London Fire Brigade evidence session examining fire survival guidance procedures, training development, and policy implementation following the Lakanal House fire.
00:00:25 would you ask mr smith to come back in please
00:00:39 right mrs smith ready to carry on yes thank you sir thank you very much yes mr miller yes thank you mr chairman uh i want to ask you some questions about the use of the riffs in practice can i take you please first to paragraph
00:00:50 can i take you please first to paragraph 32 of your statement
00:00:55 and uh you will find that uh on page
00:01:01 on page nine i think
00:01:05 uh page 13. uh the riff stored information about different types of incidents you see yes uh and what cras should do in the relevant circumstances
00:01:17 then you go on and then in the middle of the paragraph you say i seconded to cfoa shortly after the amendments to the fsg riff in 2011. and so i was not able to observe its success in practice for any
00:01:28 observe its success in practice for any significant amount of time the intention was to use cool coach to confirm the embedding of this riff on return from my supplement to cfoa the riff had been changed now the riffs went live as you
00:01:39 changed now the riffs went live as you told us this morning by reference to that email on the 23rd of february 2011 but you weren't seconded to the cfoa until september 2012 about 18 or 19
00:01:50 until september 2012 about 18 or 19 months later that's right isn't it yes it is yes so it's not shortly afterwards is it
00:01:56 is it you went to college no no
00:01:59 no no so that's we delete the word shortly from your paragraph now does that does that mean that after the riffs went live in 2011 you didn't do anything before september 2012 to observe whether they'd been embedded in the control room
00:02:11 been embedded in the control room operator's minds in practice uh not personally no not personally not not at all
00:02:20 now again the the review of uh fsg and high rise continued uh my own personal review of of all high-rise incidents continued throughout
00:02:31 high-rise incidents continued throughout that time until the time i left the seafarer so i suppose you could say i did it through that
00:02:37 that i see
00:02:38 i see so when you said not personally in fact you meant not institutionally but personally yes right
00:02:47 and so do we take it is this right just teasing the point out that the only oversight review monitoring of whether or not the newly amended rafs have been embedded into cra practice
00:02:58 cra practice through your personal review from time to time of the fsg database i would have thought that um if a control officer had had an fsg call and
00:03:09 control officer had had an fsg call and in discussion with their supervisor or their
00:03:13 their operations manager they may have fed back
00:03:16 back into
00:03:18 into the riff and if they found that useful if they did indeed use it and i think um it might have come up for discussion at brigade control management meetings because
00:03:28 because the operations managers obviously are in charge of watches on a day-to-day basis so would have seen its effectiveness in practice so would have fed back to us that way well you say i would have
00:03:39 that way well you say i would have thought and then you ended the answer
00:03:43 answer it would have did it did what you've just told us happen as a matter of fact well the om is feeding back to us what was their feedback i think there was yes right do you
00:03:54 i think there was yes right do you recall it
00:03:55 recall it not
00:03:57 not not
00:03:58 not um not really i think there was discussions at brigade control management meetings um i think when i was gathering evidence for this i saw a few emails where oms had fed back
00:04:12 saw a few emails where oms had fed back on the riff and i think they met that might have added to uh the change that took place in 2013 as well
00:04:20 well now can i ask you to look please lfb triple zero two eight four four three two eight four four three page two this is an email run in july 2011
00:04:32 in july 2011 so after the um amendments to the rifts that took place earlier that year it's an email from steve perry 21st july 2011 to lindsay turner and to you
00:04:44 and it starts hi lindsey stroke joanne further to yesterday's bcmm and the issues that were raised regarding the recent fast survival training package having reviewed the modules and discussed with aom's and some cro some
00:04:56 discussed with aom's and some cro some cros on number two watch i have the following observations and then if you go back over the page to page three paragraph
00:05:07 paragraph three at the bottom just before the sign off
00:05:11 off he says this i've asked some cras on number two watch that have experience of fsg calls and they've suggested some changes to the riff attached so that it starts with a list of the main bullet points which should help
00:05:22 main bullet points which should help crows
00:05:23 crows i'm sorry i keep calling them that cras in relaying some immediate information to a caller that said the cras believe it would be very difficult to concentrate and read the fsg riff while talking to a distressed caller having to
00:05:35 talking to a distressed caller having to scroll through it to find the pertinent questions when you have someone on the other end of the line could divert your attention elsewhere when your focus needs to be on the caller bullet points at the start of the riff may help
00:05:47 at the start of the riff may help do you remember that concern about the usability of the rifts for fsg calls being raised with you in july 2011. uh not
00:05:56 not no not specifically um but i would imagine we would have taken feedback from
00:06:02 from cros
00:06:03 cros and from the rifts and i agree with steve perry and what he's saying that the riff is there as a guidance document it is extremely hard when you're talking to a caller and
00:06:14 hard when you're talking to a caller and employing active listening and mobilizing fire engines and taking down all the details that a caller gives you to then read a detailed riff
00:06:25 a detailed riff did you do anything to the best of your recollection in response to this feedback coming back to you from steve perry
00:06:32 perry i can't recall specifically but it would be unlike me if i didn't act on on an email or some information uh stating a change because
00:06:43 uh stating a change because uh control officers have have not found it useful um i mean your more experienced cras had identified the use of the riff while talking to a
00:06:54 the use of the riff while talking to a distressed caller as something of a problem did you take that as a prompt to organize some training for cras so that they could handle that better no because as as i've said before
00:07:06 better no because as as i've said before i
00:07:08 i we didn't believe that the riff was a document to be followed while you were dealing with a caller and engaging with a caller as i've explained there's several um
00:07:20 there's several um you need to multitask and you need to employ active listening to engage with the caller and listen to what they're saying so reading a document that was
00:07:31 document that was had quite a lot of detailing wouldn't have been
00:07:33 have been easy as they've said there or possible which is why the riff was designed as an aid memoir with just some bullet points and some prompts
00:07:43 prompts to assist the control officer in a particular phase of a call
00:07:48 i see so
00:07:51 so when you say the rif as you told us before the rift was not a document to be followed while you were dealing with a caller do you mean that it wasn't a script but
00:08:02 do you mean that it wasn't a script but an aid memoir yes i see that but even as an aid memoir the more experienced cras was still finding
00:08:10 finding that
00:08:11 that uh
00:08:12 uh a problem difficult to concentrate and read the riff while talking to a distressed caller i would say all cross would right maybe depending on on on the type of calls they were
00:08:24 of calls they were dealing with yes but if it was a problem for all cras perhaps dependent upon on what calls they were dealing with why not give them some training on how to do the multitasking talking to the
00:08:35 to do the multitasking talking to the caller on the one hand and using the aid memoir on the other even if not treating it as a script i think control officers undertake that role every day when they're talking to
00:08:47 role every day when they're talking to callers on on each and every call and
00:08:51 and so i don't necessarily think training them to
00:08:54 them to take a call take the caller's detail listen to the pertinent information provide
00:08:59 provide them with advice and guidance mobilize fire engines and and then be able to read that's something that they do normally as i've
00:09:08 as i've tried to explain the riff is just there and maybe you get stuck at a certain point in a call that you might want to revert to just that point so just reading a couple of bullet points might
00:09:19 reading a couple of bullet points might prompt you to go down um that questioning technique maybe it was just to re-familiarize themselves with after they've done the assessment to look at the protect
00:09:31 to look at the protect element and and just have a read of that and what questions they could ask for the protect but
00:09:37 but it really is only a prompt
00:09:41 a prompt if they need it during a call well in the light of that answer i've got to ask you did you go back to steve perry and say that his concerns were misplaced or did you agree with his concerns and
00:09:52 or did you agree with his concerns and seek to do something about it i think i agreed with his concerns but didn't seek to do anything about it i
00:10:01 like i said to you it would be unusual that i didn't react to an email following feedback to improve the documents or the riffs that control officers use
00:10:12 officers use we haven't seen an email back to him from you
00:10:16 from you maybe lindsay responded um and lindsay and i had discussed it or all three of us had discussed it in a meeting and lindsay because a lot of this is pertaining to the
00:10:27 a lot of this is pertaining to the training
00:10:29 training she responded on our behalf and maybe spoke to ost too because they were still the people that updated the rifts we do have a response although not it's not in fact from you what happens to this email
00:10:41 fact from you what happens to this email is we can see from page one if we can get back up to page one and look at the foot of page one is that you send this email on to scott hayward
00:10:53 on the 29th of august 2011 some six weeks later in the context of your review of the fsg training we'll come back to that in due course
00:11:02 course but we haven't seen a specific response from you
00:11:05 from you saying thank you steve we'll take that into account or anything like that so i asked the question do you think you did uh no the main content of steve's feedback was training
00:11:19 steve's feedback was training so i would imagine lindsay ost would have responded to that
00:11:26 now can we go to paragraph 33 of your witness statement please uh on page 13.
00:11:35 when you say uh sorry 14 at the top you say that after the latin house fire i recall that it became mandatory for cras to look at the rif when conducting an fsg call however i recall that vision created
00:11:47 however i recall that vision created additional challenges when opening the rift due to limitations with the screen space available and then you go on to explain the work that was done to remedy that and then in the last line of the paragraph you say this however it was
00:11:59 paragraph you say this however it was still difficult to open the riff and have simultaneous access to information on the mobilizing system in 2017 this would have been particularly challenging with a large volume of calls combined with a large incident
00:12:12 with a large incident was that something that you were aware of before the grenfell tower fire
00:12:19 that it was difficult and accessing rifts was was
00:12:25 was difficult
00:12:26 difficult well um what you say there in the last is let me try the question slightly differently you say two things in those two sentences it was difficult to open the riff and have simultaneous access to the information on the mobilizing system
00:12:38 the information on the mobilizing system in 2017 that's the first thing you say and then the second thing you say is that would have been particularly challenging with a large volume of calls combined with a large incident are those two things something that you knew before the grenfell tower fire in june
00:12:51 before the grenfell tower fire in june 2017 yes
00:12:53 2017 yes sorry just to clarify yes i did know that opening the rifts was difficult uh on the new vision mobilizing system they no i'd never envisaged that it would have been particularly challenging
00:13:04 would have been particularly challenging with such a large volume of calls if you're if you're talking about right the incident of grenfell did you consider any other workarounds such as creating hard copies of the rifts
00:13:15 creating hard copies of the rifts to enable crs to access them on their desks
00:13:20 desks i think that was done at
00:13:23 at some point but i'm not sure if that was before
00:13:27 before the fire but whilst it was difficult it wasn't impossible and they did have access to the rifts
00:13:38 to the rifts in
00:13:39 in i think initially when we went live there was a lot of difficulties and they weren't able to open them and access them as easily from their main screen
00:13:50 screen but i believe there was a fix put in place or a work around them and they were able to access it from 2016 16.
00:14:04 um if it was 2016 why was there still a problem in 2017 as you say in paragraph 33 so just to
00:14:12 to explain that and to be clear our mobilising system opened um on one on a screen um but the riffs weren't contained within
00:14:23 but the riffs weren't contained within the mobilizing system so you had to come out of that and have that displayed on a separate screen that's all i mean with the difficulties the the access wasn't as easy as it was prior to the new
00:14:35 as easy as it was prior to the new mobilizing system that was a functionality of the new mobilizing system you say displayed on a separate screen do you mean a separate physical
00:14:46 a separate physical screen like this or a separate screen as it were within the within the physical window i believe in 2007 we were 2017 we were still using two separate
00:14:59 2017 we were still using two separate screens to display the the mobilizing information right and one of those would carry the ref with it one of them you could access the riff on that yes
00:15:10 could access the riff on that yes yes thank you can i now then turn to action 14 which is development of policy 790 first survival guidance calls and can we um pick this up please uh in
00:15:21 and can we um pick this up please uh in your
00:15:22 your uh statement please a paragraph 69
00:15:35 you say there i had some involvement in the development of pn 790 with patrick utting after the lack of house fire i reviewed pn 790 from a control perspective and this paragraph we saw before lunch
00:15:46 and this paragraph we saw before lunch so i'm not going to read it out again to you in full you'll remember what you said there do you remember how you became involved in the development of pn790
00:15:58 not specifically i think the lucknow board may have come to the conclusion that a policy needed to be drafted for operational
00:16:09 needed to be drafted for operational firefighters and officers and there was a natural conclusion that control would need to work
00:16:19 work with
00:16:20 with the creators of that just to make sure that it was aligned and that what they were putting into policy 790 didn't contradict uh
00:16:31 uh how control managed for survival guidance calls who supervised your work on the input you gave into policy 790 so i was just asked to
00:16:43 so i was just asked to input
00:16:44 input and
00:16:47 update it and add offer some considerations with pat and i worked with pat to do that um
00:16:54 um but i think there was always a link back to the lachenal team that i was working with so
00:17:03 with so scott hayward tom davis and tim cutville did anybody else from control assist you in your work on policy 790. that they may have done i may have
00:17:15 that they may have done i may have spoken to uh managers i may have spoken to
00:17:19 to ost as well to get their input it would be unusual that i wouldn't have consulted
00:17:26 consulted my peers and people that worked in the control room what direction were you given regarding the purpose of the policy
00:17:33 policy what were you told it was for i'm not sure i was specifically told what it was for i understood that because of the incident at lacanal
00:17:44 that because of the incident at lacanal and there was a requirement to inform and the operational staff how uh what to do and how to manage a fire survival guidance call on the instant ground so your recollection is that this was
00:17:56 your recollection is that this was specifically to address one of the coroner's recommendations arising out of lachlan
00:18:01 lachlan no not for me because i didn't think the coroner had the coroner had sat at that time when we were developing it this was from the lachnal board right so one of the 34
00:18:12 lachnal board right so one of the 34 actions
00:18:13 actions developed by the brigade before the inquest i believe so now can we look then at uh nfb triple zero two eight two seven two
00:18:25 uh uh and this is an email of the 14th of october 2010 uh from you to ac james knighton if you go to the bottom of page one
00:18:33 one can you see hi jim yes brigade control is currently updating their reference file information with regard to fast survival guidance
00:18:41 guidance and we're trying to provide the control officers with more specific instructions to assist
00:18:46 to assist from the if we turn the page from the latino board actions list it shows the policy procedure is due to be written operationally for dealing with the fsg calls it an incident has any work yet to
00:18:57 calls it an incident has any work yet to be done on this and if sayo is their information that as the ic they would like brigade control to obtain whilst talking to the caller now
00:19:06 now clearly from the timing this is october 2010
00:19:09 2010 this was written before you'd started working on policy 790. yes yes do you know whether that was in response to or
00:19:19 or did do you know whether you're working on policy 790 was in response to this email
00:19:24 email uh
00:19:26 uh i don't i don't recall no sorry i don't recall you don't recall you say has any work been done on this and was that was that what caught the attention uh of jim knighton
00:19:37 caught the attention uh of jim knighton to put you onto the job of assisting in the development of policy 790. so i don't really call it would have come from jim knight and whether he would have had that conversation with
00:19:48 would have had that conversation with with scott and and scott would have asked me i i really
00:19:53 i really don't recall um or maybe that during the discussions at the lacanal board that they would have talked about a policy that they needed for operational
00:20:04 policy that they needed for operational staff and i would have thought control should be included in that and
00:20:10 and wanted to be involved in it so that might have started it and you say in your statement paragraph 69 that we've just seen that you reviewed policy 790 from a controlled perspective you say to ensure that the
00:20:22 perspective you say to ensure that the words and descriptions were accurate uh now that's what you say there can i just show you what patrick utting says in his witness statement this is lfb double zero double one eight nine one
00:20:34 double zero double one eight nine one eight
00:20:35 eight page three paragraph eight
00:20:44 and he says there in late 2010 i was asked by ac jim knight to develop the first survival guidance policy following the lack of house fire and then a few lines on from that he
00:20:55 and then a few lines on from that he says this as brigade control already had knowledge of fire survival guidance and they are integral to responding to a far survival guidance call i worked closely with som steve ads throughout
00:21:06 closely with som steve ads throughout the drafting consultation and approvals process to ensure that the policy we developed worked with control systems and processes once the idea was developed i was responsible for the policy development consultation and
00:21:18 policy development consultation and eventual publication which took place in february 2012. do you agree with patrick gutting that you worked closely with him throughout the drafting consultation and approvals
00:21:29 the drafting consultation and approvals process
00:21:30 process in the points relevant to control yes in the points relevant to control can you explain in
00:21:37 in in short
00:21:39 in short what your method of working with patrick cutting was when you went about creating a draft
00:21:45 a draft in terms of that we he had a draft we would meet there would be
00:21:51 be some
00:21:51 some [Music]
00:21:53 [Music] points
00:21:54 points where he had either referred to control or
00:21:59 or put some actions that control take and i would have discussed those with him and and we would have talked about aligning them to what brigade control did
00:22:09 did did you split the drafting between between the two of you and focus on what you wanted no i don't believe so because it was an operational policy and he would have drafted it and i would
00:22:22 he would have drafted it and i would have had look at it for comment and commented on the the control yes items i mean his evidence was that he took the lead you were going around there on wednesdays essentially and
00:22:34 there on wednesdays essentially and uh catch up and um
00:22:37 um did that that was the way you inputted that does that accord with your recollection it does i would have been over at union street at a lacanal meeting we had weekly meetings on a wednesday and i would have seen that
00:22:49 wednesday and i would have seen that after
00:22:50 after did you
00:22:51 did you did you review all the drafts of 790 from a control perspective probably the ones i was sent um but
00:22:59 um but i couldn't be sure that all of them i reviewed all of them did you agree that your role was then simply it was more than simply reviewing to ensure that the words and descriptions were accurate you were actually involved
00:23:10 were accurate you were actually involved in the drafting of the policy now like i say the it was that the control actions were accurate
00:23:18 accurate that
00:23:19 that the they reflected what control did and aligned
00:23:24 aligned to
00:23:25 to how we managed it in control and there may have been um some additional comments that i made on the two-way communication so in terms
00:23:36 on the two-way communication so in terms of
00:23:37 of listing
00:23:38 listing the communications method we spoke
00:23:41 we spoke last week about css and the access we'd got to css to pass information so i may have added that in and but it was all functions that the
00:23:52 and but it was all functions that the control room had done and changed following the lack of house yes absolutely now patrick gutting speaks in his witness statement and just for our reference that's a paragraph 12 on page five that there were
00:24:06 five that there were changes to the policy reflecting issues that he says arose from the consultation with control he speaks of a consultation of control do you remember a consultation with control about the
00:24:17 consultation with control about the draft policy i think
00:24:20 i think we would have taken it to as it had some control actions in we would have taken it to our meeting with the representative bodies like
00:24:30 like pat would have taken it to their larger health and safety committee with the representative bodies so we probably did that as part of due diligence right maybe
00:24:41 right maybe we're across purposes what he means is that the operational side would would draft in consultation with control about the terms of the draft policy do you remember a consultation
00:24:53 you remember a consultation between the op side and the control side other than the weekly meetings that you had with pat hutting about the drafting no i don't right
00:25:08 now can we go to paragraph 70 of your statement please of page 26 page paragraph 70.
00:25:19 you say there uh in answer to the question please explain in particular whether the development of policy 790 considered how the control room should handle multiple fsg calls that are received
00:25:31 multiple fsg calls that are received concurrently and you say mentioned in response to question 6c above multiple fsg was not a known phrase at the time of the development of pn790
00:25:42 pn790 and so this was not considered pn539 covered all aspects of buddy control rooms and liaison with bt to manage call volume i also wish to emphasize the pn 790 was not a control policy at
00:25:54 the pn 790 was not a control policy at this time however since the grenfell tower incident multiple fsg is now contemplated in the current version of pn790 which is jointly owned by control
00:26:05 pn790 which is jointly owned by control now i'd like to
00:26:08 examine a little bit of the origins of the drafting of policy 790 against that background uh can we start please with the draft from the 23rd of january 2011
00:26:19 from the 23rd of january 2011 and that starts with an email that uh at lfb triple zero three 0028301
00:26:32 and you can see it's from you to him on the 23rd of january 2011. the subject is draft fire survival call policy version three hi pat i've added the information
00:26:43 hi pat i've added the information relating to the mdt and a couple of other amendments to try and align to our rifts i've also made a comment relating to the prioritization of calls quotes on quotes
00:26:54 quotes hopefully we can arrange some testing next week for the mdt information i would also like to give a copy of this draft to our training team at big great control who are currently working on our annual fsg refresher training which
00:27:06 annual fsg refresher training which should focus on this policy and our new rifts i will let them know it's it's not the final version but hopefully we're nearly there now focusing on the the sentence uh it
00:27:18 now focusing on the the sentence uh it says currently working on our annual fsg refresher training which should focus on this policy and our new rifts now the timing you'll you'll notice exactly one month before the rollout of the new
00:27:29 month before the rollout of the new rifts isn't it yes i see that let's look at the draft policy that you attached to this email lfb triple zero eight three five three one
00:27:41 one let's have page one up to start with and there
00:27:45 and there we will see
00:27:51 the very first version of this or rather the very first amended version of this with the word guidance added in red by way of a track change doesn't yet have even a draft policy
00:28:03 doesn't yet have even a draft policy number
00:28:04 number if we go please to page 4 paragraph 6.5 we can see some track changes there
00:28:15 and if you look at box 5 up from the bottom of the page
00:28:24 you can see that
00:28:28 the uh on the 15th of december which you can't i think see here uh you have to scroll to the bottom of the document but
00:28:37 but uh if you go to the box uh in the pink next to 6.5 you can see that the patrick utting inserted the following words other personnel may be
00:28:48 following words other personnel may be required
00:28:50 required to assist if a large number of calls have been received can you see that in red
00:28:54 red yes added in the track change now that's in the context of the preceding sentence which which says consider the the early ordering of an additional cu to assist in dealing
00:29:06 of an additional cu to assist in dealing with the fsgs so you could see that you could see the track change and you can see the comment next to it um before i look at the comment let me
00:29:17 um before i look at the comment let me ask you
00:29:18 ask you this is the first time in the drafting of this policy that there's any reference to the number of fsg calls that might be received as far as we can tell did you discuss with patrick utten what
00:29:29 did you discuss with patrick utten what he meant by a large number of calls no not that i can recall what did you understand him to mean by a large number of calls
00:29:42 well i'm
00:29:46 presuming he refers to multiple
00:29:51 multiple fsg calls right and you say multiple is that in the sense you understood it and you've told us about already in your evidence
00:30:03 well yes just to be clear i don't think whilst i had a figure in mind of three or potentially four in multiple calls and i think that may
00:30:14 in multiple calls and i think that may have been generated through um
00:30:18 um lfb classify multiple calls as three or more calls to an incident and
00:30:24 and multiple
00:30:26 multiple can mean
00:30:28 can mean more so i would have thought we
00:30:31 we were comfortable at settling for using multiple because that could capture a number uh yeah mr utting's evidence was that he understood multiple
00:30:42 understood multiple to mean two or more that's for our purposes day one nine eight page one one five at line eight uh and he he said that a large number meant more it meant two
00:30:54 a large number meant more it meant two or more
00:30:55 or more that that's that was his evidence did that correspond with your understanding of what he was about when he made that amendment uh
00:31:03 uh no i
00:31:05 no i i don't know and i don't know whether we would have discussed that um
00:31:11 um and spoken to each other on what he meant of large number or whether i would have then taken the opportunity you know to to be clear on in between
00:31:22 you know to to be clear on in between you know fsg calls and other calls that we would have received to an incident i may have taken the opportunity to do that
00:31:30 that and it looks like i haven't come back on that i've just commented now sticking with the comments the question comes from him and i can tell you that it's him not from this version but from the relativity version but
00:31:42 relativity version but uh
00:31:45 u7 is his question what's the large largest number received 10 i believe to the marriott hotel fire and then there's a comment j8
00:31:57 and then there's a comment j8 in response do we need this now as we are going to order acu on all fsg calls was that your response
00:32:06 response yes
00:32:07 yes well it possibly could be jr if i've seen this document and commented on it and i'm probably not responding to pat's
00:32:17 to pat's comment i'm just at 6.5 it says consider the early ordering of a cu and maybe by that time the decision had been taken to order a cu
00:32:28 order a cu when an fsg call was received for additional resources as it says on there other personnel may be required to assist on the instant ground so that might have been just a comment to that
00:32:40 been just a comment to that now given that patrick gutting had raised the issue of the marriott fire which we explored on thursday last week and you you knew encountered 17 fsg calls
00:32:52 calls no i believe sorry i don't believe that there were 17 fsg calls to the to the marriott file well he says 10 okay
00:33:03 okay there so on the face of the document he's telling you 10. did you have a discussion about the number at the marriott hotel fire with pat utting at the time
00:33:15 pat utting at the time i'm i'm not sure what we we might have done to discuss it did you just did you have a discussion along the lines of multiple fsg calls being as many as 10.
00:33:27 multiple fsg calls being as many as 10. no i i don't believe so i think as i said if if we had if it had come up in conversation i probably would have discussed it and we would have clarified that it wasn't 10 to the to the marriott
00:33:39 that it wasn't 10 to the to the marriott hotel fire but i can't recall let's then turn to the next month's draft 9th of february 2011. lfb triple zero eight five eight three five three
00:33:50 zero eight five eight three five three seven lfb triple zero eight three five three seven page one we can see uh
00:33:58 uh that's the first page of it it's by it by now has the draft number draft one five five and if you go please to page 4 paragraph
00:34:10 and if you go please to page 4 paragraph 6.5
00:34:17 there are some additions and you can see them in track change especially if control are dealing with multiple fsg calls that's your audition isn't it
00:34:30 i you you can't tell it on the face of the document perhaps i should ask the question differently was that your audition
00:34:37 audition i
00:34:38 i don't recall it but it could well have been it's unlikely to have been his one can assume can't one because um if control are dealing with multiple fsg calls is a control room input isn't
00:34:49 fsg calls is a control room input isn't it
00:34:52 i agree but this is referring to additional support on the instant ground to manage the information we are providing to them so it could
00:35:03 we are providing to them so it could well have been his update
00:35:08 we did share and and discuss uh
00:35:11 uh fsg calls and the impact in control i would have liked to thought i'd had some no influence over how he understood the operations in control to work
00:35:25 if you look at the last sentence paragraph 6.5 it says control has experience of handling up to five fsg fsg's relating to a single incident did you add that
00:35:36 did you add that no um is this a copy that you showed me that i deleted and added in multiple well this is the this is a difficulty we've had we don't unders we don't know
00:35:47 we've had we don't unders we don't know which draft uh
00:35:51 uh shows the addition of these words pat utting's evidence was that that sentence would have come from control in other words you are you able to help us
00:36:02 are you able to help us uh why or what or who added these words and why
00:36:06 and why no
00:36:08 no i i don't think i can and i just assumed when i read that that i had you'd shown me the later version where i'd removed up to five and added multiple
00:36:19 multiple to reflect uh that we could take multiple calls and i think there's an email that i said i want to share this with the training team they may have commented and added additional
00:36:31 commented and added additional information but i don't recall adding up to five
00:36:45 what was the single incident at which five fsgs were handled
00:36:56 i don't know specifically i think that's why i probably changed and removed up to five to multiple was that up to five lachlan did the five come from latin where there were
00:37:07 come from latin where there were potentially yes potentially that could be that might have
00:37:11 have that might clear things up for you in terms of pat might have added that and did you remove the five and put multiple whenever you did
00:37:23 whenever you did in order to indicate that it might be or would be fewer than five or that it could be more yes
00:37:33 yes i would imagine that's why i did that which one
00:37:37 which one both
00:37:38 both right
00:37:39 right so multiple simply being any number not limited to five that was what you intended was it yes i think we were trying not to be specific
00:37:51 and did you not want to be specific and pin your colors to the five mast so to speak
00:37:57 speak because you realized from for example the marriott hotel experience that the number of fsg calls could well exceed five um no i don't i don't recall having that
00:38:09 um no i don't i don't recall having that and
00:38:10 and thoughts in my head i just
00:38:13 i just maybe would have read that and thought well five was specific and and there could be occasions when there may be more and and could be occasions when there would be less
00:38:24 occasions when there would be less did it occur to you that policy 790 needed to prepare cras for a worst case scenario and the policy should have used the highest number of fsg calls
00:38:35 highest number of fsg calls previously received in the control room's experience as a baseline rather than a maximum so
00:38:43 so on the experience of lack and all that this policy should have contained that it did have we we have had experience of handling up to five
00:38:54 five fsg calls
00:38:57 sorry that was a question to you i didn't really understand your question you were asking apologies no no it may be it's almost certainly the fault of the question
00:39:06 question and the question there um let me try it differently did it occur to you that when identifying a figure uh or even the word multiple you you
00:39:18 uh or even the word multiple you you should be using and training off the highest number of fsg calls that the control room had received and using that as a as a minimum a baseline rather than treating it as a cap
00:39:31 treating it as a cap um
00:39:33 no i i don't believe that occurred to us um that the statement is true five would have been the most fsg calls we we had received for a single instant but now
00:39:44 received for a single instant but now that didn't occur to us on to train up to five obviously you've shown examples and evidence where we've used four in training
00:39:56 four in training um now i would like to go back if i can please to the question of vulnerabilities but now in the context of this policy policy 790 can we go back to your statement please page 27
00:40:07 to your statement please page 27 this time paragraph 71
00:40:12 and you say here pn 790 did include a list of information for control officers to obtain during an fsg call but i recall that this did reference mobility issues now if we go then to
00:40:24 now if we go then to the
00:40:25 the policy as issued on the 23rd of february 2012
00:40:30 2012 this is lfb four zeros one two five seven
00:40:42 you can see it there now has the policy new policy number 790 issued date 23rd of february 2012 and this is the one that was reviewed as current in april 14.
00:40:54 current in april 14. now
00:40:55 now um
00:40:56 um 23 23rd of february 2012 was was a year to the day after the rollout of the revised riffs as a point of chronology for you right
00:41:07 right now let's go into the detail here if we go to page three please and look at paragraph 5.5 um it says control will attempt to gather all the information on the control information form see appendix 2
00:41:21 control information form see appendix 2 and relay this information to the incident as when it becomes available and then you can see a list of bullet points
00:41:27 points of detailed information you see that yes
00:41:33 yes there's nothing there about disability mobility vulnerability illness incapacity age pregnancy
00:41:42 pregnancy or any of that nature is there no why is that
00:41:48 just because i believe that that would have been drafted with the information collated
00:41:54 collated from the control information form so that's just a lift isn't it of what information is specified on the control information form
00:42:04 form i don't recall adding that i know it it states that control will attempt to gather but the control information form i think was would have been already created or
00:42:15 was would have been already created or they were creating that at the time and that's just a lift of what is in the form and the control information form is in fact an incident ground document
00:42:26 is in fact an incident ground document isn't it as we've seen before yes it is yeah
00:42:29 yeah and so when it says control will attempt to gather all the information on the control room control information form does that mean that control will attempt to gather all the information from the caller that should go on to the incident grounds
00:42:41 should go on to the incident grounds control information form yes it does so the words all the information on the control information form means all the information signified within the control
00:42:54 information signified within the control information form format as necessary yes yes i understand now can we go to appendix 2 on page 8 which is the control information form
00:43:10 uh it's um
00:43:14 it's um a single page document this is the top half
00:43:17 half uh it's called control information form it is appendix 2 and you can see the information identified in it premise number number of persons within location location within premises and access
00:43:28 location within premises and access point condition within premises heavy smoke stroke fire etc proximity to fire is known advice to call it from control time call received by control time updated additional information it mirrors exactly the bullet points that
00:43:39 mirrors exactly the bullet points that we saw uh in the main body of the um of the uh policy at 5.5 doesn't it yes again nothing there about disability mobility vulnerability
00:43:51 mobility vulnerability illness age pregnancy is that no why not
00:43:56 why not i don't know i whilst i recall a a vague discussion about the control information form and that
00:44:05 that when they created it when operations created it there was potential to be used for different incidents so for instance if control were dealing with a
00:44:15 with a a large train crash with people trapped that they could maybe use that as well uh to take down information and but that's all that i don't recall i ever had any further
00:44:28 i don't recall i ever had any further input into development of the control information form given what we've now seen of the control information form itself is appendix ii and the policy uh covering it at paragraph 5.5 can you
00:44:39 uh covering it at paragraph 5.5 can you explain why you said in your statement that you recalled that uh policy 790 included a list of information which referenced mobility issues i i believe
00:44:50 referenced mobility issues i i believe it did in the body of the document does it not well we've seen that
00:44:55 that and it doesn't i thought that was just on the
00:44:58 on the the specific bullet points for for control i thought within the the body of the document it had that but now i can't explain that then
00:45:13 i mean to be fair to you we did see in the riff this morning at the end as one of the bullet points a reference to the control information containing information about mobility issues we saw
00:45:25 information about mobility issues we saw that
00:45:26 that and we've covered that does it come to this
00:45:29 this that the policy including its appendix did not mandate the control room to collect information about vulnerabilities and i
00:45:40 information about vulnerabilities and i used the word loosely to cover a broad number of them but left it to the individual conversation and if information was given by the caller to the to the
00:45:51 given by the caller to the to the control handler call handler then that would be recorded and transferred to the incident ground say that those on the incident ground could add it under additional information
00:46:03 information on the control information form it would it would look like that as i've explained that would be normal practice for the additional info information to be gathered by control and passed to the
00:46:15 be gathered by control and passed to the instant ground and
00:46:18 and possibly at one point as you've
00:46:22 as you've referred to the riff stating that it was in the control information form it might have had but i think that that one discussion was my limited involvement in the control information
00:46:33 involvement in the control information form
00:46:35 form and
00:46:37 and i don't know if there was a a previous version that changed i certainly wasn't aware of any or control to my knowledge was included in any
00:46:48 to my knowledge was included in any reviews of policy 790 after it went live or any updates like i say it wasn't a joint policy at the time it was specifically for operations
00:47:00 now before we leave this topic i just want to examine with you uh the process of equalities impact assessment i think it's right generally isn't it that within the brigade there is a practice whereby all new policies
00:47:12 is a practice whereby all new policies or substantially revised policies go through an equality's impact assessment yes yes
00:47:19 yes yes obviously relevant ones clearly they're not always necessary yes now we know that policy 790 did go through such an assessment in january 2011. can we go to
00:47:30 assessment in january 2011. can we go to lfb triple zero three three three seven two
00:47:42 this is an email if you look at the bottom
00:47:48 of the
00:47:50 screen from rebecca howard to pat utting and i think we need to pick it up lower down in the chain at page two at the bottom of page two
00:48:03 uh this is one date of the 9th of june 2011 where you can see that it comes from her the subject is eia for far survival guidance call policy
00:48:15 policy now you're not copied into the to any of these emails but let's look at page three and see what she says rebecca howard who um
00:48:26 who um is uh i should just tell you the equality is monitoring an audit manager within the corporate team do you know her no i don't right that's who she is um if you look at the top of page three she says this so once i have a question
00:48:38 she says this so once i have a question do control gather any information about mobility issues evacuation plans etc is this useful information to pass on to the crew there's no point in telling someone to get out if physically they
00:48:49 someone to get out if physically they can't due to disability stroke age and this may be something the crew should know or perhaps english is the person's second language and there may be a communications issue if these things are already dealt with in other areas of
00:49:00 already dealt with in other areas of procedure it might be useful to note that in your eia screening now we can see pat attends reply on page two
00:49:08 two if we just scroll up to page two please um he says uh same day hi rebecca excellent point i've tweaked it a bit any good question mark and her reply comes on page one same day
00:49:20 and her reply comes on page one same day 9th june 2011 at 11 57
00:49:26 and she says hi yes that's fine would be worth having a paragraph 4.2 that says something like policy
00:49:33 policy 359 advisors on how to deal with callers who have mobility etc issues and crews will be advised accordingly i know it's something they should already know but it reminds staff that this is something they might bear in
00:49:45 this is something they might bear in mind just a thought anyway patating replies at the top of the screen
00:49:54 same day back to rebecca howard perfect i'll put it in many thanks for your help much appreciated now you aren't copied in on any of these emails of course as we've seen but
00:50:05 emails of course as we've seen but um have you ever seen them before no never seen before before today i think this i watched
00:50:14 i watched pat's evidence so i saw it then but i that would recall wreck it that would align with my recollection that i was never involved in the eia process for policy 790. you were not
00:50:28 eia process for policy 790. you were not involved in the eia process for 790. did pat hutting ever discuss this question with you
00:50:33 with you no not to my knowledge uh no i mean it's clear that 359 should should be five three nine it looks from this as if the assumption rebecca howard was operating on is that it's is that
00:50:44 was operating on is that it's is that the the question of asking about disability would be covered in emergency call management policy um
00:50:52 um are you able to tell us what pat harting did by way of the tweak
00:50:58 no you don't
00:51:01 are you able to explain why notwithstanding rebecca howard's uh advice
00:51:08 uh advice or question during the eia process we see nothing in 790 to reflect uh the
00:51:17 uh the conversation in this email these emails no i don't
00:51:25 uh i want them to turn to the question of the control information form process
00:51:31 process in other words how information received from callers on an fsg call ought to be recorded in control information forms um and in fact we've covered most of that um and and i think the simple
00:51:43 that um and and i think the simple question is how in
00:51:48 how in practice during the period of the development of this policy and after it was published in february 2012 would
00:51:59 would control room operators gather and collect uh information that ought to go onto the control
00:52:07 control information form on the incident ground where would they note it down they have a field in their mobilising system on their when they're collecting
00:52:18 system on their when they're collecting information about the address and the type of fire it is they would have a field that's called the additional information and they would note it down in there and and how would they then
00:52:30 in there and and how would they then transmit that to the incident ground so they would then
00:52:36 depending because we're talking about two different systems but basically they would then duplicate that into a radio message frame that would be sent
00:52:48 radio message frame that would be sent to the radio operator who would then pick that up and pass that to the instant grant and on the night that was sharon darby yes it was yes can i then ask you about training on policy 790.
00:53:00 policy 790. and do you remember an fsg testing exercise at the end of may 2011.
00:53:08 even vaguely no no all right let's look at some documents can we go please first to lfb double zero one five
00:53:18 this is a chain of emails relating to us far survival guidance exercise on the 31st of may 2011 and if we go to page two in this email run we can see an email from christine
00:53:29 run we can see an email from christine sharp to you on the 17th of may bottom of the screen title for survival guidance exercise 31st of may hi joanne please would you confirm how much involvement you require
00:53:40 confirm how much involvement you require from mst on the 31st i am the training rep for the mur and would like to be involved
00:53:46 involved we'll need to move my rotor around to accommodate it also what time is it and location um mur what is that it's a mobiliser user requirement so it's a document where
00:53:58 requirement so it's a document where anyone
00:53:59 anyone that needs to request a change to the mobilizing system would
00:54:05 would enter in the details and then it goes to a board
00:54:09 a board called the mobilizing governance board where it is discussed between different departments um
00:54:16 um and agreement reached and then control then go away and work on especially the ost team work on the requirements and and make sure they're implemented
00:54:29 and and make sure they're implemented right well i don't think we have to dig too deep into that um can i ask can i ask you to be shown your response to this please which is higher up page two
00:54:40 and then onto page one please can we look at page one
00:54:48 uh when you respond here's the beginning of the email and then on to page two please top of page two hi chris the fsg testing on the 31st would only require one or two individuals in conjunction with ops
00:55:00 two individuals in conjunction with ops policy we wanted to run through all the new editions due to be implemented following the go live of the policy 155 fast survival guidance including testing the direct dial number on the iccs the new itc code for fsg the control
00:55:12 new itc code for fsg the control information pad and accessing css the idea being if any of the processes are too complex or only tweaking we can do before the major exercise on the 16th of june
00:55:24 of june i wanted to discuss with ost how best to conduct this in what environment etc i'm sure all bcsm would be appreciative if you were able to volunteer and assist us with the testing exercise schedule pat
00:55:35 with the testing exercise schedule pat hutting is attending from ops policy he has drafted policy 155 i think he's arriving at about 10 o'clock many thanks joanne
00:55:43 joanne uh now the major exercise on the 16th of june 2011 haygate challenge yes yes yes uh so that was to be a separate and earlier fsg exercise um
00:55:54 um this one to test the new fsg policy 155 before the hey gate challenge yes it looks like it is testing the lines of communication we put in between
00:56:07 lines of communication we put in between control and the incident ground prior to the exercise yeah right and that that that is the next question were you testing the the mechanics of communication
00:56:19 mechanics of communication what who spoke to what and the systems as opposed to the content of fsg call handling receiving information from callers and
00:56:30 receiving information from callers and then transmitting that information to the incident ground i believe that we were looking to test the new
00:56:39 the new methods of communicating with the instant ground that we've put in and obviously reading that the instant ground we're looking to test the control information form as well did that exercise take place
00:56:51 as well did that exercise take place i would presume so right do you remember what its format was
00:56:57 was no i don't do you remember whether there was any feedback uh no i don't but if pat was attending control to witness this um he may have taken that feedback
00:57:10 he may have taken that feedback do you remember whether the exercise resulted in any changes or suggested changes to policy 790. i don't know
00:57:20 turning then to the question of con training within control on policy 790 can we look at paragraph 46 of your witness statement of page 18
00:57:35 and you say there to the best of my recollection there was not a formal presentation on pn790 to control in 2011 to 2012. however i would expect that pn 790 would
00:57:47 however i would expect that pn 790 would have been discussed during the command unit training which control staff took part in
00:57:52 part in you see that yes now to be clear are you saying that there was no formal presentation of pn 790 to control staff in either year either 2011 when it was
00:58:03 in either year either 2011 when it was in development or in 2012 after it had been launched in the february of that year no i don't believe so i think i may have after it had gone live communicated it
00:58:17 after it had gone live communicated it out to control staff that policy 790 had been created for operational crews
00:58:26 and when the workshops took place as i say the command unit training because that covered operational staff as well as control staff i believe pm 790 was discussed then
00:58:38 i believe pm 790 was discussed then and but i think in the training in 2011 and 2012 it was training on the new
00:58:47 the new fsg
00:58:48 fsg procedures uh going back to five um sorry going back to 1093 and the four principles right
00:58:59 right i see
00:59:01 i see so just
00:59:02 so just breaking that up a little bit first are you saying that when you communicated 790 out to control staff what did you do did you just say there
00:59:13 what did you do did you just say there is a new policy did you send them the policy did you give them a presentation of the policy and its contents no i wouldn't have given them a presentation on the policy but i would have let them know that there was a policy
00:59:24 know that there was a policy and that would that would have been to all control staff i believe the operations managers and the training team and ost would have been aware of that already because they probably would have helped
00:59:35 would have helped me and some points and just to let control staff know that there is a policy for operational staff now
00:59:45 now in being um but i have also communicated out and and there was some training undertook about the new methods of communicating with the far ground or the instant ground which is um
00:59:58 the instant ground which is um what we would have shared with staff and and that was what our input and involvement and the changes were for us for pn790
01:00:08 so you would have told them there was a new policy but what steps would you have what steps did you take to ensure that all control room staff read policy 790.
01:00:22 as as much as any operational policy and procedure that comes out in lfb if there are pertinent points relating to control and there is an email sent out to let
01:00:34 and there is an email sent out to let them know it's there and there would be an expectation that they would read those there would be an expectation that they would read it but did you actually tell control room staff please read policy 790 it is relevant to
01:00:46 please read policy 790 it is relevant to your work
01:00:48 your work no because we would have felt that with the training the additional emails that i'd sent out about the communications methods to use and everything that they were well aware of the changes in there
01:00:59 were well aware of the changes in there i think we even had some control information forms it bought into control into the control room so they could see those so they were aware of the changes and that impacted them and their role
01:01:17 correct me if i'm wrong about this but i'm getting the impression from that answer and others like it that you regarded the training program and package and delivery
01:01:28 delivery as really the way in which control room operators would learn about everything relevant whether it came from 790 whether it came from pn pn539
01:01:39 whether it came from pn pn539 in other words it would all end up in the training is that is that a fair way of looking at what you're telling us i think
01:01:48 i think just in my experience of london fire brigade and and the control room that yes anything that needed to be uh that was changed and added into a policy note would have followed through
01:02:00 policy note would have followed through with
01:02:01 with training on it rather than reading
01:02:05 reading the policy now right so
01:02:08 so that would mean wouldn't it that even though you weren't expecting control room operators to read and ingest the details of the policies
01:02:19 the policies it did mean that the training you gave them had to be absolutely 100
01:02:26 100 comprehensive so that everything in that policy was the subject of the training because they wouldn't get anything else i would have expected everything that was in the policy although we would have
01:02:40 was in the policy although we would have relied on policy 539 rather than policy 790. i would expected everything that was in policy 539 to be in the training yes
01:02:49 yes well
01:02:50 well and anything that affected control room operations within policy 790 surely also 100 comprehensively to be covered in the training
01:03:01 training yes that would have been a
01:03:05 yes now the command unit training you've referred to also in the answer now a few answers ago wasn't specifically designed for control staff learning and development was it
01:03:16 development was it um
01:03:16 um [Music]
01:03:19 [Music] so as i understood it it was designed jointly and that's why we took the lead and it otherwise if it was just purely for operational staff and command unit staff
01:03:33 operational staff and command unit staff they would have had they would have taken the lead on it but it was designed created and organized by ost and the training team so yes i think it was designed
01:03:45 yes i think it was designed jointly um for both control and command unit officers and it was later expanded to
01:03:52 to upper operational senior officers can we go please to lfb 305
01:03:58 305 page 28.
01:04:02 and what i'm going to show you is scott hayward's first witness statement of paragraph 78.2.2 just in light of that evidence
01:04:11 evidence he says there the lfb introduced training for all command unit staff and associated station managers issue 20 of operational news published in november 2011 contained an
01:04:22 published in november 2011 contained an article on the fsg policy which was to be published later and issue 24 published in march 2013 included mandatory training for all operational watched based staff shx this was not
01:04:34 watched based staff shx this was not training for control officers as part of the training command units came to the control room in merton and took part in exercises about issues such as two-way communication between control
01:04:46 control and the incident ground it took about two years for all command unit crews to complete this training that's what he says there and he confirmed in his oral evidence
01:04:57 and he confirmed in his oral evidence that the command unit training was not for control officers per se do you agree with that no i don't i think that initially it started with a joint
01:05:09 started with a joint exercise between control and the command units
01:05:12 units with input from control so control would attend they would have a role-play exercise where the command unit operatives or
01:05:25 unit operatives or trainers would input fsg calls to control
01:05:29 control they would then gather the person information and then send that information down to the command unit and that's how it worked i believe for a number of
01:05:40 it worked i believe for a number of years
01:05:41 years well i just want to see how much of it how much you agree with what scott hayward says in the sentence it's five lines down in this paragraph he says this was not training for control
01:05:52 says this was not training for control officers
01:05:53 officers do you do you dispute that i do i think it was created for that i think towards the end and this may have been what scott was alluding to that towards the end
01:06:04 towards the end of
01:06:05 of the exercises in 2016 there was definite evidence that the operational input and had become quite large and that actually
01:06:16 had become quite large and that actually control staff weren't getting the benefit
01:06:19 benefit of what it was originally attended intended to do
01:06:26 now when you came back from the cfoa in 2015 moving ahead a few years after this this
01:06:35 this did you do anything to ensure that refresher training was given on pm790 even though no training appears to have been given specifically uh on the contents of the policy when it was launched no the the the training i
01:06:48 was launched no the the the training i believe fsg command unit training was still ongoing um and that's where control officers would have picked up that
01:06:58 that the pertinent elements that um covered 790. right but that was all i think the command unit training covered the exercise of communicating what
01:07:10 the exercise of communicating what control room officers knew to the incident ground didn't it it does it doesn't cover the exercise of obtaining that information from the caller originally i believe it did yes i believe there were scripts and and like
01:07:21 believe there were scripts and and like i say that control officers were asked to perform role play gather that information and then pass it to the command unit now that scripts in 2010 isn't it
01:07:32 2010 isn't it march 2010 and september 2010 when the existing staff were trained on the first train in the on the first fsg trainer-led sessions after lachnal
01:07:42 lachnal i i think it it continues and where possible and i think at times there might have been sometimes not enough staff to undertake that but i definitely recall that
01:07:53 definitely recall that with the command unit training that some of the command unit staff would input calls to role play that simulation for control staff to take uh the information down and then to pass
01:08:05 uh the information down and then to pass that to the instant ground and that was in 2015 2016. i'm pretty sure it was
01:08:16 so you is the thrust of what you're telling us was that the command unit training was the training of the control room staff on
01:08:27 staff on 790.
01:08:28 790. that's where they would have got exposure to it yes did every single cro take part in all of the cu exercises
01:08:38 exercises um i think ost tried to get every member of staff to partake in the command unit exercises it probably was a struggle
01:08:49 it probably was a struggle and it was difficult because obviously they're on a different shift pattern to us and so
01:08:54 us and so i think also we talk about the limiting of
01:08:58 of strategic results and being able to get command units to attend martin but ost did manage that aspect of it and would have tried to get all control staff to attend a cu
01:09:10 attend a cu command unit and control staff session are you able to assist us with how it comes about that scott hayward told the inquiry that this the cu exercises were not training for control
01:09:22 exercises were not training for control officers as he says well i can only speculate in terms that he would have received feedback as we all did at the end
01:09:30 end of 2016 that they were not um as valuable to control staff as we had envisaged and as as ost had created them to be
01:09:43 as ost had created them to be and that because of time constraints and staffing
01:09:46 staffing that they had undertaken a more an input role
01:09:50 role rather than the role play aspect of it and then passing information to the to the command unit and
01:09:59 and so i can only imagine he was referring to that
01:10:02 to that but i'm not sure that in between when every command unit and control exercise fsg exercise was run i believe there was always the attendance of control staff at those
01:10:15 attendance of control staff at those exercises
01:10:18 and who was monitoring or supervising the uh
01:10:23 the uh the learning of control room staff during the command unit exercises to make sure
01:10:29 make sure that they were learning what they were supposed to learn about policy 790 during those exercises so that would have been chris sharp she took the lead on organising and
01:10:40 took the lead on organising and facilitating the fsg command unit training and and she worked with a
01:10:48 watch manager that worked on the command units to make sure that they both in line so i believe she did it for control and the watch manager did it on behalf
01:10:59 and the watch manager did it on behalf of the cus
01:11:02 and was there any recording of the performance of cras during these command unit exercises which was which you could look at to make sure that they were learning what they were supposed to learn i'm i'm not sure it
01:11:14 supposed to learn i'm i'm not sure it was a an interactive session the the the point of it was to share information and make sure that exchange of information between control and the fire
01:11:25 information between control and the fire ground was was being received and was understood um and i think uh as i've said towards the latter part of
01:11:34 of 2016
01:11:35 2016 when um operational staff we'd been asked to train operational staff as well and the attendance grew i think that just
01:11:46 the attendance grew i think that just overwhelmed and controlled didn't get as much out of it as they did in the first couple of years it was running
01:12:02 can i then turn to the question of training
01:12:06 and i may come back to this question of cu training into your course but i want to start now with latino action point 11 uh which is about the training recommendations uh
01:12:17 uh and if we can go to the assurance report please at
01:12:20 please at lfb404801 page 14 we'll see action 11 set out there
01:12:32 and it says deliver initial fire survival guidance training which complies with national guidance to control room offices cras in order to develop the performance of the cras when handling fsg calls
01:12:45 handling fsg calls and then it in the first paragraph it has a final sentence which says these training presentations were initially delivered to all control staff between july and september 2011.
01:12:56 july and september 2011. now
01:12:58 now that's there we can come back to it in due course can we go to paragraph 44 of your witness statement at page 18 next
01:13:11 you say
01:13:16 paragraph 44 following the latin house fire and the full review of fsg training following the gap analysis and update to pn539 there was a complete rollout of fsg refresher training to all cross
01:13:29 fsg refresher training to all cross i recall that there were presentations delivered on separate topics such as fsg mobilizing fire behavior call handling techniques and building structures i recall that this was delivered via face-to-face training
01:13:40 face-to-face training now in this paragraph are you referring to training that took place in 2011 as mentioned in the latino assurance review or the full day of trainer-led training
01:13:51 training on fsg's that had taken place in uh 2010.
01:13:55 2010. i think i'm referring to 2011 um with all the changes that we'd been asked to make
01:14:03 make following the the lack of house review right
01:14:10 then let's take two steps back uh and and look at the training in 2010 first of all mr chairman it's 3 15 and this is a sub topic
01:14:20 topic um before i explore it i've enjoyed it you'd rather have a break now would you well it's well it no but it's a convenient moment for one well let's have it then yes i think we'll have our afternoon break
01:14:31 i think we'll have our afternoon break now then this list so we'll stop now we'll recom we'll resume please atop our three
01:14:37 three and again please don't discuss your evidence with anyone when you're out of the room thank you thank you very much
01:14:52 thank you very much i'm very then thank you
01:31:13 yes would you ask ms smith to come back in please thank you
01:31:27 all right thank you ready to go on yes thank you very much yes thank you mr chairman
01:31:33 chairman uh i'd like to explore the roles of those responsible for developing fsg training in 2010 to start with i may please can we look at paragraph 45 of your statement page 18.
01:31:47 and you say there uh
01:31:50 uh chris sharp and nicki o'shea were responsible for the creation of training packages
01:31:54 packages in 2011 to 12 my involvement in this training was to review and comment on training packages in my role as an som and due to my involvement in the latino house report along with scott hayward as a pom lindsey turner was the line manager for training
01:32:06 manager for training and at paragraph 47 underneath the question you go on well i should read you the question it says please explain how this training was deemed to comply with national guidance for control personnel in particular fire service circular 1093
01:32:19 particular fire service circular 1093 and the accompanying home office guidance entitled making people safe as confirmed in the latter house board meeting 15th september 2010. uh now you say that this would have predominantly been lindsey turner's role as the line manager for ost training and reporting
01:32:31 manager for ost training and reporting to scott hayward as the pom and then uh you you say something about the scope of the gap analysis and then at the bottom of the page i was not involved in the subsequent drafting of the new training package as this would
01:32:42 the new training package as this would have been the responsibility of lindsay turner
01:32:45 turner but i did attend the training when it was rolled out to staff to ensure that it complied with national guidance and the gap analysis js8 let's look at js8 lfb double 00121239
01:33:06 this is you attending the training in fact it's an email from you to khrushchev on the 27th of may 2010 copy to scott hayward and lindsay turner and you say hi chris as you know the current fsg training has been a recommendation
01:33:17 fsg training has been a recommendation from the latin investigation to this end and to ensure course content dac tim cut bill and dac john bradbury will be observing the fsg training taking place on 14th june
01:33:28 on 14th june scott and i will then attend to observe on 2nd july to ensure all gaps identified in the gap analysis are covered
01:33:35 covered i'll come back to this email in a moment but before i do apart from attending on the training on the 2nd of july 2010 did you play any other role in reviewing the fsg training that was originally produced and delivered in 2010
01:33:48 produced and delivered in 2010 so i think i did review it um
01:33:54 um at one point and i'm not sure if that was in early 2011 but i
01:33:59 but i comment on um the content of the training packages and just to
01:34:06 just to again with the learning that we'd uh understood from luck in our house and to make sure that that aligned with what we'd learned and it aligned with 1093. can we look at
01:34:19 it aligned with 1093. can we look at lfb00107497
01:34:25 this takes us certainly slightly earlier in the year 2010
01:34:31 it's an email from scott hayward to chris sharp copy to you and lindsey turner 25th of january 2010. good morning chris thank you for a positive update on the potential improvements to the current fsg training we've not been given any
01:34:43 fsg training we've not been given any formal notification of change at this stage as we've yet to report our findings from the outcome of the latino incident to the commissioner and then you go he goes on as you know joanne and i have
01:34:54 he goes on as you know joanne and i have been spending a considerable amount of time trawling through past documents and listening to the recordings of all the calls trying to piece together controls history as far as this procedure is concerned
01:35:05 concerned in comparison with the national guidance there are gaps especially in our training
01:35:10 training any implementation of training you intend carrying out now will be considered a pilot until ratification is given to fully implement the recommendations from us may i ask whether the revised training
01:35:21 may i ask whether the revised training package considers role play and listening to past calls so this is january 2010 just just looking at this email were you the person with scott hayward who was responsible for reviewing and ratifying
01:35:32 responsible for reviewing and ratifying the fsg training in that year
01:35:38 no who was
01:35:41 who was i would imagine that would have been lindsay
01:35:45 lindsay and chris
01:35:47 and chris looking at that we would have let them know and scott would have probably let them know
01:35:52 them know when we'd taken our findings to the board and the board had agreed them
01:35:58 them um and then come back to lindsay with the changes
01:36:06 did you review the training and ratify it yourself uh i think i
01:36:12 think i um
01:36:13 um saw
01:36:14 saw the training uh probably later in 2010 maybe in 2011 and and
01:36:21 and and the current training and i did make some comment on
01:36:26 on on some of it and again
01:36:30 and again just in terms of what we'd learned from black and all and making sure it aligned with 1093
01:36:42 can we
01:36:45 look down please at page one and see the email to which this was a response at the foot of this page it's a response to an email from chris sharp
01:36:55 sharp of the 21st of january 2010 to scott hayward copy to lindsey turner but not copy to you good evening scott and then if you turn the page to page
01:37:06 and then if you turn the page to page two
01:37:08 two the second paragraph says uh this from the discussions it became very apparent that there was a difference in response we may give when advising a caller to remain where they were or attempt to get out of the premises
01:37:20 attempt to get out of the premises in normal circumstances we would ask the caller if they can get out safely and if they can we would advise them to do so
01:37:29 and then it says gm paul jenkins and gm mark andrews explained that multi-compartmental buildings such as high-rise that are constructed after a certain date have been designed to protect occupants it
01:37:40 been designed to protect occupants it was explained that if the building had been built properly using the right materials and work practices flats can act as a refuge that means that if there were a fire in a flat the occupant could get out and close the door behind them
01:37:52 get out and close the door behind them and the fire should not spread to another flat conversely if there was a fire in a communal corridor the occupant should be safe to stay in the flat until the arrival of the brigade it very much depends on the build specification at
01:38:03 depends on the build specification at this stage of the discussion we concluded we needed guidance on what we tell control staff to say do we get them to get out sorry do we tell them to get out even though the premises have been built to
01:38:15 though the premises have been built to be defend in place i.e stay put and possibly risk or do we tell them to stay the authority could be placed at risk if information given ultimately leads to
01:38:26 information given ultimately leads to injuries or fatalities the group agreed that we needed advice from a higher authority and requested it i explained the issue to you and asked ask that you speak with ac dave brown it is our intention to get all the
01:38:37 it is our intention to get all the information in place to conduct the training for the current course planned to take place on 10th march it is also planned to invite control management to pilot completed lessons around the 22nd march for your approval
01:38:49 around the 22nd march for your approval following this training the gms will use the material and provide us with an e-learning package to be used by existing staff now i've read that in full to you because
01:38:58 because there's a lot in it but in short was the concern
01:39:02 concern that christine sharp raised there about to stay put advice to be given by control staff and what training they should have on that was that addressed in the new training
01:39:17 um so it looks like christine is raising those concerns and
01:39:24 and i'm not sure because i wasn't copied in on this i'm not sure if uh scott took those to ac dave brown i do
01:39:33 i do remember and recall from the conversations with the lachenal team that were investigating that
01:39:42 that stay put was the appropriate advice to use
01:39:46 use to call us in high roads buildings can we then go to lfb double zero two eight two five eight
01:39:55 and if we go to page two in that email run and look at the second email on the screen it's an email from chris sharp to scott hayward
01:40:07 hayward lindsey turner you and others 2nd 22nd of february 2010 hello everyone please see our notes of our meeting today at nds
01:40:19 today at nds and you can see who was there scott hayward lindsey turner you background pom scott hayward explained the background for the need for more fast survival training and that elements
01:40:30 survival training and that elements identified in the gap analysis between 1093 and bcts training have to be covered sh to send copy of gap analysis to ma
01:40:39 to ma now the gap analysis it looks on this was more or less complete in february 2010
01:40:46 2010 would that be fair
01:40:50 yes possibly yeah at any rate do you remember that whether the gap analysis was complete or at least sufficiently complete to send to ma mark andrews i would have thought we would have had yes uh a
01:41:04 yes uh a good idea of what was in the gap analysis if we probably would have completed it um and it was just a case of going back to uh tim cupbell and tom davis um just
01:41:15 uh tim cupbell and tom davis um just about any amendments that they thought would be appropriate with their experience of the the lack of board and their investigations yes is it right that this meeting was to discuss fire survival guidance training and the
01:41:26 survival guidance training and the package to be created
01:41:30 potentially yes so does that tell us that you were part of the decision making about devising the training to address the gaps no i think that tells us that as a senior
01:41:41 think that tells us that as a senior operations manager in brigade control along with lindsey and scott that i was included in the meeting um and possibly because i worked on the gap analysis with scott
01:41:56 yes and what was the point of you being there unless it was to be part of the decision-making process about what training should be introduced
01:42:07 about what training should be introduced to cover the gaps you had identified well like
01:42:11 well like i say we were a team often our work streams crossed over and it wasn't unusual
01:42:17 unusual um
01:42:18 um in any kind of meeting that all three of us didn't attend we would often attend all three of us and whether it was my work stream or or
01:42:29 whether it was my work stream or or lindsay's because there would have been some takeaways or one of us would have been able to add some value if you turn to page three you can see there's a
01:42:40 you can see there's a heading for our survival calls chris to check the outcome of the three of the three calls on dvd email sent to tsg on 22 2 at times cjs
01:42:52 at times cjs two of the calls to be played between call handling techniques and the basics of fire and fire development and the students will discuss the calls after being played so were there three calls were those were those three calls
01:43:04 were those were those three calls training calls no i well
01:43:08 no i well as i read this and i don't recall exactly i can only uh think that actually they're live calls so the email has gone to tsg who's the technical support group that
01:43:19 who's the technical support group that would have provided those calls and
01:43:22 calls and they probably would have been live calls right live calls but then let's go to page one
01:43:27 page one uh and we can see the response email the next day the 23rd of february 2010 from scott hayward to chris sharpe it's quite long uh you were copied in on it
01:43:38 were copied in on it marie far survival planning meeting 22nd of february 2010 is the subject good morning he says having reviewed what was discussed today i'm still not totally convinced
01:43:48 convinced that our particular part of the training package is right the purpose of the training is to provide a good grounding for control officers to enable them to provide fsg to a caller when required and then in the third paragraph he says
01:43:59 and then in the third paragraph he says this i agree with joanne that some sort of role play should be introduced the following day or as part of an assessment at the end of the week to consolidate the day and to give the students an opportunity to attempt to provide that guidance in a controlled
01:44:11 provide that guidance in a controlled environment now was that a suggestion to include active role play i.e control staff taking part in the role play yes
01:44:21 yes and was that your suggestion looks like it was from this email it does look like it was for my email and and that would have been just uh maybe a comment that i would have made or a discussion point
01:44:33 or a discussion point um to say
01:44:35 um to say because we'd known about 1093 and 1093 had uh suggested that role play is a useful tool to add into that i see so your aim in having that was was
01:44:47 i see so your aim in having that was was in order to cover the gap essentially to bring lfb training into line with national guidance which recommended role play yes yes
01:44:58 and was it your suggestion that that should be part of an assessment
01:45:04 yes i think there was some discussion that
01:45:07 that it should be assessed yes and
01:45:12 yes and it was important that it be assessed because then the brigade would know how well the cr is or new entrants at that stage were doing yes yes and they could that would be a discussion with them and
01:45:23 that would be a discussion with them and the trainers and they could have some feedback on their own individual performance now look up at the paragraph above that scott hayward says this i thought the fs aspects of the day are very good paul
01:45:34 aspects of the day are very good paul jenkins presentation was particularly interesting and relevant however out of the full day's training we only provide perhaps two hours worth of training a bulk of that listening to calls now it's the first sentence i want to focus on
01:45:46 the first sentence i want to focus on where he says he thought the fs aspects of the day are very good is fs fire safety
01:45:51 safety yes it looks like it as opposed to far survival fire safety fire safety did you agree with scott hayward's view that fire safety should
01:46:02 that fire safety should uh
01:46:03 uh present
01:46:05 present an element of training and fsg training days yes yes well that was that was requested in the the 1093 guidance and we'd identified that as a gap
01:46:17 identified that as a gap yes indeed it was and also as we saw i think um and if we haven't seen it we can
01:46:23 can the 1994 home office keeping people safe documents yes yes and and can you just tell us why was it important to have fire safety's input into the training
01:46:35 uh i think they were
01:46:38 they were it was just an overview for control staff on uh building um
01:46:44 um construction and
01:46:46 and compartmentation and i think there was an area where they covered uh aspects of a fire um
01:46:54 um and i think that we'd identified the gap that no fire safety officer had delivered those training packages uh previous prior to la canal um and that we wanted
01:47:06 prior to la canal um and that we wanted to amend that gap and
01:47:10 and i think
01:47:11 i think going forward and knowing that the 1093 was created in 1993 and it probably recommended a
01:47:22 in 1993 and it probably recommended a heavy fire safety aspect and i've certainly noticed it that it recommends that role play is undertaken with a fire safety officer as well um and i think perhaps that doesn't account
01:47:33 and i think perhaps that doesn't account for
01:47:34 for the
01:47:36 the some of the other learning about the incident ground and what happens in fires that control have undertaken since 1993
01:47:45 1993 but
01:47:46 but yes that's the idea was to bring it back so fire safety delivered a presentation right thank you now can we look at lfb three zero three nine four five five
01:48:01 if we start on page three of this email string you can see that this is an email of the 25th of february 2010 from steve willett
01:48:09 willett uh who was part of the training team fire safety training team uh and uh he says hi chris it's to chris sharp
01:48:18 sharp and
01:48:21 he sends a prayer he sends the presentation he says hi chris please phone attached a copy of a presentation for fire safety day on building design and concepts the idea is that the design is based around an evacuation strategy
01:48:32 is based around an evacuation strategy i've put more detail in the notes to explain and support any tutorials please let me know if it means your expectations and
01:48:42 and if you
01:48:45 look up the screen uh you go
01:48:48 uh you go to an email at the top page one
01:48:53 page one at the very top of page one from you to scott hayward on the 3rd of march 2010 where you say hi scott my thoughts are that the fire safety people are confused as to what we really want from them this presentation offers no assistance to
01:49:05 presentation offers no assistance to control officers about means of escape from various premises including high rise in fact talks about defending place and one hour fire resistance without reiteration of the government guidelines get out and stay out
01:49:16 get out and stay out i expected to see a selection of various types of housing hmo high-rise flats basement flats and possible alternative escape routes which would give our staff an awareness of possible options if
01:49:27 an awareness of possible options if callers state they cannot get out of their premises ideally this presentation will concentrate on building types where the most fire deaths occur or that are most common in lfb as these stats must be
01:49:39 common in lfb as these stats must be available
01:49:40 available do you recall what presentation you were commenting on we could see that one was attached lower in the email string but do you remember which it was i don't know what it was
01:49:51 which it was i don't know what it was um i've shown you the email from steve willit to chris sharpe uh
01:49:57 uh you you you go on four para three paragraphs on relating to these usual calls taken in control rooms involving high rise premises would be fab these are mainly to bin shoots the light
01:50:09 these are mainly to bin shoots the light causing smoke to heavily populate in the main corridor straight balcony so callers usually inform us that they cannot get out due to smoke at the front door blocking their exit what do fire safety advise we tell these callers
01:50:20 safety advise we tell these callers hindsight says we ask them to take their alternative escape route out to be honest i do not understand how this can be acceptable it does not tell you anything in relation to fsg or anything else for that matter harsh i know but we
01:50:31 else for that matter harsh i know but we are really trying to get this right and this will not help now
01:50:35 now on the question of um
01:50:38 um what should be told what advice should be given to the callers why did you want that to be included in the training why did you want
01:50:50 advice based on what fire safety advisors are telling you to be included in the training
01:50:59 so i just think after reading this email that we would have been looking for some possible options i think that stems from
01:51:10 from what i understood about uh the lack of layout which was very different diff sorry which was very different to what control officers had
01:51:21 what control officers had experienced or had um
01:51:24 um had
01:51:25 had an understanding of so we wanted to make sure that
01:51:29 sure that various types of housing and
01:51:31 and options were available and actually i think
01:51:35 think at la canal they'd talked about balconies
01:51:38 balconies running through the building and i think our focus was on
01:51:44 on that
01:51:45 that there are potential escape routes that people don't often foresee and that we should ask i see and
01:51:52 i see and were you expecting amendments to be made to the training in order to point up what you just identified um i'm not so much amendments i'd imagine like
01:52:03 imagine like the various documents that i've commented on that scott would ask me uh to review those um just in as part of my role and provide some comment to him on those and
01:52:14 provide some comment to him on those and i've obviously done that with this one and which i would have expected i'm not sure if lindsay was coppered in i usually used to copy lindsey in as well
01:52:23 well she had responsibility for training so we might have discussed it further from that
01:52:30 that do you remember whether changes were made to the training as a result of this exercise i don't but i would have liked to have thought that actually it did accommodate various types of housing and it was clear i
01:52:41 types of housing and it was clear i think from that i i'm just concerned that
01:52:45 that um
01:52:46 um control officers were getting a mixed message and and i wouldn't have wanted that
01:52:53 can we go to lfb triple zero eight six two two eight
01:52:59 this is the training that we understand from scott hayward was in place in 2010 this is
01:53:05 this is one of the number of presentations that were generated in that year um was this one that you you reviewed on the 2nd of july 2010 when you attended
01:53:16 the 2nd of july 2010 when you attended the training day
01:53:19 i'm i couldn't be sure but if that correlates with the email and and the time i've said that then that may well be it's entitled building types and concepts
01:53:30 concepts can we go to page five
01:53:36 this deals with high-rise premises evacuation strategy is domestic simultaneous defending place and if you look at the bottom of the screen
01:53:46 screen it says
01:53:47 it says for larger purpose-built blocks the defending place strategy is adopted and this is supported by the construction of the buildings and on page six it says
01:53:56 it says there is
01:53:58 there is on page six it says uh
01:54:02 uh four lines down from the beginning of that block of text there is currently no requirement for a detection and warning system in a purpose-built block of flats due to the nature of the construction compartmentation of these premises a
01:54:13 compartmentation of these premises a fire safe environment is achieved by different means other than evacuation
01:54:18 and then four lines up from the bottom it says once the dwelling has one or more floors above 4.5 metres high then alternative protected escape arrangements must be designed in however these maybe have been rendered
01:54:30 however these maybe have been rendered ineffective by modifications made by the residents
01:54:33 residents and then if we go to page 11 uh in the slide under defending place generally flat it says typically purpose-built flats at higher levels
01:54:44 purpose-built flats at higher levels not usually acceptable in converted houses building generally designed around a fire resistant box and then if you look down at the notes underneath that it says high-rise blocks of flats are designed to provide one-hour fire resistance this is okay
01:54:56 one-hour fire resistance this is okay when new but alterations made by residents or other persons may affect fire safety of the compartment each individual flat not the rooms within each flat is built as an independent fire resisting box the level
01:55:08 independent fire resisting box the level of compartmentation depends on the height of the building 30 minutes etc and it goes on like that and then
01:55:15 and then in the
01:55:16 in the last four or five lines in that block of text
01:55:20 text it says the caller should be questioned to try and form a picture of what is happening in the area are they at risk from fire heat or smoke can they move to another area from where they can make further escape if they are affected by
01:55:31 further escape if they are affected by heat and smoke they should get out these are the provisions of modern flats constructed to the requirements of the building regulations this standard cannot be applied to older housing stock
01:55:42 cannot be applied to older housing stock i've shown you quite a chunk of the training in this slide looking at it as in the round did you consider at the time that that covered your concern that you had raised in your third of march 2010 email about giving cras advice on what to tell
01:55:55 about giving cras advice on what to tell callers in high-rise premises when they felt they were trapped by smoke or fire or heat
01:56:03 um no i'm not sure is this this is before this is the presentation that i comment on or do you think this is the one that i've
01:56:12 i've they've amended well i'm asking i'm asking you i'm sorry i'm apart from my comments on that i i'm not
01:56:21 i'm not sure where right my comments went from there at all events you d you don't think that that's
01:56:28 that's that that text addressed your concern or put it this way you don't think that that text catered sufficiently for the concerns you had expressed no i probably would have liked to be
01:56:40 no i probably would have liked to be clearer i think it contains some useful information but i think i would have liked to have related back to
01:56:46 to what a control officer was doing as well now if we look at another email in march 2010 at lfb 00108083
01:56:57 this is five days later after yours is the third this is from chris sharp to scott hayward copy to you 8th of march recall handling update tech techniques updated
01:57:09 updated and we need to look at the second page in this email run it starts at the very foot of page one and as has become habitual the emails tend to be split over a
01:57:20 the emails tend to be split over a number of pages um and you can see that it is from uh scott hayward on the 8th of march to chris sharpe the top of page 2 copy to you and lindsey turner good morning
01:57:32 to you and lindsey turner good morning chris thank you for your continued effort on getting this process right having received this presentation and gone through it a couple of times we have two issues that cause some concern i'm not convinced of the
01:57:44 concern i'm not convinced of the relevance of this session in relation to fsg as we know fsg promotes its own proactive straight reactive questioning which would be tempered depending on the caller the aim for the officer is to glean as much information as quickly as
01:57:56 glean as much information as quickly as possible to ascertain the environment get the caller out make them safe until rescue or find an alternative means of escape
01:58:03 escape staff and especially new entrants will have a lot of information to take in on these days and i would rather commit an hour to a case study or fsg training
01:58:14 do you agree or did you agree at the time with these views expressed as here by scott hayward i do agree um but whether it's the we he refers to lindsay's turned in as what
01:58:27 he refers to lindsay's turned in as what copied in so he might have had a conversation with lindsay i think we all would have agreed on that i see and
01:58:34 and do you know whether he was commenting on the presentation uh well let me look at let me show it to you lfb double zero one zero four five three nine
01:58:46 one zero four five three nine if we have that on the same on the screen at the same time i'll give you the reference again lfb double zero one zero four five three nine
01:59:23 thank you now um th this one is called call handling techniques and
01:59:33 and um we've been able to identify that this has been modified on the 9th of april 2010
01:59:40 2010 so it post dates the email that we're looking at by a month or so i should also just draw your attention to the fact that the subject matter of this email run as you can see on the screen from the left is call handling
01:59:51 screen from the left is call handling techniques updated ppt which i think stands for powerpoint yes so
02:00:00 looking at these two documents is is uh the document on the right the one that was generated as a result of the discussions on the left
02:00:11 left possibly if you say that that's updated right
02:00:15 right now uh
02:00:16 now uh scott hayward told us in his witness statement and just for reference purposes
02:00:21 purposes uh that's in his third statement of paragraph 16.3
02:00:27 and a paragraph 24 in his third statement um that it was up that this was the new entrance training slide do you remember that do you agree with that
02:00:37 that i i wouldn't recall that i don't remember
02:00:41 remember was this training or other training package created to deal with the proactive straight reactive questioning required in an fsg course do you remember that i think that it was updated
02:00:53 updated as part of a suite to roll out to control officers that
02:00:58 that would have identified the gaps that we'd found from our gap analysis and to address those i think the call handling techniques i think there's another one on
02:01:10 think there's another one on specifically on fire survival guidance and and this one on call handling techniques is uh covers mainly the interaction with callers
02:01:22 callers now let's just take this a little bit in stages uh
02:01:25 stages uh let's look at what scott hayward told us was used in 2011 the following year lfb triple zero eight six two one nine
02:01:43 this is a a different version of the slide or powerpoint call handling techniques and
02:01:51 and it's very similar to the one i've just shown you from april 2010
02:01:57 um if we scroll through it slowly you can see what it's about aim we just go to page two aim to examine the challenges encountered by control staff and dealing
02:02:09 encountered by control staff and dealing with emergency calls and then
02:02:12 and then page three objectives page four
02:02:17 page four think what makes a difficult call and there's the multicolored brain and then different kinds of things details of call sound issues situational physical circumstances
02:02:28 physical circumstances and we see that there some particular features of the caller yes
02:02:35 yes emotional stressed abusive etc next page
02:02:42 page five emotional uh page six
02:02:49 communication styles non-assertive assertive aggressive page seven answers uh page eight uh transactional analysis
02:03:00 uh transactional analysis etc
02:03:03 etc uh
02:03:05 parent page 10 caring disciplinary
02:03:12 this is really about styles and behavior on a call isn't it not about the substance of the advice to be given no this is about call handling in in general terms but i'm aware that it rolled out with fire
02:03:24 i'm aware that it rolled out with fire survival guidance training and it doesn't appear to us that this training package at least this version in 2011
02:03:30 in 2011 that was delivered included any training on fsg calls um
02:03:36 um or so far as proactive or reactive questioning was concerned no i agree i think it would have been just a generic call handling package that was included uh presumably
02:03:48 package that was included uh presumably because
02:03:49 because for survival guidance calls you would mainly move through this parent child relationship with the caller and it just would have been reiterating
02:04:01 would have been reiterating call handling techniques for a control officer to use during fsg calls
02:04:07 calls did you notice the fact
02:04:10 the fact that there was no proactive reacting training on questioning when you reviewed the training on the 2nd of july 2010 the previous year i'm not sure if i reviewed i might have
02:04:21 i'm not sure if i reviewed i might have reviewed this bit but again this is generic call handling uh techniques and
02:04:28 and the proactive reactive questioning was specific for fsg and so i would have hoped it would have been in the the specific presentation for fire survival guidance
02:04:39 survival guidance yeah you see that neither the version i've shown you from 2010 but
02:04:43 but neither of the two versions from 2010 nor this version from 2011 contains in it that the point that scott hayward picked up in his communication to chris sharpe and lindsey turner
02:04:54 to chris sharpe and lindsey turner in his eighth of march email namely um how
02:04:58 um how the fsg would would use its proactive reactive questioning style to get as much information from the caller as possible as quickly as possible does it or do they no
02:05:09 no as i understood it it would have been in the specific fsg uh powerpoint the specific fsg powerpoint what what is that i believe there is there was a
02:05:20 that i believe there is there was a specific
02:05:21 specific so
02:05:23 so in the training i think there was a a package on call handling or a presentation on call handling and then there was a presentation on fast survival guidance which covered both the technical and interaction elements
02:05:36 technical and interaction elements with
02:05:38 with control staff
02:05:44 now let's go to lfb double zero one zero eight seven 701
02:05:58 this is an email if we go to page one this is an email at the foot of the page from scott hayward 14th of may 2010 to lindsay turner chris sharp copy to you
02:06:09 turner chris sharp copy to you forward fast survival guidance update 2 powerpoint good morning firstly can we please include joanne into these discussions as decisions made include the whole management team now that's another email about fsg
02:06:21 now that's another email about fsg training isn't it yes it looks like it's updating the fire survival guidance powerpoint do you agree that decisions about the training were being made or to be made from that point on at least by the whole
02:06:33 from that point on at least by the whole management team including you
02:06:37 um yes i think as i've tried to explain that was the way we worked we decided we had we all had input into different changes
02:06:48 we all had input into different changes and suggestions i'd had input in
02:06:52 in some of the changes from the gap analysis that wasn't to say they were all agreed and accepted um as they often weren't but some of them were so i would have added
02:07:04 some of them were so i would have added in what i thought and how i thought fsg training should be delivered in line with the gap analysis
02:07:12 analysis then let's turn to your review on the 2nd of july 2010 which we've touched on we saw the email um can we go to your statement please page 19 paragraph 47
02:07:25 you say in the last sentence in that paragraph
02:07:29 paragraph um
02:07:30 um you say
02:07:32 you say that
02:07:33 that you weren't involved in the drafting of the training package but you attended the rollout to ensure that it complied with national guidance and the gap analysis
02:07:40 analysis we looked at that before so i'm taking that quite shortly how did you go about that task to ensure that it complied with the national guidance and the gap analysis uh i can't recall but i think there was four of us that attended so
02:07:51 there was four of us that attended so john bradbury also attended in tim cut bill
02:07:54 bill they may have made notes and compared it and the same as scott and i may have made
02:07:59 made notes and compared that right did you sit down
02:08:02 sit down on the second or about the second of july with the training package as it then stood so far as fsg call handling was concerned and compare that with the national guidance and the gap analysis
02:08:14 gap analysis no
02:08:15 no not on the call handling although i do i think i did comment on the call handling document it would have been more specifically revolving around the fire survival guidance package
02:08:25 package that the package that was attached to the email you've just shown me did you provide any report or feedback on what you found
02:08:32 you found no because uh both scott and tim couple would have witnessed the same training i don't believe we sat down and went through the packages i think they were delivered to us we just attended a training the training session where it
02:08:43 training the training session where it was being delivered by the trainers and what was your view i think if i'd had any observations to make i would have emailed them to lindsay and scott but i can't recall you
02:08:54 lindsay and scott but i can't recall you can't recall did you remember whether you had any concerns about whether or not in fact the training did comply with the national guidance as identified by your gap analysis i'm
02:09:05 as identified by your gap analysis i'm sure we would have all had some feedback and some comments um that would have been taken into account if there were any i wasn't it wasn't
02:09:14 wasn't i wasn't the only one that was attending to make sure it complied with the gap analysis now you could you say that you wanted to make sure that it complied with the gap analysis or rather the the
02:09:26 with the gap analysis or rather the the gap
02:09:27 gap between the lfb's current procedures and the national guidance is revealed by the gap analysis more accurately uh at this time although of course the latino control report hadn't been
02:09:39 latino control report hadn't been finalized and and indeed was not to be finalized for a further two and a half years or so were you looking at whether the training that you were looking at then covered teaching cros about what had happened at
02:09:51 teaching cros about what had happened at the latino house incident
02:09:56 no so this is mid 2010 isn't a year on from lacanal yes were you not focusing on what lessons you had drawn as a control room from the latino
02:10:08 as a control room from the latino incident and seeking to reflect those in training
02:10:13 yes yes we were and i think that's that was definitely the direction from the board that to make sure it complied with 1093
02:10:23 with 1093 um
02:10:24 um and that we were to go back to that which is why the gap analysis was created and while we tried to ensure that that was rolled out through in and reflected in training well um forgive me
02:10:37 reflected in training well um forgive me for not being completely clear um
02:10:40 um was your aim to make sure no more than that the training complied with national guidance or was your aim to make to make sure that the training cured the deficiencies that you had thus
02:10:52 cured the deficiencies that you had thus far identified as manifested at the latino house fire i i'm not
02:10:59 i'm not sure i can only understand what my role was in it which was to support scott and lindsay and with my uh of the knowledge that i'd gained from
02:11:11 uh of the knowledge that i'd gained from the lack of board and the investigation to
02:11:15 to make observations um
02:11:18 um that i had noticed against what we had found out from the gap analysis
02:11:26 sorry and it sounds
02:11:28 it sounds um
02:11:30 um a little dense on my part but the gap analysis had identified not only a gap between the lfb's practice and national
02:11:41 between the lfb's practice and national guidance
02:11:42 guidance but also defects in the national guidance
02:11:45 guidance yes
02:11:47 yes sorry yes yes that's the first thing the second thing is that at this stage a year on after the latino house incident
02:11:57 incident the lfb although it hadn't completed its investigations into the learning from that incident had learned some had learned at least something about how the control room had performed on the night of that incident
02:12:08 performed on the night of that incident yes
02:12:10 yes yes yes
02:12:11 yes yes so my question is when it came to your review of the training in july 2010 were you not keen to make sure that the training that new entrants and and existing staff received
02:12:24 and existing staff received reflected what you learnt as a result of the latino house incident whether or not it was a gap between lfb practice and national guidance
02:12:35 practice and national guidance yes you'd right
02:12:40 then let's look at
02:12:44 lfb triple zero two eight two six five
02:12:55 this is a 2010 training document entitled fire survival guidance and i think it's the presentation you referred to a little while ago in your evidence and you
02:13:06 while ago in your evidence and you referred to fsg the fsg presentation itself yes now the the file name you can't see this from the document but take this from me the file name indicates to us that it was produced or generated on the 24th of
02:13:19 was produced or generated on the 24th of june 2010
02:13:20 june 2010 and we know that it was circulated by chris sharpton ned kelly station manager kelly otherwise known as ned are on the same date and just for our references that's
02:13:31 date and just for our references that's at lfbe three zeros four nine four five four
02:13:35 four looking at this document it's entitled first survival guidance brigade control training section that's bcts uh in the acronym is do you recognize this document
02:13:47 is do you recognize this document i do i believe i have i commented on this uh particular presentation and that's the training you would have observed is this right on betw on the 2nd of july 2010
02:13:58 betw on the 2nd of july 2010 the training would have been off this document
02:14:01 document potentially i can't recall that but looking at the text down below i would have made some comment on that and the timing makes sense because it was produced only a fortnight before also
02:14:14 only a fortnight before also now looking through the document if we go to page two
02:14:20 home office 1093
02:14:23 guidance based on home office circular 1093
02:14:26 1093 so it looks as if the training was based on that circular is that that correct it does look like that yes uh now we see no reference there to fire service circular 5404
02:14:37 service circular 5404 why was that
02:14:41 because it was not something lfb i believe had chosen to adopt so that's as a result of the gap analysis not taking it into account that's a result of when 5404 was
02:14:54 that's a result of when 5404 was released by uh
02:14:56 uh the home office of the government that it wasn't adopted into lfb and lfb control
02:15:02 control right
02:15:03 right and we've been around that so in short is the answer to the questions i asked you previously about 5404 and the gap analysis does that explain why there's nothing in here about 5404 yes
02:15:15 there's nothing in here about 5404 yes yes now let's head to page five fire situations
02:15:22 play number two on dvd jodie williamson four minutes and can you explain what that was
02:15:32 i think that is a call
02:15:35 call made by one of our cross uh that they then play
02:15:39 then play right the audience and how is that part of the training how is it done
02:15:48 i don't recall if i'd witnessed part of this training um but i presume they would just have played it to the audience
02:15:57 audience um
02:15:58 um and then
02:16:01 the additions are just the comments and they probably would have talked through that but i would only be speculating
02:16:14 was it a element of this training that was role play
02:16:21 i wouldn't i thought
02:16:24 i thought that it was that's not role play and i think from the the lacking aboard there was clear instruction from from scott that role play needed to be
02:16:36 scott that role play needed to be included into training so i wouldn't have thought that would have sufficed and you can see underneath the text after the words try to avoid silences
02:16:47 after the words try to avoid silences fb can you get out no fb what floor are you on first floor at the front those are obviously questions and answers or statements at least you can see who's making them
02:16:58 making them is that a verbatim quotation from the dvd or
02:17:01 dvd or or what is it i wouldn't have thought that just reading that because they go right in they go straight into protect phase and have not assessed
02:17:12 the cooler and the caller situation so no i wouldn't have said i think those are just points um maybe to cover maybe that's what they were doing in the training but i i don't know and i can't recall right witnessing
02:17:25 know and i can't recall right witnessing this you can't control witnessing it um can we turn to page 19
02:17:34 positive statements we'll get through this together help me to help you stay calm we're going to help you
02:17:41 help you and then if you look at the text underneath positive questions keeps them involved something to concentrate on makes you both feel closer together and creates a bond
02:17:53 and then if you look at page 28 called psychology
02:18:02 it says call psychology create a bond with the caller reassure the caller that they're going to survive tell the caller the firefighters are on
02:18:13 tell the caller the firefighters are on their way and we'll be there very soon now
02:18:19 that slide and
02:18:22 and the positive statement slide at page 19 makes you both feel closer together and creates a bond although is not directly contrary to the issue you yourself highlighted in your gap analysis namely
02:18:34 highlighted in your gap analysis namely that the 1993 national guidance expressly discouraged cras using phrases to create an emotional link
02:18:42 link yes
02:18:43 yes i'm extremely surprised that they're in this document in 2010 i thought they were removed after our gap analysis findings so i'm surprised that any new training to
02:18:55 i'm surprised that any new training to all cros that were rolled out was rolled out in 2010 contained that when you reviewed this
02:19:03 this slide on
02:19:04 slide on these slides on the 2nd of july did you notice that these slides were in there if i'd seen these presentation and seen some of them i would have commented on
02:19:16 some of them i would have commented on that
02:19:16 that that they shouldn't have been in there very much so with the course psychology i think i would have picked up on the first page as well it refers to afar and west mids and i would have brought that back to
02:19:26 back to what lfb and lfb her control had been through with lacinal as well well we'll trace we'll trace that through later but but i just want to work to work out if i can with you
02:19:37 work to work out if i can with you how that ended up in this training at this time
02:19:41 this time would you agree with this proposition that this presentation if not corrected would have re-embedded bad practice
02:19:52 would have re-embedded bad practice yes i would are you able to explain how come the training team so
02:19:57 so chris sharp lindsey turner thought it was appropriate to encourage the creation of a bond between the the caller and the call handler
02:20:07 no like i say at one point that had been in the training and the new entrance training from
02:20:15 from full control staff and and that was current at the time of lachanol
02:20:21 lachanol but
02:20:21 but any new subsequent training that we'd learned after our investigation
02:20:28 the uh idea of creating a bond with the caller
02:20:32 caller was removed had lindsey turner or chris sharp not been given the gap analysis or any instruction about carrying it into effect
02:20:44 about carrying it into effect uh
02:20:45 uh yes i i i believe they were and they certainly uh lindsey was certainly aware of
02:20:51 of the meetings that we were having with the lachenal board and our investigation she'd been involved in them too so so would have been aware um
02:20:59 um and i'm just very surprised that this was a training powerpoint delivered to all control staff in in 2010 when we decided to to change the training to align with
02:21:11 to change the training to align with 1093
02:21:14 are you able to tell us why this presentation doesn't mention the circumstances of the latino house fire i haven't shown it all to you it's a 28-page document but are you able to tell us why it doesn't
02:21:25 are you able to tell us why it doesn't mention the circumstances of the law which is why i'm surprised that this document was presented to all control staff
02:21:36 presented to all control staff as fsg refresher training in 2010 do you remember and it's a long time ago it was more than 11 years but do you remember being presented with this training about a year after lachnal
02:21:48 this training about a year after lachnal seeing the perpetuation of the bond point in it create a bond with the caller and reacting then as you have today
02:21:58 today do you remember that potentially i i wouldn't have seen this package and not reacted to it it's just not something i would have done
02:22:06 done that i understand my question is do you remember a reaction uh no i do remember commenting on a training package that i forwarded to
02:22:17 training package that i forwarded to another frs and reviewing that i'm not sure if this is the same one
02:22:24 did you see the role play exercise that was carried out when you carried out your review on the 2nd of july 2010 um
02:22:32 um no not that i can recall let's look at scott hayward's third witness statement at page six that's lfb double zero one two one one seven six
02:22:43 double zero one two one one seven six paragraph twenty he describes the role play at the time and i'll show it to you he says this
02:22:54 the trainer would call the cras participating in training from a separate room the trainer would then act out an fsg call and the cro would be expected to respond to the fsg call there were no required points to cover
02:23:06 there were no required points to cover however the trainer would be expected to ensure the trainee followed the structure of the fsg reference information form riff the trainer would be an experienced assistant operations manager aom and would draw upon their experience to
02:23:17 would draw upon their experience to improvise a role play scenario on for the mock call is that something you remember uh
02:23:26 uh now i can't really recall witnessing any
02:23:31 any role play
02:23:32 role play um as part of uh fsg refresher training when we rolled it out in 2010. do you know why the role play was devised in that way
02:23:43 in terms of uh participate training from a separate room and calling them on
02:23:50 i think that's how we'd uh we certainly used to train like that in terms of other calls so it wouldn't be unusual for a member of the training team to input into
02:24:03 the training team to input into and to ring and pretend to be a caller they do that in their basic training in their new entrance training all the time so
02:24:11 so that probably was the structure that they followed do you know why there were no required points to cover no i don't why was the aom not given some lessons from lachnal and told to cover those at
02:24:22 from lachnal and told to cover those at least
02:24:30 in terms of pointing out uh the difficulties in lachenal because i think
02:24:37 think um our gap analysis has identified the additions we needed to bring into training
02:24:45 training um
02:24:47 um and i'm not sure in terms of whilst the training had delivered all the points that a control officer would go through in terms of assess
02:24:58 go through in terms of assess escape assess protect and rescue and
02:25:03 and that would have covered the lessons learnt from lacking
02:25:15 i'm not sure i understand that answer with great respect and it says there were no required points to cover no why not so i'm saying it is part of the role play if they'd moved through the four areas that they had just been
02:25:28 the four areas that they had just been trained on in fsg the four key areas of five survival guidance that would have covered all the points and all the learning
02:25:39 all the points and all the learning points
02:25:40 points from the lacanal
02:25:44 well that's very general because there are a lot of learning points from the latino fire one of which was don't create a full sense of security if there were no required points to cover how would the trainer know to ensure the trainee whatever they did did
02:25:56 ensure the trainee whatever they did did not create a full sense of security in the caller or create an emotional bond because they had
02:26:04 they would have created the training that had the bonding and the role play element out but i would just be
02:26:14 guessing why they didn't do that they
02:26:17 they certainly
02:26:18 certainly in terms of the management team understanding um the
02:26:24 the issues
02:26:25 issues from la canal we were all aware of those and i
02:26:29 and i i can't imagine that the training team and ost
02:26:32 and ost wouldn't have ever seen the gap analysis before the break i'd like just to look at one document with you dated march 2010
02:26:40 2010 about role play lfb double zero one zero four five three eight
02:26:54 it's it's dated march 2010 as you can see from the top and it's entitled fast survey survival role play non-accessible is this something you saw at the time
02:27:05 is this something you saw at the time no you didn't no i don't recall you don't so you don't know you can't help me as to whether this was used in the role play sessions or or who devised it no right
02:27:16 no right can you help me do you know why it wasn't accessible uh no i don't i don't i don't know where that decision was taken if you'd asked me um and i think i comment subsequently
02:27:28 me um and i think i comment subsequently that it would be useful for it to be accessible and looking at page six learning outcomes in relation to call handling the very
02:27:40 in relation to call handling the very foot of the screen it says were positive statements used i'm here to help you you will get out of this help me to help you was a relationship built with the caller question
02:27:49 question looking at that do you agree that that part of the role play training appears to encourage the cro to create an emotional link with the caller yes i do and again contrary to national guidance yes contrary to your gap analysis yes
02:28:05 again are you able to explain how uh the march 2010 fast survival scenario was seeking to embed uh learning or embed
02:28:16 embed conduct in the cras which was directly contrary to your gap analysis which at this stage hadn't yet quite been completed but was certainly being used for the purposes of devising the training as we've seen from the february 22nd email
02:28:28 the february 22nd email no i'm
02:28:29 no i'm i probably can't recall either when we rolled out fsg refresher training in 2010
02:28:35 2010 what
02:28:36 what month it was but from the documents i've seen i would have hoped that it would have been updated
02:28:43 updated yes and and to help you uh
02:28:46 uh it looks as if from the documents the f the refresher training for exist for existing staff was rolled out in september 2010 yes after your july uh review but the new entrance training
02:28:59 uh review but the new entrance training was designed for the marks of 2010 at the time of this document i see now um do you know whether after your review on the 2nd of july you gave me feedback do you remember
02:29:11 you gave me feedback do you remember that
02:29:12 that if it had been on the documents you've just shown me i would have yes i don't think we do have documents showing your feedback do you know whether the training presentations were amended in the light of your review
02:29:23 review but both the new entrants and for existing staff i would hope so yes yes hoping is is i'm sure is right but do you remember whether it was so i don't know
02:29:38 um mr chairman is that a convenient moment
02:29:40 moment yes if it's convenient to you i think we should stop there right smith we're going to stop there for the day i'm going to have to ask you to come back tomorrow for some more questions i'm afraid but uh there it is we'll resume please at 10
02:29:52 there it is we'll resume please at 10 o'clock tomorrow morning and again please don't talk to anyone about your evidence or anything relating to it over the break
02:30:00 break thank you very much indeed you could give the usher then please
02:30:14 thank you mr miller tomorrow thank you