Evidence from Joanne Smith on LFB's fire survival guidance policies, examining failures to assess caller vulnerability, missing disability prompts, absence of equality impact assessments, and inadequate training on Language Line.
00:00:28 good morning everyone welcome to today's hearing today we're going to continue hearing evidence from this joanne smith of the london fire brigade so would you ask this to come in please
00:00:48 good morning chris good morning yes do sit down make yourself comfortable thank you
00:00:56 yes mr millet when you're ready mr chairman thank you good morning to you good morning members of the panel good morning smith good morning now before i pick up the reins again where we were on thursday afternoon i
00:01:09 where we were on thursday afternoon i want just one just want to ask you one or two additional questions about something you said about a database
00:01:15 database last thursday can i take you back please to the transcript for day 202 at page 50.
00:01:33 if you go to line if you go to line 15 you said this and i'll just show you what you said every fsg call was captured on a database so we had a database for all our fire
00:01:44 we had a database for all our fire survival guidance calls and when a control operator took a fire survival guidance call the supervisor or the operations manager would enter the details onto that database so they were always listened to
00:01:55 so they were always listened to routinely whoever was the duty brigade control senior managers would have done that on duty at the time and often we would have listened to them together in the control room we shared
00:02:06 together in the control room we shared an office say lindsay and i would listen to them together it wasn't unusual that scott was also in there too but this was specifically to do with high-rise incidents and i listened to all high-rise calls some of which were fire
00:02:18 high-rise calls some of which were fire survival guidance and had fast survival guidance calls in them now what i want to do if i may briefly is to look and see what you understood to be the database can i
00:02:29 you understood to be the database can i ask you please to be shown lfb3031757
00:02:40 and what will come up will need to be opened in its native form
00:03:05 uh now that is a document that we discovered called um with its file name fsg database
00:03:14 database uh if you all can we keep that on the screen but also have displayed at the same time
00:03:19 same time lfb triple zero 72996
00:03:37 uh this is an email uh thank you well
00:03:43 well this is an email from you to
00:03:48 say sorry we're trying to show both at the same time and we can just leave it with the email we'll be fine
00:03:54 um just display the email and we'll go back to the the spreadsheet in a moment thank you this is an email from you ms smith to andrea schuyer
00:04:06 smith to andrea schuyer subject call data dated the 16th of may 2017. hi andrea hope the journey back was easier and much improved with junk food attached is the fsg database we spoke about so have a look through and
00:04:18 spoke about so have a look through and let us know if anything interesting appeals
00:04:21 appeals now um
00:04:23 now um andrea shoya is i think as so far as we can tell at portsmouth university she is yes it was uh and
00:04:30 uh and if we have the database document back up on the screen please lfb 0031757 was that the document you were sending her on the 16th of may 2017 do you think
00:04:43 her on the 16th of may 2017 do you think uh that could possibly be it yes why were you sending it to her because we had been working with portsmouth university for a number of years really i'd been introduced to
00:04:56 years really i'd been introduced to the university when i was working on national operational guidance for control
00:05:01 control and
00:05:02 and they were undertaking a piece of work with hampshire fire i believe and another fire and rescue service control room just about engagement with a caller and best practice
00:05:14 and best practice now if we look at this document we can see that the first two columns are date of call time of call reading across the blue strip at the top incident number which has been redacted out an incident
00:05:27 which has been redacted out an incident description and then if you look at the five columns along if we can scroll along a little bit further please you come to a surname
00:05:38 a surname which is also redacted out but normally would that contain the name of the cro who took the fsg call i believe so yes then if you look seven columns along from that you can see
00:05:49 columns along from that you can see there's a densely populated column entitled notes stroke comments stroke observations would that normally contain a an abstract or short description of the
00:06:00 an abstract or short description of the event the incident yes
00:06:03 yes and the next column created is the date that would be the crea that would be is this right the date in which the description of the incident uh to the left of it was
00:06:15 left of it was inserted
00:06:18 yes possibly the observations the date the observations were made yes yeah and then the identity of the creator in column r yes yes
00:06:30 uh and and those individuals you can see listed there yvonne woodham's chris bobby
00:06:36 bobby were they aoms they are oms but it there are some aoms on there so it could have been entered by either or right either or so would that tell us that
00:06:47 either or so would that tell us that they were the supervisors in the control room at the time of the incident in question yes i would imagine sir now
00:06:55 now was this the fsg database that you were referring to when you gave the evidence i've read out to you last week yes it looks like it it's in a different format when you add the data in but obviously this is the raw data so
00:07:10 how would a supervisor decide to add an fsg call to the database when i say how what would be what would impel
00:07:19 impel a supervisor to decide to add an fsg call to the database or was it that all fsg calls were put into this database so i believe all fsg
00:07:30 into this database so i believe all fsg calls were captured in this database um
00:07:33 um now if you look at the commentary the notes commentary uh line 73 if we go down to line 73 i think we have to go back to the left left-hand column
00:07:46 if we go back to the yes if you go back to the uh the left-hand
00:07:52 left-hand column
00:07:57 uh you can see that it corresponds with the 6th of october 2013. that's the earliest date that on this document we have detailed
00:08:08 that on this document we have detailed uh
00:08:09 uh observations of or from the incident do you know why that is no i can just imagine it's probably just to do with a change of i.t system and
00:08:20 to do with a change of i.t system and the the previous document where we were recorded
00:08:23 recorded um fsg calls is stored somewhere else i just would have sent some current ones to andrea
00:08:32 to andrea right
00:08:33 right if we scroll down slowly you can see that in fact the dates of this document roll back earlier than october 2013 they go back in fact i
00:08:44 october 2013 they go back in fact i think as far back as 2009 if you scroll down a little bit lower than that you can see it goes into 2009 and indeed 2008. so does that tell us that even before lachenal you were
00:08:57 that even before lachenal you were keeping this database in some form yes i see
00:09:01 i see and
00:09:02 and in that form were notes comments observations also entered yes they were i see so this just tells us there was some sort of i.t change is this right so that this database only
00:09:14 is this right so that this database only records those inputted after october 2013.
00:09:18 2013. i can only guess right i wouldn't have extracted the data myself so i would have asked someone to do it probably from ost so
00:09:28 how were the details of the fsg review recorded between 2009 say and 2013 was it in a document like this it was exactly the same process there's a
00:09:39 exactly the same process there's a microsoft access database that the supervisors just add an entry to in and there are some specific fields to complete
00:09:49 complete if there were multiple calls to one incident would there be a different row created for each call
00:09:56 each call yes i believe so can we look at line 21 please growing right back up to an incident on the 31st of october 2015
00:10:07 2015 9 21
00:10:10 9 21 there are a number of numbers
00:10:14 numbers allocated to this incident this appears to be adair tower line 21 and if we can scroll across to the comments column please
00:10:28 uh it says this was one of nine fsg calls
00:10:33 calls to a fire in a high rise dominique spoke to the occupant redacted for 14 minutes until she was rescued from a bedroom at the rear of the flat dominique calmed redacted and passed
00:10:45 dominique calmed redacted and passed exact directions to the bedroom from the front door of the flat and stayed on the line with her until the firefighters rescued her dominique stayed focused and professional throughout the call and her actions directly influenced a successful
00:10:58 actions directly influenced a successful outcome
00:11:00 outcome uh would you agree that well first of all do you do you agree that this is the adair tower fire
00:11:08 if we can scroll back across the left-hand side we can yes if it correlates to the date incident yes
00:11:14 yes and it appears that certainly in the database
00:11:17 database there were nine fsg calls for our tower yes but that would correlate with the debrief that the operations manager wrote as well what was the purpose of adding this feedback to the database i picked adair
00:11:29 feedback to the database i picked adair as an example not just because of the nine but because of the um the quality of the observations but looking at that as typical what was the purpose of adding that feedback to the database
00:11:39 database i think that was just the initial comments by the supervisor and how would a supervisor go about assessing the performance of dominique well there could be several reasons they
00:11:51 well there could be several reasons they they could have been supervising them directly so they could have overheard be they could have listened to the call after
00:11:58 after or and they could have spoken to the control officer so i would imagine a range of of ways would dominique have used uh any particular criteria or policy
00:12:09 uh any particular criteria or policy against which to assess the call the call
00:12:14 the call taker dominic or the supervisor the supervisor would the supervisor i would have expected them to use the four principles plus
00:12:26 principles plus reassess when they were assessing that but i think this is just a general as you can see some comments are are very large and others are less detailed so
00:12:37 detailed so i can imagine that that was just their initial
00:12:40 initial feedback i see you you're right i i muddled dominique who's the call taker with the relevant supervisor but my question is and building on the answer you've just given me
00:12:51 given me um when the supervisor was assessing the call would they be working from a fixed set of principles in a policy uh or guidance document or would they
00:13:02 uh or guidance document or would they just be would they just be assessing the quality of the call from their own experience uh from their own experience but also they have had training in the the four principles so i wouldn't expect them to
00:13:14 principles so i wouldn't expect them to use a guidance document to do that right you mentioned other feedback a moment ago would there be other feedback recorded elsewhere other than this database
00:13:25 database no not other than this database but as i said
00:13:28 said whoever was the duty brigade control senior manager would also have access to this database and would have also have gone in and reviewed those calls right would
00:13:39 would this feedback whether the one for our data or indeed any that we could see on the screen in this database be used as the basis of training for cros
00:13:51 for cros in call handling going forward uh it certainly does now but i'm not sure that it did in in 2016 2017 right
00:14:02 sure that it did in in 2016 2017 right would any negative or critical feedback be recorded in this database we haven't found any no
00:14:10 no um i don't know but like i said i wasn't any of the supervisors that entered them entered the information right and once
00:14:20 and once the database for the particular um
00:14:24 um incident had been recorded and finalized in the way in which we see here what would what use would be made of that information thereafter
00:14:35 thereafter in
00:14:36 in terms of the brigade control senior manager just reviewing the information do you mean well it would sit there on the database yes what would it be used for who would look at it why would they look at it what would they do with it so
00:14:47 look at it what would they do with it so brigade senior managers would look at it and listen to the calls um and then
00:14:54 and then if
00:14:55 if they identified any issues then they would speak to the operations manager it also may be used for a plc or
00:15:05 or in fact a local debrief that control ran separately so it would be used and it would be referred to um
00:15:17 and it might if there were some trends
00:15:22 trends be placed into training it might give us some calls for concern or it might give us um and identify some really good practice
00:15:30 practice which we would use as well so i can't see any from there specifically but
00:15:37 but we have referred to it and it is a useful
00:15:39 useful database
00:15:42 yes thank you and i want to go back if i may please to where we left off on thursday evening and turn to a different topic which is uh prompts in policy 539
00:15:55 in policy 539 uh about whether a caller uh is
00:15:58 uh is uh a person who is vulnerable or is with a person who is vulnerable now can we start please with your witness statement at paragraph 40 on page 16.
00:16:13 the question there is whether guidance should be given to cros in order to establish whether a caller is or is with a person
00:16:22 a person who is disabled has poor mobility or otherwise would require assistance in the event of an evacuation and
00:16:31 and you
00:16:32 you say by way of response there i do not recall this specifically being a feature of the review of pn539 however i do recall that this was referenced in training and rift documents over the years
00:16:44 documents over the years now just pausing there do you agree that it is important for policy 539 to contain information or guidance at least that specifies that when a caller is taking a call
00:16:56 when a caller is taking a call especially a fast survival guidance call the call handler should ask for information about whether that individual or a person with them has an impairment or would require assistance in the event of
00:17:08 would require assistance in the event of evacuation i think it's important um and it's part of their general core handling skills anyway but i i do take your point that it would be important to put
00:17:20 point that it would be important to put it in there when dealing with fire survival guidance now let's look then at the 2007 version of policy five three nine this is lfb triple zero two eight
00:17:31 nine this is lfb triple zero two eight three eight two let's just have the first page up there to identify it can we then go to page twenty within it
00:17:42 this is appendix one five survival guidance and if you
00:17:50 uh if you scroll down the screen please
00:17:56 you can see the prompt questions and it's about two-thirds of the way down the page about just over halfway down your screen the question is does the caller have any disability that may affect
00:18:07 affect them carrying out any of these actions and these actions are the ones that are referred to before that
00:18:15 that now a paragraph we keep that on the screen but if we can go then to paragraph 41 of your witness statement
00:18:25 you say there appendix three of the revised policy number 539 also sets out the importance of the escape and assessed limbs of the
00:18:36 escape and assessed limbs of the four-part guidance assess sorry escape assess protect reassess whilst this does not specifically refer to a person's mobility i would expect a cro to consider a person's mobility when
00:18:47 consider a person's mobility when contemplating an escape route and assessing the situation as a whole
00:18:53 now
00:18:55 you you've picked up the point there that the amended version which was amended in september 2010 as we saw on thursday omitted any reference
00:19:06 we saw on thursday omitted any reference in what had become appendix 3 the fsg section to the disability question
00:19:13 do you know why the september 2010 version of the fsg guidance in policy 539 omitted the reference to disability which had been
00:19:25 reference to disability which had been expressed
00:19:26 expressed in the version it was amending i don't know i'm unclear of who updated the the policy in 2010 and i think i had some involvement in
00:19:38 and i think i had some involvement in the update in 2011 and
00:19:41 and but not in the 2010 update
00:19:45 update and i think that i commented previously on some of the other training materials and to make sure that those questions were in
00:19:54 were in uh said the training document and i believe it was in the reference information file as well yeah
00:20:01 yeah who who
00:20:02 who who was involved or who authorized the 2010 update
00:20:06 update i don't know you don't know did you ever come to hear of a a decision being made to omit the reference to disability from the 2010 version
00:20:15 version no
00:20:17 no did you ever go back to check that the amended version matched the guidance in the in the home office's fire service circulars
00:20:28 circulars no like i say i i know that i had commented on previous training documents to make sure that that information was in
00:20:37 in i know it was in the the riff to support staff but as i said a part of their general call handling training and and just in general when they take calls on a daily
00:20:48 general when they take calls on a daily basis
00:20:49 basis those are questions that they would encounter when dealing with people trapped in a range of situations so would it would it follow from that that you can't help us about whether
00:21:00 that you can't help us about whether anybody went and checked the 2010 version against the 2007 version to see if anything had been accidentally emitted
00:21:09 emitted no
00:21:13 now if we look at fast server secular 5404
00:21:17 5404 which was the s first ever circular identified in the gap analysis but not looked at as part of the gap analysis that's at lfb triple zero five five two
00:21:28 that's at lfb triple zero five five two zero one
00:21:31 zero one if we go to page 16 in that document this is annex d
00:21:37 file called prompts it has three stages stage one you see stage 1 stage 2 and then
00:21:48 and then if you go please to page 17
00:21:53 stage 3
00:21:56 first survival guidance and then in the box the third box down assess the situation uh and then under that you see the second box down assess the caller
00:22:08 second box down assess the caller and then you can see age gender ethnicity
00:22:12 ethnicity mental or physical disability you see that yes and then protect the caller and assist rescue
00:22:20 rescue given the specific step that this circular from 2004 demands uh particularly asking for details on
00:22:31 uh particularly asking for details on age gender ethnicity and mental and physical disability can you tell us why neither you or particularly anybody in the brigade it appears checked this document to see whether it was covered
00:22:44 document to see whether it was covered in p in policy 539 at least when it was amended in 2010. so not
00:22:50 so not 5404 because i i think as a as lfb had taken a decision not to use that document
00:23:00 document um prior to my uh arrival of joining lfb um
00:23:06 um but i i know those are points that are picked up in 1093 as well um and i'm surprised that no one went back to check the policy 539 aligned
00:23:19 the policy 539 aligned with that
00:23:20 with that and indeed even after 2011 it never had that in it did it no no do you know why that is
00:23:27 that is i don't i i can only imagine that because we had covered it in the training um because it was in the
00:23:36 rift and the documents that a control officer accesses during a fire survival guidance call
00:23:43 call that we felt that that was sufficient and and like i say it's not unusual on any call when they're talking to a caller um to assess the caller and the
00:23:56 caller um to assess the caller and the caller's um age
00:23:59 age and capabilities of exiting a building or
00:24:03 or a vehicle if you like now
00:24:07 now not unusual rather suggests that it's left to the habits and practice of the call handler to let the caller
00:24:18 to let the caller volunteer this information ah is that is that how it worked i
00:24:24 i i'm not sure that it's it's left to the operator i think most
00:24:29 most control fire control officers would say that the caller would offer such information up because when they're engaging with the caller
00:24:41 when they're engaging with the caller they would provide or that we would ask and provide some advice or guidance and they would come back with a reason why they couldn't do that so i think that is part of the practice but it's very much
00:24:53 part of the practice but it's very much dependent on on the information that the caller
00:24:56 caller gives as to what the control officer asks after that but under this national guidance do you accept that the national guidance doesn't uh
00:25:07 uh leave it to be dependent on the information that the caller gives it puts the
00:25:13 puts the burden on the call handler actually to make a positive assessment of the caller in these four respects yes yes
00:25:24 yes yes and therefore if you're do you accept this if you're leaving it to the the conversation if you like between the call handler and the caller say that these details will or might or
00:25:35 say that these details will or might or might not emerge then you're not following national guidance which which requires a positive assessment yes i certainly would agree with lfb
00:25:46 yes i certainly would agree with lfb weren't following national guidance 5404 was there a decision made to the best of your recollection by the brigade that even though national guidance required an assessment of the caller
00:25:58 required an assessment of the caller positively to be made by the call handler the lfb wasn't going to require its call handlers to do so no as i said on on thursday we had looked when we
00:26:09 on on thursday we had looked when we were
00:26:11 were investigating and the lachenal file we had looked for any decision that had been taken by lfb not to adopt 5404 but we couldn't find it but conversely
00:26:22 but we couldn't find it but conversely there was never any literature or information that we were using 5404 when you did your gap analysis did you identify the fact that even though 5404 had a positive
00:26:35 even though 5404 had a positive requirement on the call handler to assess the caller in these four respects 1093
00:26:42 1093 and the home office document keeping people safe from 1994
00:26:49 1994 did not have anything in it to the effect that the call handler should assess the caller uh i was under the impression that it did have something in there about
00:27:00 did have something in there about assessing the caller and being aware of any caller vulnerabilities there's there is well we could we i don't want to take up your time or the panel's time going back through those documents
00:27:13 going back through those documents but uh and we can read those for ourselves but do you recall is it in your mind that the 1993 guidance and the 1994 keeping people safe guidance did require
00:27:25 keeping people safe guidance did require an assessment of the caller in addition to an assessment of the caller's situation yes you did think that i did think that right
00:27:37 when you did your gap analysis did you actually specifically examine that question just to make sure that there was nothing in uh 2000 the 2004 guidance that wasn't
00:27:50 uh 2000 the 2004 guidance that wasn't exactly reflected in the 1993 and 1994 guidance no i think the decision was taken that we would not use
00:27:59 use 2004 that we would use 1093.
00:28:04 1093. can we then go to lfb401255 please
00:28:13 this is gra 3.2 fighting fires and high-rise buildings and this is the version from the 28th of february 2014 although you can't see it on the page um if we go to page 20
00:28:25 the page um if we go to page 20 in this document
00:28:30 at the top of the screen it says in the second paragraph fire and rescue authorities must also have effective arrangements in place to handle fast survival guidance calls from residents and others when they believe they are unable to leave the building
00:28:43 they are unable to leave the building due to disability poor mobility illness all the affects of fire
00:28:49 of fire now first
00:28:50 now first do you remember reading gra 3.2 when it came out in february 2014 no i didn't know of its existence until phase one of the inquiry
00:29:02 phase one of the inquiry you didn't have its existence no right so does it follow from that that i think it would follow from that that you never yourself
00:29:14 that you never yourself reflected
00:29:15 reflected whether on whether appendix 3 of policy 539 after september 2010 uh itself reflected gra 3.2 namely to
00:29:26 uh itself reflected gra 3.2 namely to ensure that there were effective arrangements in place to handle fsg calls
00:29:30 calls for those who were under these vulnerabilities no okay do you know whether anybody else in the brigade did that exercise
00:29:40 in terms of the impact for control yes no i don't are you able to explain how it comes about that lfp's own policies on first survival guidance call did not reflect
00:29:51 survival guidance call did not reflect national guidance to this extent at least in gre 3.2 in respect of persons under a disability with poor mobility or illness no and like i say i i
00:30:03 no and like i say i i wasn't aware of the existence of this document
00:30:06 document and
00:30:07 and and how it would impact control right and
00:30:10 and no one ever made me aware of it no does that surprise you yes can we look please at uh the 2014 version of policy 539 this is lfb 50737
00:30:25 version of policy 539 this is lfb 50737 and i'd like to go with you please to page 22.
00:30:32 and at the top of the page it says document history assessments and then it says an equality sustainability or health safety safety and welfare impact assessment and or risk assessment was last completed on
00:30:46 risk assessment was last completed on and you see eia 17th of september 2008. now an eia is an equality impact assessment isn't it yes it is
00:30:58 yes it is can you
00:30:59 can you help us with why after policy 539 was updated by the brigade on the 3rd of september and i think with your input on the 3rd of february 2011
00:31:10 the 3rd of february 2011 it wasn't subject to another equality impact assessment no i can't should it have been it looks like it yes but it was certainly something that i was never
00:31:22 certainly something that i was never asked to complete or had seen one attached to this document who was responsible so far as control was concerned
00:31:30 concerned at this policy particularly for ensuring that an eia was completed once the policy had been through significant amendment
00:31:41 amendment i i would imagine it would have been the the document owner the document owner uh
00:31:51 uh if we go to if we go to page one we can see the document owner
00:31:56 head of operational response who in march 2014 was who
00:32:05 dave brown dave brown thank you very much that's ac brown can i then turn to a different topic which is language can we can we go back to your witness statement please page 17
00:32:17 to your witness statement please page 17 paragraph 42
00:32:24 now you say here there's a long series of questions before this but at the top of the page whether guidance should be given to cras with regard to communicating with
00:32:36 with regard to communicating with callers whose first language is not english
00:32:39 english and you say cras can use language line for any call received not just fsg calls reference to language line is included in paragraphs 4.7 and 4.8 of policy number 539 i also
00:32:51 4.7 and 4.8 of policy number 539 i also recall that there were some updates to language line in 2018 and language line came into control to deliver training on this to crows cras i do not have access to this particular presentation to exhibit as it was provided by language
00:33:03 exhibit as it was provided by language line
00:33:05 line uh let's look at policy force let's look at policy 539 and particularly the paragraphs to which you refer there lfb 50737 again and again this is the
00:33:17 50737 again and again this is the version current as at
00:33:21 as at 2014.
00:33:24 signed off by
00:33:26 by ac dave brown and if we go to page four you see the paragraphs you refer to 4.7 4.8 under the heading interpreter service yes and i'll just look at those
00:33:38 service yes and i'll just look at those with you english may not be the first language of a person attempting to pass an emergency call agreements are in place for the use of an interpreter service language line now are you able to explain why the
00:33:49 now are you able to explain why the policy did not set out any instructions on
00:33:52 on how to speak to persons whose first language was not english just like
00:34:00 the details in this policy it really would have depended so there were some technical processes that control officers needed to follow um so
00:34:10 so that's why it isn't in there and is in a reference information file right
00:34:17 right there's no guidance or policy here as to how to get hold of an interpreter rapidly is there no that would have been in the uh riff and they would they would have all had
00:34:28 and they would they would have all had training on language line and how to access language lines so they would know that right did you yourself review this part of the policy when you were reviewing it in february 2011 no i think we did have a conversation
00:34:41 no i think we did have a conversation about if there were any other services that
00:34:45 that we could use to provide but the decision was taken to continue to use language line right now using language line and how would it work
00:34:56 and how would it work caller rings yes and they are speaking a language
00:35:01 language that the call handler simply does not recognize yes whatever it is what do they do so
00:35:08 so the control officer tries to engage with them to make them understand that they are we will contact an interpreter service
00:35:19 we will contact an interpreter service and then they are able to dial the number
00:35:23 number um
00:35:23 um whilst on the phone to the caller and they are connected to language line who can then listen in and find out the caller's language and then provide an interpretation service for
00:35:35 provide an interpretation service for that
00:35:37 that i see
00:35:38 i see and the interpretation service would be immediately on hand with it so for example you had a caller who was who could only speak amharic or tagalog would that be i'm not sure it was
00:35:49 would that be i'm not sure it was immediate no right and i think when we looked um originally and and i have explored this since with the university of portsmouth i don't believe anyone has an immediate
00:36:00 i don't believe anyone has an immediate interpreter service and offers an immediate interpreter service you're right it takes time to understand what language they are speaking and find a suitable interpreter for them can you give us an impression
00:36:11 for them can you give us an impression of how much time uh from the calls that we um use language line for um and they are infrequent so i would say about
00:36:23 infrequent so i would say about 10 a month um five to six minutes on average right
00:36:31 um i want to turn to a different topic altogether which is action nine a revision of the riffs reference information files can we go
00:36:42 can we go as we do to the starting point which is the lacking house incident assurance review from august 2018 at lfb404801
00:36:53 [Music]
00:36:56 and in that document please let's go to page 13
00:37:00 page 13 action 9
00:37:01 action 9 on the right hand side of the bottom of the screen and the action is revise the reference information file used by control officers when delivering fast survival guidance in order to ensure that they
00:37:12 guidance in order to ensure that they comply with national guidance if we go to your witness statement at paragraph 26
00:37:21 page 11
00:37:24 you say i was involved in the first revision of the fsg rif's or riffs for cras and the introduction of supervisor riffs now scott eva scott hayward said in his
00:37:35 now scott eva scott hayward said in his evidence that the rifts were revised by lindsay turner and the ost the operational support team is that correct so i think prior to
00:37:46 so i think prior to our
00:37:47 our gap analysis they were and they were the riff that scott was referring to as current at the time of la canal and that was updated by
00:37:58 time of la canal and that was updated by ost
00:38:00 ost because it was a technical process to load them onto at the mobilizing system ost would have been involved in the layout and the construction of the rifts and it would
00:38:11 construction of the rifts and it would have been down to uh one of the songs to sign off the content of that and which song was that so i believe um it was lindsay during the la canal fire
00:38:23 it was lindsay during the la canal fire but the revised version in september 2010 was myself right see fine so when you say i was involved in the first revision
00:38:33 revision you signed off on not just the technical um
00:38:36 um aspects of the rift but actually the substantive content yes
00:38:44 now uh you go on to say in the second sentence there i recall that in september 2010 i proposed a redraft of the riffs i recall that scott hayward and i discussed the types of
00:38:55 hayward and i discussed the types of useful information to obtain from callers and therefore to put onto the riff what was scott hayward's role uh in revising the riff so i think that was just as um
00:39:08 so i think that was just as um from the lessons that we've learned from la canal we were very focused on um one of the gaps which was about proactive questioning and and that we should provide some proactive questionings and i think
00:39:19 questionings and i think uh from those discussions um i've redrafted the riff so it contained
00:39:26 contained examples of proactive questionings for different building types
00:39:32 and what was his role
00:39:36 he would have known that i was doing that he may have had a look through it and but it was just as i would have discussed it with him or
00:39:47 as i would have discussed it with him or tim cupple at the time or tom davis it was part of some of the gap analysis that we had identified and this was to be clear this was cro riffs was it
00:39:59 riffs was it not nazi not only the supervisor risk but the crm and who had ultimately the responsibility for the contents of the cra riff was that was that you or was that scott hayward
00:40:11 that scott hayward so
00:40:12 so ost would have created it um on what we had
00:40:16 had requested
00:40:17 requested and
00:40:18 and they would have designed it and they would have uploaded it on the system and put that i'd signed off on it and
00:40:25 on it and but that
00:40:26 but that would have been a group
00:40:30 group decision on the content yes and in terms of hierarchy at least that would have been a sign off by you but subject to the ultimate approval or authority of scott hayward is that
00:40:41 authority of scott hayward is that correct
00:40:42 correct yes i'm not sure that the detail of each roof we would have been familiar with or what we were putting in the rift but was it approved or reviewed by
00:40:53 was it approved or reviewed by ac dave brown um i'm not sure and i'm not sure if it it went to the lucknow board at the time i know there was some some discussion and some scrutiny over
00:41:05 some discussion and some scrutiny over our rifts um so i'm not sure if it if it was presented there or just they accepted that we had updated it right and what about the training department do they see it
00:41:16 do they see it have any input into the contents lfb training yes no right
00:41:22 and you don't know whether it was before the latino board i think the minutes that we've got uh tell tell us that there were updates given
00:41:31 given we have one from september 2010
00:41:36 2010 saying that the riff had been reworked to complement the fsg package just for your for our own benefit that's lfb 3055192 page 2 paragraph 5.6
00:41:49 3055192 page 2 paragraph 5.6 that's a point of detail for us but does that accord with your recollection yes
00:41:54 yes and
00:41:55 and i
00:41:56 i i know there was some um conversations had during that time because obviously we wanted to make sure that we were covering a range of building types and and that's how we had laid
00:42:09 and and that's how we had laid that's how we were laying the riff out and and therefore we engaged with other departments in lfb about some advice and guidance for as it says their commercial buildings
00:42:20 their commercial buildings um
00:42:22 um was there a training package that was going to be delivered to cros in order to roll out the revised riffs to them i don't think so in september 2011 i don't think there was a
00:42:34 september 2011 i don't think there was a training package i think we uploaded them we communicated it with staff and asked them to familiarize themselves with it
00:42:42 with it it was a long document but it did have hyperlinks in it so the idea was that when you thought you were taking a fire survival guidance call that you could actually click on the building type
00:42:55 actually click on the building type where the caller was and that would take you to the specifics right um in paragraph 26 you go on to uh say just below halfway down
00:43:08 to uh say just below halfway down both of these individuals that's jim john bradbury and jim knighton then also attended and observed the subsequent fsg training in june 2011 to ensure all gaps identified in the gap analysis were
00:43:20 identified in the gap analysis were addressed
00:43:21 addressed did that include uh the
00:43:24 uh the training on the new raf's riffs i wouldn't imagine i wouldn't imagine that was training on the wrist now the rift is just an aid memoir there for control officers but i
00:43:37 memoir there for control officers but i would imagine that the riff
00:43:40 the riff was aligned so the training and the rift were aligned
00:43:46 the training and the riff were aligned so does that tell us that although you amended the rifts you didn't actually put in place a formal training package
00:43:57 put in place a formal training package or powerpoint or slideshow to the cross to show them what the changes were and take them through it in a structured and organized way
00:44:08 organized way no
00:44:10 no and that wouldn't have been the case for any riff really that we had we'd have
00:44:16 we'd have that they had access to why is that uh just because it is an aid memoir i mean and it is there just for their reference
00:44:26 reference some
00:44:27 some riffs contain a lot of technical information um and maybe the operators will look at them on time from time to time just because they've forgotten a process on the system and and other risks will contain
00:44:40 system and and other risks will contain some detail and maybe some questioning to ask if
00:44:44 to ask if they um get stuck or want that to help so
00:44:49 so in terms of training they would have been trained on how to access the suite of reference information files and but
00:44:57 but just being told that the reference information file had been updated they could have accessed that at any time they could have looked through that it was quite clear
00:45:07 clear and concise it wasn't in a different format it hadn't changed layout and it was aligned to what we had told them in their training i believe in terms of
00:45:19 in their training i believe in terms of proactive questioning and assessing and the four principles and reassess
00:45:27 would you accept that without a
00:45:30 a specific presentation or training package to take
00:45:36 to take the cross through the revised riff you couldn't be sure that they had all fully understood the nature and extent of the changes
00:45:47 nature and extent of the changes and that therefore there was a risk that they would still be handling calls based on
00:45:52 based on on their own their old knowledge no
00:45:56 no no i don't i don't agree with that i don't think they were that training on a riff
00:46:02 riff would have benefited them anymore they had had fsg training in 2010 that was followed in 2011 as well they would have been aware of all the
00:46:13 they would have been aware of all the changes we'd introduced and the rif like i say is just a an aid memoir to support them should they need it uh if we turn to page 27 of your
00:46:25 uh if we turn to page 27 of your statement on page 12 you say by january 2011 we had produced a final redraft of the fsg riffs and this was update
00:46:35 update this
00:46:36 this update i think i should say was passed on to all cras we amended the fsg rifts to cover a multitude of building types so that the advice could be tailored for different types of buildings i recall
00:46:47 different types of buildings i recall that we recrea that we created a separate riff for domestic dwellings high-rise buildings commercial properties and hmos i understand that vic bagnell subsequently removed the references to multiple building types in
00:46:58 references to multiple building types in the fsg riff during my secondment to cfoa
00:47:02 cfoa so sorry just to be clear it wasn't a separate riff it was all one riff and with the
00:47:08 with the multiple building types but they were hyperlinked so you didn't have to scroll through the whole document just to find one building i see so you could jump to domestic dwellings out of the riff yes
00:47:19 domestic dwellings out of the riff yes so when
00:47:20 so when you say created a separate riff you mean a separate link from the riff is that what you mean yes i do i follow now if you go on to paragraph 28 below what i've just read to you you say
00:47:32 what i've just read to you you say that
00:47:34 that in the middle of the paragraph the fsg riffs that were tailored to specific building types went live in february 2011.
00:47:42 2011. uh and and indeed we have a record from the latino house board meeting on the 4th of february 2011 which i think you attended we don't need to go to it which says uh records you
00:47:53 to go to it which says uh records you saying that it was ready to go live the following week does that accord with your recollection it does yes and um if we go to um your exhibit six which you refer to in this paragraph lfb double zero one two
00:48:05 this paragraph lfb double zero one two one two three seven i'll just put it up for you briefly now because we'll come back to it in detail a bit later on but here is an email from mutual control stuff about the riffs of the 23rd of
00:48:17 stuff about the riffs of the 23rd of february 2011. uh entitled communications measures for staff fire survival guidance and the second paragraph down fast survival guidance riff
00:48:28 riff is that about the date when
00:48:30 when the new fsg riff for cros went live yes that's the one that i would have signed off on once the policy went live did you consider arranging a workshop or test
00:48:42 consider arranging a workshop or test exercise to test out whether the riffs worked in practice uh no we didn't um but i believe there was some subsequent subsequent feedback
00:48:53 was some subsequent subsequent feedback uh from our operations managers so at one point i probably would have shared this at the brigade control management meeting and we would have had some feedback from that
00:49:05 that right
00:49:06 right why didn't you arrange a workshop or test exercise to to test it out to see whether it worked in practice so i
00:49:17 so i i think we were quite clear from the gap analysis that we wanted to add some proactive questions in there we also wanted to make sure it covered a range of building types and that was between
00:49:30 of building types and that was between uh that was a decision that the four of us had
00:49:33 us had come up with as well um who were who had been working on that and the feedback you're referring to was that informal back to you by the oms or aoms
00:49:44 aoms it would have been at the brigade control management meeting so they either would have said at the time or they would have emailed me directly
00:49:55 directly were the revised riffs tested at the haygate challenge exercise on the 16th of june 2011 five months after the new rifts went live
00:50:07 the new rifts went live i i don't recall can you think of a reason why they wouldn't have been uh no
00:50:15 uh no just that
00:50:16 just that it was an exercise so um
00:50:22 there might have been um people busy just monitoring or putting in injects and and the training team wouldn't have
00:50:33 and and the training team wouldn't have been able to observe if people were using the riff was the haygate challenge not a very good opportunity to stress test the revisions that had
00:50:45 the revisions that had been made to policy 539 twice in fact september 2010 february 2011 and the newly revised rifts to make sure they really worked
00:50:56 they really worked i think the stress test was that the training that we had delivered had worked
00:51:08 can we then go to lfb three zeros two eight three i'm so sorry lfb3028381
00:51:20 this is an email uh sent to
00:51:25 to you a second email down on the page from graham bonnet on the 27th of june 2011
00:51:33 2011 and you and lindsey turner chris sharpe and nikki o'shea are the recipients of of that email the subject is fast survival guidance and
00:51:44 and graham bonnet starts by offering some observations about the structure and content of the fsg presentation in an email below that and then he goes on to say
00:51:54 on to say um
00:51:55 um he says that i believe that some of the presentation content is inconsistent with the revised ffg operator riff that was introduced following the management review earlier this year
00:52:06 review earlier this year although fsg is based on the home office circular of 1993 as you know the lfb made several changes to the guidance which was incorporated into the rif and if we go to the top email on the
00:52:18 and if we go to the top email on the same day
00:52:20 same day this is quite early in the morning uh you um forward this on to scott hayward you see that and you say go graham exclamation mark think his comments sum up the quality of
00:52:32 think his comments sum up the quality of this quote late unquote training package what do you think
00:52:38 and now if you go down to page three of this email run we'll see what it it
00:52:45 it it it is that he says specifically it's quite there's quite a lot in this email but i just want to pick out the bits that i want to ask you about specifically and if you look about a third of the way down your screen
00:52:56 down your screen uh
00:52:59 uh it um it says
00:53:12 forgive me um the presentation covers detail about advising caller to phone back this is not included in riff although i agree it should be plus consideration needs to be
00:53:24 should be plus consideration needs to be given as to whether or not to provide advice in rif on concluding conversation with caller if they're clearly not in danger
00:53:32 danger and then
00:53:33 and then if you go low down you then see conclusions straight recommendations i believe it's vital to ensure absolute clarity and consistency in all documentation relating to fsg as the riff has been specifically
00:53:45 as the riff has been specifically designed to guide and assist staff whilst actually handling an fsg call i feel it is the riff upon which most focus should be placed when undertaking refresher training rather than a
00:53:56 refresher training rather than a separate fsg presentation that differs in both structure and content in critical areas as mentioned above now i've only read one of those to you yeah but there are others of course and then if we turn
00:54:08 if we turn well right to the very bottom of the page the last two words in the paragraph i also
00:54:14 i also and if we turn to page four suggest he says i also suggest that fsg exercises
00:54:20 exercises are held to test the suitability of the rifts operator and supervisor when dealing with fsg calls and to ascertain whether changes stroke improvements are necessary i would be happy to assist in
00:54:33 necessary i would be happy to assist in this process
00:54:36 did you or did scott hayward respond to graham bonnet on any of his criticisms or suggestions i can't remember specifically but it
00:54:47 i can't remember specifically but it would have been discussed and i'm sure lindsay and the training team would have then
00:54:52 then taken that feedback and i believe the training in 2011 did change after june 2011
00:55:03 after june 2011 i'm not sure i know um i reviewed the training package in 2011 graham has obviously commented on its need to review and i would imagine that
00:55:14 to review and i would imagine that he's made the same observation as us that we had amended the rifts to reflect um
00:55:21 um what we had learned from lachanel and about what support the operators needed and therefore that should be aligned with the training right so the rifts have been revised in feb and rolled out in february 2011. graeme bonnet makes
00:55:34 in february 2011. graeme bonnet makes these
00:55:35 these further suggestions in june 2011. can you remember re-revising the rifts to take into account some or all of his suggestions no i think
00:55:46 no i think his suggestions are the same as ours that the rifts are uh had been re-revised based on our learning from lachenal and and therefore the training should be revised to align
00:55:58 the training should be revised to align with the riff
00:56:04 so you recall amendments to the training package i i would imagine there were some i know that happened in 2011. okay now just going back to the very top of the email string we saw it earlier it's
00:56:15 the email string we saw it earlier it's you said go gray an exclamation mark was that comment to reflect your agreement with graham bonnet and to congratulate his bluntness or your disagreement with
00:56:26 his bluntness or your disagreement with him and an intention to defend the
00:56:29 the new fsg package but also the training that went with it no my agreement your agreement
00:56:35 agreement okay now can we then look at paragraph 27 of your statement please at page 12.
00:56:42 uh you say there
00:56:46 uh in the last sentence i understand that vic bangla subsequently removed the references to multiple building types in the fsg rift during my secondment to cfoa of course so that's some time
00:56:58 cfoa of course so that's some time between
00:56:59 between the 1st of september 2012 and january early january 2015 yes um can you confirm that it was the version amended by vic bagnell in 2013 and then
00:57:11 amended by vic bagnell in 2013 and then late later in 2014 those are dates we get from different documents you weren't there at the time but that the version amended by him at least was the one in force at the time of the grenfell tower fire
00:57:24 of the grenfell tower fire i
00:57:25 i can't no i couldn't be sure when you returned from your secondment to cfoa in january 2015 did you review the revised fsg riffs
00:57:36 the revised fsg riffs no
00:57:37 no but i was told that they had been changed and that was based on feedback from operations managers probably from some cross as well right um
00:57:47 um but i'm on and i was told that they have been amended
00:57:53 why weren't you keen to
00:57:56 keen to review the revised fsg riffs given that you had been told that they'd been changed
00:58:02 changed um
00:58:03 um just because as we've covered like anybody else in london fire brigade an officer that would come in and and take over a role from someone else it wasn't practice to review
00:58:16 wasn't practice to review their work and they'd had some feedback from operations managers and from cro's about
00:58:23 about some changes i believe and this is only from what was told and and they wanted to see it differently and and that had been facilitated but given your involvement in 2011 in
00:58:34 but given your involvement in 2011 in the amendments and the rollout and the training and the training packages and the revisions to those were you not interested to know what if anything had changed in your in your
00:58:45 anything had changed in your in your absence i i think i would have looked at the riff i certainly wouldn't have not not looked at it and but not in terms of reviewing
00:58:54 reviewing reviewing it and because i wasn't the only one in that department that had been involved in in the lacanal review
00:59:04 no but you were coming back and taking over that essentially taking over the running of ost which you hadn't had i think when you left for the cfoa no i hadn't done that and at that point given
00:59:16 hadn't done that and at that point given your your your overall control i just like to know why you didn't think it necessary just to check with yourself really to make sure you'd understood what had changed in your absence no i
00:59:27 what had changed in your absence no i think i was i was comfortable that the feedback that had been received had been acted on and there was a riff in place
00:59:38 and there was a riff in place did you check at that stage in and from january 2015 whether the revised rift still complied with national guidance if it ever did
00:59:53 no not personally why is that because i would have made the assumption that it would align with national guidance
01:00:08 can we go to the rift that you created
01:00:13 so that we can be familiar with it lfb double zero one two one two four zero it's your js9 smith i think you've exhibited this
01:00:24 exhibited this um
01:00:25 um is this
01:00:26 is this the uh document into which you had your input in in 2010 and rolled out in february 2011. do you think with its later amendments admittedly yes yes
01:00:41 uh and um if you go to the foot of the screen you can see under the question what type of property are you in 1.1 house 1.2 hmo flat conversion bed sit 1.3 purpose
01:00:52 flat conversion bed sit 1.3 purpose built flat caller is inside flat on fire now they're in red does that tell us that there's a hyperlink yes i see
01:01:01 and then that would take the reader to the correct part of the riff for that type of building yes that's correct so was it the intention that if a cra was talking to someone from a high-rise building who needed far survival guidance and the flyer was the fire was
01:01:13 guidance and the flyer was the fire was not inside the caller's flat they would open up the riff and click on 1.4 yes and 1.4 we can see at the top of page two
01:01:25 two at 1.4 purpose built flats fire not inside callers flat fires elsewhere in premises
01:01:31 premises and that would take them to a different section of this document would it yes if we go to page 14 i think we see where is this right the cro ends up
01:01:42 is this right the cro ends up rather than scrolling down you get dropped down to lower down in it and if you go to the bottom of the screen you can see there's section 1.4 purpose built flat yes yes so that that's where the cro goes is it yes
01:01:56 and that then sets out the steps the cra should take when speaking to a caller yes yes
01:02:03 yes yes and how did you go about revising the the rift specifically in this respect according to national guidance did you did you consult first server secular 1093 in terms of
01:02:14 in terms of purpose-built flats where the fire is not inside the caller's flat yes um not so much 1093 i don't believe that covers purpose-built flats or has one relative minor mention to it i think we used the
01:02:27 minor mention to it i think we used the current government guidance that was um extent at the time of this review just after la canal and there was definitely a focus um
01:02:38 um from the lakinal board and direction to us um to be clear on stapler guidance and and so we use that
01:02:49 guidance and and so we use that can you identify that you you say you we used the current government guidance extant at the time of this review just after latino what was that
01:02:59 was that that if you were in a purpose-built flat and you were not being affected by far heat or smoke you were to stay put what was the name of the government guidance or
01:03:11 guidance or i don't know but i think it is referenced in the control lack and all report right is that the lga document the local government association document i'm guessing i thought it was from dclg on
01:03:25 guessing i thought it was from dclg on but i couldn't be sure right but it's referenced in there you you can't tell us
01:03:32 us no i can't tell specifically right uh well we may come back to that okay um did you consider fire service secular 5404
01:03:40 5404 when carrying out these revisions no
01:03:48 and is that because as a result of the gap analysis completed in april 2010 you decided not to yes like i said that that hadn't been adopted by lfb
01:04:04 can we um go to lin group manager lindridge's review in january 2013 which we went to on thursday that's at lfb3033943
01:04:24 and if we go to page 12 in that please at the top of the page group manager lindridge has some as a summary and this is in the summary conclusions part of his report
01:04:34 report uh and this is under action reference nine entry on action log fsg revised riff reference information file expected outcome the rif files for fsg should comply with national guidance
01:04:48 should comply with national guidance and then he goes on to say review process findings the rif provides the control room operator cras with an aid memoir for handling fsg calls based on national guidance and he refers to
01:04:59 on national guidance and he refers to the
01:05:00 the circular 1093 now just bearing in mind the date of this document is january 2013.
01:05:07 2013. so you are already at the cf cfoa by then and your revision work on riffs is done
01:05:12 done yes right
01:05:13 yes right uh and uh note the reference there to the national guidance and then he goes on
01:05:18 on two versions exist one for the crm and one for the control supervisor assistant operations manager fsc 5404 has not been adopted which introduces three-stage approach to
01:05:29 introduces three-stage approach to emergency call handling and the assessment of the caller you see that we discussed that earlier yes the format of operators riff is not favored by the cras and a single page
01:05:41 favored by the cras and a single page flow chart was requested from the ops support team in march 2012 no evidence of this flowchart existence or development has been provided
01:05:52 or development has been provided so
01:05:54 so just
01:05:55 just breaking that up a bit first do you agree i think you do that fsc 5404 was not adopted into the rift he's right about that yes and i think that again you said
01:06:07 and i think that again you said consistently with what you told us earlier that was a deliberate decision was it
01:06:13 was it i'm not like i say we couldn't find any documentation to say if a decision had been made or not about adopting 5404 previously but
01:06:24 previously but it wasn't in adoption in the control room when i joined in 2007. right and and it it
01:06:33 it it that was consistent at least with the um decision not to include fsc 5404 as part of the gap analysis yes yes now um he then goes on to uh
01:06:46 yes yes now um he then goes on to uh say
01:06:48 say that
01:06:49 that the
01:06:50 the uh format was not favored by the cros and the single page flowchart was requested from the op support team in march 2012 and that was long before well some months before at least you left for
01:07:01 some months before at least you left for the cfoa do you remember that no
01:07:06 no do you know what he's talking about
01:07:10 no do you remember any feedback coming from operators that they didn't like the riff
01:07:17 not specifically during that time but that
01:07:21 that aligns with when i returned what i'd heard and why the changes had been made to the roof you so you have no recollection of anybody in the operational support team
01:07:35 anybody in the operational support team requesting a single page flow chart in march 2012 or even thereabouts i don't but i requesting a flowchart is probably something that had come from
01:07:46 probably something that had come from one of the watch or cro that would have found that useful and they might have just gone about doing that themselves
01:07:54 now let's go to the uh riff for operators that you created and the section that we looked at earlier uh four callers from a purpose-built flat where the fire is elsewhere in the block
01:08:05 where the fire is elsewhere in the block um this is we need to get back to the riff that's at lfb double zero one two one two four zero page fourteen
01:08:22 purpose built uh purpose built flat section 1.4 now let's just look at the prompts ask caller are you or is your flat being affected by heat or smoke
01:08:34 by heat or smoke if not affected tell caller you see the two bullet points and then if we um turn the page or rather the bottom of the page
01:08:45 or rather the bottom of the page um it says assess it says escape bottom of page 14 escape if calling you to get out you can't ask then top of page 15 you see it says what's stopping you from
01:08:57 you see it says what's stopping you from getting out is there another safe way to get out
01:09:00 get out example questions guidance and you can see the questions set out there about the building and then if there's a lot of smoke example guidance get as low as possible
01:09:11 example guidance get as low as possible where there is less smoke and the air is cleaner
01:09:14 cleaner if the call is still unable to get out example guidance try to stay calm i'm going to give you some advice and then obtain caller's name write it down and use it consider telling them your name
01:09:26 telling them your name and then assess assess situation before giving advice example questions do you know where the fire is where are you in relation to the fire etc
01:09:36 etc and then page 16 for the similar questions are you at the front or back of the building is anyone with you etc etc and you can read down that
01:09:46 that and then record essential information obtained from caller on procad ensure supervisor i see are notified of the details that are kept updated throughout the call if circumstances change
01:09:57 change depending on caller's response ask reactive questions as necessary and provide appropriate guidance to protect the caller as detailed below and then protect caller you could see all those questions there
01:10:10 you could see all those questions there about windows about doors about what happens if the door becomes too hot then if we turn to page 17 top of the page cover nose and mouth with cloth and then assist with rescue
01:10:23 and then assist with rescue hang sheets make noise rare shawl for sure coiler sorry reassure caller uh example guidance the firefighters are on the way the firefighters know where you are
01:10:36 the firefighters know where you are etc reassess regularly at 17 and then over the page to 18
01:10:46 use positive statements during the call
01:10:50 ask the caller to tell you something about themselves but remember to assess the situation and then imminent danger
01:11:00 and then lower down the screen window escape guidance and then page 19 last resort
01:11:09 i had to break a window and that's that's it
01:11:13 that's it now i've taken you through that slowly i hope slowly enough would you agree with the review we've just performed that those stages in the rift do not include
01:11:24 those stages in the rift do not include the stage assess the caller that we saw in fsc 5404 no
01:11:30 no not in detail well not at all just comes from
01:11:34 from asking the caller what's stopping you from leaving yes but that's uh that's not a request for age ethnicity gender or any kind of vulnerability is it no and there's
01:11:46 vulnerability is it no and there's simply no reflection would you accept of the assessment of the caller as opposed to the situation reflected anywhere in this rift for control room operators no
01:11:58 this rift for control room operators no do you agree that that meant that control room operators were not specifically directed to take information from the caller about themselves and their abilities that might impede
01:12:11 and their abilities that might impede their escape
01:12:14 i would suggest that that was covered in their training
01:12:19 training um about the engagement with the caller and asking questions about the caller as you say these are are just prompt proactive questions um
01:12:30 um that operators would look at if they needed any additional support and so not a guidance document and not a policy document to to follow but just some
01:12:42 document to to follow but just some supportive questions should you need like
01:12:45 like the email that you've referred to or the the report written by um dave lindrich you know they've obviously asked for an additional aid memoir to support them on
01:12:56 additional aid memoir to support them on that so it is the basic guidance documents
01:13:00 documents um for them to follow and not the detail that they would have received in in training
01:13:06 training what was the point of training them on the national guidance in 5404 about assessing the caller but not having a set of simple questions
01:13:18 not having a set of simple questions in the riff in addition to the questions you've got what was the problem with that but there wasn't any problem i like i say i just think that they were just proactive questions that we could
01:13:29 just proactive questions that we could ask the caller we um
01:13:32 um had discussed and the board supported by legal had come up with some phrases to use and wording that we could use and we were focused about making sure that that was
01:13:43 sure that that was there for a control officer should they need it
01:13:50 why was it thought appropriate to leave the assessment of the caller element of fire survival guidance only to training
01:14:01 only to training whenever and however that was delivered and not have it either in the policy or in the riff the detailed riff with the actual prompts that the actual cra
01:14:12 the actual prompts that the actual cra goes on during an actual call like i think
01:14:15 think i said i think that's just in our normal day-to-day call handling that's the engagement and the assessment of the caller happens naturally so maybe we we didn't specifically focus on that
01:14:27 didn't specifically focus on that well given that it's in the national guidance i would suggest to you that this was actually a positive decision taken by the brigade not to do what national guidance required namely assess not only the situation but the caller
01:14:39 not only the situation but the caller themselves well certainly not on my part i i don't believe i was we were really clear and i think some of the evidence and the comments i've made on training that we were really clear about how we wanted to focus back
01:14:52 about how we wanted to focus back on to national guidance 1093 in terms of fire survival guidance uh mr chairman is that a convenient moment i'm afraid i'm still in the middle of this topic uh and i could i
01:15:03 middle of this topic uh and i could i could probably finish it in five minutes do you mean five minutes uh no probably not
01:15:12 in that case i think we'd be wise to take our break now didn't you yes yes all right
01:15:17 all right um well i think we will have our break now miss miss so um we'll stop now we'll come back at 25 to 12 please and again while you're out of the room please don't talk to anyone about your evidence
01:15:28 don't talk to anyone about your evidence or anything related to it thanks all right please yes you'd like to go to the usher then
01:15:44 thank you mr miller 25 to 12 please
01:34:46 would you ask me smith to come back in please
01:35:00 right ready to carry on yes thank you thank you very much yes sister thank you mr chairman um smith before we broke we were looking at the control room operator riff and the omission of anything in there
01:35:11 and the omission of anything in there about assessing the caller if we go to your witness statement please at page 16 paragraph 40.
01:35:22 in the third line there you say a previous version of the riff from 2007 contemplates disability issues under the protect principle exhibit js 13.
01:35:35 protect principle exhibit js 13. if we go to that version that you exhibit that said lfb00121224
01:35:48 and am i right in thinking that's the one you amended
01:35:53 me you may not be able to tell from the first page but it doesn't have the the hyperlinks in it per on a building by building basis so that may help you yes yes um if we go to page two
01:36:09 uh you can see
01:36:12 page two
01:36:17 uh yes thank you you can see in capitals next to the bullet points suggest an alternative escape route and as a last resort of escape only if the caller suggests it
01:36:29 the caller suggests it and then if the caller can't escape off a reassurance be positive and we've got a list of those things there and if we scroll down the screen to lower down page two we can see the last asterisk
01:36:41 last asterisk protect the caller if they can't escape first bullet point does the caller have any disability is there mobility impaired that may affect them carrying out any
01:36:52 them carrying out any of these actions now we don't see that in the amended version of the riff why was that element
01:37:02 element specifically removed from the protect the caller stage in the revised riff i i'm not sure it was specifically removed i agree it is not in the the new riff um
01:37:14 the new riff um i'm not sure i can't recall if there was an agreement that it would be in the training and that actually the rift should just focus on those proactive questions i spoke about before
01:37:26 before um well you say you can't recall if there was an agreement that it would be in the training do you remember to the best of your recollection was there a discussion about what should happen
01:37:37 about what should happen to that element of protection of the caller
01:37:40 caller when you came to revise the riff in 2010 to 2011.
01:37:46 no i can't recall any specific discussion either way of it being added or
01:37:54 or removed from it are you able to explain why that element was removed from the revised riff well only as what i said to you before in the top
01:38:05 as what i said to you before in the top window when it says um is there anything stopping you from from getting out and that it would have then been re-enforced to cross in the training
01:38:17 cross in the training um
01:38:18 um if we go back to page 16 of your statement please and look at paragraph 40.
01:38:23 40. again you say in the next sentence in a later version of the riff in 2013 the capability of the caller is considered under the control information form heading which sets out information a cro
01:38:35 heading which sets out information a cro should be looking to take down during an fsg call
01:38:39 fsg call now let's i want to examine that with you please if we go to the later version of the riff that was in force on the night of the grenfell tower of fire itself
01:38:48 itself we find that at lfb double zero one two two eight three seven
01:38:56 [Music] that's the first page if we go to page six please
01:39:03 and and uh
01:39:06 look at the very well that is the whole of page six i think for present purposes you've got paragraph 2.3 control information form and it says the control information form
01:39:17 and it says the control information form is completed at the incident from information provided by brigade control to include the following where available and then if you scroll your eyes down the list of things you can see any additional information if provided or
01:39:29 additional information if provided or requested from incident other information may include age gender and capability of those involved is that what you're referring to in your statement
01:39:40 statement yes
01:39:42 yes would you agree that that's the only place in the rift that mentions age gender and capability uh well i haven't seen it for a while but yes sir right i'll take it from you
01:39:53 but yes sir right i'll take it from you that it is yeah and look looking at it it would appear do you agree that the cra would need to wait for the caller to provide that information or the incident ground to ask for it
01:40:05 so the details that are contained on the control information form um look
01:40:12 look exactly like a lift from the firefighter's control information form um but we have added in about the any additional
01:40:23 have added in about the any additional information um and that probably aligns with what i was trying to explain in terms of call taking in general terms and call handling and and the additional
01:40:35 handling and and the additional information that we tend to gather on calls um but yes we have been specific with aged gender and capability and as it says the control information form is not completed in the
01:40:47 information form is not completed in the control room it's completed at the incident it is yes uh and therefore the additional information would be would be information given by the control room to the incident ground
01:40:59 control room to the incident ground uh itself wouldn't it yes and therefore would only be as good as the information obtained by the control room operator yes yes
01:41:08 yes yes there's nothing in here i think you you would accept as there had been in the 20 2007 version of the riff which expressly indicates that the crow would actually
01:41:19 indicates that the crow would actually positively ask for that information when the when the when protecting the caller can you can you tell us why it was dropped from the riff indeed dropped
01:41:30 dropped from the riff indeed dropped from the policy and dropped from the riff
01:41:32 riff and moved
01:41:33 and moved only to a rather oblique reference in the control information form at the fire ground
01:41:39 ground no all i can say is that it
01:41:43 it must have been in the training and and the fsg training that we were rolling out to control staff
01:41:51 before the grenfell tower fire were you aware
01:41:55 aware that
01:41:56 that both the policy policy 539 and the cro riffs
01:42:03 riffs contained no specific direction that the cro should be the person to undertake an assessment of the caller as specified in 5504 national guidance
01:42:14 specified in 5504 national guidance in terms of age gender and capability if you like as a summary of the four elements under assess the caller yes no not that i can recall but i would have
01:42:25 not that i can recall but i would have as i've explained i would have thought the general assessment to begin with and how control officers undertake that would have included that in there right now i'm going to go on to a different
01:42:36 now i'm going to go on to a different topic
01:42:37 topic which is the meaning of affected by fire smoke or heat in the guidance itself before i do i just want to examine something with you you said this morning you told us
01:42:48 you you said this morning you told us this morning and for the those following in the raw transcript it's at page 12 lines 18-24 that you weren't involved in the revision
01:42:59 revision or amendment done to policy 539 in september 2010 i believe i from looking at the two versions you've
01:43:10 from looking at the two versions you've shown me i don't believe i had uh i was involved in the 2010 one the 2011 yes i was yes um i just want to show you one or two emails from the time
01:43:22 show you one or two emails from the time to see if your recollection is is as is as you've told us can we start at lfb triple zero five seven nine three four please
01:43:33 um and as always with these things we start at the foot of page three well but not always page three but the foot of the email run please
01:43:44 and this is an email
01:43:48 sent by take it from me it's at the bottom of page two emilia reynolds to lindsey turner copy to you and scott hayward subject policy 539 draft amendments and you can see it's signed off by emilia
01:43:59 you can see it's signed off by emilia reynolds who's team leader in bct um what can you just tell us what her role was what her function was so she was part of uh a team leader would have been a
01:44:10 a team leader would have been a assistance operations manager um
01:44:14 um in the training team in the training team did you have any involvement in the mechanics of the drafting or
01:44:22 creation of the revisions of policy 539 it looks like it because she's sent them to lindsay yes with the amendment um and if we if we scroll up please to the next email page two foot of page two
01:44:35 the next email page two foot of page two we can see an email from scott hayward to lindsay turner copy to you 20th july 2010
01:44:41 2010 attached as the feedback for the reviewed ecm policy document and there's a lot we've spent a good four hours reviewing this document when the purpose of amelia being detached from training was concentrate on updating and improving this
01:44:53 on updating and improving this ecm is emergency call management isn't it
01:44:56 it yes this is this is talking about policy 539 yes
01:45:00 539 yes yes yes and then next paragraph we've commented and added my own spin on the main part of the document and have some additional notes for the appendices which are detailed below and then he sets out some comments there
01:45:12 and then he sets out some comments there appendix one two and three uh
01:45:16 three uh and uh
01:45:19 and uh uh you you can see what's what he's picked up there i don't need to go to the detail for this purpose then he suggests we suggest a reread of the entire document working against the comments made and ensure what is being
01:45:30 comments made and ensure what is being stated is in a riff or delivered to staff
01:45:35 etc uh now um appendix 3 there just looking at the list of things i should have asked you is
01:45:43 is is the first survival guidance isn't it yes yes
01:45:46 yes yes um who's the wii he's referring to in his email
01:45:51 his email i don't know it could be uh scott and i and tim cut bill and tom davies now you received this at the time
01:46:02 now you received this at the time my question is did we include you as part of the reviewing team uh
01:46:08 uh yes because there were the four of us working on the the control investigation for lacking all so i wouldn't i would presume so and then if you go to the foot of page
01:46:21 and then if you go to the foot of page sorry yes foot of page one email from lindsay turner to scott hayward by way of response copy to you same day 20th july 2010 hi scott in emilia's defense she started the work
01:46:32 emilia's defense she started the work i would not want to making changes to this policy that were outside of her level of authority i agree we need to sit down and go through this and thought we were going to do this either today or yesterday
01:46:41 yesterday rather than go through the bullet points below and because it is obvious you feel this policy needs a lot of work can i suggest that either joanne or yourself meet with amelia to advise her of the way forward or maybe we should the three of us get
01:46:52 or maybe we should the three of us get together and agree what we want in developed or out before we give it to amelia personally i realize there needs to be some changes but i'm not sure where the direction has come from for such change
01:47:03 such change and i don't think we need the last paragraph
01:47:05 paragraph um now you were copied into that um did you have a meeting with her or did get involved in the three-way discussion of the amendments to policy 539 i can't recall but i would imagine that
01:47:18 i can't recall but i would imagine that there was a meeting and we would have discussed it between the three of us that's what we usually did and we can see from the top of page one there's a response
01:47:29 there's a response to lindsey turner from scott hayward not in fact a copy to you i don't think i need to show you but um perhaps i wasn't then involved in it
01:47:40 perhaps i wasn't then involved in it perhaps it was between scott and lindsay but possibly but do you remember does this prompt a recollection that in fact you were more involved than than you told us this morning
01:47:49 no i don't think so i don't think that leads whilst we would have had some discussion and i would have had some input possibly um with uh
01:48:00 uh as a group because we were investigating the lack of incident i don't recall ever amending or updating or suggesting amendments to policy
01:48:11 or suggesting amendments to policy 539 at that time there was a good rationale there wasn't there for involving you given your position at the time and given the scale of the amendments needed to policy 539. uh well scott was also party to that
01:48:23 uh well scott was also party to that group um and he may have then shared that with tim cutwell and tom davis as well maybe i was
01:48:30 was out at another meeting or on another project
01:48:33 project at the time so but you were closer to the
01:48:36 the i'm sorry
01:48:37 i'm sorry you were going to say something no sorry you were closer to the day-to-day operations of the control room than scott hayward was weren't you at the time
01:48:45 time um
01:48:46 um i think in terms of what we were doing with the lack of and you've seen scott's commented as well we had the same understanding that we'd worked on the gap analysis and understood what needed to be changed um
01:48:59 understood what needed to be changed um i don't think he was any particular i was closer than that i i understood um the concept of fire survival guidance and what it meant to take a fire survival guidance call and and then with
01:49:12 survival guidance call and and then with my knowledge of the system and perhaps added something to it but not in terms of drafting policy right
01:49:26 did you know did you look at the attachment of of to this email at the time draft amendments
01:49:36 uh possibly did you know that the uh there was an amendment to the disability paragraph which existed in the 2007 version that we've seen which was removed uh
01:49:49 we've seen which was removed uh not that i'd particularly noted but again
01:49:52 again that might have been discussed uh if it's gotten lindsay neck right i mean look at looking at the email run i've shown you and casting your mind back how sure are you that you were not
01:50:03 how sure are you that you were not involved in the amendments to policy 539 um
01:50:08 um i having read the document that you showed and displayed i'm pretty confident that the original amendments i was not involved in um but did have some
01:50:21 was not involved in um but did have some input into the updated version in 2011. can we then look at an lfb
01:50:29 triple zero
01:50:32 i'm sorry lfb double zero one zero nine one four five
01:50:46 now if we start at page four in the customary way and then scroll up
01:50:54 this is an email from gemma who is gemma ling to emilia reynolds 2nd of september 2010 so we moved
01:51:02 moved to later in the year hi emilia i found the original email if you have any questions let me know and then if you go up to page three emilia reynolds responds
01:51:14 uh and we need the bottom of page
01:51:18 two for that please uh it's an email from emilia reynolds same date to you copy to lindsay turner scott hayward and others
01:51:29 and others forwarding 539 completed hi joanne this is the most up-to-date version of the emergency call management policy 539. it is still awaiting to be published as scott is trying to make
01:51:40 published as scott is trying to make amendments to the suicide information we use in his con in consultation with advisory and counselling with regard to the fsg information the appendix on the policy relates to information i updated from 1093 and our training documentation
01:51:53 from 1093 and our training documentation it does not give the definition below the lfb consider an fsg call as being a call to the brigade control where the caller believes that they are unable to leave their premises due to the effects of fire and where the ca remains on the
01:52:04 of fire and where the ca remains on the line providing appropriate advice until either the caller is able to leave by their own means is rescued by the fire brigade all the line is cleared if you want me to add this statement to the appendix it can easily
01:52:16 the appendix it can easily be put in before it is published you see that
01:52:20 that and then your response if you go back to page two
01:52:26 from you same day back to amelia reynolds hi emilia yes please could we include it many thanks joanne yes
01:52:33 yes yes and then page one
01:52:37 page one not much on that page essentially second email back to you from amelia reynolds same day joanne all done regards emilia reynolds
01:52:48 done regards emilia reynolds your response to her the following day 3rd of september 2010 the day of publication many thanks emilia regards joanne
01:52:56 joanne looking at that do you accept that you were involved at least in part in making the actual amendments to policy 539 as amended in september 2010 uh i think amelia as that's clear from the email
01:53:07 amelia as that's clear from the email amelia has asked me to if we would like a definition in and amelia's
01:53:14 account about her updating it is quite clear in the the email and she's clearly asked me if we think the new
01:53:25 new um definition of fsg was to be added and i've i've confirmed that why would it be you she asked given as you told us you weren't the one involved in any of the
01:53:37 weren't the one involved in any of the any of the other discussions about the amendments earlier in the year um perhaps i was uh the only one in on that day perhaps because she wanted to get it published perhaps because we'd had a
01:53:48 published perhaps because we'd had a prior conversation it it it's not unusual for all three of us to be asked maybe if i hadn't been in and lindsay had been or had i hadn't been in and scott had been she
01:54:00 i hadn't been in and scott had been she would she would have asked one of them
01:54:06 now
01:54:12 can we then go to the question i wanted to come to which we may come back to that in due course but can i go to the question of the meaning of affected by fire smoke or heat
01:54:23 heat can we go back to the rift please lfp double zero one two one two four zero this is the one you created in 2010 to 11 at your js9
01:54:34 11 at your js9 and on page 14
01:54:39 it says
01:54:42 uh ask caller just under 1.4 purpose built flat for not inside caller's flat fire is elsewhere in block ask caller are you or is your flat being affected by heat
01:54:54 or is your flat being affected by heat or smoke you see that yes yes now
01:54:58 now can we look at with that in mind at paragraph 36 of your statement please on page 15. we saw this paragraph before i think i read this part to you in fact
01:55:09 read this part to you in fact and you say i asked john bradbury and jim knighton what information it would be helpful to obtain from a caller during an fsg call this including the determination of whether a caller is
01:55:20 determination of whether a caller is quotes affected close quotes by fire heat or smoke
01:55:27 did jim bradbury or jim knighton
01:55:31 john bradbury or jim knight and assist you with how a cro should determine if somebody was affected close open quotes close quotes by fire
01:55:42 close open quotes close quotes by fire heat or smoke i don't believe so did you consider putting any further explanation into the riff about how a cra should determine if a caller was
01:55:53 cra should determine if a caller was quotes affected on quotes by fire heat or smoke
01:55:57 or smoke um
01:55:58 um no
01:55:59 no but i think um
01:56:02 um the
01:56:03 the that conversation might have developed into
01:56:06 into with ost and training and and they might have asked fire safety when they were talking to them um
01:56:15 them um some detail what did you um what did you mean by affected
01:56:24 what do i mean by effect well let me try it differently um you can see the words in the riff are you or is your flat being affected by heat or smoke
01:56:35 by heat or smoke did you did you draft those words
01:56:38 uh yes i know i would have spoken to graham and together we would have formulated the wording but yes they would have effectively come from
01:56:50 effectively come from from me right what did you intend by the word affected well i think that was from policy um 1093 that we had been asked to
01:57:01 that we had been asked to go back to the principles um
01:57:05 um which says is a caller affected by fire heat or smoke what did you understand by the word affected um
01:57:13 um i would say my understanding is that if they are having a direct if smoke is directly affecting them in terms of affecting
01:57:25 affecting them in terms of affecting their breathing or their premise i.e entering their premise would be affected so not if there was smoke and fire all around them
01:57:36 around them but not either in their compartment or in affecting them physically well i think that's probably led from the presentation and the training that was delivered about
01:57:47 training that was delivered about compartmentation to all control officers that's certainly been something that i've had training in throughout my career about
01:58:00 career about compartmentation did you consider putting any further explanation into the riff about how a cra should go about determining whether a caller was affected in the way
01:58:11 whether a caller was affected in the way you intended or understood no and and i can't be sure um that that was discussed in training but i would imagine that that should have been captured in in training
01:58:23 captured in in training so
01:58:25 so not the rift but training yes right
01:58:32 and again why not insert into the riff one or two prompts or sub-prompts to
01:58:40 to help the cro make that determination yes i
01:58:47 yes i i think maybe just at the time that that we didn't foresee that that we were able to support a caller if they were being affected i.e smoke was entering their
01:58:58 affected i.e smoke was entering their property
01:58:59 property or was affecting them
01:59:05 can i then turn to assessment of safety routes of escape if they are affected in the way you explained
01:59:14 now you'll remember maybe you maybe you won't um
01:59:18 won't um there's nothing wrong with that but one of the findings of the chairman into the phase one report was that the riff operators did not contain clear guidance about how to go about assessing the safety of routes of escape if the caller
01:59:29 safety of routes of escape if the caller is or says that they are affected by heat smoke or fire or feel unsafe and just for the record that's paragraph 29.49 c of our phase one report as i said i don't expect that you would
01:59:41 as i said i don't expect that you would necessarily remember that but that is there like what comes from it is a question
01:59:46 question did you ever yourself consider whether further guidance was needed within the rif
01:59:51 rif to help cross assess the safety groups roots of escape when a caller told them that they were affected by heat smoke or fire or felt unsafe
02:00:02 well i must have at one point because when i drafted the riff we did have some bullet points and some indications about seeking alternative escape routes
02:00:20 yes
02:00:24 and we'll look at those but let's before we do that let's go to the vic bagnall's statement
02:00:30 statement uh uh he he exhibits to his statement to the inquiry uh a a document uh at lfb double zero one two two eight three three
02:00:47 and i'll just show you what i'll show you this document uh
02:00:51 uh he says that this is feedback i'll keep that on the screen but can i also show you what how he describes this document
02:00:59 document and i'm doing that because this is from april 2014 at a time when you were at cfoa
02:01:04 cfoa can we have his statement on the screen please lfb double zero two
02:01:15 and can we go in it please to page five paragraph 15. um he says there
02:01:24 uh it's got a long sentence but this is six lines up from the bottom there were further slight amendments made in the versions published in april 2014. these are the updated fsg riffs that he
02:01:35 are the updated fsg riffs that he updated in april 2014 firstly to standardize the incident type code staff would be required to use when handling fsg calls and secondly to include additional question prompts for call handlers following feedback received
02:01:47 handlers following feedback received from command unit staff during training workshops including asking whether the caller or anyone had a disability exhibit exhibit vb2 and exhibit vb2 is what is what we see
02:01:58 and exhibit vb2 is what is what we see on the left-hand side now
02:02:01 now looking at the document on the left hand side
02:02:04 side is it something you think you've ever seen before no i haven't you haven't no let's take it as quickly as we can then can we look at eight paragraphs down
02:02:15 paragraphs down uh it says
02:02:19 finding out how far from the nearest stairwell the caller's flat is this would assist crews when planning on route possible hose lengths it will also
02:02:30 route possible hose lengths it will also assist control in deciding if the caller could possibly make it to the stairwell this will also make the caller think about the layout and they may realize that actually they can get out
02:02:42 now take it from me that the version of the riff from april 2014 did not include that question as a specific prompt now you weren't there at the time so i'm
02:02:54 now you weren't there at the time so i'm going to assume that you aren't able to answer the specific question as to why it didn't
02:03:01 it didn't is that right no i wasn't there at the time i kind of answered no but when you came back did you
02:03:07 did you did you notice that that specific question wasn't in there as a specific prompt
02:03:12 prompt no and i i don't believe i'd i'd seen the feedback from from the command unit um
02:03:20 um that that you've just displayed there and neither was i aware of uh gm lindrage's report um for the lacking house board either and i wasn't made aware that that had
02:03:32 and i wasn't made aware that that had been written and was in existence right the lindridge report is january 2013
02:03:38 2013 and of course you've been at the cfoa about five months by then and we're to remain there for a further two years but are you telling us that even when you came back in january 2015 nobody nobody showed you the lingeridge review no
02:03:50 showed you the lingeridge review no when was the first time you saw the lindridge review um whilst preparing for phase two
02:03:56 phase two right
02:03:59 um going back to this point though did you ever yourself consider including this type of question or any other questions uh in the being put into the rift to help cras assess the safety routes of escape for
02:04:10 assess the safety routes of escape for callers uh no i don't recall that um if it helps the inquiry i would maybe um just to consider that there has always been
02:04:22 that there has always been discussions about control staff having um ord access and being able to view information so maybe that point was taken up
02:04:33 taken up and trying to get control staff access so they could see the layout of the flats and and how many stairwells it had in the nearest stairwell but you said there's always been discussion
02:04:44 you said there's always been discussion about that there has been discussion for a while certainly yeah for a while when
02:04:50 when before the grenfell tower fire
02:04:54 yes possibly yes right what happened to those discussions i don't know i think well um i think we were made aware that we could access it when um
02:05:05 when um we were having difficulties with vision and used
02:05:12 another program from lfb to access some address information which also contained information on uh operational risk database was that ever
02:05:25 operational risk database was that ever something that you recall
02:05:28 recall institutionalizing in the control room in other words making it a a norm that cras would go onto the ord as soon as the call came in say that they would have in front of them the layout of the building
02:05:41 layout of the building it was on a different system to the mobilising system so that would have been quite difficult to achieve and and it's it's called imapping i believe and that icon isn't
02:05:54 that icon isn't very easy to navigate when you're in there but we were aware of it because and staff were aware of it because um like i say when we were having difficulties with
02:06:05 when we were having difficulties with the vision mobilizing system would use imap in
02:06:08 imap in one or two times or maybe more to search for addresses
02:06:14 right uh and that would have been what in late 2015 early 2016. early 2016 yes yes after we'd gone live but we were still
02:06:26 after we'd gone live but we were still having technical difficulties with it and was the reason you needed to go to i mapping because you couldn't get the addresses yes because we didn't rush need to understand precisely the layout
02:06:37 need to understand precisely the layout of the building yes it was then we realized that imap in would give us access to that
02:06:45 to that now i'd like to ask you some questions next about a different topic which is assurances false assurances given to callers you've explained that you use the gap
02:06:56 you've explained that you use the gap analysis to create the rifts and we've already seen in the gap analysis that you identified the fact that and i'll just quote this back to you because we've seen it already the lfb training package tends
02:07:07 already the lfb training package tends to encourage a strong attachment between caller and fire control operator and reiterates the use of reassuring phrases which may be construed as offering a full sense of security that was a point you remember we saw
02:07:19 that was a point you remember we saw that yes
02:07:20 that yes picked up in the gap analysis and you remember we also saw that that was at odds with the national guidance contained in fsc 93 1093 yes yes because that's a gap um and
02:07:32 yes yes because that's a gap um and we've had that already just for our purposes for reference that's page 11 at lfb404750
02:07:38 within the gap analysis itself now against that background would you agree that in the fsg rifts that you created and as data amended by vic bagle in april 2014
02:07:50 2014 there was no guidance to cras that they should not offer they should not offer a full sense of security when providing reassurance to a caller
02:08:01 caller no it isn't explicit in in the rifts but again like in policy and like most policies in in london fire brigade and the route that we followed
02:08:12 the route that we followed it doesn't tend to have what you shouldn't do in it it tends to be a guidance note on what you should do rather than what you shouldn't so i'm not sure if that
02:08:23 not sure if that would have occurred to the group including me that were updating it to be specific not to add it in and but certainly it is a discussion in the training it was
02:08:34 discussion in the training it was discussed in the training right so is this again another instance of not in the policy not in the rifts but in the training
02:08:42 training yes right
02:08:44 yes right now let's look at the gap analysis uh at lfb so sorry let's look at the circular fsc 1093 lfb403617
02:09:00 we saw this on thursday paragraph two last sentence additionally in circumstances such as these which is where the caller is prevented from escaping due to locations such as
02:09:12 from escaping due to locations such as high-rise flats as one one of them a fire control operator may need to take into account that the normal procedure of calming the caller may not be appropriate and may even be dangerous in
02:09:23 appropriate and may even be dangerous in some circumstances now given that you say that the gap analysis was used to create fsg rifts why didn't you include these warnings in
02:09:34 why didn't you include these warnings in the rifts for control room operators at least to be aware of i
02:09:39 i i believe
02:09:41 i believe we were all comfortable that we'd done the revisions and and that we changed substantially and we'd removed a vast amount of bullet points and questioning and
02:09:54 bullet points and questioning and uh discussion and learning which relied and which focused on bonding with the caller and forming a relationship with the caller and and i think we felt that we had moved to a
02:10:06 think we felt that we had moved to a position where the information we were given and this had been agreed by um legal through the lack of house board or at least the lack of house team
02:10:17 lack of house team and that the statements that we provided to control staff to give to callers were
02:10:23 were factual but didn't allow callers into a full sense of security and that we didn't encourage uh bonding and i think we tried to do that
02:10:35 tried to do that um
02:10:35 um through training and and some of the the role play that was in the training yes and we'll come we'll come to that in due course but i think the answer to my question is not in the rifts but in the training yes
02:10:48 training yes uh
02:10:49 uh now when you came back from your secondment in january 2015 did you i think the answer is no because what you told us before but just confirm for us please you didn't do an exercise
02:11:00 for us please you didn't do an exercise whereby you reviewed the riffs revised by vic bagnell in april 2014 and and compare those with national guidance
02:11:10 guidance no i i didn't i was solely focused on the new mobilising system and the requirements
02:11:20 and the assumption i think you told us earlier you'd made that he wouldn't have made amendments unless they'd been in line with with national guidance i think that's what you told us earlier i think yeah and and and certainly seeing the
02:11:31 yeah and and and certainly seeing the the information provided in in gm lingerie's report they'd obviously made some changes on on that report and recommendations so
02:11:42 recommendations so will you say certainly seeing the information provided in gm lindrich's report yeah that's that's the report that you told us you didn't see until you were preparing for phase two no see after that i can understand that they made those changes
02:11:54 made those changes based on some of those the feedback in that report and some reviews that they may have undertaken so you're not telling us that you didn't undertake a review
02:12:02 review of vic bangla's amendments against the national guidance because of something you'd seen in the lingerie report at the time no i was just affirming that i can understand now after seeing dave lindage's report
02:12:13 lindage's report why
02:12:14 why they had made some changes yes now can we go back to your witness statement please paragraph 39 page 16.
02:12:27 you say there i recall that one of the updates to the riff
02:12:32 riff was that we removed comments in the riff about bonding with the caller as it was acknowledged that this should not be included in giving fsg advice following the review of policy 539 the updated operator riff
02:12:43 updated operator riff which you exhibited as js9 contains more limited guidance on how to appropriately reassure the caller whilst making only true statements such as the firefighters are on their way
02:12:55 are on their way i'm just um just looking at that um i'm focusing first on the first sentence if i can i'll come to the second one shortly you you can you please be shown lfb three zeros three three two two zero
02:13:14 this is about bonding and uh here is an email at the top of the page
02:13:21 the page that you sent to graham bonnet pueta peter suarez copper to scott hayward 3rd of january 2011. so this is at the time you're amending the riffs i think isn't it
02:13:32 amending the riffs i think isn't it yes it looks like it because they were they were rolled out on the 23rd of february 20 2011 as you we saw earlier this morning hi graham and peter please find attached the latest version of the fsg riff
02:13:42 fsg riff i've clarified the questions relating to closing vents and delete deleted the bullet point relating to rescuing babies or small children as we could not find this in clg guidance i'm happy to include it if the source is from fire
02:13:53 include it if the source is from fire kills website and or his government advice i've also removed the word bonding from the riff but the only but only the word and not the recommended actions i think it's the word the latino board will be
02:14:04 word the latino board will be uncomfortable with as this is nowhere in national government guidance if you have any any additional comments then please let me know asap as the next stop is for it to be forwarded to training department for comment before
02:14:16 training department for comment before it goes to the oms now just focusing on that second paragraph there closely why did you only remove the word bonding but not the actions
02:14:29 i'm i'm not sure in terms of where it refers to what the actions were so when i've removed the words it says i've not removed the recommended actions
02:14:40 i've not removed the recommended actions but i'm i'm not sure what those were in the rift if you could show me those i might
02:14:44 might be able to help a bit more well just on this email
02:14:51 i'm asking you about your decision to remove only the word and nothing more because you say i think it's the word the latino board would be uncomfortable with
02:15:02 with yeah why did you um why were your amendments so narrow simply semantic and not actually addressing the actions
02:15:14 and not actually addressing the actions so just on how i've seen previous riffs laid out it might have said try and bond with the caller and then given some suggested phrases and recommendations and actually
02:15:26 phrases and recommendations and actually some of the phrases and recommendations might have been in line with what we had agreed at the lack of board such as the firefighters or on the way all the firefighters know where you are
02:15:38 all the firefighters know where you are and
02:15:38 and so
02:15:39 so it might have been just that i removed the word bonding and not to bond with the caller rather than the bullet points but without seeing it
02:15:50 the bullet points but without seeing it i i can't really be sure right well let's since you asked let's look at the actions
02:15:55 actions um
02:15:56 um forgive me it's at nfb double zero one two one two four zero uh and i
02:16:02 uh and i have helped me with this look we'll look at page 12. let's have them side by side actually that that's i think the better approach so we can actually see what you want you want to see
02:16:16 if we keep the email on the screen and go to lfb double zero one two one two four zero page twelve
02:16:30 uh yep now um underneath rio show the caller example guidance and you see four bullet points there the firefighters are on their way the firefighters know where you are the firefighters are there the
02:16:42 you are the firefighters are there the firefighters are dealing with the fire that's your amended guidance i think isn't it yes yes so those are the actions they've not been removed you only remove the word bonding
02:16:53 only remove the word bonding as we've seen from the email on the left yes yes right now given that your gap analysis had identified the fact that the lfb documents were not in line with national guidance because
02:17:04 in line with national guidance because they promoted forming an attachment with the caller shouldn't you have taken further steps to remove the actions from the rif as well or amended them rather than indulging what might one call one might
02:17:15 indulging what might one call one might call semantic minimalism so
02:17:20 so i understand what i've written there about removing from the rift but this has also gone to training department for comment
02:17:26 comment and and to the oms and probably a further discussion with myself scott tim cupple and tom davies from legal as well so
02:17:37 well so that is the final version so there might be some more amendments and we might have amended it further and the original might have just had something about as i say
02:17:49 something about as i say make sure you bond with the caller and that was something we'd identified in our gap analysis and wanted to remove and it looks like it's been streamlined further
02:18:00 further to reassure the caller and and i can assure you that those statements were agreed by
02:18:09 by the legal team that were working on the lachenal house inquiry to make sure that actually they they felt that they were good
02:18:19 good pieces of advice to reassure the caller but weren't lulling them into a false insecurity or weren't false truths yes but well that's the point isn't it you just mentioned
02:18:31 just mentioned the
02:18:31 the the nub of this or the number of the last sentence of paragraph two of 1093 was that cro should not say anything to callers to lull them into a full sense
02:18:43 callers to lull them into a full sense of security yes
02:18:47 yes yes yes we've seen it i think there is a warning there yeah yes
02:18:52 yes that's the point and therefore bonding which is just another way of of saying getting them to trust you is is one thing
02:19:03 is is one thing but do you accept that by leaving the example guidance in this four-fold set of examples of reassurance you were
02:19:12 you were creating or perpetuating a situation where cros might very well lead a caller into a full sense of security
02:19:22 as i said i think the
02:19:25 the bonding compared to the previous rift that you've shown me you can see a drastic reduction in the sentences and the the phrases and the phraseology that we had suggested and
02:19:38 phraseology that we had suggested and those four phrases there were agreed um by the legal team that they were appropriate to reassure the caller and that they were what we
02:19:50 the caller and that they were what we could offer them
02:19:54 can we go back to paragraph 39 of your witness statement and the second half of the paragraph i read to you
02:20:03 following the review see that
02:20:07 see that i read it to you before following the review of pian yes more limited guidance and you say at the end there whilst making only true statements such as the firefighters are on their way
02:20:19 firefighters are on their way now the rift you created we've just seen it
02:20:22 it and indeed the 2014 version as well which i haven't shown you but take from me
02:20:27 me doesn't actually tell cras only to make true statements does it no no
02:20:37 were they ever told only to make true statements in other words statements they knew to be true and not to provide false assurances or rather assurances that they couldn't
02:20:48 rather assurances that they couldn't verify
02:20:52 not in terms of do not make untrue statements and only state true statements i don't believe so i i didn't deliver the training the content i do know that
02:21:03 content i do know that we'd removed the bonding and from that why
02:21:09 why so just to draw the threads together there's nothing in the policy that says only make true statements don't make unverified statements there's nothing in the riff to that effect
02:21:20 nothing in the riff to that effect and there's there's nothing in the training to that effect there may be something in the training i i'm not right i can't recall everything that was in the training and and didn't
02:21:31 that was in the training and and didn't create the the training but um
02:21:35 um i would imagine there were some discussions as i've said previous about not bonding with the caller why not have it in the riff after all this is in the guidance it's spelt out in in paragraph two of
02:21:48 it's spelt out in in paragraph two of the national guidance it's clearly important why not spell it out in the riff just so that no one would be under any illusion about it yes i i think that's probably true but
02:22:00 yes i i think that's probably true but um also with controller and talk call taking they would probably even though if it was written in statements they would want to offer some reassurance to callers they
02:22:11 offer some reassurance to callers they would want to try and make them feel safe in those sort of situations so even though if it was written in policy they might offer
02:22:20 offer statements up they certainly control staff were under the impression uh even after lucknow that and
02:22:29 and and really evidenced by the the number of five survival guidance calls that we'd had even after lachanel that firefighters would rescue
02:22:40 firefighters would rescue the caller and
02:22:42 and the control officers would keep them safe
02:22:45 safe until they arrived
02:22:50 it's a matter of assumption isn't it rather than fact you use the word impression well like i say on the evidence after even or prior to lachenal
02:23:02 even or prior to lachenal and then after lacking that was never not true
02:23:12 well on their way the firefighters are on their way be
02:23:18 be loosely true but it may not in fact be reliable enough
02:23:25 because the firefighters might be battling their way up a high-rise building
02:23:30 building encountering increasing difficulties yes over time yes and therefore saying that to a caller stuck high in such a building would offer an increasingly false sense
02:23:41 would offer an increasingly false sense of security wouldn't it yes like i said they were the ones that was were discussed and were suitable for control officers to say
02:23:53 can i then turn to the question of what to advise a caller once a decision had been made to revoke stay put advice can we start with paragraph 69 of your
02:24:04 can we start with paragraph 69 of your statement please at page 26
02:24:08 and this is
02:24:11 this is where you deal with policy 790.
02:24:16 the question is at the very head of the page in relation to action 14 creation of policy 790. question the inquiry understands that you were involved in the development of
02:24:28 you were involved in the development of policy 790 with patrick utting please confirm whether this is correct and set out the nature of your involvement and your answer is i had some involvement in the development of pn 790 with patrick cutting after the latin house fire i
02:24:41 cutting after the latin house fire i reviewed pn 790 from a control perspective to ensure that the words and descriptions were accurate i also recommended that a change of advice given to residents in high-rise buildings should occur and needed to be
02:24:52 buildings should occur and needed to be included in the policy this work was carried out in 2011 before i was seconded to cfoa pn 790 was not at that time a shared policy between operational firefighters and control
02:25:07 now if we look at pier 790 it's at lfb triple zero eight three four four seven
02:25:15 uh this is the addition
02:25:19 addition of what was as we know tagged uh as labeled as draft 155 uh and this this is at february 2011 10 february 2011 you can see that still in
02:25:31 february 2011 you can see that still in draft as you can see from the watermark if we go to page four
02:25:37 um if you go to page four that says section 6.6 in exceptional circumstances an ic may consider informing control that their advice to fsg callers should be altered
02:25:49 advice to fsg callers should be altered i.e to attempt to leave their property was that the sentence that you suggested should be inserted yes
02:25:58 yes what did you intend be meant by exceptional circumstances
02:26:03 i think this was just following our investigations into the
02:26:10 the lack of fire where i think we realized that
02:26:13 that um
02:26:15 um we could have advised a caller to leave their building earlier than we did
02:26:24 and it was purely from that that we had a discussion um
02:26:30 um about if we might use that in future and because uh
02:26:37 uh the board had asked us to go back directly
02:26:40 directly to
02:26:41 to 1093
02:26:42 1093 and
02:26:44 and that we wanted to make sure that that was in um and that the incident commander understood it may be um contravening our
02:26:54 national guidance which we had committed to follow
02:26:59 do you remember whether you were party to any discussion about what the ambit or meaning or content of exceptional circumstances should be
02:27:08 should be no and i i don't think i came up with the wording and i think from a controlled perspective i acknowledge that we may need to change
02:27:19 acknowledge that we may need to change advice to get callers out of the building and and i certainly think pat from an operational perspective and his work with policy 790 had realized that too
02:27:31 policy 790 had realized that too and
02:27:33 and we were focused on talking about information gathering and information sharing on the instant ground and we'd been really um
02:27:44 instant ground and we'd been really um forceful that it should be two-way communication so we wanted to make sure that that was in and and i think we probably wanted to make sure that there was a a piece in there so the incident commander just didn't make that decision
02:27:55 commander just didn't make that decision on the instant ground but needed to share it with control so the wording and i didn't i don't believe i had any input into but
02:28:06 i don't believe i had any input into but the the meaning of it and what we were trying to achieve yes i did right um you said in that last answer uh earlier on in the answer that
02:28:19 from a control perspective i acknowledged you said i acknowledged that we may we may need to change advice to get callers out of the building yes when you say we do you mean control
02:28:34 yes i would have meant control yes so did you have in mind when you were involved in the amendment of policy 790 that
02:28:42 that it would be it would be control who might
02:28:47 who might take the lead in changing that advice from stay put to leave
02:28:53 leave probably i probably would have thought that because we were talking to callers we would
02:28:58 we would be aware of of their circumstances and following the two-way communications that we thought we were putting in that we'd be aware of what was happening on the instant ground as
02:29:09 was happening on the instant ground as well
02:29:10 well and and would come to that assumption and and then share that with the incident commander and have those discussions
02:29:19 so it was your thinking at the time that the decision to
02:29:25 to revoke stay put a move to get out
02:29:30 should be one taken by the control room or the incident ground and shared mutually
02:29:40 i think they could both contribute to it right
02:29:44 right the reason i ask you that is because if you look at the words on the page at 6.6 in exceptional circumstances and ic may consider informing control that their advice
02:29:56 that their advice to fsg callers should be altered uh it tends to suggest i think doesn't it that it was a decision made by the incident commander it does yes why was that
02:30:08 commander it does yes why was that why was that language used in the end i'm not entirely sure but i would imagine that that they would have thought that it would have been the instant commander that would have all the information there and be able to make that decision
02:30:21 be able to make that decision and the control room wouldn't have been right
02:30:23 right now we know that what happened on the night of the fire in fact
02:30:27 in fact you yourself i think together with d.a.c fenton came to your own independent decision to revoke stay put yes and then you communicated that to the fire ground at the same about the same time that
02:30:38 at the same about the same time that andy robe is doing the same thing there we know that um have you ever done that before before the night of grenfell no and i don't think even though we talked about it and and discussed it after after luck and
02:30:49 and discussed it after after luck and all that was certainly some of the learning that we'd taken and i'd taken and and whilst we'd put it in policy i i don't think we'd ever foreseen us
02:31:00 i i don't think we'd ever foreseen us using it right right and we would follow from that i think you'd you'd accept that you never really considered what you would be looking for by way of exceptional circumstances let alone teaching cras what they should be
02:31:13 alone teaching cras what they should be looking for by way of exceptional circumstances um
02:31:17 um yes potentially i mean exceptional circumstances with an ic i suppose they're like on the instant ground they would be aware of what i said exceptional circumstances related to that incident
02:31:29 to that incident certainly as a brigade control senior manager i probably had my own idea of exceptional circumstances i'm not sure that would have been shared with the control officers
02:31:40 control officers it certainly wouldn't have been a decision i would have expected them to make now as you say uh after lachenal this was a possibility and that explains why it's present in this policy here
02:31:52 this policy here in this form 6.6 we'll be at a draft at that stage did you consider what advice crash would need to give to callers in order to carry out
02:32:02 carry out the
02:32:03 the new advice or to give the new advice in practice
02:32:07 i think we probably thought that actually that would change dependent on the circumstances i mean did you ever consider
02:32:17 what it was that cra cra should say to callers who called in once statement had been revoked by the incident commander and you had been told of it
02:32:29 of it um
02:32:31 um not to
02:32:32 not to add in to anything because like i said i would have thought that depending on the circumstances the advice that was coming from the incident commander might might be different um
02:32:44 be different um but from
02:32:46 but from a brigade
02:32:48 a brigade control senior manager level where it would have been one of us that would have made
02:32:53 have made that decision or consider that decision yes i would imagine that we would have had
02:32:59 had some idea of what we were saying like like on the night and and what we were telling people and we would have instructed uh control staff to do that and they are
02:33:11 uh control staff to do that and they are like all
02:33:13 like all ranks and roles in in the fire service understanding of a piece of information and implementing that
02:33:21 that order or instruction did you consider that guidance might need to be given to cros either in policy 539 or in the fsg riffs
02:33:32 or in the fsg riffs no um but i think the i can't recall having a a discussion about that um but maybe because the imminent danger part was in
02:33:45 because the imminent danger part was in and was in national guidance 1093 that we
02:33:50 we collectively said that that would cover the exceptional circumstances if a caller was in imminent danger why not amend the rifts at least
02:34:01 why not amend the rifts at least in order to contain some set of prompts so that if controlled have been told by ic that their advice should now be altered say that the caller should attempt to
02:34:12 say that the caller should attempt to leave their property the cra would know what to tell them well i think because we
02:34:18 we one we were conscious that the advice may be different so they may say that
02:34:25 that they should use a particular stairwell or just for thinking or i mean this is a generic policy this isn't specifically for high-rise so i think in sometimes you know the breaking of the window on
02:34:37 you know the breaking of the window on the top floor as you know fsg calls
02:34:41 fsg calls from the database our experience of those are from domestic dwelling fires and therefore the advice to break a window and to jump from the first floor
02:34:52 window and to jump from the first floor if you were in danger was included in there yeah it wasn't the raf the riff on fsg the place to contain prompts so as to
02:35:04 the place to contain prompts so as to cater for this possibility
02:35:09 because you're dealing with fast survival guidance whether from a high rise or anywhere else i accept that that is generic in that sense but yes given that the rifts were all about fire survival guidance wasn't that the place
02:35:20 survival guidance wasn't that the place to have in one or two prompts about what it is that the call handler should tell the caller about leaving about how to bring it home to them they
02:35:31 about how to bring it home to them they would have to leave
02:35:34 yes and why why wasn't it in there do you know because i don't think we thought of of those exa extreme circumstances um and
02:35:46 extreme circumstances um and like i say the imminent danger and the wording that we've put in you know is there anything we could you can think of to get you out of that property and
02:35:58 was a start of that conversation
02:36:02 can we just look at your police statement
02:36:09 right you say it's the start of the conversation can we just look at your police statement uh at met triple zero eight zero six zero six
02:36:19 page thirteen second paragraph down about four lines down from the start of that you say and you've cited the
02:36:30 and you've cited the part of the draft from 790 about the changed guidance and then you say cras do not have training around this potential change as we did not envisage that this would be
02:36:42 we did not envisage that this would be necessary
02:36:43 necessary particularly on the scale of the fire at grenfell tower now leaving aside for a moment whether you envisaged a fire on the same scale as occurred at grenfell
02:36:54 as occurred at grenfell given that you had inserted this paragraph into the policy why didn't you envisage that it would be necessary even in a rare situation
02:37:03 um i i don't think i had the the knowledge or the background in terms of my understanding of high-rise buildings and compartmentation to
02:37:15 buildings and compartmentation to know what we would be advising what would be the best to advise a caller
02:37:24 and if you go to the top of the page
02:37:30 you can see in the last line before the end of the paragraph there you say this is an fsg policy for operational firefighters and this policy was never designed to be used by control room
02:37:41 designed to be used by control room staff
02:37:43 what was the point of having a policy aimed at firefighters based on what cras might do in exceptional circumstances particularly if you never trained the cras on what they were to do when those circumstances arose
02:37:55 circumstances arose well policy 790 was a another request from the lack of house investigation and
02:38:04 and was to provide firefighters and an explanation about what a fire survival guidance
02:38:10 guidance call was and the actions to take when receiving that information on the incident ground and then focused on the the communication and the two-way
02:38:21 the communication and the two-way communication that should happen between the
02:38:25 the control room and and the instant ground so it was an all-encompassing policy to
02:38:33 to share with the operational staff uh what to do on the instant ground when receiving a survival guidance cool yes i understand that but when the
02:38:45 yes i understand that but when the information comes back from the incident ground
02:38:48 ground that the advice to callers should be changed and they should now be told to leave
02:38:52 leave why not develop training to assist the cras if that happened well i
02:38:58 well i i agree and i think we like we've done in in previous we've gone on the experience of the previous fire survival guidance and how many five survival guidance calls we take to a
02:39:10 survival guidance calls we take to a domestic property and train for uh that escape from a window and that immediate danger alert and helping them escape from a domestic dwelling
02:39:21 escape from a domestic dwelling and not a high-rise building
02:39:25 different topic supervisor riff
02:39:30 nfb double zero one two two eight three eight please
02:39:42 this is the far survival guidance supervisor riff
02:39:47 and if you look at the heading 1.1 initial supervisor action there's a prompt there at the very head of the page and then the text
02:39:57 the text under that title if circumstances allow supervisor or nominated person to support and assist the cra by monitoring the call and ensuring that and there's a series of things to be insured
02:40:09 series of things to be insured uh and um that's also repeated in appendix 3 of policy 539 isn't it we can go to it if you like but i think it isn't yes it is now that that's the the
02:40:21 isn't yes it is now that that's the the background can we look at vic bagnell's statement please lfb double zero one double two eight two one page six paragraph twenty
02:40:40 uh and he says there the approach to receiving and managing fsg calls is that a supervisor is allocated to each call handler receiving an fsg call ordinarily there would be three supervisors on duty
02:40:51 there would be three supervisors on duty who would have a number of other responsibilities during their shifts would you agree looking at that that the intention of the rift was for a supervisor to be allocated to each cro handling an fsg
02:41:02 allocated to each cro handling an fsg call
02:41:05 yes to provide support yes and guidance and that was from our lack of investigations as well and would you agree that the policy could not have worked in practice if the number of fsg calls
02:41:17 number of fsg calls coming in exceeded the number of supervisors available at any time um
02:41:23 um no i think the supervisors are there in my
02:41:27 my opinion the supervisors are there to provide support and guidance and the control officer has a riff or there is another usually another control room officer
02:41:38 usually another control room officer that can support them as well i wouldn't have said it was unusual that a supervisor could monitor two fire survival guidance course if they
02:41:49 fire survival guidance course if they were sitting next to them obviously depending on the location in the control room
02:41:54 room and it would depend on how they would monitor them and they could be sat next to them or they could go around and plug their headset in and listen directly with the supervisor or with the
02:42:06 directly with the supervisor or with the control officer or they could monitor from the audio positions at the back of the room it would entirely depend on on the situation but i would say
02:42:18 the situation but i would say if you had two or three fire survival guidance calls one supervisor could undertake that task with with a cro um but our
02:42:27 but our cross also receive high survival guidance training in what to do uh i think the original aim of this was from uh the lacking house fire where
02:42:39 lacking house fire where um
02:42:41 um when lindsay came into the room she monitored the call taker talking to an fsg caller and
02:42:49 and and actually we thought maybe she would be in a better position uh supervising the strategic responsibilities of the room and a supervisor could have undertook that role and that's where that came from it
02:43:01 role and that's where that came from it was a support really so
02:43:05 so in that answer is your is the thrust of your point that the policy did work in practice or would have worked in practice if the number of fsg calls received or at least received
02:43:16 calls received or at least received concurrently exceeded the number of supervisors because supervisors could divide their attention equally between two cras taking fsg calls
02:43:25 calls yes were they ever trained to do that
02:43:29 um no but they are trained to support the control room as supervisors every day with a with a variety of different calls that came
02:43:40 a variety of different calls that came in and they might have one or two cros that need answers to questions and information at one time and and that's actually
02:43:51 actually part of a skill of a control room officer and especially a supervisor that you do have um some different
02:44:02 some different you are able to take in information and concurrent information going on from callers
02:44:08 callers and information being passed to you at the same time and process that that's that's what makes you a very good control supervisor because on a daily basis you are
02:44:20 on a daily basis you are monitoring and overhearing calls and conversations that happen in the room between 10 people or 10 call takers so that's part of a skill so i would
02:44:32 that's part of a skill so i would it would be fairly normal for a control a supervisor to support a control officer taking an fsg call and and
02:44:44 call and and mobilize or carry out additional actions or support two control officers taking fsg calls
02:44:56 but i think the answer to my question is no
02:44:59 no there was no training given to supervisors so in how to how to support a call a call handler taking an fsg call
02:45:11 if they have to divide their time between one such call handler and another not specifically fsg calls i was just trying to explain that just happens that is just the role of a supervisor
02:45:23 supervisor in the control room and they would have received
02:45:26 received experiential training on a daily basis to do that have you seen any policy or any training or any any riff that would suggest that on occasions a supervisor might have to
02:45:39 supervisor might have to be allocated to more than one call handler handling an fsg call
02:45:47 no no see we haven't either and i just wonder whether we've missed something it doesn't seem to be part of the expectation that that would ever happen
02:45:59 well i think in the past and some of the incidents that you've shown me where we have received a number of fsg calls that must have occurred
02:46:09 occurred because
02:46:12 we may have only had three supervisors on with
02:46:15 on with six fsg calls so that and obviously someone needs to be there to carry out the supervisor action supervisory action so they would have always been multi-tasking so let's speak
02:46:26 always been multi-tasking so let's speak let's see if we can get an example you say six is that the air tower fire 31st october 2015. yes um so does that tell us that those six fsg calls were concurrent
02:46:37 six fsg calls were concurrent no it doesn't it was just an example i was given that actually a supervisor is more than capable of supporting a control officer giving fsg training
02:46:48 control officer giving fsg training giving fsg guidance and
02:46:51 and undertaking other roles and tasks and one of those could be listening to another call do you remember whether at the adair tower fire with those you say six fsg calls the
02:47:04 with those you say six fsg calls the records suggest nine doesn't matter for present purposes do you remember whether the supervisors on duty were dividing their monitoring time between different cros handling
02:47:16 between different cros handling different fsg calls no i don't but i would imagine they may well have done i certainly have done it when i've been in the room when we've been dealing with a an incident where we've taken two or
02:47:28 an incident where we've taken two or three first survival guidance calls to add support
02:47:35 did the experience of lachenal in july 2009 or the marriott fire in november 2010 or perhaps even the adair tower fire in october 2015 not prompt you to consider
02:47:46 consider whether your rostering of crs and supervisors needed to change in order to cater for the risk of of what i might call mass fsg a mass fsg incident
02:47:58 um in terms of increasing in terms of making sure that you had enough supervisors so that you could pursue what i might call best practice
02:48:10 pursue what i might call best practice namely the allocation of one supervisor to one control room operator handling an fsg call
02:48:15 fsg call yes i think we did i'm not sure when it increased um two four supervisors on the watch i believe that was a decision taken by
02:48:26 believe that was a decision taken by um
02:48:29 i see tom george although he might have been the deputy at the time right would that have been in 2016 possibly right but maybe in in 2017 there was some adjustment to
02:48:41 there was some adjustment to um increase the supervisory role in control was that in contemplation of an increased risk of higher numbers of concurrent fsg calls
02:48:52 higher numbers of concurrent fsg calls no i i don't believe so because i think
02:48:56 i think as i've said before if you know we didn't have sufficient supervisors or supervisors weren't able to support the control officer because of mass fsg calls then
02:49:08 officer because of mass fsg calls then we would handle the fsg calls and our arrangements with our buddy control rooms
02:49:13 rooms and bt would be able to make sure the other calls to an incident or other instance were answered
02:49:22 did you ever discuss with anybody such as scott hayward or dave brown or tom george that your policy of at least in writing of allocating one supervisor to one cro
02:49:34 of allocating one supervisor to one cro handling an fsg call was never going to work in practice if a mass fsg event happened no because i i don't think we ever foresaw um a mass fsg incident well was latino
02:49:47 a mass fsg incident well was latino house not a mass fsg event multiple fsg calls
02:49:50 calls well again that's that was the result and and as i've explained that's why we said a control supervisor could assist because
02:50:01 assist because whilst lacking if you determine a fsg incident all three supervisors were available whilst they were undertaking other tasks and we identified that one of them could
02:50:13 and we identified that one of them could have been available to support one of the control officers taking a a prolonged fsg course so i think that that was recognized and that's why
02:50:25 that was recognized and that's why as a collective we said that supervisors could support the control officers given fsg um and given them some guidance and and some training on that
02:50:37 some training on that can i ask you to look please at vic bagnell's statement lfb double zero one double two eight two one
02:50:44 one page seven paragraph uh
02:50:48 uh well the paragraph we were on in fact
02:50:54 and he says there
02:50:58 at the top of the page third line from the from the end of the paragraph there were resourcing issues at control that did not allow for a supervisor to be allocated to each call handler when receiving multiple fsg calls
02:51:09 receiving multiple fsg calls particularly if these were received during a night duty
02:51:15 do you agree with that do i agree there were resourcing issues at control yes yes well do you do you agree with everything he's written in that sentence i've just read out to you
02:51:27 i've just read out to you yes just
02:51:28 yes just through our staffing and and the shift pattern that had been introduced with
02:51:34 with uh
02:51:35 uh ten overnight then
02:51:39 then yes had we taken three or four fsg calls
02:51:43 fsg calls then are
02:51:45 then are a supervisor wouldn't be able to monitor each one what were the resourcing issues staffing
02:51:58 did you ever go to scott scott hayward or ac dave brown or ac chandler or
02:52:06 or ac george and say we've got a staffing problem
02:52:10 problem we can't
02:52:12 we can't we haven't got enough resources to allow for a supervisor to be allocated to each call handler when receiving multiple fsg calls
02:52:20 calls not in relation to multiple fsg calls but just in relation to resourcing and control yes you did yes in general but not in relation to fsg not specifically in relation to fsg calls but in in
02:52:33 in relation to fsg calls but in in issues in resourcing in general uh specifically uh when i was in charge of the the ost team with results in but that didn't
02:52:44 team with results in but that didn't sit it wasn't just the ost team it would have been
02:52:47 have been staffing in general at control we'd had periods of time where we hadn't been able to
02:52:53 able to recruit
02:52:55 recruit and
02:52:55 and we'd had a mechanism that didn't allow us to recruit as soon as we identified that someone was leaving and we'd had a number of temporary posts that all and
02:53:08 that all and that all had an impact in staffing and we'd had
02:53:12 we'd had and dealt with some incidents where we'd recognize that an increase in staffing would be beneficial but not in specifically related to multiple fsg now why not
02:53:30 just because it had been raised previously and and we deal with a significant amount of other incidents and where the impact of resourcing had been
02:53:43 the impact of resourcing had been noticed so and it hadn't been with multiple fsg calls i can only presume from your perspective ms smith was this a question of the lfb's priorities
02:54:00 yes
02:54:12 um now
02:54:16 when you came back from uh the cfoa in january 2015. did you do anything to ensure yourself to ensure that the cross and supervisors
02:54:27 ensure that the cross and supervisors reviewed and familiarized themselves with the rifts not that i can recall but i was aware i think that we'd moved to deliver some supervisory
02:54:38 we'd moved to deliver some supervisory training
02:54:39 training and and that the supervisor riff had been recreated and
02:54:43 and and they had yeah yeah let's look at the document um i think we've saw this before lfb triple zero four one seven six three
02:54:56 and now this is a training record for all fsg training from 2011 to 2018
02:55:13 uh we haven't looked at it in this phase but we've seen this before i think but do you does this document familiar to you yes i have seen it yes can you tell us what it is
02:55:24 can you tell us what it is it was something i believe we were requested to do by lfb health and safety which was to document
02:55:32 document every member of staff we had a record for joining control and then their training in fire survival guidance
02:55:44 their training in fire survival guidance now
02:55:46 now we've examined this document and and forgive me for this impressionistic question but it suggests that not all cross and supervisors were recorded as having reviewed the fsg
02:55:58 recorded as having reviewed the fsg riffs in 2012 and 2013 and there's nothing recorded after 2013 in it
02:56:04 in it now what i've just said is what we've gleaned from the document but does that sound right to you uh have you got an example so are you looking at um
02:56:16 an example so are you looking at um there's a block of empty box in there so it takes from when it started back in 2011 when we first rolled out the refresher training yes um
02:56:27 training yes um but obviously it includes all our members of staff that had joined and have joined since so maybe some of those staff hadn't joined in 2010 2011 and that it actually
02:56:39 in 2010 2011 and that it actually only catches up with their training when they joined maybe in the latter part of 2016 2017 looking at some of the names where it's blank
02:56:48 blank well rather than getting bogged down in the detail of the document can i ask it a different way do you know what was done from your recollection at least in 2012 when you were still at control to ensure that all staff
02:56:59 at control to ensure that all staff familiarize themselves with the fsg riffs that you'd amended in the previous year
02:57:06 no apart from the email right was there any plan in place that specified that existing staff must re-familiarize themselves with the rifts at regular intervals
02:57:18 uh no and i don't know if that was a feature of the training but not from my email that i sent out it just asked everyone that was employed at that time to familiarize themselves with it and the email you're referring to is the one
02:57:29 the email you're referring to is the one of the 23rd of february 2011 i think yes when you came back to control in january 2015 and headed up training did you do anything to make sure that cras and supervisors
02:57:40 supervisors did familiarize themselves with the riffs as they stood no but like i say i think um i'd seen or been told that they had had some specific training in in rifts
02:57:52 some specific training in in rifts or in the f cro and
02:57:56 cro and supervisor riff and who told you that
02:58:01 probably scott howard right given the relative infrequency of fsg calls
02:58:08 calls so that you couldn't expect crs necessarily to gather expertise through repeated exposure to fsg calls why not do something to make sure that they were well on top of
02:58:19 well on top of the content of the riffs um but
02:58:24 um but i think fsg is just one riff like i say it is a
02:58:28 it is a a prompt um to access if you need support during a call and but also we have a number of riffs i'm not sure how many we have but i would take a guess of
02:58:41 we have but i would take a guess of about 100 riffs all containing different information relating to over i think we're close to a hundred incident types that control officers deal with so
02:58:53 that control officers deal with so um
02:58:54 um fsg is one of those that they can access but there is lots more that they might need to access as well
02:59:03 as well to help them and assist them and such as a cbrn incident with stay safe advice there could be a range of them and
02:59:12 and and i was told that they had had specific training in fsg riff
02:59:18 riff uh
02:59:19 uh the year previous i believe but it might have been a bit longer thank you um is that a convenient moment yes i think it is thank you very much
02:59:30 yes i think it is thank you very much wellness swift we'll stop now for some lunch we'll come back please at two o'clock
02:59:34 o'clock uh and as i've asked you before please don't talk twin on about your evidence or anything to do with it over the break all right thank you thank you very much would you give the usher then please [Music]
02:59:54 thank you two o'clock please