Professor Jose Torero provides expert evidence on dynamic risk assessment failures, training deficiencies, and why firefighting decisions prioritized fire suppression over evacuation.
00:20:16 would you ask professor torreira to come back in please thank you
00:20:30 all right professor well ready to keep going yes good thank you very much yes thank you mr chairman um professor i'd like to ask you some questions now about what i might call
00:20:41 questions now about what i might call the cohen hatton papers from 2015 staying with the topic of training now you if we go back to your report please and have on the screen page 16 your first report that is yes let's look
00:20:52 first report that is yes let's look together at pay page 16 line 599 to 600 and you you say there at 599
00:21:06 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 and you have a footnote 21
00:21:18 and you have a footnote 21 where you pick up dr cohen hatton's and professor honey's article goal orientated training affects decision-making processes in virtual and simulated fire
00:21:29 processes in virtual and simulated fire and rescue environments journal of experimental psychology 2015 august 2015 that is in fact uh now
00:21:37 uh now um the paper is at lfb double zero double one zero six seven four um we can go to it if you like but i wasn't proposing to take you to it in any detail
00:21:49 detail but in summary do you agree that the research
00:21:52 research recorded in that paper showed or confirmed that the nature of training delivered to participants had a direct impact on both the level of situational awareness demonstrated by the
00:22:04 awareness demonstrated by the participants and on the level of explicit plan formulation exhibited by them before they took action yes and specifically when they were trained to apply decision controls
00:22:16 to apply decision controls which are rapid mental checks requiring the decision maker constantly to reevaluate why they're taking a particular decision uh and the action and and likely
00:22:27 uh and the action and and likely consequences of it they they demonstrated both greater explicit plan formulation and also great situational awareness or sa is that your understanding of their work yes that's correct
00:22:39 yes that's correct and it is also is it also the case that those who received only standard training so to speak uh that did not incorporate those rapid mental checks demonstrated less frequent explicit clan formulation and a
00:22:51 frequent explicit clan formulation and a lower situational awareness yes can you explain for us what you understand to be the benefits of both first explicit plan formulation and second situational awareness in
00:23:03 and second situational awareness in relation to operational decision making um
00:23:07 um well the the two things are are very very much correlated i think effectively what it is your capacity to be able to uh
00:23:16 uh analyze uh information organize it and formulate it in terms of the of decisions
00:23:23 decisions now this involves making all the necessary checks and uh and it involves also uh trying numerous pathways uh to try to see which one
00:23:34 pathways uh to try to see which one benefits uh the the objective now a lot of the things um you have to be trained for because you have to
00:23:45 because you have to avoid situations for example like uh sensory overload and you have to be conscious that these things are happening so there's an element of training that is necessary to
00:23:56 element of training that is necessary to be able to achieve these objectives and uh and therefore as an ensemble what they give you is the capacity to organize information and make objective driven decisions in the most effective
00:24:08 driven decisions in the most effective and in the most controlled way
00:24:12 i don't know if i answer your question yes you did i think the two essentially the two come come together but yes do i take it from that that before the plan is executed in other words before
00:24:23 other words before the incident commander gives directions to
00:24:27 to the crew and or elements of the crew giving them perhaps different tasks they
00:24:35 they think about the information having gathered as much as they can they analyze it organize it and then weigh the pros and cons of the potential plan they are developing in their minds yes
00:24:46 yes yes
00:24:47 yes and and then they formulate a set of orders that are that will be the execution part of the process uh that will then be transferred and communicated effectively to the people
00:24:58 communicated effectively to the people that they're managing and does that process
00:25:01 process involve
00:25:03 involve identifying things you haven't thought about or trying to yes i think basically this is translated into checks and balances so you have to avoid biases you have to avoid a number of different
00:25:14 you have to avoid a number of different things and among the things that you have to be very careful with are things that you've never considered yeah yes now um you go on to say in line 603 if we look just a little bit down
00:25:25 603 if we look just a little bit down the screen that
00:25:29 that there is a there is therefore a high expectation that standard firefighting protocols can be more or less universally planned executiony i'm sorry plan execution but there is also a presumption that departures from the
00:25:41 presumption that departures from the expected behavior will be sufficiently minor that firefighters at any level will be capable of conducting an effective dynamic risk assessment therefore current training in education
00:25:52 therefore current training in education within the fire and rescue services strongly favors straightforward plan execution
00:25:58 execution now that i think is a reference to another of dr cohen hatton's papers which was entitled an investigation of operational decision making in situ which was published in the human factors
00:26:10 which was published in the human factors journal in august 2015 as well and that we have at lf double zero lfb double zero double one zero six six seven
00:26:19 seven and again unless you think you need to see it professor we won't go to it is it right that her research in that paper was focused on the way that incident commanders make decisions at
00:26:30 incident commanders make decisions at real incidents yes and is it right just in summary that she found that individuals most frequently move directly from assessing the situation in front of them
00:26:41 situation in front of them to taking action or plan execution rather than explicitly formulating a specific plan or strategy before taking action
00:26:50 action yeah that's okay so basically they come in and they they have pre-planned options and they will move directly into plan plan execution yeah when you say you say when you say straightforwardly here you mean
00:27:01 you say straightforwardly here you mean directly yep yes um that would suggest i think and this was her finding that the way those personnel are trained is not conducive to explicit plan formulation
00:27:12 conducive to explicit plan formulation would that be right absolutely yes and and can you explain and in a sense you've already done it but just help help me on that particular point can you explain what problems arise in a training system that does not
00:27:23 arise in a training system that does not encourage
00:27:25 encourage that kind of process that kind of explicit plan formulation well what what what effectively happens is that you are not capable of processing the information in an
00:27:37 processing the information in an effective way so
00:27:39 so you will be very rapidly be overwhelmed by information that that you cannot discriminate so you're assimilating all this information that is coming to you that
00:27:50 information that is coming to you that is not necessarily all useful so one you cannot discriminate another form of problem that is very common is that you will find yourself giving priority to things
00:28:01 find yourself giving priority to things are not necessarily appropriate because you haven't put the checks and balances to verify that this is the important information that i need to consider as opposed to all the other information and then the the final one
00:28:13 information and then the the final one that is probably one of the most uh difficult ones is that if you have not been properly trained to be able to analyze all this information appropriately uh it is very difficult uh
00:28:25 appropriately uh it is very difficult uh to be able to process the information and convert it into decisions
00:28:30 decisions so what people do is hesitate and they hesitate very strongly because this information is all coming in all directions at a very significant speed so they cannot really convert it into
00:28:41 so they cannot really convert it into decision making
00:28:49 yes um are dr cohen hatton's observations about a failure to encourage explicit plan formulation amongst incident commanders are her findings consistent with what
00:29:00 are her findings consistent with what you've seen of how um lfb incident commanders are trained by the lfb to make decisions yes now mr mcgurk in his report has commented on what i think he called an
00:29:12 commented on what i think he called an artificially inflated confidence and blind faith in the procedures themselves that's a quotation from page 49 of his report the paragraph roman 4 for those who want to look at it at smc 6046
00:29:25 who want to look at it at smc 6046 and he says that the danger is that compliance with procedure and following a process becomes the goal he's identified those risks i think specifically as a rising in relation to what as a result of the decline
00:29:37 what as a result of the decline in fire incidents and therefore the loss of operational exposure to such fires by operational staff would you agree with that well i mean i think this is again one of
00:29:48 well i mean i think this is again one of those situations where we might be using the same words but but we're not necessarily talking about exactly the same things if you really think about it if you put procedures for your standard cases which correspond to what i was
00:29:59 cases which correspond to what i was calling the design fire you want people to have confidence so you want people to be completely sure that those procedures under those circumstances are going to work because
00:30:11 circumstances are going to work because otherwise you're going to create a necessary hesitation now on the other hand if you don't enable people to process information appropriately then you're disabling them from
00:30:22 then you're disabling them from questioning when those processes are not necessarily working and making the dynamic risk assessment or moving in the direction of an alternative solution that might be
00:30:33 an alternative solution that might be necessary given the cons the new constraints so is it is that capability to identify that you have shifted that is fundamental and uh but not the
00:30:45 that is fundamental and uh but not the problem to me is not the confidence on the procedures the confidence uh should be there and i think uh i if if i have to reinterpret mr mcgurk i mean what i think he's trying to
00:30:57 i mean what i think he's trying to convey is that that given the training that they have the procedures in which they're very very confident they apply them universally and they're incapable of identifying when they don't
00:31:09 incapable of identifying when they don't work and have the capability to shift into a different form of decision making
00:31:18 and that's a decision trap isn't it yes and with that i will fully agree yes so you become bound by the boundaries of the procedure and compliance with it
00:31:29 and compliance with it and thereby become trapped yes but the problem is not the confidence because you should have confidence in your procedures when they apply when they apply but that's a critical qualification that's that's a common
00:31:40 qualification that's that's a common yeah or if you like so far as they go yeah yes
00:31:45 yeah yes and would you agree with his conclusion that fire and rescue services display in general an artificially inflated confidence and blind faith in their procedures at the expense of more independent thinking
00:31:56 independent thinking well the the outcome you can trans translated into blind faith uh because they don't have the alternative so there's only one gospel and and of course then they will have
00:32:07 and and of course then they will have blind faith so yes i will have to agree but as i say you know this has to be interpreted quite carefully because it is not the fact that they have confidence in the procedures that is a
00:32:18 confidence in the procedures that is a problem it is the fact that they don't have the complementary skills yes
00:32:25 and to the extent that there is blind faith in the procedures as a result well is it a result necessarily of the reduction in numbers of attendance at
00:32:37 reduction in numbers of attendance at real fires or is it to do with the lack of training to enhance technical knowledge yeah i think i think this is this is again you know we go back to the way in which words are being used i think that uh uh
00:32:50 words are being used i think that uh uh i am a firm believer that in this type of activity experiential knowledge is extremely valuable and uh and i think um it is clear that as things improve and there is less and
00:33:02 as things improve and there is less and less fires there is going to be less and less
00:33:05 less on the ground experiential knowledge now the problem is that we cannot argue that the lack of experiential knowledge is an excuse not to be able to perform
00:33:17 is an excuse not to be able to perform your duties so we have alternative means by which we can achieve the same level of competency or even more competency that can supplement and substitute uh
00:33:29 that can supplement and substitute uh the the experiential knowledge and and i think one of the the key mechanisms in every discipline by which you compensate for lack of experiential knowledge is by elevating technical
00:33:42 knowledge is by elevating technical competency
00:33:46 and you would do that would you by reference to training programs which had a
00:33:51 a at least a significant element of simulation well i mean again you know the use of the words is very complicated no because then again you have this concept of simulation which i think is is again something that
00:34:03 which i think is is again something that is misused and misinterpreted you know a simulation is by definition a recreation of reality you know within a different platform it could be a digital
00:34:14 different platform it could be a digital platform for example but a simulation could also be an exercise you know by what you're simulating you know and and and and an event now you can use all those tools so long
00:34:25 now you can use all those tools so long you really understand uh what the limits are
00:34:29 are and uh and in many ways uh you have to make sure that at every level you're covering
00:34:36 covering the gaps are being left by a simulation that can never be reality and those gaps need to be carefully thought of and carefully covered because you want to make sure
00:34:47 you want to make sure that um that that people receive the full uh gamma of information that they need to be able to perform their duties yes
00:34:57 now i want to turn if i may please to the operational response on the night of the fire and your assessment of it and in particular i'd like to consider your view about the operational in
00:35:08 view about the operational in a response in the context of the topics that we've been considering already today
00:35:12 today first the failure to conduct an effective dynamic risk assessment
00:35:18 if you gave please to page 22 of your report this report you can see it line 807 to 808 as follows you say once the event was no longer a
00:35:30 you say once the event was no longer a one unit fire the response should have been driven by a dynamic risk assessment the dynamic risk assessment should include contingency plans quotes which should cover the spread of fire beyond the compartment of origin the possible
00:35:42 the compartment of origin the possible need for multiple rescues and the need for an operational evacuation plan in case stay put becomes untenable up to and including total evacuation of the building
00:35:53 the building and you quote in part there at footnote 47
00:35:57 47 from section 27.1 of the phase one report
00:36:03 and in fact i think also from the then national guidance on high-rise firefighting gra 3.2 of february 2014. yes yes yes
00:36:14 yes yes yes would you agree that national guidance gra 3.2 of february 2014 in that respect clearly contemplated the existence of buildings that were not sufficiently comp
00:36:25 that were not sufficiently comp compartmented and for which a straight a staple strategy might not be reliable yes and in your view is that likely to reflect the fact as you've referred to in your reports that the risks of facade
00:36:37 in your reports that the risks of facade fires
00:36:38 fires were known about at the time the national guidance was published in 2014 yes and indeed earlier than that yes because i think in fact if you look at the 2008
00:36:49 i think in fact if you look at the 2008 version of gra 3.2 cladding is also referred to in it yes now
00:36:56 now at
00:36:57 at line eight twelve if you look at that it says this lfb personnel including those in command were not capable of conducting an adequate dynamic risk assessment once it became obvious that the fire was propagating externally and
00:37:09 the fire was propagating externally and again you quote from various sections of the phase one report uh are you essentially referring here to the failure of anybody in the chain of command on the fire ground on that night
00:37:22 command on the fire ground on that night up until the arrival of andy rowe to formulate a clear and effective plan to attempt an evacuation of the building yes
00:37:32 yes and that is indeed the chairman's conclusion at paragraph 28.8 as you say as you footnote footnate 51 would it be right therefore to say that in your view that was due that failure was due to a
00:37:44 that was due that failure was due to a fundamental misunderstanding uh or lack of understanding as to what the fire was doing absolutely if you go to your second phase two report then please at page 21
00:37:57 report then please at page 21 this is jt06705 page 21.
00:38:02 page 21. let's look together at line 698 to 700. at 698
00:38:08 at 698 you say
00:38:10 you say uh
00:38:11 uh nevertheless once the fire has exited the building the evolution of the vertical spread of fire as well as the implications towards fire re-entry through the windows could have been predicted
00:38:23 predicted and you go on to say from the end of line 702 to line 704 all this technical information would have supported the incident commander's process of conducting an adequate
00:38:34 process of conducting an adequate dynamic risk assessment now can you explain what technical information is your expression there you're referring to that would have supported an adequate dynamic risk assessment yeah this goes back to the
00:38:47 assessment yeah this goes back to the example that that i was i was given so if if if i look at if if you think of of the the images at the time so you have a point where you can clearly recognize that there are
00:38:59 can clearly recognize that there are combustible materials that are burning external to the building and and that is a few minutes into into the event you know furthermore um if you wait another couple of minutes you would
00:39:10 wait another couple of minutes you would have seen that that fire was spreading and it was growing in size so
00:39:17 so the technical information that i am referring to is that understanding that once the fire started spreading vertically it was not going to stop so if you know now that
00:39:29 going to stop so if you know now that the fire is not going to stop then the next step in technical information is try to estimate how fast is going to grow
00:39:36 grow and once you have the technical knowledge to be able to make that estimate whether it is very coarse and conservative or is a little bit more refined then you would have come up to the conclusion that your fire safety strategy within
00:39:48 that your fire safety strategy within the building could not tolerate a staple condition
00:39:52 condition and therefore you would have made the decision
00:39:55 decision to instruct explicitly the people that you were in command to try to take all the necessary provisions to move into a position in which rescue became the priority as
00:40:07 which rescue became the priority as opposed to fighting the fire
00:40:11 and would it follow from that that if you knew at least in relative terms nothing other than the relative speed of the fire
00:40:17 the fire and that it wasn't going to stop then you would be able to calculate the time you would have to affect a significant partial or complete evacuation of the building yes
00:40:32 in your view i think is that equipped with that
00:40:35 with that really minimal technical information but technical nonetheless a proper dynamic risk assessment would have identified the potential for rapid vertical fire spread and therefore re-entry back into flats
00:40:49 and therefore re-entry back into flats back into compartments through the windows exactly because that's the other component of the technical knowledge so if if you have an understanding of the building regulations you will recognize that windows are considered to
00:41:02 recognize that windows are considered to have no provisions of fire um resistance if you want to use that terminology so they have no provision so the moment that the flame is in front of the window
00:41:13 that the flame is in front of the window your assumption should be that the fire will re-enter yes
00:41:17 yes not due to a defect in the building no it's just simply that the window represents no barrier to the fire so the conservative assumption would have been to assume that the moment the flames are
00:41:28 to assume that the moment the flames are in front of the window that the fire would have re-entered and ignited that apartment
00:41:32 apartment yes
00:41:35 yes now um
00:41:37 now um this may call for a lengthy answer but
00:41:41 but let's see how we go are you able to tell us sitting there what kind of thought processes you would expect a properly trained incident commander possessing the relevant level of technical understanding to have followed when
00:41:53 understanding to have followed when confronted with the fire at grenfell tower at the moment and just after the moment when it had exited flat 16 and got into the cladding yeah i mean this is uh uh i mean i guess
00:42:05 yeah i mean this is uh uh i mean i guess uh
00:42:06 uh yeah i can give you the the not necessarily the very long answer but but i i think that before i give you an answer
00:42:14 answer uh it it is very imp important to caveat the fact that uh that it is the commander who understands the people that they're working with and the capabilities of the individuals that
00:42:26 capabilities of the individuals that they're working with so uh the tactic tactics aspect of it is inherently related you know to the capabilities of the crew that you are managing and and
00:42:37 the crew that you are managing and and and i should not be commenting uh about that part of the decision making now on the other hand uh if i if i think purely from a technical perspective which is within the bounds of my competency um
00:42:50 within the bounds of my competency um clearly
00:42:51 clearly the kinds of decisions that would have been uh taken would have been to try to alert people and evacuate them as fast as you could possibly can take advantage full advantage of the
00:43:04 take advantage full advantage of the numerous redundancies that you have from the perspective of compartmentalization so keep in mind that these units were conformed of fire resistant walls with with fire doors and uh and you have
00:43:16 with fire doors and uh and you have three layers of compartmentalization before you actually get uh to the to the stairs you know making sure that you would do everything to try to guarantee
00:43:27 would do everything to try to guarantee that the stairs are free of smoke and uh and the reality is that while if you would have been able to do that to take advantage of all the layers of compartmentalization that you have
00:43:38 compartmentalization that you have available
00:43:39 available the reality is that you would have probably extended the amount of time that you had in the lobbies very very significantly because you had to breach all those levels before you go to the lobby and of course before
00:43:51 you go to the lobby and of course before you go to the stairs and so so from my perspective it is privileging in a coherent way you know all the attributes that the building has
00:44:03 building has that are on your favor and trying to uh get people out at the same time now one of the complexities in this particular building and um and i haven't really looked into this in in great
00:44:15 really looked into this in in great detail but i have uh listened to them uh you know to the uh the different um evidence on this uh is is the manner in which uh the the smoke extraction system
00:44:27 which uh the the smoke extraction system worked in in the lobbies that again is an element of technical um knowledge that in many ways represents one one of the potential issues that
00:44:38 one one of the potential issues that could have been uh another variable that was added uh in in to the picture so some information would have been um had to be transmitted to the to the
00:44:51 had to be transmitted to the to the commander in regards to what was the state of performance of the systems and whether they were conducting their job or actually they were making things worse
00:44:59 worse and uh and and these things should have been assessed before making any any direct decision in regards to how you displace people you know around the building yes now in relation to your
00:45:10 building yes now in relation to your dynamic risk assessment your putative dynamic risk assessment for the night of the fire can we look at your first report again please page 22 the first phase two report
00:45:22 the first phase two report page 22 and let's look together at lines 8 14 to 8 16 there you say uh at 8 14 uh well let's start at 8 13 you say as a result many decisions that were made or
00:45:34 result many decisions that were made or not made misjudged the nature of the event
00:45:37 event and you quote there from the phase one report and you say this this resulted in ineffective actions and inadequate information being transmitted between members of the lfb and between them and the occupants
00:45:48 and between them and the occupants inside the building who are seeking help and again these are all citations from the
00:45:55 the phase one report and then you say on page 23
00:46:00 at line eight one seven
00:46:05 actions taken were not consistent with the proper command structure in particular the management of information and communications were representative of individuals in charge of their own actions and not of a response which is characterized by an effective
00:46:17 characterized by an effective coordinated command structure and again those are our findings from the phase one report which you're referring there but when you refer to them are you doing
00:46:29 but when you refer to them are you doing so in order to point out the failure to establish any clear and consistent system on the incident ground for receiving receiving recording and transmitting information
00:46:40 recording and transmitting information via the control room from residents in their flats i mean i am including that what what i'm trying to do in that in that paragraph is uh provide some evidence from what
00:46:51 is uh provide some evidence from what was uh recorded in the phase one report and that
00:46:56 and that that substantiates the statements in in in the paragraph and uh and the statement in the paragraph basically
00:47:04 basically only wants to imply that it was it was very clear that there was no appropriate command structure that there was no appropriate dynamic risk assessment and therefore many of
00:47:15 risk assessment and therefore many of the decisions that were made were driven by individuals and in most cases they were not appropriate so so so the quotes are examples that help illustrate and substantiate what the the core statement
00:47:28 substantiate what the the core statement in that paragraph yeah and would a dynamic risk assessment properly done at the time have taken into account the information about the number and location of 999 calls from residents reporting smoke and fire in their flats
00:47:40 reporting smoke and fire in their flats yes of course and
00:47:42 and you i think you criticize those in command for failing to obtain information about conditions inside the tower
00:47:49 tower from that source but also from the bridgehead again so that could inform the operational strategy yes yes now
00:47:59 again it may seem obvious to you but could you explain how in your view it was necessary to obtain that information vis information coming from 999 calls and information coming from the bridgehead in order to understand how
00:48:11 bridgehead in order to understand how the fire was behaving well i mean i think the in in in in essence what you're doing is you're departing from a stapled strategy and the departure from a staple strategy in
00:48:22 the departure from a staple strategy in a situation uh like this one particularly when it had already escalated at the sort of slightly later stages
00:48:32 effectively carries the risk that you are displacing people from one place where they are unsafe to a place where they might actually be even more unsafe so you have to have a very
00:48:44 so you have to have a very as much information as you can on
00:48:48 on the means of egress and the conditions where they are to make the decisions whether people should actually migrate to a different place or they should remain you know where they are until
00:48:59 remain you know where they are until you know they get rescued or things get changed so there's a lot of decisions are happening but they all depend on what are the conditions both in the units and in the means of egress and you
00:49:10 units and in the means of egress and you have to at the end make a balance of what is the best possible option you know for those individuals
00:49:20 and are you able to tell us why in your opinion those in command at least until the arrival of assistant commissioner rowe did not seek to obtain that information as a matter of priority
00:49:31 as a matter of priority it's very it's very difficult you know to try to rebuild what what was on on people's minds but i i do believe that what you get from listening to the evidence
00:49:42 evidence that they provided is that um there was a very very strong sense of uh having lost control over the situation
00:49:50 situation and
00:49:51 and and and i think in part not knowing what information they needed to ask because they couldn't find the necessary reasoning to be able to
00:50:03 the necessary reasoning to be able to depart
00:50:04 depart from
00:50:05 from the plan execution mode in which they were from the beginning yes i'll come back to that answer just a moment before i do can i just ask you a
00:50:16 moment before i do can i just ask you a slightly different question you referred a moment ago to
00:50:21 to the undesirability of moving occupants from one place to a place of even greater danger uh
00:50:30 uh how would the how would the a dynamic risk assessment work in circumstances where the incident commander performing that assessment knew
00:50:39 knew first that the flats or some flats were smoke logged but also the means of escape was also in parts smoke logged how would that
00:50:51 how would that how would the dynamic risk assessment create a tiebreaker well this is uh that that what what you're describing is that level of complicated decision that uh that potentially has no positive
00:51:03 that uh that potentially has no positive outcome
00:51:04 outcome and uh but keep in mind that what you are describing is a state where you never want to reach and and i think i think for me the value of the dynamic risk assessment is a lot
00:51:15 of the dynamic risk assessment is a lot earlier that's where it has its greatest value and its value starts diminishing because the decision becomes more and more and more and more complicated and the variables are becoming much more involved and then you know you also have
00:51:27 involved and then you know you also have the human factors that start playing a very complex role so by the time you get to that point uh you will have to put you have to exercise a very very very high level of skill both as a commander
00:51:41 high level of skill both as a commander but also technical skill to be able to differentiate you know which of the two is worse yes and and that has helped me with this
00:51:49 with this that shows us two things perhaps first that the dynamic risk assessment is not a panacea not a cure-all at any at all stages of the incident it can become useless if the fire
00:52:01 it can become useless if the fire progresses beyond a particular point yes yes yes
00:52:04 yes yes but also perhaps that the
00:52:07 that the um the decision control process dr dr cohn happens process
00:52:14 process might then introduce would this be right that um potential at
00:52:22 at the decision control stage by which i mean that if you are using her process before you proceeded to plan execution you would ask yourself i don't i
00:52:34 you would ask yourself i don't i want to make sure that i don't by proceedings with this plan end up in a position that it's too late for me to exercise a dynamic risk assessment absolutely i mean i think that that you
00:52:46 absolutely i mean i think that that you know this is the the reason why dynamic risk assessment is something that normally tends to happen
00:52:52 happen in a continuous way through the whole process
00:52:55 process because the decision delay is one of the most complex traps that you can run into so many times by using uh the approaches that uh dr cohen halton was was putting
00:53:07 that uh dr cohen halton was was putting in this describing you know you are weighing
00:53:11 weighing the delay also as one of the variables that uh that enables you to make sure
00:53:17 make sure that the decision that you're making is the most appropriate now
00:53:22 now if we look please at line 823 you say this at the core of these failures is a profound misunderstanding of risk within modern buildings created by inadequate training in it and
00:53:34 by inadequate training in it and inadequate education and training from the evidence gathered it can be established that the training provided to members of the lfb was not adequate to understand the complexities of modern buildings in particular high-rise
00:53:45 buildings in particular high-rise buildings furthermore it became apparent that there is a strong disregard for training and education pertaining to building behavior now all of that is i think a summary of
00:53:56 now all of that is i think a summary of what you read from the phase one report uh
00:54:01 uh yes um
00:54:02 yes um and footnote 69 if we look at footnote 69 which i think we'll need to scroll down for you refer to the chairman's phase one findings of paragraph 27.9
00:54:15 findings of paragraph 27.9 of the phase one report uh that several lfb witnesses said in one way or another they didn't understand what was happening as the fire spread up the building and the buildings should not behave like that
00:54:28 buildings should not behave like that can you explain the significance of that phase one testimony namely that buildings quotes should not behave like that
00:54:36 that well i mean this is this is in many ways uh where you know one one of the these are key mis misunderstandings that uh that existed throughout the the entire um uh
00:54:48 entire um uh response
00:54:49 response uh when you say buildings should not behave like that what is exactly what you're saying what you're saying is the building for which i was trained
00:55:00 i was trained uh
00:55:01 uh to come and fight the fire was a building that didn't have a fire like this one now but that doesn't mean that this event was not foreseeable uh this basically this event is an event
00:55:13 uh this basically this event is an event given the technology that we're using right now in the built environment this is an event that we had plenty of evidence that it was foreseeable so actually in reality if you understood
00:55:24 so actually in reality if you understood building construction you will understand that buildings do behave like that
00:55:30 that so the thinking shouldn't be is this right
00:55:33 right building shouldn't this building should not behave like that but rather this building
00:55:38 building should not behave like that but very well might well this this is the the the approach that should be taken ahead of the event but during the event you should be
00:55:49 but during the event you should be trained to be able to immediately identify if it's a foreseeable pathway for the fire okay you should be able to identify that this is one of the things that you have
00:56:00 this is one of the things that you have to be prepared for now you've also referred in your your opinion here to the evidence of the former commissioner danny cotton captured i think in
00:56:11 captured i think in 75 on page 24 which was paragraph 27.14 of the phase one report uh that nobody would expect an incident like grenfell tower to occur
00:56:22 an incident like grenfell tower to occur or a building to be covered in such highly flammable product and to fail say spectacularly uh i i i'm quoting without citation but what in your view does danny cotton's
00:56:34 what in your view does danny cotton's evidence tell us about the extent of the lfb's understanding uh organizationally presented by the risk of facade fires well
00:56:44 well i mean if if you amalgamate all the international evidence that existed if you put together with all the internal communications and evidence
00:56:56 internal communications and evidence that existed on the matter if you
00:57:01 if you understood how modern building construction was
00:57:06 was developing if you had any understanding of a fire safety strategy within a high-rise building of that nature would you ever make a statement like that
00:57:21 and i take from your answer which ends with a rhetorical question that in your opinion
00:57:27 opinion the lfb
00:57:29 the lfb should have but did not algomate all the international evidence didn't put it together we should have done
00:57:36 done didn't understand but should have done how module building construct modern building construction was developing and didn't but should have understood the fire safety strategy within grenfell tower
00:57:47 tower yes and and above all um argued that that evidence didn't exist
00:57:58 i think you also say at lines eight three two
00:58:02 three two at two eight three three and eight three five two eight three six uh that at the heart of the inadequate dynamic risk assessment on the night of the fire was the fundamental
00:58:13 the fire was the fundamental misunderstanding as you put it in line eight three two that the primary role of the fire and rescue services is to fight the fire you say that's apparent at all command
00:58:25 you say that's apparent at all command ranks citing section 28.17 of the phase one report yes now can you just explain what you mean by that so uh
00:58:36 so uh if if if you look at the the actions uh that were taken and uh as described in the phase one report what you see is a strong focus in fighting the fire
00:58:48 strong focus in fighting the fire uh so that becomes sort of becomes the primary objective and uh despite the fact that the fire has gone out of control and the capabilities to actually fight the fire are minimal uh the
00:59:01 fight the fire are minimal uh the resources keep being put in an attempt to continue to fight the fire
00:59:06 fire and without understanding that you could have deployed your resources in a completely different way and given absolute priority to try to
00:59:17 and given absolute priority to try to protect your means of egress and make sure that you get as many people as fast as possible out of the building well
00:59:26 well the fire
00:59:28 the fire well would you accept this that that many fires are out of control and are successfully brought under control by a fire and rescue service that's potentially correct yes and
00:59:39 that's potentially correct yes and therefore when you say the fire was out of control might it be the case that an incident commander might have regarded the fire at least in its early stages as capable of being brought under control uh well
00:59:51 of being brought under control uh well that is that that is possible um and and i think i think that it is it is mostly a decision of understanding one when you are not capable and two when it becomes a secondary
01:00:02 and two when it becomes a secondary priority so so it's it's very different you know to be able to bring a fire under control if that is your objective and you have already fulfilled your mission of life safety so i don't really
01:00:14 mission of life safety so i don't really have a problem on putting resources in trying to bring the fire back on control but when you are facing a situation in which you have to make choices in regards to how you deploy your resources
01:00:26 regards to how you deploy your resources it is clear that the focus should have been uh on rescue and uh on trying to evacuate people in the most effective manner as early as possible and keep in mind once again i
01:00:38 mind once again i i think that i
01:00:40 i always want to insist that
01:00:44 that things are manageable when they're manageable and uh and making judgment uh on how things worked once everything has gone out of control is extremely
01:00:56 gone out of control is extremely difficult so i'm talking about making making the right decisions at the right point
01:01:01 point now there is an option that i think firefighters tend to be extremely reluctant
01:01:07 reluctant uh you know to to follow which is there are certain fires that you're better off just letting burn and uh and the reason for that is mostly the the firefighters own safety so
01:01:18 the the firefighters own safety so there's numerous reasons why you might make the decision that a are certain fires that you shall you should just let burn now obviously if if this involves the life safety of the occupants
01:01:30 the life safety of the occupants there's a much much more complicated decision but even then there is going to be a point you know where as a commander you have to make the decision that there are certain things that you cannot do
01:01:41 certain things that you cannot do without endangering unnecessarily uh you know your own crew so so i think all these decisions are are fundamental and uh but but it is clear
01:01:52 and uh but but it is clear that in the first half hour of that fire a decision should have been made of shifting as many resources as possible to try to protect the means of egress and
01:02:03 and try to get as many people out of the building
01:02:07 building and in structural terms working the dynamic risk assessment would you agree that doing that of course is not only a continuous exercise but there's a there would be a gradation
01:02:19 but there's a there would be a gradation of realization that the fire would not be capable of being brought under control yes absolutely and it's not something that suddenly you suddenly realize uh
01:02:28 uh it becomes apparent to you gradually as you continue to weigh the information exactly so that this is what you're continuously doing this diagnostic so you can at every point balance your
01:02:39 so you can at every point balance your options on the basis of understanding yes
01:02:44 yes yes
01:02:45 yes um
01:02:50 now you refer in this passage of your report to the phase one evidence of danny cotton that even had the incident commanders at grenfell
01:02:59 grenfell known about the potential for external flame spread it would have made no difference to the operational response on the night because there was no way of extinguishing such a rapidly spreading fire
01:03:10 fire why have you identified that evidence specifically by which i mean what is it in your view that says that that um
01:03:19 that um what does that say in your view about the lfb's understanding of its primary function that it is about extinguishing the fire right
01:03:28 now last i want to ask you about the need for technical knowledge generally and specifically in relation to one uh part of the operational response on the night of the fire namely radio communications
01:03:39 communications you've addressed that principally in your second phase two report i think having seen chris johnson's professor chris johnson's uh own report yes can we go to that please uh your second report
01:03:50 go to that please uh your second report uh of august this year at page four lines 83 to 87 and you say starting at line 83 an assessment
01:04:02 an assessment of firefighting tactics shows an unwarranted reliance on experiential knowledge
01:04:07 knowledge the technical complexity of fire suppression is such that the value of experiential knowledge is very limited in particular when officers have very little opportunity to acquire real fire event experience
01:04:18 event experience in these circumstances the only mechanism to achieve adequate competency is by means of enhanced technical knowledge none of the officers who were in command exhibited such a knowledge the structure and policies of the london
01:04:29 the structure and policies of the london fire brigade are currently not conducive to the recruitment education and training of professionals with such technical competency can you explain what you mean there when
01:04:40 can you explain what you mean there when you say that the value of experiential knowledge is in fact very limited given the technical complexity of fire suppression yes so uh the interaction between water and a fire
01:04:53 the interaction between water and a fire depends on multiple variables and and you can define one specific scenario one specific condition and then you can establish
01:05:04 establish your flow rate your tactics everything to try to deal with that condition so if you look at the literature what you will find is that the majority of information that defines the way in which we
01:05:16 the way in which we introduce water into the problem it is confined to fires with uh in in in the ground and also horizontal uh fires and um and
01:05:27 and also horizontal uh fires and um and they're under certain very specific conditions even the training that firefighters do uh when they go into these compartments the fire is a static fire that is sitting on on on the one side so that level of
01:05:39 on on the one side so that level of experiential knowledge is very useful to be able to understand how to use the equipment
01:05:45 equipment but it's not useful when you're trying to understand a fire that is operating in a completely different way so now you have a vertical fire that is uh where the water is going to fall off
01:05:57 the water is going to fall off uh and the interaction between the water and the fire is going to be completely different and you're going to have cavities where the fire is going to be hidden there's a number of different things that are basically very very
01:06:08 things that are basically very very different to the way in which uh your practices have been defined so this is so distant to the way in which your practices have been defined that you have to make a
01:06:19 been defined that you have to make a competent assessment of how effective your procedures are and how much they can gain you now if you really understand the interaction between the technical interaction between water and
01:06:31 technical interaction between water and fire you will really very rapidly understand in which sectors you have more potential gain you know in which sectors you probably have no potential gain and also it helps you understand
01:06:42 gain and also it helps you understand when
01:06:44 when there is really no benefit in continuing to throw water to the fire so all these things stem from really understanding you know in in a much deeper way how water interacts
01:06:56 water interacts with with the fire looking at a um a particular piece of suppression such as an aov does it tell us that experience isn't
01:07:07 does it tell us that experience isn't going to teach [Music]
01:07:09 [Music] an operational team or incident commander technical skills about such fire suppression systems how they work when they work when when they don't work
01:07:20 work or why they don't work i mean basically the experiential part will enable them to use the equipment it will enable them to produce a certain amount of water according to pre-defined
01:07:34 protocols but it will not enable them to establish if that amount of water placed in that position is effective at suppressing the fire is that
01:07:46 at suppressing the fire is that interaction between the fire and the water
01:07:49 water that will not be contemplated in that experiential knowledge and would it be right to say that what you saw of the operational uh approach on the night of the fire and
01:08:00 uh approach on the night of the fire and reliance on experiential knowledge that's consistent with what the homegrown study found yes namely a tendency to favor muscle memory type learning as opposed to
01:08:11 type learning as opposed to as opposed to science-based yes which which is reflected in the focus on
01:08:17 on managing the hardware properly as opposed to understanding what is what you're really gaining
01:08:26 gaining so if you start looking into the deployment of water and you start looking into how much
01:08:34 how much benefit
01:08:35 benefit that water was producing you know you will realize that that it is it is actually potentially very limited now i know that a lot has been said about the fact that water prevented the fire from
01:08:47 fact that water prevented the fire from going to certain places and others but it is quite easy to make those statements on the basis of a few photographs but the reality is that given the amount of water that was put into that fire
01:08:58 into that fire uh
01:08:59 uh it is quite clear that the impact was very limited and coming then to the question of radio communications um there are two particular matters you refer to in your report if we can go to
01:09:11 refer to in your report if we can go to uh page 31 of this report and look at line 1019 on that page you refer to
01:09:20 uh the self-imposed constraint of using low-power radio sets now is it and you say that's not necessary or may not be necessary is that a reference to the nfb's use of
01:09:32 that a reference to the nfb's use of low-powered intrinsic intrinsically safe barry radio sets yes now barry sets are said to be intrinsically safe because their lower power
01:09:41 power means as we've heard from various witnesses and professor johnson that they're less likely to act as a source of ignition in the presence of flammable gases yes yes now and when you say that that may not
01:09:52 now and when you say that that may not that it may not in fact be necessary are you referring to the fact that as professor chris johnson explained in his report and again orally most incidents in which battery sets are
01:10:04 most incidents in which battery sets are used don't in fact involve flammable or explosive atmospheres or our atmospheres in which there is already a an ignition source a fire yep
01:10:15 source a fire yep basically there there
01:10:17 there there's one uh key scenario where you can have a flammable atmosphere and it's a gas leakage
01:10:23 leakage and it's a very well identified scenario and it doesn't involve a fire because the moment you get the ignition you get an explosion so a gas leakage is a very well known scenario mostly in industrial cases and
01:10:35 scenario mostly in industrial cases and i will be completely in agreement that anything that could represent the source of ignition should not be used when you have a potential you know for a flammable mixture like in the case of an
01:10:46 flammable mixture like in the case of an explosion now when you are in a fire there is only one scenario in which you can actually attain a flammable mixture and that's a backdraft
01:10:56 backdraft so that's the only scenario where you can attain a flammable mixture because the moment that you have a flame the flame is already at the interface between the fuel and the oxidizer so the
01:11:07 between the fuel and the oxidizer so the two of them cannot mix without passing through the flame so either you have fuel that cannot burn on its own on the one side or you have air that cannot burn on its own on the other side and they never mix because
01:11:19 other side and they never mix because they mix at the flame that's a fire now in a backdraft is a very unusual situation because what you have is a compartment that is so enclosed that all the oxygen gets consumed
01:11:32 that all the oxygen gets consumed so once all the oxygen gets consumed the compartment is still extremely hot but now it's filled with fuel and has no oxygen so it cannot burn so if you open a door
01:11:44 so if you open a door in the back raft a fresh current of air comes in mixes with the hot fuel ignites and burns that is a lethal situation so there will never be a firefighter in a
01:11:56 there will never be a firefighter in a position in which they are inside a compartment where they could potentially create a backdraft that will not happen so the reality is that physically speaking just pure physical principles a
01:12:07 speaking just pure physical principles a combustible mixture cannot happen in a fire event unless for the exception of the background or the case where you have a gas leakage
01:12:20 and what does the fact that the lfb uh continue to use battery sets with very low wattage and intrinsic safety tell us about the
01:12:31 and intrinsic safety tell us about the lfp's understanding of radio communications and their potential more extensive uses well i think that if if the reason is that they are using this intrinsically
01:12:42 that they are using this intrinsically safe systems so that they have the low wattage so that they don't have ignition sources to prevent ignition of a combustible mixture what that means is that they don't have the technical knowledge to understand the basic
01:12:53 knowledge to understand the basic principles of fire dynamics
01:13:00 and if we go to page 31 31.989
01:13:05 you say there
01:13:09 furthermore inspection visits and training are done in a manner that does not introduce problems of congestion and interference thus circumventing the real and well-known problem now
01:13:22 and in fact you go on uh to say that that can only be interpreted as the inc as an incapability of the organization to question its practices and as a result despite their own evidence
01:13:33 result despite their own evidence changing the focus towards the equipment so as to avoid the introspection on the manner the equipment is being utilized um would it be fair to summarize uh this problem
01:13:44 problem in this way that the nfb's policies and procedures relating to porous and
01:13:49 and policy number 800 operational risk and their information gathering activities don't reflect the difficulties that are in fact regularly experienced with communication equipment on the far ground in reality
01:14:01 equipment on the far ground in reality yes i think i think that uh the i i i would agree i mean i think the the information that is being gathered is is focused mostly on the equipment and the
01:14:12 focused mostly on the equipment and the improvement of the equipment without really understanding the use and the way in which equipment is being used yes and what implications does that have for the compliance of the lfps arrange
01:14:23 compliance of the lfps arrange arrangements for obtaining information pursuant to the obligations under section 72d of the 2004 act so far as radio commas are concerned well there is there is a requirement to
01:14:35 well there is there is a requirement to establish effective means of communication you know which requires them to
01:14:39 them to it is not a requirement on the hardware is a requirement on the usage of the hardware so effectively that means that they're not complying with their obligations
01:14:50 complying with their obligations yes thank you now professor you'll be pleased to hear i've come to the end of my prepared questions for you today there may be other questions that i've overlooked and questions which may come from others
01:15:01 and questions which may come from others so i'm going to ask the chairman to take a short break mr chairman may we do that yes well as you probably know professor torreira when council gets to the what he thinks is the end of his questions we always have a break
01:15:12 a break just to give him a chance to make sure he's not left something out and also to give other people who are following your evidence but not from this room can suggest questions which perhaps we ought to put to you so we'll
01:15:24 perhaps we ought to put to you so we'll have a break now we'll come back at quarter past three minutes a minute i think that should be plenty if we need any longer may i apply yes of course we'll say quarter past three for the time being and then we'll see if there are more questions for you okay thank
01:15:36 are more questions for you okay thank you very much
01:15:47 right thank you could fast three and if you need more time you just let the ocean oceans
01:35:08 would you ask professor torreira to come back in please thank you
01:35:19 all right professor guerrero well i'm sorry we kept you waiting a bit longer than i
01:35:23 than i thought we should but still we're ready to go now so let's see if there any more questions for you yes mr one or two um professor first you say that when the fire was seen to involve materials on
01:35:34 fire was seen to involve materials on the facade and to be spreading up the building vertically uh then an incident commander knew it wasn't going to stop so and i'm summarizing that should have triggered a dynamic risk assessment
01:35:46 a dynamic risk assessment leading to evacuation um
01:35:49 um would it be would you expect that one element of that dynamic risk assessment is
01:35:58 is or might be the fact that the incident commander might think that the fire would stop at the top and burn itself out
01:36:06 um even if that was the case it would have triggered the same set of actions because once it progresses it would have still compromised a whole
01:36:18 it would have still compromised a whole array of units all the way to the top so that would most likely have triggered some form of of egress
01:36:27 of egress so
01:36:28 so uh so i think that that could have been uh an an assessment i think that that probably is one of the biggest uncertainties of this particular case because as phase one concluded there was a presence of the
01:36:40 concluded there was a presence of the crown which was quite unusual and uh so that would have been potentially one of the elements of uncertainty but it still the moment that it progressed it would have triggered all actions
01:36:52 it would have triggered all actions trying to enable evaluation and particularly to protect the means of egress right so can i just follow that up for a moment um we know that actually that the fire spread up
01:37:02 spread up the side of the building on what we call the flat sixes yes and you say it would have compromised a whole array of compartments presumably in the light of what you told
01:37:13 presumably in the light of what you told us earlier about the windows the incident commander could expect it to have broken back in at all those levels up the building is that right yes
01:37:24 that right yes and then
01:37:25 and then who knows quite where it would have spread to perhaps yes perhaps not beyond the flat sixes or perhaps it would yeah and i think uh the way i would look at it is uh you know if you take it from
01:37:36 it is uh you know if you take it from the most conservative of approaches uh i i would assume that the decision would have been be to start the process of egress as rapidly as possible but
01:37:47 egress as rapidly as possible but decisions could have been made for example of privileging the the flats are in that particular sector as opposed to the ones that are in front to make sure that you protect the means of egress because at the end at the core
01:37:58 because at the end at the core of
01:37:59 of our capability of getting people out is making sure that we protect the means of egress thank you yes yes thank you mr chairman and secondly um i think i'm right professor and correct
01:38:10 i think i'm right professor and correct me if i'm wrong that you gave a speech in july 2018 to the warren center fire safety engineering project launch do you remember that yes and i i i can quote slowly for you what
01:38:22 and i i i can quote slowly for you what you said there and you said what ended up happening in grenfell
01:38:27 grenfell was that the engineers delivered the building those engineers did not exercise competency adequately their competence was not consistent with the complexity of what they were doing and they delivered a building on fire to the
01:38:39 they delivered a building on fire to the fire service that the fire service could not manage it was not the fire service failure to address the problem of the building it is our failure to actually deliver the building that the firefighters could actually work on
01:38:51 firefighters could actually work on so the expectation that the fire service should have understood building performance the expectation that the fire service should have been able to manage the fire is a really unfair expectation uh in the light of what you've told us
01:39:02 uh in the light of what you've told us today have your views changed since july 2018 no because i think that uh the you know that that quote is one i stand uh very strongly behind and i think that the the problem with that quote in
01:39:14 the the problem with that quote in isolation uh is that it doesn't reflect what the objective of the warren center project was which was an over overall look at competency now obviously the warren center work
01:39:26 now obviously the warren center work then looks both at the competency of the fire brigade and as you can see in my reports i don't make a differentiation between engineers when it comes to
01:39:37 between engineers when it comes to engineers that design a building and engineers who should be actually informing the training and the competency of those deployed so the the the point that i wanted to make was that
01:39:48 the point that i wanted to make was that it is an unfair thing to blame those who are in the ground for all the mistakes they're making when those who actually should have the competency to enable them to do a proper job
01:39:59 job uh have not managed to deliver that level of competency that makes them capable of performing the task so should we read the word fire service when you say that the expectation that
01:40:10 when you say that the expectation that the fire service should have been able to manage the fire is a really unfair expectation as as limited to those members of the first service on the incident ground yes of course
01:40:21 course on the base in the context of the training that they had in fact been given or not given yes because uh if uh if you look at the date and you look at the words that precede that uh what i
01:40:32 the words that precede that uh what i was trying to emphasize was the people who were giving testimony at this grand republic inquiry at the time
01:40:41 time and uh and those were the people who were in the ground and so all the reflections that i made in regards to the fire service pertained to the people who actually were in the ground at the early stages of the fight
01:40:54 ground at the early stages of the fight and everything you've told us this morning i think would this be right is based on your objective view uh of what the objective fire for incident commander would do yes so basically uh the the
01:41:05 basically uh the the the way i have tried to portray things in my reports and through the um you know through this discussion is that uh uh
01:41:15 uh is trying to explain what are the necessary conditions to have an adequate operation and uh but who is responsible for the liver those conditions that is a very very different
01:41:26 conditions that is a very very different question so so if if if i may the interpretation that should be given to my reports and my uh my my evidence
01:41:37 to my reports and my uh my my evidence and those statements that i made is trying to explain how things should be done yes i understand thank you very much professor well professor those are all
01:41:49 professor well professor those are all the questions by follow-up that i have for you it only remains for me to thank you very much for for your reports and for coming to the inquiry again to assist us with our investigations
01:42:01 to assist us with our investigations i don't think that's the end of your involvement but we are extremely grateful to you for today and for your continuing invaluable assistance thank you thank you very much yes certainly well i'd like to thank you very much on
01:42:12 well i'd like to thank you very much on behalf of all three of us i think we've found your evidence really interesting and helpful and we're very grateful for all the time and effort that's been put into writing
01:42:22 writing this report or these two reports and other reports that you've provided for the inquiry so thank you very much indeed and i think we shall see you again on another occasion thank you very much thank you very much
01:42:43 yes estimate thank you well now is there anyone well else to be called today no mr chairman and that i'm glad to say is the evidence for module five
01:42:54 for module five good
01:42:55 good and uh we will begin module six uh well we will have module three closings next week and the module six part one fire opening at the end of next week good well thank you very much
01:43:06 next week good well thank you very much well at that point then we will close the hearings for today and we will resume
01:43:11 resume on monday of next week at 10 o'clock when we shall hear the module 3 closings yes thank you thank you very much indeed
01:43:29 you