Director Gary Reason gives evidence on LFB's handling of Lakanal House Rule 43 recommendations and oversight of training packages from 2012-2014.
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00:00:00 Thank you.
00:00:21 We do ask Mr Reason to come back in please.
00:00:35 Alright Mr Reason, ready to carry on?
00:00:37 Yes.
00:00:38 Thank you.
00:00:38 Yes Mr Mellott.
00:00:39 Yes, Mr Reason, the inquiry has heard extensive evidence from Mr Groves on how the LFB's training department
00:00:47 worked with other departments within the LFB and with BAMPACOC to create training packages.
00:00:52 Now, as Director of Operational Resilience and Training, I just want to ask you about the extent to which you would be expected to be involved in or perhaps be aware of training department's ongoing activities.
00:01:04 Would you be aware, for example, of internal discussions which identified a need for new training?
00:01:12 If they were generated by either meetings like the Operational Coordination Directorate Board or Corporate Management Board, then I would be aware.
00:01:24 If it was training that just came up in the course of day-to-day relationship with BAMPACOC, I would probably not be aware of the detail of that training.
00:01:32 Right. Right.
00:01:34 Now, what about the instigation of a training commissioning and alteration process or TCAP form?
00:01:41 Yes, I wouldn't normally see those documents.
00:01:44 Right. You wouldn't see those. What about discussions of the Contract Performance Monitoring Board, the CPMG, sorry, CPMB?
00:01:53 Only if there was issues that needed to be escalated to director level within BAMPACOC.
00:01:58 Right. Would you be aware of discussions of that board about whether a request for new training should be approved, for example?
00:02:06 No.
00:02:07 No. What about, would you be aware of discussions held during the TCAP process about any problems that a given training package should cover or how it should be delivered?
00:02:17 No.
00:02:18 Now, Mr Graves gave evidence that the TCAP process was seen by many as cumbersome. I think it was the word he used. Were you aware of that view?
00:02:26 Yes, I was certainly aware of that view. My personal view on that is being, and this is with the view of being a former head of training and development for two years, is it needed to be cumbersome to use that word.
00:02:41 I wouldn't call it cumbersome. It was thorough.
00:02:43 Right.
00:02:44 And that was to provide an audit of what the brigade had requested, that the due processes for the development of that training were undertaken and that there was a proper sign-off process before that training was undertaken.
00:02:55 Right.
00:02:56 Did you ever take any steps or think you needed to take any steps to modify or improve the TCAP process?
00:03:03 No, it was not raised to me that that was something that needed to be done. Obviously, if I thought it needed to be done, I would have taken action, but I thought the process in terms of its principle was delivering what it was designed to deliver.
00:03:15 Right.
00:03:17 Mr. Groves told us, I think it was day 177, page 57 to 58, that he had raised that problem, the cumbersomeness, if you like, of the TCAP process with AC Cotton and AC Apta. But do I take it that he never raised it with you?
00:03:36 No, if it was in a period, if that's concurrent, then that would have been a period after I retired.
00:03:41 Indeed it would have been, if that's the case. But he never raised it with you.
00:03:44 Right.
00:03:45 Now, can we go to your first witness statement, please, at paragraph 35 on page 9?
00:03:53 Foot of the page there. You say, during my time as DOORT, I was a standing member of the ODCB that aimed to identify operational trends, monitor various action plans, and drive operational performance.
00:04:04 If you go over the page, improvements within the brigade.
00:04:07 And if you go to paragraph 36, you go on to say, in the third line there, one of the main purposes of the ODCB meeting was to consider information from a number of the brigade's performance management data sources covering operational and training activities.
00:04:16 Now here, are you referring to the ODCB meeting?
00:04:19 Yes.
00:04:21 Now here, are you referring to the ODCB meeting?
00:04:31 Yes.
00:04:32 Yes.
00:04:33 You are?
00:04:34 Yes.
00:04:35 You are?
00:04:36 Yes.
00:04:37 You are?
00:04:38 Yes.
00:04:39 Yes.
00:04:40 You are?
00:04:41 Yes.
00:04:42 Primarily, that is the report that we took, although there were other reports taken to
00:04:47 the ODCB from other departments that we could consider.
00:04:51 It wasn't only the DACA, Ellis's report, I think, has been referred to.
00:04:55 There were other information sources that we could also consider.
00:04:59 Now we've explored and we will continue to explore these reports with other witnesses,
00:05:03 but will you confirm, I mean, can you confirm that those reports that you refer to were
00:05:10 the work of the Operational Assurance Department?
00:05:14 If you're referring to the DAC Ellis report that was a regular report to the ODCB, yes,
00:05:19 and that was the responsibility of the Ops Assurance Department to produce that report.
00:05:23 Right.
00:05:24 And it fell within your directory?
00:05:26 It fell within my directory, yes.
00:05:27 Now we'll come back to some of the specific work undertaken by the ODCB later on in your
00:05:31 evidence, but for present purposes, would it be fair to say that your presence, your
00:05:36 role on the ODCB gave you oversight, an overview, if you like, of key training needs across
00:05:43 the brigade?
00:05:44 Yes.
00:05:45 Yes.
00:05:46 And did that help you to co-ordinate policy development with development of training?
00:05:49 Yes.
00:05:50 One of the functions of the ODCB was at the time that we had considered that there needed
00:05:56 to be operational improvement through training, we'd also review the operational procedures
00:06:01 and policies that were in place to assure ourself that they were current and fit for
00:06:06 purpose or whether we needed to develop new ones or revise existing ones.
00:06:09 Right.
00:06:10 I see.
00:06:11 Against that rather general background now, I'd like to turn next to your oversight of
00:06:15 the, what I might call the Lacknell actions.
00:06:18 And I can start with the Lacknell House Board, LHB, Lacknell Preactions and the review done
00:06:25 by Group Manager Lindridge.
00:06:28 Yes.
00:06:29 Lindridge.
00:06:30 Now, in your evidence, we're going to consider the work that you did following Lacknell,
00:06:35 which as we all know happened on the 3rd of July 2009 in the London Borough of Southwark.
00:06:40 Yes.
00:06:41 And at that time, am I right, that you held the position of Head of Operational Resilience
00:06:46 July 2009?
00:06:47 No, I was still the Head of Training and Development in that period.
00:06:52 Right.
00:06:53 I didn't move to Operational Resilience until 2010.
00:06:57 I see.
00:06:58 Right.
00:06:59 Now, is you explaining your witness statement in paragraph 15?
00:07:02 We can just go to that please on page 4.
00:07:09 You say, in 2009, Ron Dobson, the then London Fire Brigade Commissioner, established the
00:07:15 Lacknell House Board.
00:07:16 At that time, I was not a standing member of this board.
00:07:19 However, in my senior management role, I was aware that the board had been established
00:07:22 to oversee the brigade's investigation into the Lacknell House Fire and ensure that any
00:07:27 lessons learned were acted upon to drive continuous development within the brigade.
00:07:32 I was also aware that the board monitored the work being undertaken to support the MPS
00:07:36 investigation and subsequently the coroner's inquest when this was announced.
00:07:41 Yes.
00:07:42 And if you go on to paragraph 16, below it, you say, I was first invited to attend the
00:07:47 Lacknell House Board meetings in January 2012 following my promotion to DORT.
00:07:53 The first Lacknell Board meeting that I attended was on 3 February 2012.
00:07:57 At this point, an action plan had already been developed and consisted of 34 separate
00:08:01 items.
00:08:02 In February 2012, only six of the items in the action plan were not marked as completed.
00:08:08 I did not have any actions allocated to my role or to me personally, although one action
00:08:12 marked as still in progress was allocated to the Head of Operational Procedures, OP,
00:08:18 the department that was within my directorate.
00:08:21 A copy of the 12th February, sorry, February 2012 Lacknell House Board meeting minutes
00:08:26 and associated action plans provided as GR1.
00:08:29 Now, the 34 items there or actions that you refer to, I think, came to be known as Lacknell
00:08:36 pre-actions, didn't they?
00:08:38 Yes.
00:08:39 Yes.
00:08:40 Is it right that those were actions that the LFB had identified internally as learning
00:08:46 or improvement points for the organisation?
00:08:48 Yes, they were self-imposed actions taken as part of the fallout from the investigation
00:08:55 that the brigade was undertaking immediately following the fire.
00:08:57 Yes, you say fallout.
00:08:59 The actions were identified as this right through the work that had been done by the
00:09:03 Lacknell House Board?
00:09:05 Yes, it was informed by the investigation team that was imposed to undertake that investigation
00:09:12 on behalf of the brigade, which were internal resources, they were fire brigade officers,
00:09:16 but yes, it was the reports and information that came from that investigation team that
00:09:20 informed the decisions taken at the board.
00:09:23 I see.
00:09:25 And those 34 items or pre-actions were, I think, identified before you joined the Lacknell
00:09:31 House Board, is that right?
00:09:32 Yes, I think the action plan had been in place for some time.
00:09:36 And yes, there was only, I think, from memory, only six actions that were not completed by
00:09:40 the time I joined the board.
00:09:42 As you say, and it's right to think also that many of those 34 actions related to the control
00:09:47 room.
00:09:48 Yes.
00:09:49 Now, given that you chaired the Lacknell House Performance Review of Command, PRC, well,
00:09:53 let me just ask you, you did, I think.
00:09:55 I did chair that.
00:09:57 Given that fact, did you have any role in identifying any of these 34 actions?
00:10:03 I don't think there was a direct correlation between the issues that I identified from
00:10:08 the Performance Review of Command.
00:10:10 And certainly, if it helps the inquiry, there was a separate debrief for the control function,
00:10:16 which didn't form part of the Performance Review of Command.
00:10:18 That was only looking at the operational incident commanders that were in attendance at Lacknell
00:10:23 House Fire.
00:10:24 You say a separate debrief.
00:10:26 Do you mean a separate incident command, sorry, separate PRC?
00:10:32 It wasn't called a Performance Review of Command because control, by definition, is not a command
00:10:37 function, but there would have been a debrief of the controls, you know, controls, input
00:10:42 and performance during the fire.
00:10:44 And I think that resulted in a control report that was presented to the Lacknell House Board.
00:10:50 Absolutely.
00:10:51 I think we've seen that.
00:10:52 Is it right that the Lacknell House Board continued to meet until, is it September 2013?
00:10:58 It did, but there was a break in the meetings to take account of the fact that the coroner
00:11:04 was starting the inquest in early 2013, was it?
00:11:10 January.
00:11:11 Yeah, January 2013.
00:11:12 So it was, I think the November 2012 meeting was the last one before the coroner started
00:11:18 that process.
00:11:20 And then I think there was another meeting around July 2013, which I think it was the
00:11:24 first one after the Rule 43 recommendations had been received.
00:11:29 And I think the final meeting, as I recall, was September 2013.
00:11:34 Right, correct.
00:11:36 That's what we have.
00:11:37 But in general, the Lacknell House Board existed for the duration of the Lacknell House Request,
00:11:44 so it met before it, didn't meet during it, but then met again afterwards.
00:11:48 Yes.
00:11:49 Now, on page 18 of your statement, at paragraph 53 and then 54, if we can just look at those
00:11:56 You see that you say there, page 18.
00:12:02 Thank you.
00:12:03 Under the heading Lacknell House Action Plan Review Report, you say this, in September
00:12:07 2012, the Commissioner, Ron Dobson, requested a review to be undertaken of the 34-point
00:12:11 Lacknell House Action Plan.
00:12:13 This was progressed through the OA Department, that's Operational Assurance, I think, as
00:12:20 independent review and assurance was one of the core responsibilities, stroke functions
00:12:24 of this department.
00:12:25 I recall that the head of OA, Danny Cotton, identified a group manager, David Lindridge,
00:12:31 to be seconded into the OA Department for a couple of months to undertake the review
00:12:35 and prepare a report.
00:12:37 Now, just to confirm, I think it's right, isn't it, that the report that group manager
00:12:42 Lindridge produced was the document dated 4th of January 2013 entitled Review of the
00:12:50 Lacknell Action Plan?
00:12:52 That's correct.
00:12:53 I'll have that up so that people can see it.
00:12:54 It's LFB 3033943.
00:12:57 And there it is, and its date, you can see, 4th January 2013.
00:13:05 That was, do you remember that that was just as the Lacknell House inquest was starting?
00:13:11 I do.
00:13:12 A few days later.
00:13:13 Was the intention of this audit to make sure that the LFB was ready for the inquest, or
00:13:17 at least in the best position it could be?
00:13:21 Probably the best person to ask that question to is the former Commissioner, Ron Dobson,
00:13:25 but yes, that was my understanding.
00:13:27 Of course we'd want to, we would have undertaken a review at some point anyway, but I suspect
00:13:30 the timing of Mr Dobson's request for me was being conscious of the fact that the coroner's
00:13:36 inquest was about to start.
00:13:38 Yes.
00:13:39 Now, can we go to the witness statement provided to the inquiry by group manager Lindridge?
00:13:43 It's at LFB 3083925.
00:13:47 I'll show you the first page of it, dated 18th December 2019.
00:13:55 And if we go in that statement to page 3, please, paragraph 12, he says this.
00:14:01 I understood that the purpose of the report was to complete an audit of the actions taken
00:14:05 to confirm what had been achieved.
00:14:07 To achieve this I determined that I would identify the state which existed prior to
00:14:11 the Lacknell House fire and determine what changes had been made in the relevant areas
00:14:15 subsequently.
00:14:17 It was not intended to be a qualitative assessment, only a factual review of the actions which
00:14:22 had been undertaken.
00:14:23 Therefore, I reached no conclusions about whether actions taken were sufficient to meet
00:14:27 the expectations of the Board.
00:14:29 I only described what steps had been taken to say that the subject matter experts could
00:14:32 make that assessment.
00:14:35 Now, why is it that David Lindridge, group manager Lindridge, was tasked only to undertake
00:14:41 a factual rather than a qualitative review?
00:14:46 Because some of the issues that he was going to review were outside of his sector competence,
00:14:52 like control.
00:14:53 He was not a trained control officer.
00:14:55 So he would not have been able to make an informed judgment on the quality of things
00:15:02 like training because he wouldn't have experienced the role of a control officer.
00:15:07 So it was more just to assess whether the actions as defined in the Lacknell House pre-inquest
00:15:13 action plan had been delivered and it would have been for officers local to those management
00:15:19 teams and functions for the qualitative aspect.
00:15:23 I see.
00:15:25 Can you tell us why you selected group manager Lindridge to do the factual review given his
00:15:33 qualifications or given his lack of qualifications in respect of the control room?
00:15:38 Why not have somebody with control room experience or perhaps two people, one with incident
00:15:42 command experience and one with control room experience, to produce a single qualitative
00:15:47 review?
00:15:48 Yes, I understand the question.
00:15:50 I didn't choose David Lindridge, but that wasn't the purpose of the review.
00:15:53 So David Lindridge had extensive experience as a senior accident investigator in terms
00:15:59 of undertaking investigations into safety events and near misses.
00:16:04 So he had the right skill set to undertake the audit as a process.
00:16:09 It was AC Cotton, as she was at the time, who put his name forward to do that piece
00:16:14 of work.
00:16:15 David Lindridge wasn't working in my directorate, as I remember, at the time, and we seconded
00:16:19 him in to just do this piece of work on behalf of the commissioner.
00:16:24 Do you know why a qualitative assessment wasn't done of the 34 actions at that stage?
00:16:31 I don't think I've thought about that at the time, so the answer to that is no.
00:16:39 OK.
00:16:40 Now, can we go to LFB 3084017?
00:16:45 This is an email chain in October 2013.
00:16:52 So after the, just chronologically for your benefit, after the inquest hearings and indeed
00:16:58 after the coroner had made her Rule 43 recommendations and the brigade had engaged with those.
00:17:06 This is an email.
00:17:07 If we go to the bottom of page one from you to Danny Cotton on the 2nd of October.
00:17:18 You see that?
00:17:19 Yes, I see that.
00:17:20 And it says this.
00:17:21 Danny, following the Lackland House Board meeting earlier in the week, I've now had
00:17:25 the opportunity to discuss with the commissioner the handling of the thematic review report.
00:17:29 The commissioner would like the report brought up to date to take account of the fact that
00:17:32 some of the outstanding ongoing actions detailed in the January version would, should have
00:17:37 progressed by now.
00:17:39 Once this work has been completed, the commissioner will then organise a Lackland House Board
00:17:43 meeting where we will formally review and accept the updated report and hopefully close
00:17:47 down the board.
00:17:48 We can discuss the detail of how to progress this work at our next one to one meeting.
00:17:53 Now just to be clear, was the thematic review report, the report prepared by Group Manager
00:17:57 Lindridge?
00:17:58 Yes, there was a second report which was dated November 2013 which is referring to just an
00:18:03 updated version of the report that you've just shown me.
00:18:05 It was dated in January, 4th of January.
00:18:10 Right, I see.
00:18:11 And that was the thematic review, was it?
00:18:13 Yes, that's just my terminology but it's the same report.
00:18:15 Which came in fact a little bit after this email.
00:18:17 Yes.
00:18:18 Which is October.
00:18:20 Why did you need to discuss that review's handling with Ron Dobson?
00:18:25 I don't think it was in context to the handling of the review, it's just the fact that an
00:18:30 elapsed period of time had gone.
00:18:33 As you know, the commissioner, deputy commissioner and director of finance and contractual services
00:18:39 had seen a copy of the 4th of January report and we hadn't had many Lackland House Board
00:18:46 meetings in that period because of the inquest.
00:18:49 Mr Dobson in my one-to-one meetings with him just asked me to get it updated.
00:18:54 There was no, as far as I remember, no discussion with Mr Dobson about handling in such as,
00:19:01 in terms of how the report would be constructed.
00:19:03 It would be the same report just with updated information.
00:19:05 Right, you say there was no discussion.
00:19:07 The email rather suggests there was, doesn't it?
00:19:09 Because it says, I've now had the opportunity to discuss with the commissioner the handling
00:19:13 of the thematic review report.
00:19:14 What did you discuss?
00:19:16 Just that it needed to be updated from my recollection.
00:19:18 Right.
00:19:19 A period of time it had elapsed and based on what we understood had happened by the
00:19:24 4th of January, inevitably some of those outstanding actions would have been completed.
00:19:30 So that we wanted to assess where we got to by this date.
00:19:34 One take on what you say there, it might be that the review was sensitive and needed to
00:19:38 be very carefully handled in discussions with the commissioner.
00:19:42 Is that fair?
00:19:43 No, I wouldn't categorise this as a sensitive report.
00:19:47 It was more of a factual report of information that was available to the organisation.
00:19:53 Now looking at the email above this one, we can see that Danny, we need to scroll up to
00:19:57 the top of the page, but you can see that Danny Cotton, we'll just go to the top of
00:20:04 page one, thank you.
00:20:06 Danny Cotton responds to, or rather writes to Adrian Bevan and David Lindridge, having
00:20:12 received this email from you as one of its recipients with three question marks and says
00:20:19 I will let you know when I've spoken to Gary!
00:20:23 Did you have a one-to-one discussion with Danny Cotton about the handling of the thematic
00:20:27 review report?
00:20:28 I would have done, but it probably would have been in the same context as the discussion
00:20:33 I had with the commissioner, which was I just needed the report to be updated with the most
00:20:37 information against all of the 34 action points.
00:20:41 Not as you describe handling per se, the report would be aired at probably a Lacknell House
00:20:49 meeting or a commissioner's group or some other board.
00:20:52 There was no sensitivity around the content of the report and it was just really getting
00:20:57 it brought up to date.
00:21:00 When you had your one-to-one discussion with Daniel Cotton, did she express any surprise
00:21:07 or dismay about anything?
00:21:11 Only that Dave Lindridge obviously wasn't one of our staff, so she was going to have
00:21:14 to ask Dave to work on behalf of our director and would have to get permission from Dave
00:21:20 Brown, I think he was a borough commander at Croydon at the time.
00:21:24 But Dave was very supportive of this and Dave Lindridge agreed to do the update in addition
00:21:29 to his new job as a borough commander at Croydon, so I don't think there was again
00:21:34 no issues about handling it, it was just more about resourcing the update.
00:21:38 When you say he obviously wasn't one of your staff, what do you mean your staff?
00:21:42 He didn't work for my directorate, so I couldn't necessarily impose a load of work on another
00:21:46 officer when he doesn't work for me.
00:21:48 That would be sort of bad form and out courtesy we would obviously talk to both his line manager
00:21:53 and his head of service before we asked him to undertake a piece of work for my directorate.
00:21:57 I see.
00:21:58 The reason I ask is because Danny Cotton's response or rather her reaction, it's not
00:22:02 a response, it's a reaction, is three question marks and I will let you know when I speak
00:22:09 to Gary!
00:22:10 My question was whether whatever it was that had surprised her perhaps was discussed with
00:22:21 you?
00:22:22 Yeah, you'll have to ask Danny Cotton about why the three question marks, I don't know
00:22:27 what they mean, but it was certainly no issue with asking Danny to do the piece of work
00:22:30 and get the update.
00:22:31 Right, very well.
00:22:32 Now if we go to LFB 3083989, we can see, this is DL 17, we can see that here is an email
00:22:44 from David Lindridge to Dave Brown, the third officer, 17th October 2013, review to be revisited,
00:22:53 and he says in the second paragraph, I've been requested by Director Reason to revisit
00:22:58 the report in order to provide an update around the areas highlighted in the opening commentary.
00:23:04 Now just pausing there, if we go back to the opening commentary in the January 2013 version
00:23:12 of Group Manager Lindridge's review, we'll find that at LFB 3083943, page four, so we're
00:23:22 going back to the document you saw earlier.
00:23:27 This is page four, and at the bottom of page four you can see key findings, and that goes
00:23:34 over to page five, and if we pick up this section five, if we go back to page four,
00:23:42 pick up this section five at the foot of page four, paragraph 5.2, of the 34 actions, see
00:23:47 appendix one, 16 of ongoing activities related to achieving the intended outcomes.
00:23:52 These ongoing activities include those dependent on a future event which cannot be simulated
00:23:59 and those which involve influencing external agencies.
00:24:02 These 16 also include those with an ongoing review of performance levels subject to the
00:24:06 action being closed on the log.
00:24:08 And then 5.3 says, this review was unable to confirm 13 actions as fully achieving their
00:24:13 expected outcome.
00:24:15 For each of these, the actions are either ongoing or dependent on a future event.
00:24:19 And then 5.4, a full list of actions and a brief explanation of the findings is appended
00:24:23 to this report.
00:24:24 Listed below are the reviewers' key findings specific to 10 actions for the commissioners'
00:24:28 group attention.
00:24:29 Now looking at that, this is January 2013, why were these particular items or actions
00:24:36 listed for the attention of the commissioners' group, do you know?
00:24:39 The whole purpose of this report was to identify progress against the Lacknell House pre-enquest
00:24:43 action plan.
00:24:45 And so I think the author's intention was to draw to the readers' attention where he
00:24:50 couldn't confirm that the action had been completed or there was work ongoing related
00:24:55 to that specific action.
00:24:57 So that was the kind of, the whole purpose of this report was to identify these issues.
00:25:02 And was it because they were incomplete or because they'd been completed to an inadequate
00:25:07 standard?
00:25:08 I think it was the former, it was because they, he hadn't seen evidence or couldn't
00:25:13 find evidence that they had been completed.
00:25:16 Now in fact, most of the actions, and we can scroll down, but I don't want to do that particularly,
00:25:21 but will you agree that most of them related to the control room and fire survival guidance
00:25:26 training?
00:25:27 Yes, a lot of them were related to training, relating specifically to control staff, yes.
00:25:32 Did you yourself have concerns about how the control room had progressed its actions?
00:25:37 Not specifically, because there is a context to this that some of the actions as Mr Lindridge
00:25:42 infers in the paragraph, that some were dependent on other future events, such as there'd been
00:25:51 training developed and produced, but it hadn't started to be rolled out.
00:25:55 So in part the action had been progressed, but it hadn't been completed because the
00:25:59 staff hadn't completed the training.
00:26:01 Yes.
00:26:03 Now if we go back to the bottom of page four, we can see, I showed you 5.2 I think, 5.1
00:26:11 says all departments offered their full support to the review and have cooperated throughout.
00:26:16 The review found that the activities reported on the action log were accurate.
00:26:23 If you now go to the updated version of this report, because what I'm showing you here
00:26:28 is January, if we now go to what I think was called the thematic review, which was published
00:26:34 as you say in November 2013, that's at LFB 3083988.
00:26:43 I'll pick it up in exactly the same place.
00:26:46 Before I do that, you'll see the date on the screen, November 2013, and now let's go to
00:26:50 page four in that document at the foot of the page, key findings again.
00:26:56 You see that?
00:26:57 Yes.
00:26:58 And you can see the updated key findings at 5.1 and 5.2, and I'll just read it to you.
00:27:03 It says all departments offered their full support to the review and have cooperated
00:27:07 throughout.
00:27:08 The review found that the activities reported on the action log were accurate.
00:27:11 That was identical to what we saw in the January version.
00:27:14 And then 5.2, of the 34 actions, see appendix 1.8 have ongoing activities related to achieving
00:27:21 the intended outcome.
00:27:24 These ongoing activities include those dependent on a future event which cannot be simulated
00:27:29 and those which involve influencing external agencies, a full list of the actions, and
00:27:32 a brief explanation of the findings as appended to this report.
00:27:37 That's the same as we saw in the January report, but there's now no longer any opening commentary
00:27:41 that flags particular actions for the commissioner's group.
00:27:44 Do you know why that was removed in the November version?
00:27:47 No, you'd have to ask Mr Lindridge.
00:27:50 Most of the actions are in the appended part of this report, so again it was completely
00:27:55 transparent in terms of the narrative that he put into the paper.
00:27:59 When this thematic review came to you for your approval, did you compare it with the
00:28:04 January version?
00:28:05 I did.
00:28:06 Did you notice that the opening commentary that flags the particular actions to the commissioner's
00:28:10 group was no longer there?
00:28:12 No, I didn't notice that as a particular issue, no.
00:28:14 Right, okay, you didn't notice.
00:28:16 Why didn't you spot that?
00:28:19 Because the intention of the report was to update the commissioner's group with an updated
00:28:25 position and actually my attention was less on the presentation in terms of the way the
00:28:31 report was structured, but more importantly what was in the table, which was the key information
00:28:37 about progress, which is really what the whole report was about, is understanding what progress
00:28:43 we've made and what still wouldn't.
00:28:45 Why re-presented in that way?
00:28:47 Why not flag up what was still a concern?
00:28:54 I don't think it was for Dave to decide what was a concern and what wasn't a concern.
00:28:57 He was literally, in effect it's a factual report that just states the fact of the matter
00:29:02 as he found it through the audit, so I don't think it was ever an expectation on my part
00:29:08 that Dave would have an opinion or a view.
00:29:10 He was providing information to aid decision making of the senior leadership team.
00:29:15 But he had clearly or somebody had made the decision that there should no longer be an
00:29:20 opening commentary that flagged particular actions for the commissioner's group.
00:29:24 Who had made that decision?
00:29:27 Certainly wasn't an intention of mine and I'm expecting Dave or Danny Cotton.
00:29:32 I think it's just a drafting issue.
00:29:34 He knew the report, where the report was going, so anything he'd written in the report would
00:29:38 be available to the top management team.
00:29:41 Did he have any reason to make a structural change like that without being instructed
00:29:47 to do so?
00:29:48 Well, he's the report author, so it's his report.
00:29:51 I gave him comments on the first report in January but I don't believe I gave him any
00:29:55 feedback in terms of presentation of the information because it was pretty much in the same format.
00:29:59 So again, that's something you'd have to ask Mr Lindridge.
00:30:02 Do you know whether Danny Cotton gave him any feedback in terms of presentation?
00:30:07 I can't answer that, you'd have to ask.
00:30:09 Was the idea to sanitise the report's findings before it was presented to the Lacknell House
00:30:14 Board?
00:30:15 Certainly not.
00:30:16 All the information is in there, so the report does exactly what it was designed to do.
00:30:21 It gives you the updated position on all 34 action points.
00:30:23 Now, at this time, which is late 2013, the Lacknell House Working Group had already been
00:30:30 established and I think had met at least twice.
00:30:33 Yes, by that date, yes.
00:30:36 Yes.
00:30:38 Was this re-presentation of this data in order to facilitate the closing down of the Lacknell
00:30:43 House Board and to assist with the start of the Lacknell House Working Group?
00:30:49 I think from my recollection, obviously this is a while ago now, it was always our intention
00:30:55 to take this report to the Lacknell House Board but as you heard earlier, the last board
00:31:00 meeting for the Lacknell House Pre-Inquest Board was September 2013 and this report post
00:31:07 dates that time so in effect we couldn't take it to that board and my recollection, which
00:31:12 is what I do in my statement, is that we would have, the commissioners group would have taken
00:31:16 this report for information.
00:31:18 Yes, and indeed that leads on to my next question.
00:31:24 You confirmed just now the Lacknell House Board never met to discuss the findings in
00:31:29 this report.
00:31:30 No, it didn't.
00:31:31 No, and just help us, why was that in brief?
00:31:34 Because the board had been concluded in terms, and that was obviously at the commissioners
00:31:40 decision to conclude the board and we took this report from memory to a commissioners
00:31:45 group meeting.
00:31:46 Yes, commissioners group meeting, but is this right not to the Lacknell House Working Group?
00:31:52 No, the Lacknell House Working Group was predominantly focused on the post-inquest Rule 43 recommendations
00:31:59 and issues arising from the coroner's inquest and other matters that the Lacknell House
00:32:04 Working Group wished officers to pursue.
00:32:07 This was more of a self-imposed internal document to assess progress against the original action
00:32:13 plan that was established as part of the Lacknell House Board meetings immediately following
00:32:18 the Lacknell House Fire.
00:32:19 Yes, was any thought given to providing the Lacknell House Working Group with this report,
00:32:26 the November final version of the Lindridge Review?
00:32:32 I don't recall a discussion with the commissioner either at a one-to-one or within the commissioners
00:32:37 group meeting that we would seek to take this report or conclusions from this report to
00:32:43 the Lacknell House Working Group.
00:32:44 No.
00:32:45 Why not give the Lacknell House Working Group, which after all consisted of elected members
00:32:50 of the assembly, why not give them this report so that they would have the benefit of the
00:32:56 insight into how the brigade itself had seen the problem at Lacknell, which might better
00:33:03 inform their own work arising out of the Rule 43 recommendations?
00:33:09 I think from memory, and this is from memory, that the elected members of the fire authority
00:33:14 were given, and I can't remember which committee it was, that took regular updates on issues
00:33:19 arising from the Lacknell House Fire.
00:33:21 So not at this level of granularity because members wouldn't have probably sought for
00:33:26 that level of information, but members as a group, the fire authority, were given regular
00:33:32 updates on issues that arose as a result of the Lacknell House Fire.
00:33:37 Can we look at paragraph 58 of your statement, your first statement please, page 19?
00:33:45 You say there that I recall, page 19, yes, I recall that the November 2013 review of
00:33:53 the Lacknell Action Plan report was reviewed by members of the brigade CMT at a commissioners
00:33:58 group meeting held at the end of 2013.
00:34:00 However, as this is an unminuted meeting, I'm unable to provide any documentary evidence
00:34:04 to support this.
00:34:06 Now you've mentioned that in your evidence to us just now.
00:34:10 Do you remember what was discussed at that meeting, even in outline?
00:34:16 This would be reaching back into my memory banks.
00:34:19 It's likely, I can't remember the meeting specifically, but I suspect all of the outstanding
00:34:28 actions were either in my directorate or Rita Dexter's directorate and we would have accepted
00:34:35 responsibility for following up any outstanding action or ongoing actions as part of core
00:34:41 business.
00:34:43 happened is that most of the things that were still outstanding, there was a good reason
00:34:50 why they were outstanding, it wasn't failures, they just hadn't either reached that point
00:34:53 or we hadn't done the work yet.
00:34:56 But it was definitely on Rita Dexter's and my radar that there were outstanding issues
00:35:01 and we would manage that as business as usual through our normal one-to-ones with the heads
00:35:05 of service that were responsible for those actions.
00:35:07 Right, so those outstanding actions, were they themselves brought to the attention of
00:35:13 the Lacknell House Working Group so that the work could be dovetailed with the response
00:35:19 to the Rule 43 recommendations?
00:35:20 No, they weren't.
00:35:21 Why is that?
00:35:22 I'd have to look at all the individual actions to see, but I suspect although the members
00:35:29 were very interested in all things post-Lacknell, I think this was a very granular level, some
00:35:34 of this work and probably wasn't within the scope of the Lacknell House Working Group.
00:35:39 Right, okay, well bear that in mind for the moment, we may come back to that topic later
00:35:43 in your evidence.
00:35:44 Just focusing on this report, do you know what was decided at this meeting that you
00:35:49 refer to in paragraph 58 about what should happen to the Lindridge Review?
00:35:55 No, it was just noted, I believe it was noted and that Rita Dexter and myself would take
00:36:02 responsibility for ensuring that any of the outstanding actions were completed as part
00:36:08 of normal business.
00:36:09 Do you accept that by not taking the review to a meeting of the Lacknell House Board with
00:36:14 its broader member base, this was something of a missed opportunity to assess whether
00:36:18 the lessons from Lacknell House had been truly learned and embedded within the brigade?
00:36:23 Well I think the thing that the inquiry needs to be aware of is all the people that own
00:36:29 the actions in terms of head to service also sat on the Lacknell House Board, so it wasn't
00:36:35 like it was a separate group of officers that had no involvement site across the whole of
00:36:42 post-Lacknell pre-inquest activities the brigade was undertaking, it's the same constituency
00:36:47 of senior managers sat on the Lacknell House Board who had the outstanding actions, so
00:36:53 none of this would have been new news to them, in fact they would have assisted David Lindridge
00:36:56 in providing these updates, so it would have been completely au fait with where the brigade
00:37:01 was and what their responsibilities were in relation to this specific action plan.
00:37:05 Yes but correct me if I'm wrong, but isn't it the case that the Lacknell House Board
00:37:09 comprised a broader member base than simply the officers who as you put it owned the outstanding
00:37:16 actions?
00:37:17 Yes indeed.
00:37:18 Yes and so isn't this a missed opportunity to disseminate the learning more widely among
00:37:22 the Lacknell House Board?
00:37:24 Well the board members would have seen the action plan development immediately following
00:37:29 because they were obviously at all the meetings and so would have been cited on the 34 points
00:37:35 and I think Dave Lindridge says in his final update in November 2013 report there's eight
00:37:40 that are still in progress or not yet been delivered, so I don't think there would have
00:37:46 been other than just you know signing it off formally at a board meeting there would have
00:37:51 been no additional improvement in the understanding from our point of view as a senior leadership
00:37:58 team because all the people would already contributed to developing those actions, so
00:38:02 that constituency of the Lacknell House Board had been the in effect the people that had
00:38:07 discussed and developed these actions as a group.
00:38:10 Yes I understand that, what I'm really seeking to get out of this question is whether you
00:38:14 accept that there are people on the Lacknell House Board who wouldn't have had the benefit
00:38:18 of reading this report and that therefore that...
00:38:20 Yes I accept that.
00:38:21 And that therefore that was something of a missed opportunity?
00:38:23 Yes, potentially yes.
00:38:24 Particularly in relation to lessons learnt vis-a-vis the control room?
00:38:28 Yes but Dave Brown obviously was one of the main people that owned those actions and he
00:38:34 was very much cited and he also sat on this, the commission's group, so Dave Brown the
00:38:38 person that was responsible ultimately for control was cited on this report.
00:38:42 Right, now I want to turn next to the Lacknell Rule 43 recommendations themselves and their
00:38:49 oversight if you like by the ODCB and the Lacknell House Working Group.
00:38:57 We've already touched on the fact that the Lacknell inquests ran from January to March
00:39:01 2013 and then 28th of March 2013 the coroner's Rule 43 recommendations came and that letter
00:39:11 is at LFB 3032158.
00:39:20 Now it's a document we're going to be going back to a number of times in your evidence
00:39:26 but you can see the first page 28th of March 2013 addressed to Mr Dobson, title Lacknell
00:39:33 House Fire 3rd July 2009, you see that?
00:39:36 Yes.
00:39:38 If you go to the very foot of the page you can see that she says this in the last paragraph,
00:39:44 before I set out my recommendations I acknowledge that London Fire Brigade have already undertaken
00:39:49 extensive work to learn from their experience with the fire at Lacknell House, have introduced
00:39:54 new policies and have reviewed existing policies in respect of a number of matters of significance
00:39:59 including and then if you go to page 2 she sets out a long list of bullet points, a list
00:40:04 of matters which includes in the second bullet point, third line, what we call 7 2 D visits,
00:40:15 familiarisation visits and visits pursuant to 7 2 D of the 2004 Fire and Rescue Services
00:40:22 Act and goes on underneath that fourth bullet awareness that fires can spread downwards
00:40:28 and laterally in a building and that burning debris might fall through open windows or
00:40:31 onto balconies and other matters such as communication between the control and the incident ground
00:40:37 and the handling of FSG calls, we can see the list.
00:40:41 Then she sets out her five recommendations which we can see from the headers in italics
00:40:47 and I'll just go through those with you, the first is public awareness of fire safety,
00:40:52 the second is visits made pursuant to section 7 2 D Fire and Rescue Services Act 2004 general
00:40:58 familiarisation visits and home fire safety visits, the third is incident commanders over
00:41:03 the page at page 3 brigade control and then communications and then at the end response
00:41:12 which stipulates the time frame during which the LFB was required to respond to the coroner's
00:41:17 recommendations. Yes.
00:41:18 Yes, now we'll explore the detail of these recommendations later on in your evidence
00:41:22 Mr Reason but for the time being I just want to ask you about some general matters particularly
00:41:27 your statement paragraph 19 if we can go to that please page 5 in your statement where
00:41:36 you say underneath the heading my role in responding to the coroner's rule 43 recommendations
00:41:41 arising out of Lacknell House fire you say this following receipt of the coroner's rule
00:41:46 43 letter dated 28th of March 2013 I was tasked by the Commissioner Ron Dobson to establish
00:41:52 a detailed action plan to address and respond to all of the coroner's recommendations my
00:41:57 first action was to call a meeting with all of the brigades heads of service HOS who had
00:42:02 corporate responsibility for the areas of work detailed in the recommendations below
00:42:06 is the list of the HOS who were directly involved in the work to develop the brigades rule 43
00:42:11 action plan. Now some of the individuals that you then proceed to list at the bottom of
00:42:16 page 5 and over onto page 6 where I think we're in within your directorate but some
00:42:22 weren't for example AC David Brown Steve Chirac. That's right.
00:42:29 So is it right that some of these areas of work were outside your normal command hierarchy?
00:42:37 Not my command hierarchy my management responsibility.
00:42:40 I see the difference. All right but management hierarchy.
00:42:44 Yes. Right.
00:42:46 Did you hold meetings with the heads of service individually or with all the heads of service
00:42:50 together? All together.
00:42:52 What sort of matters did you discuss with the heads of service during those meetings?
00:42:57 The initial the inaugural meeting of this group as set out on page 5 and 6 was to ensure
00:43:02 that they all had copies of the coroner's rule 43 recommendations. I set out the Commissioner's
00:43:09 intention that he obviously had to respond to the coroner within 56 days and it was the
00:43:14 Commissioner's intention to provide a fairly detailed response to address all of the matters
00:43:19 that you've just covered with me and so I asked them to go away with their respective
00:43:24 teams to put together a draft that we could work through so that I could get a kind of
00:43:31 very advanced working draft to the Commissioner ahead of the I think it was the 23rd of May
00:43:36 was the deadline to send the response to the coroner and so that was my initial task. It
00:43:43 was really just to set out the Commissioner's requirements and to give them some guidance
00:43:49 in the broadest sense. These are all very senior managers who are used to developing
00:43:53 action plans and of course understood the importance of this particular action plan
00:43:58 and it was just to give them a steer and give them some detail on the timescales that we
00:44:03 had to actually develop this response.
00:44:05 Moving ahead to the 11th of May 2013 so about a fortnight before the letter had to go back
00:44:12 to the coroner we can see an email LFB 3073406. Can we go to that please? It's an email
00:44:22 of the 11th of May 2013 from you to Ron Dobson, Rita Dexter and Sue Budden about the LFB's
00:44:31 response and you say this and you can see who's copied as well. All ahead of next week's
00:44:37 meetings to finalise the brigade's response to the coroner's Rule 43 recommendations
00:44:40 please find attached the completed proformers detailing our position on each issue. The
00:44:46 proformers have been completed by the four lead officers Dave B, Steve T, Jim K and Danny
00:44:51 C and they're all copied as you can see with the assistance of comms and detail a range
00:44:57 of background information that supports their respective proposals. We've also included
00:45:04 indicative timescale for completing each activity and made recommendations on how the brigade
00:45:08 could audit the effectiveness of this work. Now you refer to that ahead of next week's
00:45:14 meetings. What meetings were you referring to? It probably was a commissioners group
00:45:21 meeting probably meetings is an error is probably a meeting to take to go through this. I don't
00:45:28 believe we took it to a formally constructed board of the brigade an internal board I think
00:45:33 it was done at the commissioners group. Which is the informal weekly and unminuted meetings?
00:45:38 Yes. Right. Let's see if we can assist you. Can we get LFB 3073673? This is an email invitation
00:45:49 meeting to discuss Lacknell Commissioners Conference Room third floor Union Street Tuesday
00:45:54 the 14th of May 2013 between 12.30 and 1.30 and you can see who's copied or to whom this
00:46:02 is addressed. Was this meeting was the meeting at which the brigades rule 43 response was
00:46:09 finalised? Yes. Right. Do you remember what was discussed at it? Not in detail. No. Did
00:46:19 you have a draft of the letter from Ron Dobson which was eventually dated the 23rd of May
00:46:24 before you? I can't remember. The letter may have been in draft. Really obviously the
00:46:32 focus of this meeting I think was to look at the responses from each of those officers
00:46:37 attending that had responsibility for the actions to make sure that the commissioner
00:46:42 was comfortable that he understood what was being proposed by his head to service in terms
00:46:47 of time scales etc. And that he was satisfied that that was sufficient for him to respond
00:46:52 to the coroner. That would have been I think the sense of the meeting. The correspondence,
00:46:57 the covering letter probably was done much closer to date that it was dispatched to the
00:47:01 coroner. Right. I mean we know that the commissioners group meetings were unminuted as a matter
00:47:07 of course but was any record kept of this particular meeting? I don't believe so. No.
00:47:12 Is there any reason why not given its importance? I don't know why it wasn't minuted. I think
00:47:19 obviously the eventual outcome of this meeting was the final response to the coroner's rule
00:47:26 43 actions. So that was all visible and transparent and was copied into the response to the coroner
00:47:33 and was made more widely known internally within the organisation once it was sent to
00:47:38 the coroner. Can we go back to the 11th of May email for a minute? At NFB3073406 please.
00:47:46 And you say in the second paragraph there, for ease of review I have highlighted in yellow
00:47:53 text the sections that detail our considerations and corresponding proposals for responding
00:47:58 to each of the rule 43 recommendations. If agreed it will be this information that will
00:48:03 form the basis of the commissioners response to the coroner. Do you remember whether the
00:48:08 meeting on the 14th of May 2013 did discuss each of the recommendations?
00:48:15 Each of those proposals in detail? Yes I believe they did.
00:48:22 Now if we go to paragraph 22 of your statement on page 6 we can see that you say this, once
00:48:38 finalised and agreed the rule 43 action plan was regularly reviewed through a number of
00:48:42 governance processes, namely the Operational Directorate's Coordination Board, ODCB and
00:48:47 Lacknell House Members Working Group. These two boards were the means by which the progress
00:48:56 of the rule 43 action plan was regularly monitored. Can we first bring up the witness statement
00:49:03 of Ron Dobson, LFB3032157. This is his first statement and I just want to show you first
00:49:11 of all page 1, there it is, and now page 6 paragraph 22. He says this, on the 20th June
00:49:21 2013 at a meeting of the LFB3032157 I presented a report, Coroner's Inquests Following the
00:49:27 Fire at Lacknell House on 3rd July 2009. A copy of the relevant excerpt of the meeting
00:49:32 minutes are produced as exhibit RJD8, a copy of the report of RJD9. Set out within the
00:49:39 report it was proposed that the implementation of the proposed actions in response to the
00:49:42 rule 43 recommendations was to be monitored by the ODCB. Why was it proposed that the
00:49:48 ODCB in particular should be responsible for monitoring the progress of the LFB's rule
00:49:53 43 actions? So one of the functions of the ODCB was to look at other rule 43 recommendations,
00:50:00 so there had been a fire previously, Shirley Towers fire, the Hampshire fire where two
00:50:08 firefighters had died, before that there had been another significant fire in Hertfordshire,
00:50:14 Harrow Court, and those two fires resulted in rule 43 recommendations for those respective
00:50:20 fire and rescue services. So one of the functions of the operational assurance department was
00:50:25 to bring forward an action plan of how the brigade was going to review those rule 43s
00:50:30 if they weren't directed specifically at London Fire Brigade, of course we had to assess
00:50:36 those and then satisfy ourselves that we put in place training policies etc to respond
00:50:42 to those. So we already had a governance process where rule 43 action plans was monitored by
00:50:49 ODCB, so it felt appropriate not to create another governance process and this would
00:50:54 be added to the regular updates of the rule 43s that were already in existence, so it
00:50:59 became one composite rule 43 update report that came regularly to the ODCB. So in short,
00:51:07 is it that the ODCB was an already established organ which responded to rule 43s from coroners?
00:51:15 Now, if we go on in this statement please to page 7, paragraph 23, we can see that on
00:51:37 page 7 he says this, as can be seen from the minutes of the meeting, in addition it was
00:51:43 agreed that a task group would be established consisting of three elected members of LFIPA,
00:51:48 drawn one, I think he means one drawn, from each political group to undertake a review
00:51:52 of the LFB's response to the fire at Lacknell House and provide their recommendations into
00:51:57 the strategy committee. Was that task group the Lacknell House working group? Yes it was.
00:52:04 Why was it deemed necessary for the LFIPA members to undertake a review of the LFB's
00:52:10 response to the Lacknell House fire? This was not typical of the governance structures,
00:52:17 normally the strategy committee would normally take regular updates on these types of issues,
00:52:23 but I believe from my own understanding of it that one of the members that eventually
00:52:28 chaired the Lacknell House working group was Assembly Member Val Shawcross, who had a
00:52:34 particular interest, so one of the Assembly Member responsibilities covered the London
00:52:39 Borough of Southwark, which is where the Lacknell House fire had occurred. So I think she was
00:52:43 very persuasive at that fire authority meeting in June that she wanted to not just look at
00:52:49 the Rule 43, she wanted to look at other issues that she was very interested in pursuing and
00:52:54 asking officers to assist with, and I think obviously the decision was of the fire authority
00:53:00 that that board would be created to facilitate that work. Right. That's why we ended up
00:53:05 with reporting both to the strategy committee and the Lacknell House working group as it turned out.
00:53:09 But I think, is it not the case that the Lacknell House working group itself reported to the strategy committee?
00:53:15 Sorry, yeah, to be accurate.
00:53:17 So, yes, but is it right that both were comprised of elected members?
00:53:24 Yeah, the Lacknell House working group was a subset of people that potentially sat on the
00:53:28 Stroud Garden, but not all members sat on all committees, so I'm not sure if all three members
00:53:35 that sat on the Lacknell House working group were also constituent members of the strategy committee.
00:53:39 I can't answer that, but they were all part of the fire authority, the members.
00:53:44 Yes. Can you help us why there was this dual structure? Why have the strategy committee
00:53:51 and the Lacknell House working group overseeing the brigade's response?
00:53:55 It wasn't an officer's decision, it was a decision taken by the elected members of the fire authority,
00:54:01 it wasn't a proposal from officers, it was something that resulted from the discussion
00:54:06 on the back of the report that Mr Dobson took to the June 2013 authority meeting explaining
00:54:12 our response to the coroner's Rule 33 recommendations.
00:54:17 Yes. Was it intended that the working group should provide political oversight,
00:54:21 scrutiny and accountability of the LFB's responses to the Lacknell House
00:54:25 fire and the inquest that followed?
00:54:27 Yes, I believe that's what it was intended to do.
00:54:30 Yes. Now if we get back to your statement, please, your first witness statement at page 7, paragraph 27,
00:54:35 you say there, the commissioner, deputy commissioner, and myself were standing members of the LHWG,
00:54:45 along with the three authority members selected from the main political parties, Labour,
00:54:48 Conservative and Liberal Democrats. Other brigade officers were invited to attend specific meetings
00:54:52 when required. You see that? Yes.
00:54:58 And then if you go over the page to page 30 of your statement, you can see you say this,
00:55:04 in addition to being a standing member of the LHWG, I had a responsibility for presenting the
00:55:09 Lacknell House Rule 43 action plan monitoring report that was a standing agenda item for this
00:55:14 meeting. This involved me going through each of the actions and explaining the updated positions
00:55:19 that had been provided by each of the HAOS who had corporate responsibility for each action item.
00:55:24 The commissioner, deputy commissioner, and myself also answered any questions
00:55:27 the members had relating to the Lacknell House Rule 43 action plan updates.
00:55:35 Now we'll look in detail at some of those updates in due course, but for the time being,
00:55:40 can we look at a particular document, LFB 3029238 at page 17?
00:55:49 Yes. This is the action plan monitoring
00:55:56 report that you refer to in the paragraph we've just looked at. I say that. Am I right about that?
00:56:01 Yes, you are. Right. And this one, I think, am I right in saying is the first iteration
00:56:06 dated September 2013? Yes, I believe that's correct.
00:56:12 We could see that, I think, simply from the fact that it says action update August 2013.
00:56:17 Yes. Yes. Now in your second witness statement, and I'm sorry to dot about Mr. Reason, but if
00:56:23 you go there, LFB 3067846 page 13 paragraph 17, you say in the second line there that you produced
00:56:32 this action plan, you say, using the Rule 43 related updates that were provided by AC Cotton
00:56:38 to the ADCB meetings, along with the updates I'd received from the other lead officers who are
00:56:43 named in the action plan and who had specific responsibility for the actions that were
00:56:46 specifically generated by NHWG. Now, just cutting through all this, is it right that the task of
00:56:54 collating updates for the ODCB and the Lackland House Working Group were basically merged into one?
00:57:02 Yes. So normally the sequence in terms of chronology was that an update, because we took
00:57:08 the update on the Rule 43s at every ODCB, that we'd take the latest update from the ODC,
00:57:14 I would take the latest update from ODCB and put it into this consolidated action plan for members.
00:57:21 So ostensibly it was exactly the same information, it was just in a different,
00:57:26 slightly different format for members' consumption. Right. Now we understand that the
00:57:32 LFIPA Strategy Committee received, I think, two updates on the LFB's Rule 43 actions in total,
00:57:39 the first in November 2013, when work on the actions was continuing. And is this right,
00:57:45 the second one at the conclusion and the termination of the Lackland House Working
00:57:49 Group in July 2014? That's correct. Yes. Now, as to the first of those updates, November 2013,
00:57:56 we have a report at LFB 00089117. If we just look at the first page of that.
00:58:10 Yeah, you can see that it's on LFIPA, a note paper, the report titles Lackland House Monitoring
00:58:17 Report and Action Plan, 12th November 2013, report by Assistant Commissioner Operational Assurance,
00:58:26 uh, for the Strategy Committee meeting. And I think, am I right in, in saying that the Assistant
00:58:33 Commissioner Operational Assurance at the time was Danny Cotton? That's correct. Yes. Now,
00:58:39 let's see how she describes this. If we go to her witness statement, please, at LFB 3032737,
00:58:47 page 8, paragraph 28, third line, she says, she refers to this report.
00:59:01 She says, having reviewed it, I note that that report is in my name because I was the head of
00:59:06 the relevant department. However, it was drafted by the head of health and safety, Adrian Bevan.
00:59:11 The report included an action plan monitoring report, which was presented by Gary, that's you,
00:59:16 at regular meetings of the working group. Why was it your responsibility to update the Strategy
00:59:24 Committee on the progress of Rule 43 actions, rather than the Commissioner's responsibility?
00:59:33 I think, uh, the Strategy Committee didn't ask for a specific officer to give the update. It would
00:59:39 have been for officers to determine the most appropriate officer to give the update. Um,
00:59:45 so I would imagine, uh, given that, uh, AC Cotton, as she was at the time, was collating the updates
00:59:53 from heads of service about the Rule 43 response, that it made sense that she gave the update to
00:59:59 the Strategy Committee and the report went in her name. Right. Do you know why it was drafted by
01:00:04 the head of health and safety? Uh, well, I know Dr. Bevan, uh, is a very experienced, uh, health
01:00:11 and safety practitioner and that's really a question you'd have to direct to AC Cotton,
01:00:16 why she asked him to assist with the drafting of that report. But you don't know. No. Right. Now,
01:00:21 um, we, we, we will come back to this document very shortly. Can I just take a small detour,
01:00:28 Mr. Reason, and go to LFB 3089095? This is an email chain, um, which we see from you to Danny
01:00:37 Cotton and others on the 3rd of October, 2013. We can see you send the email to Max
01:00:44 Dissiniaki and Danny Cotton, a copy to Adrian Bevan. Uh, and you say this, dispatch of papers
01:00:53 for the 12th November Strategy Committee is for, is the fourth. So this paper will probably need
01:00:59 to be cleared by CMB either on the 17th or 25th of October. There's 25th, CMB is a performance one.
01:01:09 I think you've made the 25th of October. Yeah. Yes. Uh, so I'm assuming that the 17th would be
01:01:14 a better bet. But in fact, I've checked the forward program and all of the other Strategy
01:01:18 Committee reports are going to the CMB on the 17th. So that's what we should aim for. And then you
01:01:22 go on, um, to say, uh, in the third paragraph, given the above, it's clear we need to crack on
01:01:28 with preparing the covering report. So I get a chance to see it before the dispatch date for
01:01:33 the CMB on the 17th. We also need to ensure that the updates to the wider Rule 43 are consistent
01:01:39 in the Lacknell specific update that goes to ODCB and the one I take to members through the LHWG.
01:01:47 NB members were very challenging regarding the Lacknell Rule 43. So it may be helpful if I give
01:01:52 you some feedback on this before we submit the Rule 43 update to the next ODCB meeting.
01:01:58 Now, in what way were the LFIPA members very challenging in relation to the Lacknell Rule 43
01:02:04 actions? Um, understandably, they were very interested, uh, in what the Brigade said it
01:02:11 was going to do and what we were actually achieving. Um, I can't remember a specific,
01:02:17 the specific meeting where, that I'm referring to there, but it would have probably been about
01:02:21 the line of questioning and the level of detail that they were expecting. And I suspect, given
01:02:27 that it was quite a regular thing to present to elected members and they could be quite a fierce
01:02:32 group in terms of scrutinising officers, which is what their job was, um, that it was probably
01:02:37 around the language and whether they, they felt that there was enough information in the Rule 43
01:02:42 updates to satisfy themselves, that they understood what was going on. I suspect that's what the
01:02:46 challenging referred to. That, uh, whilst it was probably acceptable for officers who were working
01:02:50 on it, uh, for a lighter touch, that the, the elected members are a different constituency,
01:02:54 they're not operational officers, so they probably needed a bit more detail to satisfy themselves.
01:02:58 They understood what was going on. Right. I see. Before we leave this document, in the paragraph
01:03:03 I've just read to you, uh, the penultimate paragraph, you refer to the wider 43 there.
01:03:08 What's that a reference to? You say, do we need to ensure that the updates to the wider Rule 43 are
01:03:14 consistent? Yeah. So as I said earlier, there was a, there was other, there was a Rule 43 action plan
01:03:20 that went to ODCB, but it included, I think about this time, it only included, uh, actions arising
01:03:26 from the Shirley Towers fire in Hampshire, uh, and then the Lacknell House Rule 43 actions were added
01:03:31 to the bottom of that table, and then that became the, the working document. So it was probably in
01:03:36 context to the wider Rule 43 was the, the, the full plan, whereas the Lacknell House Working Group
01:03:41 only saw the Lacknell Rule 43, so it was a subset of a bigger action plan that went to ODCB. Right.
01:03:47 But I wanted them, obviously they needed to be consistent, uh, in terms of the delivery of the
01:03:51 information. Yes. Now let's get back to the report itself of the 12th of November we were looking at
01:03:56 before, LFB 3089117. And if we go to page two, um, you can see there's a heading, progress made
01:04:05 against the action plan, just about a quarter of the way down the page. And this section summarises
01:04:12 the Rule 43 monitoring report, and it then says halfway through that paragraph,
01:04:16 about halfway through paragraph six, it says, uh, this in the third line.
01:04:23 Only one activity failed to be delivered by the target date, which relates to the establishment
01:04:28 of the high-rise forum. Officers had intended to establish this new forum by the end of August,
01:04:33 but due to the availability of the key stakeholders, the inaugural meeting was actually
01:04:37 held on the 4th of October. All other tasks are progressing in accordance with the agreed
01:04:42 time scales or have been completed. And just pausing there, can we then look at the monitoring
01:04:51 report itself, appended to this document at page four, we go to page four. Um, this one is dated
01:05:03 September. Uh, were all iterations of these monitoring reports, um, prepared by you?
01:05:14 Um, I can't remember if I, I probably wouldn't have sat down and, and copied them all across.
01:05:22 I think someone, I, from recollection, I think someone in AC Cotton's department did it on my
01:05:27 behalf, but obviously I took ownership of them once they were produced. Yes, I see. And, and were
01:05:32 those iterations, uh, of these monitoring reports shared with the strategy committee?
01:05:39 Uh, only, only the ones that appeared in this report that went to the strategy committee. And
01:05:44 I can't remember if we appended an updated action, uh, when we took the final report to the strategy
01:05:50 committee on the conclusion of the Lackland House Working Group. I can't remember off the top of
01:05:53 my head whether that included a, a rule 43 table appended to that report. I don't think it did,
01:06:00 but I can't remember. Right. Well, let's just see if we can trace this through then. Um, it looks
01:06:05 to us as if, and this is where I need your help, that the next occasion when the strategy committee
01:06:09 was updated on the work of the Lackland House Working Group and the rule 43 actions was the
01:06:15 July 2014 meeting. Um, can we look at that? And perhaps you can confirm. LFB 0067819.
01:06:30 So there's the report to the strategy committee, 11th July 2014, by the deputy commissioner and
01:06:36 director of operational resilience and training. That's you this time, isn't it? Yes. Yes. Uh,
01:06:41 and, um, it's written by both you and Rita Dexter, I think. Yes. DC. And you can see that on the
01:06:49 first page there, you recommend two things. One, that the work of the Lackland House Working Group
01:06:54 be noted. Two, that this report be agreed as the formal conclusion of the work of the Lackland
01:06:59 House Working Group. Um, are you aware of any, uh, are you aware of any rule 43 updates being
01:07:09 given to the strategy committee after the presentation on the 12th of November, 2013?
01:07:14 We looked at a minute ago and this report recommending, uh, the working group's conclusion
01:07:21 on the 11th of July, 2014. No, I'm not aware of any further updates, uh, following the agreement
01:07:27 at this strategy committee that the work of the Lackland House Working Group should be concluded.
01:07:31 No. And, uh, I take it that the, the action plan document we saw appended to the November version
01:07:40 of the report, the November report that went to the strategy committee was the only such report?
01:07:45 Yes. Right.
01:07:46 Right.
01:07:51 Then let's turn to a, a different topic. Um, or I suppose which one which might be regarded
01:07:58 as a continuation of this topic, which is the rule 43 incident command recommendations.
01:08:03 And can I start by asking you some questions about your role in devising the rule 43 response?
01:08:09 We looked earlier on, I think, at the, uh, your role in collating the, the proposed actions to
01:08:13 address the coroner's recommendations under rule 43. And we looked at the 11th of May email.
01:08:20 Uh, can we just go back to that again, please?
01:08:25 LFB 3073406.
01:08:34 And, uh, in the second paragraph, which I didn't read to you, you said this,
01:08:40 um, for ease of review, I've highlighted in yellow text the sections that detail our considerations
01:08:44 and corresponding proposals for responding to each of the rule 43 recommendations. If agreed,
01:08:49 it will be this information that will form the basis of the commissioner's response to the coroner.
01:08:53 Now, um, I've come back to this document, Mr. Reason. I know you're familiar with it.
01:08:57 Yep.
01:08:57 Just to put it in its context again, this is 11th of May ahead of the 14th of May meeting with the
01:09:02 commissioner's group.
01:09:03 Yep.
01:09:04 In turn, ahead of the 23rd of May letter from Ron Dobson by way of response to the rule 43
01:09:10 recommendations. So, we're at that point. And now, if we turn to the collated, uh, pro forma
01:09:18 responses which you attached to this email, let's look at those or that, which is at LFB 3034062.
01:09:26 Um, this is a, um, a format which, uh, you can see, um, collated the pro forma responses
01:09:43 across the piece for all of the recommendations. First, um, who designed this pro forma? Do you
01:09:49 know?
01:09:50 It was the comms department, the internal communications department.
01:09:54 I see. Um, were these pro formas the subject of your meetings with the various heads of service?
01:10:00 This pro forma came out of the inaugural meeting I described earlier to put the action plan
01:10:06 together. Uh, one of the attendees of that meeting was the head of internal, well, the
01:10:11 head of communications for the London Fire Brigade, Glenn Seabright. And he kindly offered
01:10:16 to pull together a format, a working document, uh, to allow us to progress the work that we
01:10:22 needed to achieve and also to give, um, some background information in a kind of, uh, easy
01:10:28 to review structure so that when the commissioner's group took, uh, the final version of this,
01:10:35 uh, the final proposed version, that it was a little bit of context given, not just the
01:10:40 final outcome. Um, and that was obviously because of the expediency of trying to meet the
01:10:45 coroner's deadline for the response. So I wanted to give as much information to the audience that
01:10:50 would ultimately, uh, accept this as a, as the brigade's position in response to the rule 43.
01:10:57 And so this is very much a working pro forma, uh, which give all the granularity below the
01:11:03 highlighted yellow, which was the bits that I anticipated would go forward to the coroner.
01:11:07 I see. So Glenn Seabright, as it were, is this right, designed, not only designed this,
01:11:12 this document or the format of it, but also collected from the heads of service the contents?
01:11:18 He would have probably offered at that meeting, if you send me your information, I'll put it into the
01:11:24 I see form and then we can review the format subsequent meetings before we, uh, sign it off.
01:11:28 And then it came to you and then you made the yellow highlights on it?
01:11:31 Yeah, I made the yellow highlights as I thought they were the salient points, which demonstrated
01:11:37 that the brigade's intention, uh, both in terms of the immediate action, but also some of the
01:11:42 underlying issues that we were going to try to address by responding to the rule 43 recommendations.
01:11:46 Right. Now, just taking an example of the first recommendation, recommendation and the proposal
01:11:51 there, as you can see you highlighted, and it is an example only because it's on the screen in front
01:11:56 of us, but, but what role did you have in the creation of those proposals? Uh, the first one,
01:12:01 for example, targeted campaign. This, this would actually have been, uh, I think, uh, communications
01:12:08 department sat within the deputy commissioner's, uh, directorate and these recommendations would
01:12:13 have come from the, uh, communications experts and the team that we're going to deliver these
01:12:20 responses. I see. So I wouldn't have had any, uh, say, I might have had a view when we discussed
01:12:24 it, I may have commented on it, but certainly I had no involvement in the production of these
01:12:30 highlighted points. Right. Uh, did you approve or edit any of the proposals before they were
01:12:35 submitted to the commissioner? Uh, I don't think so. Not in terms of, maybe presentationally,
01:12:41 but not content. No, it doesn't look, from our examinations, it doesn't look as if it did. Um,
01:12:46 to what extent was the detailed content of those proformas discussed between you, Ron Dobson,
01:12:51 Rita Dexter and Sue Budden in your, um, commissioner's group meeting designed to
01:12:56 finalise Ron Dobson's response to the rule 43 recommendations? Well, that would have been the
01:13:02 substance of the meeting, right, to, uh, explain, uh, how we'd approached the response to give the
01:13:08 commissioner and deputy commissioner and the other attendees in the room, uh, an explanation
01:13:14 of how we'd approached the work, uh, to obviously highlight the, the areas of the response that I
01:13:20 felt would be the substantive part of the response that the commissioner would make to the coroner.
01:13:24 And then all of the kind of working document was to just give them the context so they weren't
01:13:28 coming at it cold with just the final actions, because there would have never been a discussion
01:13:33 about, you know, being able to deliver this in a reasonable timeframe. I see. Thank you very much.
01:13:38 Mr Chairman, I'm not leaving, uh, this topic, but I'm about to go into a slightly
01:13:45 more picky document. So this is a convenient moment. Is it a good time? Right. Well,
01:13:50 we have a short break during the afternoon, Mr Reason, and this looks like as good a time as
01:13:55 any. So we'll stop now. We'll resume please at half past three. And as I've said to you already,
01:14:01 when you're out of the room, please don't talk to anyone about your evidence or anything relating
01:14:05 to it. Thank you. Thank you very much. Thank you. Would you like to give the usher please?
01:14:18 Thank you. Half past three, please.
01:30:35 Okay.
01:30:54 Would you ask Mr. Reason to come back in please?
01:31:05 Okay.
01:31:11 Right. Mr. Reason, are you ready to carry on? Absolutely. Yes. Thank you very much. Yes,
01:31:16 Mr. Bennett. Yes. Now, Mr. Reason, I'd like to focus with you on the responses relating to the
01:31:22 coroner's incident command recommendations, sticking with this document at page 11. I say
01:31:28 this document needs to be brought back. LFB 3034062. Page 11, which is where we can see
01:31:40 the start of the subject, incident commanders. Yes? Yes. Now, you can see in the left-hand column,
01:31:47 this recommendation stated, NBI split coroner's recommendation into part A and B for clarity.
01:31:53 And you can see the recommendation set out in full there in italics. Now, the first one,
01:32:02 which is prefaced with the letter A, relates to the brigade's policy on changes in incident
01:32:07 commanders, doesn't it? Yes. I just want to focus on the second one prefaced with the letter B,
01:32:12 which reads, it is also recommended that consideration be given to training of ICs and
01:32:18 potential ICs to enhance their performance in relation to the following. And then there are
01:32:23 seven things, if I can put it that way, recommendations or sub-recommendations. I'm
01:32:29 going to read them to you, but I'm going to later on just to refer to them as the seven
01:32:34 recommendations in this respect, if I can. The first is use of the dynamic risk management model
01:32:39 and other management tools to enable ICs to analyze the situation and to make sure that
01:32:45 ICs are used in the right way. The second is to analyze the situation and to recognize and react
01:32:54 quickly to changing circumstances. Two, to recognize when to escalate attendance by more
01:32:59 experienced ICs. Three, to anticipate that a fire might behave in a manner inconsistent with the
01:33:04 compartmentation principle. Four, to be aware of the risks to those above and adjacent to the fire
01:33:11 and to be aware of the risk of a fire. Six, to be aware of the effective deployment of outgoing ICs.
01:33:13 Six, the collection of information from all possible sources. Seven, use of methodical
01:33:19 search patterns. Now, can we agree at this early point in the analysis of this document,
01:33:25 that there's nothing unclear or ambiguous or confusing about each of those seven recommendations?
01:33:34 I would agree. The only one I would have a slight issue with is all possible sources,
01:33:38 because all possible sources, item six, some of those sources might not be available to the
01:33:45 fire service, but that's a bit pedantic. But that's the only point. But the rest,
01:33:48 yeah, I agree with your statement. Thank you. Now, let's look at pages 12
01:33:53 through to 17. I'm going to take this as quickly as I can, but if we start with page 12, we can see
01:33:58 that this sets out the transcript of Ron Dobson's evidence to the Latinal House Inquest
01:34:04 on the 8th of March 2013. That's his witness statement, in fact, and there's an outtake,
01:34:10 paragraphs 39, 40, 41 and 42 from his statement. And then if you go to page 13,
01:34:20 you can see that there is an extract from the transcript of his examination by counsel to the
01:34:28 inquest, Mr. James Maxwell Scott. And if you run through to page 19,
01:34:39 sorry, page 17, I'm sorry, page 17, there's an extract of the LFB's extant policies there,
01:34:45 through to page 18, which is also policies, and then 19, also policies.
01:34:52 And then on the bottom of page 19, you say, or it says, the following considerations and options
01:34:58 were explored to meet the recommendation. And then there's a lengthy passage highlighted in yellow
01:35:04 over page 20, 21 and 22. Yes? Yes. If we scroll down, if we can just scroll down,
01:35:12 20, then 21, and then 22. Now, clearly, you read all this in detail and highlighted it in yellow,
01:35:19 which is why it is in yellow. And then you see 22, the box which says in the middle of your screen,
01:35:25 we propose to address the Rule 43 recommendation by the following actions. And then you have two
01:35:30 items, A and B, which were, am I right, the ultimate proposals for addressing the Rule 43
01:35:35 incident command recommendations under this heading. Sorry, I haven't seen this document
01:35:42 for a while. Yes, of course.
01:35:55 I'm not sure that the full context of A was in the final version that went to the coroner.
01:36:02 Right. I think B, definitely yes. I think A wasn't, I mean, it's a true statement,
01:36:09 and that is true. What's written in A is true. Right. But the actual action, I think, was B was
01:36:16 what we were doing. I see. Do you know which head of service you discussed incident command
01:36:24 recommendations with? Well, the incident management policy team sat within the operational
01:36:30 assurance department, so it would have been AC Danny Cotton when she was head of operational
01:36:34 assurance. Yes. Do you know why she was chosen as the relevant head of service for that recommendation?
01:36:41 Because the incident command policy was within her scope of her day job, so she was the head of
01:36:48 the department that owned incident management policy at that time. Right. And do you know what
01:36:53 her involvement was with incident command training at this point? Can I just clarify the question?
01:37:00 Is it in relation to the response in this document or more generally?
01:37:04 That's a very good request for clarification. Start with generally.
01:37:08 Yeah. AC Cotton would have been involved in the reports that come to ODCB, which, as you know,
01:37:17 included aspects of incident command. As a principal fire officer, she would have had an
01:37:25 ongoing involvement and interest in incident command matters more generally, because she would
01:37:29 obviously be mobilised as a monitoring officer or incident commander. So that's the more general
01:37:37 answer. Right. And what about specifically in relation to this proposal?
01:37:41 This would have been put together, I suspect, by Danny's incident management training team,
01:37:47 these proposals. And so she would have, one would have assumed she would have been comfortable with
01:37:52 these before they were presented to the meeting with the commissioner and deputy commissioner
01:37:56 myself and the others. Yeah. You say one would assume. Did you assume that at the time?
01:38:01 Yes, I did. Yes. Now let's look in some more details,
01:38:05 more detail that the proposals put forward for the incident command recommendations on page 22.
01:38:10 Looking at B, it says this. The NFB will engage with our training contractor to ensure the points
01:38:16 specifically listed in recommendations one to seven are addressed in the current review process
01:38:20 of incident command training. This work will aim to ensure that the training provided enhances
01:38:25 performance across the range of required skills and knowledge needed to support effective incident
01:38:29 command. The brigade will also introduce a case study which will incorporate the learning outcomes
01:38:35 from Lacknell House and from other high profile, high rise incidents such as Shirley Towers,
01:38:41 Hampshire and Harrow Court, Hertfordshire. Did you and Danny Cotton together arrive at that
01:38:49 proposal or did this just come to you from her team? My recollection is it came from her team.
01:38:56 Right. Now is it right that these two training proposals that are referred to were taken forward
01:39:05 by the LFB and then highlighted in the LFB's response to the coroner by Ron Dobson in his
01:39:11 23rd of May letter? I'm just looking at A and I don't think that actually makes a proposal
01:39:18 for a specific training or response. I think it's more factual, it's giving context. I think
01:39:26 my recollection and from what you've just shown me in terms of the action plan that we went through
01:39:30 earlier, it's substantially more B that formed the basis of the response to this particular rule 43.
01:39:38 Yes. I say there are two but that's because in fact B I think encompasses two. There's the
01:39:44 general training to ensure the points specifically listed in recommendations one to seven are
01:39:49 embedded but also a specific case study. Yes, sorry those two within B, yes, I misunderstood
01:39:54 the question. Yes, that's right. Yeah, there's two elements to B and I think that's how it was
01:39:57 expressed in the response to the coroner. Indeed and that was before, is this right, the establishment
01:40:01 of the Lackland House Working Group later in the year? Yes, this would have been. Yes. Now let's
01:40:08 then turn to the Lackland House case study which is a training package and then we'll look at that
01:40:16 before we come on to explore the LFB's engagement with Babcock on incident command. We'll do that
01:40:21 later. Now the case study's T-cap form is something you've exhibited to your second statement. It's at
01:40:28 LFB 3067857. Can we go to that please?
01:40:41 And if you go to page four of that document you can see that the name of the commissioning
01:40:52 officer under 1.2 is AC Cotton, operational assurance, and the name of a client and their
01:40:58 department is AC Brown, operations prevention and response. In his evidence Peter Groves explained
01:41:07 to us that the commissioning department, so in this case it would be the operational assurance
01:41:11 department, would identify the training needs and the learning objectives for a training package
01:41:17 before Babcock then submitted proposals for content. Can you confirm that? Yes, that's my
01:41:22 understanding in the T-cap process, yes. Yes, what was your role if any in identifying the precise
01:41:27 training needs and learning objectives associated with the Lackland House case study? I didn't have
01:41:33 any direct involvement and I didn't see this document until I saw it in my bundle to prepare
01:41:40 for this evidence. Right, I see. Well let's see how far you can help us then.
01:41:45 If you pick the document up at the very foot of page four,
01:41:50 we'll need to scroll down to the foot of the page, you can see that there's background and context,
01:41:55 you see that? Yes. And paragraph 1.6, and if you could turn the page within that section
01:42:04 in the second paragraph there it says the LFB is seeking a training case study that focuses on the
01:42:10 learning outcomes listed in section 4.1 with the coroner's seven recommendations considered
01:42:16 throughout the training as they also relate to the learning outcomes. As mentioned the purpose
01:42:21 and main objective of this T-cap is to share the learning outcomes from the Lackland incident,
01:42:26 not to develop another high-rise training pack. This training must be consistent with existing
01:42:31 training and policy and signpost existing training and policy where relevant. What was meant by the
01:42:37 intention to share the learning outcomes from the Lackland incident? Do you know? Yes, so one of the
01:42:44 things that we've done after major fires in the past in the brigade was to develop a case study
01:42:50 that actually focused on the specific incident and the learning that come out of that and any
01:42:54 work that the brigade had done to respond to the issues identified and the feedback from staff
01:43:00 particularly at fire stations was that they quite like this style of sort of raising awareness and
01:43:06 training per se. So the commissioner was very keen that we adopt a similar principle for this because
01:43:14 it was such a significant fire there was lots of issues to do with Lackland houses I'm sure the
01:43:18 inquiry is aware and this obviously proposal seemed an appropriate way to disseminate not only a lot
01:43:26 of information about what happened at Lackland but what the brigade had done and some of the new
01:43:30 procedures equipment and policies that we brought in post Lackland house fire. Looking at the last
01:43:35 sentence you could see it says training must be consistent with existing training and policy.
01:43:40 Why is that? Because what you don't want to do is have other training solutions of which there
01:43:47 will be many relating to Lackland house incident command, high-rise procedure, water supplies etc
01:43:54 and you want to make sure when you develop a new piece of training whether it's a you know
01:43:59 a station training support pack or in this case a case study that it is consistent so we're not
01:44:04 sending mixed messages to officers and operational staff. Well consistent with training but why
01:44:10 consistent with existing training after all the coroner's recommendations that identified seven
01:44:15 areas where training could be improved so why was it that the training package didn't seek to make
01:44:20 those improvements? Well I think at the time just thinking of the chronology a lot of the
01:44:27 policy work had been done in responding to what we had identified as issues at Lackland and I
01:44:34 don't know why they used the word existing obviously this wasn't meant to constrain this
01:44:39 TCAP or indeed the final training solution obviously it needed to do what it was designed to do.
01:44:45 I think that's more relating to making sure that we weren't putting information in this training
01:44:50 pack was inconsistent with other training materials policy documents that were in
01:44:54 use at that time I think that was its intent whether the wording reflects that but that would
01:44:59 be my understanding. Right because you see the wording rather suggests that the training package
01:45:06 whatever it did should be tied to existing training and policies.
01:45:11 I don't think that was the intent I'm not the author of this document but I can assure the
01:45:16 inquiry that that you know we wouldn't be introducing new training through a case study
01:45:20 if that helps to come at it from a different angle we'd want it to be consistent with
01:45:25 policies procedures equipment that is in place and current at the time this was going to go live
01:45:30 so I think that's all that sentence although it's I accept it's a bit clumsy in its meaning but
01:45:35 that's what it was intended to achieve. Right did anybody actually go back and look at the existing
01:45:39 training and policy to see whether it could remain consistent without undermining the efficacy of
01:45:46 the new training or whether it needed to be itself needed to be revised to bring it in line with
01:45:51 consistent with the new training? Well there was a as you know there was a lot of work and focus on
01:45:57 high-rise and all the associated issues to do with high-rise firefighting and rescue
01:46:02 immediately following the Lacknell House fire so again I there would have been no constraint if
01:46:07 an issue had come up in the development of this package then it would have been discussed within
01:46:13 the various forums where these t-caps were reviewed and we would have made sure that if
01:46:17 there was any new learning to come out of the development this package then we would have acted
01:46:22 upon that this certainly wouldn't have constrained that should that have been risen but this is really
01:46:28 reflecting what happened in 2009 and this is obviously dated sometime after that. Can we go
01:46:34 to page nine of this form please and we'll find the learning outcomes listed in section 4 1 referred
01:46:42 to earlier here what do you want this training to achieve is the question and again you can see
01:46:52 in the second paragraph the seven incident command training items listed verbatim lifted straight I
01:46:59 think from the coroner's 28th of March 2013 letter. Yes it is the exact lift from the letter. Yes and
01:47:05 that would rather suggest wouldn't it that our space is obvious Mr Reason that the case study
01:47:10 was intended to address those recommendations. In part it wasn't the only thing we were doing
01:47:15 to address the recommendations but in the context of this training commissioning process yes it was.
01:47:21 Yes and I think so these and those that the brigade had identified from its own internal
01:47:27 investigations and the review of the incident. Yes I mean yes to the extent to which they would
01:47:34 have all been included they would have been all I think looking at that list I think I'm quite
01:47:39 familiar with the package I've done the package myself I think they're all covered in the case
01:47:46 study but of course we had other complementary work and indeed other training delivered during
01:47:52 that period and the example I can give to the inquiry is the use of methodical search patterns
01:47:58 so as part of the response to lacanol we'd produced a brand new search and rescue policy which was
01:48:03 published from memory around 2013 so would have predated this work so we would probably
01:48:10 wouldn't have gone into very specific information about search and rescue because there was already
01:48:15 another training solution that complemented this package and from memory that this package did
01:48:20 signpost all of the other new training equipment and procedural issues that had been developed
01:48:26 since the lacanol house fire so it was a kind of composite solution that also relied on other
01:48:31 training that was going on in the brigade at that time now looking at that list
01:48:39 the list is described as learning outcomes um the verbatim transposition from your collation
01:48:47 document and in turn from the coroner's letter into this t cap might suggest that nobody had
01:48:53 actually thought about how to go about getting learning outcomes as opposed to simply identifying
01:48:59 the recommendations um i say i'm not familiar with this document in terms of its layout and
01:49:07 i don't know if it's covered elsewhere in the t cap but yeah i accept i accept what you're saying
01:49:11 but i mean if you look at items five six and seven they're not learning outcomes at all are
01:49:14 they they're just they're just simply functions and indeed functions which the coroner had
01:49:21 identified herself yeah they're not in the true sense of a learning outcome they're not they're
01:49:28 issues that obviously we wanted officers and firefighters to be aware of and that was included
01:49:33 in the case study yes did that did anybody actually sit down and work out what the trainees would have
01:49:37 to learn in order to achieve by way of learning outcome for example the collection of all of
01:49:42 information from all possible sources or the use of methodical search patterns i wouldn't know the
01:49:47 answer to that because i wasn't involved in the development of this t cap were you involved in
01:49:51 considering babcock's development of and proposed content for this case study no not now we heard
01:49:58 from peter graves that the commissioning department was required to sign off the content of the
01:50:02 training package before it was released did yourself have any role in signing it off no i
01:50:07 didn't sign off any two caps um i mean given the significance of the lacnal house fire and the fact
01:50:12 that this training was created in response to a rule 43 recommendation do you why didn't you wish
01:50:16 to assure yourself reassure yourself of its adequacy i think we invested a lot of confidence
01:50:25 and and responsibility in our heads of service they're all very experienced operational officers
01:50:31 in their own right for the majority of this t cap would have been assistant commissioners would have
01:50:35 been managing these areas of the service and so we would have expected that to be undertaken at
01:50:43 head of service level not at my level at a strategic level i mean given that you were
01:50:48 reporting to the laclan house working group and in turn perhaps in parallel the strategy committee
01:50:56 of this record of b this this two-fold proposal my question really is having set it out what were
01:51:02 you not interested in just getting into the weeds a little bit to make sure that these two new
01:51:07 training proposals were up to scratch so far as you were concerned
01:51:12 certainly that wasn't what we did as far as i can recall the question is why not
01:51:19 probably refer to my previous answer that we we put a lot of confidence
01:51:23 in the heads of service say they were a very experienced group of officers the t caps were not
01:51:29 you know new to the organization in terms of what they were intending to achieve and i think in in
01:51:35 the fullness of time as you i think you heard from miss dexter over her evidence that the odcb would
01:51:41 pick up trends so once this was delivered if if it weren't in achieving the intended outcome we
01:51:47 would have hopefully picked that up through the odcb reporting process now is it right that the
01:51:53 training this training uh in the end consisted of a cbt computer-based training study package
01:52:00 for those ranked firefighter up to watch manager and a half-day case study for um delivered by way
01:52:07 of a presentation by dac cut bill to those ranked station manager and above yeah the case study was
01:52:16 designed with two separate audiences as you've said people predominantly working at fire stations
01:52:23 and senior operational officers and so yeah one one was delivered to station which was delivered
01:52:29 through uh the watch manager who's in charge of each watch with a trainer guide to guide the
01:52:35 the trainer in effect through that process and then dac tim cut bill um led a number of uh
01:52:43 presentations which used the other half of the case study which was more focused on incident command
01:52:48 and and issues relating to senior commanders focusing on the first of those the cbt study package
01:52:56 from firefighters watch manager say station-based it would be right then wouldn't it that that
01:53:02 crew managers uh and watch managers and indeed firefighters would only receive a
01:53:09 computer-based training and no interactive or teacher-led training that's true yeah do you know
01:53:15 who made that decision who made the decision that they should only get a cbt and no interactive or
01:53:22 teacher-led training no i don't know who made that decision so you didn't sign off on that decision
01:53:27 no i was aware the case study was being developed but that was about my involvement doing your best
01:53:31 you can with the structure at the time who was it who would have made that decision uh the commissioning
01:53:37 department headed by uh i think for this series of training interventions it would have been ac
01:53:45 cotton when she was head of operational assurance right thank you now given that crew managers and
01:53:51 watch managers were still i invariably the first responders at an incident and had to make decisions
01:53:58 quickly if the fire developed unexpectedly which is one of the training points as you can see
01:54:03 yeah item three um why is it that they only got computer-based training
01:54:10 the case study itself was structured to be an interactive learning session um so i don't know
01:54:16 if you've seen the copy that we disclosed to you or the nfp disclosed to you that at each stage of
01:54:23 the development of the incident there's a break with a facilitated session uh q and a the firefighters
01:54:30 and crew manager were tasked to do certain activities and then uh the watch manager would
01:54:35 assess that against the set model answer so it wasn't uh a bit like a powerpoint it wasn't a very
01:54:41 dry i'll just watch the powerpoint it was very interactive this case study um and it had a lot
01:54:47 of information in it a lot of uh talking heads all the officers that had been in charge contributed
01:54:52 and explained their roles um very uh very articulately uh and there was questions answers
01:55:00 to reinforce these areas for the watch base context so personally as an officer i thought it was a
01:55:09 really good case study package it was interactive it was informative and it was based on a real
01:55:14 incident which is always a good combination for firefighters to take note right you say it was
01:55:18 interactive but just just on the basis of what you've told is interactive only in the sense that
01:55:24 in during the training uh firefighters and crew managers were tasked to do certain activities and
01:55:30 then they were assessed against a model answer by the watch manager yes but not interactive in any
01:55:36 greater sense than that no there was no simulation in terms of sort of uh fire ground but it was uh in
01:55:43 part in the important information that we wanted to get across to to that constituency in the
01:55:48 service right let's look at a little bit more detail at the training guide given to the station-based
01:55:55 personnel um b a b six zero seventy three this is 22nd of august 2013
01:56:07 so we are still
01:56:13 uh at the stage i think probably right to say the pre-lackland house working group stage
01:56:20 or perhaps the early stages of the lackland house working group's existence sorry can you just
01:56:24 repeat that day again yes 22nd of august 2013 yes sorry yeah uh have i got that right um
01:56:31 um yeah that predates the lack of house working group be informed that day yes um in fact i may
01:56:43 be wrong about this but if you look at the bottom of the pages it's 22nd of august 2014
01:56:48 yep um so in fact can you help me am i wrong was it 13 or 14 it looks like it was 14 in fact
01:56:53 this this document is dated correctly so the lacquer house case study from memory uh started
01:57:00 to be rolled out for the senior officer carder the senior officer senior managers by dac tim
01:57:07 cutbill and others that assisted him in the delivery of the case study and i think the fire station
01:57:13 case study was launched uh around this day end of august time right yes that's so that would be
01:57:20 consistent with that date that's helpful thank you now if we go to page uh three
01:57:25 we can see that um there is a set of instructions to watch officers at the top of the page there
01:57:33 was the expectation that this training would always be delivered in groups led by watch managers
01:57:37 yeah for the for the station-based training it would be a watched watch session so led by the
01:57:43 watch manager for that for that team who or what determined whether computer-based training packages
01:57:51 were left to individual firefighters for self-study or would be considered by a watch as a group
01:58:00 well when this was launched um as i say around end of august i think it went out to stations um
01:58:06 that was the start of the process i think we gave three months sort of as a guide
01:58:11 where senior managers wanted this to be concluded and completed by the majority of staff
01:58:16 concluded and completed by the majority of staff once information had been loaded onto the
01:58:23 computer-based training uh system which was a system called big learning i think by that stage
01:58:29 it remained on there so it was always there as a training aid for watch managers or individuals if
01:58:35 they wanted to go back in uh sometimes we uh through odcb we would instruct uh senior officers
01:58:44 and or watch base personnel to redo an existing package that was on the system
01:58:50 um i don't know if that happened with this because obviously it was only just being rolled out and
01:58:54 probably only the first wave had done it by the time i was almost retiring so but there's certainly
01:59:00 all the materials we produced both in terms of these types of packages other uh station training
01:59:07 support all the bibliography policies trainer guides trainee notes were all on the big learning
01:59:14 and it was really a repository of uh training aid for any officer and it wasn't exclusive to
01:59:21 watch base personnel it was also available to all operational senior officers right was any
01:59:25 training ever given to watch managers about how to organize and run these training sessions
01:59:29 for station-based staff beyond what's in the document uh not for this specific case study
01:59:37 what was generally uh done in certainly my time i don't know if it's still in place so when uh
01:59:43 you're promoted or you're applying for promotion uh we use national occupational standards as the
01:59:49 standard of performance for each of the roles um from firefighter right up to brigade manager
01:59:54 and when you are successful in a promotion round you commence a period of um what's called a
02:00:01 development program which again is against the national occupational standards and i'm fairly
02:00:06 certain within the well i am certain uh that one of the elements in the national occupational
02:00:12 guidance focuses on uh you know an officer's ability to identify training needs to construct
02:00:20 develop and deliver training and to assess the training they've delivered and provide feedback
02:00:25 and so i'm fairly certain when i was head of training and this would have been 2008 2009
02:00:31 that certainly the crew manager and watch manager development programs included a module and i think
02:00:37 from memory and this is from memory so apologies if it's not 100 accurate but there was a five-day
02:00:43 training module which formed part of that development program on this very subject of how do you design
02:00:50 deliver assess and feedback uh watch based training so it's not it's not true that they hadn't had any
02:00:57 training or support on this and this was just additional guidance for this particular
02:01:01 case study right no so help me when a watch manager is a point is promoted to being a watch
02:01:08 manager he gets this five-day training um on how to design and deliver training to station-based
02:01:16 staff it's certainly within the certainly when i was head of training it was certainly in the portfolio
02:01:22 uh of training uh inputs that a watch manager could undertake that would be a decision between the
02:01:29 watch manager and the line manager assessor because he might have already had the training and
02:01:33 demonstrate competence in doing that so he may not choose to do that module again but obviously
02:01:39 it would be between the candidate and the assessor what training they undertook from that development
02:01:44 program it wasn't all mandatory but it was something was mandatory but a lot of it was
02:01:48 optional depending on your training needs analysis right and where it was undertaken would it be
02:01:52 refreshed every so often um no once it was completed uh as part of a formal development
02:02:00 program it uh there was no facility i mean the training still existed so you could put your
02:02:06 staff back on the training put them through the through that bit of training but it wasn't uh
02:02:11 a cyclical or a repeating process unless it was identified as a specific training need for a
02:02:15 particular individual now this um training guide we have on our screen in front of us covers the
02:02:20 key interactive slides from the cvt package but it doesn't include the slides which contain videos
02:02:26 or graphics which explain the factual narrative to the lacnal house incident um i think that's
02:02:33 right isn't it yeah i mean it's 95 slides we've counted yeah i've not seen this particular
02:02:38 document before so i'm obviously trying to read it so i apologize if i'm being slow but um
02:02:43 yeah if that's what it says then i accept that's what it was now if we look at page seven of this
02:02:48 document this guide that relates to 72d visits
02:02:57 um on page seven and eight looking at page eight
02:03:10 what is the purpose of a 72d visit and what are their limitations
02:03:14 uh and you can see that
02:03:20 delegates are asked to create a simple line drawing of lacnal house
02:03:28 and then if you move through the next few slides pages eight and nine and ten you can see there are
02:03:33 questions on the purpose of 72d visits and their limitations let's just just looking at that for
02:03:39 the moment on page eight let's go back to page eight um what are the limitations just just pausing
02:03:47 there and picking up a question that the chairman asked miss dexter earlier this morning and you
02:03:54 could see that 72d there is referred to as a visit um was that the way the brigade routinely
02:04:00 looked at it namely that information required under that section of that statute was obtained
02:04:07 by station managers by way of a physical visit to the building that was i would say inspection
02:04:16 rather than visit but that's a play on words but um that was one way you could uh secure information
02:04:24 about a specific premise yes yes but but did did the brigade regard 72d as principally
02:04:34 visit based in other in other words the information required by the statute would be gleaned from
02:04:38 physical inspection of the building rather than looking for all information from a discrete set
02:04:44 of sources yeah i say with the description about visit versus inspection but not only that obviously
02:04:51 the regulatory fire safety department may hold information about a particular building uh which
02:04:57 may end up being put on the operational risk database which is where the the outcome of the
02:05:04 inspections would reside once the crews have decided what information they wanted to record
02:05:08 about a particular location or premise um but yeah i accept your summation that uh most of
02:05:15 the information would come from a a visual inspection of the building yes rather than
02:05:21 going to the responsible person and asking for occupancy data for example uh or a list of the
02:05:28 active and passive uh protection and prevention measures in the building
02:05:33 uh i'm not saying that that didn't happen but i don't think it was a routine uh
02:05:41 approach that was taken at that this time when i was working no thank you and if we just scroll
02:05:48 from page eight you can see there's a reference to policy number 800 which is um uh
02:05:55 uh a policy we've we've seen before at phase one of this inquiry page nine same again information
02:06:01 gathering contingency plans uh page 10 asks delegates questions about what they should do
02:06:08 if they identify building defects during a 72d visit and uh page 11 pages 11 and 12 are have
02:06:17 further discussion points for a group discussion about 72d visits now it looks just from scampering
02:06:23 through those pages is this right that the training on the information gathering under
02:06:27 section 72d was to remind trainees what the statutory obligation was and the contents of
02:06:33 the lfb policy policy number 800 um and in that sense really no more than a refresher course
02:06:41 yes because policy no 800 had been reviewed and published ahead of this which was a an
02:06:49 either a new or revised policy which was specifically in response to the lacuna house
02:06:54 rule 43 i see uh was there any study of the ways in which the information about lacuna house
02:07:00 obtained by the lfb under 72d visits before the lacuna fire was deficient in any way
02:07:09 i wasn't part of the investigation team although obviously i joined the lacuna house board in 2012
02:07:16 i i believe to the best of my recollection it would have been um similar to the investigation
02:07:21 that i started when i went back in 2017 for the gremfield tower tragedy was one of the things we
02:07:28 looked at is what the brigade had done before the incident had occurred and i would imagine
02:07:33 the same would have been done by dac tim cupper when he undertook the investigation into lacuna
02:07:37 house fire right is there any innovation in this t cap or any identification of or building on
02:07:44 mistakes made at lacuna that you can tell us about not really because i wasn't involved in
02:07:52 developing either the policy no 800 or the this t cap right so the i mean it can see we can see
02:07:59 from it that the training doesn't cover the identification of or treatment of external
02:08:04 panels facades or modern methods of construction during a 72d visit are you able to help us why
02:08:11 that is um i think it was probably because at this point and we're talking this is 2014 when
02:08:22 we deliver this training so it's obviously been developed probably in the year before this um i
02:08:27 think these took about a year to come to fruition from initial concept to delivery that the
02:08:32 understanding at the brigade at that time uh specifically around uh external cladding was
02:08:38 probably not as extensive as it clearly is post gremfield so if i put it in the context because
02:08:46 i'm not familiar with this document but i can give you my personal view as a an extremely
02:08:51 experienced officer who's attended probably hundreds of high-rise fires in my career
02:08:56 that the concept that a fire like gremfield could happen was just not something that i would have
02:09:03 ever imagined could happen in both in terms of its scale and indeed the speed of fire development
02:09:12 so whilst i accept and i you know i accept this because i've dealt with many high-rise fires and
02:09:18 been instant commander at some very major high-rise fires that fire spreading beyond the compartment
02:09:24 was not unusual in fact it was probably typical at the larger fires that i would have attended
02:09:30 um because of window failure etc but nothing that i'd have ever experienced in my
02:09:38 30 odd years as an operational commander at all levels right up to brigade manager
02:09:43 uh would have ever i would have never have managed imagined that the fire on the scale
02:09:48 of gremfield could happen uh in my in this period of my career right well we'll come back to
02:09:56 to the topic of facade fires in some detail later on but are you are you able just to
02:10:03 answer the question a bit more specifically why it is that this training august 2014 did not cover
02:10:10 with station staff the identification or treatment of external panels facades or
02:10:16 modern methods of construction when information gathering under section 72 d
02:10:21 again in the context of i do know a lot about lacanel because as you know i chaired the
02:10:27 performance review of command and obviously i spoke to steve chiric who was the incident commander at
02:10:31 then my understanding from lacanel that it was uh external panels i think it was a spandrel panel
02:10:40 which formed part of the fenestration unit at lacanel was flammable i think the thing that
02:10:45 surprised me when we we saw the outcome of the fire investigation was it was actually a collection
02:10:51 of building failures of i think seven or eight sort of strikes to be from my memory and it was
02:10:58 uh it was the combination of those seven or eight issues that you know resulted in the fire deaths
02:11:05 not a single one of those failures i think in conclusion i think the bre report which i know
02:11:10 you've seen uh actually makes that conclusion that no single building component failure probably was
02:11:17 the cause of the the tragic deaths of the six people at lacanel so i don't i just don't think
02:11:21 we had certainly in my my understanding at the time we didn't have the the depth of understanding
02:11:29 about the risk from things like rain screen cladding i mean rain screen cladding was not a term that
02:11:35 was used around this time in my career um so i suspect it's if that helps with trying to clarify
02:11:43 but i can't specifically answer for this issue or or policy note hand because i wasn't involved
02:11:48 in writing them but i suspect the corporate knowledge was not as developed as it is now
02:11:53 i wonder about that um but before i wonder with you about it can i just put put to you also there's
02:12:00 nothing in this training about external flame spread no the other part of this package does
02:12:07 about uh unusual and rapid fire spread in context but not the reasons why that might happen but not
02:12:14 external fire spread spread over the exterior of the building well i think the just the images i
02:12:21 know you talked about the embedded images and and the video clips you would have certainly got a
02:12:27 sense of from the lacanel fire even if you weren't familiar with it before you saw this case study
02:12:32 that there was some level of external fire spread and as i said fires breach in compartmentation
02:12:38 particularly on the outside face of a high-rise building was not something that was unusual
02:12:45 because windows tend to fail quite quickly because of the glazing element of the window
02:12:48 fenestration panel so fires that spread above the room of compartment once the window had fouled
02:12:56 was quite typical i would assume for the larger fires so i don't think that would have been a
02:13:01 surprise to the vast majority of firefighters that there could be the risk of unusual and
02:13:07 fire spread beyond the compartment but i accept your point that this package doesn't make it
02:13:13 specific about the potential for in effect what is a catastrophic failure of the building because
02:13:18 i don't think that was something that we imagined at this point in the brigades history of high-rise
02:13:23 firefighting do you agree that external flame spread was was considered at the time though to
02:13:30 be one of the factors that made lacanel house such a significant incident
02:13:37 i don't know if i fully agree that obviously it was involved in spreading the fire
02:13:43 but i think it from a fire and i'm talking from an incident commander perspective here and an
02:13:47 operational commander i think the challenges faced by the incident commanders and the firefighters
02:13:52 at lacanel were actually the more significant ones in terms of trying to affect a rescue for
02:13:57 the poor people that were trapped in that building was the internal compartment failure
02:14:02 of the building they were much more significant i think in terms of hampering our efforts to
02:14:07 rescue people than the external spread i think the external spread from memory was from the fire on
02:14:13 the ninth floor flat 65 and it spread up to the 11th and 12th floor partly because of there was
02:14:20 flaming on the outside but a lot of it was wind-induced fire which is the coanda effect
02:14:25 which you know flame and products of combustion tend to hug the side of a high-rise building
02:14:30 particularly the higher up you are just because of the wind shear on the building so if the wind
02:14:35 are above fouls or there's any flammable material it will ignite that that wasn't unusual as i said
02:14:41 but my understanding at the time and i'm trying not to conflate what i know now and what i knew
02:14:47 in 2013 and 14 was that the the much more challenging issues and and the issues that
02:14:56 caused the sad death of the six people were predominantly because of some of the other
02:15:01 i think six or seven failures of compartmentation and other issues around multiple paint layers which
02:15:09 hampered the fire and rescue service response to try and rescue those poor people
02:15:12 yeah and let's look at some historical documents then just to dig a little bit deeper into the
02:15:17 brigade's knowledge by august 2014 of external flame flame spread risks first can we look at lfb
02:15:27 0010 4291
02:15:34 this is a letter in december 2009 from ron dobson to saken knight who was the chief fire and rescue
02:15:42 advisor at the dclg at the time dear saken and if you look at the the first paragraph
02:15:55 it says i'm writing to inform you that as part of our investigation into the fire at lakland house
02:15:59 scow garden southwark on 3rd july 2009 we've had tests carried out on the exterior wall panels of
02:16:05 the building and that those tests have given rise to concerns which may well be relevant to other
02:16:09 high-rise premises uh they're just pausing there i mean first were you aware of this letter at the
02:16:15 time it went uh i'm not sure i saw it before it went but i certainly saw it uh when i took up my
02:16:23 role as um director i certainly i was aware of this letter yes in 2010 i think the letter is 2010
02:16:31 the letter is 2009 but sorry did you want to show see see the date again it's 14 december 2009
02:16:38 that's that's data yeah so i would have been the head of training so i wouldn't have seen this
02:16:41 letter at the time but i i became aware of this letter um when i became director exactly and that
02:16:47 was in 2010 wasn't it uh no director uh 2012 2012 i was director 2010 was i was uh moved over to the
02:16:57 head of operational well that's what i meant resilience but but but you would have but be
02:17:02 clear with me when would you first become aware of this letter uh probably when i was director
02:17:07 i think director of operations yeah right so that's 2012 now um so by then and would you have
02:17:14 read it at that stage yes yes definitely uh and then you you would therefore have seen that
02:17:20 commissioner dobson at the time was most concerned um about the public the risk to public safety
02:17:28 from um flame spread on external walls yeah if you go can you go down a bit so i can see
02:17:34 exactly well let's do that if you go to the third paragraph down he says as you'll be aware the
02:17:39 functional requirements of section b4 of the building regulations impose a number of restrictions
02:17:44 on the materials that can be used for the construction of external walls and external
02:17:47 surfaces and then he cites from approved document b and br 135 yeah uh as you can see over the page
02:17:54 and then refers to the over the page at page two the 18 meter threshold uh and um says in the
02:18:01 penultimate paragraph this um in the circumstances we believe it may be appropriate for a warning to
02:18:07 be given to housing providers that would be that it would be advisable to check the specification
02:18:11 for external wall panels in their high-rise housing stock and check that what has been installed
02:18:15 meets the correct specification i.e. that fire safety requirements for the building regulations
02:18:20 were taken into account and to include this in fire risk assessments for relevant properties
02:18:25 so you knew that that risk had been identified by the lfb and brought to the government's attention
02:18:31 in um 2009 three years before you became director no i saw this letter i think uh when i became
02:18:42 director i didn't see it in 2009 i wouldn't have no we've established that that's right but you
02:18:48 became aware of it subsequently yeah subsequently yes um uh now in his statement to the lacuna
02:18:56 inquest let's look at what ron dobson said there h o m three zeros two five three nine six
02:19:05 page 17
02:19:10 paragraph 56
02:19:14 h o m three zeros two five three nine six there it is paragraph 56 he says this
02:19:21 the challenges face just be clear this is his statement to the inquest not yeah i understand
02:19:26 he says the challenges faced by the brigade at the lacuna fire are raised due to the unusual
02:19:30 fire and smoke spread the failure of compartmentation and the fact that many communal areas became
02:19:35 filled with smoke even before the arrival of the first cruise and and then he's asked a bit more
02:19:43 about that in his oral evidence if we go to the transcript it's c wj six zeros ten page 33
02:19:59 i want to show you line seven to nine you may need to look a little a little bit more than that
02:20:05 can we have that blown up please because it's a little bit unclear
02:20:09 uh i'll start the answer at line at line one he says um uh
02:20:22 and in fact if i i wonder if i can just go back to page 32 actually just there's a little bit
02:20:26 of a run-up to it um because council to the inquest says at line 12 having gone through
02:20:36 that exercise i want to go back to the beginning and look at each much those potential factors and
02:20:42 get your evidence on changes that have been made by the london fire brigade and discuss with you
02:20:46 any other steps that could have been taken the first one of those factors i was going to ask
02:20:49 you about was the fire spread from flat 65 to flat 79 in other words a fire spreading from one
02:20:56 compartment to another is that right that's correct it may be that you think that the risk
02:21:00 of that occurring was something that was appropriately flagged up to firefighters at the time
02:21:04 but i'd be interested in your views on that and then turn the page to page 33 answer line one
02:21:09 fire spread from one compartment to another in the way in which the fire spread from flat 65 to flat
02:21:14 79 would not be uncommon to firefighters because in high-rise buildings if a fire is going to
02:21:18 spread out of the compartment of origin it's our experience that it would normally spread upwards
02:21:23 i think the rate at which it spread upwards at this factor was at this fire was a factor in the
02:21:27 handling of the incident subsequently question i think it's absolutely right as you've said that
02:21:32 at the time the upward spread of fire from one compartment to another was a recognized risk
02:21:36 yes and it was recognized in policy number 633 on high-rise firefighting yes now the focus there
02:21:43 is on on on the rate at which it's spread um given the letter of december 2009 given the
02:21:51 commissioner's evidence about the rate of fire spread at latinum i've just shown you in his
02:21:56 transcript arising out of his statement um uh do you accept looking at that now that external
02:22:04 flame spread was in fact a significant factor at lakina significant enough um to form uh part of
02:22:14 your thinking it was definitely a factor uh both in from my own knowledge of the lacuna house fire
02:22:21 and my own knowledge of attending large numbers of high-rise fires
02:22:27 the upward spread was a factor i think rate of fire spread um if we if if the intention is to
02:22:36 try and compare lacuna to gremfield my personal and professional view although i obviously didn't
02:22:43 attend gremfield is the scale of gremfield is just on a different level altogether uh i think uh i
02:22:51 won't speak for the commissioner what he meant by the term rate but i'm pretty certain he will
02:22:57 share my view that the rate of spread at lacuna was unusual but it wasn't rapid in the sense
02:23:06 as we now understand the rate of spread was at gremfield they're not anywhere in the same
02:23:11 ballpark i mean i've never seen anything spread as fast as i've seen the gremfield tower fire
02:23:18 leave aside questions of magnitude yeah the speed scale leave that on one side i'm really
02:23:25 talking i'm really asking you about types of risk and my question coming back to it is do you agree
02:23:32 me having shown you sorry i haven't shown you uh the december letter and the transcript of the
02:23:38 evidence of mr dobson at the inquest um that the that external flames spread as a risk was something
02:23:46 which was a significant factor at the lacuna house fire
02:23:52 i'll go back to my previous answer it was one of the factors i i probably not the person right
02:23:59 person to ask whether it was significant it was obviously a factor that's that's a fact um
02:24:06 and i think we do acknowledge that in the training that followed the lacuna house fire that there
02:24:10 could be unusual and i think the words are unusual and rapid fire spread we didn't quantify what
02:24:16 we meant by the term rapid obviously the case study itself when that was launched gives some
02:24:21 context to that because there was lots of images of how the fire developed um so that if i don't
02:24:29 know if that helps but well am i right in thinking that this training we can get back to it doesn't
02:24:33 cover uh anything which would tell a watch come a watch manager attending his first first responder
02:24:44 incident commander but what he's looking at is a an external flame spread or a fire which presents
02:24:53 the risk of potentially rapid external flame spread
02:24:58 it acknowledges it that it is a risk i think it's fair to say from my recollection of the case study
02:25:05 it uses those words you know rapid uh and unusual um does it go as far as giving them
02:25:15 specific guidance on recognizing it i mean the obvious answer to that is you can usually see it
02:25:22 with the greatest respect and that's not to be disrespectful to the families uh we're not
02:25:26 families when you get a very visual fire and you can see it spreading particularly on the outside
02:25:32 of the building you can see it so um i'm not sure what the training or advice would be
02:25:39 other than it will be obviously spreading um so i don't know if i can if that helps but um i know
02:25:47 the point you're driving at and i certainly concede the point that we didn't give them beyond what's
02:25:52 in the package specific guidance on uh necessarily what to do when it's spreading beyond what the
02:26:00 normal firefighting procedure is but we certainly made them aware that there was the risk of rapid
02:26:06 and unusual fire spread but we didn't say why i suppose is the point you're making we didn't
02:26:12 actually explain why it could happen with us just that it could happen and you need to be alive to
02:26:16 the fact that it could happen or what to look for what are the telltale signs well i said without
02:26:22 being obvious about it you would see it with the greatest respect mr miller if you're standing
02:26:28 outside a building and the fire is spreading rapidly up the ice outside you would see that
02:26:33 that is now a risk and a hazard that you need to deal with uh well uh do you also agree there's
02:26:42 nothing in the training package on the dynamic risk management model the dmm um like it or loathe it
02:26:50 i don't think that is true i think if you one of the slides you put up in the trainer guide actually
02:26:57 shows a copy of the decision making model which was the kind of incident command doctrine that
02:27:03 was in use at the time this package was produced so i think there is constant reference back to
02:27:10 information gathering is part of that decision making model you know setting out your objectives
02:27:15 um evaluating new objectives putting your plan in place etc communications is all part of the
02:27:20 decision making model and i think from memory it does take you through the decision making model
02:27:25 in part where it's relevant to the injects that are being used within the case study sorry it may
02:27:31 be my fault um for confusing two things which is the dmm the decision making model with dynamic
02:27:38 risk assessment sorry yeah um my question and i hope i got this right was that the training
02:27:44 package doesn't say anything about the dynamic risk assessment management model it's not the
02:27:50 same as the dmm yeah they are two distinct they are do different things yeah they are i have confused
02:27:56 you but do you accept my my what i'm putting to you that there's nothing in the training package
02:27:59 is about the package about the dynamic risk management model uh i haven't reviewed the
02:28:07 training package for a while so um i don't want to say yes or no to that in case i've got it wrong
02:28:13 um i i if you show it would be probably at the start of the package if it's going to be anywhere
02:28:19 so if you if you want to show me that i can confirm i think take it from me that that there
02:28:24 isn't also take it from me that there's nothing in the training package about fires behaving in a way
02:28:28 that's inconsistent with the compartmentation principle and my question is if i'm right about
02:28:34 that what why is that the case given that those were two of the seven topics identified by the
02:28:40 commissioner for incident command training well i'll accept your that the dynamic risk assessment
02:28:47 isn't included but i think in terms of that compartment failure is a facet or a risk at
02:28:54 high rise i think the whole package is demonstrating that very fact by the very nature of using a case
02:29:00 study where compartment failure has failed you know across a number of for a number of reasons
02:29:07 and it's resulted in a building that looks like the lacrimal house fire and then all the
02:29:11 associated challenges that that created for the incident commanders and firefighters that attended
02:29:15 that incident i think it's implicit within the training that we are actually the whole package
02:29:21 is about recognizing when the compartmentation uh as it should be uh has failed and these are the
02:29:29 problems that you are going to face or potentially going to face as firefighters incident commanders
02:29:35 and here's some tools uh some ideas about how you might resolve those challenges you say sorry
02:29:41 could you just interrupt for a moment mr risen just help me with this um if you're an incident
02:29:48 commander getting to a fire at an early stage yeah probably relatively junior officer yep junior
02:29:55 officers yeah you see a fire developing on the outside of a building perhaps in the cladding now
02:30:03 you're quite right i can understand you say you can see that it is developing on the outside
02:30:09 but what you don't know perhaps is where it's going to go from there and how quickly it might
02:30:15 go from there do you think that this training package gave an incident commander very much
02:30:21 help in understanding what was going on and how it might develop i accept i accept the proposition
02:30:30 that you're making i think from my understanding of packaging obviously my own operational knowledge
02:30:36 is it's very difficult to predict the unpredictable fires so the vast majority of fires will
02:30:43 escalate and develop in a fairly consistent way um with with regard to the external spread um
02:30:52 parking gremfield because it's you know it's on a scale as i said that we've never seen before
02:30:57 i think it would be very difficult in a training i just put my training hat on
02:31:02 to kind of second guess every permutation that could happen we were trying to impart
02:31:08 knowledge understanding and an awareness that high-rise firefighting procedures could be
02:31:15 compromised when fire starts to spread unusually or rapidly and i think that was the primary
02:31:22 intention of this package and i think the graphics and all the materials that were used
02:31:28 were self-evident i think it wasn't intended to give an example of every potential fire spread
02:31:34 because this was probably one of the more significant external fire spread
02:31:37 fires um i had one myself a year later at maddingly tower which i think the inquiry is aware of
02:31:44 which spread up four floors but again that was within kind of my understanding and experience
02:31:49 that i could deal with that uh so it wasn't intended to give a solution for every single
02:31:56 potential because the fact that the building is failing from a firefight and i don't mean this to
02:32:02 sound callous particularly for the families but from a firefighting point of view once it's
02:32:06 starting to fail you're going to have to do something different and um the the speed by
02:32:12 which the building's starting to fail will obviously inform the decisions that those
02:32:16 officers have to take because typically standard firefighting high-rise procedure will not work in
02:32:22 those situations i don't know if that helps yes that is helpful thank you very much um my question
02:32:29 mr chairman this will i think have to be the last question of the of the evening but do you accept
02:32:38 that although the station-based training might have been been intended to perhaps implicitly
02:32:44 using your words disseminate to station-based staff what to do in fact the the recommendation
02:32:55 was to train station-based staff on each one of the seven aspects of incident command
02:33:05 that was the intention yes um and and that being the case can you explain why there's there's
02:33:11 nothing in the training package on a dynamic risk management management or or um the fires behaving
02:33:18 in a way which is inconsistent with the compartmentation principle
02:33:25 i concede the first point that from what i've seen and what i remember it doesn't contain whether
02:33:30 there's uh information in the pack to point the training session to other reading materials which
02:33:36 is typically how we did station train station training uh support packages and case studies it
02:33:42 this was to be read in context to other materials that were available on the big learning system
02:33:47 so i don't know if there's an explicit reference to the dynamic risk assessment model uh and i
02:33:54 can't answer that because i can't remember what was in the package but i don't accept your second
02:33:58 point that there wasn't information in this package i mean the whole purpose of this package
02:34:04 was uh amongst other things to uh share the experience of the fairly small number of
02:34:11 operational staff and officers had experienced at lacna with the whole workforce right so just to
02:34:17 understand that answer is a bit more clearly that you saying that the support package would have
02:34:21 linked to other materials on the big learning system i i can't explicitly say that is right
02:34:27 accurate but that's that's how we normally did it it wasn't these weren't necessary they were
02:34:32 self-stand-alone packages but of course there was an awful lot of material training material
02:34:36 that that kind of complemented this package on the big learning system right so it wasn't a one stop
02:34:41 shop uh training isn't a one stop shop it you know we're training all the time uh we're trying to add
02:34:48 value in terms of new training materials like case studies uh as a way of imparting knowledge
02:34:53 understanding and improving performance um but there's so many i mean i think miss dexter covered
02:34:59 this it is a complicated organization in terms of its scale and the scope of what its statutory
02:35:05 function is in terms of fire and rescue and you know whilst i completely understand this
02:35:10 inquiry is focused on high rise we also have to deal with a multitude of other incident types
02:35:17 which have all got training materials policies so it's always a balance of um you know focusing
02:35:22 on the important stuff which clearly lacna was a significant fire and i hope you agree that you
02:35:27 know the fire service's intention was to learn from that and share that knowledge and understanding
02:35:32 but there's also an awful lot of other stuff that firefighters need to maintain their knowledge
02:35:35 understanding and skill setting in order to satisfy our statutory functions is that a
02:35:40 convenient moment yes thank you very much well we've overrun slightly but that was worth it so
02:35:46 we'll stop at that point it's the reason we'll resume if we may please at 10 o'clock tomorrow
02:35:51 yeah no problem and again please don't discuss your evidence or anything to do with anyone
02:35:55 overnight thank you thank you very much indeed would you like to go to the action thank you
02:36:12 thank you very much 10 o'clock tomorrow then please