Expert witness Stephen McGurk, former Chief Fire Officer, provides critical evidence on firefighting operations, training, and information management. McGurk analyzes LFB's Section 7.2(d) duty failures, cladding identification issues, water supply management, and the fundamental challenges of incident command training.
00:20:15 hmm
00:20:20 good morning everyone welcome to today's hearing
00:20:23 hearing today we're going to hear evidence from mr stephen mcgurk one of the experts instructed to assist the inquiry yes mr kennedy may call mr mcgurk thank you
00:20:42 good morning mr mcgurk goodbye sir i gather you're going to a firm i am a date then please would you read the words on the screen in front of you i do solemnly sincerely and truly declare and affirm that the evidence i shall give
00:20:53 affirm that the evidence i shall give shall be the truth the whole truth and nothing but the truth thank you very much please sit down make yourself comfortable
00:21:05 yes mr canoe when you're ready thanks sir would you please confirm your name for the record stephen mcguck uh mr mcgorr mr mcguck many thanks for attending today good morning there are three things i should say before you
00:21:16 three things i should say before you start to give evidence today um the intention is that my questions are short sometimes they're not um hopefully they should also be clear but sometimes they're not if they are long and unclear please say so and i will try and correct
00:21:29 please say so and i will try and correct matters secondly if any stage you need a break please say so but there'll be breaks mid-morning and mid-afternoon in any event
00:21:36 any event finally please do keep your voice up for the record that's so that the transcriber can capture everything you say and capture it accurately and please don't nod say yes or no as the case may
00:21:47 don't nod say yes or no as the case may be
00:21:48 be okay now um you have provided a report to the inquiry for the purposes of phase two that's dated the 29th of january 2021 is that correct that's correct yes
00:21:59 2021 is that correct that's correct yes and the report relates to operational uh training and other matters is that correct that's correct now we can find your phase two report at smc quadruple zero double zero four six
00:22:12 smc quadruple zero double zero four six and is that your report it is and can you confirm that the facts and matters set out in that report are true to the best of your knowledge and belief they are thank you and is it correct that you have provided
00:22:23 and is it correct that you have provided the report in the same way that you would have provided an expert report to a court of law yes and does your report set out your opinions on the matters that are relevant to phase two of this inquiry
00:22:34 relevant to phase two of this inquiry and which you've been asked to consider by the inquiry it does thank you and is it correct that your report does not address the management of fire survival guidance by control room operators a matter which falls outside
00:22:46 operators a matter which falls outside the scope of your expertise that's correct thank you now that those matters are dealt with can i briefly deal with your experience and qualifications now you have set those matters out at
00:22:57 now you have set those matters out at paragraph 6 to 14 of your report on pages 3 to 5 and appendix 1 of that report between pages 87 and 92. we don't need to go to them but i'd like to draw
00:23:09 need to go to them but i'd like to draw out certain themes um first of all is it right that you had a career in the fire service for some 39 years that's correct so and during which time you held operational roles and during the last
00:23:20 operational roles and during the last two decades of your service senior leadership roles that's correct and you continue to work in an operational capacity throughout your 39 years in the service yes and you have operational experience of
00:23:32 and you have operational experience of working in several fire and rescue services and authorities including the three largest metropolitan fire services outside london namely greater manchester west midlands and south yorkshire that's
00:23:43 west midlands and south yorkshire that's correct
00:23:45 correct your last six years of service were with the greater manchester fire and rescue service where you were the chief executive and county fire officer between 2009 and 2015. yes
00:23:56 between 2009 and 2015. yes and before that you were the chief fire officer at cheshire fire and rescue service between 1999 and 2009. yes that's correct and you were also a board member of the
00:24:07 and you were also a board member of the chief fire officers association sifoa for just under 10 years from 1999 to 2008 and you acted as president of that organization between 2006 and 2008 yes
00:24:20 organization between 2006 and 2008 yes and is it right that you were awarded the queen's fire service medal in 2002 that's correct and that you have been a fellow of the institute of fire engineers since 2004. yes thank you now if we can just discuss
00:24:33 yes thank you now if we can just discuss before we move on to the substance the purpose and scope of your report for the inquiry now your report sets out your opinion as to the matters relevant to operational firefighting that you
00:24:44 operational firefighting that you consider fall to be considered in phase two of the inquiry is that right that's correct
00:24:48 correct and am i also right in understanding that those matters of operational firefighting that you've identified as being relevant come from two sources um first the phase one evidence on
00:24:59 first the phase one evidence on operational firefighting and in particular the findings made in the chairman's phase one report that's correct and secondly your own opinion on matters that you considered to be relevant to the inquiry's terms of
00:25:10 to be relevant to the inquiry's terms of reference and were not and which were not explored in phase one because they're outside the scope of that phase yes thank you and you confirm in the introduction of your report at paragraph 19 that you
00:25:22 your report at paragraph 19 that you agree with the conclusions of the phase one report that concern the actions of the lfb on the 14th of june 2017. that's correct
00:25:31 and in particular you agree with the finding that by 0-130 hours at the earliest and 0-150 hours at the latest it was clear that reversing the state put advice and attempting to embark on
00:25:43 put advice and attempting to embark on an evacuation of the tower was the only realistic way of minimizing loss of life and serious injury i do but i would also just wish to stress i would agree with the chairman that that was not without risk and
00:25:54 that that was not without risk and associated hazard as well and my next question was and you also agree with the chairman's finding that there were nonetheless substantial risks and formidable practical difficulties uh confronting an attempted evacuation i do
00:26:06 confronting an attempted evacuation i do thank you
00:26:07 thank you now the questions of operational firefighting that you address in the report are considered in four distinct parts and these are set out at paragraph 21 of your report which we can find at smc quadruple zero double zero four six
00:26:22 smc quadruple zero double zero four six seven forward slash seven
00:26:29 and we can see at paragraph 21 towards the bottom of that page we see point a where the first matter you consider is the nature and scope of the london fire brigade duty under section 72d of the
00:26:42 brigade duty under section 72d of the fire and rescue services act 2004 is that right that's correct and although that duty is probably well familiar to everyone listening now that is the duty which in summary is imposed
00:26:53 is the duty which in summary is imposed on fire and rescue services to obtain information for the purpose of effectively carrying out firefighting activities in their area is that right that's correct and you've sought to understand the processes that the lfb had in place to
00:27:06 processes that the lfb had in place to collect and manage such information and the effectiveness of those measures yes i have
00:27:12 i have as we see the second point which is point b at the bottom of page seven you consider the operational training of the lfb's personnel to the extent that this has not already been the subject of findings in the phase one report is that
00:27:24 findings in the phase one report is that right that's correct
00:27:30 more specifically you've considered three other matters first of all how our fire and rescue service may encourage the use of initiative amongst its operational personnel whilst discouraging
00:27:41 personnel whilst discouraging freelancing or unilateral action the meaning of which we will come on to explore in due course is that right yes secondly how a fire and rescue service may seek to implement effective instant
00:27:52 may seek to implement effective instant command training for large-scale high-rise fires despite the general decline in live fires in recent years is that right that's correct and finally the adequacy of lfb's instant command
00:28:03 the adequacy of lfb's instant command training yes thank you and if we could turn over which has already been done to point c on page eight uh you have addressed uh in the third part the effectiveness of some of
00:28:14 third part the effectiveness of some of the equipment used on the knight the fire including aerial ladder platforms ground monitors positive pressure ventilation and lightweight portable pumps is that right
00:28:25 lightweight portable pumps is that right yes
00:28:26 yes and finally the fourth section of your report which is identified at point d on page eight were there any alternative firefighting strategies which in your view could have been effectively used on
00:28:38 view could have been effectively used on the night of the fire is that right that's correct now we will discuss those four topics in turn as we go through your evidence and so the first one i'd like to turn to is the question of section 72d
00:28:50 section 72d now first of all can we look at the statory background to that particular provision
00:28:55 provision my first question is this is it correct that before the 2004 act came into force the duty to collect information for firefighting purposes was found in section 1 1d of the fire services act
00:29:08 section 1 1d of the fire services act 1947. that's correct and we can see what section 11d provided because you set it out helpfully at paragraph two of your report which can be found at
00:29:19 which can be found at smc quadruple zero double zero four six forward slash nine and we see that section 1 1 d said this it shall be the duty of every fire
00:29:30 it shall be the duty of every fire authority in great britain to make provision for firefighting purposes and in particular every fire authority shall secure
00:29:38 secure little d efficient arrangements for obtaining by inspection or otherwise information required for firefighting purposes with respect to the character of the buildings and other property in
00:29:49 of the buildings and other property in the area of the fire authority the available water supplies and the means of access there too and other material local circumstances now there is one source of guidance on
00:30:00 now there is one source of guidance on the scope of that duty and pose under the 1947 act and you've identified that in your report which you consider to be relevant and that is the fire service circular 16
00:30:11 that is the fire service circular 16 forward slash 1989 is that right that's correct
00:30:15 correct now
00:30:17 now you deal
00:30:18 you deal with
00:30:19 with this matter at paragraph three of your report onwards but it seems to me there are six points that are relevant arising out of that circle and i'd like to go through them with you to see whether you agree sure um first of all the decision
00:30:32 agree sure um first of all the decision as to whether premises should be visited by the local authority under 11d was a matter for that station taking into account any relevant factors is that a fair summary
00:30:43 fair summary a matter for that individual fire rescue service which was then usually delegated to the station but it's a matter for local determination yes and secondly in terms of the nature of the inspection brigades were encouraged
00:30:54 the inspection brigades were encouraged to apply the test of whether basic firefighting techniques would be sufficient to cope with most of the incidents that could be envisaged at the premises is that a fair summary that's a fair summary
00:31:05 fair summary thirdly the frequency of inspections should be determined based on the particular circumstances of the premises including matters such as any unusual building or construction features any
00:31:16 building or construction features any risk of rapid fire spread and any high risk to life again is that a fair summary it is fourthly and this looks at pre-planning that was stated not to involve a great
00:31:27 that was stated not to involve a great level of detail and any plan should be readily accessible to the first attending cruise and be in a standard format is that fair that's fair and you've stated that in practice a hard
00:31:38 you've stated that in practice a hard copy card system was used at that time again is that right yes it was yes and specifically the circular stated that the information should be kept to a minimum in order that it could be
00:31:49 minimum in order that it could be transmitted to cruise by radio and it referred to the information being quotes limited and again in quotes in most cases general in nature again is that a fair summary it's for the tube two
00:32:00 fair summary it's for the tube two purposes it was limited because it was required for immediate use and secondly because it would probably then be required to be passed by radio so effectively flip sides are the same coin
00:32:11 effectively flip sides are the same coin now six specific items were identified as being necessary to consider during 111d visits first of all occupancy and use of the premises is that right that's right secondly access to and within the
00:32:23 secondly access to and within the premises is that right thirdly structural features and the layout of premises is that right yes fourthly the presence of hazardous materials and processes is that right
00:32:35 materials and processes is that right that's correct and fifthly firefighting resources and sorry fifthly firefighting resources and fixed installations that's correct and finally power intake at the premises yes
00:32:46 finally power intake at the premises yes thank you
00:32:47 thank you now the final sixth point i wanted to see whether you agreed with was this is it correct that brigades were encouraged to make use of 11d information during training exercises and visits would be
00:32:58 training exercises and visits would be followed up with discussions and exercises on the application of the knowledge acquired during the visits that's correct
00:33:07 taking the step back is it right to say that the circular encouraged a practical approach to the collection of information under 11d very much so it was um it was intended for that first user the
00:33:19 it was intended for that first user the first officer in charge what information do i need in order to help me make an almost instant decision certainly a very very quick decision and and that was it keeping it simple for that purpose and again
00:33:30 for that purpose and again apology if i put this crudely they were focusing on the bare essentials that the first attending crew would require the bear essentials absolutely and that the circular also actively encouraged active
00:33:41 circular also actively encouraged active participation in 11d visits including through training exercises and subsequent learning yes indeed yeah now as the title suggests the 2004 and
00:33:53 now as the title suggests the 2004 and the fire and rescue services act came into force and it may be useful to look at the explanatory notes to that act which can be found at paragraph 14 of your report
00:34:04 be found at paragraph 14 of your report on page 12. [Music]
00:34:10 thank you and it's at the bottom of that page
00:34:13 page [Music]
00:34:14 [Music] and the gloss that's provided on section 7 says this section 7 reenacts the existing statute duty for a fire and rescue authority to plan and provide arrangements for
00:34:25 plan and provide arrangements for fighting fires and protecting life and property from fires within its area a fire and rescue authority is required to secure the provision of sufficient personnel services and equipment to deal
00:34:36 personnel services and equipment to deal with all normal circumstances as well as adequate training a fire and rescue authority must also put in place effective arrangements for receiving and responding to calls for
00:34:47 receiving and responding to calls for help and for obtaining information which it needs to carry out its functions the latter might include for example information about the nature and characteristics of buildings within the authorities area or availability of and
00:35:00 authorities area or availability of and access to water supplies that's a long run up to a simple question did frs's alter the approach to information collection once the 2004 act
00:35:12 information collection once the 2004 act came into being not substantially now thank you
00:35:19 thank you now we've touched on uh this guidance with previous witnesses but i'd now like to turn to porus which is the provisions i'm sorry to interrupt you um mr
00:35:30 mr mr just help me with this you've obviously had experience in a range of different fire and rescue services did anyone ever as it were stop to ask themselves well now
00:35:41 well now what sort of information do we need do we need anything any information that a crew wouldn't be able to gather uh from a visit um not really tomorrow essentially
00:35:53 um not really tomorrow essentially there'd been a there were a series of um if you like disasters and also firefighter fatalities through the sort of 1990s and early 2000s and if anything each of those reinforced the need for
00:36:06 each of those reinforced the need for simple information accurate information but simple information in order to assist the officer in charge to make rapid decisions at the point that they arrived so if anything probably the
00:36:17 arrived so if anything probably the reverse is true that you were discouraged from as it were exploring too far into alternative sources of information at that stage thank you that's helpful yeah so we'll be coming on to the approach adopted
00:36:29 be coming on to the approach adopted both in london and outside london in due course during this year yes all right well i'll be more patient um
00:36:36 um as i said we were coming on to discuss the porous guidance that's p-o-r-i-s guidance which was published in 2012 and if we could go and look at the screen which is in front of us
00:36:47 of us you deal and explain the first sentence of paragraph 16 that in 2012 the government published what was the first substantive guidance document for the management of operational risk
00:36:58 management of operational risk information since the 2004 act had come into force and that was porous is that correct that's correct and you suggest in the second sentence of paragraph 16
00:37:10 of paragraph 16 that the porous guidance might have been prompted in part by review by the health and safety executive published in october 2010 relating to the management of operational health and safety by
00:37:22 of operational health and safety by different fire and rescue services is that
00:37:24 that your assessment that's a fair summary now we don't need to go into the detail of the review but
00:37:32 but if i could just see whether you agree with certain headline points arising from it
00:37:37 from it is it right that the review related to a series of inspections carried out into eight fine rescue services by the hsc following a number of firefighter fatalities at serious fires
00:37:49 fatalities at serious fires between 2000 and 2009 that that's correct although there was no correlation between the the fire services selected and the fatalities you know i.e it wasn't just the fire services that had firefighter fatalities
00:38:00 services that had firefighter fatalities that were selected for inspection thank you
00:38:03 you the inspections addressed a number of operational concerns but one concern related to the provision of risk information and the review found that some services did not have adequate systems to ensure the collection and
00:38:15 systems to ensure the collection and dissemination of adequate risk information on relevant premises again is that a fair if high level summary that's a fair summary and specifically the review stated that in the majority of services a need for
00:38:28 in the majority of services a need for additional training on the management of operational risk information was identified exactly and the review recommended the production of national guidance on the classification of risk premises and the
00:38:40 classification of risk premises and the collection and dissemination of risk information again is that right that's correct
00:38:45 correct now did the introduction of porus mark a shift in the understanding of the duty and what it required under section 72d i think it's fair to say it marked a shift in the requirement whether that
00:38:56 shift in the requirement whether that marked a universal shift in understanding i think is a debatable point at the time it came out under what was called a bulletin a fire and rescue service bulletin through that period of time the way
00:39:08 through that period of time the way information was transmitted by by the government by the host department took a variety of forms um and so the guidance came out under cover of a bulletin there was no massive fanfare there weren't a series of seminars or
00:39:20 weren't a series of seminars or conferences to suggest this is a radical shift and therefore and there was no requirement in fact for individual fire rescue authorities to adopt the guidance and there was no inspectors at the time so i have no way of knowing how many
00:39:32 so i have no way of knowing how many actually did and so it is true that many did and it is true that it marked a shift in the requirement for collecting risk information but i couldn't say that it was universally understood that that
00:39:44 was universally understood that that shift had been acknowledged and recognized thank you now the poorest guidance confirms that the primary aim of the collection of operational risk information continued to be the provision of timely and relevant
00:39:55 provision of timely and relevant information to operational crews but you have explained in paragraph 18 of your report on page 14
00:40:04 14 and really i want to look at the first two sentences [Music]
00:40:10 [Music] the key change that we should be focusing on is that the guidance introduced uh a much more sophisticated risk information management system is that the key point you want to emphasize here it is
00:40:22 here it is and the risk management system that the guidance set out was a five-stage process is that right that's correct and if we can go to page 45. [Music]
00:40:40 sorry i should say 45 of the porous guidance which is hom travel zero four five three six four four forty five [Music]
00:40:56 and here we have the first of the five stages set out now the first two stages which we're looking at on page 45 relate to the gathering of risk information either
00:41:07 gathering of risk information either from a
00:41:09 from a section 72d visit or some other source is that right that's correct and the guidance provides a template data capture fields which are set out in
00:41:20 data capture fields which are set out in appendix c and we can go to that in due course but in broad terms it's essentially a template for the type of document that fire and rescue services may wish to ask their station-based crews to
00:41:31 their station-based crews to complete when carrying out 72d visits in broad terms is that right that's great now as i said we can turn to appendix c and that template which staying in this document can be found at page 75 or
00:41:44 document can be found at page 75 or starts at 75.
00:41:48 now it's about 20 pages long this template is that right it is and it may be useful just so that we get a feel for the level of detail and the scope of the
00:41:59 scope of the information that the appendix anticipated required to be collected if we go through it if we go to page 77
00:42:09 now here we see that the form asks for information about the size of the building the number of floors and the floor area is that right that's correct and if we can move on to
00:42:20 that's correct and if we can move on to page 78
00:42:22 page 78 we see that this deals with building status and whether any toxic or explosive substances are stored on site is that right that's correct let me go
00:42:33 is that right that's correct let me go on to page 79. [Music]
00:42:37 [Music] this deals with occupancy
00:42:41 occupancy and suggests a very detailed breakdown on the face fit of occupancy and how this may vary throughout the day and during the week and weekend is that right it is that would recognize that different buildings have a very different profile you know
00:42:53 different profile you know london kind of empties at night and is full during the day and the buildings accordingly so that's why it's so varied and presumably um that fire and rescue services ought to be aware of that
00:43:04 services ought to be aware of that variability during the course of the day during the course of the day and seasonally as well you know um kind of coastal fire rescue services would have a differences during winter and summer thank you if we can turn over the page to page 80
00:43:17 we see that this relates to occupancy risks and includes
00:43:23 includes taking account of those with restricted mobility is that right it is if we turn over the page to 81 [Music]
00:43:32 [Music] we see that this concerns building systems including internal communications where there is a control room sprinklers and the coverage provided by sprinklers is that right it is
00:43:43 and if we go to page 82
00:43:47 this deals with
00:43:50 more technical matters such as the drencher gas fire fighting and smoke control systems is that right it is if we go over the page to 83
00:44:01 this deals with automatic fire detection escape routes as well as lighting is that right that's correct if we go over to 84
00:44:12 this deals with information about staff awareness of any emergency action plan the standard of building maintenance and building construction types and materials is that right it is
00:44:24 it is and if we turn over the page to 85 we see that matters continue there particularly in relation to construction type of materials is that right that's correct
00:44:37 correct and we can see at the top of page 85 in particular that there's a reference to cladding and the user is invited to tick which particular type of systems and construction materials are present is that right that's correct if we can turn
00:44:50 that right that's correct if we can turn over the page again to 86 this deals with matters relating to storage of large quantities of goods and and or combustible materials is that right it is and we also see in the
00:45:02 right it is and we also see in the bottom half of the page 86 water supplies including flow and pressure rates are set out as well as details of the water provider is that right that's correct and even more detail is required on those matters at
00:45:14 detail is required on those matters at page 87
00:45:17 which includes information about any available open water supplies and the type of equipment that will be required at an incident including the number of hose lanes is that right that's correct
00:45:28 hose lanes is that right that's correct and we also see on page 87 a requirement for crews to collect information about security systems the potential heritage or community loss in the event of an incident is that right that's correct
00:45:39 incident is that right that's correct and if we turn over to page 88
00:45:44 crews are directed to collect information regarding any environmental risk posed by any substances on site is that right yes
00:45:52 right yes and if we turn over the page and look at 89 through to 90 this
00:45:58 this directs crews to look at potential risks to firefighters opposed by any of the physical features of the premises and or it's a media environment is that right that's correct
00:46:09 right that's correct and page 91
00:46:13 information regarding hazardous processes on site is that right correct
00:46:17 correct and then finally page 92 information about access to the premises and operational resilience information is directed to be collected again is that right that's correct
00:46:28 that right that's correct now did porus make it clear what was expected of fire and rescue services in relation to the collection of operational risk information even if the guidance was demanding in what it required particularly of fire and rescue
00:46:40 required particularly of fire and rescue services in major cities um so just take one step back the reason why this is called a data capture form and is so comprehensive is it had emerged from a national project
00:46:52 national project called the fire control project which which was um aborted but whose goal was to
00:46:58 to increase interoperability between different fire and rescue services and so ultimately the ambition of this work when it was started was to enable data to be transmitted across different
00:47:10 data to be transmitted across different fire and rescue services and so that they were all using the same data and using the same data capture so this was a distillation if you like of the way best practice had developed or different practices and
00:47:22 developed or different practices and different pieces of information are developed in fire services over time so in terms of the specific when the documentation landed it was a matter for individual fire rescue services to determine how they would
00:47:34 services to determine how they would take the data capture form or the data capture information and use it for themselves many would already be using many of these fields and for some um some of it wouldn't be applicable but it was a matter for local determination how
00:47:46 was a matter for local determination how exactly you took the information or you took the basis upon capturing the information for your own fire rescue service
00:47:52 service but it would it be fair or appropriate for the panel to treat this as a best practice summary indeed it would yeah now is it also a correct summary of your view that this data collection
00:48:04 view that this data collection template is one of the principal ways in which the porous guidance marked a shift from the previous approach to familiarization visits indeed it was hugely more expansive than it had been the case previously and i think the
00:48:16 the case previously and i think the second part is worth mentioning for the panel is that it it was fusing together if you will 72d obligations but also health and safety obligations for
00:48:27 health and safety obligations for firefighter safety the essence being to collect the information once as it were in order to be able to fulfill multiple purposes with it and does it flow from the
00:48:38 and does it flow from the scope and level of detail required by this template that crews would require further training in order to be able to identify and correctly collect the right information in order to discharge
00:48:50 information in order to discharge properly and effectively the 72d duty it brought with a significant training implication from the previous i think in my report there's a diagram a sort of flow chart that shows what the
00:49:01 a sort of flow chart that shows what the new system looked like and when you contrast that with a simple you know need to know information aid memoir process of one 1d and then morphing into 72d in the early stages the contrast is stuck
00:49:14 the early stages the contrast is stuck put
00:49:15 put pushing my question slightly differently without specific training would a crew generally have the requisite knowledge and expertise to collect all the information that's relevant to them that set out in this appendix
00:49:27 that set out in this appendix i think in truth that would depend upon the fire and rescue service in some fire rescue services firefighters had previously fulfilled more fire safety obligations and so would have a better
00:49:39 obligations and so would have a better awareness
00:49:41 awareness in some fire rescue services they were much more focused on a purely operational role for their fire rescue crew so i think the i think would be a mixed view but certainly in some fire rescue services i would suggest probably
00:49:53 rescue services i would suggest probably the majority training would be required in order to do justice to the totality of that data capture form now looking at whether it is or was appropriate to expect station-based
00:50:05 appropriate to expect station-based operational crews to be managing this information is it your view the responsibility for managing risk information on a station's ground should remain with the local
00:50:16 ground should remain with the local station-based crews rather than being delegated to say a more specialist department it is for the purposes that it's required for an immediate operational response and it's that familiarity that's uh that's ultimately its primary
00:50:27 that's uh that's ultimately its primary purpose
00:50:29 purpose but also that those crews need to be supported by clear guidance and comprehensive consistent training as to how familiarization visits should be conducted i would agree
00:50:42 and actually following on from that crucially that crews needed to be supported by specialist advice from fire safety officers when needed particularly when uh visiting more complex sites and i appreciate this is kind of in the
00:50:54 and i appreciate this is kind of in the context of grenfell and high rise building but but it's worth just making the point that's true for many others for which fire rescue services have responsibility hazardous materials so so the 72d would apply to
00:51:05 materials so so the 72d would apply to sites like bunsfield for example where you may need your different expertise but for the purposes of the inquiry in the panel yes in this case it will be fire safety officers looking at london specifically um is the need for
00:51:17 specifically um is the need for specialist fire safety advice particularly so in the capital because of the relatively higher number of high-rise and or complex buildings
00:51:28 high-rise and or complex buildings i would say that's probably
00:51:31 probably equally applicable to cities around the country so it's the nature of a city that you would get complexity in building construction and the features that represent a city a
00:51:42 the features that represent a city a transport network whether it's an underground or a tram system so the features of a city tend to bring with them complexity of building construction you know a compact space trying to get
00:51:53 you know a compact space trying to get buildings in so you would tend to see more high-rise and over time you would see more complexity associated with those high-rise so i think it is true for london and is particularly cute in
00:52:04 london and is particularly cute in london but i think it is also broadly true for the cities around the country as well and essentially there needs to be regular and close liaison between fire safety offices and operational crews that's essential and
00:52:15 operational crews that's essential and was also important on the one monday as well so that risks can be identified and addressed on the basis of an informed assessment of those risks i i think you've got other experts talking about increased
00:52:27 other experts talking about increased complexity it's not just the risk being assessed and the crews being informed but the practical mechanics of what they would need to do upon arrival with increasingly complicated
00:52:38 complicated systems of smoke ventilation forest ventilation air control systems and so on that you know when crews turn to some incredibly
00:52:49 know when crews turn to some incredibly complex
00:52:50 complex sites
00:52:51 sites that the actions that they need to take to um
00:52:55 to um to in order to act safely and to be able to proceed with firefighter operations can actually be quite complex and therefore requires the input from a fire safety officer to advise them really
00:53:06 safety officer to advise them really right from the start would you anticipate that every high-rise building residential building is likely to require the contribution of a fire safety officer would only certain types of
00:53:17 officer would only certain types of high-rise residential building require that contribution no i think certainly i mean broadly speaking high-rise buildings remain the same unless the changed over over time unless a refurbishment
00:53:29 over time unless a refurbishment something like grenfell but over time these things have been around remember since the 60s and 70s and broadly speaking the risks have remained the same notwithstanding what the inquiry is looking at in terms of the
00:53:41 inquiry is looking at in terms of the tragedy of grenfell so there was there would be a degree of formality
00:53:46 formality familiarity with the risks associated with the high-rise and crews that had been experienced wouldn't wouldn't usually or always need the contribution of a fire safety officer in what circumstances would you envisage that
00:53:58 circumstances would you envisage that crews would require the assistance of a fire safety officer so i said this this two three approach that one i would expect there to be some sampling anyway from the fire safety
00:54:10 sampling anyway from the fire safety side of the equation to make sure that the crews remain on top of their knowledge and understanding in relationship to what they're looking for at a high rise building secondly
00:54:19 secondly in the event that there was a what you might call local intelligence so i mentioned in my report the function of fire safety officers is to enforce the relevant legislation and there are phenomena emerge as a consequence of
00:54:32 phenomena emerge as a consequence of trying to enforce that legislation science as a footnote i appreciate the inquiries looking at fire doors in um in certain high-rise buildings that would be a good example of a common phenomenon
00:54:43 be a good example of a common phenomenon that crews should be minded to keep an eye open for when they're doing their 72d visits so so phenomenon that emerged from fire safety colleagues going about their business enforcing the relevant
00:54:54 their business enforcing the relevant legislation and where there was something that arose in particular that crews should have an eye to if i give probably two examples to sort of illustrate the point please do um
00:55:07 illustrate the point please do um we'll think about balconies often these high-rise buildings have balconies and uh quite often and over time people have done all kinds of strange things on their balconies i certainly have been to
00:55:19 balconies i certainly have been to cannabis farms growing on balconies and or for example we've just had a somatic is still in a fuel crisis and what some people might do is hoard fuel and they would store it
00:55:31 hoard fuel and they would store it perhaps on a balcony i've certainly seen that so this so what the phenomenon of what's being experienced in terms of something like that and again it would often be fire safety officers
00:55:42 often be fire safety officers or operational crews to which that gets drawn attention you would expect fire safety officers to advise and perhaps coach um in that regard so balconies are another phenomenon and the second one would be
00:55:54 phenomenon and the second one would be um increasingly means of escape and part of an aging population we've certainly seen an increasing use of mobility scooters and that kind of apparatus and
00:56:07 scooters and that kind of apparatus and um
00:56:08 um some real risks associated with some of those
00:56:12 those with some of those vehicles they're kind of plastic they've got batteries and sometimes they can be stored in means of escape so again i'd expect fire safety officers to alert crews to some of those kind of risks and
00:56:23 crews to some of those kind of risks and um
00:56:24 um assist on occasions to point out what they might do to um to mitigate that risk thank you now you identified two mechanisms there sampling and local intelligence in which fire safety
00:56:35 intelligence in which fire safety officers
00:56:36 officers may play a role i just want to see nail something slightly more explicitly would you see fire safety officers having a role in identifying the types of buildings that ought to be the
00:56:48 of buildings that ought to be the subject of a sampling exercise yes i would thank you now in your experience do fire and rescue services provide the kind of specific and technical training that porous appendix appears to anticipate
00:57:01 porous appendix appears to anticipate in some cases they certainly do yeah computer-based training and fire safety officers going giving training to watches
00:57:07 watches um i couldn't speak across the piece in terms of all fire rescue services but it certainly is the case that some definitely give that level of training what evidence have you seen about whether and if so how the lfb trained
00:57:18 whether and if so how the lfb trained its crew managers and watch managers to identify the kind of technical information that porus anticipates being collected um was the same report mr king i haven't seen any evidence i've seen one
00:57:30 one sort of powerpoint slideshow um i think produced by babcocks i'm unclear whether that was indeed rolled out or the extent to which crews undertook that training notwithstanding
00:57:42 undertook that training notwithstanding that i've not seen any evidence of any training at all and specifically have you seen any evidence about whether cruel watch managers were trained to identify information about a building's cladding
00:57:53 information about a building's cladding system uh which was expressly referred to in appendix sea of porridge no i've not seen evidence returning going back to porus itself and
00:58:04 returning going back to porus itself and the next stage that set out and that set out at page 51 which is a hom triple zero four five three six four forward slash five
00:58:15 five three six four forward slash five one
00:58:17 one and we see there stage three which is detailed site risk analysis process
00:58:23 process [Music]
00:58:24 [Music] and the porous guidance
00:58:28 sets out a risk matrix in order to allow crews to
00:58:33 crews to complete stage 3 accurately and that can be found at page 60.
00:58:42 thank you now the matrix requires an assessment to be made of the likelihood of an incident occurring along with its severity is that right it is
00:58:53 it is and the risk matrix then provides a risk score for the relevant premises is that right that's correct and guidance is provided in the matrix as to how an assessment of both those factors should
00:59:05 assessment of both those factors should be carried out taking into account the information that has been gathered on a section 72d visit is that right yes
00:59:12 yes and if we turn over the page to page 61.
00:59:18 we see what is called a likelihood table and that assists the user in determining whether a risk is probable possible unlikely very unlikely or negligible is that right
00:59:29 that right it does yes and is it correct that it is also your view that the introduction of this risk matrix was another important example of the porous guidance marking a shift change
00:59:41 porous guidance marking a shift change from the previous approach to familiarization visits yes significant shift and is that because of its um more precise focus on the type of risk and the likelihood of that risk being
00:59:53 the likelihood of that risk being realised it is as well as its comprehensiveness uh and you know wider application thank you can we now turn to and go back to page 54 in this
01:00:04 54 in this document and find stage four
01:00:08 thank you and this is entitled the risk management process
01:00:14 and this uh stage of the system itself uses the risk score that is given to the property in order to determine what level of risk management processes are appropriate is that a fair
01:00:27 processes are appropriate is that a fair overview it is now looking at an example of this application for properties that pose a very low risk no further action may be required for properties posing a higher risk
01:00:39 properties posing a higher risk fire and rescue services may choose to require site-specific risk information or site-specific risk assessments as part of the information that is collected under section 72d and then
01:00:51 collected under section 72d and then that information is made available to um first attending crews again is that an accurate summary it says yes now if we get move further to the final and fifth stage of the process which can be found at page 58
01:01:05 and this governs the recording and dissemination of information that has been gathered is that right it is and in london's case that is done via the operational risk database the
01:01:16 via the operational risk database the ord which is the database on which risk information is recorded and then made available to responding crews is that right that's as i understand it yes now we'll come on to the ord in due course later
01:01:27 later but
01:01:28 but could i sort of take the step back and attempt to summarize uh the porous guidance or the effect of the porous guidance and if we could go back for this purpose to your report smc
01:01:40 back for this purpose to your report smc quadruple zero double zero four six forward slash 15 and paragraph 21 and the third sentence [Music]
01:01:53 [Music] now we see that you say this in the third sentence porus now required operational personnel to shift from collecting relatively small amounts of information specific to firefighting to becoming more rounded
01:02:06 firefighting to becoming more rounded risk assessors and to assemble and evaluate a much greater range of information having collected that information crews must then carry out a more precise analysis to interpret the information
01:02:17 analysis to interpret the information collected and make qualitative judgments about the level of risk applying a risk matrix does that remain your view it does yes did the introduction of porous trigger a
01:02:28 did the introduction of porous trigger a reassessment by fire and rescue services of what was required in order to discharge at section 72d and in particular did it trigger a reassessment by the lfb of its practices
01:02:41 by the lfb of its practices so i think on the general point i think that the only task would be it was mixed because it it didn't come out under any kind of fanfare or any conferencing or announcements
01:02:53 conferencing or announcements different fire review services picked up on it i guess dependent upon their individual circumstances and their own history um if they had serious fires or firefighter
01:03:04 if they had serious fires or firefighter fatalities then they were probably more attuned to picking up on this so i think in the general um it would have been a mixed picture i think in terms of the lfb you think the evidence
01:03:14 evidence suggests that it it landed in the lfb quite clearly i think in a report i talk about ac brown i think in his evidence he talked about a presentation he gave
01:03:25 he talked about a presentation he gave where he quite explicitly referred to the poorest guidance and an assessment that had taken place by the lfb of the extent to which their their process is complied with the poorest guidance so if
01:03:36 complied with the poorest guidance so if anything it probably landed better in the london fire brigade than it did in many other fighting rescue services at the time it was published thank you now following on from that answer
01:03:48 following on from that answer now what i want to turn to is the lfb's policies on the collection and management of operational risk information now you've considered the lfb's policies and procedures on the management of
01:03:59 and procedures on the management of operational risk and these are addressed from paragraph 28 onwards in your report which starts at page 17. [Music]
01:04:09 [Music] now
01:04:10 now we will come back to what you say in your report but i'd like to for the first stage of questions on this point look at the policies themselves and the starting point for that exercise is policy 800 which is the management of
01:04:22 policy 800 which is the management of operational risk now in broad terms policy 800 is the lfb's general management of operational risk policy and it's not specific to any particular type of building is that
01:04:33 particular type of building is that right that's correct and policy 800 sets out the general processes by which station-based crews are expected to collect assess and maintain risk information about
01:04:44 maintain risk information about properties in their areas is that right that's correct and your view i hope i summarize this correctly is that on the whole the policy mirrored the five stage processes set out in paris is that right
01:04:55 processes set out in paris is that right yes it's very close now one specific point that you raise in relation to policy 800 is the role of the fire safety department and the fire and safety inspecting
01:05:06 and the fire and safety inspecting officers in 72d visits by operational crews
01:05:11 crews now you point out that policy 800 recognizes that fire safety inspecting officers may identify premises that require a visit and they may also be best placed to provide assistance and
01:05:23 best placed to provide assistance and specialist knowledge where this is required by the nature of the premises is that a fair summary of the point you want to draw out it is yeah and i suppose it was surprising given the long-standing link
01:05:34 surprising given the long-standing link between the importance of fire safety information and its relationship to 11d previously and now 72d thank you and is it your view following from that that
01:05:47 is it your view following from that that the lfb's policies and documented procedures at least are unclear as to how that information sharing process between fire safety and operational crews should take place
01:05:58 crews should take place i certainly found it security decided to kind of go backwards and forwards between the two documents i would call the uh fsi gm one one three is it and pn seven eight four i took worked my way between them to kind of
01:06:09 worked my way between them to kind of figure out the route by which the information moved in theory moved and i think you draw at that point in the last two sentences of paragraph 29 where we can see yes indeed sorry the
01:06:20 where we can see yes indeed sorry the penalties root now um looking at the in more detail at the reasons um for that view um one the matters you identify and this is
01:06:31 one the matters you identify and this is set out at paragraph 29 which is in front of us is policy 784 which is the lfb's notification fire safety information policy is that right that's correct now we don't need to go to that
01:06:43 correct now we don't need to go to that policy
01:06:44 policy but if it if people need the references lfb0012734
01:06:50 is it correct that policy 784 is a short document that essentially directs fire safety inspecting officers to notify station-based personnel of any relevant fire safety information via a prescribed
01:07:03 fire safety information via a prescribed form it does and that on receipt the station manager should decide what action needs to be taken in response that's correct and the same applies the other way
01:07:14 and the same applies the other way around
01:07:15 around so that uh station based personnel when they come across information that they consider should be seen by the fire safety officers they use that system and a prescribed form to communicate that information india they point to each
01:07:27 information india they point to each other
01:07:28 other have you found any specific guidance to operational crews about the kinds of premises or the particular issues that should be referred to fire safety for their more specialist view and assessment
01:07:39 assessment no i've not that's what was surprising i mean if the theoretical link is there but i couldn't see any evidence of where that had actually manifested itself in reality now the chairman touched on this in an earlier
01:07:51 chairman touched on this in an earlier question to you and we'll discuss greater manchester's experience in your time in due course but in your experience how common is it for frs is to involve fire safety personnel in 72d visits and the
01:08:03 personnel in 72d visits and the management thereafter of operational risk information i would say it's pretty common i mentioned earlier that the um the circumstances through through
01:08:14 the circumstances through through history in terms of major incidents and firefighter fatalities had almost without exception in fact probably without exception drawn attention to a failure to collect or disseminate
01:08:27 a failure to collect or disseminate information under 1 1d then 72d so i think over many years final rescue services
01:08:33 services had appreciated the significance of making sure as far as they possibly could that those links and the sources of information to get
01:08:42 get to get risky information to frontline crews were as solid as they could be so i i think it was a pretty common practice that fire safety officers would inform operational crews and there will be a very strong link
01:08:54 be a very strong link looking at your particular experience in manchester the west midlands and cheshire how effective was the collaboration between fire safety departments and operational crews
01:09:06 departments and operational crews i would say it was very effective in fact
01:09:08 fact if i take one step before that and probably in detail too much from the cv but i was a fire safety inspecting governor myself in royal banks your fire rescue service and my patch as it were was windsor and
01:09:19 my patch as it were was windsor and eaton and some of those areas and i was very clear that part of my responsibility if i found anything was to bring it to the attention of the operational crews you know i had a very clear
01:09:30 you know i had a very clear responsibility to do that and it was actively managed from within you know the hierarchy of the organization and and i think it's true to say that follow through
01:09:40 through in in all the fire rescue services i worked in looking at how it worked the other way how proactive were crews in providing you in your former role as a fire safety information officer with
01:09:51 fire safety information officer with information that they thought you needed to be aware of i i would say that was much more mixed and much less a much less of a strong link i'd say in the prior to the regulator reform
01:10:03 in the prior to the regulator reform order
01:10:04 order many fire rescue services had operational crews undertaking what they used to call section 9a responsibilities which were which were lower risk premises that still had um had a requirement to
01:10:15 still had um had a requirement to provide for fire safety arrangements means of escape and so on and those low risk premises inspections were often devolved to operational crews and so there was a good awareness and a good relationship with the fire safety
01:10:26 relationship with the fire safety departments in the respective organizations that undertook those roles when the regulator before modi came in in particular um those links i think started to
01:10:37 um those links i think started to dissipate because the knowledge of operational crews the fire safety knowledge around some of the more technical aspects of fire safety management dissipated over that period of time so i think
01:10:48 of time so i think the links were were good i think the links weakened i'd say from 2005 onwards why do you think well i just said part
01:10:59 why do you think well i just said part of it was to do with the regulatory reform order and the fact that operational crews rarely now undertook fire safety inspections i think mr daley gave evidence the other day talking about a reintroduction of
01:11:11 day talking about a reintroduction of that in the lfb very recently if not still going on but i think the second was a shift of emphasis in terms of part of the role of fire rescue services towards community fire safety so
01:11:22 towards community fire safety so operational firefighters were moved much more onto
01:11:26 more onto home safety assessment community fire safety that dimension of safety if you will rather than supporting regulatory enforcement thank you
01:11:36 you miss mcgirt may i make a plea on behalf of the shorthand writer i have to remind myself sometimes at the pace that i ask questions she has to capture everything and if you wouldn't mind moderating the
01:11:47 and if you wouldn't mind moderating the pace accordingly now if we can go back to policy 800 itself
01:11:53 itself am i right in saying that the policy also directs crews to take into account vulnerabilities of residents it does now if we can go to
01:12:04 it does now if we can go to that policy which is lfb trouble zero eight three eight four nine forward slash eleven and look at paragraph thirteen point eleven
01:12:16 it's the very bottom
01:12:19 of the page there we have it and it says this particular attention should be made to the following areas to ensure information on the ord operational risk database is correct and then if we can look at uh
01:12:31 look at uh little c it says the number and vulnerability of persons within premises now
01:12:38 now that is part of the information that should be taken into account when completing the premises risk assessment template is that right that's correct now just to look at that point in slightly more
01:12:50 look at that point in slightly more detail if we could go to that template which is in this document but at page 18
01:12:59 and we see at the bottom of that page in section 3
01:13:05 is a part which gives guidance in relation to the occupancy specific information that the pra that's the premises risk assessment template requires
01:13:14 requires and if we could just turn over the page to page 19
01:13:20 section 3 sets out in bullet point form a number of matters that crews are directed to consider and we can see the fourth bullet point on page 19.
01:13:32 fourth bullet point on page 19. is dependency of individuals such as those using a medical facility oxygen therapy and or with particular vulnerability related to age or condition
01:13:44 to age or condition perhaps
01:13:45 perhaps [Music]
01:13:46 [Music] would you expect operational crews to collect that type of information about vulnerable residents from the building owner or manager when carrying out 72d visits
01:13:58 visits um
01:13:59 um to
01:14:00 to to a limited extent i would suggest the um
01:14:04 um what is that extent i think where you were talking about high-rise building a high-rise block of flats with occupants of all ages and abilities
01:14:17 occupants of all ages and abilities i think you would anticipate collecting information about whether people with for example mobility issues were clustered or where they were located was
01:14:28 clustered or where they were located was was there any attempt by the management organization to
01:14:32 to locate those people at lower levels for example um and were they clustered together so i think in that kind of facility that kind of premises you would
01:14:43 that kind of premises you would seek to collect as much of that information as possible in order to inform at least an awareness of the initial responding crews in the event of a fire
01:14:52 a fire where the most vulnerable people were in order to prioritize if possible rescue in that scenario where you would have wider premises for example a care home
01:15:05 wider premises for example a care home you would anticipate effectively part of the fact that it's a 7-2 visit in the first place is probably because the majority of people in the home are vulnerable and have some
01:15:18 in the home are vulnerable and have some impairment visual or otherwise or some form of disability so you would probably make that assumption and that would form part of your pre-planning in the event of an attendance anyway thinking about the specific example of a
01:15:30 thinking about the specific example of a high-rise residential building does it flow from that answer that crews wouldn't necessarily ask for information about dependency of individuals who were using
01:15:41 dependency of individuals who were using a medical facility i think on occasions they would um but i think there is a reality in the tenancies change very quickly i think i can stop you there what occasions would they ask for that specific type of
01:15:53 they ask for that specific type of information i think they'd ask for it on every occasion i think their expectation about the quality and accuracy of the information they would get in return if from frank would be
01:16:05 get in return if from frank would be mixed i'm not sure they would place any confidence that that if today that might be the case in a week's time the tendency could be completely different so i i think they would collect it and it would be useful
01:16:17 would collect it and it would be useful to record and particularly things like oxygen because they would have the effect of enhancing a fire in a particular flat or in a particular residency
01:16:26 residency but the extent to which they would bank on that information being accurate in the event of a real fire i think would be very mixed because essentially i hope i put this fairly it would could only be a snapshot of that particular
01:16:38 only be a snapshot of that particular it's going to the time you collected it yes
01:16:43 [Music] now finally in relation to policy 800 and did that policy recognize the importance of involving the building owner and or the responsible person in the 72d process in your view
01:16:56 the 72d process in your view it it didn't jump up i think it's in there but it didn't jump off the page at me as something that was considered an essential component it you know the the the whole thrust of
01:17:08 the the whole thrust of uh 800 was a kind of very process driven policy even the completion of the pras very you know quantitative you know quite mathematical
01:17:19 quite mathematical and um
01:17:20 and um i think i think i say in my report it's quite difficult to follow it could be better laid out but it didn't jump off the page that crews would automatically see this as a two-way
01:17:31 automatically see this as a two-way exchange every time they undertook a 72-d inspection if we can go to page seven in this document and paragraph 7.21
01:17:41 [Music]
01:17:46 and i think i'm writing saying this is the particular paragraph that we should be concerned with here now
01:17:55 now have you seen any evidence about how involvement of the responsible person was secured as a matter of practice by the lfb uh and its crews carrying out some 2d visits the only evidence i've
01:18:07 some 2d visits the only evidence i've seen is mentioned of key holders and the extent to which a crews might be able to gain access if they anticipated access difficulties but beyond that i've not seen any evidence of extensive engagement with
01:18:19 evidence of extensive engagement with responsible people thank you can we now put policy 800 to one side and turn to policy 633 which is the lfb's policy on high rise firefighting
01:18:32 lfb's policy on high rise firefighting and in particular appendix 1 of that policy
01:18:36 policy now the 633 can be found at lfb quadruple zero one two five six
01:18:46 as became very familiar to everyone during phase one this is the lfb's high-rise firefighting policy and you've considered appendix one of this document in particular which sets out guidance as
01:18:58 in particular which sets out guidance as to the type of information that should be collected by lfb crews during 72d visits of high-rise properties in particular and if we go to page 19 in
01:19:09 particular and if we go to page 19 in this document we find appendix one and there after a list of 22 points which we consider as part of the
01:19:20 which we consider as part of the inquiries phase one investigations now before we come on to the substance of that
01:19:26 of that just to get a practical steer from you are you able to give us even on a rough and ready basis an indication of how long you would expect a crew to carry out a 72d visit of a high-rise
01:19:39 out a 72d visit of a high-rise residential building if they were to consider
01:19:42 consider each
01:19:43 each of the 22 points or insofar as they are relevant to that particular building i would say at least a couple of hours even even with dividing your crew up to allocate different tasks to collect information you'd be looking at at least
01:19:54 information you'd be looking at at least a couple of hours now do you think that this list of 22 items
01:20:00 items is appropriate in the sense that crews should consider each of those items when carrying out a visit yes i do
01:20:08 yes i do why do you consider that crews would have the relevant knowledge or indeed expertise to identify for example a particular cladding system
01:20:19 cladding systems certainly insulated um insulated buildings and cladding systems have been a phenomenon um affecting firefighting for quite a long time
01:20:31 for quite a long time i think the specifics of the particular system on grenfell probably is slightly different to that the extent to which that was readily identifiable i think is a debatable point but
01:20:44 i think is a debatable point but the phenomenon of buildings being clad or insulating being part of the phenomenon that firefighters should be
01:20:51 be minded to consider is is not something especially new and in fact it's had an impact in firefighter fatalities over the years as well so i i think cladding is
01:21:03 so i i think cladding is and i think we heard evidence of that in fact that that firefighters understood the dangers and risks associated with insulated cladding and
01:21:10 and when you say here just looking at the evidence you gave you gave you said i think the specifics of the particular system at ground floor probably is slightly different to the extent that's
01:21:21 slightly different to the extent that's readily identifiable readily identifiable i think is debatable what do you mean by that in more simple terms why do you think it's debatable first of all so i think some of the evidence was
01:21:32 some of the evidence was the insulated panels and insulated cladding panels certainly those terms have kind of often got
01:21:40 got fused together i think during the inquiry and i think listen to the evidence of some of the firefighters firefighters are very aware of the risks associated with insulated panels which
01:21:53 associated with insulated panels which are the types of panels used to insulate all manner of buildings not just high-rise buildings the insulated cladding panels in a more
01:22:04 insulated cladding panels in a more recent phenomenon used as it was much to beautify buildings like grenfell as they are for an environmental purpose and i think
01:22:15 for an environmental purpose and i think remain a relatively new phenomenon um i think there is evidence in the lfb that they were well aware of the specific types of panel at grenfell particularly the fire
01:22:26 panel at grenfell particularly the fire safety department i'm sure she'll come on to that but the the generalities of insulate the risks associated with insulated panels and insulated buildings is something
01:22:37 and insulated buildings is something that would be familiar to firefighters more generally does that clarify it does i want to look at it so maybe if we can look at it slightly differently i think i'm right in saying that there is no although there's a reference to
01:22:49 is no although there's a reference to building construction features that may promote rapid or abnormal fire spread and there's an example given of sandwich panels there's no specific reference in this appendix to cladding systems per se is
01:23:01 appendix to cladding systems per se is there that's correct and that is to be contrasted with the fact that cladding systems are expressly referred to in gra 3.2 is that right that's it and this is to a degree of gra
01:23:13 that's it and this is to a degree of gra 3.2 transpose to the lfbs policy if we just take it stage by stage and if we can go to gra 3.2 which is lfb quadruple zero one two double five forward slash
01:23:24 zero one two double five forward slash eighteen
01:23:24 eighteen [Music]
01:23:28 now this is geoarray 3.2 itself and if we can look at the fourth bullet point from the bottom of that list
01:23:37 we see that in the second line that expressly refers to cladding systems being something for which crews attending on 72d visit should be collecting information is that right
01:23:48 collecting information is that right that's correct
01:23:50 now apart from the emission or the specific admission of cladding systems in the appendix of 633 and this floats from an answer you gave earlier on
01:24:01 earlier on do you consider the appendix one effectively supplements or implements policy 800 and the implementation of the porous guidance in lfb procedure
01:24:12 porous guidance in lfb procedure just like again mr can hear we know that cladding systems aren't expressly provided in appendix one yeah notwithstanding is it your view that
01:24:24 that 633 the appendix effectively is collecting the information that ought to be collected under 800 and the porous guidance yes that's correct
01:24:35 now that i think has to be subject to a necessary caveat and that
01:24:40 and that is that the problem is that it would appear based on the evidence that you reviewed
01:24:44 reviewed that neither 800 nor the additional guidance in appendix 1 of policy 633 is properly understood by operational personnel who are charged with carrying out these visits in practice is that a
01:24:56 out these visits in practice is that a first summary of the caveat you'd wish to bring to the panel's attention i would agree so what you're saying is that the documented policies are broadly appropriate but implementation may not
01:25:08 appropriate but implementation may not be
01:25:09 be as highly effective as you'd want it to be yeah i don't think i need to say quite that in the report mr yeah i agree and in your view is that likely to be because there is an insufficient understanding amongst operational
01:25:21 understanding amongst operational personnel as to what is precisely required of them when they're carrying out some 2d visits i think that's correct
01:25:31 would it also be fair to say that your view is the deficiencies in implementation were reflected in the poor quality of the information recorded on the ord
01:25:42 on the ord entry that was specific to grenfell tower indeed yes very little information which had the chairman pointed out and that
01:25:50 and that we have
01:25:51 we have the ord but i don't think we need to go to it but for example there were no plans of the tower on the ord is that right yeah the number of flaws was incorrectly recorded as 20 is that right that's correct there's no operational
01:26:03 correct there's no operational contingency plan included for the tower is that right that's correct and the emergency contact details were incorrect or out of date as you understand it yeah
01:26:14 as you understand it yeah now um you have stated that you agree with
01:26:17 with the findings of the phase one report to be clear do you agree specifically with the finding in the phase one report that the north kensington crews who carried out these 72d visits at grenfell
01:26:28 carried out these 72d visits at grenfell could and should have taken steps to obtain information directly from the tmo in relation to the materials used in the cladding system yes i mean that's part of the two-way exchange that you would anticipate crews
01:26:40 exchange that you would anticipate crews having with responsible persons at the property
01:26:43 property and would you also agree with the finding that the crews should have obtained basic floor plans from the tmo which showed flat numbers and basic layout
01:26:54 layout yeah yeah if not let's see if even a simple line drawing they could have done themselves that is also acceptable but the the purpose is to get layouts of the flows and the refrigerator means that you could seek
01:27:06 refrigerator means that you could seek to get that from and the tml would be the easiest of those [Music]
01:27:13 [Music] taking the step back what evidence have you seen
01:27:16 you seen that crews were in fact trained on how best to carry out section some 2d visits by the lfb i've seen noise essentially my my sense of it is
01:27:27 my sense of it is that the
01:27:28 that the crews
01:27:29 crews may well have been following a much more extensive procedure but culturally they
01:27:36 they they did not really see it as being very different to a one one day that they'd already done if you like it was a computerized one one day i think would be the way to characterize it from from the crew's point of view that that would
01:27:47 the crew's point of view that that would be my sense of it thank you so with less than immaculate timing and it's slightly earlier than we'd otherwise bring the case it may be best to take the mid-morning break now simply
01:27:58 to take the mid-morning break now simply because the next topic i won't be completing within five or ten minutes yes all right well mr mcguire as you were told we have a break during the course of the morning normally it comes a little later than this but it's obviously convenient to take it now so
01:28:10 obviously convenient to take it now so we'll stop now we'll resume please at 25 past 11
01:28:15 past 11 and i have to ask you while you're out of the room please not to discuss your evidence or anything relating to it thanks sir all right would you like to give the usher please thank you
01:28:28 [Music]
01:28:32 right 25 plus 11.
01:46:27 would you ask mr goat to come back in please
01:46:41 all right mr gerk are you ready to carry on yes sir thank you very much yes mr canoe sir thank you mr mcgurk in earlier evidence we touched upon the experience of discharging section 72d and other fire and rescue
01:46:53 section 72d and other fire and rescue services and it's that topic i'd like to come on to now the key question arising from the evidence and the contents of your report is this is the effective and consistent management of operational risk
01:47:05 management of operational risk information a challenge for fire and rescue services in this country it's html yeah why so i say four reasons in the report um
01:47:16 so i say four reasons in the report um one of them is that firefighting is very much um
01:47:20 much um a full contact activity it appeals to people who who like a physical career um there are lots of skills to be acquired lots of technical and knowledge to be assimilated fundamentally it is about
01:47:32 assimilated fundamentally it is about applying those skills and knowledge in an operational setting and so um
01:47:38 um i wouldn't say there's an aversion to paperwork but there's certainly an aversion to bureaucracy if you will and it really is very difficult to get rigorous
01:47:46 rigorous if you like administrative systems in place
01:47:50 place given the volume of a bureaucracy that increasingly has been applied to fire rescue services so there's something about the paperwork and the bureaucracy that really is a kind of constant struggle and i think the introduction of
01:48:01 struggle and i think the introduction of 72d and porous added your further layers to the requirements to produce a comprehensive documentation premises risk assessments and so on how do you
01:48:12 risk assessments and so on how do you deal with that problem how do you resolve that tension then so there were two culture and training i think are the two things i think the first thing you have to do is to
01:48:21 is to uh to be clear about your values as an organization that as a fire rescue service
01:48:27 service um
01:48:28 um is it where a life or death service so rigor in the way we go about everything that we do needs to be a core value if i can stop you on that sure in your experience as a chief fire officer how
01:48:39 experience as a chief fire officer how do you go about establishing in practical terms the right culture is it's an easy phrase to use but how do you go about in practical terms achieving that appropriate culture
01:48:50 terms achieving that appropriate culture so it's a combination it starts right from kind of basic training where there's a a rigor and uh and an expectation of self-discipline amongst people who join the fire and rescue
01:49:02 people who join the fire and rescue service as well as it being um when i say a disciplined environment it is not the sort of jumping up and down kind of environment that people might
01:49:11 might foresee or envisage nevertheless there does need to be a sense of rigor and discipline and order to the way fire rescue services go about doing things because it's a hazardous occupation
01:49:23 because it's a hazardous occupation and so constantly making sure that from day one on the recruits course the tone with which um the organization communicates with staff is the right tone
01:49:34 staff is the right tone and in my view that needs to be kind of straight straightforwardness is key not not dancing around in perfectly precise language or sort of dancing around in a pinhead with some potentially difficult areas being very
01:49:47 potentially difficult areas being very clear and straightforward what the expectations are of of personnel not just from the organization but because the community services that we fulfill so getting getting personnel focused on
01:49:59 so getting getting personnel focused on what it is about being a firefighter and what it is about being a modern firefighter which is beyond just the pure operational dimension and effectively continually living up to
01:50:10 effectively continually living up to those expectations from the top of the organization to the very bottom of the organization i think and flowing from that presumably flows the second point you're going to make which is in relation to training in relation to our two things mr kennedy
01:50:22 in relation to our two things mr kennedy training and clear and straightforward policy frameworks what exactly is it that we expect of people across a wide range of areas which which will come as no surprise are very significant indeed
01:50:34 no surprise are very significant indeed and supporting people to ensure that they understand what those expectations and requirements are through effective and high quality training i mean we could talk all day about
01:50:45 i mean we could talk all day about culture but in summary i think that's really a reasonable stab thank you now if i can just take a step back and put some background on your conclusion that there was a
01:50:56 there was a a challenge for achieving the effective and consistent management of operational risk information across all frses and could we go to the inspectors 2019 state of the fire service report which
01:51:08 state of the fire service report which you refer to in your own report of paragraph 65. now am i right that that inspector report raised the concern that in some of the services inspected in
01:51:19 in some of the services inspected in 2019 the risk information being relied upon was inaccurate or missing is that a fair summary that's correct and am i right in understanding that a similar concern was noted in the
01:51:30 similar concern was noted in the scottish inspectors 2019 report it was and
01:51:35 and dealt with more specifically the scottish report found that station-based staff reported making only limited use of risk information collected on their database in part because the information
01:51:46 database in part because the information can often be inaccurate again is that a fair summary of your take of this it is and in many ways you mentioned that the 2010 health and safety thematic review that was probably the trigger for porus in many respects they read very
01:51:58 in many respects they read very similarly i was about to ask you the question it seems that the underlying problem seems to remain between 2010 and 2019 and porous hasn't altered matters to the better
01:52:10 hasn't altered matters to the better it doesn't appear to have made a significant different difference to the understanding of operational personnel about the um the value and importance of risk information again apologies may retread on on previous
01:52:22 apologies may retread on on previous answers but from your particular perspective and based on your experience what is your assessment of the reason why porus hasn't achieved the step
01:52:33 why porus hasn't achieved the step change
01:52:33 change it was clearly seeking to do in my view i think the the essential problem is there's nothing wrong with porus per se because the totality of information required is
01:52:45 the totality of information required is required for one legitimate reason or another
01:52:49 another the problem with it is when you try and fuse it all together it's a heck of a lot of information for people to try to get their head around in terms of collecting it but it loses its sense of what it's
01:53:01 but it loses its sense of what it's there for which is coming back to the original intent of 11172d to be available to the initial officers in charge to make quick decisions and what information do
01:53:13 quick decisions and what information do they need to do that and i think that in collecting this wide range of information traction has been lost on that focus of its individual original intended purpose
01:53:25 its individual original intended purpose and so it's the weight of the information rather than the nature of the information itself that is recommended to be collected that's the problem it's with the weight and the
01:53:36 and the clarity of purpose of the information i would suggest it's not always clear that this will enhance the operational need at the scene of an incident
01:53:47 incident following on from that answer which aspects of the information that porus recommends be collected do you think is
01:53:55 think is less obviously useful for the operational response um so it's not so much items of information
01:54:06 items of information it's the question of the use so so essentially the
01:54:10 the there were two major functions that the operation would fulfill the first is to assist the officer in charge to make a decision about what tactics to deploy at this incident confronting us in the here
01:54:22 this incident confronting us in the here and now
01:54:23 and now and the second purpose would be to inform a dynamic risk assessment in terms of the many and varied hazards and risks associated with these circumstances um
01:54:34 um and so particularly for instant commanders i think they can get confused in what what exactly am i doing what am i using this information for am i doing a dynamic risk assessment or my
01:54:45 i doing a dynamic risk assessment or my phone my plan of attack i think dr grimm was evidence was really interesting when he talked about the simplicity of a mnemonic that gives people a kind of quick and ready reference point just to organize their thinking in the here and
01:54:57 organize their thinking in the here and now and i think to a degree dr coinham would have supported that with some of their model which we may come on to talk about later but i think it's that volume of information it it is all going
01:55:08 volume of information it it is all going to be required at some point in time during the gestation of an operational incident it's been really clear what do you need in the here and now to make a quick decision about the tactics you're
01:55:19 quick decision about the tactics you're going to deploy now and what do you need then to inform a dynamic risk assessment and it's probably the same information is a question of of being intellectually able to use it at the right time thank
01:55:30 able to use it at the right time thank you
01:55:31 you now there are a number of specific practices that you've identified in your report during pond reports that you've seen from
01:55:38 seen from west yorkshire and greater manchester foreign services these are considered from paragraph 69 of your report onwards which is smc quadruple zero double zero four six four
01:55:51 quadruple zero double zero four six four slash three one i'd like to discuss just three of those um with you [Music]
01:55:58 [Music] now um
01:55:59 now um the first point you raise is the concept of a thematic approach to 72d visits which involves different crews uh being given responsibility for visiting
01:56:10 given responsibility for visiting different types of building on their station's ground so for example the same crew may be asked to visit all hospitals in their area um what do you see as being the merits and
01:56:21 what do you see as being the merits and the disadvantages of that thematic approach
01:56:25 approach so i think i think the merits i said touch upon them in the report are that um
01:56:30 um different risks require more in-depth consideration than other risks and it's really helpful for firefighters to be able to develop just that next lay down of expertise in a particular thematic area informed by
01:56:44 particular thematic area informed by a specialist fire safety officer and they can then kind of communicate that to colleagues on the watch and they can pass that information across the station and over time you get a much better awareness across the whole station
01:56:57 awareness across the whole station of the the nuances associated with different themes and different tactics and different operational problems i suppose the only disadvantage i can see
01:57:06 i can see is a risk that as personal change and there's a churn of personnel that
01:57:13 that sometimes it's entirely possible that a particular crew may turn up to a particular risk and just the way the chronology of the order of theme themes have been been taken
01:57:24 have been been taken this might not be as quite familiar from the topic point of view as it would be to another crew that had specialized in this area but but i think that's a risk of of 72d anyway you know in the end the
01:57:35 of of 72d anyway you know in the end the fallback remains the general level of knowledge they would have about about that particular incident anyway and would it be fair to say that in addition to the acquisition of a degree of expertise um thematic approach would
01:57:48 of expertise um thematic approach would also produce a greater degree of consistency of approach to particular risks presented by particular types of buildings you you would anticipate that but i think the question of consistency also comes down
01:57:59 question of consistency also comes down to the role of the local station manager in terms of ensuring that the administration the process and the quality control is done at that local level as well thank you now the second
01:58:11 level as well thank you now the second practice that emerges from your report and you deal with this at paragraph 75 which is on page 33 is the involvement of fire safety personnel and specifically the mandatory requirement
01:58:22 the mandatory requirement in greater manchester that certain types of buildings including high rises over six stories are subject to joint inspections by operational and fire safety personnel acting together
01:58:33 safety personnel acting together now what are the advantages and disadvantages of that degree of collaboration so i think that the two obvious advantages one is that the crews develop
01:58:45 advantages one is that the crews develop um
01:58:46 um a better awareness of matters such as the principles of compartmentation and the fire safety features the passive inactive fire safety features of buildings and the awareness of the
01:58:58 buildings and the awareness of the implications of as it would design failures or breakdowns becomes much better um in terms of disadvantages um
01:59:09 in terms of disadvantages um i'm actually really there are any disadvantages at all i think it's a pretty vital component and the requirement of manchester am i right in saying it applies to all buildings above six stories
01:59:20 six stories it's certainly that's that was our policy and i assume remains the policy today
01:59:25 today [Music]
01:59:26 [Music] and so given that there's no attempt to differentiate between high-rise buildings that require specific fire safety advice and those that do not is it assumed that all buildings over six stories would benefit nonetheless from a
01:59:38 stories would benefit nonetheless from a fire safety contribution yes yes it is and driven as much by uh incidents of firefighter fatalities and high rise buildings as well as public safety issues there's um there's a twin
01:59:49 safety issues there's um there's a twin track approach to that now the third practice you identified in the report is the practice of designating a nominated fire safety officer for each operational watch and
02:00:01 officer for each operational watch and the role is to act as a single point of contact for any fire safety issues or inquiries that the operational crew may raise is that a fair summary of the it
02:00:12 raise is that a fair summary of the it is
02:00:12 is again what are the competing advantages and disadvantages of that particular approach
02:00:19 approach so if i do the disadvantages first that you can have churn amongst fire safety officers and maintaining a con a continuity uh on that fire safety side of the
02:00:30 uh on that fire safety side of the equation can be difficult and so there is there are there are some challenges in that respect but again the advantages i think are self-evident that you get an officer who's got the the latest and
02:00:42 an officer who's got the the latest and most current thinking of building design building construction as well as the point i made earlier which is an understanding of local intelligence about what's going
02:00:53 local intelligence about what's going wrong around the area are there any issues that crews should be aware of in a very localized way because sometimes these can be very very specific issues to a particular area and may only be of
02:01:05 to a particular area and may only be of a short-term duration there may not be something that's a feature for a long period of time so you also get a sense of immediacy as well as the sort of longer-term awareness of some of the risks associated
02:01:17 risks associated and in your review of these matters did you
02:01:20 you sense that there'd been an improvement in the uh
02:01:24 in the uh efficacy and effectiveness of the exchange of information between fire safety and operational crews as a result of adopting this single point of contact model it's difficult to say to be honest i mean i think the extent to which we
02:01:35 i mean i think the extent to which we you could measure efficacy of information is only in the actuality of where instance as it were better dealt with after and before and i'm not sure
02:01:46 with after and before and i'm not sure we got any basis upon which to judge that really i suppose put differently there's no evidence that it caused any harm logic would suggest it certainly couldn't do any harm and you would
02:01:58 you would assume that it would make a big improvement certainly familiarization with principles like compartmentation and some of those um some of those phenomena although other witnesses have talked about some
02:02:09 other witnesses have talked about some of the effects associated with our wind-driven fires coming and some of these effects were also able to be debated at that operational level so awareness generally was raised
02:02:21 awareness generally was raised am i right in reading your report that the three approaches you've identified in your report could be usefully combined put differently they're not mutually exclusive
02:02:31 exclusive indeed no i suspect i suspect west york should do something similar as well um you know i think i think you'll find a lot of fire rescue services look at the situation in the round thank you um
02:02:42 situation in the round thank you um mr gerk i now want to turn to the significant subject of training
02:02:49 you address training from paragraph 81 onwards of your report which can be found at page 35 and there are two primary subtopics within
02:02:58 within this area which you've considered first of all the balance be struck between the need to ensure order and discipline on the fire ground whilst at the same time allowing for and encouraging operational
02:03:10 allowing for and encouraging operational personnel to use their initiative and to adapt to the particular circumstances of the fire and how training can achieve that balance and secondly instant command training and in particular the challenge that is posed by the
02:03:21 challenge that is posed by the relatively recent decline in real live fires which has led to more limited opportunities for personnel to gain experience of a command role dealing with a live fire and those are the two principal points
02:03:33 and those are the two principal points of your concentration is that right yes indeed thank you now first of all can we start with this difficult topic of initiative and the phenomenon of freelancing now you've used the term freelancing in
02:03:45 now you've used the term freelancing in your report which we can see there the header just above paragraph 84. now
02:03:52 now you use it to describe behavior by operational personnel that can occur whether it's a breakdown of control or leadership on the fire ground as an entry definition is that a is that a fair point to start out it is and i
02:04:03 fair point to start out it is and i think it's lifted from the national operational guidance actually thank you and that's when put differently personnel unilaterally decide to take a particular course of action
02:04:13 action acting on their own accord and without the direction supervision or sometimes knowledge of the commanding officer is that right that's correct
02:04:22 now um this issue was identified by the chairman in the phase one report and we'll come on to examples of the type of conduct that he had in mind as
02:04:34 type of conduct that he had in mind as identified in the report in due course the specific difficulty that you identify is that this kind of unilateral action must be avoided because of the risks it poses
02:04:45 risks it poses what risks does this type of action present
02:04:49 present so i think it pulls his risk to the to the general public in that the um where an individual or individuals as it were freelancing they are not available to the officer in
02:05:01 they are not available to the officer in charge to
02:05:02 charge to commit to
02:05:04 commit to delivering the tactical plan that he or she has got in mind and it and because they are unaware of the act of freelancing they can make assumptions when forming that tactical
02:05:15 assumptions when forming that tactical plan that means that then the plan cannot be enacted and that can have really significant impacts on public safety
02:05:22 safety um and the delivery of the plan from a firefighter safety point of view similarly if you as it will lose track of people you don't know where they are they're they're moving into a kind of
02:05:33 they're moving into a kind of freelancing space then if anything were to happen to them you've no knowledge of that you've got a firefighter emergency without realizing it and then at the point in time that you did realize it then you would then have to commit and
02:05:45 then you would then have to commit and divert resources from what you were using them for in the first instance are you to deal with the incident to try to rescue a said firefighter who has been freelancing um am i right that your view
02:05:57 freelancing um am i right that your view is that the answer is not however to insist upon ridgid automatic adherence to procedure at all costs quite the reverse i mean the the reality is that there's no there's expression no
02:06:09 that there's no there's expression no two fighters i like and there's a there's a paragraph i use there to explain
02:06:13 explain the complexity there is no perfect or no model fire you you can construct model fires in laboratories and for experimentation purposes but in
02:06:24 and for experimentation purposes but in the in the real world fires are many variables and so i think that's a very accurate sentence no two fighters are alike and for that reason um they will
02:06:35 um they will predict unpredictably behave and there will be knock-on implications that are entirely unpredictable and you really need firefighters to be intelligent to be able to use the initiative to have
02:06:46 be able to use the initiative to have the knowledge of what to do and effectively to stitch together the most workable solution the most workable um approach to the situation that they've got in front of them and
02:06:57 that they've got in front of them and and two people may actually see the same situation differently and actually approach it differently that doesn't mean to say they couldn't both equally come to the same successful outcome there is no ordered outcome that's
02:07:08 there is no ordered outcome that's preordained at an operational incident it's easy to identify that a balance needs to be struck between initiative on the one hand and adherence to policy and
02:07:19 the one hand and adherence to policy and orders on the other given your four decades worth of experience how does in practical terms the instant commander strike that balance
02:07:30 training is is a vital component of that i think you um you heard from dr cohen hatton about the the various decision-making models i don't know whether we're going to kind of come on to that but but i think it's
02:07:41 of come on to that but but i think it's relevant here that that um reflexively and intuitively when confronted with a situation people commanders will draw on the bank
02:07:53 people commanders will draw on the bank of experience that they've got whether that's
02:07:56 that's operational experience or in some cases whether it's training and it's not to say that that experience is directly applicable to this situation hence the decision control process that was described to the panel doesn't need
02:08:08 was described to the panel doesn't need to kind of pause and reflect and not just see this situation it might look a lot like a situation of experience previously that doesn't mean it is exactly the same so you've always got to be guarded about that and that requires
02:08:20 be guarded about that and that requires both experience and training for people to understand the risk of of operating reflexively and so you've then got to give people an awful lot of training as much as
02:08:32 awful lot of training as much as anything to coach them out of that reflexive reaction that intuitive reaction and to make an instinctive and instant decision but by the same token they're still
02:08:43 but by the same token they're still going to have to make a swift decision and develop a plan of action um and enact that and so that combination of um experience and debriefing and learning
02:08:56 experience and debriefing and learning from experience and coaching and feeding back at the same time as training and assessment as part of that training and correcting where people have got it wrong and you know supporting them where
02:09:08 wrong and you know supporting them where they've got it right you put those two things together and i think that's the closest you're going to come to the giving people a position of being able to see a situation in front of them and stitched together and i use that expression very deliberately they're
02:09:20 expression very deliberately they're going to stitch together various policies various uh standard operating procedures to get the best fit for the situation that they've got in front of them thank you and although it's easy to
02:09:32 them thank you and although it's easy to focus on the incident commander striking that balance um
02:09:37 um does the balance between initiative on the one hand and compliance with orders and policy on the other is that something that needs to be struck at all levels of the operational response or is it confined to the incident commander
02:09:49 incident commander no quite the russia it absolutely needs to be at all levels i think um particularly when crews are in breathing apparatus because they really are on their own in a very isolated position when there are two people inside of a team of two what one
02:10:02 people inside of a team of two what one will be a team leader and the other will be a team member there may be more members of a team in certain circumstances but typically it will be two and they're in a smoke-filled hot building and they've got to act on their
02:10:15 building and they've got to act on their own initiative and as it were do the best that they possibly can in those circumstances in order to do that they need to be confident they need to be well trained they need to have the necessary knowledge and again they need to be able to adapt to the circumstances
02:10:27 to be able to adapt to the circumstances that confront some in the here and now now obviously the striking of this balance needs to be risk sensitive at all stages what risks do you think the instant commander needs to be alive to to be
02:10:40 commander needs to be alive to to be sensitive to when try seeking to strike this balance could you perhaps just rephrase that mr can hear
02:10:48 can hear striking the balance yeah that we've discussed
02:10:50 discussed requires uh the incident commander to be sensitive to the risks that flow from particular actions or inactions would you agree with that yes what risk does he have to be aware of
02:11:01 he have to be aware of so he or she is constantly balancing the the risks to the public of a course of action when weighed against the risks to
02:11:12 when weighed against the risks to firefighters by taking that course of action so he or she has to have sufficient knowledge to be able to evaluate
02:11:20 evaluate what are the likely outcomes of alternative courses of action and they're weighing in the balance those risks and if their view is in a very short space of time that the risks of taking action
02:11:33 risks of taking action in terms of safety the public outweigh the risks
02:11:36 the risks that firefighters would need to take to implement that plan then they would implement that plan and so it's going to be a combination of experience training and technical knowledge that
02:11:47 training and technical knowledge that will inform that assessment of risk is that fair it is now
02:11:53 now in your report you look at various examples of initiative or it is put differently freelancing and if we can examine two examples that you've set out your
02:12:05 two examples that you've set out your report to look at the advantages and disadvantages of that type of unilateral action now the first
02:12:12 first example i'd like to look at is the rescue of two residents from floor nine of the tower by crew manager tilton and his crew and you address this at paragraph 89 of your report which can be found at page 37.
02:12:27 now you've set out a lot of detail in that paragraph but could i try and summarize it more pitifully this way first of all as to the facts the crew
02:12:38 first of all as to the facts the crew were not given a briefing at the bridgehead but crew manager tillerson decided that they would go up the tower and start clearing the floors that's to say looking for residents who might be in need of assistance is that right
02:12:49 in need of assistance is that right that's right importantly crew manager tillerson informed the bridgehead commander that that is what he was intending to do is that right that's correct and crew manager tillerson decided his
02:13:00 and crew manager tillerson decided his crew would not take firefighting equipment with them because he thought it would slow them down
02:13:05 down and but that decision was against standard procedure is that right it was now prob should probably that's part of his dynamic risk assessment as well thank you and when the crew located two residents in a flat on floor nine it was
02:13:18 residents in a flat on floor nine it was decided that three of the crew would go back down to the bridgehead to collect ba sets for them plus breathing apparatus sets for them due to concerns about smoke logging in the stairwell again is that a rough and ready summary
02:13:30 again is that a rough and ready summary it is
02:13:31 it is and the other two members of the crew would stay with the residents in the flat
02:13:35 flat now that decision is again correct to say that that was against standard operating procedure it was yes the two residents were however safely brought back down and out of the tower
02:13:47 brought back down and out of the tower using this method again is that right that's correct now is it your view that the tillerson mission demonstrated an effective and appropriate way of adapting to the particular circumstances confronting the
02:13:58 particular circumstances confronting the crew and in a way that was acceptable i think quite a professional mistaking but yeah i would agree and can you amplify your reasons as to why you think this is a useful example of initiative
02:14:09 this is a useful example of initiative so i think career manager tillerson realized the risks associated he absolutely knew um he was um in breach of procedure as it were but he could see the situation in front of him
02:14:21 could see the situation in front of him and um understood the um capabilities of the crew of people he had with him and effectively made a dynamic risk assessment on the spot weighing in the
02:14:32 assessment on the spot weighing in the balance those um those principles i mentioned earlier that is to say the risk to the to the public vis-a-vis the vista firefighters and on balance believe that it was a risk worth taking
02:14:43 believe that it was a risk worth taking and therefore decided to do so in to try to take the plan of action that he did in doing so he didn't just go as it were udi he um connected with the bishop commander watch manager
02:14:54 the bishop commander watch manager o'keefe who was aware of what he was doing um you've touched upon radio communications extent to which he would have been in communication would have been
02:15:03 been a debatable point on the night nevertheless he took his crew and fulfilled that task and successfully managed to rescue the residents and it's just to draw out that point a key element of this is that he notified the
02:15:15 element of this is that he notified the bridge head commander what he was doing and where he was going indeed he wasn't asking permission to do that he was seeking agreement and informing the bridge head commander who sensibly supported him to
02:15:27 commander who sensibly supported him to uh to undertake that task so can you just go a bit further on that i mean as i
02:15:35 as i read your account and recall what happened
02:15:39 happened um
02:15:40 um tillerson
02:15:42 tillerson took the initiative only in the sense that he could see a possible use for his crew
02:15:47 crew but he got approval from the bridgehead commander which was o'keeffe is that right
02:15:54 right so he so in a way he he wasn't as it were using his own initiative other than to suggest a particular deployment for a crew which was there and then available for whatever use was
02:16:06 and then available for whatever use was required
02:16:07 required so i think there's two dimensions outside firstly whether he was seeking the permission of mr o'keefe or whether he was informing him
02:16:17 him i think i think i'd have to go back and read in detail the witness testimony um my my sense of it certainly from reading was that he was informing watch manager or keith rather than seeking his
02:16:28 or keith rather than seeking his permission but the second aspect of initiative was the decision to break the team up and to keep two members you would normally keep the team together so the decision to
02:16:40 the team together so the decision to break the team up and keep two members to reassure the residents to send people back down and get rid of the operator sets and then to bring everybody down together i thought was also as it was a second
02:16:52 thought was also as it was a second example of good use of initiative i mean i think what i'd really welcome your thoughts on is whether it is desirable
02:17:00 desirable um for the crew manager with what three other people possibly four depending on the size of his crew
02:17:08 crew to decide how to deploy his crew rather than to obtain instructions from someone more senior about how to deploy his crew i think i think the latter is preferable
02:17:20 i think i think the latter is preferable if there is a if there is a clear tactical plan that is informed to the to the crews on the fire ground i don't think grenfell i don't know was a clear plan that people were following
02:17:31 a clear plan that people were following at grenfell and therefore people
02:17:34 people crews like crew manager tillerson um
02:17:38 um were improvising on the night that's fair to sign i'm at that point quite a lot during the report and so
02:17:44 and so it's a fine line isn't it in in preference if there's a real clear tactical plan then you would hope and anticipate that cruz would follow that plan but in the absence of a plan as we saw in the night
02:17:56 absence of a plan as we saw in the night of grenfell what you wouldn't want them to do is to as it were sit tight and just allow circumstances to unfold without really doing anything is it's a difficult dilemma i don't think it's a paradox i
02:18:08 dilemma i don't think it's a paradox i don't i don't think there is a correct solution to that challenge sir no thank you
02:18:14 you so flowing on from your question um there are two respects you've identified in the report in which crew manager tillerson departed from policy one was not taking firefighting with him as they
02:18:26 not taking firefighting with him as they went up the tower the second was effectively splitting up the crew and as he some came down and two remained in the flat to what extent did the lep's policies and procedures identify
02:18:37 policies and procedures identify permit or encourage personnel to exercise their own judgement and initiative in the way that crew manager tillerson did so i mentioned the general point about operational discretion so the lfb half
02:18:51 operational discretion so the lfb half within their policy on dynamic risk assessment they have as it were a sub policy
02:18:57 policy called operational discretion where in the event that local commanders face a situation for which there is no standard procedure for which there is no
02:19:10 standard procedure for which there is no agreed um operating procedure then they are at limited to step outside procedure and to take whatever action is necessary
02:19:18 necessary particularly where there's where it's possible to save life they would seek and that's a general policy across all fire rescue services now operational discretion but it's it's set out in the lfb's policy
02:19:30 lfb's policy i would have there are quite a lot of caveats on the way that london fire began to write up that policy and i'm i couldn't say it's a policy i think is used has been used extensively but i think the policy framework is there for
02:19:42 think the policy framework is there for local commanders to make a local decision determined by the circumstances in front of them we'll come on to operational discretion in due course but i want to pick up um at that point what the parameters what the confines the
02:19:54 the parameters what the confines the limits of operational discretion are but we'll come on to that in due course flowing from your answer does the training of the lfb's operational personnel sufficiently equip them
02:20:06 personnel sufficiently equip them to identify where they need to use operation discretion and how best to exercise it safely and effectively i would say not on the basis of the evidence i've seen mr kennedy i think
02:20:17 evidence i've seen mr kennedy i think you amplified that answer yeah i think um
02:20:22 um the act of outsourcing training is a matter for the london fire brigade i think the consequence of it is that for a supplier to provide
02:20:34 is that for a supplier to provide training against some kind of a specification then the client needs to set out that specification and there needs to be a sort of um
02:20:45 a sort of um rigidity a procedural dimension you can only kind of hold somebody to a contract if it's clear what's contained within the contract so it struck me that over time what evolved was training to a policy
02:20:58 evolved was training to a policy in particular i think there were three policies which were the instant command system dynamic risk assessment and the decision making model so i think officers were trained to apply those
02:21:11 officers were trained to apply those policies and models that is not the same as being able to develop a tactical plan to deal it to to extinguish this fire or to deal with these circumstances
02:21:22 to deal with these circumstances um
02:21:23 um and so i think the lfb were in the former space that is training an awful lot against policies and policy frameworks uh with with conformity to policy being the goal
02:21:36 conformity to policy being the goal rather than necessarily resolutions to incidents
02:21:40 incidents that sounds like an unduly prescriptive model of training as opposed to a lax model of prescription of training do you follow my
02:21:51 do you follow my you were warning against the dangers of prescribed over presc the requirement for the lfb to prescribe what they want from training and your answer which focused on
02:22:02 and your answer which focused on training personnel to policy tends to just the dangers of an unduly prescriptive or limited training policy so yes i agree yeah so effectively they may well have people who can follow
02:22:14 they may well have people who can follow the the policy but that assumes that the policy is correct to start off with and and it's not been tested how do you um strike the balance because obviously firefighters need to know the policy and instant commanders need to know the
02:22:25 instant commanders need to know the policy but how do you train them to understand how best to exercise operational discretion safely and effectively so i think you have to do um um
02:22:37 so i think you have to do um um a blended approach to training uh some of it simulates so some of the straightforward teaching of policy procedure what is the right way to you know extinguish this fire to use
02:22:50 to you know extinguish this fire to use water in this way and so on so there is there is definitely a component of technical knowledge that is teaching there's a need then to have a blended approach to um
02:22:59 um training and exercising so some simulation is very extremely useful in some scenarios the case study work and
02:23:08 and working through incidents and then at break points they are talking through the implications some of these very real incidents db from very real incidents some of them you know training exercises
02:23:19 some of them you know training exercises for which you would then use inject injects all the way up to smaller scale exercises and all the way up to larger scale exercises where people actually take command and in truth it is only at
02:23:32 take command and in truth it is only at those large end of exercises i appreciate there's been a debate about where on the continuing of training is the best place to fall and i don't think there is one or the other i think all are required um
02:23:44 are required um some of the evidence that the inquiry has heard uh just yesterday about communications you can't test communications in a simulated exercise the communications never breaks down in
02:23:56 the communications never breaks down in a simulated exercise because you've got avatars and somebody doing an inject and it's it's all it's all prescripted it's all running to a script so comes don't break down in the middle of a simulated exercise if
02:24:08 the middle of a simulated exercise if you have a 20 30 pump exercise in the basement in the london underground for example and there's lots of people using comms for real they've actually got the leaky feeders out and you figure out
02:24:19 leaky feeders out and you figure out they're not working the breaking down it is only when you get to that end of testing the reality of the kit and equipment in the real world that you can also tease out learning from that so
02:24:30 also tease out learning from that so essentially mr kinnear is a it's a very blended exercise there isn't one or the other it's tabletop it's simulation it's exercises it's input and at the end of it a degree of assessment of competence
02:24:42 it a degree of assessment of competence so you can give people feedback where they've got development needs thank you we'll come on to some of the elements of that particular injects in due course can we turn back now to the second example of
02:24:53 example of initiative that you identified in your report and that was the actions of firefighter o'byrne and we can see that you deal with this on paragraph 90 of your report which is up on the screen at the moment again can i
02:25:05 on the screen at the moment again can i see if i can summarize that the relevant facts thus um firefighter byrne had assisted with preparing the hoses used by the first crews who entered flat 16 and once he
02:25:17 crews who entered flat 16 and once he had done that he started to go up the tower to see what conditions were like is that right that's correct uh importantly um firefighter burn did not inform the bridgehead or anyone else of
02:25:29 inform the bridgehead or anyone else of what he was doing or where he was going is that right that's correct and
02:25:35 and that
02:25:36 that absence of communicating what he was doing was in breach of expectations or procedure is that right it is
02:25:43 it is and firefighter burn also didn't wear breathing apparatus again that would be outside procedure is that right in the in this situation i'll say i said i wouldn't say it's always outside of procedure but uh but he was up there
02:25:55 procedure but uh but he was up there supporting the crews going again so i would say in this occasion yes and on reaching some of the higher floors and encountering smoke and residents who are attempting to leave he was unable to make radio contact with the instant commander is that right that's what the
02:26:06 commander is that right that's what the evidence is yes yes now your view and please shout if i summarize this too crudely is that firefighter burns actions whilst well intentioned amounted to freelancing
02:26:18 well intentioned amounted to freelancing that's correct and which posed a number of risks is that right indeed now can you identify the panel what risks were caused by this type of action
02:26:29 type of action so to a degree i think we can touch upon this earlier that he the officer in charge and at a crucial time when this incident was turning and the external fire was accelerating
02:26:41 external fire was accelerating effectively and resources were always going to be tight there was important resource lost to the incident commander who assumed he would have that resource at his disposable at his disposal i
02:26:52 at his disposable at his disposal i think the second risk is as firefighter o'byrne was going up the tower he had a lot of rich information about what was happening inside of the tower and that information would have
02:27:03 tower and that information would have been incredibly useful to watch manager dowden um
02:27:08 dowden um had he been aware of it and i suppose the third aspect is that in the event that anything would have happened to firefighter oil burn that would have created a firefighter
02:27:19 that would have created a firefighter emergency and at that time in particular it was a pivotal period of the incident wasn't it the the the fire breached compartmentation and effectively if i can use the expression the fire was
02:27:31 can use the expression the fire was really starting to motor and there was a real kind of sense of we we need to start committing crews and doing something here and if at that point in time firefighter burn had gone missing then
02:27:44 firefighter burn had gone missing then it would have made fire uh watch manager darren's job even harder than it already was because he would have had a dilemma do i commit crews now to search for firefighter or burn or
02:27:55 firefighter or burn or do i start to try and tackle the fire i mean watchman who doubt not enough of a challenge on his plate as it was um that would have been a real difficult even more difficult crisis facing watch manager dowden now i think
02:28:06 facing watch manager dowden now i think it's important to note and make this clear that in your report your view is that the firefighter took the action he did out of a sense of duty and effort is that right
02:28:18 duty and effort is that right indeed as i think it was a well intended action he would thought he was going to find out information that he could add value to the incident and that he went on to fulfill several valuable roles later on in the instant time indeed
02:28:31 later on in the instant time indeed does it necessarily follow from what you've concluded that you're not doubting the firefighters good intentions but you identified this example as an illustration of defects in
02:28:42 example as an illustration of defects in training
02:28:43 training yes i think that's fair much
02:28:48 now we've touched on this in earlier questioning but could i now turn to the solution um to the problem and again talk in certainly more detail of the matters we've been canvassing um during the course of the
02:28:59 canvassing um during the course of the morning
02:29:00 morning now
02:29:01 now [Music]
02:29:02 [Music] i think i'm right in saying the principle element to the solution is training as you've referred to in earlier evidence yes it is now one strategy that you identified that may be useful is what you've
02:29:14 that may be useful is what you've referred to as contingency injects is that right it is and that injects are effectively unexpected events that are included in training
02:29:27 included in training where a trainer will introduce deliberately to introduce an element of unpredictability is that a rough and ready summary anyway that's correct yeah now one of the examples you've referred
02:29:38 now one of the examples you've referred to
02:29:39 to in your report it's a paragraph 109 and we don't need to go to it but it's at page 43. you refer to the example of quotes collapsing close quotes a crew member when a group
02:29:50 close quotes a crew member when a group is carrying out a practical exercise can you help us what do what do you mean what is a collapsing crew in this way it so it was just an illustration um to kind of graphically betray what
02:30:03 to kind of graphically betray what what injecting um involves so effectively it's to try and take the
02:30:08 take the the crew
02:30:09 the crew who are fulfilling a task off what the normal trajectory of that task would be as it were to take them by surprise in order to kind of compel them to use their initiative and to figure
02:30:20 to use their initiative and to figure out how they're going to address this difficulty that's now been presented to them and um effectively taking one of their colleagues out out pretending them to collapse you've got a firefighter emergency what do you now do about the
02:30:32 emergency what do you now do about the situation do you continue do you rescue your colleague how do you deal with that situation there are other examples of what you can do with things at night it's just an example of how you are taking the trajectory of this incident
02:30:44 taking the trajectory of this incident into a different direction in order to gauge how the crews react and in order to test whether they've got an understanding of the options and possibilities that are open to them and also to see how they would use your
02:30:55 also to see how they would use your initiative to solve problems um and it would be then continued upon effective debriefing to sort of make sure people have learned from this experience of doing things differently and in your experience does maybe a certain irony this um does the consistent use of
02:31:07 this um does the consistent use of unpredictability uh get crews used to unpredictable absolutely consistency is it's unpredictability it's to take people by surprise and effectively compel them to have to use our initiative to figure out
02:31:18 have to use our initiative to figure out a way to solve this problem now another feature which emerged from your earlier answers is the importance of realism in training exercises and you deal with this in in some detail at paragraph 115
02:31:30 this in in some detail at paragraph 115 of your report which can be found at page
02:31:33 page 45.
02:31:34 45. we can go to it but um i don't think we necessarily need to for these questions um
02:31:45 how there's clearly an importance which you emphasize there of exposing crews to realistic
02:31:51 realistic training scenarios how frequently and what range of scenarios do you have to put crews through in order to ensure that they are getting used to the unpredictable nature
02:32:03 getting used to the unpredictable nature in which fires can behave in reality is that operational cruiser or commanders operational crews and if we take operational crews first and then commanders
02:32:14 commanders so i think there's two levels for operational crews if effectively it's a daily exercise the um the the lfb have talked about their uh daymop model that the
02:32:25 uh daymop model that the maintenance of operational professionalism and uh within that policy they lay out a sort of daily training regime or a daily or a program of training that covers the totality of
02:32:36 of training that covers the totality of firefighter responsibilities which then would entail practical training as well as theoretical training either on the drill yard or at a risk venue um
02:32:47 um yeah so they would do both the theoretical and practical training and during that practical training which will be organized at the local level you would anticipate the local watch manager as station manager constantly coming up
02:32:59 as station manager constantly coming up with ways of just taking crews by surprise you've now got this and then this has happened your whatever the scenario is there really is always a way just to sort of move it on to a slightly different place to get people um
02:33:11 different place to get people um consistently using their initiative so consistent unpredictability indeed and then the second dimension to that is
02:33:19 is it is introducing an element of risk into that situation in training because it can all feel very sterile um i talk about manufactured realism in the report one of the problems is if the only place
02:33:31 one of the problems is if the only place where firefighters practice and rehearse that operational training is on the drill yard at the back of the station with a drill tower that's kind of four stories high then you you really
02:33:43 of four stories high then you you really need to kind of break that idea so you do need a range of facilities which are difficult to provide but you can give firefighters a more realistic experience in real fire situation
02:33:56 experience in real fire situation and really expose them to real risk so they genuinely do feel that they are making operational decisions under some kind of pressure in order to
02:34:07 under some kind of pressure in order to to coach them to be prepared for that reality
02:34:10 reality um at an operational incident so that that those are the sort of two dimensions of operational crews thank you that's a very useful preliminary context looking at the question of realism of training of incident
02:34:22 realism of training of incident commanders and one of the points that comes out very vividly in your report and one point which you explain that it's important to consider the topic of command training within a
02:34:33 the topic of command training within a context of falling numbers of live fires is that is that a fair summary of the emphasis you want to put on the point yes it is and
02:34:42 and is the number of falling fires a particular issue or contextual point in london
02:34:48 london yes it is i think it produced some kind of graphs that illustrate the fall in london is as acute if not more acute than it is another fire rescue service but it's true for all fire rescue services and if we look at i think that the starting point of the
02:34:59 think that the starting point of the analysis just so people have a references paragraph 124 which is a page 47.
02:35:08 and this is where you
02:35:10 you give the appropriate references should people want to follow that up now you refer to various charts in relation to the london statistics and could we turn to those which can be found at page 48 so just over the page
02:35:23 found at page 48 so just over the page [Music]
02:35:25 [Music] and it's in the top half of the page and if we
02:35:29 if we could have a look at those particular charts now the top two images illustrate or set out the national figures is that right that's correct now those both show a decline indeed a
02:35:42 now those both show a decline indeed a steep decline in fire instance in the decade between 2000 and 2010 and then a leveling off is that a fair reading of those top two
02:35:54 is that a fair reading of those top two charts yes i think that's fair now the bottom two images illustrate the london specific figures is that right that's correct and again they show a figure that broadly follows the national
02:36:05 figure that broadly follows the national picture again would you is that a reading thing
02:36:10 now looking at the significance of that decline
02:36:15 decline is that the opportunity for crews to gain real experience of acting command roles has been reduced indeed considerably reduced is that your view it is
02:36:26 it is and would you accept that that phenomenon is compounded by the fact that the more senior roles in the fire service entail an increasing level of managerial non-operational duties yes
02:36:38 managerial non-operational duties yes and so
02:36:39 and so i hope again correct me if i put this too crudely the higher up you go the
02:36:47 the opportunities for experiencing command and life situations is proportionately reduced
02:36:53 reduced i think it's reduced at all levels but i think the con the the higher you go the
02:37:00 the less frequent you are going to be called out to an operational incident from a command point of view is that saying the same thing we're sticking here i don't i think it is okay now can we turn to
02:37:12 now can we turn to paragraph 126 of your report which is at page 50
02:37:17 page 50 and really i now want to look at how do you deal with the problem the consequences of the problem and you say paragraph 126 this the only way of trying to address this loss of life exposure is by the creation
02:37:29 loss of life exposure is by the creation of more realism in training events now you've seen the view expressed by professor torreira in his august report in which he states that training and realistic training is just
02:37:40 training and realistic training is just one part of the picture and that what is required is to supplement training by enhancing technical knowledge now first of all do you agree with that general proposition
02:37:51 you agree with that general proposition advanced by professor torreira i do actually i think technical knowledge i should have said that point earlier i think
02:37:56 think technical knowledge is a vital component of understanding um how to deal with with real incidents but i don't think that purely increasing the level of technical knowledge is the
02:38:07 the level of technical knowledge is the answer either i think the reality is you need to do both and effectively take a holistic approach it took a holistic approach and blend approach i don't think you're going to come on to it but dr coyne hatton did a second report where she and i think mr butler
02:38:20 report where she and i think mr butler produced a very comprehensive suite of
02:38:24 of um
02:38:25 um training opportunities or training approaches that when blended together the evidence suggested went a long way to recreating the benefits of
02:38:36 to recreating the benefits of of what her research showed from operational instant salt in a nutshell simulation many of the benefits have achieved by by simulation but not all of the benefits particularly those that affect the human
02:38:47 particularly those that affect the human factors and so the blended approach is one that you'd commend on the basis of your practical experience of instant command over four decades i think it's essential
02:38:55 essential [Music]
02:38:57 [Music] now flowing from professor torreira's point can we look at the sort of particular aspects of technical knowledge that you think would be useful as part of this holistic approach to the training of incident commanders
02:39:08 training of incident commanders would it involve as a most basic point understanding of the risk posed by certain construction materials it would building construction now um what professor torreira says
02:39:19 now um what professor torreira says again a policy if i summarize this too crudely that while the evolution of an internal compartment fire into an external facade fire is a complex matter once it is observed that a fire has
02:39:30 once it is observed that a fire has exited the building the vertical spread of that fire over the facade and its re-entry through the windows could have been predicted now in order to be able to predict that fire behavior a commander would need to have the technical knowledge and understanding of
02:39:42 technical knowledge and understanding of what those construction products were and the risks that they posed in terms of potential fire spread would you agree with that general proposition partially
02:39:53 proposition partially i think what if i can what do you agree with first and then we'll come on to what you disagree with so what do you agree with first i agree that there is an element of predictability and quite a lot can be modeled to
02:40:05 lot can be modeled to assist um operational decision making what where do you disagree with professor so where we disagree is when um
02:40:15 um when reality meets theory so if we take grenville as an example the simultaneous failure of all of the active and passive fire protection measures of the building
02:40:27 fire protection measures of the building along with the
02:40:30 the fire within the cladding and what what professor torreira refers to
02:40:35 to as kind of re-entry the windows it wasn't just that the windows enabled fire to re-enter the building effectively the nature of the construction and the workmanship
02:40:46 construction and the workmanship associated with the windows from a practical point of view they might as well have not even existed what it wasn't just that there were multiple routes for the fire to come in it was the fact that they they even
02:40:57 it was the fact that they they even contributed to the frostiness people which the fire re-entered the building in the first instance now i i don't think that is easily modelled i think i think professor terrero does say there
02:41:08 think professor terrero does say there are so many variables with some of these models that they end up being oversimplified or unmanageable and maybe paraphrasing but essentially he said one of the problems with two
02:41:19 he said one of the problems with two with so many variables is you end up at either of those extremes so i think the reality lies in the middle that incident commanders need to have sufficient understanding of building construction
02:41:30 understanding of building construction fire engineering fire dynamics human behavior um
02:41:36 um probably those four factors to understand that in this situation how are those four factors interacting with each other against the backdrop of the actual fire and
02:41:47 backdrop of the actual fire and situation that i'm facing because it's not just the fire it is the situation as well and presumably they would have to have
02:41:54 have sufficient technical knowledge as well as experience and the rest of it uh to modify their approach if the original firefighting response is not effective and it's not working
02:42:05 effective and it's not working and so if you take if grenfell would have been at two o'clock in the afternoon
02:42:09 afternoon um
02:42:11 um and and different access it could have been a very different fight you know who would have predicted that uh the consequences of the cladding you're cutting holes falling i mean it's not
02:42:23 cutting holes falling i mean it's not been mentioned very often but the lfp needed to create a second entry point into grenfell tower quite early on into the incident because of the consequence of falling debris some of those very powerful images of the police with riot shields and the fact that he was at
02:42:35 shields and the fact that he was at night people couldn't see and so on so so
02:42:38 so modeling the way the fire might behave in a laboratory using a computational model is really helpful it got some predictive power but in the real world i would still maintain that it requires a
02:42:50 would still maintain that it requires a composed individual able to understand the possibilities in front of them and stitch together a workable plan in a very short space of time and again the emphasis on the verb stitch
02:43:02 emphasis on the verb stitch yeah i i i'm sorry if i keep coming back to that expression it's it's it's deliberate it is there is no perfect solution it is a requirement that an instant commander has to stitch together do the best that
02:43:13 has to stitch together do the best that they can for this situation thank you now again this is another point you you touched upon in your earlier evidence when you
02:43:20 when you observe making certain observations on professor johnson's evidence yesterday in relation to communications would the need for technical knowledge on the part of incident commanders also embrace knowledge and understanding not
02:43:31 embrace knowledge and understanding not only of how communication systems work but their limitations in respect of certain environments uh in broad terms yes mr kafkas i suppose i should just come back and make one point if i could from earlier on
02:43:43 one point if i could from earlier on this morning when the chairman asked me how long would you expect cruz to spend doing a sort of 72d inspection that that question has prompted one thought which is about radio blind spots and communications blind spots which is
02:43:54 and communications blind spots which is one of the one of the factors of appendix one of six three three that
02:43:59 that i would expect to be developed or are looked at during exercises at risk sites not necessarily just purely as part of the 72d so this this also comes to
02:44:12 so this this also comes to the the awareness of communication so i think generally speaking you would expect officers to have an awareness of communications an awareness of the manner in which you may move channels and control channels at incidents and
02:44:24 and control channels at incidents and you would expect that to be exercised regularly and tested so you get the command unit out you'd run leaky feeders out and so on so that knowledge wouldn't just be the theoretical level it would
02:44:36 just be the theoretical level it would be that people have been able to apply it in in for real i think just following on from that answer i think it also follows on from an answer of the question that the chairman posed of um mr brown would you
02:44:49 mr brown would you expect uh 72d crews to test their comms equipment whilst carrying out section 72d visits or would that be something that was confined to exercises i think
02:45:00 that was confined to exercises i think it would be both i think yesterday you you heard from uh professor johnson that um that the test that the lrb lfb undertook you know people walking up the tower saying kind of hear me and you know
02:45:11 know that kind of um slightly cursory superficial test do the radials actually work i think you would
02:45:19 would that probably will be more often what would be done on a 72d inspection than not but all of these risk sites would have an exercise plan or a tactical plan that would be what the lfp call a training solution for each of these
02:45:30 training solution for each of these sites and i think it would be whilst undertaking that training and exercising part of that would be to test more thoroughly the communications so worrying breathing apparatus moving
02:45:41 worrying breathing apparatus moving different parts of the building and to give it a more rigorous exploration of whether any blind spots because it's a known phenomenon because i think that's one of the questions the chairman asked of mr brown i'd be i
02:45:52 chairman asked of mr brown i'd be i stand to be corrected that would 72d crews carry
02:45:57 carry web breathing apparatus and test comms equipment whilst wearing that apparatus would that be in your experience it would be unusual unusual it would be usually would be more the exercising is where you would test the comms of of or
02:46:10 where you would test the comms of of or your comms on their relationship and interaction with the building and i appreciate that's imperfect by the way why is it unusual though because the underlying point that the chairman was making it seems to be an obvious thing
02:46:21 making it seems to be an obvious thing to do in that you're familiarizing yourself with the difficulties that may confront crews if they're attending a fire say in a high-rise residential building so i think this comes back to the fusing together of the different
02:46:32 the fusing together of the different requirements and into one document porous and then doing a a premises risk visit as opposed to a pure 72d i think that you end up
02:46:44 i think that you end up separating out functions so from the operational crews perspective as i said earlier i think in the lfb they still believe they're doing a computerized 1-1-d and where they would then test the
02:46:56 1-1-d and where they would then test the operational implications of that would be training and exercising at the risk site that would be the convention if you will looking at it
02:47:07 looking at it cold in the light of day from grenfell whether that's the way to go forward in light of what we now know about granville is a matter for the inquiry but i think that was certainly would be the convention of most fire and rescue services thank you
02:47:21 services thank you mr thank you very much for your further evidence in in respect to the the comms um
02:47:26 um issues could i go back and just look at some specific instances of technical knowledge
02:47:32 knowledge that
02:47:33 that instant commanders may or may not be expected to hold professor johnson his report explained that radio signals produced by low-powered ultra high frequency uhf radios may not be capable of penetrating
02:47:46 radios may not be capable of penetrating large amounts of concrete or metal and therefore may not perform well in 1970s concrete high-rise buildings is that the level of technical knowledge you would expect an incident commander
02:47:58 you would expect an incident commander to hold
02:47:59 to hold yes
02:48:00 yes would you agree that if an incident commander held that technical knowledge he or she would be in a better position to make an informed decision to permit the use of stronger radios or indeed airwave radios at an early stage of an
02:48:13 airwave radios at an early stage of an incident in a high-rise building yes i wouldn't i would anticipate that i would have been exercised so i would anticipate um instant commands being quite familiar with that in your experience that is something that would be done
02:48:25 that would be done at an early stage in an instant would it certainly in the early stage part of setting up this command incident command structure would be to establish your communications infrastructure and make
02:48:36 communications infrastructure and make sure that they you've got the right channel allocation which from which for most incidents would have been pre-ordained i think professor johnson went through those yesterday without going through kind of the various channels as the incident
02:48:47 the various channels as the incident scales up you would get the command unit on
02:48:50 on and the command unit would normally have people with a higher level of skills and knowledge in how to establish a slightly more expansive and comprehensive
02:49:02 more expansive and comprehensive communications infrastructure for the fire ground now would you also with it flow from that you'd expect consideration by an instant commander of and radio enhancing technology and i'm
02:49:14 and radio enhancing technology and i'm thinking here of repeaters etc i would you would expect either making a communication stack to a dedicated sector so that you would have an officer solely focused on that
02:49:25 an officer solely focused on that or in some fire rescue services they would have professional radio technicians non-uniformed qualified radio technicians that will be mobilized as alongside the command unit to incidents in your experience what
02:49:38 to incidents in your experience what level and what depth of technical knowledge would you expect as an incident commander to have of the advantages and limitations of enhancing technology such as feeders uh
02:49:49 uh originally good knowledge i mean well the two types of feeders both the radial feeders and the telemetry feeders and they are very very different things i think at a basic level understanding the difference between those two would be
02:50:00 difference between those two would be absolutely a prerequisite but i expect them to have a pretty good understanding of
02:50:05 of because comms infrastructure is an essential part of command and control i mean i think i would add that one of the other
02:50:12 the other one of the um dimensions here is the ease the the kind of usability of the equipment itself certainly from from my experience at the design stage of things like command
02:50:23 design stage of things like command units and the procurement of equipment you'd be looking to get sort of one switch type equipment or making it easy to set up
02:50:33 to set up you know extra antennae boosters and so on you'd like to make the equipment itself as straightforward as possible which may require some adaptations but you'd also expect instant commanders to
02:50:44 you'd also expect instant commanders to have a a good knowledge of how to use the equipment in terms of economics infrastructure thank you now you will have seen that professor torreira in his august report um refers to a disregard he's identified
02:50:57 to a disregard he's identified for the value of technical knowledge on the part of the lfb what would be your response to that particular criticism um
02:51:07 um so i think the technical knowledge sits in a different place i think if you take the lfb as a generality as a collective organization i would suggest there's quite a lot of technical
02:51:18 there's quite a lot of technical knowledge sitting within the fire safety function of the organization but i think we've heard from a number of evidence a number of witnesses already that sort of expressed a desire for fire
02:51:29 that sort of expressed a desire for fire safety to have a whatever the right expression is a bigger seat at the table or or some such expression certainly to be and han's role enhanced role um so i think that i think the lfb and that
02:51:41 so i think that i think the lfb and that in fairness is how most fire and rescue services approach as it were technical knowledge on the fire safety side it would be vested in your fire safety departments and many fire rescue services now have qualified
02:51:53 fire rescue services now have qualified fire engineers doctorates and so on
02:51:57 and so on um
02:51:59 um i think that that would be one dimension i think it is also fair to say that the extent to which the technical knowledge of operational officers
02:52:09 officers in uh some of the phenomenon like breaches of compartmentation modern methods of construction um
02:52:16 um you know cladding and so on new materials new approaches i think the lfb um
02:52:25 um struggles in that area can you flesh out that latter response slightly more what examples what particular instances have weighed most heavily with you in reaching the
02:52:37 heavily with you in reaching the conclusion that the lfb struggled on those points to be fair mr kenny i don't think a single officer with the exception of station manager eagan actually recognized a breach in compartmentation
02:52:49 compartmentation i'm not i'm not seeing the single mention
02:52:51 mention in the witness statements of any officer in the command chain that really fundamentally suggested to me they understood what had happened in terms of abuse of compartmentation and its consequences
02:53:03 compartmentation and its consequences and the implications of what that meant in terms of operational firefighting decisions yes thank you slightly different aspect of that point but could i ask us to go to page 49 of
02:53:14 but could i ask us to go to page 49 of your report
02:53:17 and it's roman 4
02:53:20 roman 4 and it's the first sentence and you say there
02:53:24 there there's a risk of quotes artificially inflated confidence and blind faith in procedures themselves and you've gone to identify the danger that quotes compliance with procedure and following
02:53:36 compliance with procedure and following a process becomes the goal now would you say that that's an illustration of the problem that commanders are not or have insufficient technical knowledge to be able to formulate a tailored plan and so the
02:53:49 formulate a tailored plan and so the objective becomes simply to follow procedure rather than effectively extinguishing the fire and saving life others affair would you following on from that would you agree with professor torreira's
02:54:01 you agree with professor torreira's observation in his april report that the current training in education within the fire and rescue services generally tends to emphasize plan execution which i think is a cinnamon following
02:54:13 which i think is a cinnamon following procedure rather than plan formulation
02:54:18 i'm not sure what his evidence is for that i i'm i'm not sure i have enough evidence to offer a kind of clear judgment on that oh mr kinnear the the the um
02:54:29 do all fire rescue services i think it's a big statement i'm not sure i've got any evidence of that thank you we dealt with earlier on in evidence the complex question of operational discretion and i said we'd be coming to
02:54:40 discretion and i said we'd be coming to that well we're coming to it now now
02:54:44 now we probably best start with a definition and operational discretion is another measure designed to encourage the exercise of initiative by incident
02:54:55 exercise of initiative by incident commanders specifically and you've set out a broader definition of the concept which derives from national guidance as you adverted to an earlier evidence and that set out a paragraph
02:55:06 evidence and that set out a paragraph 111 of your report at page 44. [Music]
02:55:10 [Music] and we can see there the italicized quotes
02:55:13 quotes and i shall read it into the record it says this operational discretion relates to rare or exceptional circumstances where strictly following an operational procedure would be a barrier to
02:55:25 procedure would be a barrier to resolving an incident or where there is no procedure that adequately deals with the incident commanders need to be sufficiently aware of procedures the skills and qualities of crew members and
02:55:36 skills and qualities of crew members and the capability of resources available and
02:55:39 and the overarching principle should be that in the opinion of the incident commander the benefit of taking unusual unorthodox or innovative action justifies the risk
02:55:51 justifies the risk is it fair to say the first point to emphasize there is the rarity and exceptional nature of the reliance upon operational discretion it is
02:56:02 it is um
02:56:03 um yeah it is yeah and it's a discretion am i right in assuming that it's reserved to incident commanders alone yes yes now looking at paragraph 113 of your report
02:56:15 looking at paragraph 113 of your report and particularly the first and second sentences
02:56:18 sentences you set out there that you have reviewed the lfb's policy document that sets out the remit of operational discretion we don't need to go to it but is it correct that you observe there that the policy document is comprehensive but that the
02:56:31 document is comprehensive but that the question is the extent to which officers in practical terms feel able to rely upon operational discretion when it's necessary and desirable to do so yes and i think i refer in the footnote
02:56:42 yes and i think i refer in the footnote to a kind of quote from the report of emerging inspector that talks about the kind of culture of debrief did not appear to lend itself to openness in that way and there's two points really
02:56:53 that way and there's two points really i'd like to take you to in this regard first of all is the um report by ribbon star and second if we can look at the inspectorate report looking at the first one by ribbon star um that was an independent review of training
02:57:05 independent review of training commissioned by the lfb after grenfell and that noted i think materially that there was no formal training on operational discretion in place at the time of the review um is that a correct summary of the report's findings yes it
02:57:17 summary of the report's findings yes it is does that accord with your own assessment of the evidence that you have seen yeah i've seen evidence you referred to earlier on to the inspectorate report and
02:57:27 and that noted uh i think i'm right to say that there was quotes a strikingly low close quotes use of the policy and suggested that the explanation was essentially cultural
02:57:38 explanation was essentially cultural namely a lack of confidence on the part of incident commanders that the necessary support was there again is that a fair summary of the inspectorate's conclusions it is if i could just link those to my
02:57:49 it is if i could just link those to my comments on in paragraph 113 though about the comprehensiveness and restrictions the sense you've got when you put those two together is whilst operational discretion was first introduced
02:58:01 introduced with gra
02:58:02 with gra 3.2 and i appreciate the inquiry we'll be looking in detail about the development of gma 3.2 but therefore it was a national policy so the sense i got was that
02:58:14 i got was that a policy need to be in place but the the framing of the policy language
02:58:20 language really discourages quite strongly discourages the use of operational discretion rather than seeing it as a as an important enabling um
02:58:31 um piece of policy i guess so to that extent am i right in assuming that you consider the inspectorates criticism to be well made it was well made and i think that
02:58:42 made it was well made and i think that speaks to the culture of debriefing that where people may have used it then they didn't feel that they would be supported for having done so and i think i'm writing putting it this way that
02:58:53 that your
02:58:54 your explanation for the phenomenon of the strikingly low take-up rate is a combination of discouragement in the policy which and general cultural reasons as to why operational discretion isn't exercised
02:59:06 operational discretion isn't exercised more consistently one other addition to that if i could mr can heal which is the um the the existence of a number of teams
02:59:17 the the existence of a number of teams um of operational review officers uh our teams of functions monitoring officers we've heard about um service standard support officers there were a number of layers of
02:59:29 there were a number of layers of inspection slash audit slash assurance
02:59:33 assurance that
02:59:34 that seemed to kind of um anchor in observance of policy as being the central
02:59:40 central kind of tenant of the organization's culture
02:59:42 culture and it really flows from that you've we dealt with it in the past but you've observed previously in the report um to an artificially inflated confidence and blind faith and procedures themselves and compliance with procedure and
02:59:53 and compliance with procedure and following a process becomes the goal do you think that reluctance to depart from procedure is an explanation for the lack of confidence on part of our incident commanders i don't think he speaks to the same point yes so if you just let me
03:00:05 the same point yes so if you just let me finish the question it's just for the transcribers benefit and but that's part of the explanation for the lack of confidence on the part of incident commanders yes sorry i'd agree
03:00:16 i spit the flip side of all of this is how do you ensure that operational discretion is appropriately exercised how do you go about that so i think when
03:00:28 how do you go about that so i think when it is
03:00:29 it is you
03:00:29 you you debrief it in the right with the right frame of mind to start from a proposition that the officer making the decision to apply the discretion
03:00:42 the decision to apply the discretion did it for for the right reasons and that they faced exceptional circumstances and then you take the learning from that and you
03:00:49 and you publicize it far and wide and and candidly you milk it for all it's worth to get
03:00:55 to get mentioned earlier about the kind of culture you need to communicate that widely in order to send a very strong signal to the organization and incident commanders that um
03:01:05 that um because this sits against the backdrop of health and safety and the risks of being criticized for taking decisions that step outside procedure so it's a very tricky balance for incident commanders you need to be able to give them confidence
03:01:16 them confidence that they will be supported when they step outside procedure but by the same token there's not a cat blanche to do anything that they that they wish to do and so to try and get the boundaries of where those lines can be drawn when it
03:01:28 where those lines can be drawn when it happens you need to debrief it as i saying to communicate and publicize it um along the lines of the outcomes of a lack and health type incident you you would use that kind of process to make
03:01:39 would use that kind of process to make sure the whole organization was aware that it happened and that there's learning from this and that everybody had something to learn from that incident
03:01:48 incident bluntly is one difficulty facing the brigade that commanders are unable safely to identify when the circumstances call for the exercise of operational discretion yes i think the blue ribbon talks about
03:01:59 yes i think the blue ribbon talks about some a recommendation about trying to provide some boundaries or some parameters when it might be applied or some examples to give commanders a clue of the kinds of circumstances within which it would probably be appropriate
03:02:12 which it would probably be appropriate i think i stand to be corrected but i think the report refers to various cues to be provided to incident commanders yes i think thank you
03:02:22 thank you can we now turn um to the question and the topic of firefighting on the night of the 14th of june 2017. now i'm right in saying but please shout if this is not so that you've
03:02:34 shout if this is not so that you've reviewed training materials including the incident command training materials that have been provided to the inquiry by the lfb thank you and in your report at paragraphs 143 to 148 which can be found
03:02:47 paragraphs 143 to 148 which can be found at pages 54 through to 57 you've made a number of observations based on the materials that you that you have reviewed at the time you drafted your report
03:02:57 report thank you and would that since you finalize your report you've been provided with and reviewed a number of additional incident command training materials that have been subsequently provided to the inquiry by the lfb is that right that's right
03:03:09 that right that's right am i right in understanding that none of those additional materials that you have reviewed has given you cause to change any of the views that you've previously expressed in your report about the
03:03:20 expressed in your report about the adequacy of the lfb's incident command training
03:03:23 training if anything that strengthened the point so the opinions that you've expressed in paragraph 143 to 148 of your report remain an accurate reflection of your
03:03:34 remain an accurate reflection of your view of the adequacy of the lfb's instant command training taking into account the additional material that you've been provided with which you've now considered thank you
03:03:44 thank you now can we turn first of all to the question of water and its use
03:03:52 on the night now you address this a paragraph 151 onwards in your report which is at page 58. um before we deal with the substance can i deal with a number of preliminary matters um first
03:04:04 number of preliminary matters um first of all um you're not a water supply expert is that fair to say that's fair and the opinions you have set out in your report relate purely to the operational side of water supply that's to say how the lfb managed the available
03:04:16 to say how the lfb managed the available water on the night and whether they were sufficiently aware of and took steps to address any issues in relation to water supply that's correct and you have not been asked to give any opinion on the water supply to the
03:04:28 opinion on the water supply to the incident from the network on the night of the fire no and you have not been provided with any data that would enable you to make any such assessment in any event no thank you
03:04:37 you now would it be correct to say that ensuring the provision of an adequate water supply is a fundamental function of instant command yes it is
03:04:45 yes it is and broadly speaking would it be correct to summarize your conclusion by saying that in your view the command structure in place on the night of the fire failed to adequately fulfill that function at least until the early morning when
03:04:57 least until the early morning when station manager payton was mobilized that's correct now that is a broad proposition and if i could look at some of the component elements of it so that you can amplify
03:05:08 elements of it so that you can amplify your reasoning in evidence now
03:05:12 now your conclusion was informed by a number of points first of all can we look at the bulk media advisor first of all what is a bulk media advisor
03:05:23 is a bulk media advisor so it would be a specialist officer who had received extra training in how to fulfill the role of providing foreign additional water
03:05:34 providing foreign additional water supply the equipment that you would use and some of the theory behind doing so and therefore they would be able to attend an incident and as it were take that responsibility that thought process away from the incident commander within
03:05:46 away from the incident commander within the incident command structure to then to be able to establish to focus on establishing um a water supply i mean the bulk media aspect is slightly i suppose confusion it would be
03:05:57 i suppose confusion it would be predominantly water but for some incidents
03:06:00 incidents uh foam may be a necessary kind of extinguishing medium so form would fall into that category as well but for the purposes of the inquiry i think it would be useful just to say it predominantly will
03:06:12 useful just to say it predominantly will be water thank you and at grenfell at least in the early stages uh group manager welsh uh was the bulk media advisor and he arrived at around 200 hours is that right he was mobilized for
03:06:23 hours is that right he was mobilized for that reason yes thank you now group manager welsh did not continue in that role but briefly took over or purported to take over command of the incident and then was
03:06:35 command of the incident and then was designated the fire sector commander by d.a.c lockland who was the incident commander
03:06:41 commander the point you make in your report is that
03:06:43 that there appears to be no discussion of water supplies by anyone at that particular stage is that right that's correct
03:06:52 correct and
03:06:53 and drilling down more specifically there'd be no discussion about the fact that there was no person fulfilling the role of bulk media advisor given group manager welsh's change in role is that a fair summary that's
03:07:04 role is that a fair summary that's correct i mean the acl glockland have been to the actual instance and taking command their group manager welsh had gone straight to the command unit and made pumps 40 which is a
03:07:14 is a from a london point to be a very big decision it's very rare to make that number of appliances and so there was a sense that this was clearly in everybody's perspective a a very significant incident and i would have anticipated therefore
03:07:26 and i would have anticipated therefore discussion about the necessary water supplies
03:07:29 supplies would discussion of water supplies be a standard topic of discussion in any handover
03:07:36 handover yeah to be frank yes it's a pretty basic component to put a fire in it isn't it i mean
03:07:41 mean there's lots of technical discussion about how water extinguishes fire and the way it can be applied and so on but at its most basic level it's been around for 2000 years to put was to
03:07:52 been around for 2000 years to put was to put water on a fire i think that most people would understand that and again apologies if i put this too crudely and correct me if i have done um during um dac o lachlan's time as in commander you say that there was similar again
03:08:05 say that there was similar again no consideration about whether a replacement bulk media advisor was needed to be mobilized is that first summary of your view i couldn't find any evidence of that and indeed there was no meaningful consideration
03:08:16 consideration of what steps needs to be taken more generally in order to secure an adequate water supply again is that a fair reflection of your view again we have enough final evidence now um ac rose he then was assumed command of the incident at 0 to 43 hours
03:08:29 command of the incident at 0 to 43 hours and again for a number of hours after this it appears that there was no meaningful discussion or consideration of water supply by anyone within the command structure is that again a fair assessment of your reading of the
03:08:40 assessment of your reading of the evidence yes and in matica there was no discussion of the need to mobilize a bulk meter advisor again is that a first summary of your view it is
03:08:51 your view it is would it be correct to observe that throughout this time the operational response was facing difficulties to a lesser of greater extent with water supply
03:09:00 supply from the evidence it's yesterday there were various reports of problems with water supply throughout the incident and to give a a concrete example um alpha 245 the alp on the east side of the
03:09:12 245 the alp on the east side of the tower had experienced problems in securing an adequate supply of water from the alps monitor and the crew were having to improvise by using a hose fixed onto a cage is that right that's right it was lashed to a hook yes
03:09:25 right it was lashed to a hook yes now is it
03:09:26 now is it a summary a fair summary of your evidence that these difficulties with water supply were simply not taken into account by those in command until much later in the incident that's correct
03:09:37 incident that's correct and
03:09:38 and in fact a bulk meter advisor was only requested at 0 600 hours is that right that's correct station manager payton i think yes
03:09:47 think yes and station manager payton arrived at about zero six thirty hours and you estimate that it would have been closer to zero seven thirty hours by the time he had been briefed and got a an informed sense of the incident again is
03:09:59 informed sense of the incident again is that a fair summary of your view it is now that stage in the incident say from around 0-30 hours onwards are you able to give a view as to whether there were steps that station manager peyton could
03:10:11 steps that station manager peyton could have taken materially to improve the situation or is it your view by that time it was essentially too late essentially it was too late i think the incident was in the in what i would call its decay phase in the sense that it was
03:10:23 its decay phase in the sense that it was moving to
03:10:26 moving to a situation where it was effectively starting to burn itself out um and so i think that the water supplies
03:10:33 supplies came within the envelope of the fire itself by that stage rather than as it were trying to extinguish to fire on on the other side of that equation again i hope i don't put this too
03:10:44 again i hope i don't put this too simplistically but is your view in essence there was little if anything effective station manager peyton could have done by the time he arrived on site he would not have been able to materially affect the outcome of that
03:10:55 materially affect the outcome of that instance definitely you know thank you i now want to turn to um issues relating to the use of certain types of equipment on the night of the fire and in particular how effective these pits of
03:11:06 particular how effective these pits of equipment were now you address this topic from paragraph 168 onwards in your report that's can be found at page 63 onwards
03:11:16 onwards now specifically i want to ask you about the equipment that was used for the purposes of external fire fighting and two items of equipment that we used inside the tower namely a positive pressure ventilation fan and a
03:11:28 pressure ventilation fan and a lightweight portable pump now if i can first of all deal with external firefighting now you've considered in detail both the aerial appliances that were used as part
03:11:39 aerial appliances that were used as part of the external fire fighting and ground monitors now it should be stated that in addition to those two forms of water appliances there are a number of handheld jets in use on all external sides of the building as well
03:11:51 external sides of the building as well is that a fair summary it is now in relation to the aerial appliances you have noted that it was just alpha 245 which came from soho and alpha 213
03:12:02 245 which came from soho and alpha 213 which was paddington's turntable ladder that were actually operational during the period up until 0 8 30 hours is that right that's correct and of those two alpha 213 so the turntable ladder was
03:12:15 alpha 213 so the turntable ladder was only used for a relatively short period of time before it had to be moved back from its position outside the tower due to falling debris is that right it was it i think it attempted a rescue on the south face of the tower um relatively
03:12:27 south face of the tower um relatively briefly but then was returned and pulled back under the canopy thank you and just to set some more context in relation to ground monitors first of all can you briefly explain what is a grand monitor
03:12:40 briefly explain what is a grand monitor so a ground a monitor so it's probably used to do with a distinction to a handheld jet a handheld jet is as the name suggests uh normally two personnel with holes into which is connected what
03:12:51 with holes into which is connected what you would call a nozzle um a jet and
03:12:56 a jet and that would normally deliver means through a pump the holes would in part of pressure through the pump put the water through the holes and the two firefighters would hold the jet and pointed at the fire um the risks the issues with that are
03:13:08 um the risks the issues with that are there's a limit to how much pressure you can put through the holes because it creates a jet reaction and there's a limit to which you that two people can control that you might need three people on occasions so there are limits so when
03:13:19 on occasions so there are limits so when you're trying to throw water at height because you're overcoming the effects of gravity
03:13:24 gravity then there is a real tricky balance between pressure and flow and jet reaction the ground monitor on the other hand is a fixed piece of apparatus it's a monitor stuck into if you're like a metal casting
03:13:35 metal casting and you connect the holes to the casting the
03:13:39 the professor dr groom was talking about breaching so there's a he was talking about the dividing breaching there's only collecting breaching that does the reversal two into one as opposed to one into two
03:13:49 into two and you can then normally put a greater pressure through a ground monitor and therefore get a higher throw because the jet reaction goes into the ground the ground absorbs the jet reaction through
03:14:00 ground absorbs the jet reaction through the feet of the ground monitor molding if you like thank you mr mcgregor does that explain that comfortably clear it does uh mr may um repeat my plea in relation to pace so i'm afraid i think
03:14:11 relation to pace so i'm afraid i think the shorthand writer was struggling at points there so if you could um uh speak more slowly that would be much appreciated now looking at the ground monitor if you've noted that there was a grand monitor that was operational for most of the duration of
03:14:24 operational for most of the duration of the incident on the south side of the tower is that right that's correct and specifically it's located on the walkway immediately in front of the tower is that right that's correct and essentially you state that you've
03:14:35 and essentially you state that you've seen evidence suggest that there might have been ground monitors in use on other sides of the tower but the evidence you've seen is not conclusive have i summarized your view correctly you have thank you
03:14:47 you have thank you how many other grand monitors do you think were in use or potentially could have been in the news
03:14:52 news um
03:14:53 um potentially up to four um dear c d a c o clockland does i think sent a message back saying foreground monitors in houston i think in his witness statement and or his evidence
03:15:05 witness statement and or his evidence mentioned he thought there were four i've not seen evidence of any picture of that um
03:15:11 um but but i've no reason to to suggest he's um he's anything then tell them the truth um i've seen evidence probably of two um
03:15:21 two um but it but it could it could equally be up to four thank you now is it your view that the lfb's response was on the whole effective in particular reducing downward fire spread
03:15:32 downward fire spread yes i think i start the um the uh experts reports of uh dr leonard and professor bisbee in in on the limitations of that notwithstanding um as a water supply expert i'm i'm sure
03:15:44 um as a water supply expert i'm i'm sure we'll talk about water supply more generally within those constraints i think the crews did a reasonably effective job at controlling the fire and its downward spread and being able to and i think the the
03:15:55 being able to and i think the the pattern of where the fire got to very much reflects their ability to put water onto the um the external face of the tower i do also make the point
03:16:06 tower i do also make the point that um
03:16:07 that um stopping downward spread of a fire is a very different proposition we'll pick on that
03:16:13 that can we take each and the component element of your view now you referred both in your answer and in report to an image in dr barbara lane's report which provide analysis of the
03:16:24 report which provide analysis of the external fire spread and how that correlated with the external firefighting efforts and could we look at that
03:16:31 at that image
03:16:32 image briefly page 69 of your report in this figure five [Music]
03:16:40 [Music] and if that could be expanded
03:16:46 [Music] the top image shows the approximate water reach on the north and west side of the building is that right it is and we can see that there's been some effect in reducing downward spread on both of those sides up to floor 9 on the
03:16:59 both of those sides up to floor 9 on the north side and floor 7 on the west again have i summarized matters correctly you have to be clear there were no aerial appliances or ground monitors on either
03:17:10 appliances or ground monitors on either the north or west west side until later in the incident is that right that's correct so the effects are illustrated by this image are likely to have been achieved by handheld jets is that a is
03:17:21 achieved by handheld jets is that a is that your view yes handheld jets are monitors yes now the bottom image shows the approximate water reach on the south and east sides of the building there's been more extensive effect there
03:17:33 there's been more extensive effect there up to floor 10 on the south side and as high as floor 18 on the east side again is that a fair reading of those two images it is
03:17:44 two images it is would the more extensive water reach reflect the use of a grand monitor on the south side and the aerial ladder platform on the east that would be my conclusion yes
03:17:56 [Music] in terms of whether anything more could have been done to reduce fire spread on the outside of the building you've explained that it's difficult for you to offer an opinion that this would involve
03:18:09 offer an opinion that this would involve a significant element of speculation have i summarized your position fairly yes
03:18:15 yes and looking at the components of that in particular aerial appliances were not able to access all sides of the tower is that right um
03:18:26 um that's correct although there is some evidence of the possible attempt to try on the west side which was prevented by kind of concrete bollards but yes in the event there was
03:18:38 bollards but yes in the event there was no
03:18:39 no application of aerial appliances and the crew of alpha 245 itself had considerable difficulties in your view pitching the alp and had to operate outside of procedure
03:18:51 outside of procedure in order to set up on a grass verge they did yes
03:18:56 did yes and as we've referred to in relation to alpha 213 there were challenges posed by falling debris which meant that the appliance could not be safely used is that a fair reflection of your view it is i would say i think they put
03:19:07 it is i would say i think they put themselves at particular risk actually the um
03:19:11 the um so not only from the falling debris but they were unable to extend the jacks of the vehicle um and so that would have put it in a more unstable position than than it would have probably been
03:19:23 than than it would have probably been safe to do um and um that was quite a courageous approach that they took join the various strands of your view together um again correct me if i'm
03:19:34 together um again correct me if i'm summarizing this too crudely or unfairly what you're saying is that it's not possible to say whether even had a narrow appliance of greater reach been available at some unspecified time but
03:19:45 available at some unspecified time but earlier in the incident that would have materially improved the external firefighting response i don't think it's possible to say one with the other thank you
03:19:53 you so it is one o'clock yes is that a convenient point for you yes right well then it's obviously a good point at which to take a break for lunch with us tomorrow we'll stop there and we'll resume at two o'clock please
03:20:06 and we'll resume at two o'clock please and again please don't discuss your evidence with anyone while you're away from the room thanks emily thank you very much
03:20:22 thank you 2 o'clock
03:20:34 you