for Wang Tai House or Wang Chi House). Under the prevailing mechanism, as long as an RFSIC was shown to be engaged and submitting extensions, no further enquiry was initiated for up to one year. AD Keung accepted: “SDN being extended 16 times, if there were new SDNs being submitted... over seven months you did not ask how come it would take so long” — “Right” [Day 10/134/8-16]. When asked whether, regardless of the number of SDNs (85 across the estate), “there is no mechanism to follow up on the matter, even if the extension lasted for over a year,” AD Keung confirmed: “Agree.” He also acknowledged that such practice was “not ideal” [Day 10/146/12-22].

The FSD was unaware that two RFSICs (Victory Fire and China Status) were simultaneously engaged at WFC. AD Keung attributed this in part to the volume of paper-based submissions and time lags in LIFIPS, which prevented detection of the back-to-back submission of Victory Fire’s FS251 (31 March 2025) and China Status’s first SDN (7 April 2025). He acknowledged that “there is a large amount of certificates posted to our department, 300,000 every year” and that

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“there are still certificates being posted to us and there is a time lag” [Day

10/34/17 - 36/20].

A further consequence of the FS251 processing lag was that the FSD could not determine whether a “major defect” requiring enhanced enforcement action was involved. China Status did not submit its FS251 until October 2025, approximately six months after the SDN was filed in April 2025. AD Keung accepted: “in the six months nobody checked the certificate to see if a major defect [was involved]” — “Correct” [Day 10/138/16-18]. In the absence of timely FS251, the attending officer had to resort to calling China Status to ascertain the reason for the shutdown which resulted in the classification of the defect on the information provided by China Status in the telephone conversation [Day 10/136/13-15]. Putting aside the issue of an attending officer misclassifying water leakage as a “major defect” [Day 10/136/9-13], the result was that the FSD was put under the false impression that (1) the shutdown was necessitated by maintenance of the FS water tank (when this had not been assessed by China Status), and (2) that the shutdown and the relevant repair works were being carried out by an RFSIC (when China Status had no involvement), a misconception that influenced the level of enforcement follow-up that was otherwise required of the FSD.

N4. Systemic and/or operational weaknesses on the regulatory level

The evidence identifies the following systemic and operational areas requiring improvement in the FSD’s supervisory role.

First, the SDN mechanism was a notification, not approval, mechanism, and relies on RFSIC integrity and their timely and accurate / truthful reporting. The regime enforced at the time did not require the FSD to carry out physical inspections of all FSI systems at a premises to detect an inaccurate / false SDN: the on-site risk

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assessment conducted upon receipt of an SDN was directed at formulating an

appropriate contingency plan and assessing standby measures, rather than independently verifying the accuracy / truthfulness of the SDN or checking the condition of FSI systems beyond those identified in the notification.

Second, the manual, paper-based FS251 processing system create substantial time lags that render the document-checking function of limited effectiveness in real time. The 8-to-11-month lag between signing, faxing and inputting of FS251s identified in the evidence demonstrates that the existing system was unable to detect contemporaneous problems.

Third, there was no arrangement for enhanced FSI inspection or surprise checks specifically triggered by major renovation works [Day 10/72/22 – 73/2], despite the acknowledged reality that buildings under major renovation carry elevated fire risk by reason of the combination of combustible construction materials, partial FSI shutdowns, and continued residential occupation.

Fourth, the standby measures specified in the applicable procedures (fire extinguishers at alternate floors) are not fully adequate when both the FH/HR System and FAS are simultaneously inoperative. There is currently no equivalent backup measure for FAS failure. AD Keung accepted: “we need to implement other fire safety measures, but you’re right, we cannot really achieve the same effect” [Day 10/93/22 – 94/4].

Fifth, the Code of Practice applicable to WFC’s FAS is the 1979/1982 version. The 2022 version’s requirement for warning labels on the main power switch (stating “THIS SWITCH ALSO CONTROLS THE SUPPLY TO THE FIRE ALARM SYSTEM”) [B2/919] did not apply to WFC, and no equivalent labelling obligation was imposed under the earlier code. AD Keung accepted that such a

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warning label would “reduce the chance of unqualified personnel turning off the

switch” [Day 10/154/10-17].

Following the WFC fire, the FSD has implemented a comprehensive programme of immediate and medium-to-long-term reforms to enhance the current regulatory arrangements and enforcement.

In terms of immediate measures already implemented: the FSD engaged property management stakeholders to elevate fire safety awareness; established that FSI should be inspected and repaired before major renovations commence; completed functional tests on FSIs in 461 buildings undergoing major renovation by January 2026 (in coordination with the ICU and BD); established a Quick Response Team to assess FSI operation during fires and test FSI post-operation; and issued FSD Circulars Nos. 1 and 2/2026 mandating prominent notices of FSI shutdowns (A3 size, laminated, at each lift lobby floor), mailbox notifications to residents, clear marking of non-operational installations, and sealing of FSI power switches by RFSICs with green (operational) or red (under repair) tamper-evident seals391 [WS8/1918-1919]. As of 27 May 2026, the Quick Response Team has been deployed 647 times (Table of Improvement Measures, Item A4).

The FSD is also actively promoting the Fire Services Department Building Emergency Responder training scheme, aiming to train 45,000 property management personnel, OC representatives, and residents within 2026 to help them identify and proactively report FSI abnormalities. As of 27 May 2026, approximately 10,000 property management personnel have been qualified under this scheme (Table of Improvement Measures, Item A7).

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The DFS confirmed that the inspection programme has expanded significantly.

Phase 1 (Operation Outpost), commencing on 19 January 2026, covered 1,500 higher-risk target buildings, with irregularities identified in 267 buildings resulting in 69 prosecutions and FHANs issued against 395 FSIs. Phase 2 commenced in April 2026 with a target to inspect 5,000 buildings within two years. As of 27 May 2026, 272 target buildings have been inspected under Phase 2 (Table of Improvement Measures, Item A6).

The FSD has also established a two-way communication channel with the BD, Architectural Services Department (“ArchSD”), Housing Department and ICU for large-scale renovation projects: when works commence, the ICU provides a list to the FSD, and the FSD conducts more frequent inspections accordingly. The DFS confirmed: “For the buildings with scaffolding nets, whenever there is any shutdown, we inform the BD or the Housing Department at once. We will not allow any works to continue because of the shutdown of the fire service system. There were five buildings having this situation and we already ordered works to be stopped” [Day 19/70/4 - 71/5].

The operational teams now formulate contingency plans with new elements specifically addressing the WFC scenario. The DFS confirmed: “A contingency plan is also formulated by the operational team. New elements are included, including the configuration and the operation of the fire systems. Having drawn reference from the Wang Fuk Court fire, if buildings nearby have scaffolding nets, in the contingency plan they need to detail how the fire will be handled in the case of any spread” [Day 19/70/23 - 71/5].

In terms of medium-to-long-term legislative amendments under consideration: the FSD proposes requiring FSD approval for major FSI shutdowns prior to commencement (converting the notification mechanism to an approval-based

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mechanism), with a 60-day cap and Fire Hazard Abatement Notices for noncompliance. The DFS confirmed: “We want to introduce provisions to mandate approval instead of just notification in relation to any shutdown of the fire service system” [Day 19/72/1-14].

The DFS confirmed in oral evidence the scope and timetable of the proposed legislative reform.

1. On the conversion from notification to approval: “We want to introduce provisions to mandate approval instead of just notification in relation to any shutdown of the fire service system. We will check whether there is any need to shut down the fire service system concerned and we will also see whether any facilities or equipment has been put in place in the interim, that is, replacement measures” [Day 19/72/1-11]. The Government has since proposed legislative amendments to upgrade the regulatory regime of major FSI shutdowns, bringing it up from administrative “post-event notification” to statutory “pre-approval” checks. The Government published a public consultation on the proposed amendments on 26 May 2026 (Table of Improvement Measures, Item A8) [B14/6272].

2. On the 60-day cap: “We want to close the loopholes. If need be, the shutdown notices... the works need to be completed within 60 days. Otherwise, we will issue FHAN” [Day 19/72/12-14]. On the timetable: “In early May, we’re going to conduct consultation at the Legislative Council” [Day 19/72/3-4]. The relevant measures have been introduced in April 2026 (Table of Improvement Measures, Item A8). For shutdowns of major FSIs exceeding 60 days, the FSD will issue FHANs to the owners, requiring completion of repairs by a specified deadline; failure to comply will result in further enforcement action.

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The Government submits that this represents a fundamental transformation of the

SDN regime from a passive notification system to an active approval and monitoring mechanism.

The DFS provided further details on enhanced enforcement.

1. On electronic FS251 submission: “In the coming two months, we are going to issue a circular; we are going to ask all fire service contractors to submit the electronic version of FS251. Otherwise, we are going to invoke the existing legislation to handle the case by disciplinary hearing. We want to handle the situation where the submission is late” [Day 19/67/6-16]. That measure has since been implemented. The FSD issued a circular letter on 15 May 2026 notifying contractors of the mandatory submission of FS251 certificates via a designated electronic platform with effect from 1 July 2026 [B14/6257]. The upgraded online submission system was officially launched on 18 May 2026, with mandatory electronic submission commencing on 1 July 2026 (Table of Improvement Measures, Item A9).

2. On the penalty regime: “for contractors not submitting certificates or not conducting annual inspections or failure to report any defects, we’re going to increase the level of penalty by five times or even 10 times or even jail” [Day 19/69/1-5]. The proposed enhancement of penalties and criminal accountability for various offences has been included in the legislative amendments proposed by the Government in May 2026 (Table of Improvement Measures, Item A10(iv)) [B14/6285-6287].

3. On RFSIC registration reform: “within three to five years, they have to apply for renewal once. The criteria include whether they have been prosecuted by the FSD or whether they score very high scores, and we consider this basket of factors. So we will not allow underperforming

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contractors to apply for renewal” [Day 19/69/8-15]. The abovesaid

legislative proposals in May 2026 include replacing the permanent registration of RFSICs into a renewal system, made subject to “fit and proper” assessments (Table of Improvement Measures, Item A10(iii)) [B14/6278].

4. On the responsible person system: “the property management companies will be made the party responsible” [Day 19/69/7]. The abovesaid legislative proposals in May 2026 also propose to introduce the FSI “Responsible Persons” regime and to incorporate PMCs into the statutory responsibility chain alongside owners or occupiers (Table of Improvement Measures, Item A10(ii)) [B14/6275].

These proposals, taken together with the fixed penalty regime for identifiable firerelated offences and broader FSD investigation and enforcement powers, constitute a comprehensive statutory overhaul of the FSI regulatory framework.

The DFS also confirmed that upon receipt of SDNs, the FSD now conducts proactive checks beyond the system reported as shut down: “Regarding the new practice of SDNs, colleagues need to conduct inspections to check for alternate measures. At the same time, colleagues will also need to check two systems. One, the fire hydrant/hose reel system; and, two, the break-glass unit. That is the power of the BGU as well as the situation of the fire service tank. This practice has already started” [Day 19/73/7-13]. The relevant measures were introduced in April 2026 (Table of Improvement Measures, Item A8). This directly addresses the vulnerability that China Status’s SDNs - which identified only the FH/HR System as being shut down while omitting the FAS - exploited: under the new practice, the FSD independently verifies the condition of FSI systems beyond those reported as defective, eliminating the assumption that FSI systems not

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identified in the SDN remain in working order. RFSICs are also reminded of their

responsibility to identify, assess, and report any chain effects that the shutdown of one FSI would have on other FSIs, e.g. if the shutdown of the FH/HR System would lead to the failure of the FAS: the FSD Circular Letter No. 2/2026 dated 8 January 2026 [B14/6249].

A pilot programme testing fire alarms in 1,500 older residential buildings (pre1987) has been initiated and extended to 5,000 buildings, with a view to extending to 32,000 buildings territory-wide [Day 19/104/10-12]. As of 27 May 2026, 272 target buildings have been inspected (Table of Improvement Measures, Item A6). Research is also ongoing into temporary fire alarm systems for renovation sites, and the FSD is exploring FSI that can be installed on scaffolding to suppress or extinguish fire [Day 17/47/10-20]. In parallel, the FSD has promoted a voluntary fire alarm testing programme with stakeholders including the PMSA, Hong Kong Association of Property Management Companies Limited (“HKAPMC”), HA, Hong Kong Housing Society (“HS”), Real Estate Developers Association of Hong Kong (“REDA”), and the Association of Registered Fire Service Installation Contractors. Over 100 members of the HKAPMC have expressed support and will actively promote voluntary fire alarm testing in buildings under their management, covering more than 6,000 property projects. The HA has completed voluntary fire alarm testing or regular inspections of FSIs for about 1,300 public rental housing blocks (Table of Improvement Measures, Item A2).

The Government submits that this reform programme directly addresses the operational weaknesses and areas for improvements identified above. The conversion from notification to approval, electronic submission mandate, PMC Responsible Person System, enhanced penalty regime, and proactive interdepartmental communication channel collectively constitute a fundamental

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improvement of the FSI regulatory framework for buildings undergoing major

renovation.

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PART III(E): CONCERNS ON THE FIREFIGHTING AND RESCUE OPERATIONS

O. THE GOVERNMENT’S REVIEW OF THE FIREFIGHTING AND RESCUE OPERATIONS

Section H above presents the chronological narrative of the firefighting and rescue operations as they unfolded from 26 to 28 November 2025. This section constitutes the Government’s review of those operations: an assessment, informed by the evidence before the Committee, of specific aspects of the FSD’s operational response that have been the subject of questioning, criticism or concern during the evidential hearings.

The Government’s primary position is that the firefighting and rescue operations were conducted professionally, at unprecedented scale, under extraordinary conditions not previously encountered in Hong Kong or, in terms of simultaneous multi-block residential façade fire, anywhere in the comparable developed world. Over 100 persons were rescued; all 347 reported assistance locations and all remaining units were attended; and the operation was sustained over 43 hours with continuous command at the highest level.

The Government also acknowledges candidly that the evidence discloses areas where operational decisions and systemic arrangements could, with the benefit of hindsight and in light of the unprecedented circumstances that materialised, have been improved. These acknowledged areas for improvements are, in the Government’s submission, by no means individual failures by frontline officers operating under extreme pressure.

Throughout this review, the overarching factual context must be borne in mind: the firefighters could not prevent the rapid spread of fire and heavy casualties because of the presence of the five key contributing factors addressed above.

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Those factors, for which primary responsibility lies overwhelmingly with private

actors, created conditions that no fire service could have fully overcome regardless of the operational decisions taken.

This assessment is borne out by the evidence of the DFS. He stated that it was “important to recognise the truly unprecedented nature of the Wang Fuk Court fire,” observing that it “involved the full-scale involvement of seven high-rise residential blocks in close succession” in which the buildings’ compartmentation, fire-resisting construction requirements and FSIs were “completely compromis[ed], such that once the fire reached a certain magnitude, it became self-sustaining”392 [WS2/1028]. His assessment was that “there is, at present, no obviously superior or fundamentally different operational approach that fire brigades elsewhere could realistically have adopted to contain such a conflagration effectively under the circumstances” 393 [WS2/1028].

The DFS further observed that “for a fire of this scale and configuration, 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,” and emphasised that “the underlying causes and contributing factors of the Wang Fuk Court fire span across multiple domains beyond frontline firefighting operations” 394 [WS2/1028-1029]. This assessment is independently corroborated by the Committee’s experts, who concluded that “in practical terms very limited additional action that the FSD could have taken on site to materially alter the outcome” (IC Expert Report §8.1.5 [ER3/2257]). The Government adopts this analysis as the starting point of its submission in this section: the

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firefighting operation was conducted to the best of the FSD’s ability and

resources.

O1. The tactical consideration to control the fire at each affected building according to the circumstances at the early stage of the fire instead of deploying manpower to carry out evacuation

(i) The FSD’s understanding with the Police

The FSD and Police operate under an established understanding for fire incidents: upon the arrival of police at a fire scene, they assist in evacuating and directing residents to places of safety, while the FSD concentrates on firefighting and rescue. This arrangement was activated from the earliest stage of the WFC fire.

DD Chan confirmed in oral evidence: “according to our usual practice of collaboration, the police would also help us to evacuate the residents in the neighbourhood and then we would try to fight the fire so that residents would be able to get the time to run out” [Day 18/33/20-24].

This arrangement was put into practical effect. As set out in Section H above, officers of PTU X4 entered Wang Chi House and Wang Yan House between approximately 16:13 and 16:40 hours on 26 November 2025 to assist in the evacuation of residents from upper floors. Nine residents were successfully evacuated, and the FSD was informed of the evacuation initiatives 395 [WS17/2204-2206].

AD Tang confirmed in the context of the WFC fire: “As the FSD first attending crews were largely engaged in the firefighting operations and clearance of obstructions at the entrances and exits of various buildings, particularly at Wang Cheong House and Wang Tai House during the initial stage, assistance was

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sought from the Hong Kong Police Force (“HKPF”) personnel to assist in evacuation. To my knowledge, the HKPF personnel had used the Public Address system in police vehicle(s) to urge the evacuation of residents. Evacuees were guided to places of safety on the ground level by the combined efforts of both the FSD and HKPF personnel”396 [WS6/1861].

The IFITF also noted that:

1. After the fire was raised to No.3 Alarm at 1502 hours, “Concurrently, the residents from the unaffected blocks were evacuating to the ground level on their own. At 1515 hours, Police set up FCP at scene. In line with usual collaboration, the police took initiative in evacuating residents in the surrounding using vehicle’s public announcement system and loudhailers. Besides, Police Tactical Unit (PTU) entered Wang Chi House and Wang Yan House and successfully evacuated a total of 9 residents.53 FS crews were tasked to activate fire alarms in the three unaffected blocks (i.e. Wang Tao, Wang Sun and Wang Kin House). They discovered that the FAS of the three blocks were inoperative. To buy critical time for residents to evacuate, FSD concentrated most available manpower on fire suppression at Wang Cheong and Wang Tai Houses to slow its progression towards the remaining not yet affected blocks” (IFITF Report, §5.4.3.2 [ER1/65]);

2. “By prioritizing immediate fire suppression over other tasks, firefighters bought critical time for residents and maintained viable escape conditions that would have otherwise been compromised by flames spreading from the external scaffolding into the building interiors. This tactical prioritization

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likely delayed the fire spread, providing residents at Wang Sun House more time to evacuate” (IFITF Report, §9.3.2.8 [ER1/198]).

For completeness, the Government notes that the FSD-Police arrangement is described in the evidence as an established usual practice of collaboration [Day 18/33/13-24; 52/18-25].

(ii) The FSD’s tactical consideration and difficulties in carrying out evacuation

The FSD’s tactical decision at the early stage was to concentrate available resources on suppressing the fire at Wang Cheong House and Wang Tai House in order to prevent further spread, while relying on the Police to assist with evacuation of residents in less-affected areas. DD Chan explained the two options available to him in oral evidence [Day 18/51/25 - 53/13]:

“In fact, at the time there were two options available to us. Given the manpower at the scene and also the scale of the fire, there were two options available to us. One, concentrating the resources to suppress the fire; at Wang Cheong, Wang Tai House, we can spray water at these two blocks. As I said, police already arrived at the scene at 3.30. And then, according to our tacit arrangement, they would try to help the residents to evacuate. That’s the first option. The second option would be to deploy some manpower to Wang Kin, Wang Sun, Wang Tao, Wang Yan or even Wang Shing Houses, to evacuate the residents there. But then, in doing so, the fire might have spread more rapidly and the blaze could become more serious and it could also affect the other blocks more quickly.”

DD Chan acknowledged that with the benefit of hindsight, deploying manpower to evacuate other blocks earlier was an option he could have taken: “If you look at what you just said, if you look at the number of casualties, my review afterwards was that that’s also an option that I could have taken” [Day 18/53/11-

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13]. The Government presents this candidly as the judgement of a senior

commander facing unprecedented conditions. The question of which option would have produced the better outcome is one that even hindsight may not be able to provide a complete answer. The available evidence does not establish that earlier deployment of manpower to evacuation (at the cost of reduced fire suppression at Wang Cheong and Wang Tai Houses) would on balance have reduced overall casualties; the cause of those casualties was the combination of contributing factors that created conditions beyond what any resource allocation could have fully overcome.

Indeed, a difficulty in executing evacuation was the complete failure of the FAS across seven of eight blocks. DD Chan confirmed: “Given the resources available at the time, apparently there was no other device that would have worked like a fire alarm to effectively alert the residents in the units that there is a fire and you need to escape as soon as possible” [Day 18/49/13 – 50/1]. Without a functioning FAS there was no automated means of alerting residents estate-wide, and no substitute system available that could replicate the FAS’s coverage.

Another difficulty was the blockage of entrances and exits to Wang Cheong House and Wang Tai House by burning debris, which made forced evacuation of those blocks physically impossible at the initial stage and required firefighters to clear passages before any internal rescue could proceed. Shortly after FS arrival at 1456 hours (IFITF Report §5.2.2.1 [ER1/44]), blockage of entrances and exits to Wang Cheong House was observed by SStnO Hui at 1457 hours (rear exit) and 1505 hours (front entrance) (IFITF Report §10.3.3 [ER1/208]); after the fire was observed to have spread to Wang Tai House at around 1500 hours (IFITF Report §5.2.3.1 [ER1/53]), blockage of entrances and exits to Wang Tai House was observed by SStnO Hui at 1520 hours (front entrance) and 1530 hours (rear exit) (IFITF Report §10.3.3 [ER1/208]). AD Tang confirmed that “most of the

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casualties/deceased were located in Wang Cheong House and Wang Tai House”

and that “evacuation was made difficult there because the entrances/exits to those buildings were engulfed in flames and blocked by fallen bamboo sticks and debris at the initial stage”397 [WS1/55-57].

DCFO(NTN) Wong confirmed that the standard SAR protocol (sending one team to the rooftop and one to the target flat) was not applicable to fully engulfed blocks such as Wang Cheong and Wang Tai Houses. He stated: “The guidelines that I just mentioned was for general fire. But for Wang Cheong/Wang Tai House, the fire engulfed the entire two blocks so we could not invoke the guidelines that I mentioned just now. All we could do was to come up with a plan with the firefighting officers. Because we could not put out the fire, we could not send firefighters there” [Day 11/117/1-22].

There was no established written guideline for the FSD dealing with total FAS failure across a multi-block estate. SStnO Hui confirmed that there was nothing “clearly written down” directing officers what to do to direct residents to leave in such circumstances [Day 11/23/19-23]. DO Lam similarly confirmed: “No, no such guidelines... if you’re talking about a general order, we don’t have that to teach us step by step what to do when that happens” [Day 11/94/19-24].

Indeed, commenting on the evacuation efforts as a whole, the IFITF also noted that “While the evacuation process was complex and challenging, it in fact reflected the necessity of adopting an ongoing dynamic assessment when evacuating during a fire due to the rapidly changing circumstances” (IFITF Report, §9.4.3.6 [ER1/202]).

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(iii) Whether sufficient weight had been given to the failure of the fire alarms

in deciding not to deploy manpower on evacuation

At the early stage of the fire, crew members were sent to three blocks (Wang Kin House, Wang Sun House, Wang Tao House) to attempt break-glass activation at approximately 1530; by approximately 1535 to 1540, the estate-wide FAS failure was confirmed, as described in Section H above.

DD Chan confirmed he was aware of the FAS failure before his arrival at 1610. His evidence was that he considered the EAS unsuitable for this incident because the situation required localised, one-on-one communication with specific residents in the affected buildings, a need that was met by the call-back mechanism (approximately 1,500 phone calls to trapped residents made by the Support Centre) 398 [WS8/1933]. This mechanism made approximately 1,500 call-back calls during the operation, providing ongoing safety advice and updating frontline personnel on the conditions and locations of trapped residents [B13/5720] [B15/6329-6360].

The Government acknowledges that the call-back mechanism necessarily operated reactively (after residents called the FSD), not proactively (alerting residents who had not yet called). Residents who did not call 999 were not reached by call-backs. This constraint was inherent in the system which was predicated on 999 calls having been made to the FSD first. The reforms to address this inadequacy, including the potential reconfiguration of the EAS for localised use and public education on response, are addressed below (Table of Improvement Measures, Item A12(iv)).

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(iv) Whether there was sufficient attention paid on the horizontal spread of fire

from Wang Tai House to other blocks and inward spread of fire from the façade into the building

The fire spread horizontally from Wang Cheong House to Wang Tai House within approximately 10 minutes, and then to five further blocks within approximately 45 minutes. DD Chan confirmed that this building-to-building spread was “unprecedented” and that he had “never” encountered a comparable situation [Day 18/30/7-22; Day 18/36/14-19]. He further confirmed: “We only knew that it was spreading unusually fast” [Day 18/80/3-4]. The mechanism of spread (flying embers carried by east-to-southeast wind) was not predictable from the initial stage.

ADO Cheung Lok-hang confirmed that the fire’s external origin bypassed the building’s passive fire safety provisions entirely: “In terms of design, in terms of the fire-resistant compartments, there should have been smoke-free staircase so that the fire would not escalate to such a scale. But for this case, the fireresistance capabilities of the building was not up to par. Perhaps there were other reasons for why the fire spread so quickly” [Day 11/76/9-15].

The inward spread, being fire penetrating from the external façade into residential units, was the defining characteristic of this fire and fundamentally different from a standard internal building fire. The IFITF’s findings on this mechanism warrant emphasis. The IFITF observed that: “Our hypothesis posits that the fire predominantly spread into units through openings, such as broken or open windows. However, the test results from Sichuan revealed additional factors contributing to this fire spread. Apart from convective fire spread via broken windows, the radiant heat flux was sufficient to ignite combustibles inside the units. Notably, the time taken for the windows of the re-entrant to be broken by fire coincided with that for the combustibles inside units to be ignited by radiant heat. Even when windows were covered with polystyrene panels, these covers

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could potentially detach under intense heat, allowing radiation to penetrate and ignite materials within. Additionally, the investigation revealed that heat and smoke could also spread through other openings in kitchens and toilets, such as exhaust fans. These findings do not contradict our hypothesis but rather supplement it, revealing additional mechanisms of fire spread that need to be considered” (IFITF Report §8.3.2.1 [ER1/136]).

The Government acknowledges that the unprecedented nature of the horizontal and inward spread created a tactical challenge for which no established protocol existed. The FSD’s operational review, addressed below, is examining whether the contingency plan framework for renovation site fires should specifically address horizontal spread scenarios and what pre-positioned resources should be available for buildings undergoing large-scale renovation (Table of Improvement Measures, Item A12(iii)).

O2. The escalation of fire alarm levels

(i) Whether the fire could be escalated to higher fire alarm levels earlier for deployment of further resources to the fire scene

The applicable FSD guideline provides that if the Incident Commander is not confident the fire can be contained within a short period, the fire “should be upgraded immediately.” The governing principle is essentially: If in doubt, upgrade [B9/4858; Day 11/28/12-22; Day 11/42/9-13]. SStnO Hui confirmed his agreement with this principle.

The critical context should be stated at the outset: the formal alarm level was not the binding constraint on resource deployment at any stage of the WFC fire. At every stage, actual deployment significantly exceeded the formal alarm level. Officers at their posts could and did request additional resources directly through the FSCC, without in any way being constrained or hampered by the actual alarm

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level. AD Tang confirmed: “each officer at their respective post will know what

resources they need and they can make the request directly... Colleagues at their respective posts will do their best instead of being classified in their approach” [Day 19/32/15 - 33/21].

Further, the IFITF also noted that “Given the complexity and challenges of the fire, the FSD recognized that the strategy could not rely solely on established action plans to address the situation. Instead, the strategy needed to adapt and respond dynamically as the incident evolved”, with “special arrangements…not covered under existing procedures and guidelines” which “helped operational efficiency of frontline Officers” (IFITF Report, §5.4.6.1 [ER1/69] with the relevant special arrangements and their details tabulated thereunder).

As to the No. 1 to No. 3 upgrade: SStnO Hui upgraded the fire six minutes after his arrival (at 1502 hours). His witness statement confirms the criterion was met at the time: “there was a rapid spread of fire among different façades of Wang Cheong House, and the mid-lower level of east façade of Wang Tai House was well alight. At the time of my arrival, I observed that there were no evacuees from the front entrance of Wang Cheong House. In view of the fire development and potential large number of residents trapped therein, I upgraded the fire to No. 3 Alarm”399 [WS2/990].

SStnO Hui acknowledged in oral evidence that with the benefit of hindsight, he may have upgraded immediately upon arriving: “If I had known of the consequences, then upon alighting the vehicle, I would have upgraded the fire immediately. The sooner the better” [Day 11/40/21 - 41/2]. The Chairman acknowledged the practical reality of the frontline officer’s position: “You need time to observe the environment before making the decision. You cannot upgrade

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the fire immediately upon alighting the vehicle; right?” to which SStnO Hui

agreed [Day 11/42/4-8]. That said, the practical effect of such immediate upgrade may have been modest given that 12 appliances with 61 FS members were already dispatched and additional resources were already automatically triggered by the contingency plan.

By the time of the No. 3 Alarm at 1502 hours, the initial deployment had already reached approximately 80% of the PDA for a No. 3 Alarm Fire400 [WS1/41].

As to the No. 3 to No. 4 upgrade: DD Chan acknowledged in oral evidence, with hindsight, that upgrading to No. 4 Alarm earlier would have helped: “But it was quite some time afterwards when it was upgraded to No. 4 alarm. Of course with hindsight we might have asked a bit too much, but now, do you think that it would be a better time to escalate it to a No. 4 alarm earlier?” to which he answered “Yes, looking with hindsight, it would help if it had been upgraded to No. 4 alarm earlier.” When asked whether he would take that into consideration in a future review of guidelines, he confirmed “Yes” [Day 18/59/25 - 60/10].

The Government further invites the Committee to take heed of two contextualising matters.

1. First, by 1534 hours when the No. 4 upgrade occurred, 269 FS members had already been dispatched, approximately twice the PDA for a No. 5 Alarm 401 [WS1/45]. The practical resource gap that an earlier No. 4 upgrade might have addressed was already being filled by other means, including the DCP’s independent deployment of 10 additional SAR teams between 1520 and 1548 hours.

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2. Second, the above acknowledgements are made with the benefit of

hindsight and in the knowledge of a fire of unprecedented scale; the realtime decision is invariably made in less than ideal circumstances, and particularly so in the present conditions that no officer had previously encountered given the unprecedented nature and extent of the Tai Po fire.

As to the No. 4 to No. 5 upgrade: DD Chan upgraded at 1822 hours. By that time, cumulative deployment was 6.5 times the No. 5 Alarm PDA (718 FS members deployed against a PDA of 110). DD Chan’s evidence explains that the upgrade was for command-structure purposes rather than resource mobilisation: it was to “provide a clearly defined strategic command for the whole scene and to ensure that firefighting and SAR operations across all sectors were coordinated under a single incident-wide framework”402 [WS8/1930-1931].

Critically, DD Chan had already arrived at the scene at 1610 hours (well before the No. 5 upgrade) and had immediately begun providing on-site strategic advice, instructions and support to the Incident Commander. By 1635 hours, DD Chan had instructed the implementation of the building-by-building command strategy with eight operation sectors, each under a designated Senior Officer for firefighting and a separate Senior Officer as SAR leader403 [WS8/1923-1925]. The formal No. 5 upgrade at 1822 hours therefore formalised a command structure that was already substantively in place and operational, rather than representing the first point at which strategic-level direction was being exercised.

Overall, the Government submits that the pattern across all three upgrade decisions is consistent: actual deployment ran well ahead of the formal alarm level at every stage. The alarm level determined the automatic PDA deployment; it did not cap what could be requested on top of that. The Government commits

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to reviewing the alarm escalation guidelines to ensure that they accommodate and

duly respond to the particular characteristics of large-scale renovation site fires.

(ii) Whether the current fire alarm levels are capable of covering varying features at different fire scenes, e.g. the fire risks arising from large-scale renovation projects

DD Chan confirmed that the contingency plan for WFC already provided additional resources over the standard PDA at the No. 1 Alarm stage, and that he considered this to be more flexible than a fixed and automatic No. 2 Alarm classification for renovation sites: “Major renovation is temporary, not permanent. In relation to buildings undergoing major renovation, we will not treat it as a No. 2 fire alarm mobilisation at the start. However, we have put in place a contingency plan to add more appliances. This serves the same purpose but it is a temporary arrangement, not a permanent one, that is in the form of a contingency plan. Contingency plan gives us more flexibility because the local fire station can make assessments as to how many appliances should be added when they consider the sites under major renovation. There is more flexibility and it’s more suitable than rigidly setting it as a No. 2 fire to start” [Day 18/61/1-20].

AD Tang confirmed that the FSD’s post-fire operational review would examine this question directly: “Every time after there’s a fire we would conduct an operational review and the Wang Fuk Court fire would be no exception. We also had relevant committees to review different aspects of the issue in order to draw experience or draw lessons from the incident so that in terms of our tactics, our strategies, in terms of the coverage and the depth or even the details that we could undertake in putting out the fire would also be studied” [Day 19/30/13-21]. While AD Tang opined that “internal firefighting remains the primary fire suppression

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strategy for building fires”404 [WS6/1873] and confirmed that in the case of Wang

Fuk Court, turntable ladders had already been deployed at available strategic positions for external firefighting such that “further reinforcement of turntable ladders, regardless of their operational height, would not have effectively met the operational objectives” 405 [WS6/1873], when asked specifically whether the review would address whether more turntable ladders should arrive earlier for façade fires, AD Tang confirmed this “would be subject to the review” [Day 19/30/10-12].

The Government acknowledges that the contingency plan approach, while more flexible than a fixed alarm classification, in hindsight requires review given the scale and nature of what materialised at WFC. The FSD is thus conducting an operational review of all aspects of the firefighting response, including whether the contingency plan framework is adequate for façade fires at renovation sites (Table of Improvement Measures, Items A12(i) and (iii)). The Government supports a specific review of whether the current alarm level system should be amended to reflect the particular risks of buildings undergoing large-scale renovation works.

O3. The joint-handling of 999 calls by the Police and FSD in the case of fire

(i) The discretion on the Police’s side to decide whether to refer a call to the FSD’s side

The 999 hotline is managed by the PCCC. Upon confirmation that a call relates to fire or rescue, it is immediately transferred to the FSCC. The PCCC establishes a three-way phone conference connecting the caller, FSCC, and PCCC

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simultaneously, allowing the PCCC to continue providing support during the

initial stages of the handover406 [WS1/161].

The applicable Police guideline provides that where a caller “states an accident involving injury has occurred or reports a fire, or requests provision of either an ambulance or fire appliance the caller will be immediately informed that the call will be connected to Ambulance/Fire Control” 407 [WS2/1144-1145]. While waiting for the call to be picked up by the FSD, the Police console operator may ask for further details. DCFO(OP) Wong confirmed this was helpful: “[t]he police has helped us tremendously in a three-party call, the police would not hang up immediately, they would wait and see if our dispatchers have obtained all the information successfully” [Day 12/121/13 - 122/10].

DCFO(OP) Wong acknowledged, however, that in some cases on 26 November 2025, police operators collected information and asked questions before transferring calls to the FSD, which was a deviation from the intended design: “the police has already confirmed the caller’s details before forwarding the call to you and that’s not according the mechanism; is that right?” to which Wong answered “Correct” [Day 12/10/13 - 13/7].

As the Committee may recall, in one documented case (Wang Cheong House, 17/F at 15:06 hours), a caller who stated she was in a fire, on the 17th floor with smoke entering the flat, was not transferred to the FSD. The police operator ended the call after asking if she needed FS assistance and accepting her decision to close windows and stay. DCFO(OP) Wong considered this was not handled correctly: “From my experience, we have never heard of these cases. But in

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relation to this case, I do think that it should not have been handled in this way”

[Day 12/47/16 – 48/5].

The Government acknowledges that the deviation between the intended design (immediate transfer upon confirmation of a fire) and practice on 26 November 2025 (information collected first in some cases, and case(s) of non-transfer) is a joint FSD-Police issue to be addressed. A joint review of 999 call-handling procedures is being conducted. Having said the above, it bears reiteration that isolated deviation(s) from established procedures is not necessarily indicative of any systemic deficiency or failing in those procedures.

(ii) The waiting time for some calls to be referred to the FSD

On average, the FSCC answered transferred calls within approximately one minute (58 seconds) for the rest of the day following the establishment of the Support Centre at 1520 hours. The FSD considers this an adequate response given the circumstances408 [WS1/164]. This figure measures the time from the moment the call was transferred by the Police to the moment it was picked up by the FSD; it does not include any waiting time before transfer. The total elapsed time for a caller from dialling 999 to speaking with the FSD was therefore longer than one minute in some cases.

In one documented instance (Wang Shing House 2802), a longer gap existed between the 999 call (2122 hours) and the FSD’s first record of the assistance request (2211 hours). DCFO(OP) Wong acknowledged that information transfer relied in part on fax or email: “… the police would still have a mechanism to refer the information to us... They would fax to us in paper copies” [Day 12/30/12-24]. He accepted that “[i]t’s better to have this system simply transfer the data to us.

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But when we developed the system, then there was no such technology” [Day

12/31/11-13].

The Government acknowledges that the information transfer by fax was not adequate for a large-scale incident involving hundreds of simultaneous calls. FSD will actively work with the Police to refine information exchange mechanisms, enhancing the efficiency of both departments in handling emergency calls (Table of Improvement Measures, Item A12(ii)).

(iii) The repetition of requests for information and questions on the FSD’s side

The FSD’s standing practice was to independently verify key information (address, caller details) received from the Police, because the FSD has in the past made incorrect deployments by relying on unverified information from third parties. DCFO(OP) Wong explained: “This practice is longstanding. It is the result of many years of experience, which gives rise to this mechanism where both parties have to confirm the address of the call. All of the FSD dispatched has a bearing on life or death so we have to confirm the gender and age of the caller. But that’s not the most important thing. The most important things are the telephone number and the address” [Day 12/11/12-21].

The Government maintains the FSD’s rationale for independent verification as grounded in operational experience and safety. As mentioned by the DFS, the FSD and the Police are co-operating and working on the improvement of existing administrative measures [Day 19/78/22 – 79/3] in the hope that information could be obtained and passed between departments in a more seamless manner (Table of Improvement Measures, Item A12(ii)).

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(iv) The advice given to callers, in particular whether callers should generally

be advised to evacuate

The FSD’s safety advice to callers is given on a case-by-case basis. The guiding principle is avoidance of smoke. Callers are advised to check the corridor before deciding whether to leave or stay. DCFO(OP) Wong explained: “As a matter of guiding principle, callers are advised to avoid smoke, as inhaling smoke can be fatal. In practice, this means the advice given depends on the conditions immediately outside the caller’s unit rather than their specific floor level. If there is heavy smoke outside the unit, the caller will be advised to remain calm inside and seal the door gaps. On the other hand, if the corridor is clear of smoke, the caller will be advised to leave quickly using the nearest smoke-free staircase”409 [WS1/162].

The overriding aim is to ensure safe egress from the fire scene. The FSD does not specify particular evacuation routes or designate refuge locations within the building, as fire and smoke conditions can change rapidly and vary significantly throughout different sections of the building410 [WS2/1024].

DCFO(OP) Wong acknowledged in oral evidence that the call-back safety script (Temporary Operational Guideline No. 05/2024, dated 29 November 2024) was intended for call-backs rather than initial calls. For initial calls, operators gave safety advice based on their training and judgment; there was no equivalent written script. Wong stated that safety advice “will not work if we put the requirements in black and white as a rigid rule” because operators must exercise judgement in the diverse circumstances of each caller [Day 12/84/21 - 85/14].

The Government maintains that rigid scripting is not universally appropriate given the diverse circumstances of callers, and that the principle-based approach

409 WONG Sze Lut, Sunny 2nd WS §4.3.2 410 WONG Sze Lut, Sunny 2nd WS §4.2.1

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(avoid smoke; check corridor; leave if clear, stay if not) is sound. The new 4th

Generation Mobilising System will again assist with real-time information sharing to support operators in providing more targeted advice.

(v) The sharing of information within the FSD on requests for rescue, and the FSD’s recording of information

Information collected from callers requiring FS assistance was disseminated to frontline personnel through three channels: radio (for immediate operational information); FSD Messenger (screenshot of the Computerised Mobilising System interface sent to commanders’ phones); and printed paper reports at the Mobile Command Unit411 [WS1/62-63; WS1/164-165].

DCFO(OP) Wong confirmed: “Information collected from the callers requiring FS assistance was immediately disseminated by FSCC to the frontline personnel via chat group set up in the FSD Messenger. All 347 locations reportedly seeking FS assistance were all attended to by the frontline personnel through the combined efforts of all sectors”412 [WS1/164].

The Government acknowledges, however, that the FSD Messenger screenshot mechanism involved significant manual work: frontline commanders received up to several hundred images in a single group chat, each of which had to be individually opened and read. DCFO(OP) Wong accepted that “the large volume of duplicated calls did cause difficulties to operations, underscoring the importance of effective filtering and streamlining processes in managing highdemand incidents”413 [WS1/165]. He further confirmed: “Currently, when FSCC operators forward assistance requests to frontline personnel, they use an official mobile phone to photograph the information displayed on the Computerized

411 WONG Sze Lut, Sunny 1st WS §5.1.5; 2nd WS §§4.6-4.7 412 WONG Sze Lut, Sunny 2nd WS §4.6.1

413 WONG Sze Lut, Sunny 2nd WS §4.7.4

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Mobilising System screen and then transmit it via the FSD Messenger. This process still involves a significant amount of manual work. The upgraded system, by contrast, will automate these procedures”414 [WS1/166].

The Government acknowledges this as a weakness in the information relay mechanism and notes that the upgraded system, once commissioned, will automate the transmission of assistance request information to all parties simultaneously, with a view to eliminating the manual steps that characterised the operation on 26 November 2025.

(vi) The call-back arrangement

The Support Centre, established at 1520 hours on the DFS’s instruction, made approximately 1,500 call-back phone calls during the operation to update the conditions and locations of affected residents and to provide ongoing safety advice415 [WS1/51; WS2/1023] [B13/5720] [B15/6329-6360].

The Chairman specifically commended this mechanism at the hearing: “Callback is quite useful, as proven by this experience. And we had individuals talking to firefighters, count them down. Of course there is room for improvement, but I think there is some good out of it” [Day 12/108/12-16].

The Government respectfully agrees with this assessment. The call-back mechanism provided personalised, ongoing communication with trapped residents at a point where no estate-wide alerting system was available to provide safety advice. It was an initiative that proved its value under the most demanding circumstances.

414 WONG Sze Lut, Sunny 2nd WS §4.8.2

415 TANG Wing Wah 1st WS §50; WONG Sze Lut, Sunny 3rd WS §4.1.1

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O4. The sufficiency of the FSD’s various communication systems at the fire scene and between the FSD call centre / Director’s Command Post and the fire scene

The FSD’s radio telephone system uses separate talk groups for different functions; separate fire-ground channels were allocated to the affected buildings; vehicle and portable repeaters were available for long-distance communication; and the Communications Support Team maintained effective radio communication and battery checks throughout416 [WS2/975].

Communication challenges arose from the use of breathing apparatus with fullface masks. AD Tang explained: “the VoiceCOM has its limitations, as it does not provide a direct link to our handheld radio. During the incident, we observed instances where VoiceCOM messages transmitted via handheld radio lacked clarity, particularly under noisy environment or while speaking amidst hurried breath, even though successful radio connections had been established. The communication can become more challenging when the receiver is also wearing BA with full-face mask, as the receiver’s ears are covered by a protective hood” 417 [WS2/975-976].

This issue has been resolved. The new Interspiro BA system, placed into service on 19 January 2026, “features a Spirocom system mounted onto each full-face mask (with a microphone inserted into the speech cone and a flexible speaker arm set the desired speaker position against the ear). The Spirocom system is directly connected to the handheld radio of each firefighter to facilitate effective communication” 418 [WS2/976].

416 TANG Wing Wah 2nd WS §32 417 TANG Wing Wah 2nd WS §33 418 TANG Wing Wah 2nd WS §34

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The DCP also provided round-the-clock backend support. Hourly situation

reports were compiled and disseminated to Directorate Officers and the Emergency Monitoring and Support Centre. Livestreaming of drone images to DCP was enabled from 1615 hours by the ICT Division. A Command Support System allowing remote data sharing between the on-site incident scene and DCP was also set up419 [WS2/1019].

The FSD is exploring an upgrade to the computerised mobilising system with features to filter duplicate calls. Once operators enter information into the system, it will be shared simultaneously with all parties involved in the operation, eliminating the need for the manual steps described above420 [WS1/165-166].

In addition, the FSD plans to introduce SMS location sharing for callers and a video evidence collection platform to allow the public to share footage of fire scenes with the FSD in real time [Day 12/61/20 - 62/25].

The 4th Generation Mobilising System will increase the number of incoming lines to 100 and mitigate the existing capacity constraint.

1. The DFS confirmed that the system is currently in testing and training, and acknowledged delays: “Coming back to the development of the 4th generation system, in between we encountered the pandemic and there were also the black riots and the contractors also delayed the delivery of some of the products and supplies and in fact there were some 24 subsystems. We are now in the stage of testing and training, and in between we have also spent a lot of time to urge the contractors to complete their

419 FOK Chun Ming 1st WS §13.4

420 WONG Sze Lut, Sunny 2nd WS §4,.7

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work. I fully agree that the earlier that the system can be commissioned, the better” [Day 19/78/4-13].

2. In relation to the duplication of questions between the Police and FSD during call transfer, the DFS confirmed that “in terms of duplication of questions and also the cutting off of the lines and so on, some of these might have to do with communication problems and we will be working with the police in detail as to how we will be making sure that there would be no need to repeat the questions” [Day 19/78/22 - 79/3].

3. In relation to the new system’s capability to relay information to frontline commanders, the DFS confirmed that “in the new system we have this thing called a portable device or the PD, and every commander will have access to that, so they would be holding this. It’s a handheld device and right away such messages can be transmitted to them” [Day 19/79/24 - 80/2].

4. As to the filtering of duplicate calls by AI, the DFS struck a note of appropriate caution: “we’ve been looking into it. But then we would also have to be careful because for repeated calls, they might be repeating the address or there might be different people reporting the address, and if we haphazardly use AI to screen them out, then the consequence might be... you might have thought that it’s a repeated address or a repeated call, and if you screen that out, then some people who might be needing help might be screened out” [Day 19/80/13-23].

O5. The safety and tracking of firefighters entering the blaze

(i) The sufficiency of breathing apparatus and other equipment generally used by firefighters at the fire scene

The MSA 8-litre BA cylinders in service at the time of the fire (in use since May 2014) provide a theoretical working duration of 33 minutes. In a fire of this scale,

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with firefighters carrying BA plus personal protective equipment (approximately

23 kg) plus compact portable pumps (approximately 80 kg) to upper floors, the 33-minute working duration imposed significant operational constraints 421 [WS15/2196-2197; WS2/974-975].

The FSD evaluated alternatives to the 8-litre cylinder and concluded that none was suitable for high-rise firefighting operations at WFC. The Twin-Cylinder BA (56-minute duration) weighs 20.5 kg and its bulk “would have aggravated physical exertion during high-rise building firefighting operations and accelerated fatigue” 422 [WS15/2197-2198]. The Closed-Circuit BA (3-hour duration) “cannot be exposed to naked flames or high levels of radiant heat, which will shorten its effective air supply” 423 [WS15/2198]. The Airliner (unlimited duration) has an “air hose system highly susceptible to snagging, entanglement, or obstruction when navigating corners and staircases” and “its effective range is limited by its 90-metre hose length, making it impractical for operations on upper floors” 424 [WS15/2198].

The new Interspiro BA system (in service from January 2026) retains 8-litre cylinders (now slightly lighter at 7.1 kg), and adds a TeamTalk function for communication within the same BA team and an Emergency Breathing Safety System enabling air-sharing between BA team members425 [WS15/2197]. The air-sharing capability directly addresses the scenario where a team member exhausts their supply.

421 TUNG Wing Kei 2nd WS §§4-9; 1st WS §31 422 TUNG Wing Kei 2nd WS §11

423 TUNG Wing Kei 2nd WS §12

424 TUNG Wing Kei 2nd WS §12

425 TUNG Wing Kei 2nd WS §9

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(ii) The sufficiency of the Firefighter Location System

The FLS deployed at the time of the fire used a single radio frequency. Above approximately the 23rd floor in a high-rise building, concrete interference prevents the ground-floor receiver from detecting the signal. DO(BA) Tung confirmed: “even if… SFn HO had removed the red magnetic key of the PT and activated it, and the closest team and ECO on G/F had started searching for him, the signal from SFn HO’s PT on 30/F and 31/F of Wang Tai House might not have been received by the HHR on G/F of either Wang Cheong House or Wang Tai House due to the long transmission distance, as well as environmental conditions and anything that might cause interference or reflection of PT signal”426 [WS4/1811].

A new FLS system using dual-frequency signals (including low-frequency for better concrete penetration) was already in procurement before the WFC fire. DO(BA) Tung confirmed in response to a question from the Chairman: “This is also using radio signals, but it would be using two different signals. It has a high frequency and low frequency. The low frequency signal is good because it can penetrate better... It can also show the distance between me and the one being rescued. It would be useful in this case because it would show the height differential between me and the one being rescued... We tested the new and the old devices on the 23rd floor. The old system cannot receive any signal, not to mention 30th floor. For the new one, it can pick up the signal” [Day 18/15/1 - 16/8].

The Government notes that the new FLS system addresses the constraint that prevented location of SFn Ho. Its procurement was already underway before the fire, and testing confirms successful signal reception at the 23rd floor.

426 TUNG Wing Kei 1st WS §7.7

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(iii) The (lack of) ECP at the early stage of the fire

No ECP was established at Wang Cheong House or Wang Tai House at the initial stage of the fire. DD Chan explained: “It wasn’t set up yet. Because the place they needed to go to was Wang Cheong House. He was from Shatin LRU, he couldn’t enter Wang Cheong House, so they had to create an access on Wang Cheong House” [Day 18/72/11-15]. When asked whether “things were happening so fast that the entry control procedures were not set up and the colleagues already went in,” DD Chan confirmed: “Correct” [Day 18/72/16-19].

The absence of an ECP at Wang Tai House meant that SFn Ho’s FLS Personal Transmitter was not activated before his entry, directly affecting the ability to locate him after he issued his Mayday, as described in Section H above.

The Government presents this as a consequence of the speed and chaos of the initial stage rather than a systemic failure of ECP procedure. In a normal singlebuilding fire, the ECP would be established before entry teams advance. At WFC, multiple entry points were being established simultaneously at different buildings by teams arriving from different stations. The FSD is reviewing ECP procedures to address multi-block fires, including improved block identification mechanisms for officers from other districts [Day 18/72/20-22].

O6. Response to other queries / criticisms raised

(i) Coordination among different teams of the FSD at the scene to be enhanced?

The suggestion that there was a lack of coordination among different teams of the FSD at the scene is not borne out by the evidence. The FSD implemented a building-by-building command strategy with designated Sector Officers for firefighting and separate SAR leaders for each of the eight blocks, under overall direction from the Incident Commander and Rescue Officer. Each building was assigned both a Senior Officer (SDO or DO) responsible for firefighting

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operations and an additional Senior Officer dedicated as SAR leader, ensuring

that life-saving efforts were prioritised and coordinated at the tactical level within each sector427 [WS8/1924].

By 2100 hours on 26 November 2025, 22 Senior Officers and Directorate Officers from both operational and non-operational units were present at the scene, “far beyond the required PDA of attendance for a No. 5 Alarm Fire, which normally required only a single-digit number of Senior/Directorate Officers”428 [WS1/51].

The coordination framework extended beyond the sector structure. The DCP provided continuous backend support from 1520 hours, compiling hourly situation reports disseminated to all Directorate Officers and the Emergency Monitoring and Support Centre429 [WS2/1019]. Livestreaming of drone images to the DCP was enabled from 1615 hours, and a Command Support System allowed remote data sharing between the on-site incident scene and the DCP430 [WS2/1019]. At the fire scene itself, the MCU served as the central coordination and briefing point: all arriving appliance teams were required to report to the MCU for briefing before deployment, at which point they received instructions on block identification, sector assignment, and operational priorities [Day 19/31/12-25].

Officers from other districts, unfamiliar with WFC’s layout, might have faced difficulty in identifying individual blocks. The difficulty might have been compounded by the fact that the blocks were enveloped in scaffolding nets, making visual identification of individual buildings more difficult from the outside, and that some officers might have arrived and entered the blocks before

427 CHAN Derek Armstrong 1st WS §12 428 TANG Wing Wah 1st WS §50.8

429 FOK Chun Ming 2nd WS §13.1

430 FOK Chun Ming 2nd WS §13.4

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the MCU briefing system could assist them, given the extraordinary speed of the

fire’s development.

However, this was addressed through briefings at the MCU and the provision of GIS maps and layout plans. AD Tang confirmed: “During the time when I was the incident commander, the person in charge of appliances at the scene had to go to the MCU for briefing. If the appliance team had arrived, if they were not familiar with the layout and position of the individual buildings, we would give them instructions. There is the geographical information system and various information on the MCU” [Day 19/31/12-25]. In addition to briefings at the MCU, AD Tang further confirmed that there were other means by which instructions were made available to frontline officers: “There is the MDT, the mobile data terminal, with information of the layout of the blocks. I don’t think that this creates serious obstacles to the colleagues working at the scene. You follow the access in the inner court, you find BA main control, you have another team, there is the forward command post. So they would obviously see the different posts or points in addition to the reserve areas. So these people manning these points will know the locations of individual blocks” [Day 19/31/22-25 – 32/1-9].

The Government submits that the command structure established at WFC was comprehensive and unprecedented in scale. The coordination arrangements, encompassing the eight-sector building-by-building strategy, the dual firefighting and SAR leadership at each sector, the DCP backend support, the MCU briefing process, and the presence of senior and directorate officers, collectively demonstrate a structured and effective command architecture.

(ii) The bamboo scaffolds should be dismantled first?

Complete dismantling of the burning scaffolding was operationally unfeasible and counterproductive. DCFO(OP) Wong explained that dismantling would have

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required extensive manpower diverted from rescue; would have “exponentially

increased the risk of falling debris, striking both firefighters and evacuating residents on the ground level and rekindling fires in the vicinity that had already been subdued or put out”; and the “massive structure, once dismantled, would have been reduced to nothing but a voluminous pile of burning bamboo sticks and scaffolding nets left on the ground, thereby causing further blockage to the vital entrances of the buildings from which they were torn”431 [WS1/80-81].

The FSD’s paramount objective was “securing immediate interior access for firefighting and victim rescue. Saving lives is always the first priority; however, this must occur alongside firefighting efforts, as effective fire suppression is essential to ensure the successful implementation of rescue procedures. In permissive environments, the tactical decision therefore focused on clearing only essential pathways at building entrances rather than attempting comprehensive scaffolding removal” 432 [WS1/81].

(iii) The EAS should be invoked?

The EAS was considered but not used. DD Chan explained his reasoning: “The EAS is a public dissemination system for time-critical messages via mobile networks. Activation criteria include territory-wide emergencies such as massive infrastructure breakdowns, large-scale riots or bomb disposals, rather than localised incidents. I considered the EAS unsuitable for this incident because, at the material time, this situation required localised, one-on-one communication with specific residents in the affected buildings rather than broadcast to the general public due to the unpredictability of the dynamic fire development”433 [WS8/1933].

431 WONG Sze Lut, Sunny 1st WS §13.1

432 WONG Sze Lut, Sunny 1st WS §13.1.5 433 CHAN Derek Armstrong 1st WS §28

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The formal position is set out in General Circular No. 5/2020 [B2/1318], which

confined EAS use to territory-wide emergency matters.

DD Chan acknowledged in oral evidence that the decision not to use the EAS was a conscious choice: “From what we’ve heard from you, it was a conscious decision not to use it, it’s not that the system had been forgotten” to which he answered “That’s right” [Day 18/68/4-8]. When asked whether, looking back, it was not a wise decision, he reiterated the operational reasoning: “It’s not just about that. As I said, we would not know how the residents would react having received the alert. We all know about the conditions of the blocks. If residents tried to escape, they might be put in greater danger” [Day 18/66/4-9]. He confirmed that in future, “if the system is used, we will need to first look at the messages to be sent and put in place relevant public education” [Day 18/67/16 - 18] (Table of Improvement Measures, Item A12(iv)).

The Government reiterates that major causes of the evacuation difficulty lie with the FAS failure (Section N above) and the blockage of entrances and exits by burning debris, not the non-use of the EAS. The possibility of using the EAS is a possible area of improvement which merits the Government’s attention: the system was (at the time) not configured for localised use and there had been no public education on how to respond to an EAS alert. The Government has since initiated work to configure the EAS for localised use and to design a public education campaign (Table of Improvement Measures, Item A12(iv)). DD Chan confirmed: “Afterwards, the Government consider improving the EAS for the use of various government departments. Information from the public domain said that the system can be configured to be issued to a localised area” [Day 18/67/3-8].

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(iv) Helicopters and other advanced technologies such as drones should be used

in the firefighting operation?

Helicopters were not deployed for water bombing. DCFO(OP) Wong explained the technical reasons: water dropped from height “would not be able to penetrate into the interior of the building where the fire was located. Instead, it would largely fall on exterior façades or rooftops, and would therefore have little or no direct effect on controlling fires within residential units”434 [WS1/73]. Helicopter downwash “can force smoke into buildings, thereby increasing the risk to occupants who are trapped inside. It may also drive additional air into the structure, potentially intensifying the fire” 435 [WS1/73]. A helicopter water bomb carrying up to one tonne of water “when released from height, can damage temporary structures such as bamboo scaffolding and wash debris to ground level, creating additional hazards” 436 [WS1/73].

DCFO(NTN) Wong King-man also identified the steam risk from applying external water jets into residential units where residents might be trapped: “When we apply water jet from the external environment, the control is at the bottom of the vehicle. We would not know about the conditions at the block or the interior environment... there is risk arising from applying water jet from the outside into the units of the blocks because if there are firefighters inside the building, they could be injured. They could sustain fire injury” [Day 11/122/4-22].

One hundred-metre aerial ladder platforms were not deployed because they require a 10-metre wide deployment footprint (wider than any EVA in Hong Kong), weigh more than 60 tonnes (exceeding the 30-tonne load-bearing capacity of Hong Kong EVAs), and even if deployed, the sole viable location (Tai Po Road, 46 metres from Wang Sun House) would have meant the rescue cage could not

434 WONG Sze Lut, Sunny 1st WS §10.1.1 435 WONG Sze Lut, Sunny 1st WS §10.2.1 436 WONG Sze Lut, Sunny 1st WS §10.2.2

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reach the building façade437 [WS1/66-69]. AD Tang concluded: “given turntable

ladders had already been deployed at available strategic positions for external firefighting around Wang Fuk Court and the EVA near the buildings became inaccessible due to fallen burning scaffolding materials and debris, further reinforcement of turntable ladders, regardless of their operational height, would not have effectively met the operational objectives. More turntable ladders would not be able to get close enough to the buildings”438 [WS6/1873].

As to firefighting drones: DCFO(OP) Wong confirmed that according to information from the National Fire and Rescue Administration, “no firefighting drones are currently in operational use by Chinese Mainland fire departments, and using drones for firefighting is still at the research and development stage... Based on available information, there are currently no known fire departments that have utilized drones for direct fire suppression in actual fire incidents”439 [WS1/69]. In oral evidence he stated: “Frankly speaking, there are a lot of online videos showing that there are fire drones in use. Those are only videos produced by the manufacturers. They have gone through major editing. I won’t say they are completely useless, but in our actual firefighting operations, so far they are not mature enough to be deployed” [Day 12/110/12 - 112/7].

However, drones were effectively deployed for other purposes. Ten FSD drones equipped with live-streaming and thermal imaging capabilities were used for aerial surveillance, identifying two trapped persons on a rooftop, monitoring for reignition, and providing supplementary illumination at night. An additional 10 drones were borrowed from Guangdong Province. AD Tang recorded: “the UAS team identified the locations of the two persons trapped on a building rooftop who were out of sight from the ground crews. By continuously monitoring the

437 WONG Sze Lut, Sunny 1st WS §§8.2-8.4 438 TANG Wing Wah 3rd WS §39

439 WONG Sze Lut, Sunny 1st WS §8.5.2

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situation via the drones, our rescue team identified a safe window of opportunity to reach them and successfully led both individuals to safety”440 [WS6/1864] [B17/6398]. The drone-assisted rooftop rescue is a concrete example of effective technology use during the fire.

(v) Additional support from the Chinese Mainland should be sought?

The decision not to accept additional firefighting manpower from Guangdong Province was based on scene capacity constraints and operational incompatibilities. DD Chan assessed that additional resources were not required because the FSD had “already despatched over 220 FS appliances and 980 personnel to the scene, a deployment that exceeded the standard PDA for a No. 5 Alarm by approximately nine times” 441 [WS8/1931-1932] and that “due to the buildings’ structural limitations, including narrow staircases and restricted corridor space, as well as extreme heat conditions requiring a floor-by-floor advancement, there was a practical limit to the number of personnel who could be effectively and safely deployed at any one time”442 [WS8/1931-1932].

DCFO(OP) Wong identified specific operational incompatibilities in BA procedures, Mayday procedures, evacuation signals, hydrant coupling systems and portable pump designs. In his evidence, he illustrated these with a vivid example: “The terminology for issuing a Mayday message differs fundamentally between the Chinese Mainland and Hong Kong. Hong Kong firefighters follow local protocol by calling ‘Mayday, Mayday, Mayday’ in English to initiate their distress signal, while Chinese Mainland firefighters use ‘呼救、呼救、呼救’ in Putonghua. This linguistic divide means that when a Chinese Mainland firefighter trapped in a collapsed structure broadcasts his distress call in

440 TANG Wing Wah 3rd WS §13

441 CHAN Derek Armstrong 1st WS §26(a) 442 CHAN Derek Armstrong 1st WS §26(b)

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Putonghua, Hong Kong personnel may not immediately recognize it as an emergency signal”443 [WS1/75-76]. He further explained that evacuation horn blasts differ between the two jurisdictions: Hong Kong uses long blasts while the Mainland uses intermittent blasts, creating a life-critical risk of misunderstanding [Day 12/124/12 - 126/16].

Cross-boundary equipment support was, however, accepted: ten UAS with optical and thermal imaging and 20 sets of exoskeleton equipment were borrowed from Guangdong Province to support operations444 [WS2/1020; WS1/79].

The distinction between declining personnel (operationally incompatible) and accepting equipment (interoperable) reflects a professional safety assessment, not a political decision. The Guangdong-Hong Kong-Macao Emergency Management Cooperation Framework Agreement’s current phase focuses on natural disaster scenarios; work is underway to extend it to cover large-scale building fires. DCFO(OP) Wong confirmed: “the FSD will engage with its counterparts in Guangdong and Macao to explore the feasibility of expediting to operationalize mutual assistance arrangements for large-scale building fires”445 [WS1/79].

O7. Review

(i) Improvements already introduced

The following improvements had already been implemented by the time of the evidential hearings:

443 WONG Sze Lut, Sunny 1st WS §11.2.3

444 WONG Sze Lut, Sunny 1st WS §11.4; 2nd WS §16 445 WONG Sze Lut, Sunny 1st WS §12

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1. The new Interspiro BA system with Spirocom radio connectivity was

placed into service on 19 January 2026, resolving the communication limitation identified during the fire446 [WS2/976].

2. A new referral mechanism has been established: for any fire safety enquiry or complaint, the FSD now proactively refers to the relevant department with the caller’s consent and follows up to confirm receipt [Day 17/48/21

49/8] (Table of Improvement Measures, A11).

3. The DFS has also established a “Mega-scale Fire Incidents Strategic Steering Committee” (Table of Improvement Measures, A12(i)). His second witness statement records that the Committee is “led by the Deputy Director (Operations), to conduct a comprehensive review of existing firefighting and rescue strategies, protocols and equipment for incidents of mega-scale and nature” and will “undertake a thorough examination of current operational strategies, drawing on the experience and good practices of Chinese Mainland and overseas counterparts, with a view to enhancing rapid response, command and deployment, firefighting and rescue tactics and evacuation effectiveness under large-scale and complex fireground conditions”447 [WS2/1029]. During oral evidence in specific response to Member Chan, the DFS confirmed that the Committee’s work encompasses “the command structure and also the firefighting strategies and tactics and so on, how we can make use of technology and equipment to fight fires and so on, that would be a continuous process to enhance our capabilities” [Day 19/106/6-14].

446 TANG Wing Wah 2nd WS §34

447 YEUNG Yan Kin, Andy 2nd WS §7

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(ii) Improvements to be introduced, and further studies to be conducted

Beyond the immediate measures already in effect, the FSD has identified a series of medium-to-long-term improvements to be introduced across four areas: technology and systems, equipment, inter-agency coordination, and operational guidelines.

In terms of technology and communication systems:

1. The 4th Generation Mobilising System will increase the number of incoming lines to 100 and automate information relay, eliminating the manual screenshot process that characterised the 26 November operation. Once operators enter information into the system, it will be shared simultaneously with all parties involved in the operation. The DFS confirmed that the system is currently in testing and training and that “the earlier that the system can be commissioned, the better” [Day 19/78/4-13]. Complementing the FSCC upgrade, the FSD is developing SMS location sharing for callers (enabling callers to share their GPS position via a link sent to their mobile phone) and a video evidence collection platform to allow the public to share footage of fire scenes with the FSD in real time [Day 12/61/20 - 62/25].

2. The EAS is also being reconfigured for localised use so that alerts can be issued to a specific geographic area rather than territory-wide, and a public education campaign on how to respond to an EAS alert is being designed [Day 18/67/3-8] (Table of Improvement Measures, Item A12(iv)).

In terms of equipment, a new FLS with dual-frequency signals (including lowfrequency for better concrete penetration) and a height differential display is in procurement. Testing confirms successful signal reception at the 23rd floor,

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directly addressing the limitation that prevented location of SFn Ho during the

WFC fire [Day 18/15/1 - 16/8]. An electronic entry control clipboard is also being introduced to replace the paper BA log system, eliminating manual recording errors and ensuring automatic logging of firefighter entry and exit times [Day 18/24/10-18].

In terms of inter-agency coordination, the cross-boundary cooperation framework with Guangdong and Macao is being expedited to cover large-scale building fires. The current framework focuses on natural disaster scenarios; the FSD will engage with its counterparts in both jurisdictions “to explore the feasibility of expediting to operationalize mutual assistance arrangements for large-scale building fires”448 [WS1/79]. By way of example, a 3-day Guangdong-Hong Kong-Macao Greater Bay Area emergency response and rescue exercise took place in Macao from 20 to 22 May 2026 [B14/6263]. A joint review with the Police on 999 callhandling procedures is also being conducted, encompassing the elimination of duplicated questions [Day 19/78/22 - 79/3] (Table of Improvement Measures, Item A12(ii)).

In terms of operational guidelines and research, guidelines are to be developed for multi-block FAS failure scenarios (a situation for which no written guidance existed before the fire), and new ECP establishment protocols for multi-block fires are being formulated. Ongoing research is being conducted into temporary fire alarm systems for renovation sites and FSIs that can be installed on scaffolding to suppress or extinguish fire at an early stage [Day 17/47/10-25].

The Government submits that this programme of reform, encompassing immediate operational changes already in effect, medium-term legislative amendments before the legislature, and longer-term technology and research

448 WONG Sze Lut, Sunny 1st WS §12

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initiatives, represents a comprehensive and considered response to the operational

challenges revealed by the WFC fire. The reforms are systemic in nature, addressing the structural inadequacies identified in this review rather than simply augmenting resources within the existing framework.

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PART III(F): SYSTEMIC ISSUES

P. ABUSE OF THE SYSTEM BY PROFESSIONALS AND OTHER NON-GOVERNMENTAL PARTIES

Before turning to the Government’s acknowledged systemic issues, it is necessary to set out comprehensively the primary responsibilities of each private actor whose conduct directly caused the fire, its rapid spread and the heavy casualties.

The evidence addressed in Sections I to N above, taken together, establishes that the fire at WFC was not the product of a single act of negligence or a single regulatory weakness.

It was the product of sustained, multi-faceted wrongdoings with deceit by multiple private actors operating over a period of months, in circumstances where every actor bearing primary responsibility either actively participated in the creation of hazardous conditions or was grossly negligent in circumstances amounting to a complete abdication of professional duty. Worse still, it is evident that such wrongdoings specifically sought to circumvent and/or undermine the existing structural frameworks in place, thereby seriously hampering and undermining the Government’s supervisory function.

As the evidence under ToR 2 further reveals (addressed in Part IV below), the conduct observed at WFC was not an isolated aberration but reflects sector-wide patterns of non-compliance, collusion and exploitation of the self-regulatory model that have persisted in the building maintenance industry over a prolonged period (cf. paragraphs 929-930 below).

This Part addresses each culpable party in turn, drawing together the threads of their conduct across the contributing factors to demonstrate the cumulative weight of private-actor failure.

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P1. Prestige

Prestige was the main contractor engaged for the WFC renovation works at a contract price of approximately HK$336 million. It bore the primary statutory duty under the BO, FIUO, and OSHO to ensure the safety of the works, compliance of materials, and maintenance of safe systems of work. Its conduct in relation to each of the five contributing factors demonstrates a systematic pattern of non-compliance, concealment and disregard for the safety of the residents whose homes surrounded its works.

As to the start of the fire: Prestige bore primary responsibility for site management and carrying out of the works, including the enforcement of nosmoking rules, clearance of construction debris, and maintenance of a safe working environment.

Despite repeated complaints from residents, documented observations by the PMC, reminders at renovation works meetings, and warnings issued by the LD, Prestige failed to enforce an effective no-smoking regime. Prestige also failed to ensure frequent clearance of combustible construction waste from the flat roof at the point of origin, where debris had accumulated. The combination of uncontrolled smoking and accumulated combustible waste in a confined space created the conditions in which a discarded cigarette could ignite materials and start a fire.

As to the use of scaffolding nets uncertified for FR properties: Prestige deliberately supplied and used, and directed the purchase and use, of scaffolding nets uncertified for FR properties, i.e. scaffolding nets that are not certified for satisfying any of the FR standards as required by the BD’s circular letters, LD’s Code of Practice, and B(C)R. When asked to produce a test certificate, Prestige furnished a document that was subsequently found to be unreliable. The evidence

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further indicates that Prestige engaged in selective replacement of scaffolding

nets in areas likely to be inspected. If such findings are made by the Committee, Prestige’s act would be deliberate and calculated deception directed at the regulatory body exercising supervisory authority over the works.

As to the extensive use of foam boards: Prestige used combustible polyvinyl chloride foam boards to cover windows across multiple blocks for a period exceeding one year. When the ICU raised the fire hazard concern at the 28 October 2024 site inspection, Prestige’s representative expressly represented that the foam boards would be used only temporarily during active hacking works (three floors at a time) and that non-combustible materials would be used for such temporary protection. This representation was false. The foam boards remained in place across the estate, obstructing residents’ awareness of the fire, delaying their evacuation response, and contributing to the vertical spread of fire and generation of toxic gases that caused the deaths of individuals by carbon monoxide inhalation.

As to the creation of access openings at escape staircases: Prestige created and directed the creation of access openings resulting in the removal of windows and replacement with movable wooden boards or aluminium composite panels at regular five-floor intervals across all eight blocks. These openings permitted smoke and heat to infiltrate the protected staircases during the fire, rendering them incapable of providing a safe environment for evacuation. Of the 38 fatalities in the staircases and common areas of Wang Tai House, 28 were found inside the staircase; the cause of death for all 28 was inhalation of fire fumes attributable to the compromised openings. The full-scale fire tests confirmed that the wooden boards ignited within minutes, whereas the fire-rated glass windows they replaced remained intact and maintained a lower interior temperature.

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As to the failure of fire alarms: Prestige directed the drainage of the FS Water

Tanks as part of the renovation works which resulted in ISS (a non-RFSIC) physically switching off the main power switch in the booster pump rooms of all eight blocks, an act that simultaneously deactivated both the FH/HR System and FAS. Prestige arranged this despite the fact that the drainage of the FS Water Tanks did not require the main power switch to be turned off at all; the technically necessary steps were to switch off the upfeed pump and open the rooftop drain valve. Prestige engaged China Status to submit SDNs to the FSD, informed China Status that the building management company would “handle the physical shutting down,” and at no point ensured that an RFSIC was present to oversee the operation of FSIs. The consequence was that 168 people lived without a functioning fire alarm for months, and when the fire broke out, no warning sounded.

Prestige’s conduct, taken as a whole, demonstrates a pattern of systematic noncompliance.

P2. Will Power (consultant purportedly providing RI services) and Ng Yeuk (the RI)

Will Power was appointed to provide consultancy services for the renovation project (including the provision of Registered Inspector services) under the MBIS. The RI bears specific statutory responsibilities under section 30D of the BO: to provide proper supervision of the carrying out of prescribed repair works; to ensure that repair materials are not defective and comply with all relevant Ordinances, Regulations, codes of practice and practice notes; and to ensure that the building is safe or has been rendered safe.

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The evidence before the Committee discloses no attempt to discharge, let alone

any effective discharge, of these statutory responsibilities by the RI in relation to any of the five contributing factors.

There is no evidence that the RI took any steps to verify the FR properties of the scaffolding nets installed by Prestige, despite the existence of clear requirements in the BD’s circular letters and LD’s Code of Practice.

There is no evidence that the RI raised any concern about the extensive and prolonged use of foam boards to cover windows, despite the obvious departure from the representation made to the ICU that they would be used only temporarily and in a localised manner.

There is no evidence that the RI identified or reported the access openings at escape staircases as a contravention of the BO, despite the MBIS Code’s specific requirement to identify and report “unprotected openings at enclosure walls of exit routes.”

The RI’s absence of supervision was not merely passive. The MBIS Code requires the RI to certify, upon completion, that works have been carried out in compliance with the BO. The supervision plans submitted under the MWCS for the window replacement works stated that the PBPs would conduct weekly inspections. The totality of the evidence suggests that these representations to the regulatory authority were not matched by any substantive supervisory activity on the ground.

The ICAC’s evidence before the Committee identifies a broader pattern in which certain RIs in the building maintenance sector function as “mere dummies” who exercise “little or no supervision over the project” and are “only appointed to satisfy the statutory requirements imposed under the BO.” Whether or not that

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characterisation applies to Will Power’s/the RI’s conduct at WFC is a matter for

the Committee’s assessment; what the evidence does establish is that the RI’s statutory obligations were clearly not discharged.

P3. China Status

China Status was engaged by Prestige to submit SDNs and FS251 certificates to the FSD in connection with the FS Water Tank repair works. The evidence establishes that China Status performed no substantive function beyond the administrative act of completing and submitting forms – which completely defeats the purpose of its appointment and serves to make a complete mockery of the system in place.

China Status never visited the site. Its director admitted that no representative attended WFC “for the purposes of understanding first-hand 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, or the feasibility of putting in place additional fire services measures while the FH/HR System is shut down.” When asked whether China Status was “just a rubberstamp,” the DFS answered: “Yes.”

China Status submitted SDNs that consistently identified only the FH/HR System as the subject of shutdown, leaving the FAS box blank. Because China Status never visited the site, never assessed the need and consequences for the shutdown of the FH/HR Systems, and never effected the shutdown of the relevant FSI themselves, it never knew and never realised that the FAS had also been deactivated. The FSD therefore received no notification that the FAS across all eight blocks were inoperative. Had the FSD been notified, it would have updated the contingency plan, required the owner to notify residents, and demanded

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implementation of standby measures. None of this occurred because China

Status’s representations to the FSD were incomplete and misleading.

China Status’ director admitted that he “breached all of his obligations” shown to him in the FSD’s Circular Letter No. 1/2021. He admitted he did not exercise his discipline in considering whether his acts breached the requirements. The FSD’s assessment was that China Status “not only failed the expectation of the public, but also breached the FSD’s trust” by falsely representing to the FSD that the shutdown of the FH/HR Systems was due to repairs needed as a result of leakage of the FS Water Tank and that it was the responsible RFSIC carrying out the relevant repair works based on the defect(s) as detected.

Had China Status discharged its obligation to supervise the works and critically review the need for each extension, it would have noted the completion of the FS Water Tank repair works at certain blocks well before the fire. In the case of Wang Tai House, the works were completed by the end of October 2025; had China Status been aware of this, the filing of the last SDN dated 13 November 2025 would not have been necessary and the FH/HR System should have been resumed to normal operation. The same applies to other blocks where repair works were completed in September to November 2025. China Status’s failure to inquire into the progress of the works, or to attend the site at any point, meant that SDN extensions continued to be filed mechanically for works that had already been completed, prolonging the shutdown of the FSI beyond any legitimate need and maintaining a state of heightened fire risk for residents who had no knowledge that their FSIs remained inoperative.

P4. Victory Fire

Victory Fire was the long-standing RFSIC engaged by ISS for annual inspections and rectification works at WFC. It had held this role for approximately nine

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consecutive years. In October and November 2025, Victory Fire’s staff

discovered, first, that the FS Water Tanks in all eight blocks were empty (16 October 2025) and, second, that the main power switches controlling the power of both the FH/HR System and FAS of all eight blocks had been switched off (19 November 2025) when they were doing repair works on the very FH/HR Systems and FAS at WFC respectively. The second discovery meant that Victory Fire’s staff had direct knowledge that the FAS in all eight blocks were de-energised.

Victory Fire failed to make any attempt to notify the FSD of this discovery. The FSD’s Circular Letter No. 1/2021 expressly requires an RFSIC who discovers a defect involving one of 9 major FSIs (FH/HR systems and FAS included) to submit an SDN to the FSD. Victory Fire’s director conceded that this obligation existed; he sought to shelter behind the presence of China Status’s SDN for the FH/HR System, but that SDN did not cover the FAS.

Victory Fire completed its rectification works and left the site at approximately 1:00 pm on 26 November 2025 without testing the FSIs it was engaged to rectify, without issuing an FS251 for the FSIs, and without notifying the FSD of the shutdown of the SDN, let alone the empty water tank, even though it discovered during the course of its works that the shutdown had lasted more than 24 hours. Less than two hours later, the fire broke out.

P5. ISS (the PMC)

ISS occupied a central position in the management of the estate, with contractual responsibilities that placed it at the intersection between the residents, IO, and various contractors engaged for the renovation works. The PMSA Code of Conduct specifically requires licensed PMCs to monitor the progress of the RFSIC’s work, follow up timely with the RFSIC on required rectifications, follow

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up timely with the RFSIC that it has notified the DFS of FSI shutdowns, and assist

FSD officers during visits.

ISS failed in these obligations in several critical respects.

First, ISS issued job orders directing its own unlicensed electrician to physically operate FSIs, an act that was categorised by AD Keung as “against the law” and “something that one must never do.” ISS management did not enquire whether an RFSIC should be engaged for this work; its property officer accepted it “did not occur” to her that the drainage of the FS Water Tank should be done by a RFSIC rather than the property company.

Second, ISS failed to coordinate between two simultaneously engaged RFSICs (Victory Fire and China Status). When Victory Fire’s electricians discovered the FS Water Tanks were empty on 16 October 2025 and that the main power switches had been turned off on 19 November 2025, ISS’s property officer told them that an SDN had been submitted and temporary measures were in place, but did not show them the SDN, did not suggest coordination between the two contractors, and did not inform Victory Fire that the FAS had been deactivated. She confirmed that “it didn’t cross anyone’s mind that that needed to be done.”

Third, ISS’s response to persistent fire safety complaints from residents was limited to relaying them to Prestige without follow-up. Despite contractual obligations to “record, investigate and liaise and follow up on the matter with the relevant government department,” ISS’s actual practice was, as its own security guard confirmed, to play the role of “passing on the message.” ISS neither escalated unresolved complaints nor took independent steps to verify whether Prestige had remedied the hazards.

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Fourth, ISS permitted Prestige workers to enter the pump rooms without proper

registration or documentation, with the consequence that the FSI shutdown occurred without any contemporaneous record. ISS’s property officer accepted that had proper procedures been followed, “there should have been a form stating that there was a drainage, working permits were issued and the entry of whether the fire alarm system would be affected would be filled in.”

P6. Residents as victims of the cumulative effect of private-actor failure

The residents made the collective decisions to engage Will Power as consultant and to provide RI services (noting that the residents were never asked to directly engage the RI who must be an individual), and to appoint Prestige as the main contractor, through owners’ meetings at which the decisions were approved by majority vote.

The residents of WFC were not passive in the face of the concerns that would later prove to have been well-founded. Complaints were made repeatedly and to multiple departments regarding fire safety, smoking, materials, and proxy irregularities. In this context, the residents and those IO/MC members who raised concerns can be properly characterised as persons adversely affected by the misconduct rather than contributors to it. The responsibility for the decisions that led to the engagement of Prestige and Will Power lies with those who manipulated the decision-making process, not with the owners who were similarly deceived.

When the conduct of these private actors is viewed together, the picture that emerges is one of a complete and simultaneous failure of every layer of privateactor responsibility. Each contributing factor to the fire, its spread and the heavy casualties traces directly to the acts and omissions of these private actors.

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The safeguards built into the regulatory framework were designed on the

assumption that professionals would exercise a degree of integrity commensurate with the trust reposed in them and obligations imposed upon them by law. At WFC, that assumption was not borne out. It is against this background, and with this understanding of where primary responsibility lies, that the Government turns to address the systemic issues within its own supervisory framework.

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Q. SYSTEMIC ISSUES ACROSS KEY CONTRIBUTING FACTORS

This Part examines the systemic issues within the Government’s regulatory and supervisory framework that cut across the contributing factors addressed above.

These issues are distinct from the direct causes of the fire (which are addressed in Sections I to N and the primary responsibilities summarised in Part P); they concern structural, procedural and operational characteristics of the Government’s own systems that permitted the private actors’ wrongdoings to go undetected before the incident.

It is important to place these systemic issues in their proper historical context. The regulatory frameworks involved include those which began in the 1960s and in 1992 well before the first term of the HKSAR Government and developed over all six terms of HKSAR Government. They had also been subject to the scrutiny of HKSAR’s legislature over the years, and were not hastily or carelessly constructed.

1. The delegation arrangement between the BD and ICU dates from 1992 and has been renewed and refined over more than three decades.

2. The FSI regulatory framework under the FSO has been developed incrementally since the 1960s, with the SDN mechanism formalised in

3. The MWCS was introduced in 2010 with the deliberate policy objective of simplifying procedures for lower-risk works while preserving professional accountability in response to calls for streamlined regulatory procedures.

4. The MBIS was introduced in 2012 following extensive consultation and Legislative Council scrutiny.

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These frameworks were designed, debated and enacted reflecting what was then

considered to be the appropriate balance between regulatory oversight and professional self-governance. The systemic issues identified below are therefore not novel discoveries arising solely from the WFC fire. The question for the Committee is not whether these characteristics were unreasonable when adopted, but whether they remain adequate going forward, in light of what the evidence has revealed about the vulnerability of the system to organised and deliberate subversion.

As noted in the overview at Section D above, the degree of reliance on professional self-regulation in the MBIS and MWCS was the product of a deliberate policy balancing exercise. The legislative history demonstrates that these frameworks were developed in response to sustained calls from building owners, the industry and the legislature to streamline regulatory procedures, reduce compliance costs, and avoid imposing disproportionate requirements on works of lower risk. As the Chairman observed in the context of the post-Grenfell reforms in the United Kingdom, the imposition of very strict requirements “imposes a lot of hardship on the developers and as a result a lot of developers cannot finish the projects” [Day 27/76/4-6]. The trust placed in registered professionals was thus the mechanism through which the legislature’s endorsed balance was struck: professionals would bear primary responsibility for planning, supervision and compliance, and the Government would exercise oversight through audit checks, complaint-driven responses and disciplinary mechanisms.

Indeed, the evidence of the Competition Commission, ICAC and Police under ToR 2 (addressed in Part IV below) demonstrates that the systemic vulnerabilities in the building maintenance sector (including bid-rigging, the misuse of the RI role, and the exploitation of the self-regulatory model) are not

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recent developments but have persisted over a prolonged period, notwithstanding

the progressive efforts of the relevant enforcement agencies.

Q1. Reliance on the self-regulation of professionals, and sufficiency of audit checks and site inspections

The pre-fire regulatory framework for building maintenance and renovation relied heavily on the self-regulation of registered professionals and contractors for its implementation. The Government’s role is exercised through inter alia audit checking of submissions and in response to complaints.

The system was designed to detect non-compliance on a statistical sampling basis, not to provide continuous oversight of individual projects. Where a contractor and RI were actively collaborating to conceal non-compliance (as the evidence indicates was the case at WFC), the probability of detection through random audit alone was low. This was compounded by the absence of any statutory requirement for the ICU to conduct regular site inspections during the course of MBIS-related works; the ICU’s inspections at WFC were conducted solely in response to complaints and enquiries, not pursuant to any programmed monitoring regime.

The Government acknowledges that this degree of reliance on professional selfregulation, without more intensive verification during the works period, created a vulnerability that was deceptively exploited at WFC.

The improvement measures already introduced and under consideration are designed to address this vulnerability by introducing meaningful ongoing oversight during the works period rather than relying solely on pre-works and post-works certification.

The recalibrated system preserves the role of registered professionals as the primary actors responsible for compliance while introducing verification

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mechanisms with sufficient frequency and independence to detect the kind of

systematic non-compliance that occurred at WFC.

Q2. Supervision of professionals – RCs, RIs and RFSICs

The registration systems for RIs, RCs and RFSICs serve as gateway controls through which only suitably qualified professionals and contractors may undertake building works or FSI maintenance. The systems operate primarily at the point of entry (registration) and renewal, with prosecution and disciplinary action available as enforcement mechanisms for non-compliance detected subsequently.

The evidence before the Committee reveals three areas for improvement in this supervisory architecture as it operated before the fire.

First, while the registration system did subject Prestige to enhanced scrutiny at the point of renewal (including on one occasion refusing renewal of its RMWC registration in October 2019), the system operated as designed at the time did not preclude Prestige’s subsequent re-registration as an RGBC. The broader question is whether the system could be enhanced to better inform building owners of contractors' disciplinary histories at the point of engagement, and to enable more responsive regulatory action where serious incidents are involved. In this regard, the Government is actively pursuing legislative and administrative reforms, including (Table of Improvement Measures, Items B2(iii)-(iv); DEVB Paper §§3(d), 3(f), 7, 16 [WS23/2470, 2474, 2479]):

1. Empowering the BD to de-register PBPs and RCs directly without going through disciplinary procedures in cases of violations of the Prevention of Bribery Ordinance (Cap. 201) and Competition Ordinance (Cap. 619);

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2. Empowering the BD to renew registration of RCs for shorter periods and

with conditions for RCs involved in serious incidents; increasing the maximum penalty from $1 million to $10 million where works directly involved have caused serious cases of injury or death; and

3. Firming up information-sharing arrangements under which the URA will have access to conviction and disciplinary records for the purposes of compiling and maintaining pre-qualified lists under the enhanced Smart Tender service.

Second, the supervision of RIs during the works period needed enhancement. The current system expects that the RI will discharge the statutory duty; it provides no mechanism for detecting a failure to do so until completion (or until a complaint is received).

Third, the supervision of RFSICs similarly relied on the integrity of their own reporting. The FSD’s monitoring of RFSICs operated through the FS251 and SDN mechanisms, both of which depend on the accuracy / truthfulness and timeliness of the RFSIC’s submissions. The system was not designed to detect whether an SDN accurately described the FSI systems shut down or whether its corresponding FS251 accurately described the defects necessitating the repair works / shutdown. Neither was it designed to detect whether an RFSIC claiming to have conducted works had in fact visited the site, assessed the need and consequences for the shutdown, and effected the shutdown themselves.

Q3. Sufficiency of the relevant procedural guidelines, codes of practice, etc.

The evidence before the Committee identifies that private actors have sought to create and/or invoke gaps and ambiguities in the prescriptive content of the regulatory framework so as to circumvent any such safeguards altogether. The

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Government reiterates that the intactness of the regulatory framework is not the

primary cause of any contributing factor, but the Government acknowledges that there had arisen an environment in which private actors could exploit uncertainty and the current regulatory system needs clearer benchmarks for more proactive and immediate enforcement measures to be taken.

In the area of construction materials: before the fire, no specific prescriptive standard existed for temporary window protection materials (such as foam boards) in any regulation, code of practice or practice note. Section 16 of the B(C)R requires “appropriate precautionary measures” but provides no specific content as to what materials are or are not acceptable for temporary window protection. Similarly, before the fire, no specific FR standard existed for toe-boards, wooden planks or nylon strips used as scaffolding components.

In the area of inter-departmental jurisdiction: no guideline clearly delineated which department (the FSD, BD/ICU or LD) was responsible for addressing the fire safety implications of construction materials used on scaffolding. The result was that the fire safety concern raised by foam boards, canvas and other combustible materials used on the scaffolding did not receive a comprehensive response from any department.

In the area of concurrent large-scale renovation works across multiple blocks:

1. Before the fire, no regulation, code of practice or practice note required a risk assessment addressing the fire safety implications of simultaneous renovation works across multiple buildings in close proximity. AD Karen Cheung of the BD confirmed that there was no rigid requirement that works on multiple blocks in the same estate must be done separately or in phases; it depended on the contract and the works method [Day 20/36/4-7].

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2. She explained the rationale: blocks in the same complex share the same

DMC and land lease, were built around the same time with the same materials, and residents had given feedback that treating blocks differently within the same complex creates practical problems [Day 20/35/5-24].

3. The Government notes, however, that the MBIS Code already required the RI and RC to provide proper supervision and control during the course of rectification and repair works, including “adequate measures to ensure a safe working environment” (clause 6.1.2(a)) and safety measures to “safeguard the workers, occupants and the public as well as the adjacent buildings” (clause 6.2.1) [J1-2/4907]. These existing obligations, properly discharged, would encompass a fire safety risk assessment appropriate to the nature and scale of the works, including the cumulative risks arising from concurrent renovation across multiple blocks.

4. After the fire, the BD issued a circular in March 2026 (paragraph 4) [B13/5714-5719] reminding contractors and professionals to conduct risk assessments before works start, including consideration of whether phased works are appropriate having regard to fire safety, and suggesting to owners that works be done by phases. AD Karen Cheung confirmed that some complexes have since adopted this phased approach [Day 20/36/13-23].

5. In addition, an inter-departmental working group comprising the LD, BD and FSD has been established to study the requirements regarding safety distance for buildings requiring erection of scaffolding for large-scale repair works. Subject to the findings of that study, it is proposed that the BA may prescribe requirements regarding the safety distance for buildings

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undergoing concurrent large-scale repair works (Table of Improvement

Measures, Items B2(vi) and E4(i)).

Q4. Internal and external communications

(i) Internal communications between the BD and ICU under the delegation arrangement

The delegation arrangement between the BD and ICU, while conferring on the ICU the full statutory authority to exercise building control over sold HOS estates, was not invariably accompanied by communication mechanisms sufficient to ensure that developments in the BD’s practice were promptly conveyed to the ICU.

In particular, the BD had adopted a practice of selecting 20% of Class I MW with supervision plans for immediate site safety inspections by the site monitoring team from April 2023; the ICU was only informed of its existence until 22 December 2025, after the fire. The six-monthly liaison meetings between Head(ICU) and the Deputy Director of the BD covered mainly policy or overall operational issues and did not capture details of individual projects or new operational practice adopted by the BD’s teams. The Government acknowledges there is an area requiring improvements.

(ii) Internal communications between the Police and FSD during the firefighting and rescue operations

The evidence demonstrates that the intended design for 999 call-handling (immediate transfer to the FSD upon confirmation that a call relates to fire or rescue) was not consistently followed on 26 November 2025. In some cases, police operators collected information and asked questions before transferring calls to the FSD, causing callers to repeat information.

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The rescue information-sharing mechanism between the Police and FSD relied in

part on fax or email. FSD will actively work with the Police to refine information exchange mechanisms, enhancing the efficiency of both departments in handling emergency calls (Table of Improvement Measures, Item A12(ii)).

The Government acknowledges that the deviation between the intended design and actual practice is a joint FSD-Police issue requiring resolution. A joint review of 999 call-handling procedures is being conducted, encompassing the elimination of duplicated questions.

(iii) Internal communications across departments and referrals of complaints / enquiries – the roles of the 1823 hotline, the HAD and other relevant Government Departments under ToR 1 in referring complaints and enquiries to the appropriate Department(s) for handling

Complaints and enquiries relating to the WFC renovation were received by multiple departments, each of which processed the complaint within its own jurisdictional mandate and, where appropriate, referred it to another department.

The 1823 hotline served as a general intake point, routing complaints to the relevant departments. Departments also referred complaints laterally.

The post-fire reforms introduce the establishment of inter-departmental coordination mechanisms for large-scale renovation projects, including: the FSD's enhanced case referral and handling mechanism, under which the FSD will proactively refer fire safety cases to the most appropriate department (with the complainant’s consent), confirm that the referral has been taken over by the relevant department, and escalate any contested referral to Assistant Director or Deputy Director level for inter-departmental coordination (Table of Improvement Measures, Item A11); the newly-implemented notification mechanism between BD and LD whereby BD will regularly provide LD with information to facilitate

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its timely safety inspections at buildings with scaffolding work and buildings

issued with statutory notices (Table of Improvement Measures, Item E4(iii)); and the enhanced information-sharing within the RenoSafe framework.

(iv) External communications with residents

The residents of WFC made complaints to multiple departments about safety concerns over a period of months. The Government acknowledges that more transparent, accurate and informative communication with complainants would have been desirable and would have maintained confidence in the regulatory system. The reforms include enhanced complaint-handling protocols and the commitment to substantive responses that address the specific concerns raised.

(v) External communications with building professionals

The primary mechanism for communicating regulatory requirements to building professionals was through circular letters, practice notes and codes of practice published by the BD and LD. The evidence demonstrates that these communications were issued and updated (including after the Mariners’ Club and Chinachem Tower fires), and that reminder emails were sent to the RI of WFC specifically.

These communications relied on compliance by the recipients. Where the RI was not discharging his supervisory function, the communications did not produce the intended effect.

The reforms address this by the ICU requiring RIs to submit regular site supervision records during works (thereby creating a verifiable trail of supervisory activity) and by establishing regular ICU site inspections that provide an independent check on compliance during the works period.

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Q5. Status of technology application

A recurring theme across the contributing factors and firefighting operation is the extent to which critical processes relied on manual, paper-based or technologically outdated systems that were inadequate for the challenges presented by a large-scale renovation site and the incident that followed.

In the area of FSI monitoring, despite the availability of an electronic submission platform, the FSD’s FS251 processing was approximately 95% paper-based, with certificates submitted by hand, fax or post and subject to time lags of up to eleven months between signing and inputting into the LIFIPS database. The consequence was that the FSD’s monitoring system did not reflect the real-time status of FSIs at any given building, and anomalies such as the near-simultaneous submission of Victory Fire’s FS251 and China Status’s first SDN could not be detected in a timely manner. The SDN extension mechanism similarly operated through paper submissions without automated alerts or escalation triggers, such that 16 consecutive extensions over 7.5 months passed without generating any systemlevel flag.

In the area of construction material verification, neither the ICU nor LD possessed any technological tool for authenticating FR test certificates. Verification depended entirely on visual inspection of paper documents furnished by the contractor. No database of accredited laboratories, no digital signature verification, and no equivalent anti-forgery mechanism existed. A certificate bearing a slightly altered laboratory name and a plausible standard reference was sufficient to pass every check.

In the area of site inspection, the ICU’s selection of inspection locations was conducted manually rather than by computer-randomised allocation, creating at least a theoretical vulnerability to anticipation or manipulation by those subject

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to inspection. No digital monitoring tools were deployed for the ongoing

supervision of scaffolding conditions, material usage or site safety at WFC or any comparable renovation site.

In the area of firefighting operations, the information relay from the FSCC to frontline commanders relied on manual photography of computer screens and transmission via an instant messaging application. Frontline commanders received up to several hundred images in a single chat group during the WFC fire, each requiring individual attention. The Firefighter Location System was incapable of penetrating concrete above approximately the 23rd floor, rendering it ineffective for high-rise operations. The breathing apparatus communication system (VoiceCOM) lacked a direct link to handheld radios, producing unclear transmissions under operational conditions.

The Government acknowledges that earlier adoption of digital systems for FS251 processing, automated anomaly detection for SDN extensions, blockchain-based certificate verification, computer-randomised inspection selection, and enhanced firefighter communication and location systems would have been desirable. But for the delays in commissioning the 4th Generation Mobilising System, attributable in part to the pandemic and supply-chain disruptions, the 4th Generation Mobilising System would have been in service when the largest fire in Hong Kong’s history occurred.

The reforms now in progress represent a deliberate shift from manual, paperbased processes to digital systems capable of real-time monitoring and automated anomaly detection. These include the mandate for electronic FS251 submission with QR-code generation upon receipt; the PNRC 85 requirement for encrypted, digitally signed test certificates from Government-designated accredited laboratories; the LD’s corresponding amendment of the Code of Practice for

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Bamboo Scaffolding Safety to incorporate BD’s latest requirements under PNRC

85; the ICU’s adoption of computer-randomised selection for inspection locations; the new dual-frequency FLS with height-differential display; the Interspiro BA system with integrated Spirocom radio connectivity; the 4th Generation Mobilising System with 100 lines and automated simultaneous information relay; and the introduction of SMS location sharing and a video evidence collection platform for the public. Collectively, these reforms are designed to eliminate the manual vulnerabilities that the WFC fire exposed and to equip the regulatory and operational framework with technological capabilities commensurate with the risks it is required to manage.

R. THE GOVERNMENT’S SUBMISSIONS IN CONCLUSION OF TOR 1

R1. Conclusions on the direct causes of the fire, spread of fire and heavy casualties

On the basis of the evidence before the Committee, the Government submits that the following conclusions are supported on the balance of probabilities.

The fire most probably originated from a glowing source, such as a lit cigarette end, igniting combustible materials accumulated on the flat roof outside Flats 104 and 105 of Wang Cheong House. The windy and dry weather conditions (relative humidity approximately 40%, Red Fire Danger Warning in effect, east-tosoutheast wind approximately 14 km/hr) contributed to the development of the fire, but it was the abundant presence of combustible materials at the point of origin and the presence of suspected non-FR materials in the re-entrant space that allowed the fire to grow in size, intensify and rapidly spread.

The rapid vertical spread of the fire was driven by the chimney-like configuration of the re-entrant, which confined and directed rising smoke and hot gases upward, and by the large quantities of combustible materials and suspected non-FR

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materials accumulated within the re-entrant across multiple levels, including

scaffolding nets that are uncertified for and potentially lacking FR properties, non-FR canvas on catch-fans, wooden planks, toe-boards and nylon strips. The presence of safety nets potentially lacking FR properties was a critical factor: in small fire size cases, the CFD simulations demonstrated that with FR-certified nets the fire could not sustain itself, whereas with non-FR nets the result was significant fire spread and severe fire development. The non-FR canvas on catchfans allowed small fires to escalate into widespread, intense blazes, and trapped embers and burning debris rather than performing their intended protective function. Furthermore, the combustion of non-FR or potentially non-FR safety nets, canvas, toe-boards, and etc. generated flaming droplets which dripped onto lower levels, serving as ignition sources for other combustible materials below, while wind-carried embers (burning fragments light enough to travel considerable distances) were lifted by the intense flames from the re-entrants and carried to the façades of adjacent buildings, where they ignited safety nets, construction debris and other combustible materials.

The horizontal spread of fire from Wang Cheong House to adjacent blocks was caused by secondary ignitions via wind-carried embers, flaming droplets from melting safety nets, and falling burning debris. Within a two-hour period, 11 instances of rapid vertical fire spread were observed at various re-entrants across multiple buildings, and it is conservatively estimated that more than 470 units were affected within that timeframe.

The heavy casualties resulted from the combination of five factors that drastically shortened the available safe egress time while simultaneously increasing the required safe egress time: rapid and extensive fire spread leaving residents with limited time to evacuate; fire-damaged combustible scaffolding collapsing and blocking exits at ground level; failure of fire alarms in all eight blocks depriving

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residents of timely warning; polystyrene window covers obstructing residents’

awareness and delaying their response; and compromise of the means of escape through access openings in staircases that permitted smoke and heat to infiltrate protected escape routes.

The re-entrant design of the buildings (dating from 1983) and wind conditions on the day of the fire were environmental factors beyond anyone’s control that amplified the consequences. These factors explain why the fire, once started, developed with such extraordinary speed; they do not explain why the combustible loading, non-compliant materials, fire alarm shutdown and compromised escape routes existed in the first place. Those conditions were the result of human conduct.

R2. Conclusions on responsibilities of professionals and other non-governmental parties

The Government invites the Committee to find that the primary responsibility for the direct causes of the fire, its rapid spread and the heavy casualties lies overwhelmingly with private actors, specifically:

1. Prestige as main contractor, whose multiple acts of non-compliance, deception and misrepresentation across all five contributing factors were the direct and proximate cause of the hazardous conditions;

2. Will Power purportedly providing RI services and Ng Yeuk, the RI, whose complete failure to discharge statutory supervisory obligations permitted Prestige’s wrongdoings to continue unchecked throughout the renovation period;

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3. China Status, whose submission of incomplete and misleading

notifications to the FSD concealed the full extent of the FSI failure from the regulatory authority;

4. Victory Fire, whose failure to notify the FSD upon discovering the empty water tank and fire alarm shutdown in October and November 2025 was a lost opportunity to trigger the FSD’s contingency measures during the critical weeks before the fire; and

5. ISS, whose issuance of unlawful job orders, failure to coordinate between RFSICs, and passive handling of complaints facilitated and compounded the primary failures.

The Government further invites the Committee to find that these private-actor failures were not isolated or coincidental but formed a pattern of collaborative and mutually reinforcing wrongdoings.

R3. Conclusions on the Government’s systemic and operational issues

The Government acknowledges that the evidence before the Committee reveals areas requiring improvements in the regulatory and supervisory framework with the result that the private actors’ wrongdoings went undetected before the fire. These areas gave rise to conditions in which the primary causes could operate without detection or intervention.

The Government sets out below its conclusions on the systemic issues, framed in general terms as areas for improvement in the framework’s design or execution rather than as judgements on individual bureaux and departments. This framing reflects the Government’s position that the responsibility for systemic reform lies with the Government collectively, and that the reforms introduced since the fire have been developed and implemented on a cross-departmental basis.

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(i) The weaknesses of the self-regulation regime for the supervision of

building professionals under the MBIS and MWCS, and RFSICs

The self-regulation model, while sound in principle and effective in the majority of cases, proved inadequate when confronted with professionals who were either actively complicit in the contractor’s wrongdoings and/or were negligent to the degree of complete abdication. The evidence demonstrates that in certain segments of the building maintenance sector, the role of RI has been reduced to a mere formality: a professional appointed to satisfy statutory requirements without exercising any or any meaningful supervision. This phenomenon, described in the evidence as reflective of an “industry practice” in certain areas, represents an area for improvement of the professional self-regulation on which the MBIS and MWCS depend.

In the opening address [Day 2/73-83], the Committee was taken to evidence illustrating this phenomenon in the case of the RI for WFC:

1. WhatsApp conversations between Ng Yeuk and his full-time employer in which he described his role at Will Power as being “limited primarily to signing prescribed forms and inspection reports that were made available to [him], rather than actively engaging in MBIS works or related repairs, including those for [WFC]” [A2/item 170];

2. Conversations between Ng and a middleman discussing the arrangement of freelance RI work on the basis of ‘just going through the motions’ and backdating documents [A2/items 171, 173.1];

3. A “Bonus List” file recording that between 1 October and 10 November 2025, Ng signed 84 forms involving 56 different projects, including WFC (listed at $150M with a $150,000 bonus), with the only activity recorded

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being the signing of various statutory forms on batch dates [A2/item 174];

and

4. The transfer of Will Power shares to Wong Hap Yin on the evening of the fire [A2/173.2, 175].

This evidence, if accepted, demonstrates that the RI for WFC exercised no meaningful supervision whatsoever over the renovation works, and that his appointment served solely to satisfy the statutory requirements on paper.

The fact that the authority did not detect professionals’ wrongdoings is a result of the audit rates and verification mechanisms described above. The unreliable test certificate provided by Prestige passed through the LD’s and ICU’s review without detection because neither body had the basis or mechanism to authenticate the document against the issuing laboratory.

(ii) Areas for improvement concerning the audit checks and inspections to identify risks and problems

The audit-check mechanisms under the MBIS, MWCS and FSI regimes operated on statistical sampling bases with rates that, while appropriate for quality assurance in a population of generally compliant professionals, were insufficient to detect deliberate and coordinated concealment.

The audit mechanisms were designed to assess compliance across the system as a whole rather than to monitor individual projects. Where no complaint was received and no audit selection occurred, there was no sufficient mechanism for detection regardless of the severity of the non-compliance. The absence of any requirement for site inspections by the ICU during the course of MBIS-related works meant that the works period between commencement and completion was a period during which supervisory oversight was limited, filled only by

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complaint-driven responses. The practical consequence may have been that, in

the absence of complaints, the system’s reliance on statistical sampling left owners and the IO as the only parties with day-to-day visibility of conditions on site.

(iii) Inadequacies in the relevant procedural guidelines, codes of practice, etc.

The prescriptive content of the regulatory framework also contained inadequacies that hindered enforcement. No specific standard existed for temporary window protection materials. No standard existed for toe-board fire retardancy. The general language of section 16 of the B(C)R (“appropriate precautionary measures”) provided insufficient specificity for compliance and enforcement actions in the absence of a defined benchmark. The 1979 Code of Practice applicable to WFC’s FAS did not require warning labels on the main power switch.

(iv) Weaknesses in internal communications and exchanges between the BD and ICU under the delegation arrangement

The delegation arrangement gave the ICU the statutory authority to exercise building control over sold HOS estates, but the communication mechanisms accompanying that delegation were areas requiring improvements to ensure realtime alignment of operational practice. The six-monthly liaison meetings covered policy-level matters and did not descend to the operational detail necessary to identify practice divergences.

(v) The trailing in the use of more advanced technologies to assist work and/or manage risks

The evidence also demonstrates that several critical processes (FS251 submission and processing, the FSD information relay during operations, the ICU inspection location selection, firefighter location tracking in high-rise buildings) relied on

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manual or technologically outdated systems that were inadequate for the

challenges presented by a major incident at a large-scale renovation site.

R4. Executive summary of improvements and immediate steps taken by the Government after the fire

Since the fire on 26 November 2025, the Government has implemented a comprehensive programme of immediate improvement measures while simultaneously developing medium-to-long-term structural changes. This paragraph provides a consolidated summary; the detail is set out in the relevant sections above and in the Government’s Table of Improvement Measures.

In the area of FSI: the FSD has mandated prominent notices of FSI shutdowns at each lift lobby floor and mailbox notifications to residents (Table of Improvement Measures, Item A8) [B14/6235]; required tamper-evident seals on FSI power switches (Table of Improvement Measures, Item A8) [B14/6235]; established that FSI must be inspected and repaired before major renovations commence (Table of Improvement Measures, Item A3); completed functional tests on FSIs in 461 buildings undergoing major renovation by January 2026 (Table of Improvement Measures, Item A3); mandated electronic submission of FS251 forms by circular (Table of Improvement Measures, Item A9) [B14/6257]; established a Quick Response Team for FSI assessment during fires (Table of Improvement Measures, Item A4); created a two-way communication channel with the BD, ArchSD, HD and ICU for large-scale renovation projects (Table of Improvement Measures, Item A3); and initiated a pilot programme testing fire alarms in 1,500 to 5,000 older residential buildings (Table of Improvement Measures, Item A6). Legislative amendments are proposed to convert the SDN notification mechanism to an approval-based mechanism with a 60-day cap, to introduce a Responsible Person System for PMCs, to revise RFSIC registration

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to require periodic renewal, and to increase penalties for false or misleading

certificates (Table of Improvement Measures, Item A10) [B14/6268-6326].

In the area of building safety and construction materials: the BD has issued PNRC 85 [J1-2/6200-6209] requiring encrypted and digitally signed digital test certificates for scaffolding nets, mandatory sampling before installation by Government-designated accredited laboratories, and random on-site inspection with immediate cease-work orders for non-compliance (Table of Improvement Measures, Item C1). The LD has since January 2026 been deploying its staff to support the BD’s work in taking samples of scaffolding protective nets (Table of Improvement Measures, Item E4(ii)). The BD has issued a circular in March 2026 [B13/5714-5719] expressly prohibiting the use of combustible materials including foam boards on external walls or windows (with a limited exception for temporary chiselling). The BD is reviewing the BO and considering legislative amendments to empower it to specify requirements over construction methods and make non-compliance with material safety standards a new offence (Table of Improvement Measures, Item B2(v)).

In the area of the MBIS and MWCS: the ICU has introduced site inspections at least once every four months for large-scale MBIS renovation projects and has implemented the BD’s 20% site safety inspection practice for Class I MW with supervision plans. The ICU has increased the selection percentage to 30% for Class I minor works with supervision plans, effective since May 2026 (Table of Improvement Measures, Item B3(ii)(c)). The BD has also since December 2025 stepped up surprise inspections of large-scale building repair works sites at least once every six months (Table of Improvement Measures, Item B1).

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In the area of strengthening the supervision of building professionals: the

Government is reviewing the BO and considering legislative amendments to require supervision of large-scale building repair works by third-party professionals, with submission of prescribed plans and supervision plans before commencement of works; to clarify the duties of building inspection and works supervision under the existing large-scale repair works regime with a view to breaking the chain of interests between inspection consultants and contractors; and to strengthen the causes for disciplinary actions and the factors for considering registration renewal for registered building professionals and contractors. The ICU has implemented measures mandating the submission of supervision proposals by RIs, stepped up random checks on RI site inspection records, and introduced regular in-person meetings with RIs and RCs to follow up on works progress and details (Table of Improvement Measures, Items B2(i), (iii), (iv) and B3(iv)). In addition, the BD, subject to further legal advice, aims to share BO convictions with Professional Registration Boards and professional bodies starting from the fourth quarter of 2026, thereby extending the existing referral mechanism which currently covers disciplinary records under the BO only (DEVB Paper §16 [WS23/2479]). The DEVB also agrees to the suggestion to require PBPs (including RIs) appointed to supervise repair works to declare before commencement of works that they have no conflict of interests with the RC appointed to carry out the prescribed repair; any false declaration may attract prosecution or disciplinary action and is considering to take this forward when reviewing the BO (DEVB Paper §21 [WS23/2481]).

In the area of inter-departmental communication and coordination: the BD and ICU have strengthened their communication mechanism through multiple measures, including rationalising the consultation mechanism so that all consultations (including verbal consultations) require endorsement by a directorate-level officer from the BD and are recorded in a designated database

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for reference by ICU staff; increasing the frequency of regular working-level

liaison meetings from an annual basis to a quarterly basis to discuss annual enforcement targets, enforcement and implementation details, as well as specific cases, so as to ensure consistency between the practices of the ICU and BD; expanding the content of the bi-annual reports submitted by the ICU to the BD to include the handling of specific cases, the review of communication mechanisms and training matters as standing agenda items; and establishing a mutual secondment mechanism between the BD and ICU to enhance mutual understanding of each other’s standard practices and culture (Table of Improvement Measures, Item D1). The ICU and FSD have established the twoway communication channel for large-scale renovation projects. The LD, BD and FSD are developing joint inspection arrangements for RMAA sites. The RenoSafe framework is being enhanced with expanded information-sharing. The FSD is also working with the Police to refine information exchange and 999 callhandling arrangements.

In the area of occupational safety and construction site management: the LD has proposed a three-tier legislative reform to prohibit smoking at all construction sites and impose a fixed penalty of HK$3,000 on any person smoking at a construction site (amendment to Cap. 371), to empower an OSO to issue fixed penalty notices to a person who is committing or has committed the smoking offence (amendment to Cap. 600), and to impose a positive duty on contractors to take all reasonable measures to ensure that no person smokes or carries a lighted specified smoking product (e.g. cigarettes) or uses naked light to light a specified smoking product in a construction site (amendment to the CSSR) (Table of Improvement Measures, Item E1). The LD will revise the Code of Practice to specify material requirements for toe-boards and is exploring drone-assisted enforcement for the new smoking ban (Table of Improvement Measures, Items E1 and E2). Since 17 March 2026, the LD’s frontline staff has been directed to

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refer any non-conformity with the BD’s requirements on means of escape

detected during site inspections to the BD and FSD for follow-up (Table of Improvement Measures, Item E5).

In the area of firefighting technology and operations: the new Interspiro BA system with Spirocom radio connectivity was placed into service in January 2026. A new dual-frequency FLS system is in procurement. The FSD added 18 and 20 additional telephone lines in April and June 2026 respectively, bringing the total number of available lines to 68 (Table of Improvement Measures, Item A12(ii)). The 4th Generation Mobilising System with automated information relay is in testing. The EAS is being reconfigured for localised use (Table of Improvement Measures, Item 12(iv)). A steering committee on high-rise firefighting strategies has been established under the Deputy Director’s chairmanship.

The Government submits that this extensive cross-departmental programme of improvement measures, in its breadth, its speed of implementation, and its structural ambition, demonstrates the Government’s commitment to ensuring that a fire of this nature cannot recur. The measures address not merely the specific failures exposed by the WFC fire but the underlying systemic vulnerabilities that permitted those failures to occur. They are designed to create a regulatory and supervisory framework that can withstand the deliberate and coordinated abuse of the kind that occurred at WFC, while preserving the foundational principles of private ownership and professional responsibility on which Hong Kong’s building management system is based.

R5. The Government’s response to measures recommended by the Committee’s experts

The Committee’s independent experts made a series of recommendations in their expert report. The Government is giving serious consideration to these recommendations.

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The Government notes that the Committee is itself conducting further studies and

collating views from industry stakeholders and professional bodies on the matters raised by the experts. As the Chairman observed: “whatever recommendation that we make will be based on different considerations” and “the most important thing is we have to change our culture and to look at our risk — reassess our risk” [Day 27/100/19-24]. As the Chairman put it, “what we are trying to do is we put our heads together and reassess the risks and then we try to make it as best as we can and we cannot make it too ideal in that sense. Of course the experts from the academic area, they have other consideration, but you can rest assured that what we are suggesting is that we set the path forward. It will be debated, stakeholders’ interests, whatever, but I think what we are trying to do is try to raise awareness of the whole public about the risks associated with this kind of project in the future, especially with many people living, still living in the buildings” [Day 27/101/2-13]. The Chairman further indicated that the Committee’s recommendations “should not detach too much from reality” and that “every site is different” [Day 26/54/25 – 55/1, 55/10]. The Government respectfully agrees with this approach: recommendations must be grounded in practical reality while addressing the risks that this fire has exposed, and the Government will continue to bear such considerations in mind as and when the Government receives and comes to consider the Committee’s recommendations in due course.

Both the Committee’s experts and Prof Yuen of the IFITF converged on the central importance of risk assessment as the organising principle for future regulation of temporary works in occupied buildings.

The Committee’s experts recommended that “a well thought out and welldesigned risk-based methodology must be developed for approval of building maintenance and renovation works for all buildings in Hong Kong, enabling a bespoke building-specific temporary works solution to be implemented with

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appropriate safety measures including potentially redundant fire safety installations” (IC Expert Report §7.4.1 [ER3/2255]). Prof Yuen endorsed the same principle: “in the area of risk assessment, I think it’s something that should be incorporated into monitoring, design and execution of work so that the parties will be alive to the risks in order to prevent incidents” [Day 26/51/10-13].

The Chairman’s observation during the hearing encapsulates the rationale: “regulation by itself is not the end... Even if they pass regulations, it may still cause … you are actually proposing an actual project, you have to have a risk assessment” [Day 27/73/14-20]. As Prof Usmani lamented, “in Grenfell, they were not violating the regulations; they had passed the test and it still happened” [Day 27/47/13-15]. In a similar vein, the Chairman rightly cautioned: “In a way I think Grenfell taught us even with all the best legislation, it can still happen” [Day 27/100/24 – 101/1]. The lesson of both WFC and the Grenfell Tower fire is that compliance with legislation and prescriptive standards, while crucial, might not be sufficient. It might be inadequate or inapt where the combination of sitespecific factors creates additional risks. Hence, the key lies in raising awareness on risk assessment, both within the industry and socially.

The risk assessment must not be a formulaic exercise. As Prof Usmani emphasised: “Risk is a product of probability times consequence. So you cannot just look at — say the risk is reduced by reducing the probability of a fire happening. If you reduce the probability of a fire happening by fire-retardant materials, that’s fine. But if the consequence of a fire is going to be exceptionally high... then the risk is not just the probability that you have reduced but also the consequence” [Day 27/50/21 - 51/8]. Where the consequence of failure is catastrophic, the risk assessment must reflect that consequence irrespective of the assessed probability of ignition.

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The Committee’s experts made a number of further recommendations covering,

inter alia, the prohibition of combustible materials in re-entrant spaces, a ban on simultaneous cladding of adjacent buildings, stricter approvals for renovation works involving re-entrants, fire-rated glazing for staircase and lift lobby windows facing re-entrant spaces, redundant FSI systems, enhanced monitoring, strengthened worker training, fire drills for occupants, and coordination with building management (IC Expert Report §§7.3.1(a)-(l) [ER3/2252-2255]). The experts also identified areas requiring further study and research, including the development of new lightweight non-combustible protective materials, bespoke redundant FSI systems for temporary works, and technology-driven monitoring solutions (IC Expert Report §§7.4-7.5 [ER3/2255-2256]).

The Government notes that these recommendations are made from the perspective of fire engineering experts, as Prof Usmani confirmed: “this is our — essentially a view from our professional background” [Day 27/99/7-9]. As the Chairman observed, the Committee’s eventual recommendations will necessarily take into account other socioeconomic considerations [Day 27/99/4-6], and will require further consultation with stakeholders. Prof Usmani accepted this, confirming that the recommendations are “interim in nature and will need further considerations” [Day 27/98/23-24] and that implementation will depend on feasibility studies and practical constraints [Day 27/100/12-17].

The Government notes that a number of the experts’ recommendations are already addressed by or consistent with the improvement measures set out in Section R4 above, including the BD’s prohibition on combustible materials on external walls or windows (March 2026 circular) [B13/5714-5719], the interdepartmental coordination mechanisms for buildings under renovation, and the enhanced site inspection regimes. Indeed, in a manner not dissimilar to the approach adopted by the Committee’s independent experts (by differentiating

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into immediate and longer-term recommendations), the Government has

introduced improvement measures which are categorized into short, medium and longer terms, many of which have already been introduced or are being introduced now, to avert the risk in future. The Government will also give careful and serious consideration to any eventual recommendations made by the Committee in its final report, and will continue to review and introduce further improvement measures as appropriate.

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PART IV: TOR 2

S. OUTLINE OF THE SYSTEMIC ISSUES AS IDENTIFIED FROM THE EVIDENCE

Before addressing the involvement of each Government body and related institution under ToR 2, it is appropriate to set out the systemic issues as they emerge from the totality of the evidence before the Committee.

The Committee’s primary focus can properly be on the evidence available and submissions made by the relevant parties.

The Government recognises (as indicated by the Chairman) that there may be difficulties in making specific factual findings regarding certain aspects of the WFC tendering process - particularly where persons who may have direct knowledge have declined to give evidence or where matters are sub judice.

However, such difficulties need not prevent the Committee from discharging its functions under ToR 2 and making relevant recommendations. This is consistent with the approach indicated by the Chairman at the evidential hearing on 8 May 2026, in which the Committee directed that the evidence received under ToR 2 mainly focuses on the WFC renovation works and does not cover other similar works in Hong Kong, and that the Committee will accordingly make reference to the conclusions of the reports submitted by relevant law enforcement agencies concerning ToR 2, and the information received from members of the public and organisations, as the basis for its findings of fact under this ToR.

The systemic issues identified in this section are drawn from the reports, witness statements and oral evidence of the Competition Commission, ICAC, Police, URA, and HAD. They are not limited to the individual WFC project but extend to broader sector-wide patterns.

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S1. Bid-rigging and other anti-competitive / unlawful conduct – consultants / RIs and contractors

The evidence before the Committee establishes that bid-rigging in the building maintenance sector is widespread, systematic and long-standing, encompassing multiple forms of anti-competitive conduct. The Competition Commission’s Report (“CC Report”) to the Committee states in terms: “The CC believes that there is indeed a widespread, systematic, and long-standing practice between some building maintenance contractors to affect the outcome of tenders for building maintenance works.” (CC Report to the Committee §12(1) [WS22/2451]).

In his oral evidence, Wong Se King of the URA confirmed this assessment: the building rehabilitation market in Hong Kong has long been exposed to anticompetition behaviour and a lot of contractors and consultants are involved. [Day 21/93/2-9].

The Competition Commission has identified the following specific forms of anticompetitive conduct in the sector: bid suppression (one or more contractors refraining from bidding); cover bidding (a pre-agreed “designated winner” supported by deliberately less attractive bids from others); bid rotation (a marketwide coordinated scheme in which members of syndicates facilitate each other’s chances of winning over a number of tenders); market sharing; information exchange; credential sharing; and phantom bidding (CC Report to the Committee §§12(1)(a)–(c), 12(3)(a)–(d) [WS22/2451-2453]).

The Competition Commission has further found evidence of syndicate-led cartels with organised systems of “registration,” dissemination of pricing instructions (referred to by the syndicates as “homework”), and the presence of ring-leaders and coordinators. These syndicate-led cartels may involve dozens of building maintenance contractors and consultants. In different cases, the Competition

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Commission has observed syndicates working with, as well as competing against,

each other to affect the outcome of a tender (CC Report to the Committee §3(5) [WS22/2445]).

A central structural feature of the problem identified by both the Competition Commission and ICAC is the facilitation of contractor bid-rigging by consultants and RIs. The model operates as follows: a consultant wins appointment at belowcost fees, then steers the renovation contract to an affiliated contractor at an inflated price. The Competition Commission’s Report describes this practice: “These practices are sometimes facilitated by the consultants that are supposedly independently engaged by the owners / incorporated owners of a building. In these cases, the consultants may, in exchange for compensation (whether by way of outright payment or by taking a ‘cut’ from the final project works), agree to favourably recommend a building maintenance contractor for the owners and IO to select.” (CC Report to the Committee §12(2) [WS22/2451]).

The ICAC’s Report confirms that in several of its investigated cases, “the RI appointed by the consultant to oversee the project was in fact a mere dummy, who exercised little or no supervision over the project, and was only appointed to satisfy the statutory requirements imposed under the BO.” (ICAC Report §95 [WS10/1979]). Wong Se King of the URA confirmed in oral evidence that there is no effective mechanism to handle the situation where RIs use unreasonably low prices to win service contracts and then assist contractors to inflate the price. [Day 21/102/16-24].

WFC is one of at least 11 housing estates and buildings targeted by the bid-rigging syndicate in the Competition Commission’s March 2026 Competition Tribunal proceedings. The tender period alleged (April 2022–September 2023) corresponds to the period of contractor tendering at WFC. The total value of the

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relevant contracts across the 11 buildings is estimated at close to HK$700 million

(CC Press Release (25 March 2026) [U2/164]).

The Competition Commission confirms that all relevant consultancy and contractor tenders at WFC contained non-collusion clauses (“NCCs”) and that most bidders executed non-collusive tendering certificates (NCTCs) (CC Report to the Committee §26 [WS22/2458]). The significance of this finding is that any person who was knowingly party to a collusive arrangement rendering the representations in the NCTC false may be criminally liable for conspiracy to defraud (CC Report to the Committee §§24–25 [WS22/2457-2458]). This demonstrates that preventive tools were in fact deployed at WFC; the wrongdoing is attributable to private actors who deliberately subverted the existing safeguards.

The Competition Commission and ICAC, and Police, have identified triad involvement in the building renovation sector. The Competition Commission has encountered cases where threats of or actual violence were used to compel bidders to withdraw or follow syndicate instructions, and where building maintenance contractors affiliated with the same triad society coordinated their bids (CC Report to the Committee §§12(4), 3(6) [WS22/2445-2446, 2453]). The ICAC’s assessment is that “organized syndicates, employing illicit methods such as corruption, triad tactics, bid-rigging and fraud to manipulate the tendering processes, are driven by the potential profits to seek a dominant market share.” (ICAC Report §99 [WS10/1980]).

The Police also offer an important qualification: while triad involvement takes many forms (direct involvement and discreet approaches through front persons, influence over “concern groups”, participation via indirect links with consultants or contractors), it may be inaccurate to assume triads are always the dominant driver. Many bid-rigging schemes are organised and executed by ordinary market

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players, with triad elements engaged only at particular stages, or not at all449

[WS1/287].

S2. Bribery – consultants / RIs and contractors bribing the relevant stakeholders, e.g. the PMC and members of the MC of the IO

The ICAC’s evidence demonstrates a consistent pattern in which contractors bribe PMC staff and MC members through cash payments, unreasonably low consultancy fees, kickbacks, and materials supplier arrangements. These payments are designed to corrupt the procurement decision-making process at the IO/MC level.

The ICAC’s case studies provide detailed illustrations of this pattern. In one investigated case involving a $262 million renovation project, a middleman admitted his role in assisting the contractor, confirming involvement of PMC staff, MC members and the consultant, with alleged kickbacks totalling approximately

5% of the project sum (approximately $46 million), paid in cash through middlemen and dummy companies (ICAC Report §§44–52 [WS20/2280-2282]).

The ICAC observes that “corruption, undeclared conflicts of interest, fraud and bid-rigging are often hidden behind layers of intermediaries and shell companies… The illicit payments are customarily made in cash making it difficult to trace illicit funds, let alone proving its corrupt purpose.” (ICAC Report §96 [WS20/2287]).

S3. Other misconduct or dishonest conduct in the tendering and quotation processes

Evidence from multiple sources identifies a range of dishonest conduct beyond bribery and bid-rigging: preparation of inflated and misleading tender analysis

449 LAM Kai Chor (Supt, OCTB, Police) 1st WS §28

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reports; submission of false litigation records; use of below-cost consultant fees

as a loss-leader to gain appointment and thereafter steer the renovation contract; unreasonably low manday estimates; use of dummy companies and shell companies; and false accounting records (ICAC Report §§45, 95 [WS20/2280, 2288]).

The ICAC identifies the typical modus operandi: “the contractor was often part of a crime syndicate with triad connection, who would collude with the consultant and other contractors to rig the bids, corrupt members of the MC and PMC, or deploy other illegal means (e.g. faking proxies) in order to manipulate the selection of the contractor for the project.” (ICAC Report §95 [WS20/2286]).

In the context of WFC specifically, evidence before the Committee indicates that Prestige submitted litigation records certified to show “no record of being sued by IOs and management companies” in the past seven years, but a post-fire litigation search returned 108 results including prior judgments and sentences; the submitted records “at least” appear incomplete450 [WS18/2221-2222].

S4. Abuse of the proxy system

Both the ICAC and Police have identified manipulation and falsification of proxy instruments at owners’ meetings as a common tool for achieving corrupt outcomes in contractor and consultant selection. The proxy system creates structural vulnerability given the collective decision-making framework of Owners’ Corporations.

The ICAC reports that in one investigated case, suspects “might have assisted the MC Members to collect proxies from some property owners, in order to facilitate them to manipulate voting at the owners’ meetings to achieve outcomes in their

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favour.” (ICAC Report §§68–72 [WS20/2283-2284]). The same Report records

that “in respect of the investigation by the Police on proxy manipulation, it was understood that no prosecution was initiated as there was no evidence to prove who had handled or submitted the proxies in question.” (ICAC Report §§68–72 [WS20/2283-2284]).

The ICAC further observes that faking proxies is one of the “illegal means” deployed by syndicates “in order to manipulate the selection of the contractor for the project.” (ICAC Report §95 [WS20/2286]).

The Building Management (Amendment) Ordinance 2024 (effective 13 July 2025) introduced enhanced requirements for declarations of interest in the context of large-scale procurement. The HAD has proposed further improvement measures to the proxy system, including a potential cap on the number of proxies an individual may hold and a posting requirement. These measures are addressed in Section U3(ii) below.

S5. The failure of the PMCs in discharging their duties

The ICAC identifies property management companies as structurally positioned to exert corrupting influence over procurement decisions, given their operational proximity to OC meetings, voting arrangements, and tendering processes. The ICAC Report states: “In the context of building renovation projects, PMCs and PMC staff play key roles alongside other stakeholders. Their operational proximity to both building renovations and day-to-day building management functions, such as coordinating OC meetings and related voting arrangements, as well as administering tendering processes, places them in positions of considerable influence over procurement decisions.” (ICAC Report §13 [WS20/2268]).

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PMCs’ conflicts of interest are frequently undisclosed and inadequately regulated.

In one ICAC case study, “the MC confirmed that they had no system in place to deal with such conflicts of interest.” (ICAC Report §§84–88 [WS20/2285]). In another, a family member of the PMC proprietor had a financial interest in a materials supplier designated by the contractor (ICAC Report §§84–88 [WS20/2285]).

The Building Management (Amendment) Ordinance 2024 (effective 13 July 2025), which now requires a responsible person for the procurement of largescale building renovations to make a declaration of any pecuniary or other personal interest in relevant suppliers, represents a direct response to this identified vulnerability (ICAC Report fn.26 [WS20/2286]).

More broadly, the Police observe that “homeowners are heavily reliant on consultants for their professional advice in terms of building inspection, identifying suitable work options, tender analysis and subsequent supervision of works. As a result, consultants and contractors are rife with collusion, corruption and ‘silent agreements’, commonly found between organized crime groups”451 [WS1/287]. This observation encapsulates the structural vulnerability that PMC failures compound.

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T. THE INVOLVEMENT OF THE GOVERNMENT AND RELATED BODIES

T1. The URA

The URA is a statutory body established under the Urban Renewal Authority Ordinance (Cap. 563), one of whose objectives under section 5 is to promote the maintenance and improvement of individual buildings in terms of structural stability, external finishes and fire safety452 [WS18/2209-2210].

In 2016, the URA Board approved the launch of the Smart Tender scheme as a fee-based service specifically designed to reduce the risk of bid-rigging faced by building owners and OCs. The scheme was designed to address five categories of misconduct spanning the entire tendering process: internal collusion between MC members and bidders; manipulation of tender documents to filter out noncolluding bidders; bid suppression through selective invitation and obstruction; manipulation of the bid return and opening process; and manipulation of the tender analysis report453 [WS18/2210].

The WFC IO applied to join Smart Tender on 2 February 2018, and a bilateral service agreement was signed on 16 June 2018 confirming the URA’s role as agent of the OC to assist in engaging the contractor454 [WS18/2224-2225]. RS Surveyors Limited (“RS Surveyors”) was assigned as the independent consultant under Smart Tender455 [WS18/2225].

At the time WFC joined Smart Tender in 2018, the e-tendering platform did not extend to the engagement of RIs or consultants. Accordingly, the URA had no involvement in the tendering for Will Power as consultant (noting that Will Power cannot be directly engaged as RI in any event) and had no knowledge of the

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tendering arrangements456 [WS18/2225-2226]. The URA provided only limited

assistance for the RI engagement: posting the tendering notice on the URA’s platform, and preparing a one-page tender price summary based on 24 tender materials provided by the OC, without any assessment of reasonableness of prices457 [WS18/2225-2226].

Similarly, the URA had no role in the tendering for the consultant in January 2020, including preparation of tender documents, receiving and opening of tenders, and attending the bid opening on 20 January 2020. The OC also declined the URA’s offer to use the e-tendering platform for the consultant appointment 458 [WS18/2227].

The role of RS Surveyors as independent consultant under Smart Tender appeared to be defined and limited: to prepare preliminary assessment reports, an independent cost estimate (sealed until bid opening), and a returned tender analysis report. RS Surveyors did not comment on the reasonableness of optional works items, the choice of materials, or the pricing strategy of tendering consultants and contractors. RS Surveyors confirmed in its reply to the Committee that its role was “limited to preparing the cost estimate based on the draft tender documents” and that it did not conduct independent verification of tenderers’ backgrounds or connections, as “such verification falls outside the scope of our appointment as an independent consultant under the Smart Tender Scheme” [WS21/2341-2342]. Wong Se King confirmed in oral evidence that regarding anti-bid-rigging, the consultant had “very little role to play” because “at that stage tenders have already returned, we just need to make sure the tender is fair.” [Day 21/119/24 - 120/4]. He further confirmed that regarding collusion

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to conduct unnecessary works, “the consultant could not prevent this from

happening.” [Day 21/122/9-20].

The Smart Tender e-tendering platform was used for the contractor procurement in 2023. The advertisement went live on 16 May 2023; 99 contractors downloaded the final tender document; 57 tenders were submitted and opened on 5 July 2023 in the presence of a registered accountant and the OC’s representative; no tenders were withdrawn 459 [WS18/2230-2231]. The URA did not check associations among the 57 tendering companies in public records and accepted that this was not the URA’s responsibility; it relied entirely on the consultant (Will Power).

After the fire, the URA is developing an enhanced Smart Tender service (“Smart Tender 2.0”) incorporating: a pre-qualified contractor list based on police and ICAC background screening; URA-conducted tender vetting replacing reliance on the consultant; and disclosure requirements for contractor shareholding connections. Wong Se King stated: “In the future we will also get involved in the vetting of tenders… In Wang Fuk Court there were 57 tenders. In the future we will go through all 57 tenders. In the past we relied on Will Power, but in the future we will take matters into our own hands” [Day 21/139/3 - 140/15].

In early December 2025, upon learning of law enforcement action against Will Power and Prestige (including the arrest of their key personnel), the URA exercised its discretion under clause 13.1 of the Building Rehabilitation Company Registration Scheme Terms and Conditions Manual to remove their registrations in writing460 [WS18/2232].

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T2. The Competition Commission

The Competition Commission is the primary enforcement agency under the Competition Ordinance (Cap. 619). In addition to its enforcement function, one of its statutory functions is to conduct market studies into matters affecting competition in markets in Hong Kong (CC Report to the Committee §§4–5 [WS22/2449]).

The Competition Commission’s 2016 market study identified suspicious patterns consistent with widespread bid-manipulation in the building maintenance sector, including bids by consultants priced below the minimum cost of providing services — suggesting remuneration through other, possibly nefarious, means — and statistically anomalous frequency of certain consultants working with certain contractors (CC Report to the Committee §7 [WS22/2449-2450]). These findings pre-date the full commencement of the Competition Ordinance and demonstrate that the structural problem in the sector was already well-documented well before the WFC fire.

Between 2016 and 2019, the Competition Commission successfully brought three enforcement actions against 18 undertakings and 5 individuals for anticompetitive conduct (price-fixing and market sharing) in the decoration and renovation sector, obtaining declarations of contraventions, pecuniary penalties, and director disqualification orders (CC Report to the Committee §9 [WS22/2450]).

From 2022 onwards, the Competition Commission conducted five major investigations into the large-scale building maintenance sector in coordination with the Police’s Organised Crime and Triad Bureau, covering at least 68 residential estates, 15 industrial estates, and 64 companies (CC Report to the Committee §10 [WS22/2450]).

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In January 2024, the Competition Commission received a referral from the ICAC

regarding a newly-rising syndicate and thereafter conducted two joint operations with the ICAC in April and August 2024, leading to the filing of proceedings in the Competition Tribunal in March 2026 (CC Press Release (25 March 2026) [U2/164]). WFC is one of the 11 named buildings in those proceedings.

The Competition Commission’s case in the March 2026 proceedings is that the bid-rigging syndicate comprised several contractors and middlemen, was operated by a mastermind who scouted for target building maintenance projects and selected syndicate contractors to bid for those tenders. In any given tender, contractors were assigned either to be the “main character” (the syndicate’s designated winner) or “helpers” (those responsible for providing cover bids), and pricing instructions (“homework”) were prepared and distributed (CC Press Release (25 March 2026) [U2/161]).

The Competition Commission recommends the following legislative reforms: amending the Competition Ordinance to stipulate the civil standard of proof in pecuniary penalty proceedings; incorporating statutory presumptions; clarifying that the Commission need not prove bid-rigging was “not made known” to the tendering body; increasing penalties and director disqualification periods; and requiring Statutory Declarations in large-scale tenders to facilitate criminal prosecution (CC Report to the Committee §§28–32 [WS22/2458-2460]). The Competition Commission has also completed preparing an enhanced version of the NCCs (i.e. the Non-Collusion Clauses) for procurers to incorporate into their tender documents and procurement contracts, including adding a clause explicitly stating that violating the NCC may constitute a criminal offence, and introducing additional terms requiring bidders to make a Statutory Declaration affirming the warranties within the NCC. The enhanced NCC is expected to launch soon (Table of Improvement Measures, Item G4).

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T3. The ICAC

The ICAC has statutory responsibility under the ICAC Ordinance (Cap. 204) to investigate corrupt practice, examine government procedures conducive to corruption, and educate the public against corruption (ICAC Report §§1–3 [WS20/2263-2264]). It has adopted a three-pronged strategy (enforcement, prevention, education), specifically targeting the building renovation sector.

Corruption complaints regarding building management and maintenance issues have for many years accounted for approximately 25% of all complaints made to the ICAC each year. Focusing on complaints regarding building renovations over the last three years (2023–2025), the ICAC received 239 complaints, of which 220 (92%) were formally investigated (ICAC Report §§33, 34, 38 [WS20/2276-2278]).

Despite 137 arrests in 2023–2025, criminal prosecution rates are low due to the inherent nature of corruption in this sector. The ICAC explains: “Criminal activities in building renovations are inherently difficult to investigate and prosecute despite protracted investigative efforts, due to its secretive and syndicated nature. Corruption, undeclared conflicts of interest, fraud and bidrigging are often hidden behind layers of intermediaries and shell companies. Infights and disputes always complicate the issue. The illicit payments are customarily made in cash making it difficult to trace illicit funds, let alone proving its corrupt purpose. Potential witnesses, if any (including property owners or junior staff members of contractors, consultants and PMCs), may fear retaliation especially when triads are involved.” (ICAC Report §96 [WS20/2287]).

The ICAC’s Community Relations Department reached over 4,600 people from over 870 building management bodies annually and issued over 4,000 letters to

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building management bodies over three years, though the average response rate

has remained low — “reflect[ing] the generally low level of interest in BMM matters among property owners and other stakeholders.” ICAC Report §28 [WS20/2273]. The ICAC’s Corruption Prevention Department has provided recommendations to the HAD on legislative amendments to the BMO, including enhancement to procurement requirements and improvements to proxy arrangements (ICAC Report §29 [WS20/2275]).

Because of the high threshold for prosecution, the ICAC also deploys early intervention to alert building owners to risks and frustrate syndicates before they execute their schemes. Over three years, 20 early interventions were carried out covering 32 buildings and estates (ICAC Report §42 [WS20/2279]).

The ICAC’s summary assessment is stark: “This high-value environment operates largely within a framework that is built on an honour system, which relies on trust and integrity on the part of the consultants and contractors to function. It however contains inherent and apparent structural vulnerabilities.” (ICAC Report §98 [WS20/2288]). The result is “a self-perpetuating cycle: the withdrawal of ethical professionals further distorts the ecosystem in favour of nefarious elements, limiting choices for property owners and entrenching the dominance of problematic service providers. This cycle cannot be broken and reversed without targeted intervention.” (ICAC Report §100 [WS20/2288]).

As at December 2025, based on the then available survey results only 128 out of approximately 600 registered RIs had expressed interest in providing MBIS services. The small pool of RIs available in the building renovation market heightens their vulnerability (ICAC Report §21 [WS20/2271]).

Further statistics of RIs providing services in the MBIS were submitted to the Committee by the BD in its Third List of Documents dated 1 June 2026. In

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summary, according to the BD’s record as at 31 December 2025 [J3/7978], “there

were 632 RIs, of whom some 400 had handled or are handling works related to MBIS notices. On average in the past five years, 233 different RIs submitted specified forms for the MBIS each year.”

Between February and May 2026, the ICAC mounted three further major law enforcement operations against corrupt syndicates targeting building maintenance projects, including Operation “Lion Rock” and Joint Operation “Scabbard” with the Police (ICAC Report post-report note [WS20/2289]).

The Government notes the convergence of the ICAC’s analysis with that of the Competition Commission and Police: the building renovation market is infiltrated by organised syndicates exploiting structural vulnerabilities in the regulatory and facilitative ecosystem. The ICAC’s three-pronged strategy is also consistent with the Government’s broader reform programme.

T4. The Police

The Police’s involvement in ToR 2 matters falls under the Organised Crime and Triad Bureau (“OCTB”) and encompasses: the inter-departmental RenoSafe scheme; intelligence-gathering and referrals on organised crime and triad involvement in building maintenance; and their views on legislative reform461 [WS1/281].

RenoSafe was launched on 4 September 2013 as an inter-departmental publicity and education campaign by a working group initiated and chaired by the OCTB, in response to the potential infiltration of building maintenance works by criminals including triads462 [WS1/282]. Standing members of the working group

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currently comprise the Police, BD, Competition Commission, EMSD, FSD, HAD,

ICAC, PMSA, and URA463 [WS1/282].

RenoSafe members operate a risk assessment matrix (seven factors producing high, medium and low risk ratings), a 24-hour police hotline (2527 7887), periodic inter-departmental briefings, and a building enrolment system. Since its launch in September 2013 until 31 January 2026, the Police paid visits to a total of 7,100 buildings, of which 3,055 were enrolled in RenoSafe; 148 briefing sessions were conducted; and 345 enquiries were received by the police hotline464 [WS1/283-286].

The existence and growth of RenoSafe since 2013 evidences an interdepartmental coordination mechanism for building maintenance-related crime has been in place for over a decade. RenoSafe’s remit was focused on publicity, education and crime prevention rather than more specifically on site safety supervision, and recent reviews have identified potential areas for improvement.

The Police proposes enhanced information exchange among RenoSafe members covering: large-scale maintenance works arising from statutory inspection and repair orders; tender information of subsidised building maintenance works; building maintenance works that repeatedly seek extensions of deadlines for compliance; and building management or maintenance work related complaints against building representatives465 [WS1/288-289].

The Police’s view on organised crime and triad involvement, based on observation, experience and reliable intelligence, is that triad involvement takes many forms but it would be inaccurate to assume triads are always the dominant

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driver. Many bid-rigging schemes are organised and executed by ordinary market

players, with triad elements engaged only at particular stages or not at all. When the use of suppression or violence is essential, triads then become the “enforcer”. Intelligence indicates that a small number of triads had set up and were operating their own consultant and contractor companies466 [WS1/287].

The Police considers that the current civil penalty regime under the Competition Ordinance (Cap. 619) may not outweigh the potential gains from prohibited conduct, and proposes bespoke criminal legislation with clearly defines fiduciary duties for MCs, consultants and contractors. The Police further recommends immunity provisions and statutory informer protection to improve evidence gathering467 [WS1/289-290].

The Government notes the convergence of the Police’s proposals with those of the Competition Commission and ICAC.

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U. THE ROLES AND RESPONSIBILITIES OF THE HAD

U1. The regulatory context for the HAD’s involvement

(i) The HAD’s roles and responsibilities in facilitating building management

The HAD’s role in building management is facilitative, not supervisory. The foundational policy principle is that the right to private property carries with it the inherent responsibility for its proper management, including up-keeping and maintenance. Government intervention in private property management should be premised on safeguarding public interest, and should be exercised with caution and restraint given the right of private ownership468 [WS1/486].

The SHYA is the statutory Authority under the Building Management Ordinance (Cap. 344), and the HAD is her executive arm469 [WS1/486]. The HAD, through its DBMLTs in each of the 18 District Offices, provides the following services to OCs and owners: assisting in OC formation; attending owners’ meetings upon invitation and providing advice according to the BMO; advising parties of noncompliance and requesting rectification; answering BMO enquiries; and organising training and briefings for MC members and owners470 [WS1/487].

The HAD has established a Central Platform on Building Management since 2018, organising monthly briefings for OCs and owners at which relevant government departments (including the BD, FSD, EMSD, LD, and Police) and institutions (including the ICAC, URA and Competition Commission) introduce their services and schemes on building management and maintenance, including briefings on bid-rigging471 [WS1/489]; [Day 24/3/20 – 4/16].

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The HAD also provides dispute resolution services through mediation and

advisory panels. These services were made known to WFC owners but were not taken up by any resident or owner. [Day 24/5/4 – 6/4].

When attending owners’ meetings, HAD representatives maintain impartiality and professionalism, offering advice solely on BMO provisions, especially those governing procedures relating to the conduct of owners’ meetings and rights and powers of the IO and owners472 [WS1/505].

The appropriate level of HAD assistance therefore depends on the specific circumstances of the building. In the case of WFC, the HAD’s role was primarily to advise on meeting procedures and BMO matters. [Day 20/114/10-23].

(ii) The HAD’s powers under the Building Management Ordinance (Cap. 344)

Section 40A of the BMO empowers the SHYA or an authorised officer to inspect common parts of a building, attend OC general meetings, and inspect or obtain copies of OC budgets, accounts, documents and records, for the purpose of ascertaining how a building is being controlled, managed or administered 473 [WS1/492]. This power serves mostly as a “last resort” for exceptional cases. Deputy Director Te Chi Wang confirmed in oral evidence that “under most circumstances, the parties would be cooperative, they would provide you with information, you do not need to invoke section 40A.” [Day 24/19/23 - 20/3].

Section 31 of the BMO empowers the Lands Tribunal, upon application by (among others) the SHYA, to dissolve the MC and appoint an administrator. This power was invoked for the first time in relation to WFC on 6 January 2026, when Hop On (a subsidiary of the Chinachem Group) was appointed as administrator.

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DD Te confirmed: “I think this is unprecedented. That is the first time we invoked

31(1)(d).” [Day 24/21/5-19].

The BMO does not confer on the HAD a power to compel the OC chairman to convene a meeting. Where the chairman refuses, the remedy available to owners is to apply to the Lands Tribunal [Day 24/12/15-25]. Or Wai Yin acknowledged this: “if the chairman refused to hold a meeting, there was nothing you could do.” [Day 20/105/5-12]. This is a statutory constraint that manifested directly in the WFC experience.

Similarly, the BMO does not confer on the HAD a prosecution power for general non-compliance with building management obligations. The HAD’s enforcement tools are limited to advisory letters, verbal reminders, and (in the context of the present case) the exceptional resort to section 40A or section 31. [Day 24/24/22

25/12].

U2. The conduct of the relevant WFC IO / disputes and challenges, and the HAD’s involvement at different stages

(i) The stage of compliance with the MBIS and engagement of Will Power as the consultant providing RI services

The Tai Po District Office (“TPDO”) attended the 21st Annual General Meeting of the IO of WFC held on 25 January 2019, during which Will Power was appointed as the inspector. No irregularity was observed by the attending TPDO representative474 [WS1/507].

TPDO was not involved in the appointment of Will Power or the conduct of the MBIS inspection. According to file records and confirmation with the relevant TPDO colleagues, TPDO had no role in respect of Will Power’s appointment or

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the subsequent inspection carried out by that firm 475 [WS1/507]. This is

consistent with the HAD’s facilitative role.

(ii) The stage of renovation design and project procurement, and engagement of Will Power as the consultant for the subsequent renovation works

TPDO was not consulted on and had no involvement in the tendering for Will Power’s appointment as renovation consultant [WS1/508].

According to file records, TPDO had not been “consulted or approached to seek or ask to give advice in respect of the tendering process for appointment of consultant for the Wang Fuk Court Renovation and/or the eventual appointment of WP as consultant” 476 [WS1/508]. Nor did TPDO receive any complaints about the reasonableness or propriety of Will Power’s consultancy bid477 [WS1/508]. The HAD’s primary objective in this context is to safeguard the procedural transparency of the bid selection process; it was not in a position to form a view on the reasonableness of any bid or consultancy fee, but remained vigilant in referring reports of irregularities, had any been received, to the appropriate enforcement bodies478 [WS1/508].

Earlier disputes among owners in the second half of 2021 were known to TPDO. A group of owners dissatisfied with the then MC attempted to remove members of the MC by convening a meeting at the request of not less than 5% of owners. TPDO responded to 16 phone enquiries regarding meeting procedures 479 [WS1/508]. The resolution to remove MC members was not successful at the EGM held on 11 December 2021. It did not come to TPDO’s attention that there

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was any irregularity regarding improper gathering of proxy votes or exclusion of

residents from attendance at the meetings during this period480 [WS1/508-509].

(iii) The stage of contractor tendering and selection

The EGM of 28 January 2024 was the critical juncture at which Prestige was appointed as contractor for the WFC renovation works. The meeting was held at the basketball court in WFC and was attended by Or Wai Yin of TPDO481 [WS1/529].

The resolution appointing Prestige was passed by a majority of 54.79% of the owners’ votes482 [WS1/530]. At the same meeting, Option 3 for the renovation works (hacking off all original external claddings, carrying out concrete repair, adding waterproofing plastering, and covering external walls with new mosaic tiles and paint) was also passed by an 80.5% majority483 [WS1/530] [G1-1/1005].

Or Wai Yin confirmed that neither the MC, the IO, nor any residents of WFC had consulted, sought, or received advice from the HAD before or during the meeting in respect of the appointment of Prestige as contractor. As far as she could observe, she “did not see any irregularity or non-compliance with the procedural requirements under the Building Management Ordinance” during that meeting484 [WS1/530].

Or Wai Yin’s attendance at the meeting followed the HAD’s standard practice. She arrived approximately 15 minutes before the meeting to take a look at the background of the OC, checked whether notice postings were compliant, and observed registration to see “whether everything is smooth” and “whether there

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is any suspicious behaviour” [Day 20/115/10-20]. She observed that 57 potential

contractors were listed [Day 20/115/16-17].

The initial attendee count of 293 was announced by the MC at the commencement of the meeting [Day 20/93/2-7]. The subsequent increase in votes from the initial count of 293 to approximately 570–590 at the time of voting drew resident complaints. Or Wai Yin followed up with the management office and was told that the management office continued to register attendees after the initial quorum announcement; the figure of 293 represented the quorum count at approximately 1:50 pm, not the final registration total. Or Wai Yin confirmed she found this explanation acceptable [Day 20/93-95]. Or Wai Yin photographed approximately 280 proxy votes at the meeting [G4/2735]; she observed approximately 200 to 300 people in attendance and considered the number of proxies consistent with that observation [Day 20/95/8-18].

As to the proxy mechanism: under paragraph 3(5)(b) of Schedule 3 to the BMO, it is the chairman or, in his absence, the person who presides at the meeting, who determines the validity of a proxy instrument. The HAD has no statutory role in this determination.

Chan Hau Man confirmed that the HAD’s position is that proxy voting is a proper tool under the BMO for owners unable to attend meetings in person to participate in building management decisions: proxy instruments represent “a way to reflect the choice and decision of owners” and “the owner should choose a person they trust to get the proxy in order to make a decision for them” [Day 20/125/25 - 126/23]. The holding of proxies by an individual is not, of itself, a contravention of the BMO. Where allegations of criminal conduct in the obtaining of proxies arise, and specific information is provided, the appropriate course is referral to the enforcement authorities [Day 20/126/13-23; Day 20/128/21-25].

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Following this EGM, TPDO received 9 complaints touching on the manner by

which Prestige was selected as contractor, questioning the validity of proxies collected for the meeting 485 [WS1/510]. TPDO replied to complainants and followed up by referring and relaying the complaints and requests to the MC. A further 8 complaints questioned Prestige’s qualifications and suitability for appointment, carrying concerns over the validity of its licences and its previous conviction records; 4 of the 8 complaints were also lodged directly with the BD and URA by the complainants themselves486 [WS1/510].

TPDO was not aware of Prestige’s prior disciplinary record on the day of the 28 January 2024 meeting [Day 20/103/5-8]. The evidence demonstrates that, at the time the contractor appointment decision was made, the HAD’s representatives had no information before them indicating that Prestige’s record raised concerns.

(iv) The stage of contract finalisation and execution

TPDO received no complaints relating to works quality, cost escalation, supervision adequacy, and fire safety during works. TPDO did not have any other knowledge of these issues487 [WS1/512].

TPDO was aware that the renovation commenced in July 2024 with scaffolding constructed. As no BMO irregularity was involved or observed, no action by the HAD was taken488 [WS1/512]. This is a consequence of the HAD’s facilitative mandate.

TPDO was aware of the lack of an on-site works supervisor through three resident letters issued to the MC which were copied to TPDO among other departments.

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TPDO relayed the letters to the PMC for necessary follow-up actions and

provided substantive reply to the complainant489 [WS1/513]. This referral and reply is consistent with the HAD’s complaint-handling mechanism: for complaints not within the BMO’s purview, the HAD confirms receipt, refers to the relevant body, and replies substantively to the complainant.

(v) The stage of re-election of the MC up to the fire

In February 2024, the then MC Chairman Tang was requested by not less than 5% of the owners to convene an owners’ meeting. TPDO received complaints against Tang for failing to respond to the request within 14 days as required by paragraph 1(2) of Schedule 3 to the BMO.

TPDO issued 4 advisory letters to Tang [G1-1/1312-1321] and also verbally contacted him, reminding him to undertake his duties in accordance with the relevant BMO provisions 490 [WS1/511]. Or Wai Yin confirmed that if the chairman refused to hold a meeting, as a matter of practice there was nothing the HAD could do beyond issuing advisory letters [Day 20/105/5-12]. The first February 2024 request was ultimately withdrawn by the convener [Day 24/11/17-19; Day 20/117/24-25].

On 5 July 2024, Tang was again requested by not less than 5% of the owners to convene an owners’ meeting, this time seeking to re-elect the MC and extend the payment schedule. TPDO maintained close liaison with Tang, issued another 4 advisory letters, and also verbally contacted him to remind him of his duties under the BMO 491 [WS1/511]. Or Wai Yin confirmed that the tone of the letters escalated: the 29 July 2024 letter [G1-1/1319-1320] was “more detailed” and the “tone is sterner” [Day 20/105/13 - 106/2]. When Tang expressed difficulty

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finding a venue that could accommodate the large number of owners, TPDO

coordinated and facilitated the rental of the hall of CCC Fung Leung Kit Memorial Secondary School, located adjacent to WFC, for the owners’ meeting scheduled for 6 September 2024492 [WS1/511; Day 20/107/5-8].

At the 6 September 2024 EGM, 1,243 owners attended in person and by proxy [Day 20/107/9-12]. The HAD’s involvement was active and constructive. Or Wai Yin found that a significant number of owners were still queuing to register at the scheduled start time and suggested delaying the start to allow more owners to complete registration [Day 20/116/16-25]. She further suggested that a live broadcast to the outdoor playground be arranged so that owners who could not be accommodated inside the hall could participate [Day 20/116-117].

During the meeting, Tang sought to adjourn the proceedings and left the venue. The HAD representative intervened: she clarified that the decision to adjourn rested with the owners present at the meeting, and advised the owners of their rights under paragraph 3(1) of Schedule 3 to the BMO, which allowed them to appoint a substitute presiding person from among themselves if the chairman left the meeting493 [WS1/505; Day 20/113/2-12]. The meeting continued under a substitute presiding person, and the remaining items on the agenda were dealt with. The result of the meeting was that a majority voted in favour of dissolving the OC and the owners voted on, inter alia, the composition and membership of new MC [G1-1/1045-1046].

The Government submits that the HAD’s intervention at the 6 September 2024 EGM demonstrates that the HAD did not passively observe even the most difficult situations. When the chairman abandoned the meeting in a manner that would have frustrated the owners’ statutory right to have their agenda items

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considered, the HAD representative acted promptly to ensure owners were

informed of the procedural mechanism available to them. This intervention was entirely consistent with the facilitative role: advising on BMO procedure, maintaining impartiality between camps, and ensuring owners could exercise their statutory rights. The HAD did not take a side on the substance of any resolution; it ensured that the meeting could lawfully continue.

U3. Systemic and/or operational weaknesses on the regulatory level

The HAD’s mandate under the BMO does not extend to supervising construction works, materials, or fire safety. Its jurisdiction is confined to building management procedures under the BMO. As Chan Hau Man confirmed: “When it comes to building management, it’s the rights and obligations of every owner. As to what choices they make, say, in the case of major renovation, the selection of contractors and details of the works, that would be the decision of owners” [Day 20/122/22 – 123/6].

A central area as a matter of policy design identified in the evidence is the HAD’s lack of statutory power to compel the OC chairman to convene a meeting. DD Te confirmed: “According to existing regulations, it’s true that the OC chairman has the power to convene a meeting. Owners, if the OC chairman does not convene meeting, can apply to the Lands Tribunal. That’s the design of the existing legislation” [Day 24/12/15-25]. In the WFC context, this resulted in 8 advisory letters being issued to Tang across two petition cycles without producing the required EGM within the statutory timeframe. The consequence for the owners was a protracted period during which concerns about the renovation could not be formally raised or resolved through the owners’ meeting mechanism.

A further area for improvement is that the BMO complaint-handling mechanism relies on the HAD identifying BMO-specific issues and referring others to the

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appropriate department. Where complaints crossed jurisdictional lines, the

referral mechanism operated but was not always accompanied by proactive follow-up to ensure the receiving department had in fact taken substantive action. The Government acknowledges that, with the benefit of hindsight, more robust follow-through on inter-departmental referrals would have been desirable in a case of this complexity.

The Government also acknowledges that in one instance, Or Wai Yin was unable to open the audio files [G1/841-842] but she neither informed the complainant of this difficulty nor sought an alternative format [Day 20/111/10-19]. The appropriate course, had the recordings been accessible, would have been to follow up on the complaint. In any event, Chan Hau Man of the HAD confirmed that complaints involving allegations of unlawful conduct (such as fraudulent obtaining of proxy instruments) would be referred to law enforcement agencies rather than handled by the District Office itself [Day 20/128/21 – 129/1].

The Government accepts that this ought to have been followed up. The singular lapse should, however, also be viewed in its proper context. TPDO handled 44 relevant complaints in respect of WFC [Day 24/8/8-17], issued 8 advisory letters across two petition cycles, attended multiple owners’ meetings, facilitated the venue and live broadcast arrangements for the 6 September 2024 EGM, and intervened actively when the chairman abandoned that meeting. This was an isolated omission within an otherwise active pattern of engagement, and should not be treated as representative of the HAD’s overall handling of the matter.

Overall, as DD Te acknowledged in oral evidence, in the specific context of largescale renovation work, the powers conferred on the SHYA under the current BMO regime were not adequate to address the difficulties encountered by owners arising from such works [Day 24/25/2]. The HAD lacked a mandate to intervene

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in the substance of owners’ decisions, whether as to the choice of contractor, the

assessment of works quality, or the evaluation of professional advice. These were matters for the owners themselves, assisted by the professionals they engaged.

As the Chairman observed, “I think it is a long-lasting and complex problem. Since it is a private property, that’s why I can understand the position of the government. It is hard for government to make the decision on their behalf” [Day 24/29/24 – 30/3]. The Chairman further observed that “the residents do not have such subject knowledge. That’s why when they participate in the process, it will be very difficult” [Day 24/30/11–14] and identified the need for “more consultation or assistance so that they can understand better before they make the decision” [Day 24/31/6–9].

The Government respectfully agrees with these observations and submits that they identify the core challenge that the post-fire reform measures are designed to address: how to provide meaningful support and safeguards for owners facing complex decisions about large-scale renovation without overriding the foundational principle of private ownership and owners’ right to determine their own building management affairs.

It was also observed by Member Chan that the OC system itself may be structurally incapable of handling large-scale renovation and suggested greater reliance on property management companies, noting: “If the property management companies are treating the OC as an IO, it will be very different because the owners do not have to share this kind of legal responsibilities” [Day 24/32-35]. The Government notes this observation and submits that it reinforces the case for the reform measures described below, which include enhanced roles and accountability for licensed PMCs in the process.

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Turning now to the improvements already and to be introduced, and further

studies to be conducted, the Building Management (Amendment) Ordinance 2024, which came into effect in July 2025, represents a significant legislative advance in addressing the vulnerabilities exposed by the WFC experience. The Amendment Ordinance introduces defined categories for high-value procurement (Type 1, Type 2, and large-scale maintenance procurements) with corresponding tendering and declaration of interests and connections requirements. For largescale maintenance procurement specifically, the Amendment Ordinance introduces a new “voting-in-person” threshold requiring that at least 5% of owners or 100 owners (whichever is less) cast their vote personally at the meeting494 [WS1/493; Day 24/38/22-39/15] [G5/2742]. This aims to encourage more owners to personally participate in owners’ meetings concerning large-scale maintenance procurement, thereby strengthening the protection of owners’ rights.

The HAD has further announced five further amendment directions for the BMO, which have been the subject of consultation with the Legislative Council Panel on Home Affairs, Culture and Sports in February 2026 [G5/2738-2757]. These proposed amendments are as follows.

1. First, in relation to decisions on large-scale maintenance works and high-value procurement, the HAD proposes to impose higher attendance requirements and voting thresholds. For Type 2 high-value procurement, it is proposed to impose a “voting-in-person” threshold requiring 5% of the owners or 100 owners (whichever is the lesser) to attend and vote in person. For large-scale maintenance procurement, it is proposed to introduce a tiered system for quorum and voting-in-person thresholds, with projects of higher per-owner cost attracting correspondingly higher thresholds. To align with the features of the enhanced Smart Tender of the URA,

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corresponding amendments would be made to the procurement-related

provisions of the BMO to allow exemptions for projects for which the URA conducts tenders on behalf of owners. It is further proposed that a briefing session shall be convened seven days prior to the owners’ meeting for the large-scale maintenance procurement resolution, allowing owners to fully understand the details of the project [G5/2742-2743].

2. Second, in relation to proxy instruments, the HAD proposes enhancing transparency through the following initiatives: imposing a ceiling on the number of proxy instruments a person may hold (for buildings with 50 or fewer units, a person may obtain only one proxy instrument; for buildings with more than 50 units, the number shall not exceed 2% of the total number of owners or 20 instruments, whichever is the lesser); requiring the public display within the building of a list of units whose owners have signed proxy instruments, with all instruments made available for inspection by owners prior to and at the owners’ meetings concerned; adding a section to the relevant proxy instruments for meetings concerning large-scale maintenance procurement to allow owners to voluntarily specify their voting instructions to their proxies; and adding a “declaration” section to the form of proxy instrument to explicitly require the owner to confirm that the meeting agenda has been noted and clearly state that making a false instrument constitutes a criminal offence and the associated penalties [G5/2743] .

3. Third, in relation to declaration of interests, the HAD proposes that OCs be required to provide the works consultants and the contractors with designated declaration forms to disclose any conflict of interest between the two parties, with such declarations to be made publicly available to all owners. In cases where the declaration is refused, such refusal must also be

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disclosed to the owners. Any false declaration shall constitute a criminal

offence [G5/2744].

4. Fourth, in relation to meeting procedures, the HAD proposes to clarify the arrangements for convening owners’ meetings, agenda setting, cancelling, postponing or suspending meetings. Specifically: where the Chairman of the MC refuses to convene an owners’ meeting at the request of 5% of the owners, it is proposed to empower 10% of owners to apply to the SHYA for the appointment of a specified person (e.g. an owner, a licensed PMC or a PMP) to convene the meeting on their behalf; the Chairman would be prohibited from making changes to the issued agenda without reasonable cause; if the Chairman cancels a meeting without reasonable grounds, 10% of owners may apply to the SHYA for the appointment of a specified person to reschedule and chair the meeting; unless there are reasonable grounds, the Chairman cannot alone decide to postpone or suspend a meeting after it has commenced, with any such decision to be put to a vote by the owners present; and in the event of handling an emergency, the notice period for convening an MC meeting or owners’ meeting may be shortened to at least 3 hours or 12 hours respectively [G5/2744-2745].

5. Fifth, in relation to the powers of the SHYA, it is proposed that in special circumstances where the MC cannot function normally or fails to handle the affairs of the OC (e.g. when all positions in the MC are vacant, or when all MC members cannot be contacted within a reasonable period), the SHYA should be granted powers to intervene and provide assistance. For example, upon application by 10% of the owners, the SHYA would have the power to appoint a specified person to assist in convening an owners' meeting to dissolve the current MC and re-elect a new MC. In

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conjunction with these proposals, a statutory appeal board (building

management) would be established; if owners object to the decision of the SHYA, they may lodge an appeal, and any decision rendered on appeal shall be final [G5/2745].

The Government consulted the Legislative Council Panel on Home Affairs, Culture and Sports on these proposed amendments in February 2026 and has commenced consultations with the property management sector. A public consultation is planned for mid-2026, which will include collecting district views through the Working Groups on Building Management under the District Councils [G5/2748]. The Government will strive to submit the amendment bill to the Legislative Council for scrutiny as soon as practicable, with a view to further strengthening the legal framework (Table of Improvement Measures, Item F2).

Of particular note is the proposal to empower the SHYA to direct a PMC to convene a meeting where the OC chairman refuses to do so. DD Te stated: “We proposed to empower the authority to, upon receipt of 5 per cent owners’ request, identify a property management committee to convene a meeting if the OC chairman is not willing to organise such a meeting. That’s the proposed way forward” [Day 24/13/1-20]. He emphasised that the SHYA would assist in convening the meeting but would not participate in the decision-making process.

The HAD is further committed to enhancing inter-departmental collaboration and leveraging its role in liaising closely with OCs. Subject to the agreement of other relevant departments and institutions involved in building repairs and maintenance, the HAD stands ready to participate in joint initiatives for largescale building maintenance and renovation works to facilitate communication and coordination between government departments and OCs on both regular and ad

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hoc bases495 [WS1/494]. DD Te confirmed his agreement with the Chairman’s

suggestion that the HAD consider taking the lead in coordinating different organs to offer assistance to residents: “I completely agree with the chairman. There are a lot of cases we need to follow up after the fire. We have been working with the Development Bureau, also the URA. I think we are also engaging Hong Kong Institute of Surveyors. As an industry body, I hope they can offer some comments about how the cases shall be handled” [Day 24/31/16-23].

The HAD’s directions for reform, addressing the proxy system, the voting-inperson threshold, the chairman’s meeting-convening power, and the interdepartmental coordination role, represent a considered and proportionate response to the systemic issues revealed by the WFC experience. The Government will respond positively and substantively to any further recommendations the Committee may make in this area, and respectfully invites the Committee to note that the legislative and administrative reform process is already substantially advanced.

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V. IMPROVEMENT MEASURES (RELEVANT TO TOR 2) PROPOSED BY THE GOVERNMENT AS A WHOLE

The systemic issues identified under ToR 2, encompassing bid-rigging, bribery, proxy manipulation, conflicts of interest and PMC failures in the building maintenance sector, require a coordinated, multi-agency response. The Government has already taken concrete steps across these domains, and further measures are in progress.

In the area of tendering and procurement reform, DEVB, in collaboration with the URA, is preparing to launch an enhanced version of Smart Tender to assist OCs and owners in engaging consultants and contractors from pre-qualified lists to be established. A total of $300 million has been allocated to the URA for this purpose. The enhanced Smart Tender will incorporate more rigorous prequalified lists requiring consultants and contractors to pass background checks by the Police and ICAC before being eligible to participate in tendering; URA oversight of the tendering and tender evaluation processes; and, for buildings applying for government maintenance subsidies, URA will require consultants and contractors to report at critical project junctures so that URA may offer independent advice to owners. The Government aims to roll out the enhanced Smart Tender in the fourth quarter of 2026. In addition, DEVB is reviewing how to strengthen oversight of the performance of inspection consultants, supervision consultants, and contractors through legislative and administrative measures (Table of Improvement Measures, Item F1).

In the area of building management legislation, the Home and Youth Affairs Bureau is taking forward the next phase of amendments to the BMO. The five proposed amendment directions cover: raising the quorum and voting thresholds for decisions on large-scale maintenance works and high-value procurement; enhancing the handling of proxy instruments; enhancing the declaration of

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interests mechanism; clarifying meeting procedures; and enhancing the powers

of the SHYA. The Government consulted the Legislative Council Panel on Home Affairs, Culture and Sports on the proposed amendments in February 2026 and has commenced consultations with the property management sector. A public consultation is planned for mid-2026, which will include collecting district views through the Working Groups on Building Management under the District Councils (Table of Improvement Measures, Item F2).

In the area of competition law enforcement, as mentioned above, the Competition Commission has completed preparing an enhanced version of the NCCs for procurers to incorporate into their tender documents and procurement contracts. The enhanced NCC includes adding a clause explicitly stating that violating the NCC may constitute a criminal offence, and introducing additional terms requiring bidders to make a Statutory Declaration affirming the warranties within the NCC. The enhanced NCC is expected to launch soon Moreover, the Commerce and Economic Development Bureau is working closely with the Competition Commission to review the Competition Ordinance from multiple perspectives and consider the need for legislative amendments, taking into account the implementation of the Ordinance to date and the experiences of other jurisdictions, with a view to strengthening deterrence against anti-competitive conduct (Table of Improvement Measures, Item G4).

In the area of strengthening the regulation and supervision of building professionals, the DEVB and BD are further reviewing the BO to strengthen the registration and disciplinary systems for contractors. Proposals include strengthening the causes for disciplinary actions and the factors for considering registration renewal for registered building professionals and contractors, and clarifying the duties of building inspection and works supervision under the existing large-scale repair works regime with a view to breaking the chain of

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interests between inspection consultants and contractors (Table of Improvement

Measures, Item B2(iii)-(iv)).

In the area of industry practice and good governance, the Construction Industry Council is currently reviewing the practices and operations of the large-scale building maintenance industry, including its subcontracting system. The objective is to review and enhance the conduct and integrity of the sector, as well as to strengthen safety awareness and training for both management personnel and frontline workers. The Construction Industry Council is formulating a set of Good Practice Guidelines for the large-scale building maintenance industry, which will include recommendations on the subcontracting of such works to promote the healthy development of the construction industry. The Guidelines are expected to be promulgated within 2026 (Table of Improvement Measures, Item G3).

These improvement measures aim at addressing the structural conditions that permitted organised syndicates to infiltrate the building maintenance procurement process, while preserving the foundational principle that building management decisions are ultimately for the owners to make. The Government will continue to review and act robustly on further measures to address the problems identified by the Committee in due course.

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PART V: ENDING REMARKS

W. ENDING REMARKS

168 lives were lost. SFn Ho gave his life in the service of others. Thousands of residents were displaced from their homes. The scale of this incident weighs upon the Government as well as the community it serves.

The evidence before the Committee establishes that the professionals and contractors primarily entrusted with the safety and quality of the WFC renovation works abused the mechanisms designed to protect the public, betrayed the trust and expectations that the Government and regulatory framework placed in them, and through their deliberate wrongdoings and gross negligence caused the fire that took 168 lives.

In the meantime, the Government readily acknowledges the systemic and operational weaknesses in its own supervisory framework that permitted the abuse by those bearing primary responsibilities to go undetected.

Thus, since the fire, the Government has responded swiftly in reviewing the measures and practice in a number of crucial areas and took the initiative to introduce improvement measures to address immediately safety concerns. These improvement measures are set out in Section R4 above (and detailed in the table filed for the Government on 15 June 2026). They represent significant changes to the supervisory architecture, the verification mechanisms, the inter-departmental coordination arrangements, the penalty regimes and the technological infrastructure through which the Government oversees building safety.

On top of the improvement measures already implemented or soon to be implemented, the Government is fully aware that, subject to the Committee’s recommendations to become available in due course, there will be further efforts

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made on reviewing and introducing improvement measures in the major policy

areas covering at least the MBIS, MWCS and establishment of concrete joint efforts in handling enquiries and complaints arising from or generally in connection with large-scale renovation works. The Government is committed to completing and implementing these reforms with the urgency that the expectations of the public demand.

The Government respectfully invites the Committee to make such findings and recommendations on the path forward as it considers appropriate in light of the evidence. The Government pledges to respond positively, substantively and expeditiously to those recommendations, and to ensure that the system is made resilient against the kind of organised abuse that resulted in this fire.

Dated 7 July 2026.

Jenkin Suen S.C.

Calvin Cheuk S.C.

Michael Lok

Charlie Liu

Counsel for the Relevant Bureaux and Departments of the Government

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(政府结案陈词).md