Former LFB Assistant Commissioner David Brown faces intensive questioning about chronic failures in fire survival guidance (FSG) training and record-keeping at Brigade Control. Brown admits that training record systems failed for six years despite repeated audits and warnings. The inquiry reveals training was reduced from full days to half days without authorization, role-play exercises were eliminated, fire safety officers were removed from training contrary to national guidance, and by 2017 no FSG refresher training had taken place before Grenfell.
00:00:27 good morning everyone welcome to today's hearing
00:00:30 hearing today we're going to continue hearing evidence from mr david brown formerly of the london fire brigade so if mr brown is there perhaps you'd ask him to come in please thank you
00:00:45 good morning mr brown yes please sit down make yourself comfortable
00:00:50 right ready to carry on i hope absolutely yes thank you very much yes mr cleaner thanks sir good morning mr brown good morning when we broke on thursday afternoon we're going to turn to the question of record keeping and that's
00:01:01 question of record keeping and that's the topic i'd like to start to discuss with you today okay now could we first turn to h o m quadruple zero double one two four forward slash three one
00:01:14 now this is an extract from the lachnal control report which was uh published in november 2012 and we see in the bottom third of the page under the heading e7
00:01:25 page under the heading e7 a heading conclusion about control officer training and knowledge and at paragraph 167 it says this an incomplete database record of training provided by the lfb to the
00:01:37 training provided by the lfb to the control offices exists covering the period from 1981 to 2011. this record includes initial continuation and refresher training given to control officers
00:01:48 given to control officers were you aware of that conclusion at the time i was now um
00:01:53 now um could we
00:01:54 could we bearing in mind that conclusion could we turn back to pn 164 and in particular the version that was current in 2009 so at the time of the lack of fire which we
00:02:05 at the time of the lack of fire which we find at lfb trouble zero eight four zero five four if we turn to page three within it
00:02:16 thank you now here we see and if we can look at paragraph two point five under the heading watch training record it says this
00:02:23 says this a record of all training and instruction carried out is to be maintained by each watch manager now given the poor record keeping that had been identified
00:02:34 record keeping that had been identified by the control report what did you do to ensure that record keeping and control satisfied the obligations set out here in paragraph two five of pn164
00:02:46 in paragraph two five of pn164 so there were discussions with so 2011 would have been prior to when richard chandler joined so there were discussions with scott
00:02:58 discussions with scott and his team at the time in terms of the issues that we'd found at lacanal and what we already had so excel spreadsheets was effectively what was kept
00:03:10 kept and just reminding scott and his team of the need to make sure that these excel spreadsheets were kept up to date and so so there's the issue of forward planning and then there's the issue of
00:03:22 planning and then there's the issue of recording which whilst we can deal with in a holistic manner are actually two separate issues and so i was as interested in the forward plan in as i was in the
00:03:33 forward plan in as i was in the recording of information now mindful of that when you received the control report in november 2012 um did you ask to inspect the training records that apply to control to see
00:03:46 records that apply to control to see that control training was being properly and effectively carried out no i didn't but i did ask scott to go through them and to assure me that he him and his team are satisfied that they
00:03:57 him and his team are satisfied that they were being carried out appropriately now could we go to nfb trouble zero double five two zero three forward slash seven
00:04:09 now this is an extract from station manager kelly's audit from august 2010 so slightly more than two years before the lac not control report and we can see then again the bottom
00:04:21 and we can see then again the bottom third of the page the subheading planning of training and below that if we can look at paragraphs 49 and 50. 49 says this notwithstanding the above
00:04:32 49 says this notwithstanding the above it is vitally important that adequate training planning systems are implemented for all courses including appropriate training records that support the cyclical training planning process
00:04:43 planning process and paragraph 50 under the emboldened heading says this implement adequate training planning and recording systems now would you agree that it's clear
00:04:54 now would you agree that it's clear that you are aware at least in august 2010 that a system was required adequately to record training in control yes
00:05:03 yes was the remedial measure that you took at the time or was taken at your instigation uh to bring control training in line with station training and use the uh step system for that purpose
00:05:15 the uh step system for that purpose uh it was but it was still some time after this before step was fully integrated in control in the same way as it was at stations and was it expected at least
00:05:26 and was it expected at least initially that control training would be as automated as station-based training in due course that was certainly long-term plan yes now if we can turn to lfb00106101
00:05:41 [Music]
00:05:46 we see here that on the 15th of january 2013 so two months or so after the latin or control report scott hayward sent ua what he describes as a detailed training audit summary as
00:05:58 as a detailed training audit summary as directed
00:05:59 directed now we can go to that summary which we can find at [Music]
00:06:05 [Music] six lfb001061 zero two forward slash one
00:06:12 now here we can see that the document sets out or purports to set out progress made as against station manager kelly's recommendations back in the summer of
00:06:24 recommendations back in the summer of 2010.
00:06:26 2010. can you help us why had you asked scott hayward to provide this update well this was as a result of the regular meetings i had with scott and
00:06:36 and we'd been discussing it at a meeting and there was obviously a lot of information so i asked him to put him right into me so i could review it and then discuss it with him further future meetings were you mindful that the latino inquests
00:06:48 you mindful that the latino inquests were coming up soon well yes that too yes but that it wasn't this this wasn't uh
00:06:54 uh done in order just to satisfy the issues that were going to arise from the
00:07:02 the inquest
00:07:03 inquest this was as much to do with the normal day-to-day management i was having over control and you're aware these were against station manager kelly's recommendations and we'd seen what he said in respect of training you'd have
00:07:14 said in respect of training you'd have the latino control report and it had obviously made conclusions relation to training was it was your request for an update therefore prompted by the fact that little if any effective progress had been made in
00:07:25 effective progress had been made in relation to the maintenance of adequate records of training yeah i think at one of our meetings i discussed the issue with scott and i wasn't satisfied so i wanted a more detailed breakdown of
00:07:36 wanted a more detailed breakdown of exactly what was going on could we turn over the page page two and look at paragraph six please we see that the recommendation to implement adequate training planning and
00:07:47 implement adequate training planning and recording systems and the update says this in red text there is a control owned spreadsheet detailing trainer-led or external training courses for all staff
00:07:58 training courses for all staff this database has been transferred onto the step database however it is still a requirement to manually update step as staff complete courses we are still working with it to enable
00:08:10 we are still working with it to enable our training to be automatically updated onto step when the course has been completed
00:08:16 completed now can you help us as to why some two and a half years after the decision to move to recording on step it's still been updated manually
00:08:27 it's still been updated manually yes this was this was a source of of disappointment to all of us it just basically breaks down from what i can recall to
00:08:38 i can recall to interface issues between step and uh the staff attendance recording system in control and the shift system in control because there were short shifts late shifts early shifts long shifts
00:08:50 late shifts early shifts long shifts and it was my understanding it was difficult to be able to map them all together so the issue the compromise was that
00:09:01 issue the compromise was that control would send the information to information management who would load it up
00:09:05 up sometimes shortly after this control actually got access to steps they could load it up themselves and then sometime later it became automated so it was a painfully slow and gradual process
00:09:17 painfully slow and gradual process now
00:09:18 now your understanding appears to be therefore that the block to implementation was technical rather than anything else is that a first summary it was
00:09:29 it was certainly was technical and and i i intervened and spoke to people to try to hurry along to assist the management in control i think also there could have been more
00:09:42 i think also there could have been more more pushing from control side of things i think there's a combination of issues but certainly blockages were a a big issue for us
00:09:53 a big issue for us one thing that scott hayward said in his evidence was that the the glacial progress was due to quotes competing priorities rather than any particular technical problem and he
00:10:05 particular technical problem and he explained that stepp took its information from stars and that an operational change to stars took uh priority over the control elements of stars and for that reason
00:10:17 elements of stars and for that reason manual inputting remained the case were you aware of that particular problem at the time there certainly were constant upgrades to stars
00:10:28 to stars uh it isn't i don't think it's true that operational updates routinely trumped control updates uh certainly operational updates were
00:10:39 uh certainly operational updates were very important but it depending dependent on the merit of what the update contained so so certainly there were competing priorities that is absolutely true yes and were you mindful of a tendency to uh
00:10:52 and were you mindful of a tendency to uh downgrade or put differently place insufficient weight on priorities for control training as opposed to for example operational training
00:11:04 no i don't i don't think that's necessarily the case uh but as i as i've just said in terms of being more proactive and pushing it from
00:11:15 being more proactive and pushing it from control as i think we spoke about on thursday in terms of the control not being an obvious and ever-present system within headquarters it used to be i
00:11:26 within headquarters it used to be i think those two issues probably made it even more difficult difficult for control to to make their case as it were now could we go back to the replies
00:11:38 the replies you gave on the 16th of january 2013 to various questions that rita dexter had posed to you in relation to the lindridge review and if we could go to lfb trouble zero eight
00:11:49 if we could go to lfb trouble zero eight five eight five four forward slash one five
00:11:54 thank you and we see here action reference 16 is in the center of the screen
00:11:59 screen and the
00:12:00 and the bottom paragraph of the review process findings box is entitled training records and it says this currently all training control is recorded on a spreadsheet at control and
00:12:11 recorded on a spreadsheet at control and transferred to step by the information management department now in the corresponding comment rita dexter asked this and there is some evidence or verification that this has ever happened
00:12:24 verification that this has ever happened and you replied excuse me
00:12:27 excuse me i'm assured it has all been transferred from the spreadsheet to step i have randomly checked one from each watch to confirm a manual system exists for future training work is progressing
00:12:38 for future training work is progressing well to get it automated now first of all what had you checked from each watch in order to provide this assurance to the deputy commissioner that a spreadsheet existed
00:12:50 that a spreadsheet existed so when when you and i spoke on thursday and i explained i'd visit control roughly monthly i'll try to spend at least an afternoon or a morning or ideally all day there
00:13:01 or a morning or ideally all day there and do a range of different things particularly discussing with staff in the control room and i'll take the opportunity to talk to the trainers who were also in the control room virtually
00:13:12 were also in the control room virtually all the time and then took the opportunity just to look and see that these spreadsheets existed and was that spreadsheet on step at the time now the spreadsheet will be kept separately and then would be sent to
00:13:24 separately and then would be sent to information management who uploaded it onto step can you remember now what did the spreadsheet show in particular i think the spreadsheet showed names on each watch and the type of
00:13:37 names on each watch and the type of training that would have been carried out and the dates on which that training was conducted and is
00:13:44 and is you say you went to control monthly on each of those occasions did you check this spreadsheet to see whether records were being kept properly and fully no
00:13:55 and fully no can you help us to why not the reason i ask mr brown is obviously you had station manager kelly's views at the latino control report progress is clearly slow but politely
00:14:07 progress is clearly slow but politely why didn't you check the spreadsheet well if i can just briefly just give some some background to control so control was a group of staff of approximately 100 so
00:14:19 approximately 100 so it matched a very large fire station the difference between the two was a fire station had one station manager managing it control had a principal
00:14:30 managing it control had a principal operations manager two senior operations managers and the station manager uh fire station had four watches with a station officer in charge of each watch control had six operations managers two
00:14:42 control had six operations managers two of which would be on duty at the same time at a certain part of the day a fire station had between about eight and twelve crew managers control ed 22 assistant operational managers they had
00:14:54 assistant operational managers they had their own training team they had their own technical support group their own security their own engineers that they were the most highly managed group of staff that i managed
00:15:06 group of staff that i managed so my view was the last thing they need is someone else looking at the same records they've got a competent management team to do it it's my job to make sure the systems are in place and to support them in doing it so that's
00:15:18 to support them in doing it so that's the reason why i wouldn't go into that level of detail plus the fact i wanted their management team to do it and if i did it that that potentially gives an opportunity for others to say there's no
00:15:29 opportunity for others to say there's no need for me to do it could we go to an update that sue budden provided on the month of february 2015 to you and others about progress in relation to implementation
00:15:41 progress in relation to implementation of internal audit recommendations we can find this at lfb 0076158
00:15:48 0076158 forward slash 2. there we go we have the email that she sent there it appears to relate to audit recommendations that were presented to the corporate
00:15:59 were presented to the corporate management board that morning if we scroll up we can see that suit button was sent an updated version of the progress report on the 19th of february 2015.
00:16:11 2015. now if we can look at that updated report which is at lfb trouble04 640.
00:16:23 we see on page one under the summary title it says this this report summarizes the work carried out under the internal audit shared
00:16:34 out under the internal audit shared service agreement by the mayor's office for policing and crime mopac directorate of audit risk and assurance dara in the third quarter of 2014-15
00:16:46 is it right therefore that mopak's directorate of audit risk and assurance carried out internal audits for the lfb under the terms of an internal shared services agreement that's correct
00:16:57 services agreement that's correct how often would control be audited by mopac
00:17:02 mopac it wasn't a regular program this was something that we discussed at our corporate management board
00:17:09 board and uh i seem to remember suggesting that it will be beneficial if control was included in mopac audit were you interviewed as part of the audit process or was your role limited
00:17:21 audit process or was your role limited to instigating the audit i don't recall being interviewed i think it was more about instigating the audit now if we can stay in this document but go to page 25 which hopefully is annex b
00:17:37 now we can see on the left hand side the far left hand side the first column refers to brigade control and it cites a final report dated february uh 2015.
00:17:48 february uh 2015. now
00:17:49 now i'm assuming that you read the final report is that a sound assumption yes would you have read this summary report before it was circulated to the cmb
00:18:00 before it was circulated to the cmb yes
00:18:01 yes now if we look at the second column from the left
00:18:04 the left it sets out areas of quotes effective control close quotes and then moving rightwards the third column is entitled risk recommendation and category is that
00:18:16 recommendation and category is that right yes
00:18:17 right yes and in the third column it recorded the following
00:18:21 following risks
00:18:23 risks uh paragraph one the training spreadsheet may be completed inaccurately or even altered intentionally which could impact upon the ability of brigade control to
00:18:34 the ability of brigade control to effectively monitor the provision of training
00:18:36 training this could in turn result in the reporting of incorrect information to senior management paragraph two if the spreadsheet is not completed consistently and accurately then the
00:18:48 consistently and accurately then the ability to monitor training levels may become difficult and inappropriate decisions
00:18:54 decisions may be made now
00:18:57 now those particular risks appear to have been accorded a medium rating is that a correct reading yes um did you discuss these two particular risks with mr
00:19:08 these two particular risks with mr hayward yes um did you discuss them with anyone else
00:19:14 i i would have most certainly discussed it with my line manager at the time when i had my regular meetings with her just to update her what was happening
00:19:25 just to update her what was happening but in terms of in terms of progressing these it would have been scott
00:19:31 in light of those discussions um why in your view by the time we get to february 2015 were there still significant problems with the recording of training at
00:19:43 with the recording of training at control
00:19:46 i think partly because we still hadn't moved on from sending the information to information management to upload and it was soon after this in in fact i seem to recall
00:19:58 after this in in fact i seem to recall it was this that that helped achieve controls access to step rather than send to information management there was
00:20:08 there was there was always the issue of what i would call central led training versus locally led training which which is a bit of an odd analogy for control because they're so analogous but
00:20:19 but essentially their training is what will be delivered by the training team locally led training is what the operations managers would determine what was necessary for their own staff on their own watches
00:20:31 their own watches and it was it was that locally their training i think was was the weak point in this in terms of not being recorded which is why i always believe there was much more training that went on than was actually recorded
00:20:42 actually recorded by this stage we're nearly a half decade on from station manager kelly's audit just under three years on from the latino control report
00:20:53 latino control report did it
00:20:55 did it occur to you at the time that progress is not being made we are not dealing with this issue and what the root causes of such a glacial
00:21:06 what the root causes of such a glacial delay were uh yes absolutely those concerns however were were
00:21:16 were colored by the fact that there was a a large amount of individual types of training going on that that there were individual plans for and things were
00:21:27 individual plans for and things were being recorded and i think there was it wasn't
00:21:32 wasn't a few a year or so before this i'd asked for some uh details of training records in terms of fire survival guidance training and the information i got back
00:21:43 training and the information i got back was was very encouraging so
00:21:47 so that combined with the fact that the operational support team did have a training plan for delivery which isn't quite the same thing and plus the the rush to get vision uh trained and
00:22:00 the rush to get vision uh trained and sorted
00:22:01 sorted kind of took the emphasis and the focus away from the the core issue that really needs to be resolved i think noting that mr brown looking at paragraph one of the
00:22:13 mr brown looking at paragraph one of the risk
00:22:14 risk uh column and the conclusion where it says the problems could in turn result in the reporting of incorrect information senior management did that observation not give you at the very least pause for thought that what you've
00:22:26 least pause for thought that what you've been told about the nature and extent of training may not be wholly reliable put mildly yeah absolutely and as i say i'm i'm pretty sure that this
00:22:38 pretty sure that this is what was the uh emphasis and the push to actually get the the access to step although it didn't achieve our ultimate game not just yet in terms of
00:22:50 just yet in terms of automating the process can you help us we see in the fourth column from the left uh responsibility and agreed action and this number of actions set out there
00:23:01 and this number of actions set out there to make good the deficiency how did you ensure that those that quartet of actions was actually implemented well so the responsibility here was a senior operations manager
00:23:12 here was a senior operations manager which i believe at the time was probably vic bagnol stroke keith diamond i think they were the two it might maybe lindsay turner but she
00:23:23 it might maybe lindsay turner but she might have left by then and and whoever they were would have reported to scott so then i would have gone through scott to make sure that he had a handle on
00:23:34 to make sure that he had a handle on what was going on i wouldn't have gone straight to these senior operations managers
00:23:38 managers can we now turn to a separate document which is lfb trouble zero three two one six nine forward slash eleven and this is uh assistant commissioner george's review of brigade control that he
00:23:50 review of brigade control that he carried out in july 2016 so 16 months or thereabouts after the mopac audit reported and if we look at paragraph 47
00:24:01 reported and if we look at paragraph 47 and in particular the second line he said this
00:24:05 said this the review has identified that maintenance of skills training is ad hoc not planned in a robust manner and often not recorded on individuals training records itrs whilst there is a responsibility and
00:24:17 whilst there is a responsibility and onus on individuals to maintain their itrs correctly by manually entering completed training this is not often done and staff are sold and instructed to do so by their managers
00:24:30 to do so by their managers now if we could turn over the page and look at paragraph 49 c
00:24:38 top of the page we can see in the third line he recommended the following all training must be recorded on an individual's itr the pom somms should work with
00:24:49 the pom somms should work with colleagues from the brigade's information management team to introduce an i.t solution to this similar to training diaries used by station staff
00:25:00 used by station staff now
00:25:01 now looking at what the assistant commissioner has concluded there is it fair to say that the risks identified by mopac 16 months previously had still not been addressed in relation to the recording of training
00:25:14 recording of training they're not being fully addressed in the way that we wanted to since this the gap between this report and the mocap mopak reports had seen
00:25:25 had seen step
00:25:27 step access given to control but still not the fully automated system so so they're on a journey but it was still taking too long to get to the destination but
00:25:38 destination but you're on a journey for working purposes that journey started in august 20 2010 with station manager kelly's report and his recommendations in respect of record keeping hadn't been
00:25:50 record keeping hadn't been satisfactorily implemented by this stage either had they what we what we did have so for example there we was introducing training for
00:26:01 there we was introducing training for resource management center and national coordinating center and i'd ask for attributes to be allocated to stars because we had small groups of staff within each watch
00:26:14 small groups of staff within each watch trained specifically in these roles so we wanted to make sure that these numbers of staff were always available not on leave etc so that for example we got an automated
00:26:25 so that for example we got an automated solution straight away so there were certain parts of things that were working to the same standard of what was happening at fire stations it was the holistic approach to training
00:26:37 it was the holistic approach to training in its entirety that was that was behind fire stations would you accept that this recommendation here and its predecessor in the form of station managers kelly had still not been fully or properly
00:26:49 had still not been fully or properly implemented by the time you retired in march 2017 yes
00:26:56 taking the step back now would you accept that the recording of training was a chronic systemic problem that was never satisfactorily resolved whilst you were responsible for control
00:27:08 it was i would accept that it was our challenge was to bring in line with station based approach to training recording we didn't achieve that i
00:27:19 recording we didn't achieve that i wouldn't go so far as to say that it was a chronic failure because i think that's i think it's massively overstating the issue there were provisions to recall training there
00:27:30 were provisions to recall training there were provisions to plan training and aspects of it were as good as stations based staff but we'd achieved such a high bar with station based approach to training recording that control wasn't
00:27:42 training recording that control wasn't up to that standard could we move on to a separate but related topic which is the monitoring of training and to start could we go to your first statement and paragraph 66 which can be found at lfb
00:27:56 paragraph 66 which can be found at lfb travel zero three two one double six forward slash two one
00:28:04 now there you say uh this it was not my role to personally audit the control rating training records to ensure that fsg refresher training was taking place on a systemic basis or
00:28:16 taking place on a systemic basis or annually i relied on the management structure and control led by pom scott haywood to schedule and monitor the completion of fsg refresher training which i tested at monthly management
00:28:28 which i tested at monthly management meetings
00:28:29 meetings with these monthly management meetings the one to ones which we discussed on thursday
00:28:34 thursday uh yes but also at the principal management board where we would quarterly discuss departmental plans and risk registers would you be provided with
00:28:45 would you be provided with written reports for these purposes of testing what was going on or would you rely upon verbal assurances given by scott hayward or a combination it'll be a combination
00:28:58 did those meetings the one to ones routinely take place monthly uh
00:29:04 uh yes i think with we've established uh on the odd occasion one would be cancelled but it will be rescheduled it certainly won't be the case that monthly meeting will be missed
00:29:15 will be missed and would that be would that routine be kept even when even in for example assistant commissioner chandler's absence oh yes once
00:29:26 oh yes once uh
00:29:27 uh in
00:29:28 in when when richard uh left then i re-established the meetings with scott even for the period when richard was on extended leave for about four-month period whilst he was in post
00:29:39 four-month period whilst he was in post i then re-established the meetings with scott and if scott wasn't available for a period he was going to be on annual leave then then i would make sure i met with one of his sons
00:29:50 sons and those monthly meetings am i right understanding they'd you keep that routine even when assistant commissioner commissioners chandler and george were imposed
00:30:01 chandler and george were imposed i know once once they was in post then the monthly meetings uh reverted to them so i only met scott when richie chandler or tom george were
00:30:12 when richie chandler or tom george were not imposed
00:30:16 in when you had your meetings with scott haywood how frequently would training be a topic for discussion it would
00:30:27 it would it would effectively be a a standing item to discuss now scott hayward said in evidence that you didn't exercise much oversight in relation to training what be your
00:30:38 relation to training what be your response to that evidence i think what he's probably referring to is i didn't exercise much in terms of looking at specific records
00:30:49 looking at specific records but then my response to that would be as as i said
00:30:53 as i said earlier
00:30:54 earlier training control was effectively the size of a large fire station and the reason we had so much uh
00:31:01 uh performance management fire stations because there was 102 of them there was only one of control and it was highly managed so the reason i didn't go into that level of detail was because of those very
00:31:12 of detail was because of those very reasons so i think that's what scott is probably referring to not the overall interest in trying could we turn to lfb double00109092
00:31:24 now this is the version of the kelly audit on which you commented in august 2010 and could we go to page three and paragraph one
00:31:39 expanded
00:31:43 we see in the second line that it says that the audit had been approved by the training management board what was that body
00:31:53 sorry where is that paragraph one all right second line
00:32:00 i think the training management board was a
00:32:03 was a a subset of the [Music]
00:32:07 [Music] this would have been prior to babcock
00:32:11 so when there was a training department within the brigade i think the training management board was a a strategic decision making board within it i don't believe i sat on that can you remember
00:32:22 believe i sat on that can you remember now who did sit on it if you can't remember i can't remember i could have an educated guess but i can't i don't know for sure can you remember now how frequently it met if it was a strategic body if it
00:32:33 met if it was a strategic body if it strategic body it would be able to admit every three or four weeks
00:32:39 can you remember now what substantive role it played in the monitoring of training
00:32:48 i i seem to recall it was it was more about training delivery in terms of uh
00:33:01 not not not delivering so much is looking at how successful the delivery was but about arranging delivery looking at what courses needed to be delivered based on what information could we go to page nine
00:33:13 could we go to page nine and really look at the heading quality management and assurance if possible and if we see a paragraph 63 mr kelly said this
00:33:24 mr kelly said this any overarching quality management plan should document how the quality of training is reviewed maintained and managed uh bcts presumably brigade control
00:33:34 control uh training services does not have such a plan and if we turn over the page to page 10 and look at the summary of paragraph 74
00:33:45 he said this the development of a formal quality management plan would provide a robust framework
00:33:52 framework to effectively manage all aspects of brigade control training now while that was not part of his formal recommendation did you consider implementing a quality management plan
00:34:04 implementing a quality management plan to ensure the robustness of control training
00:34:09 yes first of all i wanted to move from just a delivery plan to an overall holistic plan as i've called it and then we could move on to a quality
00:34:20 and then we could move on to a quality management plan i would add that that there were as i've said there were aspects of this so there was quality assurance processes in place but they relate to specific parts of the
00:34:34 but they relate to specific parts of the control and there were there was assessment of the uh the outcome of the training that went on at the end of the training course and then the ongoing monitoring of the
00:34:46 then the ongoing monitoring of the performance of control officers so so there were aspects of all of this it just
00:34:51 just without wishing to sound like a broken record it was that they weren't all pulled together into one overall plan and whose responsibility was
00:35:02 and whose responsibility was was it to pull together the various strands well the responsibility sat with those immediately managing training the overall accountability would have sat with the ac or myself
00:35:14 with the ac or myself now if we look at paragraph 75 mr kelly says this the call coach system is an effective tool for managing staff performance in terms of their response to emergency calls
00:35:25 to emergency calls were you aware at the time that call coach was used to monitor and quality assure emergency calls yes i'd authorize the purchase of it
00:35:34 it now in her evidence joe smith thought that an agreement had been reached before the latter fire that fsg calls would not be quality assured by call coach
00:35:45 coach her recollection was that an agreement had been reached between dac payton that's payton and representative bodies by trade unions on the joint committee for
00:35:56 unions on the joint committee for controlled staff now do you
00:35:59 do you remember any such agreement no
00:36:03 no alan payton had been a long standing uh deputy assistant commissioner in charge of control and he retired about nine months after i took over the role of assistant
00:36:15 took over the role of assistant commissioner in may 2009 yes so it had been in there for some considerable time so if he had made such an arrangement it would have been an arrangement that would have existed for
00:36:26 for some time i wasn't aware of any such arrangement if indeed it exists but you hadn't come across it during your time um in charge no i'm well aware of dealing with unions that they are
00:36:37 of dealing with unions that they are very
00:36:38 very uh acute to the idea of specific monitoring that could lead to disciplinary action for their members so it doesn't surprise me that this would be discussed but if it ever existed i
00:36:50 be discussed but if it ever existed i wasn't aware of it if
00:36:53 if they weren't being monitored by call coach um what was your understanding for what arrangements were in place to quality assure fsg calls well fsg calls and i know from the best
00:37:05 well fsg calls and i know from the best value review i carried out in the early 2000s were always listened to by senior officers
00:37:12 officers after the fsg course so they were they were supervised and then listened to by the senior management team and on the basis that there was very few fs calls in relation to the
00:37:24 very few fs calls in relation to the total number of calls then that wasn't an onerous task um can we turn now to
00:37:32 to the separate question which is that joe smith
00:37:36 joe smith said that you never asked to consider the outcome of her call coach reviews is that accurate
00:37:44 uh i certainly i certainly wouldn't have asked joe directly that no [Music]
00:37:50 [Music] i don't recall asking scott such a specific question it would have been a more general question in terms of the
00:38:00 the the success of our qa on fsg which could involve a number of things in which call codes would be one now could we go back to the latino control report please which we can find
00:38:12 control report please which we can find at h o m quadruple zero double one two four
00:38:16 four forward slash five three
00:38:27 and we can see recommendation six which is the third box down from the head of the page and it says this the arrangements for the performance management of control staff should be
00:38:38 management of control staff should be set out clearly in a policy including the standards that staff are expected to reach how performance will be assessed and monitored particularly in relation to calls where fire survival guidance is
00:38:49 to calls where fire survival guidance is given
00:38:50 given now in the action paragraph immediately below that the recommendation is marked as completed and it goes on to say this since the latin incident brigade control
00:39:02 since the latin incident brigade control senior managers have undertaken an extensive review on all high-rise or fsg calls that have occurred now do you agree that the response is not
00:39:13 not an adequate answer to recommendation that uh commended the setting up of a policy setting out the arrangements for performance management particularly in relation to fsg calls yeah i think the
00:39:25 relation to fsg calls yeah i think the gap here is the policy note 164 training wasn't sufficiently updated to uh to recognize this i think that i think control have concentrated on policy note
00:39:37 control have concentrated on policy note 539
00:39:39 539 so i think you accept that that wasn't that action is not an answer to the recommendation is that a fair reading uh
00:39:47 uh it's not it's not completely inaccurate but it could be it could be a fuller answer if it included 164. can you help us as to why a bespoke
00:39:58 can you help us as to why a bespoke policy was not created to meet the recommendation set out here at recommendation 6. i think because
00:40:08 because the attention was on the creation of a new policy ie790 about fire survival guidance calls and because uh
00:40:16 uh as far as control were concerned that updated policy note 539 that updated the reference information files are updated to training documents i think in in in their mind then all of
00:40:27 i think in in in their mind then all of that
00:40:29 that dealt with this recommendation can we now turn to lfb trouble zero four two three two six now this will be a document which is entitled performance information folder
00:40:42 entitled performance information folder operations prevention and response that appears to have been prepared for the performance corporate management board in february
00:40:54 corporate management board in february 2014 as we can see there in the center of the page first of all can you remember seeing this document at the time i can remember seeing documents like this i can't recall this particular one
00:41:05 this i can't recall this particular one but this was a regular document i would have looked at and i think i'm right in saying that you were a regular a 10-year performance cmb is that right i was yes now if we can go to page three
00:41:20 you see there the contents table but below that at the bottom of the page it says prepared by odsg
00:41:30 what was that body
00:41:35 operational directorate support group i think
00:41:39 think there's a hint of doubt in your voice there i know it's not an acronym that strikes
00:41:44 strikes struck you as immediately i haven't seen that acronym for some time and i'm just i think it's operational director support group now looking above that in the contents table it includes a reference to quotes
00:41:55 it includes a reference to quotes departmental performance including four quotes mobilizing rmc that appears to include control is that a fair reading yes
00:42:07 a fair reading yes can we go to page 68
00:42:14 if we turn over the page
00:42:27 there we go we've got various forms of performance data in relation to control is that right yes and if we go further into the document page 73
00:42:40 we see there are an organogram and we've touched this on this with um in previous evidence but we can see that the position of head of mobilizing rmc
00:42:51 of mobilizing rmc was vacant just below the top of the tree just below you is that right yes because that was after assistant commissioner chandler had left in october 2013 is that right yes
00:43:04 october 2013 is that right yes i think as we've discussed before um scott hayward was without a direct line management um in the interregnum and certainly about this time in february 2014 yes
00:43:18 now if we go to page 75
00:43:23 we find the risk register for control and then if we turn over the page to page 76
00:43:31 page 76 we have what is described as plan
00:43:37 can you remember now was the plan for control or mobilizing or both
00:43:44 or both uh both
00:43:45 uh both can you remember who developed the plan that would have been a joint effort between control and
00:43:56 control and whoever was managing them so either myself or richard chandler or or quite possibly some of before i ever came along between alan payton and john anthony i think was the assistant
00:44:08 john anthony i think was the assistant commissioner at the time can you remember ever seeing the plan itself the reason i ask is um it's not been possible to locate it
00:44:19 locate it uh
00:44:20 uh yes yes this this was something that i really pushed on as a way to try to uh manage
00:44:29 uh manage uh
00:44:29 uh you know the overall planning of control and we would we would update this throughout the year our performance our principal management board and so it would be the benchmark against which you
00:44:40 would be the benchmark against which you judge performance yes yeah a very strategic level yes can we go further into the document to page 78 and look at item mb 44 which is
00:44:52 44 which is roughly two thirds of the way down the page
00:44:55 page and it identified the following task develop and improving upon current training practices within control it is marked as on target
00:45:07 it is marked as on target can you help us now what was the type that particular target in relation to mb 44 so it wouldn't have been a target in in sumatra's uh a numerical target it was
00:45:21 sumatra's uh a numerical target it was looking at the uh
00:45:24 uh text which is working towards adopting the authority's standard bespoke software for planning recording training still awaiting full accreditation to the step programme so on if this was 2014 i've been before the
00:45:37 on if this was 2014 i've been before the mopac called it and it was working towards a getting control access to step and then
00:45:45 and then automating steps so it it refers to that journey that i'd mentioned
00:45:51 mentioned another signpost on the way yes if we look at mb 44.2
00:45:59 the task is and i quote arrange ongoing control training and that task is marked as completed can you remember now what the target was for that task
00:46:23 no this this is i so so scott and his team would have completed the uh
00:46:30 uh the text to this i suspect they're referring to uh fire survival guidance training that fell out of lachenal whereas strictly speaking this should be as a sound more holistic approach to
00:46:42 as a sound more holistic approach to training in which case it wouldn't really have been completed it wouldn't have been completed not if it was not if it was the holistic approach to training because as i've
00:46:53 approach to training because as i've explained it was the various component parts
00:46:56 parts that they would look at as being completed not this overall training plan can you help us as to the basis on which mb 44.2 had been
00:47:08 mb 44.2 had been marked as completed i think because they're referring to fire survival guidance training in terms of a program for it you say you think that is that um are you in the realms of educated guests yeah yeah so it's an educated guess yeah
00:47:20 yeah yeah so it's an educated guess yeah yeah not your recollection no can we turn to mb 44.3 uh the task there is arrange call handling training
00:47:31 handling training that is said to be quotes on target close quotes can you help us as to what the target was for that particular task
00:47:41 call handling training is is normal business for control staff and so assuming the answer that you've given previously
00:47:53 the answer that you've given previously applies to this for the purposes of the performance cmb you were relying upon information provided by scott hayward is that right yes so so call hand in training he's just
00:48:04 just refresher training in the very bread and butter role of a control officer other than performance cmb and the latino house board was controlled training monitored by any
00:48:15 controlled training monitored by any other lfb committee body group only when this particular departmental plan and the risk register would be presented to a performance management board which i
00:48:27 a performance management board which i chaired and scott sat on and but the performance cmb continued to sit throughout your time at the lfb is that right yes
00:48:34 right yes can we now turn on to a sub-topic related to training and that's insofar as it had regard to the issues arising from the latino fire and
00:48:45 issues arising from the latino fire and particularly on control fsg training and if we could turn first of all to pre-inquest action 11 which concerned the delivery of initial fsg training
00:48:56 the delivery of initial fsg training which complies with national guidance to develop the performance of cros now the starting point here i'd like to take you to is your second statement and paragraph 24 which can be
00:49:07 statement and paragraph 24 which can be found lfb travel zero eight four zero two zero forward slash eleven
00:49:18 now here you say in paragraph 24 at the bottom of the page you say this i did not have any direct involvement in the delivery of the initial fsg training
00:49:30 the delivery of the initial fsg training to brigade cros i believe this task was overseen by scott hayward with the support of the brigade training officers did you have any indirect involvement
00:49:42 did you have any indirect involvement only in terms of uh asking for updates from scott as to progress were you involved in the review or scrutiny of the new fsg training
00:49:53 scrutiny of the new fsg training packages no how did you satisfy yourself that the new packages satisfied the requirements of fire service circular 1093 and the supplementary guidance in 5404
00:50:08 supplementary guidance in 5404 because
00:50:09 because this well we're in a number of ways so this was being completed by scott and his team lindsey stroke joe when joe was available i.e not
00:50:21 joe when joe was available i.e not seconded
00:50:22 seconded but then there was also the lacking house team that tim cuthbill and tom davis were involved in for various aspects of the lachenal house recommendations and i was receiving
00:50:35 recommendations and i was receiving updates from tim cuthbill on a frequent basis as well as from scott so with those rounded conversations uh and also discussions at the latino house
00:50:46 also discussions at the latino house board where scott stroke joanne
00:50:49 joanne were
00:50:51 were were asked questions those issues put together
00:50:54 together gave me the uh the the structure of assurance that i was required could we go back to mr kelly's report from august 2010
00:51:05 mr kelly's report from august 2010 lfb double one
00:51:10 and page six
00:51:17 and we can see in the bottom third of this page under the heading assessments and results recording
00:51:24 recording and at the very bottom of the page we see paragraph 41 when mr kelly said this whilst the assessor does provide some measure of performance assessment of candidates during this role play is
00:51:36 candidates during this role play is carried out in a very informal manner there is no documented list of expected actions behaviors against which candidates performance should be measured
00:51:46 measured nor are there any records of performance documented at the time or after the role play
00:51:51 play this may potentially expose the brigade should such records wish to be scrutinized at a later date furthermore candidates are exposed to only one role-play scenario
00:52:03 role-play scenario whilst there are limitations on the course in terms of time it should be recognized that such role plays provide candidates opportunity to a demonstrate that they have achieved the
00:52:14 demonstrate that they have achieved the learning outcomes of the course excuse me and to b demonstrate under controlled conditions their current level of performance as such every effort should be made to ensure that candidates are given the
00:52:26 ensure that candidates are given the fullest opportunity to demonstrate both a and b and that suitable records of achievement are being kept and we see below 43 observed candidates
00:52:37 and we see below 43 observed candidates have commented that the role plays they undertook were fairly straightforward and not particularly challenging 44
00:52:45 44 opportunity therefore exists to strengthen the performance assessment element of the course this may include lengthening the course to provide candidates with more exposure to role-play scenarios
00:52:57 role-play scenarios building a robust expected actions and behaviors assessment recording sheet providing extra assessors during the role play elements improving training performance recording
00:53:09 improving training performance recording and we see that he then went on to recommend the following review the role play element of the course and ensure that a robust assessment and recording process is implemented
00:53:20 process is implemented now looking at what is set out there practical role play appear to be considered vital for two principal reasons
00:53:28 reasons first to ensure that learning outcomes were achieved secondly to assess uh cro's present level of
00:53:38 level of of performance and understanding is that a fair summary yes did you take any steps to ensure that role play uh was made more robustly realistic
00:53:50 realistic not directly no my my involvement here would have been to what was to discuss this with scott and and seek his assurances that he would
00:54:02 and seek his assurances that he would implement this of course
00:54:05 of course it appeared to go in the opposite direction
00:54:09 beyond discussing matters with scott hayward did you take any specific steps to ensure that mr kelly's recommendations were effectively implemented no apart from apart from monitoring so
00:54:21 no apart from apart from monitoring so when i visited control i would always discuss
00:54:26 discuss with the training team when i was there look at what they were doing talk to staff
00:54:31 staff and then to take the strategic approach to monitoring to look at what was going on in the brigade how control were performing etc but beyond that no i didn't
00:54:42 no i didn't take any particular role in specifically getting involved in the course and ensuring role play i saw that as a role for the the training team and the brigade management to deal with could we
00:54:54 brigade management to deal with could we turn over the page and look at paragraph 55
00:55:01 roughly midway down the page and under the heading management of level 2 acquisition of learning information mr kelly said this the emergency call handling techniques from fire survival guidance training
00:55:12 from fire survival guidance training document
00:55:13 document states that role play should be assessed however little detail is provided as to how that assessment should be conducted you see that he then went on to repeat his concerns about the robustness of the
00:55:25 his concerns about the robustness of the assessment process for fsg training and at paragraph 57 he said this furthermore without the implementation of a robust assessment process the achievement of all course learning
00:55:37 achievement of all course learning outcomes remains unconfirmed and therefore leaves the value of the file survival course open to challenge now in relation to that particular conclusion you commented this
00:55:49 conclusion you commented this from whom
00:55:50 from whom and over what first of all what prompted you to ask that question uh well because i felt that the uh the
00:56:02 uh well because i felt that the uh the content of paragraph 57 whilst uh
00:56:07 uh was valuable it didn't go into the detail that i wanted to know hence i just wanted him to expand more on what he was saying so i can make a judgment in terms of what we do with the
00:56:18 in terms of what we do with the recommendation were you disagreeing with the conclusion that if fsg training failed robustly to test whether learning outcomes had been achieved
00:56:27 achieved it would be susceptible to criticism from whatever quarter no absolutely not but yet equally i just wanted to explore and scratch away what was being said to
00:56:38 and scratch away what was being said to make sure that it was a valid and appropriate comment can we now put mr kelly's report aside for the moment at least and go to the minutes of the lagnal house board on the
00:56:50 minutes of the lagnal house board on the 15th of september at 2010. we can find that at lfb one 005
00:56:57 one 005 two
00:57:03 and we can see the very bottom of the page is item 5.4
00:57:09 and that says this fsg training has been reviewed to ensure it fully aligns with 1093 subject to recommendations made to clg all control staff have now received
00:57:21 all control staff have now received refresher training in fsg can you remember now who provided that particular update i should note that you did attend uh this meeting can i can i
00:57:33 did attend uh this meeting can i can i see the attendees please
00:57:44 i noticed that scott and joanne were both in attendance so it would have most likely have been scott
00:57:51 scott was pre-action inquest 11 which is to deliver initial fsg training can we take it from this document that that action was
00:58:00 was considered to have been completed by this stage i.e september 2010 yes because i i recall that action 11 was to do with moving the fire survival
00:58:11 to do with moving the fire survival guidance training element in the initial entrance course i think from the middle of the course to later in the course and and that was completed that was a that was a relatively simple
00:58:23 was a that was a relatively simple amendment to make can we turn over the page and look at item 5.8
00:58:36 that item says this lfb training came to audit control training team they recommended introducing role play on a number of call types now was the reference to an audit there
00:58:48 now was the reference to an audit there a reference to mr kelly's audit of august 2010 yes
00:58:55 can you remember now what in particular was discussed about the role play recommendation at the election house board yes giving you some more specificity was
00:59:06 giving you some more specificity was there any discussion of the substance of mr kelly's recommendations uh that for example it be strengthened by increasing for example the number of the amount of time afforded to it
00:59:18 time afforded to it i
00:59:19 i i can't recall the specifics of the discussion but that seems not an unreasonable summary
00:59:27 summary but you can't remember now can we turn to another pre inquest action and that is number eight uh you'll you may not recall but it was to do with uh including fire safety
00:59:39 to do with uh including fire safety input into fsg training to ensure that it complied with fire service circular and now for these purposes can we look at 1093 itself and particular appendix b
00:59:52 at 1093 itself and particular appendix b which we can find at lfb quadruple zero three six one seven forward slash six
01:00:03 there we have appendix b and we see at the top of the page there's the heading structure and that paragraph says this the training should be presented jointly by fire control and fire safety
01:00:14 by fire control and fire safety personnel and should comprise a lecture session of one to one and a half hours followed by a practical role play session to confirm the instruction it then goes on to set out that fire
01:00:26 it then goes on to set out that fire safety officers should deliver subjects at three which is fire safety introduction four effects of fire five escape from fire
01:00:37 five escape from fire six assessing the situation and jointly with control nine which is the practical session and role play were you aware of that particular guidance yes
01:00:49 guidance yes now if we can go back to your first witness statement which we can find at lfb trouble zero three two one double six four slash two one
01:01:00 and if we look at paragraph 65 roughly halfway down that page you said this it is correct that fire safety officers fsos were not involved in the delivery
01:01:11 fsos were not involved in the delivery of refresher training to control officers
01:01:14 officers steve churek the ac for fire safety regulation was satisfied that fsos had significant involvement in the design and content of the new fire survival guidance fsg
01:01:25 the new fire survival guidance fsg training for control officers and they delivered training to new starters to have involved fsos in the delivery of refresher training in mine and as i understand ac turex opinion was
01:01:36 understand ac turex opinion was unnecessary and an unnecessary use of lfb resources when there was a dedicated control training team in place to provide this training and fsos could be better
01:01:47 training and fsos could be better utilized in their intended role of inspecting premises when was that particular decision made not to involve fsas this would have been in
01:01:58 fsas this would have been in 2012 and if i can just add it coincided with
01:02:04 with a restructure in the brigade so prior to the middle of 2012 fire safety officers had reported through a line management
01:02:15 had reported through a line management chain
01:02:16 chain to
01:02:17 to borough commanders but then fire safety was taken out of that role
01:02:23 that role and they reported violence management into steve tarreck thank you could we go now to your second statement which we can find at lfb trouble zero eight four
01:02:35 can find at lfb trouble zero eight four zero two zero four slash ten
01:02:41 and if we could look at paragraph 19 which is in the top third of that page you say this ac turek and i did not undertake a formal assessment in order
01:02:52 undertake a formal assessment in order to reach this decision i.e not to involve fsos at that time my office was situated next to ac turek's office we would regularly meet face to face to
01:03:03 we would regularly meet face to face to discuss initiatives that had a joint impact on his and my teams i have no notes of any discussion i held with ac church about this action point and given the wide range of informal meetings and discussions i had with
01:03:14 meetings and discussions i had with colleagues it would have been outside of my normal practice to do so can you help us as to why you didn't record
01:03:22 record even in summary form the reason the fact of the decision and the reasons for it
01:03:31 we we ultimately discussed it at board and that was either the departmental management board or the lacrimal house
01:03:42 management board or the lacrimal house management board but outside of that we we
01:03:49 we we knew we was going to take it to a board so i guess that's why we didn't feel the need to discuss it also rather document it when we had our private discussions
01:04:01 it when we had our private discussions on it which board are you referring to there well it was i it was either the the lack of house board or the our departmental management board where the heads of service would sit and
01:04:12 where the heads of service would sit and it would be chaired by the deputy commissioner it was one of those two balls where we we raised the issue of what we'd agreed can we stay on this page and look at the
01:04:23 can we stay on this page and look at the next paragraph paragraph 20 where you say this
01:04:26 say this from what i remember ac church and i were satisfied that the involvement of the fsos in the design and content of the new fsg training package was sufficient and we jointly agreed that they should
01:04:38 and we jointly agreed that they should not be required to deliver the fsg refresher training to brigade cros the factors that influenced that decision were firstly fsos were already involved in the delivery of all initial
01:04:50 involved in the delivery of all initial or induction training of brigade cros secondly based on feedback from their line managers i was satisfied with the level of competency of the control training team to deliver
01:05:02 training team to deliver all the aspects of the new fsg training package and thirdly given the resource constraints the brigade was operating operating under we felt that fsos were better utilized in undertaking their core functions
01:05:14 in undertaking their core functions rather than being deployed to deliver a training package to brigade cros i felt that this was a sensible way forward in light of the performance targets and budgetary constraints facing
01:05:25 targets and budgetary constraints facing the brigade i accept that this decision was contrary to national guidance but based on sound reasoning and professional judgment it was a decision for individual fire and rescue services to excise discretion
01:05:37 rescue services to excise discretion over the extent to which they applied national guidance
01:05:43 now what basis were you satisfied that fso involvement in the design and content of new fsg of the new fsg training package was sufficient
01:05:55 so uh
01:05:56 uh so the fsos had had input into the design of the course and on the first refresher course in 2010 they had
01:06:08 they had been present so
01:06:10 so all available control officer had been trained on a full day in 2010 and also we were made by control of fire safety officers and we were also
01:06:21 safety officers and we were also maintaining the attendance of fire safety officers for new entrance training
01:06:25 training so so i was satisfied that everyone had sat opposite a fire safety officer in the last year or so how do you review the content of the training package
01:06:37 the content of the training package itself before reaching this view with ac turek no but my understanding is that steve turek had and did he say that to you directly yes how did the decision not to involve fsos
01:06:49 how did the decision not to involve fsos address for example the requirement for fso involvement in role play exercises
01:06:57 it was it was the the same rationale that we felt i felt that at steve's request because of the restructure and the need for him to allocate
01:07:08 allocate fire safety officers which appeared to be a greater priority and my confidence in the training team that they were able to undertake the role play element that we could
01:07:19 we could move on from refreshers without involving directly fire safety officers in your discussions with mr turek did either or both of you consider
01:07:30 either or both of you consider the extent to which fsu fso contribution was necessary to address the uncertainty in control about high-rise buildings and stay put advice which had been such a notable feature at lagnal
01:07:42 notable feature at lagnal we felt that the involvement in the creation of the packages and their continued involvement with new entrants was
01:07:49 was sufficient but did you specifically consider the need to address the uncertainty that had been noted in control about high-rise buildings and maintenance of
01:08:00 high-rise buildings and maintenance of state-put advice we didn't have a discussion specifically about high-rise buildings now
01:08:09 what feedback or information had you received about the competency of controls training team to provide this the new fsg training package uh well feedback from
01:08:22 uh well feedback from the control management but also my my personal uh
01:08:28 uh knowledge
01:08:29 knowledge of the control training team particularly two or three members that were long-standing members that were in my view competent trainers had you been able to form a view on the
01:08:42 had you been able to form a view on the competency of control staff to address matters
01:08:45 matters concerning fire safety i hadn't witnessed that first hand had you done anything to satisfy yourself as to the competency of
01:08:56 satisfy yourself as to the competency of controlled training to deal with matters that touched upon fire safety for example
01:09:03 my my assurances in those regards is that we
01:09:07 that we to to deliver a training program is these two essential component parts one is
01:09:12 is a quality training package and two is competent
01:09:16 competent officers to deliver and i felt that we had both of those component parts in place
01:09:26 given the issues that you raise in the paragraphs 19 and 20 of your second statement
01:09:32 statement did you consider taking this point about resources to deputy commissioner dexter and saying for example um i don't have enough resource or fsg training resource in order to
01:09:44 or fsg training resource in order to comply with national guidance help it wasn't the issue about the issue of resource wasn't my issue of resource it was more
01:09:55 resource it was more fire safety's issue of resource because with the restructure of fire safety and the re-emphasis on post-fire audits
01:10:06 post-fire audits and fire inspections and also the we were going through london safety plan five and there were efficiencies cuts being made to a
01:10:17 efficiencies cuts being made to a variety of departments of which fire safety was won it was for those reasons that we were trying to rationalize our resources and you know whether mr church raised
01:10:28 and you know whether mr church raised specifically with the deputy commissioner the need for additional fso resource to assist fsg training
01:10:37 i i don't know whether
01:10:41 whether that was specifically raised i somehow doubt that steve turret would have raised that it wouldn't have been his position to raise that but absolutely the whole issue of the numbers of fire
01:10:52 the whole issue of the numbers of fire safety inspection officers was a constant source of discussion why wouldn't it have been mr turek's position to have done that uh only because
01:11:03 uh only because he his his core role in terms of fire safety inspecting officers was to satisfy
01:11:11 satisfy that role of a fire safety inspection officer which is to carry out fire safety inspections and uh and post fire audits uh can we stay on this page but go to paragraph 21 of your second statement uh
01:11:23 paragraph 21 of your second statement uh where you say this i note that this action point was addressed by scott hayward at the board meeting of 22nd of june 2010 when ac turek and i both attended
01:11:35 turek and i both attended 0.8.7 of the minute states annual refresher training in line with fsc 1093 is being planned and the expectation is that all control staff will receive a bi-annual one-day refresher with the
01:11:48 bi-annual one-day refresher with the training team and an on watch package including an e-learning package from fire safety and confirmation of learning accordingly by june 2010 the limitations
01:12:01 accordingly by june 2010 the limitations on the intended involvement of the fsos in the fsg continuation or refresher training had been presented to and approved by the board was the board told in clear and
01:12:12 was the board told in clear and unambiguous terms of your decision that fsos would not play a role in the provision of refresher training
01:12:21 i can't recall exactly the words i used but it certainly would have been something we would have discussed absolutely were they told for example that the approach that had been adopted was
01:12:32 approach that had been adopted was inconsistent with the advice in fire service circular 1093 whether i'll have laid out in those terms uh i can't recall but i certainly wouldn't have uh
01:12:43 uh uh omitted that fact just if i can just add if i could just follow up on that point though here in paragraph 21 you quote the minute
01:12:54 paragraph 21 you quote the minute which says that annual refresher training in line with fsc 1093
01:13:00 fsc 1093 wouldn't it have been material to advise the board
01:13:03 the board that
01:13:04 that the absence of fso involvement was inconsistent with the advice contained in 1093. that was a material factor wasn't it
01:13:12 wasn't it absolutely and it may well i'm i'm sure it would have been the case that we did raise that this is just obviously the way the minutes were were taken but it's a pertinent fact to
01:13:24 were taken but it's a pertinent fact to say
01:13:25 say they obviously consider it to be sufficiently important to record that the training was in line with fsc 1093 but it's equally important in those circumstances to note that it's materially inconsistent with 1093 isn't
01:13:38 materially inconsistent with 1093 isn't it
01:13:39 it yeah i can i can see that the minutes don't necessarily support the point i'm trying to make now yes so it's
01:13:48 so it's nearly
01:13:49 nearly just alerted but it's this would be an appropriate temperature time for you yes sir can i just briefly just just add just a footnote to what we were just saying
01:13:58 saying so
01:13:59 so one of the discussions that we were constantly having is the fact that around this time was
01:14:05 was london safety plans but based on what we call the integrated risk management plan so the whole point of an integrated risk management plan was to devolve more thinking to fire services in terms of
01:14:17 thinking to fire services in terms of how they
01:14:18 how they delivered their service so the government had moved away from things like attendance times and left out to fire services to decide when that they would how often frequent
01:14:29 when that they would how often frequent they would attend an incident so the reason i raised this is because on the one hand we've got national guidance from what was 17 years ago at this point in time or 19 years ago
01:14:40 this point in time or 19 years ago and then on the other hand we've got a a loosening a development in terms of thinking very much encouraging fire services to think about what's best for them so it was in the background of that
01:14:51 them so it was in the background of that that we were very much thinking steve tarek and i about what's best for the london fire brigade and why we allocate our resources which comparing it to national guidance from 93 i can see why
01:15:02 93 i can see why the line of questioning that's being leveled but nevertheless the environment was completely different in terms of devolved thinking yeah yes helpful thank you very much and do you want to follow the deaf talk at
01:15:13 do you want to follow the deaf talk at this point all right well well thank you mr brown and we'll take our short break now and we'll come back please at half past 11 and then carry on then thank you please as before don't talk to anyone about
01:15:25 as before don't talk to anyone about your evidence okay thank you you're out of the room thank you
01:15:36 right thank you very much how fast
01:31:56 would you ask mr brown to come back in please
01:32:08 right mr brown all ready to carry on yes thank you sir thank you yes mr canoe when you're ready um can we go back to the minutes of the latino house board meeting of the 15th of september 2010 uh which you attended
01:32:20 of september 2010 uh which you attended and which can be found at lfb 005 192
01:32:25 005 192 slash one
01:32:29 and we can see again we looked at earlier obviously at the bottom of the page paragraph uh 5.4 says this fsg training has been reviewed to ensure it fully aligns with 1093
01:32:41 it fully aligns with 1093 subject to recommendations made by clg all control staff have now received refresher training in fsg and if we could look at 5.5
01:32:51 a full day of refresher training if you turn over the page
01:33:04 thank you a full day of refresher training has been introduced half of which is delivered by the fire safety team
01:33:10 team role play has also been introduced now at that stage on the face of the minutes the board was not told about any
01:33:19 any constraints or limits or exceptions to compliance with 1093 do you agree with that
01:33:30 i can't see anything in the minutes that affects now that's correct on the contrary they were given explicit assurance that training was fully aligned with 1093 and that fire safety would deliver half
01:33:42 and that fire safety would deliver half of the refresher training do you agree with that yes that tends to suggest that the decision that you and mr turek reached was made after
01:33:53 after this meeting in september 2010. now
01:33:57 now does that sound about right yes i i realize in my statement i mentioned
01:34:02 mentioned 2010
01:34:04 2010 but
01:34:05 but sitting here now i i think it was closer to 2012 when the uh the structural change was made [Music]
01:34:14 [Music] thank you as that was the necessary context which yes set out to the panel now mr hayward said that he didn't recall knowing anything about the decision that you mr turek reached and
01:34:26 decision that you mr turek reached and couldn't recall discussing it with you can you remember did you ever discuss the particular subject of the involvement of fsos in the provision of refresher fsg training to control staff
01:34:38 refresher fsg training to control staff i'm sure i did because i wanted the assurance that the control officers could
01:34:45 could deliver the training in the absence of fire safety staff and also because
01:34:51 because i wanted to make sure scott was involved in things that were happening rather than having things done to control could we turn to the latino control report again
01:35:03 the latino control report again which can be found at h o m quadruple zero double one two four forward slash five three and if we could look at action four two
01:35:12 two b
01:35:17 thank you and we can see there that the coroner was informed that continuation refresher fsg training for cros included and i quote inputs from brigade fire safety officers
01:35:29 inputs from brigade fire safety officers covering aspects of building design and construction coupled with current fire safety advice to educate control officers on fire behavior and building types
01:35:39 types can you help us as to why the coroner was not involved i was not informed rather about your decision not to involve fsos in refresher fsg training
01:35:57 no i can see i can see 42b doesn't mention that i mean 4-2 talks about
01:36:03 about in the context of the initial training in august 2010 but i accept that it doesn't go on to say that subsequent decisions have been made can you help us as to why not
01:36:18 no it certainly wasn't the it wasn't the intention to keep it from the coroner i i suspect it was because it was an internal decision and we felt
01:36:31 it was an internal decision and we felt that we were still meeting what we needed to meet but but i accept it it doesn't explicitly say that no can we turn to a separate pre-action action now which is preaction 12
01:36:43 preaction 12 that dealt with the recurring program of fsg training and could we start with
01:36:51 with 10 93 on this point which can be found at lfb quadruple zero three six one seven forward slash two and if we could look at paragraph seven in particular
01:37:05 now you'll see the heading for paragraph seven is continuation of training and the paragraph in particular says this
01:37:12 this following completion of initial training when the recruiters attach the watch further continuation training should be carried out progressively with the aim of improving skills and knowledge gradually this should include the
01:37:24 gradually this should include the training set out in appendix b were you aware of that particular guidance yes now we touched on this earlier but if we could go to appendix b which is found at
01:37:35 could go to appendix b which is found at page six of the circular
01:37:39 we can see the particular advice and requirements in relation to fsg training which covered nine distinct topics delivered in part by fsos and
01:37:51 topics delivered in part by fsos and with practical role play to confirm the instruction is that a fair summary yes do you agree therefore that the expectation in
01:38:00 in 1093 was that continuation fsg training would be delivered to this syllabus and to this method uh the expectation in the guidance yes
01:38:11 uh the expectation in the guidance yes now if we can stay in this
01:38:14 this circular but go to back to page 3 and paragraph 11.
01:38:21 you'll see paragraph 11 has the heading watch refresher training and it says this
01:38:26 this it is recommended that on watch refresher training should be given to all fire control staff on a systematic basis i.e it should be both scheduled and monitored the subject matter will depend on local
01:38:38 the subject matter will depend on local circumstances but emphasis should be given to little used procedures or areas of weakness it is recommended that brigade training officers should be encouraged to participate in the training to augment
01:38:50 participate in the training to augment the efforts of fire control officers were you aware of that particular recommendation yes
01:38:57 yes was fsg call handling a little used procedure as well as an area of weakness uh having regard to the problems that had been identified following the lack of fire
01:39:08 of fire uh it was
01:39:10 uh it was i would agree it was a a little used procedure
01:39:14 procedure operationally because
01:39:17 because there's a purely statistically that bears that out in terms of an area of weakness no i wouldn't say it was an area of weakness
01:39:26 weakness uh i would say that it was it was certainly an area that lacrimal house action plan had highlighted but i think that was because of the
01:39:37 think that was because of the uh some of some of the the traumatic issues that were associated with black and all the the issue of fire survival guidance for control staff in general
01:39:48 guidance for control staff in general i i wouldn't say was an area of weakness but yet equally i would say it's something that was open for continued improvement as everything is and indeed as you said it seems statistically it was a little use procedure yeah
01:40:00 was a little use procedure yeah statistically i couldn't argue against the fact it is a little used procedure and so to use the the wording of the circular fsg refresher training that needed to be emphasized to control staff
01:40:11 needed to be emphasized to control staff would you accept that yes now if we can go to lfb double zero double one eight nine four eight forward slash one
01:40:25 again this is a document we looked at last week it's keeping people safe from 1994.
01:40:31 1994. it's the fsg training package that accompanied fire service circular 1093 and if we go to page 12
01:40:44 you see there the the heading for fire survival guidance and below in the bottom third of the page
01:40:50 page the heading training requirement and continuation is the very last subheading on that page it says this refresher training is recommended at intervals of not more than
01:41:01 than 12 months
01:41:02 12 months were you aware of that particular device yes now can we put that aside and go to the minutes of the latino house board from the 22nd of june 2010 and that can
01:41:15 from the 22nd of june 2010 and that can be found at lfb trouble zero eight four zero two nine forward slash three now take it from me you attended but could we look at item 8.7
01:41:27 could we look at item 8.7 and it says this annual refresher training in line with fsc 1093 is being planned and the expectation is that all control staff will receive a bi-annual
01:41:38 control staff will receive a bi-annual one-day refresher with the training team and an on-watch package including an e-learning package from fire safety and confirmation of learning can you remember now who provided that
01:41:49 can you remember now who provided that information to the latino house board meeting it would have almost certainly have been provided by whichever of this senior control management team were in attendance with
01:42:01 management team were in attendance with me it was rarely if ever the case that i was there without one of joel scott now bearing in mind the meeting was more than 11 years ago are you able to help us now with the substance of any
01:42:12 us now with the substance of any discussion about for example the relevant terms of 1093 or the particular requirements of the keeping people safe guidance i'd be i'd it'd just be educated guesses i'm afraid i can't say for sure
01:42:30 can you remember though mindful of that but there was any discussion of whether the actions that had been taken uh fully met the pre-inquest action
01:42:44 i remember discussion on these at board meetings whether this one or just in general and we were we were quite open that we were going to
01:42:56 we were quite open that we were going to do
01:42:57 do an alternate approach and when i say biannual
01:43:01 biannual that's
01:43:01 that's [Music]
01:43:03 [Music] strictly true it's biennial so one day full one one year full day one year half day one year full day one year half a day the half days would be cbt packages so
01:43:15 the half days would be cbt packages so we were quite open about that we were quite hoping that fire safety had inputted into both of those and i i'm i am of the view that we were quite
01:43:26 i'm i am of the view that we were quite open to the fact that fire safety would not be involved in refresher courses apart from the initial 2010 refresher calls now
01:43:39 2010 refresher calls now pressing you on this it we saw that keeping people safe recommended the refresher training was recommended at intervals of not more than 12 months
01:43:51 intervals of not more than 12 months did you consider that provision of e-learning every other year gave sufficient emphasis to fsg training mindful of the advice in 1093 and also
01:44:03 mindful of the advice in 1093 and also mindful of the lfb's experience following latino cbt was something that was becoming a routine in the brigade it was it was an accepted approach it
01:44:15 it was it was an accepted approach it wasn't popular with all members of staff that's for sure but nevertheless it was organisationally an efficient way of delivering training and i i was of the opinion that given
01:44:28 and i i was of the opinion that given all the competing factors all the issues to take into account the fact that it was part of initial training the fact that there was a full day on refresh training every year that having cbt
01:44:41 training every year that having cbt every in-year as it were was a reasonable approach what was the problem uh preventing you from providing full fsg training every year as recommended
01:44:54 fsg training every year as recommended by 1093
01:44:56 by 1093 and keeping people safe so
01:45:00 so so by having full uh training which would involve a trainer
01:45:06 a trainer then
01:45:07 then you have the training room that's probably equipped for about six or seven members of staff so you've got 96 staff in control so straight away that's
01:45:18 so straight away that's about 16 courses that you would need to be able to do that plus mop up courses because inevitably you wouldn't get everyone something would happen and someone wouldn't be able to attend
01:45:29 able to attend so it suddenly becomes a significant uh workload for a training team that are already delivering a range of other training events as well so if we can utilize computer-based
01:45:41 so if we can utilize computer-based training where operations managers uh can deal with it what i would call locally and they can find periods of quiet quite possibly in the
01:45:52 periods of quiet quite possibly in the at three o'clock in the morning maybe and we're you know where they could go through issues with their staff then so it seemed a far more efficient way of dealing with the training than it would
01:46:04 dealing with the training than it would be to have a trainer come in every year can we look at lfb five two one three which are minutes of the latino house board meeting
01:46:16 board meeting from the 8th of november 2010 you didn't attend or weren't able to attend
01:46:23 attend if we could look at the foot of page 1 and item 4.6 in particular it says this action point 12 the one we're discussing about refresher training
01:46:34 training the bulk of this is complete training has been completed for any staff on sick etc when the original training was carried out a computer-based cbt package for 2011 is now being formulated
01:46:46 now being formulated every other year the full package will be used with a refresher cbt course in between
01:46:52 between it would appear therefore that the biennial
01:46:55 biennial plan had been approved before this date is that a fair reading of that item i believe so yes and that's an approach with which you were content yes it's sanctioned yes now if we can stay in this document and
01:47:07 now if we can stay in this document and go to page six and you'll see as against action 12 and the top of the page it records
01:47:18 in the what would it be the fifth column to the left 8th november 2010 cbt package being formulated for
01:47:29 cbt package being formulated for alternate years and in the far right column the action is marked yes as complete now mr hayward said that the action was closed at that meeting based on assurances about the delivery
01:47:42 based on assurances about the delivery of that biannual plan can you remember now whether the board formally approved that approach it the fact that it was marked as yes would only be marked at yes if it had
01:47:55 would only be marked at yes if it had formally approved so it wouldn't be me that was marking it as yes it would be the minute taker who would have uh who would have taken the lead from the chair to say mark is complete so so yes i am
01:48:06 to say mark is complete so so yes i am satisfied that it was marked to complete at that meeting um the marking of something as complete to the layer somewhat surprising given the subject matter is continuing training
01:48:17 training the latino board meetings i think continued till september 2013 or thereabouts was the continued oversight of the board not considered necessary in relation to this particular action plan then
01:48:30 this particular action plan then it was
01:48:31 it was i think i should just explain the context of when we say complete if we're not careful then uh recommendations can stay open for a significant amount of time and you
01:48:43 for a significant amount of time and you you kind of need to ask yourself the question when is something complete and in our view complete was when the the system for delivery had been established not
01:48:54 for delivery had been established not necessarily when all delivery had been established could we now turn on to a separate but linked topic and it's the one you you've touched on previously and that's the delay in terms of implementing computer
01:49:07 delay in terms of implementing computer based training packages and the first document i'd like to take to is an email from mr hayward which was sent to som turner and you weren't copied in that email can be found at lfb
01:49:20 copied in that email can be found at lfb zero five eight zero double seven forward slash two
01:49:28 now 12th of may 2011 um scott hayward emailed mr turner asking can you let me know how we are training staff in fsg this year please and a
01:49:39 staff in fsg this year please and a timeline
01:49:40 timeline now we see if we go to the foot of page one
01:49:45 i see it's lindsay turner is that a he or she it's a shay um she then forwarded the email onto a nicola o'shea and christine sharp and said this we are still waiting to
01:49:57 and said this we are still waiting to hear from steve smith read the cbt issue but i think this is not likely to happen in time for us to achieve this for this year so please can you look at a timeline for delivering the training via
01:50:09 timeline for delivering the training via ppt powerpoint presumably yes which was our reserve plan for this year and also when this will be ready to go and watches can start can you remember now were you informed
01:50:21 can you remember now were you informed this time that cbt would not be provided in 2011.
01:50:28 i don't specifically remember being informed
01:50:32 informed [Music]
01:50:34 [Music] but i would have there was so much traffic going on about it i can't see how i wasn't made aware at some point it's
01:50:44 it's it's a level of detail that you'd expect to be uh
01:50:47 to be uh absolutely yes
01:50:51 now if uh i can go to um
01:50:55 um mr hayward's statement at this point a second statement and that could be found at lfb treble zero eight six two one three forward slash eleven
01:51:10 and we can see paragraph 55 there in the in the top half of that page could we look at the second line of that paragraph in which he says this in 2011 refresher training was delivered
01:51:21 in 2011 refresher training was delivered by way of self-study where staff were able to review the training presentation and he refers to an exhibit were you informed at this at this particular time that refresher training
01:51:32 particular time that refresher training rather than being facilitated online or in person was to be achieved by what's described as a self-study review of the training materials a similar answer i can't remember
01:51:43 a similar answer i can't remember exactly the point but at some point it was common knowledge would you accept that what's euphemistically described as self-study is a significant deviation
01:51:56 self-study is a significant deviation from the recommendation contained in fsc 1093
01:52:01 well certainly 1093 talks about facilitated and self-study is clearly uh not facilitated so yes i will i will be more concerned though that the
01:52:13 more concerned though that the if the content was significantly different rather than the manner in which the information was imparted
01:52:21 imparted and it's substantially different from what the latino house board had been led to believe would be implemented would you accept that it was uh but nevertheless there were there was reason for it it wasn't a
01:52:34 there was reason for it it wasn't a deliberate decision to ignore it um could we now turn to the lindridge review and its first iteration in january 2013. and if we can go to lfb travel zero
01:52:47 and if we can go to lfb travel zero eight five eight five four forward slash twelve
01:52:57 we've gone to this a number of times it has in the comment boxes uh the record of the conversation you had with uh rita dexter regarding certain the points identified by mr lindridge and we see
01:53:09 identified by mr lindridge and we see here on page 12 as against action 8 not action 12 action 8. mr lindridge wrote this
01:53:20 fse 1093 recommends fsg refresher training is conducted annually in lfb a full fsg training package is now conducted every other year
01:53:32 conducted every other year reading down for the alternate years a computer-based training cbt package has been developed this does not include the input of an fso
01:53:42 fso but it is worth noting that the national guidance is not definitive as to what is expected for refresher training it is also worth noting that cbt was not available in 2011 and a locally produced
01:53:54 available in 2011 and a locally produced powerpoint presentation was used to deliver refresher training the cbt will be used from 2013. now if we can go to the top of
01:54:05 now if we can go to the top of page 13.
01:54:09 you'll see there that rita dexter commented am i right it's in the very top of that page in blue
01:54:18 blue and track change am i right in concluding that we agreed something that happened once 2010 and since then it's all gone awry to which you replied
01:54:29 to which you replied consolingly it may be thought not at all the fact is that full training was given in 2010 a locally produced powerpoint in 2011 due to the cbt not being ready for
01:54:41 2011 due to the cbt not being ready for training in 1012
01:54:46 1012 you mean 2012 there yes cbt in 2013 for training in 2014 etc can you help us now why
01:54:56 why mrs dexter had formed the impression that after 2010 fsg training had quote gone all awry well i think it was purely on the basis of dave lindrich's comments
01:55:08 on the basis of dave lindrich's comments and she said nothing further to you in any discussions you might have had it was solely on the base of lindridge as far as you recall i think that was what prompted it rita and i spoke daily
01:55:19 daily and and uh so i've sent her this reply this would inevitably have come up in in subsequent discussions but but in my mind i felt it was
01:55:31 but but in my mind i felt it was reasonable to assure her not at all because
01:55:35 because subject to influences outside of our control we were meeting the spirit of what we were asked to meet as best we could can we turn over the page to pay
01:55:47 could can we turn over the page to pay 14
01:55:49 14 and go down to action 12
01:55:54 which is in the top half of the page and against the sentence which read all control personnel complete fsg training on an annual basis
01:56:05 on an annual basis rita dexter asked this please tell me how many did complete it each year since 2010 expressed as x out of y for each year please and then you replied giving the
01:56:17 and then you replied giving the statistics in 2010 108 of 116 staff have been refreshed
01:56:23 refreshed 2011 106 of 116 staff have been refreshed 2012 94 of 104 staff have been refreshed she then asked are there any
01:56:34 refreshed she then asked are there any who have not done it in any year to which you replied no all staff have completed at least one refresher session now
01:56:44 now mr hayward said that you did not get that information from him first of all is that right well i would have so i i did go through scott for
01:56:56 so i i did go through scott for everything if if he is adamant that i didn't get it from him then it must have been because he was unavailable or on leave in which case i would have gone to a somme but i
01:57:08 case i would have gone to a somme but i certainly would have gone through the line management chain that was my normal practice and one i was specifically and religiously followed if we can go back in the document to
01:57:19 if we can go back in the document to page six
01:57:28 and if we can scroll up to what mr lindrich said in his key findings section about pre-inquest action 12 again
01:57:37 again just roughly a third of the way down the page he wrote this in the first paragraph
01:57:42 paragraph control training records have no recorded fsg training for two watches since watches two and three in 2011. conversations with members of control staff and managers suggest that this is
01:57:54 staff and managers suggest that this is a recording error were you aware of that particular finding
01:57:59 finding i was when it was made here yes i wasn't prior to this now mindful of that can we go back to page 14 and the statistics that you identified for those three particular years
01:58:13 and if your comments can be expanded my question is this how did you reconcile the finding we've just looked at at page six with the information you communicated
01:58:25 with the information you communicated here
01:58:26 here that 106 of 116 had been refreshed in 2011
01:58:30 2011 if there were no records for two of the watches
01:58:34 watches on the basis of 16 staff per watch
01:58:39 per watch it was my it was my belief that training was going on but it wasn't being recorded and my recollection is that when
01:58:49 that when i
01:58:50 i i'm bearing in mind that dave lindridge was
01:58:53 was giving me updates on his progress on his review so when i read it here this wasn't the first time i was aware of it it's my recollection that when i was made aware that there were
01:59:05 made aware that there were there was a gaping hole in two of the watches
01:59:07 watches that i discussed this with scott and
01:59:11 and and said to him basically is this the case that no training has gone on or is it the case that training has gone on and it's just not being recorded and it was the latter and so my recollection is that on that
01:59:22 and so my recollection is that on that basis
01:59:24 basis then
01:59:25 then those watches were spoken to and the training that they knew that carried out was entered hence these figures at this point did you ever have pause for thought
01:59:37 for thought given the concerns that had been raised historically about record keeping that these statistics were not in fact reliable
01:59:44 reliable my concern was the fact that there was spreadsheets not being filled in that that that was my that was my real concern it wasn't the concern so much that training wasn't happening because i
01:59:57 that training wasn't happening because i was confident it was it's just the recording was the thing that that bothered me there is no doubt or caveat or reservation expressed here though
02:00:09 reservation expressed here though about the reliability of the statistics so that
02:00:12 so that mrs dexter was aware of the no no this is true i haven't uh i haven't caveated these no but but i was i wouldn't have provided
02:00:23 but but i was i wouldn't have provided those figures if i thought that they were
02:00:26 were in in any way some kind of guess or an estimate i'd only provide these figures on the basis that they were i was assured they were accurate now could we keep this particular
02:00:37 now could we keep this particular document on the screen but put alongside it another one which is
02:00:43 which is lfb
02:00:44 lfb trouble zero double five one nine one forward slash two six and the table of staff who'd carried out some fsg training which
02:00:56 training which mr hayward had identified a paragraph 74 of his
02:00:59 of his statement
02:01:05 now you don't need to be a professional statistician mr brown to see that the figures are very different
02:01:13 different and looking at 2012 for example we can see that mr hayward said
02:01:21 it was 58 staff out of a total of 86 who had been trained
02:01:27 trained that can be compared and contrasted with the statistic which you provided to mrs dexter which was 94 out of 104 are you able to explain such a marked
02:01:38 are you able to explain such a marked inconsistency between the two statistics
02:01:43 i can i can only say that in the kindest possible way i've absolutely no faith in in these figures in scott's statement that they for me they completely lack credibility
02:01:56 for me they completely lack credibility now mr george said that as well um can you help us as to the principal reasons why you think the statistics below paragraph 74 lack
02:02:07 lack credibility well one is the wild deviation in the numbers of staff that existed over the years that's just not
02:02:18 that's just not an accurate reflection of the staffing available
02:02:22 available and then also in 2015 it says zero percent and and just from my experience nothing is ever that absolute if it said 100 i equally wouldn't have believed it it's
02:02:35 equally wouldn't have believed it it's if if it
02:02:37 if if it it it just it just does not ring true and on that basis the numbers of staff and that zero percent and also what we know was going on uh i'm not for one minute suggesting
02:02:49 uh i'm not for one minute suggesting that the curve that this suggests which is a downward curve from 13 through to 16
02:02:57 16 uh isn't accurate i think that is accurate
02:03:00 accurate but the level to which this curve sinks i think completely lacks credibility mr hayward was not able to explain the discrepancy either so it may well be the the panel have to form their own view
02:03:12 the panel have to form their own view and due course can we move on to a separate topic which is the reduction of time to four hours for training and the absence of role play and the starting document i'd like to take you to is an email from a thomas
02:03:25 take you to is an email from a thomas davis to mr hayward seeking information for the inquests and if we find that lfb trouble zero six zero eight seven two forward slash three
02:03:42 and we see the email at the bottom of the page sent on the 6th of february 2013
02:03:47 2013 and we see that mr davis at point 2 asked the following we need some clarity about what refresher training takes place is it every other year all day with role
02:03:58 is it every other year all day with role play and fire safety officers and the other year computer based on watch i'm afraid we still aren't clear about the situation
02:04:05 situation we've told the coroner in the report that it is full day training if it isn't we need to have a detailed answer why we've modified this position and precisely what the position retraining
02:04:16 precisely what the position retraining is now
02:04:18 is now now first of all mr davis the email there is uh legal he's an in-house lawyer at lfb is that right that's correct
02:04:25 correct now the reference is to the lac law control report is that right yes
02:04:31 yes now if we
02:04:32 now if we stay in this chain but go on to page two
02:04:38 uh we see on the 7th of february 2013 at 0 6 11 hours a response from mr hayward uh it's a partial response sorry should that's unfair it's a
02:04:50 sorry should that's unfair it's a response to the first part of the request in the second paragraph from the very bottom and what he says is this and it's in the blue text a management decision was made
02:05:03 blue text a management decision was made that trainers and an fs officer would provide training every other year as with this year in between staff will access the information we have made available which
02:05:14 information we have made available which we then validate with role play next year staff will access the knowledge center and complete the cbt packages
02:05:21 packages just to confirm the first fsg training in 2010 was a full day's training 2011 staff access powerpoint presentations
02:05:33 access powerpoint presentations excuse me
02:05:35 excuse me and we validated with role play 2012 trainers and a fire safety officer provided half a day's training 2013 staff will complete the online cbt packages
02:05:46 packages and then if we go on further we see in response the second part at the very bottom of the page he says this it was assessed if we go further down
02:06:03 and agreed by the training manager the refresher training did not need to take a full day to utilize the on watch training allocation the training took place from 1400 hours to 1800 hours
02:06:15 1400 hours to 1800 hours when we started the training in 2010 the training itself took seven hours including lunch and breaks the training has just been condensed into the time frame allocated and not so
02:06:26 into the time frame allocated and not so much time has been to the subject on difficult calls mock fsg calls are also recorded and played back to the trainees to identify shortfalls in the delivery of the call
02:06:37 of the call now if we can go back to page two of this
02:06:42 of this chain we can see that he forwarded the email to you at 1253 we find that in the top part of this page with one line which says some further
02:06:54 with one line which says some further detail as discussed this morning now
02:06:58 now in relation to that discussion uh mr hayward had separately emailed som bagnol vic bagnol and we can find that email at lfb treble zero
02:07:10 that email at lfb treble zero three double nine three five forward slash one
02:07:18 we've seen this on a number of occasions mr brown there mr hayward says this morning vic i've just had my ass kicked about the length of the full fsg training in the report
02:07:29 of the full fsg training in the report we say it as a full day and yet we have just carried out the training of four hours with no role play dave was very unhappy and made it very clear to me it makes us look unprofessional in court
02:07:41 it makes us look unprofessional in court i appreciate that you've just picked this up but we need tighter control of the trainers and not let them freelance as they appear to have done on this occasion
02:07:52 is ask kicking the appropriate description to the uh discussion you'd had with mr hayward
02:07:59 hayward not literally but but it was i uh metaphorically it was a very clear discussion we had yes had you not been previously told the length of full fsg refresher training had been reduced
02:08:11 fsg refresher training had been reduced and that it didn't include role play no i'd only become aware of it based on the the discussions that we've just alluded to mr hayward said that you told him to get
02:08:23 mr hayward said that you told him to get the role play and duration of training quotes back to the way they were um is that right absolutely yes and by that did you mean full day refresher training we're not the cbt year and active
02:08:36 we're not the cbt year and active practical and assessed role play yes
02:08:41 now if we can return to the parallel email corresponds going on at this time and we can find we can go back to lfb treble 0 6 0 8 7 2.
02:08:59 and here we can see that you emailed mr hayward on the 9th of february 2013 seeking his views on the position that you had set out in relation to training
02:09:10 you had set out in relation to training now under the heading refresher training just further down the page thank you can we look at the second bullet point
02:09:21 can we look at the second bullet point and what it says a half days training was given in 2011. the reason this was a half day is due to the amount of resources required for a full day's training year on year and how
02:09:32 full day's training year on year and how this needs to be balanced with other training commitments as well as workload in control who informed you that a half days training was given in 2011 was it mr hayward yes
02:09:45 hayward yes now as we've looked at a few moments ago mr hayward said the training in 2011 was by way of a self-study of a powerpoint did he correct you on that point
02:10:04 uh i believe so because i i'll go on to say in this that records show that we use the powerpoint presentation was it mr hayward who told you that training had been reduced to half a day
02:10:16 training had been reduced to half a day because of a resource issue and the need to balance other training and workload in control
02:10:24 yes
02:10:27 did you accept that explanation in the sense of being content with it i i accepted it in terms of
02:10:36 it had been gone and it happened so it
02:10:40 it that was a that was a matter of fact in terms of being content with it no
02:10:45 no what steps did you take uh to overcome the obstacles uh that are set out here so to ensure that full and proper fsg training was provided and prioritized
02:10:56 training was provided and prioritized appropriately well to make it clear first of all i think just to put some brief context to it the the reason it was changed was
02:11:09 the the reason it was changed was in the minds of those who had made that decision
02:11:12 decision uh training level was made for for the best of intentions it wasn't a deliberate scheme to ignore what they were asked to do
02:11:24 do where my frustration was is the fact that i had happened it happened without anyone's knowledge including scots so i told him to just return it to the way it was regardless of whatever the
02:11:36 way it was regardless of whatever the reasons were for changing it and if we needed to address it again in the future then we'd have a proper discussion where we'd sit down and properly assess the reasons and look at it in the round
02:11:48 it in the round can we look at the foot of this page of course your final sentence of your email where you said this in the future training will consist of alternate full days training as specified in the report i think you're
02:12:00 specified in the report i think you're referring that to the latino control report and half day cbt packages therefore in 2013 a full day's training will be delivered and in 2014 a half day cbt package then in 2015 a full day and
02:12:14 cbt package then in 2015 a full day and so on
02:12:16 so on put bluntly that was your expectation as to the future provision of fsg uh training is that right yes and and i had deliberately switched the order because it was 2010 full day therefore
02:12:28 because it was 2010 full day therefore 2012 therefore 2014 even years and i'd switch the order because i was conscious that
02:12:35 that in 11 it was a half day it will now realize it was 12 and a half day and 13 if i'd have stuck to the original there would have also been a half day so i was concerned that this
02:12:46 concerned that this this uh deviation from the plan would have an ongoing effect so that is why i switched it around
02:12:55 now you referred there to the report which we understand to be the latino control report
02:13:01 report could we go back and look at what the control report in fact said and for that purpose could we go to h o m
02:13:08 h o m quadruple zero double one two four forward slash five three
02:13:18 we looked at this earlier on this morning and if we look at the action under 4 2
02:13:26 2 and if we look at little a
02:13:31 the recommendation of the lack of control report was this role play to ensure confirmation of learning was introduced into training this allows all new and existing staff to experience a number of fsg course scenarios and a
02:13:43 number of fsg course scenarios and a safe supportive environment go down to see fsg training has been extended to encompass whole day training now bearing in mind what you discovered
02:13:55 what you discovered and bearing in mind what this report said
02:13:58 said did you
02:13:59 did you update or cause the coroner to be updated in fact role play had not been provided to staff as described in the control report well the the email that we were just
02:14:10 well the the email that we were just looking at the one i'd sent to scott for his views
02:14:15 his views my recollection is that email was designed to be sent to the lachen house inquiry team who would then use it to inform the coroner so i'd i'd run it
02:14:28 inform the coroner so i'd i'd run it past scottfield's views to make sure that i was factually correct in what i was saying because i based it on discussions and previous email chains so so yes that was to be shared with the coroner by the team during the inquest
02:14:41 coroner by the team during the inquest and equally the point that the duration of the fsg training had similarly not been as intended by the latino control report was that another point which he wanted to be communicated to the coroner yes so i made it aware because of tom
02:14:54 yes so i made it aware because of tom davis's
02:14:55 davis's proactive work in asking these questions which is how i found out about it this was our response and this was our position for for the team then to share with the coroner during the inquest
02:15:07 with the coroner during the inquest can i now turn to a separate topic and that's information provided to the health and safety executive in 2014
02:15:14 in 2014 and the first document i'd like to go to is an email you sent to adrian bevan who's at the lfb on the third of july 2014 which can be found at lfb trouble zero three seven four two eight
02:15:27 trouble zero three seven four two eight forward slash one
02:15:36 now you see your email on 3rd of july there 1406.
02:15:41 1406. this is a response to a number of requests the health and safety executive had made
02:15:46 had made of the london fire brigade in relation to control training and if we could turn over the page to page two
02:15:54 and if we can look at the first point to see on that page the first words of which are training deliverance the top third of the page and it says this training delivery
02:16:05 and it says this training delivery detail of attendance of staff at training i.e collective training records when and how many staff etc now you replied thus 277
02:16:16 277 individual fire survival guidance training sessions have been carried out run by senior control officers in addition to the regular control watch training sessions these training sessions took place
02:16:27 these training sessions took place between february 2011 and june 2014 all available control officers have received additional training in call handling techniques and handling of fire survival guidance calls
02:16:39 survival guidance calls now first of all what was an individual fire survival guidance training session that would have been the uh the
02:16:50 the four-day half-day full day half day approach
02:16:53 approach was the regular control watch training the annual fsg refresher training
02:17:02 no so in addition to regular control watch training sessions what i would what i meant by that is whatever the operations manager had determined was appropriate for his or her watch based on individual training
02:17:15 her watch based on individual training needs
02:17:16 needs what was the additional training in call handling techniques and handling of fire survival guidance calls
02:17:30 i'm just i'm just reminded just reading through please do point one and two again
02:17:42 i think i think that's really just underlining point one so in point one where i say two seven seven individual five survival guidance training sessions have
02:17:53 survival guidance training sessions have been carried out i mean just underlined in the point that all available controllers have received the additional training because that is additional training
02:18:05 was mr hayward the source of the information contained in this email including the statistic of 277. i i always went through scott if he wasn't available so
02:18:16 wasn't available so either him or one of his senior operations managers this is another instance where mr hayward has no recollection of providing the information and said that you may
02:18:27 the information and said that you may have asked the som or ost from what you've said that might be a possibility would you accept that not not straight to the ost it wouldn't because that just wasn't the way i
02:18:39 because that just wasn't the way i worked but one of the soms possibly but only if scott wasn't available if scott was available i would have made i'll say would because i know bearing in mind the issues we've
02:18:50 bearing in mind the issues we've discussed i would go through him absolutely to get the information because i wanted him to be part of this whole performance management approach if i went around the person
02:19:02 if i went around the person all that does is just compound the existing performance management issues what's striking here is that you haven't sought to provide the executive
02:19:13 sought to provide the executive with the year-on-year breakdown you provided to rita dexter can you help us to why that breakdown was not provided to the executive
02:19:27 is it possible to see points a and b what i've said about yes of course
02:19:41 and so in point c again please
02:19:47 [Music]
02:19:51 no particular reason i think i'm just looking at the questions i'm being asked it hasn't asked for that particular breakdown
02:19:59 breakdown they've just asked for detail of the tents of staff at training so i've given them a collective figure
02:20:07 can i now go back to the mopac audit and again that can be found at lfb travel zero double four six four zero forward slash two five and it's the
02:20:18 forward slash two five and it's the report summary we looked at earlier on
02:20:26 again if we can look at the third column either central one and the bottom row which is under the heading rating slash medium and it starts with the words
02:20:37 medium and it starts with the words failure to effectively monitor and it says this failure to effectively monitor the receipt of fsg training could result in staff receiving insufficient levels of this mandatory
02:20:48 insufficient levels of this mandatory training
02:20:49 training this could result in reputational damage in the event of a serious incident involving persons trapped being dealt with by staff who had not received the required level of training
02:21:00 required level of training and in the road below that failure to ensure that training records are accurately maintained could result in training levels being inappropriately reported and or staff not receiving the
02:21:12 reported and or staff not receiving the required training potentially leading to an inappropriate response to an incident did you agree with the identification of those
02:21:23 with the identification of those particular risks yes i'll certainly agree that they are that's an accurate description of what could occur yes did it occur to you that beyond
02:21:35 did it occur to you that beyond reputational damage a failure to ensure that staff had been properly trained in relation to fsgs may in certain circumstances lead to death or at least serious injury
02:21:46 serious injury yeah i can assure you that the reputational issue whilst obviously important is not wouldn't be the driver for me the driver is to actually make sure that we are providing the best
02:21:58 sure that we are providing the best possible service to the people that need us
02:22:01 us now the agreed action in relation to fsg training was it's probably easier if we go to the preceding page it said this an independent report
02:22:14 see it's in the bottom right hand corner sorry these things are sometimes quite difficult to read the agreed action was an independent report of the provision of fire survival guidance training for all control staff
02:22:25 guidance training for all control staff will be maintained and monitored to ensure that all staff are in receipt of this training at least annually a monthly report will be produced by ost providing the annual fsg training update
02:22:37 providing the annual fsg training update and we will be directing oms to notify the training team if individuals are nearing their annual refresher so we can get them on a refresher course now
02:22:48 now if we go to lfb travel zero five nine five nine seven forward slash one uh we find an updated version of this particular report
02:23:00 now what we see here is an addition of the agreed actions have been assigned and control comments in the in the far
02:23:11 and control comments in the in the far right hand side column if we go to page two and i want to look at the bottom row of the third column
02:23:21 we can see that som smith was assigned the action to maintain and monitor the monthly records and that had been marked as completed
02:23:33 having regard to that endorsement what steps did you take to make sure that an independent record of fsg training had in fact been created
02:23:47 the only steps i would have taken would be to use this report as a basis for discussion
02:23:58 basis for discussion to assure myself uh with some basic discussion with with scott or or whoever whoever was uh deputising for him and then when i
02:24:09 then when i visit control to in my discussions with staff or and or control team to satisfy myself that i feel the outcomes are working accurately i wouldn't go any further than that in
02:24:21 i wouldn't go any further than that in terms of physically inspecting the records
02:24:26 now mr hayward said in his evidence that the focus was solely on vision training at this time so mid-2015 and that while a record would have been set he doubted whether any other work
02:24:38 set he doubted whether any other work would have been done were you aware of the limited extent to which work had been done on this topic certainly
02:24:46 certainly scott and i had discussions about vision and uh
02:24:51 and uh and the all-consuming nature of the training around it yes now if we can go back to your second statement on this point which can be found at lfb trouble zero eight four zero two zero forward
02:25:04 zero eight four zero two zero forward slash
02:25:05 slash thirteen
02:25:08 we see a paragraph 28 and particularly the final line in relation to your monthly meetings with mr haywood you say this at the meetings therefore i would require scott
02:25:19 meetings therefore i would require scott to report back to me with up-to-date statistics on the delivery of those targets that are targets we've been discussing now after the mopac audit in february 2015
02:25:31 2015 mr hayward did not recall you requesting up-to-date statistics on fsg training being delivered first of all is that right
02:25:40 right quite possibly because we had reached the position where vision was due to go live i was discussing with capita
02:25:51 i was discussing with capita the reasons why we couldn't accept it and everything was about vision so the the my recollection is the agreement that i've reached with scott was
02:26:02 was i can i can see the the severe challenges in terms of trying to adhere to the fire survival guidance training so the assurance is our salt was
02:26:13 assurance is our salt was that what was the level of of competency of his staff so we had a number of new entrants that had received training in terms of fire survival guidance
02:26:24 survival guidance and then we had others who would receive the packages relatively recently so i asked for a training needs analysis to determine that we made sure that there was no one
02:26:36 that we made sure that there was no one that was in need of fire survival guidance train that wasn't having it and that we'd have to accept the uh the risk at that moment in time that we wasn't adhering to
02:26:48 we wasn't adhering to what had fallen out of the lack of house action plan because of the the immense training that was going on with vision you say everything was about vision mr
02:26:59 you say everything was about vision mr george gave the impression that vision and the technical problems left little time for anything else you seem to agree with that
02:27:08 there was other things going on but but certainly it was by far and away the the biggest show in town going back to your second statement looking at paragraph 29 which is on on
02:27:19 looking at paragraph 29 which is on on the screen at the moment you said this i was left with the impression that fsg refresher training was where practically possible being delivered i gained that impression from my discussion with scott
02:27:30 impression from my discussion with scott but also my discussion with individual brigade cros when i visited visited them in their workplace now
02:27:39 now there appears to be a euphemistic phrase there where practically possible what precisely did you mean by that where resources allowed and it it wasn't just the availability of the control
02:27:51 just the availability of the control officers it was the it was the fact that we had uh training officers that were being drawn away to write training packages and deliver training for vision
02:28:04 packages and deliver training for vision so much so that i agreed to increase the staffing from the operational support team i think from four to six to be able to service this demand and so where practically possible was
02:28:17 and so where practically possible was when there was a trainer available when there were staff available and
02:28:23 and and just also when when they had the the
02:28:28 how can i put it the the headspace if you like to be able to receive this uh refresher training because so much was being
02:28:36 being pumped into staff in terms of a completely new way of working now you say that that you that was an impression that you had formed at the point that rises from that is why
02:28:48 at the point that rises from that is why didn't you know what the state of play was in relation to the provision of fsg training given that it had consumed so much attention at the latino inquest and thereafter
02:29:01 so when you say no so no i didn't know the actual figures but i had reached the position where i was comfortable for that moment in time to
02:29:13 comfortable for that moment in time to deviate from it in terms of the assurances about staff
02:29:18 staff being given training in fire survival guidance calls relatively recently be it through new entrants and so
02:29:26 and so by the time i left i think about a third of news a third of staff were new entrants so therefore as a matter of fact they would have received training uh within the last few
02:29:38 received training uh within the last few years which is not what the lack of action plan was asking for but we had this massive competing priority so i knew strategically what was going on i
02:29:49 i knew strategically what was going on i didn't necessarily know exactly specifically how many staff had received it that actual year can i now move on to a separate issue which is the apparent absence of
02:30:00 which is the apparent absence of refresher training from 2015 onwards and the useful starting point for this is paragraph 30 of your second statement which is at the bottom of the screen now
02:30:12 screen now you say that you say this and there scott made me aware when there were occasions when fsg refresher training was not being delivered in accordance with agreed time scales
02:30:23 with agreed time scales this occurred when there were competing priorities in brigade control for example in 2015 to 2017 a considerable amount of time was invested in training brigade cros on the vision
02:30:35 in training brigade cros on the vision mobilizing system which meant there was an impact on the delivery of fsg refresher training during that period
02:30:43 period the vision mobilizing system was a risk critical project which was crucial that the brigade delivered on time
02:30:51 time now mr hayward said in evidence that he told you
02:30:55 told you what would have been 2015 that the only training taking place was vision training was that accord with your recollection
02:31:05 uh no because there was other training going on there was there was
02:31:13 training in resource management and the national coordinating center where we were more formalized in that so there were there were other training there was other training going on but it
02:31:24 there was other training going on but it is true
02:31:25 is true the vision was
02:31:27 was by far and away uh the the biggest piece of training and did dominate everything else given the issues that had been identified most recently by mopac
02:31:39 identified most recently by mopac and in particular the risks that they'd identified for the brigade what more were you doing to ensure that fsg refresher training was not squeezed
02:31:50 fsg refresher training was not squeezed out
02:31:51 out by the
02:31:52 by the onerous demands of vision training so
02:31:56 so increasing the operational support team so there were more trainers available putting real pressure on capita to provide trainers to assist with vision
02:32:07 provide trainers to assist with vision giving as much support around visions which therefore by default left more time to do the other training for which we were committed and then having having an end date in
02:32:19 and then having having an end date in sight in terms of when vision will be introduced and when the training could start to
02:32:26 start to slow down so we could therefore pick up our commitments with other training given what had happened at latino given what mopac had identified would you also agree
02:32:38 would you also agree that refresher training was risk critical
02:32:49 yes yes we could call uh yes fire survival guidance training could could yes be described as risk critical we were though
02:32:58 though still monitoring what was going on with it so i'll refer back to our earlier discussion that every fire survival guidance call was monitored and reviewed thereafter so
02:33:09 thereafter so so whilst i accept that the uh the amount of refresher training wasn't in accordance with what we had promised there was a unfortunate but yet sound reason for it
02:33:22 unfortunate but yet sound reason for it and b there was continual quality assurance of it so it wasn't as if the whole topic had been completely sidelined
02:33:31 sidelined would you accept that the practical result
02:33:33 result was that fsg refresher training was not given the priority it deserved following lachnal and in particular given the risks identified by mopac in early 2015.
02:33:47 that particular moment in time it wasn't in accordance with what we had imagined but we'd equally hadn't imagined that vision was going to take up this amount of time that he was doing
02:33:59 up this amount of time that he was doing so over the whole period and also we shouldn't forget whilst whilst i wouldn't offer this as a a substitute for the year on year five survival guidance
02:34:11 year on year five survival guidance training we were also running the courses around information uh transfer to the fire ground in accordance with policy note 790. so there was other fsg training
02:34:24 790. so there was other fsg training going on so what with the monitoring of calls and the use of call coach and the policy number 790 there was an array of issues that did shine a light on fire survival guidance although i will accept that
02:34:36 guidance although i will accept that what is missing is the training that was expected but yet it was missing for good reason because without a mobilizing system then
02:34:47 system then everything else falls by the wayside now flying on from that can we go back to your first statement which can be found at lfb travel zero three two one double six forward slash two one and
02:34:58 double six forward slash two one and paragraph 66 in particular
02:35:02 now what you say here is five lines down this
02:35:07 this following the rollout of the initial fsg training after the latin house fire there were no service delivery criticisms of the control staff on fsg calls which gave me any cause to
02:35:19 calls which gave me any cause to question whether refresher training was taking place now did the service delivery criticisms of control at lachnal not give you the impetus
02:35:30 not give you the impetus to make sure that fsg training was taking place and taking place consistently uh well absolutely uh and the 34 actions
02:35:42 uh well absolutely uh and the 34 actions uh a large portion of which uh were aimed at control were actions that we had as an organization identified for ourselves so i think that is uh an example of how
02:35:55 so i think that is uh an example of how seriously we had taken uh what had happened at la canal before we got anywhere near a coroner's inquest can we now go to assistant commissioner george's review of control
02:36:07 george's review of control in july 2016 and staying in your first statement could we go back to page 13 and paragraph 35
02:36:25 thank you we see it at the bottom of that page and paragraph 35 you say this between march and july 2016 i instigated a review of control in response to
02:36:36 a review of control in response to findings from stress workshops and staff engagement sessions ac tom george provided me with some detail of staff engagement sessions and these were taken into consideration when preparing the terms of reference for the
02:36:48 preparing the terms of reference for the review
02:36:49 review if we could turn over the page to page 14 and paragraph 36
02:36:57 you say this the review team was led by ac tom george my brief was that the review should be wide-ranging but a not designed to deal with vision which has been discussed in a separate ongoing
02:37:09 has been discussed in a separate ongoing work group with staffside handed over to ac george after my retirement and b
02:37:15 and b not designed to return to the shift system prior to 2010 which would negatively impact on the demand and supply approach and training opportunities
02:37:26 opportunities if however during the course of the review a new shift system was proposed which still provided the benefits of the post 2010 shift system then it should be considered outside of those parameters
02:37:37 considered outside of those parameters ac tom george was given free rein to complete a comprehensive review and make recommendations to ensure the control was in the best possible position to deliver its functions effectively and
02:37:49 deliver its functions effectively and efficiently now did you consider asking to refer back to the pre-inquest control related actions for latino to check whether they had been properly and fully completed
02:38:03 no i didn't specifically mention those i was i was mindful of the issues that still remain much of which we've discussed this morning
02:38:15 which we've discussed this morning so i was conscious that they uh manifested themselves in this report but no i didn't sit down with tom jordan and say here's this report look at this as you're as you're looking at this as well
02:38:26 well did your consciousness extend to informing him about the existence of mr kelly's audit of august 2010 uh i don't i don't believe i specifically
02:38:38 specifically mentioned that report no but the the issues that flow from it in terms of training and training plans were in my mind and and i was keen that
02:38:49 were in my mind and and i was keen that they were in here and and indeed they were a bullet point i believe did you refer mr george to the various matters highlighted in mr lindrage's audits of
02:39:01 highlighted in mr lindrage's audits of january and november 2013. not the report itself no but any issues that still existed that flowed out of that
02:39:12 existed that flowed out of that in my mind made sure that they was in this report did you refer him to the mopac audit of february 2015
02:39:24 again i don't recall showing him that in particular i think he would have been aware of that though because because he he would have been sitting at performance management board meetings
02:39:36 at performance management board meetings where that kind of report would have flowed back and forth so i think he probably would have been aware of his existence wouldn't it have helped mr george to
02:39:48 wouldn't it have helped mr george to understand the nature and duration of the problems affecting control if he'd been provided with all the various reports audits reviews completed since august 2010
02:40:04 it would have it would have been advantageous yes i think the main issue the thread of the main issue that's come out of all of those
02:40:15 those was the issue of recording training and training plans and that was uh in the forefront of my mind and that was considered by tom george in the review
02:40:26 considered by tom george in the review so so i accept to be completely uh rounded to given give him a pack of reviews would have been helpful but the key issue about training
02:40:38 key issue about training was included in this there was no good reason not to provide mr george with those various audits and reviews was there no can we go to nfb trouble zero eight
02:40:50 no can we go to nfb trouble zero eight three eight seven three forward slash one
02:41:00 now we can see at the foot of page one um mr george sent you a copy of his report on the first of july 2016. and if we scroll up we can see that you
02:41:11 and if we scroll up we can see that you replied on the 5th of july 2016. and you said this thanks for all your hard work i've made quite a few changes and comments to this some of which are self-explanatory and others we may need
02:41:23 self-explanatory and others we may need to talk through now staying in this document can we go to
02:41:27 to page nine
02:41:32 this is where we find the draft report and your comments on it and if i could ask you to look at page paragraph 25 which is at the top of page nine and mr george wrote this
02:41:45 and mr george wrote this some staff feel that they are not adequately developed enroll or receive development to progress to a higher role the review has identified that maintenance of skills training is ad hoc not planned in a robust manner and often
02:41:57 not planned in a robust manner and often not recorded on individuals training records
02:42:00 records it could be argued that the current shift system does not support the ability for individuals to easily undertake maintenance of skills training as there is no facility for an om to conduct watch training or watch meetings
02:42:12 conduct watch training or watch meetings away from the main control room in a way that station staff could do or can do by utilizing the strategic resource facility as an example now as against that paragraph you
02:42:23 now as against that paragraph you commented thus i would completely disagree with this comment
02:42:27 comment as the facility exists albeit local management amended it during the day when three shifts are at work we should tone it down a bit
02:42:37 now didn't that reflect exactly the issue identified in the fire service manual we looked at last week with on-watch training and the need to maintain staff in the control
02:42:49 need to maintain staff in the control room hindering the ability to deliver training
02:42:58 the the manual uh when it refers to staff in the control room and delivering training is in my opinion uh talking about
02:43:10 is in my opinion uh talking about trying to deliver training to someone who's sitting at their workstation the way the london operations center was designed is uh with separate wings to the
02:43:22 is uh with separate wings to the building there's a range of units and sections that work in there quite successfully we've got nothing to do with training it's a purpose-built training venue and there is a separate
02:43:33 training venue and there is a separate training control room so i don't think the manual had the likes of the london operations center in its mind
02:43:41 its mind well indeed it didn't because it manifests itself years after manual was written but i think it had that kind of arrangement in mind when it was saying the things it was saying
02:43:53 i was mindful of that answer it doesn't have mr george's observation that there was no facility for training away from the control room echo again the recommendation the advice in the
02:44:04 the recommendation the advice in the fire service manual the watch training away from the control room should be considered
02:44:10 if you if you look at this in its purest form uh quite possibly but i would contest
02:44:16 contest that training was taken away from the control room because it was in a dedicated training facility within the footprint of the london operations center but it was away from the control room
02:44:28 the control room and if you if you then insist is not you personally mr kinnear but if one insists that it needs to be outside of the footprint of
02:44:39 outside of the footprint of control then you face a range of other challenges that actually hinders good training so i i feel that a compromise was being reached and and i felt that
02:44:50 was being reached and and i felt that the way tom george's comments were phrased here it was almost making excuses for things that actually could be done quite simply
02:45:01 could be done quite simply did you have the fire service manual was published in 98 um was it a document that you ever had cause to uh consult no
02:45:10 no and why was that oh sorry uh you mean you mean me consult in terms of refreshing my own mind or just
02:45:18 just having having a look to see what it recommended on particular matters of operational practice management etc uh so i thought you meant consult in terms of its publication uh
02:45:30 terms of its publication uh no it wasn't it wasn't document that i would uh consult i would expect brigade control uh management to consult that and bring to my attention if there's something in there that we are contravening now can we stay in this
02:45:42 contravening now can we stay in this document but move to page 16 and look at paragraph 59 which is in the
02:45:54 which we see there now the second hole from the top of the page um ac george concluded this one reason for a lack of regular maintenance of skills training has been the difficulty
02:46:05 skills training has been the difficulty in getting the watch together away from the control room to undertake team-based training sessions when the shift changed in 2011 it was proposed that such training would be carried out on the short shift however
02:46:17 carried out on the short shift however this has rarely been achieved for a number of reasons including a shortage of staff
02:46:23 of staff the inflexibility of brakes and the necessity for control staff to support other functions including rmc rml and ncc
02:46:33 ncc now what was your reaction to the finding that training during the short shift had been rarely achieved well i was really disappointed because
02:46:43 i was disappointed on two levels so firstly
02:46:48 firstly i'd been involved years ago with control staff and the need to do something to be able to release more of them for training so by
02:47:00 of them for training so by by working hard with staff side representatives to introduce a training or sorry a shift system that supported training it was disappointing
02:47:11 supported training it was disappointing to see that it wasn't being used effectively but the second reason i was disappointed is this focus on it's all about the short shift and whilst the short shift clearly
02:47:23 and whilst the short shift clearly supplies
02:47:24 supplies a lot of staff that are able to be released for training it's not only about a short shift so for me it was a complete misunderstanding of what was there to utilize
02:47:36 there to utilize now mr george didn't mention fsg training at all did its absence give you cause for concern this doesn't that doesn't appear to be a comment about it i was just wondering whether it prompted any
02:47:47 wondering whether it prompted any further concerns from you
02:47:52 when when tom george did this report i knew that the command unit training was well
02:48:01 was well up and running so i knew there was a
02:48:05 a fire survival guidance training of sorts going on
02:48:11 and i was also aware because i think tom had been in position for about three or four months now so prior to him taking over i was aware that that
02:48:23 that curve if you like in terms of fire survival guidance training was on the up again so no i wasn't overly concerned that he hadn't specifically mentioned it i took
02:48:34 hadn't specifically mentioned it i took it as read that in his broad discussions around training plan that that include was included in that and that explains the absence of any comment from you on this draft report on the subject of fsg's yes now staying on this page can
02:48:47 fsg's yes now staying on this page can we look at paragraph 59 b b for bravo where mr
02:48:51 where mr george recommended the following use babcock the brigades training provider to provide easily accessible cbt computer-based training packages within big learning and introduce new
02:49:03 within big learning and introduce new control specific training when necessary including tactical decision making exercises
02:49:09 exercises now you commented in the sidebar we agreed this some time ago what's happened since now is the reference there to an agreement to the plan in 2010 for cbt to
02:49:20 agreement to the plan in 2010 for cbt to be used to deliver fsg refresher training in the alternate year program well it's partly that but it's also discussions i had with
02:49:31 discussions i had with colleagues who were responsible for this it's the uh it's things that fell out the mopac report it was work that richard chandler had done so it was a combination of things were all
02:49:42 it was a combination of things were all pointing to this uh so it wasn't i that comment was aimed at one specific action because the impression you get from the comment what's happened since is that you are unaware
02:49:53 you are unaware of what had been happening in this regard since 2010 what would you say to that observation well no not since 2010 i i was aware of what been happening since 2010 but
02:50:05 2010 but but it still caught me slightly by surprise in terms of the whole issue with big learning and accessible cbt packages and yet we're now in 2016
02:50:17 cbt packages and yet we're now in 2016 so it wasn't 2010 versus 2016 it was just going back to this journey that where are we on this journey now because this journey appears to be a
02:50:28 because this journey appears to be a somewhat prolonged exercise because we're now six years on uh from the original proposal in respect of cb cbt training and it appeared to still not be happening
02:50:39 happening now would you accept that six years evidence is a chronic failing
02:50:47 if you if you time it back from 2010 then clearly it's uh it's a position that
02:50:53 that that we clearly didn't want to be in but it i wouldn't take it back to that it was things that were improving as we went but we still weren't getting to where we ultimately wanted to
02:51:04 getting to where we ultimately wanted to be
02:51:06 be with respect mr brown that's this it's a touch merely mouthed isn't it what we've got here is a clear recommendation that cbtb provided in 2010 it's 2016
02:51:19 in 2010 it's 2016 and nothing or at least nothing effective seems to have happened it's difficult to think of a starker example of a chronic failing isn't it
02:51:28 it clearly is something that no one was no one was proud of and and obviously we look back and there's
02:51:38 there's more i guess that could have been done at various points but it was it was incremental improvements and and yes i accept that we were off the mark in terms of where we
02:51:50 off the mark in terms of where we ultimately wanted to be with the cbt package
02:51:53 package but i wouldn't accept that nothing had been done in the interim period just wasn't enough could we turn to lfb trouble zero three two eight two four
02:52:06 now this is the review of brigade control dated february 2017 uh which effectively summarized mr george's report
02:52:16 report now can you help us as to why mr george's report prepared in july 2016 had not been provided to cmb or some other senior body or individuals
02:52:28 or some other senior body or individuals before february 2017. uh well well it had so
02:52:34 so so firstly when when i received tom george's report it was in its uh first draft shall we say and i think we've just illustrated that
02:52:46 and i think we've just illustrated that there are a number of comments i had on it it was also uh quite a long report as well i think it was around 30 odd pages so i asked tom jules to do some
02:52:58 pages so i asked tom jules to do some work on it to make it more concise and a lot of the recommendations were whilst i agreed with all the recommendations some of them were very minor recommendations
02:53:09 recommendations and so i asked him to do some more work on that and that took a period of time then we took it or tom at my request took it through staff side consultation
02:53:20 took it through staff side consultation then it would go through a process of coming through our own governance procedures so our own performance management board and then prior to any report going to
02:53:31 and then prior to any report going to corporate management board which is brigade practice and due process it would then also go for head-to-service consultation so there was a variety of processes it needed to go through which
02:53:42 processes it needed to go through which was good governance and that's the reason for for between july 16 and february 17. now you are listed as the author
02:53:53 are listed as the author and the top uh left there is it correct though that this document was drafted substantially by mr george oh yeah and i don't think that suggests i'm the author i can i can understand
02:54:04 i'm the author i can i can understand why you'd say that it was just being presented
02:54:07 presented so it again it was practiced that the director would present it but i think tom came to cnb and presented it himself which which uh we would have agreed
02:54:18 which which uh we would have agreed because in the next six weeks he was about to take my role so it was only appropriate um mr george indicated that the
02:54:27 the report was brought before cmb at the prompting of commissioner cotton does that accord with your recollection uh i think i think danny cotton might have
02:54:37 have asked if it was coming to cnb before i left
02:54:41 left and i'd absolutely no objection to it going to cmb it was it was a report that was based on findings prompted by a staff survey which was a quite rightly a
02:54:53 staff survey which was a quite rightly a big issue in the brigade at the time so so absolutely no issue with it going to corporate management and could we turn to page six in the document
02:55:06 and we see the heading uh progress post review
02:55:10 review and underneath that paragraph 22 identified a number of improvements and if we go to the third bullet point which says this additional familiarization training to all staff on ncc and fire
02:55:22 training to all staff on ncc and fire survival guidance can you remember now what had prompted an update on fsg training to be included bearing in mind that fsg training had
02:55:33 bearing in mind that fsg training had not been mentioned by mr george in the original the underlying report i think this refers to or is a nod to the
02:55:45 the other
02:55:46 other fire survival guidance work and i i i deliberately don't use the term training because it relates to command unit exercises where staff are being involved in that
02:55:59 where staff are being involved in that triangulation of transfer of information to the fire ground
02:56:05 why did you why are you hesitant about using the word training to describe that type of exercise
02:56:11 exercise uh
02:56:12 uh because i i think if if to be purist about it there is a difference between an exercise and training so whilst whilst it is uh it's obviously very
02:56:23 whilst it is uh it's obviously very useful to have staff involved in exercise where they can practice their skills and trainers on hand to give them feedback that's strictly speaking not the same as training in terms of a
02:56:36 the same as training in terms of a trainer student relationship now um
02:56:40 now um how do you discuss that particular point with mr george uh hence why it was included in this uh summary of his views i don't believe so i think one of the issues when i asked tom to
02:56:54 one of the issues when i asked tom to take up this role was to take responsibility for command units and i actually wanted the same person specifically looking at command units integration into
02:57:07 command units integration into base staff and control because that fed so perfectly into policy note 790. to the lay eye at least that third bullet point gives the impression
02:57:20 bullet point gives the impression that additional training had been provided since july 2016. um
02:57:26 2016. um what additional training had in fact been provided mindful of your caveat about that word on flight survival guidance
02:57:38 additional familiarization training would would refer to the the fact that we had uh come through vision and we were carrying on with the
02:57:50 carrying on with the year-on-year fire survival guidance training as planned plus the 790. it's only me being overly pedantic in terms of training and
02:58:03 so it was certainly much more interaction between control staff and the whole fire survival guidance ethos uh at this moment in time than there had
02:58:14 uh at this moment in time than there had been previously the reason i ask is just looking at the word additional um it's not immediately clear what additional training had been provided are you able to assist us on the substance of what
02:58:26 to assist us on the substance of what additional training is referred to here i think i think additional refers to the cumulative effects of uh
02:58:33 uh the the reference information files being far more specific to fire survival guidance the fact that fire survival guidance reference information forms were used after every fight survival
02:58:45 were used after every fight survival guidance called the fact that we were doing policy notes 790 training that we'd we'd got back to close where we wanted to be on the lacanal house year on year for survival guidance training
02:58:56 on year for survival guidance training so technically you could say well what's additional in all of that but i think it was meant to encompass everything that was going on um just one final question before lunch
02:59:08 um just one final question before lunch could i ask you to go to lfb triple zero double five one nine one forward slash 26
02:59:14 26 you'll recall this this is the table in mr hayward's statement below paragraph 74.
02:59:20 74. and if that table could be expanded we can see that only 46 of staff had received some fsg training in 2016 and only 32 in 2017.
02:59:32 in 2017. now
02:59:34 now mindful of those statistics can we go further into his statement to paragraph 78.4 which can be found at page 29.
02:59:46 that's at the very bottom of the page we see that mr hayward in evidence said this
02:59:50 this in 2017 up to the date of the grenfell tower fire no refresher fsg training had taken place
03:00:00 now mindful of those statistics what was the source of the information that was presented to the corporate management board about additional fsg training
03:00:14 well it would have it would have referred to the policy note 790 exercises that were going on it would have referred to the uh
03:00:25 the uh as i believe that there there was fire survival guidance training as specified continuing uh it's just the issue about the level of recording that
03:00:38 issue about the level of recording that was
03:00:39 was a severe
03:00:40 a severe problem and challenge for us i i
03:00:44 i i i don't agree with that no refi survival guidance professional training taken place because in my conversations with scott 2015 was the
03:00:56 2015 was the the crunchier because of vision and then in early 2016 and then this graphical curve started to pick up again so i would that that is not my recollection of the
03:01:07 that that is not my recollection of the way things were would you accept though that mr hayward was best placed to speak directly as to what training had been provided given the immediacy of his control
03:01:17 control yes yes i can't i can't argue with that point but what i can say is that if that's true in 78.4
03:01:25 in 78.4 then
03:01:27 then then that certainly wasn't brought to my attention and that's not my understanding of things as a result with discussions with scott mr brown thank you
03:01:36 you that's a good point isn't it good point sir thank you yes well mr ram will stop there so we can all have some lunch we'll come back at two o'clock please and again please don't discuss your evidence with anyone
03:01:47 evidence with anyone the world thank you sir thank you very much
03:01:49 much [Music]
03:01:59 all right thank you two o'clock