Senior Fire Commander testifies on critical decisions during the Grenfell night including the change from stay-put advice and communication challenges on the incident ground.
00:00:12 good morning of one welcome to today's hearing and we're going to hear any moment now from mr. rota and good morning mr. chairman
00:00:31 or illustrator only certain points that I want in chemistry before I do mr. chairman can I just make a housekeeping all-time tabling point yes to use You mr. chairman woodshed I think other
00:00:42 mr. chairman woodshed I think other members of the public don't know yet at the moment in our schedule for today we have watch manager Kent field yes and we he was scheduled to come to give
00:00:53 he was scheduled to come to give evidence this afternoon at just after the end of hearing yesterday we received from the Metropolitan Police a statement from him running to some 21 or so pages very
00:01:05 running to some 21 or so pages very recently signed which we have yet to study in detail and it has not been disclosed I mean and it would need to go through the redactions and disclosure process before it were disclosed in the
00:01:18 process before it were disclosed in the light of that it would be unfair to everybody I think including mr. Kent field to be called to give evidence this afternoon when his evidence would be based only on his contemporaneous note in those circumstances we have taken the
00:01:31 in those circumstances we have taken the steps with the lfb to postpone his evidence to a date to be fixed as it were pending detailed consideration of his statement and its disclosure to all
00:01:42 his statement and its disclosure to all CPS so that they can consider it as well and we will update you and the public in in due course on whether and if so when we intend to call it may well be that
00:01:53 we intend to call it may well be that all the questions that we had for him are answered by by his statement so that's the position with mr. Kent field which well thank you for drawing everyone's attention to that it's regretful that we can't take his
00:02:04 regretful that we can't take his evidence today and I'm sorry particularly because it's another disruption to the aleph peers in its arrangements yes yes I agree thank you
00:02:17 arrangements yes yes I agree thank you sir thank you for telling us yes mr. a no good morning sir can I ask you to revisit with me a topic very briefly that we discussed yesterday
00:02:30 very briefly that we discussed yesterday were you aware at any time of a pilot exercise developed by a watch manager called Peter Johnson who was on the command unit team which demonstrated the
00:02:42 command unit team which demonstrated the operational difficulties tee's the crews would run into once FSG numbers got up to seven or so no I wasn't aware of that you weren't were
00:02:57 wasn't aware of that you weren't were you aware that a watch manager had developed a an exercise or training exercise of that kind which was deemed not necessary or relevant by senior
00:03:09 not necessary or relevant by senior members of the NFB no I wasn't aware of that
00:03:12 that now can I then turn to the topic of stay put if you go to your row log which is M et quadruple zero five 404 and turn to
00:03:26 et quadruple zero five 404 and turn to the first page of that please we can see that at 2:47 the very first entry on the log we see a cero takes over and receives handover from da CEO Lockean a
00:03:39 receives handover from da CEO Lockean a CEO records decision to deviate from FSG advice being delivered to FSG callers by controls staff and advised people to make efforts to leave the building fire
00:03:51 make efforts to leave the building fire sector is briefed to that effect now
00:03:59 in your statement you say and I can ask you to look at the page four of that in
00:04:10 you to look at the page four of that in the penultimate paragraph at o2 47 hours I ask see you just page four of your your first statement I think we're on
00:04:22 your first statement I think we're on the second statement right yeah policies are calm no no you'll be given the wrong state this is the second statement on what the first statement page four
00:04:31 page four they're now at 247 this is the penultimate paragraph you say I asked to see you to contact control and ask them to stop giving stay-put advice if they still were this was based on the fire
00:04:42 still were this was based on the fire spread in the building and the number of persons trapped at the same time control asks the same thing I agreed and asked them to now advise people to make best efforts to escape yes
00:04:56 efforts to escape yes so when I'll tell you can I just tell Paula geez just showing you that so you know what
00:05:02 know what what's record what's recorded about this decision now I don't know if you've been following the inquiry but we've heard evidence from DAC a Lachlan that he was the one who was told by control that the
00:05:16 the one who was told by control that the stay-put advice had been changed at control by Joe Smith and Adrian Fenton and he told you that the decision had been taken when you arrived on the
00:05:27 been taken when you arrived on the command unit is that your recollection or is your recollection something different my recollection is something different but that's that's not to say that Hadley didn't say that you know at the end of the day I was in charge in
00:05:38 the end of the day I was in charge in Houston for a long time and there were many interactions with Andy but I don't remember that why I remember is thinking very clearly as I go into the Union that I wanted to end to stay put I had a
00:05:49 I wanted to end to stay put I had a brief conversation with Nick Thatcher in the first instance about the civil disorder situation that was the first conversation I had he was the acting MPs inspector on interns Jackie McConnachie
00:06:01 inspector on interns Jackie McConnachie and although speaking to her basically informing the entire command unit I was taking over so I wanted to take that responsibility from Andy and I wanted that logged and there she was to be my luggage and then said the first
00:06:12 luggage and then said the first I wanted record it was that I wanted to end staple advice I then turned to the command unit staff to then give them
00:06:23 command unit staff to then give them that same instruction to make contact with control and oddly found I didn't have to because the control were on the phone and I don't know what command unit
00:06:34 phone and I don't know what command unit officer it was I don't know their name accom remember then anymore I can tell you see he was a white middle-aged man bald was a currency in my head it may
00:06:46 bald was a currency in my head it may well be it may well have been Pete Johnson turned across me territory let's also hear that that was that was under my breath - sorry my neck space Johnson he turned he turned to me holding the
00:06:58 he turned he turned to me holding the phone and said controller are on the phone asking to end stay put advise what do you want to do I said well I want to end it anyway so you can tell them yes and I think we should be
00:07:10 tell them yes and I think we should be advising people they need to make their best efforts to escape right now neither Joe Smith nor DAC Fenton recalled that they asked for permission to change the advice but that and they said they made
00:07:23 advice but that and they said they made the decision themselves within the control room and was simply communicating that decision to them to the incident ground that that may well have been the case what was communicated to me bearing in mind I didn't have
00:07:34 to me bearing in mind I didn't have direct conversation with either Joe or Adrian about this was that they were asking I just said yes because if that concurred with my own assessment of what was occurring at the incident I see
00:07:46 was occurring at the incident I see so when in the log we see that you recalled the decision to deviate do we read that as decision made by the incident by the control room with which
00:07:57 incident by the control room with which you were agreeing or your decision is I would hold that as my decision because I determined I was going to make that decision before I'd stepped onto the unit right I think what it shows is that there was a kind of a triangulation in
00:08:10 there was a kind of a triangulation in terms of my own assessment of the incident and I'll see what had occurred in control I wasn't aware as you've just explained to me that control had taken that decision earlier that hadn't been communicated to me I had no awareness of
00:08:22 communicated to me I had no awareness of that as far as I was concerned to that assessment on the basis of what I heard in control what I've seen as regards the tower itself and the viability of the advice
00:08:33 itself and the viability of the advice that we would have been given as regards taper considering the conditions in the building right and then having got onto the unit found you know in that moment obviously they had come to the same
00:08:44 obviously they had come to the same conclusion and he may well have briefed me to that effect afterwards but I don't remember it did you do you remember investigating with or through Peter Johnson or whoever it was with control
00:08:56 Johnson or whoever it was with control the what were the factors which went into making that decision no and actually at that point in the incident that wasn't my priority because I was very clear about what I'm a mess well I
00:09:07 very clear about what I'm a mess well I think it's important I own it was my decision is the sense that I was there I had some situational awareness I saw how the tower was behaving I knew that although that was a difficult decision and it's not a straightforward decision
00:09:19 and it's not a straightforward decision to end stay put it isn't gonna guarantee necessarily that you know a greater level of survivability for those poor people who were trapped inside the tower but what I was very clear about it was no longer valid advice it's not
00:09:31 no longer valid advice it's not something we could reasonably give people because actually all of the safeguards the building regulation would normally give you had been stripped away and therefore we shouldn't be advising people that in that regard so that that
00:09:43 people that in that regard so that that was where my decision lay and why I saw him the instant ground did not permit me to allow that to continue because it just wasn't correct no um did you get
00:09:54 just wasn't correct no um did you get any sense though when he arrived on the command unit and and the decision was made that the decision had not only have previously been made some time before
00:10:05 previously been made some time before that but was now being acted on by the control room nope right I didn't you didn't but at that point obviously what I've done he's walked by the tower had a snapshot of how the fire Survival Guide
00:10:18 snapshot of how the fire Survival Guide and sector was being run from Tom Goodell so it's all happened quite quickly sequentially you know I'm starting to form an opinion in my own mind using this decision-making model about what my priorities were my primary objectives and how I was going to
00:10:29 objectives and how I was going to deliver activity to meet those objectives so I was very fixated on my own needs to establish a structure to meet those priorities and actually
00:10:40 to meet those priorities and actually that you know once I've come to the decision that that was the right decision I didn't necessarily me to die set that in depth there was too much dynamic on the incident ground to do that and in particular I was very
00:10:52 that and in particular I was very concerned about the civil disorder potential for civil disorder right that was actually my priority getting on the back of the unit I felt that at the point we were at you know yes stay put was extremely important that
00:11:04 stay put was extremely important that was the first decision I wanted to make but actually an even more basic level I needed someone to regain control of the incident ground as a whole I needed better cordons in place I needed might
00:11:16 better cordons in place I needed might people given the space to operate without facing the moral pressure completely understandably from the families and community that were there faced with this you know awful sigh but
00:11:27 faced with this you know awful sigh but actually I really didn't need that space that was my greatest concern my feeling was that I wouldn't be able to get the numbers of people into the block that I wanted from the fire service if we didn't create some space at the base of
00:11:38 didn't create some space at the base of the town I was worried actually about safety of residents and members of the community who I felt were on the edge of almost taking matters into their own hands to go back into the tower there's almost that sense from the conversations
00:11:49 almost that sense from the conversations you know that people had attempted to have with me on the way that was actually my priority which is why the first thing I said to anyone when seeing the police officer McPhatter when I got in the unit was actually expressing to
00:12:01 in the unit was actually expressing to him my concern about that and the desire that he called him extra resources to take control of the situation which to their credit they did and in fact I think I specifically asked for the
00:12:12 think I specifically asked for the territorial support group so the you know police who specialized in managing civil disorder and they turn out to be very very useful in a different context
00:12:23 very very useful in a different context later in in Syria right now going back to if I can we can can we focus on the change in the statehood advice recorded in your log or small pieces as tight as possible to that issue regardless of who
00:12:35 possible to that issue regardless of who made the decision and whether there were separate decisions or when what advice did you think should now be given to people who are still in the building I think that
00:12:49 I think that is extremely difficult I think the advice would be an honest one which would be that the conditions inside the building was such that we could no longer guarantee the integrity of the
00:13:02 longer guarantee the integrity of the compartment ation that was going to protect them and therefore they almost had to take their own judgement as to what was going to place them at greater risk so actually I would have expected control operators you know in if there
00:13:14 control operators you know in if there been less cause by the way to perhaps interrogate a caller about the nature of the conditions in their flat what kind of risk was posed to them and then perhaps help them come to that decision themselves because actually of my sense
00:13:26 themselves because actually of my sense was that conditions could have been so variable inside the time that some people might have continued to be safer staying put other people would have benefited from leaving the flats there
00:13:38 benefited from leaving the flats there was every possibility actually from what I've seen even briefly coming past the tower that the lobby was compromised I wasn't necessarily that we were putting people into a hugely safer environment by suggesting they could leave the flat
00:13:49 by suggesting they could leave the flat than they were in the flap to be honest with you it was like a devil's choice I mean people were just in a terrible place where the whole of the building had failed but what we couldn't it was reasonably suggests that they were safe
00:14:00 reasonably suggests that they were safe staying put so I think he would have been about a discussion about their individual circumstances trying to gauge whether we were going to get to them in
00:14:11 whether we were going to get to them in time which again I think would have been almost impossible in the context of the volume of calls coming in and we talked about the difficulties of feedback that feedback loop yesterday so I think actually controlled operators were
00:14:23 actually controlled operators were themselves there in an almost impossible position
00:14:25 position in terms of managing the volume of calls trying to judge a distant situation having recognized themselves and from the incident ground that stay-put was no longer valid actually I think we're in
00:14:36 longer valid actually I think we're in the realms of something we hadn't encountered before either on that scale or of that nature what did you expect or at least hope would change for the
00:14:47 at least hope would change for the better or perhaps not change for the worse as a result of the change to the stay-put advice or the advice that you were giving to him I wanted to give to our thirsty corners I hoped that for
00:14:58 our thirsty corners I hoped that for some residents in the building it would give them the opportunity to escaped via the lobby whilst they still had a chance to do - so I would caveat that by saying that I was under no illusions absolutely no illusions that
00:15:10 illusions absolutely no illusions that we are a state of that instant at the point I took over that anyone inside that building including my own firefighters were at great power they it wouldn't have mattered where you were in
00:15:21 wouldn't have mattered where you were in the building above that fourth floor you you were in great danger because there was no way we could guarantee control of fire spread their level of fight here was like a fire storm is the only way I can describe me
00:15:33 storm is the only way I can describe me at the level of fire spread lateral you know horizontally vertically downwards was to such an extreme that I think it would have become very difficult to
00:15:44 would have become very difficult to provide good advice to call as in particular because whilst they might be able to describe the circumstances of fire spread in their own flap what they wouldn't have an awareness self is the
00:15:56 wouldn't have an awareness self is the conditions if they were worsening immediately outside the flap or maybe two floors below so we've heard evidence of you know floors above the fire being a better state than ones below and then
00:16:08 a better state than ones below and then yet another floor above being in a worse state you know that's very unusual to have that inconsistency between different floors because the fire is spreading in such an unpredictable and
00:16:20 spreading in such an unpredictable and wild manner where the three voids are just through the ferocity of the fire itself so I think they were in an extremely difficult position the control operators did can I ask you to look
00:16:33 operators did can I ask you to look please at the control debrief which is lfb quadruple zero three one one three
00:16:46 and go please to page six in that this is a PRC review for the control room I should just tell you and these are also
00:16:57 should just tell you and these are also many script notes of a meeting which was held on the 24th of July 2017 Joe Smith was present at it as well as a number of other control room officers and if you
00:17:09 other control room officers and if you go to page 6 at 235 stay put advise changed in fro from incident ground to aught and to see you via station manager
00:17:20 aught and to see you via station manager Olaf D AC vent Fenton views news on TV and BCC Joe Smith aware of latinum house one hour Joe Smith listening to Stratfor control room and forming an opinion DAC
00:17:32 control room and forming an opinion DAC Fenton wants to check with fire ground Joe Smith makes decision and tells Alex Norman advice and here it is to hold wet to wet towels over mouth hold hands stay
00:17:44 to wet towels over mouth hold hands stay together
00:17:44 together get out could be last chance now first question is go back to the topic we looked at a minute minute ago were you aware that that advice had been given or and was being given from 2:35 no I
00:17:58 and was being given from 2:35 no I wasn't and I wasn't aware at the level of detail that was being given in terms of advice right so in terms of the detail of that advice get out could be
00:18:10 detail of that advice get out could be last chance when you advised as we see in the log that people make efforts to leave the building would that be similar to or consistent with the advice that
00:18:21 to or consistent with the advice that Joe Smith was telling her control room operators to give I think Joe's giving some excellent guidance said I think that's about as good advice as you can give actually know you know whether that
00:18:32 give actually know you know whether that would have necessarily protected people in the circumstances they found themselves no right actually in terms of the best advice of control operator could give off a nice excellent night how let me just ask you this did you go
00:18:45 how let me just ask you this did you go about even briefly an exercise of balancing the risk of leaving the caller in a flat which which may become affected by smoke or fire or heat on the
00:18:56 affected by smoke or fire or heat on the one hand with on the other the risks hiren in taking them through a smoke logged exit route well sorry could you repeat a question did you balance the two two risks one against the other
00:19:07 against the other leaving the caller in a flat which may become smoke affected or heat affected or fire affected on the one hand with on the other hand the risks inherent in taking the through a smoke logged exit
00:19:18 taking the through a smoke logged exit route yes so that was the thought process I've gone through as I walked from the base of the tower and I did grapple with that because it's not a straightforward decision but what drove me to my final decision whereas a sense
00:19:30 me to my final decision whereas a sense that internal compartment ation of failed to such an extent I couldn't see any flat ultimately in that building remaining as a survivable environment and up because I couldn't gauge fully
00:19:42 and up because I couldn't gauge fully the extent to which that would happen so the timescales within that would happen bearing in mind that what I had seen was that every flat I could see was it fully involved vented you know fire inside it
00:19:54 involved vented you know fire inside it I felt I had to take a sittin on the bigger picture because I suppose again that's what I'm there for in my role and I didn't think it was manageable actually because of the volume of calls to try and dissect it
00:20:06 volume of calls to try and dissect it into individual flats that point at that point at that moment I was thinking I guess about the broader picture and as many people as we could save as possible right did you ask da co Lachlan at any time at
00:20:22 did you ask da co Lachlan at any time at this time during his briefing or at the moment you made your decision that the advice should be changed as to why he hadn't taken the decision to depart from stay put
00:20:32 stay put already no because it wouldn't have affected the progress of the incident moving forward I think it would have been unhelpful to I need to do that I wasn't there at the point where he may or may not have made that decision I
00:20:43 or may not have made that decision I wasn't aware of the conditions in the tower at the point he was there and may or may not have made that decision so it to be honest we didn't even crossed my mind because I had what I had I know I
00:20:54 mind because I had what I had I know I had a job to do turning up there taking over setting priorities and setting activity to meet those priorities actually was fairly pointless to go back and dissect at that point why a decision had a hand be made
00:21:06 point why a decision had a hand be made I was just clearing my own decision and I knew what I needed to do to push activity
00:21:12 activity because I just don't think he would have been helpful at that point and also I need it handy to do a job for me you know and he had absorbed you know massive pressure for a period of time as instant commander I still needed him to
00:21:23 instant commander I still needed him to go out with confidence with my trust to handle a really difficult job maintaining momentum tactically against my objectives did he had been there on
00:21:36 my objectives did he had been there on the incident ground for some 45 to 50 minutes for almost an hour before you had a little bit incident commander for
00:21:47 had a little bit incident commander for some 45 minutes or so before you took over were you not interested to know as part of your own assessment of this risk why he hadn't made the decision that you
00:22:00 why he hadn't made the decision that you were about to make no because I think what I was presented with was so stark that actually from my perspective I was very clear about my decision that what may have happened before actually could
00:22:12 may have happened before actually could have been entirely different than our before the conditions inside the building could have been entirely different an hour before or even actually looking at the fire in the way the fire was spreading before my eyes very different quarter of an hour before in some ways it would have been almost
00:22:24 in some ways it would have been almost irrelevant to dissect that what I saw was what I saw the information I've been getting from control kind of verified my own feelings in terms of the volume of FSG calls so genuinely I just wouldn't
00:22:38 FSG calls so genuinely I just wouldn't have needed to dissect that piece of decision-making at that point I think it's entirely appropriate that the inquiry does I think it's entirely appropriate that how PRC digs is important to learn why people make decisions to take learning forward but
00:22:50 decisions to take learning forward but at that point in time in the dynamic of that incident with a job to do and needing to maintain the confidence of Andy in himself and to maintain you know a view that I trusted him and I need him
00:23:02 a view that I trusted him and I need him to get out there and do a job I think it would have been unhelpful for him because it's such a big decision with such obvious ramifications that actually I'm not sure he'd have been helpful in the context of instant command at that
00:23:13 the context of instant command at that point and it wouldn't have changed my decision but given that it was as you just said a big decision with important ramifications and not one you could just make just
00:23:24 and not one you could just make just like that I know wouldn't it have been helpful to you to know what he hadn't seen but you could now see and why he hadn't seen it no I don't think it would
00:23:37 hadn't seen it no I don't think it would because as I've said again I think it's very hard standing here today to explain to you the visual impact of that incident so I think there are some things absolutely yeah that's a entirely
00:23:49 things absolutely yeah that's a entirely reasonable question because there's some incidents you would want to have that discursive kind of brief where you understood how we got to that point and why perhaps the decision you were
00:24:00 why perhaps the decision you were considering was perhaps not appropriate or was perhaps more more nuanced than it might there might be in these circumstances but I can only tell you
00:24:11 circumstances but I can only tell you that what I had seen in terms of fire spread in all directions the full failure of compartment ation left me in no doubt that we could no longer reasonably offer that advice how we had
00:24:23 reasonably offer that advice how we had got to that point if I pay you no money to sound brutal was almost irrelevant to me I knew what I had I knew what I had to do I didn't have the time in that
00:24:34 to do I didn't have the time in that moment faced actually with the potential for some civil disorder with what I could see was a massive breathing apparatus operation already underway to try and dissect what had happened in the
00:24:47 try and dissect what had happened in the previous hour if I felt I didn't need to and that that may well sound cold-hearted but I think that's part of the decision-making process you take the information you need at that point in
00:24:58 information you need at that point in time I was satisfied that I had enough information to take that decision and having taken it I didn't mend me to kind of go over and I needed to get on with other things and start to place a structure onto being seven I understand
00:25:10 structure onto being seven I understand that in terms of leadership style but very what I'm after is is this process of making this decision it comes to this what why were you not curious to understand why what was obvious to you was not obvious to an da laufen who was
00:25:23 was not obvious to an da laufen who was the incident commander you were taking over from and because I knew I had and the risk of sort of repeating myself I think that it wouldn't have been how
00:25:34 think that it wouldn't have been how for at that point to dissect that it was more about me having taken a clear decision because I was faced with the reality of what I was faced with not actually because I hadn't seen conditions prior to me taking over you
00:25:48 conditions prior to me taking over you know there could have been a wide range of variables that men and his experience of that instant was very different so for example my Calvin's experience would have been very different from mine because he was there right at the start
00:25:59 because he was there right at the start when it was just a free July so Mike's journey through that incident we're being hugely different from mine because he was decision making in the context of an incident that was getting away that was actually started as one
00:26:10 away that was actually started as one thing but then had become something unbelievable and he actually if I was to imagine what it might have been like the hour before me and I don't know what it was like was probably in a not
00:26:22 was like was probably in a not dissimilar place where he was looking at an incident where he thought maybe he had more of an opportunity to do something where perhaps there was more protection inside the building than at the point where I took over and that was
00:26:34 the point where I took over and that was possibly why he didn't do that but in a way I didn't need to know that because what I did know was at the point I took over that advice was no longer appropriate for the people inside the
00:26:45 appropriate for the people inside the building despite the challenge of then giving them alternative ice because of the internal conditions that made almost any part of the building perilous so I just didn't need to dissect it and actually I have to say I don't think I
00:26:57 actually I have to say I don't think I consciously even thought that I needed to dissect it I didn't think oh I could ask him that but I'm not going to I just think I was so clear in my own mind about that one particular decision having thought about it having gathered
00:27:09 having thought about it having gathered information from a variety of sources but having made it you know I just needed to state it record it ensure it was communicated to the incident ground verify that control knew that I had
00:27:22 verify that control knew that I had understood why they wanted to know we were going to hold to that and then move forward with taking control with the incident how did you know though whether an da Lachlan had or didn't have good
00:27:36 an da Lachlan had or didn't have good reasons for holding on to the statehood advice because I think if he had he would have challenged me at the point I made that decision I couldn't have been any clearer in my communication he was on the command unit I stated it to me
00:27:48 on the command unit I stated it to me c'mon unit and he absolutely had an opportunity that points a and we've got a relationship I've known Andy a long time is a good officer he would have said Andy actually how have you come to that we have enough of a relationship
00:28:00 that we have enough of a relationship that he could have challenged me and I you know everyone I think one of the other things to reiterate to give you a context is that I knew most of the officers who were working for me very very well the senior officers and I have
00:28:12 very well the senior officers and I have an open leadership style where I would welcome critical challenge to laying as part of being a good leader yes it's my decision to hold but I would give people the space to ask questions and challenge and I would have expected Andy and Andy
00:28:24 and I would have expected Andy and Andy knows me well enough that he could have stepped forward and said actually with a greater respect Andy you have taken that decision over the course of the last ten minutes I have other information I think
00:28:35 minutes I have other information I think you might need to think about that at no point did Andy challenge that decision he was entirely comfortable with it and then we moved on you know on to what my priorities and how he was going to help
00:28:47 priorities and how he was going to help me as part of the overall structure given his lack of challenge and his lack of presentation to you of any further information that he had which you didn't did you did it occur to you that he must
00:29:02 did you did it occur to you that he must have been operating or at least was operating it in an information gap you had information that he didn't have absolutely but again I think as I said yesterday I think that that is the
00:29:13 yesterday I think that that is the normality of a dynamic incident so you're constantly operating an information gap what I can only talk about is my own decision-making and I was comfortable on the basis of the information I had that I was right to
00:29:26 information I had that I was right to take that decision and that decision was right at that point in time so in a way what happened before I could have dwelled on it but I'm not sure that would have been effective leadership or decision-making at that point in time at
00:29:38 decision-making at that point in time at the incident I think what I needed to do at that incident it was very clear to me was that I needed to establish some very basic structure and control to enable us
00:29:51 basic structure and control to enable us to sustain what was going to be a massive breathing apparatus operation Mike my greatest concern at that point actually was firstly creating more open space for our people to
00:30:02 more open space for our people to operate in so getting effective callings in with the help of the police and ensuring that we could resource it because my greatest fear we have enough resources absolutely in the London Fire
00:30:13 resources absolutely in the London Fire Brigade to sustain instant for getting them there turning them over ensuring there was a system to safely deploy people into the building so that we could have this mass VA operation that they were the things that are in my mind
00:30:25 they were the things that are in my mind because without that logistic support and resourcing we were simply not going to be able to sustain the tempo of operations that I had seen as I walk past the tower so they were the things that really grabbed me as a priority in
00:30:36 that really grabbed me as a priority in a way the advice that was given to people was obviously very important in terms of you know help him manage an impossible situation providing some care
00:30:47 impossible situation providing some care and reassurance to people in a desperate situation on the end of the phone but in many ways in the context of that big operation the advice was somewhat irrelevant because everyone inside that
00:30:59 irrelevant because everyone inside that tower was in absolute danger and actually my sense was it was going to be a minimal number of people who were going to be able to get themselves out on their own absolutely minimal and we were going to have to rescue everyone
00:31:10 were going to have to rescue everyone that was still in there my thought was it was a mass rescue operation and no one was getting out there without a VA crew helping them even if they could walk down the stairs we would need a crew with them so that was what my focus
00:31:22 crew with them so that was what my focus was on why wasn't the stay-put advice changed earlier I can't tell you that because I wasn't there at that point in the instant and I think he would be genuinely unfair on Andy and other
00:31:34 genuinely unfair on Andy and other officers to kind of hypothesize on the basis of hindsight because what I did see about fire when I turned up it was that it was changing at such a rate of knots that almost anything could have
00:31:47 knots that almost anything could have been occurring inside the building an earlier point in the incident so I actually think it's unfair I think people have to hold their own decisions at that point based on the information
00:31:58 at that point based on the information they had I think it would be easy for me to hypothesize and criticize based on a subjective opinion but I really don't know what the conditions were inside
00:32:09 know what the conditions were inside that block 10 minutes earlier before I arrived an hour and therefore thing could be wrong with me to try and decide what should have been the right advice at that point all
00:32:20 been the right advice at that point all I know is at the point I turned up that advice was absolutely unsustainable Tommy what plan did you have for ensuring that the
00:32:32 did you have for ensuring that the occupants who were still within the building knew that the advice had changed and that they now had to leave at all costs so there was no way of effective mass communication from the
00:32:44 effective mass communication from the scene because the building had deteriorated to such an extent that actually you know just the overall level of sound the chaos of it would have meant it be very difficult to
00:32:55 meant it be very difficult to communicate to residents on mass anyway you know without wanting to sound facetious and lobbying a loud hailer would have been of no use there was no tannoy system I can't think of a method
00:33:06 tannoy system I can't think of a method at the point at which that building was where we could have communicated with all the residents from scene my expectation was that it all hinged on the advice that control was going to
00:33:17 the advice that control was going to give people because inevitably people work on a ring our control for reassurance and an update on what we were doing and that was where the communication was going to have to happen from the only way we were going
00:33:29 happen from the only way we were going to communicate with residents from the scene was when we got to be a crew to them so it was very important that how the a crews knew that we were taking people out of there and that everyone part of me was going to have to be
00:33:40 part of me was going to have to be rescued did you take steps to find out whether control were doing callbacks to residents who had already called no because apologies and at the end of the
00:33:54 because apologies and at the end of the day we had very experienced commanders inside control so if we talk about delegated command gain that is a normal part process I would have expected callbacks to callers who they've had to
00:34:06 callbacks to callers who they've had to come off the line from however again I think I've got to set it in the context of the volume I was aware because at some point not spoken to aging about it that we had maybe nine control operators
00:34:19 that we had maybe nine control operators in the control room that night now if they're handling the volume of calls we were my expectation was some of that would have gone out to other control room
00:34:26 room around the country potentially the overspill and actually just to manage that volume and call back would have been very difficult for them but that would have been that would have been a you know an expectation for me based on
00:34:37 you know an expectation for me based on our processes that some level of call back would be occurring right so does that mean that the in a normal incident a call back would occur as a matter of
00:34:48 a call back would occur as a matter of practice absolutely yes and that's my experience of FSG where there's more manageable numbers you know our call handlers would make every effort to
00:34:59 handlers would make every effort to maintain contact with those people and close the feedback loop because again I suppose I'd ask inquire perhaps to reflect on the position those control operators find themselves in I think
00:35:11 operators find themselves in I think actually they are the most exposed people in many ways because they are remote from the instance they have very little power as it were to immediately affect the rescue they are handling the emotions and the challenge of having an
00:35:24 emotions and the challenge of having an immensely distressed and scared person on the end of the phone my experience of our control operators is that they are always desperate to maintain conduct contact and provide reassurance because
00:35:36 contact and provide reassurance because that's what they're that's what their role is so yes they were I would imagine I'd have been very motivated and I I know because I've spoken to them since I visited them at control that for many of
00:35:47 visited them at control that for many of them the burden of not being able to do that in a way they wanted to I would have normally expected to do to has weighed very very heavy on them it's been immensely distressing for them Joe Smith gave us some evidence when she
00:35:59 Smith gave us some evidence when she gave evidence that as a matter of practice I think she said custom and practice control room officers don't tend to call back callers unless they're on a mobile and have been cut off
00:36:10 on a mobile and have been cut off because they didn't we wouldn't want to take them through a fire back to a landline to answer it again if that might put them in danger it was the effect of her evidence I'm summarizing it I hope accurately you are and that's
00:36:23 it I hope accurately you are and that's all I'm talking about so we're talking about people who've made a call have come off the line on mobile could be recontacting you say come off the line they've cut off she was talking about yes it's so late so the lines been cut dead right so that's my understanding of
00:36:34 dead right so that's my understanding of how the callback process works and I would have expected them to be doing that where they could I think that have been extraordinarily difficult in the circumstances where they weren't cut off but where the cold had ended because the the controller had ended it or
00:36:46 the the controller had ended it or because the caller had ended it my question is more directed to calling people back who had called historically and whose numbers were on the system to tell them that the advice have now changed no I wouldn't have an expectation of them doing that and again
00:36:59 expectation of them doing that and again particularly in the volume of calls that they had received that's not my understanding of how the process works by I should I should hasten to add I'm not controlling specialists and I'm not
00:37:10 not controlling specialists and I'm not intimately involved with those processes my focus would be on ensuring that we are providing the information back into them to engage with callers and has per our procedures and that that enables
00:37:22 our procedures and that that enables them to do their role did you did you have any thoughts as to how where people had called and been told to stay put by controllers and then the advice had
00:37:34 by controllers and then the advice had changed how you were going to communicate to those callers that the advice had changed so that the advice they'd been given previously should not be acted on I have to say that I didn't drill down to that level of detail I
00:37:46 drill down to that level of detail I felt that was the responsibility of control having taken part in that decision themselves to manage that process from there and what was my utmost importance to me was that we got
00:37:58 utmost importance to me was that we got crews to people as quickly as possible having the volume to kind of honor the change in advice now did you know that
00:38:09 change in advice now did you know that the building had an intercom system so you press a buzzer and could be let into a flat so you mean like a door entry system yes I didn't but I guess that's a normal thing for a block of that size
00:38:21 normal thing for a block of that size and did you explore whether that could be used to communicate with residents to communicate to them that the staples advice had changed I have to serve didn't and I didn't consider it but then again I think in the context of knowing
00:38:33 again I think in the context of knowing that the fire lift wasn't operating that we've lost almost every other building system including the fixed installations though the smoke ventilation system perhaps I you know if I had even thought
00:38:46 perhaps I you know if I had even thought of it I wouldn't have assumed it would particularly have been useful and again there is something about the fact that someone's got to are to that and I'm presuming that you would have to contact individual flats I'm not
00:38:57 have to contact individual flats I'm not sure how manageable that would because my experience of intercom systems is that they don't generally have a function where you can press one button and contact every flap but no I have to
00:39:09 and contact every flap but no I have to say wasn't a consideration at the time that wasn't how we were going to make contact with and communicate with people from the Instagram okay now then moving on to sort of moving back to your entry in the row log you say in the last
00:39:24 in the row log you say in the last sentence under 247 fire sector is briefed to that effect now fire sector was the bridgehead was it it was the everyone inside the tower basically so not just the bridgehead so
00:39:36 basically so not just the bridgehead so what I wanted was Pat and Richard to be briefed to that effect I asked for that message to be consent from the command unit out to the fire sector so Pat and Richard specifically to let them know
00:39:47 Richard specifically to let them know that staple of ice had ended and that's what jackie has recorded there so I will have verbalize that I'd have said to the command unit can we make sure now that the advice has changed that is passed out to the fire ground as an immediate
00:39:59 out to the fire ground as an immediate priority and to the fire sector right did you hear the briefing to that effect yourself no right
00:40:10 turning to how you would then act on this changed advice how would in practical terms
00:40:21 practical terms how would you go about evacuating everybody in the tower I think evacuations the wrong term at the point I took over the innocent there was going to be no evacuation there was going to be multiple individual rescues
00:40:32 going to be multiple individual rescues so an evacuation gives you the idea that we were going to somehow take large groups of people out in a managed way you know through some form of mass communication which is what a normal
00:40:43 communication which is what a normal stage phased evacuation would be there was no evacuation in the context of that building it was going to be individual rescues from individual facts bringing people out in challenging circumstances my my major priority was to ensure we
00:40:57 my my major priority was to ensure we had the volume of people inside to be able to do that as best we could I'm sorry I think evacuation in some ways is a bit of a misleading term there is no way you could have effected a mass evacuation from that building it was
00:41:09 evacuation from that building it was going to be about how crews leading people out through a really difficult situation right so building on that answer
00:41:17 answer what was your plan to effect mass rescue in outline you know the nuts and bolts of that plan right so so very simply I and perhaps if we can wind it back a bit
00:41:29 and perhaps if we can wind it back a bit I had actually had a more immediate problem in terms of effective mass rescue which is about getting firefighters into the building without them being very seriously injured or killed so I had a very serious concern about the level of February 4 I've seen
00:41:41 about the level of February 4 I've seen large pieces of concrete I was seeing very large metal sheets my fear was actually that probably the most dangerous element at that point was getting firefighters into the building
00:41:54 getting firefighters into the building so I wanted that consider there's a primary objective for Andy O'Laughlin to try and establish some form of safe access and egress for our crews and any casualties they bought out so a very
00:42:05 casualties they bought out so a very basic level I just needed to safely get people into the building as though nothing that gives you an idea again of the sort of diamond dynamism of the incident there as a commander at my level I was actually having to think
00:42:17 level I was actually having to think about how we even got people into the building never mind a plan beyond that as to how we would manage their progress inside the bill so having said that as an immediate priority and actually that's where the
00:42:29 priority and actually that's where the territorial support group and I I'd like to say for the record what immensely brave men and women they are because some of those people did hundreds of runs back and forth under the debris form and that is not what they're
00:42:42 form and that is not what they're trained for so I would like placed on the record what you know how immensely grateful we are as a service to the Metropolitan Police Service for doing that because they they absolutely went above and beyond by having established
00:42:53 above and beyond by having established access egress my plan was that to build on what Andy had already established I thought you had a good basic structure that was simple enough for everyone to understand and it was about assuring we had a volume of people inside be a main
00:43:06 had a volume of people inside be a main control that behind that we had a logistic system where appliances were arriving onto the incident ground where officers were being briefed at the point they arrived that they were likely to be used with breathing apparatus that they
00:43:18 used with breathing apparatus that they would then move in to be a main control the be a main control would be in direct communication with the fire sector and that the fire sector would be advising with Andy's oversight because he was seeing overseeing be a main control FSG
00:43:31 seeing overseeing be a main control FSG and the fire sector the numbers of people to safely go in so that we didn't compromise ourselves in terms of having too many people in there so that we couldn't operate effectively and I wanted that to be continuous my
00:43:43 wanted that to be continuous my challenge I said handing it was that I did not want to break in VA operations I wanted that to be continuous because I knew that prioritization would be difficult I knew that we were likely to be compromised by the nature of the
00:43:57 be compromised by the nature of the building and therefore the only way we were really going to make progress was just to ensure ensure a continuous volume of Leuven that was it possible that the change in stay put meant that
00:44:11 that the change in stay put meant that you now had people coming in to the stairs and into the lobbies that you otherwise wouldn't have had before and that would have affected the dynamics of people flow in the building absolutely
00:44:23 people flow in the building absolutely so and that's the balance of that decision so I was acutely aware that we had a single staircase yes you know it's not designed for both our personnel and personnel trying to leave being on it
00:44:35 personnel trying to leave being on it but I didn't not even have a choice so again that's why I was important to fire sector knew the advice had changed because they then needed to be aware that they might need to manage that flow
00:44:46 that they might need to manage that flow of people out against the stream of people we wanted to go in my general sense though was that very few people were going to be able to make their way out on their own so actually I thought it was more likely that it was about
00:44:58 it was more likely that it was about ensuring we had a constant flow of breathing apparatus screws up inside the building as far as they could to rescue people did you talk to Pat Goulbourne and Richard Welch at the bridgehead
00:45:10 and Richard Welch at the bridgehead specifically about how the change in stay-put advice might affect the way they were briefing and deploying crews into the tower and the pattern of that deployment no because again I think
00:45:21 deployment no because again I think that's a level of detail that I wouldn't need to go in to with two such experienced officers particularly having delegated then the tact of Google pardon me the tactical command of that sector I would expect them to know that as
00:45:32 would expect them to know that as professional fire officers there inevitably going to have to manage that is it it's a fairly sort common sense kind of factor to manage within that environment you've got a single access staircase we are going to commit crews
00:45:45 staircase we are going to commit crews in if we've changed the stay-put advice there is very obviously every possibility that people are going to be coming out and therefore pattern Richard we're going to have to manage that but you've quite rightly perhaps described
00:45:56 you've quite rightly perhaps described how unusual this event was and but you now say that it is a fairly common sense factor to manage within that environment how sure were you that pattern Richard
00:46:09 how sure were you that pattern Richard had the right experience and training to manage a sudden influx of potential sudden influx of people into the exit route single exit route which was smoke
00:46:20 route single exit route which was smoke logged in a twenty four storey building which was a whole building fire very short because I trust those offices and I've been on many incidents with them including high-rise and actually he's probably again worth setting a wider
00:46:31 probably again worth setting a wider context post la canal we experienced actually for probably two years and we've experienced a post grateful you know unsurprisingly a period of time where people no longer felt secure in in
00:46:44 where people no longer felt secure in in the context of statement advice so itself evacuate in very large numbers whilst we were trying to get into high-rise buildings I've attended a number of high-rises where you've only got a single flat fire of no real great
00:46:56 got a single flat fire of no real great significance but the entire block on discovering that post Lacan all have emptied out so actually it was for experienced commanders like Patton Richard who had served in the Eastern
00:47:07 Richard who had served in the Eastern Command which is our busiest command I knew they'd encountered that and I would have expected them to understand how they might have to manage that problem so I was confident about that's based on my relationship with them and my experience of being other instance
00:47:19 my experience of being other instance with them but you say in that last answer that experienced commanders like
00:47:30 answer that experienced commanders like Patton Richard having served in Eastern Command had had encountered that I mean are you sure they had actually encountered afar like Grenfell before in their lives so that they could operate
00:47:41 their lives so that they could operate from the basis of experience no none of us had encountered a fire like Gregg Furth I think Frankel is an exceptional event in any fire officers career so I'd absolutely not suggest that but what
00:47:53 absolutely not suggest that but what they would have encountered is the difficulties of managing our entry into a block even for a relatively minor fire where residents were trying to get out that that is a fairly common phenomenon posted a Qunari you know it tailed off
00:48:06 posted a Qunari you know it tailed off after a couple of years but certainly post breakfa we've experienced it again with high-rise fires completely understandably because residents feel very anxious about the validity of the staple advice unfortunately okay to be
00:48:18 staple advice unfortunately okay to be frank I mean this was an experience new to you on the night I think we've all got from yesterday's evidence that this was the first time you as an incident commander had had to change the statehood advice so that everybody in a
00:48:29 statehood advice so that everybody in a tower block had to be rescued and to cut a long story short and given that that was new and new to you as incident commander how could you be sure without
00:48:40 commander how could you be sure without going and talking to them about the granular bit nuts and bolts of their plan the pattern and Richard knew ought to do because I did go and talk to him about the detail of their plan right that I think is falls into the category
00:48:52 that I think is falls into the category of one of the general principles and understanding that I would expect so far officer to have that you all have to manage the flow in and the flow out of people that's not necessarily so thing that I would need to discuss
00:49:03 thing that I would need to discuss because actually I think that's an assumption I could make I think there are other elements to their plan I was much more interested in I either challenge of progressing within the building what were fire conditions like them preventing them for example
00:49:14 like them preventing them for example progressing beyond a certain floor I was much more interested in that in the context of my primary objectives that calls me much more anxiety about general progress in terms of clearing floors and
00:49:25 progress in terms of clearing floors and moving up the building because there are certainly times during the incident where I I didn't have a comfortable feeling about how we were progressing and that was where the focus of my discussions lay with Pat and Richard when I did see them I wanted to know
00:49:36 when I did see them I wanted to know what was preventing them moving at a quicker pace up the building I thought it was my job to drive that I was less concerned about their management of people in and out because I feel that's a level of detail that as you know group
00:49:48 a level of detail that as you know group commander's senior experienced operational officers I would expect them to manage as in the course of their duties right now you said about the beginning of the last answer you did go and talk to them about the detail of
00:49:59 and talk to them about the detail of their plan first question when did you go and do that at what point I can't remember exact timings by I went into the tower on a number of occasions I would have to
00:50:10 number of occasions I would have to probably refer back to the locks I went early on into the tower I saw Pat and Richard maybe just Pat at that point and I had a conversation
00:50:21 that point and I had a conversation about how far they thought they could push up inside the building my conversation each time actually focused on pretty much the same elements because I had once I've made the stay-put decision that was kind of done and part for me we weren't going to reverse that
00:50:32 for me we weren't going to reverse that the conditions in the tower weren't gonna get any better so in a way that when what then became a continuous revaluation of important decision-making was actually how long could I safely
00:50:43 was actually how long could I safely keep on putting firefighters into the building and how how we were progressing they were my two questions really continuously throughout the ten hours I was in command because they were the two things that are going to affect both the
00:50:55 things that are going to affect both the safety of my firefighters and the efficacy of our operations how far were we progressing and was it still safe you know reasonably to put firefighters into there taking into account you know our
00:51:07 there taking into account you know our own powers and duties right and my second question is what did you discover about the nuts and bolts of the and the bridgehead what I discovered was that pattern richard was sharing
00:51:18 that pattern richard was sharing responsibility for it which I was comfortable with they know each other they have a good relationship as far as I'm aware it was too big for one person to handle that it appeared to me from
00:51:29 to handle that it appeared to me from the short conversation I had that Richard was on the whole handling the bridgehead and the Pat was ensuring that there was a throughput of crews up and through although I'm quite sure that swapped over at times over the course of
00:51:42 swapped over at times over the course of the incident what was clear to me that was that there was some system for ensuring capacity information got to the crews the crews were continuously being committed through the bridgehead and that most importantly Pat and Richard
00:51:55 that most importantly Pat and Richard were very very focused on maintaining progress so as the overall incident commander looking at in the big picture I needed to be assured that Patton Richard had no illusions of what was important to me was that we were
00:52:06 important to me was that we were continuously driving momentum and progress and we could not let that stall and that even if that it so it's a constant judgment for them about how much risk they were prepared to expose
00:52:17 much risk they were prepared to expose our firefighters to and that was actually very difficult decision-making for a host of reasons so that was what the majority of my conversations focused on right how far they could get what would be preventing and why couldn't we
00:52:29 would be preventing and why couldn't we overcome that and as part of the nuts and bolts of their plan did you investigate with them what they were doing with particular FSG information
00:52:43 doing with particular FSG information absolutely not and I think it would be have been inappropriate of my level of command overseeing the entire operation to try and drill down into that level of detail
00:52:53 detail I've got drawn into the detail of what crews were going to what flap it don't merely be absolutely different if it maybe been 10 F SG calls I would have had the time the space and I would have
00:53:04 had the time the space and I would have wanted to know how we were prioritizing in the context of over a hundred FSG calls I think actually I could have lost myself in that detail what I needed to ensure because it wasn't a given was
00:53:16 ensure because it wasn't a given was that we were continuing to maintain promise that we had enough resources that we were managing the wider environment that I was mindful of the welfare of our people
00:53:27 welfare of our people that actually just a macro level I was still right in my decision to continue to commit Cruz into the building because that should not be taken as an assumption you know that caused me great
00:53:38 assumption you know that caused me great concern whilst I was very sure that the core of the building was hold actually from what I'd seen in terms of the debrief all what I was hearing from the building the amount of time of fire of that ferocity have been burning I was
00:53:50 that ferocity have been burning I was very much less sure about the edges of the building the edges of the four plate the columns at the edge of the building which were taking the brunt of a he you know I was fairly sure that significant
00:54:01 know I was fairly sure that significant spawning was occurring so breakdown at the concrete which would expose the rebar and that I had the potential of losing edges of the building partial collapses and I had to constantly juggle whether or not it was still okay for me
00:54:13 whether or not it was still okay for me to commit firefighters into that environment knowing that there are very great risk so everyone in our job accepts that there are times when you're going to have to risk your own life in a
00:54:24 going to have to risk your own life in a measured way to save others but this incident took us to a place actually somewhere beyond and that was something I had to come back to continuously to
00:54:35 I had to come back to continuously to judge actually whether I was doing the right thing by my own people under what he's laid down in the Human Rights Act for example and whether what I was doing was justified by the powers we have under the foreign risky service I now you say in the middle of that last
00:54:46 you say in the middle of that last answer that if it had been ten FSG calls you'd have the time the space and wanted to know how we are prioritizing my quick third question is did you ask the simple
00:54:57 third question is did you ask the simple question how are you prioritizing I'd asked it of Tom Goodell in terms of had he got a system but I didn't delve into in the detail I know from Tom's board
00:55:09 in the detail I know from Tom's board that he had prioritized but I think as I said yesterday that that wasn't my priority because my sense was that that prioritization was only good in the
00:55:20 prioritization was only good in the moment because conditions were changing continuously they would have been almost impossible to judge who was of greater priority than another and therefore my focus had to be on just making sure that I was supporting my sector commanders by
00:55:32 I was supporting my sector commanders by ensuring they never ran out of resources and that they understood we must maintain continual progress did you endeavor to make sure that other emergency services like the NPS the NA s and the NPA s were aware of the change
00:55:46 and the NPA s were aware of the change in the advice I think at some point I had mentioned it in their tactical command meeting so I think either the first one or a subsequent one I informed all the other agencies that we had ended
00:55:58 all the other agencies that we had ended stay-put advise a quorum my exact words bar thing I think I did that now mr. chairman we're going to turn turn to a different topic it's not as ten yeah
00:56:10 different topic it's not as ten yeah well it might be a good time for a short break short break like a short break now
00:56:16 thank you so you go the usher if you would please don't talk to anyone
00:56:36 right 22:11 please
01:10:07 where I'm straight before we continue can I just mention one thing you probably know that your every word is being taken down by the stenographer but I think would make her task little
01:10:19 I think would make her task little easier if you could try and speak a little more slowly absolutely maybe keep your answers a little shorter then she catches up to some extent between you and mr. burrows all right I promise it thank you very
01:10:30 all right I promise it thank you very much I said I was coming to a new topic and I will but I just want to backtrack a little bit on one or two things just
01:10:42 a little bit on one or two things just in terms of the statehood advice being changed can you from a an institutional perspective tell us what information you as an
01:10:54 tell us what information you as an incident commander would need to have in front of you in order to make the decision whether to keep the stay-put advice as we called it in place or to
01:11:05 advice as we called it in place or to depart from it and give the advice you gave do you mean that in terms of info so it's clear Phi's the information we would provide to our officers to aid them with that decision no let me let me
01:11:17 them with that decision no let me let me put the questions like again and I hope more clearly to you as an incident commander what information would you need to have in front of you in order
01:11:29 need to have in front of you in order reliably to make the decision to depart from stake hood so I'd want to have as I did on the night an understanding of what callers might be facing in their flats so I said
01:11:43 might be facing in their flats so I said it was happening at the control end I think that would be very important I would like to know the extent of fire spread as far as I could through the building I would need to see clear proof
01:11:54 building I would need to see clear proof the compartment ation had failed on a scale that meant that stake was no longer viable and I would need to understand the level of compartment
01:12:05 understand the level of compartment hesitation failure in a whole building context so you know where they're past the building the way it was still viable to maintain that advice and actually if we had a smaller number of callers would you not change device and totality for a
01:12:18 you not change device and totality for a block
01:12:18 block you know partially for a block for example right so that both they're the sort of sources of information I would go to and the information I would want right now those factors which you very
01:12:33 right now those factors which you very set up set out very clearly to the best of your knowledge and experience were they to be found in any policy or any training as it existed in June 2017 I
01:12:44 training as it existed in June 2017 I think the only training law I'd had that was relevant to it was the post lakyn all training package which I can't remember whether it specifically refers to anything stay put I'm not sure it
01:12:55 to anything stay put I'm not sure it does but certainly made it clear to officers that you had to consider the possibility of buildings not reacting in a high-rise residential environment in the way you would expect that's that's
01:13:06 the way you would expect that's that's the only training package I think we've provided that were bare elements to that right now coming back to this question of the nuts and bolts of the bridgehead plan we were discussing together before the break I just want to explore the
01:13:19 the break I just want to explore the timing of that first of all can you tell us did you leave to go to the tower before or after your first TCM I'm not
01:13:32 before or after your first TCM I'm not sure is the honest answer because I was in charge for a very long time where I've got things date stamped time stamped rather by other people you know I've got a great security about my timings there's clearly things that I am
01:13:45 timings there's clearly things that I am sure about because I remember the conversations all I can tell you is I was in the tower very early on during my time at the incident I can't remember it was before the TCM or after the TCM
01:13:57 was before the TCM or after the TCM obviously I've got a situational awareness into the unit by going past the tower but a time either shortly after the TCM or potentially before the TCM I've been in the Tower Records I had
01:14:08 TCM I've been in the Tower Records I had spoken to crews I remember early on in the instance speaking to crews in on mass both outside and at the base of the tower sorry I'm inside the tower okay
01:14:20 tower sorry I'm inside the tower okay let's see if we can just drill a bit further down into this can I ask you to be showing your contemporaneous note now that we could see from page - oh sorry three that at 2:47 this is
01:14:33 - oh sorry three that at 2:47 this is the second entry down you refer to the state with advice being changed then that 254 is the briefings and that goes
01:14:44 that 254 is the briefings and that goes on and then over the page you see at 309 you ask that they see you'd orderly drawbridge on to the incident at 310 to
01:14:55 drawbridge on to the incident at 310 to see you confirm you had a possible firefighter emergency I stuck my head outside the unit you say in saw that the same police officer 315 you asked to see you to request the urged attendance of
01:15:07 you to request the urged attendance of dangerous structures engineer and then a320 the first TCM and then there's the detail of that and then at 339 Matt Cooke and Andy O'Laughlin getting onto the unit and you get your first update
01:15:21 the unit and you get your first update and then it's not until we get to over the page sometime after 339 page five middle of the page you say I then went to the base of the tower to go into the lobby now on the basis of our read of
01:15:34 lobby now on the basis of our read of the contemporaneous notes that you did after the incident it looks as if you didn't go to the base of the tower to go into the lobby until are a tall man after and probably after 339 is that
01:15:48 after and probably after 339 is that right I think what the statement reflects is what I can remember with accuracy hmm to be fair I may well have gone into the tower before but I couldn't tell you when I went into the
01:16:00 couldn't tell you when I went into the tower a number of times the reason I remember that particularly was because of the incident involving you know poor gentleman who jumped from the tower that stuck very very clearly in my mind
01:16:11 stuck very very clearly in my mind because unfortunately he just missed me and hit the firefighter in front of me so that is pretty much imprinted on my mind actually as a visit to the tower so I'm able to remember that very clearly I
01:16:24 I'm able to remember that very clearly I can't say with any confidence whether I went before that or if I win after that again until another occasion when I went in where I am clear about it cuz I
01:16:36 in where I am clear about it cuz I remember going in with the Commissioner and I remember thinking at the time the Commissioner was putting herself with very considerable danger and this was an extremely unusual situation to be in when one's own Commissioner is running
01:16:47 when one's own Commissioner is running the possibility of being badly injured or killed in monsoon okay let's see if we can let's see if we can get the detail by some pictures can I ask first of all for pull to put
01:16:58 can I ask first of all for pull to put up a photograph on the CCTV that we have
01:17:16 now it's not the clearest this is an adjusted time of about 302 I'm afraid I'm a label at the moment to give you
01:17:27 I'm a label at the moment to give you the precise adjusted title second do you see yourself in that picture I think I do
01:17:33 do I think I'm there's no point pointing on this is I think I'm standing behind the gentleman wearing a command staffed a bard and Matt Cooke is standing to my right Danny cotton is standing between
01:17:45 right Danny cotton is standing between Matt Cooke and someone else I don't know who that is standing in the corner right I'm sorry I'm not entirely sure where
01:17:58 I'm sorry I'm not entirely sure where your where your your point so on yes there where the arrow is I think that's me
01:18:04 me you think that's why do you think that's you because of my helmet markings because I recognize my hand movements actually I'll move my hands a lot in a talk right so that guides me and I was talking to all the BA I would imagine
01:18:17 talking to all the BA I would imagine that's one of the points I was talking to all the be a crews in there right about the extremity of the situation they were in and that whilst we were continuing to commit them into the building I expected them to take particular care with each other because
01:18:29 particular care with each other because we were trusting their professional judgment to progress as far as they could without putting themselves in you know the danger of losing their lives right just tell me tell us about the
01:18:41 right just tell me tell us about the helmet markings what are the distinguishing marks on the helmet that identifies that as you that's the mark is for an Assistant Commissioner so that the thick the single thick band right
01:18:52 the thick the single thick band right and I'm wearing the incident command at a part as well oh I think so that that is certainly me right okay now on that visit how long was that visit because as I say it's not
01:19:04 was that visit because as I say it's not in your contemporaneous note or or indeed in your lot I've got to say it's come as a surprise to me I was in the tower at that time this is the first time I've seen this and understood myself to be in the tower at that time
01:19:16 myself to be in the tower at that time but I think it reflects what I said earlier which is you know I think I've got a good memory of a number of things throughout the incident obviously where Jackie was making a log of my decisions I'm clear about the time
01:19:28 I'm clear about the time referred back to vision for times when orders went from me although I would accept that although the vision looks as a certain time I'm likely to have given the order either earlier potentially and
01:19:39 the order either earlier potentially and it's been some delay to going actually from you know if I'm honest I'm surprised I was in the tower at that point right I don't remember going before the TCM particularly didn't I'm
01:19:53 before the TCM particularly didn't I'm doing the best you can mister and I know it's difficult did you have a discussion with Richard Walsh Richard worked Richard Welsh and and Pat Goulbourne at the bridgehead at this
01:20:04 Goulbourne at the bridgehead at this time I would have seen one of them at this point because there was the one thing I do know is I know I went into the tower on the number of occasions if there wasn't an occasion I don't think we're I didn't speak to either Richard or Pat because of the sole purpose of me
01:20:15 or Pat because of the sole purpose of me going into that tower would have been to consider what the tempo of operations was did we have a system whereby we were maintaining continuous committal of crews up inside the tower you know what
01:20:26 crews up inside the tower you know what was actually the general composure of my firefighters what was the internal condition of the building actually even from Lobby level to be able to make a you know some sort of assessment of that
01:20:39 you know some sort of assessment of that did you go upstairs at this point no and actually I didn't go upstairs at any point more than a few steps I didn't I didn't go to the bridgehead at any point
01:20:50 didn't go to the bridgehead at any point so that wasn't my purpose for going in there I needed to speak to my sector commanders primarily as an information gathering exercise to see them face to face because our own communications on
01:21:02 face because our own communications on the fire ground for challenging because of eleven of radio now at about this time well at this time adjusted it appears that the bridgehead was still on
01:21:13 appears that the bridgehead was still on the third floor from what you could see was the bridgehead down on the ground floor by that stage as best you recall I don't recall the bridge had been on the ground floor at that stage no I think it
01:21:24 ground floor at that stage no I think it was still upstairs so in order so not everyone can remember it correctly I mean I have to say my memory of this happening at this time this has genuinely come as a surprise to me that I'm inside the tower at this point at
01:21:36 I'm inside the tower at this point at that time but probably reflects the length of time I was in command and dynamic nature of the incident now does
01:21:47 dynamic nature of the incident now does that mean that you didn't have a nuts-and-bolts discussion or any discussion at all with with Richard Welch and Pat Goulbourne no I think I
01:21:59 Welch and Pat Goulbourne no I think I did because whilst I might I've got the time-out sequence what I do know is every time I was finished the quickest our apologies my fault and I should I should finish the question does that mean that you didn't have a nuts and
01:22:10 mean that you didn't have a nuts and bolts discussion or any discussion at all with Richard Welch and Pat Goulbourne at this time no because my record as far as I can recollect every time I went into the tower a priority for me was to speak to either Richard or
01:22:22 for me was to speak to either Richard or Pat because really they would have been whilst I would have gained some situational awareness from observing the real purpose of going into there was to get first-hand update from Pat or
01:22:33 get first-hand update from Pat or Richard because they were my fire sector commanders right and from what I recollect there was an occasion when I went into the tower I didn't speak to them at least briefly to ascertain progress and and have an understanding
01:22:45 progress and and have an understanding of their broad outline plan right so I'm just trying to get a handle on when you did first have this briefing with Pat Goulbourne and Richard Welch if we go on
01:22:57 Goulbourne and Richard Welch if we go on to page five of your contemporaneous note which is in the long block of text or narrative which follows the time mark of a 339 on page four mr. Rowe it's the foot of the page
01:23:08 foot of the page I received a quick brief from Pat Goulbourne of Richard Welch you'll see that look on the screen Polly juice yeah and this is this is in the block of
01:23:21 and this is this is in the block of narrative which starts the page before with the time mark of a 339 I received a quick brief from Pat Goulbourne and Richard Welch who were running the fire sector between them they told me they cleared up they've cleared as best as
01:23:33 cleared up they've cleared as best as possible up to the 8th of that point etc I don't need the detail at this point I'll come to it later but just in terms of timing are we to take it that you're
01:23:45 of timing are we to take it that you're the first time you had a brief from Pat Goulbourne and Richard wells to discover what they were doing in the fire sector was after 339 no I don't I don't think
01:23:56 was after 339 no I don't I don't think so now you've shown me that because if I've been in the tire at 302 I would have had a brief from Pat and Richard it may well be that I've conflate you've more than one visit because of the span of timers at the incident so oh I
01:24:09 of timers at the incident so oh I remember going into the tower a number of times the ones I can absolutely pin down in terms of detail or the ones I record it because I know I left the unit because it was clear as stats and
01:24:22 because it was clear as stats and recorded that I've gone but I would not have not received a brief from brief from Pat or Richard when I was in the tower you know to the best of my
01:24:34 tower you know to the best of my recollection every time I was in the tower I had a brief from power Richard because I simply would not have gone into the tower without wanting that now whether I've got the time wrong within my statement yes quite possibly or whether in fact
01:24:46 yes quite possibly or whether in fact I've combined two conversations I think that's entirely possible in the context of my memory but I actually if I had
01:24:57 of my memory but I actually if I had gone in to get a brief inside the tab and I would have got it earlier hmm well let's just try and take this in stages at 3:02 or there abouts allowing for the adjustment of the time you would have
01:25:10 adjustment of the time you would have had to have gone up to the bridgehead which was on the third floor so do you remember doing that no and I don't think I did so I can I can only tell you what I remember right
01:25:22 can only tell you what I remember right so do you remember in and I know you don't remember very much of that early 3:02 visit to the tower but do you remember whether then or later either of
01:25:33 remember whether then or later either of Platt Goulbourne or Richard Welch came down came down from the bridge head to speak to you yes definitely I spoke to Pat and Richard or either Patton his own or Richard on his own the foot of this
01:25:45 or Richard on his own the foot of this stairs or more than one occasion did you ever brief did you ever speak to them at the foot of the stairs when the bridge head was not at the foot of the stairs so sorry could you ask that
01:25:58 stairs so sorry could you ask that question again did you ever speak to either of Pat Goulbourne or Richard Welch
01:26:03 Welch the foot of the stairs as you've just said when the bridge head was not itself at the foot of the stairs I can't recollect that that level of detail all I know is that I would have expected to speak to Pat or Richard when
01:26:14 expected to speak to Pat or Richard when I went it to be fair I can't remember going in a 301 but that would have been my expectation and that's what my memory is but as I said it's a surprise to me I was in the tower 301 mmm
01:26:25 was in the tower 301 mmm 302 how long doing the best you can with your recollection how long after the
01:26:38 your recollection how long after the change in the statehood advice at 2:47 did you speak do you think - Richard Welch and Pat Goulbourne about their plan well before I'd seen that CCTV
01:26:50 plan well before I'd seen that CCTV footage I would have said it would have been the visit that's recorded on the statement 339 I would have thought it was then yes because prior to that I was relying very heavily on Matt Cooke and
01:27:01 relying very heavily on Matt Cooke and macmail Holland to keep me updated in the context of situational awareness while I was putting in the structures to support and drive Vincent and in fact they were invaluable to me because of
01:27:12 they were invaluable to me because of the difficulties with communications they effectively became for long periods of time my conduit of information back and forth being carried out face to face so going to my ideological and going
01:27:25 so going to my ideological and going into the fire sector triangulating the information from fire sector - Andy and back to me and giving me a situational brief you know that's a very important part they're wrong well I showed you the photograph at 3:02 in fairness to you because it's
01:27:39 at 3:02 in fairness to you because it's evidence as you've confirmed that you were in the tower at that stage but if you ignore that for the moment would what on the basis of your recollection that you had prior to seeing that picture be that mean that you didn't in
01:27:50 picture be that mean that you didn't in fact do a face to face brief with Richard Welch or Pat Goulbourne about but what they were doing until almost an hour after the check the statehood advice was changed after 339 I think on
01:28:01 advice was changed after 339 I think on the basis of my recollection I would like to think it was in the tower I did but that has come as a surprise to me seeing that and actually yeah you know if I'm going by the statement it would have been as its timestamp which is 339
01:28:14 have been as its timestamp which is 339 and yes that would be the case so I would have got a face face brief from richard and pat at that point yes so that I'm certain I did have a face-to-face brief with other patter Richard at that point the fact I was in
01:28:27 Richard at that point the fact I was in there earlier you know you know you've done me caught me by surprise and I mean to think about the events of the evening he's actually did I have a face-to-face briefer three in the morning from one of them okay and you can't remember and
01:28:39 them okay and you can't remember and that's fair enough but but on the footing of your statement and the contemporaneous notes can you help me with this why would you have left it from 247 till after 339 to have a face-to-face discussion with Pat
01:28:50 face-to-face discussion with Pat Goulbourne and Richard Welch because I had officers to provide me with an update of situational awareness who was speaking to those officers face to face on a regular basis I was at the very beginning of taking over a major
01:29:02 beginning of taking over a major incident that was likely to have an effect across the whole of the London environment never mind the local environment who was in that I needed to be sure that the structures that were going to support any activity on the
01:29:13 going to support any activity on the instagram regardless of the tactical plan were being gathered and managed appropriately and I needed to brief officers who were going to take those roles forward into a delegated command so I think it's more about I could have
01:29:25 so I think it's more about I could have taken the time and clearly I did go into the tower that's ready to gather some situational awareness batchi my recollection was focusing on putting in places the structures to drive the incident forward I think again
01:29:38 drive the incident forward I think again while situational awareness is absolutely vital for an instant commander in my position why I am relying on inevitably because the size of the incident the spans of control I had was trust in the officers who had
01:29:51 had was trust in the officers who had delegated command to make sensible decisions within their sector based on their own situation awareness and receive continual update on that basis through whatever means I could and I had that from a number of me so I had Dave
01:30:02 that from a number of me so I had Dave O'Neill was very very important to me in terms of information update so the sector safety commander he was giving me regular updates about the challenges of
01:30:13 regular updates about the challenges of getting into the building the scale of debrief all the potential of just collapse and Davies urban search-and-rescue specialist so he's advice was particularly valuable I had Matt cook a Mick Mulholland were
01:30:25 I had Matt cook a Mick Mulholland were pretty much on a just a cycle of going out to the incident ground confirming situational awareness as I had asked them to then coming back to me
01:30:36 had asked them to then coming back to me and confirming my understanding of what was going on and whether we were maintaining progress against my objectives and I had Andy Lachlan checking in face to face with me I think because of the challenges of communication they tended all those
01:30:47 communication they tended all those conversations tend to be face to face either coming on to the unit or me occasionally getting off the unit to have the conversations helicopters different topic helicopters were you
01:31:00 different topic helicopters were you aware that there was an N pas helicopter on at the incident or above the incident at about 247 when you took over gone at the time you took over command I may
01:31:12 the time you took over command I may have been I can't remember it's a points of detail but I would have expected them to be there because it was inevitable the the met helicopter would have been our right can I ask you to look please at M et triple zero one eight seven six
01:31:26 at M et triple zero one eight seven six one and could you please turn to why should I tell you what this is this is a an N pass report dated 3rd of October
01:31:39 an N pass report dated 3rd of October 2017 by inspector Simon Hepworth and I can take you please to page two last bullet point
01:31:53 and this is three lines down from the start of that bullet point where we see this the tactical options available in an incident such as Grenville tower include video and/or thermal imaging
01:32:06 include video and/or thermal imaging down link to the incident commander recording of video evidence monitoring by the crew and verbal information passed to the incident commander and stills photography other options might also be available for example use of
01:32:17 also be available for example use of high intensity light or a loudhailer now did you discuss those tactical options
01:32:28 did you discuss those tactical options listed there with anybody not not as I remember but actually we have an issue or we had an issue at that time from what I remember generally with the availability of the downlink working on
01:32:42 availability of the downlink working on the command unit so actually whilst the head of the information helicopter gives you in many instances very useful so so if I had a large industrial building where I didn't have a full view of the roof and I
01:32:53 have a full view of the roof and I wanted to understand the fire spread very useful information and I would request it to be fair I don't think in the context of Grenville would have been my immediate priority because it wasn't
01:33:04 my immediate priority because it wasn't going to give me anything I didn't already know I already knew the extent that fire spread I could see it very clearly we were close to the tower it was obvious what it was a vertical view of that was not going to really tell me anything other than perhaps what
01:33:17 tell me anything other than perhaps what what buildings might be at risk close to it but I'd already had that information from elsewhere high intensity light now halo would have been not useful at all
01:33:28 halo would have been not useful at all in that context for two reasons firstly that volume of noise the only thing I can describe to is perhaps go back to my military experience which is I had never heard a volume of noise an incident in
01:33:40 heard a volume of noise an incident in the fire service that I could compare it to the only comparison I had was to very very serious large-scale civil disorder at Drumcree actually where the level of noise was absolutely deafening so to
01:33:52 noise was absolutely deafening so to have tried to have spoken with a loud hailer to anyone would have been impossible because of that volume in order so you couldn't hear anything and if you were going to use a high intensity light if that one have helped
01:34:04 intensity light if that one have helped us we didn't have an issue with on the external of the building and actually I wouldn't have wanted a helicopter too close to the building full stop because it would have been difficult to judge a car again I'm I'm
01:34:15 difficult to judge a car again I'm I'm not a PI that they were being difficult to judge a safe proximity because of the scale of the fire and the price of combustion coming from it the effect of downdraft would possibly have had a
01:34:27 downdraft would possibly have had a really detrimental effect on the building as well so to use those two final tactical options would have been I think inappropriate I think later on we considered as a very limited possibility
01:34:39 considered as a very limited possibility calling in Coast Guard search and rescue because of reports of people on the roof I have to say I don't think I've ever views that we consider it as an option but in the context of the building I don't think I would have been a safe
01:34:51 don't think I would have been a safe option for rescue we just had to consider it was a tool in our Arsenal
01:34:57 well I think you've answered it not just my question but several other questions that I was going to follow up with but just somewhere in there those the aren't that there was something about the history inc not working did you know
01:35:09 history inc not working did you know whether it was not working or whether the message was actually scrambled to be fair to me it had been the same thing so my understanding of that is the organization we discovered I don't where
01:35:20 organization we discovered I don't where there was pregame for or post gratefully or something about the encrypting of information from the helicopter meant we couldn't pick it up for a period of time on our unit that's my understanding of it on the night I cannot genuinely
01:35:31 it on the night I cannot genuinely recollect whether I had that conversation I would expect I would have done that it's not recorded in any of my decisions logs I can rightfully claim to say I definitely did but it's kind of a
01:35:42 say I definitely did but it's kind of a normal expectation as an incident commander at my level to say have we got the helicopter up have you got a heavy telle downing unfortunately my experience over a period of time around that time was that the answer was
01:35:53 that time was that the answer was normally no we haven't because we can't receive the information can I ask you to go to the InP report for this incident which is a tab 30 of the documents bundle
01:36:06 and turn in that to page two please this is lfb quadruple zero three one one four
01:36:17 is lfb quadruple zero three one one four there it is and at page two you can see well first of all I should just ask are you familiar with this this document I jumped in rather at page I haven't read it since the PRC but yeah I recognized
01:36:28 it since the PRC but yeah I recognized the document okay I mean you want I can show you page one if you want no let's look then together with the second entry down to under development and the observation there is there was no access
01:36:40 observation there is there was no access to the helicopter dandling heli tele at stratford control fall back review the equipment of our control fall back locations now as a development item that that am i right in thinking that this
01:36:52 that am i right in thinking that this indicates that the absence of a helicopter downlink and Stratford was a problem I think I mean I can't speak for the people who are at Stratford but
01:37:03 the people who are at Stratford but clearly it's there because they might I can only assume they must have thought it was something it would have been useful for them to being recorded as a development comment that has been picked up through the PRC process right my bad
01:37:14 up through the PRC process right my bad thing that would have arisen from them from my point of view it would certainly be something I would have wanted to be working on the unit so you could apply that logic as equally to the command
01:37:25 that logic as equally to the command unit as you could to Stratford control I think ideally we would want that it's a very useful piece of information right and therefore were you hampered in any way by not having the heli Turley downlink working and giving you images
01:37:37 downlink working and giving you images on the Scylla incident I don't think in the context of this incident it would have made much difference but it is always useful to have a vertical view I wouldn't say hampered my decision-making no well I typically change my situation
01:37:49 no well I typically change my situation awareness might you've been able through the head Italian league to identify still living occupant at windows no I don't think that from the view they had you know my experience of heavy telly as
01:38:01 you know my experience of heavy telly as I think that would have been difficult I mean I couldn't rule that out to be fair I'm not an expert and I don't fly the helicopter and I don't operate the imaging equipment but I doubt it would
01:38:13 imaging equipment but I doubt it would have had much use to us and then we would have had the issue of tying that information up with we were giving two crews internally and what we were committing them to so no I don't think that would have been a major
01:38:25 don't think that would have been a major factor in terms of our overall decision-making or our intent in terms of the rescue operation right now can I ask you please to go to your contemporary Gnaeus notes of page three
01:38:37 contemporary Gnaeus notes of page three we're in the middle of the page you describe your briefings and do you ask that you say you are I asked Ally to become my operations commander with responsibility for the fire sector FSG operation are and be a main control and
01:38:51 operation are and be a main control and Steve West has come and support responsible for keeping the fire sector resources I shown you that there's a platform for your witness statement
01:39:02 platform for your witness statement where on page five if you just go to that you you add to that and as your first statement page five at the top of
01:39:13 first statement page five at the top of the page you say I explained to Andy I had two priorities for him the first and most important was to work with Dave O'Neal to establish safe access and
01:39:25 O'Neal to establish safe access and egress due to significant amounts of debris coming off the building and you've discussed that already we've discussed that already this morning the second was to drive the rescue effort as hard as possible focusing on savable life and did you give Andy a lot in any
01:39:40 life and did you give Andy a lot in any clue as to how in practical terms to go about that I can't remember the detail of the briefing to that level what I do know is I set those priorities out we
01:39:51 know is I set those priorities out we talked about the need for continual assessment of how safety was to come in our crews into the building which ties in in part with the instruction to work with Dave O'Neal and be mindful of the
01:40:02 with Dave O'Neal and be mindful of the possible possibility of building collapse I would have expected Andy because of the discussion we had to just focus on volume of be a cruising I do
01:40:14 focus on volume of be a cruising I do remember saying something along the lines of we just need to maintain a continuous breathing apparatus operation at great volume into the building when you received your briefing and I know this is you giving Andy a lot of
01:40:26 know this is you giving Andy a lot of your effort as ops commander but when you received your briefing from him did he give you any clear about the strategy being carried out in the fire sector yes because he confirmed
01:40:39 the fire sector yes because he confirmed that he put in place an operation to commit as many breathing apparatus crews as possible into the building and I concurred with his view on that that it was going to be very difficult to prioritize in detail and therefore we
01:40:52 prioritize in detail and therefore we had to focus on just continuous volume of crews in to make sure we swept everyone up in the rescue operation and the only way we could do that was to ensure we had that volume in there and that was very challenging so to you know
01:41:03 that was very challenging so to you know I think I need to set that in a context so to maintain the volume and actually I'm really proud of the officers like Dan Kipling your own ba main control and Dave O'Neill who was securing and managing the access egress those were
01:41:15 managing the access egress those were extremely complex tasks it's not as simple as people just walking into a building this was the management the recovery you know the refreshing of sets you know be a sense to maintain a continuous stream of people into a
01:41:28 continuous stream of people into a building which was very difficult to access maintaining you know egress for the other crews coming out to not have a break in that operation as far as I'm aware I think was entirely impressive on those officers part I think that was
01:41:40 those officers part I think that was very very very difficult and actually whilst I think you you can focus on the question of prioritization my sense of it was the best way we were going to
01:41:51 it was the best way we were going to give people the best chance of being rescued was simply to flood the building with firefighters and to do that you know it was it was and if you know there's a massive effort to do that as safely as we possibly could maintain the
01:42:03 safely as we possibly could maintain the throughput of resources so it wasn't a break to my knowledge there was never a break in committal unless there was a reason to fight the fire to enable committal to continue mister I'm sorry
01:42:15 committal to continue mister I'm sorry I've apologized for what I'm about to say and don't mean any disrespect that's not just a very long answer to a simple short question but what I'm trying to do is to elicit the facts on the night by
01:42:28 is to elicit the facts on the night by asking you a set of questions to which should be short answers well I'm not after is your opinion of how things went unless I ask for that so I wonder if we can might shorten things and help you if if we just focus on if we can they
01:42:40 if we just focus on if we can they answer to my question because I normally leads to another question that bill on that do you see absolutely okay just so it's just tried that out and see how we go
01:42:48 we go so my next question following on from the answer to my last question which was which was yes I think was did he give you a specific details of the way in
01:42:59 you a specific details of the way in which he was carrying out the strategy of search and rescue I think that was the answer I was trying to give you so it was that process by which we were committing into people into the building
01:43:11 committing into people into the building and then ensuring that they went up into the building and as greater volume as possible in terms of detail do you mean detail in terms of what floors they would search first or how they would
01:43:22 would search first or how they would progress inside the building is that perhaps what you mean you tell me I mean I go with em yes did he know anything we had a conversation on general principles about we wanted to progress as far as
01:43:33 about we wanted to progress as far as firefighting conditions would allow and that we should seek to push beyond that I think he may have made reference to a specific flaw but I can't remember but
01:43:44 specific flaw but I can't remember but my general thrust was that he was an experienced officer you know as long as progress was maintained as best as possible in the face of difficult firefighting conditions the tactical plan in terms of taking people out the
01:43:58 plan in terms of taking people out the building would sense began to him and Richard and Pat specifically did Andy a lot in tele during the course of his briefing to you on handover that he had
01:44:10 briefing to you on handover that he had been trying to get information both from the fire sector and from the FSG sector for some time but to no avail I know you didn't mention that in in
01:44:21 I know you didn't mention that in in that handover right would you have expected him to do that to tell me that he hadn't had any information from them if he had been a relevant factor and I had been operating in an absence of
01:44:32 had been operating in an absence of information yes I didn't feel I was operating in an absence of information in terms of determining the primary objectives and driving progress forward now on page 5 of your statement just a
01:44:46 now on page 5 of your statement just a little bit lower down you say as far as four lines up from that same paragraph we were on the final part of my brief - and he was see you would set up channel 2 as a
01:44:55 2 as a come on channel on the fire ground radio and that my prayer my immediate priority was to get the police to secure the cordon on that question of the radio channel why did you think you needed to
01:45:07 channel why did you think you needed to set up a separate channel I wanted a separate command channel so we had the space to talk and discuss the shared situation information confirming agreed priorities that was going to be very
01:45:19 priorities that was going to be very difficult in channel 1 because of the volume of traffic on channel 1 simply because of the numbers of firefighters we had on the incident ground and therefore constantly interrupting and trying to take a priority I think for
01:45:30 trying to take a priority I think for everyone on the radio that night everything they were saying was a priority obviously within their individual circumstances I wanted a space where the command team could talk to each other you know discuss decisions
01:45:41 to each other you know discuss decisions drive progress without constantly having to find space within the overall level of you know radio communication and were you concerned that a system such as channel 2 had not already been
01:45:52 channel 2 had not already been established by the time you arrived no I wasn't concerned but I wanted it set up again I wasn't reflecting on what had come previously I didn't really have the time and space to do that I just wanted
01:46:03 time and space to do that I just wanted it because I knew that would be a better way of communicating it I wasn't seeking to judge anything at that point I just needed to put in place a structure and drive progress did it did you set one up
01:46:14 drive progress did it did you set one up tried to so I gave an instruction to the see you to set channel to our I asked them to pass that information out to
01:46:25 them to pass that information out to Instagram that channel 2 would be set up and therefore the command team should turn to channel 2 only to find not long after that they had been unable to say channel 2 up which you know to be frank
01:46:36 channel 2 up which you know to be frank was frustrating and that we would have to revert to channel 1 later stage we had a limited air wave network between myself and lead Rogich to talk about the
01:46:49 myself and lead Rogich to talk about the logistics and resourcing which became increasingly important but after that point we had to work on the basis of runners face-to-face communication and
01:47:01 runners face-to-face communication and doing our best with channel 1 all mobile phones in the next paragraph we see you say that at 2:57 after references PPV third line down channel two would not work say we reverted back
01:47:12 two would not work say we reverted back to channel 1 does that mean that in fact by 257 only ten minutes after you've taken command also you discovered the channel who didn't work that that feels
01:47:23 channel who didn't work that that feels about right yes do you know why it didn't work to be honest I got the intersect it in entirety I may have said can we be sure about that that's probably the extent of it but the
01:47:34 probably the extent of it but the command unit crew were very definite in telling me that channel 2 was not working you know in fact they were they were they were upset about it because I'm sure they understood how important that would have been to me and why would
01:47:46 that would have been to me and why would have been an important factor in 9/7 Young
01:47:48 Young can I ask you please to be shown page 25 of a short incident
01:48:02 and you'll see on that page that at 3:44 in 20 seconds that there's a makeup
01:48:13 in 20 seconds that there's a makeup request from control SI su p sub cu8 request urgent attendance of radio engineer to assist with channel 2 for fire ground now that it appears that
01:48:24 fire ground now that it appears that that message went at 344 as you can see and we don't I think have a message at least in the in the short incident log
01:48:39 least in the in the short incident log before before that relating to channel 2 can you explain why the message didn't wasn't sent or the service request wasn't made until then no I can't and I
01:48:51 wasn't made until then no I can't and I wouldn't see to excuse it that probably something it could have gone earlier actually and seeing that right did you actually know that a radio engineer had been paged to attend the incident at 135
01:49:04 been paged to attend the incident at 135 27 I didn't know that right but I do remember that request going you remember that request good I do that how do you know how did you because I do remember and that's looking at it you
01:49:17 remember and that's looking at it you know makes me remember a conversation about a radio engineer coming because I was frustrated with the communications on the night because we were relying so much on mobile phone face-to-face and
01:49:28 much on mobile phone face-to-face and runners right do you remember when you first discovered that a radio engineer had been paged some time before your arrival in fact look good now or a quarter before your arrival I don't think I did know that I think you
01:49:39 think I did know that I think you telling me now is the first time that I've heard a radio engineer was paged at 135 oh I see sorry because you say I do remember that request going no no I remember the requests this requests
01:49:51 remember the requests this requests going off the CEO I see but you don't remember that there was a paged a requested one night life right nicey and do you know from your recollection when
01:50:02 do you know from your recollection when the radio engineer arrived to try to sort out channel - no I don't recollect when they arrived all I do know is that there was never a successful setting up of channel to weather the radio engineer
01:50:14 of channel to weather the radio engineer or not and do their hamper your communications as I see on the night yes communications are extremely difficult in the night you know people really have to work very hard to ensure we were maintaining each other situational
01:50:25 maintaining each other situational awareness yes you mentioned this a minute ago I think that's right that an air wave command channel was then set up at some point yes and that was using I think two channels flops one & Flom ops three do you remember that I do I don't
01:50:39 three do you remember that I do I don't remember the specifics of the channels use but I remember using that air wave channel to talk to lea and possibly to other officers as well right and do you recall when those air wave command
01:50:52 recall when those air wave command channels were later set up roughly what time off I think they were set up about the time that Lea drawbridge had arrived at the incident so I think it coincided with when Lea arrived and then we set
01:51:03 with when Lea arrived and then we set those up because I now had someone who was going to handle a very significant resourcing effort for me and I really really didn't need to be in communication with him and I will that
01:51:15 communication with him and I will that difficult course up most of the time I'm not handling my own communication I'm giving instruction and I've got someone who's doing that for me on the command unit so I wouldn't necessarily be me directly talking to those officers you know I would have been seeking
01:51:26 know I would have been seeking information using that network via you know a proxy by one of my offices is doing it for me right now in fact we can see from page seven of your log that you
01:51:40 see from page seven of your log that you briefed Lord Li drawbridge at 4:35 a.m.
01:51:56 oh sorry let me just live it's put a slightly different point to you in fact bleep drawbridge says in his statement that the second airwave channel was set up I think just shortly after 4:00 a.m.
01:52:08 up I think just shortly after 4:00 a.m. that's what he says it's a simpler way of going about the same point does that is that does that accord with your recollection yeah I think it does right do you know why it wasn't set up sooner than that I don't think that we had the structures in place to make best use of
01:52:20 structures in place to make best use of it actually I think we were still in a stage there where we were ensuring people were briefed that we had people actually in a physical position to start managing the resources and also that the
01:52:33 managing the resources and also that the issue was setting up an air wave Network is that not all officers who has practice carry their hand hold air wave you would need to confirm that people had it yes
01:52:44 had it yes can I ask you then to go to the PRC notes just to pick up on that last point and go to page six
01:52:55 and go to page six this is lfb quadruple zero three one one two and two-thirds of the way down that page you see issues with cons you see
01:53:06 page you see issues with cons you see officers left airwaves in car I felt really constrained by coms officers left airwaves in car I want to focus on our officers meant to take their airwave
01:53:17 officers meant to take their airwave radios with them on to the incident ground has written on our policy no which I think should be changed right no no and I'll nod felt that to be fair prior to this incident because we set up
01:53:29 prior to this incident because we set up an air wave comms network on the croydon tram crash and it was immensely useful right and I've done it on other incidents previously so I felt that was something in a policy that was focused
01:53:40 something in a policy that was focused on security because of the need for you know digital communications to remain secure and a multi-agency emergency service environment so they left in the car for security but actually I think
01:53:51 car for security but actually I think that bit of policy needed to change because I would rather they had had their handheld Airways with them yes so exactly deal with the source situation I faced by I had no confidence
01:54:03 situation I faced by I had no confidence that they all would have because of that policy
01:54:05 policy yeah well the Chairman is listening carefully to what you've just said about that
01:54:08 that but just going back to the night was the view that that policy should be changed a view that you held the four grand felt our incident yes was it something you
01:54:20 our incident yes was it something you raised with the very few people who are senior to who yes and I think there have been a discussion about changing it I can't remember the exact particulars but I'm sure that it had probably arisen as
01:54:31 I'm sure that it had probably arisen as a PRC point perhaps in other incidents really yeah do you know why no was it being taken forward at that stage as I obviously change I don't know but people
01:54:42 obviously change I don't know but people the conversations I had people that agree with it I don't have hold responsibility for that policy but my sense was that yes people understood that I mean I think there is a debate about the security of those airwave
01:54:54 about the security of those airwave because whilst is very important tasks for us to communicate on the fire ground obviously they're a very security sensitive piece of kit that would enable someone if it went to the wrong place to
01:55:06 someone if it went to the wrong place to have access to secure digital communications for example the police responding to a terrorist incident so there is always a balance between the security and the availability of that equipment and I guess that's where that
01:55:17 equipment and I guess that's where that come from but on the balance for me my personal opinion is that we should end that piece of policy and officers should be carrying their airwave onto the instagram now to go thank you now to go back to page five of your witness statement at the same paragraph we were
01:55:29 statement at the same paragraph we were looking at the second paragraph you say at 2:57 I requested positive pressure ventilations stroke specialist entry recovery team cert via the duty DAC and
01:55:41 recovery team cert via the duty DAC and then you go on to say my reasoning was whether we might be able to use to fan and high-pressure land as technology in some way how did you think the PPV would
01:55:52 some way how did you think the PPV would be able to work it in in the circumstances you were seeing I couldn't say for definite very would work but it's again it's about having the tools in your arsenal available so even if you discount them there's you know nothing
01:56:04 discount them there's you know nothing to hurt getting them there and things have always got to move a distance so you might as well get the movie so it wasn't that I was definite the PPV would be of use but I could see that we might use it in some way to improve conditions
01:56:15 use it in some way to improve conditions potentially in the lobby that we might be able to strive smoke out the lobby area so it was better for officers and crews in that part of the building did you did you make an inquiry of anybody on the incident ground about
01:56:26 of anybody on the incident ground about whether there was a smoke ventilation or extraction system in the building I don't know whether I made the inquiry but I certainly had a conversation at one point with you know it might have
01:56:38 one point with you know it might have been Matt or make a conversation with someone about the fact that there was a smoke ventilation system that wasn't working so I knew that there was a fixed installation but it wasn't working right did you investigate why it wasn't
01:56:50 did you investigate why it wasn't working
01:56:50 working no because I think looking at the building I was convinced that along with the file IFFT and other aspects of the building's system it was the extent of
01:57:03 building's system it was the extent of damage and fire spread to the building that was preventing it working
01:57:09 now you also say that in the last
01:57:20 now you also say that in the last sentence of this paragraph I asked the unit to get a better map but they confirmed the command support system wasn't working short sentence two issues
01:57:32 wasn't working short sentence two issues first of all when you say better map what will you what were you after was that up is that a diagram of the plan of the building often coughing a map in all context so a better map of the wider
01:57:45 context so a better map of the wider area that we could see a larger scale so I had an understanding of other things that were likely to be impacted so for example you've got Latimer Road tube very close to Granville I was greatly concerned about the possible impact as
01:57:57 concerned about the possible impact as we got closer to rush hour on the tube line both in terms of risk to people on that cheap line the wider impacts you know on the transport network right and
01:58:08 know on the transport network right and you know would have liked an understanding of that I wanted better plans at the floor place because I'll have liked the be a crews to have that yes so I think it was on every level I wanted better information visually right
01:58:21 wanted better information visually right about the area in the specifics of the tower itself I see and we'll come to talk about plans specifically in a minute but just focusing then on the command system not working
01:58:33 command system not working was that the see the command support system or CSS on cu8 which you were on
01:58:41 so yes I was told that CSS wasn't working on CUA we were surprised no does that tell us that they don't often work although I think that they they they
01:58:53 although I think that they they they work inconsistently so it didn't particularly surprise me because I've been at a number of incidents where CSS hadn't worked and it wasn't for one organization you're trying to fix it
01:59:04 organization you're trying to fix it there's been a huge amount of effort in trying to fix what is an aging system and we're now in the process of procuring an entirely new system to replace it but no I wasn't surprised
01:59:15 replace it but no I wasn't surprised when you say you're now in the process of procuring an entirely new system were you in that process prior to the Grenfell tower fire yes the big my understanding is that process had started before the ground full tower fire so again it's not my own responsibility but there you know there
01:59:28 responsibility but there you know there have been continued organizational frustration with CSS that was well known it was well noted it was a repeated point raised on prc's PR o--'s on the instant management database work was
01:59:40 instant management database work was beginning as far as I understand it to procure a new system to replace CSS which was an aging system at times inconsistently operating did the absence of CSS hamper you personally in your
01:59:52 of CSS hamper you personally in your role as I see on the night in some aspects because I would you know you get access to better mapping actually I think the organizational part of CSS
02:00:04 think the organizational part of CSS would have been less useful because of the scale of the incident actually so you can create an organizational structure now we're in use to in some ways but actually it was so large in terms of the resources coming on often
02:00:15 terms of the resources coming on often the information would have been crowded it was primarily the mapping really okay I was going to ask you in what aspects specifically that were you hampered by the absence of working CSS I think it
02:00:27 the absence of working CSS I think it was more than anything the mapping I would really have liked the mapping okay
02:00:35 non-functioning of CSS looks from your statement to be something you experience the 257 is that right if that's what it says in the statement that would be to
02:00:47 says in the statement that would be to the best of my recollection right and the reason I ask you is but if you go to your log at page 2 you can see that at 403 which is a good hour and a quarter
02:00:58 403 which is a good hour and a quarter or so later it says the three entries up from the bottom the command system has gone that command support system has gone down and I'm I'm asking really
02:01:09 gone down and I'm I'm asking really whether that was the first time it had gone down but had been operating until then or whether it had not been operating at all no it not been operating at all so this is Jackie's log isn't it so whether I've asked her to do that or whether she's noted that I
02:01:21 that or whether she's noted that I couldn't tell you right and but no I command support would not be working prior today no right you sure it wasn't do you know why Jackie would have needed it at that time rather than at the start genuinely no okay
02:01:34 genuinely no okay mr. Chan I'm going to turn to a different different topic I would say that I hope to stick to it it may be a convenient moment for another of our ally breaks yes and as before please
02:01:48 ally breaks yes and as before please don't talk to anyone else about your evidence and we'll resume at quarter to twelve please write to give the usher thank you
02:02:05 right course the trophies
02:04:58 you
02:14:40 right mister we're ready to continue mr. oh thank you for coming back to us can I take you now to 320 and your first TCM
02:14:51 take you now to 320 and your first TCM in your witness statement of page six if you please go to that you see that in the middle of the page you say of 320 hours I chaired the first tactical
02:15:02 hours I chaired the first tactical coordination meeting details are recorded in the decision log that you exhibit in summary that's included the use of TSG to deal with a deteriorating public order situation safety of
02:15:14 public order situation safety of partners within the inner cordon and no one should be moving independently of the fire service etc and then at the end of the paragraph you say I requested plans from the local authority which I did not get I just want to focus on that
02:15:27 did not get I just want to focus on that there's this question of plans at that stage did you that not having plans of the building was affecting your ability
02:15:39 the building was affecting your ability to make command decisions I think the level I was operating no because I was making big command decisions about the broad thrust of the incident but for
02:15:50 broad thrust of the incident but for those officers I've delegated command to to form a tactical plan so for example Patton Richards particularly we're going to have to continuously judge to what level they could push people up inside
02:16:01 level they could push people up inside the building sometimes have to draw people back what would be their priority as to what level they would go to perhaps even missing floors and to do that it was always going to be better if
02:16:13 that it was always going to be better if they had detailed plans that showed the floor plates did you know they didn't have plans I I didn't know that they didn't have well to be fair I didn't I'd assume they
02:16:25 to be fair I didn't I'd assume they didn't have plans because we didn't have anything on the Ord and I'd asked whether we had plans from local authority and we did it it's our dive assume they didn't have plans in that saying right okay let's explore that a
02:16:36 saying right okay let's explore that a little bit just if we can I understand your last answer about you not needing them but they would did they tell you we don't have any plans can you get them for us
02:16:48 for us I can't remember but I would have wanted them as a matter of course because I think that is a very important part of information for our crews to have saw would have asked anyway now you said also that you didn't have anything on
02:17:02 also that you didn't have anything on the ORD anticipate some questions I have later but did you check the ORD when he got onto the command unit I think I answered that yes actually that I hadn't
02:17:14 answered that yes actually that I hadn't checked it in the detail but I'd asked the command unit staff to tell me whether or not there was useful information on the Ord whether it was be of use to me and I was told actually no
02:17:26 of use to me and I was told actually no no you you also I think covered this but I just want to look at it a bit more closely would you expect on the night of the fire and they put it this way would
02:17:37 the fire and they put it this way would you have expected that the plans would be available to the incident commander who was first at the scene yes I would have expected a plan of the floor plate on the ort right and if not on the Ord
02:17:50 on the ort right and if not on the Ord would you expect it in a premises information box or an electronic premises information box depending on the type of building yes it's not it's
02:18:01 the type of building yes it's not it's not mandatory for a tower of Grenville's type to have a premises information box but I would have expected crews to that access to a plan of some sort through
02:18:12 access to a plan of some sort through those systems yes and you say plan of some sort can you just give us a rough feel of how detailed the plans that you would ordinarily expect to be to be available would be on an Ord entry for a
02:18:23 available would be on an Ord entry for a block of this nature yes so an outline plan of the floor plate in particular so numbers of flats on each floor and you know that you know an outline drawing of
02:18:34 know that you know an outline drawing of the size and shape of the building right with marking as to where perhaps dry riser out this might be hydrants external to the building so a plan that would allow people to put our high-rise
02:18:45 would allow people to put our high-rise procedure into effect so where the hydrogen is where you're augmenting supply the nature of the block in terms of how the flats are split within the block and an understanding of the floor
02:18:56 block and an understanding of the floor plate you know is there four flats on each floor is there to the nature of the lobby so that sorts of detail right okay and if it wasn't if that sort of detail as you've described
02:19:07 that sort of detail as you've described it wasn't available on the Ord then where would you expect a watch manager or incident commander of any level to get them from well if they were lucky
02:19:20 get them from well if they were lucky enough to have a premises information box there you might go to that a larger incident as I did you would perhaps ask the local authority would have access to housing records to maps and plans of all
02:19:32 housing records to maps and plans of all the buildings within their their you know their purview so there's two possible sources depending on the type of building a responsible person who was responsible for the fire risk assessment their building in a you know in a
02:19:43 their building in a you know in a commercial building where one was required and they might have maps so lots of sources where you might get a map from or in worst case actually I would expect a degree of common sense to be applied as an officer because you
02:19:54 be applied as an officer because you want to know that floor plate and the layout of the flats you would normally go to an uneffective floor if you didn't have a good plan and draw yourself a plan so you go to an unaffected floor I
02:20:05 plan so you go to an unaffected floor I have a look at the makeup of that floor and then enjoy yourself a diagrammatic you know representation of that floor so you could plan off that and work off that yes and in your last answer you
02:20:17 that yes and in your last answer you said and I just want to follow this up if they were lucky enough to have a premises information box and you might go to that would you say lucky enough does that indicate that actually
02:20:28 does that indicate that actually premises information boxes to your experience were rarities in London no not rarities in that there's a lot there's a lot of them but obviously
02:20:40 there's a lot of them but obviously there's a huge amount of building stock in London and you don't need a premises information box on every type of premises on home or to a high-rise in particular high-rise in particular no my experience is that you wouldn't normally have a premises information box actually
02:20:52 have a premises information box actually so I think one of the reasons for ending up with the e pip was that actually it was a challenge to have the metal floor diagram plates and premises information
02:21:04 diagram plates and premises information block box in every high-rise that's part of the reason for the EP system the electronic way to swipe the lead excellent plan
02:21:15 excellent plan because actually there isn't a premises information box every high-rise premise night right okay are you aware of the
02:21:26 night right okay are you aware of the contents of the London resilience plan not in detail as regarding premises information box is not okay all right well you may have to come and visit that
02:21:38 well you may have to come and visit that either later or with somebody else would you have expected any previous incident command or attending this incident to
02:21:49 command or attending this incident to have requested plans of some kind of this building before your arrival before my arrival I think that's an early expectation of incident commanders yes
02:22:01 expectation of incident commanders yes but again you know in defense of my junior officers that night they had a an awful lot to deal with and actually they may not have had someone immediately available to request those plans from so
02:22:13 available to request those plans from so if they weren't on our system and there wasn't someone from the local authority they would have been able to get them for more if they haven't identified a premises information box then actually I
02:22:24 premises information box then actually I think I can excuse them that but yes I'd that that is something that I would have expected in the gathering information part of the decision-making model so that's one of the first things you would think about is how I got plans where can
02:22:36 think about is how I got plans where can I get plans from right okay now turning to you what efforts did you make to request plans of the building a repeated request through a number of
02:22:47 repeated request through a number of tactical command meetings so directly to the local authority representative for those meetings I think repeatedly outside of those meetings possibly as well I think is a question I kept on
02:22:58 well I think is a question I kept on coming back to because I became I couldn't understand why they weren't able to get in to me actually I think he took her an unreasonably long amount of time to get those plans to us we did get
02:23:09 time to get those plans to us we did get them in the end but it was very much later in the incident yeah we'll come to that but did you request plans at the very first TCM do you think I can't recollect I know I know I certainly did a number of teams whether
02:23:21 certainly did a number of teams whether I did on the first one I can't recollect I know from really my own decision log that it's not recorded there quite far can't remember whether I did or didn't okay is it something that you would have expected Jackie Makana key to
02:23:32 would have expected Jackie Makana key to have logged your request but to be fair to Jackie not necessarily because although Jackie is an experienced officer and had worked in far investigation we don't formally trained
02:23:44 investigation we don't formally trained large numbers of people to be incident loggers so she was doing her best as a locust right so I think to assume anything about that would be wrong with me I think she's again I think she did a an incredible job over a very long
02:23:55 an incredible job over a very long period of time logging you know many decisions now if you go to your witness statement which I think we've probably still on actually at page six you you do you do time the request for plans at as
02:24:08 you do time the request for plans at as at the first tactical coordination meeting at 3:20 but we don't see it in the log or or indeed in your contemporaneous note my question is where did you get that time from as the
02:24:23 where did you get that time from as the time at which you asked for plans so is this one of the police interviews well this is your yes this is your first one yes so I think this was so the first interview I had with the police was very
02:24:34 interview I had with the police was very long and I was recalling as best I could at that point within the interview so I guess it probably came from there and I would have I think when I asked I when I
02:24:45 would have I think when I asked I when I was talking about the detail of what I've covered in the TCM that would have been one of the things I would have expected to ask okay and and that that was what my men you know it's been recorded faithfully by the police officer who is recording that interview
02:24:58 officer who is recording that interview so that's what I said and that's what I believed at that time right
02:25:05 if you turn to page five of your of your
02:25:24 if you turn to page five of your of your of your of your log
02:25:35 you you can see that that page at page five halfway down the page there's a discussion of 613 with the DSE district
02:25:48 discussion of 613 with the DSE district severe and at the end of that it says will attempt to locate plans do you think that was the first time in the
02:26:00 think that was the first time in the night when you discuss plans no definitely not I'll discuss plans over a period of time much earlier than that this is the first mention in your log of any discussion
02:26:11 mention in your log of any discussion about plans no I'm certain I'd asked about plans on more than one occasion prior to that right I can't give you the exact timing I'm sorry but I'm really certain about now doing the best you do
02:26:22 certain about now doing the best you do the best you can to recollect you remember who you asked the plans of well I think I asked the local authority representative for and tactical command means for the plans that's why I recollect I can't recall necessarily the
02:26:36 recollect I can't recall necessarily the first meeting I did ask them but my feeling is that I did it earlier I certainly asked the Cu crews to see if they could get me plans earlier on and I had that I know I asked that question on
02:26:48 had that I know I asked that question on more than one occasion because they're the people who like to facilitate that contact with the other agencies who are there and I'd asked on more than one occasion was definitely before 6:13 in the world do you remember the name of the local authority liaison officer or
02:27:03 the local authority liaison officer or other officer that you asked to get the plans no but it would have been whoever had attended the meetings because I think we'd had a change of lay low at some point in the incident as well yes
02:27:14 some point in the incident as well yes you did
02:27:14 you did there's the name Nick Leighton ring a bell Nick Leighton toss ring a bell yes and then my crumble my crumble yet they bow to both names now you said them to be barbecue no I wouldn't immediately remember now he reminded me Nick
02:27:26 remember now he reminded me Nick Leighton we have a statement from and he hasn't come to give evidence yet so we'll need to explore this with him but I want your recollection he says that and he was there between 2:30 and 7:00
02:27:39 and he was there between 2:30 and 7:00 a.m. we came on to the see you at 2:30 and left the incident at 7:00 but during that period he wasn't asked for plans at all can you comment on that
02:27:50 for plans at all can you comment on that that's not my recollection of it I recollect asking and again you're gonna have to forgive me obviously I was talking to many people over the course of a very long period of time and my recollection is that I made requests
02:28:02 recollection is that I made requests through the see you and certainly earlier in 6:13 and spoke it to someone in the local authority about availability of plans that is my recollection right and well you want to see we're on the command unit at that time when you when you made that request
02:28:14 time when you when you made that request or yes so at any point I've made I would have made that request out of being on the command unit right if you go on in the log to page seven a third of the way
02:28:33 the log to page seven a third of the way down I suppose just above half the way down just above the time mark of at Oh 735 and this is at the very end of or appears at the very end of the note
02:28:44 appears at the very end of the note dealing with a TCM that starts to print the page before is 713 do you see that yes I do it says and Eero requests plans
02:29:00 yes I do it says and Eero requests plans from local authority Lalo is mister rumble this is the fourth TCM it looks
02:29:12 rumble this is the fourth TCM it looks from that as if you didn't ask the Lalo for any plans at any earlier stage according to this log can you comment on that that may well be as recorded in a
02:29:27 that that may well be as recorded in a log but I am certain that I asked for plans either via to see you or directly some in the local authority prior to that time that is my recollection right and if you go to your second witness
02:29:40 and if you go to your second witness statement at page 7
02:29:43 just around this point
02:29:50 off a bit you say they're about halfway down the page in the text I asked for
02:30:01 down the page in the text I asked for five hours for the building plans from the local authority I would have wanted these a lot earlier to get a better understanding of the building the how do you measure that five hours I
02:30:13 couldn't tell you now where I've measured that from to but I have a very clear recollection of being frustrated that I didn't have a detailed set of plans from the local authority and I had to ask repeatedly I thought over an
02:30:25 to ask repeatedly I thought over an extended period of time so that that is what my recollection is I remember requesting by the Cu and certainly to someone directly in the local authority
02:30:37 someone directly in the local authority of more than one occasion plans and over an extended period of time if you go to your contemporaneous notes and turn to page 8 we see under the time mark of Oh
02:30:52 page 8 we see under the time mark of Oh 451 this is the last entry before Oh 516 I asked the Cu crew why we still didn't have plans of the building they confirmed again there were none on the
02:31:03 confirmed again there were none on the Ord but they were meant to be in a set of premises information box sorry there were meant to be a set in the premises information box in the lobby of the tower according to the Ord entry I
02:31:14 the tower according to the Ord entry I asked for this information to be relate to the fire sector and made a note to ask for a set from the LA at the meeting again that last comment there rather suggests that you were asking the Cu
02:31:27 suggests that you were asking the Cu crew but you haven't yet asked for that ask the LA unless you wait there's the word again rather indicates you had already asked can you could just explain
02:31:39 already asked can you could just explain you say you made a note to ask for a set from the LA the local authority at the meeting again can you just help us with that absolutely I mean I don't know
02:31:50 that absolutely I mean I don't know whether I'd ask the local authority before this point for certain but what I can confirm is our strong recollection of asking to see you to contact someone in the local
02:32:01 to contact someone in the local authority to ask for the plans I think I did ask before this time but I can't give you an exact time I just I just know there's something that actually became very important to me and I remember thinking over the course of
02:32:12 I remember thinking over the course of the incident I don't understand why I haven't been furnished with this set of plans because they would be very useful to my crews if it came something the hatch here I felt had taken far too long to be given to us so I can only
02:32:24 to be given to us so I can only apologize if I can't give you the exact sort of starts and finish times of that process to try and get something but I'm very clear that I had earlier
02:32:35 very clear that I had earlier conversations than 6:13 about wanting those plans and wanting the local authority to supply them do you remember being told by the Cu crew that there was
02:32:49 being told by the Cu crew that there was an information premises information box according to the Ord entry and well as it was written on that statement I must have been because that was when the
02:33:00 have been because that was when the memories were fresher in my minds but I can't remember the exact conversation if I've written it I imagined at that point I must have remembered it so yes did right
02:33:17 did you know that in fact the ORD had a an entry of false underneath the box in the premises information box part of the
02:33:28 the premises information box part of the ORD no I didn't right
02:33:37 so can you explain at all why the Cu crew well let me ask you this way do you remember who told you that the LD did say that those premises information box no I don't I don't remember who
02:33:49 no I don't I don't remember who specifically on the CEO crew did but I do remember there being a conversation about PIV and I do remember asking that information went to the instant you know
02:34:00 information went to the instant you know to the fire sector the you know the exact detail a conversation the length of the icon right in sort granular detail but I do remember that conversation happening yes when you were told as a call if your note by the Cu
02:34:12 told as a call if your note by the Cu crew that there wasn't in premises information box according to the Rd entry did you did you chase up somebody to go know open the premises information box and get the plans no because we're
02:34:23 box and get the plans no because we're that was a bit use was for Pat and Richard and that was one small piece of information within a massive information and I just want to confirm that that message had gone to the incident ground
02:34:34 message had gone to the incident ground and therefore they would have the opportunity to Paul plans out in following up again repeatedly on where detailed plans were again I would have expected a return of information about
02:34:46 expected a return of information about that if they had found a very detailed set of plans do you know if anybody from the TMO or the council were asked about the premises information box about the
02:34:57 the premises information box about the premises information box no I don't do you know why not no I don't do you you remember what time you eventually did receive the plans I can't men with the exact time but I
02:35:08 I can't men with the exact time but I know we did receive a set plans right and that was I don't know whether it's recorded within a TCM I can't remember the detail of my own log but we certainly did receive plans of the floor
02:35:19 certainly did receive plans of the floor play but as in since you mention it that it is recorded it's 8:45 and if you go to page
02:35:41 well let me just show you this it's actually seven
02:35:54 forgive me I've got a wrong reference there the thing I want to show you then is the plans themselves if you go to lfb quadruple four quadruple zero one nine six eight let's try it this way
02:36:07 six eight let's try it this way LFP quadruple zero one nine six eight
02:36:20 and go please to page is 49 and 51 with those or are those the plans that you
02:36:31 those or are those the plans that you received at some point yes nothing they are cuz I saw them briefly right I'll do have a memory of that so that that seems familiar to me yes yeah well let's just see if we can pin this down as a time can I ask you to be shown em et triple
02:36:45 can I ask you to be shown em et triple zero one eight seven two nine one eight seven two nine
02:36:58 now that's a photograph taken on cu8 and if we blow it up there it is do you think we can see those plans on that picture yes I can so they came in at some time and if I
02:37:17 so they came in at some time and if I can ask you to be shown inq quadruple sorry quintuple zero 164
02:37:39 okay no no I'm gonna cancel that laughter your relief and I suspect that of others let's move on you had those those plans at some point but roughly
02:37:50 those plans at some point but roughly roughly do you remember when you first saw them no I can't give you an exact time I know I did though cuz now seeing them that does remind me okay did you send those plans or can make a
02:38:03 did you send those plans or can make a copy of those plans and get a copy sent to the bridgehead yes so I made a request for them to be copied either the original to go because I see I think what's pinned up is a photocopy actually from me from somewhere and I don't know
02:38:15 from me from somewhere and I don't know whether that came from outside of the unit but I think we held a copy and that I think the originals went to the fire sector so I did ask for those to go
02:38:26 sector so I did ask for those to go right on a related point can I ask you to be shown well do you remember seeing a board on see you on cu8 showing the
02:38:39 a board on see you on cu8 showing the flats and floors and I can't recollect the detail of it no okay let's see if I could help you could you please be shown a meaty triple zero one five nine two seven now this is another photograph
02:38:55 seven now this is another photograph taken on cu8
02:39:02 now the fact you can see the time at 6:44 in the morning and on the right hand side of the picture you can see a plate or board with floor level of flat
02:39:13 plate or board with floor level of flat numbers do you remember seeing that at any point on the night I actually don't know right okay it if it was on cu7
02:39:25 know right okay it if it was on cu7 which it might have been do you remember seeing it there knowing I did right do you know anything about the removal of this kind of thing kind of plate from the building by a watch manager or any
02:39:36 the building by a watch manager or any other officer no I have no recollection about that wasn't a piece of information I was made aware of okay so we remove the pipe with the floor numbers on right not so the best of my recollection anyway okay now we've had some evidence
02:39:49 anyway okay now we've had some evidence from watch manager Watson who was a watch manager at the incident assisting the coordination of FSG information to the bridgehead at an earlier stage in the incident that he drew or asked a
02:40:03 the incident that he drew or asked a crew manager to draw a plan or on the wall of the second floor mezzanine we said that be a cruise could be briefed about where to go do you remember seeing
02:40:15 about where to go do you remember seeing that on the wall at any stage during the night nights I don't think I went up to the mezzanine right
02:40:26 [Music]
02:40:34 can I just show you one or two informative messages from the scene first of all page 25 of the short incident
02:40:53 we're at 3:48 17 halfway down the page so this is pretty much exactly an hour after you took over to stay over an hour
02:41:05 after you took over to stay over an hour after you took an over incident command there's an informative message sup CUA from AC wrote that comes from you a residential block of 24 floors far from to a second to 24th floor approximately
02:41:18 to a second to 24th floor approximately 100 individuals involved FS to you major incident declared high-rise procedure implemented etc that says the building has 24 floors is that what you believed
02:41:30 has 24 floors is that what you believed at the time yes right which did you think was the topmost floor the well in terms o in terms of the numberings there's a a building of 24 floors but in
02:41:42 there's a a building of 24 floors but in terms of numbering its number from ground to 23rd i Salif okay see it's a building it's correct to say that as a building of 24 floors that is how we would describe it in that's our protocols for describing it you know in
02:41:54 protocols for describing it you know in an informative metabolic I've a in terms of the wire remember is it's ground to 23rd I see so just in brief you count the ground floors floor one yes yes so it's 24 floors that's the number of
02:42:06 it's 24 floors that's the number of floors yes I see were you just sticking with this short incident log do you have
02:42:17 with this short incident log do you have access to the to this log in cu8 no because it wouldn't know I didn't okay were you listening out to radio messages coming from control my control up ways
02:42:29 coming from control my control up ways would be again I think I've got go back to my role at the incident because it's necessary for me to have the space to hold the full span of control across all those different commanders the bigger
02:42:40 those different commanders the bigger picture you know talking to the morning officer Danny thinking about the big piece what I can't do is monitor the radio so I've got a radio operator to do that we will highlight relevant messages
02:42:51 that we will highlight relevant messages to me where they you know and I'm relying again on the professional skills and judgment of those control/command unit operators I would have known that message went because I would verify all messages that went because someone who
02:43:03 messages that went because someone who have drafted it based on information gathered from a number of sources whether it's the team leader with the Cu going out and gathering their own situational awareness
02:43:12 awareness talking to our auntie coming back in or interrogating Artie or another you know another command officer from that information just focusing on some detail in that message and we can use the one
02:43:23 in that message and we can use the one at 3:48 17 although there are similar messages like it elsewhere in the log you can see approximately hundred individuals involved did you get that hundred figure from Tom Goodell yes so
02:43:38 hundred figure from Tom Goodell yes so at that point I still don't think we had a complete handle from my perspective on the numbers of FSG calls because they were coming in so that is my memory of
02:43:50 were coming in so that is my memory of that right so it's an approximation to and that the purpose of that message is to inform those people who are monitoring remotely and the wider organization about the scale of the
02:44:02 organization about the scale of the incident rather than acting as a definitive record of exactly how many people were involved at that point obviously if we can give that that's very important that would be your aspiration but actually what is more important is that we're telling the story of the incident
02:44:14 we're telling the story of the incident so that people understand how it's progressing the challenge we're facing and therefore can use it to inform their own decision-making remote from the incident yes did you get that information from Tom Goodell do you
02:44:26 information from Tom Goodell do you think face to face or earn by some kind of radio communication I couldn't tell you in the context of how that message was composed I couldn't tell you right but I would I would think that would be where it would come from okay now if you
02:44:39 where it would come from okay now if you go to your contemporaneous note
02:44:48 and look at page 5 which is the second page of the narrative which starts on
02:45:01 page of the narrative which starts on page 4 under the timestamp of a 339 you see in the third entry down on page 5 as we passed cu7 I stepped on to take a short brief from Tom Goodell he told me he had over a hundred people involved in
02:45:12 he had over a hundred people involved in the foot in fire survival calls it and his best estimate and would it be right then that you got the hundred from him then oh I would think so yes but
02:45:23 then oh I would think so yes but actually it was very hard to get accurate information for quite a long time at the instant about over numbers because my sense every time I spoke to Tom was that they were changing constantly yes and they it was hard actually to
02:45:35 yes and they it was hard actually to verify whether an original call that come from the flat hadn't then been duplicated because the same he did we had a conversation about the fact that people were moving it was very difficult to pin down whether or not that was a
02:45:46 to pin down whether or not that was a new call a separate call or whether it was the same group of people who've already called earlier if that makes sense yes I said he he was you know he was doing his absolute best in the face of very considerable volume of course
02:45:57 of very considerable volume of course yes just just continuing with the timing so you you step onto the cu7 and get that information from him as you just told us can I just ask you to look at M et triple zero one five seven zero five
02:46:08 et triple zero one five seven zero five one five seven zero five which is a photograph we just swivel it around so
02:46:19 photograph we just swivel it around so we can see it this is the photograph taken by the ACA Lachlan on cu7 and you can see that at 3:47 so sometime
02:46:33 and you can see that at 3:47 so sometime after 339 which fits in your narrative that annual contemporaneous native page five you can see that on the whiteboard there and although it's not crystal
02:46:44 there and although it's not crystal clear from the picture on the right hand side 347 127 adults and 38 kids which is as we can see quite a lot more than 100
02:46:55 as we can see quite a lot more than 100 or involve 166 my question is did Tom good Tom good will not give you that information no I think I commend that information what I do remember is a conversation
02:47:06 what I do remember is a conversation about how the numbers didn't necessarily reflect the FSGS because one FSG could incorporate you know any number of people and also those people had potentially moved right I see so what
02:47:17 potentially moved right I see so what what did you see that at that time do you think when you stepped on something oh I can't I can't say for certain I did and I think me know that I know that I had a conversation with Tom Goodall and he reflected that we had approximately a
02:47:28 he reflected that we had approximately a hundred FSGS and that he was trying to basically try and get out the information so he could get to a better place about the accuracy yes I see okay well we'll just help me with
02:47:39 okay well we'll just help me with another picture this is MIT quadruple zero eight 735 and this is taken on see you well let me ask you
02:48:02 do you recognize this whiteboard in this investor state I think that's the not in the exact detail of it but that that is the forward off cui I think yes yeah
02:48:13 the forward off cui I think yes yeah that was my next question see you eight now it says in the middle just a little bit below the top a 347 in black ink do you see I do and it says
02:48:26 FSGS FS g FS g 1847 114 adults 35 children and then rescues three from flat 92
02:48:36 flat 92 so that's 149 people in total did you see this board at that time do you think I was constantly going back to the board but I think what the board doesn't reflect is the constant requests by
02:48:48 reflect is the constant requests by myself for information about FS G's and trying to drive you know the sensitivity as I could Tom to gain to a place where we were accurately capturing the numbers right that that was very difficult throughout
02:49:00 that that was very difficult throughout the evening I felt that we were constantly fluctuating in terms of those numbers and I never felt I got a complete handle on the numbers at any one time I never had that confidence because it just felt like the volume of
02:49:11 because it just felt like the volume of calls coming in and the way it was changing both because of people being rescued and coming out probably the change of tasking to crews meant it was very hard and callers coming off the
02:49:22 very hard and callers coming off the line so the fact that information was being held in so many places actually it was really really difficult to ever get to a definitive point it was something obviously I wanted to know because you know I told you the story of the
02:49:34 know I told you the story of the incident and how we were progressing yes those numbers okay okay I'm just going back then we've seen the times of these totals 347 both on both see use we and
02:49:47 totals 347 both on both see use we and I've shown you the informative message going at 348 and 17 seconds on page 25 is a short incident law which says approximately a hundred individuals do you think that the message 100
02:49:59 you think that the message 100 individuals approximately 100 individuals was accurate I think that what it reflects is that we didn't have confidence in exact numbers and it would have been wrong to put them into the informative message so again I'd like to
02:50:10 informative message so again I'd like to reflect on a piece of experience in my past the tram we're another agency had made a mistake about the numbers of fatalities and the numbers of persons involved I think until you have that information with
02:50:22 until you have that information with certainty actually to place it on the record as a certainty is wrong because I think that can be very damaging at a later date to survivors families you know I think what it says is the truth it was approximately a hundred people
02:50:34 it was approximately a hundred people because that felt about the scale of it and it reflected a conversation I had with Tom but I would be very reluctant to put a definitive figure into an informative message that is going to go
02:50:45 informative message that is going to go into the record if I didn't know it to be entirely accurate my great problem throughout the incident was it was almost impossible to get with any degree of accuracy any one moment in time where
02:50:56 of accuracy any one moment in time where we were with the FSG comes because of the volume and the nature of continuous breathing apparatus rescue activity yeah and I've shown you two photographs from around 347 one showing that 166 persons
02:51:09 around 347 one showing that 166 persons were involved one showing in that 149 persons were involved my question is would it not have been more accurate for those reading informative messages to for you to have written or perhaps corrected the informative message to say
02:51:20 corrected the informative message to say approximately a hundred and fifty rather than leaving at a hut at 100 which might suggest understating the persons involved could we just go back to the informative message sake would you mind
02:51:32 informative message sake would you mind it's page 25 of the sial short incident log thank you it's 348 17 in the middle of the page how many showing me that information I don't think you're being
02:51:43 information I don't think you're being correct to say that that probably would have been a better approximation but that is why I have recorded on the message at that point I may well have had my reasons for that in terms of approving the message but in terms of
02:51:55 approving the message but in terms of that wording I would agree with that I think 150 might be more accurate at that point right what did that lead or might that have led to a tendency to
02:52:06 might that have led to a tendency to understate the urgency or need for resourcing of this incident to people reading the log absolutely not people are under no illusions from the conversations I have with colleagues at
02:52:17 conversations I have with colleagues at a senior level with Danny as the Commissioner that we were facing the most exceptional incident of our careers you know to be frank that just hundred alone is still more FSG calls
02:52:30 hundred alone is still more FSG calls than we had experienced in the previous 10 years it was it will absolutely not have affected the resourcing of the incident or the height of the incident I believe we had 75 appliances there in total largest single deployment of
02:52:42 total largest single deployment of appliances since the Second World War so no can I then just move you forward same point but move you forward in your in your log and go please to page 5 in that
02:52:54 your log and go please to page 5 in that log which has a time mark of 550 just below the top of the page at this time
02:53:05 below the top of the page at this time this is another TC n middle of that first chunk it says Tom running FSG Tom Riddle FS g17 one person's 38 children
02:53:18 Riddle FS g17 one person's 38 children and 133 adults from 45 flats 58 persons from 21 flats P 3 against
02:53:32 58 persons from 21 flats P 3 against that background can I then show you so we can have paths both on at the same time Paul if we can put both up at the same time page 33 of the short incident log we're at 648 we have another
02:53:51 informative from you 3/4 of the way down the page you see we put both up at the
02:54:02 the page you see we put both up at the same time you can perhaps do this more easily mr. Eyre 648 43 and the informative message as you can see so
02:54:13 informative message as you can see so cu8 from AC ro residential block of 24 floors etc aprox a hundred individuals involved now just on that it looks as if the 100 individuals involved hasn't
02:54:25 the 100 individuals involved hasn't changed at all since this informative message first went at 348 some three hours before 648 when we see this in
02:54:37 hours before 648 when we see this in message
02:54:38 message putting the two pieces of information up on the screen my question is why didn't you why did you send a message which said that it was approximately 100 individuals involved when you were told
02:54:52 individuals involved when you were told we were about to be told that in fact it was up to 171 I couldn't tell you to be honest a minute so what I would reflect
02:55:03 honest a minute so what I would reflect is that you know it may well have been more accurate to state that number as higher I think I think I would accept that point absolutely but I don't think it changes the course of that incident nor the nature of resourcing we placed
02:55:16 nor the nature of resourcing we placed on it and it may well be just a symptom of the fact that I was extremely busy that the broad thrust of the message satisfied me and that at that point it was used for internal information and
02:55:29 was used for internal information and again although you know that does seem very different from 0 550 I'm not sure what the numbers were at 0 648 Nesmith and to be fair to you I the the message
02:55:41 and to be fair to you I the the message comes two minutes before the tactical coordination meeting so the next question would be will having sent a message saying approximately a hundred which stay the same as it had for the last three hours why didn't you then correct it after the the 550 tactical
02:55:54 correct it after the the 550 tactical coordination meeting to bring it up to date and show one-seven-one isn't zero 648 an hour later than the tactical coordination meeting your opponent's you're absolutely right that's why I'm saying up in that process of an hour I'm
02:56:05 saying up in that process of an hour I'm not sure what would have changed but I would absolutely tell you a point I think we probably could have reflected more accurately but I would have had an anxiety about that because I originally stated because it was very difficult to
02:56:16 stated because it was very difficult to ever get to an accurate number yeah yes I was being perhaps over over fair to you perhaps but that is that's helpful now can I then turn to the question of
02:56:30 now can I then turn to the question of information flow regarding FSGS in general were you kept up to date of the FSG picture throughout the night yes I
02:56:41 FSG picture throughout the night yes I was so I felt comfortable from the situational updates that Matt and Mick were giving me that I had an understanding of the general progress of FSG Nam with Stan the great difficulty in tying down the
02:56:54 the great difficulty in tying down the detail of it yes I was which was that we were continuously committing crews to the information we were receiving and were making progress what I did at a
02:57:05 were making progress what I did at a later stage of the incident when Tom had the space to do it so to begin with Tom girdle
02:57:10 girdle I would not wanted to take him off cu7 he was too busy he was too fundamental to the operation of that FSG operation you know to the FSG system but as we got further into the incident and it was
02:57:21 further into the incident and it was clear that those numbers were reducing I felt we were moving to a stage where we need to try and accurately catch him record within the decision log the numbers because you know tragically we had to prepare ourselves for the fact we
02:57:33 had to prepare ourselves for the fact we may be removing from rescuing my survivors to recovery and then I started to bring him into the unit to give me those numbers okay so the answer my question is yes and then what I want now
02:57:45 question is yes and then what I want now to do is just to work out what the if you can give us a shopping list of sources of information we can run down those did you get up-to-date information from DEA co Lachlan throughout the night yes I did it face to face and via map
02:57:59 yes I did it face to face and via map and Mick right and was that mainly at the hourly TCM meetings or separate from that night both actually so across across the piece so he both gave me a
02:58:13 across the piece so he both gave me a regular update face to face Matt and Mick were constantly on and off the unit updating me they were basically doing a cycle between the units the tower and back I think that's what they basically did all night right did you get direct
02:58:25 did all night right did you get direct information from Tom Goodell on a regular basis about the progress of FS cheese fire Matt and Mick to begin with and then face to face within the TCM yes face to face within the TCS right yes and who gave briefings on fgs at the
02:58:40 and who gave briefings on fgs at the TCMS one FSG I mean Tom spoke about the numbers from what I remember because he held the numbers and far better for him because he's coming on with that information firsthand to say it so I would have
02:58:51 firsthand to say it so I would have turned to Tom as part of the progress of the meeting so Tom could you know if they all concerned with where we are with the fire Survival Guide it's cause the numbers of people who you think are involved okay just going to the 550 T
02:59:03 involved okay just going to the 550 T I'm meeting at page 5 of your log you see that you get a briefing from Tom Goodell there we've looked at it before have it back again Tom running FSG 171
02:59:14 have it back again Tom running FSG 171 is that the kind of level of detail that you were getting in that in the and the TCM meeting yes were you getting any greater level of detail outside the TCM meetings from Tom good Tom Goodell no it
02:59:26 meetings from Tom good Tom Goodell no it was generally a reflection of where he was a snapshot in time of how many calls they were having to hand or you know the general fact that information was going into the town up it was a constantly shifting picture so I wasn't looking in
02:59:38 shifting picture so I wasn't looking in my position I wasn't looking for a level of detail about individuals where they were in flats really what I wanted desperately was for the number to reduce and the number of recorded rescues to increase and that again was something I
02:59:52 increase and that again was something I began to press more for as time went on because I wanted to close that loop you know as how we ended up at the number of 65
03:00:00 65 you know we had someone sent out to try and triangulate that information which was difficult to get up do you remember Tom Goodell giving you any other detailed information about precise figures of FSGS
03:00:12 precise figures of FSGS other than these I remember putting my head in to see you seven and receiving a brief from Tom on a number of occasions where he told me where he thought he was at and the accuracy of that information
03:00:23 at and the accuracy of that information increased obviously as the incident went on although there was never you know complete confidence in the numbers because of the shifting nature of it otherwise it was coming back in from
03:00:35 otherwise it was coming back in from primarily make Matt and when I was pretty fired a lot of that did you receive during the course of the night information about particular patterns of
03:00:47 information about particular patterns of success or failure of deployments to particular flaws yes so but that was in the context of the progress of the VA operation as a whole so it was more about where we'll
03:00:58 whole so it was more about where we'll be able to send be a cruise to so you know I was very interested in how we were progressing up the building and what might prevent us from progressing further and won't got reflected back to
03:01:10 further and won't got reflected back to me was that there it kind of egg team floats there were times where you thought you had taken control of a floor into
03:01:16 into firefighting and have been able to progress past only then to find that the floor had again become involved very significantly in fire and crews were having to come back down through it so
03:01:28 having to come back down through it so that again had been a bit shifted pattern Richards tactics perhaps Paul Cruz back a bit and then recommit to try and push further back upwards right so in that sort of macro sense did you
03:01:39 in that sort of macro sense did you become aware at any time of difficulties getting above the 15th floor yes and not only the 15th floor by other floors so okay but let's just come to those let's
03:01:51 okay but let's just come to those let's just focus on the 15th floor do you remember when you were told about difficulties getting above the 15th floor no I don't I don't remember the timeline right we have some evidence that from from one of the wall drawings
03:02:02 that from from one of the wall drawings and we'll look at it that it was about 425 but that does that ring a bell it doesn't ring a bell but I would have thought that's accurate if that's what's recorded what about the 11th floors another candidate I remember having
03:02:13 another candidate I remember having specific conversations about the 11th floor and the challenge of dealing with the 11th floor the 11th floor seemed to become a problem actually right in terms of fire spreads and how people progressing beyond it so the challenge
03:02:24 progressing beyond it so the challenge of the BA operation and I think is worth just focusing on the fact that that bi operation was entirely devoted to rescue the only reason to firefight was to progress rescue not not to control the
03:02:37 progress rescue not not to control the fire to extinguish it but just to progress rescue operations so when talking about progress of crews that in my mine was inextricably linked to the rescue operation not the ability to
03:02:48 rescue operation not the ability to extinguish the fire so that's why I needed to know that the physical process you know progressive crews the 11th floor was certainly a problem right I remember having a conversation I think
03:03:01 remember having a conversation I think with cap packable about progress and on the 11 do you have a roughly what time that was
03:03:08 that was I don't but it'll be a record if it still would have been when I went inside the towers I never spoke to Pat or Richard except when I was in the tower right and do you remember what what the
03:03:20 right and do you remember what what the particular problem was about getting above the 11th floor yeah the conditions on the 11th floor deteriorated to the extent it was not possible to put far into it so I think what describes they
03:03:31 into it so I think what describes they describe to me were basically unsustainable firefighting conditions so an immense configuration of heat smoke fire that made progress of the rescue operation almost impossible so therefore
03:03:43 operation almost impossible so therefore they needed to resolve the firefighting situation on the 11th floor to be all progressive beyond it but the 11th floor wasn't the only time that happened we had a number of conversations throughout the night where this was happening on peated occasions on different floors
03:03:54 peated occasions on different floors sometimes in a way that surprises so thinking we'd work pass the floor only to find that the way that fire was behaving he had come back down the building was back underneath those crews
03:04:05 building was back underneath those crews and we were having to pull back and repeat the process continuously to make progress did you when you received information about particular floors
03:04:16 information about particular floors rather than specific responses to FSG deployments which I'll come back to but in in relation to floors did you then feedback or get somebody on the command
03:04:28 feedback or get somebody on the command unit to feed that back to control its in terms of progress past the flaws in terms of difficulty getting above particular flaws I can't react with recollect whether I did would it would I
03:04:41 recollect whether I did would it would I would have I would have liked to think I did but I can't remember whether I did would it yes you say I would like to think I did is that because it was essential the control wouldn't it would know if they had callers above
03:04:53 know if they had callers above particular floors I think has to be balanced actually with what you tell those callers because actually that was rapidly changing so I would be wary of telling someone that we weren't going to
03:05:05 telling someone that we weren't going to put any crews above the 11th floor when actually I was determined that we work in a perfect crews above the 11th floor it was just a matter of time so it was about but I would acknowledge that that
03:05:17 about but I would acknowledge that that is useful information for control operators to have an understanding of progress within the building yes did you have a direct line of contact with the control room yourself I didn't because
03:05:30 control room yourself I didn't because they were so I mean my impression of control at that point was that they were at the point of being overwhelmed by the volume of calls there was a direct line from an officer
03:05:41 from an officer called Jason Olaf into the FSG unit and that was the direct linking so their focus was on was on maintaining that
03:05:53 focus was on was on maintaining that operation because that's what they were fully occupied with I could have asked the command unit to pick up the phone to control and we did have and we did have contact with control throughout the
03:06:04 contact with control throughout the night periodically so it's not that there wouldn't have been a line of communication in terms of a continuous line of communication that would have been maintained rightly with the fire survival guidance sector right and am i
03:06:19 survival guidance sector right and am i right in thinking that it's not you personally who spoke to control but the operator on c7 no it would have been the operator on c7 speaking into control yes
03:06:30 operator on c7 speaking into control yes overnight so you personally didn't make any contact with control now I wouldn't have picked the phone up to control or got on to the radio control myself personally how are you given that you were in cu8
03:06:41 how are you given that you were in cu8 and the Tom Goodell was on cu7 and was that line of control how did you monitor or continually observe the communications that he was having with
03:06:52 communications that he was having with control because as part the FSG system that as part of Tom's brief to me about how the system was working and whether we would be able to maintain a complete
03:07:03 we would be able to maintain a complete throughput of information from control into the tower I was assured that you had a continuous open line of communication into control he had been clear about that and at no point did I
03:07:15 clear about that and at no point did I have any reason to believe that stopped because the times I did see him it was clear actually when I was on the unit someone was continuously talking to control and he was clear that information was passing because things
03:07:26 information was passing because things were shifting all the time and in general terms and we'll come to some specifics later on but in general terms were you aware that there were there were there was an absence of information
03:07:37 were there was an absence of information coming back from the bridgehead about particular deployments in response to FSG calls to Cu 7 I think generally I was aware of the fact that we were struggling to close the loop yes I mean it's the same as I responded yesterday is the high knew that that was something
03:07:49 is the high knew that that was something we needed to improve on yeah and just struggled throughout the evening to close that loop
03:07:57 are you happy to continue on we can all take a break now I'm conscious that we do hourly rests if you saw I would mind five million see that's okay yes we do
03:08:09 five million see that's okay yes we do and we're going to stop anyway sorry I'm not aware at the time is it no no you can't see the clock you know it's 20 to 1
03:08:18 20 to 1 we normally stop for a break at 1 o'clock we don't have to we can stop at any time that seems convenient so if you feel that it's time to have a break now we could break and maybe take an early
03:08:29 we could break and maybe take an early lunch and come back then we're dirty if mister minutes in the flow there's questions I'm happy to carry on till one o'clock oh hi yes well let's see if we can find a suitable point yeah this side
03:08:40 can find a suitable point yeah this side of one o'clock should yes yes certainly okay maybe maybe I just couldn't see the clock I wasn't sure no take a I'm watching it now 339 can I take you to
03:08:54 watching it now 339 can I take you to your first of all your your log of RO log page to where there is a reference at that time site rep my sit read with
03:09:08 at that time site rep my sit read with mat could just hop what's a sitrep so a situational update so a brief to me right what sorry what's read so a situational respondents note report
03:09:21 situational respondents note report right I sorry so situational report from that Cove okay now this is after the first TCM as we can see and it says there Pat Goulbourne in fire sector
03:09:32 there Pat Goulbourne in fire sector carried out a tactical withdrawal or all be a and move bridgehead to ground floor EDB a being committed a fourth floor for search and rescue firefighting make up three DBA requested from PG now
03:09:51 just focusing on first of all you're being told that the bridgehead had moved to the ground floor and EDB a being committed to the 4th floor for search
03:10:03 committed to the 4th floor for search and rescue I just want to understand what you understood by that did that mean to you at the time that the entry control point was on the 4th floor or that they can only get to the 4th floor at highest I understood that that caused
03:10:18 at highest I understood that that caused me great concern actually right particular sitrep so I felt it indicated a considerable worsening conditions inside the town and actually I needed to
03:10:30 inside the town and actually I needed to unpick why we were using the DBA that way but I trusted Pat I reason that he had a good reason for doing it but actually I did meet Tom Pickett and I think he's after this point I went into the tower so I really wanted to talk to
03:10:41 the tower so I really wanted to talk to Pat face-to-face about the use of a DBA and actually the fact we've moved the bridgehead and what I'm into progress right did Pat come to the command unit
03:10:53 right did Pat come to the command unit to have this discussion with you or was this oh no these were being told about by Matt this was related to me by Matt Cooke ok so just going back to my my question what was to your understanding
03:11:06 question what was to your understanding was the entry control point on the fourth floor or was the fourth floor the highest point which be a cruise could get to at that point at that point when I got told that I wasn't clear I wanted to
03:11:19 that I wasn't clear I wanted to understand exactly how a DBA was being used and what did you learn when we went inside at the point I then did speak to Pat it was the the bridge header moved
03:11:30 Pat it was the the bridge header moved to the ground floor and that we were committing crews from the ground floor upwards at that point was the information I then received and that we were pushing our way back up the building it had been a complete
03:11:42 building it had been a complete withdrawal because of conditions and then I pushed back into the building but they progress relatively quickly with that I can't remember the exact floor they had got to write can I just deviate slightly this is a situation
03:11:54 slightly this is a situation situation report with Matt Cooke did it happen on the see you yes and there's that we know that because it's been logged yes ok and so do we take it that Jackie Makana key I think you said this yesterday didn't get around the incident gran with you know
03:12:06 around the incident gran with you know so any discussion we see here as one that takes place on the CEO yes so everything recorded here is taken place on the sea okay now at that point you're still on the sea you and you're being told this by Matt cook did you explore with him what he meant when he said EDB am being
03:12:19 he meant when he said EDB am being committed to fourth floor for search and rescue I can't remember the conversation in the detail this point I just want to remember about that conversation is wanting to understand about the use of Adva yeah and how we were balancing the
03:12:30 Adva yeah and how we were balancing the use of AEDPA with SCBA because II DBA is a very useful resource obviously we have a limited amount of AEDPA in London and I wanted to know that we were using it in a way that made sense right now you
03:12:43 in a way that made sense right now you say make a make up 3 DBA or Jackey Jackey records make up for EDI be a requested from PG AR I'm assuming as you update from LOC reference EDB a web
03:12:55 update from LOC reference EDB a web resources just explain what what you mean by up warm what sheet size by update from loc so I went back I wanted an update from London opto control and
03:13:08 an update from London opto control and because that's where the brigade Coordination Center the BCC was situated I wanted to know where every single e DBA set in London was including our reserves so I know that we hold reserves
03:13:21 reserves so I know that we hold reserves at the protective equipment group come depo in Croydon and the conclusion I was coming to that I wanted every IDI be a set in London and everyone who could
03:13:32 set in London and everyone who could constantly wear any DBA said to be on that incident right did you or Matt Cooke speak to Adrienne Fenton in control about what extra a DBA was
03:13:46 control about what extra a DBA was available in London I don't think I did personally I don't know who did but that would have been that update would have been requested in the context of my command unit staff so someone's going to
03:13:57 command unit staff so someone's going to have gone and done it and I would have expected some feedback about where what the disposition was in terms of locations of edpa support pumps so it's not just the FI use that can where you go you have the
03:14:09 use that can where you go you have the support pumps as well and I just wanted to understand exactly what we had left yeah to get them there did you were you given to think at that point that they weren't
03:14:20 think at that point that they weren't enough EDB a present on the incident ground at that time no that was the first I'd heard that Pat wanted more EDTA right did you find out why I think
03:14:34 EDTA right did you find out why I think when we went into the town I had an answer yes which was that we wanted EVP a because that was going to allow us to reach the highest points in the tower eventually but even in the context of
03:14:46 eventually but even in the context of firefighting in the lower reaches of the tower he enabled us to carry out tasks for a longer duration and could be used in that sense but it was more it's about
03:14:57 in that sense but it was more it's about the wear time because that's what edpa gives you right so it gives you generation and reach effectively because of regeneration yes I think it is correct me if I'm wrong and what happens after this discussion is that you then
03:15:09 after this discussion is that you then go to the tower because we see yes that after 339 a youngster temporary is no yes okay we'll come to that just before we do can I show you the short incident
03:15:20 we do can I show you the short incident log page 26
03:15:29 and I like I'd like to go to time mark 3 55 and 39 on page 26
03:15:46 where it starts at the top of the page it actually starts at the bottom of the previous page that doesn't matter 3:55 39 user comment and then there's a
03:15:57 3:55 39 user comment and then there's a turning out message free DBA and that that gets repeated you can see down the page in between the user comments you can see turning out with message for e DBA and it's repeated several times and
03:16:11 DBA and it's repeated several times and then ends up at 403 with a turning out message to attend with all a DBA sets available with those your requests
03:16:26 available with those your requests rather sorry did they come from you originally I think requests for EDP a happen from more than one place because and I can't remember the exact sequence of it I know that I wanted it and had
03:16:39 of it I know that I wanted it and had left an instruction to get poorly DBA at one point I think Danny had also received some information and ordered all the DBA sets actually in London at
03:16:50 all the DBA sets actually in London at one point yeah I think what we found was when we came back together for those two things that occurred yes and will will will no doubt explore this with her when she comes to give evidence but it looks as if she actually also made a command
03:17:01 as if she actually also made a command decision that there be more a DBA found we can see that actually in the incident log your bro log rather hmm at 3:58 it's
03:17:16 log your bro log rather hmm at 3:58 it's just below 339 page two of the log Ollie DB n Brigade to be ordered to the incident that comes from the commissioner so you recall that and you'd left the Cu by then I think had you yeah I had right
03:17:28 by then I think had you yeah I had right okay so looking at the turning out messages to attend with Ollie DBA sets available which I showed you on the short incident with those your messages
03:17:39 short incident with those your messages I can't recollect all right did you think at that stage that there was a deficit in the supply of e DBA it wasn't
03:17:50 deficit in the supply of e DBA it wasn't necessary I thought there was a deficit but what I did anticipate having heard that was that we were going to need to make greater use of edpa and actually we were so close to having nearly always the egain London there
03:18:01 nearly always the egain London there anyway I just factored in that actually if at this stage of the incident Pat was making the request we should factor forward that we were going to recently make use of all of the EBA available Zeus and therefore I would
03:18:14 EBA available Zeus and therefore I would want just a couple of detail points do you recall a problem with there being telemetry batteries being flat on EDP a supplied cylinders I only learnt that after the incident right you didn't know
03:18:25 after the incident right you didn't know during the incident no I didn't know Jerry means okay did you do do you recall whether there was a problem with the BA covers not being available for
03:18:37 the BA covers not being available for some of the cylinders not during the incident of post-incident I learnt my understanding as these were the reserve sets that came from the protective equipment group
03:18:48 protective equipment group Beppo in Croydon right I didn't know at the time instant now okay as far as you're concerned neither of those called calls you or anybody else the problem is that in the context of
03:18:59 the problem is that in the context of maintaining a continuous for even appropriate apparatus operation no right did it cause any specific problems because I wasn't aware of it no I'm not aware that it did mr. Chairman I think
03:19:10 aware that it did mr. Chairman I think that is a convenient moment I'm I'm going to move to something else where I wore my suit on in these your indecent how are we getting off or getting on it okay I'm sure I'm sure we almost a
03:19:21 okay I'm sure I'm sure we almost a minute but I was really wondering whether we could say two o'clock and rather we could say two o'clock well we will break there mister oh never slightly longer than usual lunch break please don't talk to anyone about your
03:19:33 please don't talk to anyone about your evidence while they are out of the room and we'll resume at two o'clock please thank you Sarah thank you very much you gave the action
03:19:51 Thank You 2 o'clock please