Professor Jose Torero's expert evidence on fire safety strategy, design fires, building performance, technical competency, dynamic risk assessment, and the relationship between building design and firefighting operations.
00:21:26 good morning everyone welcome to today's hearing today we're going to hear evidence from professor jose torreira one of the export experts appointed to assist the inquiry
00:21:38 to assist the inquiry yes mr minute morning mr chairman morning members of the panel i now call please professor jose tarrero thank you
00:21:53 good morning professor good morning uh i understand you're going to make the affirmation yes so could i ask you please to read out the words on the screen yes i do solemnly sincerely and truly declare and affirm that the
00:22:04 truly declare and affirm that the evidence i shall give shall be the truth the whole truth and nothing by the truth thank you very much indeed would you like to sit down thank you i'm comfortable there
00:22:17 yes mr miller when you're ready thank you um good morning professor good morning can i start please by asking you to state your full name for the record jose luis torreira cullen thank you now i i should also start by
00:22:30 thank you now i i should also start by thanking you very much indeed for coming to the inquiry and assisting us with your expert opinions both in your reports and your oral evidence that you're going to give us today you've given us two reports for the purposes of
00:22:42 given us two reports for the purposes of this phase two so far and am i right that those reports essentially consider the correlation between the fire safety strategy for grenfell tower and the various aspects
00:22:53 grenfell tower and the various aspects of the adequacy of the lfb's procedures and training yes yes now the first of those reports is that jtor702
00:23:05 can we please have that up that as you can see is dated the 21st of april 2021. is that your signature yes thank you uh and have you read this report recently yes thank you can we go
00:23:17 report recently yes thank you can we go to the second of your phase two reports please jto705
00:23:25 and that is dated the 15th of august 2021 and again is that your signature on that page yes and have you read that report recently yes uh is it right that your second report
00:23:36 uh is it right that your second report the one on the screen contains what you call further considerations on the presumption of technical competency yes and does that build on the general analysis that you propounded in your
00:23:47 analysis that you propounded in your first report and consider some of the analysis provided respectively by professor christopher johnson on uh incident ground communications and steve mcgurk in relation to matters of operational
00:23:58 in relation to matters of operational firefighting procedures and and training yes it does and i think i'm also right in saying that you have considered some of the opinions of uh professor ivan stoyanov
00:24:09 opinions of uh professor ivan stoyanov in relation to water supply on the night of the fire yes we will not be exploring those matters with you today i should tell you can you subject to those things can you confirm that the facts and matters set out in each of those reports
00:24:21 matters set out in each of those reports are are true to the best of your knowledge and belief i can confirm that and that the opinions set out there are your true and honestly held professional opinions yes and is it right that you've provided the experts reports to the
00:24:33 provided the experts reports to the inquiry in the same way that you would have provided an expert report or reports to the court yes i did the english court that is yes and uh am i right that your opinions
00:24:44 yes and uh am i right that your opinions on the matters that are relevant to phase two of the inquiry thus far um relate to the uh the matters we've discussed the adequacy of the lfb's training and procedures so
00:24:55 of the lfb's training and procedures so far as they informed the operational response of the lfb on the night yes now to be clear and just to set it in context the the reports that you provided for phase two
00:25:07 reports that you provided for phase two of these investigations are further too and billed to some extent on the initial report the updated report and the addendum that you provided to the inquiry for the purposes of its phase one investigations is that
00:25:18 of its phase one investigations is that right yes i do yes now your phase two reports i think also build on the uh the findings and uh recommendations um provided following the
00:25:30 provided following the well in the in the phase one report itself yes building on what you provided to the inquiry um for that purpose yes i do yes now can i then look at your experience and qualifications i think i
00:25:41 experience and qualifications i think i can take this quite quickly because you have set out your background and your fields of expertise on pages 8 to 10 of your first report at section 1.4 um we can have that on on the screen
00:25:53 um we can have that on on the screen so the people know where to find it but can i can i touch on some specific points identified there so that those watching um can understand some of the basics
00:26:02 basics first and correct me if i'm wrong about any of this you you specialize in fire safety and you've worked in that field for more than 24 years having originally trained as a mechanical engineer and then gone on to obtain a phd with a
00:26:14 then gone on to obtain a phd with a specialization in fire safety yes and you're a chartered engineer by the engineering council division of the institute of fire engineers in the united kingdom yes
00:26:25 united kingdom yes also a registered professional engineer in queensland and a full member of the society of fire protection engineers in the united states yes also a fellow of a number of engineering
00:26:36 also a fellow of a number of engineering schools and institutions both here in the united kingdom and abroad yes and you were awarded the arthur b guys medal in 2008 by the society of fire protection engineers in the united
00:26:47 protection engineers in the united states
00:26:49 states yes and in 2011 the david rasbash meddled by the institution of fire engineers in the united kingdom in recognition of your eminent achievement in the education engineering and science
00:27:00 in the education engineering and science of fire safety yes and currently you are professor of civil engineering and head of department of civil engineer civil environmental and geomatic engineering at ucl university
00:27:12 geomatic engineering at ucl university college london and before that you had held the john l bryan chair of the department of fire protection engineering and you were the director of the center for disaster resilience at the department of civil
00:27:24 resilience at the department of civil engineering at the university of maryland in the united states yes yes that's correct and before that professor of civil engineering and head of the school of civil engineering in the university of queensland in australia
00:27:36 university of queensland in australia between 2012 and 2017. yes and before that you held the landault and company chair for innovation for a sustainable future at the eccol polytechnique federal de
00:27:47 polytechnique federal de in switzerland in 2012. yes and also
00:27:52 and also we will come to the end of this quite soon but also the bre trust royal academy engineering chair in fire safety at the university of edinburgh between 2004 and 2011. that's correct editor in chief of the
00:28:03 that's correct editor in chief of the fire safety journal 2010 to 2016. yes and that's a very respected journal in this field isn't it it's a leading journal it's a leading journal and you've been an editor on a number of other academic publications and journals
00:28:15 other academic publications and journals too yes
00:28:17 too yes and
00:28:18 and involved in a number of fire investigations including between 2001 and 2011 into the world trade center buildings one and two collapses yes and you've done dispersion fire
00:28:31 and you've done dispersion fire modelling supporting the litigation relating to buntsfield the bunsfield explosion and the seagull mine explosion in the united states yes and also i think you conducted the post-fire structural assessment of the
00:28:42 post-fire structural assessment of the abu dhabi plaza fire in kazakhstan yes which i think you say is the biggest ever of a building under construction yes
00:28:52 yes and you've developed training programs on investigation for fire and rescue services in the united kingdom yes taught courses for fire and rescue services in many different countries across the world and developed curricula and taught fire
00:29:04 and developed curricula and taught fire engineering courses at a number of universities including those we've looked at but not exclusively so and also in the united kingdom i think it's right that between 2007 and 2010 you'd have led the development of the
00:29:16 you'd have led the development of the fire grid project funded by the department for trade and industry as it was then called which involved a detailed study into the role of information in fire brigade emergency responses yes
00:29:28 responses yes and that project i think concerned very much in summary the use of info and specifically the use of information in order to predict how a fire is likely to behave at an incident that's correct
00:29:41 behave at an incident that's correct and you've also acted this is finally in numerous advisory roles both for government and industry in the united kingdom and abroad including the fire service yes and at the time of these phase two
00:29:54 and at the time of these phase two reports i think is it right you were acting as special adviser to the minister of housing in queensland australia in relation to facade fires yes thank you um i want to touch just on the the scope
00:30:07 um i want to touch just on the the scope of your um of what we're going to discuss today um
00:30:12 when you refer to the fire safety strategy for grenfell tower that i'd like just to clarify what you mean you've told us that you aren't referring to any specific document that
00:30:23 referring to any specific document that might have been produced in relation to the tower is that right yes and i think is it right that you're using the term fire safety strategy to refer to the collection of measures that are implemented in order to ensure
00:30:36 implemented in order to ensure fire safety in high-rise buildings yes i see
00:30:40 see and and also that firefighting operational protocols are an integral part of the fire safety strategy itself absolutely now i want to address really four issues with you
00:30:51 with you uh that arise from your two reports in this phase two first
00:30:56 first what you refer to as design fires and the significance of building performance in the context of increasingly complex modern structures so design fires second i want to
00:31:07 second i want to ask you about what you refer to as the societal
00:31:11 societal expectations and presumed competency of the fire service to deal with fires in that context third
00:31:19 third the significance of the dynamic risk assessment which you i think identify as the means by which fire services are able to respond to unexpected uh
00:31:29 uh fire and building behavior yes yes and fourth i'm going to ask you about the operational response to the fire at grenfell tower on the night of the 14th of june 2017. yes
00:31:40 of june 2017. yes now against that background and
00:31:43 and apologies in advance for presenting you with the risk of oversimplification can i
00:31:50 can i or can we
00:31:52 or can we reduce your opinions to three
00:31:56 to three basic theses first
00:32:01 first the fire brigades regularly and wrongly assume that the building in front of them is compliant with regulation when it isn't
00:32:12 that's a difficult question to answer while postulated in those terms but they do regularly make that assumption you know whether it is wrongly or not depends on whether the building uh is compliant or
00:32:24 whether the building uh is compliant or not with the building regulations but i agree they will assume that when they arrive
00:32:29 arrive to a scene of a fire that building is compliant with the building regulations when i say unwrongly then what i think i mean is unsafely potentially yes second
00:32:39 second that modern fire brigades need to have the technical competence at all levels necessary and sufficient to be able to put out fires and save life in all buildings
00:32:51 and save life in all buildings regardless of their complexity and their regulatory deficiencies does what they are there for third
00:33:01 third technical competence requires a technical understanding at all levels of the construction methods and materials used in any particular building that buildings layout and how it presents
00:33:15 buildings layout and how it presents risk and how it will aid or hinder effective firefighting and rescue operations yeah that statement is correct and but again it needs to be caveated with what is the definition of technical
00:33:27 with what is the definition of technical competency and who will have which level of technical competency within the hierarchy of the fire brigades subject to those caveats
00:33:38 subject to those caveats are we able to reduce your opinions further to a single proposition and again at risk of oversimplification that you say that the design and the construction of buildings and the work
00:33:50 construction of buildings and the work of fire brigades are inextricably interlocked as a singularity but neither legislation regulation nor professional standards and attitudes in the united kingdom fire and rescue
00:34:01 the united kingdom fire and rescue services see it like that i agree
00:34:08 and i might also write that you consider that neither society at large nor the lfb in particular consider that fire and rescue services are an integral part of safety strategy as you
00:34:20 integral part of safety strategy as you define it
00:34:23 that that is is correct but once again it goes back to the problem of the definition there is an expectation of the fire and rescue services in regards to their role
00:34:36 rescue services in regards to their role the moment they arrive on a fire scene and that expectation in principle responds to what you just said nevertheless how do you define those terms can be quite complicated yes
00:34:50 and is it your view that
00:34:54 neither society at large for which perhaps they could be forgiven but fire rescue fire and rescue services in particular do not understand the degree of competence required for an incident commander to perform a
00:35:06 for an incident commander to perform a dynamic risk assessment in the case of a building design failure i would agree with that and your solution for that fundamental problem is in summary what
00:35:18 problem is in summary what uh that there has to be a very clear um respect for the role that technical competency has in the activities that the fire brigade
00:35:30 in the activities that the fire brigade is expected to perform yes now can i turn to the first of the topics i identified for you a few moments ago that is uh design fires and modern construction can i ask you to
00:35:42 modern construction can i ask you to look at your first phase 2 report please jtor702
00:35:46 jtor702 page 12.
00:35:48 page 12. let's look at lines 434-435
00:35:52 434-435 you say there to fully establish the need for a fire and rescue service to evolve
00:35:59 to evolve it is first essential to discuss the relationship between firefighting and the provision of building performance in the design process and beyond uh apologies but i think i'm not getting
00:36:10 uh apologies but i think i'm not getting the no i'm just about to say i think we're looking at a different part we are yes we're looking at yes i said two uh in fact we're looking at the different the second report and then and i'm quoting
00:36:22 i'm quoting um we go to page 12 of two that looks more like it that is it i'll read it to you again uh to 434 to fully establish the need for fire and
00:36:33 fully establish the need for fire and rescue service to evolve it is first essential to discuss the relationship between firefighting and the provision of building performance in the design process
00:36:41 process and beyond would it be right to say that the point you're making here is that it's crucial to consider the function and performance of the fire and rescue service in the context of how buildings are designed yes
00:36:52 are designed yes and that's because is it that the the level of competence that's necessary for the fire and rescue service to demonstrate is directly related to the design of the building absolutely if you have a building that uh requires for the
00:37:05 have a building that uh requires for the fire brigades to have a very very high level of competency then that has to be made very clear from the onset because that is the job they're coming to perform if you have a building that
00:37:16 perform if you have a building that requires a much less level of competency then that has to be made very clear so that they understand what is the job they came to perform yes and you go on to say at lines 436 and 437
00:37:29 lines 436 and 437 currently building and infrastructure development in the broad sense is conducted through design principles that are based on a series of fundamental assumptions and are executed by a range of design
00:37:41 and are executed by a range of design tools
00:37:42 tools can you explain here what you mean by a series of fundamental assumptions yes absolutely so if we take as an example a proof document b so a proof document b has two parts it
00:37:53 so a proof document b has two parts it has guidance and it has the building regulations as they pertain for example in the case of facades the functional requirements like b4 so in principle
00:38:05 so in principle that gives you the way in which you are executing the plan but what a proof document b doesn't give you
00:38:14 you is
00:38:15 is the problem formulation or the plan formulation which is it never requires you to perform an adequate fire safety strategy that fire safety strategy is going to determine
00:38:27 is going to determine how all the bits and pieces fit together and how you're utilizing the functionality requirements and how you're utilizing the guidance or any other tools to meet the requirements of the building
00:38:38 the requirements of the building regulations the assumption that is embedded in the documentation that we have that regiments the way in which we design buildings uh is that somebody will
00:38:49 buildings uh is that somebody will create that fire safety strategy it is not required it is not part of the process there is a a core assumption that somebody is creating that fire safety strategy and that fire
00:39:01 that fire safety strategy and that fire safety strategy has to include the role and definition of competencies of the fire brigade they expect to respond to an event in that building right i mean
00:39:12 an event in that building right i mean who is making who is it assumed will perform the role of creating a fire safety strategy
00:39:21 strategy uh the creation of the fire safety strategy formulation of the problem in principle should be done by a fire engineer
00:39:29 engineer and uh by the designer of the building in accordance with the other stakeholders which obviously includes the fire brigades because the fire brigades
00:39:39 brigades are going their working place is going to be the building in the event of the fire
00:39:48 now if we go to line 437 where we've just been looking and look at the next sentence you go on to say the design can either be regulated by
00:39:59 the design can either be regulated by compliance with codes stroke standards or by explicit demonstration of adequate performance via professional stroke technical analysis engineering the design is then implemented and the
00:40:10 design is then implemented and the building is assumed to provide adequate performance including delivering societally acceptable levels of fire safety now is what you're saying there that once the building has been shown to be
00:40:21 once the building has been shown to be compliant with the relevant codes and standards at the design stage it is assumed by fire and rescue services
00:40:30 services they all the services uh responsible for the building in which the area in which they are responsible sits that the building will perform in accordance with that design in the event of a fire
00:40:41 that design in the event of a fire that is correct the day of the handover of the building but buildings are living entities and they're going to evolve in time and users are going to use them in in different ways so in principle
00:40:52 in different ways so in principle this is why we introduce what we call a feedback loop in other words the inspections and fire risk assessments and so forth that come afterwards so that we can guarantee that that building
00:41:03 that we can guarantee that that building continues to perform as design now the assumption that the building uh was designed according you know to uh to the adequate performance requirements at the day of
00:41:15 performance requirements at the day of the
00:41:16 the incorporation of the building you know into the system you know it's it's a correct assumption
00:41:27 you say it's a correct assumption is it a safe assumption well that really well i mean it it depends on how well the process works now obviously if you're operating on the principles of functionality requirements
00:41:40 principles of functionality requirements then there has to be an explicit demonstration that that safety has been attained and that explicit demonstration has to be agreed by other stakeholders
00:41:51 has to be agreed by other stakeholders including the fire brigades and going back to your feedback loop as you put it a moment ago where you say that inspections and fire risk assessments and so forth that come after design and construction
00:42:05 design and construction so that you can guarantee that the building continues to perform as designed does that does that tell us that those conducting the inspections and fire risk assessments need to have at least a reasonable grasp of how the
00:42:18 at least a reasonable grasp of how the building was designed at least in relation to its fire safety performance [Music]
00:42:25 [Music] most definitely because in many ways what they're looking for is if the building has evolved in a way such that might lead you know to an unsafe situation and for that you
00:42:37 to an unsafe situation and for that you need to really understand what the limits of the provisions are so just to give you an example if i put a sprinkler system and the sprinkler system is designed for an office space like this one but i decide to convert this place
00:42:49 one but i decide to convert this place into a warehouse and i start putting boxes that go all the way to the ceiling whoever inspects that has to be able to recognize that the sprinkler system was designed on a series of assumptions and
00:43:01 designed on a series of assumptions and limitations that requires the building to have chairs and desks and cannot have storage racks so that level of competency is essential in the process
00:43:12 competency is essential in the process of an inspection because otherwise you will end up missing the details now there's another aspect that is very important about inspections is that as i say things are not static
00:43:23 say things are not static and as we progress we learn and many times you know through either disasters or through uh events we start figuring out that there are certain problems
00:43:35 out that there are certain problems and certain things that we had presumed that were actually safe all of a sudden we start realizing that technology has evolved in a way such that we're introducing things that might actually
00:43:46 introducing things that might actually not be safe so we need to have the presence of mind and the competency to be able to identify when those things have
00:43:54 have penetrated you know and they were unnoticed and at that point you need to highlight the fact that those things might have an impact on the safety of the building on the safety of firefighting operations and or the
00:44:06 firefighting operations and or the capability to deliver the job yes
00:44:09 yes can we um go please to page 13 the next page in this document and look at lines 466 to 468 together at 466 you say this in respect to most fire safety
00:44:20 in respect to most fire safety provisions on-game performance assessment is indirect and therefore not truly quantified beyond the design process it is assumed that if a provision introduced through the design process remains unaltered then
00:44:32 process remains unaltered then performance should be as dictated by the design now can you just clarify for us uh what you mean here
00:44:41 mean here uh particularly in relation uh to what you mean by um
00:44:49 indirect ongoing performance assessment is in indirect and therefore not truly quantified yeah just to give give you an example to illustrate that so for example uh these columns will have there
00:45:01 example uh these columns will have there will be an expectation that they have a certain fire resistance and that fire resistance was embedded into the column during the process of design so unless i have something that
00:45:12 so unless i have something that evidences the possibility that the columns might not be performing appropriately for example a big crack or a missing piece of plasterboard i will make the assumption
00:45:23 make the assumption that this column still retains the file resistance with which it was designed and uh and and and i don't have any direct means to demonstrate that that's why it's
00:45:34 to demonstrate that that's why it's indirect because i cannot pick up the column bring it to a furnace and test it for fire resistance and then put it back so in principle i just simply have to rely on this indirect means to achieve the objective
00:45:45 the objective yes i follow now you go on i think to discuss the relationship between building design and firefighting activity
00:45:51 activity uh in a number of different places here but if we look at line 472 you say this it is in the design process where provisions are made to support firefighting activities and these are based on preconceived modes of operation
00:46:03 based on preconceived modes of operation or known policy now just to be clear when you're referring here to preconceived modes of operation or known policy
00:46:11 policy are you referring to preconceived firefighting modes of operation and known firefighting policy yes so just to give you an example you will put in a building a certain set
00:46:23 you will put in a building a certain set of
00:46:24 of water supply systems and those water supply systems have to be consistent with the tools the firefighters will bring in you know to use the water in the building so basically you have a clear idea
00:46:35 clear idea of what are the list of things that the firefighters will need to perform their job and in the design process you're supposed to embed those and the fire brigades are supposed to make sure that
00:46:47 brigades are supposed to make sure that they have uh everything that they need to conduct their operations i follow so would one simple example be a dry rising main exactly yes now then you go on to say from the middle of line 473 thus the design process will deliver a
00:46:59 thus the design process will deliver a building where where the fires that can occur and you call them design fires uh are only those that can be fought using existing protocols which you call operational protocol
00:47:12 operational protocol now you use the word design fires there's a footnote which we can have up on the screen if the page can be scrolled down footnote 16 and you say there the term design fire
00:47:24 and you say there the term design fire is commonly used by fire safety engineers and not by fire and rescue services when referring to operations nevertheless the meaning i.e a fire event of sufficiently high probability
00:47:36 event of sufficiently high probability applies both to the design of a fire safety strategy or operational protocols for fire for firefighter response that are an integral part of such a strategy
00:47:47 are an integral part of such a strategy does that tell us that when buildings are designed it is intended that any fire or should be intended that any fire event may that may occur would be capable of being fought using existing established
00:47:59 fought using existing established operation um operational firefighting procedures yes that's correct in other words the predicted operational response will be designed in yes so in principle you are designing all the
00:48:10 principle you are designing all the necessary provisions and those necessary prohibitions will lead under most circumstances you know to a condition that is consistent with the condition that the fire brigade
00:48:21 the condition that the fire brigade would expect upon arrival to the fire scene yes now just breaking that up a bit does it mean first that conversely the operational firefighting protocols that are developed by the fire and
00:48:32 that are developed by the fire and rescue services will will be developed on the footing that they will be effective in dealing with the fire in a building because the building has been designed specifically with those firefighting
00:48:43 specifically with those firefighting procedures in mind yes that's what would be correct yes and also that there's a in a sense a reciprocal reliance by both building designers and fire and
00:48:54 by both building designers and fire and rescue services in that context yes they're in a strictly coupled there is no way to separate the two of them um so to make the point perhaps a bit clearer
00:49:05 to make the point perhaps a bit clearer do you agree that building designers would rely on the fire and rescue service to be able to implement existing operational protocol in the event of a fire
00:49:13 fire and the fire and rescue service rely on building designers to design a building that is capable of being fought applying existing operational protocol exactly yes and just help me with this would also be right to understand that
00:49:26 also be right to understand that designers of buildings have in mind a certain range of fires which are likely to occur for which the building so to speak is designed to respond
00:49:37 designed to respond but it's not an unlimited range of fires that's as it is yeah no that that that is correct i think you put the necessary provisions in such a way that you bound the possible fires to things or to
00:49:50 the possible fires to things or to events that you can actually manage appropriately so so it is not an infinite number of fires now this is a it's a very very good question because i think this is a matter of great confusion when people
00:50:03 matter of great confusion when people say that fires are unpredictable and they can go in all directions you know fires it is true if you look at it at a very refined grade and try to for example predict you know to the
00:50:15 example predict you know to the millimeter or to the millisecond the progression of a fire the fire can be treated as almost a random event but the reality is that when you start looking at the design
00:50:27 when you start looking at the design level you make things a little bit coarser so you become a bit more conservative you put safety factors you work your way in a way such that you bound the event to a space where you know that it cannot exceed a certain
00:50:40 know that it cannot exceed a certain maximum temperature it cannot exceed a certain maximum volume and so you create an event that will maybe random you know in this highest fidelity it is actually perfectly predictable you know in its
00:50:52 perfectly predictable you know in its broad you know representation thank you
00:50:56 thank you yes now
00:50:58 yes now in relation to this mutual reliance um on each other by the fire and rescue service and the building designer respectively i think that's what you refer to as the two-way link in line yes
00:51:10 refer to as the two-way link in line yes um
00:51:11 um what do you contemplate in particular would be included in the operational protocol
00:51:17 protocol can can you expand a little bit so i can understand better what do you mean well you use the expression at lines four seven four to six uh operational protocol which is about
00:51:28 operational protocol which is about firefighting using existing protocols what do you contemplate should be included in an operational protocol given the mutuality of the relationship with the designer
00:51:39 of the relationship with the designer uh there's a multiplicity of things there's going to be you know the sort of active event of fighting the fire uh so you have to really understand what resources you have available the
00:51:50 resources you have available the competency capacity of those resources
00:51:54 resources you have to understand the structure under which they operate you will have to understand the tools that they have available and you will have to understand the capacity so just to give you a simple example uh
00:52:06 so just to give you a simple example uh if you have a a very very large warehouse that is filled up with expanded polystyrene uh you will not expect the fire brigades to have the capacity to fight a fire of
00:52:18 have the capacity to fight a fire of that nature so in that case you're designing for a total loss and all that you're guaranteeing is that life safety is preserved and in that case for example because you recognize that the protocols
00:52:30 because you recognize that the protocols everything that the fire service has is not capable of delivering the control of the fire then you just have to expect the total loss
00:52:40 and you design for it right um
00:52:43 um taking a sort of slightly sideways look at that would you expect a designer to take into account absence of com competence within a fire and rescue service
00:52:56 within a fire and rescue service when confronted with a particular building design feature
00:53:02 feature no and this is this is a presumption of competency right so you are presuming that the skills that the firefighters in principle are supposed to have to be
00:53:13 in principle are supposed to have to be able to do their job are all present at the moment they will arrive to the scene so just just simplifying it and again at risk of over doing so
00:53:26 again at risk of over doing so you wouldn't expect a building designer or a refurbishment designer to say well i'm not going to do that to the building because if i do that then the local fire and rescue
00:53:37 that then the local fire and rescue service won't have a clue about what to do with it if it burns uh
00:53:42 uh the
00:53:43 the there's there's a theory and there's the practice so in theory absolutely you what you said is is correct but the reality is that as a designer you also have the onus to introduce robustness into your building and uh and
00:53:56 robustness into your building and uh and if you have too heavy of a reliance on the fire service you you might end up in a situation where you are putting too much weight on a presumed level of
00:54:07 much weight on a presumed level of competency that you probably cannot guarantee so you have the owners of putting robustness into your design yes i see now can we then look a little bit lower down the page page at line 488
00:54:20 lower down the page page at line 488 you say there that uh
00:54:25 that uh uh that this limited range of outcomes
00:54:30 about i'll start at the beginning is probably uh easier and as explained above the implementation of an appropriate feedback loop is of particular importance in fire safety
00:54:43 because design decisions are intended to limit the range of outcomes of a fire this limited range of outcomes enables fire and rescue services to define a specific range of response protocols which responders can be trained to carry
00:54:54 which responders can be trained to carry out efficiently and safely um
00:54:58 um can you just explain what you mean there uh yes so
00:55:03 uh yes so if if if you are going to perform a task you have to understand what that task is so if i
00:55:11 so if i basically do not narrow down the potential of a fire to a series of events that can be defined as the task
00:55:22 events that can be defined as the task then the fire brigades cannot develop a series of protocols that can actually perform the task
00:55:30 when you say if you're going to perform a task are you referring to the designer uh or the firefighter i i'm i'm i'm referring to the fire brigades right
00:55:41 the fire brigades right so the task of the fire brigades is is basically to come in and uh and take a role within the fire safety strategy and that role is to in the event that there is a design failure
00:55:54 the event that there is a design failure you then the firefighters are there to try to control the event and bring it to a level that is an acceptable level of safety that is the task yes i see because they follow from that but if the
00:56:05 because they follow from that but if the fire and rescue service proceeds on the basis that only design fires will ever occur
00:56:10 occur the nature and extent of operational procedures and training that need to be be developed is relatively limited well it could potentially be so if if if the the window
00:56:22 the the window of potential events that you have like um you know like it used to be in sort of the very compartmentalized all residential type of buildings you know then fundamentally you have a very
00:56:34 then fundamentally you have a very narrow set of events that could possibly happen and because you have a very narrow set of events that could possibly happen you could focus your training and education into those events
00:56:45 and education into those events so if a fire and rescue service were only ever dealing with design fires then they wouldn't need to have any knowledge would they or any insight into building behavior because they could
00:56:56 building behavior because they could always trust the design to support their firefighting that is completely correct if you ignore what their fundamental role is they are the ultimate redundancy so in principle they are part of the
00:57:07 so in principle they are part of the fire safety strategy as the ultimate redundancy so you can if if you assume that a building is always going to perform as designed then there will be no need for fire
00:57:18 then there will be no need for fire intervention but we know very well that we have human factors we have a number of different issues that need to be addressed we have deterioration of buildings we even have design mistakes and and therefore you introduce this
00:57:30 and and therefore you introduce this ultimate redundancy to your system to your fire safety strategy that enables you to pick up the pieces when something doesn't go right i see so does that mean
00:57:41 doesn't go right i see so does that mean that if the fire and rescue service limit their training and preparation to what you
00:57:46 what you call design fires then they can't deal with undesigned fires in other words fires that happen despite the design this is why they need to be trained on this concept of the dynamic risk assessment because at some point they
00:57:58 assessment because at some point they will have to make an assessment if the the event has departed from the design fire and then introduce you know alternative ways of confronting the problem
00:58:09 ways of confronting the problem yes and you go on to say uh in
00:58:13 in in the previous paragraph you say um and i'll summarize you you say essentially you can't offer infallible guarantees that all fires will be as anticipated therefore you said 484 fire and rescue
00:58:25 therefore you said 484 fire and rescue services have to possess a means to provide an adequate response to events that differ from the design fire the dynamic risk assessment is the most common means to achieve this when you say behave as anticipated do you mean
00:58:36 say behave as anticipated do you mean design fire as defined yet yes i see uh and and you refer to the the dynamic risk assessment there we're going to come to that later but for the moment can you just explain in in short in
00:58:47 can you just explain in in short in brief terms if you can what a dynamic risk assessment is in in in conceptual terms a dynamic risk assessment is you take the information that is available to you and on the
00:58:59 that is available to you and on the basis of that information you make an assessment and that assessment might either confirm that your procedures and protocols are operating correctly or it might
00:59:10 it might lead you to believe that you actually have to alter the product the the the the process so in a way that continuous evaluation of the event
00:59:21 evaluation of the event is what the dynamic risk assessment is is the usage of the information that you have available to inform your decision making yes and of course we know there was a
00:59:30 was a policy for that i think policy 342 revised this current in august 2016 uh for the london fire brigade yes that's correct yes now um we'll come to
00:59:42 that's correct yes now um we'll come to we'll come to dynamic risk assessments a little bit more
00:59:46 more closely later but you've explained that the ability uh to carry out an effective dynamic risk assessment depends on the uh the fire and rescue service having obtained sufficient and relevant
00:59:57 obtained sufficient and relevant information about the building before a fire occurs is that is that right uh
01:00:04 uh your dynamic risk assessment is only going to be as good as the information that you have so if you don't have adequate information on the building its fabric and its characteristics it is very clear
01:00:16 and its characteristics it is very clear that you're missing a bit a big part of the picture so the quality of your dynamic risk assessment will deteriorate in the absence of that type of information and the information you're
01:00:27 information and the information you're referring to would that ordinarily be collected under section 72d of the 2004 act yes so that would be one of the means by which you collect that information yes
01:00:39 collect that information yes uh yes and another means would be what i mean in it it varies in different in different parts of the world you know in some places for example you have continuous assessment of fire hydrants
01:00:51 continuous assessment of fire hydrants and uh so fire brigades will come in on a regular basis and evaluate the fire hydrants in the in in different areas and make sure that they're operating correctly uh in in in
01:01:03 they're operating correctly uh in in in in in other cases there is um you know processes by which you are required to report uh information on buildings by the building managers are constantly coming to the fire services
01:01:15 constantly coming to the fire services there's many ways by which you can acquire the information but in the uk you know is through that process of inspection the main way by which you you acquire the information are we able to add to that and maybe add
01:01:27 are we able to add to that and maybe add is the wrong word in this this context but
01:01:30 but uh the information gleaned by fire and rescue services as either inspecting bodies or um enforcing bodies under the regulatory reform order yes yes which would depend
01:01:43 reform order yes yes which would depend heavily on the building owner or the responsible person having the information in the first place exactly now we'll come to that
01:01:54 that question i think later but in in summary if you look at line 495
01:02:01 495 over on page 14 you say this uh
01:02:09 you say the end of the line it is important to note that that as the complexity of the building and its fire protection systems increases
01:02:18 increases the degree of competency required of those gathering the information inevitably increases now when you say degree of competency increases
01:02:27 increases do you mean that or do you mean that they would need to become competent at new or more complex things not more competent at things they already know about
01:02:37 about uh well
01:02:39 uh well both both i think i think that if any professional practice is due to keep up you know with the technology as it's coming in and uh and as such you have to
01:02:50 coming in and uh and as such you have to in you have to expand your competency into areas that become relevant to you but at the same time refining your knowledge on areas where you were already deemed to be competent is always an appropriate uh
01:03:03 an appropriate uh course of action is continuous learning basically so does that mean that those responsible for collecting information by whatever source or from whatever source need to acquire new skills and experience commensurate
01:03:15 experience commensurate innovation and increased complexity of buildings
01:03:19 buildings not only those collecting the information but everybody who manages that approach because there's many ways as you said of collecting that information and a lot of that information comes internally so you will
01:03:30 information comes internally so you will have
01:03:31 have individuals are a higher management level that will be acquiring information from other events from other uh institutions and they is their responsibility to make sure the
01:03:42 responsibility to make sure the information is transferred to those conducted conducting the inspection so basically you're collecting inspection but the competency has also to be informed by information that is being
01:03:53 informed by information that is being collected by the
01:03:55 the the organization in itself as a whole and that would filter down the levels to firefighting absolutely i mean that was a question but you agree with you agree with the proposition yes um going back to the notion of design fire if we can
01:04:07 to the notion of design fire if we can professor you refer uh
01:04:10 uh to the beginning of the fire the outset of the fire on the 14th of june 2017 namely the kitchen fire in flat 16 on floor 4 of grenfell tower as a very high
01:04:21 floor 4 of grenfell tower as a very high probability event for a building of that nature
01:04:24 nature and that's um on page 14 at line 520 we can just scroll down to that it's at the bottom of your screen but you go on to say
01:04:33 to say from the end of line 520 this you say the expected performance i.e the design fire was such that such a fire would remain within the unit of origin and therefore flames and
01:04:45 unit of origin and therefore flames and smoke would not compromise other units the compartmentalization recommended by government issued guidance aims to contain the fire within the unit of origin and thus allows implementation of
01:04:57 origin and thus allows implementation of what is called a stay put strategy now
01:05:01 now would it be right to say that a the stay put strategy or policy is an example of a fire safety strategy premised on the design of the building the stapled strategy is one component of
01:05:13 the stapled strategy is one component of the overall fire safety strategy that's a component that leads you know with the evacuation or egress practices so in this particular case you are making the decision that people
01:05:24 you are making the decision that people will remain in place and you put all sorts of other provisions around it and that represents the fire safety strategy that will make sure that people will stay in the building and they will remain safe i see so just to be clear
01:05:37 remain safe i see so just to be clear it's not a strategy that is imposed from outside on an existing design it it is a strategy that is designed for yes it is a choice so you choose a staple strategy and as a function of
01:05:48 staple strategy and as a function of that you put adequate provisions to support a staple strategy including the provisions necessary for the fire brigades uh and forgive the simplicity of the next question but would it be right to say therefore that a that stay
01:06:00 right to say therefore that a that stay put is reliant on the building performing as expected in the event of a fire in other words it's appropriate in uh in the context of a design fire but not otherwise exactly
01:06:12 not otherwise exactly now you refer it lines 5 30 on the next page please page 15 and line 531 to some statistics uh on the frequency
01:06:23 uh on the frequency of uh
01:06:25 of uh of high-rise fires requiring generalized evacuation i think you're referring here to colin todd's phase one report of the inquiry yes that's correct now um
01:06:36 now um the
01:06:37 the um you will go on you say that that one of the statistics is that eight more than eight thousand fires in high-rise high-rises in the uk in the last 20 years only two cases justify generalized evacuation and again you refer to colin
01:06:50 evacuation and again you refer to colin todd's
01:06:51 todd's statement am i right that in fact i think that's a typographical error because his report refers to 22 cases that required evacuation of more than five people in over eight thousand fires in blocks of flats that's correct
01:07:02 in blocks of flats that's correct apologies for that it's somehow the 20 disappeared okay so it's 22. but the point you're making is is it right just despite that error remains the same that but before the grenfell tower fire the
01:07:13 but before the grenfell tower fire the statistics showed that only an extremely small proportion of fires in residential high-rise buildings resulted in in some form of evacuation yes
01:07:23 yes so would it be right to say looking at it objectively that they were statistically insignificant yes there is that that is correct there is two ways always to look at this type of problems
01:07:34 always to look at this type of problems one of them is looking at the past and that's where the past statistics reinforce your position and the other one is looking at the evolution of things and and
01:07:43 and in parallel what you have is an increased awareness of these large-scale fires that were effectively breaking the compartmentation and potentially requiring a full equation so you have in
01:07:54 requiring a full equation so you have in this case the two things going in parallel but it is correct that if you use the approach of looking at past statistics as a reference of what you're doing
01:08:03 doing then effectively this will reinforce uh the position that uh that fires will remain in the unit of origin yes of course i imagine that looking at the
01:08:14 course i imagine that looking at the statistics for the past is very valuable so long as you haven't changed your practices for the future exactly and this is why you have to look at both um
01:08:26 what do those statistics tell you about the risk of a fire requiring evacuation and by way of departure from stay put in any
01:08:37 departure from stay put in any particular building uh unfortunately very little
01:08:43 what do they tell you they may tell you about frequency risk but do they tell you about severity risk no the reality is the risk is always defined by the probability multiplied by the consequence and uh and this is one
01:08:55 the consequence and uh and this is one of those cases where if that component failed
01:08:59 failed then the consequences are massive and you cannot ignore the potential of the consequences even if the probability is small
01:09:07 small yes
01:09:10 now in his phase two witness statements commissioner rowe andy rowe
01:09:17 andy rowe uh has told us that to the best of his knowledge the grammar tower fire represented the first departure uh from the standard stay put strategy in england and wales
01:09:28 in england and wales is that consistent with your understanding uh no i i think that uh that again you know i think many times uh we use language in very different ways and many times we use the same type
01:09:39 ways and many times we use the same type of words and mean completely different things i think the the the question for me is uh when the problem is that when you look at past statistics you have to really be careful
01:09:50 statistics you have to really be careful in the way in which you take the information and also what information is available to you because at the end what you really want to understand is whether a state put strategy should have remained
01:10:01 put strategy should have remained not whether it was done or not because you might have been in in many very near misses
01:10:08 misses and uh and those don't get recorded so the way in which we collect the statistics define the way in which we think and unfortunately because we are not collecting the near misses then we're missing all these cases where we
01:10:20 we're missing all these cases where we had all the alarm bells and all the warnings you know that were telling us that we were going in a certain direction but because we didn't take the action
01:10:28 action of going to a full evacuation then it got recorded as a success and not as a near miss
01:10:34 near miss yes
01:10:37 yes now can we look at 531
01:10:43 uh you say thus a strong perception that building regulations support the operational protocols of the fire and rescue services is backed by statistical confidence when you say
01:10:54 when you say statistical confidence uh are you endorsing the statistical confidence or are you observing that others have statistical consequences because of the numbers no
01:11:05 consequences because of the numbers no i'm i'm definitely not not endorsing the statistical confidence because as i say this is where the competency comes in if you are seeing what is happening and you're looking at how things are
01:11:16 you're looking at how things are evolving and how our practices are changing
01:11:19 changing you know we cannot look at the past because we know that the buildings that we were designing 30 years ago are completely different to the buildings that we are designing today
01:11:30 that we are designing today and going back to the point we discussed a moment ago about frequency risk and severity risk would you agree with this that in relation to statistical confidence there is a
01:11:41 there is a a risk of conflating the apparent rarity of an event so a behind a fire behaving in a way that's inconsistent with building design for example by breaching compartmentation or bypassing
01:11:53 breaching compartmentation or bypassing it on the one hand with the level of risk that's presented should that event come to pass yeah i mean that's that's really the the problem i tried to describe that in my
01:12:04 problem i tried to describe that in my phase one report where i basically showed that the the the severity or the potential consequences of this particular form of failure were so large in magnitude that they had
01:12:17 were so large in magnitude that they had to be treated in a very careful way because they unzipped every element of the fire safety strategy so in a way when we look at grenfell and we look at grenfell as a failure event and we
01:12:29 grenfell as a failure event and we identify all the things that failed what we never we should never forget is why they failed and the reason why they failed is because we lost compartmentation so we disabled the fire
01:12:41 compartmentation so we disabled the fire service we disabled the other measures of compartmentation we disabled the doors we rely too much on self-closures all these things are a chain of events that is generated by a single point
01:12:52 that is generated by a single point failure that was capable of creating massive consequences and just
01:12:59 and just exploring that a little bit more does it tell us that or would you agree that the fact that an event is rare and therefore unlikely even statistically insignificantly
01:13:11 even statistically insignificantly likely tells you nothing about its potential severity in the five percent of cases
01:13:17 of cases you need much more information to be able to assess severity that's not sufficient information to make that statement
01:13:23 statement and say statistical confidence leads may it to the mistaken assurance that because an event doesn't happen often or happens so infrequently is to be statistically insignificant
01:13:34 statistically insignificant it poses at a risk reliance on purely on statistics and not using all the other available information is actually a measure of lack of competency and does that mean
01:13:46 lack of competency and does that mean that if an event is is rare to the extent demonstrated or deducible from these statistics but has a very high risk of
01:13:57 but has a very high risk of severe harm if it happens there's a greater need to prepare for it absolutely because the operational personnel who are responding to the event when it does occur are less likely to have any direct
01:14:09 occur are less likely to have any direct prior experience of it absolutely right and in your experience of working with fire and rescue services before the grenfell tower fire in particular in relation to operational training
01:14:21 relation to operational training uh would you say that you observed any statistical confidence on the part of those organizations you worked with in other words they relied on what you've referred to as statistical confidence
01:14:33 referred to as statistical confidence there's a very significant reliance on on statistics i mean the declining uh events the declining fire deaths all the things are constantly being used in support of current practices yes now
01:14:45 support of current practices yes now when you say in line 531 here that there is a strong perception that building regulations support the operational protocols backed by statistical significance sorry confidence uh what's who is it who
01:14:58 sorry confidence uh what's who is it who had that strong perception whose strong perception is it everybody's everybody but you well i mean i think this is this is really the the one of the problems that we always tend to face is like
01:15:11 we always tend to face is like when you're dealing with events like fire and fire provisions that require investment and require effort in the design process and so forth the easiest thing to do
01:15:23 the easiest thing to do is fundamentally back yourself up with the fact that those events are not happening
01:15:28 happening so so people use the fact that we have declining fire events that we have declining fire deaths that we just basically to support all our practices it's not only the fire brigades but it is the way in which we
01:15:41 brigades but it is the way in which we design the documents that we use the policies that we implement everything is backed by the fact it's not going to happen to me yes uh i mean the answer everybody slightly it troubles me because
01:15:54 slightly it troubles me because uh i i rather thought you you were excluding those people who knew something about fire engineering well this is this is what happened so that that you're going to have a conflict between those individuals who
01:16:06 a conflict between those individuals who actually understand the problem understand the complexity of the problem and the magnitude of the problem trying to tell you that you need to put all these provisions in place now when you create that conflict you
01:16:18 now when you create that conflict you are creating an unavoidable crash because what ends up happening is that in a market in which you have to make decisions of who you're going to employ you're going to basically employ the
01:16:30 you're going to basically employ the people who are going to give you the answers that you want for the minimum cost
01:16:34 cost so if i'm working with an architect the best possible answer i can give an architect is don't change anything the moment i start saying you have to change this you have to improve this you have to fix this very rapidly what ends
01:16:46 have to fix this very rapidly what ends up happening is i'm becoming you know the the nasty person that is ruining everything now on top of that they have to pay me for it okay so if you are in that situation
01:16:57 okay so if you are in that situation eventually the natural outcome of it is that what is going to happen is those who are actually pushing poor practice practice that completely overshadows the complexity of the problem are going to
01:17:09 complexity of the problem are going to be reinforced and the fire brigades are no different in this case so effectively you might have the best possible people and with the best level of competency and then eventually they will get
01:17:20 and then eventually they will get undermined by a system that actually favors the people that actually say there is no problem because the statistics say so yes thank you
01:17:31 yes thank you and
01:17:32 and as an aspect of that answer do you agree that because of the statistical improbability of the need for
01:17:41 for a full or significant partial evacuation of a high-res residential building which has a staple strategy built in
01:17:48 built in for
01:17:49 for fire and rescue service policy makers decided not to train firefighters or incident commanders on that eventuality or only did so in a less than
01:18:01 or only did so in a less than thorough way yeah this is how things become part of the
01:18:05 the become institutionalized in the sense that then the policies start reinforcing this and then eventually you know you you go into the cycle uh you know that judith hackett describes the spiral down
01:18:22 say
01:18:26 we put it this way that the fire and rescue services considered that the presence of a state but policy was effective to eliminate risk altogether both in frequency and in severity terms
01:18:39 both in frequency and in severity terms in all but a statistically insignificant number of cases uh yes and uh and what was missed is the consideration that building fabric was changing
01:18:50 building fabric was changing you know in the process making that assumption are not necessarily correct and
01:18:56 and to put that point a different way and i apologize for doing it it's it's so that i understand it apart from anything else was the flaw in that thinking that at least the severity of the risk could be magnified and know unknown and
01:19:08 could be magnified and know unknown and uncertain ways by new building products and methods uh the new building process and methods bring a certain level of complexity right that adds an enormous amount of
01:19:19 right that adds an enormous amount of uncertainty now that doesn't mean that it is in an unpredictable manner all that that means is that you're making the problem much more complicated to assess
01:19:30 to assess yes
01:19:34 would it be right to say that the the problem of dealing with the very rare
01:19:42 very rare but
01:19:43 but very serious event involves the degree of judgment i mean to call it a cost benefit analysis is rather demeans it i think but it is a question i imagine in some cases
01:19:55 it is a question i imagine in some cases of deciding whether the cost of guarding against a very low risk
01:20:02 low risk is worth the uh is worth it yes this is why you consider both probability and consequence but you've got to know what the consequence
01:20:13 you've got to know what the consequence is exactly so that you can make that judgment exactly exactly that's that's the whole thing you you need to know what the potential consequence is so you can actually make the judgment if the
01:20:24 can actually make the judgment if the probability you know is low enough this is what earthquake engineers will always do you know you design for a certain level of earthquake that is the one in 100 years one in 200 years and and you
01:20:35 100 years one in 200 years and and you don't design for one that is a one in ten thousand years because the cost will be too high now in the case of fire this is particularly complex because it is our decisions in design that create the
01:20:46 our decisions in design that create the event
01:20:48 event so
01:20:49 so if we make if if a building has no fire safety provisions every building will perform as bad as grenfell did you know but if we start putting provisions in place then we are drifting
01:21:01 provisions in place then we are drifting the the problem into this design fire that we can manage and uh so our mistakes in the design process effectively determine the one in 100 event that you could potentially you
01:21:12 100 event that you could potentially you know achieve so that that that balance is very difficult in fire
01:21:17 in fire and i don't know it sounds to me as though the one criticism would be that
01:21:24 people didn't sufficiently understand the magnitude of the
01:21:30 of the consequences if the unlikely event were to occur and therefore couldn't decide whether it was worth the cost of providing for it or not i i
01:21:43 the cost of providing for it or not i i completely accept what you're saying but the reality is that given the date of this refurbishment and everything that had happened in the past 10 years
01:21:55 10 years i actually think that there is a measure of incompetence yeah at all levels because the signals were there they were all there
01:22:01 all there thank you
01:22:03 thank you which actually answers my last question on that topic um
01:22:08 um uh let's turn to the second topic which i wanted to cover with you which was uh what you call societal expectations and presumed competency of the fire service uh
01:22:19 uh can we look please at your executive summary of your report at page two this report page two
01:22:29 line twenty nine you say this there's a strong societal expectation of the fire and rescue services reinforced by the fire and rescue services act 2004
01:22:40 fire and rescue services act 2004 that the structure of the london fire brigade and the policies that govern the organization are conducive to the recruitment education and training of professionals such that and you go on to
01:22:51 such that and you go on to give some examples um if we go to page three
01:22:55 three and look at one or two of those if we go to line 43 there you say this thus and you've set out four above it you say thus there is an expectation that the fire and rescue services can identify potential design and implementation
01:23:07 potential design and implementation failures that can affect the performance of a building prior to a fire event and then you go on furthermore in the event of a fire that progresses in a manner that is not
01:23:18 progresses in a manner that is not consistent with expectations that the london fire brigade can alter response procedures in a manner that enables them to fulfill their duties as defined by the fire and rescue services act 2004.
01:23:31 the fire and rescue services act 2004. now
01:23:31 now i i haven't taken you through the four the four instances uh which we looked which are above that i don't think we need to do that but we can if we like if you like but would it be right to say that when you refer to
01:23:42 be right to say that when you refer to the societal expectation you're referring to the level of competency and skill that members of the public expect that fire and rescue services will have and display yes
01:23:55 and display yes and that's is what is that what you mean by the presumption of competency yes so basically there is a presumption that the fire brigades will come in and they will perform their job adequately according to the four points that i
01:24:07 according to the four points that i listed above yes we probably just ought to look at those if we go back to the bottom of page three sorry page two the first one is
01:24:18 the first one is through inspections capability of gathering information identifying and enforcing rectification issues that would result in a less than satisfactory outcome in the complex in the in the event of a fire in complex modern
01:24:30 event of a fire in complex modern infrastructure and if you turn the page to
01:24:33 to page three uh recognition of how the actions as responders intersect with design philosophies three is operational command structure functions
01:24:42 functions and the fourth is a further expectation that the commander and subordinates will communicate in a manner that enables a response that will lead to a satisfactory outcome so those are the assumptions would it be right to say
01:24:53 assumptions would it be right to say that all of those societal expectations uh are
01:24:57 uh are specifically uh the assumption that the frs will be able to identify and understand potential design failures uh
01:25:07 uh are justified yes so this isn't a question of society making unrealistic expectations and demands on fire and rescue services i don't believe so no
01:25:21 does it follow from that that the legislative framework under the fire and rescue service act 2004 contemplates that fire and rescue services will
01:25:33 that fire and rescue services will provide
01:25:35 provide personnel with the degree of competence commensurate with the proper discharge of the obligations under that act i believe so and particularly section seven yes yes you've set out the text of
01:25:47 yes yes you've set out the text of section seven in the in the report we don't need to to look at it but if you go on at page 15 if we can turn to page 15 in this report and look please at page page 15 line 538
01:25:59 please at page page 15 line 538 you say
01:26:01 you say there
01:26:02 there as clearly articulated in my phase one report
01:26:06 there was sufficient evidence from fires worldwide that indicated that certain facade systems represented a significant risk to external fire spread and therefore the safe implementation of a
01:26:17 therefore the safe implementation of a stay put strategy now
01:26:21 now is it right that what you're suggesting there
01:26:23 there that the societal expectation that fire and rescue services would be prepared for the need to deal with a fire that did that was rational and justified absolutely yes and that was
01:26:35 justified absolutely yes and that was reflected as i think you go on to say in the broad terms of the legislation yes right now you then go on i think at five five three if we can uh look lower down
01:26:46 five three if we can uh look lower down the page that's now in front of you in the screen on the screen uh to say at 553 as follows in the third line this perception
01:26:57 in the third line this perception is also very strong with it within the fire service itself where there is a clear sense of ownership of everything related to fires is that something that you've observed in your own experience
01:27:08 you've observed in your own experience of working with fire and rescue services yes very strongly and would you say that that strong internal presumption of competency is part of the problem i will say so uh a lack of awareness is this right
01:27:20 uh a lack of awareness is this right within the fire and rescue sector itself as to the limits of firefighter competence a key aspect of professional practice is to know the limits of your competency and the awareness of the limits of your
01:27:32 awareness of the limits of your competency is a fundamental practice of a professional and uh and and i think that this is this is an aspect of the fire and rescue services that i i
01:27:43 of the fire and rescue services that i i do believe uh is not very well developed and when you say your competency we're not talking necessarily here about individuals but organizations
01:27:54 individuals but organizations absolutely particularly when it's an organization uh if i'm exercising as a professional that is my own responsibility but if i'm exercising as part of the organization is the organization's responsibility to
01:28:06 is the organization's responsibility to make sure that those who they deploy are only deployed in in spaces where they are bounded by their levels of competency
01:28:17 yes and that that level and presence of competence is this right needs to be present in those parts of the organization where it's needed absolutely because because if you think about it if if i manage an engineering
01:28:30 about it if if i manage an engineering company and uh and i'm sending an engineer that is completely under qualified to perform a job and the job is done really poorly then am i going to blame the engineer
01:28:41 then am i going to blame the engineer who did the job for doing a very very bad job
01:28:44 bad job if i am aware that the competency was not sufficient you know this is where the organizational responsibility comes in because the organization being aware of the necessary level of competency
01:28:56 the necessary level of competency is bounded to transmit the level of competency down and only deploy professionals within the bounds of their competency and to be to cut through it in relation
01:29:07 and to be to cut through it in relation at least to the lfb and the grenfell tower fire itself are you referring to the limit specifically in relation to two things first the ability of those within the lfb to understand building
01:29:18 within the lfb to understand building design and the potential for design failure
01:29:21 failure that's one and the second or a second the ability to alter operational response procedures when faced with a building that fails that's two um
01:29:32 um can i say a three a third please you know they they fulfill a role within the fire safety strategy and they have to be perfectly aware of what that role within the fire safety strategy is
01:29:46 and if the fire safety strategy
01:29:50 contains or demands things that the fire and rescue service have never seen before what then well this is where the dynamic risk assessment comes in and being prepared
01:30:02 assessment comes in and being prepared to take the appropriate actions it is an element of the competency that you have to provide you know particularly to your officers is it just that or or is it that at the
01:30:14 is it just that or or is it that at the information gathering stage before an event
01:30:17 event and therefore before the dynamic risk assessment ever needs to be made that the frs has the relevant information and competence to interpret it no absolutely i mean i think the feedback loop is is
01:30:29 i mean i think the feedback loop is is the first point by which you gather that information and then of course once you are at the scene then your ultimate uh approach is to follow an adequate fire risk assessment yes
01:30:40 yes now uh mr chairman we're about to turn to a new topic which will not comfortably be finished by 11 15. we're making excellent progress but it might be an appropriate moment for us that would suit you yes it would all
01:30:52 that would suit you yes it would all right well as you know professor torreira we have a break during the morning in the afternoon sessions we normally have it a bit later than this but
01:31:00 but it's better not to interrupt a flow of questions and answers so we'll take it now um we'll come back at 25 past 11 please
01:31:07 please and as with all the other witnesses i have to ask you please not to discuss your evidence with anyone while you're out of the room no problem all right thank you very much would you like to go with the usher please
01:31:25 thank you 25 11.
01:47:33 yes would you ask professor torreira to come back in please thank you
01:47:45 all right professor ready to carry on yes thank you very much yes mr thank you mr chairman uh professor i'd like to ask you now some questions about the fire and rescue services duty to obtain
01:47:57 and rescue services duty to obtain relevant risk information about a building we've looked already uh at the concept of the dynamic risk assessment briefly and that's i think the means by which a fire and rescue service
01:48:09 which a fire and rescue service implements adequate uh and effective operational responses in the face of a fire where it doesn't behave as a design fire yes yes yes now you've explained i think
01:48:20 yes yes yes now you've explained i think that a an effective dynamic risk assessment is underpinned by the information that the fire and rescue service has obtained about the building during its inspections yes
01:48:31 inspections yes uh now to be clear when you refer to inspections i think you're referring to the requirement imposed on fire and rescue services under section 72d
01:48:40 72d of the 2004 act that's correct yes um and that um
01:48:46 um it process of collecting and maintaining information is this right may well be different across different fire and rescue services in the uk yes
01:48:57 yes so there's a there may be local variations in uh the manner and efficiency of collecting and holding such information you know i would say it
01:49:09 such information you know i would say it should be objective driven so depending on different jurisdictions you might make different decisions on what information you collect how you collect it and how you keep it
01:49:21 collect it and how you keep it and distribute it you say depending on different jurisdictions do you mean local jurisdictions within the uk or do you mean internationally no no no i i mean i mean within the uk i
01:49:33 no no i i mean i mean within the uk i will say when i use the term jurisdiction i just mean an area
01:49:38 an area and with those different decisions on what information you keep or you collect and keep
01:49:43 and keep very
01:49:45 very because of the different types of the built environment or building density absolutely i mean it will not be the same type of information that you will collect in the city
01:49:57 collect in the city as you will connecting collecting hamster for example or you know any any highgate
01:50:03 highgate these are different areas with different characteristics and uh and you have to take that into consideration nonetheless do you is it your opinion that the
01:50:14 that the level of competence uh thoroughness and efficiency
01:50:20 assessing those different risks in different areas of the country must be uh to the to to the same to the same high standard yes it has to be consistent with the complexity of the
01:50:31 consistent with the complexity of the problem that you're dealing with yes now when we looked at the concept of design fires earlier we um we looked at the question of what happens when a building is shown to be compliant
01:50:43 be compliant and the assumption that the building will then perform in accordance with that design at the in the event of a fire
01:50:49 fire can we look at page 13 of your report please
01:50:53 please first report and if you go to line 479 we can have that blown up uh
01:51:01 uh line 479 says in what concerns fire safety the inspection is perceived as the relevant approach to monitoring the inspection guarantees that all fire safety provisions defined during design
01:51:13 safety provisions defined during design remain and therefore it can be inferred that the expected performance as conceived at the moment of design is maintained there is therefore an expectation that those conducting the
01:51:24 expectation that those conducting the inspection have the necessary knowledge and competencies in respect to building design to enable them to perform such a diagnostic effectively so in summary would it be right to say
01:51:35 so in summary would it be right to say that
01:51:36 that first
01:51:37 first the process of monitoring building performance is imperfect because that monitoring can usually only take the form of seeking confirmation that a building is
01:51:49 that a building is consistent with its design
01:51:53 that is correct to some extent but um i think this is this is where competency comes in because we operate in a system that is based on functional requirements so there's multiple solutions to every
01:52:05 so there's multiple solutions to every problem
01:52:07 problem and therefore the fact that the building is deemed to be compliant uh doesn't necessarily mean that you know on the one hand has evolved correctly on the other hand that current
01:52:18 correctly on the other hand that current knowledge hasn't superseded uh you know what is what is happening and uh and also that the solutions that might have been implemented could be very different at each stage so you you
01:52:30 very different at each stage so you you really have to be able to understand the system and then you really have to be able to make an assessment uh if the building still meets the functionality requirements for which it
01:52:41 functionality requirements for which it was designed
01:52:45 so
01:52:49 yes i see say does that tell us that even a
01:52:53 even a building that complies with the functional requirements may still present the risk of a
01:53:01 of a fire that is a departure from a design fire occurring yeah of course you say of course um
01:53:08 um it may be obvious to you but i mean have i got that right then yeah you've got in compliance yeah you've got you've got it right for for for two reasons uh because you know the the the the process of compliance is a
01:53:20 the the process of compliance is a static process so uh you are deemed compliant at some point okay so that doesn't necessarily mean that the building will evolve in a manner such that it remains
01:53:32 in a manner such that it remains compliant and therefore you need to make that assessment now on the other hand the building was deemed compliant according to an interpretation of a set of ambiguous rules
01:53:42 rules that are set you know for the process of compliance at some point and you might have acquired knowledge through time you know past the point where the
01:53:53 you know past the point where the building was team compliant that now makes you believe that this particular systems require a much more detailed attention so there's a number of different ways in which that
01:54:04 which that evolution in time can affect your understanding whether the building meets the intention of the building codes you know and this is what the inspection is for to make sure that none of these
01:54:16 is for to make sure that none of these things escape you and all that information is there and if you assess that there's a departure from this concept of compliance you might request a rectification or
01:54:27 or you might if if it is not a significant issue one that can be covered within the operations that you expect to be able to perform in that place then you basically just inform
01:54:38 just inform the local
01:54:39 the local fire brigades that this is an issue that needs to be considered when introducing operations and the process of gathering the information says to be able to inform yourself as an
01:54:50 says to be able to inform yourself as an organization requires does it a level of technical competence and knowledge on the part of those carrying out the inspection yes because it's necessary for those individuals
01:55:01 individuals to do two things first relevant identify the relevant construction features of the building and then to understand how those features may fail in the event of a fire exactly and these are all complex systems yes
01:55:13 systems yes now um
01:55:15 now um you refer in your uh your reports i think throughout to inspection that's a word you use um
01:55:23 um to be clear do you
01:55:26 do you uh accept that the obligation on the fire and rescue service under section 72d is not limited to an inspection but is is
01:55:34 is is wider than that it's to arrange to obtain information for the purpose of extinguishing fires in its area and protecting life and property in the event of a fire i mean that that is exactly the the case if if you if you
01:55:45 exactly the the case if if you if you think
01:55:46 think of what their obligation is their obligation is to gather whatever way that information comes in all the information that is necessary so that they can perform their
01:55:58 necessary so that they can perform their job appropriately and uh and if you take the case of grenfell tower if you look at that building and all the fire safety provisions that that
01:56:09 fire safety provisions that that building has the one critical piece of information was the performance of the external cladding without that piece of information there is absolutely no way
01:56:20 information there is absolutely no way you can construct a response strategy
01:56:26 yes now you
01:56:30 now you say at page 15 if we can just turn back to page 15 please that lines 533 uh as follows you say there is an expectation
01:56:41 you say there is an expectation that through inspections the fire and rescue services could identify if a specific design could allow a fire to exit the unit of origin now to be clear when you're referring to
01:56:53 now to be clear when you're referring to this is an expectation is it also your view that the expectation in fact reflects the extent of the duty the obligation imposed on fire and rescue services under the 2004 act yes because if they
01:57:07 under the 2004 act yes because if they don't identify that potential scenario then they cannot identify the processes that need to be put in place you know to release the state put strategy and then
01:57:18 release the state put strategy and then continue the operations
01:57:22 yes
01:57:25 uh and is it that if is this right that if there is a feature of let it be assumed a high-rise residential building uh
01:57:34 uh that presents a risk of compartmentation breach or bypass then that's information which must be gathered
01:57:42 gathered and used
01:57:43 and used for the purposes of the section there is in in the fire safety strategy of a conventional residential building there is no fire safety provision
01:57:54 there is no fire safety provision that
01:57:54 that is a single point failure mode everything has multiple redundancies the only provision that has a single point failure mode is the external clouding
01:58:08 yes i see now in relation to grenfell tower to page three of your report if you go back to that um picking up on the point you made a moment ago if you go to line 69 you can see that you say there
01:58:20 you can see that you say there i'll start at 67 to give it the context you say given that the evolution of the grenfell tower fire was a foreseeable event that there was an awareness in the london fire brigade of such events and that the link
01:58:31 brigade of such events and that the link between these fires and specific types of products was known a competent inspection would have identified the potential for a large external fire
01:58:42 external fire is that because the risks posed by certain facade materials was sufficiently well known before the grenfell tower fire that lfb ought to have been seeking to identify the presence of those materials uh on
01:58:54 presence of those materials uh on high-rise buildings yes and that is that because if they'd done that that would have indicated that there was at least the potential for a large external flame spread in the event of a fire
01:59:06 flame spread in the event of a fire escaping from the compartment of origin not only the potential for a large scale event happening but also the potential for this
01:59:14 for this complete cascade of consequences that comes from having a single point failure mode and a single point failure mode could be
01:59:25 and a single point failure mode could be as could simply be the dry rising main is blocked all the the fighting lifts if they were there didn't work no because for example if you take the case of the of the dry rice doesn't have any water and the
01:59:37 doesn't have any water and the firefighters don't fight the fire at all you will have three layers of compartmentation that will retain the fire within the unit of origin and the process would
01:59:49 unit of origin and the process would have undergone with absolutely no intervention of the fire service and the building would have picked up the problem so that's not a single point failure mode because there are redundancies that will basically stop
02:00:00 redundancies that will basically stop the event from escalating if one component doesn't work but if you breach compartmentation from the external facade that cascades into a number of different things that disable
02:00:12 number of different things that disable the fire brigades that disable egress that disable your doors that disable everything in the building so in many ways this was the critical failure mode of the building yes
02:00:23 of the building yes and i would have expected people to be able to identify that
02:00:28 that i was just seeking to understand what you mean where how far single point motor failure goes uh a failure of the firefighting lifts is this right would not be a single point mode of failure no
02:00:39 failure no but a failure of building designs say that compartmentation no longer held would because of the adverse consequences that then cascade thereafter and there's nothing to stop it
02:00:50 it there's nothing to stop it
02:00:53 uh
02:00:57 yeah yeah so what that has to prompt the question what would that be or should there be to stop it well you see this is where the fire safety strategy come comes up if a proper fire safety strategy would have
02:01:09 proper fire safety strategy would have done been done for that building people would have identified that there was a single point failure mode and they would have basically corrected because in matters of safety you always have to have redundancies now in this
02:01:21 have to have redundancies now in this particular case the redundancy was always perceived as being the fire brigade but without recognizing that the single point failure mode disabled the fire brigade 2.
02:01:37 yes now you go on to say uh
02:01:41 uh that or suggest that the inspector this is at line 71 uh
02:01:46 uh you go on to say there that uh
02:01:51 that uh the inspector which is i think in other words the firearm rescue service obtaining information under section 72d should obtain test test results and desktop studies uh that's what the suggestion you make
02:02:02 uh that's what the suggestion you make in line 72 there are you suggesting that the lfb for the purposes of grenfell and its refurbishment should have obtained the actual test results for rayna bond 55 pe
02:02:15 actual test results for rayna bond 55 pe cassette panels and rs 5000 celotex rs5000 and kingspan k15 the operations of the fire service and whatever strategy they put in place
02:02:26 whatever strategy they put in place depends
02:02:28 depends on vertical compartmentation so if if it depends on vertical compartmentation wouldn't you want to know everything that you need to know to guarantee that the vertical compartmentation is retained
02:02:41 compartmentation is retained and some might say that that was a council of perfection is it realistic to suggest that the lfb should obtain not just know what's going
02:02:52 should obtain not just know what's going on the building but should actually obtain
02:02:54 obtain the actual test results for the
02:02:58 the cassette rain screen and for the insulation panels well you can take the opposite approach and you can say that they really don't have to have that information but then they would have had to include
02:03:09 to include within the protocols and practices the potential for that event to happen and they would have had to put all the mitigating uh elements to make sure that they could respond appropriately to that
02:03:21 they could respond appropriately to that event and have you ever come across a situation where a fire and rescue service in the uk has
02:03:27 has asked for or been let alone being given the test results or desktop studies for these products or these kinds of products yes you have yeah by the manufacturers
02:03:38 by the manufacturers yep really can you can you give us an example well i mean there will mostly be now paul's grandfather right before grenfell no before grandfather i was not in the uk so i
02:03:50 grandfather i was not in the uk so i i didn't have a regular practice uh on engineering project so i i didn't really um
02:03:57 um i had the opportunity to witness that i follow but i mean i imagine the first step would be to find out more about the construction of the cladding of course and
02:04:09 cladding of course and if that had led as it perhaps it might have done
02:04:12 have done to an understanding that the insulation was bir bur whatever but was essentially combustible in nature the inquiry might have stopped there
02:04:23 the inquiry might have stopped there without the test results is that possible well it is possible but i think you see when when when you understand the problem that you're facing you look at these variables and then you look at what
02:04:35 variables and then you look at what redundancies you have and then on the basis of that you make a decision whether that is an acceptable risk to take or not and on the basis of that you create protocols and processes that enable you to actually perform your
02:04:47 enable you to actually perform your duties
02:04:47 duties that's the way i see it now i'm as i say there is no single answer to the question because you can take many routes to achieve the same objective but it has to be objective
02:04:58 objective but it has to be objective driven at the end the fire and rescue services have a job to do and the job depends on information and and that is what enables them to do the job and i would expect them to find the information that they need to make sure
02:05:10 information that they need to make sure that their job is enabled
02:05:15 yes and the reason i ask the question is that you say without qualification it's incumbent on the inspector to to seek this knowledge example test results and desktop studies and i just i wondered whether
02:05:27 and i just i wondered whether uh it was really realistic to uh make that suggestion at least in in the time before the grenfell tower fire i mean i i i think i think it it it is perfectly
02:05:38 perfectly realistic
02:05:39 realistic uh because you know it's it's at the core of your capacity to deliver your job
02:05:46 your job so when you say it's incumbent you're not making a statement about what the obligations were necessarily uh but but but what it what they ought to be
02:05:57 but what it what they ought to be it's more what they ought to be keep in mind that we operate in a system that is driven by functionality requirements where there's no black and white so uh what what
02:06:08 so uh what what this is objective driven and and the fire and rescue services are part of the fire safety strategy and as such they're part of this objective driven model in which we operate and therefore
02:06:19 model in which we operate and therefore i would expect them to gather the information that they need to be able to do their part of the job within the fire safety strategy and that would is this right separating day from night if one can that would
02:06:30 day from night if one can that would that
02:06:31 that mean
02:06:32 mean that those the manufacturers and those in the supply chain need also to do their job and
02:06:39 and provide
02:06:41 provide with full candor the the test results and death top studies to
02:06:46 to either the building owner for onward transmission to the
02:06:49 to the fire and rescue service or directly to the fire and rescue service absolutely the the safety is is is an aspect that has to be one first transparent
02:07:00 one first transparent and everybody needs to do their part because it is like a chain and if you have one weak link that's where it's going to break so every single component should have done the job appropriately
02:07:18 now we know that the crews who've carried out the visits to grenfell tower before june 2017
02:07:26 june 2017 uh did not identify the presence of
02:07:30 of cladding on the building nor its significance and indeed we know already from the evidence before this inquiry that the
02:07:40 that the london fire brigades policy number 633 on high-rise firefighting did not even include cladding in the list of things that a crew should be directed to have regard when visiting high-rise buildings
02:07:51 regard when visiting high-rise buildings are you able to tell us whether with appropriate training in education it's likely to be within the competence of station-based operational crews to identify that information
02:08:03 identify that information i i think so i mean because you see
02:08:05 you see when you are operating within an organization that has all the adequate levels of competency uh the person who is deployed to do the inspection
02:08:16 to do the inspection basically gets a series of simple instructions that enable them to do what they have to do so if this individuals would have been told to identify the product number
02:08:27 product number e and and its characteristics that's all the information they needed to provide to somebody that was higher up in the chain to deliver the appropriate analysis
02:08:39 so does it follow from that that your your view is that the responsibility for for collecting the information can be relatively instruction driven
02:08:50 can be relatively instruction driven but then it needs to be sent higher up in the organization for interpretation and decision making exactly with the appropriate level of expertise at each level exactly so so you don't
02:09:01 at each level exactly so so you don't have to always deplo deploy the very very high level of expertise you know at the delivery point you can have that expertise behind the scenes and but the role of the people that are
02:09:13 and but the role of the people that are behind the scenes to make sure that those who are going to the field that don't have the detailed level of competency that they know exactly what to look for and presumably vice versa
02:09:25 presumably vice versa those higher up the organization who will be
02:09:30 looking at and interpreting the information would be in the best position to provide clear instructions to those collecting it as to what they needed to be looking at and exactly
02:09:41 needed to be looking at and exactly now
02:09:42 now in your second phase two statement if we can go to that at jto705
02:09:50 at page 22 you refer to the provisional operation the provision of operational risk information systems guidance or porous
02:10:01 information systems guidance or porous uh and i think we've heard um mr mcgurk give evidence this week on that if you go to line 735 on that page 735
02:10:12 well 734 and 735 you say so by defining risk information in these terms having referred to porous both the hm fsi expectations manual and the porous document presume an
02:10:25 the porous document presume an exceptionally high level of technical competency of the fire service i'm just pausing there
02:10:32 this paris guidance was published by the department of communities and local government in conjunction with the chief fire and rescue advisor in 2012 i think wasn't it yes yes now in your view
02:10:45 yes yes now in your view is that likely to have to reflect the fact that there was a strong public presumption of competency on the part of the
02:10:53 the fire and rescue services which we've already considered which was shared by government departments yes in other words everybody uh behind porus was working on a particular assumption of a particular
02:11:04 particular assumption of a particular level of competency yes and in contrast to the complexity and the assumed competence of the user of the porous guidance document
02:11:15 guidance document we've heard evidence of phase one from watch manager dean ricketts you'll remember i think there's evidence he was a watch manager from the north kensington fire station he had conducted
02:11:27 kensington fire station he had conducted a 72d visit or series of visits to grenfell tower before the fire and told us that he'd never received any training on how to go about that task
02:11:38 about that task could you explain uh it may seem obvious but can you explain what the dangers of not giving any or any consistent training to station-based operational personnel
02:11:49 to station-based operational personnel about how to carry out such visits are well i mean the first and foremost is that you will never gather the information that you need and uh and the second one is and and you know this is unfortunately the problem
02:12:01 know this is unfortunately the problem with this uh complex systems like like like porus is that the terminology that is being used can be treated in a very subjective way so it can be extremely misleading so
02:12:12 way so it can be extremely misleading so if i make a statement that talks about the characteristics of the fires that can be fought if you think about the complexity of that statement
02:12:23 that statement it implies an enormous understanding of building behavior it implies an enormous understanding of equipment it implies an enormous understanding of the personnel and the competencies of
02:12:34 the personnel and the competencies of the personnel that you are deploying all these things are sunk into a term and that term then if i am not competent enough to gather the information that i need i might just
02:12:46 the information that i need i might just simply conclude and say yes it can be fought
02:12:50 fought can you give me give us an example of such a term um what do you mean by an example well you take you say um in your last answer that
02:13:01 that um it's a question of language often uh and
02:13:06 and terminology can can be used in a very subjective way so that it can be extremely misleading can you give give us an example of of where you see that yeah so i i was trying to give the example of of that
02:13:18 trying to give the example of of that statement so you know if if i ask an individual uh in in the london fire brigade
02:13:24 brigade what is a fire that can be fought
02:13:29 okay the answer might just simply be oh well this big
02:13:34 this big right okay now i might actually say the same thing okay this big okay but behind the answer that i'm giving i'm making an
02:13:45 the answer that i'm giving i'm making an analysis of what is the material that is burning i'm making an analysis of what is the configuration of the fire i'm trying to understand what else is in the building how it can ignite other things
02:13:56 building how it can ignite other things okay and i can give you the same exactly the same answer now on the other hand if i don't have the competency okay i might look at the fire think of a
02:14:07 okay i might look at the fire think of a fire extinguisher and say well maybe i can deal with that and we will both give you exactly the same answer right okay now the problem with with this complex systems is that they use
02:14:19 complex systems is that they use terminology like that so they use terminology that hide an enormous amount of complexity and therefore you can give a very superficial answer with the wrong information that be completely
02:14:31 information that be completely misleading and give you a false sense of safety
02:14:34 safety well in reality what has happened is that they have not introduced all the complexity that is necessary and they should have come up with a completely different answer in your opinion
02:14:45 in your opinion focusing particularly on on grenfell tower as a paradigm is it your view that the national guidance framework that was porous assumed a high level of
02:14:58 that was porous assumed a high level of technical competency yes and that that high level of competency was not in fact present generally in fire and rescue services yes
02:15:08 yes now if we go to line 745 about halfway down your screen just below
02:15:17 below uh you say there
02:15:21 uh this uh of particular importance is the absence of any methodology that allows to establish what are the fires that can be controlled or suppressed with the equipment and personnel available to the lfb
02:15:32 available to the lfb and when rescue should be prioritized over fire suppression actions finally none of this guidance provides any information as to the technical competency required from the user of these systems thus the presumed
02:15:44 these systems thus the presumed technical competency of the incident commander remains undefined would it be right to say that those responsible for collecting operational risk information in respect
02:15:55 operational risk information in respect of modern buildings and refurbishments need to have a far deeper understanding of fire safety engineering principles and up-to-date construction methods and practices in order to do their job
02:16:06 practices in order to do their job i believe so yes now um i want to turn next please to the dynamic risk assessment which we touched on earlier but i want to look at it now a little bit more closely with you
02:16:18 a little bit more closely with you if you go to page 16 of your first report please your first report jto 702 page 16.
02:16:30 and if you look at pay if you look at line 575 you say this any variation from the norm then becomes a matter for a dynamic risk assessment plan formulation
02:16:41 plan formulation defined by those preparing to interact with the fire for a dynamic risk assessment to be effective
02:16:47 effective the fire event must be understood by those conducting the assessment thus a dynamic risk assessment is only expected to extend firefighting protocols to variants that are re reasonably close to
02:17:01 variants that are re reasonably close to a more typical fire event the design fire
02:17:05 fire now
02:17:06 now to be clear the reference to variation from the norm is that a reference to an unexpected fire or building behavior yes so in other words a non-design fire yes yes
02:17:17 other words a non-design fire yes yes and are you able to explain exactly what you mean there by plan formulation yes so uh
02:17:23 yes so uh i
02:17:24 i i again you know i'm very careful with the way i use the language i think one of the biggest problems that we have in the space of fire safety is that a lot of the research that we use to discuss this matters
02:17:37 use to discuss this matters is borrowed from other disciplines and therefore the language that we import sometimes is used by people in completely different ways so the i defined uh plant formulation
02:17:48 defined uh plant formulation you know as opposed to plant execution as a as as two distinct processes plant formulation is when you define the problem so you take all the information that you
02:17:59 so you take all the information that you have you define what your problem is the plan execution is the resolution of the problem
02:18:05 problem now normally when the problem is very well known and it is predefined so the design fires so you've already pre-defined that problem you can move straight into plan execution because you
02:18:17 straight into plan execution because you define policies and practices that have already been defined to solve that problem so you create a set of instructions a recipe and then people can actually utilize that recipe to
02:18:28 can actually utilize that recipe to develop
02:18:30 develop uh the solution that's a direct plan execution process now when you have plant formulation is when you are required to do the dynamic risk assessment because your original
02:18:42 your original set of premises are no longer valid and you have to make a decision of how you're going to change an approach to the solution how you're going to execute the solution so
02:18:54 you're going to execute the solution so you're going to formulate the problem first assess your different approaches and this is where the different uh forms of command for example happen that you can have
02:19:05 for example happen that you can have different ways that uh that doctor coinhatton was talking about different ways in which you can approach this and eventually leads you to a position where you're confident that you can actually
02:19:16 you're confident that you can actually execute a plan okay so in this case when i'm talking about plant formulation is what are the variables that you need to be able to define an appropriate plan
02:19:27 to be able to define an appropriate plan of action in the event of a situation like what happened at grenfell and uh and maybe if you indulge me with an ex with an example maybe i can illustrate that uh you know what exactly
02:19:39 illustrate that uh you know what exactly do i mean so the the moment that that so you have a you have a fire that is in the kitchen and you have your plan execution process of going and fighting that fire in the unit
02:19:50 fighting that fire in the unit okay at some point you realize that that is not working and you see a fire on the outside
02:19:57 outside okay this is a moment where you have to get all your information the first piece of information is what is the consequence of losing compartmentalization if you don't
02:20:08 compartmentalization if you don't understand what the consequences of losing compartmentalization are you will not be able to define and appropriate or formulate an appropriate plan so that's one piece of information then
02:20:19 so that's one piece of information then you need to start by what you are observing the information that is coming to you from the rest of the people working with you and by your own competence and knowledge you have to define how this event is evolving so
02:20:32 define how this event is evolving so that you can direct your decisions now i can be extremely simplistic in the approach and say okay when i fire the moment a fire exits a window
02:20:43 a window if i just simply take pure statistics of the events that had happened in the past
02:20:49 past i will tell you that it would probably be between something of the order of one meter per minute you know to 15 meters per minute at the ma at the most
02:21:00 at the ma at the most okay so basically the speed of the fire would have been of the order of that all i had to do was take past statistics and just basically say well this more or less bounce it i know i
02:21:12 this more or less bounce it i know i have a fire that is going to be progressing at the speed then now i can make a decision of what to do next now if i have more sophisticated knowledge i can actually refine that because i can say oh well these fires
02:21:24 because i can say oh well these fires grow at a certain rate and the loss of physics defines a function of time that determines the fire growth and i might be able to refine it and say well actually i don't
02:21:36 refine it and say well actually i don't have
02:21:37 have 20 minutes but actually i have about 40 minutes okay or i can actually use information in other words i can look at the flames and i can start monitoring the variable that i think matters which is how fast
02:21:50 that i think matters which is how fast the fire spreads all i need to do is take my watch and look at how the flame is growing and i can assess what the velocity is going to be and that will give me the time that the fire will get to the top and i
02:22:02 that the fire will get to the top and i will do it just purely on observation but on the basis of that information which is my knowledge the observations the information that i have the understanding of the fire safety strategy in the building i can construct
02:22:16 strategy in the building i can construct an approach towards the intervention that's what plant formulation is let's see can i just there are a couple of things in that answer which i just want to go back on the first you say the first the first
02:22:28 on the first you say the first the first question is is compartmentation going to hold uh or words to that effect i i was wondering whether in fact the first question that an incident commander seeing
02:22:38 seeing uh that the ex that there was a flame outside the window
02:22:43 window uh
02:22:44 uh and the kitchen fire had not been contained
02:22:48 contained is or might be what is on fire out there and why is it on fire would that be fair well that that that would be fair now keep in mind that of a flame outside the
02:23:00 keep in mind that of a flame outside the window is an acceptable proposition it is when the flame progresses beyond the unit of origin and starts entering or you know sort of moving into the space
02:23:12 you know sort of moving into the space of the next unit when when you have theoretically breached compartmentation so it is not an unusual event for flames to be outside the window now the moment that you start seeing polyethylene dripping in flames
02:23:24 dripping in flames okay and the flames creeping into the cladding you know which is a few minutes in in into the event at that point you recognize that there is no barrier to stop that and at that
02:23:36 no barrier to stop that and at that point you have to start thinking now i might be
02:23:39 might be too demanding of the commander that was at the time and of course i am being too demanding of the commander that was at the time okay i'm not expecting maybe those nuances to be able to define at
02:23:50 those nuances to be able to define at that point but then three minutes later now you have a flame that is impinging on the window above now you know you have breached compartmentation
02:24:01 you have breached compartmentation because once the flame is impinging on the window above then at that point you know that your fire safety strategy has fallen down and then you have to start taking all these measures now obviously
02:24:12 these measures now obviously my position is that that information that knowledge that understanding of how to formulate a plan is something that commanders would have come in
02:24:22 come in you know with that training and competency second thing that follows from that longer answer but also what you've just said is would it also mean that the incident commander
02:24:35 that the incident commander uh responding wouldn't simply look at
02:24:40 look at visually
02:24:41 visually at what the fire was doing but would also be
02:24:46 be alert to other sources of information for example whether people were self-evacuating at what rate from which floors were any
02:24:57 at what rate from which floors were any survival guidance calls being made how many somehow fire survival guidance calls were being made from which floors absolutely so you formulate a plan on the basis of of the all the information
02:25:10 the basis of of the all the information that you have available
02:25:12 available and uh and in some cases it's going to be less in some cases it's going to be more and uh but the more you have uh you know most likely the better your plan is going to be
02:25:24 going to be and would it be accurate to define plan formulation coming back to the expression as the identification and prioritization of objectives at the incident based on information from as wide a variety of
02:25:35 information from as wide a variety of sources as you as you can that's exactly what it is and is what enables you to then formulate a plan yes and you've you've distinguished plan formulation from plan
02:25:46 distinguished plan formulation from plan execution
02:25:47 execution plan execution is this right is just um executing the plan you formulated exactly so in in the case that you go through plan formulation then you execute the plan but in the case that
02:25:58 execute the plan but in the case that everything performs according to the design fire then the plan would have been already formulated by guidance by policy because that's what we expect yes and on that having done your
02:26:09 and on that having done your um plan formulation and go to the execution stage would you expect a comp
02:26:16 a comp a competence with the levels of competency that you're proposing a competent
02:26:22 competent incident commander having done the assessment and formed the plan
02:26:27 the plan then to execute it in accordance with the plan
02:26:31 the plan not necessarily in accordance with a predefined procedural protocol well
02:26:37 well there is no if at the moment that you do a dynamic risk assessment there is no predefined you might use components of procedure and protocol so
02:26:48 components of procedure and protocol so you're not going to change the way in which a firefighter should be holding the hose
02:26:53 the hose okay so there's elements of procedure that will remain in your plan but there is no longer a procedure or protocol that is predefined even if all you're changing is a tiny small element of the entire
02:27:06 is a tiny small element of the entire thing yes
02:27:07 thing yes and
02:27:08 and would i be right to detect in your answer
02:27:12 answer the concept that the more you reduce operations to policy to protocols if you like
02:27:19 like the less space there is for plan formulation which does not accord with those policies well i mean this is this is a i think i think one of the biggest problems that we have and and again it always brings
02:27:32 we have and and again it always brings us to a misunderstanding of of language the moment that you define everything that you do in terms of policy it can only mean two things one is that you know everything
02:27:45 things one is that you know everything so you can turn everything into policy so you have literally defined all the potential options there is nothing else that can happen and therefore you know i can have a protocol or a policy for everything
02:27:56 protocol or a policy for everything that's a purely prescriptive environment okay now the moment that there is an element of uncertainty or is an element of lack of knowledge then you have to depart from that
02:28:07 depart from that now if the if it's very very very small then you probably have to depart in a very forceful way because obviously you have a culture that is functioning in terms of prescription so you have to be very forceful and
02:28:19 so you have to be very forceful and making sure that there will be individuals within the organization that can understand this and transmit the value of it now when you start making the environment more lacks and then you get more and more and more options that
02:28:32 get more and more and more options that could potentially happen then this becomes the routine and you operate in spaces where you're fundamentally always operating in plant formulation this will be the operating
02:28:43 formulation this will be the operating table for a brain surgeon you know there's very little procedure for the brain surgeon you know most of it is going to be its own plant formulation
02:28:56 yes i see
02:28:59 now going back to the uh the report at line 577
02:29:05 577 which is about a third of the way down your screen you say thus a dynamic risk assessment is only expected to extend firefighting protocols to variants that are
02:29:16 protocols to variants that are reasonably close to a more typical fire event the design fire um
02:29:21 um can i ask you this if if the dynamic risk assessment is being used where there is any any variation from the norm what makes it only expected to extend to variants
02:29:32 it only expected to extend to variants that are closer to the norm well i mean this is this is a one of the complications or the variables that needs to be addressed because clearly you have uh staff and equipment
02:29:43 staff and equipment that have a capacity and when you have staff and equipment that have a capacity you cannot have a variant
02:29:51 variant that exceeds the capacity of what you're bringing in now obviously we have the capacity to escalate that but we have seen you know all the problems that get generated you know congestion the radio problems all these
02:30:04 congestion the radio problems all these different things that start happening when the event escalates to a situation in which uh it is has deflected itself way
02:30:13 way far from the you know from the design condition now the way you prevent that is through the inspection and by identifying the things ahead of time so you have to make sure that those
02:30:25 you have to make sure that those variants or the range of variants that you're operating with have to be has to be a range of variants that is consistent with the skills equipment you know and and a number of personnel that
02:30:36 know and and a number of personnel that you're deploying to the event um
02:30:40 um i'm just wondering whether there's a contradiction in terms here in this line in your report because uh you you say that a dynamic risk assessment is only expected to extend firefighting protocols to
02:30:51 to extend firefighting protocols to variants that are reasonably close to a more typical fire event and yet you use it when
02:30:56 it when the design fire has been departed from so what
02:31:00 so what how does this work d do you use a dynamic risk assessment uh
02:31:04 uh when you when you haven't got a design file you've got a non-design fire and if that's the case why are you bounding it to a a fire that is reasonably close to a design fire
02:31:15 reasonably close to a design fire because you're bounded by your hardware and you're bounded by the number of people that you have available so so in in many ways uh i have a design file and i can respond to to to those design
02:31:26 i can respond to to to those design fires appropriately okay but i can have variance to that and i need to conduct a dynamic risk assessment but i only have this many tools so if i run out of tools then i cannot address the problem even
02:31:38 then i cannot address the problem even if i'm doing the perfect competent decision if the conclusion is i need 400 men now
02:31:44 men now you will never be able to address the problem
02:31:46 problem so it's always bounded you know by the constraints that are imposed by the physical means that the commander has to deploy
02:31:55 deploy i see so when you say a dynamic risk assessment is only expected to extend firefighting protocols etc you mean i think you mean that in reality an incident commander
02:32:06 that in reality an incident commander can only conduct an effective dynamic risk assessment within the limitations of
02:32:13 of what they have exactly
02:32:17 now there are two further questions on dynamic risk assessment i think you identify in your in your first phase two report this report first can we look at 581 the following paragraph you say this
02:32:29 following paragraph you say this firefighters that directly interact with the fire will have the greatest capacity to acquire information and therefore the natural tendency is for those individuals to conduct the dynamic risk
02:32:40 individuals to conduct the dynamic risk assessment and consequently make all subsequent decisions fires evolve rapidly in time so time is at a premium and firefighters will generally privilege a rapid decision to the transfer of information to a command
02:32:52 transfer of information to a command unit
02:32:53 unit and at 589 you say
02:32:57 you say conducting a dynamic risk assessment is therefore not necessarily the prerogative of the officer in command but there is a presumption that that all responders are equally responsible and
02:33:08 responders are equally responsible and qualified to deliver these assessments now i've shown you those two passages now first
02:33:15 now first uh
02:33:16 uh to be clear you say all responders and is that because the lfb's dynamic risk assessment policy 342 says
02:33:26 says it's a paragraph 1.10 that all written in bold type personnel in the operating and training environment must undertake a dynamic risk assessment continuously
02:33:37 risk assessment continuously yeah i mean i think this is uh this is something that that we always have to keep in mind fire is a very unique type of event because it evolves in space and time in
02:33:48 because it evolves in space and time in a very rapid manner so there there is a convergence of the event with different types of individuals at different types of of situations now obviously the decision
02:34:01 situations now obviously the decision making the dynamic risk assessment that a commander will make that implies the deployment of resources and the overall assessment of the situation will be completely different you know to the
02:34:12 completely different you know to the individual who arrives sees a room on fire and finds a child under the bed in which case they will have to change the path and make a decision so they will be conducting a dynamic risk
02:34:23 will be conducting a dynamic risk assessment they will have a lot less variables it will be much more localized and it might actually be much simpler in in nature so that would be the competency that the firefighter that is at the tip
02:34:35 that the firefighter that is at the tip you know of of the whole structure will have to exercise which is very very different to the competency that that dynamic risk assessment conducted by a commander you know will have to be
02:34:46 commander you know will have to be exercised that involves numerous other variables yes and does that mean
02:34:53 mean that
02:34:55 that there is a risk that if everybody's doing their own dynamic risk assessment their scope for confusion and inconsistency in the decision making well i mean that is uh that that is one of the fundamental
02:35:07 of the fundamental risks in in firefighting command and and i think this is one of the biggest weaknesses that that we have uh in our understanding of firefighting command many times to say we try to import
02:35:19 many times to say we try to import and uh the the different approaches that are followed in different sectors like the police or the military and try to adapt those concepts into fire fighting
02:35:30 adapt those concepts into fire fighting now unfortunately we have never ever given the attention to firefighting command the sufficient attention to firefighting command to understand how you resolve those conflicts because the
02:35:41 you resolve those conflicts because the conflicts are natural it is the fact that you have an individual in front of the event having to make decisions where they have to make priorities and those priorities might result in informing the commander
02:35:53 might result in informing the commander after executing the task just because the event is evolving in space and time okay now the problem is that if we don't really truly understand
02:36:04 really truly understand how command for fire fighting works and how you resolve those conflicts we will never be able to actually create a proper command structure and how would you how would you address
02:36:15 and how would you how would you address that problem to be honest with you i have absolutely no idea
02:36:20 no idea you know this is an area of research that has been ignored for decades and uh it's an area of research that has been left completely untouched and uh and i have to say that uh the work of of
02:36:31 and i have to say that uh the work of of dr coyne hatton is probably you know a light you know in this darkness there's very very few people they have actually put the effort to understand what is necessary to be able to solve all these
02:36:42 necessary to be able to solve all these conflicts that are absolutely the nature of the problem so this is nothing that we're going to resolve from one day to the other one this is something that really needs long-term and serious attention
02:36:54 long-term and serious attention involving you know sociologists psychologists uh you know individuals who understand concepts of command as well as engineers who understand fire
02:37:05 well as engineers who understand fire yes
02:37:06 yes we'll come to dr cohn hatton's papers short one a little bit later perhaps but
02:37:17 is the fact that that a dynamic risk assessment is not necessarily the prerogative of the officer in command as you say a sign of a weak command structure
02:37:27 structure improperly managed of course that's what ends up happening that are that if you're not managing it appropriately the natural tendency is to a weak command structure and this is why
02:37:38 a weak command structure and this is why in many ways the fire service is a single entry flat environment because everybody is perceived as being the same and the way in which you acquire the experiences and the way in which you progress among the ranks
02:37:50 progress among the ranks is in many ways uh undifferentiated you know when it comes to your competency skills and attributes when i noticed you saying in
02:38:01 in line 586 you refer to the hierarchies existing
02:38:06 existing i think in effect you're saying more and more in theory than in practice absolutely and is that a weakness that you would identify yeah it's a resulting witness of us not really truly
02:38:18 witness of us not really truly understanding how to establish a proper command structure within the fire service
02:38:24 yes thank you now
02:38:27 now the the question of a variation in quality and effectiveness of decisions made by different operating personnel
02:38:35 personnel is a matter that mr mcgurk considered in his phase 2 report and he i'll give you a little bit of a run-up to the question but he uh referred to two examples of
02:38:46 uh referred to two examples of activities carried out on the night of the grenfell tower fire by a ba crew crew manager tillotson's crew
02:38:54 crew and also uh by an individual firefighter firefighter o'byrne who both made the decision to take action that had not they had not been explicitly uh instructed to carry out
02:39:05 uh instructed to carry out uh now uh
02:39:07 uh now uh mr mcgurk's view was that they were slightly different um the action taken by the crew manager crewmate crew manager tillotson even though outside procedure was an example
02:39:20 though outside procedure was an example he he thought of effective and legitimate exercise of initiative involving a proportionate degree of risk that resulted from this resulted in the successful rescue of some residents
02:39:31 successful rescue of some residents that was his view would you agree with that
02:39:35 that um
02:39:36 um i mean the outcome was successful yes but in
02:39:41 but in structural terms would you agree that it it should be applauded and uh retained well the the question that i will ask is what was the logic that was followed and
02:39:52 what was the logic that was followed and i will do an analysis of what are the potential consequences of that action and uh and learn from the outcome i mean obviously
02:40:02 obviously there is an element of intuition there's an element of experience all these things are going to play but for every positive
02:40:11 positive outcome there is potentially a negative one when you depart completely from protocol without having a proper logical justification
02:40:22 logical justification so for me it would be more about why he did it and how he reached to that conclusion and in the tillets and cruz case it was it was in the exercise of initiative as it was i think called by going down and
02:40:34 i think called by going down and collecting two ba sets and taking them back up to the ninth floor to allow the residents to on that floor to use them and and effect a successful evacuation
02:40:45 and and effect a successful evacuation so the outcome was the same yeah yeah so the outcome was the same but how can we come up to the conclusion that one was an inappropriate use of dynamic risk assessment and the other one was an
02:40:56 assessment and the other one was an appropriate use of dynamic risk assessment the way mr mcgurk wraps today's decision is by making an analysis of the pro the pros and cons and he is doing the analysis of posteriori and he's coming up to that
02:41:07 posteriori and he's coming up to that conclusion i think that is a perfectly valid approach to analyzing that type of information which to me
02:41:15 to me you know all that that means is that this is part of the process of understanding how these decisions are made but it is not really uh
02:41:24 uh a way in which you can put judgment on whether one decision was good or it was not because they both attained the same objective i don't know if i if i'm
02:41:35 same objective i don't know if i if i'm being clear with that well let's see if we can illustrate let's see if i can help illustrate your opinion by reference to that example
02:41:43 example if the outcome had been that the residents were rescued but taking two ba sets from a pile in the lobby had meant that two incoming firefighters did not have a
02:41:55 two incoming firefighters did not have a ba set available which would have affected firefighting operations that would have been an adverse outcome well once you balance it yes if those two ba sets then were needed for
02:42:07 two ba sets then were needed for something else that probably for example disabled the rescue of other eight people you know you would have made that assessment a posteriori but this is the kind of assessment that you would expect
02:42:18 kind of assessment that you would expect the individual uh you know who is taking the action would have waited before taking such an action
02:42:27 action that's my next question so the the use of the dynamic risk assessment by that crew would have involved weighing the pros and cons first of all of leaving the residents where they were and going down and collecting the sets
02:42:38 and going down and collecting the sets and coming back and secondly taking the sets themselves yes and i think i think the you know one of the things that many times tends to confuse things that i think is very
02:42:50 confuse things that i think is very important to clarify is that when we are making this a posteriori assessments uh we're talking about a period in the fire where effectively the whole system had broken down
02:43:03 the whole system had broken down and the fire service was no longer capable of operating in a structured and rational manner so they were they were basically overwhelmed by by
02:43:14 they were basically overwhelmed by by the event you know from my perspective i think
02:43:17 think focusing too much in that period is completely missing the point because the reality is that the the full objective of the intervention is to never get there
02:43:28 there and where all the proper dynamic risk assessment and the proper decisions should have been made is at the point where we did not have to escalate
02:43:39 where we did not have to escalate the event to that level of confusion and that level of chaos where then of course making an a posteriori analysis looking at what happened is perfectly logical and perfectly fine as a learning exercise
02:43:51 exercise but not as a judgment of whether this was an appropriate approach or not i see so is what you're saying that you look at the outcomes and you can learn from the outcomes but that tells you it doesn't tell you necessarily about the quality of the
02:44:02 necessarily about the quality of the decision making that led to it exactly because you are at a point where decision-making is not only what prevails
02:44:08 prevails you're basically scrambling trying to fix a problem that has already overwhelmed you taking the second of his examples of the use of initiative this was firefighter o'byrne
02:44:19 o'byrne uh
02:44:20 uh his view was that and i should just say he
02:44:23 he ascended the tower and got as far as about we think that the 12th floor at an early stage very early stage before
02:44:34 before the
02:44:35 the fire in the cladding had really got hold and his action was regarded by mr mcgurk as well-intentioned but not reasonable or an effective course of action not least because it carried the risk of a
02:44:48 least because it carried the risk of a lost firefighter and therefore the diversion of firefighting resources because no one knew where he was and had no radio comms now that's an example um at
02:45:00 radio comms now that's an example um at a time before the fire got out of control
02:45:03 control would you agree with mr mcgurk there that that was um that was uh not a good ide not not a a useful or sensible use of initiative yeah i would agree and and it is at a stage where you
02:45:15 agree and and it is at a stage where you actually can make that judgment and are you able to offer a view based on your experience of working with fire and rescue services as to why it is that this type of unilateral action
02:45:26 this type of unilateral action uh occurs amongst operational personnel
02:45:29 personnel it it it it is something that tends to happen
02:45:32 happen because
02:45:33 because it is the
02:45:35 it is the individual who is in front of the fire who is the closest to the event so if you're constantly being psychologically reinforced that you have the right information to make the decision on the spot
02:45:48 make the decision on the spot so it is nothing uh that we don't know this this has been known for a long time that when when you're very very close to the event cognitively speaking very rapidly you
02:45:59 cognitively speaking very rapidly you believe that you are the one who has the most information to make the decision so this is why a lot of procedures are put in place to try to pull people away from feeling in in you
02:46:11 pull people away from feeling in in you know that
02:46:12 know that in in that way so so it is it is a natural
02:46:16 natural um you know thing to happen and uh but when it contravenes procedures and it creates situations are known uh to be negative you know this is when
02:46:28 uh to be negative you know this is when you realize that either the training that you provide this individual was inappropriate so it was ineffective and uh or this individual was actually not conducting uh
02:46:39 uh you know himself in an appropriate manner yes i see now um this that was the first issue divided into two but the second issue that you identify in relation to dynamic risk assessment is one that you set out
02:46:52 risk assessment is one that you set out at 576
02:46:54 at 576 on this page and
02:46:56 and you say at line 576 you say the fire event must be
02:47:03 must be understood by those conduct conducting the assessment when you say that the fire event must be understood what do you mean then what was very very much the example that that i gave the moment that i see the
02:47:14 that i gave the moment that i see the flames coming out of the window there is an element of understanding of the event that i can that i have that enables me to get a sense of what the progression of that
02:47:26 sense of what the progression of that event is going to be now keep in mind that
02:47:29 that one of the the key aspects about current approaches towards firefighting is given the delays in arrival and you know from the moment of detection you know alarm and uh and
02:47:41 of detection you know alarm and uh and calling the fire brigade until the moment of arrival most of the fires in compartments that firefighters are fighting are fires that are already fully developed and they're contained by walls
02:47:53 contained by walls so you're going to have a fire that already has reached its maximum stage and it is contained by walls now firefighters are very familiar and very confident with that type of event and uh
02:48:04 confident with that type of event and uh is one that is embedded in in in the mindset of firefighting now when you have other types of fires like are spreading and therefore they're growing at you know in an unrestrained
02:48:16 growing at you know in an unrestrained manner you know then you need a much higher level of competency to be able to make that level of assessment
02:48:25 and does it follow from that that the person conducting that assessment not only needs to understand what the fire is doing but why it's doing it how the building is responding and how
02:48:36 how the building is responding and how the building will continue to respond and the fire will likely develop absolutely and and as i say they are uh you know many times people think and i've expressed it in my second report
02:48:48 i've expressed it in my second report that if i want to precisely model the speed at which the fire grows it's an incredibly complicated process but i can start using simpler models and i did that in my phase one report that i
02:49:00 i did that in my phase one report that i insisted that given the information that we had we wanted a much coarser and simpler model and
02:49:06 and or we can go to just simply estimates at each stage we'll go conservative but different uh
02:49:14 uh you know within the hierarchy of command you know different levels of commander you know will be able to be more refined but even the first incident commander should have some level of understanding that enables
02:49:27 some level of understanding that enables them to make these early decisions on the basis of an understanding of what are the potential consequences of what they're actually seeing i'm interested in what you mean there by some level of understanding
02:49:40 some level of understanding is it right that in order to do a proper dynamic risk assessment as you identify here
02:49:47 here the person doing it needs to have the same amount and quality of information that should be gleaned should be gleaned from an adequate 72d information gathering exercise about
02:49:59 information gathering exercise about that building i mean that would be key that will make their life much much much easier if they had all that information and that information had already been assimilated so they would not have to do the entire
02:50:11 so they would not have to do the entire processing you know in place all that would have been done ahead of time and so if you knew that you have this type of materials and you decided to accept them
02:50:20 them then you would have processed what kind of intervention you will have in the event of a fire because you would have understood what was the potential failure mode of that particular building now if you don't have that information that doesn't
02:50:32 don't have that information that doesn't completely disable you from making a dynamic risk assessment you still can respond you are handicapped by not having all the information but nevertheless uh if if i was to go to a
02:50:43 nevertheless uh if if i was to go to a classroom and teach a commander that was going to come in and said if you see a fire that compromises any adjacent unit
02:50:52 unit you have to understand that your whole fire safety strategy has collapsed and that your fire will grow between 5 and 15 meters per second yes that information
02:51:04 yes that information is information that is that will become universal
02:51:08 universal for this type of buildings that's all that they need to have to be able to understand that that fire is not going to stop
02:51:15 to stop now you you uh mr mcgurk showed for example the effect of water in trying to control the spread so they will understand also that if they throw water at the fire externally
02:51:27 they throw water at the fire externally very rapidly you know that might slow things down and gain them a bit of time but in principle they should be working on the premise that they understand the range of velocities that that spread of
02:51:38 range of velocities that that spread of the fire will have and what are the potential consequences for all the people that are there and given them their resources you know they will deploy them in the most effective way to try to get the
02:51:50 most effective way to try to get the best possible outcome or call for more resources but they can start making decisions they can they formulated a plan and they can start executing that plan
02:52:02 so
02:52:05 i think you say that is this right that to do a proper risk dynamic risk assessment an incident commander or the person properly making it
02:52:16 properly making it they should have the same amount of quality of information that would be gleaned from a statutory information gathering exercise but if they don't have that then then the fallback would at least at least that be to know that where you
02:52:29 at least that be to know that where you have an external fire you're going to have or may well have uh uncontrolled and rapid fire growth yeah so
02:52:37 yeah so basically would not be ideal not having the information but that doesn't mean that you cannot formulate a plan
02:52:46 and am i right in thinking that the formulation of that plan based on at least the minimum amount of information to do it is not something that can be left to all responders
02:52:57 left to all responders but uh only to those only to the incident commander properly trained and with all relevant information exactly yes now about the level of confidence
02:53:08 now about the level of confidence uh you say at line 594 at the foot of your screen now in the middle of your screen the level of competency required to successfully conduct a dynamic risk assessment is directly linked to the
02:53:20 assessment is directly linked to the extent that the building's characteristics have to enable a fire to depart from the standard characteristics i.e the design fire the more complex the building the more the potential for a significant
02:53:32 the potential for a significant departure and the more difficult it therefore becomes to identify the course that will be followed by the fire consequently the competency required from those performing a dynamic risk assessment is intimately linked to
02:53:43 assessment is intimately linked to building complexity furthermore research has shown that the situational awareness necessary for an effective dynamic risk assessment is intimately related to the nature of the training and education of the responder
02:53:56 training and education of the responder now looking at the first sentence there the
02:54:00 the the first sentence which starts the level of competency required to successfully conduct a dynamic risk assessment uh he is linked to the extent that a building's characteristics have to
02:54:11 building's characteristics have to enable a fire to depart from the standard characteristics i either design fire i'm afraid i i had a bit of trouble understanding that could you just explain what you mean there yeah so
02:54:23 explain what you mean there yeah so depending on the building complexity um if there is a greater potential for
02:54:31 unforeseen uh progression of the fire so if you have a very very simple building then it is actually very simple to predict with a lot of precision
02:54:42 lot of precision what is going to happen well when you have a very complicated building with complex components and so forth then the the complexity of the system makes it more and more and more difficult to come up with a proper assessment of all the
02:54:55 up with a proper assessment of all the possibilities that um that can happen this is what we have redundancies and and and so forth so if i'm if when when i say that the level of of competency required to successfully
02:55:06 competency required to successfully conduct a dynamic risk assessment is directly linked to the extent that a building characteristics have to enable a fire to depart from the standard condition what you know what i mean is that if i have a
02:55:17 know what i mean is that if i have a really complicated building that has the potential to depart you know quite widely you know that will require an individual with a much higher level of competency to be able to do a proper dynamic risk assessment is it
02:55:30 proper dynamic risk assessment is it always the case that the more complex the building the greater the likelihood that a fire will depart from the design fire
02:55:36 fire uh it well you see this is the the it shouldn't be at the end we should guarantee that all buildings should have the same level of safety when you introduce complexity it is incumbent to
02:55:47 introduce complexity it is incumbent to the designer to introduce robustness and so if the complexity is very high and you know you have multiple possibilities that you actually don't have the tools to predict appropriately
02:55:58 have the tools to predict appropriately in principle you should be putting in place other elements of robustness that help you compensate for that so you could have a a very complex building
02:56:09 a very complex building but one which has superbly well fire engineered prevention and protection systems designed into it where the fire which does happen is very likely to be a design fire yes
02:56:21 design fire yes is there an inevitable connection then between building complexity and the probability of a design fire uh yeah absolutely and why is that well because i mean
02:56:33 well because i mean sorry can i put the question again yeah an inevitable connection between building complexity and the probability of a non-design fire yeah i mean i i would interpret both the same way but uh right but but yeah no i mean
02:56:46 but uh right but but yeah no i mean basically if you enhance the complexity okay you're going to enhance the probability of a non-design file but it is incumbent to the designer to bring the probability back
02:56:58 designer to bring the probability back to a place where it's appropriate okay that's one element so you can actually operate by putting robustness to bring the probability back okay or you can operate by putting
02:57:09 okay or you can operate by putting robustness by bringing the consequences down so you can do the two things now that depends doesn't it on whether your building designer
02:57:21 whether your building designer understands the concept of complexity as a starting point could you give us some idea of what constitutes a complex building
02:57:30 building it's very interesting i mean there's a very uh important question because many times people think that a very tall high-rise building you know is a complex building and they are they are complex buildings but sometimes very very small buildings are
02:57:43 sometimes very very small buildings are incredibly complex you know it is the way in which you construct the building what are the components that you put in place but particularly how well you understand those components
02:57:54 understand those components so for example i can design uh you know two buildings you know four-story buildings that are identical okay one is designed using timber as a structural material and the other one is designed
02:58:05 material and the other one is designed using steel as a structural material the complexity of the timber building is much much much much higher than the complexity of the steel building when it comes to fire nevertheless i can design
02:58:16 comes to fire nevertheless i can design both buildings to equal level of safety to probability and consequence but the designer of the steel building could probably be a conventional graduate but the designer of a timber
02:58:27 graduate but the designer of a timber building will have to be a top-notch engineer
02:58:31 engineer so is the competency of the people performing the design that brings you to what society wants which is an equal level of safety
02:58:41 yes is there do you detect uh an absence of competence in those designing buildings in the united kingdom to understand that what they are designing whether it's from
02:58:52 they are designing whether it's from scratch or by way of refurbishment is complex uh well this is this is one of the biggest problems that we have and i think when i started my my first report i made sure that when i put the list i
02:59:03 i made sure that when i put the list i went from manufacturers to fire brigades because i think everybody has the same responsibility and and it is very clear that when it comes to the design you know of buildings we suffer from
02:59:15 know of buildings we suffer from fundamentally the same problems so we have this building regulations that have no problem formulation because they don't require a fire safety strategy so we're still operating under
02:59:26 under basically planned execution and so everybody the whole mindset of fire safety in general is driven in a very very similar way so the same deficiencies of
02:59:38 similar way so the same deficiencies of competency that you might be identifying in this module in regards to the fire brigades applied across the board you know to every single aspect of the whole discipline
02:59:49 single aspect of the whole discipline because we have never been able to move away
02:59:52 away from execution on the basis of very prescriptive set of rules into a place where we actually need to formulate a plan
03:00:01 plan that enables us to attain the objective
03:00:06 um would it be oversimplifying it though to say that on the whole modern residential high-rise buildings are complex constructions that protect that
03:00:17 constructions that protect that potentially present significant risk of unexpected fire behavior the
03:00:23 the modern residential buildings right now are extremely complex
03:00:33 and as a result do they present significant potential for unexpected fire behavior yes because the complexity stems from our on our misunderstanding or lack of understanding of the performance of the components
03:00:45 performance of the components we've created components that we do not know how to implement correctly we have no idea how to assess their performance and we don't know how to maintain them
03:00:56 to maintain them so we've embedded all this complexity into the system uh
03:01:00 uh and as a function of a complete misunderstanding of performance when it comes to fire focusing more on the level of competency actually required for those carrying out dynamic risk assessments at an incident
03:01:12 risk assessments at an incident involving a high-rise a modern high-rise residential building is that level of competence essentially the same level of competence as required of those responsible for collecting the
03:01:23 of those responsible for collecting the risk information about a building before the fire happens
03:01:28 the answer is yes but with the caveat that it's not the ones who collect but is the ones who request
03:01:37 request the information and the ones who will be analyzing the information the person that collects in the same manner as the firefighter who is actually the the direct responder might have a different
03:01:48 direct responder might have a different level of competency so long they are directed by somebody who has the competency yes i see you see you said that before i when i said collect i think i probably meant collect and interpret yep yes now if you go to page 17 of your report this report
03:02:01 17 of your report this report you say that line 646
03:02:07 in the middle of your screen you say
03:02:11 you say the
03:02:16 it's page 17 yes 646 you say the education and training structure of the phone rescue services is consistent with professional practice nevertheless the view that dominates
03:02:27 nevertheless the view that dominates among
03:02:28 among the fire and rescue services is that their education and training should primarily contribute to the developing practical professional skills in the form of familiarity with equipment and methods and techniques to enable them to
03:02:39 methods and techniques to enable them to operationally handle various kinds of accidents in a confident and safe manner
03:02:46 would it be right to say that in your view and in your experience of working with fire and rescue services there is an over emphasis on the practical operational side of firefighting i i would say that there is
03:02:59 firefighting i i would say that there is an under emphasis on the technical uh of
03:03:04 uh of aspects of of of operations and uh and and i think again uh this is where once again we run into the problem of definitions and uh
03:03:14 and uh for many
03:03:15 for many uh a technical the definition of technical knowledge you know means you know to know how much pressure i can put in a pipe uh or means you know how a ladder is going to work
03:03:27 you know how a ladder is going to work that's perceived many times as technical knowledge you know what i perceive as technical knowledge or the way i interpret the word technical knowledge is more understanding the principles of how a fire behaves and particularly the
03:03:38 how a fire behaves and particularly the principles of how a fire behaves and interacts within the context of the environment in which they want to operate whether it is a building or a factory or it is a forest fire you know
03:03:49 factory or it is a forest fire you know there is a need to understand um
03:03:52 um those principles and that's the part of the technical knowledge that is generally ignored you know there's a perception that technical knowledge it is being proficient with equipment
03:04:08 yes i see
03:04:12 uh and would it flow from that that your view is that there's not enough focus on technical knowledge and education required to underpin practical operations even though
03:04:24 even though that technical knowledge and education may be
03:04:27 may be more theoretical perhaps well again the use of the word theoretical is one that i have to say i actually uh take offense uh because it is not theoretical and i think it is
03:04:38 is not theoretical and i think it is based on theory in the same way that understanding what the pressure of a pipe is based on theory it is deeply applied knowledge that is actually used for the purpose of understanding your
03:04:49 for the purpose of understanding your job and the fact that people refuse or do not want to
03:04:54 to take that knowledge arguing that is theoretical i think is a mechanism to deflect an obligation yes what didn't come across in my question perhaps was the inverted commas around the word theoretical yes i'm not positing it to
03:05:07 theoretical yes i'm not positing it to you as a
03:05:08 you as a as a truth um but i think i understand your the answer was was answered by question yes uh now um i'd like to turn next developing this theme
03:05:20 developing this theme uh to the homeground paper 2014. you cover this in your first phase two report this one on page 17 itself
03:05:31 page 17 itself uh indeed it's on the screen at the moment in footnotes 25 26 and 27
03:05:39 and that i think is a paper is this right published by robert holmgren in the nordic journal of vocational education and training in 2014. yes and it uh it considered reforms that
03:05:50 yes and it uh it considered reforms that have been made to swedish firefighter training yes yes now the paper is at jto703
03:06:00 and i'd like to consider some of its findings with you professor um
03:06:06 um there it is on the screen we'll look at the detail in a moment but am i right in thinking that these swedish reforms were intended in summary to broaden the basic national firefighter training program yes
03:06:18 firefighter training program yes and
03:06:20 and you know included by extending the length of the training program from 15 weeks to two years yes and and giving it tertiary education status absolutely and also i think supplementing previous
03:06:32 and also i think supplementing previous experience based knowledge orientation with um science-based approaches and knowledge yes on the development of a fire engineering program at lund university yes and the expression
03:06:43 university yes and the expression science-based approaches and knowledge is what i think i intended to convey in my use of the word theoretical interested commerce so i don't want to um
03:06:52 um you to think that it's it's my view um i think this was part of a general objective wasn't it to develop the the students independent decision making skills and problem-solving skills yes
03:07:04 skills and problem-solving skills yes and the introduction of those science-based approaches meant that academically orientated professionals such as fire engineers were employed to deliver part of the training
03:07:15 deliver part of the training yes yes
03:07:16 yes yes now the study that robert holmgren carried out i think involved conducting interviews with instructors both from the operational side of the training program excuse me
03:07:27 excuse me and from the more science-based side of the program yes yeah
03:07:32 yes yeah and that the purpose of that on my right was to explore the instructors views about what the students should learn why they should learn it and whether and how those conceptions should uh have been affected by implementation yes yes
03:07:46 been affected by implementation yes yes now
03:07:47 now and i i'm really summarizing for for others what you well you already know i think but
03:07:52 think but two trends emerged is this right first that the instructors from the operational side of the training program or their are as they were designated which stands for rescue yes
03:08:05 which stands for rescue yes tended to express the view that education should primarily contribute to developing students practical professional skills in the form of familiarity with um equipment methods and techniques yes kit in other words
03:08:18 and techniques yes kit in other words yes
03:08:18 yes and that was consistent with the observations i think you've made in your report and uh in in your evidence just now about the approach of the lfb to the
03:08:30 about the approach of the lfb to the function of operational training and procedure yes uh if we go to page seven of the paper
03:08:40 please uh we can see uh in the second substantive paragraph under the heading professional learning it says
03:08:50 it says uh in this view which dominates among far instructors sorry
03:08:54 sorry a little bit higher up instructor conceptions about professional learning two dominant conceptions of professional learning are prominent among instructors one is widely shared by the r instructors while the other is most
03:09:06 instructors while the other is most prevalent among the s instructors and i think the s stood for science doesn't it safety yup yes and
03:09:15 and uh
03:09:16 uh it goes on in the uh
03:09:21 in the uh third paragraph there under the rubric professional learning in this view which dominates among fire instructors are the education should primarily contribute to developing students practical professional skills etc
03:09:34 practical professional skills etc and then it goes on to enable them to operatively handle various kinds of accidents in a confident and safe manner the practice and criteria of the rescue services are often stated as the
03:09:46 services are often stated as the yardstick for these skills to which training and teaching should relate the training should in other words be stamped by the endeavor to educate for and adapt to the norms and criteria attributed to the professional practice
03:09:57 attributed to the professional practice of the rescue services and then it goes on to enable such learning the emphasis is on teaching dominated by quantitative training and drill type exercises which
03:10:09 training and drill type exercises which are considered to turn knowledge and skills into second nature and part of the muscle memory now i i i've shown you quite a lot of that to what extent
03:10:20 that to what extent in your opinion professor is that approach to training the emphasis on on quantitative training and muscle memory type learning reflected in the evidence that you've seen about the way in which firefighters in
03:10:31 about the way in which firefighters in the lfb were trained before the grenfell tower fire it's very strong very strong emphasis on quantitative training and muscle memory
03:10:43 training and muscle memory and is that type of approach to operational training a problem
03:10:48 a problem uh it it it is a problem in the sense that um
03:10:52 that um that it translates upwards in the hierarchy and in the decision making where you actually need different attributes and fundamentally you need a different purpose and
03:11:03 you need a different purpose and motivation i think i think one of the things that people don't recognize is that one of the key elements of professional learning
03:11:13 learning is purpose when when you're trying to educate a professional in a university for example to become a professional the first thing that you need to make sure is that that person has a purpose
03:11:26 sure is that that person has a purpose so you're not going to have a civil engineer
03:11:29 engineer being successful if all they wanted to be was an artist and so there has to be that element of purpose and so the the type of individual that is recruited to conduct this type of work with this
03:11:42 to conduct this type of work with this type of training is very different to the type of individual that you should be recruiting to conduct more analytical skills and uh more analytical jobs and uh and and more technically oriented uh
03:11:56 uh and and more technically oriented uh you know work because they have a different purpose and if you don't develop that purpose there is no way in which these individuals can reach autonomy and uh at the end what you want from a
03:12:08 and uh at the end what you want from a professional is that level of autonomy and that starts with purpose only after that you can provide structure so this is a well-known concept called the past and it's purpose autonomy and structure so if you start
03:12:20 structure so if you start with individuals that have the wrong purpose it's not about their skills is the purpose is what they want to do what they feel attune doing if you don't have people with the right purpose in in the space of professional practice you will
03:12:32 space of professional practice you will get the wrong outcome so this is about recruitment so it starts at the recruitment process and is reinforced by the training and is reinforced by the practice
03:12:48 yes now the second trend i might come back to that answer if i may when i thought about it a bit more but uh the second trend i think observed in the homegrown study the swedish study was
03:12:59 homegrown study the swedish study was that instructors from the science-based side of the training program which i think was recorded an s or safety
03:13:07 or safety uh considered uh
03:13:10 uh and if we go to page seven at the bottom of the page you can see what's said among the instructors within the risk and safety area s the conception is that knowledge oriented towards the
03:13:21 knowledge oriented towards the understanding of both actions and situations should be the education endeavor ready-made routines and checklists are thus discarded in favor of subject integrated learning which can facilitate the understanding
03:13:32 which can facilitate the understanding of the complexity and the circumstances prevailing in in risk and injury situations and in relation to the resources available now
03:13:43 now the paper also i think suggests that that kind of approach to training and the more drill type approach that was favored by the operational side of the program are not mutually exclusive would you agree with
03:13:54 mutually exclusive would you agree with that i i think it's it's difficult to marry but they're not mutually exclusive an individual that has the right purpose could assimilate both sides difficult to marry but not mutually
03:14:05 difficult to marry but not mutually exclusive
03:14:06 exclusive um
03:14:08 um would you consider therefore that an effective
03:14:11 effective recruitment and training regime
03:14:15 regime needs to encompass both types of training an element of drill type or muscle memory that fosters familiarity with procedures with equipment as well as a
03:14:27 as well as a an element of knowledge oriented learning that fosters independent decision-making and understanding of risk absolutely there has to be a balance between the two that not only enables you know to get the
03:14:39 not only enables you know to get the right people in the right position but also allows for individuals who actually can do both and can migrate you know from one position into the other you know that will be a very effective
03:14:51 know that will be a very effective recruitment and training process and
03:14:56 the word balance in that answer is is is interesting how in practical terms would would a fire and rescue service go about balancing those skills well i i
03:15:09 go about balancing those skills well i i tried to describe a skeleton uh of the concept in in in my report where i said there had to be uh you know this there's three components you know one is the
03:15:20 three components you know one is the command skills the other one are the technical skills and then the other ones that you described as muscle memory skills so you have these three sets of skills and there has to be an
03:15:31 skills and there has to be an interaction between all three of them in a way such that they feed each other because they're complementary in nature they all work together at the end to deliver the objective so they they have to coexist the problem that we have
03:15:43 to coexist the problem that we have right now and the reason why there is no balance
03:15:46 balance is because you really only have one
03:15:50 and that one progresses through all the ranks and while people are acquiring managerial skills and so forth uh at the end their purpose remains the same and uh and therefore their
03:16:03 uh and therefore their uh
03:16:04 uh their inclination to put effort attention and assimilate the technical information or the
03:16:13 the command related information uh is really not there and therefore they're very inefficient at assimilating this type of information well they're very efficient at assimilating the information for
03:16:24 at assimilating the information for which they have a purpose and uh and this is really where they imbalance the the imbalance is so what we end up is with one side and we miss completely the other two sides
03:16:35 other two sides and this can is this right did you think that that could lead to structural imbalances in a fire and rescue service absolutely um is it right that perhaps the most significant finding of
03:16:47 perhaps the most significant finding of the homegrown study is that despite the move towards new programs encompassing both practical and operational and more as it says academic science-based
03:16:58 more as it says academic science-based learning it was the practical operational side of the training that continued to dominate the program yes
03:17:05 yes and is it right that there was a general resistance on the part of the operational instructors the r instructors to accommodate the new science-based learning from s
03:17:17 science-based learning from s yes that that is correct and and and i think again you know this is one of those spaces where
03:17:23 where you know once again it would be great if i could give you an explanation and an answer of why was that the case but um as you might imagine by the fact that i got a norwegian study this studies are
03:17:35 got a norwegian study this studies are really
03:17:36 really very far between i mean the the the type of work this type of work that really needs to be done in a very careful way is work that has never ever been given priority and while the
03:17:47 been given priority and while the swedish experiment was an experiment that to some extent resulted in very positive outcomes um it is by it is it is far from being perfect but nonetheless has an element of
03:17:58 but nonetheless has an element of universality about it absolutely yes um
03:18:02 um as i think it was recorded in the conclusions uh on page 13 we don't need to go to them but the the um
03:18:09 the um s side of the program was effectively marginalized yes yes
03:18:14 yes yes and to put it in blunt gender terms if i may it does it appear that as part of the findings there is a a powerful driving gender bias male over female
03:18:26 female that is uh i mean that has been recorded for many years and therefore i would say therefore and a strong resistance to change based on established conceptions about
03:18:37 on established conceptions about professional learning and on teaching tradition and training structures yes so
03:18:45 so in a nutshell this study the swedish studies is right found that despite an attempt at a change of direction
03:18:52 direction the male hero rescue culture if i can put it that way almost borrowing from dave beijing's 2001 article and conservatism and
03:19:03 and conservatism and resistance to change continue to dominate to the subordination of science-based more theoretical inverted commas if you like academic science-based learning which was regarded as more
03:19:14 learning which was regarded as more female
03:19:15 female yes i mean i think a lot of these traits were identified and recorded is that type of resistance that i just summarized based on the homegrown paper
03:19:27 summarized based on the homegrown paper something you observed in fire and rescue services in the united kingdom uh yes and i will say it's a global and what
03:19:36 and what and what about the london fire brigade specifically do you consider from what you've seen that there's a problem with not prioritizing more academic science based learning i think it's a very strong problem
03:19:51 now where
03:19:54 where mr chairman i've got two more or three more questions on this finish the topic when um assistant commissioner dan daly came to give evidence uh on day 118 he was head of the lfb's
03:20:06 uh on day 118 he was head of the lfb's fire safety department and he gave evidence to us uh and said that um and this was in his witness statement the fire safety issues were not always top of the list within the brigade and that the perception of
03:20:18 the brigade and that the perception of fire safety issues in this case using the shepherds caught fire in august 2016 as an example were
03:20:25 were you use his words technical and geeky technical and geeky he said and also
03:20:33 and also there's a tendency for operational issues to take precedence when it when it comes to learning um opportunities and dissemination is that approach that he encapsulated consistent with your own experience and
03:20:45 consistent with your own experience and understanding of the approach to uh learning within fire and rescue services in this country uh yes i i am
03:20:54 i am i'm gonna make a joke but uh so as permission but i normally tell my students that to be able to work in an educational manner with the fire service in the uk you have to be
03:21:06 fire service in the uk you have to be willing to accept have an endless capability to accept humiliation right
03:21:13 that is a joke but with an edge to it
03:21:18 do you know whether this is a problem unique to the london fire brigade or whether it's reflects a more a broader trend in the united kingdom no i think it's a much broader trend and it's not only the united kingdom is uh
03:21:30 it's not only the united kingdom is uh it's you know i've i have worked with uh with the opposite side when when i lived in australia with the queensland fire and rescue services and um
03:21:40 and um and it is exceptional when you find the opposite
03:21:43 opposite within the lfe as we know there was a fire safety department which included a fire engineering group the members of which were qualified and in some some instances were chartered fire engineers
03:21:54 instances were chartered fire engineers uh does it follow from what you've told us this morning and your reports that you do not consider that that level of technical expertise was reflected in lfb's training side and operational side
03:22:07 lfb's training side and operational side it's not it's not and
03:22:11 and are you able to give us any insight into why that was the case well i mean i think it goes back to the point i was making about purpose to to be able to devote yourself to
03:22:22 to to be able to devote yourself to understand a problem appropriately and lift your level of professional competency you have to have a purpose you have to believe that that is important
03:22:30 important and while people don't believe that that is important that other aspects of firefighting are much much more important
03:22:38 important then you will never be able to acquire those technical competencies
03:22:44 looking at the events on the night of the fire do you do you see parallels between the conclusions of the homegrown study and the realities of the london fire brigade's response to that fire
03:22:55 fire brigade's response to that fire very much yes mr chairman that's a convenient moment we've come to a slightly different topic yes
03:23:02 yes well we'll stop there for some lunch thank you very much you're doing quite well while you're with the witness uh yes i'm doing very well uh and um we will be finished well within this afternoon right
03:23:13 afternoon right in that case i shall er on the side of generosity and say we'll come back at five past two very good it's time we had a break for lunch professor torreira says i say we'll come back at five past two and again please don't talk to
03:23:25 two and again please don't talk to anyone about your evidence over the break thank you thank you very much
03:23:36 thank you very much too
03:23:48 you