London Fire Brigade control room supervisor testimony on stay-put policy, FSG calls, communication systems between control and incident ground during the fire.
00:00:12 good morning everyone welcome to today's hearing and we're going to continue with the evidence of mr. Smith's morning mr. chairman good morning mr. Page may be please have miss me back
00:00:36 good morning before we get started can I just say that I think it would be in everyone's interests yours and ours as well if we have slightly shorter periods
00:00:47 well if we have slightly shorter periods of answering questions with short breaks in between would that suit you yes right well then we'll I'll ask mr. millet perhaps try and find a convenient point around course 211 yes certainly and then
00:01:01 around course 211 yes certainly and then we'll have a break okay very good thank you very much yes good morning this morning I'm going to take a little bit of a step back to some policy work that we looked at yesterday
00:01:12 policy work that we looked at yesterday okay
00:01:13 okay so bear with me if there's anything you don't recognize or unfamiliar with and can I start with a document that I think you referred to yesterday but I'll be corrected if I'm wrong about that and
00:01:25 corrected if I'm wrong about that and that's the National stay put guidance I'd like you to be shown the 2012
00:01:32 2012 DCL G high-rise report if I can summarize it which is CTA R and then
00:01:43 summarize it which is CTA R and then there are six zeros three three and it's called fire safety and purpose-built flats and it was published by the DC LG in May 2012 and it followed the Lakmal
00:01:59 in May 2012 and it followed the Lakmal house fire inquest do you are you familiar with this document at all you know right let me see if I can just see whether you're familiar with the principle in it about stay put and if
00:02:11 principle in it about stay put and if you could please be shown page twenty-seven internally under Section nineteen stay put policy are you
00:02:23 nineteen stay put policy are you together a stay put policy involves the following approach first bullet when a fire occurs within a flat the occupants alert others in the flat make their way out of the building and some of the Fire
00:02:34 out of the building and some of the Fire and Rescue Service if a fire starts in the common parts anyone in these areas makes their way out of the building and summons the Fire and Rescue Service third bullet all other residents not directly affected by
00:02:46 other residents not directly affected by the fire would be expected to stay put and remain in their flat unless directed to leave by the Fire and Rescue Service that's a governmental summation of stay
00:02:57 that's a governmental summation of stay put in a government document in 2012 as a result of or following on from latinum house yes
00:03:05 house yes Oh at least following on from the fire Platinum House is that is that a familiar articulation statement of the state policy in your experience so when
00:03:20 state policy in your experience so when we were investigating the black noir house incident we refer to a book clip that was issued by DC LG to homeowners
00:03:31 that was issued by DC LG to homeowners and I don't that's not very different to the one that was issued okay can we just look at the next page and see if there's anything on there that we need to look at and then at 19 to it
00:03:45 need to look at and then at 19 to it there's a double negative not mine this time it is not implied that those not directly involved who wish to leave the building should be prevented from doing so nor does this preclude those
00:03:58 so nor does this preclude those evacuating a flat that is on fire from a letting neighbor their neighbors so that they can also escape if they feel threatened is that is that a familiar statement no there's not a minister yeah right is that part are you ever if you
00:04:11 right is that part are you ever if you ever come across that no approach no
00:04:21 and then nineteen three the alternative to a stay put policy is one involving simultaneous evacuation is that something you're familiar with I've heard the term stay per and simultaneous
00:04:34 heard the term stay per and simultaneous evacuation okay are you familiar from training or your experience with the idea that the alternative so to stay put is simultaneous evacuation as bluntly as
00:04:45 is simultaneous evacuation as bluntly as that no and it wouldn't be something in a control room that control officers could achieve simultaneous evacuation okay right can I then ask you to look at
00:05:07 policy 539 appendix 3
00:05:18 [Music] just to look a little bit more at the actual kinds of advice that a bit better
00:05:29 actual kinds of advice that a bit better to be given on the FSG this is appendix 3 to be found on internal page 16 or page 16 of the relativity document and
00:05:44 page 16 of the relativity document and we looked at this yesterday but I just want to get back to it if I can it says in the fourth paragraph down you are usually safest to remain in your premises unless affected by fire heat or
00:05:58 premises unless affected by fire heat or smoke if the situation changes you should leave your premises and dial 999 if you need further assistance now unless the words unless affected by fire
00:06:11 unless the words unless affected by fire heat or smoke in your experience as an SI P would that mean would that be implemented as unless affected by either heat fire or heat or smoke or a
00:06:24 heat fire or heat or smoke or a combination of the threat of any of those sorry one of them one of them one of them is enough is this if the caller says they are affected by smoke for example yes what does the FSG call
00:06:37 example yes what does the FSG call handler do so that would then they would have asked why they were affected by heat or smoke so if the caller then said that they couldn't leave their premise they didn't feel they could leave their
00:06:48 they didn't feel they could leave their premises because of the smoke then we would go on to assess the situation and provide protection advice right but if you were told there's smoke in my
00:06:59 you were told there's smoke in my premises it's smoky yes just then that's that's not really all the information you've had on a call what advice would be ordinarily big be given well it would
00:07:10 be ordinarily big be given well it would depend on the circumstances but if a caller rang and said that there was smoke in their flat and and I think the operator may well ask us an additional question to say is there far in your
00:07:22 question to say is there far in your flat and and depending on where the smoke is coming from they would offer protection advice right so it wouldn't be normal then for the cool handle to investigate
00:07:33 then for the cool handle to investigate the amount of smoke the seriousness and density of the smoke and where it was coming from yes by reassessment throughout the conversation right
00:07:50 okay can I ask you to look at a transcript of a call which is lfb six zeroes 311
00:08:05 [Music]
00:08:16 and it's a call this is a transcript created by the created for the inquiry but it's timed at oh one thirty thirty
00:08:32 but it's timed at oh one thirty thirty eight on do 14th of June and
00:08:40 it doesn't matter for present purposes who the call handler is okay even though you may go into guess but I would want
00:08:51 you may go into guess but I would want to show it to you it's not a long call
00:08:57 the caller I can tell you is from the 22nd floor because we get that from the transcript and we think that it's flat 193 in
00:09:09 and we think that it's flat 193 in Granville Tower and operator says fire brigade caller hello it's from Grenville tower yeah and several inaudible words the 22nd floor operator you're on the
00:09:22 the 22nd floor operator you're on the 22nd yes and there's all smoke now so that's what the caller says and the operator says yeah we are you need to get to the window and get some fresh air ok and you can read on yeah I'll let
00:09:33 ok and you can read on yeah I'll let them know you're up there so can you make sure we're and operate a year for speaking caller like can you actually do you know do you actually know actually which floor it's a fire there's a fire
00:09:44 which floor it's a fire there's a fire operator it's a block a flat on the fourth floor alight caller yeah well our neighbor told us is actually from inaudible and oh I see okay the operator goes on yeah well we're there and I'll
00:09:55 goes on yeah well we're there and I'll let them know you're on the 20th but you just got some smoke up there you're okay and then there's some over speaking and then though yeah caller yeah we're still we're still in the neighbor's house now
00:10:07 we're still in the neighbor's house now okay all right well it's on the 20th you're on the 20th it's on the fourth caller says 22nd floor operates 22nd call a 22nd floor yeah all right okay
00:10:18 call a 22nd floor yeah all right okay and then there's over speaking operator we are there all right I'll let them know thank you and then over the page okay bye says the operator the caller says over speaking the the flat query
00:10:30 says over speaking the the flat query sorry do we stay in the flat operator well I obviously can't really advise you to I'll let the fireman know you're there okay okay all right okay thanks thank you bye-bye now a number of
00:10:43 thank you bye-bye now a number of questions I got to you about that call
00:10:47 first of all is where the questions that are being asked by the operator about the about the smoke enough do you think for the operator to get a good amount of
00:10:58 for the operator to get a good amount of information to be able to give accurate fire survival guidance to the caller I wouldn't really class that as a fast Survival Guide it's cold because she she doesn't provide any advice with regard
00:11:10 doesn't provide any advice with regard to that No so in in terms I would imagine that's a call we've received from Graham for tower and the operator still believes that the fires on the fourth floor right and and again the
00:11:22 fourth floor right and and again the caller saying that is on the 22nd floor so I wouldn't technically it plus that as a fast survival Gardens call it is a call from an individual in the building obviously right looking at the policy
00:11:35 obviously right looking at the policy though would you say going back to the expression you're usually safest to remain in your premises unless affected by fire heat or smoke any one of those
00:11:47 by fire heat or smoke any one of those three as you said yeah would you say that the caller was telling the operator that their premises were affected by smoke I would say that that there was
00:11:58 smoke I would say that that there was smoke on the 22nd floor yes and and wouldn't that mean off let me ask it this way
00:12:03 this way would that mean that given that the call the caller was saying there was smoke in the flat that it was not safe to remain in the premises I think at the end with
00:12:15 in the premises I think at the end with the operator saying that she can't really advise you and we did let the firefighters on scene know that there were people on the 22nd floor and I'm sure you've seen that from that she'll
00:12:26 sure you've seen that from that she'll insert a dog yeah well look at the short incident long as to what information was passed on and indeed the alright it was passed on at oh one thirty two twenty nine and the reference for the
00:12:37 nine and the reference for the transcript we can look at at his page eighteen in the short incident log but I'm just focusing on the on the information is passed to the operator by the caller the caller says verse smoking in the in the flat and says it says it a
00:12:50 in the in the flat and says it says it a couple of times yes and then asks for advice and I'm just trying to work out with you
00:12:56 with you having been told that they smoke in the flat that the policy is engaged whereby it's now not safe for the caller to remain in the premises because this
00:13:07 remain in the premises because this because the flat is affected by smoke the flat is affected by smoke so had that call progressed and they'd gone on to it being a fire Survival Guide at
00:13:18 to it being a fire Survival Guide at school I would have expected the operator to assess the situation and offer advice to keep them safe that may well have been and probably would have been to protect them in their own dwelling rather than leave the building
00:13:32 dwelling rather than leave the building right you say it wasn't too fast a viable guidance call what would make it a faster viable diamonds call it circumstances where the flat is already affected by smoke yes they would actually have spoken to the caller and
00:13:44 actually have spoken to the caller and to get there to ask and provide advice
00:13:52 and assess the situation I think during this time and to just explain to you what was going on in the control room there was a huge volume of course coming in and I think there was there would
00:14:07 in and I think there was there would have been we were been handling over a hundred within that hour or from people within the tower and wantin advice I would imagine that the operators were trying to get to everyone as quickly as
00:14:19 trying to get to everyone as quickly as possible and offer advice about what they can do and update them in the situation about where the fire was yes
00:14:32 situation about where the fire was yes this is and if this comes from the short from the operational response report this is the 33rd 999 call into Brigade
00:14:43 this is the 33rd 999 call into Brigade control but just just as an example I'm just trying to get a handle on what would be the difference between and as
00:14:55 would be the difference between and as it were an ordinary 999 call or or a fire survive ins fire survival guidance cool what makes the difference between one and the other a fast survival burger
00:15:06 one and the other a fast survival burger it's called between an ordinary 909 call yes sorry could you say well I've tried a different way here's the call we've seen the transcript the operator is told there is smoke in the flat my question
00:15:19 there is smoke in the flat my question is looking back at the policy which says you're usually safest to remain in your premises and less affected by smoke yeah why is that not a far survival guidance call which would require orally suggest
00:15:33 call which would require orally suggest to the operator that they should be advising the occupants to leave so I think if you go back to the definition of a fire survival to guidance call it the first survival violence call
00:15:44 the first survival violence call actually kicks in when a caller believes they aren't able to leave their premise due to the effects of fire heat and smoke so that would be when we would provide those four principles four sets advice right protects and rescue I see
00:15:58 advice right protects and rescue I see so
00:15:59 so it is it actually a more staged approach the caller calls if the caller says I'm affected by smoke that doesn't become a
00:16:10 affected by smoke that doesn't become a fire survival guidance call unless it then emerges that not only is this making the flat or fire or heat but that the caller also can't escape yes right now before you get to that and at that
00:16:23 now before you get to that and at that stage that no escape stage that's when survive our survival guidance kicks in yes right now before you get to that stage at this intermediate stage where there is smoke in the flat that the
00:16:37 there is smoke in the flat that the policy says you're usually safest to remain in your premises unless affected by fire heat or smoke so that would indicate that when there's smoke the next stage stage two if you like is escape if you can safely yes that's
00:16:51 escape if you can safely yes that's right is it yes now gain back then to the transcript of the call we've just been looking at we don't see that the operator says are well given that you've got smoke in your flat can you escape safely let's explore
00:17:04 flat can you escape safely let's explore that what is that a deficiency in the advice being given do you think I wasn't there at the time but I can only imagine the situation and I really would believe that that individual would have known
00:17:16 that that individual would have known that they were on the 22nd floor that the fire was on the 4th floor and that actually and they might be called as lower down that did need for survival guidance help and actually they would
00:17:29 guidance help and actually they would have also been concerned because they wouldn't have known what was going on in the building that actually had they asked them to leave and evacuate they would have put them into a more dangerous situation by sending them down
00:17:40 dangerous situation by sending them down a stairwell to the fourth pass the fourth floor which was on fire I understand that and that leads on to another question which is when assessing
00:17:51 another question which is when assessing together with the caller at that stage - before you get too far survival guidance properly so called as you described it at that stage - we're making the assessment about his scale
00:18:03 assessment about his scale how does the control room operator make an assessment about the safety event of an escape route unless they've got information from the incident commander
00:18:14 information from the incident commander yes they they can't do that that is just a pure conversation with the caller and it would be it will it would be between us and the caller asking them about the situation that's the only assessment
00:18:26 situation that's the only assessment they can make so we've seen this transcript and coming back to the last page where the operator says in answer to the question do we stay in the flat so the sill at stage 2 routes of escape
00:18:38 so the sill at stage 2 routes of escape well obviously I can't really advise you but I let the family know you're there ok my question is it was that that the the kind of advice you would expect an
00:18:50 the kind of advice you would expect an operator to be given or would you expect the operator looking at the policy to say well can we now examine what your escape routes are and whether they are safe together I would imagine that when
00:19:05 safe together I would imagine that when she said I can't really advise you that that was for thought in her mind that she didn't want to send them down into a corridor that may be heavily smoke-filled into a worse situation I
00:19:16 smoke-filled into a worse situation I believe she made an assessment at that time that they were on the 22nd floor and the father's on the 4th floor right I know you weren't on this call and indeed you and you know you were on roof
00:19:27 indeed you and you know you were on roof at this stage I think just about yeah so you weren't there so I'm not asking you about your personal involvement in the call but it would be very early on in the in the incident and I think we only
00:19:38 the in the incident and I think we only started to receive fire Survival Guide its course or provide guidance to people but 1:20 was it the first call we received about that yes my question
00:19:51 received about that yes my question really is this and I can leave it there is the advice that she gives obviously I can't really advise you in line with policy where the policy of seems to
00:20:04 policy where the policy of seems to require an assessment of escape possibilities I would said every cause different that policy is a guideline for
00:20:16 different that policy is a guideline for us to go through the stages again within that amount of course coming in she would have made a decision about where
00:20:28 would have made a decision about where they were in the premise and believed them to be safe right where they were would it be usual practice in the control room to leave matters there or
00:20:39 control room to leave matters there or would it be usual practice in the control room to go on to explore means of safe escape it would have been usual practice to go on and explore means of escape but that
00:20:50 on and explore means of escape but that would be if we were receiving one auto course and not the large volume of course for help that we were receiving on that night right so the usual
00:21:01 on that night right so the usual practice is yes you were but the unusual volume of calls meant that there was a departure from that practice is that is that what I don't say all the time no I
00:21:14 that what I don't say all the time no I would say on this Court yes okay all right now excuse me can I ask you to look at a different document
00:21:27 ask you to look at a different document you mentioned I think 1093 yesterday and there are no times in your in your evidence and we we looked at references to that in paragraph I think 51.5 point nineteen with policy 539 can I ask you
00:21:41 nineteen with policy 539 can I ask you to look at the document that you referred to so as a point in it I just want to ask you this is LFP zero zero zero zero three six one seven
00:22:01 just looking at it on the page on the screen is that is that a document or familiar with yes right is that the one you were referring to yesterday yes right I just want to ask you about one sentence and it isn't if you if you
00:22:13 sentence and it isn't if you if you think I'm taking it out of context please tell me but but it's called a long document at I'm told to spend time reading it out to you but it's a document dated 12th of October 1993 from
00:22:24 document dated 12th of October 1993 from the Home Office who at that stage had responsibility for the for foreign rescue the paragraph two were paragraph
00:22:41 rescue the paragraph two were paragraph one refers to training or of fire control staff and refers to the aim being to equip staff with the basic
00:22:52 being to equip staff with the basic knowledge which would enable them to give advice get out close the doors etc paragraph two says this while this approach is out to quit in the vast majority of cases in some cases a different approach may be needed in the
00:23:03 different approach may be needed in the situation where for example the caller is prevented from escaping to two locations such as high-rise flats and or smoke density or some other reason is in danger the operator taking the call may
00:23:14 danger the operator taking the call may need to give very specific safety instructions in addition to establishing the location of the incident from mobilizing purposes and then it says this additionally in circumstances such as these a fire control operator may
00:23:26 as these a fire control operator may need to take into account that the normal procedure of calming the caller may not be appropriate and may even be dangerous in some circumstances that
00:23:37 dangerous in some circumstances that last sentence did to your knowledge did that ever come into policy lfb policy during your time with the NFB
00:23:52 so that prior to the lack of house fire it is that was in our policy and that was removed after in 2011 it was until
00:24:08 was removed after in 2011 it was until 2011 yes and you know why it was removed yes because we recognized that sometimes at the process as if there of calming the caller may the lower them into a
00:24:20 the caller may the lower them into a false sense of security and that's why we replaced that with the reassessment from our control staff right
00:24:36 also further on in the document it refers to in the training manual that all our control staff have it refers to following advice given by the government
00:24:48 following advice given by the government on high-rise buildings absolutely ok so I think you're just so I can understand your answer it was it was replaced with
00:25:02 your answer it was it was replaced with this reassessment approach whereby you reassess talk comm and also gather information yes sir prior to or the 1011 and there
00:25:14 yes sir prior to or the 1011 and there was a heavy influence on talking to the caller and exchanging names and trying to distract them from the situation they were in
00:25:23 were in rather than reassess the situation so after 2011 we changed that and we changed our training to affect that the control officer should focus more on the
00:25:34 control officer should focus more on the reassessment and the worsening of conditions rather than sharing names and the destruction technique I see so I think you're saying is in fact the post
00:25:45 think you're saying is in fact the post 2011 policy did take account of this advice that we saw in 1993 namely that carving the caller isn't necessarily the best thing to do and it's all about
00:25:56 best thing to do and it's all about gathering information yes after 2011 our current training is in line with that right so can I answer so when we see the reference to reassurance in the rift and
00:26:07 reference to reassurance in the rift and end in policy 539 down I think you said this yesterday but just to be clear that that is is in the context of the priority being the gathering of
00:26:19 priority being the gathering of information and the giving of practical advice yes um but as I explained before that's quite it that's quite a linear approach to look at it and obviously if someone is ringing up and on the cell
00:26:30 someone is ringing up and on the cell phone call very distressed upset and you can't get an address out of them when you first try then you will try a reassuring technique before and try to calm the corner
00:26:43 kind ask you now to look at a document we looked at yesterday which is the GRA
00:26:53 the generic risk assessment 3.2 through February 2014 which we'll find in the policy bundle at Tab 7 we looked at this
00:27:06 policy bundle at Tab 7 we looked at this yesterday and I know you're not familiar with it as a document but again just say just to give you a give your reassurance
00:27:16 I'm not going to ask you about the actual document itself I'm just going to ask you about some of the principles in it if you turn first of all please to page 17 internally this is within the
00:27:31 page 17 internally this is within the part of this document which starts a number of pages before called key control measures and planning and this is national as I says national guidance 2014 put out by the DC LG and on this
00:27:45 2014 put out by the DC LG and on this page it says contingency plans for particular premises should cover and there are two things at the top the bullet point is fires thread beyond the
00:27:57 bullet point is fires thread beyond the compartment of origin and the potential for multiple rescues and then underneath it an operational evacuation plan being required in the event for stay-put policy becomes untenable and my question
00:28:11 policy becomes untenable and my question is looking particularly at the second as an som when you're dealing with a high-rise fire what assumptions do you make as to the existence of any
00:28:24 make as to the existence of any operational evacuation plan in the event that stay-put fails for that building I wouldn't say we do every is different
00:28:37 wouldn't say we do every is different and being in the control room I believe we plan and and I think if you referred to my statement later on after we were receiving that large amount of calls we were also thinking about other
00:28:49 calls we were also thinking about other issues
00:28:49 issues could happen are they incident what resources we'd need that's part of our function and so it's it's a constant update and planning and thinking about a range of alternative things that could
00:29:00 range of alternative things that could happen so it's never focused on one particular item it wouldn't be focused on an operational evacuation plan but it would be focused on how we could support the incident if they wanted to introduce
00:29:13 the incident if they wanted to introduce an operational evacuation plan I see okay I mean I think I think that answers
00:29:24 okay I mean I think I think that answers my question for the most part we tried a different way would you always assume in the case of any fire in any given high-rise block that there is an available alternative
00:29:36 that there is an available alternative plan namely evacuation which could be called upon in the event the staple policy became untenable no we would always assume and with a large majority
00:29:49 always assume and with a large majority of incidents and high-rise that we would be able to keep the calm call as calm and reassured and provide protection advice until the firefighters either
00:30:01 advice until the firefighters either extinguish the fire or reach them right I see so I think the on we try this question with a slightly different way one more time would you ever think to yourself as an som well there's a fire in a high-rise block I'm I'm not going to worry about
00:30:14 block I'm I'm not going to worry about about it because if compartment ation fails there's an operational evacuation plan in place as an alternative would that be part of your thinking no not
00:30:26 that be part of your thinking no not that I wasn't going to worry about it now that it would be part of my thinking and was on the night it would be part of your thinking you would think there is an alternative I think there's an
00:30:39 an alternative I think there's an alternative I wouldn't sorry that is the confusion with regard to operation or an incident ground with regards to what I do in the control room mr. méliès
00:30:51 do in the control room mr. méliès question if I understood it correctly whether you would have at the back of your mind at least that it might be necessary to get everyone out and there ought to be a plan to do that there's a
00:31:04 ought to be a plan to do that there's a flexural question yes yes from from the control room you were such as changing the advice you wouldn't make that assumption yes yes yes thank you sorry that's that's Thank You mr. chairman
00:31:16 that's that's Thank You mr. chairman clarifying it can I then turn to page 20 it's a similar question with a slightly different angle here we have a bullet
00:31:30 different angle here we have a bullet point list on the first part of the page which starts the place before and I should just show you the page before page 19 it starts training which will
00:31:42 page 19 it starts training which will cover high rise it in high rise incidents must include and then if you turn to page 24 but it points up from the end of the list
00:31:54 the end of the list it says evacuation and casualty removal tactics incident commanders should understand when a possible full evacuation strategy might become necessary in a residential building
00:32:05 necessary in a residential building where a state of policy is normally in place first of all were you aware and that that advice are imperative if you
00:32:17 that that advice are imperative if you like was part of national policy
00:32:23 in what context in this written into the GRA yeah yeah well no never mind that the GRA were you aware that that there was national guidance which required training to cover what we see in that
00:32:37 training to cover what we see in that bullet point namely the incident commander should understand by the full or partial evacuation strategy should become this yes operationally yeah now the question is then do you do you as an SI om in the
00:32:50 is then do you do you as an SI om in the control room rely on the incident commander to consider and then advise you as to whether a partial or full evacuation strategy might be necessary
00:33:01 evacuation strategy might be necessary in the building where stay-put is in place
00:33:04 place well that is written into policy seven nine zero but as we spoke about before I believe it should be a joint conversation an update of the information prior to that decision being
00:33:15 information prior to that decision being made yes absolutely but your is it right that you're reliant on the incident commander and his under or her understanding as to when a partial or
00:33:26 understanding as to when a partial or full evacuation strategy might be necessary well we've regard to a partial or full evacuation strategy and you would be relying on individuals on scene so yes the instant commander with regard
00:33:38 so yes the instant commander with regard to a change in state policy from helping keep people safe to telling them to leave that would be down to the control
00:33:49 leave that would be down to the control room because only the control room operators will be able to engage with those callers and only those callers not talk to in every individual in that building yes so it's slightly different
00:34:01 building yes so it's slightly different yes I understand and in that connection I think that takes me to the next part of this document page 18 going back a bit a
00:34:12 document page 18 going back a bit a third of the way down page 18 it covers far survival guidance call arrangements and this this pot is also 6:00 in the section of this document
00:34:25 6:00 in the section of this document about planning when it says there's fast survival guidance called arrangements should include and then the last bullet point is how information will be exchanged between callers fire control
00:34:37 exchanged between callers fire control and commanders of the incident and note the word exchange there my question is what would you expect to be the arrangements for exchange of information
00:34:49 arrangements for exchange of information between fire control and commanders at the incident with regard to passing a
00:35:00 the incident with regard to passing a fast survival guidance information well with regard to exchange say I understand where we are we are with fire control talking to commanders at the incident my question is in relation to information
00:35:12 question is in relation to information coming back the other way what would you ordinarily expect there to be by wherever arrangements for commanders of the incident in passing information to fire control I would have
00:35:25 information to fire control I would have expected on a smaller scale instant there to be an update with regard to an FSG call if it was a prolonged call and they were having difficulty reaching
00:35:38 they were having difficulty reaching that floor right so ordinarily in the ordinary case you would expect there to be a two-way street not so much a two-way street but sufficient information just about the progress okay
00:35:51 information just about the progress okay a particular call of a particular calm yes
00:35:59 and then finally on this document page 29
00:36:13 for paragraphs done from the top this sits within a section called fast survival guidance which starts on the page before in the fourth paragraph on
00:36:30 page before in the fourth paragraph on page 29 it says the advice offered to callers to remain in their property during fire survival guidance calls must be re-evaluated throughout an incident where circumstances make it necessary an
00:36:42 where circumstances make it necessary an incident commander may need to consider changing the advice given for example callers may need to be advised to leave their property or to be guided from it by firefighters and in the incident commander should also consider making
00:36:53 commander should also consider making use of all available systems within the building to communicate with occupants now I just want to focus with you on the sentence where circumstances make it necessary an incident commander may need to consider changing the advice given
00:37:06 to consider changing the advice given now since the incident commander as you told us is not the person communicating with the caller is it the case that in
00:37:23 with the caller is it the case that in order to change the advice given the incident commander has to communicate with the control room yes right and unless the incident commander
00:37:34 unless the incident commander communicated with the control room in relation to any particular fire survival guidance call where the advice needed to be checked needed to be changed the advice couldn't be changed no right
00:37:46 advice couldn't be changed no right thank you
00:37:52 now can I then go back to but I think I'd left off last night ain't about the deviation in it mr. Chen it's rather
00:38:03 deviation in it mr. Chen it's rather disappointing to me to say this but maybe this may be a different point for a brother pass through my mind as well until getting to something different it might be so it is something different than where we were Lawson have thought all right we'll take a short break a
00:38:15 all right we'll take a short break a little Earl is and I suggested we'll come back at course to little just doing five minutes all right so given the eye shadow foot turn on about for evidence please during the
00:38:26 about for evidence please during the break of course 2:11 then please
00:38:45 you
00:45:28 don't question
00:45:54 all right happy to carry all yes thank you Thank You mr. chairman thank you very much for coming back mr. Chairman I have a something say not a not not a question for the witness but
00:46:07 not not a question for the witness but on instructions or by request from someone with instructions on behalf of the caller on who made the call yes the transcript of which I showed Miss Smith
00:46:18 transcript of which I showed Miss Smith just before the break it's the call from the 22nd floor at Oh 1 30 38 and I'm asked to say and I think it's right that I do that that is the call from near me
00:46:31 I do that that is the call from near me Lee who lived at flat one-nine-five by the time of the call at a 1:30 38 she had moved to her neighbor's flat 193 and
00:46:42 had moved to her neighbor's flat 193 and that's the home of Nadia chew cares and blessings you care it's important I think I do understand why I'm asked to say that it's important for those who aren't necessarily here you understand yes that these aren't just numbers they
00:46:54 yes that these aren't just numbers they are they are people's homes of course yes yes all right well thank you very much for clarifying that yes um miss myth can we now get back to your transit as it were to the control
00:47:07 your transit as it were to the control room on the night of the fire on page three of your witness statement you said
00:47:20 three of your witness statement you said that five minutes from Stratford Adam informed me that the fire had been upgraded yet further to a 40 pump incident an unprecedented and first of
00:47:33 incident an unprecedented and first of all Adam that's Adam cranium I think yeses right and he occupied the role well what was his role so he his role as
00:47:44 well what was his role so he his role as Senior Operations Manager the same as me right and and on that night he was post as well because he was shadowing me he joined the organization in May 2007 said he was shadow okay and he was also on route at the
00:47:56 okay and he was also on route at the same time I think he was so bleep of control and paced him yes as you say and he told you that the far had been upgraded
00:48:03 upgraded how were you told that did he call you on your mobile I believe so yeah we were driving so how did you receive a call I have hands-free ministry okay so it
00:48:16 I have hands-free ministry okay so it wasn't something that's okay motoring offense all right but my point is it wasn't over that wasn't over your airway frightened radio no okay and you say my
00:48:31 frightened radio no okay and you say my role in such circumstances is one of oversight what do you mean by that so whenever we come into an incident we are obviously not there at the beginning of the incident so we come in halfway
00:48:42 the incident so we come in halfway through and it really is support to the staff and the supervisors at the back of the room
00:48:50 the room and we receive a number of causes have already said from senior managers and and maybe pres wanting to know some updated information and we can take those calls off the supervisors to let
00:49:03 those calls off the supervisors to let them focus on mobilizing and responding to resource requests yes I see and and you say that when you were told that it was a 40 pump fire what was your all
00:49:15 was a 40 pump fire what was your all your thoughts that it was a large fire is it something you've ever experienced before
00:49:24 before not when I've been on duty so we have had a 44 hunt fire before but I've not been on duty for it nothing right you say we've had a 45 that's deer that visit at the LF basin which was that you
00:49:35 visit at the LF basin which was that you know believe it was an incident in Stratford in Stratford yes right okay and when was that 2012 yes okay what was it but require
00:49:48 2012 yes okay what was it but require the attendance of 40 pumps do you remember no okay and faced with the faulty pump fire did you have any thoughts about what needed to be done in the control room once you arrived or even before you arrived no I
00:50:01 arrived or even before you arrived no I couldn't imagine I knew they were receiving multiple fire Survival Guide that's cause I knew that they 40 pump fire is more than 40 fire engines to be mobilized there's an awful lot of
00:50:12 mobilized there's an awful lot of additional appliances and resources there informing of officers mobilizing those that needed to be done so I need knew that they would need some support okay now if I can ask you to go please
00:50:25 okay now if I can ask you to go please to page 86 of the ORR the operational response report and look at the time stamp 401 57:21 it records that you call
00:50:48 stamp 401 57:21 it records that you call brigade mode controlled by telephone and speak to a OMA and ask for an update do you remember doing that No
00:51:02 I'll go on and see if this triggers it AOM may explains it's quite difficult to get a handle on things because it's so busy but says they are taking a lot of FSG calls som Smith asks if callers are
00:51:15 FSG calls som Smith asks if callers are staying on the line and AOM May says he knows of at least one she reports she is at the Elephant & Castle and enroute remember speaking to Peter main at about elephant I do I didn't realize I was at
00:51:27 elephant I do I didn't realize I was at Elephant Castle I thought was much nearer right okay that may have been when I spoke to I turn on the telephone okay and again you asked if if callers
00:51:38 okay and again you asked if if callers are staying on the line is that because that would indicate that that was a far survival Gardens call in progress yes as you told us yesterday yes and what what answer did he give you he says he this
00:51:50 answer did he give you he says he this records him saying that he knew of at least one what did that tell you what about to inform you of that one of our control officers had been on the phone and write to a caller for some
00:52:02 and write to a caller for some considerable time did you know what advice was being given to callers as part of it FSG advice no I would assume the four principles that we've talked
00:52:13 the four principles that we've talked about previously right look I can tell you for definite okay and what assumptions did you make if any about whether stay-put advice was still being being given I didn't at that time you I
00:52:28 being given I didn't at that time you I didn't make any is you didn't make any assumptions but one way or the other nope
00:52:36 now I think we've got one more call that you made while enroute to Adam Quinn Ian
00:52:49 if I can just show you that that is in the lfb log it's a slightly different document is tab seven of the of the documents bundle lfb document number
00:53:02 documents bundle lfb document number three
00:53:17 and
00:53:23 at o2 o4 o 9 we see message from incident cu8 make pumps 40 so I put the question originally to you wrongly but
00:53:36 question originally to you wrongly but looking at that time mark do you remember that the command message from the incident may pumps 40 had come from cu8 No okay now
00:53:54 do you remember while enroute whether you were told that group manager Welch was now in attendance no and that
00:54:08 was now in attendance no and that wouldn't have been something that I would have been told okay now in your statement going back to it at page
00:54:24 three third paragraph on page three you say when I arrived I could see that absolutely everyone was on the phones we're trying to get a time for your
00:54:36 we're trying to get a time for your arrival because obviously you don't book in a status three because you're not allowing the incident is is there another way of recording your arrival formally at the incident
00:54:47 your arrival formally at the incident but the controller yes so someone could enter it on the log that's just a message and I think after I'd arrived and spoken to the supervisor and
00:54:58 and spoken to the supervisor and everything I think Debbie real may have added it to the log I believe my arrival time was around 2:15 yes and I think she added it to the log
00:55:10 yes and I think she added it to the log about 2:20 and if we go to page 22 of the short incident log at tab 23 of the
00:55:22 the short incident log at tab 23 of the documents bundle I think we do see that 202
00:55:29 202 22 33 dr as you write you write this a daily real use a comment vco2 we know
00:55:40 daily real use a comment vco2 we know that's you in attendance at control yes okay
00:55:44 okay so Debbie adds that is that normal so when an som arrives in the control room yes or they would lock it on there yeah right instant lock okay and you know how
00:55:57 right instant lock okay and you know how long after you arrived that she logged it because you think he arrived at 2:15 you say she's logged she loves that 222 222 yeah that would mean there's about seven minutes difference what
00:56:09 about seven minutes difference what happen you account for that they were all extremely busy I would imagine they'd just gone forty pump fire head net and by then said they will probably still doing all the peripheral standby moves making sure we
00:56:21 peripheral standby moves making sure we had fire cover believe Debbie took a number of calls as well right and on page three of your statement was getting back
00:56:29 back you you say you made you made your way to the duty supervisor and immediately said that you okay what can we do to help and who was a duty supervisor
00:56:43 help and who was a duty supervisor that's just an arrow in the supervisory desk oh I see who was there who was on it was on it Debbie real Pete May and Alex Melman
00:56:57 okay and you then spoke to the officer of the day or Jason Olaf you say who had already present passing information about callers to the command unit and
00:57:10 about callers to the command unit and wanted did he say to you remember what he said to you I think I just acknowledged him said hello I could
00:57:22 acknowledged him said hello I could gather that he was passing the fast survival garden it's information and I think Alex also told me that she had asked Jason to ring the command unit and
00:57:33 asked Jason to ring the command unit and pass the first survival guidance information that they had been receiving right did you have a any greater or
00:57:44 right did you have a any greater or wider conversation with Alex Norman at that point and I may have done right I can't recall the specific detail you can't live what she said to you I think she told me that that's what Jason
00:57:56 think she told me that that's what Jason was doing okay and I had gathered that already because I'd walked past him whilst entering the room and could hear him on the telephone passing information did you either at stack that stage or
00:58:08 did you either at stack that stage or afterwards have a discussion with Alex Norman about the stay-put advice not at that stage that would have been ten minutes later ten minutes later okay but
00:58:20 minutes later ten minutes later okay but you did have a discussion did you with Alex Norman and about 225 I suppose yes you arrived at 2:15 she logs you in at 222 W real man so about 225 you have
00:58:32 222 W real man so about 225 you have that calm
00:58:32 that calm vividly and it was anybody else involved in that conversation when you first had it with Alex Norman with Alex no it was more a it was more flown a decision
00:58:45 more a it was more flown a decision about what we were going to do and I asked her to tell or go around the room and speak to all the control room offices individually with regard to the changing her voice right so you asked
00:59:02 changing her voice right so you asked Alex Norman to go around the room and ask all the CEOs who are on calls a question no I asked her to provide to tell the sea arrows that we were going to change the advice and what advice to
00:59:13 to change the advice and what advice to give out to callers okay right I've got to come can I just freeze that there yeah come back to it
00:59:25 when you spoke to Jason Olaf as you say in the third line did you speak to him about the statehood advice no okay when
00:59:38 about the statehood advice no okay when you came into the control room did you see a white board system in operation no he didn't I believe that came in when Adrian Fenton arrived okay because I was
00:59:51 Adrian Fenton arrived okay because I was gonna say it four lines up from the bottom of the page you say we utilize the white board system to logged cool data for the most badly affected flats so when did that start you just said
01:00:02 so when did that start you just said when I think when Adam Fenton arrived so from from memory Adrian arrived five minutes after me and I at that time was with Pam and then I spoke to Peter
01:00:16 with Pam and then I spoke to Peter Adrian had arrived in control I'm not sure if he'd spoken he'd probably spoken to Alex and maybe Jason and he began to move some white
01:00:28 Jason and he began to move some white bolts that were in the corner that we use for our secondary mobilizing and and write the flats and the information on those white boards okay
01:00:39 those white boards okay now
01:00:45 before the whiteboard system was implemented but what do you remember was the system of recording FSG quo calls
01:00:58 the system of recording FSG quo calls coming in the details of those calls and what and the nature of the advice being given to callers sorry could you work yeah when you arrived in the control
01:01:11 yeah when you arrived in the control room what was the system of recording the calls that were coming in the nature of those calls and the advice being given to callers so we were collecting
01:01:22 given to callers so we were collecting the call information we were making a call of it so an incident of it we were looking it on the incident log and any details about the caller situation their
01:01:34 details about the caller situation their location we were updating the incident log we probably created some service requests looking at the incident log and we made sure that information was passed
01:01:45 we made sure that information was passed to Jason Olaf who would then pass it on to the command unit by that time a system had already been set up in place I couldn't tell you if it was Alex collecting that additional information
01:01:56 collecting that additional information or control officers making sure that Jason Olaf had it okay
01:02:15 apart from entering information onto the incident log yes electronically what other logs written records were being
01:02:27 other logs written records were being kept in the control room about calls or of course at the moment you arrived at the time you arrived there I believe there were some paper I can only speak
01:02:38 there were some paper I can only speak for after I arrived so we wrote information down on paper right and and made sure that it was duplicated on the whiteboard Jason was sitting right beside the
01:02:49 Jason was sitting right beside the whiteboard so he could easily reel that off when that was updated okay but before the one I think you said that the whiteboard system was implemented what anyone once Adrian Fenton arrived yes but before that was there a system of
01:03:01 but before that was there a system of recording information by writing it down on pieces of paper as well as entering it into I can only assume that there was because it was quite a smooth operation when I was robed in there the information was going to Jason Olaf and
01:03:12 information was going to Jason Olaf and he had a list of information that he was given out okay but I couldn't tell you how that was getting to him right and that list was at a written list possibly did you see it no okay and
01:03:25 list possibly did you see it no okay and now when we come to the whiteboard system which starts after Adrian Fenton arrives
01:03:33 arrives we've Chuck we jump ahead in time I think well can I ask you this the whiteboard system was that introduced before or after the change in the state of policy
01:03:47 I would imagine that that was at the same similar time maybe a little bit before that information started to be written on whiteboards okay now at the
01:04:00 written on whiteboards okay now at the bottom of page three you say we utilize the whiteboard system to log cool data of the most badly affected flats so that it was easier for the CRS to relate to should any further calls come in from
01:04:11 should any further calls come in from the same properties or numbers yeah whiteboard system would not have been normal procedure but instead was a case of thinking on our feet to ensure that correct information was known at the
01:04:22 correct information was known at the relevant times he's saying because the volume of information that was coming in was so quick it needed to be displayed immediately I've read all that all to you because I've got a number of questions if first of all if a flat
01:04:34 questions if first of all if a flat wasn't considered to be badly affected
01:04:40 how was the information recorded it was recorded in the same way we recorded everyone's details I think that's just an bad wording on my part is my
01:04:51 an bad wording on my part is my statement so what do you say didn't mean to highlight that we weren't recording everyone's information from those corners we were so so when we read the words to log cool data of the most
01:05:04 the words to log cool data of the most badly affected flats it was it was all the flats that was all but we were also conscious that we'd received a number of calls or lfb had received an a call and
01:05:17 calls or lfb had received an a call and then the Met Police had rung us with a call from the same caller in the same flat so I think when I refer to that I'm referring to actually there's been occasions where a call is called back
01:05:28 occasions where a call is called back several times and with the conditions worsening and we'd updated that on our whiteboard list okay so as I understand it you you keep a whiteboard list of all
01:05:39 it you you keep a whiteboard list of all of all the calls but as the repeat calls come in with the worsening conditions you update the whiteboard as you dare I say okay
01:05:51 did that information that was transferred to the whiteboard then get passed to the come on the relevant command unit yes so as we were updating them and it was a system the control
01:06:04 them and it was a system the control officers that were on the phone that had taken updated or new information we're writing it down as well as writing it down on the system were writing it down on paper and I was going around collecting the paper
01:06:15 collecting the paper I was checking with the white board and so as Adrian that we knew we had that updating any additional information and Jason Olaf was sitting by the white board passing that information okay to
01:06:27 board passing that information okay to the command unit that's very helpful can I can I just see if I can just put further color onto that very clear picture you just given us so and this is within the control room once the white
01:06:39 within the control room once the white board system is in operation yes a call comes in it's handled by our CRO but correct me if I get any of this wrong okay okay
01:06:49 okay okay the CRA then inputs the updated information into the into the into the log is that right yes does the CRA then also recalled new information or
01:07:04 also recalled new information or different information on a piece of paper the same information or maybe a bit more detail just because they can scribble it quite quickly on that piece of paper sometimes when we were walking
01:07:17 of paper sometimes when we were walking past and there would have been different I think Alex did this as well on occasions that we would actually over here because control officers to have a technique of when they're trying to relay information for a conversation
01:07:29 relay information for a conversation that they will ask the caller a question and then repeat what the caller was saying back so sometimes I ever heard what the callers were saying and and the location so I was able to take those
01:07:40 location so I was able to take those details down and check them that we had the month on the white board and they were updated okay I'm just trying to get a visual picture in my head so you've got the CRO with the screen in front of them telephone on there
01:07:52 them telephone on there a headset and they've also got a pen and paper is that right yes okay and the paper is that the controlled information form yeah that's a difference of just a blank piece of paper yes right and they're writing and
01:08:04 paper yes right and they're writing and you're walking around hearing but also writing on a pad is yes yes so I have some paper sometimes I take it from the control offices and take it over to the whiteboard make sure that information is
01:08:17 whiteboard make sure that information is there sometimes I overhear it and confirm that we've got that information okay and the transmission of the pieces of paper to the person at the whiteboard
01:08:28 of paper to the person at the whiteboard that who was doing that may you and Alex I think by the time and it progressed somewhat so Adam and Scott would have
01:08:39 somewhat so Adam and Scott would have been assisting with this as well I couldn't say for definite Scott that Scott he would yes and so the pieces of paper then come to the person who's running the whiteboard
01:08:51 the person who's running the whiteboard which was I believe by that time Adrian there was another station manager or watch manager in the control room as well who was doing that I can't recall
01:09:02 well who was doing that I can't recall if I see okay what about Jason olive he was still on the phone talking to the command unit right so he's on the yeah I was gonna come to him I'm just trying to get an idea of
01:09:14 him I'm just trying to get an idea of the passage of the pieces of paper to the people at the whiteboard say pieces of paper get taken to the personnel running the whiteboard yeah who's you think Adam and Scott not running the
01:09:27 think Adam and Scott not running the whiteboard they were also collecting information right and who's running the whiteboard I believe a watch manager or a station manager who was that I don't know his name right and what was what about Adrian
01:09:38 right and what was what about Adrian Fenton Adrian was there too he was writing on the whiteboard to write I wrote on the whiteboard sometimes okay so it was just a case of updating Adrian was also on the phone to the incident
01:09:49 was also on the phone to the incident ground right okay
01:09:54 and then Jason Olaf and sometimes Adrian Fenton are on the phone to the incident ground they use inner Adrian sorry Jason
01:10:07 ground they use inner Adrian sorry Jason on the phone constantly constantly I didn't see him get off the phone it was a constant update it's a night where's he getting the information he's
01:10:18 where's he getting the information he's getting the information from the whiteboard right okay so it goes in summary gaze telephone call pieces of paper pieces of paper taken by you up to
01:10:29 paper pieces of paper taken by you up to the white board the white ball then reflects the information on the pieces of paper and then that is transmitted by Jason olive on his mobile to the relevant command unit yes that's it is it
01:10:39 it yes very good okay [Music]
01:10:47 in terms of transmission of the information to the see you we have Jason olive doing that by mobile is that then
01:10:59 olive doing that by mobile is that then also recorded by anybody in the control room into the incident Lord yes how's that how is that done so sometimes some
01:11:10 that how is that done so sometimes some operators would have done that Forest Service request not the ones we looked at yesterday and others it would have been just to use a comment how would
01:11:21 been just to use a comment how would just can you give me an idea of how this would work and physically it was physically you have Jason ollie on the phone to see you let's say see you seven by this stage 2:30 let's say sickness I
01:11:34 by this stage 2:30 let's say sickness I see you seven I think all calls are supposed to run through c7 by no 22333 how does Jason Olaf communicate to any
01:11:48 how does Jason Olaf communicate to any of the CRA s the information which is to go into the internet log which he's passing to see you seven he doesn't he has it on the whiteboard as well right so where is the person who is inputting
01:12:02 so where is the person who is inputting the information into the log getting the information from that would be the caller so the control operator will be inputting the information into the log whilst they were talking to the caller
01:12:13 whilst they were talking to the caller and providing advice and guidance so by way of examples if we can get this yeah get this one right we have we look at
01:12:26 get this one right we have we look at the short incident log tab 23 page 22 this is after your after you're there and I'm tried to find an example close to 230
01:12:40 and perhaps the best example is page 23 at the top where we have o to 2931 service request created RT for to see
01:12:51 service request created RT for to see you 8 flat 40 flat 142 on the 17th floor and that's creation of a service request by heidi fox HJ a yes and then that
01:13:03 by heidi fox HJ a yes and then that service request is completed at a couple of minutes later at o2 3107 by sharon darby you can see the same rubric and that information there
01:13:18 how does sharon darby know whether to complete the service request given that
01:13:30 complete the service request given that it's Jason Olaf on a mobile who's doing the speaking so either she would have transmitted that message yes or she was in the center of the room she was 2
01:13:41 in the center of the room she was 2 positions away from the whiteboard right so she would have been over to hear Stratford is that it's a smaller location the mountain and and you were able to have visible eyesight with everyone and you can hear conversations
01:13:53 everyone and you can hear conversations and contact I would have expect if she didn't put that information over the radio that she would have known that Heidi had already mentioned it and we
01:14:05 Heidi had already mentioned it and we had already passed the information and recorded that information on the whiteboard Sharon could have seen that from where she was sitting right easily so you've got you've got the station
01:14:17 so you've got you've got the station manager I think in cu7 and let's ignore for the moment that the the the problem created by the reference to see you ate there let's assume that it's been corrected by Sharon Darby when doing the call she's on she's on she's
01:14:29 doing the call she's on she's on she's the radio operator says she's passing this message to to the command unit by RT 4 yes she she may were done but she also might have just completed it
01:14:40 also might have just completed it because she knew that we already had the information and that all information was being passed to see you 7 by Jason Olaf I see you will have to check they're so good was she listening out to Jason
01:14:53 good was she listening out to Jason olive passing the information to the command unit yes part of them that happens day to day in the control room and radio operators are listen now for what the callers are say or call takers
01:15:05 what the callers are say or call takers are saying and what else is going in the room right I'm just trying to get a feel for how Shannon Darby and Jason all have been working together because it looks as if they pop they're both passing the same information to the command unit at
01:15:17 same information to the command unit at the same time Jason or live by mobile Sharon Darby are by RT for yes right Sharon could have or she could have seen that that information was up on the whiteboard right and known the system
01:15:28 whiteboard right and known the system that we had in place that Jason was reading the whiteboard and passing that information to see you 7:00 right I see so you've got a double system have you got the information going to the white
01:15:39 got the information going to the white board I would like to think it's a single system but Sharon might have picked that up and passed that but you could check that okay deathcor according to say she did that I would imagine at that time she wasn't she was just
01:15:51 that time she wasn't she was just completing it and the information was going only for one point which was Jason Olaf after we'd collected it right did okay
01:16:02 okay do you know whether Jason Olaf was speaking to the command unit officer sorry try this again the in terms of the
01:16:15 sorry try this again the in terms of the command unit officer who was receiving the information from the control room was that person receiving it by mobile from Jason or live and by radio from
01:16:26 from Jason or live and by radio from Sharon Darby or was it a different person in the command unit I would imagine it would have been a different person in the command unit I wrote down it you could have talked on the telephone and responded to the radio
01:16:39 telephone and responded to the radio okay at the same time so again I I would imagine by that time they're all information about people trapped and stuck in there
01:16:50 stuck in there was going via the whiteboard in control by Jason Olaf to see you seven rows and not going by the radio at one point I have a conversation with Sharon and she's extremely frustrated because she
01:17:02 she's extremely frustrated because she can see the high number of calls coming in but obviously there's no radio traffic at the moment because we're passing it all through cu7 by voice and she just wants to get in help her
01:17:13 she just wants to get in help her colleagues but she's extremely frustrated because she know she's got to remain on the radio so I would imagine by that time that had happened so is it from that answer it could be just follow
01:17:24 from that answer it could be just follow that Imus does that mean that where we read in the incident log where a service request is created and completed by Sharon Darby in fact she is or she that
01:17:36 Sharon Darby in fact she is or she that actually is a record of the mobile telephone call made by Jason olive to the command unit and not a record of a radio transmission from Sharon Darby to the command unit at that point I would
01:17:48 the command unit at that point I would imagine that Sharon has just completed that service request and to stop it getting into the list so service requests build up in a list and obviously once the message is completed
01:18:00 obviously once the message is completed we send it she would have completed it because she would have known or believed that that information had gone by the whiteboard to see you seven right okay and when does when does shown Derby stop
01:18:12 and when does when does shown Derby stop sending messages herself I can't recall that time I just know that conversation I had with her at one point during the night see is it right to summarize it
01:18:26 night see is it right to summarize it this way that at some point after the whiteboard system had been instituted that radio transmissions from the control room stopped and the only method
01:18:38 control room stopped and the only method of communication of FSG information to the fire ground was via mobile Jason olive to the command unit yes but but but a record was being kept of what
01:18:50 but but a record was being kept of what those were by Sharon Darby completing service requests yes so some of the control officers would have still typed in that valuable information they were taking from callers and put them as a
01:19:01 taking from callers and put them as a service request right okay as normal habit would they would just be happy probably given the volume and torrent of advice available Gardens calls being passed by Jason or lift to the see you
01:19:12 passed by Jason or lift to the see you yeah do you know whether any of those got missed when being recorded by either Sharon Darby or the or the CRO in the in the incident log did the CRO miss any
01:19:24 the incident log did the CRO miss any recording of information did a Saros do you know do you know whether they did or I don't know categorically but I would be extremely surprised if they were I would say no no information was missed by Cantrell whose prints to be surprised
01:19:38 by Cantrell whose prints to be surprised if they were missed I would be very yes okay
01:19:50 and do you know we've got we've got a very good picture now of communication within the control room and out of the control room do you know whether any information was coming back to the
01:20:02 information was coming back to the control room from the command unit via mobile to Jason all this no I don't I wasn't aware of that I don't know if that he'd passed some updates and
01:20:13 that he'd passed some updates and messages on - Adrian Fenton right do you know whether there was any difficulty in the command unit passing back to Jason or live by mobile and he updates changes
01:20:24 or live by mobile and he updates changes on the fire ground that that command unit officer but knew about no I don't I never I never received any okay
01:20:45 I'm gonna look at one or two details of some particular chunks of information of the surface if we if how we go with those is now a convenient moment for a
01:20:58 those is now a convenient moment for a break I think it might be mr. first yes and I think possibly this occasion will be a little bit more generous to us so as if I said I'll be very generous 20 22
01:21:09 as if I said I'll be very generous 20 22 12 you are going to require this witness with quite a bit of the day but I think all day well you better warn me a favor look that I'm going to be too generous
01:21:20 look that I'm going to be too generous in terms of in overt you think 20 min if we say 15 that is actually into your leisure time no it's just that it's it's more practical to have a pair time on
01:21:32 more practical to have a pair time on the tops worked then everyone knows where they are right 22 12 so I was going to err on the side of giving us an extra two minutes that's very good which I'm eating up and for the rest of time we'll say 22 chef this time thank you
01:21:43 you please don't talk about your evidence to anyone else all right like to go to the offshore peace safe enough
01:21:53 well 22:12 geez
01:22:04 you
01:39:38 right very prompt I'm very good thank you
01:40:04 alright ready to carry on yes thank you very much yes mr. Smith thank you for coming back can I ask you to help me with an exercise we were talking about
01:40:15 with an exercise we were talking about whether there was a possibility of doubling up the messages going both by radio and through the olive mobile yes put it that way off the whiteboard can I ask you first to look at the short
01:40:27 can I ask you first to look at the short incident log page 23 and this is an example so this is tab 23 page 23 and
01:40:39 example so this is tab 23 page 23 and they a service request created by Heidi Fox at 8:02 29:31 rt4 to see you 8 flat 1 for 2 on the 17th floor level 5 adults
01:40:50 1 for 2 on the 17th floor level 5 adults including two elderly persons inside flat and that you'll see that at o2 3107 Sharon Darby completes that service request in exactly the same way can I
01:41:05 request in exactly the same way can I ask you to look at chat 71 of the documents bundle which is ne T triple zero one six 906 and this is one of two
01:41:18 zero one six 906 and this is one of two photographs of
01:41:23 the well let me just ask you what it is me telling you right what is that that's
01:41:35 me telling you right what is that that's one of the whiteboards we are using in extracted control okay we have a second one I better just shave both see we've got a big picture it's the it's the
01:41:46 got a big picture it's the it's the document before and in the tab before she's met triple zero one six nine one two and there there it is so to say
01:41:58 two and there there it is so to say those are the two whiteboards are they that you have been telling us about yes yeah so to go back to the first one that I showed you which is one nine six zero
01:42:11 I showed you which is one nine six zero six we can see there on the left hand side in the column flat one forty two and then they in the next column
01:42:23 and then they in the next column seventeenth you see that
01:42:30 one footer yes and then 17th and then next to it it says five adults yes now
01:42:41 next to it it says five adults yes now that information is not as full as the service request that we were looking at a page one three eight to a page 23 because it doesn't have the information
01:42:54 because it doesn't have the information about the two elderly persons inside the flat yeah now do you know why the white board didn't capture that information the service request and the completion
01:43:06 the service request and the completion of the request did but the white board didn't do you know why that is I would remind you because the white board was that checking system so if we had it on a piece of paper to update it with five
01:43:17 a piece of paper to update it with five adults then that would have been sufficient information for us to check that we had that flap recorded and then there were people inside on the 17th
01:43:30 there were people inside on the 17th floor right but it wouldn't record the fact that of those five adults two elderly persons no it obviously has
01:43:41 elderly persons no it obviously has earlier didn't so what would that mean for Jason Olaf when Jason olive was communicating the details to the fire
01:43:53 communicating the details to the fire ground he he may have heard overheard that said that may have come via another piece of paper that contained the information and then gone to Jason our lives so he might have overheard that or
01:44:04 lives so he might have overheard that or he might have just passed on five adults on the seventeenth floor in flat 140 do you know whether elderly persons were being prioritized in any way on the
01:44:17 being prioritized in any way on the night know that from a control room we would pass all the information and we wouldn't prioritize you wouldn't priority
01:44:26 priority did you think that there was some system of prioritization at the incident ground to be honest I think our focus was away from the incident ground we were focusing on getting the information and
01:44:37 focusing on getting the information and dealing with the the number of course that were coming in and operators were more updating the incident they can see on their X how many calls are waiting to be answered that was often throughout
01:44:49 be answered that was often throughout the night up to the 15-20 calls waiting at a time and and they were trying to process that information deal with callers at the same time and that were extremely distressed as you can imagine
01:45:00 extremely distressed as you can imagine and so I don't think our focus or any of our focus was on the incident ground and what they were doing on the incident ground
01:45:07 ground we were we were contemplating what would happen next would they want more resources and would would something happen to the building like it would collapse that went through our minds and
01:45:18 collapse that went through our minds and what we'd be able to provide then and what would what the impact would be but we weren't and we generally tend not to speculate what happens on the incident ground and I'll control ramiz
01:45:30 incident ground and I'll control ramiz off Instagram so that's where our focus is on how important would be would it be to tell the incident ground that all five adults - of early persons were
01:45:41 five adults - of early persons were included in them they would have known the five adults were there yes but - or - elderly how important was it for the fire ground to know that of those five
01:45:52 fire ground to know that of those five adults - were elderly I I can't answer that you'd have to ask it and an incident commander who would prioritize that I wouldn't know and what that meant in terms of rescuing call us in it if
01:46:06 in terms of rescuing call us in it if the work that's right I wouldn't know what what that meant and in terms of resources on the incident grant if if the white board only said five adults but didn't have the additional
01:46:18 but didn't have the additional information that of those five - were elderly would that information on the white board be incomplete in an important respect no I think then the
01:46:30 important respect no I think then the main priority is that that information has been transferred and and they the instant grand know that there are five adults and we've taken a call from that and if you look at some
01:46:42 call from that and if you look at some of the detail in the other calls and I'm not sure how long that call lasted or whether they did call back we would have a record of that but had they we might have updated to a bit more as you can
01:46:53 have updated to a bit more as you can see we've made some notes about other callers that we've spoken to on numerous occasions if the fire ground was prioritizing elderly people or children
01:47:05 prioritizing elderly people or children or people with mobility difficulties would it not be important for the fire ground to know which flats they were in
01:47:15 okay I'm not sure how the incident commander or the incident would prioritize him and the key information that we've given to them if you as you
01:47:28 that we've given to them if you as you can see it was a vast amount to process and I would say that five adults on the 17th floor would be sufficient for them to know that we've received a call there and there there are people inside that
01:47:39 and there there are people inside that flat have you had experience in the past before Granville Tower of systems of prioritization or fire survival guidance
01:47:51 prioritization or fire survival guidance callers no like I say all our information we've tried to pass across as quickly as we can to the instant ground
01:48:06 can I ask you to look at the before I ask you this before your arrival were you aware of any requests by the
01:48:19 you aware of any requests by the incident ground to prioritize fire survival guidance calls yeah can I ask you to look at the short incident alone sorry the ORR at page 81
01:48:39 and we'll look together at the time mark of Oh 150 49 which starts with control remote officer Adams telephones the Cu
01:48:52 remote officer Adams telephones the Cu believed to be cu8 watch man managed America answers the phone and she relays the following FSG call information flat one three three floor 16 a flat one eight two twenty first floor and then it
01:49:05 eight two twenty first floor and then it says there see you request an idea of priority from control who confirm the following and then they set out further information see you ask if control can
01:49:17 information see you ask if control can prioritize calls based on smoke density going forward do you do you remember before your arrival that that that was a
01:49:30 before your arrival that that that was a request made by the command unit to control no and I'm not sure how we would be able to achieve that because it's not one person talking to a caller or
01:49:43 one person talking to a caller or talking to numerous callers there are there were eleven controlling officers each talking and how would in different conversations with individual callers
01:49:54 conversations with individual callers I'm not sure how that they would be able to prioritise prioritize smoke density when everyone had a different view of what was going on and we were
01:50:05 what was going on and we were reassessing everyone's viewing their house one one caller might think that that was very dense and smoke in a bedroom and but another one might say it's not very I'm not sure
01:50:16 one might say it's not very I'm not sure how we would have ever achieved that so our main goal was to provide every all the information with regard to individuals where they were located and what floor they were on right so in that
01:50:30 what floor they were on right so in that case we prioritized the basic information to send and to make sure that reached the fire ground either on your mobile on route or when you arrived did anybody talk to you about a request
01:50:45 did anybody talk to you about a request from the command unit asking if you at control could prioritize calls you know you don't remember a conversation about prioritization no but had they I had it I would have had a discussion with them
01:50:57 I would have had a discussion with them about that understand know back then to the whiteboard
01:51:10 and and the missing information about the elderly persons just wonder I've asked this before it's sort of ask it
01:51:21 asked this before it's sort of ask it again perhaps a slightly different way would the into your mind would it not be important for the fire ground to know that of particular people in respect of
01:51:33 that of particular people in respect of whom a fire survival guidance call is in operation some of them are elderly or children or have mobility issues would that not be important information I
01:51:44 that not be important information I would imagine that's part of the information gathering and and during a normal incident you would have expected that information and a lot more to go across if the crews were dealing with one or two or a few if I Survival Guide
01:51:58 one or two or a few if I Survival Guide in its course as I saying the amount of information that was coming in the the detail that we had to get and passed to that that information could have gone by
01:52:09 that that information could have gone by Jason only if he could have overheard that conversation or we could have handed him a piece of paper the whiteboard was a way of recording that information and updating it when we've got more information if all the jason
01:52:23 got more information if all the jason Olaf knew was what was written on the wire and if that's all he communicated to see you eight would it not be a material omission from that information that those five adults included two
01:52:35 that those five adults included two elderly people I can I can say that that would may have been helpful to the insistent ground I don't think it's a particular admission I think we managed
01:52:46 particular admission I think we managed to get the basics out there and but and again as I've said I'm not sure how they were prioritizing on the incident ground and whether they needed more resources because they were two elderly people in
01:53:00 because they were two elderly people in that flat looking a little bit higher up on the white board we have flat 83 on the 11th floor
01:53:10 disabled brackets blind brackets and then next to 183 21st floor we've got two adults brackets pregnant brackets
01:53:21 two adults brackets pregnant brackets three children it looks as though whoever was recording the information on this whiteboard was aware of the relevance of the information about who
01:53:33 relevance of the information about who the people in these flats were whether they elderly were they blind were they've children so but would that be would that be fair that actually the the scribe onto the whiteboard was aware
01:53:46 scribe onto the whiteboard was aware that that was information which was relevant for the fire ground to know yes and he would have plated that so possibly who who wrote that would have others so they're in different handwriting right so some of them may be
01:54:00 handwriting right so some of them may be that information would have come there and Jason Olaf would have passed that information but they would have scribed it so for that 7/3 on the 20th to adults 22nd in stairwell they're not as
01:54:11 22nd in stairwell they're not as detailed as the the person that has scribed
01:54:14 scribed Dearlove no and that's why I ask you looking at the complete information so far as the makeup of those other flats are concerned when it says five adults and omits the information elderly
01:54:25 and omits the information elderly persons that information if it was passed over by Jason North without mentioning elderly people would be materially importantly incomplete wouldn't it yes but I'm not sure if the
01:54:38 wouldn't it yes but I'm not sure if the recording and the whiteboard is I'm trying to say was the full detail that got passed over to the CEO it may have just been the way some individuals
01:54:49 just been the way some individuals updated the whiteboard
01:55:04 in fact we have a radio message which shows that Sharon Darby not only completed this service request but
01:55:17 completed this service request but actually also radioed this message in full to see you seven at 2:30 and 42 seconds and I wonder whether we can see the transcript of the radio message it's
01:55:29 the transcript of the radio message it's lfb quadruple zero to seven a four
01:55:53 I like
01:55:57 it's short it's timed at o2 3042 control information flat 1 4 2 CU 7 so we can
01:56:08 information flat 1 4 2 CU 7 so we can see that it has gone to CU 7 or not CU 8 yeah so you're right about what you were saying yesterday now it confirms it Charlie uniform 7 flat 1 4 2 1 4 2 on
01:56:19 Charlie uniform 7 flat 1 4 2 1 4 2 on the 17th one 7 17th all level-5 adults including two elderly persons are trapped inside over and that's that's it
01:56:31 do you do you know who the operator was looking at the at that and the short incident Lord yes Sharon - Sharon Dombey so it would it be the case that know
01:56:45 so it would it be the case that know that she sent that message by radio we can see but but Jason Olaf was also sending the message albeit possibly
01:56:56 sending the message albeit possibly incompletely by mobile yes so could have happened right so is that an example of a what I call a double system of communication to the fire ground in operation one shandar be on the radio
01:57:09 operation one shandar be on the radio and secondly white board Jason Olaf to the command unit yes they were both going to the same place er right okay
01:57:31 now can I just ask you to look at another one which is Oh two forty set the same page short into the log page 23
01:57:42 the same page short into the log page 23 at o2 4011 service request created by heidi fox call the state's fire is now
01:57:53 heidi fox call the state's fire is now in flat one five two for adults and five children ages eleven years to three years and one pregnant lady are now trapped in flat one five three unable to
01:58:05 trapped in flat one five three unable to get out due to the smoke
01:58:21 and if I asked you to
01:58:27 look at the whiteboard first of all a tab 68 which is triple zero one six nine
01:58:39 tab 68 which is triple zero one six nine two
01:58:56 you'll see 153 18th floor it says I think I think for adults five children you see that yes and when we and when we
01:59:07 you see that yes and when we and when we look at the short incident law we don't have on the whiteboard the details of the ages or or the pregnancy or the
01:59:20 the ages or or the pregnancy or the reason for the inability to get out due to the smoke so again is it would you say that the whiteboard information was importantly incomplete so look before it
01:59:35 importantly incomplete so look before it if we haven't got a radio transmission or did do you know Sharon transmitted that so she if she transmitted it she would have transmitted it in full justice I'll come to that before you do
01:59:49 justice I'll come to that before you do maybe I'm misunderstanding what I'm seeing here but it on this sheet I see one five two at the bottom is that right it's one five three which one five three I'm sorry oh yes got it will come to the
02:00:04 I'm sorry oh yes got it will come to the radio message in a moment but just comparing the service request created by Heidi Fox and the whiteboard information it's clear just comparing the two that
02:00:16 it's clear just comparing the two that the service request is detailed and contains details of a pregnant lady but the whiteboard doesn't for example so would that be an important respect my
02:00:27 would that be an important respect my question is definitely is would that be an important respect in which the whiteboard information was incomplete so the whiteboard information wasn't it wasn't ever supposed to be a way were
02:00:39 wasn't ever supposed to be a way were recorded every detail of every individual in every flat but it was supposed to way that we could check we could know if we'd had a previous quarter that that Jason could confirm if
02:00:50 quarter that that Jason could confirm if he'd sent that information to the CEO and the whole room I believe could see it so they could easily update them the time that Heidi has written that service
02:01:03 time that Heidi has written that service request and we were telling everybody to leave their premise I'll come back to that as well understand that did chase a knowledge have access to these short incident log service request on the
02:01:16 incident log service request on the screen in front of him no he would have overheard it in a conversation or it would have gone via the radio so if Jason Olaf was only working from his
02:01:27 Jason Olaf was only working from his from the whiteboard information and didn't have access to the short incident log data the detailed data which we see from the service request what would enable him to give full details in
02:01:40 enable him to give full details in relation to that flat to the incident ground that would have been a conversation that he may have overheard or he may have had a scrap of paper with that information on all right but he
02:01:53 that information on all right but he wouldn't okay you say it may have been do you know I don't know not going in terms of a system would it be fair to say that the system the Jason on if
02:02:08 say that the system the Jason on if would not have reliable information as to the fullness of the information he was giving to the incident ground because it wasn't entered into on the whiteboard and he would therefore be relying on pieces of paper where the
02:02:20 relying on pieces of paper where the information hadn't got onto the whiteboard no but that was that would have been the only way he could have done it if you can imagine the the incident log in front either short instant long it's 300 pages ready and if
02:02:31 instant long it's 300 pages ready and if that was on your screen and Jason had access to that he would have just been scrolling through and would have missed vital vital bits of information such as their location and the floor number this
02:02:42 their location and the floor number this way he actually was able to pass that relevant information I understand we were saying it was complete because we have obviously missed a few bits of information relating to some of the ages
02:02:55 information relating to some of the ages or the conditions of the adults was there any reason why Jason Oliver wouldn't be able to have in front of him a screen showing the service requests as they were made and there is no reason he could have we
02:03:09 there is no reason he could have we could have locked him on that takes time and again it would be interpretation of the data it's not something they used to read in a vision file that's for control staff and to know so that would have taken time to update him to show what he
02:03:21 taken time to update him to show what he was reading and to understand and interpret the data and so again this was a much quicker method and got the information straight away to the command unit quicker maybe but would it be fair
02:03:33 unit quicker maybe but would it be fair to say at risk of incompleteness no I think there would have been a risk of incompleteness had he had access and and would have been scrolling down pages and pages in very quick time he may have
02:03:48 pages in very quick time he may have missed excuse me just one name
02:04:15 can I ask you please to be shown lfb quadruple zero two three four zero which is a transcript of an l FB radio
02:04:28 is a transcript of an l FB radio transmission their control give information to see you seven again I think it's Sharon dog well I'll ask you
02:04:41 this is control of time dat Oh 248 a7 control information flat 153 cu7 and
02:04:53 control information flat 153 cu7 and what just want to compare what's on this transcript with what's on the short incident log that responder / operator charlie uniform 7 we've got a caller
02:05:07 charlie uniform 7 we've got a caller who's trapped in their flat on flat 153 on the 18th floor over I think I think mr. documents director is that the
02:05:19 mr. documents director is that the totality of the message
02:05:26 I think there's no other page you think I think that's the only that is the only page so just comparing that information
02:05:37 page so just comparing that information which goes by radio to see you seven with the service request details can you help me
02:05:46 help me why was the information we see in the service requests created by Heidi Fox about for our adults five children and the ages and the pregnancy and indeed
02:05:59 the ages and the pregnancy and indeed the inability to get out due to the smoke not recorded or not transmitted by the radio operator to see you seven so
02:06:10 the radio operator to see you seven so that's that's the only transmission that she made regard in that flat one five three you know that is the message of o2 48 so could I have a look at the SHA
02:06:24 48 so could I have a look at the SHA incident look yes I'm salute all consider long as of o2 4011 page 23
02:06:40 and that says at 2:40 that's the service request being created there is one other
02:06:53 request being created there is one other there is one of a message to defer to you there is another message which I'll show you which is lfb 0 0 0 0 2 0 3 1 we just look at that
02:07:13 and that's all we have for that
02:07:21 which is of o2 4835
02:07:26 okay can go back to the short instant lock yes
02:07:34 yes that's sir tab 23 at o2 4011 that's the service request
02:07:47 at o2 4011
02:07:54 so that's one and then at 2:41 that's where the service request completes it and that's been completed by heidi as
02:08:05 and that's been completed by heidi as well right so it imagine that she has passed that information on either for a scrap of paper or someone talking to her right to JSON Olaf and then it's going to open the whiteboard okay but I can
02:08:16 to open the whiteboard okay but I can only assume I see can you tell us from that whether that was a message sent by radio because it says Artie for to see
02:08:27 radio because it says Artie for to see you ate this is not a reservist request completed by Sharon Darby no do you know why that might be because I would imagine that Heidi had sent the information a different way so it didn't
02:08:39 information a different way so it didn't go by the radio right I see she was sitting behind Jason Olaf so may have passed it directly one of us may have
02:08:50 passed it directly one of us may have picked it up and passed it was on a piece of paper I see and then I did it to the white board so that's very helpful so so is it is it I think we're
02:09:02 helpful so so is it is it I think we're saying is that it's possible but you don't know that this message wasn't sent by radio it was sent by mobile and the details she's completing there although
02:09:13 details she's completing there although they're not on the white board were on a piece of paper and transmitted by Jason Olaf yes but we don't know we did and those mobile that that mobile as I think
02:09:25 those mobile that that mobile as I think we discovered yesterday or established yesterday it wasn't those conversations were not recorded no that's what she'll I won't write because by this stage she was on his personal mobile yeah Jason they live
02:09:36 personal mobile yeah Jason they live however I do remember that and I do remember there was a pregnant lady trapped in the fart on the night and so that may have been some information that
02:09:47 that may have been some information that I had overheard as well and that would have been passed on
02:09:52 um can I get back in time a little bit into the night - earlier in the night and look with you at some transfer of information before you arrived and you
02:10:04 information before you arrived and you may not be able to help with this at all but I just want to see how far we get is that Alright yeah okay can I ask you please to look at the ORR at page 60
02:10:27 and the
02:10:39 top of page 60 we see a table of information being passed as a cu8 it
02:10:52 information being passed as a cu8 it looks like four calls do you and at the time of this I should just help you with is before 135 and 25 okay so these were
02:11:06 is before 135 and 25 okay so these were the initial yes that's a receiving yes that's right those are the calls that we looked at in the transcript yesterday would you describe those as FSG calls I
02:11:21 wouldn't be able to tell from from that information okay with regard to the remarks I don't know who it's smoke coming into the premises that's just a general comment to read
02:11:32 that's just a general comment to read them the transcript or listen to the call okay um well we won't get we won't get back to that tomorrow to today we looked at it yesterday and the question I have is looking at the arrow if you go
02:11:46 I have is looking at the arrow if you go to page 74 of the ORR you can see there that at the bottom of 73 in the top of
02:11:58 that at the bottom of 73 in the top of 74 this is a summary
02:12:05 I'm so sorry I got that giving you the wrong one it's um
02:12:13 it's page 73 we should be looking at and we have a table at the top of the page there and we've got some seven calls and
02:12:27 there and we've got some seven calls and this is Sharon Darby contacting cu8 and passing information of our fire survival calls recently received at one forty three thirty now do you know whether she
02:12:39 three thirty now do you know whether she passed on any information earlier than that to see you eight I don't know okay
02:12:52 it looks as if but by that time by 143 we've got seven or so calls passed on at one forty-three and also the the calls
02:13:06 one forty-three and also the the calls that were passed on at 135 on page sixty which we looked at a minute ago that's it looks like seven plus four total of
02:13:17 it looks like seven plus four total of eleven now we don't know whether the first forward properly FSG calls but bye-bye 143 we've got eleven identified calls passed to see
02:13:28 eleven identified calls passed to see you eight by Sharon Darby would that be about right do you think oh I wouldn't know that you wouldn't regard to that if
02:13:39 know that you wouldn't regard to that if I didn't see the time line okay if we look at the operational response report at page 61 and 62 and I'm sorry to ask
02:13:52 at page 61 and 62 and I'm sorry to ask you to keep tossing around it's 61
02:13:59 we've got a number of calls there which is a summary of FSG calls that brigade control have received by this time they start at a 120 120 force I think you
02:14:12 start at a 120 120 force I think you pointed out yesterday then they run 201 3450 and that's some 13 calls at all and
02:14:24 3450 and that's some 13 calls at all and then if you look at page 73 or 74 again we've got a further set of calls between
02:14:39 we've got a further set of calls between 136 and 141 which image which had come in and I think the total number of calls were put recorded by the operational
02:14:51 were put recorded by the operational response report on both of these pages page 61 and 62 and 73 and 74 Josh a new totals 23 FSG calls 13 between o 2o 121
02:15:05 totals 23 FSG calls 13 between o 2o 121 and a 134 and 11 between 136 and o 141
02:15:14 there's 24 calls sorry do you know why only 11 of those total calls total total of 24 calls were passed to the incident
02:15:25 of 24 calls were passed to the incident ground
02:15:30 so can you just confirm you're sailing up from the information only eleven yes flats were past it look yes it looks
02:15:41 flats were past it look yes it looks like from from this analysis done by the NFB that although a total of some twenty four calls had been FSG calls had been made to the fire ground before one or
02:15:52 made to the fire ground before one or buy one 4121 only eleven had been passed to the incident ground and those of the the eleven is the seven that got at one
02:16:03 the eleven is the seven that got at one at that on page 73 at 143 thirteen and then earlier on before we looked at at 135 I wasn't involved in the creation of this report I don't know how okay and
02:16:15 this report I don't know how okay and they classified the first survival guidance course and what the to the differences in the two tables okay all right
02:16:27 [Applause]
02:16:35 when we look at the summary of the radio messages at page 73 of this table for this report and again you may not be able to help me with this this is the
02:16:48 able to help me with this this is the top table the calls which were passed by Sharon Darby to see you eight we see
02:16:59 Sharon Darby to see you eight we see seven of them there can you see that there are a number of instances where information like flat number and the number of people inside aren't given yes
02:17:11 number of people inside aren't given yes okay now assuming as I'm going to ask you to that that is an accurate summation of the messages that are summarized there with that would the
02:17:23 summarized there with that would the absence of flat numbers and numbers of people be in accordance with policy or not in accordance with policy so again
02:17:34 not in accordance with policy so again depending on the classification of the fire survive regardless cold I would be surprised if they were providing fire survival guidance and and protect advice
02:17:45 survival guidance and and protect advice so callers that they haven't got the flat number but again without listening to every core region a transcript of every call you can't really surmise the
02:17:57 every call you can't really surmise the difficulties every call is so different and dependent on what the caller says what advice you give so looking at a blank summary you can it would be unfair to say that it was against policy and
02:18:10 to say that it was against policy and you'd really need to listen to every call
02:18:15 call okay I understand why you what you're saying on why you say there let me see if I can get it slightly different different way can I ask you two terms policy 790 and look at paragraph five
02:18:33 policy 790 and look at paragraph five one
02:18:45 and and that's the start of this passage about information transfer to the incident about what should be passed
02:18:57 incident about what should be passed over as soon as Control has confirmed that NFS G called is in progress now the reason I'm asking you this question is because in the in the ORR the LF B's
02:19:10 because in the in the ORR the LF B's report they have listened to the transcript and this is a summary and I'm just working from that and vena said these are fire survival quarters that's
02:19:21 these are fire survival quarters that's the best expression they use but and that's what CH and RB is passing to the to see you eight looking at the policy
02:19:32 to see you eight looking at the policy but five one says as soon as controllers confirmed that al FSG call is in progress they will contact the incident ground and start to pass over the initial details but this stage is likely to be basic information relating to the
02:19:43 to be basic information relating to the number of persons involved and their location within the property and then if you turn to page or the next page paragraph five point five it says that
02:19:54 paragraph five point five it says that control will attempt we've got it back control will attempt to gather all the information on the control information form we looked at that yesterday and relay this information to incident as as
02:20:07 relay this information to incident as as and when it becomes available and then you've got number of flat or house
02:20:15 and among other things number of persons involved and those are the two first
02:20:29 involved and those are the two first bullet points I'm not sure they're necessarily in a priority order but they are there so my question is if these
02:20:40 are there so my question is if these calls that we're looking at summarized on page 73 of the ORR are properly to be characterized as far survival calls being passed by Sharon Darby to see you
02:20:53 being passed by Sharon Darby to see you ate and where they don't include the number of the flat or the number of persons involved would that not be a a
02:21:05 persons involved would that not be a a departure from what the policy requires so that may have been the initial basic information to tell cu8 that a fire
02:21:16 information to tell cu8 that a fire Survival Guide was caused in progress it depends on each Co the calls could have lasted 10 15 45 minutes and so that information might have been updated on
02:21:28 information might have been updated on every different call that the policy does refer to the incident the initial information and and definitely is likely to have contain the flat number and the
02:21:40 to have contain the flat number and the numbers of persons involved but had we been dealing with a particularly difficult call or one where we had a language barrier or something it might have taken the control room operator longer to obtain those details and after
02:21:53 longer to obtain those details and after they had that they may have been passed on
02:22:03 mr. Chang had to continue with this line of questioning so I'm middle at midstream that I am conscious of with witnesses yes I mean could we break at this point because we could break at this point for a short
02:22:14 could break at this point for a short break in five minutes won't release until how fast should we say to have passed and give us probably quite like a break again now Andrew yes alright well we'll break for just over five minutes we'll resume at half past twelve and
02:22:26 we'll resume at half past twelve and again their discussions anyone please thank you thank you
02:22:42 you
02:30:53 the young picture of flat 153 and I was
02:31:04 the young picture of flat 153 and I was which is met triple zero one six nine one two and I was asking you lots of questions about the absence of the
02:31:15 questions about the absence of the information which which appeared on Shannon Darby's service message what I did not do and I'm now going to do is to show you what what turned up in this
02:31:26 show you what what turned up in this command unit by way of a record of what they got okay and see if you can help explain how that got there if it is you look please at MIT
02:31:35 MIT triple zero one five nine two four
02:31:45 this is it's gonna have to be enlarged now I'll just tell you what this is because I I'm glad to see we've never seen this before now I had no this is a photograph of a
02:31:57 now I had no this is a photograph of a whiteboard taken or created within cu7 from the time at cu7 started operating fully so they'll have to explore the
02:32:09 fully so they'll have to explore the precise time with others but it was it was after the move from cu8 to see you see you seven and if you look at flat one five three just focus on the entry
02:32:21 one five three just focus on the entry for flat one five three we see that the personnel in cu7 have recorded quite a
02:32:32 personnel in cu7 have recorded quite a lot of information about flat one five three including that I'd trouble you with the key but for adults in green five children in in black and then
02:32:44 five children in in black and then someone's put a three in a ring and then a pea in a ring now piano ring needs priority nobody could explain that the
02:32:55 priority nobody could explain that the three in a ring I did I didn't imagine you'd be able to do so
02:33:06 but it looks as if rather more information was passed to see you seven about flat one five three then it was contained on the whiteboard where it
02:33:17 contained on the whiteboard where it simply said for adults five children can you assist with how further detail whatever that is was passed to one five
02:33:28 whatever that is was passed to one five three than appears on the whiteboard where did they get the do you know where they might have got the detail from that appears therefore one five three which wasn't on the whiteboard so I would imagine that would have been through
02:33:39 imagine that would have been through Jason Olaf passing that information to see you seven right again as we've said the whiteboard might think control might have had some basic information but Jason might have overheard conversations
02:33:51 Jason might have overheard conversations or might have had notes pass to them additionally right if you look on the the other whiteboard that you showed that was in control I believe the top entry has your flat
02:34:04 I believe the top entry has your flat number and and ten people as an example I wrote that ten people but I know that more information about that the
02:34:16 more information about that the occupants of those flats we to the sea okay let's let's see let's see where we go to go
02:34:21 go to go that's MIT triple zero one nine sorry one six nine oh six second so secondary down ingredient yeah right we use one with a green pen I write that
02:34:33 use one with a green pen I write that yeah you read that you're memorizing that yes
02:34:36 that yes okay well that's as that's against I'm afraid this picture doesn't show it very well but my version says one ninety three twenty second floor and there's
02:34:48 three twenty second floor and there's smudged deep toe can you help with Danny white says one says ninety three but it should say one nine three yeah I think it's just cut the fact it is I think take it from me that it is and it says
02:35:00 take it from me that it is and it says ten people what extra information do you have about that flat so I would imagine as that maybe that was the first bit of information that came through so I'd
02:35:11 information that came through so I'd have written that up and the control officer was still on the phone to them because then it's been under two adults three children and then the additional instruction that we provided to them I'm just giving an example of
02:35:23 to them I'm just giving an example of how some sometimes basic information went up there but yet further details were passed to the CEO five voice okay where did you get that information from ten people and then someone else's where
02:35:36 ten people and then someone else's where did you get ten people from that would have been one of the control officers during that call and who wrote what looks like two adults three children yeah do you know I don't know know who
02:35:50 yeah do you know I don't know know who wrote told to leave flat do you know I believe that Adrian's writing by I couldn't confirm I would just assume that right and the rest of the
02:36:03 that right and the rest of the handwriting looks similar do you know whether that's his handwriting the rest of it on that board whiteboard I'm just assuming it was because he was there okay not the time okay and ten people to
02:36:18 okay not the time okay and ten people to it it looks like two adults three children if we follow that then through to the command unit white board from
02:36:29 to the command unit white board from flat one nine three
02:36:34 we just enlarge that that looks like again to two adults three children so that could have been updated information that would have gone well let me design
02:36:45 that would have gone well let me design yes the difficulty is we're all interpreting it together there's a there's a faint one next to the two on the Left I can speculate about whether
02:36:59 the Left I can speculate about whether that's supposed to be 12 or - do you remember passing information about this
02:37:11 remember passing information about this flat to control or witnessing it being passed to control know so at one point I would have had that information and written it on the whiteboard right and
02:37:23 written it on the whiteboard right and but again it's speculation but there could have been a 10 and then they as they got updated information it could have been left as a two and a three so two adults three children listen they
02:37:35 two adults three children listen they were told to they were taught by control staff after we changed the decision to leave their premise so maybe a number did oh okay I don't know all right
02:38:12 now
02:38:29 well I'm on this I've been asked to ask you this Oh see how we go if you go to the white board which is one six nine
02:38:43 the white board which is one six nine one two and look at the entry for that one nine to twenty second floor and I'm not going to do this with every every flat favor
02:38:54 flat favor this is okay just because I've been asked to one nine two says 22nd floor fire entering flat and then there's an asterisk brackets left flat seems to
02:39:07 asterisk brackets left flat seems to have been deleted and then it says it looks like bedroom living room and then two women three children so let's go on the whiteboard do do you know how that
02:39:22 the whiteboard do do you know how that information would have been transmitted to the far ground would that be again we're back to the mobile but yeah I would imagine that that would be the mobile right and and we can compare that
02:39:34 mobile right and and we can compare that by reading across to the c7 whiteboard flat 192 you just enlarge that
02:39:46 that shows at 192 - two adults five children but doesn't say anything about
02:39:59 children but doesn't say anything about fire entering flat or any of the other information we saw on the whiteboard it just says two in green which is adults of five in black which is
02:40:10 adults of five in black which is children and then a P in a circle so that's that's prioritization you've built that by mr. egan can you help us to how the or why the information we see
02:40:22 to how the or why the information we see on the whiteboard about fire entering flat doesn't enter the c7 whiteboard I
02:40:33 flat doesn't enter the c7 whiteboard I can only surmise that it doesn't look like any details regarding flats and smoke a written in there but maybe that is why it's got a P and they prioritized
02:40:44 is why it's got a P and they prioritized it yeah okay that would be can you account for that the yes I see okay now
02:41:09 turning to the formalization of messages coming from the incident ground are you aware that control room I think was only given to informative messages from the
02:41:22 given to informative messages from the incident ground I think if we can look at them indeed in the shortest along during what time period just think well it's now it's a good question let's look at them and the first one is in the
02:41:33 at them and the first one is in the short incident log o 114 or rather a 1
02:41:47 it's oh one 1602 in fact oh one fourteen is the make up to one area so this is very early on in the incident it's a short into the log of page 17 and it
02:42:02 short into the log of page 17 and it says informative sup from G 272 residential block of flats do you see do you see that yes it is that kind of message does it conform with a sort of
02:42:15 message does it conform with a sort of standard yes that is that that's what an informative message looks like is it yes both message sounded and within the time so okay
02:42:25 so okay would that I'm sorry I'm sorry I was just gonna say that um we have an alert on our system if we haven't received an informative within 20 minutes of the resources been in attendance and and if
02:42:39 resources been in attendance and and if they weren't we would prompt them and ask them for a message but we received one within the time frame okay and what would that how would that help you
02:42:50 would that how would that help you how would that in for me information help you in the control room at that time what would that tell you I would it would confirm what we'd been caught it that we were dealing with afar on the
02:43:02 that we were dealing with afar on the fourth floor as the initial call stated and that they had implemented high-rise procedure so they were beginning to tackle the fire right
02:43:17 but I believe in general terms whilst it gives a control room a picture it also gives all the senior officers attending a picture that are actually going to the incident so I would say it was more for
02:43:29 incident so I would say it was more for them and information for them and officers monitoring rather than information from for the control room
02:43:40 and the next one we have is add there's one at o2 o4 20 which is c7 GM Welch now
02:43:55 one at o2 o4 20 which is c7 GM Welch now I see but that doesn't tell you anything other than what it tells you it doesn't tell you anything about the about what's happening on the fire ground no and then
02:44:06 happening on the fire ground no and then we have the next one at o2 4203 that's page 23 of the short incident log and we
02:44:21 page 23 of the short incident log and we can see that there informative sup cu8 and it's quite a lot more information there than we saw before what would that
02:44:35 there than we saw before what would that information tell you in the control room how would that help you make decisions so we were together that ready so it says major incident declared we were
02:44:47 says major incident declared we were aware of that and we were aware of the equipment that would have been in use because they just requested that from the incident ground prior to that and obviously we were aware that there were a large number of fire survival guidance
02:44:59 a large number of fire survival guidance of course because we were the ones that were dealing with them and with regard to the floors I think we we were already
02:45:10 to the floors I think we we were already aware at 2:42 that he it had sprayed from what the call is him what the callers were telling us on those calls right so yes we were aware that it wasn't a fire on the fourth floor
02:45:21 wasn't a fire on the fourth floor anymore right if you've only had two informative messages about what was happening on the fire ground coming into the control room in that period up to
02:45:37 the control room in that period up to 242 or so would that be would that be normal for a substantial incident I would say my experience sometimes it would be normal yes sometimes a large a
02:45:50 would be normal yes sometimes a large a large incident we would receive an initial message and then we wouldn't receive one floor an hour an hour and a half after yes especially if they'd been a number of makeups right between the
02:46:03 a number of makeups right between the first informative inuring in your own experience
02:46:10 how well equipped in terms of information would that leave you in the control room in my experience we wouldn't be dependent on it we would always be considering some possibilities
02:46:22 always be considering some possibilities if we hadn't had a message we may occasionally have prompted the incident or the CEO for a message right and but it wouldn't stop us doing our role and carrying out our role and we were just
02:46:35 carrying out our role and we were just a number of options before we had them confirmed by the CEO right do you did you think at the time come to 4242 that
02:46:46 you think at the time come to 4242 that you had received enough information to be able to have your control room officers give adequate advice to callers
02:46:57 officers give adequate advice to callers who were calling in yes by 2:42 we had changed the advice I come to the change in the advice but in terms of information coming from the control from
02:47:08 information coming from the control from the incident ground by 242 did you think that you were getting enough information to be able to make decisions or did you think that the information was insufficient that you were getting from the incident ground I think if we'd had
02:47:20 the incident ground I think if we'd had some further information with regard to the location of be a cruise and where they were and we would have been able to pass that on to callers and I made an
02:47:32 pass that on to callers and I made an assessment by there but again at that time we weren't informing callers that we had fire crews there and they were on
02:47:43 we had fire crews there and they were on their way and what information about the location of be a cruise were you receiving in the incident in the control room no we didn't have any information
02:47:55 room no we didn't have any information did you take any steps to ask the command unit for that information no we were aware at one point Adrian
02:48:06 no we were aware at one point Adrian Fenty was on the phone to the incident and when we were aware that they were struggling to get past the 15th floor what time is that do you think I think
02:48:17 what time is that do you think I think that was
02:48:19 that was one of the reasons that we decided to change the advice so it would have been around 225
02:48:48 did you have no information at all prior to let's say 2:30 about whether VA crews
02:49:00 to let's say 2:30 about whether VA crews have been deployed to flats where FS G's are coming from no can I just ask you to
02:49:11 are coming from no can I just ask you to look at her at the control debrief document which is tab 54 of the of the documents bundle we look at it yesterday
02:49:29 turning it to you
02:49:35 a page for please
02:49:45 and first of all at the bottom of the page they think we looked at this yesterday but at the bottom of the page no see this is part of the debrief we
02:49:57 no see this is part of the debrief we had been you had in July 2017 it says no info coming back from incident ground as to progress straight rescues straight flats cleared the time you did this
02:50:08 flats cleared the time you did this debrief
02:50:11 debrief what kind of his first ask who said that at this meeting I would imagine we all did
02:50:19 did you all did yeah and did you all say that because the absence of information coming back from the incident ground about those matters was a problem no I
02:50:30 about those matters was a problem no I think it was a consensus of information that we didn't receive any information back I can't remember the conversation whether we had been asked if it was a
02:50:41 whether we had been asked if it was a problem or if we had just volunteered that there was no information coming back right why was it relevant to mention the absence of information coming back from the incident ground if
02:50:55 coming back from the incident ground if it wasn't a problem okay I said I can't remember the context is it but it it we didn't have we didn't receive any information back into the control room
02:51:06 information back into the control room regard to progress and rescues and those attempting to reach the flats where we have first survival guidance causing progress okay just a little higher up the page a third of the way down there's
02:51:18 the page a third of the way down there's a bullet point that says control new firefighters were being committed to rescue you can just have that highlighted
02:51:32 it's the second part of the first yellow chunk second bullet point you see it says control new firefighters were being committed to rescue expectation this will happen is that right the control
02:51:47 will happen is that right the control did at least know that firefighters were being committed to rescue no I think that's what they believed and that we maintain an expectation that that will
02:51:59 maintain an expectation that that will happen right so to be clear this is this document isn't recording the fact that control did know that firefighters were being committed it's controlling its
02:52:11 being committed it's controlling its complete recording the expectation that it was it's recording that the expectation of control staff and you can hear that in the course that they will firefighters will be committed to rescue
02:52:23 firefighters will be committed to rescue I would imagine that we we would have all assumed and maybe from the first informative that indicated that their high-rise procedure employee did that firefighters had been committed to the
02:52:35 firefighters had been committed to the incident but you didn't know but with regard to the location of those firefighters in the building no we didn't know did you know whether
02:52:46 didn't know did you know whether particular sorry do you know whether ba crews have been committed in response to a particular FSG call even though you
02:52:57 a particular FSG call even though you didn't know where they were in the building
02:52:58 building no right
02:53:04 now I'm going to go on to the change to the staple policy and mr. Chandler it all that's a change in topic it might be sensible to start it I don't mind am in your own in your
02:53:15 I don't mind am in your own in your hands how you doing I'm thinking like well so well that we need to make it pause now it would be better to pause now rather than break a topic so long as we're not pressed for the odd few minutes at the end of the afternoon
02:53:27 minutes at the end of the afternoon whether if we are we can I can apply to make them up I think you'd be wiser to stop that again the moon took we're going to move to another topic and it's well it's a bit disruptive to break it
02:53:38 well it's a bit disruptive to break it up after five minutes so you know we'll stop now until two o'clock and please don't talk about your evidence over the break thank you very much thank you two
02:53:57 break thank you very much thank you two o'clock please
02:54:07 you