Expert testimony on communication system failures during the Grenfell Tower fire, examining radio equipment, policy failures, and inadequate preparedness for high-rise incidents.
00:26:12 would you ask professor johnson to come back in please
00:26:27 all right johnson very good thank you thank you thank you when you're ready mr millet
00:26:32 millet yes mr chairman thank you uh professor johnson welcome back i'd like now to turn to a different topic if i may namely how fire and rescue services can prepare for and mitigate communications problems in high-rise buildings
00:26:45 problems in high-rise buildings and i'd like to start that topic with radio repeaters and leaky feeders we've already looked at that technology in the context of enhancing propagation of signals
00:26:56 of signals if we go next to paragraph 7.1.1 on page 173 of your report we'll pick up what you say about gra 3.2 there do you quote from it
00:27:08 there do you quote from it whether a communications difficulty specialist equipment such as leaky feeder radio cable airwave radios or repeater equipment can be used and the incident commander should also consider the use of internal or mobile telephones
00:27:20 the use of internal or mobile telephones public address systems or loud hailers to communicate with building occupants and the citation from footnate 349 which you don't have on your screen is gra 3.2 page 33
00:27:34 is gra 3.2 page 33 now you go on i think to identify in the paragraphs of your report which follow that there are limitations to how effective leaky feeders can be we've already covered quite a few of them this morning so i think i can take
00:27:45 them this morning so i think i can take them quickly first am i right um one of the limitations is they are typically effective only within line of sight yes second the need to amplify their signal propagation resulting in the need to lay
00:27:57 propagation resulting in the need to lay a number of repeaters yes every 200 meters i think yes if you look at policy 700 um thirdly the possibility that there will be they'll be a victim of their own success by as you told us earlier increasing congestion because
00:28:09 earlier increasing congestion because more people want to use it that's correct
00:28:11 correct now to what extent do those limitations that we've just enumerated apply to fit to fix leaky feeders or radio repeaters
00:28:20 most of the arguments will continue to remain for fixed leaky feeders however obviously some of the inconvenience with the installation um
00:28:31 um will not be so apparent because the cables etc can be uh appropriately cited
00:28:39 i think there are several other issues though within that context that i've mentioned before that the mobile repeaters are likely to be more resilient to damage to the building because they can be deployed with
00:28:50 because they can be deployed with with any
00:28:51 with any damage ongoing taken into account so again there are benefits and also concerns now if we go to page 189 of the report please section 7.9.1
00:29:03 report please section 7.9.1 you quote here at length from the evidence of former commissioner ron dobson to the latino house inquest yes and the transcript there at
00:29:14 inquest yes and the transcript there at 189
00:29:15 189 of your report is something we looked at with um
00:29:20 um assistant commissioner gary reason when he came to give evidence but let's just look at it a little bit more closely again
00:29:26 again if you go to page 190 in the final line of this page what he says is it would not be the incident commander's first choice we could turn the page to use leaky
00:29:38 we could turn the page to use leaky feeders in a scenario such as lachinol because they would firstly they would divert attention from other priority tasks to lay the cable out but more importantly they would institute it would represent a further hazard in the
00:29:49 would represent a further hazard in the stairwell where they have to lay the cable up so it would not be the incident commander's preference but it would be a piece of equipment that would be available to them i think you agree
00:30:00 i think you agree that he's right about the practical limitations identified there as we've just discussed very much so and if we go on then to your report at page 197 if we can look at section 7.13.1
00:30:13 section 7.13.1 you
00:30:14 you say there
00:30:16 say there that i think you consider the substantial size and weight of the equipment to be another practical limitation on its use yes i'm summarizing but is that that's your view is it yes yes
00:30:27 is it yes yes do you know how heavy this equipment is i don't but i'm taking this directly from the evidence as presented to the inquiry
00:30:33 inquiry yes do you know do you know whether you could lay or use leaky feeders in a stairway full of smoke i think full of smoke smoke logged i think there are several issues around
00:30:44 think there are several issues around that again because obviously with a single stairwell you have ingress and egress
00:30:49 egress occurring at the same time as you might be trying to lay the leaky feeders and so i think it's a significant decision to deploy them and as suggested in
00:31:00 in commissioner dobson's evidence it would not necessarily be the first thing that you would think of doing that would be um
00:31:08 um aggravated uh by the fact that a particular stairwell was the sole means of escape very much so and would it also be aggravated in addition by the fact that they might at some stage of the
00:31:19 that they might at some stage of the incident be water gushing down it yes uh might that affect the electrics yes now you've given consideration at page 189 of your report if we can go back to that please to the findings of the 7-7
00:31:32 that please to the findings of the 7-7 committee
00:31:33 committee and if we look at 784
00:31:37 784 section 7.8.4 in the middle of that page you say this the 7-7 committee argued that the deployment of mobile leaky feeders was a quote interim backup stroke solution and quotes unlikely to
00:31:48 stroke solution and quotes unlikely to help in the critical first hours of an emergency
00:31:52 emergency close quotes and that's a quotation uh from the london assembly's report of the 7th of july um review committee at page 22. um you go you you go on i think to say these
00:32:04 go you you go on i think to say these warnings do not seem to have informed frs policy advocating the use of this technology as a primary means of restoring incident ground communication and you give the example we've cited
00:32:15 and you give the example we've cited already from which was gra 3.2 itself do you agree or do you disagree with the opinion that leaky feeders are unlikely to help in the critical first hours of an emergency
00:32:29 i agree i also feel that my concern would have been mitigated if more personnel had had experience of using them and deploying them and
00:32:41 and um
00:32:44 that there were more examples of their successful deployment in operational practice than i could find in the evidence presented to me right and can you just explain briefly why you agree that in the early hours the first
00:32:56 that in the early hours the first critical hours of the incident use of leaky feeders would not be uh unlike would be unlikely to help if i go back to commissioner dobson's point that they
00:33:08 that they would not be the first solution if you like for an instant commander i think that what he's alluding to there is that there would have to be significant and sustained communication problems before
00:33:19 sustained communication problems before somebody felt that the effort was worthwhile and also the point that we noted earlier about other operational priorities um taking precedent over the deployment of of the leaky
00:33:32 over the deployment of of the leaky feeders
00:33:33 feeders so this is a this is not a technical objection
00:33:37 objection in
00:33:38 in the sense of functionality of the equipment itself as opposed to operational considerations about the effort and timing of deployment
00:33:49 effort and timing of deployment i think those two things are very closely entwined because the the the argument for using them has to be made on experience of communication failures however i felt i feel that if
00:34:01 failures however i felt i feel that if um
00:34:03 um if sufficient pre pre-inspections had been done then that might encourage the use of their deployment at an earlier stage however that does not also invalidate
00:34:14 however that does not also invalidate the argument that other more immediate concerns such as following up fsg and other other priorities would maybe take importance um over the deployment of leaky feeders
00:34:26 um over the deployment of leaky feeders and i
00:34:27 and i i think
00:34:28 i think as i said before it's it's complicated in the sense of if you only have a num a small number of people trained to deploy them for example the extended duration teams
00:34:40 teams um
00:34:41 um it you may make an operational decision that
00:34:43 that that uses them in other ways than deployment of leaky feeders so
00:34:50 so in principle technically i agree with you that that does not prevent their early deployment however the evidence that i've seen from their operational use and all of the arguments i presented there i think
00:35:03 i presented there i think convince me that it's a significant step and normally they are only deployed after a
00:35:08 after a sustained communication failure now you go on in the paragraph to say that the warnings don't seem to have informed frs policy advocating the use of this technology as a primary means of
00:35:19 of this technology as a primary means of restoring incident ground communications are you saying that fire and rescue services such as the lfb ignored the warning from the 77 review committee i think that the warning that the 77
00:35:32 i think that the warning that the 77 committee issues in their report argues against the overconfidence in the ability to deploy leaky feeders as a way of mitigating communication communication problems and i would have
00:35:43 communication problems and i would have liked to have seen a more sustained argument in any of the policies advocating their use about why these problems identified by seven seven do you criticize gra 3.2 itself which of course was the national guidance well i
00:35:55 course was the national guidance well i think gra 3.2 isn't isn't is not it is correct it's going to use a double negative there is correct in the sense that it advocates the use of a range of alternate communication means but those
00:36:07 alternate communication means but those communication means as we've discussed very enormously in terms of their operational ability to be used so mobile telephones are useful in certain situations but probably not very useful in
00:36:18 probably not very useful in the operational situation where people are using breathing apparatus etc now page 34 if we of your report if we can go back to that uh you'll see that on that page you have
00:36:29 uh you'll see that on that page you have section 220.2 with the sub this is within it and there's a subparagraph four at the foot of the screen adopt layered fullback arrangements and then you have a
00:36:40 arrangements and then you have a quotation
00:36:44 and after that it says the lfps fallback mechanisms failed to provide the intended levels of resilience at the grenfell tower fire in particular the failure to to correctly deploy radio repeaters and leaky feeders eliminated a
00:36:56 repeaters and leaky feeders eliminated a key fallback arrangement why do you describe leaky feeders there as a key fullback arrangement for the lfb
00:37:06 lfb i think that aligns well with your previous points in that um
00:37:11 um if
00:37:12 if given all the caveats that we've raised about the problem the physical problems of deploying them um it's only the case i think that they would be used if sustained communication failures were
00:37:24 sustained communication failures were experienced
00:37:27 and as we'll presumably discuss shortly voice repeaters were not [Music]
00:37:34 [Music] deployed um and
00:37:38 and and therefore that ability to to improve the communication infrastructure through the use of this technology was not available to those who had to fight the fire and rescue the the occupants of the building
00:37:49 building now if we go to page 57 of your report let's look at section 4.3.9
00:37:56 um which runs over two pages to page 58 you set out there the clg and the cfra's national operational guidance or nog
00:38:08 national operational guidance or nog document entitled breathing apparatus and if you go to page 58 of the second paragraph on that page please you'll see that it says
00:38:20 that it says ba wearers and ba control operatives should be aware of the potential for limited penetration of radio signals into buildings and structures below ground and either make other arrangements or
00:38:31 and either make other arrangements or put contingencies in place to ensure the safety and effectiveness of communications with ba teams and if you go to page 58 at the bottom the next
00:38:41 the next paragraph but one down paragraph 4.3.11 you say you've seen no evidence that that guidance informed policy or resulted in any action specific actions why is it that you don't consider leaky feeders and radio repeaters to fall into
00:38:53 feeders and radio repeaters to fall into the category of other arrangements or contingencies
00:39:00 i i think there are a number of points i would make i i think that um
00:39:13 i think it was so from reading the witness statements i feel that there was great confusion about these contingencies if we viewed them as a contingency
00:39:24 them as a contingency and
00:39:25 and um
00:39:27 my feeling was that that [Music]
00:39:34 i don't think that sufficient arrangements had put in place to ensure that those contingencies were effective i have a couple of other related
00:39:42 related very short points on in this which is that um
00:39:46 that um we have to remember that intrinsic safety
00:39:49 safety is used in environments of where where flammable or explosive substances may be found
00:39:56 found and at the same time the other
00:39:59 the other area apart from high rises in which leaky feeders are recommended is in the use of tunnels however as we discussed this morning leaky feeders as they are as we as we've seen them at ciu's now are not
00:40:10 seen them at ciu's now are not intrinsically safe so that raises the question about if it were another scenario rather than a high rise but a tunnel incident how would you maintain communication with leaky feeders which violate the intrinsic safety requirements and this is another
00:40:22 safety requirements and this is another example of that kind of more detailed system level thinking about what dangers might face future communication that if you like to to me
00:40:33 communication that if you like to to me also speaks to the point that you've just made not just about high rises but also structures below ground as is referred to in that quotation now looking at page 190 of the report please if we can skip to
00:40:44 of the report please if we can skip to that and look at section 7.9.3 you
00:40:50 explain your view and you say it is unclear what measures the lfe put in place to mitigate the risks associated with or to enhance the efficacy of deploying leaky feeders and
00:41:01 efficacy of deploying leaky feeders and radio repeaters in high-rise buildings what sort of measures might you expect a fire and rescue service to consider i would
00:41:10 i would just
00:41:10 just at the very simplest level how to deal with the trip hazards that could be incurred when trying to install this equipment and how to coordinate it with the other activities through a single stairwell
00:41:22 stairwell i mean that might seem very trivial but that that's about installation and deployment which is in which is entirely physical but what about the
00:41:33 but what about the electronic or functional technical efficacy i think as we discussed this morning um the with the line of sight characteristics of leaky feeders and the
00:41:45 of leaky feeders and the and the construction of high-rise buildings as you asked me this morning about the topology and how far would the signal reach out of the stairwells i mean again i found no no evidence base
00:41:57 mean again i found no no evidence base on which to place faith that leaky feeders would restore the communications problems
00:42:02 problems in the majority of high-rise buildings that might be found in london absolutely but what i'm really trying to get at is is whether you can tell us what sort of mitigation measures you would expect a
00:42:14 mitigation measures you would expect a fire firearm rescue service as of june 2017 to have considered where the lfb did not well i would have considered i have not found any detailed evidence about how to
00:42:25 found any detailed evidence about how to mitigate things like the drip hazards and how to coordinate them with the other uses of a stairwell just very simple functional requirements about how to how to reduce the risks to residents being evacuated and firefighters
00:42:36 being evacuated and firefighters ingressing into the building right but you're the risk associated with the efficacy of deploying leaky leaders and radio repeaters in high-rise buildings isn't limited to trip hazards it's also i think as we explained earlier you
00:42:47 i think as we explained earlier you explained earlier um to do with the technical efficacy such as the inability to penetrate concrete or steel absolutely and what so what sort of mitigation measures would you have expected lfe reasonably to have put in place to to have uh overcome those
00:43:00 place to to have uh overcome those problems well there it's possible to have additional repeaters that branch at different floors and so there are technical measures that could have been put in place to um
00:43:11 put in place to um to create more elaborate structures if needed within high-rise uh buildings but again the installation of more cables and more repeaters diverts staff for longer from
00:43:22 repeaters diverts staff for longer from those other activities and so forth so it's it's to me it's
00:43:28 it's this policy is put in place but i i would really love to see more evidence about the benefits associated with leaky feeders in terms of their communication versus the costs of to in terms of operational outcomes
00:43:41 of to in terms of operational outcomes through the installation of additional equipment it would be easy to sit here and say we can address the communication problems by installing more elaborate architectures of communications but then if that has a significant increased risk
00:43:55 if that has a significant increased risk to put people in in confined spaces or has a negative effect in terms of the operational resources that we have available in other words if we divide everyone to doing this and not enough to
00:44:07 everyone to doing this and not enough to to answering the uh you know fsg calls etc i i think again
00:44:13 again there is a need to do that more detailed planning and risk assessment to to determine what is the best policy in the future going forward with an evidence base not
00:44:23 base not not based on on my subjective assessments now now part of your work professor was to demonstrate that the firefighters at grenfell tower inadvertently deployed telemetry repeaters rather than radio
00:44:34 telemetry repeaters rather than radio peters and that is why attempts on the night to use channel 2 could not have been successful um and i think you offer the view and this is a paragraph 7.14.4 on page 199
00:44:47 7.14.4 on page 199 that the confusion between radio repeaters and telemetry repeaters you say was indicative of the limited training in an exposure to the use of these communications aids
00:44:58 these communications aids you can see it there on the screen and you also say elsewhere i think and and this is two paragraphs earlier on page one one nine three that uh that only edba personnel had actually
00:45:09 uh that only edba personnel had actually been trained in the deployment of radio repeaters yes um first as a general question how how complex
00:45:16 complex if at all is the setup and operation of a leaky feeder and radio repeater i think with adequate training it it should not be complex at all and would you expect training to be given
00:45:27 you expect training to be given i see that it is being subsequently since
00:45:31 since since the fire yes um right but you know there are again issues in the sense that i can understand at one that one level why it may have
00:45:42 at one that one level why it may have been reserved to the edba whereas in the sense that if additional time in the building is spent laying the cables and putting the repeaters into place there may be additional risk in terms of the amount of time that that
00:45:53 in terms of the amount of time that that takes so
00:45:54 takes so it's not simply the connectivity it's the physical effort involved in taking the equipment to the to the level that you want to install it at and then safely navigating through the building
00:46:05 safely navigating through the building etc
00:46:08 looking a little bit more closely then at training can we go to page 83 and 84 was um both together uh of uh of your report at section 4.16
00:46:20 of your report at section 4.16 uh and under that's uh um
00:46:23 uh um underneath the rubric training reform following the latter house fire and you you say that following the latin house fire the lfb's training commissioning and alterations form the
00:46:34 commissioning and alterations form the use of authority issued radio communication equipment tcap 0-0-39 was drafted with the aim of creating a training package to cover the effective use of communications equipment but
00:46:45 use of communications equipment but operational incidents including both high-rise and sub-surface incidents and then you cite from some of the evidence there if we go then to tcat but that tcap form
00:46:58 if we go then to tcat but that tcap form zero zero three nine we see that at some lfb three zeros four one nine five eight
00:47:07 uh that's the first page if we go to page 11 in it we can see from the bullet point list that um computer-based training
00:47:15 training if you look at the bullet points uh computer-based training cbt was due to be provided on amongst other things operation of the radios airwave and uhf as well as the radio repeater equipment
00:47:27 as well as the radio repeater equipment wasn't it yes certainly to station-based operational stuff um yes now let's look at the packages which were developed which i think not but which were not released um can we go to lfb double zero one
00:47:38 um can we go to lfb double zero one double two eight four six this is a copy when it comes up there it is this is a copy of the station based radio equipment training package uploaded on the 14th of march
00:47:49 package uploaded on the 14th of march 2014
00:47:50 2014 and it will be familiar to those who are following assistant commissioner gary reason's evidence on day 182 when i put it to him and if we go to page two of this document we can see that there are four objectives of this
00:48:02 that there are four objectives of this session and i'll just show them to you list one list the range of radio equipment used operationally within the london fire brigade two describe the function of the radio equipment three select radio equipment is appropriate
00:48:15 select radio equipment is appropriate for use in operational scenarios four demonstrate the assembly and use of barry radio equipment and the package goes on to describe key items of communications equipment so we can go to page 14
00:48:27 can go to page 14 you can see that there's a an explanation of the battery set and the page 20 there's a description of a radio repeaters capability page 20 there and at page 21 we can see
00:48:40 there and at page 21 we can see there is
00:48:41 there is an explanation of what is available in the brigade about repeaters 17 uhf repeaters are available one on each cu
00:48:53 one on each cu but that's a total that is the totality of the guidance on repeaters
00:48:59 repeaters for completeness can i show you lfb double zero one double two eight four four
00:49:05 four which is the senior officer package released the follow the previous week the sixth of march 2014 and if we go to page three and that we can see the objectives of the package
00:49:17 can see the objectives of the package four bullet points describe the functions
00:49:20 functions and use of the analog handheld radio radio repeater in digital mainstream radio describe situations where interagency voice communications and procedures can be used and how it would be implemented identify and find solutions for radio
00:49:32 identify and find solutions for radio communication issues apply your knowledge of how radio equipment can be used to an exercise scenario
00:49:39 scenario if we jump ahead to page 23 this has a title large and complex buildings or underground structures may adversely affect radio uh communications
00:49:51 uh communications that's the text under the under the heading communication issues and solutions
00:49:55 solutions uh and as it's a rollover for the images so it's interactive but that is the totality of the guidance on the role that buildings such as high-rise buildings can have on communications
00:50:07 communications the slides themselves start on page 17 and there you can see um the functionality of the radio repeaters and leaky feeders and how to set them up but again that's the totality of the the
00:50:19 again that's the totality of the the guidance on repeaters i i've shown you both these programs now do you have any particular views about whether those training packages had they been rolled out
00:50:30 had they been rolled out would have adequately trained individuals uh to whom they were aimed in the setup and operation of this kind of equipment on their own they would not have prepared people to be able to
00:50:41 have prepared people to be able to deploy the equipment they would simply have alerted them to the to the presence of the equipment and i noticed that the um
00:50:49 um there's there's no distinction made clearly in the slides between a radio repeater and a telemetry repeater you say not on their own what else would you need in order if you were rolling
00:51:01 you need in order if you were rolling this out to have trained individuals sufficiently well in the setup and operation of this kind of equipment i think practical experience would have been essential
00:51:12 been essential when you say practical experience in the field or um or simulated in physical training
00:51:19 training i think it's clear to me that a mixture would be required so practicing skills in a in a simulated environment and then gradually introducing other operational complexities such as the as i ment as we
00:51:31 complexities such as the as i ment as we we both or all of us discussed the issue to the the point at which somebody would be confident to deploy them is an absolutely crucial question and how that interferes with other operational
00:51:42 interferes with other operational business
00:51:43 business and that's why i say both sorts of training if you train with the equipment in a controlled environment in a in an office or in a hall or outside in a training ground that's different from
00:51:55 a training ground that's different from the
00:51:56 the operational consequences of making the decision in a single stairwell with other hazards available now can we go back to page 24 of your report and look at section 2.9
00:52:09 section 2.9 uh
00:52:10 uh this is within that section on page 24 sub paragraph 14 you say extended duration breathing apparatus edba crews were trained to install leaky feeders however the lfb's
00:52:22 install leaky feeders however the lfb's operational focus on the night of the fire was on deploying as many of these teams into the tower as possible to facilitate rescues this may have delayed attempts to deploy repeaters and leaky feeders do you have any views about the
00:52:34 feeders do you have any views about the optimal time window in which this equipment
00:52:38 equipment should be deployed [Music]
00:52:42 i i think
00:52:46 there's an awful lot of ambiguity as it presently arises in the policies in terms of when would be appropriate to deploy them i i think that um when a certain number of units are called that
00:52:58 certain number of units are called that i don't know make five make ten whatever you would prefer to whatever could be justified in terms of risk assessment that an assumption might be made that there are so many people
00:53:08 people attending to that incident the communication is a top level priority
00:53:13 priority and so by default at a particular level you might decide that that's the time to install it or you would have a communications officer deployed who in turn assumed explicit responsibility through a checklist
00:53:26 responsibility through a checklist and
00:53:28 and you know at that at that point they would be responsible so in other words there would be a predetermined point at which
00:53:34 which it was decided to install it or not install it and that would be in a consistent way rather than leaving it totally at the discretion of a commander based on what's so you say to you that the timing of the
00:53:46 so you say to you that the timing of the deployment of leaky feeders and radio repeaters if you're going to use them is a function of the number of offices on the incident ground i i would suggest that that
00:53:59 i i think what worries me the most is that for the reasons presented by commissioner dobson that this would not be an attractive choice that there should be at some point a
00:54:10 that there should be at some point a documented decision that they've at least been considered and that that should in some way be related to the level of risk posed to both the firefighters and the occupants of the building however that may be
00:54:22 of the building however that may be determined yes i chose i chose that the the number of appliances as a proxy for that risk assessment because it's simpler and but i you know i think it would be that
00:54:34 but i you know i think it would be that that kind of decision would require operational input but i think the key thing
00:54:38 thing is to have consistency and to have a clear point at which or threshold at which
00:54:45 which the decision is taken to deploy them or not take or not or not deploy them [Music]
00:54:49 [Music] this is the kind of world i'm i'm familiar with in terms of aviation or the nuclear industry and so on where um there are checklists to be followed and those checklists can be triggered by different things
00:55:00 different things but that but at that point if the checklist is triggered you should follow a consistent set of procedures and it's not purely left up to the decision of a pilot as to improvise if you like what things are or
00:55:11 improvise if you like what things are or are not done at that point just to go back to the point about telemetry repeaters as opposed to radio repeaters
00:55:20 repeaters we looked at earlier where you said that the two got confused on the night inadvertently by firefighters we also saw that tcap0039 did not distinguish between
00:55:33 tcap0039 did not distinguish between radio repeaters and telemetry repeaters are you able to did well do you have a view about whether um
00:55:41 um there was something more than an an an incident-related confusion between the two did you in other words is it your view that the confusion between telemetry repeaters and radio repeaters
00:55:52 telemetry repeaters and radio repeaters might be more institutional yes i think there's there's ample evidence from the witnesses to this inquiry that people were often not familiar with the distinction and um i think that that i think it's
00:56:03 and um i think that that i think it's important
00:56:05 important there's a much more general point here about training in in the frs which is that
00:56:10 that um
00:56:11 um in my job somebody continually assesses the effectiveness of my education so my educational provision isn't determined by my own exams or the students taking those exams they're independent agencies
00:56:23 those exams they're independent agencies every year that come in and assess whether or not my university education meets national and international standards
00:56:31 standards and very much the impression i get from the training and the witnesses that have been to this inquiry is that the quality of the training is often dependent on the experience of individual fire officers
00:56:42 officers and also the external providers in some from the evidence i've seen are not exposed to the level of scrutiny that i would be even in a non-safety critical environment
00:56:53 environment so in the context of what you've seen and studied for the purposes of this inquiry you see inconsistent is this right you see inconsistency as a result of lack of standardization imposed from
00:57:04 of lack of standardization imposed from outside lack of independent monitoring of training and outcome based uh assessment of training so i think although we could focus on telemetry
00:57:15 although we could focus on telemetry repeaters and voice repeaters i think there are longer or rather deeper questions about the effectiveness of training so my my feeling about the question that you asked in terms of tcap and also in
00:57:27 you asked in terms of tcap and also in terms of the drills and exercises it is that and as i understand it typical training for a fire officer goes through a cycle and that they may only be exposed to a particular
00:57:38 be exposed to a particular piece of pedagogy for a short time and then if it's not used operationally for a long period of time they may then have lost that knowledge that they at one time had
00:57:48 time had and i would like more confidence as a member of the public that that's assessed and and the um the degradation of knowledge over time when it's not being practiced is is
00:57:59 time when it's not being practiced is is in some way uh assessed because simply saying that somebody's been through one of these procedures or or one of these exercises doesn't mean that they're capable of repeating that
00:58:10 repeating that throughout their their lifetime and their and their period of operation um indeed okay and can i then turn to a different topic which is section 72d
00:58:23 different topic which is section 72d and
00:58:24 and what i would call 72d visits with the caveat that the word visit does not appear in the section apologies it's about arrangements for obtaining information
00:58:36 arrangements for obtaining information for the statutory purpose contained in section 7.1 but uh
00:58:41 but uh now we look at that in your report at uh page seven uh page 96 at section five that's where it's um it's where
00:58:53 five that's where it's um it's where uh it starts um although it is it is of course in the context of opportunities for guidance training and site visits to mitigate technical and operational constraints on
00:59:04 technical and operational constraints on barrier sets and other radio communication equipment in grenfell tower so the context of this is uh mitigation but using what you call site visits yes now can we go to page one eight one zero two please section
00:59:17 one eight one zero two please section 5.3.4
00:59:19 5.3.4 on page 102. and you say there by reference to lfbs policy number 800 which is on the management of operational risk information you say in 5.3.4 it is remarkable how
00:59:33 you say in 5.3.4 it is remarkable how little of pn800 is devoted to potential communications concerns given their importance during the lachenal house fire
00:59:42 fire uh now policy 800 is the lfb policy entitled management of operational risk information isn't it yes yes and um you set out various excerpts from that
00:59:53 set out various excerpts from that policy within this section of your report in what ways do you consider in general that that guidance was deficient so far as concerns communications as i mentioned this morning
01:00:05 as i mentioned this morning i felt that the coroner outlined the communication difficulties that can arise with barrie sets and with other uh forms of communication in high-rise buildings
01:00:17 high-rise buildings and i felt that that combined with other national policy in this area and gr 3.2 is a good example created a situation where
01:00:28 created a situation where greater attention should have been paid to the potential for communication problems in high-rise buildings and
01:00:36 and i felt that the the practices that are described in the witness statements to this inquiry illustrate great inconsistency in terms of the level of care that was taken
01:00:49 of the level of care that was taken in considering issues of communication i should also have said which is the context of all of my evidence that i believe communication is essential as is made clear in national policy and not something
01:01:01 something um
01:01:02 um that should willingly at any time be sacrificed in an incident or any similar incident in the future now if you look at the foot of page 102 and look at footnote 188 this is the
01:01:13 and look at footnote 188 this is the most convenient place to find it but policy 800 was reviewed as current at 25th of august 2015 that some
01:01:22 that some two and a half years after the coroner's recommendations on the 28th of march 2013. uh
01:01:31 uh it just given the time lag
01:01:36 have you a view about whether or not uh sufficient attention was given by the lfb to the communications difficulties identified in the coroner's rule 43 reports i i don't think so i feel that
01:01:52 the opportunities to learn lessons from that incident were not taken up as enthusiastically as i would have i hope taken them up in that situation i feel that the coroner's comments on
01:02:05 i feel that the coroner's comments on channels
01:02:07 channels were dealt with and i and but i felt that the commissioner dobson's comments especially about leaky feeders and about the
01:02:17 the about the potential hazards and limitations from using them in a high-rise building um were
01:02:24 um were in my view not sufficiently reflected in the
01:02:29 72d assessments um
01:02:34 um and also
01:02:36 and also i'd reflect on the conversation that we had before lunch about the post site inspections and all the caveats that the lfb's own assessment teams made about the reliability of those inspections
01:02:49 reliability of those inspections and that again echoes the words of of commissioner dobson in evidence to the coroner who where he made exactly the same point about the reliability of any on-site inspections
01:03:00 on-site inspections of
01:03:00 of which involved to assess radio communications equipment so i think that there's a huge inconsistency or there's a huge difficulty in arguing that the lessons of that previous incident were learned
01:03:12 of that previous incident were learned and then reflected in the 72d visits in the 72d visits but in in the form in a policy 800. yes yes yes sorry i'm sorry well i i'm
01:03:24 yes yes yes sorry i'm sorry well i i'm correcting you through no you're being really careful and that's exactly right well
01:03:29 well let me be clear uh as to why i mean i tried to hint at it before but but often one hears of 72d in the context of inspections or visits which tend to indicate that it was a it was a visual
01:03:41 indicate that it was a it was a visual exercise yeah uh do you do you have a let me ask it this way if i can do you have a view about whether that's corr it is as narrow as that
01:03:51 that i i don't feel competent to comment on that because i i've only seen the evidence coming through from the inquiry so very well let's look at the policy then well let's look at
01:04:04 your report at page 105.
01:04:12 at section 5.3.11
01:04:16 11 you say gra 3.2 in turn inform the lfb's local policy for fighting high-rise fires notice policy number 633 high-rise firefighting
01:04:27 high-rise firefighting appendix 1 of policy number 633 entitled 72d acts as a guide when conducting visits in buildings over 18 meters in height or with six or more floors
01:04:39 now um let's look at uh at um 72d
01:04:45 at um 72d in that context you you go on i think later in this section of your report to say that the evidence in phase one demonstrates that not all section 2d visits were carried out in accordance with the guidance yes and the
01:04:57 with the guidance yes and the communications testing wasn't a routine part of a 72d visit even a visit is that a fair summary of your observations yes and if we go then
01:05:08 and if we go then with that um under our wing then to page 110 of your report let's look at section 5.4.4 and five you you say there
01:05:21 you you say there the top of the screen it's important to note that uh watch officer ricketts inspection focused on the quality of the communications using his personal radio and not the lower powered is devices integrated within the battery sets
01:05:33 integrated within the battery sets furthermore watch officer ricketts only used his radio to communicate from the basement to the ground floor straight base of the tower this is unlikely to have provided a proper understanding of the potential communications concerns
01:05:44 the potential communications concerns for signal propagation between higher and lower floors taking the first of those he tested his personal radio and not the lower powered barry set radio uh why did you consider that to be a significant of significance
01:05:56 that to be a significant of significance again for all the reasons that we've rehearsed this morning between intrinsically safe and non-intrinsically safe devices and secondly as you see he tested communications as between the basement and the ground floor or the
01:06:07 basement and the ground floor or the base of the tower why did why did you consider that to be a limitation on his testing
01:06:12 testing um again if i uh refer back to commissioner dobson's evidence to the previous inquiry he made it very clear that um the specific location even
01:06:23 that um the specific location even within a floor can provide you know
01:06:26 you know unreliable evidence as to communication across the remainder of that floor and then obviously as we described this morning um the higher you go into a building the more likely you are to get attenuation through the materials and
01:06:38 attenuation through the materials and other other factors leaving aside everything else that we've said about meteorology and fire and the congestion issues now if we go to page 112 of your report at section 7 section 5.7.3
01:06:52 you say the lack of systematic procedures within pn800 for testing communications concerns and blind spots during 72d visits makes them open to the issues that were raised by ron dobson
01:07:05 that were raised by ron dobson former commissioner of the lfb in statements to the national coroner cited in
01:07:09 in section 4.17.6 of my report and then you've set out some of the transcript there could you explain briefly what you mean by a lack of systematic procedures
01:07:21 by a lack of systematic procedures as i again said this morning i think there is a really significant learning opportunity here to identify certain types of structure for which the risk is sufficiently high to do a more detailed
01:07:33 sufficiently high to do a more detailed communications inspection it lies outside the scope of my report but one of the outcomes of that might be to argue in favor of a permanent form of repeater system or
01:07:45 permanent form of repeater system or other form of interrupt infrastructure mitigation as is the case with certain types of underground station
01:07:52 station [Music]
01:07:54 [Music] and
01:07:55 and this idea of a systematic procedure is that we have some agreed set of criteria for
01:08:02 for a building being likely to render significant communication problems in the event of a fire or similar incident taking place and that could be for reasons of
01:08:13 and that could be for reasons of construction it could be for reasons to do of the with the scale of the building or the volume of the building or the sensitivity of its content but again i come back to the evidence i presented this morning about the static
01:08:25 presented this morning about the static installed repeater systems within the world trade center and
01:08:30 and uh the benefits that they provided in one tower but not in the other even though the system functions so it's not a panacea but i do feel greater consistency especially
01:08:41 i do feel greater consistency especially in those buildings that are seen to pose greatest risk to the public or to firefighters would justify more detailed consideration and then if another threshold was reached then an argument about whether a permanent
01:08:52 argument about whether a permanent installation is necessary now we don't need to turn it up but at section 5.7.8 on page 114 of your report you i think recommend the adoption of
01:09:04 you i think recommend the adoption of validated test procedures for use during visits conducted pursuant to section 72d and when you say validated test procedures what can you explain what you mean
01:09:15 mean i
01:09:17 i um
01:09:19 i've tried to lay out where my areas of expertise lie i'm not an expert in the lower level physical properties of radio signals and so properly validated study would be by somebody with an appropriate
01:09:30 would be by somebody with an appropriate level of
01:09:32 level of qualification in those more physical aspects rather than the the safety related aspects that i'm more familiar with
01:09:39 with and then
01:09:40 and then um
01:09:42 um also supplemented by empirical evidence so not purely a theoretical analysis of building structure but um
01:09:51 but um taking the relevant equipment into a range of buildings around london to see whether they were actually realized obviously that won't be the same as in a fire for all the things that we've described or or another incident but it would give me
01:10:02 or another incident but it would give me greater confidence that the conclusions of of a pre-site visit were likely to prepare those people on the way to a visit for communications problems and then as you alluded to earlier a building that had
01:10:14 alluded to earlier a building that had gone through that form of assessment which didn't already have a pre-installed communication system might might be a strong case for the early deployment of a repeater
01:10:26 early deployment of a repeater as a prior as an operational priority rather than what we saw in in the case of the grenfell tower incident so does it come to this that you're advocating
01:10:38 advocating a a a standardized and validated form of test for all at least all high-rise buildings
01:10:46 buildings almost residential buildings uh where um or for the purposes of gathering information under section 72d yes and i'm very open to more detailed
01:10:57 yes and i'm very open to more detailed discussions with qualified people about other risk mitigations that might be there so for example if there were two easily easily traversed stairwells an argument might therefore be made that
01:11:10 argument might therefore be made that it would be easier to deploy repeaters and and uh leaky feeders in that situation where you have another one for ingress and egress but
01:11:19 but those that kind of that is the level of detail that i would like to see considered in buildings of sufficiently high risk
01:11:26 high risk and at the end of this this is to increase the confidence both the firefighters and the and of the residents yeah let me put it a slightly different way would i be right in thinking that in your view it's not enough to leave it to
01:11:37 your view it's not enough to leave it to individual fire and rescue services to adopt their own policies and training absolutely it needs to be a nationalised standardized test applied by all fire and rescue services in the
01:11:48 all fire and rescue services in the discharge of section 72d absolutely right i i
01:11:52 right i i strongly feel that that does not compromise the local identity of fire and rescue services with their local knowledge which i think is important but equally will give me and the public confidence
01:12:03 confidence when i enter a high-rise building in glasgow or belfast i have the same level of protection that i do in london
01:12:10 can i then turn to uh airwave radio again we looked a lot of it earlier and we discussed enhanced transmitting power and signal benefits
01:12:21 transmitting power and signal benefits don't think there's a need to turn it up but uh at section 8.9.1 at page 218 of your report you observe i think that on the night of the grenfell tower fire airwave appeared to provide better coverage than the uhf handheld radios
01:12:36 coverage than the uhf handheld radios and you also say that they were in short supply and a more flexible approach to communications might have anticipated such a requirement when you when you say a more flexible approach to communications what do you mean
01:12:49 communications what do you mean if we take a step back the airwave radios were intended in the in the frs to be used tactically and and rather than operationally and the reason for that was a perception
01:13:01 and the reason for that was a perception that
01:13:02 that well the home office requires that there's a responsible person who um if you like
01:13:08 you like accounts for every airwave device and the feeling was that if they were given out in an operational basis uh some of the devices would be potentially lost and enable others
01:13:19 lost and enable others unauthorized users to eavesdrop on that communication mechanism
01:13:25 mechanism and
01:13:30 while i understand the reasons for that argument at the time at which it was made i don't think that's sustainable anymore technically in the sense that it's relatively easy with more modern devices to be able to
01:13:43 with more modern devices to be able to block a device that's lost from access to the network and also a more flexible use might have been to have a pool of additional airway devices to supplement operational uses in large-scale incidents that to me
01:13:57 in large-scale incidents that to me under exceptional circumstances might have enhanced communication on the fire ground yes now can we go then to page 222 of your report
01:14:07 report and look at section 8.12.3
01:14:14 the text of your report there says airwave could have provided direct communication between the control room the command units of the bridgehead rather than using the chain of communications including
01:14:26 chain of communications including runners that were deployed on the night now
01:14:29 now as a background to that i think we we know that handheld airwave radios were restricted to senior officers namely those of rank of station manager and above weren't they yeah yes now looking at what you say
01:14:42 yeah yes now looking at what you say there in the text is it your suggestion uh or is your suggestion premised on command personnel having an airwave device or are you suggesting that a greater number of firefighters should
01:14:53 greater number of firefighters should have been issued with an airwave radio i think
01:14:58 i think as i
01:15:00 as i discussed with you previously about the cabinet office cabinet office advice on resilient communication where we were discussing layered fallback mechanisms in the context of
01:15:11 in the context of leaky feeders and repeaters i think that having the ability to use other forms of devices and communication infrastructure at a fire ground in
01:15:22 infrastructure at a fire ground in response to urgent need would have created that resilience that the cabinet office intends
01:15:29 are you suggesting that a greater number of firefighters should have had away radios yes i might be suggested yes yes thank you now um can we then turn the page to two to four please turn two
01:15:41 page to two to four please turn two pages to two to four section eight point twelve point six um and uh
01:15:47 um and uh there you say at the top of the screen it's remarkable to me that greater care was not taken by the lfb before and during the fire to ensure robust and resilient communications between the command units and the
01:15:59 between the command units and the bridgehead of major incidents uh
01:16:04 uh when you say um uh greater care there what are you referring to i
01:16:12 i um
01:16:13 um and i continue to be um
01:16:19 can i say surprised that runners are
01:16:24 are considered acceptable means of communication given the risk that they were put at
01:16:31 that's a euphemism for saying i'm really really shocked that there was still that that was what they were forced to do on the night of this incident yes
01:16:40 yes having worked in other industries i couldn't envisage it in any of the other industries i've worked in my life
01:16:48 and um what steps specifically would you expect a fire and rescue service to take as you contemplate here well the the very lowest uh level of technical sophistication would be field telephones
01:17:00 sophistication would be field telephones that were available on the night but
01:17:03 but um
01:17:05 um obviously they could have been cut by falling debris etc i have not you know but
01:17:09 but this
01:17:11 this if i was doing a post-incident review as an independent safety consultant the risk that was posed to runners to me stands out as a
01:17:22 stands out as a as something that i would never like to see again
01:17:27 now uh at page 53 of your report we have section four
01:17:34 page 53 uh and the heading to that is the extent to which uh the technical and operational functionality of barry sets is affected when used in concrete high-rise
01:17:45 when used in concrete high-rise buildings including incidents which predated the grenfell tower of fire and this section i think focuses am i right in on the subject of previous large-scale
01:17:56 on the subject of previous large-scale incidents involving communications difficulties in the context of high-rise for buildings and other environments where there have been a lot of concrete and metal
01:18:05 and metal can we go to page 53 page 4.1.6 at the bottom of the page where you say it says lfb staff were aware
01:18:14 aware the propagation issues affected the use of uhf radios in high-rise concrete buildings concerns were raised by and you've got a list the health and safety executive after the shirley tower fire the coroner's recommendations after
01:18:26 fire the coroner's recommendations after the lack of house fire the local government association's 2015 fire pier challenge
01:18:32 challenge and a clg incident ground communications study
01:18:37 study from 2008
01:18:41 uh now uh that uh study uh which i think appears referred to at footnote 85 on page 53 we if we just pick up that foot of that page there you can see it
01:18:54 foot of that page there you can see it there it is it's a fire research technical report 21 of 2008. can we go to it it's at cwj 6092.
01:19:07 uh now uh
01:19:09 uh there's the first page of it um am i right that it was commissioned by the dclg as part of its bdag or building disaster assessment group in the wake of 9 11. as i understand it yes and my
01:19:22 9 11. as i understand it yes and my right also is that its intention well we can see this actually if we go to page six go to section 1.1 we can quote from it
01:19:30 it on that page it says um
01:19:33 um uh
01:19:35 uh in the uh
01:19:36 in the uh first paragraph at line two that it was to consider the issues for fire and rescue services in the uk that have been highlighted by the world trade center incident of 11th september 2001 or 9 11.
01:19:48 incident of 11th september 2001 or 9 11. now you've reproduced i think a number of the reports recommendations but i'd like to focus if i can in particular on recommendations seven and eight bearing in mind the fact that this was published in 2008
01:20:00 fact that this was published in 2008 so nine years before the greenville tower fire if we get to page eight of this document and look at paragraph 1.2.3
01:20:10 on at incident communications recommendation seven and i think i can summarize it was that no decision should be taken at that time in 2008 on
01:20:21 be taken at that time in 2008 on replacing uhf radio with a tetra solution
01:20:26 solution am i right in summarizing it that way yep
01:20:29 yep uh now first looking at tetra am i right in thinking that tetra is the type of network that airwave radio utilizes yes and the recommendation goes on five
01:20:40 and the recommendation goes on five lines from the very bottom of that paragraph
01:20:43 paragraph it says even then the suitability of tetra pmr
01:20:47 tetra pmr is subject to the availability of all required direct mode operation dmo functionality and should be confirmed by appropriate trials in the built and open environments any decision to replace the
01:20:58 environments any decision to replace the current analog uhf technology must be informed by a rigorous cost benefit analysis
01:21:04 analysis now first could you just explain to us in layman's terms if you can what what pmr is
01:21:11 pmr is uh
01:21:13 uh i think that's a reference to the protocols that are used by tetra pulse mode i see yeah could you help us with what it means when it says it's subject to the availability of all required direct mode operation functionality so as i
01:21:25 mode operation functionality so as i said this morning there are two different modes within um airwave and tetra so there's this trunk mode operation which is where you communicate through a base station in a
01:21:36 communicate through a base station in a similar an analogous way to a mobile phone communicating to a base station or there's direct mode operation which is where you communicate in a way that's analogous to the uhf walkie-talkies so
01:21:47 analogous to the uhf walkie-talkies so you're not going through a base station but you're going hand to hand does the functionality of tetra use airwaves talk groups or is it independent of them i believe that tetra is the foundation
01:21:59 i believe that tetra is the foundation on which airwave is built i see i see it so it's a platform yeah i follow and now is this report this clg report saying that the suitability of the broader role
01:22:10 that the suitability of the broader role of airwave relies on there being a dmo direct mode operation or if you like walkie-talkie functionality yeah
01:22:18 yeah i think
01:22:19 i think what it's saying is that this possibility exists but a cost-benefit trade-off has to be considered before replacing the uhf devices because for example airwave devices are more
01:22:30 for example airwave devices are more expensive
01:22:31 expensive they have that security consideration um and none of these things apply to the uhf radios yeah and so you know i um
01:22:45 again there's a wider context to all of this discussion which is about the value for money for airwave which is a current focus for the competition and markets authorities investigation
01:22:56 authorities investigation and also the delay and three billion pound overrun on the emergency services network
01:23:04 network okay i'll wait for your questions on that um
01:23:08 that um but have i explained enough about the context of that which is that the fire and rescue service use of um airway for operational reasons
01:23:21 um airway for operational reasons was
01:23:22 was rejected because of the security and the cost as the two principal reasons the provision of direct direct mode operation
01:23:33 operation if that if that had been accepted as an operational requirement could have been provided in the same way that it would have been available for the police and other agencies right now looking at that last sentence that you focused on the
01:23:45 you focused on the um the trade-off with the rigorous cost-benefit analysis are you aware whether any such analysis was ever conducted either by the dclg or the lfb or anybody else i've not seen that
01:23:56 or anybody else i've not seen that detailed form of cost benefit analysis and in particular i would suggest that i've not seen it in the context of something like grenfell tower or la canha
01:24:05 canha which i feel would be warranted in that
01:24:12 in that as i said before many of these comparisons tend to be done on device characteristics rather on the operational benefits that they might yield to the public and firefighters under those kind of situations
01:24:27 now looking at recommendation eight that says the existing uhf channel assignments should be examined to see whether it might be possible to modify the channel assignments to further minimize the potential technical limitations of the current channels and
01:24:39 limitations of the current channels and whether the number of available channels could be increased perhaps by utilizing channels vacated by the police service in its transition to the airwave service uh
01:24:49 uh are you aware whether any such analysis was conducted again either by the lfb or more broadly such as by the department i have not seen such an analysis and as we
01:25:00 seen such an analysis and as we discussed this morning with interference identified between the existing channel allocations on possible channel that could have been used uh i don't think that it was done um but uh
01:25:13 um but uh you know i i feel that that would have come to light in evidence based on the questions that have already been asked about the effectiveness of channels but i have not seen any any such document now if we go to the bottom of page eight
01:25:25 now if we go to the bottom of page eight and scroll down please to recommendation 12.
01:25:29 12. you'll see there it says this that the set of recommendations from this study be used to form a program of further work be they new projects or additions to the terms of reference of existing groups
01:25:41 groups are you aware of whether any further work was ever conducted in accordance with that recommendation i'm unaware of any further work now if i understand your your report
01:25:52 now if i understand your your report correctly professor i think you've observed that the lfd's decision not to broaden its use of airwave radio appears to have been made on the grounds of security concerns as well as the relative cost of airwave radios is that
01:26:04 relative cost of airwave radios is that correct yes now i should say that when assistant commissioner gary reason came to give evidence he told us that he was not aware of of cost being a consideration when the nfp were considering the use of
01:26:16 when the nfp were considering the use of airwave radio in response to the lack of coroner's rule 43 recommendations he said that at day 182 page 87 lines two to six
01:26:25 to six that was his evidence um but in terms of security are you able to give us a brief overview of the security concerns which might have surrounded the broader use of airwave radio by the lfb
01:26:37 broader use of airwave radio by the lfb um i'll say two things on that um if you look in my report at one point there is evidence cited on the cost objection um which refers to
01:26:48 which refers to the cost of the handsets and also the cost of the additional rental that would be paid on each device um i can't point you to the page immediately because certainly find it after after this session
01:27:00 after after this session um and and secondly again in the report there are sections which deal with concerns over security expressed by those personnel within lfb who are responsible for accounting for the
01:27:11 responsible for accounting for the handsets
01:27:13 i think we can track that down great helpfully prompted sorry no it's very helpful if you look at page 211 of your report and look at paragraph 8.4.10
01:27:24 8.4.10 you may we may find the point you're recalling
01:27:28 recalling great i'm sorry i got the cost wrong uh internal emails predating the grenfell tower fire reiterated security and financial concerns about the broader use of airwave radio so you're you're you
01:27:39 of airwave radio so you're you're you recalled your own report correctly uh
01:27:42 uh my question really is in light of that uh
01:27:47 uh and i should just tell you i mean this is a a
01:27:50 is a a an email that runs over to page 211. yeah
01:27:56 yeah um
01:27:57 um from an email chain discussing proposals on the management of life critical information from brigade control to incident ground i'm not sure we've seen in
01:28:05 in in the factual evidence but you're relying on that are you yes this is in the context i think of of fsg yes uh yes i see
01:28:14 i see but just going back to the security point can you give us a brief overview of the security concerns surrounding the the wider use of airwave airwave is viewed as part of the uk national critical infrastructure and
01:28:26 national critical infrastructure and many years after its intended end date it's still in operation um from what i don't for obvious reasons know the details of how it's secured but it remains a matter of some
01:28:38 but it remains a matter of some amazement to me that these arguments could still be used when one of my areas of expertise is in cyber security
01:28:46 security and
01:28:47 and in
01:28:48 in almost every con conceivable situation i would see today and for many years in the past it should be possible to deny access to a network for a device that's stolen or lost in the same way it's possible to
01:28:59 lost in the same way it's possible to deny access to a mobile phone which is stolen or lost however i can only assume from the the eagerness by which people account for these airwave devices that for whatever reason is not possible presumably is a
01:29:12 reason is not possible presumably is a legacy feature of that infrastructure so no encryption possible i believe that they are encrypted but the problem would be that if the device access
01:29:22 access resides in some way with the hardware on the device and there's no way to account for it i i from a technical point of view i'm at a loss
01:29:29 loss to understand why this should really be a problem
01:29:32 a problem but it's not the sort of thing that would be advertised to somebody outside of the
01:29:37 of the operational team working with airwaves so i can't answer your question from a technical perspective now if we go to page 210
01:29:48 uh you record i think the requirement in airwave policy 664 this is a paragraph 8.4.5 that handheld airwave radios were not being used
01:29:59 airwave radios were not being used should be
01:30:00 should be either worn by the user or double locked kept behind two locked doors which might include a locked glove compartment in a locked car for example yes yes
01:30:10 yes yes um now dealing with the possibility first of wearing the devices you picked that issue up a little earlier on at page 205 of your report at paragraph 8.1.9
01:30:24 at paragraph 8.1.9 and
01:30:25 and there you come back to the point about them not being intrinsically safe
01:30:32 now as to that at 8.1.9 as to that is that because of their transmission strength
01:30:39 strength yes although as i've said before it is possible to get higher transmit and strength devices which are purposely designed to be intrinsically safe right but that would be a requirement to purchase yes and in fact you say that in
01:30:51 purchase yes and in fact you say that in the next paragraph there are intrinsically safe variants of airwave devices but it's unclear if any were held by the lfb on the night of the fire and how would those variants differ from a normal airwave radio do you think
01:31:02 a normal airwave radio do you think probably in terms of cost but okay but how they more how are they technically different well the reason for the additional cost would be that the the
01:31:12 the fabrication and the components used would have to pass more stringent tests to be
01:31:17 to be safely used in an intrinsically safe environment and as we've discussed previously in my opinion it's likely that even those that were intrinsically safe would
01:31:29 those that were intrinsically safe would not
01:31:30 not not reach the highest levels of stringency that we described this morning
01:31:34 morning for the lower powered devices yes i follow now earlier on your evidence you touched on the lack of house coroner's rule 43 recommendation to the nfb that it should consider using additional
01:31:45 that it should consider using additional radio channels that major incidents and we looked at that and in particular the lfps position that the risks of doing so outweigh the benefits that's the background to what i'm about
01:31:56 that's the background to what i'm about to ask you about if you go please to page 78 of your report and go to paragraph
01:32:03 4.13.7 on that page you set out the draft response to the coroner's rule 43 recommendation proposals
01:32:13 proposals and
01:32:14 and the source document that you're citing here and you're replicating within the box on that page is i think a draft set of proposals which could be submitted to the coroner now we've got a later draft of that from april 2013 which i'd like
01:32:27 of that from april 2013 which i'd like to show you it's at nfb triple zero three four zero six two [Music]
01:32:34 [Music] if we look at the first page of that there it is there's the document that was familiar to us when we looked at when we looked at this with assistant commissioner gary reason and
01:32:45 assistant commissioner gary reason and if we go to page 9 that's where the communications proposals start and the passage i want to ask you about is on page 10 if we go to that please and look at the top row
01:32:57 and look at the top row it sets out the options considered by the lfb and if you look at the fourth paragraph done there's an italic it says use of airwave digital radios you see that yes and it goes on
01:33:08 you see that yes and it goes on currently these radios issued to all flexible duty officers are used primarily for communications between the incident ground and the brigades mobilizing control expanding the use of digital radio talk groups for example
01:33:20 digital radio talk groups for example for the incident command team would provide the opportunity to free up analog radio channels this does however bring another level of complexity in managing information flows at an incident
01:33:31 incident now in your view does using both analog and digital radio technology on the fire ground add a level of complexity to communications [Music]
01:33:45 i i i don't think that one necessarily follows from the other i think that there are ways of mitigating that complexity and integrating the use
01:33:58 of those technologies just as there are ways of integrating the use of battery sets with handheld radios as in the existing in the existing policy it does i think add
01:34:12 a level of complexity but you could also argue it adds another level of improved resilience and under circumstances where this technology might improve communication
01:34:23 technology might improve communication that would be worth paying what do you want sorry i was just going to say that to me a lack of communication is is the greatest danger
01:34:34 greatest danger in instance of this nature as i said before the lack of communication could be communication failure or it could be through injury and
01:34:44 and and incident to to the personnel affected
01:34:48 affected um
01:34:50 are you able to help us understand looked at objectively what the complexities would be quotes in managing information flows at an incident and why that might be a
01:35:02 an incident and why that might be a problem
01:35:04 problem well i i i
01:35:08 with all the documents i've seen i think this is a much much bigger issue and it's not there are many many many levels to this and so
01:35:17 and so you know if i probably later on you want to talk about the key cad system used by the ambulance service and by the metropolitan police but to me that's a very effective tool
01:35:28 very effective tool in in managing information flow because it stores information in a textual form that could be searched and looked up after the event and
01:35:38 and to me
01:35:40 to me one of the recommendations that that i
01:35:44 that i that
01:35:46 that i i believe is that grenfell teaches us about the need to manage information as much about devices i feel there's so much focus on intrinsically safe not intrinsically safe
01:35:58 safe digital versus analog to me it's it's what happens to fsg information from the moment it at which it arrives into the system to the point at which
01:36:10 into the system to the point at which it's used what happens in terms of the flow of information in the opposite direction from from the operational crews back out to the instant commander that's making really critical
01:36:21 making really critical risk-based decisions and and to me from what i've seen in the witness statements there is like a mosaic or patchwork of devices each of which fills a kind of a
01:36:33 devices each of which fills a kind of a niche need and then there's an awful lot of policy around that that people perhaps didn't always understand that is intended to form the interface between those devices so
01:36:43 so i understand this quote and in the context of how things are managed at the moment i perhaps agree that adding airwave would add an unnecessary layer of complexity but i
01:36:54 unnecessary layer of complexity but i would rather people take a step back and say
01:36:58 say what do we require for a digital fire ground that manages the seamless transfer of information and doesn't rely on many many procedures and policies to be remembered by crew and commanders
01:37:12 to be remembered by crew and commanders in a complex dynamic site where things will fail and do fail so to me
01:37:19 to me my focus is on that sentence managing information flows an incident rather than on the caveat about airwave devices now moving on with how airwave could be
01:37:30 now moving on with how airwave could be used you told us earlier uh and your report says it that talk groups are not immune from congestion but nonetheless that could be addressed on a case-by-case basis by the creation of talk groups
01:37:42 creation of talk groups have i got that right exactly yes now let's then look in light of that at page 211 of your report at section 8.4.8 [Music]
01:37:53 [Music] uh
01:37:54 uh you i think acknowledged the concern set up by dominic ellis in his witness statement
01:37:58 statement and you've set out a quotation there from his witness statement at page 18 paragraph 80 but um you stay say
01:38:07 stay say well it says in quotation line six in the text
01:38:10 the text where it starts airwave devices can you see it says airwave devices work differently in that they have a national coverage meaning that different incidents or functions would have to be
01:38:21 incidents or functions would have to be directed to use specific torque groups to ensure that there was no two incidents using the frame same frequency this could cause delays at incident sites and needs new talk groups being allocated to ba or specific sector roles
01:38:33 allocated to ba or specific sector roles etc the airwave network does not have an infinite capacity and was developed on the presumption that fire and rescue services do and would continue to use uhf radios for incident ground
01:38:44 uhf radios for incident ground communications it is not necessarily the case that the current airwave network has the capacity to handle the large amount of communications generated at incidents within its area even assuming
01:38:55 incidents within its area even assuming the issues identified above could be overcome
01:38:58 overcome now do you have any feel for
01:39:02 for first how
01:39:04 first how long it takes to set up an airwave talk group
01:39:09 i i in the report refer to the metropolitan police's guidance on the manipulation and creation of the talk groups which is partly the technical time but also deals with the policy that
01:39:21 time but also deals with the policy that needs so that individuals can't spontaneously create a talk group that would then create an information ghetto if you like and
01:39:29 and so i think it's it's it's you know it's a considered process but something which other other emergency services have guidance on an operational experience of
01:39:43 i see uh is dominica ellis's point that i've read at length to you here a valid one in your opinion professor again i think there are a number of
01:39:54 again i think there are a number of issues to be considered so he's writing suggesting that the airwave network does have finite capacity but as mentioned elsewhere in my report there are ways of working with the operators of the
01:40:05 working with the operators of the network to increase capacity and response to specific incidents and that's a facility which is far harder to achieve with uhf point-to-point devices
01:40:16 with uhf point-to-point devices and
01:40:18 so to me
01:40:22 to me as we'll have seen in many different areas of the evidence the prima facie arguments are used without the subtlety of exploring you know very very often in the evidence i've seen i want to ask why and what alternatives exist
01:40:34 and what alternatives exist rather than simply accept it at face value
01:40:38 value so it's it's i feel
01:40:41 i feel i think you'll have seen that um from a technical perspective many of these objections could have been overcome with a degree of support from the manufacturers and the willingness to
01:40:52 manufacturers and the willingness to question
01:40:52 question the existing level of provision i think the phrase i use in the report is the making do culture so so people may do with systems far longer than i
01:41:03 may do with systems far longer than i think they should have done in terms of the technical provision from those systems
01:41:08 uh mr chairman i i'm in the middle of the topic and there's no immediately obvious place to ask you for a break so i'll ask you for one now yes all right well probably is a good thing to have a break now
01:41:19 good thing to have a break now we'll stop we'll resume at uh half past three please thank you as before and please don't talk to anyone about your evidence thank you thank you thank you
01:41:38 right thank you for streaming
01:59:38 would you ask mr johnson to come back in please
01:59:54 all right professor johnson ready to keep going yes very thank you yes yes mr chairman thank you can we please go to page 212 of your report and look at section 8.4.13 now you discuss here the experience of
02:00:06 now you discuss here the experience of the metropolitan police and the las in exclusively using airwave radio and you say that both organizations have successfully avoided the problems that might otherwise arise from a proliferation of talk groups across the incident ground
02:00:17 incident ground see that there how in your view have the metropolitan police service and the las successfully avoided those problems i think by creating distinctions between tactical
02:00:28 creating distinctions between tactical and operational talk groups and
02:00:34 i think that
02:00:38 um i i feel that some of the lessons could be applicable more generally to an frs but that um
02:00:47 that um there would need to be some um adaptation but i don't to me it's seen that the
02:00:56 the from the previous quotation from the clg report you know you would have seen that um
02:01:01 um this is seen as an insurmountable problem but with the guidance and the operational experience that's been gained since that time i don't think that that objection holds in the way that it maybe did before
02:01:12 in the way that it maybe did before there was that operational experience i think that's the point that i'm trying to make
02:01:16 to make thank you can we get back a page to page 211 please and pick up the passage of dominic ellis's statement at paragraph 8.4.8 i read this all to you but i just want to have a look at um the second
02:01:28 want to have a look at um the second part of the parent passage of the paragraph i read to you where it says the airwave network does not have an infinite capacity and it continues uh and it refers to the complexity of setting up talk groups for
02:01:40 complexity of setting up talk groups for specific incidents as we've seen can you tell us what is your view about how likely it is that the airwave network could accommodate additional traffic from fire and rescue services
02:01:51 from fire and rescue services the
02:01:53 the the national contract for airwaves specifies coverage in a percentage of the uk and then
02:02:02 and then the amount of capacity will differ as i understand it depending on the location within that coverage so if it were a relatively remote location the amount of capacity would be
02:02:14 the amount of capacity would be more limited than if it were in a an urban environment um all other things being equal so if there were multiple incidents within an urban environment at the same time then the capacity again might be limited in
02:02:26 the capacity again might be limited in that in that situation yes i see and i link to that i think we find something similar at page 225 if we can look at that and specifically section 8.13.8
02:02:39 section 8.13.8 now you say there
02:02:43 by reference to the dmo tmo approach uh and
02:02:49 uh and uh the the the uh that i think is dual use radio and just just to be clear uh tmo i think is trunk mode operation yes if you remember from earlier that
02:03:01 yes if you remember from earlier that direct mode is is equivalent to walkie-talkie use without a base station and trunk mode is through the base station into the national network as we've described yes and
02:03:13 and essentially that's dual technology isn't it
02:03:15 it it's it's just two different architectures of using the same thing well you say here that that uh the flexibility would have required coordination to ensure that teams used consistent means of conveying
02:03:26 used consistent means of conveying critical information during the fire for instance teams might have to summarize information communicated over dma when they returned to tmo network coverage
02:03:36 does that mean that there has to be coordination to ensure that critical information about the incident is is conveyed across different operational teams yes so if i communicated to you on a dmo
02:03:49 yes so if i communicated to you on a dmo mode we would be the only potentially the two people that would hear it and when one of us goes back to the ability to communicate nationwide we would have to then pass the message on that we'd conveyed in direct in the
02:04:01 on that we'd conveyed in direct in the direct mode indeed just as it would between the barrier sets and um and the wider fire ground communication if they were isolated now on page 229 of your report let's have it up page
02:04:12 of your report let's have it up page paragraph 8.16.5 page 229 you explain that a cad system or computer-aided dispatch system could help
02:04:20 help um could you tell us briefly how you envisage a cad system helping in the coordination of radio types and radio channels yes um as i alluded to earlier one of the
02:04:31 um as i alluded to earlier one of the limitations that we have with voice communication is that the communication is transient and so if you have interruption or you're disconnected and you don't hear a message there's no effective way
02:04:42 hear a message there's no effective way for you to replay that message and instead when you go back into coverage you take out more finite bandwidth by saying did i miss anything or repeating a message did you hear me
02:04:54 or repeating a message did you hear me whereas the cad system provides a text-based interface to be able to replay previous decisions or previous information or previous radio messages
02:05:04 messages and so rather than communi if i can't communicate with you if you're too busy for me to pass a message to using voice communication i could log a message on the cad system which you could then scroll to or another person could scroll
02:05:16 scroll to or another person could scroll to
02:05:17 to um later on so i feel like it provides an archive of communication and and very importantly if we were to decide to change channel for instance this decision could be logged within the cad system and communicated even to
02:05:29 cad system and communicated even to those people who didn't hear it at the time but may have seen it at a later date
02:05:33 date now so just to make sure we understand how do you log in log a message into the cad system will it take an oral message one of the arguments that i've made elsewhere in the report is that with
02:05:44 elsewhere in the report is that with speech recognition technology it would be possible potentially to store a message even on a firefighter's personal equipment and for them then when they go into coverage not to be forced to repeat
02:05:55 into coverage not to be forced to repeat that message but for the system to automatically replay it in the same way as a voicemail message if you could think of it once coverage is resumed and that message could be conveyed on an information
02:06:07 could be conveyed on an information channel that's separate from a voice channel i didn't go into all the elaborate architectures in the report but
02:06:13 but a more modern form of integrated information management system could take an awful lot of load away from the voice communication and use forms of messaging
02:06:24 communication and use forms of messaging and also reduce a lot of pressure on the firefighters in terms of making sure the information was conveyed another particular advantage of that would be that the transfer of messages could be
02:06:35 that the transfer of messages could be done
02:06:36 done automatically between people so my message could be stored on my system but then copied to you and then if you go back into radio contact even my messages might be forwarded from your
02:06:47 messages might be forwarded from your system so a whole group of communication could be passed on automatically without the need for additional voice overheads through the use of speech recognition and
02:06:57 and other technologies which are beyond what's on involved in cad but they're not beyond what is technically possible even for a modest amount of processing today is there a difference between the
02:07:08 is there a difference between the airwaves text messaging functionality and account system um
02:07:14 um the way i view airwave text messaging system is much more in terms of direct communication whereas the cad system for me is a more integrated information management system with the ability to to
02:07:25 management system with the ability to to store messages in a more structured fashion now in the event that the fire and rescue service chose not to adopt a broader use of airwave handsets i think you're of the view
02:07:36 you're of the view as you set out at page 213 uh paragraph 8.5.3 we just look at it do you say in extremists these higher powered radios could be
02:07:47 these higher powered radios could be deployed by the lfe to address the communications problems in high-rise buildings but only if such contingency has been anticipated and trained for could you explain how it is that you see airwave operating as a contingency in
02:07:59 airwave operating as a contingency in extremis this is a really interesting for me an interesting point that i probably haven't emphasized enough in the report but in the original work i did in 911 there was a a really noted
02:08:10 did in 911 there was a a really noted difference between the ability of
02:08:13 of fire department of north new york and similarly equipped personnel to penetrate into the world trade center compared to something called new york police department emergency
02:08:24 new york police department emergency service units the police department emergency service units
02:08:30 units in many cases did not have breathing apparatus but did have high powered radios
02:08:35 radios and they got further into the world trade center and were able to communicate faster back to the ground stations than the firestop fighters were and so in many cases the police heard the order to
02:08:46 many cases the police heard the order to withdraw whereas the firefighters didn't because they were using lower powered devices
02:08:52 devices that's a very very practical example where
02:08:55 where um
02:08:56 um and i don't think it was taken as a coherent decision it just happened that the emergency service units were equipped in that way but there is clear operational benefit in the in the case of 911
02:09:08 of 911 for more lightly equipped people penetrating further with higher powered radios
02:09:13 radios what would be the problem about equipping
02:09:15 equipping london fire brigade with an equivalent of high powered radios used by the new york police department i think the intrinsic safety issues that we've rehearsed and the the and the and again the meta-level issues that we've
02:09:27 the meta-level issues that we've rehearsed over that who would take the decision to deploy them and at what point and i think that depends on reliable communication as to the risk that people are encountering when they go in with intrinsically safe devices
02:09:39 devices right
02:09:40 right now can i just ask you briefly about some other digital technologies starting with the css or command support system which you covered at 8.17 of your reported page 229 and following now
02:09:52 reported page 229 and following now we know from evidence of phase one of the inquiry that the css didn't work as intended on the night of the fire but could um could you tell us in brief if you can how the css would be capable in
02:10:04 you can how the css would be capable in theory at least of helping fire ground communications i think it would have acted as a central repository for information drawing on many different sources as we can see from from the quotations that i've given
02:10:16 from from the quotations that i've given here
02:10:17 here and i think there was an ambition for it to serve that that purpose and sorry sorry would a functioning css provide the same or similar benefits as a cad system
02:10:31 i it would have provided some of them but i i
02:10:37 but i i struggle to understand why this is not a joint procurement exercise as it would be for example in some areas of the military this to me is the information management
02:10:48 this to me is the information management and information integration is a core technology and
02:10:53 and i i
02:10:54 i i this is a very important to me general point which is that the the very different levels of provision of service even within the london users of airwave
02:11:05 london users of airwave is a mystery to me why why london fire brigade were unable to get access to text messaging facilities on airwave whereas other other agencies were and so to me
02:11:16 and so to me integrated procurement of emergency services and integrated information management and i think also the ability to use open
02:11:28 and i think also the ability to use open standards so that even if one supplier provides a product it can connect to the products of other suppliers without endless communication and misunderstanding and delays
02:11:39 misunderstanding and delays to me this this is part of the deeper cultural issues about technology management
02:11:46 now looking at a little bit more closely at mobile's mobile telephone technology uh first how do mobile signals compare with digital airwave radio signals um
02:11:58 let's say how do they compare how do they compare in functionality terms well i think for obvious reasons the the digital telephones that we rely on today have gone through many series of
02:12:09 have gone through many series of upgrades and obviously offer higher levels of capacity and bandwidth but there's less guarantee in terms of coverage
02:12:19 coverage which is obviously essential for an emergency service network um
02:12:23 um so
02:12:25 so but i but you know this is this is a very difficult comparison to make given the legacy nature of airwave and
02:12:34 and [Music]
02:12:35 [Music] obviously the expectation that the emergency service network would have been deployed long before now let me try and get a little bit differently yeah to what extent if at all our mobile phone signals subject to
02:12:46 all our mobile phone signals subject to the propagation issues that you've and i have discussed today and in your report they are i mean they are subject to to those propagation issues but the intrinsic safety is is not a significant
02:12:57 intrinsic safety is is not a significant issue in the use of mobile phones and hence you shouldn't use them in garage four courts and so forth um
02:13:06 um although the wattage is again capped in the way that i've described in the report
02:13:11 report but they're operating on radio signals something yes in sense it's intrinsically the same as airwave radio exactly just operating on different frequencies exactly exactly exactly
02:13:25 frequencies exactly exactly exactly now uh
02:13:28 if we go please to uh
02:13:32 uh page one page 267 of your report and look at section 9.8 that's headed bandwidth limitations uh you can see there that you give your view
02:13:43 that you give your view any analysis of the the actual and future uses of a mobile telephony and it's in incident ground communications must consider how many devices could be in operation at any one time without adversely affecting performance
02:13:56 adversely affecting performance uh
02:13:59 uh now
02:14:00 now are you referring there to how many calls could successfully take place in and around the fire ground
02:14:07 yes um again we have experience of this in 7 7 and 9 11
02:14:14 and 9 11 where
02:14:15 where um as i mentioned previously today that there were privilege access schemes that the emergency services could use so in the uk's uh context our system would
02:14:26 the uk's uh context our system would block public use of the mobile phone network within particular areas if it were to be activated so it's a very major step to do that
02:14:35 if that was not done then the number of calls made by the public for very understandable reasons would interfere with the ability of the fire and rescue services to complete a call and so we
02:14:46 services to complete a call and so we see in some of the witness statements that attempts were used to make mobile phone calls by frs personnel and they didn't complete within that it's also important to understand that you can use different
02:14:57 understand that you can use different techniques to increase your likelihood of the information getting through so in general the advice is under such circumstances to use text messaging because it uses less bandwidth and is
02:15:08 because it uses less bandwidth and is more likely to complete than a voice call for the reasons that we've described before yes that's helpful yes i see
02:15:13 i see now um can i then turn to a different topic uh which is the need for holistic communication systems and i want to ask you about the safety case um can we start please at page 167 of your report
02:15:25 start please at page 167 of your report to section 6.17
02:15:29 uh and you you've made a number of references in your report to safety cases and you me and you recommend that safety cases be adopted by fire and rescue services as you do here and could you just
02:15:40 as you do here and could you just explain first to the panel what is a safety case a safety case is used in the ministry of defense and in the offshore industry and
02:15:52 defense and in the offshore industry and in
02:15:54 in various branches of transport extensively in aviation and it's a structured argument about the evidence i would use to show that my system is acceptably safe
02:16:05 system is acceptably safe and so sorry that's helpful and you wanted to finish your answer i was just going to say very importantly that that it's usually a diagrammatic structure which breaks the argument down into
02:16:16 which breaks the argument down into different steps but at the bottom of it are documents that provide the evidence that your system is safe so if i say very frequently in the evidence i see people making assertions that we conducted a risk assessment
02:16:28 conducted a risk assessment and we determined that a medium level of intrinsic safety was an appropriate policy for future acquisition in lfb that's a statement from one of the witnesses now
02:16:39 now in a safety case i would be obliged to provide a reference to the document that indeed showed that risk assessment so
02:16:46 so and
02:16:47 and the key point i would make here is in the arguments that i've presented to you and you've asked questions about we've had to refer to hundreds of documents
02:16:56 documents and it's very difficult for us i mean it should be evident to everyone that this argument that we're going through has been rehearsed over close to two years
02:17:05 two years in forming a view of all of these documents together and uh
02:17:10 and uh this should have been done before the incident and exposed so if something like this happened again god forbid or if the an incident like um i can haul would
02:17:21 an incident like um i can haul would were to occur again then what you do is you examine each piece of evidence that's referred to in the safety case and you challenge whether that's true so if you say you did a risk assessment on on the use of intrinsically safe devices
02:17:35 on the use of intrinsically safe devices and the communication failed in a previous incident because of the power issues or you had the coroner's recommendations you would then say actually my argument no longer holds because that evidence has been challenged in court
02:17:47 has been challenged in court so you review your safety case in the light of subsequent experience and that's a formal obligation within many other industries to do that now if you go to page 167 of your report sorry
02:17:59 you go to page 167 of your report sorry on page 167 if you go to section 6.17.3 you see you say a formal safety case should be developed by all frs to explain in a single coherent document why their existing fire ground
02:18:10 why their existing fire ground communication equipment provides an acceptable level of safety together with the evidence that supports this argument you refer to a single coherent document what level of detail would you expect a
02:18:21 what level of detail would you expect a safety case in such a document to provide
02:18:24 provide the safety case itself could be quite high level because really what you're wanting to do is to provide a structure that can then be challenged by inquiries like this but the evidence that it refers to in
02:18:36 but the evidence that it refers to in the documents below it should be a level of detail greater than we've seen i think in some cases here and if we look at as the next paragraph
02:18:49 and if we look at as the next paragraph 6 17 4
02:18:51 6 17 4 you say the fire ground communication safety case must then be maintained as new operational evidence becomes available or as new systems are procured and then at five if communications fail
02:19:02 and then at five if communications fail during an incident then existing evidence must be re-examined and the overarching arguments that the system is acceptably safe must be challenged are you are you um well you see what you say but um
02:19:15 well you see what you say but um how often would you expect a safety case to be reviewed i'm i'm used to reviewing them depending on the criticality of the system but certainly if an incident
02:19:27 system but certainly if an incident occurred i would automatically do a review of the safety case where it was it was felt to be relevant or germane to the system and i would in the context of an frs an incident involving
02:19:38 involving ba equipment anywhere in the uk should trigger a review from each frs in a systematic way and
02:19:47 and conventionally it's more determined i think by changes in the environment or changes in policy or changes in equipment as well as operational practice all of those things would trigger a change rather than
02:19:58 would trigger a change rather than months
02:20:00 months i think there's a difference where you might have to update it in terms of a digital system with security considerations because cyber security threats change more frequently than um the environment
02:20:11 more frequently than um the environment in which a safety case itself
02:20:15 would change simply because adversaries are deliberately trying to attack digital systems so this this same technique that i've been talking about here is also used um to increase confidence in the security
02:20:27 to increase confidence in the security of the system and the frequency with which you review the evidence for a security case is more frequent than in the case of safety because you've got an adversary who's trying to attack your system right
02:20:38 who's trying to attack your system right so the same the same rules and ideas apply here now um
02:20:44 now um at various points in your report you've advocated for organizations to take a systemic view of communications frameworks to which they which applies to them
02:20:54 to them and we've seen some of that in the report and can we look please at page 26 of your report and look at section 2.10
02:21:05 now this is within 2.10 subparagraph 21 you say the successful uptake of such innovations requires an organization to take a systemic view of its
02:21:17 take a systemic view of its communications framework focusing on the integration and resilience of multiple infrastructures this should be supported by coherent evidence-based arguments to demonstrate that incident ground communication systems meet acceptable
02:21:28 communication systems meet acceptable levels of safety and then at 22 you say such a systemic view focuses less on the functionality of individual technologies and more on the way in which different systems are used together to respond to operational
02:21:39 used together to respond to operational requirements as demonstrated by the evidence for training drills and incidents now based on that and on what you've told us already this afternoon does it follow that it's your opinion professor that an organization's
02:21:51 opinion professor that an organization's communications system uh is just as important as its communication equipment emphatically so yes exactly now if we go to uh page 29
02:22:02 yes exactly now if we go to uh page 29 you say
02:22:03 you say in section 2.12 at the top of the page
02:22:08 by reference to nfb 488 which says this effective communications are the key to success a reliable communications network is essential for safe operation at incidents and
02:22:20 safe operation at incidents and fundamental for securing the level of command required to manage operational resources effectively you say at 213 the systems available on the night of the fire did not meet an acceptable
02:22:32 the fire did not meet an acceptable level of reliability so can we take it that your opinion is that the lfb policy as quoted here in 488 was an aspiration only not reflecting the realities
02:22:44 reflecting the realities yes
02:22:45 yes [Music]
02:22:46 [Music] could you explain why you've reached that view
02:22:49 that view apart from by reference to everything you've told me i i think my my ultimate feeling is this that
02:22:57 that irrespective of whether this well individually leaving aside the question of whether the systems did or did not function correctly on the night there are so many questions about
02:23:10 there are so many questions about what should have happened and would have happened when those devices failed that i don't believe that the there was adequate thought about the integration and recovery of communication during the incident
02:23:21 incident so very simply um if you were to decide to switch channel or deploy leaky wiki feeders how is that communication handled and how do you how do you ensure the safety
02:23:32 how do you how do you ensure the safety of of personnel and and another aspect of that would be when the bridge heads were moved for example and the communication of the consequences of that yeah so i i i agree with your earlier statement
02:23:46 i i i agree with your earlier statement now going back to page 22 of your report if we can look together at paragraph 10 there you
02:23:51 there you you say this page 22 paragraph 10 what's up paragraph 10 i've been unable to find
02:23:59 to find any evidence of sustained planning to recover from the widespread loss of ba communications in a complex fire ground for example during the relocation of the a entry control stroke of the bridgehead now when you use the phrase sustained
02:24:11 now when you use the phrase sustained planning what do you mean i
02:24:17 i would have liked to have either within the training that you've shown the computer-based training or other forms of training a series of of exercises and drills
02:24:29 exercises and drills um
02:24:30 um that prepared people for recovering communication during an instant of this nature so that
02:24:37 so that there was less of a feeling that people were battling against communication faders on the night without resorting to whichever which is as you've argued and
02:24:49 whichever which is as you've argued and and or as if you've you've
02:24:51 you've pointed to in the previous uh discussion um things like the use of the personal radios without a risk assessment being communicated
02:25:02 risk assessment being communicated um and these seem to have been ad hoc decisions that were not i think either sufficiently rehearsed or or or planned for in terms of the
02:25:14 or or planned for in terms of the training in order to feel confident that that was anything other than a a a response of individual firefighters to an increasing lack of communication would your phrase sustained planning not
02:25:26 would your phrase sustained planning not only include training which would of course be brigade wide and not building specific
02:25:31 specific but also
02:25:32 but also planning for specific fires in specific buildings pursuant to the information gathering obligation under 72d i strongly agree with that now
02:25:44 now if we go to page 196 of your report at section 7.12.12 your conclusion i think is is this right that
02:25:55 that uh the lfb's training left firefighters unprepared to address the communications problems they encountered in the grenfell tower of fire does it follow from from that and what we've just said that it's training both in relation to
02:26:07 that it's training both in relation to uh how to recover generally from a communications failure on any fire ground but but also how to collect building specific information under 72d i
02:26:18 under 72d i i i would find it difficult to enumerate the many levels at which that statement applies i think it also applies to the decision making for instance to
02:26:29 decision making for instance to to deploy
02:26:31 to deploy leaky feeders and repeaters to then
02:26:34 to then absolutely validate that the decision is is what has actually been implemented on the fire ground and also to
02:26:45 and also to to ensure that adequate consideration was taken for communication in comparison to all the other operational demands that were pointed out by commissioner dobson as reasons why the
02:26:56 commissioner dobson as reasons why the decision might have been delayed to do that so
02:26:59 that so i think
02:27:00 i think there is a level of complexity in in in the experience that we've seen of fighting high-rise fires that i don't think people were prepared for when i read the witness statements
02:27:11 for when i read the witness statements to this inquiry [Music]
02:27:14 [Music] i don't think the training was adequate in the in the view of the firefighters as their evidence is collected now building on that if i may can i just pick up your references in a number of
02:27:25 pick up your references in a number of places to
02:27:27 places to what you i think have identified as a need for cultural change within the london fire brigade when it comes to incident communications and i just want to work out what it is you mean with by that by reference to some of the
02:27:38 by that by reference to some of the specific points you make in your report can we start please at page 33
02:27:46 where you uh say this at sections two point nineteen point one and two uh you and the heading is to communications failures stem from cultural issues
02:27:57 cultural issues and you say the decisions that helped undermine situation awareness of grenfell tower were taken in the months and years before the fire in particular these decisions exacerbated delays in replacing aging analog and digital
02:28:08 replacing aging analog and digital communications infrastructures the delays can be explained by a culture of making do and failing to tackle the limitations of existing radio systems in concrete
02:28:19 existing radio systems in concrete rise structures
02:28:22 now there are two issues it seems there first delay explained by a culture of making do as you put it and secondly failing to tackle the limitations of existing radio communication systems in
02:28:33 existing radio communication systems in concrete high-rise structures i want to break those down if i can starting with the first delays can we go to um
02:28:42 section 2.19.3 is the next paragraph done where you say this there was arguably a sense of complacency which is because the aging communications infrastructures have not
02:28:53 communications infrastructures have not been exposed to a disaster on the scale of events that unfolded at grenfell tower even though other events in the uk and abroad had illustrated the need for a more systemic for more systemic
02:29:04 a more systemic for more systemic approaches to incident ground communications now
02:29:09 now you say they were aging communications infrastructures why do you describe them as aging
02:29:15 as aging um
02:29:17 um all of the infrastructures that we've described so far were the subject of replacement programs that had been delayed at the point of the fire as i understand it
02:29:28 many of them are still not being completed today in the case of airwaves for instance and to a certain extent the battery sets but i also go back to evidence presented
02:29:39 but i also go back to evidence presented to this inquiry on numerous occasions where very senior members of the london fire brigade make that very point especially in relation to for instance the the problems of roving the wired
02:29:52 the the problems of roving the wired barry sets um
02:29:56 um you know there was some very disparaging remarks made about how obsolete this technology was by the top level leadership on on that point
02:30:04 point when you say roving you mean coming loose in the headset yeah exactly put it looping them through the tunic and then making sure that they were in contact with the headset and again to say that that's a
02:30:16 to say that that's a you know obsolete technology in the leadership group and then to see that this this was a frequent complaint of firefighters on this on the scene of the of the fire to me
02:30:28 the of the fire to me illustrates that making do was seem to be not necessarily acceptable but i don't think it had sufficient challenge as a technologist i i wouldn't have
02:30:39 as a technologist i i wouldn't have accepted that myself can we go to para to page 51 of your report and let's look at section 3.6.2
02:30:48 you uh talk about delays under the paragraph there and you you say in the previous paragraph that the personal radios and barry sets were introduced in 2005 and 2006 and in this
02:31:00 introduced in 2005 and 2006 and in this paragraph 3.6.2 you say following the grenfell tower fire the lfb have acknowledged that quotes the anticipated life expectancy of the radios was 10 to 12 years while the barry was expected to
02:31:11 12 years while the barry was expected to need replacement after eight to ten years and that's a quotation from an update called replacement of incident ground communications now
02:31:20 now uh
02:31:22 uh given
02:31:23 given the age of this equipment and its date of initial introduction that i think am i right would would result in an anticipated replacement date of between 2015 and 2017 for the
02:31:34 of between 2015 and 2017 for the handheld uf uhf radios and 2013 to 15 for the for the barrys yeah yeah that's my understanding would you expect an organization to replace communications equipment at
02:31:46 to replace communications equipment at the end of its life expectancy irrespective of its performance or would they wait until that equipment had reached the end of its usable life there's no simple answer to that but i
02:31:58 there's no simple answer to that but i think the question should be based on the risks posed by continuing to use those equip those pieces of equipment in the light of operational experience such as the previous incidents that we've described involving high-rise buildings
02:32:12 i also have seen arguments used in and again it's cited in my report where people say that a device continues to be adequate because it's still it's still sold in the marketplace which to me
02:32:24 sold in the marketplace which to me uh is not a convincing argument explain why not well i could probably go out and find a vhs video recorder being sold but that doesn't mean that it's an except you
02:32:35 doesn't mean that it's an except you know
02:32:37 know an adequate means of digital communication in today's society i mean you know
02:32:42 you know i think there's an opportunity cost in not upgrading technology which can be measured at least in terms of the additional risk that could have been mitigated by the use of more flexible or modern forms of
02:32:53 use of more flexible or modern forms of communication certainly i think the roving headsets is an example of that and
02:32:59 and at the very least i would have and in answer to an earlier question you were suggesting about the uh the use of more detailed evidence i would have liked to have seen
02:33:10 would have liked to have seen more detailed and coherent evidence to explain why the status quo was acceptable given the range of more potentially more flexible alternatives that were being discounted
02:33:21 that were being discounted now if we look at paragraph 3.6.6 on page 52 the next page you excerpt from the 2014-15 departmental plan of lfb's operational resilience and
02:33:33 lfb's operational resilience and training department ought as follows and there's a quotation 7th january 2015 quarter 3 2014 to 15 during the information gathering stage
02:33:45 during the information gathering stage for this activity it became apparent that the current barrier sets are still available and supported and that they continue to operate effectively based on this information action has been taken to defer the replacement of barry and is
02:33:57 to defer the replacement of barry and is radios until 2018. the relevant cmb corporate management board report has been written on behalf of the lead department i.t it is anticipated that this will be accepted by cnb at that
02:34:08 this will be accepted by cnb at that point this activity will be shown as complete
02:34:13 complete now
02:34:14 now others may recall that this document from which you are quoting was shown to assistant commissioner gary reason uh now as i understand it your opinion is that the conclusion that set out
02:34:25 is that the conclusion that set out there was unsustainable is that correct i
02:34:29 i i think this and many similar conclusions throughout my report which were used to justify the delay of procurement should have been supported by a more detailed technical analysis laying out the potential risks of
02:34:40 laying out the potential risks of following that policy yes and
02:34:43 yes and and
02:34:44 and can i put this to you that it was it was it was also an unsustainable conclusion because of first communication problems experienced at previous incidents not least latino house i'd 100 agree with you on that
02:34:57 house i'd 100 agree with you on that point and usability issues such as barry headsets
02:35:00 headsets roving as you put it becoming loose and dislodged i agree again with that point and also the conclusions of the cfoa and local government association peer review of the lfb in march april 2015 would you
02:35:12 of the lfb in march april 2015 would you refer to in your footnote on page 51 at section 3.6.3 the only caveat i would raise is that i think that the arguments that you're
02:35:23 think that the arguments that you're making are really good examples of a more general problem and this is not this is not the only instance in which arguments are made against a system a more coherent replacement policy of
02:35:34 a more coherent replacement policy of different pieces of equipment so yes i agree with all that you said right can you identify anything that the lfb was not aware of in relation to the aging nature of its comms equipment
02:35:46 aging nature of its comms equipment in 2015 nothing
02:35:50 thank you now
02:35:53 can i raise a small caveat to that though again really which is very important to me personally which is that many of the incidents that i've cited from in my report the the reports
02:36:05 cited from in my report the the reports were extremely difficult to find and i so although i agree with you that most of this information or all of the information that we've reviewed was available to them was it available to every person that
02:36:16 was it available to every person that was in a significant decision-making role within the organization i can't answer that is there any central resource where somebody with an interest in
02:36:27 in asking significant questions about technical infrastructure supporting uk frs again i think that that's a significant omission that undermines the future safety of firefighters and
02:36:38 future safety of firefighters and residents
02:36:40 residents sorry about that i just wanted to make that really clear yes thank you very much for that clarification um i'd like then to move from the issue of delay and on to what you've described as the failure to tackle the limitations of existing radio systems in concrete
02:36:52 of existing radio systems in concrete high-rise structures which we saw in in
02:36:55 in in the reported earlier if we go back to page 31 please
02:37:03 you can see it section 216 that's your conclusion communications concerns were known
02:37:09 known and then if you look at 216 4.4
02:37:13 4.4 you
02:37:14 you say there
02:37:15 say there senior officers argued that they could not reasonably have foreseen an incident on the scale of grenfell tower and then at 2.16.5 however many of the incident ground communications problems that were
02:37:26 communications problems that were experienced during the fire were well known particularly in the aftermath of the latino house fire but also from other previous fires in the uk and from terrorist attacks all summarized in section 4 of my report
02:37:39 section 4 of my report and then at subparagraph 6 you say significant opportunities to learn lessons from previous incidents were not taken and you give examples
02:37:50 taken and you give examples now if you go to paragraph 24 on page uh on page 26 within section 2.10 you
02:37:59 you considerable cultural change is required if the lfb is to fully exploit the opportunities offered by these technologies in the future digital incident ground
02:38:10 incident ground in summary what do you mean by cultural change
02:38:16 i think that there are fantastic opportunities although my evidence today might have seemed slightly negative and critical i think this is a real turning point and there's a there is an opportunity to do things better here
02:38:29 opportunity to do things better here the cultural change i've talked about in many sections of my report so the first point i would make is to reiterate something that we've just said which is that there is ample evidence of
02:38:41 that there is ample evidence of communication problems on the fire ground with breathing apparatus equipment from from many of the incidents that appear in my report i i've not seen any other easily accessible source that brings all
02:38:52 easily accessible source that brings all that evidence together um the second point i would make is that um
02:39:00 um the existing experience in the uk of our ability to handle the technologies to support emergency services is not good and it's characterized by delay and a
02:39:11 and it's characterized by delay and a lack of budgetary control and i think part of that is a is a rejection of things like open standards which could allow
02:39:23 which could allow more more
02:39:24 more more suppliers to provide products and services that are more agile in meeting the needs of fire and rescue services into the future and that cuts across one-to-one relationships with very large
02:39:36 one-to-one relationships with very large suppliers
02:39:38 suppliers and and i think that that's important when you look at later in my report when i discuss for instance the communication with the supplier of the text facility within airwave and that to me is a really
02:39:51 and that to me is a really eloquent example of the problems that i think exist at present
02:40:01 and finally i think if we go to page 36 in your report to section 2.22 professor you you have a heading cultural change from making do
02:40:12 from making do to technical excellence and you say this in uh section 2 22 a precondition for change is the acceptance that the lfb should
02:40:23 is the acceptance that the lfb should move away from a culture of focusing on device specifications towards resilient and systemic approaches where policy training and procurement are continually examined in the light of operational experiences
02:40:35 experiences not just from within their own organization but also from other frs and from other industries would it be fair to say that this cultural change which you have identified as needed is inherently
02:40:47 identified as needed is inherently connected to your suggestion of a safety case
02:40:49 case yes it is yes uh professor i've come to the end of my prepared questions for you there may be one or two others i need to come back to and others that others may wish me to ask but i get to ask the
02:41:00 wish me to ask but i get to ask the chairman now for a short break if i may yes
02:41:03 yes so that we can look at those well professor johnson when we get to this stage and the proceedings we always have a break to partly to enable council to check that he's not left anything out
02:41:14 to check that he's not left anything out that he should have covered and partly to enable others who are not here but are following the proceedings to suggest questions that perhaps we should put to you so we're going to break now we'll come back at half past four mr
02:41:26 we'll come back at half past four mr millet i i think that would be all right if i well if you need longer just send the ocean yeah thank you i think we'll get back if we can at first fall and we'll then see if there are any further questions for you thank you very
02:41:38 further questions for you thank you very much everyone thank you thank you would you like to go to the ocean
02:41:52 right mr miller well we'll say how fast four but if it turns out that more time is required you can just let us know thank you
02:55:34 yes you asked professor johnson to come back in yes
02:55:48 all right professor johnson well we'll see if there's any more questions for you
02:55:52 you yes yes mr miller mr chairman there are no further questions for you professor johnson
02:55:56 johnson so it only remains for me to express our gratitude to you for coming to the inquiry and giving us the benefit the very great benefit of your opinions and your oral evidence today as well as your
02:56:07 your oral evidence today as well as your your report so thank you very much indeed well thank you for everything that you're doing well professor johnson i really
02:56:13 i really think we should i should thank you on behalf of all three members of the panel we've
02:56:18 we've uh we found it very interesting to read your report and to hear your evidence today which has been really uh illuminating so thank you very much indeed a lot of work gone into your
02:56:29 much indeed a lot of work gone into your report we can see that and um it's good of you to give us a day it's your time to be here to give us your evidence so we're very grateful i'm very grateful well thank you very much indeed and now
02:56:40 well thank you very much indeed and now you're free to go thank you all right thank you
02:56:54 mr miller that is a convenient point for today i imagine it is thank you very much and we have another witness tomorrow we have an expert witness tomorrow it's steve mcgurk thank you very much well then we'll
02:57:05 very much well then we'll end the day at that point and we'll resume at 10 o'clock tomorrow morning thank you very much thank you very much