London Fire Brigade Evidence - Monday 1st November 2021 (1/2)

Full transcript

00:00:27 hmm

00:00:32 good morning everyone welcome to today's hearing

00:00:35 hearing today we're going to start hearing evidence from mr peter carr formerly of the london fire brigade yes mr clear man call mr carp thank you

00:00:54 good morning mr carp good morning i gather you're going to make the earth so would you take the testament and read the

00:01:00 the words on the screen please i swear by almighty god that the evidence i shall give shall be the truth the whole truth and nothing but the truth thank you very much please sit down make yourself comfortable thank you

00:01:12 down make yourself comfortable thank you thank you all right

00:01:19 yes when you're ready mr kennedy thanks sir um first of all would you please confirm your name for the record uh peter cow up mr kerp uh good morning thank you very much for attending to give evidence today um before we start i

00:01:30 give evidence today um before we start i should say my questions are intended to be short and simple sometimes it doesn't work out that way um if they're long or not clear please say so and i'll rephrase them secondly if any time you

00:01:41 rephrase them secondly if any time you need a break please say so that's not a problem

00:01:44 problem thirdly if when giving evidence could you give keep your voice up that allows the transcriber to capture everything you say and everything you say correctly and finally please don't nod an answer

00:01:56 and finally please don't nod an answer to a question say yes or no as the case may be understood thank you now um you've made three statements for the inquiry um the first statement is dated the 16th of february 2019 and can

00:02:08 dated the 16th of february 2019 and can be found at lfb treble zero three two seven eight four is that it that's correct and if we could turn to page eight

00:02:34 so

00:02:41 thank you is that your signature that is indeed thank you now that statement exhibited amongst other documents an exhibit entitled pc-6

00:02:52 documents an exhibit entitled pc-6 which is your report entitled national guidance and london fire brigade operational policy for fighting fires and high-rise buildings and that can be found at lfb zero three two seven eight three

00:03:06 zero three two seven eight three is that it that's correct thank you and your second statement is dated the eighth of may 2019 and can be found at lfb trouble zero double five two four

00:03:17 lfb trouble zero double five two four eight

00:03:18 eight is that it indeed and if we can turn to page seven is that your signature it is thank you now in that second statement you confirm that you drafted pc6 and you provided an

00:03:31 that you drafted pc6 and you provided an affirmation that its contents are correct to the best of your knowledge is that right that's correct and

00:03:37 and finally if we can look at your third statement which is dated the 14th of october 2020 which can be found at lfb double zero double one nine eight four nine

00:03:48 nine is that it it is and if we could turn to your signature on page one one six is that your signature it is now there are a large number of documents exhibited to each of the three

00:04:00 documents exhibited to each of the three statements is that right indeed

00:04:03 indeed and have you read first of all your statements recently i have have you read the exhibited documents recently i have and can you confirm that the contents of the three statements that choose the best of your

00:04:14 statements that choose the best of your knowledge absolutely thank you and you happy for those statements and indeed your report pc6 to be taken as your evidence to this inquiry indeed and finally have you discussed your

00:04:25 and finally have you discussed your evidence with anyone before attending the inquiry today only my legal team mr kurt thank you now the first topic i'd like to discuss with you today is your roles and responsibilities at the

00:04:36 your roles and responsibilities at the lfb

00:04:37 lfb now you state in the first sentence of paragraph four of your first statement which can be found at lfb treble zero three two seven eight four forward slash two that you're employed by the lfb

00:04:49 two that you're employed by the lfb between 1982 and march 2016 when you retired is that correct that's correct now you say that you're employed as an operational firefighter did you perform operational duties

00:05:00 did you perform operational duties throughout your time at the lfb until you retired in 2016. i did now you state in the final sentence of paragraph eight of your first statement which can be found at page three

00:05:16 that in april 2009 you were promoted to deputy assistant commissioner in operational tactics which was a team in the operational policy department was that your first role in the operational

00:05:28 that your first role in the operational policy department uh

00:05:32 uh it was my first substantive role previously i'd i i think it's mentioned earlier in my statement i'd been an assistant divisional officer

00:05:43 divisional officer in uh the contingency planning team which was part of what was called operational policy at the time thank you following your appointment as a deputy assistant commissioner what was

00:05:55 a deputy assistant commissioner what was your experience of live incident command so throughout my career obviously i attended many incidents both as a firefighter initially and then

00:06:06 both as a firefighter initially and then as a supervisory officer up to an including deputy assistant commissioner uh so i did attend a lot of incidents yes thank you um

00:06:16 um it's an unfortunate phrase but you then acted up

00:06:19 acted up as head of service and operational policy from the 7th of june 2013 is that right that's correct and then following that you were promoted to assistant commissioner in operational policy from august 2014 onwards is that right that's

00:06:31 august 2014 onwards is that right that's correct

00:06:32 correct now did that mean that you were the effective head of the operational department between june 2013 until your retirement in march 2016. yes

00:06:43 retirement in march 2016. yes now if we can stay on page three of your statement your first statement and look at paragraph 10 in the first statement there the first sentence rather you say this and i quote

00:06:54 sentence rather you say this and i quote my primary responsibilities in the role of ac such assistant commissioner in operational policy were to head up the department that was responsible for the creation and maintenance of approximately 80

00:07:06 maintenance of approximately 80 of all lfb operational policies and risk assessments did that percentage include the lfb's policy on high-rise firefighting it did and when you say that the operational

00:07:17 and when you say that the operational policy department was responsible for the creation and maintenance of lfb operational policies can i just see what in detail your department was responsible for

00:07:29 responsible for first of all were you responsible for identifying when it was necessary to create a new policy

00:07:37 yes although that responsibility was shared across the organization because the source of policy i think we've submitted to a flowchart that shows the various drivers for policy either to

00:07:49 the various drivers for policy either to be created or changed so the source of change could come from without you know outside of the department and indeed on occasions outside of london fire brigade so if um

00:08:02 outside of london fire brigade so if um a new or amended policy were required the actual carrying out of the work required to implement that new or amended policy where responsibility for that undertaking lie

00:08:14 that undertaking lie so so the department was organized into a series of teams uh that had a kind of thematic responsibility for different areas of operations but it lies within your old

00:08:25 operations but it lies within your old operations department generally but as i've said in my statement there were areas of operational policy such as relating to transport certain aspects of national

00:08:36 transport certain aspects of national resilience which sat with other departments because of their particular needs and sensitivities mainly because of the expertise for those areas would have sat

00:08:47 those areas would have sat in departments other than operational policy and who was responsible for drafting the policy and managing the process of internal consultation that the lfb's procedures required in

00:08:59 the lfb's procedures required in relation to a newer amended policy so so the process of consultation was in different phases so

00:09:08 so they would it would generally start with a peer review which would be within the department the owning department after that there would be a formal heads of service consultation

00:09:20 heads of service consultation and then after that there would be formal consultation with the trade unions through a group called brigade committee for health and safety and welfare of staff

00:09:31 health and safety and welfare of staff but generally would your response your department be responsible for managing that process of consultation even though there were different constituent elements to it my department didn't manage the process

00:09:43 my department didn't manage the process for example the well we manage the health and sorry the heads of service consultation for sure and we managed a peer review but the formal consultation with the trade unions

00:09:54 unions was run through the health and safety department because they administered and managed

00:10:00 managed that joint committee to deal with a particular instance um would your department have managed the process for a revision of pn 633 the lfb's policy on high-rise firefighter

00:10:11 lfb's policy on high-rise firefighter yes

00:10:14 now you go on to say in the second sentence of paragraph 10 this the department was also responsible for specifying requirements for some operational training now was it the responsibility of your

00:10:26 now was it the responsibility of your department to identify any training requirements that arose as a result of a new or amended policy that's correct and so if the operational policy department decided that it was necessary

00:10:38 department decided that it was necessary to create a new one or amend an existing one it fell to your department to identify whether that new or revised policy brought with it a new or revised training requirement is that right

00:10:49 training requirement is that right that's correct thank you now having dealt with those high level structural matters can i now turn to the generic risk assessment process that carried out between 2010 and 2014 and i

00:11:01 carried out between 2010 and 2014 and i want to ask you some general questions first of all emphasize the word general and the review of national generic risk assessments that was undertaken during that period once we've done that we will

00:11:12 that period once we've done that we will then turn to the specifics of gra 3.2 okay now the first topic i'd like to discuss with you this morning is generic risk assessments what's their role and what's their purpose

00:11:24 what's their purpose and if we come on to some particular questions so i can anchor you in your report now can we go to pc6 first of all which is a lfb trouble zero three two seven

00:11:34 seven eight three

00:11:38 there's your report and if we go to page six within that report

00:11:46 and if we could look at paragraphs 2.1.2 and

00:11:50 and 2.1.3 and you say this gra that's generic risk assessments were provided by the dclg the department for communities and local government

00:12:01 communities and local government to assist fire and rescue services frs in identifying and recording significant risks their employees and others affected by their operations frs are responsible for ensuring that gras are

00:12:13 responsible for ensuring that gras are valid within the setting of their own systems of work and they are encouraged to use them to inform and develop their own practices and procedures in this context gras are intended to

00:12:24 in this context gras are intended to support those personnel in frs who are responsible for creating and amending service risk assessments operational policy and procedures gras are not intended to be used

00:12:35 gras are not intended to be used directly to guide operations or to be used at incidents although they are publicly available through the government gateway gov dot uk website there is no requirement for operational

00:12:47 there is no requirement for operational personnel to know about or make use of these documents but some may make reference to them for training and personal development purposes

00:12:56 purposes now there were a large number of gras when the review started in 2010 is that right that's that's correct i believe there was

00:13:04 there was in the order of 40. that's the that's the number we've seen 40 and if reference were needed for that it's pc6 paragraph 2.2.5 on this page what's the purpose of the

00:13:16 on this page what's the purpose of the generic risk assessments to provide a guide to individual fire and rescue services when preparing their own operational policies and procedures yeah absolutely they were i mean they

00:13:27 yeah absolutely they were i mean they were written by

00:13:29 by seconded people from different fire services or at least the the review that i took part in that's how that was managed i can't speak for how they were first created

00:13:40 first created because i wasn't involved and each each service took the lead and and created a document that the expectation was that local fire services

00:13:51 expectation was that local fire services would then take that document and use it to inform and create their own first of all risk assessment and secondly policy now we've referred to the fact and your

00:14:03 now we've referred to the fact and your department's general responsibility in relation to new policy and amendment of existing policy does it follow that the burden primarily fell on your department to be familiar

00:14:14 fell on your department to be familiar with the substance of gras the way we worked in in london at the time was that i was the representative for london fire brigade on the gra

00:14:26 on the gra committee

00:14:28 committee to distinguish between that and there was also a bald and as a result i was the conduit through which gra's were shared with london and my role at in that respect was to

00:14:40 and my role at in that respect was to either pass them out to whoever in my team was best place to deal with them or

00:14:47 or if they went into another department to pass it to that head of service and to ask them to carry out a review so there was a over the course of the two or three years that the gras were under review

00:14:59 years that the gras were under review there was a constant series of

00:15:03 series of reviews of individual documents as they were produced and released by clg for consultation so there was a two-round

00:15:12 two-round a two-stage process to consult on each gra

00:15:16 gra now we'll come on to the substance of members and all the rest of it but would it be fair to summarize your evidence this way that you were the gra point man at the lfb

00:15:27 at the lfb that would be very fair thank you now could we look um in broad terms of the operational guidance review program that was carried out between 2010 and 2014 now we

00:15:38 now we if we look at paragraph 2.2.1 on this page let you say this the gra series was reviewed between 2010

00:15:49 the gra series was reviewed between 2010 and 2014 as part of a broader operational guidance health and safety guidance review program this program was commissioned by dclg

00:16:00 this program was commissioned by dclg and the chief fire and rescue advisor the cfra as the owners of this guidance now did that broader operational guidance review consider all the various

00:16:11 guidance review consider all the various 40 odd gras yes i believe so and you explain uh just below at paragraph 2.2.2 that and i quote responsibility for

00:16:22 that and i quote responsibility for program management and delivery was contracted to surrey fire and rescue service and first of all by whom was it contracted to surrey my understanding is that was an arrangement between dclg and and surrey

00:16:36 arrangement between dclg and and surrey fire service i don't know the precise arrangements of the contract i was not privy to that but they had a seconded surrey officer derrick clough who was in effect the

00:16:48 derrick clough who was in effect the program manager thank you well come on to mr clough in india and i believe he was seconded for the period of that work thank you and what was the substance of surrey's role in the broader operational guidance review

00:17:00 broader operational guidance review program

00:17:03 program i think this i think their role was primarily one of program management and administration uh i can't recall whether as a service they also took on

00:17:15 whether as a service they also took on review responsibilities because most fire services did take on one or two of the gras to review london for example we took on two

00:17:27 we took on two now you say that the program was quotes commissioned by dclg what was the substance of dclg's involvement in the um the operational guidance review program

00:17:41 i can't really answer that in any detail because i was never particularly aware of their

00:17:46 of their active involvement derek clough led the meetings that i attended i think occasionally chris bolton who was his line manager i think he occasionally

00:17:58 line manager i think he occasionally attended one or two of the meetings but other than that i weren't aware of dclg staff being directly involved in the process thank you now following on from your evidence in relation to mr

00:18:10 from your evidence in relation to mr clough can we now look at the governance of the review program in particular the the um project board and the gra committee

00:18:17 committee now if we can just uh look at paragraph 2.2

00:18:22 2.2 0.7 which i think is at the bottom of page six

00:18:28 there he goes um you say there this

00:18:32 this governance for this review process was provided by project board and all sifoa at cfoa regions the devolved administrations and other stakeholders

00:18:43 administrations and other stakeholders were represented on a larger review committee

00:18:46 committee the board and review committee met monthly to discuss progress and discuss issues arising during the programme or associated with specific gras am i right in understanding that you were not a

00:18:57 in understanding that you were not a member of the project board correct you provided a document kindly which as you explained at paragraph 20 of your third witness statement we don't need to go to it but the reference is

00:19:09 go to it but the reference is zero double one nine eight four nine four slash eight that document identifies the board members and gives an overview of the gra process and if we could briefly look at that document

00:19:20 could briefly look at that document which can be found at lfb

00:19:22 lfb double zero one zero two three two eight

00:19:40 thank you and if we can see in the first paragraph on the first page and it's under the heading purpose and introduction the document says this this document describes the

00:19:51 this document describes the responsibility and relationship between the strategic mountain board and the gra committee now is the reference to the strategic management board there the same as the project board that you

00:20:02 same as the project board that you discuss in your evidence i believe so thank you now if we can turn to page three in this terms of reference document

00:20:12 and we can see at the top

00:20:16 um the membership is set out and we can see that that includes and i think it's the bottom two lines um the project manager chief fire and rescue advisor who's derrick clough to whom you've referred

00:20:28 whom you've referred and as well as the clg project advisor chris sull derrick clough was from surrey but had been

00:20:35 been seconded to the sifoa unit and for the purpose of the gra review program is that right uh not the seafarer unit i think he'd been

00:20:44 been seconded to cfrau the chief fire rescue advisors team sorry

00:20:50 sorry you're right apologies that was me and did he report to the ken knight who was then the chief fire and rescue adviser i believe he reported to chris bolton who in turn would have reported to sir

00:21:02 who in turn would have reported to sir ken knight and the only foreign rescue authorities that are represented are it would appear west sussex and the west midlands is that right

00:21:13 based on this document i i'll be honest i had no direct involvement or sight of the board so beyond what's said here i can't really comment and if we look at the third subheading on page three it sets out committee

00:21:25 on page three it sets out committee members

00:21:27 members there we go and it sets out there in the first entry sifoa regions then representative bodies the health and safety executive and the program manager

00:21:38 and the program manager is that the larger committee to which you refer on your report pc6 that's correct and you're a member of this committee representing the lfb is that right that's correct and to be clear about the membership of

00:21:50 and to be clear about the membership of uh this gra committee the country was divided into regions so for example the west midlands is a seafowa region and west midlands captures all the fire and rescue services within that particular

00:22:02 rescue services within that particular area is that right i'm not sure that is correct i think west midlands fire service were part of a

00:22:08 a wider region i think the only fire service that constituted the region was london fire brigade i think all the other nine were multiple services thank you and that answered my next question

00:22:20 you and that answered my next question london was its own seafarer region correct and is it correct that a representative from dclg also sat on the gre committee

00:22:30 you remember now i honestly well other than i i took derek clough to be

00:22:37 to be the representative of dclg i don't

00:22:41 i don't recall

00:22:43 recall anyone else from dclg chris bolton occasionally i think attended and another staff may have occasionally attended but in a routine sense um the

00:22:54 attended but in a routine sense um the minutes will show who was present at each meeting that derek clough was who you understood to be that's correct representing the interests of dclg yes and did any member of the committee have any specific expertise in high-rise

00:23:06 any specific expertise in high-rise buildings or high-rise firefighting the committee was a mixture of operational officers like myself so we had our operational experience

00:23:18 had our operational experience some of those also had regulatory fire safety backgrounds and experience so they would have brought that knowledge to the table and the other primary membership was

00:23:32 and the other primary membership was people that were in health and safety roles within their service so mark bishop for example was not a uniform member of staff he was a non-operational member of staff with i

00:23:45 non-operational member of staff with i believe a health and safety background we also had the health and safety executive there and and obviously as it says the trade unions did you have much to do with chris

00:23:56 did you have much to do with chris sewell

00:23:56 sewell in terms of your work on the committee i didn't know were you satisfied that the committee had the right spread of expertise and experience to consider the gres that

00:24:07 experience to consider the gres that felt to be considered

00:24:10 my experience was that the committee had knowledgeable officers whether we had the completely right mix i'm not sure it

00:24:21 the completely right mix i'm not sure it was my place to make that judgment but certainly the people i met and interacted with were professional officers they clearly were experienced officers so they would have had the right skills and knowledge and

00:24:33 had the right skills and knowledge and understanding for the topics that we were being asked to consider put it slightly differently did you ever have a concern that there were any gaps in the knowledge or expertise of the committee members no thank you can i

00:24:46 committee members no thank you can i turn on to a separate topic now which is responsibility for gras and for this can we go back to pc6 which can be found at lfb

00:24:55 lfb 00327 83 forward slash 7.

00:25:01 and if we look at paragraph 2.2.9 you say this members of the review committee also took responsibility for leading on the production of one or more revised gra

00:25:14 production of one or more revised gra although this did not always mean that they were the authors of these documents and in some cases that role was undertaken by personnel from another frs in the nominated region

00:25:25 in the nominated region now in relation to gra 3.2 the review of which we know you were appointed to lead there was no involvement from any other fire and rescue service or indeed any other sifo region is that right

00:25:38 other sifo region is that right that is correct although i am aware from minutes

00:25:43 minutes of the gra committee meetings that originally the intention was for other services scotland i believe being one of them to be involved but for reasons that i'm not

00:25:55 i'm not able to share with you because i wasn't involved in the decision making when it come to the point of review it was given to london alone and if the reference is needed for

00:26:06 and if the reference is needed for anyone following it's paragraph 29 of your third witness statement which is at lfb double zero double one nine eight four nine forward slash seventeen and am i right understanding that you were primarily assisted by philip morton

00:26:18 were primarily assisted by philip morton from the lfb with some minor involvement from other individuals at the lfb is that in broad terms is that right that's correct

00:26:26 correct and mr morton was a station manager in the operational policy department at the time of the review is that right that's correct

00:26:33 correct and so he reported to you his line manager was someone in my team but yes he was part of my team and as between you and philip morton um who was his

00:26:46 you and philip morton um who was his line manager

00:26:50 i think originally it would have been someone called malcolm ettridge uh after that spencer alden smith uh he was part of the fire policy team

00:27:01 uh he was part of the fire policy team and we'll come on to email correspondence involving those gentlemen due course but as between you philip morton mr ettridge and mr olden smith who decided the direction in which to

00:27:13 who decided the direction in which to take gra 3.2

00:27:18 the original work in terms of the early drafts was was very much driven by the lessons that have been identified through lacking or the lack of house fire

00:27:30 fire of which people in the policy team myself included were familiar

00:27:35 familiar beyond that as the document matured it was very much driven by the consultation responses that we received from from all the people that were consulted upon

00:27:47 were consulted upon the initial thinking though about what direction to take gra 3.2 in it had you for the initial if you let me for this question sorry um had you mr morton and the others um

00:27:58 and the others um coalesced around the view that the starting point would be the lessons learned from that not

00:28:04 i think i think the best way to characterize it is that the starting point for the document was version two so we weren't starting from a blank sheet of paper so we obviously were very we we made

00:28:17 so we obviously were very we we made ourselves very familiar with that document because we didn't want to lose the learning that had already been crystallized as a result of that document being created

00:28:29 document being created of the things i felt quite strongly was that the

00:28:33 that the order of material would benefit from being changed so we adopted a more chronological approach to the to the way in which we describe the control

00:28:44 in which we describe the control measures

00:28:48 in terms of the initial learning and recognizing that the lack of house fire was the reason why gra 3.2 version 3 was being reviewed

00:28:59 gra 3.2 version 3 was being reviewed again

00:29:00 again because unlike all the other gra's it had been reviewed in 2008 clearly it was important that we captured all of the lack of house

00:29:11 captured all of the lack of house fire learning so as a starting point but i was in due course obviously very much aware that there was shirley towers and there were other incidents that we needed to

00:29:22 were other incidents that we needed to pick up from thank you that's very helpful

00:29:25 helpful now you're clear in your third witness statement um that it was the department for communities and local government as it was then called that retained overall control over the publication of gra

00:29:36 control over the publication of gra series is that a fair summary that's absolutely the case now and just so that you and people watching uh can see what you say in your witness statement if we can go to lfb double

00:29:49 statement if we can go to lfb double zero double one nine eight four nine four seventeen

00:29:56 if we look at paragraph 28 in its first sentence

00:29:59 sentence you say this the dclg owned and were responsible for the content and publication of the whole of the gra series

00:30:07 series and if we look at the first two sentences of paragraph 32 which is just over the page

00:30:14 you say this in the course of this review the feedback received was either assimilated into the text of gra 3.2 or reject it in which case a rationale for this decision was provided to the

00:30:26 this decision was provided to the contributor whilst i was responsible for that process

00:30:30 process final editorial control of gra 3.2 and all other gras rested with dclg now

00:30:38 now who did you understand to be ultimately responsible for the content of gra 3.2

00:30:45 in personal terms or deal with the corporate body first

00:30:50 first dclg

00:30:52 dclg and within dclg who had

00:30:55 who had the responsibility of final sign off

00:31:00 i don't believe this was written down but i would have if if you'd have asked me then i would have said it was the chief fire rescue advisor would be the ultimate authority

00:31:14 possibly the bald as well the lead on the board sean roof he may have in practical terms he may have taken the day-to-day decision making were there to be a

00:31:25 making were there to be a any kind of dispute or issue about content and when you say board it's the gra board you're referring to there yes now to what extent were you anticipating at the start of the review that dclg

00:31:37 at the start of the review that dclg would be substantively involved in the review of and the revisions made to gra 3.2 be honest i didn't really have any preconceived ideas i hadn't

00:31:50 preconceived ideas i hadn't participated in this work previously so and there were no there were no detailed guidance documents explaining how the process would work i

00:32:01 process would work i i understood it was a collective effort that there was as i say two main phases of consultation that we as the lead brigade would take responsibility for drafting

00:32:14 would take responsibility for drafting and that the committee and and the board and sea for our ultimately would agree or not whether the content was uh appropriate did you have any sense of

00:32:26 appropriate did you have any sense of the operational knowledge expertise and experience on the part of the chief fire and rescue advisor in his unit

00:32:35 unit well i knew him personally well when it was peter holland and i think it was peter holland for most of the time that i was working on this and i knew him personally as a result of having acted as a liaison

00:32:47 as a result of having acted as a liaison officer during the industrial disputes so i knew peter holland to be a very experienced and very knowledgeable fire officer did you have any knowledge of the experience and expertise of other

00:33:00 experience and expertise of other officials within the chief fire and rescue advisors unit on operational matters i knew some of them as a result of having been involved in the london 2012

00:33:12 having been involved in the london 2012 preparations and delivery because they used to be involved in the national

00:33:18 national gold nation center for the games so i did i did have personal knowledge of them and i knew them to be generally experienced and knowledgeable fire officers uh use the word generally there

00:33:30 officers uh use the word generally there were there any exceptions to that view that you formed not particularly no now were you and we're talking at the start of the review process itself were you aware of any intention on the part

00:33:42 you aware of any intention on the part of the department the responsibility for operational guidance documents such as the gra series we're looking at today should eventually be transferred to the sector let's say fire and rescue services rather than landing with

00:33:54 services rather than landing with government

00:33:57 i think when i started the if those discussions were taking place they were taking place at a level above me

00:34:06 me i was aware towards the end of the program

00:34:10 program that the intention was for the sector to take

00:34:13 take responsibility and control but

00:34:17 but for the bulk of the time that i was working on gra 3.2 i was very clear that it was clg that we were working for and my understanding was that

00:34:28 was that the gra is because they were at a very late stage of development by the time that sector transfer was actually taking place that at no time

00:34:39 time did responsibility for the gra pass to the sector thank you sir ken knight in his second witness statement to the inquiry said that it was agreed in 2012 that the

00:34:51 said that it was agreed in 2012 that the lfb would take over responsibility for the operational guidance program as part of this sector-led approach were you aware of that decision in 2012 to transfer responsibility from dclg

00:35:03 transfer responsibility from dclg effectively to the sector i don't recall being aware of it in 2012 i certainly became aware of it later on

00:35:14 i certainly became aware of it later on as i said just now i i don't believe that that ever included the gra series so i think that was more in the context of national operational guidance and the

00:35:26 operational guidance and the guidance documents that clg had produced alongside gras would it be fair to say therefore that given that gra wasn't part of that transfer of responsibility it had very

00:35:37 transfer of responsibility it had very little if any effect on your work on the gra program i'm sorry what what had little effect the transfer of responsibility from government to the sector it was going on

00:35:48 government to the sector it was going on in the background it it made no material difference to what i was doing um can you remember now who within the lfb was intended to be responsible for managing the operational guidance program

00:35:58 program once it's been transferred my recollection was that in day-to-day terms passed to susan ellison bunts and and she was head of

00:36:09 ellison bunts and and she was head of strategy and performance is the department i think it was called at the time

00:36:14 time and i think she she was the person who was going to manage national operational guidance and so it wasn't a ball that fell into the court of your department no we

00:36:25 we at that stage we were very much aware of it and we had discussions with them i was very keen for london's policy portfolio to play its part in in shaping national guidance

00:36:37 its part in in shaping national guidance and why was that i'm sorry why were you king because i felt we had a very comprehensive and uh detailed set of policies that would assist both other services

00:36:50 assist both other services and the program itself to deliver a viable product now sir ken uh went on to say in his witness statement and we don't need to go to it but the reference is h o m

00:37:01 is h o m zero

00:37:02 zero five double zero eight zero forward slash three and it's paragraph eleven in the final two sentences he said in relation to the lfb's taking responsibility of the program he said this it was agreed that

00:37:14 this it was agreed that nogpb

00:37:15 nogpb so the national operation guidance project board i think i think that's correct and nopg would remain until the revised structure of strategic governance was put in place in 2012 the

00:37:27 governance was put in place in 2012 the minister and cfra would remain responsible for the final sign-off and publication so when sir ken says that the minister and the chief fire and rescue adviser

00:37:38 and the chief fire and rescue adviser were to remain responsible for the final sign-off and publication and do you know if that was intended to be on an interim basis pending as he says implementation of a revised structure

00:37:49 of a revised structure my understanding for gras and i'm not speaking about any other kind of national guidance was that that would remain with clg throughout

00:38:00 remain with clg throughout thank you

00:38:02 thank you now if we can turn to the review process itself

00:38:05 itself now in terms of the process um that it was intended uh would be followed for each gra you've exhibited a document that you state was circulated by lee brinton that's

00:38:16 brinton that's l-e-i-g-h brinton to members of the gre committee in july 2011. now before we before we look at that um am i right an understanding that lee brynton is from surrey frs which was

00:38:29 lee brynton is from surrey frs which was as we discussed responsible for the overall management of the review program that's correct she was brought into the program to provide administrative support and if we can look at the document that she circulated which is

00:38:41 document that she circulated which is lfb double zero one zero two five 8 4.

00:38:51 now if we can go through you'll see a number of milestones to use their description are contained in this document and the first one is on the left hand side third box down in

00:39:03 the left hand side third box down in bold

00:39:04 bold and it's recorded as intended to take up 20 working days now that is the production of the draft gra by quotes the gra owner regional grcm

00:39:18 by quotes the gra owner regional grcm in consultation with rep bodies and other relevant groups first of all regional grcm was what or whom

00:39:31 i honestly don't know um was the gra owner whichever cfoa regional representative on the committee had taken responsibility for leading on any particular gra

00:39:43 any particular gra yeah and i i i recognize throughout my involvement in this process that the term owner has has been a point of possible contention so i think to be really clear what i understood that to

00:39:55 really clear what i understood that to mean in this context was the fire service or region to be more accurate that was taking responsibility for drafting so taking the lead on draft

00:40:08 for drafting so taking the lead on draft taking the league on drafting would be a much more accurate way to describe it and does therefore in light of that does the phrase regional grcm simply mean the regional gra committee member do you think it could well do yeah

00:40:21 think it could well do yeah or put differently um can you think of any other possible ex plausible explanation for that uh abbreviation i can't i mean i was very clear that of what i was expected to do

00:40:33 what i was expected to do and and

00:40:34 and and that clarity extended to the fact i knew i wasn't owning the document i was a caretaker i was the person taking the lead on drafting it i didn't own it i wasn't taking final decisions regarding

00:40:46 wasn't taking final decisions regarding it and by owner that's i want just to make that absolutely clear you mean the person who's responsible for the final sign-off is that fair correct

00:40:56 correct now who are the rep bodies referred to here in milestone one so the rep bodies is representative bodies fire brigade union

00:41:07 fire brigade union the retained firefighters union and the fire officers association are the three trade unions that i believe were represented on the panel or sorry the

00:41:19 represented on the panel or sorry the committee

00:41:20 committee now looking at how it's set out and explained here milestone 1 appears essentially to be a initial period of consultation with the identified representatives conducted

00:41:32 the identified representatives conducted in theory over 20 working days is that a fair summary that is a fair summary yes um can you help us who were the um vaguely described other relevant groups

00:41:46 i think that probably would have varied region to region and anyone the lead thinks needs to be spoken to or consulted basically yes and and in certain cases i'll give you a

00:41:58 in certain cases i'll give you a concrete example we also led on the lift and escalator gra and for that document we did consult with the relevant trade body

00:42:09 relevant trade body so that that's an example of who the relevant group might be outside of the fire service depending on the topic

00:42:16 the topic and the issues to be discussed in relation to gra 3.2 um can you remember now who the other relevant groups might have been that you consulted for the purposes of milestone

00:42:27 consulted for the purposes of milestone one

00:42:28 one well because we were a region in our own right it was primarily within lfb thank you now following that on the left hand side fourth box down in bold um we

00:42:39 hand side fourth box down in bold um we see that circulation of the draft gra by the project manager to all other regional gcrms rep bodies and devolved administrations for consultation and that would take um

00:42:52 for consultation and that would take um a further five days um the project manager was as you say derek clough is that right that's correct and who were the other other regional gcrms the relevant leaders on it would be the

00:43:04 relevant leaders on it would be the people that were named in the committee but

00:43:07 but i think for the sake of accuracy the committee was subject to a fair amount of churn

00:43:15 churn so the membership did change quite frequently as as would be the case with these kind of bodies now we can see the next emboldened box is milestone two

00:43:26 next emboldened box is milestone two that's the fifth box down in bold which is recorded as taking another 20 working days to complete that's the point at which the receiving regional gcrm was intended to distribute the drafty array

00:43:39 intended to distribute the drafty array to their region's health and safety and ops committee team members for consultation um now who is the receiving regional grcm for these purposes so my understanding of that that's the

00:43:52 so my understanding of that that's the committee member that wasn't involved or the regions that weren't involved in the drafting work so they would take the draft and ensure that all the fire services within their region were cited

00:44:05 services within their region were cited on it

00:44:06 on it it's giving some prompts there as to the fact you should put it in front of your health and safety department as well as your operational policy and operational planning departments

00:44:18 operational planning departments so that you've got a well-rounded appreciation of the topic thank you and then the next stage is milestone three again on the left left hand side six box down and

00:44:29 left left hand side six box down and that was to take five working days and at that stage the gra owner was to collate consultation returns and forward the draft to the gra author now can you

00:44:40 the draft to the gra author now can you help us

00:44:43 help us at risk of getting excessively procedural and formalistic what's the difference between the gra owner and the gra author it's a very good question i suspect that in

00:44:56 i suspect that in in some regions there was a a difference between who was representing the region on the committee and and who was actually working on the gra

00:45:07 gra so i know in many cases it wasn't the service that attended the meetings that did the work so looking at uh using the specific example of gra 3.2

00:45:19 specific example of gra 3.2 the gra owner and the gra author would appear to be the same person as that right that's correct thank you now the next stage immediately below milestone three was consideration of the consultation

00:45:31 consideration of the consultation returns by the gra author an amendment of the draft gra taking into account those responses and that was intended to take 10 working days is that right that's correct and if we can turn to the

00:45:42 that's correct and if we can turn to the right hand side and the top box a further five days were allowed for the grey project manager to quote check close quotes the draft and either send it back to the gra author for further

00:45:54 it back to the gra author for further work or it's dispatched to quote key stakeholders for national consultation now just remind ourselves the project manager was mr clough

00:46:06 and the next question is who were quotes key stakeholders for national consultation using the specific example of gra 3.2 is probably the most helpful my understanding of the term it

00:46:19 my understanding of the term it primarily was uk fire services obviously also trade unions health and safety executive and then i guess it would have been

00:46:30 and then i guess it would have been anyone else that the project manager deemed

00:46:34 deemed appropriate for the topic that was under review thank you now after the start of national consultation we come to milestone four which you see is still on the right hand

00:46:45 which you see is still on the right hand side that was when stakeholders would be canvassed as part of the national consultation is that right yes that's when the document went back out

00:46:56 out the distinction it's a difficult thing on reflection to to explain this because the first stage of consultation was was via the regions and via the people directly

00:47:08 regions and via the people directly involved and i think for clarity the second

00:47:13 second national consultation was more or less a repeat of the same thing but it was directed to chief fire officers rather than the regional reps

00:47:24 officers rather than the regional reps that's helpful thank you very much and you'll see the letter that that reinforces that for 3.2 thank you impressionistically taking it around it looks as if the national consultation is effectively

00:47:35 national consultation is effectively replicating the earlier initial consultation i think that's a very fair way to characterize it okay milestone five

00:47:45 this was consideration by the gra owner author of the feedback received from the national consultation and making any uh consequential amendments to the draft before he sent it back to the project

00:47:56 before he sent it back to the project manager is that right that's correct and 10 days again is allowed for that yes now following that there's another five days allowed for the gra project manager

00:48:07 days allowed for the gra project manager to check

00:48:08 to check in quotes the final gra draft again and then send it to the department of communications doc and prepare the gra for publication

00:48:20 and prepare the gra for publication what was the department of communications i believe that was a group within dclg that i think

00:48:30 i think we might know them as a majesty stationary office i think it was the typesetters the people who took the draft which was generally created in word and turned it into the format

00:48:42 format that they

00:48:43 that they uh used for publication thank you and now the process seems to anticipate a period of 100 days from production of the first draft gra to dispatching it for publication does that accord with

00:48:56 for publication does that accord with your recollection of the time frame of what was intended anyway it calls with what was intended i think practice proved that that was incredibly optimistic and then gra 3.2 took

00:49:08 optimistic and then gra 3.2 took considerably longer than that we'll come on to that in india of course and that process involved as we discuss a period of regional as well as national consultation with feedback from both those processes being fed into the final

00:49:21 those processes being fed into the final draft is that right correct

00:49:27 looking at it as it's summarized here there is no substantive role for dclg is that a fair observation both as to what's set out here and what in practice happened

00:49:41 my understanding was that where it says gra project manager

00:49:47 manager that that's a way of saying clg and so when it's referred the verb that's used to check yes that those are the two instances where that's used that was where clj clg

00:50:00 where that's used that was where clj clg would become substantively involved very much so by mr clough so they so they were

00:50:07 they were clearly responsible for the quality assurance of the of the final product and of the not just the final product but of the emerging product at these two consultation stages

00:50:19 consultation stages when you say quality assurance is one of those vexed phrases that may have different meanings what did you understand quality assurance to mean in practice

00:50:29 practice in terms of the clg's role here i would i mean i'm reflecting on it now rather than what i thought about it at the time at the time what we what were you

00:50:40 the time what we what were you anticipating clg to be doing i would have anticipated that they would have ensured the document was fit for purpose that it was accurate current complete and coherent presumably and

00:50:51 complete and coherent presumably and coherent of course so they were taking the step back and ensuring that it was consistent practical

00:50:58 practical and capable of enforcement on the ground is that a fair summary do you think well enforcement on the ground may be going a step too far because it was never intended to be used

00:51:09 never intended to be used by the front line at incidents it was there to guide people right in local policy but yes to make sure that it was fit for that purpose absolutely so practicable for

00:51:21 purpose absolutely so practicable for those with practicable yes can we turn on to the specifics of gra 3.2 of course now um you set out in your third witness statement it's probably useful to go to

00:51:32 statement it's probably useful to go to it lfb double zero double one nine eight four nine forward slash nine

00:51:41 we look at paragraph 22.1 you say that it was agreed at a meeting of the gra committee on the 14th of july 2009. so very shortly after the lachmal house fire on the 3rd of july 2009

00:51:54 house fire on the 3rd of july 2009 that equating from the minutes of the meeting

00:51:57 meeting i quote

00:51:58 i quote following the recent fire in camberwell london involving a high-rise residential block of flats dc has been asked if the gra review team could prioritize a review of the

00:52:09 team could prioritize a review of the current high-rise gra now dc presumably is derek clough is that right that's correct now that etsa excerpt indicates that the review of gra 3.2 was prioritized as early as the 14th of july

00:52:22 prioritized as early as the 14th of july 2009

00:52:23 2009 and specifically in response to the latino house fire is that a fair reading of people's thinking that's certainly a fair reading of the of the note i i'm not sure

00:52:35 of the note i i'm not sure that i was present at that meeting uh

00:52:40 uh that would have been around about the time that i joined the group my predecessor a gentleman called neil thieben

00:52:48 thieben may have attended that meeting i can't recall whether i was there or not because i don't i've picked up on the reference to east region and scotland as a result of

00:52:59 east region and scotland as a result of preparing for this but i wasn't aware that they were going to be part of it and certainly when i became involved it was london that was going to lead but you've got no reason to doubt that

00:53:11 but you've got no reason to doubt that it was the fact of the lack of fire which gave the prioritization to the work on gra 3.2 no none at all thank you now the excerpt in your third witness statement and looking at the third and

00:53:23 statement and looking at the third and fourth bullet points in particular also referred and this flows on from the answer you've just given in earlier the intention to establish a review team and for london east region and scotland to

00:53:34 for london east region and scotland to act as the core team and you go on to explain at the top of page 10 of your statement just over the page that the review team was never established and that the east region and scotland did not form part of the core

00:53:45 scotland did not form part of the core team with london now you've covered this previously but is that summary still correct yes thank you now was london seen as the region that was best placed to lead on the review of gra 3.2 is the sheer number of high-rise

00:53:58 gra 3.2 is the sheer number of high-rise buildings in this area i believe so and also clearly

00:54:03 clearly not exclusively but an awful lot of the learning that was going to need to be brought into the document would be associated with black and all and so i think it was felt and in my opinion

00:54:14 think it was felt and in my opinion quite rightly that london was best placed to

00:54:18 placed to to lead on that work can you help the panel as to who made that decision or is it taken before you were fully engaged in the project i can't say for sure who made it

00:54:30 for sure who made it i was privy to some of the discussions you

00:54:33 you you're aware from my statement at the fire brigade union were not very happy with the idea of london leading they felt there was a conflict of interest

00:54:45 conflict of interest so i was aware of some of the discussions but in terms of who made the final decision i would assume that was derrick clough possibly

00:54:54 possibly involving chris bolton and or see throughout thank you

00:54:59 thank you can we now turn to look at a number of documents that were produced by the lfb relating to the then current gra 3.2 uh during this initial period and

00:55:10 during this initial period and immediately after the lachnal house fire in july 2009 and the first one of those documents i'd like to go to is gary dobson's review of operational procedures following that fire

00:55:21 procedures following that fire now first of all can we turn to document which can be found at lfb trouble zero three double six zero two which is a three page

00:55:32 which is a three page and heavily revised documents sent by gary dobson to tim cut bill and mick titchner on the 27th of july 2009. now first of all we know that tim

00:55:44 now first of all we know that tim cuthbill had been appointed as the head of the lfb's latino investigation project were you aware of that role at the time

00:55:54 the time oh sorry could you retake that question of course now we know that tim cut bill was appointed as the head of the lfb's internal lachlan investigation team were you aware of the fact that tim cut bill

00:56:05 you aware of the fact that tim cut bill had that role when you joined the gra 3.2 working group if i could call it that yes

00:56:12 and was his involvement in the lfb zone investigation considered to be an asset for these purposes to inform your work on gra 3.2 absolutely that the the review team had

00:56:24 absolutely that the the review team had a lot of

00:56:25 a lot of valuable information that was going to need to find its way into the gra mick titchner what was his role he was a station manager in the operational policy department again

00:56:39 operational policy department again just for clarity i think this document slightly predates my

00:56:45 my time in the department that's why we will go through it simply because there's some points which may well set the context the lfb's deliberations on on this score now mick titchner i think

00:56:56 titchner i think had at least attended a number of the gra

00:56:59 gra review committee meetings is that right that's correct he he attended with me uh you know when phil morton wasn't available now

00:57:09 now following on from the answer just given have you seen this or did you see this document at the time i when you started work on gra 3.2 i don't recall

00:57:20 i don't recall seeing it and looking at the i think it's dated 2009 yes it may well just pre-date either my time in the department or my time on on that work

00:57:32 department or my time on on that work stream

00:57:33 stream now

00:57:35 now the document has track changes that are attributed to dobson g we're assuming that's gary dobson is there any reason to think that assumption isn't sound no that's correct i would think that's correct

00:57:47 i would think that's correct now mindful of the evidence you've given i just want to go see how far we can go through some of the points arising in this document just to see what to what extent it reflected your understanding of when you started work on 3.2 now it's

00:58:00 of when you started work on 3.2 now it's entitled lachnal house review of operational procedures and the first subheading on page one is guidance that is not included in either the generic

00:58:11 is not included in either the generic risk assessment 3.2 high-rise firefighting version 2 gra or the london fire brigade standard operating procedure policy number 633

00:58:23 operating procedure policy number 633 high-rise firefighting open brackets sop close brackets now

00:58:29 now you've referred to this in earlier evidence but jlra 3.2 version 2 that was the version published in 2008 is that right that's correct and that was the version that was current at the time of the latino house

00:58:40 current at the time of the latino house fire yes

00:58:42 fire yes now

00:58:43 now we've got a list of bullet points underneath that first subheading mr carrup

00:58:47 carrup and the first uh bullet point states this no guidance on the possibility of downward vertical spread of fire from upper floors is that right

00:58:58 right well that's very true and that's that was something that was not uncovered in version two of the gri thank you and the second bullet point states limited information on the possibility of rapid

00:59:09 information on the possibility of rapid fire spread and subsequent failure of compartmentation on the fire floors is that right there was i believe there was reference to fire spread in the

00:59:19 the version two of the gra it probably wasn't it probably didn't give the emphasis to it that lack and all showed needed to be applied

00:59:30 all showed needed to be applied and if we look um there's a reference to evacuation in the final bullet point uh within this first subsection which says this

00:59:41 guidance is not provided on how to control large numbers of residents that could evacuate from a residential high rise and hamper access of firefighting crews is that right

00:59:53 crews is that right it's correct to say there was no there was no particular reference to evacuation in version two of the gri

01:00:03 do you think the the point set out here underneath the first subject heading um constitutes a considered reflection of the operational issues that the lfb thought were insufficiently addressed in

01:00:15 thought were insufficiently addressed in the contemporaneous national guidance that appears to be the case as i say i'm not

01:00:21 not i've not seen this document before and i'm not especially familiar with it but i would

01:00:26 i would say that's a fair way to characterize it yes

01:00:30 yes now

01:00:31 now um would you probably be useful to look at what the lfp had identified as being the principal characteristics of the latino fire in its immediate aftermath

01:00:42 fire in its immediate aftermath the first principle characteristic would appear to be please say if you disagree or it's unfair in any way

01:00:48 any way the basic fact that compartmentation had not subsisted at the incident and the lfb knew at the time that the fire had spread unexpectedly and rapidly from the fire flat on the

01:00:59 and rapidly from the fire flat on the ninth floor to other flats on and above the five floor is that a fair summary it is i mean it also spread laterally within the building i believe and it also spread downwards

01:01:12 also spread downwards as a result of falling debris and and those

01:01:15 those issues were not especially well covered in the gra and looking at the second principle characteristic that would have been known all that was known to the lfb um in the immediate aftermath of the latino

01:01:27 in the immediate aftermath of the latino fire the external spread had been facilitated at least in part by the presence of non-compliant facade panels on the external wall of the building again is that a fair summary

01:01:39 building again is that a fair summary i believe it is now i don't know whether when this was written we we would have known they were non-compliant but certainly we knew that the panels that were involved which were

01:01:50 were constructed from upvc and insulation material

01:01:54 material were

01:01:55 were not particularly uh resistant to fire and in fact have burnt through quite quickly and it's not it's more than that though isn't it it's the fact that they were non-compliant and on that point if we

01:02:07 non-compliant and on that point if we can go to a letter that the then commissioner sent to sir ken knight we know that the lfb identified the non-compliance as an issue um and it was the subject of a letter from commissioner dobson to ken knight on the

01:02:19 commissioner dobson to ken knight on the 14th of december 2009 and we can go to it um h o m

01:02:26 trouble zero double zero six two eight i think this has been flagged up with previous witnesses

01:02:36 and basically commissioner dobson alerted sir ken to the lfb's investigations and suggesting that warnings should be issued to housing providers to carry out checks of their own external panels because the

01:02:47 their own external panels because the lfb understood that this type of panel had been supplied by more than one company now were you aware first of all of the fact this letter had been sent in the substance i was not aware of this letter

01:02:59 i was not aware of this letter until

01:03:01 until uh in preparing for this inquiry i saw you show it to other witnesses and that's the first time that i'd seen it um were you aware the extent of the lfb's knowledge and concern about this

01:03:12 lfb's knowledge and concern about this type of panel that had been put on high-rise buildings in a general sense i was aware that lfb had serious concerns about the way in which

01:03:23 about the way in which lachenal house had been maintained and refurbished in a general sense i didn't have specific knowledge of this issue

01:03:34 of this issue now looking at those two principle characteristics of the of the lachnal fire

01:03:39 fire the fact that compartmentation had not subsisted and that this external spread had been facilitated by non-compliant panels

01:03:46 panels can you help us as to what extent when your work started on the review of gra 3.2 those two principal characteristics informed your deliberations they were they were very significant

01:03:59 they were they were very significant they they were clearly two of the key lessons identified from the lack of house fire so yeah they were they were clearly in

01:04:11 so yeah they were they were clearly in our minds and and i think as i've explained in my witness statement we've done a lot of work

01:04:18 work in the immediate up before we started on the gra we've done a lot of work on pn 633 and so unusually for the way in which these things normally work

01:04:30 these things normally work lfb's policy was ahead of national guidance

01:04:35 guidance at that point because it incorporated the lessons identified from lacanal i believe we published the revised policy in november

01:04:46 policy in november 2011

01:04:48 2011 and that was around about the time that we started work on gra 3.2 probably we'd started several months before so so there was a large

01:04:59 months before so so there was a large amount of input from lfb's policy into the national guidance which as i say is unusual because normally national guidance shapes policy

01:05:11 guidance shapes policy thank you um so it's a little earlier than usual the next topic will take some time and it's probably unfair on mr cap to start it and then abruptly stop well i'm quite

01:05:22 and then abruptly stop well i'm quite prepared to take your advice on that but you reckon it'll take more than 10 or 15 minutes to yes it will

01:05:28 it will perhaps we should take the chance while we have it mr carp we as you probably know we have a break during the morning normally it comes a little later than this but there you are it sounds like it's a good

01:05:39 there you are it sounds like it's a good time to do it so we'll we'll break now we'll come back please at 25 past 11 and pick up again then and i have to ask you please as i have over all the other witnesses uh not talk

01:05:50 over all the other witnesses uh not talk about your evidence or anything relating to it while you're out of the room all right thank you very much would you like to go to the usher please

01:06:08 all right 25 box 11 please

01:24:28 would you ask mr carp to come back in please

01:24:43 all right mr carp indeed thank you then thank you yes mr canoe thanks sir uh mr cowan i now want to turn to the second internal lfb document that i said i take you to and that is mr kevin hughes's gap analysis

01:24:55 that is mr kevin hughes's gap analysis where he compared gra 3.2 the 2008 version with policy 633 the 2008 version of that as well now can we go to lfb

01:25:08 now can we go to lfb trouble zero five seven nine double eight

01:25:17 now i presume you've seen this before this is an exhibit to your third witness statement

01:25:22 statement and it's a gap analysis that was carried out by dac kevin hughes as we can see there in november 2009 and he carried out a comparison exercise between as we discussed jra 3.2 and pn 633 both in

01:25:36 discussed jra 3.2 and pn 633 both in their 2008 iterations now you were familiar with this document at the time because you considered it when you prepared a report for the corporate management board a year later

01:25:48 corporate management board a year later in november 2010. is that right that's correct

01:25:52 correct and we're going to come on to that report shortly but staying with the gap analysis for the moment um first of all who instructed dac hughes to carry out the analysis

01:26:04 analysis i'm not sure uh i would think it would have either been gary dobson as the director for resilience at the time or possibly

01:26:15 for resilience at the time or possibly assistant commissioner jim knighton but it wasn't you it wasn't me i was a co-worker of kevin's at the time now we can see from the front page uh

01:26:26 now we can see from the front page uh that um kevin hughes was a dac when the document was drafted can you remember now what his specific responsibility was at the time of drafting so in november 2009 yes i believed that at the time

01:26:39 2009 yes i believed that at the time he was head of the [Music]

01:26:43 [Music] planning group within operations and also i think he headed up the operational review team

01:26:54 which was a group of officers that i think you've heard about them before that attended incidents

01:27:00 incidents to provide support and to monitor performance and i think i'm right in saying later on certainly from 2013 onwards he was head of learning is that right

01:27:12 if you can't sounds a rather grand title doesn't it he he was i think he he was part of the team that managed the babcock

01:27:23 the babcock training contract and i think in particular uh

01:27:28 uh played a part in developing and implementing the training commissioning process

01:27:34 process tcap that you've heard a lot about we have

01:27:36 have um

01:27:38 um would it be or can you help us as to what the purpose of this gap analysis was was it to provide a basis for the review of 3.2 and pn 63

01:27:49 and pn 63 and or some other purpose i think it it had a primarily well not primary i'd imagine solely internal purpose

01:27:58 purpose i think

01:27:59 i think it was felt necessary to make sure that our

01:28:03 our local policy 633 was wholly compatible with

01:28:09 with the national guidance which was 2008 and i've lost track i can't remember the iterations of 633 as to whether or not it had been reviewed post 2008. thank

01:28:21 it had been reviewed post 2008. thank you now the gap analysis as isn't the nature of things these things identified a number of gaps and if we can turn to consider and discuss some of those and the first one i'd be grateful for um you to look at is page

01:28:34 grateful for um you to look at is page nine and it's the very bottom row which is under the heading key control measures

01:28:43 now as you can see this address is pre-planning and information gathering and we can see in the far left hand side column at the very bottom of this page that the material parts of gray 3.2

01:28:55 that the material parts of gray 3.2 version two are quoted and these include and then apologies we have to jump over to the next page for some of this

01:29:03 we can see in the second paragraph of that far left column it says this that the direction we find the direction that and i quote pre-planning arrangement should also include and turning to the

01:29:15 should also include and turning to the second bullet point the development of contingency plans for a range of reasonably foreseeable events such as fire spread beyond the compartment of origin and the potential for multiple

01:29:27 origin and the potential for multiple rescues

01:29:28 rescues and if we can move rightwards but staying at the top of page 10 we see in the next column the relevant text from the then version of policy 633 um

01:29:39 um looking at that though this does not refer to the need for contingency plans um or far spread beyond the compartment of origin is that a fair observation yes

01:29:50 yes if we look at the third column from the left the analysis the gap analysis is set out and this states and apologies for this purpose if we just go back to the bottom of page nine

01:30:02 the bottom of page nine and this states this the gra's guidance in this section is slightly more detailed than lfe policy 633

01:30:11 633 lfb policy is also less explicit on the development of contingency plans and in the next final column we see under the heading recommendations this lfb policy could be enhanced with the

01:30:24 lfb policy could be enhanced with the inclusion of further information on going to

01:30:28 going to page 10 second bullet point development of operational contingency plans is that right

01:30:35 right that's correct honest what it says yeah thank you now what did you understand the phrase contingency plans to mean in this context my understanding of the phrase

01:30:46 my understanding of the phrase contingency plan in this context is the kind of plan that you would develop for a high risk premises so clearly

01:30:57 premises so clearly we can't have individual contingency plans for every building in london that the task would be impracticable so my understanding of operational contingency plans and they

01:31:09 operational contingency plans and they were

01:31:11 were referred to in various guises during my service so sometimes they were called operational note 300 sometimes they were called a 0 1 0 was where individual buildings that were

01:31:23 individual buildings that were considered to be of particular risk or particular value so i'm thinking about national

01:31:29 national heritage sites would have a detailed contingency plan for that premises so the operational policy gives you the guidance for

01:31:42 the guidance for an incident type and these plans would tell you specific features of those buildings

01:31:49 buildings and are those the same type of contingency plans you'd expect a crew to carry out on a 72d visit for example

01:31:58 uh they may inform the the contingency plan but the the 72d visit is is an information gathering activity

01:32:09 gathering activity uh

01:32:11 uh under which the if if the premises or location

01:32:15 location is considered of sufficient risk there may be a need to devise a tactical plan but i think in this context kevin was referring to the higher level

01:32:27 kevin was referring to the higher level contingency plans which were produced at headquarters on a brigade-wide basis so not necessarily those contingency plans that you'd expect to see recorded

01:32:39 plans that you'd expect to see recorded on the ord for example correct thank you

01:32:44 now given the higher level nature of the contingency plans that are discussed here

01:32:50 here oh

01:32:51 oh can you recall whether any of these high-level ones uh concerned high-rise residential buildings

01:33:01 uh

01:33:03 we certainly had them for

01:33:07 what i would describe as landmark high-rise buildings in london tower 42 the shard the walkie-talkie buildings of that

01:33:18 the walkie-talkie buildings of that nature which had were often of mixed use so it has a residential component specifically residential buildings i can't think of

01:33:30 residential buildings i can't think of any off the top my head thank you

01:33:36 now the need for contingency plans did not feature on gary dobson's review that we looked at just before the break which he carried out in july 2009

01:33:47 out in july 2009 but would it be correct to say that by the time this gap analysis was compiled so broadly six months later the lfb was aware that its own local policy as the 633

01:33:58 633 did not refer to the need for contingency plans in the event of fire spread beyond the compartment of origin despite that being referred to in gra 3.2

01:34:07 3.2 that would appear to be the case yes were you concerned by that absence in the lfb's own policy of any reference the need for contingency plans in the event of fire spread beyond the

01:34:18 event of fire spread beyond the compartment of origin

01:34:21 well i think in terms of the changes that we made to 633 that were published in november 2011 we we did address

01:34:31 address that issue i believe that's my recollection uh we'll come on to those in due course if probably easier when we come back to that topic because i don't want to ask you questions in the vacuum

01:34:42 you questions in the vacuum but well i can assure you we'll come back to that course now

01:34:47 now the second point um in the gap analysis i'd like to discuss with you concerns uh rapid fire spread and failure of compartmentation and for this purpose can we look at page three

01:34:58 this purpose can we look at page three of this document and the top row which addresses vertical fire spread

01:35:07 now that was a reference to rapid vertical external fire spread and both gre 3.2

01:35:14 gre 3.2 and 633

01:35:16 and 633 and in the first column on the left hand side the far left hand side again it sets out the relevant extracts from

01:35:23 from the then gra and it says this verticals fire spread can be extensive and rapid

01:35:30 and rapid such spread may travel internally but more commonly occurs externally when fire breaks out of windows and hugs the building where it can quickly travel to stories above this is

01:35:41 quickly travel to stories above this is known as the coanda effect and if we move rightwards and look in the second column it rehearses what was set out in policy 633

01:35:52 policy 633 and we can see the text is almost identical to that of 3.2 now would

01:35:59 now would that near identical nature of the text be because whoever drafted 633 had been guided by the provisions of gra 3.2 i would strongly suspect so yes and

01:36:10 i would strongly suspect so yes and simply lifted the text but basically absolutely looking forward we look in the recommendation uh section it says uh this and the second paragraph down from the top

01:36:22 second paragraph down from the top both documents so 3.2 and 633 provide limited information on rapid fire spread and subsequent failure of compartmentation on the fire floor now would you agree that that

01:36:34 now would you agree that that observation mirrored one of the points that gary dobson had identified in july 2009 indeed thank you and we can see from the text in both the first and second columns on that page

01:36:46 first and second columns on that page that there was in fact reference to rapid external fire spread in both of them is that right i believe so yes would it also be correct to say that the issue that kevin hughes had identified

01:36:58 issue that kevin hughes had identified was the absence of guidance on the combination of rapid external fire spread which leads the subsequent internal breach of compartmentation could you of course yes would you agree

01:37:10 could you of course yes would you agree with me that the issue that mr hughes has identified here in his gap analysis was the absence of guidance on the combination of rapid external fire spread which then led to the subsequent

01:37:22 spread which then led to the subsequent internal breach of compartmentation i mean he clearly broke the two together i don't think that necessarily means that the two are always present so

01:37:34 are always present so it's possible to have rapid external spread without necessarily having a failure of compartment compartmentation within the building

01:37:45 within the building so if that helps thank you but nonetheless mr hughes has identified both

01:37:51 both he has and he's brought them together in one sentence i'm just trying to point out that the two may not necessarily always accompany each other thank you now looking

01:38:02 now looking at the guidance itself um would you expect

01:38:06 expect guidance whether it's 3.2 or 633 um to

01:38:11 um to give advice as to what operationally needs to be done or should be done when faced with rapid external fire spread in conjunction with uh compartmentation failure would you expect that to be found in the gra in the local policy or

01:38:24 found in the gra in the local policy or both

01:38:25 both both

01:38:27 both and can you help us why should it be in both well because clearly the whole point of both documents is to shape firefighters behaviour and to provide them with information and

01:38:38 and to provide them with information and guidance on on the actions that need to be taken so in the case of external fire spread it's about being aware of it seeing it

01:38:48 seeing it and responding to it and in terms of internal failure that's very much about fire spread but it's also about firefighter safety and being aware of where the fire may be

01:39:00 being aware of where the fire may be reaching even though it may not be visible

01:39:04 visible thank you now the third point in mr hughes's gap analysis that i'd like to turn to is evacuation and can we turn to page eight excuse me

01:39:16 and we can see there in the first uh substantive row addresses evacuations specifically in the context of how this may

01:39:25 this may affect

01:39:26 affect firefighting operations and we can see in the first column on the left it records again the text of the then contemporaneous 3.2 and the gap analysis refers to evacuation in the particular context of

01:39:38 evacuation in the particular context of congestion of access and egress routes obviously that can occur when residents are evacuating and firefighters are entering the building to conduct operations and there's also a

01:39:49 to conduct operations and there's also a reference there i think i'm right in saying to evacuation in the context of operational pre-planning and whether the building is designed for phased evacuation stay put or simultaneous evacuation is that a fair reading yes

01:40:01 evacuation is that a fair reading yes have i brought out the points that are relevant there in relation to evacuation i believe so yes and we can see just moving rightwards in the second column

01:40:10 column again it sets out the position under 633 and it says this and i quote firefighting operations can be affected by the type of evacuation being undertaken the progress of the

01:40:21 undertaken the progress of the evacuation and the number and type of people being evacuated consider both the effect of firefighting tactics on evacuation of occupants and conversely the effect of evacuation on tactics

01:40:35 the effect of evacuation on tactics now taking the step back neither extract seems to address when an emergency evacuation may need to be implemented in a residential high-rise building that normally has a state put policy in place

01:40:48 normally has a state put policy in place is that a fair reading of what is set out there in the in the table i would say it is yes thank you

01:40:56 now again looking at the recommendation column in the far right hand side of the table it says this lfb policy could be enhanced with the inclusion of further information on

01:41:07 inclusion of further information on building evacuation strategies can you help us what did you what was your understanding of what that recommendation intended my understanding of that was was that

01:41:18 my understanding of that was was that the evacuation strategy is clearly devised by the responsible person

01:41:23 person either building owner or whoever is responsible for the building in fire safety terms and i think what that is alluding to is the fact that

01:41:34 that when and if a fire escalates it's clearly important that the firefighters responding to that incident and in particular the incident commander

01:41:44 commander is unaware of the strategy and be aware of the need to change it if the fire situation dictates that's appropriate

01:41:55 appropriate so i think that is what kevin was referring to and that is some learning that we did indeed take forward into 633 and gra 3.2

01:42:06 forward into 633 and gra 3.2 mr

01:42:07 mr we've got the benefit of your three decades plus experience looking at what's set out on this page bearing in mind your expertise and experience what type of further

01:42:18 experience what type of further information on evacuation strategies do you think should have been provided in either 3.2 or 633 looking at that now

01:42:30 looking at that now with the benefit of what i know now i think it's fair to say evacuation was a blind spot both for london fire brigade but

01:42:41 both for london fire brigade but probably more importantly at the time for the entire uk fire service so there was there was no national guidance on evacuation and indeed i don't believe there still

01:42:53 and indeed i don't believe there still is

01:42:54 is london fire brigade has recently written a policy on that but i think it's fair to say as a service we were not as aware

01:43:04 as aware of that issue as we should have been i think we made steps in the right direction because we included a section on evacuation and fire survival guidance in both

01:43:15 fire survival guidance in both six uh 3.2 and 633 but when i reflect on it now

01:43:21 it now we didn't cover that subject in as much detail as we should have done and

01:43:27 and looking back now what detail do you think should have been provided that you feel was missing

01:43:35 from my own opinion is is that what we should really have been telling people is the triggers the signs and symptoms what to look out for what to look out for

01:43:47 for what to look out for to move from whatever the evacuation strategy might be and and i think it's important to point out that both gra 3.2 and pn 633

01:44:01 point out that both gra 3.2 and pn 633 cover all high-rise buildings so there are a number of evacuation strategies that firefighters might encounter so i know the inquiry has understandably got

01:44:12 the inquiry has understandably got focused on stay put but of course there's zonal evacuation there's phased evacuation and and they're all different so so we need to know what the

01:44:23 so so we need to know what the evacuation strategy is but we need to recognize when events are overtaking it so the signs and symptoms which i believe lfb have now addressed

01:44:34 which i believe lfb have now addressed is what was missing for sure what to look out for yes what your options are yes and what options are appropriate to the circumstances that are confronting the incident commander is that a

01:44:45 the incident commander is that a three-fold fair summary i think it is a fair summary and just to add to the comment you made about options i think it's fair to say there are when the evacuation strategy is

01:44:58 when the evacuation strategy is required to be changed there's really only two options which is some form of partial evacuation which would probably be

01:45:09 which would probably be the fire floor and the floor above in normal circumstances progressing beyond that if the fire situation dictated or if the syria if the situation was so

01:45:20 if the syria if the situation was so serious to carry out a full evacuation so it's i don't think there are an endless range of permutations i think there are two basic considerations for

01:45:31 there are two basic considerations for an incident commander which would be to either partially evacuate the affected floor and possibly an adjacent floor or to fully evacuate going back to an answer you gave earlier

01:45:42 going back to an answer you gave earlier on use the phrase a blind spot in the sector generally yes about evacuation why do you think that blind spot existed

01:45:58 why do i think that blind spot existed

01:46:02 i think it's because evacuation is something we carried out and i've been involved in it myself and

01:46:11 and in many respects it's fairly intuitive and and people of course often act of their own volition so our role is really to facilitate what is happening on the ground

01:46:23 happening on the ground often when we arrive in office buildings in particular you know they've got decreed evacuation procedures and often when you attend a fire in an office building an evacuation is in progress so

01:46:35 building an evacuation is in progress so our role was to allow that to progress to to assist if anyone needed assistance but

01:46:43 but you know often that's not the case but to answer your your question i just don't think we understood before the grenfell tower tragedy i don't think we understood

01:46:57 our possible role in evacuation and the need to provide firefighters with specific guidance to deal with it and in particular instant commanders presumably there and in particular

01:47:09 presumably there and in particular incident commanders does it follow that looking at this particular this early stage in the review process was the group proceeding on the basis that evacuation would only ever be need

01:47:21 that evacuation would only ever be need to be carried out in a building with a pre-existing explicit evacuation plan

01:47:28 it was my understanding that any hierarchy we're talking specifically about high-rise we are yes sorry absolutely made that clear it's my understanding that any high-rise building

01:47:39 building would be covered by the legislation and therefore there would be a requirement upon the responsible person to devise an evacuation strategy that would be appropriate to the building and

01:47:50 would be appropriate to the building and to the risk so i would expect an evacuation strategy to exist for every high-rise building yes even one with the state put policy in place

01:48:01 well if i accept stay put is not truly an evacuation strategy it's a more of a design principle but it's a strategy in the sense that

01:48:12 but it's a strategy in the sense that you're saying for that building that people will be safe in their flats in their homes unless they are directly affected by fire or smoke

01:48:25 affected by fire or smoke so so generally you're saying in those buildings

01:48:29 buildings that that only the people who are directly involved in the fire will need to leave their premises thank you

01:48:37 thank you can i turn on to another aspect of the gap analysis mr carp and that's can be found at page 18 and it's the bottom half of that page

01:48:50 and we see here there's a subheading additional issues not covered by either lfb policy 633 or the gra and paragraph number two says this and i quote

01:49:01 number two says this and i quote neither the gra nor lfb policy 633 gives guidance on the specific challenges of crews tasked to deploy to the bridgehead becoming involved in assisting residents evacuating

01:49:13 evacuating lfb policy could be enhanced with the inclusion of further information on the challenges of the competing demands of assisting residents evacuate from a place of relative safety and deploying

01:49:24 place of relative safety and deploying to attack the fire additionally how to control large numbers of residents that could evacuate from a residential high rise now taking the step back is it fair to say that what this extract is getting at

01:49:37 say that what this extract is getting at in and in particular the need to be able to assist residents who are evacuating and the control of a large number of residents evacuating is how to manage an emergency evacuation at a high-rise building and the emphasis

01:49:49 at a high-rise building and the emphasis been on the word emergency yes

01:49:53 yes yes i think that's that's a fair characterization i think what certainly what kevin was getting to in the second sentence there is

01:50:02 is to be aware that these things can be very resource intensive so when your emergency evacuations you're talking about yes um i mean one of the key lessons from la canal

01:50:14 of the key lessons from la canal was that crews that were deployed for one task

01:50:18 one task were diverted to assist people before they reached the location for that task so for incident commanders to be aware of

01:50:28 of the need to to have sufficient resources available and possibly to request additional resources if necessary

01:50:37 necessary in terms of controlling large numbers of residents

01:50:41 residents uh

01:50:43 uh again

01:50:44 again yeah i think that's a valid point uh

01:50:49 i think both the gra and 633 refer to the fact that you may have to mount your response alongside people leaving the building so you need to give

01:51:01 leaving the building so you need to give consideration to how to do that one of the ways of achieving that is to designate an attack staircase and an evacuation staircase if the

01:51:12 and an evacuation staircase if the building provides two staircases so

01:51:17 so that's an example of of how you might control

01:51:21 control the evacuation of a larger number of people obviously difficulties are presented with buildings such as grandfather hat the one staircase of course absolutely now did

01:51:30 now did mr hughes's gap analysis is a very rich detailed document did you discuss it with him the substance at the time i didn't discuss it at the time it was

01:51:41 i didn't discuss it at the time it was written in fact i don't think i was immediately aware he'd done it you asked who he did it for i think it was the whoever he did it for would have seen it first i think it went

01:51:52 would have seen it first i think it went into the

01:51:54 into the to the lack of bald process that was running at the time so i'm not sure that i saw it

01:52:02 i saw it i think it was written in 2009 wasn't it it was and i think in your evidence you say you first you certainly were aware of it no later than november 2010 yes

01:52:13 yes and so

01:52:13 and so did the points that mr hughes set out here did it certainly inform your consideration of the requirements for revision of both 3.2 and 633 absolutely i mean we did we did go

01:52:25 absolutely i mean we did we did go through this document and seek to address both the gaps and the recommendations did you use it in a manner of a benchmark so you went back to it to check that you covered off

01:52:36 to it to check that you covered off everything in the new drafting that mr hughes had identified as missing we certainly made extensive reference to it i can't remember whether we specifically

01:52:47 specifically did we specifically ordered what we wrote against this i can't say that with 100 certainty but we certainly had regard to it it was in your mind absolutely

01:53:00 your mind absolutely can i turn now to the lfb's memorandum to the chief fire and rescue advisor and

01:53:05 and just to give you some context following mr hughes's gap analysis um tim cut bill prepared a two-page memorandum to chris bolton who i think you referred to in evidence earlier on and it's dated the

01:53:16 evidence earlier on and it's dated the 21st of january 2020 and if we go to that sorry 2010 okay if we could go to lfb travel zero four one nine seven eight

01:53:30 now as you can see the memorandum is entitled the brief for f r a u and i think that stands for the fire and rescue advisors unit is that right i've yes i believe so

01:53:42 i've yes i believe so um with considerations for a review of the generic risk assessment for high-rise firefighting following the fire at lachnal house and the first uh substantive the first sentence of the first substantive

01:53:54 sentence of the first substantive paragraph explains that this brief is given to assist clg with a review of generic risk assessment gra 3.2 high-rise firefighting

01:54:09 now i think i'm right in saying but please shout if this is wrong that um chris bolton was a senior fire and rescue advisor at the time that's correct and again just make this clear from your

01:54:21 and again just make this clear from your previous evidence he would report it directly to sir ken or whoever was the chief fire uh and rescue advisor i believe so and at the time january 2010 it was second night

01:54:32 night yes

01:54:33 yes um have you seen this before i have not mindful of that answer can i just go through some of the points just to bring it to your attention can we look at point one which is the

01:54:45 can we look at point one which is the bottom half of the first page of the moment of the memo and it says this fire spread the potential for wind-driven products of combustion and burning materials being forced back into other areas of

01:54:57 being forced back into other areas of the building creating multi-seated fires on various floors look at 0.2 spread the risks associated with early failure of compartmentation to contain

01:55:08 failure of compartmentation to contain the spread of fire and particularly the products of combustion e.g due to age poor design workmanship maintenance or alterations leading to the spread of

01:55:19 alterations leading to the spread of fire and smoke logging extensively through the building and point five fire service tactics the difficulties that may be experienced conducting search rescue and evacuation of a large

01:55:31 search rescue and evacuation of a large number of properties or areas within a high-rise building and the complexity of recording and monitoring the progress of this activity now

01:55:42 now looking at what's set out there mr kerb these points confirmed that the lfb was concerned that the review of gra 3.2 should address the need for guidance in relation to smoke and fire spread beyond

01:55:54 relation to smoke and fire spread beyond the compartment of origin fires on multiple floors and difficulties posed by evacuation in such circumstances is that a fair reading of that memo yes

01:56:05 that memo yes would you agree with me that there is no reference there to stay put

01:56:11 in this document yeah no i can't see any i've not seen it before but what i've read there's no mention of stay put and there's equally no reference the possibility of evacuating

01:56:22 reference the possibility of evacuating a building with a staple policy is that right

01:56:26 right it's not expanding you could argue it's implicit

01:56:30 implicit in five but it's not stated explicitly no

01:56:35 is the fact that it's not clearly set out using a neutral phrase um indicate that it was simply not a possibility that the lfb was envisaging

01:56:46 possibility that the lfb was envisaging at the time i.e evacuating a building with a state policy i i don't think that's a fair characterization in what ways is it unfair well because when you look at the changes we made to

01:56:57 when you look at the changes we made to both gra 3.2 and pn 633 both of those documents are very clear about the need to for the incident commander

01:57:08 commander to consider revoking stay put or the evacuation strategy whatever that might be whether that's phased or whatever

01:57:19 phased or whatever and carrying out a fuller evacuation so i think in terms of our responses we did address it this particular memorandum i accept doesn't doesn't cover it but i'm

01:57:31 accept doesn't doesn't cover it but i'm not sure the status of this or what it was used

01:57:34 was used to it certainly wasn't given to me by by dclg that was something i was about to say it's not something that tim cutville said listen you need to see this peter he didn't share it with me no

01:57:45 he didn't share it with me no thank you

01:57:46 thank you now can we turn to your own report to the corporate management board in november 2010 so some 10 months after the cut bill memorandum now you prepared um

01:57:58 now you prepared um a report for the is it the corporate management board the cmb that's correct in november 2010 regarding the lfb's review of policy 633 which was continuing at that time and we can find

01:58:10 continuing at that time and we can find the report at lfb00101356

01:58:16 and if we can have a look at the first few paragraphs on that page page one under the heading introduction and you wrote the following the purpose of this report is is to

01:58:27 the purpose of this report is is to explain the rationale for the changes that have been made to policy 633 which has recently been updated and is presented as draft for corporate management board approval this report also explains how the

01:58:39 this report also explains how the amendments of the policy have been underpinned by the outcomes from a risk assessment panel and how the new policy will be introduced to the operational workforce utilizing appropriate training

01:58:50 workforce utilizing appropriate training interventions and internal communications next is a heading policy review process and apologies for reading it out but it's probably easier for people at home a key driver underpinning the review of

01:59:02 a key driver underpinning the review of this policy was the lachnal house fire which occurred on third of july 2009 the ac hughes undertook a gap analysis following this incident and made recommendations regarding any areas that

01:59:14 recommendations regarding any areas that are covered in the national generic risk assessment gra but are either only partially covered or omitted from lfb policy 633 all dac hughes's recommendations as set

01:59:25 all dac hughes's recommendations as set out in his report dated november 2009 have been acted upon within the revised policy 633 with the exception of provision of new equipment system to

01:59:37 provision of new equipment system to record search information this is subject to an rnd project to help define user requirements for this equipment controlling smoke travel this issue requires further travel by fsr

01:59:50 requires further travel by fsr can you help us remind us what fsr stands for fire safety regulation and will be covered to some extent by revised policy regarding fixed installations the fixed installation policy will be

02:00:02 the fixed installation policy will be applicable to all building types not just high-rise and will be a cross-reference to high-rise note when published it is anticipated that the possible provision of positive pressure ventilation ppv

02:00:14 of positive pressure ventilation ppv will form part of the project to replace pumping appliances revised ba policies that breathing apparatus

02:00:21 apparatus including multi-agency ba commitment eg heart and you can remind us again that heart stands for hazardous area response team it's an ambulance

02:00:32 response team it's an ambulance team that can commit into irrespirable atmospheres with breathing apparatus thank you and we'll follow from revised national ba guidance which currently remains in draft provision of

02:00:43 currently remains in draft provision of premises information boxes at high-rise premises is an fsr issue op

02:00:49 op operational procedures correct are working on a draft search policy which when published will be cross referenced from the high rise policy now we'll come on to the substantive

02:01:00 now we'll come on to the substantive review of 633 and due course as we've discussed but for the moment looking at these elements of your report was it your review that the aspects of the hughes gap analysis

02:01:11 hughes gap analysis had each been addressed in the revision of 633 subject to the exception set out there i believe so yes

02:01:23 now am i right that the revisions to 633 to which you were referring to there were revisions that appeared in 633 which was published in november 2011. i

02:01:34 which was published in november 2011. i believe so now could we turn to look at that policy was it something you referred to um several times in your evidence and you've exhibited it hopefully to your witness statement and it can be found at lfb00102306

02:01:47 it can be found at lfb00102306 [Music]

02:01:59 now i'm assuming that you are familiar with the terms of this policy i'm indeed yes now would you agree that despite the identification of a lack of guidance on contingency plans

02:02:10 contingency plans for fire spread beyond the compartment of origin in the hughes analysis this policy does not refer to contingency plans at all

02:02:20 it refers to pre-planning and

02:02:25 and the policy for pre-planning was obviously a separate document so and i think it refers to that separate document it's what became pn800 i'm not sure if it was called

02:02:37 pn800 i'm not sure if it was called pn800 at this time and so when you say pre-planning do you have in mind that reference to contingency plans ought to be found in appendix one

02:02:48 be found in appendix one yes so can we turn to that at page fifteen

02:03:00 i don't wish to proceed on a false assumption mr co-op and if i am getting this wrong please do shout but could you help the panel where in appendix one of 633 there's a

02:03:12 in appendix one of 633 there's a reference to express reference to contingency plans if you need time to refresh your memory please say so [Music]

02:03:31 the the third bullet point in one i accept it doesn't use the word contingency planning

02:03:39 planning but

02:03:40 but the description there recalls with what i understand to be contingency planning but the words aren't used are they i accept the word contingency is not used

02:03:51 is not used but detailed planning for specific buildings

02:03:54 buildings including tactical and command plans that

02:03:57 that that is a way of describing a contingency plan could we look at paragraph four of course and the tenth bullet point apologies you have to count down is the fourth is the tenth bullet point which

02:04:09 fourth is the tenth bullet point which starts with the words the likelihood and impact of any fire spread beyond the compartment of origin and the potential for multiple rescues yes

02:04:19 yes that seems to be closest to the point that a contingency plan is meant to address but there's no reference to contingency plan there either is there is that a fair criticism

02:04:30 either is there is that a fair criticism it's a fair criticism looking back on it now yes taking the step back mr carrup there doesn't appear to be guidance at

02:04:41 there doesn't appear to be guidance at least in this document and again if you want to refresh your memory that's not a problem please say so there's no reference to any guidance to crews about what should be done if the building does in fact appear to

02:04:52 if the building does in fact appear to present a risk of fire spread beyond the compartment of origin and the potential for multiple rescues again is that a fair point to make in relation to appendix 1 of 633 can i ask is that question in the

02:05:05 can i ask is that question in the context of planning or in the context of response during an incident or both first of all planning okay so

02:05:14 okay so i think it's fair to say that the detailed guidance for planning was set out in a separate policy document which which i think is pn800

02:05:25 which which i think is pn800 and i think that does cover fire spread

02:05:30 there's no and please again if i've got this wrong just say so is there a cross-reference to 800 in this appendix one

02:05:42 in this appendix one not in this appendix one but i believe the policy as a whole cross-references pn800 and i think in the main text it refers to it

02:05:55 in the planning section of the main document would you like to if we go back to the first page of this policy yes and then you can direct the document manager to the point you'd like to make so if we

02:06:06 to the point you'd like to make so if we look at page seven

02:06:14 okay so i apologize there was a renumbering process going on so i think where it refers there to policy note 521 information gathering

02:06:27 policy note 521 information gathering that's what became pn 800 so it is referring staff to to that specific guidance thank you

02:06:47 [Music]

02:06:51 now in relation to the point identified by kevin hughes about the existing guidance on rapid external fire spread and compartmentation failure being limited

02:07:03 being limited as far as i can see there are two additional references to rapid fire spread in in the policy the first one we can find is in the pre-planning section on page 15 so we can go to that

02:07:17 and it's the 12th bullet point which starts with the phrase floor layouts

02:07:27 and the second reference can we go back to page two

02:07:35 and it's the eighth bullet point under the heading hazards where there's reference to rapid and unpredictable fire spread up and down and laterally in a building

02:07:48 and laterally in a building to the best of your recollection are those the two references to rapid fire spread in 633 or this iteration of it

02:07:55 it no because i think if you look in the hazards section you'll find that information probably expanded slightly so the the bullet point that starts

02:08:06 so the the bullet point that starts rapid and unpredictable fire spread is is an outtake the key point summary is an outtake from the main policy so i think if we look at the hazard section of course let's go to it

02:08:17 of course let's go to it we should go to if we go to the first page

02:08:23 see hazards at page four

02:08:30 section two what are the points you'd like to highlight to the panel there

02:08:44 we will need to go through this whole section

02:08:46 section mr kinnear if you don't mind because i'm not i'm not as familiar with this version as as i am with the version that was current at the time of the grenfell fire so this is an older version but

02:08:57 so this is an older version but somewhere here it should say because it wouldn't be in the key point summary if we hadn't have included in hazard section so it may be under fired behavior and development if we can go to

02:09:08 behavior and development if we can go to page five

02:09:10 page five and power 2.15 is that what you had in mind

02:09:17 yes

02:09:20 now looking at that section under fire behavior and development and bearing mind your knowledge of the development of this particular policy is it right to say that despite

02:09:33 is it right to say that despite the two references to rapid fire spread and looking at what's set out here um in paris 2.15 onwards there's no guidance as to what operational steps should be taken when

02:09:44 operational steps should be taken when faced when firefighters an instant commander is facing a fire that is rapidly spreading and breaching complementation i wouldn't expect guidance to be provided in this section but i think if

02:09:55 provided in this section but i think if we move to the section that talks about procedure

02:10:00 procedure we will find in the round we will find guidance for managing

02:10:06 managing an escalating fire and if we can go to page one again which sets out the index is it operational procedure you have in mind that's correct if we go to page

02:10:18 mind that's correct if we go to page nine

02:10:25 it's not going to be if sorry if it can be d de-amplified

02:10:31 the advice isn't going to be in the screwing water section it's not in securing using the firefighting lift so it can turn over the page

02:10:40 it's not going to be in establishing a bridgehead so if we turn over the page

02:10:47 committing crews it's not going to be in that section so we can turn over the page

02:10:53 and then we come to evacuation and it's not there as far as i can see ventilation it's not there if we can see if we turn over the page

02:11:06 and then we're into building design and fire safety measures it's not there is it it's the words are not there as they're used in the hazard section but you can i think you can draw it clearly

02:11:18 you can i think you can draw it clearly from

02:11:19 from you know 744 refers to the building's design measures being compromised a lot of compartmentation if any of the fire safety measures in

02:11:30 if any of the fire safety measures in 746 have been compromised you need to require consider requesting additional resources and implement alternative tactics

02:11:41 and implement alternative tactics i think it's there i accept it's not there as explicitly as as it could be but i think it is there in the text implicitly there's not

02:11:52 there in the text implicitly there's not much detail there though is there no i accept that and you said you accept it's not there as explicitly as it could be

02:12:03 how could you make what further detail if you think more detail is needed what further detail would you have put in then

02:12:11 then had you had the oh given that if you're minded to do so well i think as i said previously to one of your previous questions uh an indication

02:12:22 previous questions uh an indication of the signs and symptoms of a spreading fire would would be useful guidance to include

02:12:28 include and then

02:12:29 and then some

02:12:30 some reference to the alternative tactics that might then be necessary to be employed and it's the detail of those alternative tactics really that's important yes now can we turn to a separate topic

02:12:41 now can we turn to a separate topic which is the review of gra 3.2 and its formal allocation to the lfb now um you say we don't need to go to it unless you'd like to

02:12:51 like to you say paragraph 2.3.4 of the pc six report which can be found at lfb travel zero three two seven eight three four seven

02:13:01 seven that gra 3.2 was allocated to lfb by the program manager in march 2011. is that correct yes now the documents we've just looked at

02:13:12 now the documents we've just looked at appear to indicate that it was agreed much earlier than that shortly after the latter house fire in july 2009 that london was to take the lead on the review of gra 3.2

02:13:23 review of gra 3.2 is that a fair observation it appears to be from the written records but i think as i said earlier i don't remember being party to that discussion and i certainly don't remember the the

02:13:35 and i certainly don't remember the the consideration that it might be free services that lead on it can you help us as to what was happening about the review of gra 3.2 between july 2009

02:13:47 2009 when a priority was given to it and the decision to allocate the review to london in march 2011. no i can't does that mean that nothing was happening no it doesn't it just means

02:13:58 happening no it doesn't it just means i'm not cited on it i mean clearly from from the documents that we've found that was clearly a discussion that was happening at clg

02:14:10 happening at clg i wasn't party to that discussion and in terms of the prioritization of it i wasn't uh aware of why it wasn't dealt with sooner now in fairness to you we've

02:14:21 with sooner now in fairness to you we've obviously looked at some certain documents so we looked at the huge gap analysis we've looked at the cut bill memorandum we've looked at your own report of november 2010 so it's consideration of issues but was any sort

02:14:33 consideration of issues but was any sort of basic

02:14:34 of basic drafting going on during that period of gra 3.2 yeah not not by me because i don't think we've been formally allocated it and so far as you're aware no one else

02:14:45 no one else i can't

02:14:47 i can't as far as i'm aware yes were you ever presented with a working draft

02:14:53 draft no

02:14:55 no so it's safe to infer that no one else is doing any drafting there presumably i don't believe so was the delay a source of concern either at the lfb or with any other interested

02:15:07 at the lfb or with any other interested party

02:15:10 i'm not really able to answer that i i'm certainly not aware i wasn't made aware of any concerns about the gra being delayed so the commissioner wasn't saying anything to

02:15:22 commissioner wasn't saying anything to you he he wasn't saying anything to me that's not to say he wasn't concerned or that he didn't sat someone else i i can only fairly ask you about what yeah he certainly didn't say anything to me no

02:15:33 certainly didn't say anything to me no you certainly give him no instruction to crack on because nothing's happening no put crudely no

02:15:39 no crudely or otherwise no thank you now in your third statement of paragraph 36 you refer to a document entitled the generic risk assessment review program

02:15:50 generic risk assessment review program schedule of work 2011 2012 which you state shows that london had been given responsibility for gra 3.2 with a start date of october

02:16:02 for gra 3.2 with a start date of october 2011 for that work and if we go to the schedule

02:16:05 schedule and i'm afraid the trial director will have to download the native file it can be found to lfb00102323

02:16:22 so

02:16:44 now we can see that gra 3.2 is listed on line 19

02:16:51 line 19 and the start date for work is identified in column e as october 2011. and we see it column f the end date is february 2012. have i read it right you

02:17:04 february 2012. have i read it right you have

02:17:06 have and does that time period between october 2011 and february 2012 reflect the 100-day period that was set out in lee brinton's flowchart of milestones i'm sure it does i've done the

02:17:18 i'm sure it does i've done the calculation but i suspect it would have reflected that yes

02:17:22 yes when you prepared this schedule so at the start of matters and did you have any reservations about the realism of the 100-day target firstly i didn't prepare this schedule

02:17:33 firstly i didn't prepare this schedule this was prepared by derek clough or possibly lee brinton yes i expressed my concerns on a number of occasions that i thought

02:17:45 on a number of occasions that i thought the time scales were to say the least optimistic they were revised uh as a result i'm not quite sure when but they were extended and and

02:17:57 but they were extended and and particularly for high-rise i i anticipated that there was going to be a lot of feedback and that that time scale was was very optimistic now in terms of london's role as lead

02:18:10 now in terms of london's role as lead you explained in your third statement on paragraph 31 which can be found at lfb double zero double one nine eight four nine four slash eighteen

02:18:21 four nine four slash eighteen probably worth going to just so jcc what i'm referring to you say there this role about london's lead role included gathering information regarding

02:18:33 included gathering information regarding new hazards and any tactical learning that had been identified from recent uk high-rise fires this was used to determine any new control measures deemed necessary to

02:18:44 control measures deemed necessary to address the identified hazards and to produce a number of draft versions of the gra for other members of the review committee and the organizations they represented to comment upon

02:18:55 represented to comment upon first of all is that an accurate summary yes

02:18:58 yes now that process would have included presumably any lessons that the lfb had identified arising from lachnal indeed

02:19:06 indeed and at this time so 2011 the inquest had not yet taken place but the lfb had carried out his own internal investigations is that right that's correct

02:19:16 correct so that would have included the two principal characteristics that the lfb had identified arising from the latino file which we discussed earlier yes

02:19:26 would it also be your role to manage the two rounds of consultation that lee brinton's milestone document identified partly

02:19:37 partly so who else would have been involved very much derek clough he was

02:19:42 he was so he was responsible certainly at the national stage he was responsible for issuing the document and following discussion with myself we

02:19:54 discussion with myself we we agreed it was sensible to delay that pending the coroner's

02:20:00 coroner's inquest from both lachen or and shirley towers we'll come on to that in due course but don't worry but were you primarily responsible for considering all the consultation responses received

02:20:11 all the consultation responses received from the various safer regional reps in consultation with uh phil moulton and and others in ops policy i didn't when i mean you i mean you as the

02:20:22 when i mean you i mean you as the collective yes me as the collective absolutely and equally were you in that collective sense responsible for considering all the consultation responses received from the individual

02:20:33 responses received from the individual fire and rescue authorities yes

02:20:37 did the burden of drafting the revised gra 3.2 fall to you personally or you collectively i given its importance there was a lot of it that was me

02:20:48 there was a lot of it that was me personally but phil morton played his part and and and indeed some other people from ops policy

02:20:55 policy provided track change comments and and suggested ideas so it was a team effort but i did play a very direct and personal role in it yes

02:21:05 yes to use the pompous lawyer's phrase did you primarily hold the pen

02:21:11 i suppose i did yeah i mean rank has its privileges uh but

02:21:16 but i think i was fairly democratic so i don't think i held the pin uh held the pen maliciously and were you happy uh that you had the knowledge and expertise available to you

02:21:29 knowledge and expertise available to you to carry out the drafting process effectively yes

02:21:35 yes yeah i mean in terms of my own knowledge and experience i felt i was well placed to do that work but i was very much open to taking advice and views from from

02:21:47 to taking advice and views from from others and that was the point of the consultation process thank you now if we can go through each of the stage of the review process and the first bit i'd like to discuss with you is internal consultation with the

02:21:59 you is internal consultation with the lfb itself now if we can take for that purpose could i first take you to an email which attached a draft version of gra 3.2 that you sent on 18th of october 2011 to

02:22:11 that you sent on 18th of october 2011 to your colleagues in the lfb so it's malcolm etteridge spencer alden smith and andrew porter and certainly the first two you referred to an earlier answer now the email can be found at lfb00102337

02:22:23 lfb00102337 [Music]

02:22:28 there we go that's the email and you're explaining your third statement and we don't need to go to it but these three individuals were quotes the three gm policy leads that's

02:22:39 quotes the three gm policy leads that's group manager policy leads in my department at the time and were familiar with the developments with pn 633 they also had a significant degree of both operational and policy

02:22:50 both operational and policy risk assessment writing experience and therefore i invited their feedback on the draft

02:22:56 the draft now the draft that you attached we don't necessarily have to go to it quite yet but the references are

02:23:03 two double lfb0010203

02:23:04 eight but did the draft that you produced draw on the existing version of three point two and make amendments to reflect the issues that have been under discussion internally at the lfb arising from lagnal

02:23:15 from lagnal that's my recollection yes and the attachment to this email was that the first working draft uh that you produced it's certainly the first one we've been able to locate

02:23:26 able to locate i couldn't swear to that with with any certainty as i think i said earlier one of my

02:23:37 one of my aims in carrying out this work was to take the information from version two make sure we didn't lose any of that add to it in terms of the learning from

02:23:48 to it in terms of the learning from lacrinal and other incidents and then present that back in a more logical framework which was to provide it more chronologically in terms of the

02:23:59 it more chronologically in terms of the order in which the information would be needed at an incident i thought that was easier to understand but crucially it would be easier for

02:24:10 it would be easier for local policy writers to then convert that into a working local policy and flowing from that could we look at the fourth paragraph of your covering email

02:24:22 covering email where you set out this the overriding aim of the revised draft is to provide a document which permits both frs and individual ics so instant commanders

02:24:33 commanders the freedom to exercise discretion from the standard operating procedure recognizing this is a national document i see this as an opportunity to create the space necessary

02:24:45 the space necessary for individual frs's to write a less prescriptive policy if they choose to do so

02:24:51 so and so that they can determine their own risk appetite within a robust but pragmatic

02:24:57 pragmatic national statement of hazards and risk for this instant type my first question is who sanctioned that particular approach

02:25:10 i don't know that it was formally explicitly sanctioned it was my view and certainly the view that i was hearing in the committee was that

02:25:20 was that we should be writing national guidance in a way that allows local fire services to implement it in a way that works for

02:25:31 implement it in a way that works for their service in terms of their resourcing and their equipment and also in terms of their local risk what did you precisely mean by the phrase permitting the freedom to

02:25:42 phrase permitting the freedom to exercise discretion from the standard operating procedure that was

02:25:47 that was possibly uh an oblique reference to the concept of operational discretion which is something we were working on alongside this policy work

02:25:58 alongside this policy work and and that was a recognition that you cannot write fire service procedure to anticipate every single scenario

02:26:09 every single scenario and

02:26:10 and we need to empower staff to exercise their judgment now up until the time the operational discretion was articulated the the only

02:26:21 the the only guidance we provided was a statement in the dra policy that says you can exercise professional judgment

02:26:29 judgment if i'm honest i was never exactly sure what that meant and i thought we needed to tell people that what we really meant was

02:26:41 that what we really meant was you need to do the right thing and that may be outside of procedure and if it is provided you do a risk benefit analysis in other words a dynamic risk assessment

02:26:54 in other words a dynamic risk assessment and you feel that that action is justified then it is reasonable for you to exercise that discretion and i was very keen at this time to get that concept

02:27:06 to get that concept embedded nationally because it was at this time

02:27:10 this time only really had any currency within london and even in london hadn't been adopted formally but i knew in terms of endorsement i knew that

02:27:21 knew that commissioner ron dobson gary reason and various other key officers were very supportive of that general approach what is striking is when going through

02:27:33 what is striking is when going through the documents we've been considering this morning is that all those documents focus on what's missing from the gra or 633 as the case may be none appears to set out

02:27:46 none appears to set out the overriding aim as you set it out in this email is that a fair comment to make

02:27:51 make on what have preceded this

02:27:56 clearly it's accurate whether it's fair in in the context of implicitly criticizing those documents i think to be fair though i'm not it's it's just a little basic there's no there's no

02:28:08 little basic there's no there's no hidden point it was just to say what is striking about the documents we've looked at is they're concentrating on what's missing what they're not setting out is that the overriding item of 3.2 should be as

02:28:20 overriding item of 3.2 should be as you've set it out here it's just a question of fact on anything else i think that's a fair characterization but i think to be fair to the people who wrote the documents you're referring to they

02:28:32 the documents you're referring to they were probably given quite a specific

02:28:36 specific task and brief and and they would have addressed that this this concept of discretion and the whole idea of are we going to allow people are we going to

02:28:48 allow people are we going to explicitly sanction people to

02:28:52 to break with procedure was new and i have to say it wasn't universally agreed to so there were people in the gra committee who were quite passionately against it

02:29:03 passionately against it there were people in lfb i had very interesting discussions with some of lfb lawyers

02:29:09 lawyers about this concept because they felt a policy to break policy wasn't necessarily a good idea personally because of where it came from which was

02:29:20 because of where it came from which was our experience at 7 7 but also some other national incidents where fire services had slavishly followed policy

02:29:31 services had slavishly followed policy and as a result people had been injured and indeed lost their lives so to me this this was very much an important change but it was

02:29:42 very much an important change but it was quite vague and

02:29:45 and at the time and also new and and this was a journey this was a journey towards getting this concept accepted and understood what's another striking feature of this email

02:29:57 another striking feature of this email is that you haven't set out even in high-level terms the

02:30:03 the emissions that have been picked up by cut bill hughes and indeed yourself can you help the panelists to why even in high level terms you hadn't flagged up those omissions

02:30:15 up those omissions to members of your team with whom you'd be working on 3.2 i think

02:30:20 i think i can't say this for 100 certainty but i'm

02:30:23 i'm very confident all three of those individuals would have known certainly about kevin hughes's document uh

02:30:32 uh and

02:30:34 and i don't know whether they'd have been aware of gary dobson's document but they might have been so i think that these were people who were dealing with this

02:30:42 with this uh subject very frequently uh and therefore i there is an assumption here of a level of knowledge that

02:30:52 that you know i didn't feel the need to make that very explicit you don't need to articulate those matters on each and every occasion is what you're saying yes can we look at the penultimate paragraph

02:31:03 can we look at the penultimate paragraph on this page which says this obviously before this goes for national consultation the gra will be sanctioned by ac knighton and gary dobson but before i pass it to them for approval i

02:31:15 before i pass it to them for approval i would welcome your views now as far as you were concerned at the time subject to any views expressed by um

02:31:23 um ettredge alton smith and porter was the draft ready to go out for at least the first round of consultation

02:31:34 it's a long while ago and

02:31:37 and you're asking me what was my level of confidence with the document at this particular time i think i don't think i would have shared it in the way that i have if i didn't think it was a reasonable first

02:31:49 didn't think it was a reasonable first draft but to be clear i knew it hadn't benefited from other fire services input so i had no idea i had no

02:32:00 idea i had no perception that it was complete but i think i felt it was a reasonably mature draft so with some hesitation you were content for it to be subject to at least the first round of consultation

02:32:11 the first round of consultation yes

02:32:13 yes now if we can look at the draft that you did attach this email which can be found at lfb double zero one zero two double three eight

02:32:29 draft slightly obliquely watermark there but if we can turn to page 14.

02:32:38 and this is the section entitled evacuation and fire survival guidance uh fsg calls i think that is the new section that you're referring to earlier in your evidence is that right it's one of the new sections yeah

02:32:53 and apologies it's probably useful for me to read this for people following it um outside but also so let's refresh your memory the first sub-heading says evacuation and fire survival guidance

02:33:05 evacuation and fire survival guidance fsg called fsg calls can be particularly prevalent during a high-rise incident and the ic will need to prioritize these calls by taking any action necessary to either

02:33:17 taking any action necessary to either rescue or reassure building occupants the ic should normally follow any evacuation plan devised as part of the occupiers fire risk assessment unless

02:33:28 occupiers fire risk assessment unless the fire situation dictates otherwise in residential buildings occupants should only evacuate if the fire or smoke is in their property firefighting operations can be adversely

02:33:40 firefighting operations can be adversely affected by the type of evacuation being undertaken the progress of the evacuation and the number of type of people being evacuated evacuation can be made more resource

02:33:52 evacuation can be made more resource intensive

02:33:53 intensive if the occupants have an impaired ability to make their own way to safety the ic should consider the effect of firefighting tactics on evacuation and vice versa

02:34:05 evacuation and vice versa using other emergency service personnel to assist with evacuation and that widespread evacuation may divert crews from the tasks that they were the tasks they were brief to

02:34:17 were the tasks they were brief to undertake

02:34:18 undertake and this may require additional resources

02:34:21 resources now just looking at what is said here about fsg calls you say

02:34:28 you say the draft states fsg calls can be particularly prevalent during a high-rise incident and the ic will need to prioritize these calls by taking any action necessary to either rescue or reassure building occupants

02:34:40 reassure building occupants can you explain what you meant by fsg calls being or potentially being particularly prevalent i can indeed uh

02:34:49 uh i think i'm right in saying at this time that lfb was the only fire service that had a fire survival guidance

02:34:58 guidance policy

02:34:59 policy i'm not sure if it'd been published it certainly was in draft for

02:35:04 for personnel on the ground so fire services had guidance for their control staff but they didn't have guidance for their

02:35:13 for their uh

02:35:15 uh operational staff that were attending the incident so

02:35:19 so i played some part in the definition of that policy and i actually attended one of the incidents where we'd had multiple fire survival guidance calls so

02:35:30 multiple fire survival guidance calls so i had some direct appreciation of the challenges of dealing with that and

02:35:36 and i think it's fair to say in london all of the fire survival guidance calls we've had certainly all the multiple fire survival guidance calls we'd had had been in high-rise buildings so and

02:35:48 had been in high-rise buildings so and if i could apologize for interrupting you miss cup when you described multiple fsg calls can you give the panel a rough idea an approximate idea of the numbers that you're

02:35:59 that you're thinking about there so the incident that i attended was in poplar

02:36:05 poplar and we had 36 calls

02:36:10 36 calls and that was prior to that policy being in place so what we did there was was instrumental in in the subsequent policy in terms of putting practice into into policy terms uh

02:36:22 into policy terms uh obviously lack and all you know we had multiple fire survival guidance calls there i believe we had multiple calls to maddingly as well but i don't believe i think we've only

02:36:35 but i don't believe i think we've only had

02:36:36 had multiple calls to on about four or five occasions

02:36:40 occasions and

02:36:41 and i think i'm right in um saying that a key feature indeed learning point from lachnal had been the occurrence of multiple fsg calls um at the same incident and the consequential

02:36:52 the same incident and the consequential challenges that pose for control room staff is that right absolutely and we're not just control room staff but staff on the ground as well and would it flow from all of that that the

02:37:04 flow from all of that that the number of multiple fsg calls at a high rise incident and the consequential

02:37:12 burden that places on control room to manage those effectively and efficiently was a matter for consideration as part of the gra 3.2 process

02:37:22 to be fair the gra was very the whole gra series not just 3.2 was very much focused on operational personnel and what happens

02:37:33 operational personnel and what happens at the incident but i think when you read gra 3.2 there's there is an acknowledgement of the key role that brigade control play and control room staff in terms of managing and that

02:37:45 staff in terms of managing and that inter play and exchange of information being key when you're dealing with fire survival guidance calls now in the second part of the sentence we're looking at the draft states that the incident commander will need to

02:37:57 the incident commander will need to prioritize these calls by taking any action necessary to either rescue or reassure building occupants

02:38:06 occupants in practical terms what did you have in mind when you referred to prioritizing those calls what i have in mind there is is is that saving life always comes first

02:38:17 saving life always comes first so

02:38:18 so it may well mean in the short term that resources are redeployed towards rescue and and reassurance i think that's a really important point that's there for

02:38:29 really important point that's there for a reason

02:38:31 a reason often people are actually relatively safe where they are but they're very concerned and understandably so so firefighters need to act to give them

02:38:42 firefighters need to act to give them that reassurance that actually they they are safe to stay where they are and that the fire is under control or being brought under control now looking at the phrase action necessary to either rescue or reassure

02:38:54 necessary to either rescue or reassure building occupants did you consider whether guidance needed to be provided about when it would be appropriate for an instant commander to

02:39:03 to issue orders for the rescue of ffsg callers and when it would be appropriate to reassure callers uh

02:39:14 i mean we're in a you're a very granular level of detail there and and i think the difference between rescue and reassurance in reality on the ground he's he's

02:39:27 in reality on the ground he's he's fairly clear-cut so so people need rescuing when they are in smoke or being affected by smoke and fire

02:39:36 fire i would see reassurance as being in the situation where they're not in any immediate danger but they are understandably concerned by what they're seeing or what they're hearing

02:39:48 seeing or what they're hearing and therefore they require some some advice and support but they don't require rescue rescue is where you physically need to assist someone to leave the premises or

02:40:00 assist someone to leave the premises or to move them to a place of relative safety

02:40:05 safety put differently and apologies if this is uh it's

02:40:09 uh it's insufficiently uh qualified but essentially incident commanders know it when they see it what they ought to do yes and not just incident commanders but firefighters as well

02:40:20 firefighters as well [Music]

02:40:21 [Music] now reassuring callers was an issue that was specifically identified in the nfb's own internal investigations in relation to the actions taken by control room at lachnal

02:40:33 taken by control room at lachnal now

02:40:35 now the lfb's latino control report was published in november 2012 and for the purpose of the latino inquest and it noted that control room operators who had taken fsg calls had a

02:40:46 operators who had taken fsg calls had a clear expectation that fire crews would reach the callers quickly and that this carries the risk that the control room operator moves too quickly uh to reassure the caller that they will

02:40:57 uh to reassure the caller that they will be rescued now the reference for that is two nine 29 293

02:41:03 29 293 of the latino control report which is hmo quadruple zero double one two four forward slash fifty now we can go to it if you want to but does that ring true to

02:41:14 does that ring true to you it does i think i go back to my basic distinction between a rescue and a reassurance you've made that point it's just looking at that particular

02:41:25 just looking at that particular quotation from the control report at the time you're working on the draft of the gra were you aware of that particular danger of providing reassurance to callers that something was being

02:41:36 callers that something was being considered by lfb control arising out of lachnal

02:41:40 lachnal no

02:41:42 had you spoken to anyone in lfb control about this particular section of draft 3.2 and sought to discuss with them the way you intended to address fsg calls

02:41:53 way you intended to address fsg calls and their management

02:41:56 i hadn't certainly at this stage i hadn't personally spoken to anyone in control but

02:42:02 but as you track through the iteration of this document the consultation included control representatives can you help us as to why you didn't consult lfb control

02:42:14 as to why you didn't consult lfb control for the purposes of this first mature draft that was going to be subject to consultation because it was based on work we'd already done to create the fire survival guidance

02:42:25 to create the fire survival guidance call policy which had

02:42:29 which had been based very much on a joint effort with control room staff so i was comfortable that what what i was saying there in in that section of document was

02:42:41 in in that section of document was wholly in accordance with what had been agreed with control to create what i think at this time would have been the draft of the fsg policy

02:42:51 policy looking back at the draft text we've got on the screen do you agree that there's no reference there to stay put i do [Music]

02:43:01 [Music] can you help us as to why there was no reference to stay put there i can

02:43:07 staple is a design strategy particularly applied to residential buildings this this document and lfb's 633 policy

02:43:18 and lfb's 633 policy were both

02:43:19 were both very clearly about high-rise buildings in their totality so

02:43:27 it didn't seem appropriate to mention stapa as one option of many because otherwise we would also need to mention phased evacuation

02:43:38 mention phased evacuation zone or evacuation and all the other strategies that could be encountered by firefighters at an incident so it was to keep the policy and particularly national guidance to keep it suitably

02:43:50 national guidance to keep it suitably generic

02:43:52 generic put bluntly it was a conscious decision am i right in saying not to refer to stay put when you drafted this section at this time it was and again i'm jumping ahead so you'll

02:44:04 and again i'm jumping ahead so you'll probably correct me but when clg

02:44:07 when clg suggested that stay put should be mentioned

02:44:11 mentioned and we had a discussion around it i i entirely understood their point of view and and we made that change straight away we'll come on to that in due course as you anticipate mr carrick absolutely

02:44:23 you anticipate mr carrick absolutely now looking at the second paragraph of uh this section um it says this the ic should normally follow any evacuation plan devised as part of the

02:44:36 evacuation plan devised as part of the occupiers fire risk assessment unless the fire such situation dictates otherwise

02:44:42 otherwise in residential buildings occupants should only evacuate if the fire or smoke is in their property now what circumstances were you anticipating

02:44:53 anticipating when you use the phrase fire situation dictating otherwise

02:45:01 an escalating fire that was spreading beyond the compartment or the location of origin so the floor of origin or or a part of it if it was a larger building that would prompt an

02:45:12 larger building that would prompt an evacuation not necessarily an evacuation but would prompt

02:45:18 prompt as i said earlier if you come away from the planned evacuation you've really only got two options so that would either be a partial evacuation which might well be

02:45:29 partial evacuation which might well be and again it very much depends on the building and its layout but it might well be the fire floor the floor above possibly the floor above that but it would very much depend on what

02:45:40 but it would very much depend on what you you know the signs and symptoms that you were seeing and if you could see the fire spreading further than that you would clearly need to extend the evacuation zone and indeed

02:45:51 evacuation zone and indeed possibly go for a full evacuation for the purposes of uh drafting this particular text did you consider whether you needed to provide specific or detailed guidance on the type of situations that might

02:46:03 on the type of situations that might require an incident commander to depart from an existing evacuation plan or how an incident commander should go about making that decision

02:46:13 i think as i've said before i i fully acknowledge that our consideration of the evacuation at this time

02:46:22 this time was something of a blind spot there was no national guidance to cover it

02:46:28 i think we made progress if you compare this with what was in the version two but i don't think we went far enough i think it might help the inquiry if i

02:46:40 i think it might help the inquiry if i just draw a distinction between policy and training at this stage because you keep referring to how i think if we can come on to these there are other matters we want to come on to in due course but is the blunt fact that

02:46:54 in due course but is the blunt fact that giving specific advice on the lines i suggested it just wasn't considered at this stage for the reasons you've given correct

02:47:02 correct now it's correct i think i'm right in saying that there was no more detailed guidance in the lfb's policy 633 either the version that was in force at the time of the review or indeed the

02:47:13 at the time of the review or indeed the version that was enforced at the time of grenfell as to how instant commanders should make the decision to depart from a building's existing evacuation plan is that a fair point to make it is a fair point to make but the point

02:47:25 it is a fair point to make but the point i was trying to make just now was that there's a subtle distinction subtle but important distinction between what and how and and policy is very much concerned

02:47:38 and and policy is very much concerned with what

02:47:39 with what so a statement of what you should do and

02:47:43 and training is where we set out how you would do it if that helps it does but and we'll come on to those matters in due course now looking at the second sentence of this

02:47:55 looking at the second sentence of this paragraph and the draft geo rate says this in residential buildings occupants should only evacuate if the fire or smoke is in their property

02:48:06 smoke is in their property was that intended to be a tangential or a bleak reference to stay put

02:48:13 stay put clearly it is because it's embodying the principle

02:48:16 principle i think that was in there because i think that reflected lfb's policy at the time and the information we were sharing through our partners particularly with

02:48:28 through our partners particularly with landlords

02:48:29 landlords as as to what we would expect occupants in residential buildings to do so so that that was simply reflecting lfb's position at that time in relation to

02:48:40 position at that time in relation to that issue now you say that but under the guidance that existed at the time

02:48:46 time residents were told to stay put unless they were quotes affected by heat and smoke in their flat would you accept that i would and the word heat's missing it would be far better to use the word

02:48:58 it would be far better to use the word products or combustion on reflection because that covers everything it's not quite the same thing as what's set out there though is it

02:49:09 set out there though is it even allowing for the emission of reference to heat what

02:49:13 affected by heat and smoke that they should only evacuate in those circumstances that's somewhat different to

02:49:21 to only evacuating if fire or smoke fire or smoke is in their property would you accept that i accept the point that you're saying that that doesn't necessarily say affected by it saying

02:49:33 necessarily say affected by it saying it's in there i mean if it's in their property

02:49:37 property it almost certainly will affect them so it's kind of by default it would affect them but i accept it doesn't use the words effect and so

02:49:47 and so that last sentence doesn't properly or accurately reflect the guidance that was given at the time does it to the extent it doesn't use the word

02:49:58 to the extent it doesn't use the word effect i'd accept that yeah

02:50:02 but i think it's i do think it's implicit and fairly intuitive from the sentence that if you're in a flat where there's a fire you you need to leave there's been quite a lot that's implicit

02:50:13 there's been quite a lot that's implicit or intuitive thus far on the guidance though isn't there there's not much when we come down to these details that's expressly set out

02:50:23 they are i mean all of these documents are written for professional firefighters and incident commanders so so there is inevitably some level of

02:50:35 so there is inevitably some level of assumption in what in what we think people

02:50:38 people will will understand and but i accept that in certain respects and this is probably one of them we could have been more explicit

02:50:47 explicit but it's not clear that if the fire is outside your flat but you are affected by heat and smoke you should leave i accept that the text does not advise that it may

02:50:58 the text does not advise that it may become necessary for state advice to be changed during an instant can you help us as to why not sorry can you repeat this of course the text does not advise that it may become necessary for stay put advice to be

02:51:10 necessary for stay put advice to be changed during an instant depending on how the fire progresses can you help us to why not

02:51:18 it i i accept it doesn't hear but i think when we look at a later draft that that point has been addressed so in this fairly early

02:51:29 fairly early draft we didn't explicitly state that i mean it's implicit again in the first sentence that if the fire situation dictates otherwise you would need to change the plan but i

02:51:40 you would need to change the plan but i accept it doesn't explicitly state that

02:51:47 now we know as you intimated this is a section of the text that was amended before

02:51:52 before uh publication but i'd like to ask you whether you had in mind at the time that you circulated this draft the need for incident commanders continues to keep under review the advice being given to

02:52:04 review the advice being given to residents at a high rise fire and whether that advice needed to change at any point depending upon the behavior of the fire

02:52:12 the fire well as as summed up in that second paragraph

02:52:16 paragraph me and others that were involved in this certainly recognized the the fact that when a situation when a fire escalates it may be necessary to to change the

02:52:27 it may be necessary to to change the advice and and to ask people to leave in reality is it blunter than that that at the time of drafting neither you nor your team

02:52:36 your team um

02:52:38 um had it in your mind that there may be a need to change stay put advice i no i don't accept that i think we did understand it it was a clear lesson identified from lachenau and i

02:52:50 lesson identified from lachenau and i and whilst i accept the paragraph you pointed to is not as explicit as it could be i i think that people would have taken from it the fact that you may need to change the

02:53:03 fact that you may need to change the the pre-ordained evacuation strategy if and when the situation makes that appropriate now could we go to another element of this draft george 3.2 and that's on page

02:53:14 this draft george 3.2 and that's on page nine and it's within the section competence and training

02:53:36 i think the highlighting indicates it was

02:53:39 was another change that you executed is that right

02:53:44 yes i i think what that highlighting uh

02:53:50 uh refers to is and it was something myself and london fire brigade brought to the gra process more generally which is the the fact that all of the

02:54:02 which is the the fact that all of the documents all 40 of the gras had

02:54:06 had a number of common elements to them competence and training being one of them and my suggestion to derek clough which he adopted was that we should have what i term standard text

02:54:19 what i term standard text so that we settle consistency to ensure consistency and i think the fact that's highlighted in yellow that looks to me like one of the earlier drafts of what we come to use as standard text so this

02:54:32 come to use as standard text so this might have applied in every gra that's what i'm saying thank you now if we could look at the list that starts at the bottom of page nine um and starts with the phrase training for highrise instance should include

02:54:45 instance should include and then it goes on to say in the second bullet point recognition of the signs and symptoms of backdraft the effects of wind risk of fire spread and the adoption of

02:54:56 risk of fire spread and the adoption of appropriate tactics to mitigate these what was your reasoning for including this direction about high-rise training were you intending to refer specifically to the need to train firefighters to be

02:55:08 to the need to train firefighters to be able to identify fire spread beyond the compartment of origin

02:55:13 origin yes

02:55:14 yes why not say so explicitly

02:55:19 i'm not sure i understand the question well why not say for example in the words i put to you specific there is a specific need to train firefighters to be able to

02:55:31 train firefighters to be able to identify fire spread beyond the compartment of origin

02:55:40 i haven't really got an answer for that i mean i think what's there

02:55:47 says much of that it may not it may not mention compartment of origin but it it talks about fire spread you would you referred to training earlier on and the link between policy

02:55:59 earlier on and the link between policy and training did

02:56:01 did that particular sentence prompt you to consider what training the nfb needed to provide to its firefighters to identify or to be aware of the risk of fire spread from the compartment of origin

02:56:14 spread from the compartment of origin yes because i i mean a clear lesson from from lacanal but other incidents as well is that when you're fighting a fire in a high-rise building there is a there is a

02:56:25 high-rise building there is a there is a good possibility it will leave the compartment of origin now at the time you were drafting this mature draft will be the first one um did you have a view as to whether the lfb's training

02:56:37 lfb's training was uh providing its firefighters with sufficient knowledge to be aware of the risk of fire spread from the compartment of origin

02:56:47 i can't at this precise time i can't recollect

02:56:53 recollect with any accuracy what what lfb's high-rise training package said i would expect it to have said something around the risk of spread i

02:57:04 something around the risk of spread i think it was updated certainly in the light of of the november 11 2011 policy that whether it when it was updated

02:57:15 that whether it when it was updated i can't be certain so at this particular point in time i i can't really give you a definitive answer to your question do you remember any general concerns as to whether lfb's

02:57:27 any general concerns as to whether lfb's training

02:57:28 training addressed

02:57:30 addressed sufficiently the awareness of its firefighters to spot the risk of spread beyond the compartment of origin i remember very clearly that as a result

02:57:41 i remember very clearly that as a result of lachenal we were we were very attuned as a brigade we were very attuned to those risks and i believe through through various training packages i mean there was the

02:57:52 training packages i mean there was the lack of case study for example and i think that very much covered fire spread and alternative tactics

02:57:59 tactics now um i

02:58:01 now um i i don't need to go to it for these purposes but you receive limited feedback from uh etteridge and porter is that right as a result of which you slightly updated the the draft before it was then

02:58:12 updated the the draft before it was then forwarded to ac nighting and mr dobson gary dobson i'm sure that's correct can you help us um jim knighton was head of operational policy at the time at this moment what was gary dobson's

02:58:24 at this moment what was gary dobson's role gary dobson was the director of i think it was called resilience and training at this time thank you and then they gave you sign off and you forwarded

02:58:35 they gave you sign off and you forwarded the draft to derek clough is that right yes and then he initiated the first round the regional round of consultation correct thank you so it's one o'clock that concludes at

02:58:46 so it's one o'clock that concludes at least questions on the this stage of matter all right good so that's a convenient point at which to break because it is yes well mr carf it's time we had a break so we can all get some lunch so

02:58:57 break so we can all get some lunch so we'll break now we'll resume please at two o'clock and again please don't talk to anyone about your evidence or anything relating to it while you're out of the room okay so all right thank you very much thank

02:59:08 so all right thank you very much thank you

02:59:09 you yes please go to the usher yes

02:59:21 thank you mr two o'clock thank you

02:59:43 you