Senior fire officer Andy Roe testifies about arriving at Grenfell as Assistant Commissioner, witnessing complete building system failure, and taking command of the unprecedented rescue operation.
00:00:22 Right. Mr. Row, you ready to carry on? Thank you, sir. Good. Yes, Mr. Mr. Good afternoon. I I wanted just to ask you one or two questions about the contents of GRA 3.2, but to be absolutely clear it's on the footing
00:00:34 absolutely clear it's on the footing that uh you wouldn't be necessarily familiar with the detailed content contents of the document, but the principles in it because I understand what you said just before lunch about it being a template for individual fire and
00:00:45 being a template for individual fire and rescue services to create their own policies around. Can I start by asking you please to look at um page 8 internally within the document? It's LFB quadruple01255
00:00:56 quadruple01255 page eight that's um uh there and I want to to show you under construction technique in the middle of the page. Do you see in the second paragraph
00:01:05 paragraph it says combustible material in voids and cavities and poor quality construction can also contribute to the spread of fire and smoke beyond the compartment of origin. Um my question is
00:01:17 compartment of origin. Um my question is as a general principle as at Gr the night of Granfell were you aware of that as a risk? Yes absolutely. Did you ever have any training yourself in how to assess uh
00:01:28 training yourself in how to assess uh the risk of combustible material in voids and cavities and poor quality construction contributing to the spread of fire and smoke? I've had training about the general principles of building instruction that
00:01:39 principles of building instruction that included um passages about the possibility of this occurring. In terms of assessing, it'd be very difficult to make an assessment of the detail of that from, you know, the externals of a
00:01:50 from, you know, the externals of a building without knowing how it had been, you know, how it had been built during the construction phrase. So, the answer is yes, I'm fully aware of the risk, but I wouldn't have had detailed training around how you would then
00:02:01 training around how you would then assess it, particularly from our perspective at an incident. Right. So, how would the fire brigade or any fire brigade but the LFB in your case actually go about making any kind
00:02:12 case actually go about making any kind of assessment of that risk without some detailed training on what's in front of them?
00:02:16 them? Well, I think you get some good training about the way that particular materials react. So, I'd have have an understanding of how a particular material might react, whether it was, for example, wood or plastics or
00:02:29 for example, wood or plastics or compressed foam or any of a number of materials that might be used in the construction of a building. um I would be making a judgment um at an incident in the context of what the fire was
00:02:40 in the context of what the fire was doing. So for example, if I can, could I use Grenville as an example? Yes.
00:02:44 Yes. So when I arrived at Grenford, it was very clear to me that there there was an issue with the building that went well beyond the external fascia because to have had the extent of internal fire spread that I was that I immediately
00:02:56 spread that I was that I immediately saw, it was very clear to me there must have been voids within the building through which that fire had spread. Um so that would have im immediately led me to believe that there was an issue possibly due to prior building works or
00:03:07 possibly due to prior building works or renovations that had meant that fire compartmentation hadn't been maintained through voids whether that was through service ducks or whether it was the poor fitting of doors or whether it was of something of an inappropriate nature
00:03:18 something of an inappropriate nature within the construction. So that's the sort of assessment I would have made and then I would have had to have made my instant planning based on that assumption. In terms of the specifics of construction, um I would have known
00:03:30 construction, um I would have known again in the context of Grefall, I would have known almost immediately through experience and the training I had around high-rise that that was concrete slab construction of a certain age. I could
00:03:41 construction of a certain age. I could see that there was a some sort of facial on it. But I would also know that a lot of those blocks have gone through the better homes renovation program, for example, and that are likely to have had previous renovation works on them. and
00:03:52 previous renovation works on them. and that actually we had had incidents across London in other blocks where those renovations hadn't been completed to an appropriate standard and there had been fire spread. So actually Lac canal
00:04:03 been fire spread. So actually Lac canal is perhaps one example of that. So that it was definitely in my mind and there's been a variety of training where I've picked up that information both specifically about high-rise and incidents but also about building construction.
00:04:14 construction. Right. Okay. We'll come to an example of that shortly perhaps. But before I leave this document, can I just show you one or two other passages in it? Turn same sort of theme. Turn to page 16 internally 18 of the relativity
00:04:26 internally 18 of the relativity reference. Now this is under this is part of the way through the passage which starts two two pages before page 14 key control measures planning uh and
00:04:37 14 key control measures planning uh and at the top of the page it says information to be gathered in relation to high-rise incidents should include and there's a very long list um and uh four bullet points up from the bottom it
00:04:48 four bullet points up from the bottom it says building construction features such as the presence and location of mason style construction sandwich panels timber framing cladding systems service mounted trunk sunking, ducting and voids in addition to features which present a
00:05:00 in addition to features which present a specific hazard such as asbestos. Now I should tell you because you may not know this uh that the word clad or phrase cladding systems does not appear in the LFB list which is appendix one of
00:05:12 in the LFB list which is appendix one of policy 633 but so just you should have that fairly in mind.
00:05:18 in mind. Leaving that on one side, were you familiar as at Gr as at the time of Granfell Tower that it was important or essential for uh um fire and rescue
00:05:29 essential for uh um fire and rescue services to gather information pre-inccidents about cladding systems? Not specifically cladding systems, but the the premises risk assessment process, which we have embedded within
00:05:40 process, which we have embedded within the brigade, is a fundamental part of of pre-planning for an incident and preparing crews for what they might face. Um, so I wouldn't say specifically about cladding. Right. Okay. Do you while I'm on the
00:05:51 Right. Okay. Do you while I'm on the point, do you did you know that the LFB version of of this didn't contain the word cladding cladding systems? No, I didn't. Right. Right.
00:06:03 Right. Right. Uh,
00:06:07 did you have any involvement, and I'm straying a little bit, but forgive me. Did did you have any involvement in drafting or supervising the drafting of policy 633? No, I didn't.
00:06:18 No, I didn't. Right. Um do you um could you then turn on to page 17 internally of this document
00:06:29 internally of this document uh which would be 19 of the relativity reference and it says at the top of the page contingency plans for particular premises should cover fire spread beyond the compartment of origin and the potential for multiple rescues and an operational evacuation
00:06:42 rescues and an operational evacuation plan being required in the event of the stay put policy becomes untenable. Um, as at the time of Granfell, were you familiar uh with the principle that bu contingency plans for high-rise
00:06:53 contingency plans for high-rise buildings should contain or cover those things?
00:06:57 things? Yes, I was. And I think it's covered internally for us in policy 790, which is the FSG. So whilst it might not be written exactly like that, that policy does refer to the fact that actually as
00:07:08 does refer to the fact that actually as an incident commander, you might have to consider the possibility that the stay put advice that to be frank works in 99.9% of cases and is proven to keep people safe might not apply in very
00:07:20 people safe might not apply in very extreme circumstances and you therefore might have to consider a strategy whereby that um advice was reversed and consider how you might then manage that incident.
00:07:30 incident. Right. Okay. Well, we'll come to the reversal in due course because I know there's a lot you can tell us about that. But just looking on this page um itself, uh would would you expect
00:07:41 itself, uh would would you expect incident commanders as at the time of Grenell Tower to to to be looking out for contingency plans at premises on attendance which would cover those matters?
00:07:51 matters? I think it's very unlikely that you're going to have a pre-written evacuation plan in the context of a residential block because it flies in the face of um actually the kind of framework that building regulations lay down and our
00:08:03 building regulations lay down and our expectations at that at that building. It would be more that I would expect it to be in the minds of an instant commander that there is the possibility that things can spread beyond the compartment of origin and therefore you
00:08:14 compartment of origin and therefore you might have to manage an evacuation any sort of building actually. Right. Um um but in terms of your question about whether I'd expect people to have an understanding that they would need to look at our entry on the
00:08:26 need to look at our entry on the premises risk assessment database. Yes, I absolutely would.
00:08:31 Right. So does that mean that the entry for the high-rise block on the premises risk assessment would or would need to be sufficiently detailed so that an
00:08:42 be sufficiently detailed so that an incident commander attending the scene would be able to have in mind clearly and accessibly contingency plans covering those two items.
00:08:53 items. I don't think I would expect our our plan to cover um the an evacuation of the block because again it flies in the face of national guidance and policy. I
00:09:04 face of national guidance and policy. I would expect them generally as a principle to have that thought in mind. I would expect there to be particulars about types of construction if they were likely to pose um either a particular challenge to us or they would be of
00:09:16 challenge to us or they would be of interest to us because that might affect the way the building operated in a fire or it might be that it's an interim um entry covering a period of renovation for example or particular changes to
00:09:27 for example or particular changes to firefighting installations. That's the sort of information I expect to see there in respect to our tactical plan. What I wouldn't expect is for example a detailed plan of how you might evacuate a building because frankly how you
00:09:39 a building because frankly how you evacuate a building would be affected by the location of the fire, the nature of fire spread and the resources you had available to you. I think it'd be very difficult to write something you know that would cover all aspects and
00:09:50 that would cover all aspects and therefore there's a danger in that. It's more about understanding the general principle. Right. On the assumption, well, on the assumption that the contingency plans would be made by the building owner, would you expect the uh fire and
00:10:04 owner, would you expect the uh fire and rescue service, in this case, the LFB, to be able easily to have to have access to those contingency plans? Yes, I would. I would I would expect any building which has a premises risk assessment on it. So I'm I'm talking
00:10:15 assessment on it. So I'm I'm talking about our own risk assessment on the one hand, but if we're talking about the responsibility of a building owner under the regulatory reform order to have undertaken a risk assessment and there to be something sufficient there in
00:10:27 to be something sufficient there in terms of a contingency plan. Yes, I would expect as an incident commander to have that available to me so I could refer to both sets of information to aid my decision-m. Right. So just taking this taking this
00:10:38 Right. So just taking this taking this incident, does that mean that your expectation would be that when Mike Davin attended as incident commander first on the night of the incident, he should have been able to access
00:10:49 should have been able to access contingency plans such as those in the OAD?
00:10:52 OAD? From the OAD, yes, but that's that's not the same as uh a contingency plan written by the building owner. So, in the context of that high-rise block, I wouldn't have expected um a contingency
00:11:03 wouldn't have expected um a contingency plan to be available from the um housing provider, I would have expected sufficient entry on the OAD to enable Mike to formulate a plan with some
00:11:15 Mike to formulate a plan with some informed um you know, some some information that would help him. Yes. And I expect him to interrogate that. I would expect at some point in the incident to have a detailed set of plans
00:11:26 incident to have a detailed set of plans particularly as time went on and we had the attendance of the local authority there from the local authority to help us. Yes.
00:11:32 us. Yes. Yeah. Well, again, we keep promising we'll come to things. We will pro well I promise you we will come back to the the plans point in a moment, but just going back to Mike's what you would expect Mike to be able to do by way of formulating a plan with some information
00:11:44 formulating a plan with some information that would help him. Would you expect him to be able to access contingency plans which would cover fire spread as you see here uh in the first
00:11:55 spread as you see here uh in the first bullet point and an operational evacuation plan? I would expect him to access information from our OD that gave um him a good understanding of the size of the building, the design of the floor plate,
00:12:06 building, the design of the floor plate, where the fixed installations were. So the things that are going to help him firefight or any officer firefight um whether there was a smoke ventilation system um whether there was anything particular about the layout of the
00:12:17 particular about the layout of the building that might prevent present challenges to us. So these that's one of the lessons from Lacanal. So whether it was a um a scissor block or whether it was mason you know whether there was more than one point of access whether
00:12:28 more than one point of access whether there was a single staircase or whether there was more than one staircase. These are the bits of information that would have helped Mike at that point to formulate a plan because they would have influenced his tactics to attack the fire and make entry into the building
00:12:39 fire and make entry into the building where the hydrant is. All of those things.
00:12:41 things. Have you ever had a chance to review the OD entry for Grenfield Tower as it stood as of June 2017? Only subsequent to this incident, right? You didn't ask for it on the night.
00:12:52 night. I did ask for it on the night more than once.
00:12:54 once. Did you say it? Um, and an an officer at the time pulled up the information for me on the command unit and actually briefed me as to what was on it. And to be honest with you, I don't think the information that was on it was adequate
00:13:06 information that was on it was adequate at the point I was in command of the incident to really give me anything additional that I didn't already know. Right. Was it adequate at all, did you think?
00:13:13 think? Um, it wasn't to the standard I would have liked to have seen. In what in what respect? in the sense of the detail held upon it and the and um perhaps the detail of the tactical plan.
00:13:27 perhaps the detail of the tactical plan. Yes,
00:13:27 Yes, I can't remember the exact detail of the OD. I I wouldn't be able to give you that detail now. It'd be wrong to suggest that. But at risk of deviating substantially from my tactical plan, can I just ask
00:13:38 from my tactical plan, can I just ask you to um look at the OAD um just briefly um you you'll find it. It's in our master documents bundle at tab 13. Uh, and it's LFB quadruple03116.
00:13:51 tab 13. Uh, and it's LFB quadruple03116. There it is. If I could just ask you to turn to page three. I'm so sorry. Page four.
00:14:02 Um, you can see there what? Well, you can see the words at the top of the page. Tactical plan and then operational contingency plan. C. Do you see anything on on on on that page
00:14:14 on on on on that page um or the next page when we look at it which would um have given Mike Dunn, do you think full enough information to be able to attack it? It's given Michael some information. So, for example, the hydrant location, I
00:14:28 So, for example, the hydrant location, I mean, I think it's unhelpful that it says it's a high-rise block of 20 floors because clearly it's not a high-rise block of 24s, it's a block of 24 floors. Um,
00:14:38 Um, again, you know, I think there's some useful detail about the smoke extraction system. The fact it's got a dry rising main, the fact that they've referred to the coms in the subb is useful because that's often an issue for us and that
00:14:49 that's often an issue for us and that someone's obviously checked that. Um, I don't think there's a particular issue with the operational hazards, but they're very generic, right?
00:14:55 right? Um, that could be applicable to any number of highrises throughout London.
00:15:02 Yes. But there's not a huge amount of detail. No. None.
00:15:05 No. None. Right. Uh now we may need to come back to that in due course so we look at the detail. Just going back to where I was if I may. Going back to the generic risk assessment 3.2. If I can just ask you
00:15:16 assessment 3.2. If I can just ask you please to turn on
00:15:21 uh where we were we were at page 17 internally. Can I ask you to turn on please two pages to page 19. That's um page 21 in the relativity reference. uh and at the foot of the page you'll see a
00:15:32 and at the foot of the page you'll see a paragraph which starts training which will cover high-rise incidents must include and this sits within the part of this policy which is headed training competence and training training which
00:15:43 competence and training training which will cover high-rise incidents must include and there are two bullet points the first is the development of knowledge skills and understanding for firefighters on the impact of fire on the building's construction layout contents and occupant behavior
00:15:55 contents and occupant behavior now just just focusing on that first one um did you yourself ever personally ly receive any training of that kind? Yes, I think over the years I've received a lot of training of of that kind across lots of different packages.
00:16:08 kind across lots of different packages. Not not always necessarily referring to high-rise um firefighting, but particularly around the general principles of construction, the importance of understanding a building layout um across all areas of our
00:16:20 layout um across all areas of our operational business, whether it's how you might manage hose inside a building or how you might search a building when conducting breathing apparatus op um operations. you know, the particular challenges of managing, you know,
00:16:31 challenges of managing, you know, specific contents. For example, you know, a Yankee hazard, an explosive hazard, or the possibility, for example, that we might have oxygen cylinders because people were on medical oxygen in a block. So, lots and lots of different
00:16:42 a block. So, lots and lots of different training packages which are relevant to build a wide knowledge base as a professional firefighter. Yeah. Did you ever receive training in the context of this bullet point uh on
00:16:53 the context of this bullet point uh on the impact of fire spread over the exterior facade of a high-rise block? Yes, I did. in the in the sense that I'd received the post lacanal training package and obviously that refers quite
00:17:05 package and obviously that refers quite clearly to the possibility of lateral downwards fire spread, vertical fire spread, the possibility of it moving between the compartment of origin to other compartments and the possibility that there could be voids within a
00:17:17 that there could be voids within a building that would allow that and the challenging layout of certain buildings might also enable that. Right. What was that training? Uh it was the post I can't remember the exact title of it but it was the post lacanol incident training package. I
00:17:28 lacanol incident training package. I think I received that in probably 2014. Right. And did you train as part of that training exercise on how to um deal with
00:17:39 training exercise on how to um deal with or extinguish a a fire on the exterior above 32 m? Uh no, not specifically. No. Right. So, um Right. I see.
00:17:51 Right. So, um Right. I see. Did you did any part of that training cover um multiple failure of compartments within a high-rise block? Um it did to an extent in that it made it clear that that was a potential risk
00:18:02 it clear that that was a potential risk depending on the building's construction and that you might be faced with a situation where you couldn't necessarily rely on the extent kind of um regulatory framework I guess that you couldn't
00:18:13 framework I guess that you couldn't always rely on the state policy or the protection that compartments normally offer. Right. So I think that training package was clear in that and it made that risk real for firefighters and officers.
00:18:24 for firefighters and officers. Right. Does does that just follow up on that? Does that mean that although a firefighter or even an incident commander might normally expect or that the building regulations have been complied with?
00:18:36 complied with? Um nonetheless they had to be alert to the idea that they might not have been. I think that again I want to answer the question perhaps in a bigger principle which is I would expect as part of
00:18:47 which is I would expect as part of instant command we use a decision-m model that you should always make your assessment on the basis of what you see in front of you and part of that may well be to expect the unexpected. I think you start out with a reasonable
00:18:58 think you start out with a reasonable set of expectations that building regulations in particular are going to create an environment that is safe as possible for firefighters to operate in and is as safe as possible for people to work and live in. But that obviously
00:19:10 work and live in. But that obviously because of human nature, because of the fact that humans are building these buildings, there there is always the possibility of error, there is always a possibility that something might not have been done to the correct standard and therefore the building might react
00:19:21 and therefore the building might react in a different way and you will have to adjust your plan in that context. Yes. Sticking with this page, second bullet point, effective call handling and management of any fire survival guidance calls. Um
00:19:32 of any fire survival guidance calls. Um did did you yourself ever receive any training on effective call handling and management of fire survival guidance calls? Yes, definitely. And I think particularly post Lacanel there was a big push really to review that policy
00:19:45 big push really to review that policy and then again go out to officers and stationbased crews to disseminate the learning that came from Lacanau. Um because there was some learning around fire survival guidance that came from
00:19:56 fire survival guidance that came from lacal. So yes, and then uh next page in the GR page 20 internally page 22 of the relativity reference um
00:20:08 page 22 of the relativity reference um as the last no four four bullets up from the bottom um towards the middle of the page that the bullet point says evacuation and casualty removal tactics and then it
00:20:19 casualty removal tactics and then it says this incident commander should understand when a partial or full evacuation strategy might become necessary in a residential building where a stay put policy is normally in place. My question is did you as a in
00:20:33 place. My question is did you as a in when doing incident command training um ever get any training on how you should make the assessment as to when a full or partial evacuation strategy might become
00:20:45 partial evacuation strategy might become necessary? No, I haven't. Although I I am acutely aware that it is in both our high-rise policy, it's implied in our high-rise policy uh and is in our fire survival guidance policy. But I've not received
00:20:56 guidance policy. But I've not received specific training as to how I might carry out um a partial or full evacuation. Does it follow from that, Mr. Ray, that you therefore wouldn't expect a first
00:21:07 you therefore wouldn't expect a first responding incident commander at an incident to be able uh to um assess or or be fully equipped to be able to assess uh whether a full or partial
00:21:20 assess uh whether a full or partial evacuation would become necessary. I think that um I would expect them to make um a reasonable judgment based on their own experience and what they saw in front of them as to whether one was
00:21:32 in front of them as to whether one was necessary as to how the building was reacted. Cuz actually I think there is an element of common sense to this as well that if things have spread beyond the initial compartment, you're you're going to have to take a judgment on how far beyond the the initial compartment
00:21:43 far beyond the the initial compartment it has spread as to when a partial or full evacuation might be required. Um, so I would have an expectation that people could apply common sense in the context of their experience as to when
00:21:54 context of their experience as to when that might be necessary. But what I wouldn't expect um is for example a junior officer like Mike Dowen to have taken that decision at Grenville because we were talking about something that was
00:22:05 we were talking about something that was on such an exceptional scale and with such profound difficulty that it was almost an impossible decision to take actually.
00:22:12 actually. Let me
00:22:12 Let me on a simpler instant potentially. Yeah, let me just see if I can focus a little bit more on that. Can I ask you to look at 6 633 uh
00:22:24 uh high-rise firefighting? Uh and I'd like you to go please to paragraph uh
00:22:37 um so I'm so sorry I've given you the wrong reference. What I'd like you to look at is is 790 [Music]
00:22:43 [Music] which is FSG. And look please at paragraph 8.7
00:22:54 and paragraph 8.7 um you can see that the it says in exceptional circumstances an IC may consider informing control that their
00:23:05 consider informing control that their advice to FSG callers should be altered for example to attempt to leave their property.
00:23:12 property. Now
00:23:13 Now my question on on that is did you ever or would you ever expect a watch manager to receive training on how
00:23:24 watch manager to receive training on how to go about making that judgment call namely altering this the advice to FSG callers say that they should now attempt to leave.
00:23:35 to leave. Genuinely, I think that that is an extremely difficult decision for a junior officer to hold. And I think we haven't provided training that would necessarily equip them for that magnitude of decision because you're
00:23:46 magnitude of decision because you're flying completely in the face of national guidance everything we're taught to understand about buildings. I think that at the point you get to, you know, telling control that people may
00:23:57 know, telling control that people may have to leave their flats contrary to that policy, you're probably at a very significant incident cuz my experience tells me that, well, this is the only instant over a really busy operational career that I've
00:24:09 really busy operational career that I've had to attend where we've had to reverse that policy. Right?
00:24:12 Right? I think that's a very difficult decision for a junior officer to hold. And whilst it's in the policy, I don't think that we've provided specific training that would perhaps allow them to fully explore the possibility of that.
00:24:26 explore the possibility of that. Okay. Um,
00:24:29 Okay. Um, do you recall either receiving or delivering uh training on tall buildings facads?
00:24:38 facads? No.
00:24:40 No. Can I show you a document? Uh, it's uh a slideshow. LFB quadruple03521. It's tab 10 of our master documents bundle. Uh now this is an LFB tall
00:24:51 bundle. Uh now this is an LFB tall buildings facade slideshow. It runs for some 35 pages. Uh it it bears the date of the 13th of July 2016. Um but it is it in fact was rolled out sometime in
00:25:02 it in fact was rolled out sometime in October 2016 as we're as we're informed. Uh and it postdates uh the fire at Shepherd's Court in August 2016. Just to give you some background. First question
00:25:13 give you some background. First question is, have you ever seen this document before?
00:25:15 before? No, I haven't. Right. Can I ask you please to turn to page 25?
00:25:21 page 25? Um, this is the general conclusion. It's not at the end of the document. It's somewhere buried in the middle of it. But this is the general conclusion. And um, you can see what stated there. As a general principle, the external envelope
00:25:32 general principle, the external envelope of the building should not contribute to the fire spread along the facade. New construction material and method of construction are being used in facades and with a limited understanding of their fire behavior stroke performance.
00:25:44 their fire behavior stroke performance. There is a need to understand what products are being used in the facade system and their behavior and if they are used appropriately and meet the relevant guidance. These could affect
00:25:55 relevant guidance. These could affect the way fires develop and spread in a building. I've read it all out to you because there may be quite a lot to unpick. But in general terms, as at the time of the Granfell Tower, did you understand uh that new construction
00:26:07 understand uh that new construction material and methods of construction uh were being used with a limited understanding of their behavior uh fire behavior and performance? No.
00:26:17 No. Right. I
00:26:17 Right. I I wouldn't I wouldn't have assumed that. I would assume that there are challenges around the use of modern methods of construction because actually the building industry is continuously innovating and developing the way it
00:26:28 innovating and developing the way it builds buildings and I think we're constantly having to learn about new materials and the way they react in fire. But my base assumption would always be that these buildings are being constructed within the framework of
00:26:39 constructed within the framework of building regulations which have very clear principles about external fire spread. as it says at the top of that slide, a general principle that the facade will not contribute to the fire spread itself. Um, and therefore any new
00:26:52 spread itself. Um, and therefore any new building materials that did come onto the market were used particularly in the building of residential blocks, I would have assumed have been tested and considered in the context of that framework and that guidance. So no, my I wouldn't have gone to a fire expecting
00:27:05 wouldn't have gone to a fire expecting it to react the way it did. No. Were you although you did you obviously weren't aware of of that principle were you aware that there was in any event a general need for the LFB in general an
00:27:16 general need for the LFB in general an incident commander in in particular to understand what products are being used in the facade system and their behavior. Um I'm I'm not sure that it's possible for a fire officer to maintain that
00:27:29 for a fire officer to maintain that level of detailed construction knowledge probably to the level of detail you need because there are so many different products on the market. There's so many different ways of frankly putting a building together. It is about being able to trust the building regulation
00:27:41 able to trust the building regulation framework, knowing generally how a building is going to react. What I would say I do expect as a general principle is that you must always as an instant commander and and I've said it more than once, expect the unexpected. So it's
00:27:53 once, expect the unexpected. So it's more about having an open-minded attitude to decision-m when you arrive at an incident and then intelligently using a decision-m model to unpick what might have happened. If you then have a good understanding of basic material
00:28:05 good understanding of basic material behavior. So there's only a certain range of materials that uh anything can be built out of whether it's plastics, whether it's wood, whether it's metal, concrete, all of those materials, you know, most firefighters are going to
00:28:16 know, most firefighters are going to have an understanding of how they're generally going to react. There may be some specifics and actually I think there was with Grenall which really catch you out. Um but generally I would be working on those base principles that
00:28:27 be working on those base principles that if I come to an understanding there's a certain sort of construction within a building and I then look at that in the context of what's happening with the fire even if I don't have specific awareness of that building system I'm
00:28:39 awareness of that building system I'm likely to be able to make a professional judgment about the tactics to apply because I have a good general understanding I've been trained with a good general understanding of the basic materials and methods of construction
00:28:51 materials and methods of construction as as part of the unexpected that you would expect an incident commander to expect? Would one of those unexpecteds be uh the unusual development of a fire
00:29:05 be uh the unusual development of a fire and its spread because of uh the particular products being used in the facade? I think as a general, not necessarily in the facade, but really
00:29:16 necessarily in the facade, but really just as a general principle, I would expect any incident commander to arrive at an incident with an open mind, understanding the principles by which a building would normally operate because obviously you need people to prepare
00:29:27 obviously you need people to prepare before they even arrive at the incident with their on arrival tactics, what I would reasonably expect them to start doing at the start of an incident. So you don't want them to come so open-minded that they deviate from a normal course of action that generally
00:29:38 normal course of action that generally keeps people safe and and will properly resolve the incident. But at the same time they need to be open-minded enough that if that initial plan clearly isn't meeting the needs of
00:29:49 plan clearly isn't meeting the needs of the incident, they go back around the decision-m cycle and consider all other particulars. The facade will fall into that. But I wouldn't limit it to the facade. It'd be any aspect of that building's construction. And actually in the in the case of Grimalt one of the
00:30:03 the in the case of Grimalt one of the first things that I thought was not about the facade but there must have been significant failure of the internal compartmentation because the facade alone could not explain what I saw. So I
00:30:14 alone could not explain what I saw. So I think it quite rightly the questions have been focused on cladding and facade for a lot of you know um this inquiry and and the media itself. But actually, I think the bigger story is about how we
00:30:25 I think the bigger story is about how we got to that place of such rapid and catastrophic internal fire spread. And and my immediate thought was that something had gone very wrong inside the building as well. It wasn't just about
00:30:36 building as well. It wasn't just about the facade cuz it couldn't explain the level of internal fire spread that I was witnessed to within the time scales with which it had occurred. Okay, I'm going to come back to this in just a moment. I I have to ask you this
00:30:49 just a moment. I I have to ask you this question and rising out what what you've just said. What was it about what hap about the internal structure uh which led to that catastrophic failure you've just described? Well, obviously I can't tell you in
00:31:00 Well, obviously I can't tell you in detail because I'm not a fire investigator. I haven't been inside the the building since the fire, but my assumption as an instant commander when I got there was that, you know, I can only describe what I saw. So, when I arrived at the building, I was able to
00:31:11 arrived at the building, I was able to look laterally through the building and see right through compartments and see that flame spread. And although I couldn't see exactly, I judged that it actually had probably breached the lobby as well cuz I could just see through the
00:31:24 as well cuz I could just see through the building. So my guess was that therefore that was spreading through voids or through a failure of some piece of internal compartmentation. It couldn't just be about the facade. And and my
00:31:35 just be about the facade. And and my guess was that and that it was a guess but it was a professional judgment taken on the night was that perhaps had occurred because of previous renovation works
00:31:45 works that that would that would have been my professional judgment at that point. I looked at the block and thought it's extraordinary the facade has spread like this that I couldn't believe cuz that was utterly exceptional. Um but I was far more shocked about the
00:31:58 Um but I was far more shocked about the level of internal fire spread. So the fact that the facade had you know kind of acted as uh the petrol as it were to spread the fire all over the building was one thing that was obviously genuinely shocking but it was the
00:32:09 genuinely shocking but it was the complete failure of the building system that caught me by surprise. You know, you you might reasonably have judged if the internal com compartmentation was okay that although the facade had
00:32:20 okay that although the facade had behaved in a way we absolutely wouldn't have expected and shouldn't have perhaps have been allowed. What I wouldn't have expected is the complete failure of the internal compartmentation as well. You know,
00:32:31 compartmentation as well. You know, there would be a degree of that because it was a warm summer's day and windows were open. You know, that was a lesson from Lacanau. I could accept it might have been about the window frames themselves because again, that was a lesson from Lacanau. I thought about that. But to then see the level of fire
00:32:45 that. But to then see the level of fire spread through the building, I mean I I still don't know the reasons for that. So it's just my professional judgment would be there must be some fundamental issues with the internal compartmentation and its maintenance. Thank you for that. Just going back to
00:32:57 Thank you for that. Just going back to this slideshow and and ignoring the details. Um, at the time of the Granfield Tower fire, were you aware that there was an emerging question or issue uh about the risks of fire spread
00:33:09 issue uh about the risks of fire spread posed by exterior facade systems? Yes. Although I hadn't seen this presentation, you know, as a professional officer at the level I'm at, I I want to have an understanding of what's happening elsewhere in the world.
00:33:20 what's happening elsewhere in the world. And I I know that there had been fires I think in the Middle East and in Europe um and perhaps somewhere on the Indian subcontinent um where there had been a spread of uh fire um through external
00:33:33 spread of uh fire um through external fasc. But what I was also aware of was that those fires generally hadn't resulted in the complete failure of internal compartmentation I was witnessed to on the night. It was more about the the fact that you know you
00:33:46 about the the fact that you know you could possibly encounter this but that was really quite close to going to the instant itself. Right. So you were aware there was an emerging issue based on your knowledge of those fire just professional interests. Right. I
00:33:58 just professional interests. Right. I see. But was there any training or any intelligence being shared within the senior LFB community about the risks of fire spread unexpected fire spread posed
00:34:09 fire spread unexpected fire spread posed by these systems. These are facade systems.
00:34:11 systems. No there wasn't. I think it was just something I picked up in myself and I I'd seen it and and was interested in it.
00:34:16 it. Um, as of at June 2017, had you had any training or experience on how to assess the risk that a a fire spreading over the exterior of a high-rise building
00:34:27 the exterior of a high-rise building could break back into the building. I had I think that's covered in the lacanal training package because I think that package makes it really clear that there is the possibility of vertical
00:34:38 there is the possibility of vertical horizontal and downward fire spread where elements of the building fail. So I think again it's about a general principle that I would have taken as an officer and then I can either apply that on a smaller scale or I can apply it on
00:34:50 on a smaller scale or I can apply it on a much larger scale. I have to say you know I think it was some of the training within that package that informed some of my decision- making on the night. that understanding that actually
00:35:01 that understanding that actually because of the terrible effects of that fire as well that you couldn't always rely on a building system to react as it it possibly should. Can I ask you to look at that then? Um
00:35:12 Can I ask you to look at that then? Um and see if we can get it correct. It look at LFB quadruple03621
00:35:18 and this takes us to the coroner's rule 43 recommendations action plan produced by the LFB. Um this is the first page of it. Are you familiar with this document?
00:35:29 it. Are you familiar with this document? I'm not familiar with this document specifically. No. Well, let's see how see how we go. Can I just show you pages 25 to 26 uh which um covers item 19
00:35:41 uh which um covers item 19 uh and the coroner's recommendation is training to be given to incident commanders to enhance their training in relation to the following. And it's um then set out and if you look at um the
00:35:54 then set out and if you look at um the the first one it's use of the dynamic risk management model and other management tools to enable IC's to analyze the situation and to recognize and react quickly to changing circumstances um
00:36:06 um a and then uh over the page
00:36:18 Three. Three is the one I want to focus on
00:36:22 on to anticipate that a fire might behave in a manner inconsistent with the compartmentation principle. Uh did you have any training yourself in
00:36:33 Uh did you have any training yourself in how to uh go about anticipating a a behavior of a fire in that way as an incident commander? I think I'd refer back to um the answer
00:36:45 I think I'd refer back to um the answer I gave Brucey which is yes. I think that's what the postlacale training package gave me. And I also think that was embodied in and I couldn't give you the details cuz I've been on quite a lot of them, but I think that was embodied in quite a fair number of the scenarios
00:36:58 in quite a fair number of the scenarios I received in instant command training. So the instant command exercises there, you know, was often um a scenario presented to you where it had breached one flat or it had gone beyond the
00:37:09 one flat or it had gone beyond the original compartment into other compartments just not to the scale of Grenful because again I think if you had presented that within an instant command exercise actually and I'm not being facitious here we I
00:37:20 and I'm not being facitious here we I probably would have criticized it as being unrealistic. Yes. As it was very unlikely that we would experience something like that. No, I understand. And looking at item six, the collection of information from all possible sources. Did you ever
00:37:31 all possible sources. Did you ever receive or deliver training on how an incident commander uh such as a watch commander like Mike Den would actually go about collecting information from all possible sources? I think that's hammered home to us from
00:37:42 I think that's hammered home to us from the start of your officer career. So the decision-m model is very well embedded in the London Fire Brigade. You know, I think it's a really simple model which helps officers um calmly come to
00:37:53 helps officers um calmly come to decisions under great pressure. And actually the officers there that night were under huge pressure. Um but that is that is probably one of the first lessons you're given as a crew manager
00:38:05 lessons you're given as a crew manager um or or even looking back further beyond that. I remember receiving it as a leading firefighter, as a temporary leading firefighter, my watch officer sitting down and running through the decision-making model for me. And if you follow that model, it forces you into a
00:38:17 follow that model, it forces you into a thought process that tells you you must gather information from all available sources, whether that's building owner, other people on the Instagram, other agencies. You know, it's a doctrine that
00:38:28 agencies. You know, it's a doctrine that I think we've embedded really well. And just following that through, just in general terms, does that mean that you would expect an incident commander, whether it was the first watch commander on scene or whether it was a group
00:38:39 on scene or whether it was a group manager or DAC who taken over incident command, any of them, to uh sit down and stand up and collect information from within the building and from control and
00:38:50 within the building and from control and put it all together with a view to forming strategy? I would, but my caveat on that is that in the early stages, so when an officer turns up in the early stages of an incident, they're in a very different position from me. I personally
00:39:02 different position from me. I personally think that the watch officer, the crew manager's role, that first station manager, I think they're the most difficult roles on the instant ground. I think they're the people under the most severe pressure with probably not enough resources at that point because
00:39:13 resources at that point because resources will be on route. They're dealing with the dynamics of a situation, often with distressed people. Um, so they're having to decision making that cycle very quickly. So it's not, you know, I wouldn't want it to be
00:39:24 you know, I wouldn't want it to be portrayed as a slow analytical process. Someone's having to take that process and maybe run through it in seconds in a cycle through their head and they're almost always at that stage of an incident working on an incomplete
00:39:35 incident working on an incomplete information and having to make really difficult decisions on the basis of incomplete information. And it's about just building that information over time by going around the cycle. I would absolutely expect them to apply it, but
00:39:46 absolutely expect them to apply it, but I I would want to acknowledge that it's actually in the early stages of a very dynamic incident and and this was the most dynamic incident I've ever attended. You know, it's extremely difficult for junior officers. That is a
00:39:57 difficult for junior officers. That is a real challenge. I always look at watch office and think you have the hardest job without a doubt. As a minimum though, would you expect an an incident commander first on the scene to to when
00:40:09 commander first on the scene to to when collecting information from all possible sources to collect information he was getting from inside a high-rise block and put it together with what he was seeing on the outside? Uh, as far as it was possible because
00:40:20 Uh, as far as it was possible because again, you're limited somewhat by resources. So, it depends where he's going to get that information from or she's going to get that information from. Have they got people up inside the block far enough to gather that information or where the source of the
00:40:31 information or where the source of the fire is? you know actually can they reasonably connect what's happening outside to inside I don't think you come to these things immediately I think that you you're con you know again just want to reiterate really that you're
00:40:42 to reiterate really that you're constantly making decisions in this cycle so what your first decision might be is is based on incomplete information may then change later because the both the situation is developing and so is
00:40:53 the situation is developing and so is your situational awareness hopefully as more resources arrive it gives you the space to decision make so in my position I think I'm very privileged because by the time I get there, I've got the time and the space to a degree. Not so much
00:41:06 and the space to a degree. Not so much at this instant, but generally you've got the time and the space to be more analytical and work more methodically through that process. What's difficult for initial instant commanders and I would suggest at this incident in terms
00:41:17 would suggest at this incident in terms of the timing and what I saw of the fire when I turned up, everyone up to DAC level was almost in a watch officer's position. They were in a very very difficult situation where they were having to go around the cycle not really
00:41:31 having to go around the cycle not really having enough information to decision make at the point they're trying to and not only that having to take enormous decisions uh on the basis of very many people's lives in a very short space of
00:41:42 people's lives in a very short space of time. Can
00:41:43 time. Can thank you. Can I just turn back then to evacuation and and FSGS? Do you need a break?
00:41:49 break? No, not at all. Sorry. Okay. All right. Um
00:41:52 Um first of all, evacuation. Now, you told us a little bit about the difficulty in assessing
00:41:58 assessing when it's appropriate to revoke, stay put, and evacuate fully or partially. Um, would you, just being specific, ever get training in how to carry out a full
00:42:09 get training in how to carry out a full or partial evacuation of a high-rise residential block? No, I haven't. But I think that actually it's quite difficult to provide that training because you would have to be very careful about laying too
00:42:20 very careful about laying too prescriptive a plan on evacuation because particularly with partial evacuation there may be parts of the building that are safe, parts that aren't. It's going to be very um it's going to be very location dependent and
00:42:33 going to be very location dependent and I really I think that you could over complicate something is in itself relatively simple. You've got to think about who is at the greatest. So in terms of evacuation that what I would expect officers to think about who is at the greatest risk and therefore needs to
00:42:44 the greatest risk and therefore needs to leave first. How do I manage it so that we maintain access as well as guaranteeing their egress? And you might have to think about that in the context of a building that's absolutely not designed for mass evacuation.
00:42:57 designed for mass evacuation. Um I think it'd be very dangerous potentially to try and lay down prescriptive training about how you might carry that out. I think um what I would want is officers to think in a
00:43:09 would want is officers to think in a common sense way about where the greatest risk was and how we remove the people closest to that risk first in an orderly manner. You know, using our officers to facilitate potentially or
00:43:20 officers to facilitate potentially or other agencies and we'll come to that in just a moment. My next question is, did you ever receive or deliver any training in how to prevent or mitigate the effects of smoke logging in in exit
00:43:32 effects of smoke logging in in exit routes in a high-rise residential block so as to allow people who did wish to leave or could leave to do so safely? Not that specifically, but what I have received training in is the possibility of there being smoke logging in the
00:43:43 of there being smoke logging in the lobby because of the way that we need to run water supply to ensure the safe deployment of our firefighters. So the breaching of a lobby door and how you would need to take that into consideration because obviously it's
00:43:55 consideration because obviously it's it's neither in the interest of anyone coming out the building or ourselves using the lobby to have that happen. That's a built-in that's essentially a built-in compromise of the smoke proof
00:44:09 built-in compromise of the smoke proof nature of a an exit stair, isn't it? It is to an extent. I mean in some buildings you can mitigate that depending on where the riser outlets are, but yes. Right now, I just want to focus on FSGs. Um,
00:44:21 focus on FSGs. Um, I'm going to assume you've had training on FSG policy and and how to how it works. When was the last training do you think you had prior to the Granfell Tower fire on on FSGS? I'm terribly sorry, I can't remember.
00:44:33 terribly sorry, I can't remember. Right. Um, h have you ever had training on how as an incident commander you would manage multiple FSGs at a single incident? Yes, I think I've had that over a range of instant command
00:44:45 over a range of instant command refresher training. But again, I need to send set that in a context. So, it would have been perhaps up to 10 FSGs or, you know, the sort of scenarios that were built into instant command exercises
00:44:56 built into instant command exercises wouldn't have pushed it beyond that. I think in fact once you get into double figures, um, it becomes almost a different beast potentially. And I hadn't received training to do anything
00:45:08 hadn't received training to do anything on the scale of Grenful. I mean, I think it's worth reflecting. I think that night we received more FSG calls than we'd received in the previous 10 years. It's just an unbelievable scale. So we've never trained people to that level. What we have done is I've
00:45:21 level. What we have done is I've certainly taken part in scenarios where I was required to think about multiple FSGs, how you might prioritize them um and then how you might apply strategy and tactics to the incident to resolve
00:45:33 and tactics to the incident to resolve it in that context. Yes. In your experience, what was the highest the highest number of FSG calls you had to deal with as an incident commander at a single at a single incident prior to Granfell?
00:45:42 Granfell? In reality, uh I think possibly two. Two.
00:45:45 Two. Two. Yeah. My common so I've actually been to quite a number of incidents where there've been fire survival guidance calls in progress, but my general experience is there's normally only one. It's very rare that we would
00:45:56 only one. It's very rare that we would get genuine multiple fire survival guidance calls. Um, you know, you might often at a high-rise get calls from people who would feel that it's a fire survival guidance call, but actually
00:46:07 survival guidance call, but actually because of the general efficacy of the stay put policy, aren't in any danger, can be reassured and actually we'll be able to get advice to them to stay put whether we send crews to that floor and tell people to stay in. Um, but
00:46:19 tell people to stay in. Um, but generally in terms of, you know, people being at real risk, it being a genuine fire survival guidance call, my experience is it's either one or two at most. So actually prioritization doesn't become as much of an issue because
00:46:32 become as much of an issue because they're all a priority and we'll have the resources there to effectively commit to resolve them. Yes.
00:46:38 Yes. Well, that leads to my next question which is about prioritization. Can I ask you please to look at policy 790 again uh and this time go please to paragraph 4.2 two
00:46:56 uh which says the IC based on their situational awareness and the information provided by control will decide how to prioritize FSG calls and the actions to be taken on the incident ground.
00:47:07 ground. The IC should direct resources to those callers at greatest risk, high priority if practicable. other callers not seen as at greatest risk. Medium priority should be allocated resources when
00:47:19 should be allocated resources when available. Now
00:47:23 Now it just correct me if I'm wrong about this Mr. but it looks from that as if at least as a matter of policy um this LFB policy did anticipate that there might be situations when FSG calls were so
00:47:34 be situations when FSG calls were so numerous that you would need to prioritize them. Um I think it it anticipates a situation where you get might get more than one or you might get a number of flats perhaps on one level
00:47:47 a number of flats perhaps on one level or across two floors where there's been a if we're talking about in the context of high-rise where there's been a breach of compartmentmentation. Um but certainly not in the volume we encountered. It's not designed for that. This policy isn't designed for the
00:47:58 This policy isn't designed for the volume of calls we received that night. Yeah. And I think that um if you were to talk about prioritization in the context of Gref, I think that's an entirely different matter from the premise set
00:48:10 different matter from the premise set out
00:48:11 out in this policy. Let take even taking a a lower number though for example seven which I think is the number of FSG calls set out on the casualty information sheet attached to the policy.
00:48:24 sheet attached to the policy. Just taking that number, do you know whether uh there was training available in the LFB as to how as to how a incident commander should go about prioritizing even between that number?
00:48:36 prioritizing even between that number? Yes, I think that was given at the point where the policy was refreshed and people were updated on the policy and it would be about again taking into context the individual circumstances of the incident, who was at greatest risk, who
00:48:48 incident, who was at greatest risk, who was the most vulnerable and prioritizing on that basis. It may be that, you know, it would be the person highest up the building, so the most difficult to get to. It could be that it was the person closest to the seat of the fire or
00:49:00 closest to the seat of the fire or directly involved in a compartment, you know, in a in a flat that's involved in the fire. There's a number of variables there, but there would be a way of arriving at that priority. Yes, a number of variables. The factors you mentioned though, were they the subject
00:49:11 mentioned though, were they the subject matter of training? Um, I can't remember in that detail, but for me to state that I I would think it must have been in delivered in a manner similar to that. Yes. that you would think about those different factors
00:49:23 think about those different factors where the individuals were in the building, their individual circumstances. No. So, for example, if you have a disabled person, elderly person, a vulnerable person, they might be further up the priority list if you've got a manageable number of calls
00:49:35 you've got a manageable number of calls and you knew it was going to be difficult to remove that person from the building.
00:49:38 building. Yes. And and would that be something that you would regard as the incident commander's ultimate responsibility to ensure the prioritization was happening effectively? I think it depends on the scale of the incident. So I think if you're in an
00:49:49 incident. So I think if you're in an incident where you've got um a relatively small number of FSGs and you've got a very direct link from the instant commander into the tactical
00:50:01 the instant commander into the tactical sector, then it may well be that they have the time and space within that decision-m cycle to consider that level of prioritization. I think uh a larger incident, you know, not necessarily even
00:50:12 incident, you know, not necessarily even the size of Grimfield, you would be relying on the sector commander who had responsibility. Well, in fact, you'd be relying on two sector commanders. be relying on the fire sector commander and the uh fire the fire survival guidance
00:50:25 the uh fire the fire survival guidance sector commander to communicate with each other to determine priority because the fire survival guidance commander is going to determine priority on the basis of information received from control to a degree and the fire sector commander
00:50:37 a degree and the fire sector commander is then going to have to take that information and make a judgment based on what can be rapidly changing circumstances faced by the crews who are doing the firefighting. So the communication between those two sectors
00:50:48 communication between those two sectors is vital and it may well be that the fire se sector commander because they are committing the crews from the bridge head would hold that final decision actually in terms of the tactics and I
00:50:59 actually in terms of the tactics and I think that would be entirely reasonable in terms of delegated command. Yeah. Can I now turn Thank you. Can I now turn to
00:51:09 to the night of the fire uh and look at some
00:51:13 some um look at some facts uh of of perhaps smaller detail. Um on the night of the fire and you say this in your first witness statement in the second paragraph, you were paged I think at 136
00:51:25 paragraph, you were paged I think at 136 to attend a 25 pump fire at Grrenfell Tower.
00:51:28 Tower. That's correct. Yes. And I think you then immediately rang the officer of the watch in the control room. Yes. Yes. Sorry. I'm trying to cover this quickly because I think this is you I'm just summarizing
00:51:40 I think this is you I'm just summarizing what's in your statement. Um when would you normally be paged as an AC?
00:51:44 an AC? Um I I would have been paged um actually informed on um an eight pump fire because uh you would have had a group
00:51:56 because uh you would have had a group manager deployed onto that taken over. You would have had a DAC monitoring and then I would have been the remote monitoring officer. Right. And
00:52:07 Right. And the importance of a remote monitoring officer's role is is what? Can you just explain?
00:52:13 explain? Um,
00:52:14 Um, it's another it's another check and balance sitting behind the monitoring officer who's obviously deploying to the incident. So, you'll be listening to messages. You'll be judging from the messages whether or not um the incident
00:52:27 messages whether or not um the incident is progressing perhaps the way you would expect. I.e., is it growing exponentially? Is it contained? Is fire surrounded? you know, whatever it might be. Uh, and you're providing a voice on the end of the phone to the monitoring officer as well to provide advice and
00:52:39 officer as well to provide advice and support. So, that's that's the general role of the remote monitoring officer. And also, because you're sitting one stage remote, uh, there's an opportunity, if required, for you to look at the wider brigade picture and
00:52:50 look at the wider brigade picture and tie officers into those lines of support as well. U before you called the control room and I appreciate it may not have been very long. Had you turned on your
00:53:01 been very long. Had you turned on your airwave radio? Was it on? Uh no. I I rang the control room um almost straight away. Right. Okay. Now we've got a transcript of that call um with the officer of the
00:53:13 of that call um with the officer of the watch and it's inq quintuple0202 and the call is at 13851. And we can quickly look at the transcript on page two.
00:53:25 transcript on page two. Uh if you just go to that or be taken to it. Um
00:53:30 it. Um uh it it looks like Peter May in the control room. It was Pete May. Yeah. And you're BM8 for this purpose. Um and we know that because you go hello there. It's a Bravo
00:53:42 because you go hello there. It's a Bravo M8 Andy Row. Uh, and then, um, if you just go down the page a little bit, uh, you're told halfway down, Peter May
00:53:53 uh, you're told halfway down, Peter May says it's gone up, uh, 6, 10, 15, 20, then 25, 30, you know, straight away. Yeah.
00:53:59 Yeah. And then you ask him about about that acceleration. So, 25 pump fire now. He he says, uh, 68, no, it's 68, 10, 15, 20, 25 now. Uh, and then he goes on to
00:54:10 20, 25 now. Uh, and then he goes on to say, nine or two down, 25 pump fire. We've had loads of people um and then over the page because I think you interrupt him and say two over
00:54:21 think you interrupt him and say two over the page trapped trapped in flats BM8 that's you loads of people trapped in flats may we're talking to them now and and then you go into into staffing questions now just at that point when
00:54:33 questions now just at that point when you're told about the acceleration or the rate of makeup by Peter May and loads of people trapped in flats Um, what did that tell you in that moment
00:54:45 what did that tell you in that moment about what was happening? That I was faced with an absolutely exceptional incident. And I think what this transcript doesn't give you is the background noise in control and actually the level of stress in Pete's voice. You
00:54:56 the level of stress in Pete's voice. You know, Pete's a really experienced officer of the watch, a control officer. I've got a lot of respect for, really decent chap. And for him to, and it wasn't panic, absolutely not. He was,
00:55:07 wasn't panic, absolutely not. He was, you know, he was in control, but I could hear there was a very considerable level of stress in his voice, which I had never heard before. And I've spoken to Peter on many occasions on the phone to respond to incidents.
00:55:18 respond to incidents. Right now, so I felt that it was I was facing something even in those few moments that was absolutely exceptional. Right now, on page four, if we just skip to that, you are told,
00:55:30 to that, you are told, you're given essentially the the informative message. Yeah. at the top of the page residential block of flats 20 floors 25x 25 fire on flat 4 to 75% of light high-rise
00:55:42 fire on flat 4 to 75% of light high-rise proceed high-rise procedure implemented etc. So he reads it out to you. Um by the end of that call, what was your thought about the fire spread and the nature of the fire that was being
00:55:54 nature of the fire that was being experienced on the basis of the information I received that the informative at that point wasn't accurate. But I wasn't judgmental about that. That was because I think events had outstripped the officers there because I felt that that
00:56:06 officers there because I felt that that that surely couldn't um if it had just been five room flat on the fourth floor 75% align that is a very common occurrence and I would not have expected Pete to have that level of stress. So my
00:56:18 Pete to have that level of stress. So my sense was that we had a very dynamic incident that had grown exponentially quickly and therefore it was outstripping officer's ability probably to effectively decision make at that point. Um certainly to pass effective
00:56:31 point. Um certainly to pass effective messages that control room would be under massive pressure because they must have been handling multiple FSGs. Um, and that actually the best thing for me to do is get in my car and go there because I was going to go anyway and take over. And that actually if
00:56:43 take over. And that actually if something's developing that rapidly, I guess it was going to carry on developing. And that by getting in the car and then starting to make other phone calls back into the wider brigade machinery, I would start to set in place the framework and conditions that will
00:56:55 the framework and conditions that will enable me to take over that incident effectively and sustain it. Right. All of my instincts as a professional officer told me I was driving towards a major incident. That that would be it, I guess.
00:57:06 that would be it, I guess. Did you
00:57:09 Did you did you have any specific thoughts about compartmentation breach? Not at that point because I wouldn't have wanted to work on those assumptions. All I knew is that I had a very very significant incident with
00:57:20 very very significant incident with large members of the public involved and that I would try and gather more information on the way but I wouldn't have made any assumptions at that point. Right.
00:57:28 Right. I think about the same time I had been sent some photos though. Right. Yes. We'll look at those in a moment. Um because I want to ask you about those. Um would you is now a convenient moment for a break.
00:57:40 convenient moment for a break. Um you happy to carry on? I'm happy to carry on, Mr. Chairman. Perhaps we can carry on for another 10 minutes and I can Yeah. Yes. Uh now um right that's very helpful. Um
00:57:53 Uh now um right that's very helpful. Um looking at page four of the transcript which we've got on the page on the screen. Um we've got you asking um
00:58:02 um you look a little bit further down. Sorry.
00:58:06 Who's in charge? You say, "Who's who's in charge? Have you got any idea who's in charge at the moment so I can make some phone calls?" And Peter May says, "No, I now I can't really tell you." And you say, "You can't tell me." Uh, just
00:58:18 you say, "You can't tell me." Uh, just at that point, did it surprise you that Peter couldn't tell you who was incident commander? Um,
00:58:25 Um, no. Because I'd gathered already from the early part of the conversation that things were very difficult, but I I wasn't pleased about that. No, because my guess was that because control was
00:58:36 my guess was that because control was facing such significant pressure from FSGS,
00:58:39 FSGS, what I would do, and this is what I would do as a standard piece of process anyway, is I would try and contact the OT officer that was there, even if they were on route, to ask them to give me a brief as soon as they got there, or I
00:58:50 brief as soon as they got there, or I would try and speak to the monitoring officer. So, actually knowing the officers in charge was key to me because they would have been mobilized before me. they're going to have gone there. They're going to have started gathering some sort of situational awareness. And
00:59:02 some sort of situational awareness. And even though I'm driving, you know, I've got the opportunity to provide a bit of support, a bit of guidance, gather some information myself. Ideally, I wouldn't contact the incident commander because they need to have the space to make decisions, but I would like to talk to
00:59:14 decisions, but I would like to talk to either the monitoring officer or the RT officer if I can't get the information from control because obviously it's better for me to start building my situational awareness on route so I can start to consider how I might best
00:59:25 best run that incident. Yes. Now you ask you ask Peter May. So we got a group manager actually on it. Yeah. Got group manager group manager Pat Gborn. So Pat Gborn, is he status
00:59:36 Pat Gborn. So Pat Gborn, is he status three? And then if we turn the page,
00:59:44 uh you're told he hasn't booked status 2 with us yet with us. He may well again he may well be on the way. Uh and then you asked to put be put the status 2. Did you realize at that point
00:59:57 status 2. Did you realize at that point that the incident commander was still a watch manager? Um, no. I made any assumptions about that because I didn't know again I don't think it's uncommon to have a change of
01:00:08 think it's uncommon to have a change of command and that not immediately be reflected. My hope and that's why I was asking repeatedly is that we had someone of a senior rank either mobile and close to it or arrived at the incident who I might be able to gather some situation
01:00:20 might be able to gather some situation awareness from and just get an understanding from on the ground from eyes on what we were facing as a service and therefore how we might best right
01:00:28 right you know deal with it. Okay. Now turning to your contemporaneous note if I can. That's appendix A. Um 5405 Paul. Um you say at 0141
01:00:41 you you say I rang Adrien Fenton the duty DAC and asked him to set up BCC. My rationale was that whilst it had not been declared as such it felt like a major incident and with it already being
01:00:52 major incident and with it already being a 25 pump fire would have implications for pan London NFB resources. Um,
01:01:01 what was it about what you'd heard from Peter May that told you this was a major incident specifically? Um, I think just professional judgment, a gut feeling at home being a very experienced officer, having attended
01:01:12 experienced officer, having attended many incidents, having run major incidents with the London Fire Brigade, right?
01:01:16 right? And and the fact that it had escalated in such a short period of time to 25 pumping appliances made me think that we probably weren't going to end there. and the inability of Pete to really give me
01:01:27 the inability of Pete to really give me any really relevant information. It it was it was a professional judgment call. My feeling was that we would set up BCC because actually it wasn't going to hurt anyone. We were going to put officers in somewhere who could start to do some
01:01:39 somewhere who could start to do some ground work to do pan London planning around resourcing media gathering intelligence so that we would we could continue to service the incident but also run the rest of the London fire
01:01:50 also run the rest of the London fire brigade. Um, if it had been the wrong judgment call, all I would have done was been to have sent some people into Stratford and we could have sent them home again. But I felt it was I had enough of a gut feeling that it was
01:02:02 enough of a gut feeling that it was going that way that I wanted BCC set up and as early as possible so that that framework was in place when I turned up. Yes, I see. Would you have expected the incident commander at the scene who was
01:02:14 incident commander at the scene who was still Mike Den at that point to have declared a major incident? Um, no, not necessarily. I think again, um, whilst we train people to make a judgment about
01:02:25 we train people to make a judgment about major incident, I would imagine in Mike's mind it was still very much a a fire incident, a very large fire. Um, but no, not necessarily. What did you know, do you think that
01:02:37 What did you know, do you think that made you think that it was a major incident which he didn't know? um because I think that he probably wouldn't have been aware of the scale of activity inside control because he would
01:02:48 activity inside control because he would have been inside such a difficult decision-m environment that he he he just wouldn't have the time or space to have access to that information. I think he hasn't got the experience of running
01:02:59 he hasn't got the experience of running major incidents. he hasn't had the benefit of going on a magic course and that whilst we would have taught him that an incident of a certain size there should be a consideration around major incident actually in that moment in the
01:03:11 incident actually in that moment in the dynamic phase of the incident I wouldn't necessarily expect him to you know if he did great you know and watch managers do make incidents major incident the cud and crown crash which I was in charge of
01:03:23 and crown crash which I was in charge of the original watch officer Danny Kelly made it major incident but I would suggest that what Mike Dowen faced was so exceptional that I I certainly They wouldn't necessarily have expected that. And you mentioned magic, the magic
01:03:34 And you mentioned magic, the magic course. What? That's an acronym. I apologize. It was the course you referred to earlier, the multi- agency gold instant command course. Okay.
01:03:40 Okay. And um
01:03:42 And um did you at that stage you spoken to Adrien Fenton? Did did you at that stage think to get hold of anybody at the scene um to tell them to declare a major incident?
01:03:53 incident? Um I was going to I think my statement comes to that actually. So there was a sequence of calls I wanted to follow. I wanted to call Adrian to get the BCC set up because that was going to help do the planning to resource the incident
01:04:05 planning to resource the incident because ultimately if you can't resource the incident, we haven't got an operational response. So that was very important to me, the logistics side of it from the beginning. I then ran I think the duty AC because I was AC1 so
01:04:18 think the duty AC because I was AC1 so what we call AC1 and I wanted my colleague Richard Mills who was on as AC2 to know that he was going to become AC1 and therefore hold the pan London picture and also because I felt it was going to be a major incident he should
01:04:30 going to be a major incident he should give consideration to whether or not at the point it may or may not get called major incident that he might have to go into the special operations briefing room of the Metropolitan Police. So start start think about the pan London
01:04:41 start start think about the pan London picture so that I could focus on the detail of resolving that incident. So it's about putting the layers in behind.
01:04:48 behind. Right. My next step after that was to be to either get hold of Andy Lachlan as the DAC going or one of the OT officers to ask them what the situation actually was because obviously I still didn't
01:05:00 was because obviously I still didn't have any real situational awareness and just wanted some confirmation as to whether I was overegging it or actually what I had judged was correct and we needed to prepare ourselves for a major incident.
01:05:10 incident. Yes. Okay. Um Mr. Chairman, I'm going to ask a break there if I can. And can can I just say before I I do that that I'm going to come on now to the email that was referred to a moment ago by the
01:05:22 was referred to a moment ago by the witness. We're going to look at that and there's but I should just say there are some photographs which are attached to it which some people may find distressing. So really for the benefit of those who may find it them distressing um I just tell them that if
01:05:33 distressing um I just tell them that if they want to avert their eyes or perhaps not be present in front of the screens for about 10 minutes or so after we 15 minutes after we resume and that would be sensible. They show photographs of the building on fire on the night. Yes.
01:05:46 the building on fire on the night. Yes. Good. Well, thank you for giving that warning.
01:05:48 warning. And we we'll have a break now. Um I think we'll have just over 10 minutes. So come back at 25 3 if you would. And uh please don't talk to anyone about your evidence while they're out of the
01:05:59 your evidence while they're out of the room.
01:06:01 room. I'd
01:06:01 I'd like to go to the usher. We got
01:06:12 25 please.
01:19:31 Right. Happy to go on, Mr. Row. Thank you, sir. Thank you. Yes, Mr. Thank you, Mr. Chairman. Mr. Ray, thank you for coming back to us. Can I ask you please to look at your contemporaneous notes page one uh and look at the
01:19:44 notes page one uh and look at the um
01:19:49 uh time mark of 041 still in the second chunk of which you say I received some photos by email you see that yes I can
01:19:57 yes I can from station manager Gareth Cook at the incident they showed 100% of one side of significant size tower block al light I sent them to Richard Mills, Adrien Fenton, and Key Foster, the
01:20:09 Fenton, and Key Foster, the commissioner's staff officer. Now, um, I want to show you those photographs. I've given the trigger warning about them. Anyone who's rejoined or joined the the room or the live stream and didn't hear
01:20:20 room or the live stream and didn't hear my trigger warning, I should just repeat it. I'm going to show some photographs of the building on fire. And if they if anybody finds that distressing, then they should either leave now or avert their avert their eyes. Um, can I start
01:20:33 their avert their eyes. Um, can I start by asking you to look at the email? Uh, it's me 016929. And can I just go down to the bottom of the email to start with? It's it's the
01:20:44 the email to start with? It's it's the email from Gareth Cook to you. And it's timed at 1:43 a.m. on the 14th of June. And was it to that email that the
01:20:55 And was it to that email that the photographs were attached? Um, yes, I believe so. Right. We'll look at the photographs in just a moment. Just following the email chain up. The next email up, you send those on. It looks like just sent from
01:21:06 those on. It looks like just sent from scene on route and this is 0156 uh to Andy Lachlan, Richard Mills, Adrien Fenton, and Key Foster, and uh also Robert Davis. Uh so there was a
01:21:19 also Robert Davis. Uh so there was a period of 143 to 156, 13 minutes or so. U did did you send those to them while you were on route? Um, I'm not sure to be honest with you in
01:21:30 I'm not sure to be honest with you in terms of the timing. It may well have been,
01:21:32 been, right?
01:21:33 right? Okay.
01:21:33 Okay. But all I knew is that I wanted to send those photos to someone who was going to discuss it with the commissioner cuz she was likely to come out and monitor me. Um, to Tom George, who's director of
01:21:45 Um, to Tom George, who's director of operations, who was the other brigade manager, um, who would who would have had an interest, right? um Adrien Fenton because he was running the BCC and I wanted him to at least share the same understanding I did
01:21:57 least share the same understanding I did Richard Mills who was obviously then going to become AC1 and actually I sent them to Andy so I wasn't sure whether Andy was there or not um probably at the point I sent them um so I thought well actually if he's on route you know and
01:22:09 actually if he's on route you know and he's got an opportunity to pick them up whether just before he stops or if he pulls over and picks them up that might have been
01:22:14 have been the opportunity for him to gather some situational awareness. Did you um let's have a look at those photographs, shall we? Um they're attached to the email and then I think if you go on in the in in
01:22:25 then I think if you go on in the in in the exhibit, we can see them. Just flip through them. This is the first of those photographs, is it?
01:22:34 is it? Yes.
01:22:35 Yes. Okay. And then let's look at the next one.
01:22:38 one. Yes.
01:22:39 Yes. Now, just looking at that, just looking at that picture at the time, what did you observe? Well, let me ask you this way. Did you observe anything from that picture about whether or not this fire had penetrated individual flats?
01:22:51 had penetrated individual flats? I couldn't tell from the photo because it wasn't of that size. So it was on, if I could just, if you would, pardon me. So it was on this phone, right?
01:22:59 right? Um, and it occupied probably just a part of the screen. So I was looking at it in very small size, but what I saw concerned me greatly. I I couldn't define whether or not there was spread into internal compartmentation, but obviously what I
01:23:10 compartmentation, but obviously what I could see was very very significant external fire spread. Um, and that kind of confirmed my worst fears really that we were facing something exceptional. Right. I had never seen a tower block of light in that way in this country. I'd
01:23:22 light in that way in this country. I'd seen footage of foreign fires which resembled it, but not a fire in a tower block in this country. No. Right.
01:23:29 Right. And my immediate thought actually was that there had been some failure of the regulations. It was it was quite astonishing to see that photo and think, how on earth has this happened in the context of how we build buildings in
01:23:42 context of how we build buildings in this country? really let's just look at one or two of them more of them so we've got we've got a complete run so everybody can see them there's a there's there's the next one and then uh if if any anything in that picture or any of
01:23:54 any anything in that picture or any of the following picture stands out please tell me but anything in that picture that stands out no nothing except that it's obvious that it's an extremely well-developed vented fire so it's it's not just smoke it's it's visible orange flame covering the
01:24:05 it's visible orange flame covering the entire surface of the building and so therefore my assumption was that there had been very significant very rapid fire spread I I couldn't tell from that whether it had breached internal compartmentation, but whatever had
01:24:16 compartmentation, but whatever had spread it was significantly alike. You know, I wasn't looking at an isolated column of smoke punching out with some flame or even just flame at one level. I was looking at significant
01:24:27 one level. I was looking at significant fire spray up the whole of the side of uh what looked to be a significant size tower block. Um can we look at the next picture, please?
01:24:37 please? Uh so same again. I think it's very much the same as the first photo you showed me. It's just absolutely extraordinary fire spread. Yes. Could you tell from the pictures which direction the fire was spreading
01:24:48 which direction the fire was spreading in?
01:24:48 in? Uh, no I couldn't. Okay. Not from the size I was of photo I was looking at. But in a way that was irrelevant at that point. It was just the fact that whatever way it was spreading. It was it was clearly of a of a a scale that I had
01:25:01 was clearly of a of a a scale that I had not witnessed in a tower block before. Right. Let's just finish off the the run of photographs if we can. Again, very similar. Very similar. And the next one,
01:25:12 Very similar. And the next one, I think it may be it actually. I've got to say, I'm not sure I opened all of those either. I think once I'd seen a couple of them, I had enough information really to confirm my worst fears, actually. Right. Given those pictures and given
01:25:23 Right. Given those pictures and given what you've been told by Peter May on your call, did you consider the implications for this fire at this point for the residents? Yes.
01:25:33 Yes. What did you think? I thought that anyone who was inside that building was at very significant risk of potentially losing their life, right? Because regardless of whether it had breached internal compartmentation at
01:25:44 breached internal compartmentation at that point, you know, if I was lucky, I was going to turn up and find that because of the quality of the photos I was seeing actually it was perhaps scrim on scaffolding or a very significant
01:25:55 scaffolding or a very significant scaffolding fire. I have attended those, they can look really impressive in the early stages. It burns really, you know, fiercely, but it effectively burns away. I thought if I was really lucky that
01:26:06 I thought if I was really lucky that whatever was burning, you know, and I thought it was reasonable at that point to assume it was some sort of facade again was going to burn itself out and not penetrate the building, but part of me just had a gut feeling that something
01:26:19 me just had a gut feeling that something was very very wrong because of the number of fire survival guidance calls as well.
01:26:22 as well. Right. I see. at that stage does that did you consider what advice residents who were calling into the control room should be given? No. And it wouldn't have been appropriate me for me too because I
01:26:34 appropriate me for me too because I wouldn't have been able to judge what was happening inside that building. So it it would actually have been entirely possible that whilst the entire facade was a light and perhaps it had breached some compartments within the building,
01:26:46 some compartments within the building, it may have been that the central lobby was entirely clear that the other side of the building you we would have been you know right to ensure that residents stayed in their flats. It could even be that people on that side of the building
01:26:57 that people on that side of the building would have been safer in their flats under some circumstances if it hasn't breached compartmentation. So it would have been wrong to try and involve myself in any decision- making around that.
01:27:08 Um, your answer to the last question was that anyone who was inside that building was at very significant risk of potentially losing their life. That was what what you said.
01:27:19 what what you said. That was my gut feeling. That was my answer because when I looked at the photos, that's what I that's how I felt. So on the on that basis that that was your gut feeling, did you my question was really did you did you then did that lead to any thoughts about what advice
01:27:30 lead to any thoughts about what advice they should be those people at that risk should be should be advised? Yes, but it wasn't something that I was going to consider enacting until I arrived on the instant ground and could make my own decision
01:27:40 decision because I think it's such a big decision and it's got to be taken in the context of at least sufficient situational awareness to take it that it would have wrong I think it would have been wrong to try and influence it from a distance
01:27:51 to try and influence it from a distance as well because it can only really be taken by that instant commander is seeing what's happening in front of them in conversation with whoever is in command of the control room and piecing those two bits of information together
01:28:03 those two bits of information together really.
01:28:04 really. Did you have any thoughts at that early stage? And it is early stage when you're looking at these photographs and putting them together with the information you've got from control about how you were going to attack the fire on the on
01:28:15 were going to attack the fire on the on the exterior of the building that you'd seen.
01:28:17 seen. Um my thoughts actually as I drove there was that with that level of external fire spread, which was clearly right up to the top of the building, I was likely to be less bothered about external fire spread and more about the safety of the
01:28:29 spread and more about the safety of the residents inside. So my gut feeling was that my focus and I had started to think about what the incident might encompass. My my guess was that my focus was going to be on the residents and not on
01:28:40 to be on the residents and not on external firefighting necessarily cuz actually you know our ability to fight a fire that has spread that significantly externally is relatively limited because again we are basing our equipment and
01:28:52 again we are basing our equipment and tactics on the presumption that you're not going to get external fire spread to that basis. So actually our aerials will operate up to 30 odd meters. They're going to have a throw um beyond that um
01:29:06 going to have a throw um beyond that um of maybe another two or three floors potentially. So it's unlikely I was going to be able to use an aerial to attack it at that stage of the fire. Uh I was unlikely to put people above the fire to try and get water down onto it. I think I'd have been placing them in
01:29:17 I think I'd have been placing them in significant risk to say for example put them on the roof and try and get water down it that way. And actually, even from the scale of the fire, I could see my sense was that that that was going to have to burn itself out. We might be
01:29:29 have to burn itself out. We might be able to do something at the lower reaches of the building, but it probably wouldn't be my priority. My priority would be making sure that the residents were okay. That was always going to be my priority. Right. Now, going back to your movements
01:29:41 Right. Now, going back to your movements on the night, you um say on page one of your contemporaneous note that after you sent the photographs, I I got in my car. You say, "I then got in my car and started to proceed to the incident on
01:29:52 started to proceed to the incident on blue light." Does that mean that you uh started to proceed uh after having sent those um sent that email on at 156?
01:30:03 sent that email on at 156? No, I think I've got to be honest with you. So, I've written this on the my best guess around timings. I think I had I think I had moved before 156 for certain. I can't reasonably explain when
01:30:15 certain. I can't reasonably explain when I sent that. I genuinely can't. But I obviously sent it at that time because it says 156. But I'm sure I moved before then because I live in southeast London in Brmley and it is a long way from um
01:30:28 in Brmley and it is a long way from um Grenful Tower. Yes.
01:30:29 Yes. And I remember the journey taking roughly uh you know 50 odd minutes. Um so I would presume that I've probably done this perhaps on route.
01:30:40 done this perhaps on route. Right. Okay. Um uh we have a time of status 2 for you in the short incident log 14124 and that's at page 14 of of that log. I
01:30:53 and that's at page 14 of of that log. I don't need to take you to it but does that sound about right to you? I think so and I think what I would say is that I would have booked status 2 with control but I was still making phone calls. I was probably, you know, I'd taken the call actually in my toilet
01:31:05 I'd taken the call actually in my toilet of all places and then got myself dressed, had gathered my kit together, including my airwave radio, you know, so it was a bit of messing about to get ready, get out of the house, try and get
01:31:17 ready, get out of the house, try and get my mind in gear to run a major incident cuz I knew it was going something significant. Um, and I've taken the times from the call log. I know I made those calls cuz I spoke to those people, but the the times have come from the
01:31:28 but the the times have come from the call log.
01:31:29 call log. Yes, I see. Okay. You then say on your um uh on page one of your contemporariness in his note 145, I rang AC Richard Mills. He was AC2. Uh and um you said I felt I said I felt
01:31:43 Uh and um you said I felt I said I felt we had what sounded like a major incident on our hands. Um
01:31:48 Um did were you on route by that stage? I think I was. Did you call him on your brigade mobile or
01:31:54 or I called him on? Yes. So it's all on my grade mobile because these times were part of the mobile phone log timings. Yes.
01:32:00 Yes. And I had a look after when I wrote this statement. I went back onto my own call record on the phone to see but I remember speaking to Richard when I was in the car. You say you tried to contact DAC
01:32:11 You say you tried to contact DAC Lachland at 159 just looking down the page to confirm his location and situational awareness and you couldn't get hold of him I think. No, but to be fair to Andy I'd not sure of the timings for when Andy arrived genuinely. Um, but my thought was, well,
01:32:24 genuinely. Um, but my thought was, well, actually this confirms my worst fears, which is I've got a DAC there and he hasn't got the space to pick up the phone to me and he's either got there before the GMs or,
01:32:33 or, you know, there could be any number of reasons for that, but that didn't make me feel good. No. Right. Okay. In fact, we have an arrival time for him of about 155. So, well, I'm I'm Yeah, not surprised at all that Andy didn't pick up the phone. Now
01:32:45 that Andy didn't pick up the phone. Now by the point in time when you attempt to ring Andy Olllin 159 had you heard FSG information over the main scheme radio from control. Um I had my airwave on but because I was making phone calls really
01:32:56 because I was making phone calls really I wasn't taking in the detail of it and I was already aware that we had a massive FSG calls really at my level I think it's dangerous to get sucked into the details of some of the individual aspects of an incident because again you
01:33:08 aspects of an incident because again you know if we're talking about the decision-m cycle what was important for me and is important to the London Fire Brigade is that I went there with a mindset that I needed to resource this incident effectively structure the incident
01:33:19 incident and drive you know primary objectives. The only thing that those messages would have given me on airwave in their detail is is just more situational awareness about the kind of desperate nature of
01:33:30 about the kind of desperate nature of the incident itself. I I wouldn't have been fixated on the detail at all. Would you have picked up the fact that there were there was there were people trapped on the 22nd floor for example?
01:33:41 trapped on the 22nd floor for example? Uh I don't remember that point of detail, but I do remember hearing detail passed about FSG calls. I I don't remember the detail at all. I just thought that actually we've got a lot of people trapped in this building. That's
01:33:52 people trapped in this building. That's what I gathered from that as a general sense of what was occurring. Uh did did that sense extend to getting a feeling at least even if not a clear piece of information that fire had broken back into flats higher up in the
01:34:03 broken back into flats higher up in the building for example on the 12th floor? Um
01:34:08 Um I feared that but I I wouldn't have thought about a specific floor. I feared that there had obviously been some sort of breach of compartmentation to have so many FSG calls. Um, but again, genuinely
01:34:19 many FSG calls. Um, but again, genuinely my own approach to instant command is I'm I'm very careful about making assumptions distant from the scene. Really, I want to do the best I can on the the information I've got. I wouldn't
01:34:30 the the information I've got. I wouldn't necessarily assume that cuz I have been in a place where, for example, scaffold scream has been a light and people inside are going to be very concerned. They're going to look out of their window and see burning scaffolding and scrim. They're as terrified as someone
01:34:42 scrim. They're as terrified as someone who's got the fire inside their flat. So, I wouldn't necessarily have made that assumption, but yeah, that there was a fear there. I wouldn't have known it for definite till I got there. Now, at 2:00, just continuing with your contemporaneous notes if we can. You
01:34:53 contemporaneous notes if we can. You say, "I rang group manager Matt Cook, who was at the scene. He confirmed that there was a very significant fire involving the majority of a 24-story tower block. I explained that I would be taking over on arrival and asked if they
01:35:05 taking over on arrival and asked if they needed to consider making it a major incident." Uh
01:35:11 what exactly do you recall telling group manager Cook about the progress of the fire?
01:35:17 fire? Um
01:35:18 Um so far as you understood it from what you'd heard on it was it was less about me confirming it was less about me telling him. It was more about him providing me with a situational update and me confirming my
01:35:30 situational update and me confirming my understanding of that. I see. And more importantly on the basis of what he then told me I was almost certain it was a major incident. And whilst I couldn't take that decision remotely, the detail of that conversation is that I think it
01:35:41 of that conversation is that I think it was with Richard Welsh at the time. I said it's not my decision to make this a major incident. But I would suggest very strongly in light of what you just told me, which was that basically it was a 24tory story block, the majority of
01:35:52 24tory story block, the majority of which was involved with multiple FSGs, that actually it would be of everyone's benefit to make that a major incident because it would start the wider scale machinery that sits behind a major incident,
01:36:03 incident, right,
01:36:03 right, starting to roll out. Matt agreed with that and Matt's a good RT officer um and suggested that he was going to talk to Richard about that. Now Richard may have come to that decision on his own. I didn't have any interaction before he
01:36:15 didn't have any interaction before he made made it major in I was very reassured
01:36:18 reassured um when I heard Richard take over make pumps 40 and then later not much later make it major incident. Right. Did you hear him become incident commander? Yes. So I heard him on the way. That was one something I did hear. So I heard him
01:36:29 one something I did hear. So I heard him take over. I heard him make pumps faulty and I heard major incident. All of those things gave me a degree of you know I wouldn't want to overe this but a degree of reassurance
01:36:41 overe this but a degree of reassurance cuz it felt to me that that sounded right in terms of resourcing in terms of the scale of the incident and I was glad that someone now of a senior rank had taken over. Right. Okay. Did you wonder where uh DAC
01:36:52 Right. Okay. Did you wonder where uh DAC Lachling was given that you heard that group manager Welch was taking over as as incident commander? No, because I know I actually know where Andy lives and I know that Andy's got to travel some distance and it wasn't my assumption he necessarily got there or
01:37:04 assumption he necessarily got there or if he had got there it may well be that you know Richard there was some sort of time lag Richard had taken over maybe he was getting a briefing so no I I would have liked Andy to be in charge
01:37:15 have liked Andy to be in charge obviously but I I wouldn't have felt particularly that it was unreasonable for him not to be at that point. Now, just focusing on the conversation you had with Matt Cook at 2:00. Did you actually ask him who the incident
01:37:26 actually ask him who the incident commander was? Yes. And I also asked where Andy Lachlan was and he couldn't confirm where he was at that point. Right. What did Matt Cook or who did Matt Cook tell you was incident commander?
01:37:37 commander? Um, he told me that Richard Welsh was going to take over as instant commander. So, he was clear about that. Okay. Did you have a conversation with Matt Cook about whether the fire had yet breached into flats?
01:37:49 breached into flats? It was clear. It was clear from what Matt said to me that he thought there was a degree of internal fire spread, right?
01:37:56 right? But he, you know, it was a very short conversation because he was under pressure himself. You know, he's on the and I was conscious. I didn't want to take up too much of his time. I needed enough situational awareness to frame my own thoughts but not take so much of
01:38:08 own thoughts but not take so much of Matt's time that he wasn't providing advice and guidance and support in his role as an ORT officer to instant commander who would desperately have needed at that point another officer to bounce off and think about the decision-m. M I see.
01:38:19 decision-m. M I see. So it's a balance. Yeah. And during that conversation, did you have any discussion about what advice should be given to residents by control?
01:38:25 control? Absolutely not at that point. No. Now uh
01:38:29 Now uh uh once you had discovered that Richard Welch either had taken over or was going to take over, did you think to call him and speak to him about what he should be doing until you arrived?
01:38:40 doing until you arrived? No. I at the point where I understood Richard had taken over. And now having a better understanding of the scale of the incident, I thought the last thing that Richard needed was me to ring him because I would have wanted him to be
01:38:51 because I would have wanted him to be taking decisions rather than providing me with a situational update. So my preferred route in there would have been um via Matt Cook. And in fact, you know, I debated with myself whether or not to
01:39:02 I debated with myself whether or not to call Andy. I can't remember whether I did call Andy again or not off the top of my head. I I don't think I did. Um because I would have wanted them to be making decisions and carrying out activity on the fire ground. Whereas
01:39:13 activity on the fire ground. Whereas Matt as an RT officer has a degree of distance and objectivity because they're in a support and um tactical advice and audit role. So they've got the time to take a phone call and join up the dots
01:39:24 take a phone call and join up the dots in terms of situational awareness is a very important part of being an RT officer.
01:39:28 officer. So he would be my route into the incident particularly because he'd pick the phone up to me. Right. I see. Turning to page two of your contemporaneous note, you can see the second entry down. It says at 207, I
01:39:39 the second entry down. It says at 207, I rang Matt Cook and he gave me a situational update regarding the scale and rapid uh rapid offspread of the fire. I let him know I was about 20 minutes away and that the commissioner was also on route. Um in terms of the
01:39:52 was also on route. Um in terms of the situational update regarding the scale and rapid spread of the fire, what did he tell you? I can't remember the exact detail of the conversation, but what I do remember at that point was that he told me it was it
01:40:04 that point was that he told me it was it was definitely on two sides of the building. So, what I remember is it was on two sides of the building that it was spreading extremely rapidly. Um, words to the effect that he'd never seen fire spread like it. It was the most
01:40:16 spread like it. It was the most significant fire he'd been at. Right.
01:40:18 Right. Um, and again, I think I need to reiterate, Matt himself sounded sounded under enormous pressure, you know, and again, he's a good officer. He's a calm officer. He's experienced good instant commander, good RT officer.
01:40:31 commander, good RT officer. I think it's important to state that it's not just the information people give you as an instant commander that informs your situational awareness. It's also the tempo of what you can hear in the background, the sound of people's
01:40:42 the background, the sound of people's voices, you know, the way that they communicate with you. They are as important clues. particularly because I would say almost every officer I worked with that night I knew extremely well had been on multiple incidents with had
01:40:53 had been on multiple incidents with had you know Richard Welsh for example Pat Gold very experienced officers who I've been at difficult fires before special service incidents calm people who really know how to run an incident Matt Cook
01:41:05 know how to run an incident Matt Cook falls into that category so if I'm hearing Matt Cook on the phone with a heightened degree of emotion and sounding stressed then I know that something very significant is going on I think that's important to note as It was
01:41:16 think that's important to note as It was clear from the tenor of his voice that he didn't have a lot of time to speak to me and that actually something very significant was occurring. And again, same question as before. Did did the subject of changing stay put or
01:41:27 did the subject of changing stay put or the question of advice to residents crop up during that conversation? No, it didn't. Now, you arrived at the scene and we've got your status three time arrival on scene is 231 and that's um short incident log at page
01:41:39 and that's um short incident log at page 14 right at the top. Can I just ask you to be shown uh that 23118 just to just to make sure you got it in your So I think I arrived a couple of minutes
01:41:50 So I think I arrived a couple of minutes before that because I phoned Adrien Fenton at 2:29 on my phone log when I arrived um because I wasn't going to bother control with trying to book in because my sense was they'd be overwhelmed with calls and I was going
01:42:02 overwhelmed with calls and I was going to waste my time trying to phone into control to change my status. Whereas I knew that Adrian was in the same location as control. So I'd asked him to set up BCC at Stratford Fullback. And I just told him I'm arrived and could he
01:42:14 just told him I'm arrived and could he just update vision and confirm me as status 3. It probably took him a couple of minutes to walk across the room and do that.
01:42:19 do that. I see. I was going to ask you, you you've put in your if you just go back to it. It's the second page of your contemporaneous note. Fourth entry down. You do have a time of 2:29. Yeah.
01:42:28 Yeah. For arriving at scene, parking and ringing Andrew and Fenton. Where did you get the time of 0229 from? That came off the phone log. Your personal? Yeah. So, it came off the mo the personal mobile. That's when I phoned
01:42:39 personal mobile. That's when I phoned Adrian in and asked him to put me in. Okay. And you had already arrived by that stage. Yeah. So, I'd arrived. I got out the car. That was the first thing I did cuz I knew then that was done. Everyone would know I'd arrived and there was some shity that I'd arrived and would be
01:42:50 some shity that I'd arrived and would be taking over. Do you think you booked attendance three before or after you uh rang uh Adrien Fenton?
01:42:56 Fenton? No, I booked it through Adrian. Through Adrian. So, I knew Adrian was coll-located with control. I didn't want to bother control operators because I felt they were under significant pressure. Yes.
01:43:05 Yes. I knew that he was in there and would simply walk across to the officer of the watch and say Andy Rose now in attendance. Yes. I see. So you didn't you I see. It also served a dual purpose actually of confirming that I was in attendance
01:43:17 of confirming that I was in attendance to him because he's an important part of that wider command framework sitting outside the incident. Right.
01:43:22 Right. Um and as it says there I could hear in the background, you know, the volume of calls coming into control. That was quite disturbing in itself actually.
01:43:33 quite disturbing in itself actually. Now, at the bottom of page two of your first witness statement, if we could just go back to that and go to the top of page three, you say uh um after arriving and parking um I
01:43:45 um after arriving and parking um I rigged in my fire gear and began to make my way towards the block. It was 400 meters away and clearly 100% of light on two sides at that point. Yeah. And then you go on to say it was
01:43:56 Yeah. And then you go on to say it was difficult to get there due to the very large numbers of people on the street and the traffic congestion. Um at that point you arrive, you park, you rig. Did you begin to have a plan in your head
01:44:08 you begin to have a plan in your head about what you should be doing? I didn't have a plan in terms of a tactical plan, but um what I did have was some perhaps expectations about what I might find, i.e. a plan to structure
01:44:20 I might find, i.e. a plan to structure the incident in some kind of way which I would have expected the officers ahead of me perhaps taking into account the exceptional nature of this incident not massively formed but at least a building block to grow on um I would say at that
01:44:32 block to grow on um I would say at that point I was in the so if we go back to that decision-m cycle you know I'm fairly institutionalized I do use that so I started working my way through it and in my own head I was looking at the task event part of the decision-m model
01:44:43 task event part of the decision-m model so really it's just about getting a proper understanding of what I was facing and that started from the moment I got out of the car um with what I consider to be on the edge of a civil disorder situation actually and that's
01:44:55 disorder situation actually and that's um unsurprising considering the nature of this incident. Did you go straight to the base of the tower?
01:45:01 tower? I walked past the tower because I could see the tower and I I you know I don't know the area well. I just thought if I head towards the tower I'm obviously going to find the command unit. Right.
01:45:09 Right. Um so I headed towards the tower which I could see as I got out. I think I'd parked on Bramley Road. Yes. Um, and as I was walking there, I encountered more and more groups of
01:45:20 encountered more and more groups of people who were clearly distressed, clearly horrified, as you would understand that community would be, by what they saw in front of them. People on mobile phones, not anger, but
01:45:31 on mobile phones, not anger, but agitation, concern that perhaps things weren't being done. You could hear it in the voice. People were asking me, "What's happening? Are they going inside the building? Are they rescuing?" So, people trying to stop me on the way. It was
01:45:43 trying to stop me on the way. It was quite difficult to get to the unit actually. So, there was a number of occasions where groups of people tried to stop me and ask me questions and I had to politely say, "I'm really sorry. I'm I'm making way to take over this incident. I can't talk to you, I'm
01:45:54 incident. I can't talk to you, I'm afraid."
01:45:54 afraid." Did you aim to go to the tower first or to the command unit first? Um, it wouldn't have mattered to me where I'd gone first because I would have taken myself to the tower very quickly afterwards to get an understanding of it. As it happened, I
01:46:05 understanding of it. As it happened, I walked past the base of the tower and came to what I think is CU7 if I remember rightly, which had the fire survival guidance crews on it. But I came via the base of the tower and that
01:46:16 came via the base of the tower and that was very useful to me because it gave me a very clear understanding of probably the first couple of decisions I was going to have to make. Yes, I see. Okay. Many many of those attending had actually come from the southeast of the
01:46:28 actually come from the southeast of the tower and had passed the command unit first. You'd come from Bramley Road and approached it from the northwest. Don't don't ask me how I got to it. I couldn't tell you now. But I came via the tower and then into right past CU7, then on to CU8. My journey
01:46:41 past CU7, then on to CU8. My journey took me that way. Right. Now, um uh you say on page three of your witness statement in your in the second paragraph there,
01:46:53 second paragraph there, um
01:46:55 um significant debris was falling from it. Some pieces being meters wide. The volume of noise was incredible. Along with the sound of falling debris, there were screams of people at the windows trapped in the tower and their relatives
01:47:06 trapped in the tower and their relatives and friends shouting up to them. The block was 100% a light from what appeared to be the third floor to the top floor with fire showing inside many windows.
01:47:17 windows. Um, was that the first time that you knew for sure that the fire had got into the building? Yes. And that I came to that conclusion very quickly because to me it was very obvious that at that point of the
01:47:29 obvious that at that point of the incident there had been an absolute building system failure. Right? I've never seen anything like it. I've never seen such a complete building system failure in my life. It was genuinely shocking. I could look laterally through
01:47:40 shocking. I could look laterally through the building and see that the fire had gone cuz I took the time to stop and look for that reason that I could see it had breached initial compartments into the compartments beyond. And then taking
01:47:51 the compartments beyond. And then taking a wider perspective that the scene to say it was dynamic would be an understatement. You know, there was a really difficult mix of people not involved directly in the tower at the
01:48:02 involved directly in the tower at the base, friends, relatives, members of the community, desperate, as you would understand, to have people out of that tower.
01:48:08 tower. My own crews and officers doing their best to get people into the tower. That was obvious. It was obviously I had people in there. So that gave me definite pause for thought in the scale of the fire I was seeing and the fact we
01:48:20 of the fire I was seeing and the fact we had people committed. I was immediately concerned about that and firefighter safety. Um and I was at the same time very sure because I had been thinking about it on the way that we were no
01:48:32 about it on the way that we were no longer going to be able to reasonably advise people they should stay put. That was the first thing that was in my head if that answers my next question. Yeah.
01:48:39 Yeah. Right. But then the second question, my second question is, did do you still think that fighting the fire was a viable option? No. The only reason we were going to be fighting that fire was to maintain the
01:48:51 fighting that fire was to maintain the commission, the conditions in which we could put BA crews as far as we could to mitigate the risk to them. And I have to say, I think at times we went beyond what was acceptable to put a firefighter into. I should be clear about that as
01:49:02 into. I should be clear about that as instant commander and hold that decision. Um I think we were right from the very start of that job on the absolute margins of what's acceptable to commit a firefighter into and um my sense was that we could no
01:49:15 and um my sense was that we could no longer in the same way focus on fighting the fire. We had to really focus on getting everyone out of that building. That was my absolute priority. The the building was gone. There had been a complete building system failure. You
01:49:27 complete building system failure. You know the facade was entirely alike. Every window I could see there had been a breach of compartmentation. um there was no viable way of saving that building. I can't talk about the
01:49:38 that building. I can't talk about the detail of everything inside the building, but as a general principle, I was very clear that all our efforts had to be about, and I'm talking almost instantly, had to be about putting the maximum amount of people with breathing
01:49:49 maximum amount of people with breathing apparatus into that building and making the maximum effort to take as many people out over as quick a period of time as we could. Did you at that moment or even later but focusing on that moment for the time being did you stop
01:50:01 moment for the time being did you stop and and ask yourself what is the mechanism of internal fire spread to this degree in this building? Yes. And my only thought was that it was going to be a combination of things. It
01:50:12 going to be a combination of things. It was going to be a combination of whatever was a light on the outside allowing fire to spread across the external surface in a way that was you know unbelievable. But then there must have been a failure perhaps through
01:50:23 have been a failure perhaps through renovation or because a combination of renovation open windows because of the time of year perhaps again because of the training I'd got from the lack and all house package whether the window system itself had failed so it was
01:50:35 system itself had failed so it was dripping plastic and spreading there was all sorts of things in my head if I'm honest you know went for it very quickly but I just considered there would be a whole set of variables which could have led to that failure of um you know
01:50:47 led to that failure of um you know internal compartmentation but that scale of failure must have been very very very significant cuz it was every single floor.
01:50:54 floor. Every single floor I could see where there was flame on the outside. You know, the impression I got very quickly was that there was significant internal fire spread as well. And did you have any thoughts or even
01:51:06 And did you have any thoughts or even suspicions about what the cause or causes of that internal fire spread were?
01:51:11 were? No, I would have been working on the general assumption that they would have been spreading through voids. It would have been all the things that make a fire spread under any circumstances, which is a route to travel. So, it was clear to me that whatever way you looked
01:51:23 clear to me that whatever way you looked at it, I mean, to put it in lay person's terms, you had an accelerant on the outside, and it felt to me like the building was punched full of holes. It was like it was like the, you know, like a like a cheese grater in the sense that
01:51:35 a like a cheese grater in the sense that there must have been a route for that fire cuz it's the only way you can explain that in a concrete building. The concrete's not going to burn in that way. You know, the window system shouldn't fail in that way, but perhaps
01:51:46 shouldn't fail in that way, but perhaps there being open windows. The facade definitely shouldn't burn in that way, but therefore, there's got to be an element of combustible material or a route for fire through that building that cannot be readily explained by the
01:51:57 that cannot be readily explained by the concrete structure. So, it had to be through voids or through material in those voids that enabled that fire spread or because there was wasn't any compartmentation because doors were open
01:52:08 compartmentation because doors were open because there was lots of people there. Um, you know, there there's so many variables that could have led to that internal fire spread. But in a way, without wanting to sound crass, it was almost irrelevant at that point because
01:52:19 almost irrelevant at that point because I had what I had. I had a building that had failed completely. There was massive internal spread. Therefore, what I was faced with was how I was going to get as many residents out of that block in a shorter time as possible, keeping my
01:52:31 shorter time as possible, keeping my firefighters as safe as possible. They they were my priorities. That was it. In many ways, I didn't really need to know why it had happened because I wasn't going to attempt to extinguish that fire. I was only going to attempt to
01:52:42 fire. I was only going to attempt to create the conditions by which we could rescue people and control the fire, at least to an extent internally where I could commit crews. Now, we're going to come to your takeover of command
01:52:54 takeover of command in due course. Before we do that, to tell you where we're going, we're going to go first to CU7 and then to CU8. Yeah. Uh
01:53:03 Yeah. Uh on page three of your witness statement, you say in the third paragraph uh that near the near the base of the tower, I came to the first command unit, CU7. On it, I found group manager Tom
01:53:14 CU7. On it, I found group manager Tom Goodle and a CU crew of three watch managers. I didn't know them, but I recognized them. And then you go on to um say uh
01:53:25 um say uh three lines down, he briefed me that there was that he was responsible for fire survival guidance FSG. I asked him how many FSG entries he had in total, but at that point he was unable to tell me as they were adding to them
01:53:36 me as they were adding to them constantly. His estimation of the number of people who had called to say they were trapped was over 100. Uh and and then you say uh I was more than happy with the system they had in
01:53:47 than happy with the system they had in place. I asked that they take photographs of the borders it changed. So we maintained a record and praised them on on their work. I then left for CU8. Now I read that all to you because I just want to unpack that a little bit
01:53:58 I just want to unpack that a little bit with you if I can. Um did did group manager Good uh tell you um how um he was um handling the FSGS? Yeah, I was very clear about the system
01:54:10 Yeah, I was very clear about the system employed. So basically he had a number of watch managers. So he had someone answering the phone. Uh that information was then passed to another watch manager and they had a grid up um um
01:54:22 and they had a grid up um um with loads and loads and loads of lines which they were filling information into of where residents were located. Um, that information was then inscribed onto one of our FSG sheets. That sheet went
01:54:34 one of our FSG sheets. That sheet went from the unit into the base of the tower via a runner. There was then someone inside and I can't remember who um at that point, I can't remember who it was when he briefed me, but there was an officer inside who was then making sure
01:54:46 officer inside who was then making sure that information was passed on my understanding at that time to the bridge head. uh so any crews committed would be committed on the basis of having an individual task to complete.
01:54:58 individual task to complete. So that was how the passage of information was going to get into the tower and I was satisfied with that. I think happy is the wrong word. You'll have to apologize me. So I think happy is not how I would describe it. I
01:55:10 happy is not how I would describe it. I was entirely satisfied that he was doing his best.
01:55:12 his best. I think what I should also reflect is that Tom is an officer I've worked with for many years. He ran the fire policy team. Again, he's a very experienced operational officer. I trusted him and I
01:55:23 operational officer. I trusted him and I was going to have to trust him to effectively command that incident. Sure. C can I take you to your contemporaneous notes at page two where you describe that briefing in a perhaps
01:55:34 you describe that briefing in a perhaps a little bit more detail um and pick up the sentence um in the third in the fifth line where you say um recording or
01:55:45 fifth line where you say um recording or fourth line I'm sorry fourth line recording the first survival call sent to him by control passing the locations of trapped persons on to an SM in the tower who was then briefing BA crews directly
01:55:57 directly Uh did did he tell you that it was a station manager in the tower actually providing their deployments to breathing apparatus crews? From what I remember he just said that
01:56:08 From what I remember he just said that there was an officer in the tower, one of whom was definitely a station manager. I think he had more than he he told me there was more than one officer in the tower, right?
01:56:15 right? Um and that BA crews were being briefed as to the fire survival guidance calls and then obviously committed via the bridge head. And my expectation because that's our policy is that there would be
01:56:26 that's our policy is that there would be a direct form of communication between the bridge head and whoever is handling and briefing those crews in respect to fire survival guidance. It's got to be a continuous process. Yes. Would would you
01:56:38 continuous process. Yes. Would would you expect the bridge head to be doing the briefing or would you expect the bridge head simply be to be doing the deployment with the briefing coming from somebody higher up or lower down the
01:56:50 somebody higher up or lower down the chain of communication depending on how you look at I think it could happen either way. I think it's about what works for that instant. What what what is vital is that there is a consistent communication between the bridge head
01:57:02 communication between the bridge head and whoever is briefing people for FSG, whether that's at the bridge head itself or whether it's happening prior to the bridge head. It would just be about whoever's in charge of the bridge head having a clear understanding of the route in for FSG information
01:57:14 of the route in for FSG information having a clear line of communication to whoever is running FSG because the two sectors are symbiotic. They have to work together. So I I wouldn't be I wouldn't be um you know kind of doctrinally fixed
01:57:26 be um you know kind of doctrinally fixed on what was the right way to do it. It would be how experienced officers worked together to ensure there was a clear system to get that information out of that command unit into the tower into the crews going to the bridge head. That
01:57:38 the crews going to the bridge head. That that would be what I would expect and actually it should be down to them to design and operate that system. I think it's my role to maintain progress and validate whether the system was working
01:57:51 validate whether the system was working right. So would that mean that where the watch manager in in possession of the FSG information was giving a brief to a BA crew and then that brief was
01:58:02 to a BA crew and then that brief was being overridden or changed by the bridge head. I don't think there's necessarily an issue with that as long as there's a return of information because the bridge head is having to act on sometimes what can be very rapidly changing information. So perhaps I can give a
01:58:13 information. So perhaps I can give a hypothetical example. If you were given a flat to get to to rescue someone, but the fire conditions have changed between the time where you've and I think that's entirely possible in the context of this
01:58:25 entirely possible in the context of this incident between the time you'd received the information to the point you got the bridge head. Then actually it's very possible the bridge head would say actually we think on the basis of information we've got we might need you
01:58:36 information we've got we might need you to do something else. What it would then need to happen though is that there was a return of information. Now again to set this in a context that's your ideal world in you know the scale of this incident that
01:58:48 know the scale of this incident that would have been extremely difficult whatever system was employed the volume of information the turnover of BA crews this is this is the largest I've now learned post incident the largest
01:58:59 learned post incident the largest breathing apparatus ever carried out in the history of firefighting so just the volume of committal of BA crews the turnover and again I think something that perhaps hasn't been talked about previously is the psychology of the crew
01:59:11 previously is the psychology of the crew who's committing. So obviously the information loop is closed by the people who are undertaking the tasks is closed by the officers who are undertaking the briefing and committing. What what I can
01:59:23 briefing and committing. What what I can tell you and I'm sure we'll come to it is when I went into the tower what I became acutely aware of is that we were committing people into the most extreme firefighting circumstances I'd ever seen and people were scared and that's going
01:59:34 and people were scared and that's going to affect their decision-m and it's going to affect their ability to communicate. I was also seeing firefighters coming out of there exhausted, carrying casualties. And again, I remember thinking on the night,
01:59:46 again, I remember thinking on the night, this is going to affect the information I received back. I'm not I'm not necessarily always going to be able to halt people to the level of information I want. It was that sort of incident where something was moving the whole
01:59:57 where something was moving the whole time. So my priority came in the end to be about volume because my reasoning was that as long as I ensured a continuous volume of breathing apparatus wearers inside that tower whilst we were not
02:00:09 inside that tower whilst we were not always necessarily going to be able to prioritize on the basis of risk because actually everyone was at risk and I think because of the volume of calls it would have been almost impossible to determine that priority for those officers involved. What I had to do was
02:00:21 officers involved. What I had to do was flood it with a volume of BARE is to such an extent that there was continuous operation to give us the best chance of getting people out. I think that was the scenario we found ourselves in. Okay. Can I then just pick out from that
02:00:32 Okay. Can I then just pick out from that answer long answer? No, not being critical. There's a lot in it and I need to be clear that I follow things up. Um can I just discuss with you then a little bit about the return of
02:00:43 little bit about the return of information from the bridge head um through CU7 which was the FSG sector. Uh did you check during your discussion
02:00:54 Uh did you check during your discussion your first discussion with Tom Good if he was passing if he was receiving back from the bridge head any information about the outcome of particular deployments in response to particular
02:01:06 deployments in response to particular FSGS?
02:01:07 FSGS? I can't remember the exact date of the conversation. I don't remember if I had it then or later. I'd have to look at the notes, but I do remember having a conversation with Tom where he articulated that he was finding it very difficult to get information back and
02:01:19 difficult to get information back and actually he just didn't have the space or the time to pass that information back into control to the degree he'd like to have done. And the other thing he reflected on in that conversation, I do remember the
02:01:30 that conversation, I do remember the conversation is that it was very difficult cuz people were moving flats as well. So it wasn't even that people were staying in one location. There was no shorty that where someone had originally phoned from and said they
02:01:41 originally phoned from and said they were they were going to end up cuz he was aware and he told me more than once that people were moving between flat locations. So I think the ability to pin that information down both in the nature
02:01:53 that information down both in the nature of the volume of calls, the extremity of the internal firefighting conditions, the continuously changing nature of those conditions. So at one moment, one floor it would be sustainable to have
02:02:04 floor it would be sustainable to have firefighting operations on the next minute it wouldn't be. Just meant that return of information was enormously difficult. I I know that all through that instant as incident commander, I was never satisfied at the return of information about the number
02:02:16 return of information about the number of people we bought out. So I think the recorded level of rescues and I sent people out specifically for that task is 65. I know full well that we rescued far more people than that. I think from what
02:02:27 more people than that. I think from what I've been told, the CCTV evidence alone shows that. But in terms of actually been able to gather that information from crews who were traumatized, who were tired, who were coming past officers who themselves were tired, we
02:02:38 officers who themselves were tired, we just never got to the bottom of that. Can I just ask you to look at the PRC notes, um, which is LFB03112. Now,
02:02:48 Now, I don't know whether you've ever seen this document before, Mr. Ray. It's a We've been working on this. This is a handwritten record of a PRC meeting of the 3rd of July 2017 at which you and
02:02:59 the 3rd of July 2017 at which you and the other incident commanders I think were present. Do you recall that meeting in general terms? Yes, very much. There was a logist there or somebody writing down what people were saying. Can I ask you to to turn be turned to to
02:03:10 Can I ask you to to turn be turned to to page 12, please?
02:03:19 Uh, and
02:03:34 in um, uh, it's it's it's the it's the top quarter of the page actually where it says Tom Good. Yeah. Uh do you remember a discussion
02:03:46 Yeah. Uh do you remember a discussion between you and Tom Goodle at this meeting about passing information back? Yeah, absolutely. Because if the point of a performance review of command is to honestly examine your own
02:03:57 honestly examine your own decision-making at an incident to take learning forward for individuals in the organization and if you were to ask me in hindsight an area that I would like to have improved on, it would have been that return of information. I think very very
02:04:09 return of information. I think very very difficult in a context. As you say, Tom Goodle at this meeting says, "In hindsight, didn't really pass much info back to control, but we were overwhelmed." And you say, "In hindsight, I should have ensured info was passed back to control."
02:04:21 was passed back to control." I mean, that's Tom's notes, but I wouldn't know if I've expressed it exactly like that, but it's not No, they're not Tom's notes to be clear. These are these are the logist notes of what was said at the meeting. Okay.
02:04:30 Okay. Um, so I mean my first question I suppose is do you remember saying that at the meeting? I remember saying something similar which is I didn't feel it was right for Tom to just hold that responsibility because whilst he had
02:04:41 responsibility because whilst he had that delegated command to run the FSG sector actually I was the overall instant commander and I was aware and I think you'll see from my own decision log I was chasing that information much
02:04:52 log I was chasing that information much more frequently further into the incident um and found it very frustrating actually that we couldn't get that information back right
02:05:00 right um
02:05:01 um if I was asked honestly and and I think those processes are very important for us to take learning forward. There was an area of the structure and command that I would like to have done more
02:05:12 that I would like to have done more efficiently. It would have been that return doesn't necessarily mean we would have achieved that because actually the volume of information, the dynamics of the incident, the terrible pressure that
02:05:23 the incident, the terrible pressure that officers and crews were under meant that gathering that information was at at best very difficult. My question, sorry having shown you that when you say I should, in hindsight I should have ensured information was passed back to
02:05:35 ensured information was passed back to control. My question is what would you have done to ensure that information was passed back to control? I think I could have gone back to Tom more regularly about that specific
02:05:46 more regularly about that specific point, right? I guess um we could have considered perhaps some sort of additional layer to the system but actually I think in terms of taking
02:05:57 actually I think in terms of taking learning forward it'd be more about a general principle I would take into another incident and I would think about a structure appropriate to that incident you know I think it's quite difficult to see how we would have done the incident
02:06:08 see how we would have done the incident differently on the scale of that particular incident but it was just an honest reflection that I didn't want Tom I felt that Tom had been honest in the PRC there that he knew that he hadn't passed perhaps as much information as he would have
02:06:20 much information as he would have wanted. I'm not sure actually he'd have had the capacity to and I felt that it wasn't just his responsibility to hold that. I was the incident commander. I'm ultimately responsible for helping close that loop. Truthfully, I'm not sure that
02:06:32 that loop. Truthfully, I'm not sure that would have made a lot of difference to the operations within the tower though because I don't think we were in a position because of the volume of calls and the dynamic nature of the incident to keep on bringing that information back out of control to that level of
02:06:45 back out of control to that level of change into the incident ground if that makes sense. Yes. Yes. Okay. Does um does that mean Well, let me ask you this way. Are you familiar with the provisions of
02:06:57 familiar with the provisions of paragraph 9 of FS of FSG policy 790? I'll show it to you if you like. It's about
02:07:04 about be helpful if you do cuz I can't remember the exact paragraph. Right. Even your not able to remember them off by heart. Um this is about well if you go to that it's 790
02:07:16 well if you go to that it's 790 tab five of our policy bundle. Um, paragraph 9.1 says, "It's vital that controllers kept informed of the actions being taken to resolve each FSG call. The fact that controllers is aware of
02:07:27 The fact that controllers is aware of the actions being carried out on the incident ground will greatly enhance the advice given to FSG callers." And just pausing there, first of all, were you aware of that policy requirement? Yeah, absolutely.
02:07:38 Yeah, absolutely. The closing of that loop is a very important part of FSG. The second question is what efforts did you take make if any to to do your best to ensure that control was kept informed uh to uh
02:07:49 that control was kept informed uh to uh resolve each FSG call so far as you could see. I reminded Tom of that in the conversations we had. But whilst at that incident, my sense was
02:08:00 whilst at that incident, my sense was that those officers who were handling FSG calls and the volume of information coming in were working at absolute capacity and then to pass the information back. You know, I would like the loop closed. Of course, I would
02:08:11 the loop closed. Of course, I would because I think it's useful. But I had a concern about capacity on both sides. So not only were people changing locations, the fire conditions were changing so rapidly all the time internally that
02:08:23 rapidly all the time internally that there was a real danger actually of providing advice on the basis of so say for example we told them a crew was coming a crew is going to be with you soon we've committed a crew and then that crew is deviated in the moment obviously that information is correct so
02:08:36 obviously that information is correct so I think it was just the scale of it was at times almost overwhelming for those officers and closing the loop was just very very difficult what I think would have been helpful would have been to update control perhaps more um on the
02:08:49 update control perhaps more um on the overall return. So how many maybe even just numbers and I think that did happen a couple of times across the night. So we told them how many people we thought we had out uh and I know that Tom at times tried to pass some information
02:09:01 times tried to pass some information back but I think it was such a volume and changing so rapidly that was very very difficult because they were constantly taking that information. But if you're talking about an aspiration, which is what learning is about, and and
02:09:12 which is what learning is about, and and trying to do your absolute best, then I I would hold by the point made in the PRC is that we would always want to try and close that loop. Right. And then 93, while we're on it, the outcome of every FSG call must be
02:09:23 the outcome of every FSG call must be communicated to control. And my question is, was that possible? No. Absolutely not. In the context of that incident, there was no possibility of communicating the outcome of every call for a variety of reasons. Number
02:09:35 call for a variety of reasons. Number one, it wasn't clear necessarily what flat number you were going to at times because that information was, you know, deteriorating by the moment because of the firefighting conditions. People had moved um flats. Um the people you were
02:09:49 moved um flats. Um the people you were rescuing were invariably extremely distressed and actually probably weren't going to give breathing apparatus crews particularly accurate information. The crews themselves are wearing breathing apparatus which is not ideal to
02:10:01 apparatus which is not ideal to communicate in terms of, you know, speech. Um there's so many things there that might affect the outcome of an FSG call that no I think it would have been absolutely impossible when combined with
02:10:13 absolutely impossible when combined with the volume of calls and the fact that the people we were bringing out of there were often themselves incapacitated. You know we were working quite often with a deficiency of valid information throughout the entire incident.
02:10:25 throughout the entire incident. During your briefing that initial briefing with Tom Good on CU7 did you ask him how he was prioritizing between FSG calls? Um, I don't know if I've stated it exactly like that, but I did ask how we were determining
02:10:38 ask how we were determining how crews would be committed. Um, again, my immediate impression was that my focus shouldn't be on that because the volume of calls would have meant it was almost I felt from the start that the
02:10:49 almost I felt from the start that the volume of calls would make it almost impossible to prioritize on an individual basis unless there was some really extreme examples of someone who needed everyone needed immediate rescue
02:11:00 needed everyone needed immediate rescue for a start. But I felt that for them to go through that process continuously faced with the volume of calls they had actually
02:11:08 actually might have slowed down the process of getting crews committed. I was more interested in getting a volume of crews in because that in the end was what was going to get those people rescued. And because of the level of internal
02:11:20 because of the level of internal compartmentation fire spread I'd seen, my judgment was that it would be very difficult to pick who was at greater or lesser risk within that building. I think anyone who was caught up within that incident by the time I got on the
02:11:33 that incident by the time I got on the unit to take over, I'd come to the conclusion they were all at very great risk and therefore our focus should be on that broad approach that we just commit as many people as possible and we don't stop committing them until we've
02:11:44 don't stop committing them until we've got as many people as we can out. Did you discuss with Tom Good the importance of getting to elderly people or children or people with mobility issues as a as a prioritization? No, I
02:11:55 issues as a as a prioritization? No, I didn't because I felt that we were well beyond that stage at the incident. My my sense was that if we'd started to try and extrapolate that information, they would have been caught in a level of detail that was not going to help us.
02:12:06 detail that was not going to help us. What I really needed was then to confirm broadly location and someone needing rescue.
02:12:12 rescue. That's what I really wanted Tom to do. I wanted a crew to get as soon as possible where a flat was with someone in it and then put a volume of crews through because that was the most efficient way timewise to ensure that we had the
02:12:24 timewise to ensure that we had the maximum amount of people committed in and a turnaround of crews to keep on pulling people out of the building. Now, we know because we've heard from Tom Goodall and seen some photographs that he did in fact put in play place a
02:12:36 he did in fact put in play place a system of prioritization and the earliest photograph of the checkerboard we have where he did that was about well sometime between 3:15 and 4:00 a.m. Um, did you did there come a time when you
02:12:47 did you did there come a time when you discovered that he had in fact attempted at least put a I was aware that he was prioritizing but it was to exception. So I think he had red peas.
02:12:54 red peas. Yes, he did. From what I remember, I don't I don't remember all the detail of it because you got to remember I'm responsible for the whole incident and I'm taking a snapshot at each part of the incident. I'm going to look at to kind of validate my own sense of whether things are working as best they can. I
02:13:06 things are working as best they can. I remember there being red peas which I took to be prioritization of an individual for whatever reason. I wouldn't have wanted to break down the individual detail of those. It would
02:13:17 individual detail of those. It would have sucked me into a level of detail I didn't need to consider. I was satisfied that he did have a system for prioritizing to exception. But again, I wasn't obsessed with that. Did you
02:13:26 Did you No, that wasn't my priority. Sorry. Sorry. Did Did you take any steps to find out how um Tom Good or indeed um anybody at the bridge head or in the building if not at
02:13:37 bridge head or in the building if not at the bridge head was capturing information from residents who had been uh rescued or had self evacuated? Yes. I mean that was not um I didn't
02:13:49 Yes. I mean that was not um I didn't feel good about that actually but I thought there was very little that the crews could do. So I came across a watch manager I now understand I think it was Glenn Williams from Soho. So when I went into the tower to try and give myself
02:14:01 into the tower to try and give myself some assurance about the control of BA crews internally it was clear that we were transferring FSG information onto a wall which is actually what had happened at Lacano and why we bought in the fibboard system. But again, I think it tells you the
02:14:13 But again, I think it tells you the story about this incident that we'd had this extremely tragic incident at Lacanol where we recognized that the systems we did have, so instant command wallets, the recording systems we had prior to Lacanol weren't the size or
02:14:24 prior to Lacanol weren't the size or sufficient to capture a number of FSGs. We then designed, implemented and delivered a system to contra, you know, to counter that we thought to our satisfaction as an organization. So fit
02:14:35 satisfaction as an organization. So fit boards are large. To find that we had run out of space on the forward information boards and multiple forward information boards and we're now once again in the situation of having to write on walls was a horrifying thing
02:14:46 write on walls was a horrifying thing for me to see. I mean it just told me all I needed to know about the incident that the system the very system we put in place to manage multiple FSGs had now failed because of the volume of FSGs we
02:14:57 failed because of the volume of FSGs we were encountering. Right. Uh going to your second witness statement if I can. Looking at page five,
02:15:05 five, you say, I think threequarters of the way down that page, one of the first questions I asked at the scene was whether we had any tactical plans for Grrenful Tower that were relevant on our system. The answer
02:15:18 were relevant on our system. The answer was not really of any significance. My first question is is did you ask that question on CU7 or was that a question you asked when you got to CU8? CU8 and the I knew the I can't remember his name. I knew the watch officer.
02:15:29 his name. I knew the watch officer. I trusted him. He said that there was very limited information on it. It was just about the size of the building. Um, and that they got that wrong. Right. So, I decided at that point I wasn't going to waste my time looking at
02:15:40 going to waste my time looking at information that probably wasn't correct. Didn't contain The one question I did ask was whether there was any sort of um floor plan of any significance. He said there wasn't. So, that that was enough for me at that point. I had other
02:15:52 enough for me at that point. I had other things to concentrate on. Yes. I see. Okay. So, that's a CU8 question. You don't remember who the watch manager was you asked? I'm afraid I don't know. All right. Let's go to your arrival on CU8. Um, when you arrived on CU8, did you immediately order a radio
02:16:03 you immediately order a radio announcement that you were incident commander? Yes, that was one of the first things I said. I just got on and said, I'll be taking this incident over. Could you let the fire ground know that I've become the instant commander? And could you let control that I've become the incident
02:16:14 control that I've become the incident commander? Okay. And who did you give that instruction to? To one of the um control unit operators. Do you know who that was? No.
02:16:23 No. Okay. Now, I addressed them directly and they confirmed they were going to do it. Okay. Right. We've got a time stamp for that of 0244. Um, and that's page 23 of the short incident log. I don't need to take you
02:16:34 incident log. I don't need to take you to it, but at 0244. Well, there it is. Um, informative C80 is now I see. To the best of your recollection, is that around the time you think you arrive on? I would say so. Give or take a couple of
02:16:46 I would say so. Give or take a couple of minutes perhaps before. Yeah. Right. Okay. Did you notice or know that 2 minutes before uh Andy Lachlan who was in command at that stage had received information or put out an informative
02:16:57 information or put out an informative that 58 adults and 16 children were believed involved? Uh yes, cuz I think I was on the I was on the unit at that point when that went. So I think I heard the informative go.
02:17:06 go. So I was very aware at that point of the sort of numbers we thought might be involved.
02:17:10 involved. Right. Now turning back to w your first witness statement at page four. You say in the second paragraph on that page uh you at 244 I told DAC Andy Lachlan
02:17:23 uh you at 244 I told DAC Andy Lachlan group manager Steve West station manager Jackie McConny and a CU crew of three whom I didn't know by name but only by sight that I was taking over with immediate effect. This was communicated over the radio. Um,
02:17:36 over the radio. Um, and then you go on to say in halfway down that paragraph, Andy, who had taken over for a short time, gave me a brief. And then you go on to say, he confirmed that Grenfell was alike from the third floor to the 24th floor with multiple
02:17:47 floor to the 24th floor with multiple people trapped inside. Richard Welch and Pat Gulborn had fire sector which encompassed the entire building. Dave O'Neal safety sector and asked for BA main control to be set up in front of the ledger center opposite
02:17:58 in front of the ledger center opposite the block. We had BA crews rigged in the block who were progressing rescue efforts well up into the building. Um, did Andy Olllin tell you anything about whether the fire had penetrated into flats from his point of view
02:18:10 flats from his point of view at that point? Um, I I think I communicated that. So, I don't think we had that discussion. I think I think there's a general understanding that we we'd face in building system failure. I
02:18:21 we'd face in building system failure. I don't remember that piece of detail. What I do remember is that Andy gave me a really good brief about um the structure he put in place, what he thought our priorities were in terms of
02:18:32 thought our priorities were in terms of objectives, which wasn't to firefight, it was to rescue. Um and that he talked about how he was going to ensure a supply of BA wearers into the tower. So the fact that BA main control had been
02:18:44 the fact that BA main control had been set up that Pat and Richard were effectively sharing responsibility for the fire sector. Obviously, I knew Tom was already running the fire survival guidance sector. Um, and I felt I felt
02:18:55 guidance sector. Um, and I felt I felt assured actually by Andy's plan. He'd clearly thought about a structure that was likely to work moving forward. Right. Um, did he tell you what his strategy was? His his strategy was
02:19:06 strategy was? His his strategy was broadly along the same lines of thought as me, which was to focus on rescue, get as many people as possible inside the building, you know, as high as we could, and basically flood the building with BA
02:19:17 and basically flood the building with BA to get people into the flats to get residents out. Right.
02:19:21 Right. That's as much as I remember from that in terms of broad strategy, which I know sounds very simple, but in many ways, Grenful, for all its horror and its complexity and its dynamism, was quite a simple incident. It was a whole building of light, and we knew what we had to do.
02:19:33 of light, and we knew what we had to do. Now, he hadn't revoked the stayput at that stage. No.
02:19:36 No. And we're going to come to that decision in a moment. Um, did he tell you that he hadn't had any information back from the from the fire sector or the FSG sector for the for the previous 25 minutes or so?
02:19:47 so? No.
02:19:47 No. Despite his efforts to get some? No, he didn't at that point. Were you Did he give you any FSG numbers?
02:19:54 numbers? Um, I remember having a discussion about FSG numbers, but not the detail of it. And I think I probably reflected the fact that even from the last time he checked um that those numbers were rapidly rising. So I think there was
02:20:06 rapidly rising. So I think there was something along the lines of me reflecting what Tom Good had said to me cuz obviously I was getting on to the back of the unit knowing that there might be perhaps a hundred that they were the sort of numbers that Tom had talked about.
02:20:17 numbers that Tom had talked about. Yes.
02:20:18 Yes. Um but I wanted that brief done as quickly as possible. So to the extent I was controlling the brief, I already had some situational awareness. I needed to know what Andy's structure was so that I
02:20:29 know what Andy's structure was so that I could take over effectively as quickly as possible and so I would know what officers I had were responsible for different parts of that kind of delegated command structure. So that was my priority. Once I knew
02:20:40 So that was my priority. Once I knew that his primary objectives were in line with my own assessment of it, I didn't really want to pull that all apart. You know, I needed him out there really acting in the role of operations commander. I knew I was going to need
02:20:51 commander. I knew I was going to need one of those because of the scope and the scale of the incident. So did you note the discrepancy between what Tom Goodler had told you about persons trapped 100 and what uh uh you got from
02:21:02 trapped 100 and what uh uh you got from Andy Lachlin which was 58 adults and 16 children.
02:21:05 children. Uh I can't remember markedly noting it in the conversation. I do remember thinking it when I heard the informative, but I'll put it down to the fact that actually what what that told me is that we were getting a continuous
02:21:16 me is that we were getting a continuous stream of fire survival guidance calls and this incident was, you know, just so rapid in its development that I might have to look well beyond it. In fact, I remember the thought I actually had was
02:21:27 remember the thought I actually had was that this is a block my own estimate. So, I done a quick bit of mental arithmetic walking in could contain 450 people maybe. I knew that it was Eid and that we we had a significant um Muslim
02:21:40 that we we had a significant um Muslim population in that community. So my expectation would have been that families would have been there and celebrating, you know. So I thought that figure could have been inflated. I I I was less concerned about the discrepancy
02:21:51 was less concerned about the discrepancy between 100 and whatever um Andy thought it was and the possibility that there were actually far greater numbers of people involved potentially because of the time in the morning that the fire
02:22:02 the time in the morning that the fire had occurred. And obviously at that point in terms of my situational awareness, I had absolutely no idea of how many people had managed to escape the building before the fire had spread to the extent it had. Right. At that stage, did you know that
02:22:14 Right. At that stage, did you know that there was only one staircase in the building?
02:22:16 building? Um, yes. I can't tell you where I'd got that information from, but I know that when I got onto the unit, I was well aware that we weren't using the firefighting lift and that there was only one staircase. Someone had someone
02:22:28 only one staircase. Someone had someone had told me that and I passed a number of officers but that again was not good news for me. Did you know did you know that there was smoke logging in that single staircase? I didn't know there was smoke logging at
02:22:39 I didn't know there was smoke logging at that point but because of the scale of the fire spread I I had already assumed that the lobby would have been compromised in some places. I was working on that assumption immediately. Did anybody tell you that uh Adrien
02:22:52 Did anybody tell you that uh Adrien Fenton and Joe Smith at brigade control had been told that crews had been struggling to get above the 15th floor? No, not at that point. Right. Did you know anything about unsuccessful rescue attempts? No, not at that point.
02:23:04 No, not at that point. Can I ask you in the minute or so we've got before 4:30, Mr. Chairman, uh to look at the PRC notes again, LFB quadruple 03112 and turn to page one.
02:23:19 uh you say in the middle of the page there after brief from DAC this is under the part of the meeting which deals with what you were saying wanted to ensure clear structure major effort was rescue of savable life I'd written building off
02:23:33 of savable life I'd written building off and then you go on to say what you gave uh and then you say I wasn't going to worry about nicks nic it was beyond NIC so dynamic
02:23:46 so dynamic My my question is in in in forming those conclusions, how much were you relying on what you'd seen separately and how much were you relying on what Andy Lachlan was telling you in his brief? Composite of the whole thing. So I think
02:23:57 Composite of the whole thing. So I think again if we go back to the decision-m model, what what you're doing at that stage of an incident is you're gathering information from all available resources and you're trying to build a a picture
02:24:08 and you're trying to build a a picture of the incident based on those. So I'd seen the fire itself. I was sure internal compartmentation had failed to a significant extent. I had seen that we were committing crews into the building. So therefore, I was thinking about the
02:24:19 So therefore, I was thinking about the safety of crews and what it meant to carry out that operation. I knew because of the time of day, because of the nature of the community, um because of what I've been told on Tom Good's unit, we had significant
02:24:30 Good's unit, we had significant involvement of people inside and all the information I'd gathered on route. Andy simply confirmed everything I knew. He didn't tell me anything particularly I didn't know. And therefore, my priority was to get control as much as we could
02:24:42 was to get control as much as we could on that incident. I think if I if you wouldn't mind I think my role is at the point I come because I've had the benefit of not being involved generally I would say Grenville slightly different
02:24:53 I would say Grenville slightly different in the horrendously dynamic stage of an incident I've come with a bit of time and space already to have thought about it and it's my job to relieve those officers who've been there for some time
02:25:04 officers who've been there for some time from the burden of trying to structure that incident and try and build on what they'd already done to bring some order to what are inherently chaotic situations because I've generally got the support and the resources to do so.
02:25:16 the support and the resources to do so. So that was my priority. I wanted to get onto that unit, relieve them of the burden of responsibility of being the instant commander regardless of whether I've been briefed or not. I wanted to take that responsibility from Andy so
02:25:27 take that responsibility from Andy so that he didn't have to feel that in that way and then I wanted to build a structure because that is what my role was was to try and put all the pieces in place that would allow us to resolve the incident.
02:25:37 incident. How were you? We have actually reached up fast for now. Can I just ask this final question? It's it's related. Yes. All right. Otherwise, I'll have to ask it tomorrow morning. Yes.
02:25:46 Yes. Okay. Just building on on what you've just said to us and on the PRC notes. My my question is what method of saving rescuable lives in
02:25:58 what method of saving rescuable lives in that building? Uh were you going to adopt?
02:26:01 adopt? Um very simply passing a combination of things. So passing information where we had specific information to crew. So if we knew where someone was in a flat, sending a crew to that flat and then
02:26:13 sending a crew to that flat and then ensuring we had a volume of firefighters in breathing apparatus, generally undertaking a systemic sweep of that building over a period probably of hours was my judgment to clear any areas
02:26:25 was my judgment to clear any areas whether we've had any information or not. So it was two twopronged really. you're working on the intelligence you have got specifically to individual flats but also a general principle that at some point every single floor and
02:26:37 at some point every single floor and every single flat would have to be searched. Now how long it would take us to get to that I was unclear of at that point because of the scale of what was facing it. I just knew that as an outcome that would have to be the case.
02:26:49 outcome that would have to be the case. Whether it was an hour later, whether it was 10 hours later, whether it was a day later, that was the principle we were going to operate to that there would be no flat and no compartment left unarched
02:27:00 no flat and no compartment left unarched in that building. Yes. Thank you. Is that a convenient moment?
02:27:04 moment? I think it is, Mr. Bill. Yes. Now um before we break it was crossing my mind whether having got slightly behind ourselves today we needed to sit early
02:27:15 ourselves today we needed to sit early tomorrow but maybe we don't I don't know what
02:27:18 what I can I just say this but I think partly for Mr. Row's benefit as well as everybody else's and say Mr. Forgive me while I we have a bit of housekeeping. Um, we did have a plan uh to have uh
02:27:31 Um, we did have a plan uh to have uh some other firefighters here tomorrow. Uh, namely um, station manager Davis, uh, watch manager Rickettts and, uh, station manager O'Neal. Uh, group
02:27:44 station manager O'Neal. Uh, group manager O'Neal, group manager O'Neal. Um, very helpfully, the LFB have agreed uh, that we should postpone their evidence until Tuesday next week. Um, because we are, I'm afraid, as is
02:27:55 because we are, I'm afraid, as is obvious, running a little bit behind this week. But it's very important that we get um the incident commanders evidence in full and they have a lot to tell us
02:28:03 tell us and I've very consciously not been stopping people telling us telling them what
02:28:07 what um they they want to tell us. uh that means that the pressure on tomorrow is less and if um assistant commissioner Ray doesn't mind coming back at 9:30 then there will be a clear a clear route
02:28:19 then there will be a clear a clear route finishing tomorrow and covering uh watch man um watch manager Kentfield at the same time after um Assistant Commissioner Row has finished his evidence. So the idea is in a nutshell
02:28:32 evidence. So the idea is in a nutshell start at 9:30 finish Mr. Ray's evidence and uh deal with Mr. to Kentfields and then sit on Tuesday to finish the rest of the um LFB witnesses that we were going to cover tomorrow but can't.
02:28:44 going to cover tomorrow but can't. All right. Well, that's very helpful. Thank you very much. And that would leave it clear. Just to say that would leave it absolutely clear for the commissioner on Thursday. Yes. Well, I think I should record my gratitude to the LFB for making people
02:28:55 gratitude to the LFB for making people available often at very short notice and in a way which I suspect disrupts their schedules. But we are grateful for that. What I think that means for you Mr. Rose, if you don't mind coming back,
02:29:06 Rose, if you don't mind coming back, please at 9 tomorrow. It's earlier than we usually start, but it means there's a good chance that we finish the evidence scheduled for tomorrow during the day and then we'll certainly finish you. As
02:29:17 and then we'll certainly finish you. As I say, I hope the others as well, of course. Yes. So, thank you very much. Um, you're free to go now back at 9 tomorrow. And as I said earlier, please don't talk to anyone about your evidence overnight.
02:29:30 anyone about your evidence overnight. Thank you, S. Thank you very much. Um, Mr. before you rise and I it doesn't matter
02:29:36 matter first. You you go with the This isn't for you. No, no, we've got perfectly reasonable step to take.
02:29:51 Yes, sir. Um there are just a couple of things I should have said that of course that was Tuesday is subject to final confirmation by the LFB as I understand it but certainly so far as tomorrow is concerned and and Thursday we are clear.
02:30:03 concerned and and Thursday we are clear. Yes.
02:30:03 Yes. Um it also means that Monday is a I wouldn't say a day off but um it's a non-sitting day uh as would be Friday. Um Mr. Chairman, there's one other very small point of detail I need to correct from some
02:30:16 detail I need to correct from some evidence earlier on today that I I think I asked um DAC Lachlan about. Um I I suggested to him that Hashamshun uh was from RBKC. For the record, I need to
02:30:27 from RBKC. For the record, I need to correct that um uh that that person is from the TMO. Was from the TMO on the night. Just just so the record is clear. Yeah. Good. Thank you very much. Right. Well, we'll break now and resume at 9
02:30:39 Well, we'll break now and resume at 9 tomorrow then. Yes. Yes. Thank you very much. Half past 9 tomorrow, please.